NRS 3026 Chapter 17 Postpartum Adaptations and Nursing Care

involution of the uterus changes: contraction of muscle

controls bleeding from site of placental attachment

decreases size of uterus (big uterus, more bleeding)

involution of the uterus changes: catabolism

reduction in cell size

byproducts are excreted in the urine

involution of the uterus changes: regeneration of uterine epithelium

decidua, basal layer, endometrial layer

due to immense amount of pressure on the bladder and urethra causing micro tears

descent of uterine fundus

assess fundal height → feels like a rock

document in relation to umbilicus (day 1-2 = above belly button, 24hr = at belly button)

Subinvolution

cause postpartum hemorrhage when organ does not return to it’s original shape and size

after pains etiology

2-3min pain per session, occurs over 2-3 weeks

Etiology

• more acute for multiparas

• bladder distention (d/t more stretching of uterus therefore too weak to contract)

  • breastfeeding (release of oxytocin increases with nursing)

after pains considerations

analgesic → vaginal birth (motrin & tylenol), c-section & 4º tear (norco PRN)

medicate and empty bladder before breastfeeding

enhance comfort and relaxation to facilitate letdown of milk

Lochia colors

Day 1-3 = lochia rubra (flows like heavy period, small golf ball sized clots, period cramps)

Day 3-10 = lochia serosa (pinkish-brown, 4-12 days, moderate flow, less/no clots)

Day >10 = lochia alba (yellowish white discharge, little to no blood, 12d-16w)

lochia serosa

Day 3-10 = pinkish-brown, 4-12 days, moderate flow, less/no clots

lochia rubra

Day 1-3 = flows like heavy period, small golf ball sized clots, period cramps

lochia alba

Day >10: (yellowish white discharge, little to no blood, 12d-16w)

lochia amounts: scant

less than a 2.5cm (1in) stain on the peripad

lochia amounts: light

less than 10cm (4in) stain

lochia amounts: moderate

less than 15cm (6in) stain

lochia amounts: heavy

saturated peripad in 1 hour

lochia amounts: excessive

saturated peripad in 15 mins

cervix changes after birth

dilated, edematous, bruised

small tears or lacerations may be present

rapid healing

vaginal changes after birth

greatly stretched, edematous walls, multiple small lacerations are possible

few vaginal rugae (folds) present

vaginal wall regains thickmess

dysparenuria (discomfort during intercourse)

rugae begin to reappear by

3-4 weeks

vaginal epithelium is restored by…

6-10 weeks

perineum changes after birth

pelvic floor muscles stretched and thinned, may be edematous or bruised

hematoma possible → prune/grape → notify Dr

laceration and episiotomy

nursing considerations for perineum changes after birth

ice pack, sitz bath, topicals (tucks pads and dermoplast spray)

relief of perineal discomfort, teaching self care with kegals or other pelvic floor exercises

perineal tears: 1º

small and skin deep tearing

perineal tears: 2º

deeper tears that affect muscles of the perineum

perineal tears: 3º

tears that involve the muscle that controls your anus (anal sphincter)

perineal tears: 4º

tears that goes further into the lining of your anus or bowel

requires antibiotics

anovulatory

no ovulation during the first few cycles for lactating and non-lactating women

when may ovulation resume?

at 6 weeks or before first postpartum follow-up

Is breastfeeding a form of birth control?

NO

when do non-lactating women usually resume menstruation?

6-10 weeks

breastfeeding delays ovulation and menstruation return, so menses usually return around what time?

10 weeks to 6 months

what two hormones prepare the breasts for lactation during pregnancy?

increase in estrogen and progesterone

after expulsion of the placenta, what happens to estrogen and progesterone levels?

rapid decline

prolactin initiates milk production in how many days after child birth

2-3 days (or up to 5 days)

what is required for milk-ejection or let down?

oxytocin (takes some suckling to release milk)

cardiac output after birth

increased BF back to the heart

decreased pressure from the pregnant uterus on the vessels

mobilization of excess ECF into vascular compartment

cardiac output returns to pre-pregnancy levels in most women by?

6-12 weeks

what are the two main ways the the body rids itself of excess plasma volume?

1. diuresis (increased urine excretion)

   1. diaphoresis (profuse perspiration or night sweats)

what happens to the WBC after birth?

increases due to stress from laboring and tissue healing

why is Hgb and Hct difficult to interpret within the 4-6 weeks post birth?

remobilization of excess volume dilutes values therefore they present as falsely low

what happens to clotting factors after birth?

clotting factors are elevated and can contribute to risk of thrombus formation but can be decreased with early ambulation

when does hemostasis return?

4-6 weeks

GI changes after birth

increased hunger and thirst

constipation (c-section must pass gas before departure)

stool softeners → encourage first BM after birth because no straining allowed d/t hemorrhoid or popping a stitch risk

kidneys return to normal function how long after birth?

4 weeks post birth

GU changes after birth

proteinuria

loss of bladder muscle tone

traumatized meatus (opening to the urethra → common)

diminished sensitivity to fluid pressure

diuresis

complications of an over-distended bladder

uterus is trying to go back into its spot → bladder in the way → no contraction → deviates to the right → boggy uterus → bleeding

causes: urinary retention or hemorrhage (uterine atony)

abdominal wall changes after birth

diastasis recti: longitudinal muscles of abdomen separate, returns to normal by 6 weeks pp

requires: tone, strength, exercise

neurologic changes of pharmacology

frontal and bilateral headaches are common

• spinal headache (severe & not common) are related to post-dural puncture from regional anesthesia

  • improves by laying down, caffeine, or blood patch

if you receive spinal anesthesia, how long do you have to give birth?

2 hours

after expulsion of the placenta, what hormones decline?

estrogen, progesterone, human placental lactogen

how many pounds are lost in childbirth?

10-13lbs of water weight

when can you start exercising after birth?

6 weeks or until cleared

what fluids do a diabetic mother get?

what fluids does a non-diabetic mother get?

diabetic = NS

non-diabetic = LR

how often do you assess BP after vaginal birth?

first hour: every 15 mins

second hour: every 30 mins

first 24 hours: every 4 hours

after first 24 hours: every 8-12hrs

BUBBLE-DEP

breasts, uterus, bladder, bowel, lochia, episiotomy/incision, DVT, emotional status, pain

BUBBLE-DEP: normal breast appearance day 1-2 after birth

soft and nontender

BUBBLE-DEP: uterus

should be firm and near umbilicus

support uterus when expelling clots to prevent inversion

BUBBLE-DEP: bladder

assess for: distention, displacement of uterus, fundus after emptying, straight cath depending on laceration/swelling

BUBBLE-DEP: bowel

assess: bowel sounds, positive flatus, last BM, N/V?

BUBBLE-DEP: lochia

assess:

• amount: constant trickle, dribble, oozing can indicate excessive bleeding and immediate attention

• color: rubra for the first few days after delivery

  • odor: fleshy, earthy, musy, foul = infection

BUBBLE-DEP: episiotomy/laceration/incision

Redness, Edema, Ecchymosis, Discharge, Approximation

healed=0, mod=1-5, mild=6-10, not healed=11-15

you do not want to see trickle from incision when pushing on stomach

BUBBLE-DEP: DVT

assess: pedal pulses, edema, DTR (especially for moms on Mag sulfate)

homan’s sign: unilateral calf pain = DVT risk, b/l pain = muscular issues

BUBBLE-DEP: Emotion

assess: emotional status, baby blues vs PPD (after 6 weeks), maternal/infant bonding

BUBBLE-DEP: pain

assess: 0-10, pain goal, offer comfort measures

mastitis

baby not feeding well, infection, unilateral, fever

engorgement

edema, vascular issue, overfilling, b/l

goal for volume of urine the first 2 times after giving birth

150cc

providing comfort immediately post-partum for downstairs

ice packs

sitz bath: cool water first 24h, warm water after 24h (not common, peribottle is tho)

analgesics, perineal care, topical medications

promoting bladder elimination

medication for relaxation

run water in sink or shower and place mom’s hand in warm water or pour over vulva

drink hot tea or fluids

blow bubbles through a straw

encourage urination in shower or sitz bath

food and fluids postpartum

2000mL fluids per day or IV fluids if unable to tolerate PO due to general anesthesia

eat to replenish nutrients

duramorph

single dose of this opioid is injected into the epidural or subarachnoid space immediately after surgery to provide 18-24hrs of post c-section analgesia

assessment after c-section

respirations, abdomen, I&Os, RASS (4+=combative, -5=unarousable)

how long after a c-section can normal activities resume?

24 hours

how long after vaginal vs c-section can you be discharged?

vaginal: 24-48hrs

c-section: 48-72hrs