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Slide 1

Postpartum period- interval between the birth of the newborn and the return of the

reproductive organs to their non-pregnant state.

Slide 3 Although changes are normal, in no other period of life is there such marked and rapid physiological catabolism.

Slide 4 Uterus- Involution occurs immediately after explosion of the placenta. At the end of the 3rd stage of labor the uterus is midline, aprrox 2cm below the level of the umbilicus. After 12 hrs the fundus rises to aprrox the level of the umbilicus. The fundus then descends 1-2 cm every 24 hrs. Unable to palpates after 9th day PP.

Breasts- Colostrum or early milk is expressed from breasts after birth. The breast gradually become fuller and heavier as the colostrum transitions to mature milk by 72-96 hrs after birth. The breast may feel warm, firm, and somewhat tender. As milk glands and milk ducts fill with milk, breast tissue may fell somewhat nodular or lumpy. Some women may experience engorement but with frequent breast feeding and proper care this conditions is temporary and last only 24-48 hrs. In non breast feeding mothers breast feel nodular and its typically bilaterally and diffuse. Palpation of the breast on the 2nd or 3rd day as milk production begins, may reveal tissue tenderness, on the 3rd or 4th day engorgement may occur. The breast are distended, firm, tender, and warm to touch because of vasocongestation. Teach mother not to stimulate breasts in any way -- warm water in shower, nipple stimulation, manual expression, suckling. Will resolve spontaneously in 24 - 36 hours. Teach comfort measures -- breast binder or tight bra, ice packs, mild analgesics.

Perineum- The greatly distended smooth-walled vagina gradually decreases on size and regains tone but never completely return to its prepregnancy state. Immeditaley after birth the introitus is erythematous and edematous. Assess lacerations and episiotomies with women lying on her side with her buttock raised or placed in litthotomy. Assess for signs of infection, loss of approximation. Assess for hemorrhoids.

Bowel- Woman may not have bowel movement for 2-3 days after

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childbirth. Delay can be explained by decreased muscle tone in the intestines and prelabor diarrhea, lack of food, or dehydration. Also mom may resist the urge to defecate because of the anticipation of pain from hemorrhoids, epis, or lacerations.

Bladder- Birth-induced trauma, increased bladder capacity after childbirth, and effects of conduction anesthesia combine to cause a decreased urge to void. You want to avoid bladder distention because it can cause excessive bleeding by pushing the uterus up and the side and preventing it from contracting firmly. With adequate emptying of the bladder, bladder tome is usually restored 5-7 days after birth.

Cardiovascular- Blood volume- Changes in blood volume depend on several factors such as blood loss during childbirth and the amount of extravascular water mobilized and excreted. Pregnancy-induced hypervolemia (an increase in blood volume of at least 35% more than prepregnancy values near term) allows most women to tolerate considerable blood loss during childbirth. Average blood loss for vaginal delivery ranges from 300 to 500ml (10% blood volume). C-section delivery is 500-100ml (15%-30% blood volume). During the first few days after childbirth the plasma volume decreases further as a result of diuresis. The woman’s response to blood loss after delivery is different than when in nonpregnant state. Three pp physiologic changes protect the woman by increasing circulating blood volume: 1) elimination of uteroplacenatal circulation reduces blood volume; 2) loss of placental endocrine function removes the stimulus fro vasodilation, and 3) mobilization of extravascular water stored during pregnancy occurs. By the 3rd pp day the plasma volume has been replenished as extravascular fluid returns to the intravascular space. Cardiac output- Pulse rate, stroke volume, and cardiac output increase throughout pregnancy and remains increased for first 48 hrs postpartum. CO decreases by 30% by 2 weeks after childbirth and then gradually decreases to nonpregnant values by 6-12 weeks in most women.

Blood- Hct and HGB- After childbirth the total blood volume decreases apprx 16% from its prebirth value, resulting in a transient anemia. After 8 weeks the number of red blood cells has increased and the majority of women have a normal hematocrit. WBC- During

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first 10-12 days after childbirth, WBC values can be between 20,000-25,000. This can obcure a dx of acute infection at this time.

Abdominal musculature- During the first days after birth, abdomen still protrudes and gives her a still pregnant appearance. Approx 6 weeks is required for the abdominal wall to approximate its prepregnancy state. The return of time depends on previous tone, proper exercise, and the amount of adipose tissue present.

Slide 6 Breasts: [B]• Before lactation begins breasts are soft and colostrum, a yellow fluid, can be expressed from the nipples. Colostrum is rich in antibodies and protein.• After lactation begins [2nd or 3rd day] breasts are firm, warm and tender. Tenderness lasts ~48 hours after lactation begins. Bluish white milk can be expressed from the nipples.• Examine the nipples for erectility and signs of irritation -- cracks, blisters, reddening. May feel a mass in breast that shifts position day to day -- fluid filled milk sac. Observe for signs of redness and pain in breast that may signal a clogged milk duct. • Engorgement -- occurs on 3rd or 4th day in women who choose not to breastfeed. Breasts are swollen, firm, tender, warm. Teach mother not to stimulate breasts in any way -- warm water in shower, nipple stimulation, manual expression, suckling. Will resolve spontaneously in 24 - 36 hours. • Teach comfort measures -- breast binder or tight bra, ice packs, mild analgesics

Slide 7 Uterus: [U]• Involution -- end of third stage uterus is at the midline and 2 cm below umbilicus. By 12 hours uterus is at or 1 cm above the umbilicus. Fundus will descend 1 to 2 cms each day. Unable to palpate after ninth postpartum day. Uterus involutes because of hormone withdrawal (estrogen and progesterone). Remains firm and contracted under the influence of oxytocin from the posterior pituitary. Breastfeeding and fundal massage facilitate involution. Suckling stimulates the release of oxytocin.• Subinvolution -- failure of uterus to involute. Most common causes are retained placental fragments and infection.• Teach fundal massage.

Slide 8 Bladder: [B]• Trauma and effects of anesthesia may cause a decrease in the urge to void. • Decreased voiding along with postpartum diuresis may result in a distended bladder.

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• Immediately, a distended bladder pushes the uterus up and to the side preventing the uterus from firmly contracting. This results in excessive bleeding. • Later, a distended bladder increases the risk for infection. • With adequate emptying of the bladder, tone is usually restored in 5 to 7 days after birth.• Teach methods to stimulate voiding -- early ambulation, listening to running water, placing hands in warm water, warm water poured over perineum. Catheterization may be necessary if efforts to stimulate voiding are unsuccessful.

Slide 9 Bowels: [B]• Spontaneous evacuation may be delayed until 2 to 3 days because of decreased muscle tone in the intestines during labor, prelabor diarrhea, lack of food or dehydration.• Mother may resist the urge to deficate because of anticpated discomfort from episiotomy, lacerations, hemorrhoids. • Regular bowel habits need to be reestablished when bowel tone returns. Medications may be given to assist -- stool softeners, laxatives, etc.• Teach importance of high fiber diet, plenty of fluids, and exercise.

Slide 10 Lochia:[L]Color and Character• rubra -- red in color; mainly blood and decidual and trophoblastic debris; lasts ~3 days• serosa -- pink in color; old blood, serum, leukocytes, tissue debris; lasts until ~day 10• alba -- color is yellow/white; leukocytes, decidua, epithelial cells, mucus, serum, and bacteria; lasts up to and beyond 6 weeks pp

Amount: [see text fig. 23-5 page 597]• scant (<2.5 cm [1 inch] in 1 hr) • light (<10 cm [4 inches] in 1 hr.)• moderate (<15 cm [6 inches] in 1 hr)• heavy (saturated in 2 hours)• excessive (saturated in 15 minutes).

• Flow in women who have received an oxytocic is usually scant until effects of medication wear off

• less after cesarean birth

• increases with ambulation and breastfeeding -- pools in vagina when lying down then gushes upon standing

• Teach color changes. Report any change in opposite direction. Green and foul smelling is never normal. Rubra after alba may mean late

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PPH from retained fragments or infection.Slide 11 Episiotomy:

• An incision made in the perineum to enlarge the vaginal outlet. Midline is the most common type in the US.

Slide 12 Episiotomy:• An incision made in the perineum to enlarge the vaginal outlet. Midline is the most common type in the US.• Types:

• first degree -- extends through the skin and structure superficial to muscles [vaginal membranes]• second degree -- extends through muscles of the perineal body [vaginal membranes + fascia]• third degree -- extends through the anal sphincter muscle [membranes + fascia + anal sphincter]• fourth degree -- involves anterior rectal wall [membranes + fascia + anal sphicter + anal canal]

• Most frequently used:• nulliparity• occiput posterior position• large infants• use of instruments to facilitate birth• prolonged second stage• fetal distress

Slide 14 Emotion: [E]• Baby “blues” are experienced by most women as a period of emotional lability -- crying easily for no apparent reason. These feelings peak at about day 5 and are gone by day 10.

• Etiology is unknown but a let-down feeling, restlessness, fatigue, insomnia, and anxiety contribute to feelings of depression. May be overwhelmed by parental responsibilities, deprived of supportive care experienced during pregnancy, fatigued from the round-the clock demands of the new baby.

• Teach: “blues” are normal. Get plenty of rest by napping when baby naps, going to bed early, controlling visits from family and friends. Use relaxation techniques. Do something special for yourself. Talk to your partner about how you feel. Call provider if symptoms of depression intensify or persist past the baby’s first few weeks. May be a sign of postpartum depression that rarely disappears without outside help and pharmacologic intervention. May develop into postpartum psychosis -- a syndrome of depression, delusions, and suicide/infanticide ideation.

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Slide 15 Dependent Phase [Taking In]: • first 24 to 48 hours after childbirth• mother’s dependency needs predominate -- she needs “mothering” herself to “mother”• Nurturing and protective care are required by the new mother• Mothers suspend their involvement in everyday responsibilities and rely on others to satisfy their needs for comfort, rest, and nourishment.• Parents need to verbalize their experience of pregnancy and birth. Focusing on, analyzing and accepting these experiences help the parents move on to the next phase.

Dependent-Independent Phase [Taking Hold]:• occurs by 2nd or 3rd day and lasts ~10 days• desire for independent action reasserts itself• mother alternates between a need for nurturing and acceptance and the desire to “take charge” once again.• Enthusiastic response to learning or carrying out baby care• Taking hold behaviors are enhanced by current OB practices -- childbirth preparation classes, OB pain management, early contact with newborn, rooming-in, early discharge• Mothers are discharged during this phase• Main concerns during this phase -- fatigue, loss of weight or figure, pain from episiotomy or cesarean incision, sexual relations, hemorrhoids. “Baby Blues” are a recurring emotional concern but feelings of depression are transient (<1 week).

Interdependent Phase [Letting Go]:• Interdependent behavior reasserts itself, and the mother and her family move forward as a unit with interacting members.• May be a time when new father feels alienated and jealous of the infant• A stressful period as the parental pair resolve issues of divergent interests and needs. Partners are grappling with the effects on the relationship of child rearing, homemaking and career demands.

Slide 17 You are the nursing supervisor when Maggie’s nurse makes this complaint. How will you respond to this nurse?Dependent Phase [Taking In]:

• first 24 to 48 hours after childbirth• mother’s dependency needs predominate -- she needs “mothering” herself to “mother”• Nurturing and protective care are required by the new mother• Mothers suspend their involvement in everyday responsibilities and rely on others to satisfy their needs for comfort, rest, and nourishment.• Parents need to verbalize their experience of pregnancy and birth. Focusing on, analyzing and accepting these experiences help the parents move on to the next phase.

Dependent-Independent Phase [Taking Hold]:

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• occurs by 2nd or 3rd day and lasts ~10 days• desire for independent action reasserts itself• mother alternates between a need for nurturing and acceptance and the desire to “take charge” once again.• Enthusiastic response to learning or carrying out baby care• Taking hold behaviors are enhanced by current OB practices -- childbirth preparation classes, OB pain management, early contact with newborn, rooming-in, early discharge• Mothers are discharged during this phase• Main concerns during this phase -- fatigue, loss of weight or figure, pain from episiotomy or cesarean incision, sexual relations, hemorrhoids. “Baby Blues” are a recurring emotional concern but feelings of depression are transient (<1 week).

Slide 23 Nursing Judgment:• Normal postpartum period

• Fundus at the umbilicus • Normal involution-

• end of the 3rd stage- in the midline, approx 2 cm below, fundus resting on the sacral promontory• within 12 hours- rises to umbilicus• Fundus descends 1 -2 cm every 24 hours

• Moderate lochia rubra• VSS -- see table 21-2, pg 489

• Temp increases in first 24 hours due to dehydration or epidural, then afebrile • Heart rate and Pulse – returns to non-pregnant value within a few days

• at risk for orthostatic hypotension within first 48 hours. • Bonding with newborn• Expect profuse diaphoresis within 12 hrs, especially at night for 2-3 days -- loss of extra tissue fluid due to decrease in estrogen.

• Risks for postpartum hemorrhage include:• high parity (G4) -- uterine atony• anesthesia -- uterine atony• bladder distention -- uterine atony• 3rd degree episiotomy -- vaginal hematoma

Slide 26 Essential data in the postpartum period includes:• blood type and Rh factor• rubella status• infant feeding method• support system

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Slide 27 The nurse gathers additional assessment data on Maggie:• What is the significance of these findings?

• Mother’s and baby’s blood type are both O -- no risk for ABO incompatibility• Rh negative• Direct and indirect Coombs are negative

• indirect tests mother’s serum for antibodies to Rh antigen -- first penatal visit, repeat at 28 weeks• direct test infant’s cord blood for antibodies to Rh antigen• Maggie has not been sensitized and is therefore a candidate for Rhogam

• Rubella status is non-immune• Rubella vaccine is recommended for women who have not had rubella or are serologically negative in the immediate postpartum period.

• Rubella titer is < 1:8. Therefore Maggie is non-immune and will require a rubella vaccine prior to discharge. Since she will also be receiving Rhogam that suppresses the immune response she may need to repeat the Rubella titer in 3 months to see if she will need another dose of vaccine.• Rubella vaccine is reconstituted with the diluent provided by the manufacturer. A single does [,5 mL] is administered SC in the outer aspect of the upper arm with a 25 gauge 5/8 in needle.

• Rubella vaccine is a live attenuated virus that is not communicable therefore breastfeeding women may receive it. However, it is shed in urine and other body fluids and should not be given if mother or household member is immuno-compromised. Vaccine is made from duck eggs -- allergic reaction may require adrenaline.

• Rubella vaccine is teratogenic -- requires informed consent and an understanding that pregnancy must be avoided for 1 month following vaccination.

• Hospital is still teaching to avoid pregnancy for 3 monthsSlide 28 Rh Disease:

• Affects mothers with a negative Rh Factor when the baby is Rh positive• Fetal blood crosses the placental barrier and the mother develops antibodies to the Rh antigen. This is referred to as maternal sensitization. • The first pregnancy in which sensitization occurs is not affected. In subsequent pregnancies the maternal antibodies will attack and lyse fetal red blood cells resulting in a severe fetal hemolytic anemia -- erythroblastosis fetalis or hydrops fetalis.• Maternal sensitization can occur as the result of: previous pregnancy with an Rh-pos fetus; transfusion with Rh-pos blood; spontaneous or elective abortion after the eighth week of gestation [hematopoiesis begins in 8th week]; amniocentesis; premature separation of the placenta, and trauma.• The nurse takes a history to determine if any of these events have occurred. Then checks records to determine if Rhogam was administered.

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Indirect Coombs test at first PNV and again at 28 weeks will determine presence of antibodies.

• Rhogam is a preparation of passive antibodies that bind with fetal RBC antigens causing the cells to phagocytose before the woman’s immune system is activated to produce antibodies.

• Administered at 28 weeks and within 72 hours of birth• 1 vial (300 ug) is usually sufficient -- handles 15 mL of fetal blood in maternal circulation. • If large fetomaternal transfusion is suspected perform a Kleihauer-Betke test to detect the amount of fetal blood in maternal circulation and adjust the Rhogam dose accordingly.• Treat Rhogam as a blood product -- identification, lot number, expiration date, religious beliefs.

Slide 29 What needs intervention?• Voiding frequent small amounts -- should be 150 cc each voiding to be adequate. Spontaneous voiding returns in 6-8 hours.• Last bowel movement prior to delivery -- expect return of normal function by day 2 or 3. May administer a stool softener.

Slide 30 What is Maggie experiencing? Why?• Afterpains -- uncomfortable cramping more notable in multiparas than primiparas. Maggie is a G4.

• Breastfeeding and exogenous oxytocic medications intensify afterpains since both stimulate uterine contractions. Maggie is breastfeeding.

• Other risk factors for afterpains -- overdistended uterus from a large baby or twin gestation.

Slide 31 What is wrong with Lillian?Uterine Atony: -- Failure of the uterine muscle to contract firmly resulting in marked hypotonia. It is the leading cause of PPH.Risk factors:• “overstretched” uterus that contracts poorly after birth

• grand multiparity• hydramnios• macrosomic or large fetus• multifetal gestation

• traumatic birth• magnesium sulfate• rapid or prolonged labor• chorioamnionitis

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• pitocin induction or augmentation

Assessment: Figure 37-1 pg 978• Blood pressure is not a reliable indicator of impending shock from early hemorrhage. Why? Volume expansion in pregnancy• Better assessment parameters include -- respirations, pulse, skin condition, urinary output, level of consciousness.

Slide 32 What is the most likely cause of her severe pain?

• Vaginal hematoma -- a collection of blood in the connective tissue

• Risk factors -- forceps-assisted birth, episiotomy, primagravidy

• Assess for hematoma if patient c/o persistent perineal or rectal pain or feeling of pressure in the vagina

• A subperitoneal hematoma may cause minimal pain. Initial symptoms may be signs of shock.

Slide 33 Splanchnic Engorgement:• rapid decrease in intraabdominal pressure after birth results in a dilation of blood vessels supplying the intestines• causes blood to pool in the viscera• contributes to the development of orthostatic hypotension• may occur when woman who recently gave birth sit or stands up, first ambulates, or takes a warm shower or sitz bath.

Other considerations:• baseline blood pressure• amount of blood loss• type, amount, timing of analgesic or anesthetic medications

Slide 34 Bath --• may shower independently as early as 9 hours after birth• no scientific evidence that bath water in the vagina increases the risk of infection• recommend showering until bleeding stops and episiotomy is healed -- 2 to 4 weeks.

Work --

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• return to occupational or educational settings depends on the nature of the activity and the woman’s unique circumstances• healthy women who deliver vaginally safely return in 4 - 6 weeks providing the planned activities are not too strenuous. Following cesearean birth wait at least 6 - 8 weeks.

Sexual intercourse -- • recommend waiting until after 6 week pp check-up• many couples will resume before 6 weeks -- safe after 2 - 4 weeks when bleeding has stopped and episiotomy has healed.• risk of hemorrhage and infection are minimal after 2 weeks pp

Prenatal vitamins and iron -- • continue until 6 weeks pp or current supply has been used

Exercise -- • soon after birth• recommend starting with simple exercise and slowly progressing to more strenuous [text - pg 602 exercises for new mother]• recommend Kegel exercises to strengthen muscle tone