Normal Postpartum PeriodNormal Postpartum Period

The Postpartum PeriodThe Postpartum Period

Puerperium = fourth trimester of Puerperium = fourth trimester of pregnancypregnancy - the 6-week interval - the 6-week interval between the birth of the newborn and between the birth of the newborn and the return of the reproductive organs to the return of the reproductive organs to their normal nonpregnant statetheir normal nonpregnant state

Uterine InvolutionUterine Involution Uterine Involution: Uterine Involution:

return of the uterus to its pre-return of the uterus to its pre-pregnancy size and condition, which pregnancy size and condition, which begins immediately after expulsion of begins immediately after expulsion of the placenta with contraction of the the placenta with contraction of the uterine smooth muscleuterine smooth muscle

Uterine fundal descent: Uterine fundal descent: immediately after birth immediately after birth uterus is in uterus is in

the midline approximately 2 cm below the midline approximately 2 cm below the level of the umbilicus, size of the level of the umbilicus, size of grapefruit (like 16 weeks of grapefruit (like 16 weeks of gestation), weighs approximately gestation), weighs approximately 1000 g.1000 g.

Within 12 hours the fundus may be Within 12 hours the fundus may be approximately 1 cm above the approximately 1 cm above the umbilicusumbilicus

During next few days the fundus During next few days the fundus descends 1 to 2 cm (fingerbreadth) descends 1 to 2 cm (fingerbreadth) every 24 hours. every 24 hours.

By the sixth postpartum day the By the sixth postpartum day the fundus is normally located halfway fundus is normally located halfway between the umbilicus and the between the umbilicus and the symphysis pubis. symphysis pubis.

A week after birth the uterus once A week after birth the uterus once again lies in the true pelvis. again lies in the true pelvis.

After the ninth postpartum day the After the ninth postpartum day the uterus should not be palpable uterus should not be palpable abdominally.abdominally.

Uterine InvolutionUterine Involution Increased estrogen and progesterone levels are Increased estrogen and progesterone levels are

responsible for stimulating the massive growth of responsible for stimulating the massive growth of the uterus during pregnancy. Prenatal uterine the uterus during pregnancy. Prenatal uterine growth results from both hyperplasia, an increase in growth results from both hyperplasia, an increase in the number of muscle cells, and from hypertrophy, the number of muscle cells, and from hypertrophy, an enlargement of the existing cells. Postpartally, an enlargement of the existing cells. Postpartally, the decrease in these hormones causes the decrease in these hormones causes autolysis, autolysis, the self-destruction of excess hypertrophied tissue. the self-destruction of excess hypertrophied tissue. The additional cells laid down during pregnancy The additional cells laid down during pregnancy remain and account for the slight increase in uterine remain and account for the slight increase in uterine size after each pregnancy.size after each pregnancy.

Subinvolution Subinvolution is the failure of the uterus to return is the failure of the uterus to return to a nonpregnant state. The most common causes of to a nonpregnant state. The most common causes of subinvolution are retained placental fragments and subinvolution are retained placental fragments and infection.infection.

LLochia Assessmentochia Assessment Lochia–vaginal discharge after childbirth.Lochia–vaginal discharge after childbirth. It takes 6 weeks for the vagina to regain its pre-pregnancy It takes 6 weeks for the vagina to regain its pre-pregnancy

contour.contour. For the first 2 hours after birth the amount of uterine discharge For the first 2 hours after birth the amount of uterine discharge

should be approximately that of a heavy menstrual period. After should be approximately that of a heavy menstrual period. After that time, the lochia flow should steadily decrease. that time, the lochia flow should steadily decrease.

Lochia: rubra, serosa or alba Assessment of lochia includes noting color, presence and size of clots Assessment of lochia includes noting color, presence and size of clots

and foul odor.and foul odor.

Day 1- 3 - lochia rubra Day 1- 3 - lochia rubra (blood with small pieces of decidua and (blood with small pieces of decidua and mucus)  mucus)                                                             

Day 4-10-22-27 – lochia serosa Day 4-10-22-27 – lochia serosa (pink or pinkish brown serous exudate (pink or pinkish brown serous exudate with old blood, cervical mucus, erythrocytes and leukocytes, tissue with old blood, cervical mucus, erythrocytes and leukocytes, tissue debrisdebris))

Day 11- 21 - lochia alba Day 11- 21 - lochia alba ((yellowish white discharge with leucocytes, yellowish white discharge with leucocytes, decidua, epithelian cells, mucus, serum, bacteria)decidua, epithelian cells, mucus, serum, bacteria)

The amount of lochia is usually less after cesarean births. Flow of lochia usually increases with ambulation and breastfeeding and receives an oxytocin medication

LOCHIAL AND NONLOCHIAL LOCHIAL AND NONLOCHIAL BLEEDINGLOCHIAL BLEEDINGLOCHIAL

BLEEDINGNONLOCHIAL BLEEDINGBLEEDINGNONLOCHIAL BLEEDINGLochiaLochia

Lochia usually trickles Lochia usually trickles from the vaginal opening. from the vaginal opening. The steady flow is greater The steady flow is greater as the uterus contractsas the uterus contracts

A gush of lochia may A gush of lochia may result as the uterus is result as the uterus is massaged. If it is dark in massaged. If it is dark in color, it has been pooled color, it has been pooled in the relaxed vagina, in the relaxed vagina, and the amount soon and the amount soon lessens to a trickle of lessens to a trickle of bright red lochia (in the bright red lochia (in the early puerperium).early puerperium).

Bleeding Bleeding If the bloody If the bloody

discharge spurts from discharge spurts from the vagina, there may the vagina, there may be cervical or vaginal be cervical or vaginal tears in addition to tears in addition to the normal lochia. the normal lochia.

If the amount of If the amount of bleeding continues to bleeding continues to be excessive and be excessive and bright red, a tear may bright red, a tear may be the source.be the source.

CervixCervix The cervix is soft immediately after birth. The cervix is soft immediately after birth. By 18 hours postpartum it has shortened, become firm, and By 18 hours postpartum it has shortened, become firm, and

regained its form. regained its form. The cervix up to the lower uterine segment remains The cervix up to the lower uterine segment remains

edematous, thin, and fragile for several days after birth. edematous, thin, and fragile for several days after birth. The ectocervix (portion of the cervix that protrudes into the The ectocervix (portion of the cervix that protrudes into the

vagina) appears bruised and has some small lacerations—vagina) appears bruised and has some small lacerations—optimal conditions for the development of infection. optimal conditions for the development of infection.

The cervical os, which dilated to 10 cm during labor, closes The cervical os, which dilated to 10 cm during labor, closes gradually. gradually.

Two fingers may still be introduced into the cervical os for the Two fingers may still be introduced into the cervical os for the first 4 to 6 days postpartum; however, only the smallest first 4 to 6 days postpartum; however, only the smallest curette can be introduced by the end of 2 weeks. curette can be introduced by the end of 2 weeks.

The external cervical os never regains its prepregnant The external cervical os never regains its prepregnant appearance; it is no longer shaped like a circle but appears as appearance; it is no longer shaped like a circle but appears as a jagged slit that is often described as a "fishmouth." a jagged slit that is often described as a "fishmouth."

Lactation delays the production of cervical and other estrogen-Lactation delays the production of cervical and other estrogen-influenced mucus and mucosal characteristics.influenced mucus and mucosal characteristics.

VAGINA AND PERINEUMVAGINA AND PERINEUM VaginaVagina

vaginal mucosa is thin, atrophic, with decrease amount of lubrication and vaginal mucosa is thin, atrophic, with decrease amount of lubrication and without rugae as a result of estrogen deprivation which lead to coital without rugae as a result of estrogen deprivation which lead to coital discomfort (dyspareunia) until ovarian function returns and menstruation discomfort (dyspareunia) until ovarian function returns and menstruation resumes.resumes.

The greatly distended, smooth-walled vagina gradually returns to its The greatly distended, smooth-walled vagina gradually returns to its

prepregnancy size by 6 to 8 weeks after childbirth. Rugae reappear by prepregnancy size by 6 to 8 weeks after childbirth. Rugae reappear by approximately the fourth week, but they are never as prominent as they approximately the fourth week, but they are never as prominent as they are in the nulliparous woman. Most rugae are permanently flattened. are in the nulliparous woman. Most rugae are permanently flattened.

PerineumPerineum the introitus is erythematous and edematous, especially in the area of the the introitus is erythematous and edematous, especially in the area of the

episiotomy or laceration repair. It is barely distinguishable from that of a episiotomy or laceration repair. It is barely distinguishable from that of a nulliparous womannulliparous woman

Episiotomy. Most episiotomies are visible only if the woman is lying on her Episiotomy. Most episiotomies are visible only if the woman is lying on her side with her upper buttock raised or if she is placed in the lithotomy side with her upper buttock raised or if she is placed in the lithotomy position. position.

Hemorrhoids (anal varicosities) are commonly seen. Internal hemorrhoids Hemorrhoids (anal varicosities) are commonly seen. Internal hemorrhoids may evert while the woman is pushing during birth. Women often may evert while the woman is pushing during birth. Women often experience associated symptoms such as itching, discomfort, and bright experience associated symptoms such as itching, discomfort, and bright red bleeding with defecation. Hemorrhoids usually decrease in size within 6 red bleeding with defecation. Hemorrhoids usually decrease in size within 6 weeks of childbirth.weeks of childbirth.

Pelvic muscular supportPelvic muscular support The supporting structure of the uterus and vagina The supporting structure of the uterus and vagina

may be injured during childbirth and may contribute may be injured during childbirth and may contribute to later gynecologic problems. to later gynecologic problems.

Supportive tissues of the pelvic floor that are torn or Supportive tissues of the pelvic floor that are torn or stretched during childbirth may require up to 6 stretched during childbirth may require up to 6 months to regain tone. months to regain tone.

Kegel exercisesKegel exercises, which help to strengthen perineal , which help to strengthen perineal muscles and encourage healing, are recommended muscles and encourage healing, are recommended after childbirth. after childbirth.

Later in life, women can experience pelvic Later in life, women can experience pelvic relaxation, the lengthening and weakening of the relaxation, the lengthening and weakening of the fascial supports of pelvic structures. fascial supports of pelvic structures.

These structures include the uterus, upper posterior These structures include the uterus, upper posterior vaginal wall, urethra, bladder, and rectum.vaginal wall, urethra, bladder, and rectum.

Endocrine SystemEndocrine System Placental hormones (human chorionic Placental hormones (human chorionic

somatomammotropin, estrogens, cortisol, and the somatomammotropin, estrogens, cortisol, and the placental enzyme insulinase)placental enzyme insulinase) dramatically decrease and reverse the diabetogenic effects dramatically decrease and reverse the diabetogenic effects

of pregnancy, resulting in significantly lower blood sugar of pregnancy, resulting in significantly lower blood sugar levels in the immediate puerperium.levels in the immediate puerperium.

Estrogen and progesterone levels drop markedly after Estrogen and progesterone levels drop markedly after expulsion of the placenta and reach their lowest levels 1 expulsion of the placenta and reach their lowest levels 1 week postpartum. Decreased estrogen levels are associated week postpartum. Decreased estrogen levels are associated with breast engorgement and with the diuresis of excess with breast engorgement and with the diuresis of excess extracellular fluid accumulated during pregnancy.extracellular fluid accumulated during pregnancy.

In nonlactating women, estrogen levels begin to rise by 2 In nonlactating women, estrogen levels begin to rise by 2 weeks after birth and by postpartum day 17 are higher than weeks after birth and by postpartum day 17 are higher than in women who breastfeedin women who breastfeed

β-Human chorionic gonadotropin disappears from maternal β-Human chorionic gonadotropin disappears from maternal circulation in 14 dayscirculation in 14 days

Endocrine SystemEndocrine System Pituitary hormones and ovarian functionPituitary hormones and ovarian function

The persistence of elevated serum prolactin levels in breastfeeding women The persistence of elevated serum prolactin levels in breastfeeding women appears to be responsible for suppressing ovulation. Because levels of appears to be responsible for suppressing ovulation. Because levels of follicle-stimulating hormone (FSH) have been shown to be identical in follicle-stimulating hormone (FSH) have been shown to be identical in lactating and nonlactating women, it is thought that the ovulation is lactating and nonlactating women, it is thought that the ovulation is suppressed in lactating women because the ovary does not respond to FSH suppressed in lactating women because the ovary does not respond to FSH stimulation when increased prolactin levels are presentstimulation when increased prolactin levels are present

Prolactin levels in blood rise progressively throughout pregnancy. Prolactin levels in blood rise progressively throughout pregnancy. In nonlactating women, prolactin levels decline after birth and reach the In nonlactating women, prolactin levels decline after birth and reach the

prepregnant range in 4 to 6 weeks prepregnant range in 4 to 6 weeks In breastfeeding woman prolactin levels remain elevated into the sixth week In breastfeeding woman prolactin levels remain elevated into the sixth week

after birth, and influence by the frequency of breastfeeding, the duration of after birth, and influence by the frequency of breastfeeding, the duration of each feeding, and the degree to which supplementary feedings are used. each feeding, and the degree to which supplementary feedings are used.

Ovulation occurs as early as 27 days after birth in Ovulation occurs as early as 27 days after birth in nonlactatingnonlactating women, with women, with a mean time of 70 to 75 days. Approximately 70% of nonbreastfeeding a mean time of 70 to 75 days. Approximately 70% of nonbreastfeeding women resume menstruating by 3 months after birth.women resume menstruating by 3 months after birth.

In women who In women who breastfeedbreastfeed, the mean length of time to initial ovulation is 17 , the mean length of time to initial ovulation is 17 weeks. In lactating women, both resumption of ovulation and return of weeks. In lactating women, both resumption of ovulation and return of menses are determined in large part by breastfeeding patterns. Many women menses are determined in large part by breastfeeding patterns. Many women ovulate before their first postpartum menstrual period occurs; thus there is ovulate before their first postpartum menstrual period occurs; thus there is need to discuss contraceptive options early in the puerperium.need to discuss contraceptive options early in the puerperium.

The first menstrual flow after childbirth is usually heavier than normal. Within The first menstrual flow after childbirth is usually heavier than normal. Within three to four cycles the amount of menstrual flow returns to the woman's three to four cycles the amount of menstrual flow returns to the woman's prepregnancy volumeprepregnancy volume

AbdomenAbdomen

During the first 2 weeks after birth the During the first 2 weeks after birth the abdominal wall is relaxed. abdominal wall is relaxed.

Returns to prepregnancy state 6 weeks Returns to prepregnancy state 6 weeks after birth after birth

The skin regains most of its previous The skin regains most of its previous elasticity, but some striae may persist.elasticity, but some striae may persist.

The return of muscle tone depends on The return of muscle tone depends on previous tone, proper exercise, and the previous tone, proper exercise, and the amount of adipose tissue.amount of adipose tissue.

Occasionally, with or without Occasionally, with or without overdistention because of a large fetus overdistention because of a large fetus or multiple fetuses, the abdominal wall or multiple fetuses, the abdominal wall muscles separate, a condition termed muscles separate, a condition termed diastasis recti abdominis. Persistence of diastasis recti abdominis. Persistence of this defect may be disturbing to the this defect may be disturbing to the woman, but surgical correction rarely is woman, but surgical correction rarely is necessary. With time, the defect necessary. With time, the defect becomes less apparent.becomes less apparent.

Urinary SystemUrinary System Renal function reduced as a result of diminishing steroid levels Renal function reduced as a result of diminishing steroid levels

after childbirth after childbirth Kidney function returns to normal within 1 month after birth.Kidney function returns to normal within 1 month after birth. From 2 to 8 weeks are required for the pregnancy-induced From 2 to 8 weeks are required for the pregnancy-induced

hypotonia and dilation of the ureters and renal pelvis to return hypotonia and dilation of the ureters and renal pelvis to return to the nonpregnant state. to the nonpregnant state.

In a small percentage of women, dilation of the urinary tract In a small percentage of women, dilation of the urinary tract may persist for 3 months, which increases the chance of may persist for 3 months, which increases the chance of developing a urinary tract infection.developing a urinary tract infection.

URINE COMPONENTSURINE COMPONENTS renal glycosuria disappears, renal glycosuria disappears, but lactosuria may occur in lactating women. but lactosuria may occur in lactating women. The blood urea nitrogen increases during the puerperium as The blood urea nitrogen increases during the puerperium as

autolysis of the involuting uterus occurs. This breakdown of excess autolysis of the involuting uterus occurs. This breakdown of excess protein in the uterine muscle cells also results in a mild (+1) protein in the uterine muscle cells also results in a mild (+1) proteinuria for 1 to 2 days after childbirth in approximately 50% of proteinuria for 1 to 2 days after childbirth in approximately 50% of women women

Ketonuria may occur in women with an uncomplicated birth or Ketonuria may occur in women with an uncomplicated birth or after a prolonged labor with dehydration.after a prolonged labor with dehydration.

Urinary SystemUrinary System POSTPARTAL DIURESISPOSTPARTAL DIURESIS

Within 12 hours of birth, women begin to lose excess tissue fluid accumulated Within 12 hours of birth, women begin to lose excess tissue fluid accumulated during pregnancy.during pregnancy.

Profuse diaphoresis often occurs, especially at night, for the first 2 or 3 days Profuse diaphoresis often occurs, especially at night, for the first 2 or 3 days after childbirth.after childbirth.

Postpartal diuresis, caused by decreased estrogen levels, removal of Postpartal diuresis, caused by decreased estrogen levels, removal of increased venous pressure in the lower extremities, and loss of the remaining increased venous pressure in the lower extremities, and loss of the remaining pregnancy-induced increase in blood volume, also aids the body to rid itself of pregnancy-induced increase in blood volume, also aids the body to rid itself of excess fluid. excess fluid.

Fluid loss through perspiration and increased urinary output accounts for a Fluid loss through perspiration and increased urinary output accounts for a weight loss of approximately 2.25 kg during the puerperium.weight loss of approximately 2.25 kg during the puerperium.

URETHRA AND BLADDERURETHRA AND BLADDER Birth-induced trauma, increased bladder capacity following childbirth, and the Birth-induced trauma, increased bladder capacity following childbirth, and the

effects of conduction anesthesia combine to cause a decreased urge to void.effects of conduction anesthesia combine to cause a decreased urge to void. In addition, pelvic soreness caused by the forces of labor, vaginal lacerations, In addition, pelvic soreness caused by the forces of labor, vaginal lacerations,

or the episiotomy reduces or alters the voiding reflex.or the episiotomy reduces or alters the voiding reflex. Decreased voiding combined with postpartal diuresis may result in bladder Decreased voiding combined with postpartal diuresis may result in bladder

distention. Immediately after birth, excessive bleeding can occur if the distention. Immediately after birth, excessive bleeding can occur if the bladder becomes distended because it pushes the uterus up and to the side bladder becomes distended because it pushes the uterus up and to the side and prevents the uterus from contracting firmly. and prevents the uterus from contracting firmly.

Later in the puerperium overdistention can make the bladder more Later in the puerperium overdistention can make the bladder more susceptible to infection and impede the resumption of normal voiding. With susceptible to infection and impede the resumption of normal voiding. With adequate emptying of the bladder, bladder tone is usually restored 5 to 7 adequate emptying of the bladder, bladder tone is usually restored 5 to 7 days after childbirth.days after childbirth.

GASTROINTESTINAL GASTROINTESTINAL SYSTEMSYSTEM

APPETITEAPPETITE The mother usually is hungry shortly after the birth and can The mother usually is hungry shortly after the birth and can

tolerate a light diet. tolerate a light diet. Most new mothers are very hungry after full recovery from Most new mothers are very hungry after full recovery from

analgesia, anesthesia, and fatigue. Requests for double portions of analgesia, anesthesia, and fatigue. Requests for double portions of food and frequent snacks are not uncommonfood and frequent snacks are not uncommon

BOWEL EVACUATIONBOWEL EVACUATION A spontaneous bowel evacuation may not occur for 2 to 3 days A spontaneous bowel evacuation may not occur for 2 to 3 days

after childbirth. This delay can be explained by decreased muscle after childbirth. This delay can be explained by decreased muscle tone in the intestines during labor and the immediate puerperium, tone in the intestines during labor and the immediate puerperium, prelabor diarrhea, lack of food, or dehydration. The mother often prelabor diarrhea, lack of food, or dehydration. The mother often anticipates discomfort during the bowel movement because of anticipates discomfort during the bowel movement because of perineal tenderness as a result of episiotomy, lacerations, or perineal tenderness as a result of episiotomy, lacerations, or hemorrhoids and resists the urge to defecate. Regular bowel habits hemorrhoids and resists the urge to defecate. Regular bowel habits should be reestablished when bowel tone returns.should be reestablished when bowel tone returns.

Obstetric trauma (e.g., direct injury to the sphincter muscle, Obstetric trauma (e.g., direct injury to the sphincter muscle, damage to the innervation of the pelvic floor) is perhaps the damage to the innervation of the pelvic floor) is perhaps the leading cause of anal incontinence in otherwise healthy women. leading cause of anal incontinence in otherwise healthy women. Women should be taught during pregnancy about episiotomy and Women should be taught during pregnancy about episiotomy and its possible sequelae. Pelvic floor (Kegel) exercises should be its possible sequelae. Pelvic floor (Kegel) exercises should be encouraged.encouraged.

BREASTSBREASTS Promptly after birth, there is a decrease in the concentrations of hormones (i.e., estrogen, Promptly after birth, there is a decrease in the concentrations of hormones (i.e., estrogen,

progesterone, hCG, prolactin, cortisol, and insulin) that stimulated breast development progesterone, hCG, prolactin, cortisol, and insulin) that stimulated breast development during pregnancy. The time it takes for these hormones to return to prepregnancy levels is during pregnancy. The time it takes for these hormones to return to prepregnancy levels is determined in part by whether the mother breastfeeds her infant.determined in part by whether the mother breastfeeds her infant.

BREASTFEEDING MOTHERSBREASTFEEDING MOTHERS As lactation is established, a mass (lump) may be felt in the breast. Unlike the lumps As lactation is established, a mass (lump) may be felt in the breast. Unlike the lumps

associated with fibrocystic breast disease or cancer (which may be consistently palpated associated with fibrocystic breast disease or cancer (which may be consistently palpated in the same location), a filled milk sac shifts position from day to day. Before lactation in the same location), a filled milk sac shifts position from day to day. Before lactation begins, the breasts feel soft and a yellowish fluid, colostrum, can be expressed from the begins, the breasts feel soft and a yellowish fluid, colostrum, can be expressed from the nipples. After lactation begins, the breasts feel warm and firm. Tenderness may persist for nipples. After lactation begins, the breasts feel warm and firm. Tenderness may persist for approximately 48 hours after the start of lactation. Bluish-white milk with a skim-milk approximately 48 hours after the start of lactation. Bluish-white milk with a skim-milk appearance (true milk) can be expressed from the nipples. The nipples are examined for appearance (true milk) can be expressed from the nipples. The nipples are examined for erectility and signs of irritation such as cracks, blisters, or reddening. erectility and signs of irritation such as cracks, blisters, or reddening.

NONBREASTFEEDING MOTHERSNONBREASTFEEDING MOTHERS The breasts generally feel nodular in contrast to the granular feel of breasts in The breasts generally feel nodular in contrast to the granular feel of breasts in

nonpregnant women. The nodularity is bilateral and diffuse. Prolactin levels drop rapidly. nonpregnant women. The nodularity is bilateral and diffuse. Prolactin levels drop rapidly. Colostrum is present for the first few days after childbirth. Palpation of the breast on the Colostrum is present for the first few days after childbirth. Palpation of the breast on the second or third day, as milk production begins, may reveal tissue tenderness in some second or third day, as milk production begins, may reveal tissue tenderness in some women. On the third or fourth postpartum day, engorgement may occur. The breasts are women. On the third or fourth postpartum day, engorgement may occur. The breasts are distended (swollen), firm, tender, and warm to the touch (because of vasocongestion). distended (swollen), firm, tender, and warm to the touch (because of vasocongestion). Breast distention is caused primarily by the temporary congestion of veins and lymphatics Breast distention is caused primarily by the temporary congestion of veins and lymphatics rather than by an accumulation of milk. Milk is present but should not be expressed. rather than by an accumulation of milk. Milk is present but should not be expressed. Axillary breast tissue (the tail of Spence) and any accessory breast or nipple tissue along Axillary breast tissue (the tail of Spence) and any accessory breast or nipple tissue along the milk line may be involved. Engorgement resolves spontaneously, and discomfort the milk line may be involved. Engorgement resolves spontaneously, and discomfort decreases usually within 24 to 36 hours. A breast binder or tight bra, ice packs, or mild decreases usually within 24 to 36 hours. A breast binder or tight bra, ice packs, or mild analgesics may be used to relieve discomfort. Nipple stimulation is avoided. If suckling is analgesics may be used to relieve discomfort. Nipple stimulation is avoided. If suckling is never begun (or is discontinued), lactation ceases within a few days to a week.never begun (or is discontinued), lactation ceases within a few days to a week.

CARDIOVASCULAR CARDIOVASCULAR SYSTEMSYSTEM

BLOOD VOLUMEBLOOD VOLUME Changes in blood volume after birth depend on several factors, such as Changes in blood volume after birth depend on several factors, such as

blood loss during childbirth and the amount of extravascular water blood loss during childbirth and the amount of extravascular water (physiologic edema) mobilized and excreted. Blood loss results in an (physiologic edema) mobilized and excreted. Blood loss results in an immediate but limited decrease in total blood volume. Thereafter, most immediate but limited decrease in total blood volume. Thereafter, most of the blood volume increase during pregnancy (1000 to 1500 ml) is of the blood volume increase during pregnancy (1000 to 1500 ml) is eliminated within the first 2 weeks after birth, with return to eliminated within the first 2 weeks after birth, with return to nonpregnancy values by 6 weeks postpartumnonpregnancy values by 6 weeks postpartum

Pregnancy-induced hypervolemia allows most women to tolerate Pregnancy-induced hypervolemia allows most women to tolerate considerable blood loss during childbirth. Many women lose considerable blood loss during childbirth. Many women lose approximately 300 to 400 ml of blood during vaginal birth of a single approximately 300 to 400 ml of blood during vaginal birth of a single fetus and approximately twice this much during cesarean birth.fetus and approximately twice this much during cesarean birth.

Readjustments in the maternal vasculature after childbirth are dramatic Readjustments in the maternal vasculature after childbirth are dramatic and rapid. The woman's response to blood loss during the early and rapid. The woman's response to blood loss during the early puerperium differs from that in a nonpregnant woman. Three postpartal puerperium differs from that in a nonpregnant woman. Three postpartal physiologic changes protect the woman by increasing the blood volume: physiologic changes protect the woman by increasing the blood volume:

elimination of uteroplacental circulation reduces the size of the maternal elimination of uteroplacental circulation reduces the size of the maternal vascular bed by 10% to 15%, vascular bed by 10% to 15%,

loss of placental endocrine function removes the stimulus for vasodilation, loss of placental endocrine function removes the stimulus for vasodilation, mobilization of extravascular water stored during pregnancy occurs. Thus mobilization of extravascular water stored during pregnancy occurs. Thus

hypovolemic shock usually does not occur in women who experience a normal hypovolemic shock usually does not occur in women who experience a normal blood loss.blood loss.

CARDIOVASCULAR CARDIOVASCULAR SYSTEMSYSTEM

CARDIAC OUTPUTCARDIAC OUTPUT Pulse rate, stroke volume, and cardiac output increase throughout Pulse rate, stroke volume, and cardiac output increase throughout

pregnancy. Immediately after the birth they remain elevated or pregnancy. Immediately after the birth they remain elevated or rise even higher for 30 to 60 minutes as the blood that was rise even higher for 30 to 60 minutes as the blood that was shunted through the uteroplacental circuit suddenly returns to the shunted through the uteroplacental circuit suddenly returns to the maternal systemic venous circulation. maternal systemic venous circulation.

Data regarding the exact time of return of cardiac hemodynamic Data regarding the exact time of return of cardiac hemodynamic levels to normal are not available, but cardiac output values levels to normal are not available, but cardiac output values remain elevated for at least 48 hours after birth, decrease rapidly remain elevated for at least 48 hours after birth, decrease rapidly in the first 2 weeks postpartum, and return to prepregnancy level in the first 2 weeks postpartum, and return to prepregnancy level by 24 weeks postpartum.by 24 weeks postpartum.

Stroke volume, cardiac output, end-diastolic volume, and systemic Stroke volume, cardiac output, end-diastolic volume, and systemic vascular resistance values have been shown to remain greatly vascular resistance values have been shown to remain greatly elevated for as long as 12 weeks postpartumelevated for as long as 12 weeks postpartum

VITAL SIGNSVITAL SIGNS Few alterations in vital signs are seen under normal circumstances. Few alterations in vital signs are seen under normal circumstances.

There may be a small, transient rise in both systolic and diastolic There may be a small, transient rise in both systolic and diastolic blood pressure that lasts approximately 4 days after the birth blood pressure that lasts approximately 4 days after the birth

Respiratory function returns to nonpregnant levels by 6 to 8 weeks Respiratory function returns to nonpregnant levels by 6 to 8 weeks after birth. After the uterus is emptied, the diaphragm descends, after birth. After the uterus is emptied, the diaphragm descends, the normal cardiac axis is restored, and the point of maximal the normal cardiac axis is restored, and the point of maximal impulse and the electrocardiogram are normalized.impulse and the electrocardiogram are normalized.

CARDIOVASCULAR CARDIOVASCULAR SYSTEMSYSTEM

BLOOD COMPONENTSBLOOD COMPONENTS Hematocrit and hemoglobinHematocrit and hemoglobin

During the first 72 hours after childbirth, there is a greater loss of plasma volume During the first 72 hours after childbirth, there is a greater loss of plasma volume than in the number of blood cells. This results in a rise in hematocrit and hemoglobin than in the number of blood cells. This results in a rise in hematocrit and hemoglobin levels by the seventh day after the birth. There is no increased red blood cell (RBC) levels by the seventh day after the birth. There is no increased red blood cell (RBC) destruction during the puerperium, but any excess will disappear gradually in destruction during the puerperium, but any excess will disappear gradually in accordance with the life span of the RBC. The exact time at which RBC volume accordance with the life span of the RBC. The exact time at which RBC volume returns to prepregnancy values is not known, but it is within normal limits when returns to prepregnancy values is not known, but it is within normal limits when measured 8 weeks after childbirthmeasured 8 weeks after childbirth

White blood cell countWhite blood cell count Normal leukocytosis of pregnancy averages approximately 12,000/mm3. During the Normal leukocytosis of pregnancy averages approximately 12,000/mm3. During the

first 10 to 12 days after childbirth, values between 20,000 and 25,000/mm3 are first 10 to 12 days after childbirth, values between 20,000 and 25,000/mm3 are common. Neutrophils are the most numerous white blood cells. Leukocytosis coupled common. Neutrophils are the most numerous white blood cells. Leukocytosis coupled with the normal increase in erythrocyte sedimentation rate that occurs may obscure with the normal increase in erythrocyte sedimentation rate that occurs may obscure the diagnosis of acute infections at this time.the diagnosis of acute infections at this time.

Coagulation factorsCoagulation factors Clotting factors and fibrinogen are normally increased during pregnancy and remain Clotting factors and fibrinogen are normally increased during pregnancy and remain

elevated in the immediate puerperium. When combined with vessel damage and elevated in the immediate puerperium. When combined with vessel damage and immobility, this hypercoagulable state causes an increased risk of immobility, this hypercoagulable state causes an increased risk of thromboembolism, especially after a cesarean birth. Fibrinolytic activity also thromboembolism, especially after a cesarean birth. Fibrinolytic activity also increases during the first few days after childbirth. Factors I, II, VIII, IX, and X increases during the first few days after childbirth. Factors I, II, VIII, IX, and X decrease within a few days to nonpregnant levels. Fibrin split products, probably decrease within a few days to nonpregnant levels. Fibrin split products, probably released from the placental site, can also be found in maternal blood.released from the placental site, can also be found in maternal blood.

VARICOSITIESVARICOSITIES Varicosities (varices) of the legs and around the anus (hemorrhoids) are common Varicosities (varices) of the legs and around the anus (hemorrhoids) are common

during pregnancy. Varices, even the less common vulvar varices, regress (empty) during pregnancy. Varices, even the less common vulvar varices, regress (empty) rapidly immediately after childbirth. Surgical repair of varicosities is not considered rapidly immediately after childbirth. Surgical repair of varicosities is not considered during pregnancy. Total or nearly total regression of varicosities is expected after during pregnancy. Total or nearly total regression of varicosities is expected after childbirth.childbirth.

NEUROLOGIC SYSTEMNEUROLOGIC SYSTEM Neurologic changes during the puerperium are those that Neurologic changes during the puerperium are those that

result from a reversal of maternal adaptations to pregnancy result from a reversal of maternal adaptations to pregnancy and those resulting from trauma during labor and childbirth. and those resulting from trauma during labor and childbirth.

Pregnancy-induced neurologic discomforts abate after birth. Pregnancy-induced neurologic discomforts abate after birth. Elimination of physiologic edema through the diuresis that Elimination of physiologic edema through the diuresis that follows childbirth relieves carpal tunnel syndrome by easing follows childbirth relieves carpal tunnel syndrome by easing compression of the median nerve. compression of the median nerve.

The periodic numbness and tingling of fingers that afflicts 5% The periodic numbness and tingling of fingers that afflicts 5% of pregnant women usually disappears after the birth unless of pregnant women usually disappears after the birth unless lifting and carrying the baby aggravates the condition. lifting and carrying the baby aggravates the condition.

Headache requires careful assessment. Postpartum headaches Headache requires careful assessment. Postpartum headaches may be caused by various conditions, including pregnancy-may be caused by various conditions, including pregnancy-induced hypertension, stress, and leakage of cerebrospinal induced hypertension, stress, and leakage of cerebrospinal fluid into the extradural space during placement of the needle fluid into the extradural space during placement of the needle for epidural or spinal anesthesia. for epidural or spinal anesthesia.

Depending on the cause and effectiveness of the treatment, Depending on the cause and effectiveness of the treatment, the duration of the headaches can vary from 1 to 3 days to the duration of the headaches can vary from 1 to 3 days to several weeks.several weeks.

Postpartum DepressionPostpartum Depression Postpartum depression is a nonpsychotic Postpartum depression is a nonpsychotic

depressive episode that begins in the depressive episode that begins in the postpartum period due to decreased postpartum period due to decreased estrogen levelestrogen level

Symptoms: changes in appetite or Symptoms: changes in appetite or weight, sleep, and psychomotor activity; weight, sleep, and psychomotor activity; decreased energy; feeling of decreased energy; feeling of worthlessness or guilt; difficulty thinking, worthlessness or guilt; difficulty thinking, concentrating or making decisions; or concentrating or making decisions; or recurrent thoughts of death or suicidal recurrent thoughts of death or suicidal ideation, plans, or attempts. ideation, plans, or attempts.

Postpartum Postpartum PsychosisPsychosis

A very serious type of A very serious type of PPD illness that can PPD illness that can affect new mothers. affect new mothers.

Begin 2-3 weeks post Begin 2-3 weeks post deliverydelivery

Fatigue, restlessness, Fatigue, restlessness, insomnia, crying liable insomnia, crying liable emotions, inability to emotions, inability to move, irrationally move, irrationally statements incoherence statements incoherence confusion and obsessive confusion and obsessive concerns about the concerns about the infant’s healthinfant’s health

Psychiatric emergencyPsychiatric emergency

MUSCULOSKELETAL MUSCULOSKELETAL SYSTEMSYSTEM

Adaptations to pregnancy include the Adaptations to pregnancy include the relaxation and subsequent hypermobility of relaxation and subsequent hypermobility of the joints and the change in the mother's the joints and the change in the mother's center of gravity in response to the enlarging center of gravity in response to the enlarging uterus. uterus.

The joints are completely stabilized by 6 to 8 The joints are completely stabilized by 6 to 8 weeks after birth. However, although all weeks after birth. However, although all other joints return to their normal other joints return to their normal prepregnancy state, those in the parous prepregnancy state, those in the parous woman's feet do not. woman's feet do not.

The new mother may notice a permanent The new mother may notice a permanent increase in her shoe size.increase in her shoe size.

INTEGUMENTARY INTEGUMENTARY SYSTEMSYSTEM

Chloasma of pregnancy usually disappears at the end of Chloasma of pregnancy usually disappears at the end of pregnancy.pregnancy.

Hyperpigmentation of the areolae and linea nigra may not Hyperpigmentation of the areolae and linea nigra may not regress completely after childbirth. Some women will have regress completely after childbirth. Some women will have permanent darker pigmentation of those areas. permanent darker pigmentation of those areas.

Striae gravidarum (stretch marks) on the breasts, abdomen, Striae gravidarum (stretch marks) on the breasts, abdomen, and thighs may fade but usually do not disappear. and thighs may fade but usually do not disappear.

Vascular abnormalities such as spider angiomas (nevi), palmar Vascular abnormalities such as spider angiomas (nevi), palmar erythema, and epulis generally regress in response to the rapid erythema, and epulis generally regress in response to the rapid decline in estrogens after the end of pregnancy. For some decline in estrogens after the end of pregnancy. For some woman, spider nevi persist indefinitely. woman, spider nevi persist indefinitely.

The abundance of fine hair seen during pregnancy usually The abundance of fine hair seen during pregnancy usually disappears after giving birth; however, any coarse or bristly disappears after giving birth; however, any coarse or bristly hair that appears during pregnancy usually remains. hair that appears during pregnancy usually remains. Fingernails return to their prepregnancy consistency and Fingernails return to their prepregnancy consistency and strength. strength.

Profuse diaphoresis that occurs in the immediate postpartum Profuse diaphoresis that occurs in the immediate postpartum period is the most noticeable change in the integumentary period is the most noticeable change in the integumentary system.system.

IMMUNE SYSTEMIMMUNE SYSTEM

No significant changes in the maternal No significant changes in the maternal immune system occur during the immune system occur during the postpartum period. postpartum period.

The mother's need for a rubella The mother's need for a rubella vaccination or for prevention of Rh vaccination or for prevention of Rh isoimmunization is determined.isoimmunization is determined.

Nursing Care Nursing Care of the Postpartum Womanof the Postpartum Woman

Fourth Stage of LaborFourth Stage of Labor Goal of nursing care is to assist woman Goal of nursing care is to assist woman

and their partners during their initial and their partners during their initial transition to parentingtransition to parenting

Nursing's role is to monitor the Nursing's role is to monitor the recovery of the new mother and infant, recovery of the new mother and infant, to identify and manage promptly any to identify and manage promptly any deviations from the normal processes deviations from the normal processes that may occur, and to promote and that may occur, and to promote and support parent-infant attachment support parent-infant attachment

Fourth Stage of LaborFourth Stage of Labor First 1 to 2 hours after birthFirst 1 to 2 hours after birth

During this time, maternal organs undergo During this time, maternal organs undergo their initial readjustment to the their initial readjustment to the nonpregnant state and the functions of nonpregnant state and the functions of body systems begin to stabilize.body systems begin to stabilize.

Meanwhile, the newborn continues the Meanwhile, the newborn continues the transition from intrauterine to extrauterine transition from intrauterine to extrauterine existenceexistence

Excellent time to Excellent time to begin Breastfeeding begin Breastfeeding Encouraging of the motherEncouraging of the mother Colostrum prompting elimination of meconiumColostrum prompting elimination of meconium

Care in the Immediate Care in the Immediate Postpartum PeriodPostpartum Period

AssessmentAssessment During first hour every 15 minutesDuring first hour every 15 minutes During second hours every 30 minutesDuring second hours every 30 minutes

VS (Ps, BP, T) VS (Ps, BP, T) fundal height and firmnessfundal height and firmness bladder distensionbladder distension amount of lochiaamount of lochia presence of edemapresence of edema status of perineum, status of perineum,

Postanesthesia recovery (every 15 min)Postanesthesia recovery (every 15 min) ActivityActivity RespirationRespiration BPBP Level of cosciousnessLevel of cosciousness ColorColor general anesthesiageneral anesthesia

Awake, alert, orient to time, place, and person, respiratory rate, oxygen saturation levels at least 95%, as Awake, alert, orient to time, place, and person, respiratory rate, oxygen saturation levels at least 95%, as measured by a pulse oximetermeasured by a pulse oximeter

epidural or spinal anesthesiaepidural or spinal anesthesia should be able to raise her legs, extended at the knees, off the bed, or to flex her knees, place her feet flat on the should be able to raise her legs, extended at the knees, off the bed, or to flex her knees, place her feet flat on the

bed, and raise her buttocks well off the bed. The numb or tingling, prickly sensation should be entirely gone from bed, and raise her buttocks well off the bed. The numb or tingling, prickly sensation should be entirely gone from her legs. Often, it takes 1.5 to 2 hours for these anesthetic effects to disappear.her legs. Often, it takes 1.5 to 2 hours for these anesthetic effects to disappear.

Providing comfort measuresProviding comfort measures AnalgesicsAnalgesics Promoting bladder eliminationPromoting bladder elimination Providing fluid and foodProviding fluid and food

Slide 30

Nursing Care After Cesarean Nursing Care After Cesarean BirthBirth

Same as with normal vaginal delivery Same as with normal vaginal delivery exceptexcept Postanesthesia recoveryPostanesthesia recovery Monitoring of abdominal dressingMonitoring of abdominal dressing Urinary catheterUrinary catheter Respiratory careRespiratory care Prevention of thrombophlebitisPrevention of thrombophlebitis Interventions for painInterventions for pain

Postpartum Physical Postpartum Physical AssessmentAssessment

B B - breast- breast U U - uterus- uterus BB - bowels - bowels B B - bladder- bladder L L - lochia- lochia E E - episiotomy - episiotomy

General AssessmentGeneral Assessment

Enter the room quietly, speak quietly.

Wash hands and provide for privacy. Inform patient before turning on

lights. Note LOC, activity level, position,

color, general demeanor. Take note of the total environment:

Safety/patient considerations Note equipment and medical devices

BBreast Assessmentreast Assessment Breasts: Soft, engorged, filling, swelling, Breasts: Soft, engorged, filling, swelling,

redness, tenderness.redness, tenderness. Nipples: Inverted, everted, cracked, Nipples: Inverted, everted, cracked,

bleeding, bruised, presence of colostrum bleeding, bruised, presence of colostrum or breastmilk.or breastmilk.

Colostrum–yellowish fluid rich in antibodies Colostrum–yellowish fluid rich in antibodies and high in protein.and high in protein.

Engorgement occurs by day 3 or 4. Due to Engorgement occurs by day 3 or 4. Due to vasoconstriction as milk production beginsvasoconstriction as milk production begins

Lactation ceases within a week if Lactation ceases within a week if breastfeeding is never begun or is breastfeeding is never begun or is stopped.stopped.

Nipple soreness is a portal of entry for Nipple soreness is a portal of entry for bacteria - breast infection (Mastitis).bacteria - breast infection (Mastitis).

Maternal after pains: may be due to Maternal after pains: may be due to breastfeeding and multiparitybreastfeeding and multiparity

Always stay with the client when getting Always stay with the client when getting out of bed for the first time – out of bed for the first time – hypotension effect and excess bleedinghypotension effect and excess bleeding

When assessing fundal height, if you When assessing fundal height, if you notice any discrepancies in fundal notice any discrepancies in fundal height have patient void and then height have patient void and then reassess.reassess.

Nursing Diagnosis Related to Breasts and Nursing Diagnosis Related to Breasts and BreastfeedingBreastfeeding

Pain r/t improper positioning, engorged breasts

Ineffective breastfeeding r/t maternal discomfort, improper infant positioning

Knowledge deficit r/t normal physiologic changes, breastfeeding

Infection r/t improper breastfeeding techniques, improper breast care

Assessing Assessing UUterine Fundusterine Fundus

Location in relation to Location in relation to umbilicusumbilicus

Degree of firmnessDegree of firmness Is it at Midline or Is it at Midline or

deviated to one side?deviated to one side? Bladder Full?Bladder Full? A boggy uterus may

indicate uterine atony or retained placental fragments.

Boggy refers to being inadequately contracted and having a spongy rather than firm feeling.

Massaging the FundusMassaging the Fundus Every 15 mins during the 1Every 15 mins during the 1stst hr, hr,

every 30 mins during the next hr, every 30 mins during the next hr, and then, every hr until the patient and then, every hr until the patient is ready for transfer. is ready for transfer.

Document fundal height. Document fundal height. Evaluate from the umbilicus Evaluate from the umbilicus

using fingerbreadths. using fingerbreadths. This is recorded as 2 fingers This is recorded as 2 fingers

below the umbilicus (U/2), one below the umbilicus (U/2), one finger above the umbilicus (1/U), finger above the umbilicus (1/U), and so forth. and so forth.

The fundus should remain in the The fundus should remain in the midline. If it deviates from the midline. If it deviates from the middle- distended bladdermiddle- distended bladder. .

Uterine AtonyUterine Atony Lack of muscle tone in the cervix.Lack of muscle tone in the cervix. Uterus feels soft and boggyUterus feels soft and boggy The bladder has increased capacity The bladder has increased capacity

and decreased muscle tone.  and decreased muscle tone.  This leads to over-distension of the This leads to over-distension of the

bladder, incomplete emptying of bladder, incomplete emptying of bladder, retention of residual urine bladder, retention of residual urine and increased risk of UTI and and increased risk of UTI and postpartum hemorrhage. postpartum hemorrhage.

BBowels & owels & BBladderladder When was the patients last bowel movement?When was the patients last bowel movement? Is she passing flatus? (gas)Is she passing flatus? (gas) Assess for bowel soundsAssess for bowel sounds Voiding pattern - without difficulty/pain, urine

may be blood tinged from lochia Nursing interventions: Assist to the bathroom.

Use measures to encourage voiding (privacy). Encourage use of peri-bottle with warm water, fluids, fiber, frequent ambulation, stool softeners; teach effects of pain medication.

Slide 40

Urinary SystemUrinary System A full bladder can displace the uterus and A full bladder can displace the uterus and

lead to postpartum hemorrhagelead to postpartum hemorrhage In the woman who voids frequently, small In the woman who voids frequently, small

amounts of urine may have increased amounts of urine may have increased residual urine because her bladder does not residual urine because her bladder does not empty completelyempty completely

Residual urine in the bladder may promote Residual urine in the bladder may promote the growth of microorganismsthe growth of microorganisms

Lochia: Pad Lochia: Pad

CountCount 1. Scant: 1-inch stain on pad in 1 hour2. Light/small: 4 inches in 1 hour3. Moderate: 6 inches in 1 hour4. Heavy/large: Pad saturated in 1 hour Excessive: Pad saturated in 15 min Can estimate blood loss by weighing pads: 500 mL = 1 lb. or 454 g

EEpisiotomy/Perineal pisiotomy/Perineal AssessmentAssessment

Patient in lateral Sims (side lying) position.Patient in lateral Sims (side lying) position. Use the acronym Use the acronym REEDAREEDA

RRedness, edness, EEdema, dema, EEcchymosis, cchymosis, DDischarge, ischarge, AApproximation of suture lines “edges of pproximation of suture lines “edges of episiotomy”) to guide assessment.episiotomy”) to guide assessment.

Even if there is no episiotomy, the perineum Even if there is no episiotomy, the perineum should still be assessed. should still be assessed. Nursing care and patient teachingNursing care and patient teaching

Cold packsCold packs Topical and systemic medicationsTopical and systemic medications Nonpharmacologic pain relief methods Nonpharmacologic pain relief methods

Unusual perineal discomfort may be a Unusual perineal discomfort may be a symptom of impending infection or symptom of impending infection or hematoma.hematoma.Hemorrhoids ?Hemorrhoids ?

Episiotomy Pain Relief Episiotomy Pain Relief

Instruct Mother:Instruct Mother: Tighten her buttocks and perineum before Tighten her buttocks and perineum before

sitting to prevent pulling on the sitting to prevent pulling on the episiotomy and perineal area and to episiotomy and perineal area and to release tightening after being seated.release tightening after being seated.

Rest several times a day with feet Rest several times a day with feet elevated.elevated.

Practice Kegel exercise many times a day Practice Kegel exercise many times a day to increase circulation to the perineal area to increase circulation to the perineal area and to strengthen the perineal muscles.and to strengthen the perineal muscles.

Discharge: Before 24 Hours and Discharge: Before 24 Hours and After 48 Hours After 48 Hours

Terms for decreasing length of stay of Terms for decreasing length of stay of mothers and newborns after a low risk mothers and newborns after a low risk birth birth Early postpartum dischargeEarly postpartum discharge Shortened hospital stayShortened hospital stay 1-day maternity stay1-day maternity stay

Discharge: Before 24 Hours and Discharge: Before 24 Hours and After 48 Hours After 48 Hours

Laws relating to dischargeLaws relating to discharge Advantages and disadvantages of early Advantages and disadvantages of early

postpartum dischargepostpartum discharge Criteria for early dischargeCriteria for early discharge

Mother recovered and able to care for self Mother recovered and able to care for self and babyand baby

RhoGAM RhoGAM

It is given to an RhIt is given to an Rh-- mother within 72 mother within 72 hours after delivery of an Rhhours after delivery of an Rh++ infant infant or if the Rh is unknown. or if the Rh is unknown.

The dose must be repeated after The dose must be repeated after each subsequent delivery. RhoGAM each subsequent delivery. RhoGAM 300 mcg is the standard dose.300 mcg is the standard dose.

Rubella vaccinationRubella vaccination For women who have not had rubella (10% to For women who have not had rubella (10% to

20% of all women) or women who are 20% of all women) or women who are serologically not immune (titer of 1:8 or serologically not immune (titer of 1:8 or enzyme immunoassay level less than 0.8), a enzyme immunoassay level less than 0.8), a subcutaneous injection of rubella vaccine is subcutaneous injection of rubella vaccine is recommended in the immediate postpartum recommended in the immediate postpartum period to prevent the possibility of period to prevent the possibility of contracting rubella in future pregnancies. contracting rubella in future pregnancies.

The live attenuated rubella virus is not The live attenuated rubella virus is not communicable in breast milk; therefore communicable in breast milk; therefore breastfeeding mothers can be vaccinated. breastfeeding mothers can be vaccinated. However, because the virus is shed in urine However, because the virus is shed in urine and other body fluids, the vaccine should not and other body fluids, the vaccine should not be given if the mother or other household be given if the mother or other household members are immunocompromised. members are immunocompromised.

Discharge Teaching Discharge Teaching Teaching for self-care: signs of Teaching for self-care: signs of

complicationscomplications Sexual activity/contraceptionSexual activity/contraception Prescribed medicationsPrescribed medications Routine mother and baby checkupsRoutine mother and baby checkups

Discharge Teaching Discharge Teaching Follow-up after dischargeFollow-up after discharge

Home visitsHome visits Telephone follow-upTelephone follow-up Warm linesWarm lines Support groupsSupport groups Referral to community resourcesReferral to community resources

Process of Becoming Process of Becoming AcquaintedAcquainted

BondingBonding AttachmentAttachment Maternal touchMaternal touch Verbal behaviorsVerbal behaviors

Factors Affecting Family Factors Affecting Family AdaptationAdaptation

Parental fatigueParental fatigue Previous experience with a newbornPrevious experience with a newborn Parental expectations of newbornParental expectations of newborn Knowledge of and confidence in Knowledge of and confidence in

providing for newborn needsproviding for newborn needs Temperament of the newbornTemperament of the newborn Temperament of parentsTemperament of parents Age of parentsAge of parents Available support systemAvailable support system Unexpected eventsUnexpected events

Cultural Influences on Cultural Influences on AdaptationAdaptation

Provide care that is culture specificProvide care that is culture specific CommunicationCommunication Health beliefsHealth beliefs Dietary practicesDietary practices

The Process of Family The Process of Family AdaptationAdaptation

FatherFather SiblingsSiblings GrandparentsGrandparents

Process of Maternal AdaptationProcess of Maternal Adaptation Maternal role attainmentMaternal role attainment Heading toward a new normalHeading toward a new normal Redefining rolesRedefining roles Role conflictRole conflict Major maternal concernsMajor maternal concerns Body imageBody image Postpartum bluesPostpartum blues

Application of the Nursing Application of the Nursing Process: Maternal AdaptationProcess: Maternal Adaptation

AssessmentAssessment AnalysisAnalysis PlanningPlanning

InterventionsInterventions Assist motherAssist mother Monitor and protectMonitor and protect ListenListen Foster independenceFoster independence Promote bondingPromote bonding Involve parents in Involve parents in

carecare EvaluationEvaluation

Slide 59

FathersFathers EngrossmentEngrossment Four phases of adjustmentFour phases of adjustment

Having expectations and personal Having expectations and personal intentionsintentions

Confronting reality and overcoming Confronting reality and overcoming frustrationsfrustrations

Creating one’s own personal father roleCreating one’s own personal father role Reaping rewards of fatherhoodReaping rewards of fatherhood

Slide 60

Family Care PlanFamily Care Plan Studying the Studying the family,family, as the patient can offer as the patient can offer

insight into community-based careinsight into community-based care

Slide 61

Data Collection for the Data Collection for the Family Care PlanFamily Care Plan

Demographic Demographic informationinformation

Family compositionFamily composition OccupationOccupation Cultural groupCultural group Religious/spiritual Religious/spiritual

affiliationaffiliation Developmental Developmental

taskstasks Health concernsHealth concerns Communication Communication

patternspatterns

Decision makingDecision making Family valuesFamily values SocializationSocialization Coping patternsCoping patterns HousingHousing Cognitive abilitiesCognitive abilities Support systemSupport system Response to careResponse to care

Key Points Key Points Nurse provides teaching and Nurse provides teaching and

counseling to promote the woman’s counseling to promote the woman’s feelings of competence in self-care and feelings of competence in self-care and baby carebaby care

Key Points Key Points Postpartum care is modeled on the Postpartum care is modeled on the

concept of healthconcept of health Cultural beliefs and practices affect the Cultural beliefs and practices affect the

client’s response to the puerperiumclient’s response to the puerperium Nursing plan of care includes:Nursing plan of care includes:

Assessments to detect deviations from Assessments to detect deviations from normal normal

Comfort measures to relieve discomfort or Comfort measures to relieve discomfort or pain pain

Safety measures to prevent injury or Safety measures to prevent injury or infectioninfection

Key Points Key Points Common nursing interventions include: Common nursing interventions include:

Evaluating and treating the boggy uterus Evaluating and treating the boggy uterus and the full urinary bladderand the full urinary bladder

Providing for pharmacologic and Providing for pharmacologic and nonpharmacologic relief of pain and nonpharmacologic relief of pain and discomfort associated with the episiotomy discomfort associated with the episiotomy or lacerationsor lacerations

Instituting measures to promote or Instituting measures to promote or suppress lactationsuppress lactation

Key Points Key Points Effective means to prevent crisis and Effective means to prevent crisis and

facilitate physiologic and psychologic facilitate physiologic and psychologic adjustments used in combination adjustments used in combination include:include: Home visitsHome visits Telephone follow-upTelephone follow-up Warm linesWarm lines Support groupsSupport groups Referral to community resourcesReferral to community resources

Key Points Key Points Short-stay option is safer when Short-stay option is safer when

selection criteria are used to determine selection criteria are used to determine a woman’s eligibility for early discharge a woman’s eligibility for early discharge and when home care follow-up is and when home care follow-up is availableavailable

Key Points Key Points Early postpartum discharge will Early postpartum discharge will

continue to be the trend as a result of:continue to be the trend as a result of: Consumer demandConsumer demand Medical necessityMedical necessity Discharge criteria for low risk childbirthDischarge criteria for low risk childbirth Cost-containment measuresCost-containment measures

Key Points Key Points Nurses promote the health of the Nurses promote the health of the

woman’s future pregnancies by woman’s future pregnancies by administering rubella vaccine and Rh administering rubella vaccine and Rh immune globulin if indicatedimmune globulin if indicated

Meeting psychosocial needs of new Meeting psychosocial needs of new mothers involves planning care that mothers involves planning care that considers the composition and considers the composition and functioning of the entire familyfunctioning of the entire family

Key Points Key Points Under normal circumstances, few Under normal circumstances, few

alterations in vital signs are seen after alterations in vital signs are seen after childbirthchildbirth

Activation of blood-clotting factors, Activation of blood-clotting factors, immobility, and sepsis predispose immobility, and sepsis predispose woman to thromboembolismwoman to thromboembolism

Marked diuresis, decreased bladder Marked diuresis, decreased bladder sensitivity, and overdistention of sensitivity, and overdistention of bladder can lead to problems with bladder can lead to problems with urinary eliminationurinary elimination

Дякую за увагу!Дякую за увагу!

Assessment of Edema & Homan’s Assessment of Edema & Homan’s SignSign

Assess legs for presence and degree of edema; may have dependent edema in feet and legs.

Assess for Homan’s sign- thromboembolism should be negative

Press down gently on the patient’s knee (legs extended flat on bed) ask her to flex her foot (dorsiflex)

Homan’s SignHoman’s Sign

Thromboembolic ConditionsThromboembolic Conditions Thrombophlebitis–the formation of a Thrombophlebitis–the formation of a

clot in an inflamed vein.clot in an inflamed vein. Risk factors include maternal age over Risk factors include maternal age over

35, cesarean birth, prolonged time in 35, cesarean birth, prolonged time in stirrups, obesity, smoking, and history stirrups, obesity, smoking, and history of varicosities or venous thromboses.of varicosities or venous thromboses.

Prevention: client needs to ambulate Prevention: client needs to ambulate early after delivery.early after delivery.

Postpartum Cesarean Postpartum Cesarean Incision site…redness swelling, discharge. Incision site…redness swelling, discharge.

Intact?Intact? Abdomen soft, distended? Bowel sounds heard Abdomen soft, distended? Bowel sounds heard

all 4 quadrantsall 4 quadrants Flatus? Flatus? Lochia is less amount than in normal Lochia is less amount than in normal

spontaneous vaginal delivery (NSVD) because spontaneous vaginal delivery (NSVD) because uterus is wiped with sponges during c/section.uterus is wiped with sponges during c/section.

If lochia indicates excessive bleeding, combine If lochia indicates excessive bleeding, combine palpation and pain management measures. palpation and pain management measures.

Auscultate breath soundsAuscultate breath sounds Fluid intake and outputFluid intake and output Pain?Pain?

Postpartum Disseminated Intravascular Postpartum Disseminated Intravascular CoagulationCoagulation

Abnormal stimulation of clotting Abnormal stimulation of clotting mechanism.mechanism.

Normally, the body forms a blood clot Normally, the body forms a blood clot in reaction to an injury. in reaction to an injury.

Small blood clots throughout the body, Small blood clots throughout the body, depleting the body of clotting factors depleting the body of clotting factors and platelets. –Massive bleedingand platelets. –Massive bleeding

Causes may include amniotic fluid Causes may include amniotic fluid clots, fetal demise, abruptio placenta. clots, fetal demise, abruptio placenta. Eclampsia or Retained placenta Eclampsia or Retained placenta

Symptoms: Sometimes severe Symptoms: Sometimes severe bleeding and sudden bruising .bleeding and sudden bruising .

Postpartum HemorrhagePostpartum Hemorrhage Blood loss of more than 500 ml after vaginal Blood loss of more than 500 ml after vaginal

birth or 1,000 ml after a cesarean birth. birth or 1,000 ml after a cesarean birth. Early hemorrhage –Cervical or vaginal tears, Early hemorrhage –Cervical or vaginal tears,

uterine atony, retained placental fragments, uterine atony, retained placental fragments, lacerations, hematomas.lacerations, hematomas.

Late hemorrhage –subinvolution, retained Late hemorrhage –subinvolution, retained placental fragments.placental fragments.

Subinvolution: failure of the uterus to return Subinvolution: failure of the uterus to return to normal size.to normal size.

Management may include CBC, Management may include CBC, sedimentation rate, type and cross, fluid sedimentation rate, type and cross, fluid resuscitation with normal saline and blood, resuscitation with normal saline and blood, vaginal examination, diagnosis, and vaginal examination, diagnosis, and correction of the underlying cause. correction of the underlying cause.

InterventionsInterventions Prevention of ComplicationsPrevention of Complications Reduce DiscomfortReduce Discomfort ADLADL

NutritionNutrition Rest & SleepRest & Sleep AmbulationAmbulation BathingBathing Kegel ExercisesKegel Exercises

Process of Maternal Process of Maternal AdaptationAdaptation

Puerperal phasesPuerperal phases Taking-inTaking-in Taking-holdTaking-hold Letting-goLetting-go

Elsevier items and derived items © 2006, 2002, 1998, 1994 by Elsevier, Inc