Newborn Adaptations + Postpartum Period

Thermoregulation w/Newborn: What is it? Why are they at risk? Type of mechanisms? How to prevent heat loss?

What is it?

• bebe ability to produce heat & maintain a stable body temp

• Expected:

  • 36.5-37.5

Hypothermia?

• High Body Surface Area → easier to lose heat

• Limited Fat → harder to retain heat

• Limited ability to shiver → Cannot generate enough heat via shivering

  • Weak muscles

NonShivering Thermogenesis:

• Brown adipose tissue produces eat w/out requiring contractions

  • Exposure to cold → activates tissue → lipolysis → energy released as heat

  • REQUIRES OXYGEN; hypoxia = no thermogenesis

• Location:

  • Back muscles, kidneys, neck, abd, axillae

Mechanisms:

• Evaporation

  • Covered in amniotic fluid → evaporates → cold

  • Thoroughly dry, remove wet blankets, delay first bath

• Conduction: direct contact w/cold surface

  • Use warm blankets between bebe & cold surfaces

• Convection: Heat lost w/cooler air

  • Avoid placing them near open window or A/C vent

  • Maintain good A/C temp

• Radiation: Transfered from the newborn to colder object W/OUT direct contact

  • Avoid placing near cold window

Interventions:

• Skin-skin ocntact: first line

  • Dry bebe → remove wet linens → Skin-Skin

Respiratory System: Before birth? What happens during first breath? Role of Surfacant? Resp. A/x?

What happens to the lungs before birth?

• Filled w/fluid due to epithelium secretion → transition after birth

• First breath → air enters + expands lungs → alveoli expand → ^^^ pulmonary blood flow → o2 in blood stream → independent gas exchange

  • Must also clear fluid to establish good breathing

Surfacant:

• v surface tension inside alveoli → prevents collapse when expirating

Resp A/x:

• 30-60 RR

Cardiovascular System: Fetal circulation shunts; Changes after birth; CV a/x:

Shunts:

• Ductus Venosus: connects umbilical cord to IVC

• Foramen Ovale: connection from RA to LA

• Ductus Arteriosus: connects pulmonary artery to aorta

Changes after birth: pathway

• Umbilical cord cut + first breath → lungs expand → O2 enters lungs → v Pulmonary vascular resistance → ^ b.f. to lungs → Oxygenated blood returns to left side of heart → closure of foramen ovale → other shunts close after

CV A/x:

• 110-160 BPM

Hematological System: Blood production, HbF, & Vitamin K role

Blood production:

• Before Birth: liver responsible

• After: Bone marrow responsible

Fetal Hgb (HbF): extracts o2 from mother’s hgb → placenta → bebe’s tissue & organs

• Higher affinity for o2; stays w/bebe after birth

  • Gradually replaced by regular Hgb after 3rd month

  • 18-20 g/dL in fetus

• Lower arterial o2 pressure

Vitamin K & Clotting:

• Immature hepatic function → deficient in clotting factors:

  • II, VII, IX, and X

• VK prophylaxis: via IM → prevents bleeding

Neuromuscular System: Expected newborn tone

Expected findings:

• Arms + Legs flexed

• Hands closed in fist

• Resistance when RN attempts to move extremities

Gestational age assessment

New Ballard Score:

• Physical Maturity:

  • Skin, Lanugo, Palmar crease

  • Breast tissue, Ear/Eye, Genitals

• Neuromuscular Maturity:

  • Posture, Scarf Sign, heel-ear maneuver

  • Square window, Arm recoil, popliteal angle

• “May possible OVERestimate age”

Gastrointestinal System: Before/After birth; GI functions important for newborn

Before:

• Sterile in utero

After:

• Exposure to microorganisms

• Adapts to colstrum/milk

Functions:

• Digestion + Absorption

• Suck-Swallow Coordination

• Gastric Emptying + Peristalsis

Renal System: Before/After birth; possible weight loss; Issues with bebe’s immature kidneys:

Before:

• Placenta the one responsible for kidney’s function

• 34-36 wks gestation → mature kidneys

• 10 wks gestation → urine production

After:

• ^ RBF + GFR → ^ Urine output → possible weight loss

  • 10% weight loss is normal

  • Newborn’s GFR power is 20-30% of adult’s power

Issues with Kidney immaturity:

• Medication elimination: prolongued med effects

• Fluid balance:

  • ^ Surface area → ^ fluid loss → fluid-balance issues

Hepatic System: How does an immature bebe liver affect processes? Common hepatic findings in newborns?

Alteration in different processes:

• Glucose Regulation

• Med metabolism is delayed → stays in body longer

• Bilirubin conjugation:

  • Liver conjugates bilirubin w/glucuronic aci → excreted via bile

  • Difficulty w/conjugation in peds → potential accumulation & jaundice s/s

    • Yellow skin, sclera, & mucous membranes

  • If seen in first 24 hrs → ER

Immune system: How is it provided in newborns? Benefits?

Breast milk is rich in

• Antibodies, Ig, WBCs

• May lower r/x of developing:

  • Asthma, Food allergies, Diarrhea

  • Ear or URI

  • DM or Obesity

Integumentary System: Expected findings? Changes after 2-3 days PP

Newborn skin appearance:

• Deep red or purple; thick epidermis

• Acrocyanosis in hands & feet

• Vernix: Protects skin from amniotic fluid

  • Should remain on skin 6hr PP

• Lanugo: soft hair in

  • Scalp, forehead, cheecks, shoulder, back

  • Disappears 1wk PP

2-3 PP:

• Skin becomes lighter, drier, more flaky

• May become red if crying

Skeletal system: Development of bones; Cranial development:

Bone development

• Cartilage framework → Ossification

• From embryonic stage → Mid 20s

• Bone #

  • Newborn: 270

  • Adult: 206-213

    • Changes in ribs, digits, & vertebrae

Newborn skull:

• 1 occipital + 2 frontal + 2 parietal

• Sutures: allow molding & space for rapid growth

• Fontanels: Anterior + Posterior

Regulation of State & Sleep in Newborns: What is state regulation? Sleep Patterns & # of sleep? Types of sleep? Development?

State regulation:

• Bebe ability to manage their lv of alerness

• Six states:

  • Quiet sleep

  • Active Sleep

  • Drowsy

  • Alert

  • Fussy

  • Crying

Newborn sleep patterns:

• Utilize circadian rhythms

  • 16-18 hrs per day

    • Continuous sleep episode: 2.5-4 hours

• Quiet sleep: peaceful sleep w/minimal movement

• Active sleep: movements & activity while sleeping

• Transitional: between sleep & awake

Development:

• After 2-3 months, developing → more organized pattens → nocturnal sleeping

Newborn Social Interaction & Communication: Eye contact & bonding; Crying; Temperament:

Eye contact

• Respond positevily to these behaviors

Crying: Make cry/fuss for 3hr/day

• Hungry, Tired, ill, discomfort, pain

• Interventions:

  • Swaddle, rock baby, massage, take bebe for a walk

• If parent is frustrated → place bebe in crib → walk away → come back

What is temperament?

• Individual’s way of reacting; develops during 1st year

• Some may be easier to soothe than others

Newborn Motor development: What should be expected?

A/x as general head-to-toe pattern

• Closed first, arms flexed

• Bebe lifts their head when lying on their back; can turn their head

  • Neck muscles still may be weak → support bebe’s neck when lifting

What is autonomic stability? What are some newborn reflexes?

ANS: regulates involuntary body functions like:

• Resp, GI, CV, Higher brain functions that work for emotions

  • A/x via HR, RR, BP

• Very sensitive to changes which may alter its development

Newborn reflexes: Disappear after 4-6 months

• Sucking

• Rooting: developed 32 wk gestation → decreases 4 wks PP

• Tonic neck

• Moro: present 28 wk gestation → disappear 6 months PP

  • Absent may signify clavicular fracture OR brachial plexus injury

• Grasping: 28 wk → 6 months

• Babinski

Newborn Development of the Senses:

Visual:

• 8-10 inches distances; detect light vs dark

  • If very light → blinking or squinting

    • May follow bright light a short distance

  • Still cannot differentiate colors

• Habituation:

  • Helps bby become familiar w/familliar faces/stimuli

• Object permanence: still not developed

Auditory:

• Can hear once amniotic fluid is removed

  • Recognizes mom voice; responds to sound

    • Calm when hearing her voice

    • They know mom’s voice due to being exposed to maternal voice in utero

  • Localization of sound is still underdeveloped

Olfactory:

• Can smell after clearance of fluid

• Recognize areolar glands & milk

Taste:

• Developed before birth

• Facial expressions change when responding to different flavors

Touch:

• Pain receptors developed before birth

APGAR:

Component	0 points	1 point	2 points
Appearance (color)	Blue or pale	Pink body with acrocyanosis	Completely pink
Pulse (HR)	Absent	Below 100/min	Above 100/min
Grimace (reflex)	No response	Grimace	Cry, cough, or sneeze
Activity (tone)	Limp	Some flexion	Flexed with recoil
Respiration	Absent	Slow, irregular, weak, or gasping	Vigorous crying

7-10 = reassuring

4-6: moderately abnormal

0-3: Resuscitation needed

Newborn VS:

RR: 30-60/min

• Count for FULL minute while bby resting

HR: 110-160/min

• PMI at 4/5 ICS slightly lateral to midclavicular line

Temp: 36.5-37.5C

• Axilllae as it is noninvasive

Newborn Measurements: Classifications, Weight, Length, Head, Chest:

Classifications:

• SGA

• AGA

• LGA

Weight:

• 3,500g (7.7 lb)

• Careful w/fall r/x when weighing them on the scale

Length:

• 59 cm (20 in)

• Supine → place hands on knees → extend legs → keep feet flexed → mark crib sheet at bottom of feet & head → remove bby & measure length

• Obtain 2 MEASUREMENTS; average it out after

Head circumference:

• 35 cm (14 in)

• Use tape → place above eyebrows & over ears → wrap and make it snug → 2 measurements then average it

• Head growth:

  • 3 months → 2cm/month

  • 1 year → 12cm total

Chest circumference:

• 2cm smaller < head

• Position tap under axillae (nipple line)

Gestational Age assessment:

During pregnancy:

• Naegele’s rule

• Uterine size measurement

• Ultrasonography

After birth, if GA is unknown:

• Dubowitze method:

  • 34 physical + neuro a/x; long time to complete

  • Hard to do w/premature or sick bby

• New Ballard score:

  • 12 physical + neuromuscular a/x

  • Quicker but may overestimate GA

Findings in Newborn Head-to-toe that require further a/x:

Head:

• Caput succedaneum: swelling of scalp’s soft tissue from PSI during labor & birth

  • May cross suture lines due to the swelling

    • Diffused swelling

  • Resolves by itself

• Cephalohematoma: blood collection between skull bone ←> periosteum

  • B.v. rupture during birth → more noticable after birth

    • Happens in one cranial bone & resolves after wks/months

      • Localized swelling

  • Breakdown of blood → Tbilli → jaundice s/s

• Craniosynostosis: 1+ sutures fuses earily → restricts expansion → abnormal skull shape & issues w/brain growth

Eyes:

• Subconjuctival hemorrhage: bleeding below conjuctiva

  • Due to psi during delivery; resovles w/out t/x

  • Red reflex: red/orange reflection from retina = GOOD

    • If white/absent → eye abnormality

Mouth:

• Cleft lip: fusion of upper lip causing an opening

• Cleft palate: opening of rooth of mouth → issues w/feeding & suction mechanisms bby uses to feed

• Tounge-tie: frenulum attaches too close to tip of tongue → issues w/tongue movement

  • Poor feeding, milk transfer, latching, nipple discomfort whilts feeding

Clavicle:

• Crepitus: crackling sensation when palpating → fractured bone fragements

  • Issues during delivery; shoulder dystocia

  • Decreased arm movement

Chest/Lungs:

• Diminished breath sounds on 1 side =

  • Diaphragmatic hernia: intestines move into chest → opening in diaphragm

  • Pneumothorax

  • Pleural effusion

Umbillical:

• 2 arteries + 1 vein

  • Issues may mean congenital abonrmalities (renal or CV related)

• Umbilical hernia: abd contents protrude through area near umbillicus

  • Noticeable when bby cries → resolves often by iteself

• Umbilical stump:

  • Omphalitis:

    • Red, swelling, drainage, foul odor

Hips:

• DDH:

  • Assymetric gluteal, thighs folds, unequal leg lengths, assymetric hyip abduction

  • Barlow maneuver: flex hips → adduct thigh → check if it can be displaced

    • “Push hips OUT”

  • Ortolani: Abduct hips → upward psi →check if it can be reducted back

    • “Bring hips IN”

  • Both not done routinely by nurse due to r/x of dislocating

Genitalea:

• Hypospaidas: urerthal opening in ventral surface

  • Avoid circumsision due to skin needed for repair

• Epispadias: urethral opening on dorsal surface

• Cryptorchidism: undescended tests

• Inguinal hernia

  • Abnormal bulge seen

• Ambiguous:

  • Undescended testes, small pp, bifid scrotum (divided into 2 portions)

Anus:

• Meconium should be expected to pass w/in 48 hrs PP

  • If not, =

    • Intestinal obstruction, anorectal malformation, Hischsprung

Extremities:

• Polydactyly

• Syndactyly: fusion

• Clubfoot

Spine:

• Simple sacral dimple = not concerning

  • Small sizes (<0.5cm), near coccyz

  • Visible, intact base

• Neural tube defect dimple if:

  • Deep, >0.5 cm, gluteal cleft located

  • W/sacral hair tuft

Skin:

• Acrocyanosis: Blue hands and feet

  • Common shortly after birth

• Jaundice: Yellow skin and sclera

  • Assess bilirubin; early onset is concerning

• Milia: Tiny white papules

  • Benign

• Slate gray nevus: Blue-gray patches

  • Benign; document

• Erythema toxicum: Red blotches with papules

  • Benign newborn rash

• Lanugo: Fine soft hair

  • Normal finding

• Vernix: White waxy coating

  • Protective

• Nevus simplex: Flat pink patch

  • Usually fades

• Nevus flammeus: Red-purple port-wine stain

  • Usually persists

• Café-au-lait spots: Light-brown patches

  • Multiple lesions may require evaluation

Common Newborn Procedures:

Heel stick: collects capillary blood for newbron screening, glucose testing

• COllected via lateral aspects to prevent injury in calcaneous

• Avoid test in site if bby has:

  • Injury, infection, abnormalitity, or swelling

• May lead to pain, infection or scarring

Urine Specimen collection: Done via urine collection bag

• Clean perineum → dry skin → collection bad w/ adhesive side → make sure adhesive is smooth & secure → collect → transfer to specimen cup

  • Male: ensure pp is inside

  • Female: ensure bag is over the labia

  • Diapeer may be placed

Immunizations + Meds:

• HBV:

  • If mother does not have it: w/in 24 hours for FIRST dose

  • If mother has it: w/in 12 hours + HBIG → complete vaccine series w/follow up

• RSV: leading cause of death in <6 months

  • Nersivimab: Monoclonal antibodies (passive immunity)

    • October-March → w/in first week

    • April-September → wait till start of RSV season

Male Circumsision: Benefits? Contraindications? Post-care?

Potential benefits: v r/x of:

• UTI, candidiasis, HIV, HPV, cancer

Contraindications:

• Micropenis, Hypospadias

• Bleeding disorders, v BG, anuria

• Bacterial infection

Post-care:

• Pain management; swaddling is a good pain non-pharm measure

• Petroleum jelly: prevents healing site from sticking to diaper

  • Apply w/every diaper change, use gauze pad to cover direct region

• Hygiene: soap + water; careful cleaning

• Plastic ring: placed when site heals → removed after 3-7 days

• MONITOR FOR BLEEDING OR INFECTIONSS

Universal Newborn Screening:

Blood tests:

• W/in 24-48 hrs PP; heel stick into special filter paper card

• Screens for:

  • PKU, CH, CAH, CF, Sickle cell, B-thalaessemia

Hearing Screen:

• Checks for possible hearing issues that may come from:

  • Meningitis, infections, trauma to CNS

  • ^ Tbilli, ototoxic meds, Premature, LBW, v APGAR score

  • 50% tho of newborns are idiopathic → everyone does this screen

• Types:

  • Otoacousic Emissions: small probe placed → cochlear hair cell movement recorded

  • Auditory Brainstem Response: electrodes placed on scalp → external stimuli → EEG record waves

CCHD:

• S/s:

  • Irritable, poor activity & feeding & weight gain, sweating, crying

  • Cyanosis, ^ HR, RR, WOB

  • PE, hepatomegaly, murmur, poor perfusion

• Pulse oximetry:

  • Done when bebe is AT least 1 day old

    • Screening before may ^ r/x of false + results

  • Right hand/foot

  • Positive results:

    • <90%

    • <95% both extremities

    • >3% difference between right hand & foot; separated by 1 hour

Safe vs Unsafe Sleep practices

- Safe:

• Sleeping on the back

• Own crib or bassinet

• Firm, flat mattress

• Fitted sheet

• Empty sleeping space

• Room sharing

• Appropriate swaddling before rolling

• Avoiding overheating

- Unsafe:

• Sleeping on the stomach

• Bed sharing

• Soft mattress

• Loose blankets

• Pillows and stuffed toys

• Sleeping alone in a separate room before 6 months as the routine recommendation

• Weighted swaddles

• Excessive clothing and indoor hats during sleep

SBS:

Vigorous shaking →

• Fussiness, Vomiting, AMS

• Complications:

  • Subdural hemorrhage, retinal hemorrhage

  • Rib fractures, long-bone fractures

• May lead to signifitcant neuro dmg or death

Parents r/x:

• Young parents without adequate support

• No prenatal care

• Limited childcare experience

• Behavioral health problems, including depression

• History of partner violence

• Low educational status

• Low socioeconomic status

Newborn Infection Control:

Hand hygiene:

• Before, after contact

• Before aspectic proceudre, after exposure to fluids

• After contact w/surrounding

Umbilical Cord Care:

• Proper way is to DRY cord:

  • Keep it clean, exposed to air, dry

  • Fold diaper BELOW stump, dont apply products (antispetics, dyes, ABX, petroleum jelly, ETOH)

• If contaminated → wash w/soap + sterile water → dry

• Avoid baths till it falls off (often 10-14 days PP)

Eyes Prophilaxis:

• Erythromycin → kills bacteria causing eye infectins

  • Prevents ophthalmia neonatorum, which can lead to:

    • Corneal ulceration, perforation, or blindness

  • Its okay if vision is slightly blrruy after

Infections Disaease Transmission:

• If bby exposed to mother’s HIV, HBV, HCV → Bathe as soon as possible after birth w/aseptic technique

  • Also use aseptic technique w/injections or heelstick procedures

Newborn abduction prevention:

• ID bands in arm + leg; another one for mother

  • 4th may be applied to other parent

  • Check for footprints too

• Electronic security systems or ID alarms

Newborn nutrition:

Daily req = 100 kcal/kg/day

• Breast milk:

  • WBC, antimicrobials, anti-inflammatories, IG properties

  • v r/x of:

    • Resp, ear infections, IBD, Diarrhea

    • Asthma, Obesity, T2DM. allergies

• Colostrum: first milk; thick consistency & yellow color

  • Provides immunity (IgA), gut microbiome, protein,

  • Promotes early feeding: eastablishes suck + swallow + breathe cycle

• Formula Feeding:

  • Digested more slowly than breastmilk → not need to be fed as frequently

  • Formula → 19-20 kcal/oz

  • Iron fortified to support growth

Initiation of breastfeeding:

• Skin-skin contact encouraged

• Feeding cues:

  • Early:

    • Rooting, opening/closing of mouth

    • Lip smacking, sucking of fingers

  • Crying is LATE STAGE CUE

• Feed 2-3 hrs ad-lib

Breastfeeding effectiveness:

• Positioning: One that is comforting for mother

• Effective Latch:

  • Check for sucking pattern, sounds

  • Nipple pain or lucks compressed, if they unlatch

    • Compressed = tongue involvement issues

• Satiety:

  • Relaxed hand, faical muscles

  • Content

Newborn Pain Management:

NIPS: Max score is

Assessment category	0 points	1 point	2 points
Facial expression	Relaxed	Grimace	—
Cry	No cry	Whimper	Vigorous cry
Breathing	Relaxed	Changed from baseline	—
Arms	Relaxed	Flexed/extended	—
Legs	Relaxed	Flexed/extended	—
Alertness	Sleeping/calm	Fussy/uncomfortable	—

0-1= no pain

2= mild pain

3-4= moderate pain

5-7= severe

Nonpharm measures:

• Feeding, nonnutritive suckling

• Swaddling; skin-skin

• Facilitated sucking: holding newborn in flexed contained position → lowers pain during painfu

Factors that can influence postpartum vital signs:

• Emotional excitement: The excitement and stress surrounding childbirth can temporarily influence vital signs.

• Diuresis: Increased urine production as the body eliminates excess pregnancy-related fluid.

• Lactogenesis: The process of initiating breast milk production.

Vital Signs: What changes should be expected postpartum?

• Expected vital signs:

  • Generally similar to those of any nonpregnant adult

  • Minor variations can occur due to:

    • Emotional excitement

    • Diuresis

    • Lactogenesis (breast milk production)

• Nursing considerations:

  • Monitor vital signs according to agency policy

  • Confirm and address unexpected findings

  • Correlate minor variations w/ other clinical findings before determining their significance

Neurological System: What changes occur postpartum?

- Nerve compression:

• Pregnancy-related nerve compression can occur due to edema and pressure from the fetus and uterus

• After birth → pressure decreases + diuresis eliminates excess fluids → nerve compression begins to resolve

- Postpartum neuropathy:

• Can occur following:

  • Prolonged 2nd stage of labor

  • Improper positioning of the legs during birth

- Headaches:

• Can occur during the first week postpartum

• Possible causes:

  • Postpartum preeclampsia

  • CSF leakage following epidural placement → spinal headache

- Clinical significance:

• A postpartum client reporting a headache requires evaluation for postpartum preeclampsia and a possible spinal headache

• Do not automatically attribute headaches to normal postpartum changes

Endocrine System: What hormonal changes occur postpartum?

Placental Hormones: Estrogen, Progesterone, and hCG

- Estrogen + Progesterone:

• Levels ↓ significantly after expulsion of placenta

• ↓ Estrogen + progesterone → signals anterior pituitary to produce prolactin → stimulates breast milk production

- hCG (Human Chorionic Gonadotropin):

• Placenta is expelled → hCG levels ↓ drastically

• Levels fall dramatically by the end of the first week postpartum

Pituitary Hormones: Prolactin and Oxytocin

- Prolactin:

• Progesterone ↓ after birth → prolactin + prolactin receptors ↑

• Stimulates milk secretion from the nipples (lactation)

• Levels ↑ with nipple stimulation:

  • Newborn suckling

  • Breast pumping

• If there is NO nipple stimulation postpartum → prolactin returns to nonpregnant levels within 2 weeks

- Oxytocin:

• Produced by posterior pituitary gland

• Breastfeeding → nipple stimulation → oxytocin ↑ → milk ejection reflex → milk released from mammary lobe alveoli

• Also promotes uterine contractions and involution

Thyroid: What happens to thyroid function postpartum?

- Normal thyroid recovery:

• Thyroid function returns to baseline by 3 months postpartum

- Postpartum thyroiditis:

• Occurs in approximately 5% of individuals who gave birth within the previous year

• Can present as:

  • Hypothyroidism followed by hyperthyroidism

  • Hyperthyroidism followed by hypothyroidism

• Usually resolves spontaneously within a few months

• May have no manifestations or only mild manifestations

- Hyperthyroid state:

• S&S:

  • Irritability

  • Fatigue

  • Heat intolerance

• Labs:

  • ↑ or high-normal T4 (thyroxine)

  • ↑ or high-normal T3 (triiodothyronine)

  • ↓ TSH (thyroid-stimulating hormone)

- Hypothyroid state:

• S&S:

  • Constipation

  • Dry skin

  • Fatigue

  • Cold intolerance

  • Paresthesia (tingling/numbness)

• Labs:

  • ↓ or low-normal T4

  • ↓ or low-normal T3

  • ↑ TSH

Pancreas/Liver: What happens to insulin and glucose postpartum? POSTAPARTUM HORMONES

- Insulin:

• Placenta expelled → insulin requirements ↓ + insulin levels ↓

• Insulin sensitivity returns to prepregnancy levels:

  • Usually within 2–3 days postpartum

  • May take up to 16 weeks in individuals who are obese

- Blood glucose:

• Can return to prepregnancy levels very quickly postpartum

• Clients w/ gestational diabetes mellitus (GDM) need postpartum glucose monitoring to determine whether medication or dietary adjustments are necessary

- GDM: Long-term risks + screening:

• History of GDM → 10× increased risk of developing type 2 diabetes compared w/ individuals without GDM

• ADA recommends:

  • 75-g oral glucose tolerance test (OGTT) at 4–12 weeks postpartum

  • Use nonpregnant diagnostic criteria

• Lifelong screening every 1–3 years, even if initial postpartum OGTT is normal

• Screening options:

  • Annual HbA1c

  • Annual fasting plasma glucose (FPG)

  • 75-g OGTT every 3 years

Postpartum Hormones: What are their roles and changes?

• Estrogen + Progesterone: Levels ↓ postpartum → stimulate anterior pituitary to produce prolactin

• hCG: Falls drastically following placental expulsion

• Prolactin: Stimulates milk secretion; ↑ w/ nipple stimulation

• Oxytocin: Stimulates milk ejection reflex

• Insulin: Requirements and levels ↓ postpartum; sensitivity returns toward prepregnancy levels

Cardiovascular System: What changes occur immediately postpartum?

- Cardiac output (CO):

• Immediately postpartum:

  • Contracting uterus → blood is pushed back into circulation → circulating blood volume ↑

  • Birth of newborn → pressure on inferior vena cava decreases → venous return/preload ↑

  • ↑ Preload → ↑ stroke volume + ↑ heart rate

  • Result → cardiac output ↑ by approximately 60–80%

• Recovery:

  • CO declines to prelabor levels within 1–2 hr postpartum

  • Returns to prepregnancy levels within a few weeks

- Cardiovascular disease (CVD) risk:

• Clients w/ adverse pregnancy outcomes have an increased lifetime risk of CVD

• AHA recommends cardiovascular screening at:

  • 6 weeks postpartum

  • 12 weeks postpartum

  • 6 months postpartum

  • 12 months postpartum

• Transition to primary care between 8–12 weeks postpartum

• Provide counseling + comprehensive cardiovascular risk assessment

• Promote lifestyle modifications through multidisciplinary care, including in-person and telehealth approaches

- Varicosities:

• Common locations during pregnancy:

  • Legs

  • Ankles

  • Vulva

• Usually resolve within 6 weeks postpartum

Hematological System: What changes occur postpartum?

- Blood volume:

• ↑ throughout pregnancy

• ↓ rapidly postpartum due to:

  • Blood loss during birth

  • Diuresis

  • Diaphoresis

  • Fluid shifting from extravascular → intravascular spaces

- Postpartum hemorrhage (PPH):

• ACOG definition:

  • Cumulative blood loss ≥1,000 mL

  • OR any amount of blood loss accompanied by manifestations of hypovolemia

  • Occurring within 24 hr following delivery

- Hemoglobin (Hgb) + Hematocrit (Hct):

• NOT accurate indicators of blood loss immediately postpartum

  • Why? Extracellular fluid shifts into vascular circulation → hemodilution

• First 24 hr:

  • Slight ↓ in Hgb + Hct

  • Gradually ↑ afterward

• Expected pregnancy reference ranges:

  • Hgb: 11–16 g/dL

  • Hct: 33–47%

• Return to prepregnancy levels within 4–6 months postpartum

- Clotting factors + Fibrinogen:

• Remain ↑ for weeks following birth

• ↑ clotting factors + fibrinogen → ↑ risk for thromboembolism

• Expected fibrinogen reference range: 200–400 mg/dL

- White blood cells (WBCs):

• Labor stress → WBC count can ↑ to approximately 25,000/mm³

• Returns to prepregnancy levels within 1 month postpartum

Pulmonary/Respiratory System: What changes occur postpartum?

- Pulmonary function:

• During pregnancy:

  • Enlarging uterus → pushes diaphragm upward → affects lung expansion

• After birth:

  • Uterus no longer pushes diaphragm upward → intra-abdominal pressure ↓

  • Pulmonary function returns to prepregnancy status shortly after birth

- Respiratory rate:

• Remains around 10–22 breaths/min

Gastrointestinal System: What changes occur postpartum?

- Common postpartum GI issues:

• Constipation

• Hemorrhoids

• Incontinence

Peristalsis + Constipation: Why does constipation occur postpartum?

- Peristalsis:

• Elevated progesterone levels during pregnancy can persist postpartum

• Progesterone affects GI smooth muscle → ↓ peristalsis → slower movement through digestive tract

- Constipation:

• Multiple contributing factors:

  • Changes in diet

  • Dehydration from fluid loss + inadequate fluid intake during labor

  • Opioids for pain management:

    • Inhibit gastric emptying + peristalsis

    • Delay medication absorption

    • Increase fluid absorption → harder stools

  • Pain from perineal tears, episiotomy, or C-section incision → client may avoid bowel movements due to discomfort

Hemorrhoids: What are the risk factors and how can discomfort be managed?

- Risk factors:

• Vaginal birth, especially assisted/instrumental birth

• Prolonged 2nd stage of labor

• Longer duration of active pushing

• Newborn weighing >4,000 g (8.8 lb)

• Birth after 40 weeks gestation

• Approximately 35% of pregnant individuals develop hemorrhoids

- Expected course:

• Usually resolve spontaneously within a few days to weeks postpartum

- Management:

• Avoid straining during bowel movements

• Stay hydrated

• Eat a fiber-rich diet

• Use wipes after bowel movements

• Use topical or OTC treatments as recommended by provider

Anal Incontinence: What is OASI and what increases the risk?

- Obstetric anal sphincter injury (OASI):

• Injury to the anal sphincter during childbirth → can cause anal incontinence

• Approximately 11% of clients who give birth vaginally experience OASI

- Risk factors:

• Assisted birth (forceps or vacuum)

• Episiotomy

• Higher newborn birth weight

• Labor induction or augmentation

• Epidural anesthesia

• Persistent occiput posterior position

Renal System: What changes occur postpartum?

Kidney Function

- GFR (glomerular filtration rate), renal blood flow + plasma creatinine:

• Return to prepregnancy levels by 6 weeks postpartum

- Proteinuria:

• Mild proteinuria can begin 1–2 days postpartum

• May persist for more than 6 weeks

Postpartum Diuresis: What causes increased urine output?

- Postpartum diuresis:

• Begins after birth and may continue throughout the first week

• Placenta delivered → estrogen ↓ → contributes to elimination of extracellular fluids

• ↓ aldosterone → ↓ sodium retention → ↑ urine output

• Urine output can reach 3,000 mL/day during the first few days postpartum

Bladder: Why is voiding difficult postpartum?

- Difficulty voiding:

• Labor + epidural anesthesia → ↓ sensation of needing to urinate

• Perineal pain + swelling → makes urination more difficult

• Encourage voiding every 3–4 hr

- Urinary retention:

• Can lead to:

  • Prolonged voiding dysfunction

  • Urinary tract infection (UTI)

• Approximately 5% of postpartum individuals experience long-term bladder damage

- Risk factors for urinary retention:

• Primigravida (first pregnancy)

• Prolonged labor

• Epidural anesthesia

• Catheterization during labor

• Newborn w/ macrosomia (excessively large birth weight)

• Forceps or vacuum-assisted birth

• Perineal or vaginal lacerations

• Previous voiding dysfunction

• Immobility

Bladder Distention: Why is frequent emptying important?

- Bladder changes:

• During the first 24 hr postpartum, the bladder can become:

  • Swollen

  • Hypotonic (reduced muscle tone)

• Labor + anesthesia → ↓ ability to sense bladder distention

- Clinical significance:

• Full bladder → interferes w/ uterine contraction → uterus cannot contract down effectively

• Poor uterine contraction → ↑ risk of postpartum hemorrhage (PPH)

• Encourage frequent bladder emptying during the immediate postpartum period

Urinary Incontinence: What is expected postpartum?

• Approximately 30% of postpartum individuals experience urinary incontinence

• Urge incontinence is particularly common

• Associated w/ stress of childbirth

• Management:

  • Pelvic floor physical therapy

  • Catheterization may be necessary in some cases of urinary retention

Reproductive System: What changes occur postpartum?

Uterine Involution: What is it and how does the uterus return to prepregnancy size?

- Involution:

• Process of the uterus shrinking back toward its prepregnancy size after birth

• Immediately after birth → uterus weighs approximately 1,000 g (2.2 lb)

• Within the first 6 weeks → uterus decreases to approximately 50 g (0.22 lb) or less

  • Usually slightly heavier than a nulliparous uterus

• Myometrial cell size decreases during involution

- Why is involution important?

• Uterine contractions → compress blood vessels where placenta was attached → prevent excessive bleeding

• Inadequate uterine contraction → ↑ risk of PPH

• Oxytocin promotes uterine contractions and involution

  • Released in response to placental separation/expulsion

  • Released with uterine contractions

  • Released during breastfeeding

Fundus: Where should it be located postpartum?

- Immediately postpartum:

• Fundus should be:

  • Firm

  • Nontender

  • Globular

  • Located between the symphysis pubis and umbilicus

- Around 12 hr postpartum:

• Fundus rises to at or below the umbilicus

- After 12 hr:

• Fundus descends approximately 1 cm/day

• By the end of the first week → returns to between the symphysis pubis and umbilicus

- By 2 weeks:

• Fundus should no longer be palpable

- By 6–8 weeks:

• Uterus returns to nonpregnant size

- Important assessment:

• A client 4 hr after birth should have a fundus between the umbilicus and symphysis pubis

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Lochia: What are the stages, colors, and timelines?

- Lochia:

• Vaginal discharge following birth

• Changes in color, appearance, and consistency as the uterus heals

• Can continue for up to 6 weeks postpartum

• Usually less lochia following C-section compared w/ vaginal birth

- Lochia rubra:

• Days 1–3/4

• Dark red

• May contain blood clots

- Lochia serosa:

• Days 4–10

• Pink to brown

• Less thick than rubra

- Lochia alba:

• Days 10–14

• White or yellow

Cervix: What changes occur after vaginal birth?

- Immediately postpartum:

• May be swollen

• Remains soft and dilated

- Healing:

• Heals within a few weeks postpartum

- External cervical os:

• Before vaginal birth/nulliparous → small, round opening

• After vaginal birth → larger transverse slit

• This change is permanent after vaginal birth

Ovaries: When does ovulation return postpartum?

- Immediately postpartum:

• Gonadotropins + sex steroids remain low during the first 2–3 weeks

- Nonlactating clients:

• Mean return to ovulation: 45–94 days postpartum

• Can occur as early as 25 days postpartum

- Breastfeeding + ovulation:

• Nipple stimulation from suckling or pumping → suppresses GnRH secretion → can suppress ovulation

• Adequate breastfeeding/pumping all or most of the time:

  • Approximately 40% of individuals will not ovulate during the first 6 months postpartum

  • This is called lactational amenorrhea

- Important contraception teaching:

• Return of ovulation varies widely between individuals

• Ovulation can occur BEFORE the first postpartum menstrual period

• Breastfeeding does NOT guarantee prevention of pregnancy

• Use additional contraception if pregnancy is not desired

Postpartum Contraception: What should the nurse teach?

- Combined hormonal contraceptives:

• Contraindicated during the first 21 days postpartum due to ↑ VTE risk

• Remain restricted for some women until 42 days postpartum

- Progestin-only methods + most IUDs:

• Can generally be initiated immediately postpartum, including in breastfeeding clients

• Few exceptions, such as active infection

- Long-acting reversible contraception (LARC):

• Immediate postpartum placement → significantly improves initiation rates

• However, postpartum IUD placement has a higher risk of expulsion

- Improving access:

• Prenatal counseling

• Hospital stocking of contraceptive devices

• System-level support

- DMPA-SC:

• CDC recommends making self-administered subcutaneous depot medroxyprogesterone acetate available as another approach to injectable contraception

Vagina: What changes occur postpartum?

- First few weeks:

• Vaginal epithelium appears atrophic under microscopic examination

• Vaginal walls appear smooth

- Rugae:

• In nonlactating clients → return within 3 weeks

- Vaginal tone:

• Does NOT return completely to prepregnancy state

Perineum + Pelvic Musculature: What changes occur after vaginal birth?

- Perineal trauma:

• Spontaneous tears or episiotomy can occur during vaginal birth

• Approximately 53–79% of vaginal births involve some degree of perineal trauma

• Third- and fourth-degree lacerations occur in approximately 5% of births

• Second-, third-, and fourth-degree tears will likely require stitches/repair

- Pelvic muscles:

• Pregnancy + vaginal birth → pelvic muscles relax and stretch

• Regain tone during the first 6 weeks postpartum

- Kegel exercises:

• Tightening/contracting the pelvic floor and perineal muscles

• Helps restore pelvic muscle tone and aid recovery

Breasts: What changes occur during lactation postpartum?

- Colostrum:

• Produced toward the end of pregnancy and during the first few days postpartum

• Early breast milk produced before mature milk

- Hyperlactation:

• Excessive milk production

• Possible causes:

  • Excess mammary glandular tissue growth

  • Underlying hormonal signaling

  • Overstimulation of breasts/nipples for milk removal

- Hypolactation:

• Insufficient milk production

• Possible causes:

  • Health conditions:

    • Diabetes

    • Polycystic ovarian syndrome (PCOS)

    • Thyroid disorders

  • Medications

  • Smoking

  • Previous breast surgery

  • Lack of milk-producing breast tissue

  • Newborn latch difficulties or weak sucking strength

  • Preterm birth

  • Insufficient breast emptying or nipple stimulation

- Prolactin + milk production:

• Within a few months postpartum → prolactin levels ↓

• Milk synthesis shifts from mostly hormonal control → local control at the breast

Musculoskeletal System: What changes occur postpartum?

Muscle Tone

- Abdominal muscles:

• Pregnancy → abdominal muscles stretch → ↓ muscle tone postpartum

• Some clients develop diastasis recti:

  • Separation of the rectus abdominal muscles

• Recovery:

  • Can take weeks to months

  • Depends on degree of muscle weakness + use of core-strengthening exercises

Joint Hypermobility

- Pregnancy-related joint changes begin returning to prepregnancy stability around 8 weeks postpartum

Integumentary System: What skin changes occur postpartum?

- Chloasma/Melasma:

• Hyperpigmentation that develops during pregnancy

• Occurs in approximately 15–50% of pregnant individuals

• Usually lightens or disappears within the first few months postpartum

- Areola hyperpigmentation:

• Areola becomes darker during pregnancy

• Gradually lightens postpartum

- Linea nigra:

• Dark vertical line on the abdomen caused by increased pregnancy hormones

• Fades as hormones return to prepregnancy levels

• May NEVER completely disappear

- Striae gravidarum (stretch marks):

• Develop due to excessive stretching of skin as abdomen grows

• May NOT disappear postpartum

• Usually become less prominent

- Hair loss:

• Around 3 months postpartum → increased scalp hair loss may occur

• Pregnancy:

  • ↑ ratio of growing hair to resting hair

• Postpartum:

  • Hormone levels return toward prepregnancy patterns → hair growth/loss cycle reverses → increased shedding

• Hair growth returns to prepregnancy thickness within 6–15 months

Breasts & Nipples: What Should Be Assessed? What Are the Types of Engorgement?

- Breast assessment:

• Inspect and palpate to determine if breasts are:

  • Soft

  • Filling

  • Firm

  • Engorged (full or hard)

• Usually assessed every 8 hr or per facility protocol

- Primary engorgement:

• Can occur during the first 72 hr PP

• Related to interstitial edema + breast milk coming in

- Secondary engorgement:

• Occurs when the newborn consumes less breast milk than the maternal client produces

Risk factors for impaired lactation / low milk supply: Assessment

• Complicated birth

• Hormonal dysregulation

• Overweight or obesity

• Separation from newborn

• Inability to express breast milk

• History of breast reduction surgery may increase risk for hypolactation

- Nipple assessment:

• Check for redness, pain, erectness, and cracks

• Observe breastfeeding and latch to identify problems and provide assistance

Breastfeeding Latch: What Does a Proper Latch Look Like? How Do You Help the Newborn Latch?

- Proper latch:

• Wide and deep latch, covering most of the areola, not just the nipple

• Newborn's lips should be around the nipple

• Most of the areola near the lower lip should be covered

• Top of the areola should remain visible above the newborn's upper lip

• No areola should be visible below the lower lip

• Chin should be buried in the breast

• Nose should remain free

• No pain should occur during latching

- Steps to help the newborn latch:

• Newborn's abdomen flat against the client's body

• Head and neck aligned (not turned to the side) → Promotes swallowing and decreases choking risk

• Encourage newborn to open mouth wide (like a large yawn)

• Place newborn's chin underneath the breast

• Wait for newborn to open mouth and latch

• Bring the newborn to the nipple

- If latch is painful:

• Insert client's finger into the corner of the newborn's mouth to gently break the seal

• Do not pull the newborn directly off the breast

• Relatch using the steps above

Breastfeeding Assessment: What Is the LATCH Scoring System? What If the Client Does Not Want to Breastfeed?

- LATCH scoring system: Standardized tool used to evaluate breastfeeding effectiveness

• L – Latch: Newborn's attachment to breast

• A – Audible swallowing: Ability to hear swallowing

• T – Type of nipple: Nipple characteristics

• C – Comfort: Mother's breast/nipple comfort

• H – Hold: Positioning and assistance needed

- Scoring:

• Each component = 0–2 points

• Total score = 0–10

• 0–3 → Poor breastfeeding effectiveness

• 4–7 → Moderate breastfeeding effectiveness

• 8–10 → Good breastfeeding effectiveness

• Lower scores → Need for additional lactation support or intervention

- If client does NOT wish to breastfeed:

• Reduce breast stimulation to decrease milk production

• Use cold compresses or cold cabbage leaves

• Wear a well-fitted shirt and supportive bra

• Avoid breast stimulation

Uterine Tone & Lochia: What Are the Expected Findings? What Indicates Postpartum Hemorrhage (PPH)? T/x?

- Uterine tone / fundal assessment:

• Critical for identifying excessive vaginal bleeding

• Assess fundus frequently during the first 24 hr PP, according to facility protocol

• Expected finding:

  • Firm, well-contracted fundus

  • At or below the maternal umbilicus

• If fundus is soft/boggy:

  • Perform fundal massage

  • Encourage client to empty bladder

• Full bladder can displace the uterus and prevent proper contraction → ↑ risk of PPH

- Lochia assessment:

• Document amount and characteristics of vaginal flow

• Assess frequently immediately PP or if acute blood loss is suspected

• Usually assessed every 8 hr afterward, per facility policy

• Document amount of flow on the perineal pad after 1 hr

- Lochia amount:

• Scant: Less than 2.5 cm on pad

• Light: Less than 10 cm on pad

• Moderate: 15 cm on pad

• Heavy: Pad saturated within 1 hr → Possible PPH

- Abnormal lochia findings:

• Foul-smelling lochia

• Unusually heavy flow

• Large clots

• Lochia rubra continuing beyond 4 days PP

• These findings require further investigation

- E-MOTIVE trial: Early PPH detection

• Uses calibrated blood-collection drapes to objectively measure blood loss every 15 min during the first hour PP

• PPH is triggered by:

  • Clinical concern at any time

  • Blood loss ≥300 mL but less than 500 mL + unexpected vital signs or clinical observations

  • Blood loss ≥500 mL

- MOTIVE treatment bundle: Components delivered concurrently or in rapid succession

• M – Massage: Uterine massage

• O – Oxytocic drugs: Oxytocin infusion

• T – Tranexamic acid

• I – Intravenous crystalloid fluids

• V/E – Examination: Genital tract examination + escalation of care as needed

Perineum & Episiotomy: What Should Be Assessed? What Is the REEDA Score?

- Perineal assessment:

• Assess immediately PP and throughout the facility stay, per policy

• Birth trauma can affect:

  • Vaginal wall

  • Urethra

  • Clitoris

  • Perineal muscles

  • External/internal anal sphincters

  • Anal canal

• Most clients who give birth vaginally experience some degree of perineal laceration

• Lacerations are classified as 1st–4th degree

• Assess for pain, swelling, and discharge

- Episiotomy:

• Current evidence does NOT recommend routine episiotomy

• If performed, assess incision healing using the REEDA score

- REEDA scoring system: Evaluates perineal healing

• R – Redness

• E – Edema

• E – Ecchymosis

• D – Discharge

• A – Approximation: How well the skin edges are together

• Total score: 0–15

• Higher score → More impaired healing

REEDA Specific score findings:

Score	Redness	Edema	Ecchymosis	Discharge	Approximation
0	None	None	None	None	None
1	Bilateral, within 0.25 cm of incision	Perineal only, less than 1 cm	Bilateral within 0.25 cm OR unilateral within 0.5 cm	Serous	Skin separation ≤3 mm
2	Bilateral, within 0.5 cm	Perineal and/or vulvar, 1–2 cm	Bilateral 0.25–1 cm OR unilateral 0.5–2 cm	Serosanguinous	Skin + subcutaneous fat separated
3	Bilateral, more than 0.5 cm beyond incision	Perineal and/or vulvar, more than 2 cm	Bilateral more than 1 cm OR 2 cm on one side	Sanguinous or purulent	Skin + subcutaneous fat + fascial layer separated

Rectal Area: What Should Be Assessed?

• Assess rectal area according to facility policy

• Hemorrhoids:

  • Assess for:

    • Pain

    • Bleeding

    • Pruritus (itching)

    • Burning

    • Swelling

  • Perform visual + physical examination

  • Use gloves and lubricant on fingers to make assessment more comfortable

• Assess for tears or injuries involving the anal sphincter area from vaginal birth

Urinary Elimination: What Are the Expected Findings? Why Is Voiding Important?

• Encourage urination as soon as possible after birth

• Assess:

  • Time of first void

  • Urine volume

  • Ability to void

  • Pain or burning

• Expected findings:

  • First void within 6 hr PP

  • Post-void residual (PVR) less than 150 mL

- Why is bladder emptying important?

• Full bladder → Displaces uterus

• Displaced uterus → Cannot contract effectively

• Poor uterine contraction → ↑ risk of PPH

• If fundus is deviated, ALWAYS encourage client to empty bladder

Abdomen: What Is Expected Postpartum? What Is Diastasis Recti?

- Expected findings:

• Abdominal protrusion and relaxation immediately PP

• Becomes less pronounced within 6 weeks PP

• Abdominal skin may be lax due to excessive stretching of elastic fibers

- Diastasis recti:

• Separation of the abdominal muscles

• Assess at least once during the postpartum period

• Have client lie supine and lift head

• A visible tent-like protrusion in the lower abdomen indicates diastasis recti

• Becomes less apparent later in the postpartum period

Lower Extremities: What Are the Signs of DVT?

- Assess for:

• Pain

• Weakness

• Sensory changes

• Tenderness

• Warmth

• Vein color changes

• Fever

• Swelling

- Deep vein thrombosis (DVT) manifestations:

• Calf pain

• Redness

• Tenderness

• Unexplained fever

• Swelling in one leg that is more than 2 cm greater in diameter than the other

- Assess according to facility policy and whenever the client reports these symptoms

Energy Level & Pain Management: What Should Be Assessed? What Are Common Types of Postpartum Pain?

- Energy level:

• Ask how the client is feeling during every nurse–client interaction

• Assess for fatigue and possible postpartum depression

- Afterpains:

• Uterine contractions experienced after birth

• More common with:

  • Overdistended uterus (multiple gestations or polyhydramnios)

  • History of dysmenorrhea (painful menstruation)

• Generally resolve by 1 week PP

- Other sources of pain:

• Perineal pain from vaginal birth, lacerations, or episiotomy

• Pain following cesarean birth

  • Pain control promotes recovery and mobility so the client can care for the newborn

  • Consider limiting opioid use

- Pain assessment:

• At least every 8 hr or per facility policy

• Assess location, intensity, and level each time

- Pain management options:

• Oral, topical, IV, and epidural medications

• Hot and cold therapy

• Movement

• Distraction

Parent–Newborn Interactions: What Is Rooming-In? What Are Its Benefits?

• Rooming-in: Newborn stays in the same room with the parent after birth

- Benefits for parents:

• ↑ Confidence in caring for newborn

• Better ability to recognize newborn cues:

  • Sleepiness

  • Stress

  • Hunger

• ↓ Likelihood of postpartum depression

• ↑ Successful breastfeeding initiation and continuation

• ↑ Opportunity for skin-to-skin contact

• Helps establish the family unit and encourages family involvement in newborn care

- Benefits for newborn:

• Improved sleep quality

• More stable body temperature

• Greater contentment and less crying

• ↓ Stress levels

• Greater exposure to normal bacteria on parent's/guardian's skin → May protect against pathogenic bacteria

- Newborn nursery:

• Some facilities offer a nursery, while others only offer rooming-in

• Nursery use can allow the client to rest and receive additional support

• May be especially helpful when the client has limited family/friend support in the hospital

• Nurses should support parents based on their needs and facility policies

• The goal is to allow the parent to rest while remaining involved in newborn care

Postpartum Pain Management: What Is the Stepwise Approach? What Should Be Considered?

• Pain experience and relief needs are individualized

• Assess:

  • Pain location

  • Pain intensity

• Stepwise approach:

  • Begin with nonopioid methods

  • Use multiple modalities together when appropriate:

    • Cold therapy

    • Topical treatments

    • Nonopioid medications

  • Use opioids only if necessary

• Assess for history of or current opioid addiction before offering opioids

  • Avoid worsening an existing addiction or interfering with recovery

Sitz Bath: What Is It? What Are Its Benefits? How Is It Used?

• Sitz bath: Shallow basin placed inside a toilet bowl that allows the client to sit in water to bathe the perineal tissues

• Benefits:

  • Relieves pain and inflammation

  • Promotes healing of perineal tissues

  • Helps manage hemorrhoids after childbirth

- Water temperature:

• Cool water → Reduces inflammation and perineal discomfort

• Warm water → Promotes circulation, relieves pain, and relaxes perineal muscles

• Required temperature: 34–37°C (94–98°F), according to facility policy

• ALWAYS measure water temperature

- How it works:

• Kit includes a water bag + tubing

• Basin is placed along the rim of the toilet bowl

• Water flows through tubing into the basin

• Water circulates around perineal tissues and drains into the toilet

Postpartum Pain Medications: What Are the Main Medications? What Are the Breastfeeding Considerations?

- Nonopioid medications:

• Acetaminophen → Mild to moderate general pain + fever

• Ibuprofen → Mild to moderate pain + inflammation

• Preferred before opioids when appropriate

- Opioids:

• Used sparingly for moderate to severe pain

• May be needed after:

  • Forceps or vacuum-assisted vaginal birth

  • Perineal repairs

  • Cesarean birth

- Breastfeeding considerations:

• Check medication safety during breastfeeding (e.g., LactMed)

  • Anesthetic and analgesic medications generally transfer into breast milk in very low, clinically insignificant amounts

    • Opioids may transfer in higher amounts → Reduce opioid requirements whenever possible

• Use multimodal pain management to limit opioid use

  • Avoid codeine and tramadol

• Clients should NOT avoid necessary pain medication

• If using opioids:

  • Monitor newborn for sedation

  • Risk is especially important if newborn is at high risk for apnea

• Breastfeeding can resume as soon as desired after surgery

  • No need to "pump and dump"

  • Regional anesthesia is preferred for cesarean birth to minimize postoperative opioid requirements

Topical Treatments: How Are Cold Therapy & Topical Anesthetics Used?

- Cold therapy:

• Ice packs or frozen perineal pads

• Apply to perineum for 10–20 min at a time

• Helps relieve pain and reduce swelling

• Ice or chemical cold packs are recommended as first-line postpartum pain treatment due to their simplicity

- Topical treatments:

• First gently clean perineum using:

  • Peri-bottle with warm water

  • Sitz bath

• Then apply topical treatments as appropriate:

  • Medicated cooling pads for hemorrhoids or perineal pain

  • Topical anesthetics to numb perineal tissues

- Dermoplast:

• Combination of benzocaine, menthol, acetylated lanolin, and aloe vera gel

• Helps numb the postpartum perineum and reduce pain

Strengthening Muscles: How Can Diastasis Recti & Pelvic Floor Weakness Be Managed?

- Diastasis recti:

• Separation of abdominal muscles

• Can be treated with physical therapy if it does NOT resolve by 8 weeks PP

- Pelvic floor muscle exercises:

• Help rebuild strength in weakened pelvic floor muscles

• Involve:

  • Short squeezes

  • Long squeezes

• Benefits:

  • Restore pelvic floor strength

  • Prevent or improve urinary incontinence

Postpartum Immunizations: What Should Be Considered Before Administration?

• Clients may have different comfort levels with immunizations due to:

  • Personal experiences

  • Beliefs

  • Cultural background

• Discuss risks and benefits before administering vaccines

13. Rubella (MMR): When Should It Be Given? Why Is It Contraindicated During Pregnancy?

• MMR vaccine: Protects against measles, mumps, and rubella

• During pregnancy:

  • CONTRAINDICATED because it is a live vaccine → Potential risk to fetus

- Postpartum administration:

• Give as soon as possible if client:

  • Has NOT been immunized against rubella

  • Was immunized but does NOT show immunity on titers

• Must be administered at least 28 days before the next pregnancy

- Purpose:

• Prevents rubella infection

• Prevents congenital rubella syndrome in future pregnancies

Varicella Vaccine: When Should It Be Given? What Is the Schedule?

During pregnancy:

• CONTRAINDICATED because it is a live vaccine → Potential risk to fetus

- Postpartum administration:

• If client has NO immunity to varicella:

  • Give 1st dose after birth and before discharge

  • Give 2nd dose 4–8 weeks later

  • 2nd dose can be given at postpartum visit

- Lack of immunity:

• No previous immunization

• No history of having varicella (chickenpox)

Tdap: When Should It Be Given? Why Is It Important for the Newborn?

• Tdap: Tetanus–diphtheria–acellular pertussis vaccine

• Why it matters:

  • Pertussis morbidity and mortality occur most frequently in newborns under 3 months old

  • Newborns do NOT receive their first Tdap immunization until 2 months of age

- During pregnancy:

• Administer during EACH pregnancy

• Ideally between 27–36 weeks' gestation

• Maximizes transfer of protective antibodies to newborn during their most vulnerable period

- Benefits of maternal Tdap:

• Protects maternal client from pertussis

• Transfers protective antibodies to newborn

• Reduces transmission to newborn

• May prevent infant hospitalizations and deaths

- If NOT given during pregnancy:

• Administer immediately PP

- Close contacts:

• People who will have close contact with newborn should also receive Tdap if they have not already

Rh Immune Globulin: Who Needs It? When Is It Given? Why?

- Who needs it?

• Pregnant clients with Rh-negative blood type

- When is it given?

• At 28 weeks' gestation

• Again within 72 hr after birth IF newborn is Rh-positive

• Must be given during EVERY pregnancy and after each birth of an Rh-positive infant

- Purpose:

• Prevents the Rh-negative maternal client from forming antibodies against Rh-positive blood

• Prevents antibody formation that could harm future Rh-positive fetuses

- Additional administration:

• An earlier dose may be given if maternal Rh-negative blood is suspected to have mixed with fetal blood