OB- Postpartum

4th Stage of Labor

1st 1-2 hrs after birth

complications can occur during these first 2 hrs

Postpartum Period

interval between birth and return of reproductive organs to non-pregnant state

What is the Duration of postpartum?

~6 wks but can vary

referred to as 4th trimester

may include 1st 3 months of birth

Immediate Postpartum Care

Breastfeeding recommended to begin early

assessment of mother during recovery (1st check VS q15 and fundus)

Post anesthesia recovery

transfer from recovery to postpartum unit

What is afterbirth pain caused by?

uterus contracting

What is 1st line med given for afterbirth pain?

ibuprofen

usually 600-800 mg

give w/food because it is hard on stomach

What bladder is full and patient can’t get out of bed?

can try bedpan, if not straight cath

Involution

return of uterus to non-pregnant state

fundus descends 1 to 2 cm every 24 hrs

should assess lvl of fundus; should be at umbilicus

Subinvolution

failure of uterus to return to nonpregnant state

not normal

happens if uterus remains above umbilicus

tends to bleed more (massage the fundus)

Contractions

cause afterpains

stronger w/more deliveries

more babies=more pain

Hemostasis

compression of intramyometrial blood vessels as uterine muscle contracts

oxytocin released from posterior pituitary gland/administered

Oxytocin

can be used to induce labor

Pitocin

synthetic version of oxytocin

a bolus of pitocin given after baby and placenta is out

given to everyone

makes uterus clamp down to prevent bleeding

Placental Site

where the bleeding (lochia) comes from

nothing should go inside vagina (tampons, menstrual cups, etc.)

Endometrium

regenerates

upward growth

Fundal Check: U-

below umbilicus

Fundal Check: U+

above umbilicus

not good

What can cause U+?

over-distended bladder

will not contract

empty bladder

Fundal Check: @U

at umbilicus

Fundal Check: Other components

firm

firm w/massage

boggy (squishy, massage fundus, not normal)

Lochia

post birth uterine discharge

lochia rubra, serosa, alba

present up to 4-8 wks after birth

assess amount, type, and odor (odor can be sign of infection)

Lochia Rubra

dark red

occurs days 1-3

normal to have bleeeding

Lochia Serosa

brownish red or pink

occurs days 4-10

Lochia Alba

yellowish white

occurs 10-14 days after birth

Blood loss

assessed by the extent of perineal pad saturation

scant, light, moderate. heavy

Blood Loss: Scant

<2.4 cm

Blood Loss: Light

<10 cm

Blood Loss: Moderate

>10 cm

Blood Loss: Heavy

one pad saturated within 2 hrs

Quantitative Blood Loss (QBL)

if chux gets blood, weigh the chux and see how much total blood was loss

Example of QBL

chux weighs= 20 g

chux w/blood weighs= 100 g —> 80 mL

previously lost 300 mL

300+80= 380 mL total

Cervix

shortens and firm by 12-18 hrs after birth

cervical os closes gradually 2-3 cm by day and 1 cm at 1 wk

Vagina

thin vaginal mucosa and absence of rugae r/t decreased estrogen

thickening of vaginal mucosa occurs w/return of ovarian function

decreased vaginal lubrication r/t decreased estrogen

Perineum

episiotomy, lacerations, hemorrhoids (initial healing 2-3 wks)

Pelvic muscles

up to 6 months to regain tone

Kegel exercises to help vaginal tone

Placenta

rapid decrease in estrogen and progesterone lvls after expulsion of placenta is responsible for triggering anatomic fluid (can cause baby blues)

decrease estrogen = diuresis of excess fluid (pees lots to remove fluids)

Pituitary

prolactin increase

Ovarian Function returning

as early as 27 days, mean of 7-9 wks if nonlactating (returns faster)

6 months if breastfeeding (supreses ovarian function)

Postpartum Diuresis

removes excess tissue fluid

within 12 hrs diuresis begins, 3000 mL or more first 2-3 days

normal

Diaphoresis

profuse (at night) 2-3 days

normal

Its it normal during postpartum to urinate a lot?

yes, normal

Is it normal to sweat more if the temp is normal?

yes

Urethra and Bladder

decreased urge to void after delivery (may need to straight cath)

distended bladder displaces uterus, interferes w/uterine contraction (excessive bleeding)

Postpartum period: GI

appetite

constipation: decreased food and fluid intake during labor, reduced muscle and bowel tone, fear of pain during defecation, opioids

Postpartum period: Breasts- Breastfeeding

colostrum present at birth 72-96 hrs milk comes in

Postpartum period: Breasts- Non-Breastfeeding

colostrum present at birth, engorgement on day 3 or 4, resolves spontaneously, discomfort decreases within 24-36 hrs

Postpartum period: Delivery Blood Loss

offset by increase in volume during pregnancy

Vaginal: 300-500 mL

C-section: 500-1000

Is it normal if a postpartum pt loses more than 500mL of blood if they had a vaginal delivery?

no, if its over 500 mL it indicate postpartum hemorrhage

Is it normal if a postpartum pt loses more than 1000mL of blood if they had a c-section delivery?

no, if its over 1000 mL it indicate postpartum hemorrhage

Postpartum period: Hematocrit

decreases for 3-4 days, non pregnant lvl by 8 wks since everyone bleeds

Postpartum period: WBC Count

during pregnancy 5,000-10,000 mm3

after labor and delivery 30,000mm3

Can infection be determined based on WBCs in postpartum?

no

if there is a fever of 100.4 F and discharge w/odor then yes

Postpartum period: Coagulation

clotting factors and fibrinogen increased, vessel damage, and immobility predispose woman to thromboembolism

more coagulable which helps in childbirth not to bleed out

Signs of DVT and what to do

unilateral swelling, loss of pedal pulses, pain leg

1st intervention: call doctor —> anticipate u/s order

Postpartum period: Abd

still pregnant appearance

returns to almost to pre-pregnancy state 6 wks

joints stabilized- 6-8 wks

Chloasma

persists in 30% of women

melasma or mask pregnancy

darkening color

Hyperpigmentation of areolae and linea nigra

normal to not regress

Striae gravidarum

stretch marks

may fade but not disappear

normal

Is spider nevi normal

yes, spider veins is normal

Is palmer erythema normal?

yes, reddish palms is normal

Nursing Care and Physical Needs

nutrition, hydration, rest, breast care

Other components of Postpartum

routine VS, pain management (cramping, edema, perineum)

routine lab tests, nursing interventions, infant security to prevent infant abduction

Primary Nursing Actions: Prevent Complications

Fundal massage

peri care (intact, laceration, episiotomy)- squeeze bottle, ice, witch hazel pads, dermaplast spray, sitz bath

Signs and Symptoms of Complications

Infection in uterine, perineum, breasts

bleeding

DVTs

depression- hormonal changes, sleep disturbances

BUBBLEHEE

Breasts

Uterus

Bowel

Bladder

Lochia

Episiotomy

Hemorrhoids

Edema

Emotional State

Postpartum Assessment

VS

heart/lungs

breast

fundus

abd/incision

bladder elimination

lochia

perineum

Homan’s sign (no longer done, just know)

lower extremities (edema/deep tendon refelxes)

Care Management and Psychosocial Needs

effect of the birth experience

maternal self image

adaptation to parenthood and parent-infant interactions

family structure and functioning

impact of cultural diversity

discharge teaching

Attachment, Bonding, and Acquaintance

done through Rubin’s Stages

Rubin Stage: Taking In

Day 1-2

passive, focused on own experience

Rubin Stage: Taking Hold

Day 2-3+

begins really understanding and learning infant care, becoming more independent

Rubin Stage: Letting Go

accepts knew role and integrates infant into life

Attachment, Bonding, and Acquaintance: Parents/partners

process- not instant

attachment, bonding, does not require immediate contact w/the newborn

parents who are speerated from infant often worry

Attachment, Bonding, and Acquaintance: Sibilings

reactions manifested in behavioral changes

involvement in planning and care

acquaintance process

normal for them to regress

Planning Future Pregnancies: Rubella Vaccine

if woman is not immune, vaccination is recommended

MMR is live vaccine and should not be given during pregnancy, but can get it after birth

also get varicella vaccination

Planning Future Pregnancies: Tdap

can be given during pregnancy

Planning Future Pregnancies: Rh Isoimmunization

Rh immune globulin should be given within 72 hrs for Rh-negative person who delivers a Rh positive infant

can attack future fetus if not given

Discharge Teaching

sexual activity/contraception

prescribed meds

routine pt and baby check ups

ADLs at home

postpartum blue (80%)

follow up w/home visits, telephone follow up, warm lines, support groups, referral to community resources

Barrier Methods

condoms and diaphragm

safe immediately postpartum

NO effect on breastfeeding

Long Acting Reversible Contraceptives (LARC)

IUD, Implant (Nexplanon)

low maintenance, safe immediately postpartum

NO effect on breast feeding

Permanent methods

tubal ligation

vasectomy

Hormonal Methods

Progestin- only (mini pill, shot, implant)

safe immediately postpartum

NO effect on breastfeeding

Combined (Estrogen + Progestin)

Vaginal Ring, transdermal Patch, combined oral contraceptives (COCs)

AVOID early postpartum—> drops milk supply

risk of blood clots (VTE)

Which contraceptive has an effect on breast feeding?

vaginal ring

Signs of Complications

fever

change in lochia (too much, odor)

excessive bleeding

pain at incision/laceration sign

reddened/tender area of breast

calf pain/tenderness/redness

s/s of UTI

headache, blurred vision, epigastric pain

depression(> 2wks of not functioning well)