Module 4 Postpartum

What is the process of involution?

It is the contraction of uterine smooth muscle, returning the uterus to its pre-pregnancy state.

How much does the uterus shrink from birth to 6 weeks postpartum?

From ~1,000g to 60–80g.

How much does the fundal height descend each day postpartum?

About 1 cm or one fingerbreadth per day.

Where should the fundus be immediately after birth?

Palpable, firm, midline, and about 2 cm below the umbilicus.

Where should the fundus be by day 6 postpartum?

Halfway between the symphysis pubis and the umbilicus.

When should the uterus no longer be palpable?

By 2 weeks postpartum, when it has descended into the true pelvis.

What indicates that involution is progressing normally during assessment?

A firm, midline fundus descending about 1 cm per day.

What are the stages of lochial changes after childbirth and when do they occur?

Lochia Rubra (0-3 days):

• Appearance: Bright red

• Composition: Blood, tissue, and mucus

• Amount: Similar to a heavy menstrual period initially

• Duration: 3 days post-birth

What are the stages of lochial changes after childbirth and when do they occur?

Lochia Serosa (4-10 days):

• Appearance: Pinkish or brownish

• Composition: Blood, serous fluid, and mucus

• Amount: Decreases and becomes lighter

• Duration: 4-10 days post-birth

What are the stages of lochial changes after childbirth and when do they occur?

• Lochia Alba (10 days - 6 weeks):

  • Appearance: White or yellowish-white

  • Composition: Mucus, leukocytes, and tissue debris

  • Amount: Much lighter than earlier stages

  • Duration: Up to 6 weeks post-birth

How is the amount of lochia assessed based on perineal pad saturation?

• Scant: Less than 2.5 cm

• Light: 2.5 to 10 cm

• Moderate: More than 10 cm

• Heavy: One pad saturated within 2 hours

• Excessive Blood Loss: One pad saturated in 15 minutes or less, or pooling of blood under the buttocks

What nursing care is required to care for a post-cesarean patient?

• Monitor for infection and bleeding at the incision site.

• Assess the uterine fundus for firmness or tenderness (tender uterus and foul-smelling lochia can indicate endometritis).

• Assess lochia for amount and characteristics.

• Assess for pneumonia symptoms (productive cough, chills).

• Assess for thrombophlebitis (tenderness, pain, and heat on palpation).

• Apply SCDs to prevent DVT and hypotension from epidural placement.

• Monitor I&O and VS per protocol.

• Provide pain relief and antiemetics as prescribed.

• Encourage turning, coughing, and deep breathing to prevent pulmonary complications.

• Encourage splinting of the incision with a pillow.

• Encourage ambulation to prevent thrombus formation.

• Assess for UTI symptoms (burning, pain on urination)

What physical assessments are needed for an adolescent during the postpartum period?

• Monitor vital signs and check for complications (e.g., bleeding, infection).

• Assess uterine fundus for firmness and position.

• Monitor perineal area for signs of infection or healing.

• Assess for postpartum depression or emotional distress.

• Provide pain management as needed (NSAIDs, acetaminophen, prescribed medication).

• Encourage rest and hydration for recovery.

What education and support should be provided to an adolescent during the postpartum period?

• Offer age-appropriate education on postpartum care (vaginal care, breastfeeding, birth control).

• Teach proper infant care (diapering, feeding, bonding).

• Discuss the importance of nutrition, hydration, and sleep for both mother and infant.

• Address body image concerns and help build confidence in their new role as a mother.

• Educate on emotional changes and encourage open communication.

What psychosocial support is important for an adolescent during the postpartum period?

• Offer support for emotional health, recognizing the challenges of being a new parent.

• Ensure support from family or partners and provide counseling resources if needed.

• Be aware of signs of postpartum depression or anxiety, offering referrals for mental health support.

• Help adolescent understand the importance of social support and managing relationships.

How should family involvement be encouraged during the postpartum period for an adolescent?

• Encourage family involvement to ensure the adolescent has support.

• Discuss how family members can help with both the infant and adolescent’s care.

What follow-up care should be provided for an adolescent in the postpartum period?

• Schedule follow-up visits to monitor the adolescent’s and infant’s health.

• Provide information on expected changes (e.g., menstruation, emotional well-being).

What assessments should be performed during a postpartum assessment?

• B: Breast (check for engorgement, nipple condition, and infant latch).

• U: Uterus (fundal height, uterine placement, and consistency).

• B: Bowel (ensure passing of gas, normal GI function).

• B: Bladder function (ensure the bladder is empty and there are no issues with urination).

• L: Lochia (assess for color, odor, consistency, and amount [COCA]).

• E: Episiotomy (inspect for edema, ecchymosis, and approximation).

• E: Extremities (check for redness, swelling, or pain).

What is expected at 2 hours after delivery during a postpartum assessment?

• Blood pressure and pulse monitored every 15 minutes.

• Uterus: Firm, at or near the umbilicus, and in midline.

• Lochia: Moderate amount, similar to a heavy menstrual period.

• Episiotomy: Mild edema, some discomfort, no excessive swelling or infection.

• Extremities: No signs of thrombus or clot formation.

What is expected at 12 hours after delivery during a postpartum assessment?

• Uterus: Firm, around 1-2 cm above the umbilicus.

• Lochia: Moderate amount, red (rubra), may begin to lighten in amount.

• Episiotomy: Mild swelling, good approximation, no infection.

• Extremities: No signs of thrombus or clot formation.

What is expected at 24 hours after delivery during a postpartum assessment?

• Uterus: Firm, around the level of the umbilicus.

• Lochia: Moderate to light, red (rubra), less in amount than earlier.

• Episiotomy: Signs of healing, minimal swelling or bruising.

• Extremities: No signs of redness, pain, or swelling.

What is the rubella immunization given during the postpartum period for?

• To protect a subsequent fetus from malformations if the mother is nonimmune or has a negative/low titer.

• The rubella vaccine or the MMR vaccine is administered via subcutaneous injection.

What are nursing considerations for a patient receiving the rubella or MMR vaccine in the postpartum period?

• Ensure the patient is nonpregnant and is not planning pregnancy within 4 weeks (28 days) following the immunization.

• Educate the patient to avoid pregnancy for at least 4 weeks after receiving the vaccine.

What is the typical timeline for discharge following childbirth?

Clients and newborns are typically discharged 48 hours after a vaginal birth or 72 hours after a cesarean birth.

What discharge teaching should be provided to parents regarding newborn care?

• Bathing: How to safely bathe the newborn.

• Umbilical cord care: Proper cleaning and care to prevent infection.

• Circumcision care: If applicable, instructions for care of the circumcision site.

• Car seat safety: Proper use of a car seat.

• Environmental safety: How to create a safe environment for the newborn.

• Newborn behaviors: Understanding typical newborn behaviors.

• Feeding and elimination: Normal feeding patterns and how to monitor elimination (urine and stool).

• Clinical findings of illness: What symptoms indicate the need to call a provider.

What specific things should parents be aware of regarding their newborn's behavior?

• Causes of crying: Understanding why the newborn might cry and how to manage it.

• Quieting techniques: Strategies to calm the baby.

• Sleeping patterns: Typical newborn sleep cycles and safe sleep practices.

• Hunger cues: Recognizing when the baby is hungry.

• Feeding: How often and how much the baby should be fed.

• Bathing: How to safely bathe the newborn.

• Clothing: How to dress the baby appropriately for the environment.

What are important follow-up considerations for parents after discharge?

• Well-newborn checkups: Importance of scheduling and attending well-child visits.

• Immunization schedules: Keeping track of the baby's immunization timeline.

• When to call the provider: Understanding when to contact the provider for any signs of illness or concern.

When should a new mother receive RhoGam (Rho(D) immune globulin)?

• A new mother who is Rh-negative and has a newborn who is Rh-positive should receive RhoGam within 72 hours of delivery.

Why is RhoGam administered to a new mother?

RhoGam is given to prevent antibody formation in the mother, specifically to suppress the formation of anti-D antibodies, which could affect future pregnancies.

What should the nurse check before administering RhoGam?

The nurse should verify that the client has not been sensitized and has not produced anti-D antibodies prior to giving RhoGam.

When would RhoGam not be given to a new mother?

• If the mother is Rh-positive.

• If the mother has already developed Rh antibodies.

• If the mother has a history of severe allergic reactions to human immune globulin.

What could excessive spurting of bright red blood from the vagina indicate during the early postpartum period?

Cervical or vaginal tear.

What could numerous large clots and excessive blood loss (saturation of one pad in 15 minutes or less) indicate?

Hemorrhage.

What does a foul odor in the lochia suggest?

Infection.

What could persistent heavy lochia rubra beyond day 3 indicate?

Retained placental fragments.

What could continued flow of lochia serosa or alba beyond the normal time frame indicate?

• Endometritis, especially if accompanied by fever, pain, or abdominal tenderness.

What should you do if you find a boggy uterus during a postpartum assessment?

Lightly massage the fundus in a circular motion to help it firm.

What should you do if the uterus does not firm after massaging?

Continue massaging and notify the provider if the uterus remains boggy.

What does it mean if the uterus is high and displaced from midline?

It could be caused by a full bladder, which displaces the uterus laterally.

What nursing care should be provided to correct a high and displaced uterus?

Encourage the patient to empty their bladder to relieve the displacement and prevent uterine atony.

A normal urine output is 30mL/hr.

How should the nurse document the position of the uterus if it is above or below the umbilicus?

• If above the umbilicus, document as +1, U+1, or 1/U.

• If below the umbilicus, document as -1, U-1, or U/1.

What should the nurse be mindful of when palpating the fundus after a cesarean section?

Be mindful of surgical incisions when palpating the fundus.

How often should the fundus be assessed after the recovery period post-delivery?

The fundus should be assessed at least every 8 hours after the recovery period has ended.

What should the nurse explain to the client before palpating the fundus?

• The nurse should explain the procedure to the client before palpation to ensure understanding and cooperation.

How should the client be positioned for a fundal assessment?

Position the client supine with their knees slightly flexed to avoid influencing the fundal height.

What precautions should the nurse take during fundal palpation?

Apply clean gloves and a lower perineal pad to observe lochia flow as the fundus is palpated.

How should the nurse palpate the fundus?

• Support the lower segment of the uterus by cupping one hand just above the symphysis pubis.

• With the other hand, palpate the abdomen to locate the fundus.

• Never palpate the fundus without cupping the uterus.

What should the nurse document after palpating the fundus?

Document the fundal height, location, and uterine consistency.

What is the most common cause of increased bleeding in the postpartum period?

Uterine atony is the most common cause of postpartum bleeding.

What can cause increased bleeding in a postpartum patient besides uterine atony?

• Lacerations

• Episiotomy

• Uterine inversions

• Coagulation disorders

What are postpartum blues, and how common are they?

• Postpartum blues occur in up to 85% of clients within the first few days after birth.

• They are characterized by mood swings, anxiety, feelings of sadness, crying, insomnia, and a lack of appetite.

• Typically, they resolve within 10 days without intervention.

How long do postpartum blues generally last?

Postpartum blues generally last up to 10 days after birth.

What should the nurse assess in a client experiencing postpartum blues?

• Assess the client’s mood and anxiety.

• Monitor interactions between the client and their newborn.

• Encourage bonding activities.

• Monitor the client’s mood and affect.

What advice should the nurse give to a client experiencing postpartum blues?

• Reinforce that feeling down in the postpartum period is normal and self-limiting.

• Encourage the client to notify the provider if the feelings persist.

What should the nurse encourage the client to do if experiencing postpartum blues?

Encourage the client to communicate feelings, validate and address personal conflicts, and reinforce personal power and autonomy.

What should the nurse do for clients at high risk for postpartum depression?

• Contact a community resource to schedule a follow-up visit after discharge.

What safety precautions should the nurse take if the client shows signs of self-harm or harm to the newborn?

• Ask the client if they have thoughts of self-harm, suicide, or harming their newborn.

• Ensure the safety of the newborn and client as the priority of care.

How can a nurse incorporate cultural issues into postpartum care?

• Actively ask patients about their cultural practices and beliefs related to the postpartum period.

• Respect their traditions.

• Adapt care plans based on cultural practices (e.g., dietary recommendations, family involvement, resting periods, appropriate clothing choices).

What should the nurse do while adapting care plans based on cultural practices?

• Ensure cultural practices are respected, while also addressing potentially harmful practices.

Why are postpartum patients at higher risk for thrombophlebitis?

• Postpartum patients are at a higher risk due to changes in circulation, hormonal influences, and increased clotting factors during and after pregnancy.

• Thrombophlebitis occurs when a thrombus (blood clot) is associated with inflammation.

• It is most commonly found in the femoral, saphenous, or popliteal veins.

• A deep vein thrombosis (DVT) can lead to a pulmonary embolism if left untreated.

What veins are most often affected by thrombophlebitis in postpartum patients?

The femoral, saphenous, and popliteal veins are most commonly affected by thrombophlebitis in the lower extremities.

How would you assess a postpartum patient for thrombophlebitis?

• Assess for redness, swelling, tenderness, and warmth in the affected leg.

• Look for signs of pain or distended veins.

• Monitor for signs of a DVT: leg pain, swelling, or redness in one leg, or pain with dorsiflexion (Homan's sign, although it is not a reliable indicator).

• Monitor for signs of a pulmonary embolism: shortness of breath, chest pain, or hemoptysis.

What are the expected findings of thrombophlebitis in a postpartum patient?

Leg pain and tenderness.

What are the physical assessment findings for thrombophlebitis?

• Unilateral swelling, warmth, and redness in the affected leg.

• Hardened vein over the thrombosis.

• Calf tenderness.

What noninvasive diagnostic procedures can be used to assess for thrombophlebitis?

• Doppler ultrasound scanning.

• Computed tomography (CT) scan.

• Magnetic resonance imaging (MRI).

What is a postpartum infection and what is its time frame?

Postpartum infections are complications that can occur up to 28 days following childbirth, spontaneous abortion, medication abortion, or abortion procedure.

What fever is indicative of a postpartum infection?

A fever of 38°C (100.4°F) or higher after the first 24 hours or for 2 days during the first 10 days postpartum indicates a possible infection and requires further investigation.

What are the major causes of postpartum infections?

• Infections can be present in the bladder, uterus, wound, or breast.

• Major infections include endometritis (uterine infection), wound infections, mastitis, and UTIs.

What is the major complication of puerperal infection?

• Septicemia is the major complication of puerperal infections (any infection that occurs in the postpartum period).

What are the risk factors for postpartum infections?

UTI, mastitis, pneumonia, history of venous thrombus, DM, immunosuppression, anemia, malnutrition, alcohol/substance use disorder, cesarean birth, prolonged rupture of membranes, retained placental fragments, manual extraction of placenta, bladder catheterization, intrauterine infection, internal fetal/uterine pressure monitoring, multiple vaginal exams, prolonged labor, postpartum hemorrhage, operative vaginal birth, epidural analgesia, hematomas, episiotomy or lacerations.

What are the flu-like manifestations of puerperal infections?

• Body aches, chills, fever, malaise, anorexia, and nausea.

• Elevated temperature of at least 38°C (100.4°F) for 2 or more consecutive days.

• Tachycardia.

What are the symptoms of endometritis (uterine infection)?

• Pelvic pain, chills, fatigue, and loss of appetite.

• Uterine tenderness, dark profuse lochia, and malodorous or purulent lochia.

• Temperature greater than 38°C (100.4°F), tachycardia.

What are the symptoms of mastitis (breast infection)?

• Painful or tender localized hard mass and reddened area on one breast.

• Influenza-like manifestations: chills, fever, headache, body aches, fatigue.

• Axillary adenopathy (enlarged tender axillary lymph nodes) with redness, swelling, warmth, and tenderness in the affected area.

What are the symptoms of a wound infection in the postpartum period?

• Wound warmth, erythema, tenderness, pain, edema, seropurulent drainage.

• Wound dehiscence (separation of wound or incision edges) or evisceration (protrusion of internal contents).

• Temperature greater than 38°C (100.4°F) for 2 or more consecutive days.

What are the stages of maternal touch?

• Stage 1: Initial Touch (En face touch) - Tentative, light touch as the mother gazes at her newborn.

• Stage 2: Extended Touch - Prolonged, more affectionate touch, such as holding and stroking the baby.

• Stage 3: Enfolding Touch - Full embrace and holding of the baby, signifying deep connection.

• Stage 4: Newborn to Infant Transition - Interactive touch as the baby begins to respond to the mother's touch and voice.

What emotional tone is associated with the Initial Touch (Stage 1)?

Emotional tone includes awe, amazement, and sometimes hesitancy, especially for first-time mothers or those with difficult births.

What emotional tone is associated with Extended Touch (Stage 2)?

The emotional tone is one of growing confidence and affection as the mother becomes more comfortable with her role.

What is the significance of Enfolding Touch (Stage 3)?

This stage signifies a deep emotional connection and nurturing, with the mother fully embracing and holding the baby.

How does Newborn to Infant Transition (Stage 4) evolve?

The relationship becomes more interactive, with the baby responding to the mother's touch and voice, and physical engagement increases.

How do cultural beliefs influence maternal touch?

Cultural beliefs shape the frequency, manner, and significance of physical contact with newborns, with some cultures emphasizing close bonding and others being more restrained.

How do postpartum traditions impact maternal touch in different cultures?

Some cultures may have specific rituals or restrictions that limit or encourage touch, such as promoting early bonding or instructing mothers to limit contact to promote healing.

How do cultural practices affect maternal-infant attachment?

In some cultures, immediate and continuous physical bonding is crucial, while in others, extended family members may play a significant role in caregiving, affecting the bonding process.

How does family involvement impact maternal touch in different cultures?

Cultural norms may dictate whether the mother or extended family takes on caregiving roles, which influences how the maternal touch stages progress.

What is the nursing consideration when dealing with cultural issues related to maternal touch?

Nurses should respect cultural beliefs, provide education about the benefits of maternal touch, and support bonding while being culturally sensitive to family dynamics.

What is the function of Oxytocin (Pitocin)?

Oxytocin is a uterine stimulant that promotes uterine contractions.

What should be assessed when administering Oxytocin (Pitocin)?

Assess uterine tone and vaginal bleeding.

What are the signs of water intoxication as a side effect of Oxytocin (Pitocin)?

Lightheadedness, nausea, vomiting, headache, and malaise. These can progress to cerebral edema, seizures, coma, and death.

What is the function of Methylergonovine (Methergine)?

Methylergonovine is a uterine stimulant that controls postpartum hemorrhage.

hat should be assessed when administering Methylergonovine (Methergine)?

Assess uterine tone and vaginal bleeding.

Who should Methylergonovine (Methergine) NOT be administered to?

It should not be administered to clients with hypertension.

What are the potential adverse reactions to Methylergonovine (Methergine)?

Hypertension, nausea, vomiting, and headache.

What is the function of Misoprostol (Cytotec)?

Misoprostol is a uterine stimulant that controls postpartum hemorrhage.

What should be assessed when administering Misoprostol (Cytotec)?

Assess uterine tone and vaginal bleeding.

What is the function of Carbopost tromethamine (Hemabate)?

Carbopost tromethamine is a uterine stimulant that controls postpartum hemorrhage.

What should be assessed when administering Carbopost tromethamine (Hemabate)?

Assess uterine tone and vaginal bleeding.

What are the potential adverse reactions to Carbopost tromethamine (Hemabate)?

Fever, hypertension, chills, headache, nausea, vomiting, and diarrhea.

What is the function of Tranexamic acid (TXA)?

Tranexamic acid is an antifibrinolytic that works to improve blood clotting.

When is Tranexamic acid (TXA) recommended to be administered?

It is recommended to administer TXA to clients who experience postpartum hemorrhage within 3 hours of birth.

What education should be provided to a postpartum client regarding recovery?

Limit physical activity to conserve strength, increase iron and protein intake to promote RBC rebuilding, and take iron with vitamin C to enhance absorption.

What is Mastitis and what can happen if it is untreated?

Mastitis is an infection of the breast involving the interlobular connective tissue and is usually unilateral. It can progress to an abscess if untreated.