Assessment and Care of the
Newly Delivered Mother
Normal Postpartum Changes Uterus
• Rapid contraction of the uterine muscle and arteries
– compresses blood vessels
– thrombi form
– endometrium undermines site, area heals
Normal Postpartum Changes Uterus
• Normal size decrease ~1 cm/day
• Weight from 1000g to ~50-100g
• Size affected by parity, multiple gestation, or bladder distension
• After-pains start to in frequency
LOCHIA Rubra Serosa Alba
Normal
Color
Red Pink, brown
tinged
Yellowish-
white
Normal
Duration
1-3 days 3-10 days 10-14 days,
Can be
longer
Normal
Discharge
Bloody w/
clots
Serosang.,
Fleshy odor
Mostly
musus, no
strong odor
Abnormal
Discharge
Foul smell;
many lg.
clots,
saturate pad
Foul smell,
quickly
saturate pad
Foul smell,
rubra or
serosa flow;
lasts > 4 wks
Factors Affecting Lochia
• Factors: – Uterine atony, retained placental fragments/membranes, activity, distended bladder
– Duration not affected by choice of feeding method or use of oral contraceptives
• Warning signs – Foul-smelling lochia, unusually heavy flow, large clots, rubra continues by PPD4, saturates > 1pad/hr
• Final sloughing at 7-14 days
Perineum
• Perineal lacerations – 1º skin & superficial structures
– 2º reaches into perineal muscle
– 3º extends into anal sphincter muscle
– 4º involves anterior rectal wall
Perineum
• Comfort measures: warm or cool baths, ice packs, witch hazel pads, anesthetic sprays, po analgesics
• Report unusual discomfort, pain, drainage
• Continue perineal hygiene
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Cervix, Vagina, & Pelvic Floor
• Cervix & lower uterine segment flaccid immediately PP
• Cervix – by 2-3 days has resumed its usual appearance but remains dilated 2-3 cm., 1 cm by end of 1st week – Cervical edema may last several months
Vagina
• Vagina & vaginal outlet may appear bruised early after delivery; caused by pelvic congestion, disappears quickly after birth
• Involutes by contraction – Walls become gradually thicker, rugae return by ~ 3 weeks
• Pelvic floor tone regained during first 6 wks PP
Return of Menses
• Menses – return varies – First menses usually occurs within 7-9 wks PP if non-nursing
– Great variation in menses return if BF due to depressed estrogen levels. Usually returns between 2-18 months
• First menstrual cycle is usually anovulatory, but 25% may ovulate before menstruation
• Mean return of ovulation – ~ 10 wks PP if non-nursing – ~ 17 wks PP if breastfeeding
Return of Ovulation
Family Planning
• Discuss family planning – Wait until bleeding stops & have seen provider for 6 week follow-up appt.
– Discuss with provider at 6 wk. checkup
Fertility Care Program, 322-4434 (Creighton Model)
• 99.5% effective in spacing pregnancy
• Can an infertile couple’s chance of conceiving by 20-80%
• Simple charting based on external exams
• Can be used to treat GYN conditions: – Infertility, menstrual cramps, PMS, ovarian cysts,
abnormal bleeding, PCOS, repetitive miscarriage, PP depression, hormonal abnormalities, chronic discharge, pelvic pain
Normal Postpartum Changes Bladder
• Extensive diuresis to excrete excess fluid (2-3 L)
• capacity, tone • Risk of over-distention and incomplete
emptying
• Leakage, urinary frequency common • Mild proteinuria (1+) may exist for 1-2
days in ~ half of women
Normal Postpartum Changes Bladder
• Spontaneous voiding should occur by 6-8 hours PP; enc. Frequent voiding
• If cath’d, remove no more than 800 cc at one time
• Stress incontinence common
• Encourage Kegel exercises
• Observe for s/s UTI
Hemodynamic/Hematologic
• Normal EBL up to 500 ml vaginal birth, up to 1000 ml cesarean birth
• By 3rd day PP plasma volume as fluid shifts from extracellular to intravascular
• Excess fluid by 2 wks PP by diuresis and diaphoresis
• Leukocytosis to 14-16,000 during labor (or higher): remains 2-3 days PP
Hemodynamic/Hematologic
• Cardiac output peaks immediately after birth (autotransfusion)
• Decreases to pre-labor by 1 hour, remains for 24 hours, then to normal levels by 2 weeks
• Clotting factors in preg. & early PP – Assess for thrombus formation
Gastrointestinal • Relaxin slows GI tract, delays passage of stool
• Incontinence 6x more common w/ 3 and 4° lacerations
• Prevent constipation - should have BM by 2-3 days PP
• Hemorrhoids common
GI System
• Encourage non-pharmacological methods (fiber, fluids, warm drinks in AM, walking, etc.)
• OTC stool softeners
• Hemorrhoid OTC preparations
• Use care w/suppositories if
3 or 4 lacerations
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Musculoskeletal • Skin
– diaphoresis – stretch marks, pigmentation chg – varicosities, spider veins
• Stretched muscles and ligaments return to former state – Diastasis separation 2-3 fingerwidths; lasts ~ 2 wks
• Edema decreases 1-3 days PP • Hormonal effects regress over time
Neurologic
• DTR’s remain normal
• Multiple sources of discomfort – Fatigue, afterpains, incisions, muscle aches, breast engorgement or sore nipples, headaches
• Sleep disturbances r/t hormones
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Endocrine • Thyroid - risk of thyroiditis
– May develop during first month PP, most likely in weeks 3-4.
• Followed by thyroid storm – Life threatening emergency, caused by excessive amounts of thyroid hormones
– S/S: fever, marked weakness, extreme restlessness w/wide emotional swings, confusion, psychosis, even coma
• Followed by hypothyroidism – Extreme lethargy, fatigue, weight loss or later wt. gain, goiter formation
Endocrine: Glucose Metabolism
• Levels change r/t absence of pregnancy hormones – Decreased insulin needs if diabetic – Gestational diabetics return to normal
– 6 wk 75 gm glucose screen to R/O Type 2 DM (fasting BG ok if no further pregnancies planned)
Initial Postpartum Assessment
• Vital signs – Vag birth – q. 15 min. x 4, q. 30 min. x 2, then 1 hour, then q. 12 hrs or more frequent if indicated
– C/birth – q. 15 min. in PAR; then q. 30 min. x 2; q. 1 hr x 4 or 10; q. 2 hr x6 (if duramorph); then q. 4 hrs until 24 hour post-op. After 24 hrs: QID
• Physical assessment • Emotional considerations
Vital Signs
• Temp should be normal. Call if temp for 2 days (> 100.4° F) – Incisions, IV site, breasts, S/S UTI
• Pulse remains normal or decreases slightly after birth
• BP normal – Assess patients w/ DBP for HTN – Orthostatic BP common – BP can be late sign of hemorrhage
Assessment: BUBBLE-HEAD
• B Breasts
• U Uterus
• B Bladder
• B Bowels
• L Lochia/lungs
• E Episiotomy/ lacerations
• H Homan’s sign
• E Edema
• A Affect
• D Discomfort
Monitoring of Incisions
• Assessment of incisions – REEDA scale (Redness, Edema, Ecchymosis, Discharge, Approximation)
• Healing – Stitches absorb
(10 days)
Interventions for Incisions
• Episiotomy (perineal) – Wash hands before and after pad change, ice pack 1st 24 hours, change pads frequently, peri bottle after voiding, wipe front to back, wash with soap & water daily, tub/sitz baths
– Stitches dissolve in about 10 days
– Healing generally takes 4-6 weeks - may take longer for “no pain” (type of epis, ability to heal, infections, etc.)
Incisions
• Abdominal – Wash with soap & water daily, rinse well; keep clean and dry, soft cloth to whisk away moisture, assess daily for healing, remove steri strips in 7-10 days
– Healing takes ~ 6 weeks
Cesarean Considerations
• Recovery from anesthesia
• Auscultate bowel sounds q. 4 hours
• Observe for bladder distension, adequate urinary output
• Auscultate lung sounds
• Ambulate early & often!
Pain Control
• Perineal pain – Ice, topical anesthetics, Tucks, whirlpool
• Oral medications
• Protective positioning, splinting (C/S)
Other Issues
• Restructuring patient education – teaching in antepartum period about self and baby care
– age of informed consumer
– intrapartum & PP notoriously poor retention of teaching. Need time to rest and “practice” what has been learned earlier.
PP Teaching
• PP women have transient deficits in cognition, particularlyin memory function, the first day after giving birth (Rana, Lindheimer, Hibbard, & Pliskin, 2005).
• Verbal instruction immediately after birth or first PP day will be poorly remembered
• Need appropriate written materials
• Priorities for most women in 1st 24 hrs PP are rest, time to touch, hold, and get to know their baby, and an opportunity to review and discuss their L&D
Other Issues
• Providing alternative support services – Postpartum follow-up clinic/phone calls
– Lactation services
– Support groups
– Early parenting education
Questions???
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