unit 5: Post partum

uterine involution

• how much does it descend in what time?

• when can we not palpate it

• how long does it take

• uterus contracting to pre-pregnant state

• descends 1-2 cm every 24 hours

• should not be palpable after 2 weeks pp

• takes 6 weeks to fully return

when palpating the uterus

• supine

• full bladder will displace uterus up and to the right

• empty bladder!

autolysis

destruction of excess tissue in uterus

• due to decreasing hormones

sub involution

• due to?

failure of uterus to contract back down to pre-pregnant state

• due to ineffective contractions

• can be caused by retained placenta or infection

afterpains

• caused by?

• primi vs multipara?

• contractions/ cramping after birth

• caused by natural oxytocin release after baby is born

• can also be caused by postpartum pitocin

• primipara - milder cramping

• multipara - more painful cramping, the muscle takes more work to get back to pre pregnant statee\

placental site healing

• will slough off necrotic tissue

• usually happens without and issue and will allow for a new placenta to implant

lochia

• heavy during?

• meds?

• less lochia when?

• increases with?

• hemorrhage or lochia?

• heavy during 4th stage of labor

• oxytocic medications may make lochia scant

• less lochia after C-section

• increases with ambulation

• may pool in vagina with immobility, do not confuse for hemorrhage when she stand up, and it gushes.

If lochia remains heavy

• may be the first sign if hemorrhage

• may be caused by retained placenta

• always asses firmness of uterus first

cervix post partum

• what can it look like

• infection?

• dilation

• cervical os?

• may be edematous

• lacerations can get infected

• 2-3 days after birth it is dilated 2-3 cm

• 7 days after birth it is dilated 1cm

• cervical os will permanently appear as a jagged slit

REEDA scale assessment

• what does it assess

• redness

• edema

• ecchymosis - not as common, should not be excessive

• discharge - none at all

• approximation

• assesses episiotomies and lacerations

episiotomies and lacerations healing

• initial vs completely

• what can help healing

• Initial healing occurs within 2 to 3 weeks

• 4 to 6 months to heal completely

• with hazel pads, hemorrhoid cream, ice, peri bottle, sitz bath

pelvic muscular changes

• how long to regain tone ?

• what do we teach

• can take 6 months to regain tone

• teach Kegel excersises to avoid pelvic relaxation

pelvic relaxation

• higher risk if

• may lead to?

• possible consequence of childbirth

• higher the risk the more children she has

• can lead to urinary frequency and incontinence later in life

brast changes

• early changes

• as milk comes in?

• engorgement

• slight changes observable by mom in first 24 hours

• warmness, fullness and tenderness as milk comes in

• engorment - lasts 24-48 hrs, can cause elevated temp

engorgement in a non breastfeeding mom

• engorgement resolves in 24-36 hrs after milk comes in

• avoid stimulation, wear tight bra

• ceases in a few days up to 1 week

blood volume changes post-partum

• blood loss in vaginal vs c-section

• plasma ?

• vaginal blood loss - 300-500 ml

• c section 500-1000 ml

• plasma volume decreases with diuresis

Cardiac output post partum

• directly after birth

• when does it return to pre labor values

• how much does it decrease by weeks 2

• when does it go back to pre-pregnant levels

• increases directly after birth

• returns to pre-labor values during initial recovery period (1hr)

• decreases by 30% within 2 week

• decreases to pre-pregnant levels in 6-8 weeks

hemorrhoids and varicosities

• will regress after birth

hematocrit & hemoglobin of mom

• drops when

• when is it normal

• drops 3-4 days after birth

• goes back to normal by 8 weeks

WBC postpartum

• can get as high as 30,000

• may mask infections

• must assess other s/s of infection

coagulation factors postpartum

• remains in a hypercoaguable state

• r/o VTE

• ambulate!

respiratory postpartum

• decreases ?

• reduced?

• decline in ? causes what to rise?

• decreased pressure on diaphragm

• reduced pulmonary blood flow

• decline in progesterone (from loss of placenta) causes PaCO₂ to rise

hormones postpartum

• what decreases

• what stays elevated in who?

• thyroid?

• estrogen and progesterone decrease

• prolactin remains elevated in breastfeeding women

• thyroid gland returns to normal 3 months pp

when does Ovulation occur in BF women vs non-BF women

• Non BF: 27 days pp

• BF: 70-75 days pp

GU postpartum

• how does she lose fluid? how long after birth?

• caused by?

• urge? when does tone come back?

• how often should she void

• consequences of not losing fluid?

• within 12 hrs after birth, mom loses excess fluid via diuresis

• caused by drop in hormones and pressure on lower extremities

• may also lose fluid via diaphoresis

• may not feel urge to void (tone comes back in 5-7 days)

• make sure she voids every 2-3 hours with our without the urge

• displaced bladder may cause pressure & hemorrhage of the uterus

GI system postpartum

• when will she have BM?

• difficulties?

• interventions?

• may not happen for 2-3 days after birth

• may be more difficult if she was on opioids (constiption)

• lacerations & episiotomies cause fear of a BM & incontinence

• most women are on colace pp

• encourage fluid, water and ambulation

integumentary postpartum

• what does away and what does not?

• hair?

• melasma recedes, but may come back with hormonal BC use

• hyperpigmentation/ linea negra may not fully go away

• striae gravidarum will not go away

• angiomata (vascular spiders) go away

• may have pp hair loss

musculoskeletal system postpartum

• abd wall takes how long to return

• what is the term for the abd wall muscles separating

• joints

• 6 wks for abdominal wall to return to pre-pregnant state

• diastasis recti abdominis - abd wall musscles seperate

• joints are stabilized 6-8 wks after birth

nuerologic postpartum

• issues that happened in pregnancy will recede (headaches, congestion)

• hedaches are common 1week pp

women w/ autoimmune conditions

• in pregnancy vs postpartum

• may have flare ups after pregnancy

• during pregnancy, autoimmune diseases will go through a period of remission

stay after vaginal birth vs c section

• 2 days vaginal

• 4 days c-section

when do are women transferred to postpartum / in postpartum care in LDRP setting

• When maternal condition is stable

• usually 1-2 hours but may take longer

postanestesia recovery

• must be cleared by Anesthesia before put into postpartum

what does the L&D nurse say in report to the postpartum nurse for mom?

• name, age, MD

• GP/ GTPAL

• anesthesia

• any meds

• length of labor

• time of ROM (after 24hr r/o infection)

• induced or augmented?

• vaginal or c-section

• laceration or episiotomy?

• perineum? incision?

• blood type & Rh status

• viruses, STDs or other infections?

• IV

• fundus checks

• emotional status

what does the L&D nurse say in report to the postpartum nurse for baby

• gender

• weight

• date and time of birth

• any abnormalities

• bonding with mom?

• Apgar scores?

• void or stool

• newborns meds given?

what does the length of postpartum stay depend on

• physical condition of mom and baby

• mental & emotional status of mom (PPD survey?)

• support at home

• education needs

• financial constraints

those at low risk can be discharged when?

• birth center vs hospital

• as early as 6 hours from a birth center

• 24-36 hours from the hospital

• fundal checks/BUBBLEHE how often

• q 15 min for first 2 hours (initial recovery period)

• q1hr for first 4 hours

• q 4 hours for 24 hours

• q shift until d/c

what labs are drawn pp1

• CBC

• WBC

• H&H

• platelet count

how de we prevent excessive bleeding 5

• ambulation

• voiding every 2-3 hrs & drinking lots of fluid

• changing pads and being mindful of the blood amount

• breastfeeding - increases oxytocin

• prevent infection (use peri bottle, wipe front to back, hand washing etc.)

nonpharmacolgic interventions in pp

• ambulation

• position changes

pharmacolgic interventions in pp

• NSAIDs better for cramping than Tylenol

• opioids used carefully and sparingly (CNS depressant and constipation)

how do we promote rest

• what does it contribute to?

• cluster care

• keep lights off

• limit visitors

• keep partner comfortable as well as mom

• lack of sleep can contribute to PPD

extreme fatigue can be sign of

anemia

first time mom gets out of bed

• needs to be with a nurse or nurse aide

• may be dizzy or lightheaded

• if she remains dizzy she needs to stay in bed and use call bell when she needs to void

how do we prevent vte if mom is on bed rest and cannot ambulate

• In - bed leg exercises

• SCDs

when can mom start ab exercise

• 4-6 wks pp with doctorrs permission

caloric intake for non lactating mom vs BF mom

• adjusted for?

• non lactating 1800-2200 cals

• BF: 450-500 cals more

• adjusted in overweight or underweight mom

DHA in breast-feeding diet

• amount?

• sources?

• 200-300 mg

• low mercury fish (shrimp, salmon, canned white tuna)

If mom H&H are low

• foods rich in iron (red meat, green leafy vegetables)

• may need IV iron

how soon after birth should she void

• 6-8 hours

• may need to catheterize her

rubella & varicella vaccines

• live vaccines CANNOT be given in pregnancy

• they can be given postpartum and are safe for breastfeeding

TDAP vaccine

• given to mom @ 36 weeks to pass immunity to baby

preventing Rh isoimmunization

• titter needs to be drawn

• rogham must be given 72hrs pp

s/s of Postpartum Psychosocial Concerns (12)

• Unable or unwilling to discuss labor and birth experience

• Refers to self as ugly and useless

• Excessively preoccupied with self (body image)

• Markedly depressed

• Lacks a support system

• Partner or other family members react negatively to the baby

• Refuses to interact with or care for baby; for example, does not name baby, does not want to hold or feed baby, is upset by vomiting and wet or soiled diapers (cultural appropriateness of actions must be considered)

• Expresses disappointment over baby’s sex

• Sees baby as messy or unattractive

• Baby reminds mother of family member or friend she does not like

• Has difficulty sleeping

• Experiences loss of appetite

sexual activity pp

• can be resumed in 2-4 weeks, but she needs to be healed & not bleeding

• lacerations & episiotomy may cause discomfort

birth control pp

• hormonal bc cannot be used for 6 weeks

• should be discussed before the 6 weeks

follow up visits

• do all women go

• when should It be done

• c-section?

• 40% miss their follow up visits

• should be done @ 6 weeks, no later than 12 weeks

• if c-section in 2 weeks for surgical post op check

processes of parent-infant relationships

• attachment

• bonding

• proximity

• mutuality

• acquaintance

• claiming process

bonding

the emotions and feelings experienced by the mother (or parent) in relation to the infant

attachment

two-way interaction between the mother (or primary caregiver) and the infant that develops during the first year of the infant’s life

proximity

staying close to the infant

mutuality

the infant’s behaviors and characteristics elicit a corresponding set of parental behaviors and characteristics

acquaintance

eye contact, touching, talking, and exploring to become acquainted with their infant

claiming

• first, then finally?

• the identification of the new infant

• The child is first identified in terms of likeness to other family members, then in terms of differences, and finally in terms of uniqueness

early interaction

• skin to skin with mom or partner

• helps with bonding and breastfeeding

couplet care / rooming in / dyading

• promotes?

• drawbacks?

• mom and bay stay in the same room for the length of hospital stay

• promotes bonding and learning but mom is required to be with baby 24/7

• she may lose rest

biorhythmicity

• the fetus is in tune with the mother’s natural rhythms, such as her heartbeat

en face is when

• baby is 12 inches from mom making eye contact

entrainment

• allows for?

• what are the babies doing

• Newborns move in time with the structure of adult speech

• allows babies to begin to acquire speech

• They wave their arms, lift their heads, and kick their legs, seemingly “dancing in tune” to a parent’s voice.

Reciprocity

• baby’s part

• mom’s part

• Reciprocity is a type of body movement or behavior that provides the observer with cues

• newborn fusses and cries, the mother responds by picking up and cradling the infant,

• the baby becomes quiet and alert and establishes eye contact, and the mother verbalizes, sings, and coos while the baby maintains eye contact

• back and forth

  
  

synchrony

• the “fit” between the infant’s cues and the parent’s response

• synchronous interaction is mutually rewarding

• specific cry in response to different situations such as boredom, loneliness, hunger, and discomfort

• Parents learn to interpret

• parent may need assistance in interpreting these cries, along with trial-and-error interventions, before synchrony develops

common issues parents face

• sexual intimacy

• division of responsibilities

• financial concerns

• balancing work and parental responsibilities

• social activities

adolescent moms are more at risk for

• 5 physiologic

• 3 emotional

• lack of?

• more at risk for preeclampsia, anemia, infection, preterm birth, LBW

• PPD, IPV, substance abuse

• lack of prenatal care

babies of adolescent moms are more at risk for

• growth and development issues

• language and speech delays / cognitive delays

• neglect and abuse

issues with adolescent dads

• may not live with mom & baby

• limited education

• live in poverty

• cannot help financially

advanced maternal age issues

• may lack time & energy

• may have less support

• may also be taking care of their own parents

same sex couples at risk for

• lack of support bc of attitude of caregiver

visually impaired parents

• need oral teaching by health care providers

• needs an orientation to the hospital room that allows the parent to move about the room independently. For example, “Go to the left of the bed and trail the wall until you feel the first door. That is the bathroom.”

• need explanations of routines.

• need to feel devices and to hear descriptions of the devices.

• chance to ask questions.

• need the opportunity to hold and touch the infant after birth.

• Nurses need to demonstrate infant care by touch and to follow with, “Now show me how you would do it.”

• Nurses need to give instructions such as “I’m going to give you the baby. The head is to your left side.

hearing impaired parents

• Before initiating communication, be aware of the parent’s preferences and capabilities. Do they wear a hearing aid? Do they read lips? Do they wish to have an interpreter

• Make certain that the parent sees you approaching to avoid startling the parent.

• Before speaking, be directly in front of the parent and have their full attention.

• Avoid standing in front of a light or a window while speaking to the parent.

• If the parent relies on lip-reading, sit close enough so that the parent can easily see your lip movements.

• Speak clearly with a regular voice volume and lip movements while maintaining eye contact.

• Speak in short, simple sentences to facilitate understanding.

• If the parent does not understand something, it is better to find a different way to say what needs to be communicated rather than repeating the same words over and over.

• Written / visual messages aid in communication. A small white or black erasable board can be useful.

• Give educational materials to the hearing-impaired parent and ask them to read the materials before doing parent teaching. They can refer to the materials after discharge.

• When doing parent teaching, it is helpful for a hearing person (partner or family member) to be present.

• Allow ample time to communicate with the hearing-impaired parent; being in a rush can evoke stress and create barriers to effective communication.

Strategies for Facilitating Sibling Acceptance of a New Baby in Prenatal period

• take child where 3

• involvement

• move the child where? when?

• questions?

• Take your child on a prenatal visit. Let the child listen to the fetal heartbeat and feel the infant move.

• Involve the child in preparations for the infant, such as helping to decorate the infant’s room.

• Move the child to a bed (if still sleeping in a crib) at least 2 months before the infant is due.

• Read books, show videos or DVDs, and/or take your child to sibling preparation classes, including a hospital tour.

• Answer your child’s questions about the coming birth and what babies are like and any other questions.

• Take your child to the homes of friends who have newborns so that the child has realistic expectations of what babies are like

Strategies for Facilitating Sibling Acceptance of a New Baby During the Stay in the Birth Facility

• when the child arrives?

• interactions?

• help the child do what

• give the child ?

• Have someone bring the child to the birth facility to visit you and the infant (unless you plan to have the child attend the birth).

• When the child arrives, make sure your arms are open to embrace the child.

• Do not force interactions between the child and the infant. Often the child will be more interested in seeing you and being reassured of your love.

• Help the child explore the infant by showing how and where to touch the infant.

• Give the child a gift (from you, from the father or your partner, and the infant).

Strategies for Facilitating Sibling Acceptance of a New Baby Going Home

• who should stay with the child

• who should Carry the baby

• Have the grandmother or another adult available to focus on the child during discharge from the birth facility and on the trip home.

• Have someone else carry the infant from the car so that you can hug the child first.

Strategies for Facilitating Sibling Acceptance of a New Baby after the baby is home

• time?

• during feedings?

• gifts?

• praise the child for?

• Arrange a special time for the child to be alone with each parent.

• Do not exclude the child during infant feeding times. The child can sit with you and the infant and feed a doll or drink juice or milk or sit quietly with a game. You can read aloud to the child while you are feeding the infant.

• Prepare small gifts for the child so that when the infant receives gifts, the child will not feel left out. The child can also help open the infant’s gifts.

• praise the child for acting age appropriately (so that being an infant does not seem better than being older).

Postpartum Hemorrhage (PPH)

• 2 defining factors

• leading cause of

• when is it recognized

• (1) cumulative blood loss ≥1000 mL or

• (2) bleeding associated with signs/symptoms of hypovolemia within 24 hours of the birth process regardless of type of birth

• Leading cause of maternal morbidity and mortality

• Often unrecognized until mother has profound symptoms

Early, acute, or primary PPH occurs when

• occurs within 24 hours of the birth

Late or secondary PPH occurs when

• occurs more than 24 hours but less than 6 weeks after the birth

Estimated vs quantitative blood loss

• how much is blood loss underestimated by

• EBL is looked at and estimated, under estimated by 50%

• QBL is weighed - (blood and any pads or chucks with blood on them)

uterine atony is the ?

• #1 cause of PPH

• aka marked hypotonia of uterus

• inadequate uterine contractions

• uterus remains flaccid and rapid blood loss follows

uterine atony is asscoiated with

• Overdistended uterus

• Macrosmic (Large) fetus

• Multiple fetuses

• polyhydramnios

• high parity

causes of pph other than uterine atony

• Anesthesia and analgesia

• Previous history of uterine atony

• High parity

• Obesity

• Prolonged labor, oxytocin-induced labor

• Chorioamnionitis

• Trauma during labor and birth

• Forceps-assisted birth

• Vacuum-assisted birth

• Cesarean birth

• Unrepaired lacerations of the birth canal

• Ruptured uterus

• Inversion of the uterus

• Placenta accreta syndrome/morbidly adherent placenta (placenta accreta, increta, or percreta)

• Coagulation disorders

• Placental abruption

• Placenta previa

• Manual removal of retained placenta

• Magnesium sulfate administration during labor or postpartum period

• Uterine subinvolution

• Hypertensive disorders

• Intrauterine fetal demise

• Failure to progress during second stage of labor

if the blood is dark red

• it originated from veins, usually varicosities

if the blood is bright red

• it is from arteries

• deep lacerations of the cervix or genital tract

• increased risk if vacuum or forceps used

• can be trickle of blood or full blown hemorrhage

if there is increased bleeding during placenta separation

• indicative of incomplete placental separation

if there is increased bleeding after placenta separation

• it is either uterine atony or prolapsed uterus

late or secondary PPH Is indicative of

• caused by

• s/s?

• subinvolution

• uterus didn’t contract back down

• from retained placenta/ endometriosis/ pelvic infection

• Signs and symptoms include prolonged lochial discharge, irregular or excessive bleeding, and sometimes hemorrhage

subinvolution tx

• D&curettage

• antibitoics if infection

• methergine - oxytocic drug

retained placenta

• how long do we give the placenta to expel

• if it doesn’t come out? what may we give her during this procedure?

• what drug works best

• after 30 mins of the placenta is not out it can cause PPH

• may need manual removal - needs anesthesia & tocolytic to relax uterus so doc can remove easier

• terbutaline works fastest

risk of giving tocolytic for manual removal

• what can we give to combat?

• increases risk of uterine atony bc it relaxes uterus

• pitocin, cytotec, hemabate can be given to stimulate contractions after the procedure

unusual placental adherence (placenta accreta)

• 3 degrees

• r/o?

• placenta accreta - slight penetration of myometrium

• placenta increta - deep penetration of myometrium

• placenta percreta - perforation of myometrium and uterine serosa, may involve adjacent organs

• r/o PPH and previa for all 3