Normal Postpartum

Jodie Fuller, MSN, RN Jennie Hensley, CNM, EdD

Immediate Postpartum Period

Prevent hemorrhage

1. Tone

Atony #1 cause

Have oxytoxics! Empty bladder

2. Tissue 3. Trauma

Have suture

4. Thromboemboic disorders

Keep woman warm Initiate breastfeeding when mother and baby stable Offer food and beverage

Postpartal Assessments
During Recovery

On Mother-Baby

V/S q15x4, q30x2 Anesthesia recovery Fundus Lochia Perineum Voiding Food, water Attachment, bonding Feeding the baby

V/S Head to toe PE Fundus Lochia Perineum Voiding Stooling Bonding Feeding her & the baby Infant care

The FUNDUS during Recovery

The fundus must remain firm to control bleeding from the placental site, otherwise a hemorrhage can occur When the fundus is boggy, lochia rubra increases due to:

Uterine atony (one tired muscle) Full bladder Retained placental fragments or membranes Firm, 2 fingerbreadths below the umbilicus: F@U-2 Firm, 2 fingerbreadths above the umbilicus: F@U+2

Charting the fundal exam:

Fundal Check immediately postpartum

Lochia Rubra during Recovery

First discharge from the uterus is lochia rubra, or bright red blood + debris (dedidua, etc.)

Described as: scant, moderate, heavy Charting w/ fundal exam

Fundus firm at 3 fingerbreadths below umbilicus w/ scant lochia rubra:

FF@U-3, sct. rubra

Fundus firm w/ massage at umbilicus, rubra moderate dwindling down to scant:

FF w/ massage @ U, mod sct. rubra

Lochial vs Non-Lochial Flow (Free Blood)

Lochia usually has a slow flow from vaginal opening Greater flow with uterine contraction or fundal massage Blood that has pooled in vaginal vault will be darker in color May be accompanied by huge clots

If flow is heavy or spurts, may be an unrepaired vaginal or cervical laceration Bleeding from a laceration will continue to be heavy and bright red

Anesthesia Recovery

IV pain medications? Narcotics? Sedative?

What time? How many doses?

Epidural, intrathecal, or spinal block? Long acting narcotics injected?

Astromorph, Duramorph, fentanyl

Requires hourly respiratory rate checks x 12-24 hrs. Pulse oximetry reading (Sa02)

Moving both legs?

Sensory and motor activity

Chills during Recovery

Postpartum chills not uncommon loss of placental unit loss of 12- 13 lbs = shock to system large volume of IVFs at room temperature decreased temp normal, cant control it, dont try to, but do :

offer warm blankets offer warm fluids keep her away from chilly areas

Cramps during Recovery

Afterbirth pains not uncommon

Worse in multiparous women Can be from Pitocin (oxytocin) in IV bag

slow down rate if she is not bleeding

Can be from breastfeeding Can be from a full bladder

empty bladder
call the provider

Can be due to large blood clots in cervical os

Treatment(s)

Massage uterus Tx underlying cause Empty bladder, offer ibuprofen, oxy/hydrocodone

Postpartum Days 1-3

Normal spontaneous vaginal delivery

24-48 hours 48-72 hours

Cesarean birth

Immune System

Rh isoimmunization prevention with Rhogam administration to Rh mothers Rubella immunization given to mothers who are nonimmune or equivocal (prenatal labs)

Breast enhancements can Usually breastfeed.

Breast reductions may not be able to.

Breastfeeding mothers

Breastfeeding mothers:

Little change in 1st 24 hours Colostrum can be expressed Assess for signs of irritation (usually only lasts 24 to 48 hours)

Assess nipples for erectility

As the milk ducts fill, the breasts get nodular/lumpy feeling to them

Usually after woman goes home Bluish-white milk can be expressed at this time

Engorgement heralds change to true milk

Breastfeeding Problems
Nipple Breakdown Causes: positioning, cracks, yeast Tx: positioning, soothies, lanolin, antifungals, lactation consult

Formula feeding mothers Breasts - cont

Colostrum is present for first few days Rapid decline in prolactin levels Engorgement may occur on 3rd or 4th day PP

discomfort usually resolves in 24 to 36 hours

Milk should not be expressed Educate mother to wear tight fitting bra Use ice packs and avoid warm showers on breasts Avoid nipple stimulation Lactation usually stops in a few days to a week Mild analgesics can be used for discomfort Reabsorbs in 48 hour

Fundal location on day 2

Bladder Distention

Pushes the uterus up and over to one side Prevents adequate uterine contractions May cause increased bleeding (especially in the first couple of hours after birth) Increased risk for UTI Unable to void

secondary to anesthesia or trauma bladder should be emptied by catheterization

Lochia amounts

Scant or minimal Moderate Heavy Hemorrhaging

The Perineum

Should be non-edematous, not bruised, approximated (not gaping open) & the sutures should appear intact REEDA System checks for:

Redness Edema Ecchymosis Discharge Approximation

Care of Laceration/Episiotomy

Introitus often swollen and bruised

especially with laceration or episiotomy repair

Keep area clean Use peri bottle with warm water Benzocaine spray Tucks Swelling, hematomas and pain prevented/treated by:

early and continued ice packs anti-inflammatory medication (as ordered) warm Sitz baths do-nut pillow

Evaluation of Episiotomy/ Laceration Repairs

Easiest to see if woman on her side and upper buttock raised Considered a surgical incision

should be approximated

Watch for signs of:

infection pain redness swelling drainage warmth sutures coming out

Know your lacerations & episiotomies

You cant check to see if its approximated if you dont know what you are looking for Periurethral (is that why it burns when she pees?) Periclitoral Labial Vaginal 1st degree 2nd degree Through the rectal sphincter (3rd degree) Through the rectum too (4th degree) Episiotomies Midline, mediolateral

Lochia

Woman should report saturation of > than 1 pad / hour or clots bigger than an egg Lochial flow gradually decreases with a total volume of about 225 mls

Hemorrhoids

May evert while pushing and cause PP discomfort Tucks pads (witch hazel) helpful

Intact perineum with hemorrhoids

Involution

Return of the reproductive organs to the nonpregnant state

42 days All systems and body organs

Involution of the uterus

Reduction in size of the uterus to its prepregnant state

uterine cells atrophy size of the cells shrink

Dramatic decrease in hormones following birth of placenta

Involution of the Uterus on day 2

Involution of the Uterus on day 4

Lochial changes during involution

Rubra

Bright red - dark red discharge Present for first 2-3 day Pinkish Between days 3 to 10 Creamy white or yellowish discharge Continues for an additional week or 2

Serosa

Alba

Cervical changes during involution

Immediately after birth cervix is soft, edematous, thin, bruised and fragile External os has very small lacerations which cause increased risk for infection The os slowly closes so that by the end of 2 weeks only a small curette can be passed through

Pre-pregnant/Postpartum Cervical Os

Vagina

Decreased estrogen levels cause:

Thinning of mucosa Smoothing of vaginal walls Decreased vaginal lubrication

Vagina returns to pre-pregnancy size in about 4 to 6 weeks Returns to pre-pregnant state with return of ovarian function and resumption of menstruation

Pelvic Muscle Support

Muscles of the pelvic floor can be injured

pelvic relaxation help in healing and strengthening of pubococcygeous muscles

Kegel exercises recommended

Up to 6 months to regain tone

Kegel Exercises

Placental Hormones

Chorionic somatomammotropin Estrogens Cortisol Placental enzyme insulinase

Placental Hormones cont.

Decrease in these hormones occurs immediately Reverses the diabetogenic effects of pregnancy Decrease in estrogen associated with breast engorgement and diuresis of extracellular fluid Lower estrogen levels continue as long as the woman is breastfeeding

Pitutary Hormones & Ovarian Function

Lactating women:

Prolactin hormone responsible for delay in ovulation and menstruation in breastfeeding women Serum levels are affected by:

Frequency of breastfeeding Duration of feedings

Average time to ovulation is 6 months

BF not a effective form of contraception

Non-lactating women:

Prolactin levels decline and return to pre-pregnant levels by 3rd week PP Ovulation can occur as early as 27 days PP

average of about 70 to 75 days need contraception

Abdomen

Abdominal wall stays relaxed for first 2 weeks PP

looks like she is still pregnant

Can take up to 6 weeks for abdominal wall to return to pre-pregnancy state

striae persist

Diastasis Recti Abdominis

Diastasis recti abdominis can occur

rarely needs surgical repair abs of steel gone

Urinary Changes

Increased renal function of pregnancy (from hormonal changes) decreases after birth Kidney function returns to normal within 1 month Hypotonia and dilation of the ureters and renal pelves return to normal in 2 to 8 weeks Dilation of the urinary tract puts women at increased risk for UTI until back to non-pregnant state May be a transient increase in BUN and proteinurea (+1) due to breakdown or excess uterine tissue

Gastrointestinal

Appetite

New mother is usually hungry! She may eat and should be fed a light diet in the immediate PP period if she is not nauseous and stable Decreased gastric motility for up to a week

Bowels

The first PP bowel movement may be delayed by 2 to 3 days secondary to:

Decreased intestinal tone Pre-labor diarrhea Lack of food Dehydration Anticipated pain from lacs/epis repairs & hemorrhoids

Bowel cont.

Encourage re-establishment of regular bowel habits Administer stool softeners and/or laxatives to ease passing first BM Encourage fluid intake to help prevent constipation Encourage adequate fiber in her diet

Cardiovascular

Blood volume decrease

From immediate blood loss with birth

average of 500 ml

Diuresis of edema Total loss of the increased volume in pregnancy

1000 ml to 1500 ml within the 1st 2 weeks

Cardiovascular cont

Cardiac output remains increased for 48 hours due to return of blood volume from the uterus and extravascula fluid shifts Generally returns to normal by 6 weeks PP but can take as long as 12 weeks

Cardiovascular

Vital signs
Initially after birth, woman gives herself an autotransfusion of 500 ml (the blood which was in the placental unit) Due to baroreceptors in the heart, postpartum bradycardia is not uncommon Vital signs should remain normal during recovery & on mother-baby B/P should remain stable @ ~ < 120/80 or less Heart rate ~ 50-100 Respirations ~ 18-22 Temp may go initially to 100.4 due to dehydration, sympathetic stimulation from the epidural & exhaustion Otherwise, should be afebrile

Cardiovascular

Varicosities in legs, vulva, and hemorrhoids usually regress after birth Assessment and prevention of clot formation, particularly in the C/birth patient is important

TED hose SCD Exercises to promote circulation

Blood Components

H&H

May drop in first 24 hours secondary to blood loss Rises over the next 48 to 72 hours due to a reduction in plasma volume

Blood Components cont.

WBCs

Increase from 12,000 to 20,000 - 25,000 in first 10 to 12 days is common This may mask the presentation of infection

Blood Components

Coagulation Factors

Increase in clotting factors and fibrinogen in pregnancy continues into PP period as healing occurs

Neurologic

Any neurologic symptoms that the mother may have experienced (for instance carpal tunnel) usually resolve soon after birth Complaints of postpartum headache should be carefully assessed, especially if:

history of hypertensive disorders during pregnancy woman had an epidural/spinal in labor

Musculoskeletal

Any musculoskeletal changes like hypermobility and relaxation of joints return to pre-pregnant state in 6 to 8 weeks Joints in feet may have permanent increase in the size of the feet

Integumentary

Chloasma (mask of pregnancy) usually goes away at the end of pregnancy Other hyperpigmentations (linea negra, striae, aereolae) may not completely go away Hair growth may slow or the mother may experience hair loss

Hair growth stuck in anaphase during pregnancy

Psychosocial Assessment

Attachment with the baby Parents should exhibit signs of successful adaptation to parenthood:

Positive reaction to newborn Taking pleasure in caring for and providing comfort the baby Reading infant cues Wanting the baby at the bedside

Parent-Infant Attachment

Positive behaviors

holding baby en face examining all body parts from head to toe

Maternal getting to know the baby Acquaintance phase

baby responds to mother, mother feels confident each enjoy the other RECIPROCITY synchronous & mutually gratifying interaction

Phase of mutual regulation

Reciprocity

Paternal

Engrossment: preoccupation with infant

The Sibs

Expect jealousy & regression of older sibs Pay special attention to older sib(s) when baby is asleep Ask to help as much as possible Have a dolly for them

The Fam

Whos in charge? Who should be in charge? Is there support at home? Is there money & transportation? Is there abuse? Whos abusing?

Anticipatory Guidance

Sleep deprivation Sleep deprivation Sleep deprivation No alone time No time for your needs

Cultural Considerations

Much of a womans behavior is influenced by cultural factors A careful assessment of cultural beliefs and values is important Assess for baby blues or postpartum depression

Education & Discharge Teaching

Self care and signs of complications Sexual activity and contraception

May resume sexual activity after 6 weeks Discuss contraceptive options

Discuss and provide information about prescribed medication and safe medications for breastfeeding Routine mom/baby checkups Postpartum depression

Postpartum Danger S/S: Call STAT

Uncontrollable crying

Wanting to hurt self or baby

Fever 101 Blood filling up peri-pads & clots > size of quarter Foul smelling discharge from vagina Red, hot area on one breast w/ fever Inability to void or stool

Birth Control

Foam & condoms Mini-pill (progestin only) Depo-Provera shot (progestin only) Combined birth control pills

Formula feeding only

Intrauterine device Breastfeeding NOT a method of birth control, but of pregnancy spacing

The New Baby at Home

Show parents how to hold infant

Support neck, otherwise they dont usually break Corners of eyes out w/ clean cloth Warm water, dont boil the baby Controversy as to whether or not sponge bath necessary until cord falls off +/- Alcohol after diaper changes No ointment on the Plastibell (falls off 5-8 days)

Bathing

Umbilical cord

Circ care

The New Baby at Homecontd

T-shirt dressing

Back of head 1st, then the squiggly arms No Mercury thermoms Breastfed & Formula fed: 5-8 voids/day Breast: 6-10 poops Formula: 1-2 poops

Temp

Ins & Outs

SIDS

Risk factors

Sleeping prone, cig smoking in home, soft mattress, overheating Sleep on back Firm mattress Not too warmly dressed

Back to Sleep Program

Follow-ups

Newborn

2-3 days to check on breastfeeding 2 weeks C/S 2 weeks for surgery check 6 weeks for postpartum exam, Pap & birth control

Mother

Early Postpartum Discharge

Discharge from the hospital before 24 hours Is discouraged as some complications with both mother and baby can occur after the first 24 hours Newborns and mothers health protection act ~ 1996

All health plans are required to allow vaginal deliveries to stay 48 hours and C/sections 96 hours