Postpartum and Neonatal Care: Labor, Complications, and Newborn Assessment

Fourth Stage of Labor

Begins with the delivery of the placenta and lasts 1-2 hours after placenta delivery.

Recovery

Also known as the Fourth Stage of Labor.

Hypovolemic Shock

A condition to monitor for during the recovery phase.

PP Hemorrhage

A condition to monitor for during the recovery phase.

Infection Prevention

A key focus during the recovery phase.

Involution of uterus

Decreases size of uterus and returns to normal condition/position.

Time for uterus to return to non-pregnant state

Takes 5-6 weeks.

Fundal rubs

Performed to avoid uterine atony.

Oxytocin

Hormone responsible for uterus involution and let down of breast milk.

Fundal Assessments

After delivery, fundus is at umbilicus and grapefruit size.

Expected findings for fundal assessments

At or below umbilicus, FIRM, Midline.

Deviation in fundal assessments

Can mean Full Bladder or Clot.

Fundal Massages

Support Lower Uterine Segment with non-dominant hand and find fundus with dominant hand.

Lochia

Assessed for quantity, type, and characteristics.

Lochia Rubra

Lasts 3-4 days, bright red bloody discharge, like a heavy period.

Lochia Serosa

Lasts 4-10 days, brownish pink discharge, may seem more stringy.

Lochia Alba

Lasts 10-28 days, white or yellow discharge, no blood or clots.

Lochia Assessment - Amount

1 Pad/hr = normal.

Terminology for Lochia

Scant - Less than 1 inch, Light - Less than 4 inches, Moderate - Less than 6 inches, Heavy - Saturated pad, Excessive - Saturated pad in 15 min.

Afterpains

Painful, intermittent uterine contractions, increase in pain during breastfeeding and with a full bladder.

Cervix Changes Postpartum

Regains muscle tone, some edema persists for a few weeks.

Vagina Changes Postpartum

Returns to normal state 3-4 weeks postpartum.

Perineum Changes Postpartum

Without episiotomy regains muscle tone in 2-3 weeks, episiotomy heals in 5-6 weeks.

Breast Hygiene

Want to keep them dry, lanolin for cracked nipples.

Perineal Care

Front to back cleaning, can use Peri-bottle instead of wiping.

Sitz baths

Used to be a staple in every postpartum room, allows for swirling water to soothe the perineum area.

Disposable Sitz baths

Used for hygiene and comfort during postpartum recovery.

Lactation

Production of milk influenced by estrogen and progesterone.

Colostrum

Yellowish fluid rich in protective antibodies; the infant's first breastmilk.

Transitional Milk

Produced by Oxytocin and stimulated by the infant's sucking.

Supply and Demand

The principle that lactation is based on the infant's needs.

Ovulation Return

Returns in 12-18 weeks postpartum.

Menstrual Cycle for Non-nursing Mothers

Resumes between 4-12 weeks postpartum.

Menstrual Cycle for Lactating Mothers

Resumes between 6 weeks and 10 months postpartum.

Estimated Blood Loss (EBL) Vaginal Delivery

200-500 mL.

Estimated Blood Loss (EBL) C-Section

700-1000 mL.

Postpartum H&H

May detect anemia; H&H may fluctuate.

Chills

A nervous response or vasomotor changes in the body; considered normal.

Diuresis in Early Postpartum

HUGE fluid shift; can pee 3L/day.

Full Bladder

Can lead to a boggy uterus and bleeding.

Urinary System Return to Normal

Returns to normal within 6 weeks postpartum.

GI Activity Post-Delivery

Returns shortly after delivery; vaginal delivery can eat whatever once stable.

C-Section Dietary Restrictions

Must wait 6-8 hours post-op to eat; start on clear liquids first.

Bowel Movement Post-Delivery

Bowels move 2-3 days after delivery; first stool can be scary for mom.

Weight Loss Postpartum

Weight loss of 12-13 pounds with an additional 5 pounds lost through diuresis between the 2nd and 5th PP day.

Rh Sensitivity

When do we give RhoGAM?

Rubella Complications

Very serious complications to the infant if the mother contracts rubella while pregnant, including deafness, cataracts, heart defects, and low birth weight.

MMR Vaccine Timing

Mother cannot get MMR while pregnant; must wait until after delivery.

Emotional Changes Postpartum

Includes taking in, taking hold, letting go, and postpartum depression.

Taking In Phase

1-2 days after delivery; reflects on what happened and involves discussing the birth story.

Cathartic

This is cathartic for her

Dependent on healthcare provider

Dependent on healthcare provider/support persons for daily tasks and decision making

Emotional Changes - Taking Hold

2-4 days after delivery; Starts to initiate own actions; Starts to focus on newborn rather than herself; Positive reinforcement; Allow her to be deliberate with her decisions

Emotional Changes - Letting Go

Accepting her new role and giving up her old role; Postpartum Depression may set in; Readjustment of relationships need to take place

Airway management

Removal of secretions with bulb syringe; Suction mouth then nose; Depress the bulb syringe while it is not in the baby; Keeping it depressed, place it in the baby's mouth or nose and let go

Breathing initiation

Begins within seconds or resuscitation measures may need to begin; APGAR Score evaluated at 1 and 5 minutes; Unless resuscitation is going on - then more frequently; 8/10 = good condition

APGAR Score

APGAR guides resuscitation measures - does not predict how the child will do in the future

Blood Coagulation

Vitamin K (AquaMEPHYTON) IM injection - Vastis Lateralis; Help promotes blood clotting and prevent hemorrhage in newborn; Gut makes Vitamin K; Infant's gut is sterile at birth...therefore, no Vitamin K; Cannot synthesize Vitamin K; Cannot form Factors VII, IX, and X (eek)

Hypoglycemia

Common in newborns; High risk population of newborns: GDM moms, Small for gestational age (SGA), Large for gestational age (LGA), 36 weeks or younger

Cold Stress

Keep newborn warm; Increases rate at which glucose is metabolized

Hypoglycemia treatment

Breastfeed; Formula supplementation; Oral Glucose Gel

Meconium Aspiration

May occur with first breath; Respiratory difficulty: Tachypnea, Retractions, Grunting, Cyanosis

Preventing Infection

Hand washing! Identification - facility specific; Band on baby and band on mom/support person

Gestational Age Assessment

Assessment of various reflexes/characteristics of infant to estimate gestation age.

Newborn Screening

Screening tests required by all 50 States for inborn errors in newborns.

Phenylketonuria (PKU)

Inborn error of metabolism of amino acids due to missing enzyme to break down phenylalanine.

Untreated PKU

Can lead to irreversible brain damage, intellectual disability, seizures/tremors, and behavioral problems.

Diagnosis of PKU

Guthrie Blood Test required by all states before discharge home (2-3 days after delivery) and repeated in 4-6 weeks.

Treatment of PKU

Dietary management including no artificial sweeteners and evaluation of phenylalanine levels.

Sickle Cell Anemia

Affects red blood cells which are shaped like a sickle, causing damage to vessels and insufficient oxygen transport.

Maple Syrup Urine Disease

Amino acid metabolism issue where urine, sweat, or earwax smells like maple syrup, leading to poor feeding and developmental delays.

Congenital Hypothyroidism

Inherited disease that can cause extreme developmental delays if not caught early, requiring treatment with Synthroid.

Breastfeeding

A mother's choice that should be supported with education on benefits without making her feel inferior for choosing formula.

Engorgement

Occurs 3-4 days after delivery when milk comes into the breast, causing distension and taut/shiny skin.

Engorgement Relief

Apply cold between feedings and warm compresses before feeding to relieve pain and assist with let-down reflex.

Burping

Removes swallowed air from the stomach; most breastfed babies do not need burping due to little air intake.

Postpartum Hemorrhage

Leading cause of maternal mortality, accounting for 25% of all maternal deaths from hemorrhagic complications.

Normal Blood Loss - Vaginal Delivery

500mL of blood loss is considered normal.

Normal Blood Loss - C-Section

1000mL of blood loss is considered normal.

Early Postpartum Hemorrhage

Occurs within the first 24 hours, with an incidence of one in 200 births.

Late Postpartum Hemorrhage

Occurs between day 2 and 6 weeks, with an incidence of one in 1,000 births.

Uterine Atony

Most common cause of postpartum hemorrhage.

Breastfeeding Challenges

Breastfeeding is not easy and requires support and education.

Breastfeeding Engorgement Duration

25% of mothers may experience engorgement lasting longer than 3-4 days.

Seizures in PKU

Approximately 1/3 of individuals with PKU will experience seizures.

Lacerations

Retained placental fragments leads to uterine atony.

Cervical Tear

Excessive bleeding and ROCK hard uterus.

Boggy uterus

Indicates uterine atony; when massaged, we want a boggy uterus to firm up.

Maternal hypovolemic shock

Manifestations include rapid pulse, pale clammy skin, diaphoresis, and restlessness.

Blood loss assessment

May have to start weighing chux; 1 gram = 1 mL.

Nursing interventions for postpartum hemorrhage

Includes massage fundus, notify MD, assess LOC, monitor Vital Signs and I&O, and medication administration.

Medications for postpartum hemorrhage

Pitocin, Methergine, Hemabate, Cytotec.

Transfusion

A nursing intervention for severe postpartum hemorrhage.

Bakari Balloon

Used in the management of postpartum hemorrhage.

Hematoma

Collection of blood, often on external genitalia, can be internal.

Hematoma incidence

1 in every 500-1,000 deliveries.

Hematoma etiology

Prolonged pressure of fetal head on vaginal mucosa or forceps delivery.

Hematoma signs and symptoms

Includes severe perineal pain, visible large mass, bruising, pain on palpation, and inability to void.

Clinical manifestations of shock

Uterus firm with no visible signs of bleeding.

Hematomas capacity

Can hold LOTS of blood, up to 1,000 mL.