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What is the postpartum period
6 week time frame between birth of the baby and return of the organs to pre-pregnancy state
Immediate = first 24 h
Early = first week
Late= 2-6 week
Involution
process of the uterus returning to a pre pregnant state
begins after expulsion of placenta
uterus reduces in size and weight rapidly
caused by sudden decrease in estrogen and progesterone
What factors SLOW involution
prolonged labor
incomplete expulsion of placenta
anesthesia
previous labors
full bladder
What can INCREASE involution
uncomplicated birth
early ambulation
breastfeeing
What method is used to asses uterine involution
Fundal height measurement
descent of uterus usually 1 cm per day
Before preforming fundal massage, what do you instruct the women to do?
Empty her bladder
How to preform fundal massage
cup one hand above the symphisis pubis to support the lower uterine segment
With the other hand palpate the top of fundus, if not firm, lightly massage
indicated if the uterus is boggy, causing increased bleeding
Sub-involution
failure of the uterus to go back to pre pregnancy state
usually caused by retained placental fragments
Afterpains
uterine contractions occurring first 2-3 days post birth
caused by hormone oxytocin to contract uterus and stop bleeding
breastfeeding can cause worsening afterpains due to the increase of oxytocin during this time
NSAIDS are most effective
Lochia
postpartum vaginal discharge
contains blood from placental site, uterine tissue, mucus
fleshy odor
Different types of lochia
Lochia rubia = bright red (1-3 days postpartum)
Lochia serosa= pink to brown (4-10 days)
Lochia Alba = yellowish (10 days to 6 weeks)
Assessment of lochia/bleeding
fundus firmness (not firm = excessive bleeding possible)
weighing pads (1mL of blood = 1 gram)
Lochia increases briefly during ambulation (normal)
excessive bleeding can indicate retained placenta, sub involution or infection
REEDA scale
Assessment of episiotomy site
Redness
edema
eccymosis (bruising)
discharge
approximation
Nursing care for pain of perineum
cold sitz baths
warm and cold application
pads with witch hazel
medications
During the first few days what hormone regarding muscles decreases?
Relaxin
ligaments and cartridge of the pelvis begin to return to pre pregnancy state
What should the nurse do to asses for a beginning DVT?
passive dorsiflexion of women's feet that causes pain is a POSITIVE HOMANS sign.
May be an early sign of venus thrombosis.
Also watch for redness, swelling and warmth of calf
How much blood loss is normal during birth?
Vaginal = 200-500 mL
C-section 1,000 mL
more than that is considered a hemorrhage
How is fluid built up during pregnancy eliminated?
increased urinary output (may be as much as 3000ml/day)
heavy sweating (diaphoresis)
Labs that change after birth
temporary rise in Hct and Hgb (returns to normal in 2-4 wks)
lekocytosis (incresed WBC) (returns to normal in 10 days
GFR increased (returns to normal in 8 weeks or less)
Mild protienuria as a result of uterine cell breakdown
fibrinogen remains high (returns to normal within 2 weeks)
Changes to VS after birth
temp may be 100.4 or above during first 24 hours, but if it remains high could indiate infection
Bradycardia for first 6-8 days postpartum
B/P should be the SAME
Factors that cause urinary retention post partum
tissue around the bladder is traumatized
anesthetic drugs
Bladder had reduced ability to contract
Decreased sensation of needing to void
WATCH FOR URINARY RETENTION
Complications of urinary retention postpartum
bladder distends, pushing the uterus to the side which causes uterus to not be able to contract
inability of the uterus to contract can lead to excessive bleeding
MAKE SURE TO MONITOR URINARY OUTPUT to prevent
urinate q2-3 hours to prevent
Hormone changes post birth
estrogen and progesterone drop right after birth
if NOT breastfeeding, estrogen returns in 3 weeks which leads to return of the period in about 3 months
ovulation returns in 1 month
Prolactin increases in women who are breastfeeding to stimulate milk
oxytocin triggers the release of milk (also contractions which is why some feel afterpains while breastfeeding)
How is weight lost after pregnancy
loses 10-13 lbs right away from baby and placenta
lochia
increased urination and perspiration
involution
fat stored for feeding is gradually used up as the women breastfeeds
normal weight is back by 6mo
What are some major causes of hemorrhage postpartum
Early Postpartum Hemorrhage:
uterine lacerations
uterine atony (lack of proper contraction of uterus)
Late Postpartum Hemorrhage:
retained placental fragments (causes inability for uterus to contract all the way)
decreased involution
Methods to relive discomfort from breast engorgement
supportive bra worn for 72 hours
ice packs
analgesics (ibuprofen, Tylenol)
Engorgement usually occurs 3-5 days postpartum
phases of postpartum adaption
Phase 1: Taking in: mother is willing to let others do things for her, hold the baby, ect. Focus is on recovery
Phase 2: Taking hold: Mother becomes interested in caring for infants, increased concern. BEST TIME FOR TEACHING
Phase 3: Letting go: giving up previous lifestyle, accepting the real child (not the ideal)
Postpartum check acronym
B: breasts and nipples (engorgement, lactation, redness)
U: Uterus (fundal height, location, firmness)
B: Bladder (intake/output frequency, pain)
B: Bowel (BM?)
L: Lochia (amount, color, odor, clots?)
E: Episiotomy (REEDA scale)
-
H: Homans Sign (passive dorsiflextion of foot causing pain)
E: Emotional status
Is postpartum chill (shaking) normal/common after birth
yes, as long as it is not accompanied by a fever
Cold vs heat on perinium
Cold: for first 24 hours
Heat: after 24h
Nursing management for application of pain creams to perinial area
apply after a sitz bath
wait 1-2 minutes before putting on pad
Sexual intercourse after birth
safe after discharge turns white
episiotimy is healed (about 3 weeks after birth)
use contraceptives!! Breastfeeding is not effective
oral contraceptives begin 2-3 weeks after birth for non-lactating, and as soon as lactation is well established in lactating women
Identifying amount of fluid on perineal pad
Scant= 2 inch stain (10 mL)
Small = 4 inch stain (10-25 mL)
Moderate = 6 inch stain (25-50 mL)
Large = >6 inch stain (50-80 mL)
Postpartum hemorrhage
Blood loss more than 500 mL for a vaginal birth and 1000 mL for c section
greatest risk in the first 24h
can be caused by: uterine atony, laceration in early, later hemorrhage may be caused by retained placental fragments or sub-involution
When is peri pad changed
after BM
after voiding
if soiled
Physical s/s of hemmorage
cold, clammy skin
increased HR and RR
Pale skin
dizziness
Uterine atony
inability of the myometrium to contract
vessels cannot heal
occurs in first hours after birth
Hematoma
caused by trauma
bulging mass
may form in upper portion of vagina, leading to massive hemorrhage
S/S = perineal pain (not usually bleeding), edema, uterus may be firm, decreased B/P, inability to void, urge to defecate
Normal height of fundus post birth
after birth, fundus is 2 cm below umbilicus
decreases 1 fingerbreadth below the umbilicus
after 2 weeks, fundus cannot be seen or felt
A fundus that is higher than normal after birth may be because of sub involution
Anahpylactic syndrome of pregnancy (amniotic fluid embolism)
entrance of amniotic fluid into maternal circulation
triggers release of cells that cause pulmonary artery hypoxia
hypoxia of pulmonary artery causes heart muscle damage and can lead to L sided heart failure
Mastitis
Infection of the breasts
usually cased by entrance of bacteria into from cracks in nipples
can be caused by blocked duct/stasis of milk, nipple trauma, poor breastfeeding, inadequate hand-washing in between peri care and breast care
S/S = painful reddened area, enlarged glands, fever, chills, malaise
Treated by antibiotics, ice, warm packs, supportive bra
Diastasis Recti
Separated abdominal muscles
strengthening exsersize to fix
Colostrum
yellowish fluid secreted by breasts
nutrient rich
stimulated peristalsis in baby
normal
Are bowels sluggish after birth?
Yes! Constipation common
Risk factors for postpartum hemorrhage
oxytocin labor induction/augmentation
multiple fetuses (twins)
preeclampsia
operative delivery
chorioamnionitis (infected amniotic fluid)
hx of past uterine surgery or past hemorrhage
prolonged or difficult labor
placenta previa
aburuptio placente
large baby
episiotomy
traumatic delivery, use of forceps or vacuum
thrombocytopenia (low platelets)
fetal demise
Thrombocytopenia S/S
nosebleeds
ecchymosis
petechiae on lower extremities
bleeding from gums
Postpartum (puerperal) infection
Endometritis most common
higher risk for:
c section births
Foley caths
episiotiomy
frequent vaginal exams
retained placenta
chorioamnionitis (infected amniotic fluid)
traumatic birth
Normal vital signs for the newborn
RR: 30-60/min
periods of apnea not greater than 15 seconds = normal
HR: 110-160
auscultate all heart sounds (APTM) to look for murmurs
B/P: 60-80/40-50
Weight: 5.5-8.8
Length: 18-22 inches
Newborn temperature
Only take auxiliary temp
approx. same temp of mother at birth, may drop 1- 2 degrees but should return to normal in 8 hrs
HIGH RISK for hyPOthermia
cold stress causes oxygen demands increase and acidosis can occur
Non-shivering thermogenesis
Because newborns cannot shiver to increase body heat, they use non-shivering themogenisis
uses the metabolism of brown adipose tissue (brown fat)
Brown fat metabolizes and creates warmth
If Infant is exposed to lots of cold stress, brown fat stores are depleted causing impaired thermoregulation
drugs such as meperidine (demorol) given during labor can mess with brown fat
Where is brown fat found and when does it go away?
found on
neck
axille
around kidneys
adrenals
sternum
along abdominal aorta
Dissapears after three months
Cold stress potential consequences
Hypoglycemia (CBG less than 40)
Acidosis
reopening of fetal circulation
Skin asessment of the infant
Acrocyanosis (bluish hands and feet) normal for first 6-12 hrs post birth
Pallor/dusky, cyanosis
decreased O2, CNS depression, anemia
Harlequin sign
half of body is pale, other half is red
Jaundice
Physiologic Jaundice
benign
r/t breakdown of RBC and liver immaturity
increase in bilirubin
usually shows up after 3rd day of life
Pathological Jaundice
within the first 24 hours
bilirubin more than 12
r/t RH or ABO incompatibility
shows up BEFORE 3rd day of life
Hydrocephalus
excessive cerebral fluid within brain cavity surrounding brain
Fontanel abnormabolities
bulging when baby is not crying = increased ICP
depressed fontanel = dehydration
third fontanel can = down syndrome
Phenalkeytoneuria (PKU)
Newborn cannot metabolize phenylalanine which is in protein, including breast milk
levels accumulate in blood
causes mental problems
Gutherine test to determine
goal to maintain levels between 2-10
Ear/eye height
Top of ear should be level with other canthus of eye
low set ears can indicate chromosomal abnormalities
Newborn tremors
newborn tremors are common
asses to ensure they are not seizures
What indicates hip dysplasia
Asymmetric creases on thighs + limited hip abduction
Newborn reflexes
Rooting = searching for nipple
Gag: on stimulation of uvula
Blinking: stimulate with flashlight
Moro’s: allowing head and trunk of newborn to fall
Tonic neck: head turns to one side quickly, arm and leg extend on that side (fencing posture )
Crawl: placed on abd will make crawling motions
Dance/step: stimulates walking (while holding up) dissapears and three weeks
Newborn car safety
rear facing seat until 2
safety seat reclines 45 degrees to maintain airway
How should newborns be placed after feeding
on thier right side to prevent aspiration
Should you wait to bathe an infant after feeding?
Yes, risk of regurgitation due to increased handling
Preventing SIDS
firm crib mattress
placed on back during sleep!
Nutrition during breastfeeding
500 more calories than non pregnant diet
Protein 65mg/day
8-10 glasses of non caffeinated liquid per day
some foods the mother eats may cause infant gas
Stages of milk production
Colostrum = first 3-4 days postpartum
easier to digest
antibodies
Transitional Milk
between mature and colostrum
5 days to two weeks
Mature milk
looks like skim milk can be bluish
How long on each breast for feeding
15-20 min
what position should the newborn be in during feeding
chest to chest (babies chest facing mothers chest)
turning the infants head may interfere with swallowing
Hand position during breastfeeding
Hand in a C position
supporting breast from below
thumb above the nipple below the areola
Storing breast milk
store in glass or hard plastic
do not keep at room temp for over 4 hours
DO NOT use plastic with numbers 3,6 or 7 on the bottom
can stay in fridge for 5 days
fridge freezer for 2 weeks
deep freezer for 12 months
Preterm/premature infant
Born before 38 weeks, regardless of weight
late preterm is between 34-36 weeks
Term infant
Born between 38-42 weeks, regardless of weight
Low birth weight
Newborn who weighs less than 5.5 lbs or 2500g
Small for gestational age
Below the 10th percentile for weight
prone to hypoglycemia r/t glucagon stores being depleted
calorie needs are high
Large for gestational age
Above the 90th percentile for weight
more than 8.8 lbs
Postterm
Born after 42 weeks
What can cause fetal growth restriction (leading to SGA)
small parents
reduced blood flow to uterus (DM,hypertension, kidney disease)
smoking + substance abuse
malnutrition of mother
placental abnormalities
multi fetal pregnancy
Size of newborn if mother has DM
In women with DM who do not have vascular changes
high glucose levels cross into placenta, leading to large for gestational age newborn
Complication of post-term newborns
hypoxia due to placenta not giving adequate oxygenation anymore due to it being old
When is the newborns resp system fully developed?
After 35 weeks
Nutrition intake is considered sufficient when the preterm newborn gains ___ per day
20-30 grams per day
kangaroo care
Skin to skin contact
Retinopothy of prematurity is caused by
Oxygen toxicity
Most premature infants catch up by__
24 months (2 years) of age
Physical characteristics of preterm newborn
wrinkled skin
lanugo covered skin
weak cry
poor muscle tone
Physical characteristics of post-term newborn
thin with loose skin
cracked and dry skin, leathery appearance
long fingernails
little lanugo
Blanch test for jaundice
Apply pressure on skin over a bony area (nose, forehead, sternum)
yellow tinge in the blanched area indicated jaundice
S/S of hypoglycemia in newborn
lethargy
jitteriness
poor feeding
tachapnea
apnea
sweating
shrill cry
low temperature
Spina Bifida
Imperfect closure of spinal vertibre
small opening on spine, may have protrusions
Needs surgical correction
protect membrane w/ sterile moist dressing to prevent drying
Infants of DM mothers have
High glucose in the fetus during pregnancy
high maternal glucose is cut off when cord is clamped
prone to hypoglycemia
Respiratory distress syndrome
Caused by surfactent (keeps alveoli from collapsing and helps gas exchange) deficiency leading to poor gas exchange
respiratory acidosis can occur
S/S of dehydration in the infant
urine output of less than 1mL/kg/hr
weight loss
dry MM
no skin turgor
sunken fontanells
Nursing care for the infant receiving photo-therapy
keep eyes and genitalia covered
keep baby naked
do not apply lotions or creams before
remove from photo-therapy q4h and remove mask to check for injury
Reposition q2h
check aux temp q4h
is bronze discoloration and maculopapular skin rash during photo-therapy normal?
Yes, this is normal
Do however watch for sunken fontanells indicating dehydration
Note 
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