Postpartum Period (week 6)

postpartum period

• birth to return of reproductive organs to non-preganant state

• 6-12 weeks

uterus changes

• involution immediately after placenta delivered

  • at umbilicus = 12hrs

  • descends 1-2cm every 24hrs

• contactions

  • oxytocin via pituitary gland promotes homeostasis

• lochia PP uterine discharge

  • initial = bright red + small clots

  • 2hr PP = heavy period then decreases

  • rubra = 3-4 days = blood/trophoblast

  • serosa = 4 days - 2-4 weeks = brown/pink = blood, leukocytes, tissue

  • alba = >10-14 days = white  

cervix changes

• VAGINAL BIRTH

• Os closes gradually

• 1 week = 1cm dilated

• never pre-pregnancy state

vagina and perineum changes

• size decreases

• tone increases

• introitus = edematous (swell) with episiotomy/laceration

• never pre-pregnancy state

abdomen changes

6 weeks return to pre-pregnancy

placental hormone changes

• decrease in human placental lactogen, estrogen, cortisol, insulinase

  • b/c of delivery of placenta

  • REVERSE diabetic effects 

• estrogen/progesterone decrease = diuresis (increase urine)

• hCG - 3-4 weeks 

pituitary hormones

• prolactin rises in pregnancy, PP = drop in estrogen/progesterone = INCREASES

  • higher in 1st month of BF and until BF continues

• ovulation and menses

  • non-lactating = return as soon as 27 days, mean = 7-9 weeks, 70% by 12 weeks

  • BF = 6 months til ovulation 

urine component changes

• glycosuria

• lactosuria

• BUN

• proteinuria

• ketonuria

• b/c of prolonged labour/dehydration 

fluid loss changes (urine)

• PP diuresis (increased production of urine)

  • b/c decreased in estrogen/progesterone

urethra and bladder changes

• trauma (forceps, etc)

• anesthesia (decreased sensation)

• increased bladder capacity

  • DECREASED urge to void

    • PPH RISK (uterus CANNOT contract)

    • intervention = encourage void/foley catheter 

appetite changes

increased after birth, diet as tolerated

bowel movement changes

• delay 2-3 days = normal

• decreased muscle tone, dehydration, lack of food, pre-labour diarrhea

• vaginal delivery

  • forceps/vacuum = anal sphincter laceration 

• C/S

  • abdo pain = gas build-up

  • can appear as referred shoulder pain 

  • encourage fluids, fibre, early ambulation 

breastfeeding changes

• 24hrs = little change + colostrum (nutrient rich, 1st type)

• feel soft, become fuller/heavier as milk comes in

  • 72-96hrs 

non-breastfeeding changes

• milk still comes in

• breast feel full/engorged

• resolve spontaneously

• AVOID stimulation

  • well fitted/right bra

cardiovascular changes

• hypervolemia of pregnancy = tolerates blood loss

  • vaginal = 300-500 mL

  • C/S = 500-1,000mL

respiratory system changes

• immediate decrease of intra abdominal pressure

• decreased progesterone = PaCO2 INCREASES

neurological system changes

• reversal of adaptions to pregnancy

• ex. carpel tunnel

• *headache = hypertension

MSK system changes

• stabilizes by 6-8 weeks

• foot size may not decrease 

integumentary system changes

gradual resolve of changes from pregnancy

immune system changes

• immunosuppression returns to pre-pregancy state 

  • immunosuppressed during pregnancy b/c did not want to recognize embryo as foreign 

• autoimmune conditions

  • can trigger a FLARE-UP

  • follow-up with specialist

vital sign changes

• few alterations under normal circumstances

• HR and BP return to pre-pregnancy levels in a few days

• respiratory functions return rapidly to pre-pregnant function

PP assessment - 24hr

afternal initial recovery (1-2hrs) pt transferred to PP unit 

9 components of TOA PP

1. type of labour/birth, unusual observations of placenta

2. GTPAL, age

3. anesthesia and analgesia used

4. condition of perineum

5. events since birth

6. condition and sex of newborn, other info

7. relevant info from prenatal record

8. miscellaneous info, IV drip

9. social factors 

maternal/newborn - type of labour/birth, unusual observations of placenta

• spontaneous or assisted (forceps, vacuum) vaginal birth

• C/S birth

• vertex presentation

• time of ROM (artificial or spontaneous)

maternal/newborn - GTPAL, age

• GTPAL

• maternal age

• gestational age

maternal/newborn - anaesthesia/analgesia used

• none 

• epidural

• spinal

• local 

maternal - condition of perineum

• episiotomy = cut for birth

• laceration

  • repair

  • intact

maternal - events since birth

• vital signs

• BP

• fundas

• lochia

• intake/output

• medications (dosage, time of admin, results)

• length of time NB was skin-skin, with whom

• response to NB

• observation of family interactions, including siblings

newborn - events since birth

• vital signs

• blood glucose

• nursed for __ (BF or formula or combo)

• void

• eye prophylaxis

• vitamin K 

• skin-skin for __ min

• family interactions

  • ex. held by siblings who are happy 

maternal - condition and sex of NB, other info

• time of birth

• weight

• BF or bottle

• sex of baby

newborn - condition and sex of NB, other info

• time of birth

• apgar score at 1 and 5 min

• sex

• weight

• name of healthcare provider

• BF or bottle

maternal - relevant info from prenatal record

• need for rubella vaccine

• presence of infection

• Hep B status

• HIV status

• bloody type

• Rh status

• GBS status and treatment 

newborn - relevant info from prenatal record

• mother’s GBS status and treatment 

maternal - miscellaneous info, IV drop

• IV drip

• rate of infusion

• meds added

  • ex. oxytocin

• whether to open/close/continue/discontinue 

newborn - miscellaneous info, IV drop

• whether mother received MgSO4

• time of last systemic analgesia

• IV solution and rate 

maternal - social factors

• pt keeping or releasing NB for adoption

• if pt wants to see NB

• BF or bottle

• allowing visitors or not

• other preferences

newborn - social factors

• NB up for adoption 

PP assessment first 24hrs

• Vital signs

• BUBBLLEE

  • breasts

  • uterus

  • bladder

  • bowel

  • lochia

  • legs

  • episiotomy or C/S incision

  • emotional status

PP assessment

• BP

• temp

• pulse

• respirations

• breath sounds

• nipples

• uterus

• bladder

• bowels/abdomen

• lochia

• legs

• perineum/incision

• rectal area

• emotional status/energy

blood pressure - normal findings

• consistent with baseline during pregnancy

• orthostatic hypotension x 48 hrs 

blood pressure - complications

• HYPERtension

  • anxiety, pre-eclampsia, hypertension

• HYPOtension = PPH RISK

temp - normal findings

36.2 - 38ºC

temp - complications

• >38ºC

  • infection

pulse - normal findings

60-100 bpm

pulse - complications

• TACHYcardia 

  • pain, fever, dehydration, PPH

respirations - normal findings

12-24 breaths/min

respirations - complications

• TACHYpnea = anxiety

• BRADYpnea = effects of narcotics

breath sounds - normal findings

clear

breath sounds - complications

• crackles = fluid overload

breasts - normal findings

• day 1 = soft

• day 2-3 = filing

• day 3-5 = full, soften with BF

breasts - complications

• firmness

• heat

• pain

• engorgement

• redness of breast tissue

• fever

• body aches

• CAUSE = mastitis = infection 

nipples - normal findings

skin intact

nipples - complications

• redness

• brusing

• cracks

• fissures

• abrasions

• blisters

• CAUSE = latching difficulties

uterus - normal findings

• firm

• midline

• 24hrs @ umbilicus

• descends 1-2 cm per day

uterus - complications

• soft

• boggy

• higher than umbilicus

• CAUSES

  • uterine atony = fail to contracts = PPH risk 

  • deviated = lateral = bladder distension (full)

bladder - normal findings

• able to void 8hrs after catheter removal

• diuresis (increased urine) 

bladder - complications

• overdistended = uterine atony + excessive lochia

• UTI = dysuria (painful urination), frequency, urgency

bowel/abdo - normal findings

• BM 2-3 days

• soft abdo

• active bowel sounds in all quadrants

• C/S passing of flatus 

bowel/abdo - complications

• no BM 3-4 days

• diarrhea 

lochia - normal findings

• birth - 3-4 days = rubra

• day 4 - 2-4 weeks = serosa (pink/brown)

• >10-14 days = alba

• amount = scant-moderate

• few clots, fleshy odour 

lochia - complications

• large amount = uterine atony, vaginal cervical laceration

• odour = infection

legs - normal findings

• peripheral edema possibly present 

legs - complications

• redness, tenderness, pain = VTE

perineum/incision - normal findings

• minimal edema

• laceration/epis = edges well approximated

• C/S = incision dry/clean, well approximated 

perineum/incision - complications

• pronounced edema

• hematoma

• bruising

• redness

• warmth

• drainage

• infection

rectal area - normal findings

• no hemorrhoids

  • if present, soft, pink

rectal area - complications

• discoloured hemorrhoid tissue

• severe pain

• thrombosed hemorrhoid (dark blue, clots)

emotional status/energy - normal findings

• able to care for self, infant

• able to sleep

• happy, excited

• interested/involved in care

• sad/tearful 3-14 days = PPB

emotional status/energy - complications

• lethargy, extreme fatigue, difficulty sleeping = PPD

• sad, tearful, disinterested in NB care = PP mood disorder 

perinatal moods (5)

1. postpartum blues (PPB)

2. postpartum mood disorders (PMD)

3. perinatal anxiety disorders 

4. perinatal depression

5. postpartum psychosis 

postpartum blues (PPB)

• baby blues

• 50-80%

• tearful, agitation, mood swing, sleep/appetite disturbances, feeling overwhelmed

• resolves in 2 weeks

• DOES NOT interfere with care of self/NB

nursing education - PPB

• validation, reassurance, education

• normalize, encourage rest, relaxation techniques, time for self, plant day out of house, share feelings with partner, monitor self of S/S of anxiety/depression, seek out community recourses, be patient with self if BF

postpartum mood disorders (PMD)

• 23% report feelings of PPD or anxiety disorder 

• indigenous 87% higher chance 

  • hx of colonization, intergenerational trauma, discrimination, racism, marginalization, poverty, lack of cultural safe care

• biological, psychological, situation, multifactorial 

• higher risk with hx of anxiety, depression 

strong risk factors - PMD

• hx of psychiatric illness, depression, anxiety

• prenatal symptoms of anxiety

• onset of depression during pregnancy or PP 

moderate risk factors - PDM

• stressful life events

• refugee/immigrant status

• low social support

• unfavourable obstetrical outcomes

• low self-esteem

• hx of physical or sexual abuse

• intimate partner violence (IPV)

• hx of reproductive trauma (ex. infertility)

• grief re. miscarriage, stillbirth, infant loss

• substance use, including tobacco 

weak risk factors - PMD

• low socioeconomic status

• lack of significant other/partner

• pregnancy unwanted

• BF challenges 

perinatal anxiety disorders

• 1 in 5 pt 

• GAD (gen anxiety), OCD, panic attacks, phobias, social anxiety, PTSD

• increased risk with hx of anxiety 

collaborative care - perinatal anxiety disorders

• psychotherapy, CBT, ERP (exposure response prevention) (individual or group) 

• SSRIs and anti-anxiety meds = 2 weeks to be effective

• nursing education

  • guidance, reassurance, recognizing triggers

  • family/social supports

perinatal depression

• 10-15%

• mild-severe

  • intense and pervasive sadness with severe mood swings, guilt, inadequacy feed worries = incompetent parent

  • irritability = distinct characteristic 

collaborative care - perinatal depression

• psychotherapy

• antidepressants

• anti anxiety meds 

postpartum psychosis

• most severe PMD

• 50-80% more likely to develop psych disorder (biopoal)

• 50% = recurring PP psychosis 

• S/S 2 weeks PP

• rapid onset of bizarre behaviour, hallucinations, paranoia, delusions, delirium/disorientation, extreme deficits in judgement, high impulsivity

• risk factor = pre-existing bipolar disorder

collaborative care - postpartum psychosis

• emergency = hospitalization

• good prognosis if early identified/treated

• antipsychotics, mood stabilizers, benzodiazepines, psychotherapy 

PP nursing prevention interventions

• excessive bleeding

• infection

• bladder distension 

excessive bleeding - prevention

• maintain uterine tone

  • uterine atony = matain tone and prevent bladder distension

  • 1g = 1mL = weighing peri pads

infection - prevention

• hygiene

• clean environment

• change peri pads frequently 

bladder distension - prevention

• empty bladder frequently

• running tap

• pour water over perineum

• sitz bath 

nursing interventions - promotion

• pain relief ex/ ibuprofen at discharge 

• comfort and rest

• ambulation and exercise (decrease chance of VTE)

• nutrition (normal cal, increased 350-450 cal if BF)

• bowel function (prevent constipation by ambulation, fluids, fibre)

• breastfeeding (ASAP)

future pregnancy planning

1. rubella

• not immune - subQ injection immediate PP period

• MMR = live attenuated = safe fro BF

  • avoid pregnancy for 4 weeks

  • DO NOT give if immunocompromised (mother/household)

2. Rh isoimmunization 

• injection of Rh immune globulin within 72hrs of birth (second, 1st was during 3rd trimester) 

postpartum complications (3)

1. Postpartum Hemorrhage (PPH)

2. Venous Thromboembolism (VTE)

3. Infection 

PPH

• leading cause of maternal mortality worldwide

• >500mL (vaginal)

• >1,000 mL (C/S)

• primary - 24hrs of birth

• secondary = >24hrs - <12 weeks (generally)

risk factors of PPH

• 4 T’s

  • tone

  • tissue

  • trauma

  • thrombin 

tone - PPH risk factor

• uterine atony

• overdistended uterus (LGA, multi fetuses, hydramnios, distension with clots)

• anesthesia/analgesia

• previous hx of uterine atony

• high parity

• prolonged labour

• oxytocin induced labour

• MgSO4 admin in labour or PP

• chorioamnionitis

• uterine subinvolution (fail to return to normal size)

• obesity

trauma - PPH risk factor

• laceration of birth canal

• trauma during labour (forceps, vacuum, C/S)

• rupture uterus

• inversion of uterus

• manual removal of retained placenta 

tissue - PPH risk factor

• retained placental fragments

• placenta accreta, increta, percreta

• placental abruption

• placenta previa 

thrombin - PPH risk factor

coagulation disorders (clotting disorders)

PPH nursing assessment

1. find uterus boggy

2. massage and keep hands on

3. pull call-bell = emergency

4. collaborative care = PPH kit

5. place IV - CBC

6. empty bladder

7. PPH meds admin

8. MRP = eternal exam (retained placenta, clots)

verbalize out loud what you have done

always someone documenting times/interventions 

venous thromboembolism

• superficial, deep (DVT) or pulmonary (PE)

• 15 x risk of thromboembolism in pregnancy/PP

• restless/agitation

DVT S/S - Venous Thromboembolism 

• unilateral (no bilateral) leg pain

• calf tenderness

• swelling

• redness

• warmth

Pulmonary Embolism - Venous Thromboembolism 

• dyspnea

• tachycardia

• apprehension

• COUGH

• hemoptysis

• fever

• syncope (faint)

superficial venous thromboembolism - collaborative care

• analgesia (pain reliever)

• rest with elevation

• compression stockings

• heat