NURS 371: CH 20

Postpartum (PP) period

◦ is the interval between birth and return of the reproductive organs to their nonpregnant state

Puerperium

◦ fourth trimester of pregnancy

Involution process

◦return of the uterus to non-pregnant state

return of the uterus to nonpregnant state

•Fundus should be easily palpated using the maternal umbilicus as a reference point. Fundus descends postpartally 1-2cm every 24 hours. 12 hours after delivery fundus is approximately 1cm above umbilicus. 6^th postpartum day fundus is half way between symphysis and umbilicus. 2 weeks postpartum uterus should not be able to be palpated abdominally. Six weeks after birth= return to pre-pregnancy location   (uterus never returns to pre pregnancy size)

Subinvolution

◦ failure of the uterus to return to non-pregnancy state

Causes of subinvolution- placenta, infections

Contractions

uterus contracts to go down in size; compress blood vessels to stop bleeding; upward growth of uterine tissue (no scarring), slothing of necrotic tissue

Afterpains

Uncomfortable cramping. More common and intense in multiparous women. Why? Uterus has to contract to reach pre pregnancy size.everytime the utuerus contracts there are contractions of the intra. No scare- getting ready for implentatio of another pregnancy. More common in multiparas- uturus has stretched more; multiple babies; a big/macrosomy abby; polyhydramous- excess of amniotic fluid.  Breastfeeding affect on afterpains- causes mom pituitary glands to release oxytocin- body way to get uturus down- last longer. Decrease risk of postpartum hemmorage.

Placental Site

 Unique healing process that prevents formation of scar tissue. Upward growth of endomethrium causing slothing of necrotic tissue.

Lochia:

post birth uterine discharge (Table 20.1 page 418)

◦Rubra

◦Serosa

◦Alba

usually less after a C-Section (manually remove placenta, suction uturus- get a lot of debrief out- less bleeding after birth) (blood pools in utures- a gush when get up- normal not a hemorage)

Heavier with ambulation and breastfeeding after pooling- gush-not to be confused with hemorrhage

Should smell fleshy-like a normal menstrual flow; should not smell foul/offensive

Rubra

bright red bleeding- right after delivery

-last 3-4 days

Serosa

pink/brown bleeding

• 4-10 days

Alba

whitish/yellow color

-day 10- 6 weeks

Cervix

◦The external os never regains it pre-pregnancy shape

By day 2-3 the cervical dilation has decreased to 2-3cm (from 10cm at the time of vaginal birth), by 1 week it is approximately 1 cm

The external os never regains it pre-pregnancy shape; has a jagged “slit mouthed” appearance

Lochia saturation

scant

light

moderate

heavy

Weighing pad is the most accurate form of measurement- weigh in grams (chart in ml) (1g=1ml)

Multipara mom may have more bleeding.

Scant saturation

less than 2.5 cm

Light saturation

2.5-10 cm

Moderate saturation

  10-15 cm

Heavy saturation

pad saturated in an hour

Fundal message

Stimulant uterus tp Reduce uterine atoni and restore muscle tone. (firm and promote contractions)

Every 15min the first hour after delivery.

◦Episiotomy and laceration assessments

Best position to assess- side lying or lithotomy (in stir ups)

Episiotomy= doctor cuts to make room for baby delivery (midlin, RML, LML)

laceration= body tears on its own (chart as degree)

Signs of infection- malodor, pain, discharge, swelling, wramth, redness

Recovery depends on degree.

Hemorrhoids

commonly seen, itching/discomfort/ bright bleeding with defecation

Usually decrease in size 6 weeks after birth

Nursing intervention: ice pads, sitzs bath (warm water), derma plast (lidocaine spray), stool softeners, tucks pads (witch hazel)

Kegel exercises-

•help strengthen and tone pelvic tone

•The woman can pretend that she is attempting to stop the passing of gas or the flow of urine midstream, which will replicate the sensation of the muscles drawing upward and inward. Each contraction should be as intense as possible without contracting the abdomen, buttocks, or thighs. Guidelines suggest that these exercises should be performed 24 to 100 times per day. Positive results are shown with a minimum of 24 to 45 repetitions per day. The best position to learn Kegel exercises is to lie supine with the knees bent. A secondary position is on the hands and knees.

Estrogen and progesterone levels 

decrease with explosion of placenta

-Human lactogen: promotes increase blood sugar during pregnancy to fuel fetus

Basal metabolic rate

remains elevated 1-2 weeks after birth

-increase with breastfeeding

Prolactin remains _________ in women who breastfeed.

increase

Ovulation

◦Ovulation in 27 days after birth for nonlactating women

◦Ovulation in 70 to 75 days for lactating women

◦** Breastfeeding women take longer to resume ovulation. Prolactin thought to suppress ovulation** Breastfeeding is not a form of contraception.

◦Caused by decreased ______ levels, removal of increased venous pressure to lower extremities, and loss of remaining increased blood volume due to pregnancy

estrogen

◦Over distention of bladder can impede ___________ , impede return of normal bladder function and potentially lead to ____.  

involution; infection

Kidney function usually returns to normal in approximately

6 weeks.

Bladder & Urethra

We need to encourage water intake!!!

Increase capacity, decrease sensitivity- urge to void,

I&Os after birth- greater than 150mL 2 measurements after birth

Appetite

increased depending on N/V; c-section progress diet as tolerated (NPO first hour- progress to ice chips- bland foods- regular diet); uncomplicatated vaginal delivery can eat right away

Bowel evacuation

Vaginal: scared, birth trauma

C-section: decrease parastysis, opoid meds

listen to bowel sounds before giving food

Nursing Interventions:  relive constipation

1.) ambulation

2.)  increase water intake

3.)  stool softeners

◦Breastfeeding mothers

◦First 24 hours colostrum

◦Transitions to milk in 72 to 96 hours- breast become fuller/heavier as  colostrum transitions to mature milk (Lactogenesis II)

◦Engorgement comfort measures for lactating mothers

Tx for engorgement:

Feeding every 2 hours, Pumping to soften breast, cold packs after BF, cabbage leaves, warm compresses before BF, anti-inflammatory medications and breast massages

s/s- hard, hot, uncomfortable nipple fullness

If not resolves= decrease in milk prododuction

Nonbreastfeeding mothers

◦Engorgement resolves in 24 to 36 hours after milk comes in

◦Breast binder, Ice, cabbage leaves, no stimulation

◦Lactation will decrease within a few days to a week

◦Typical blood loss vaginal birth verses C-Section

Vaginal birth: 300-500 Ml (>500mL- hemorrage)

C-section: 500-1000mL (>1000mL- hemoragge)

◦Temperature will slightly ___ after birth related to dehydration during labor.

increased

Leukocytosis

increases 4 to 7 days after childbirth, which can obscure the diagnosis of acute infections, producing false-negative test results.

Coagulation Factors

The hypercoagulable state increases the risk of thromboembolism, especially after a cesarean birth.

-increase risk for DVT, PE; SCD remain on until get up for first time

Respirations

should decrease to within the woman’s normal prepregnancy range by 6 to 8 hours after childbirth.

◦What are some other conditions that could cause headaches in the postpartum phase?

Spinal HA- loss of CSF (goes away if lay flat)

-stress/lack of rest

-preeclampsia- BP, vision changes

Abdomen

◦Returns to pre-pregnancy state 6 weeks after birth

First 2 weeks after birth the abdominal wall relaxes.

Diastasis recti

separation of abdominal wall muscle. Will eventually heal on its own.

Integumenatry system

◦Melasma (mask of pregnancy) disappears but will reappear with subsequent pregnancies

◦Hair loss often reported during the first 3 months postpartum

◦Some women will have permanent darker pigmentation of areolae and linea nigra

◦Stretch marks usually do not completely disappear