Postpartum Care Notes

Postpartum Care: Physiologic Changes

• Postpartum Period:

  • From birth to the return of reproductive organs to a non-pregnant state.

  • Also known as the "Fourth Trimester" or Puerperium.

  • Typically lasts from delivery of the placenta to 6 weeks postpartum.

  • Recovery period is defined as the first 2 hours after birth.

  • Greatest risks during this time include postpartum hemorrhage (PPH), shock, and infection.

  • Assessments are done every 15 minutes for the first hour, then every 30 minutes for the next 2 hours.

Physiologic Adaptations: The Uterus

• Involution: Contraction of smooth muscle to facilitate the uterus returning to its pre-pregnancy size.

  • Immediately after delivery, the uterus returns to the size of a 16-week pregnancy (grapefruit).

  • Fundus is located at the umbilicus.

  • After the first 24 hours, the fundus descends 1-2 cm every 24 hours.

  • By 6 days postpartum, the fundus is halfway between the symphysis pubis and the umbilicus.

  • By 2 weeks postpartum, the uterus is typically not palpable abdominally.

Involution & "Afterpains"

• Recovery period is a critical phase.

• What happens during involution:

  • Contraction of muscle fibers.

  • Catabolism: shrinking of myometrial cells.

  • Regeneration of uterine epithelium.

• This is the primary mechanism to prevent postpartum hemorrhage.

• Endogenous oxytocin release is stimulated by nipple stimulation.

• Exogenous oxytocin (IV administration) reduces PPH by half.

• Afterpains are more intense in multiparas and with breastfeeding.

• Nursing Actions:

  • Assess for pain frequently and identify the source.

  • Comfort measures: relaxation, heat, cold, sitz baths, witch hazel pads, peri bottles.

  • Medications: NSAIDs, narcotics.

  • Organize nursing care to allow for rest/naps, especially when the infant is sleeping.

Uterine Assessment

• Fundal height: location in relation to the umbilicus.

• Placement: midline or deviated.

• Consistency: firm or boggy.

• Ideally, the patient should void before the assessment.

• Subinvolution: the uterus does not return to the normal non-pregnant state.

• Factors that slow or cause abnormal involution process:

  • Over distended uterus.

  • Long labors.

  • Retained placenta.

  • C-sections.

  • Infection.

  • Overdistended uterus (twins, triplets, polyhydramnios).

• Nursing Actions to facilitate uterine involution:

  • Administer Oxytocin after placenta.

  • Encourage early breastfeeding.

  • Facilitate emptying bladder.

  • Massage and frequent assessment.

  • FF @ U refers to fundus firm at umbilicus; FF @ U-1 refers to fundus firm one fingerbreadth below the umbilicus.

Pelvic Floor/Muscle Tone Support

• May take 6 months to regain tone.

• May be injured during birth, leading to future gynecologic problems.

• Most women still look pregnant for a bit after delivery.

• Abdominal wall is relaxed for approximately 6 weeks.

• Diastasis recti may occur.

• Interventions:

  • Kegels.

  • Early ambulation.

  • Body mechanics, posture.

  • No abdominal exercises after C-section until provider follow up.

Endocrine System

• Delivery of the placenta leads to rapid clearance of placental hormones, reversing diabetogenic effects and significantly lowering blood sugar levels in the immediate puerperium.

• Estrogen & Progesterone drop immediately after placenta separates and delivers.

• Lowest levels at about 1 week postpartum.

• Helps with lactation and diuresis of excess extracellular fluid.

• Return of Menses:

  • Nonlactating patients: 4-10 weeks.

  • Lactating patients: 6+ months.

Urinary System

• Kidney function returns to normal within a month; urinary tract structures return to normal within 2-8 weeks.

• Diuresis and diaphoresis (especially at night) result in a weight loss of about 5 pounds.

• Causes:

  • Decreased estrogen.

  • Decrease aldosterone= loose NA and water.

  • Can be 2500cc/day.

• Trauma to urethra and bladder can make voiding difficult (and uncomfortable/painful).

• Decreased urge or inability to void.

• Full bladder = uterine atony = ^ bleeding.

Urinary System Assessment

• Sensation.

• Ability to void.

• Output.

• May be excessive 2-3 days PP.

• Amount < 150 = consider urinary retention.

• Signs/Symptoms of distended bladder:

  • Fundal height above umbilicus.

  • Displaced uterus.

  • Bladder bulge.

  • Tenderness or pressure when palpated bladder area.

  • Excessive lochia.

• Interventions:

  • Frequently empty bladder.

  • Measure 1st 2-3 voids.

  • Increase PO fluids.

  • Consider catheterization.

    • I&O cath or Foley.

    • If bladder distended and patient unable to void.

Ambulation Safety

• Check blood pressure first.

• Assess motor function and sensation after epidural/spinal.

• Elevate HOB prior to ambulating.

• Dangle at side of bed.

• Help client stand and test strength of legs and assess for signs/symptoms dizziness, lightheadedness.

• Stay with the patient for their first ambulation.

GI System

• Feed Mom!

• Bowel tone may be reduced, but bowel function readily returns to normal.

• Obstetric trauma can lead to incontinence.

• Most have orders for stool softener – offer it!

• NOTHING in the rectum for patients with 3rd or 4th degree laceration.

• Nursing Interventions:

  • Water 8 glasses/day.

  • Ambulate.

  • Fiber.

  • Goal is to have BM by day 3 PP.

  • Assess bowels sounds.

  • Increased risk for ileus with c/s moms- passing gas to advance diet.

  • Consider interventions for gas pain.

Cardiovascular System

• Average blood loss:

  • 300-500 ml SVD.

  • 700-1500 C/S.

• Postpartum diaphoresis and diuresis 2-5 days PP due to elimination of excess fluid.

• Stroke volume increases for at least 48 hours due to autotransfusion (may decrease HR to 50).

• Cardiac output: remains high in recovery period, returns to pre-labor values at 24-48 hours then gradually returns to normal by 6-8 weeks.

• Physiologic flow murmur may be present.

• Labs:

  • HCT: decreases then returns to normal by 8 weeks PP.

  • HGB: decreases slightly and then rises slowly for 2 weeks PP.

  • Postpartum leukocytosis:

    • WBCs - Can rise to 20,000-25,000.

    • This allows healing and infection prevention.

  • Coagulation factors - remain hypercoagulable (remains elevated 2-3 weeks PP).

Vital Signs

• Temperature may rise to 100.4F/38C due to dehydrating effects of labor; within 24 hours, it should be back to normal. Remember – this is not a fever!!!

• Elevation of temp after 24 hours OR that persists >2 days = consider infection.

• Respirations should decrease to within the woman's normal pre- pregnancy range within 6-8 weeks.

• Pulse returns to nonpregnant levels within a few short days (may be as low as 50 first day pp).

• Blood pressure is altered slightly, if at all.

• Orthostatic hypotension due to blood redistribution.

• Assess:

  • Compare VS to baseline.

  • Assess pedal pulse, skin turgor, edema.

  • Assess for signs/symptoms of DVT.

• Interventions:

  • Fluids – PO.

  • Early ambulation.

  • SCDs.

  • Lovenox if high risk.

Physical Assessment

• Standard adult assessment with a few pieces added - or Holistic assessment: labs, immunizations status, admission hx , L&D data, cultural considerations.

• Every 15 minutes in recovery, on admission to postpartum, every 4 hours or every shift (if stable).

• BUBBLEE:

  • B - breasts.

  • U - uterus.

  • B - bowel.

  • B - bladder.

  • L – lochia.

  • E – episiotomy, laceration or incision.

  • E – extremities (edema).

  • E – epidural.

  • E- emotional status.

Breasts

• Sudden decrease in progesterone causes onset of milk production.

• Prolactin produces the breastmilk; sustained and effective sucking releases adequate amounts of prolactin.

• Oxytocin stimulates milk ejection (letdown); high levels of oxytocin in the first hours after delivery.

• Assessment:

  • Soft, filling, engorged.

  • Stage of milk development - colostrum or true milk.

  • Nipple structure, pain, damage.

• TEACH: Breast care, supportive bra, no soap to nipples.

Breastmilk

• Colostrum- lactogenesis I (2-4 days): High protein (stabilizes infant glucose levels), high antibodies (immune protection; igA, igG), laxative (helps get rid of bilirubin).

• Transitional Milk: Starts around the 3rd day, high in fat, calories, lactose.

• Mature milk- lactogenesis II: More volume= lower fat, greater volume in early morning hours.

• Foremilk- 90% water, low fat, low calories- satisfied thirst= wet diapers.

• Hindmilk- creamier, thick, high fat- satisfied hunger= poopy diapers.

Breast Anatomy

• External Structure:

  • Areola: darker area, 2-3 inches diameter, most sensitive part.

  • Montgomery Glands: bumpy places on the Areola, functions to lubricate skin, lower pH of skin, odor and dark color draw baby to the nipple, may stimulate infant oral cavity.

  • Nipples: 4-10 openings appear on the surface.

• Internal Structure:

  • Ducts: Transports milk from alveoli to nipple openings.

  • Lobes: Groups of alveoli, 7-10 in each breast.

  • Alveoli: Cluster of alveolus, resembles a cluster of grapes.

Breastfeeding Education

• Initiate 1st feed within 1-2 hours of birth.

• Nurse the baby, not the clock.

• Latch q2-3hours 20-40mins ***8-12 times in 24 hours.

• Breastfeeding burns 500cal/day.

• Drink adequate fluids & EAT.

• Assessing for bonding.

• Assess latch: no dimples, no smacking, deep latch with good tissue in NB mouth.

• Wear well-fitted bra (avoid underwire).

Breastfeeding Holds

• Football hold.

• Side lying.

• Cross cradle.

• Cradle hold.

• Layed back.

• Benefits:

  • Promotes brain growth.

  • Fatty acids for brain and CNS development.

  • Passive antibodies.

  • Bonding.

  • Financial.

Engorgement and Mastitis

• MASTITIS:

  • Affects about 1% of women; almost always unilateral.

  • Develops after milk flow established

  • Signs/Symptoms: chills, fever, malaise, and local breast tenderness. Pain, swelling, redness and axillary adenopathy may occur.

  • Most commonly caused by S. Aureus.

  • Antibiotics are prescribed; maintain lactation by emptying breast q 2-4 hours.

• ENGORGEMENT:

  • Signs/Symptoms: appears tight and full, tender, warm, breast congestion and/or obstruction of the ducts.

  • Normal occurrence on day 3-5 postpartum.

  • Hand express first so baby can latch, warm packs before latch, ice after.

  • Frequent feeds, Tylenol/ibuprofen PRN.

Non-Nursing Mothers

• Who shouldn’t breastfeed?

  • HIV.

  • Chemo/radiation.

  • TB.

  • HSV lesions on breast (can feed on unaffected side).

• Teach about lactation suppression:

  • Tight-fitting, supportive bra 24/7.

  • No breast/nipple stimulation.

  • Ice pack (15 on, 45 off, repeat) or cabbage leaves.

  • Mild analgesics, anti-inflammatory meds.

Postpartum Assessment: BUBBLE-EE

• B - breasts.

• U - uterus: Fundus – firm, firm with massage, or boggy; Vertical position in relation to umbilicus; Midline or shifted to right or left; TEACH: how to palpate for self, massage.

• B - bowel: Bowel sounds (Remember to do this before you assess uterus); Abdomen soft, distended-soft, distended- firm; Tympany; Flatus/BMs; TEACH: fiber/fluids/ambulation, peribottle for cleansing.

• B - bladder: Is it full? (consider fundal assessment); Palpable?; Emptying? Measure first 3 voids 150cc or more; Urine quantity, color, clarity; Dysuria; TEACH: Diuresis, peribottle (for cleansing and to stimulate stream).

• L – lochia: Post birth uterine discharge; Assess color, amount, odor consistency; Amount: Scant, Light, Moderate: <Heavy- saturating a pad in 1hr, Excessive- saturating pad in 15 mins; Clots- smaller than silver dollar; Odor - fleshy (similar to menstrual blood); TEACH: change pad every couple of hours, at least every time to bathroom, peribottle, change over time, amt for concern.

• E – episiotomy, laceration or incision: Roll Mom to her side and separate the buttocks to visualize the perineum; Check for REEDA (Redness, Edema, Ecchymosis, Discharge, Approximation); Check for hemorrhoids; Check for hematomas; If applicable, assess cesarean incision; TEACH: Peribottle, changing pad & wiping front to back, wipe gently, Sitz bath, dermaplast.

• E – extremities (edema).

• E – epidural.

• E- emotional status.

Lochia

• Post birth uterine discharge.

• Assess color, amount, odor consistency.

• Amount:

  • Scant.

  • Light.

  • Moderate.

  • <Heavy- saturating a pad in 1hr.

  • Excessive- saturating pad in 15 mins.

• Clots- smaller than silver dollar.

• Odor - fleshy (similar to menstrual blood).

• TEACH: change pad every couple of hours, at least every time to the bathroom, peribottle, change over time, amt for concern.

Lochia Types

• Rubra - appears red & bloody, birth to 3-4 days – may have small clots.

• Serosa - becomes pink or brown, begins day 3-4 and may last up to 22-27 days.

• Alba – (primarily of leukocytes )may drain 6 weeks or longer; average is 10-14 days.

• TEACH:

  • Change pad every couple of hours.

  • Perform hand hygiene when doing perineal care.

  • Use peri-bottle.

  • Wipe/blot front to back.

  • Nothing in the vagina for 6 weeks.

  • Multips have heavier bleeding than primips.

  • Bleeding may be lighter in cesarean sections vs vaginal delivery.

Episiotomy and Lacerations

• Roll Mom to her side and separate the buttocks to visualize the perineum.

• Check for REEDA.

• Check for hemorrhoids; Check for hematomas.

• If applicable, assess cesarean incision.

• TEACH: Peribottle, changing pad & wiping front to back, wipe gently, Sitz bath, dermaplast.

• LACERATION:

  • 1st Degree - extends through the skin and structures superficial to the muscles.

  • 2nd Degree - extends through muscles.

  • 3rd Degree - continues through anal sphincter muscle (NO rectal suppositories).

  • 4th Degree - extends through anterior rectal wall (NO rectal suppositories).

• Other types:

  • Vaginal sidewall lacerations.

  • Periurethral lacerations, Abrasion “skid mark”, clitoral.

• Laceration risk factors: macrosomia, rapid delivery, operative delivery, nulliparity, congenital abnormalities of maternal soft parts; contracted pelvis, skill level of delivery attendant; Requires Surgical repair.

• Ice to perineum for 24 hours, Sitz bath after 24 hours (20 min BID), Analgesics only if needed (PO vs Topical).

Extremities, Edema & Epidural Site

• Assessment of extremities (edema) and epidural site.

VTE Prevention

• Venous thromboembolism (VTE); Most likely cause = DVT.

• Risk factors:

  • Pregnancy.

  • Prolonged immobility (bedrest, c-section).

  • Obesity, Smoking, Multiple gestation, Age, Hx of thromboembolism.

• Assess:

  • Leg pain, Warmth, redness, edema, Calf enlargement and pain, heaving aching

Infant Security

• Inform parents of infant security plan.

• Instruct not to give baby to anyone without proper identification.

• Always match bands.

Postpartum Hemorrhage (PPH)

• Accounts for 25% of maternal deaths.

• Cumulative blood loss of >1000ml with signs/symptoms of hypovolemia.

• Saturating a perineal pad in 15 or less and collection of blood under patient.

• EBL (estimated blood loss) vs QBL (quantified blood loss).

• Late PPH:

  • Occurs 24 hours to 6 weeks after delivery; may cause rapid onset of shock.

  • Causes - retained placental fragments, subinvolution, infection, lacerations.

• The 4 T's of PPH:

  • Tone: (atony).

  • Trauma: (lacerations, expanding hematoma or uterine rupture).

  • Tissue: (retained placental tissue).

  • Thrombin (coags).

  • Traction: pulling on the umbilical cord>uterine inversion.

Prevention of Excessive Bleeding

• Uterine atony is the leading cause of early PPH.

• Uterine massage - gentle massage to firm uterus and expel clots – MASSAGE 1ST BEFORE you attempt to express clots!

• Prevent bladder distention - assist to the bathroom, teach mother importance of emptying the bladder catheterize if necessary.

• Soft boggy uterus accounts for > 90% of PP hemorrhage.

• 2/3 of PP hemorrhages occur without any predisposing factors.

• Risk factors for uterine atony:

  • Overdistended uterus – macrosomia, multifetal pregnancy, polyhydramnios.

  • Anesthesia and analgesia, H/O uterine atony.

  • High parity, Prolonged labor; oxytocin induction.

  • Trauma during labor and birth – operative abdominal or vaginal delivery.

Managing Trauma

• Suspect a pelvic hematoma if a woman reports a persistent perineal or rectal pain or a feeling of vaginal pressure: Bleeding into the tissues of the reproductive tract.

• Increasing perineal or pelvic pain, Perineal, pelvic, or rectal pressure, Difficulty voiding.

• Bulging, bluish swelling painful to palpate; Suspect laceration with steady bright red bleeding and firm fundus.

Where is the Bleeding Coming From?

• Uterus: Fundus boggy, Lochia dark, Diminishes with massage or oxytocic's.

• Laceration: Fundus firm, Frank, bright red bleeding.

PPH Interventions

• Massage, Empty bladder, VS q5min, O2, EKG; IV x2 at least an 18g, Oxytocin.

• Labs- type and cross, CBC, Pt/PTT/Fibrinogen, Balloon tamponade.

• Massive blood transfusion protocol: Whole blood, PRBC, PLT’s, Fresh Frozen Plasma, Cryoprecipitate.

PPH Management

• Massage, Breastfeeding, Bimanual Massage; Compression.

• Medications:

  • Oxytocin (Syntocinon® Pitocin®) first line.

  • Methylergonovine (Methergine®) don’t give with HTN.

  • Prostaglandin F2alpha – (Hemabate®) don’t give with asthmatic.

  • Misoprostol – (Cytotec®)– off-label use.

  • Tranexamic Acid (TXA)- stops the breakdown of fibrinogen and fibrin clots. Given with trauma.

  • Last resort – Hysterectomy.

Infection Prevention

• Standard precautions and handwashing - for all staff, parents, visitors.

• Teach mother perineal care (peri bottle).

• Teach mother to change pads with each trip to the bathroom and to remove and replace pad front to back.

• Signs/Symptoms:

  • Maternal temp >100.4 on two successive PP days, not including the 24 hours after delivery.

  • Fever, localized pain, redness, swelling, purulent discharge, dysuria.

• Risk factors: vaginal exams and procedures, trauma, hemorrhage.

• Pathogens – numerous streptococci and anaerobic organisms most common.

Reproductive Tract Infections

• Chorioamnionitis- a disorder characterized by acute inflammation of the membranes and fetal portion (chorion) of the placenta, typically due to polymicrobial bacterial infection in patients whose membranes have ruptured.

• Endometritis - infection of uterine lining, fever, chills, flu-like symptoms, prolonged afterpains, uterine tenderness, foul lochia.

• Parametritis - pelvic cellulitis, infection into the broad ligaments, usually unilateral, may progress to pelvic abscess.

• Peritonitis - infection of the peritoneum, may lead to ileus.

• Risk factors:

  • Cesarean Section – most significant risk.

  • PROM, Multiple vaginal exams, Compromised health status, Internal monitors, Trauma.

  • Chorioamnionitis, vaginal infections, Operative vaginal delivery, Manual extraction of placenta.

Wound Infection Signs and Symptoms

• Wound warmth, Erythema, Tenderness, Pain, Edema, Seropurulent drainage.

• Wound dehiscence, Evisceration, Temp >100.4 X 2 consec days.

Family Adaptation

• Attachment: formation of a relationship between a parent and a newborn through physical and emotional interactions.

  • Taking in- mom is focused on herself, lasts 2 days (birth – 48 hours), reviews birth experience, dependent and passive.

  • Taking hold- concerned about her care and infants care, often feels vulnerable, mood swings, begins day 2-3 but last 10 days (up to several weeks).

  • Letting go- reestablishes relations with others (partner, children), confidence grows, focus on family unit.

Nursing Actions to Facilitate Bonding

• Engrossment: a time of intense absorption, preoccupation, and interest in the newborn as a partner develops a bond.

• Skin to skin; can be done with partner as well; Newborn facing position - observe similarities in features; Rooming in.

• Quiet and private environment, Teach about newborn care, Encourage cuddling, bathing, feeding, diapering, swaddling, talking, singing, reading, etc.

• Provide praise, support, and reassurance; Allow parents to express their feelings.

Postpartum Mood Disorders

• Mood and anxiety disorders likely to start in or present itself in the post-partum time frame.

• Can impact how the mother and family adapt to the newborn.

Baby Blues

• Up to 85% of women experience “The Blues”; Does not interfere with caring for self or newborn.

• Usually peaks day 2-3 and lasts up to 3 weeks; Typically resolves in 10 days without intervention.

• Signs/Symptoms:

  • Feelings of sadness, Lack of appetite, Sleep pattern disturbances; Feeling of inadequacies.

  • Crying easily for no apparent reason; Restlessness, insomnia, fatigue, Headache, Anxiety, anger, sadness.

  • Letdown feeling, irritability.

Postpartum Depression (PPD)

• Definition: Depression occurring within 12 months of childbirth lasting longer than postpartum blues; can interfere with the ADL’s and caring for the infant.

• Occurs in approx 10-20% of postpartum women (up to 60% in adolescent mothers); May be influenced by estrogen fluctuations.

• NEED TO look for post-partum patients who are agitated, overactive, confused, complaining, or suspicious.

• Treatment:

  • Psychotherapy, antidepressants, or antianxiety medications.

  • Encourage her to ask for help from friends, family, SO (remember the lack of support system is a factor in developing PPD), Sleep, exercise, and nutrition.

• Signs and Symptoms:

  • Feelings of guilt and inadequacies, Irritability, Anxiety, Fatigue persisting beyond a reasonable amount of time, Feeling of loss, Lack of appetite.

  • Persistent feelings of sadness, Intense mood swings, Sleep pattern disturbances, Thoughts of harming self or newborn.

PPD Risk Factors

• Primip, Hx of PPD, History of depression, including prenatal depression, Low self-esteem, Traumatic delivery.

• Lack of social support, Unresolved feelings about the pregnancy, Single with multiple life stressors.

• Fatigue from delivery and change in sleep patterns, May be caused by biological, psychologic, situational, or multifactorial.

• Frequently have had prior major depressive disorder or personal and family history of psychiatric disorders.

Postpartum Psychosis

• Medical Emergency!!!. With Psychotic Features: 0.1-0.2% of pp women; Usually presents itself in the first 2 weeks pp.

• Includes auditory or visual hallucinations, elements of delirium, poor impulse control and judgment, delusions.

• Increased risk of suicide &/or homicide, May have auditory hallucinations related to injuring or killing infant.

• Hospitalization required, Tends to reoccur.

Discharge Teaching

• Rubella vaccination - requires maternal consent; avoid pregnancy for at least 1 month (some recommend 2-3 months).

• Varicella vaccination before d/c and at 1st PP visit, TDAP vaccine, Signs/Symptoms infection, excessive bleeding, pain, swelling of one leg.

• Follow up appointments for mom and baby; May be reluctant to bring it up – resuming sexual intimacy (contraception, fear, pain, decreased vaginal moisture).

• Self-care and signs of complications; Sexual activity - pelvic rest for 6 weeks, Contraception - consider lactation.

• Prescribed medications and continue prenatal vitamins (*iron); Check-ups and follow-ups

• Resources - telephone follow-up, warm lines, support groups, community resources.

Birth Control Review of Types

• Abstinence, Male or Female condom, Diaphragm or cervical cap.

• Oral birth control pills – variety of strengths with varying amounts of a combination of hormones(estrogen/progestin) – requires prescription, taken daily.

• Progestin only- fewer side effects- can take while breastfeeding or w/ hx of DVT/high BP, Injectables – typically every 12 weeks – when started? (5 days after delivery/menstrual period).

• Implantable (Implanon: left in to approx. 4 years, When started?, IUDs – good for 5-10 years, may be with or without hormones.

• Surgical- Bilateral tubal / bilateral salpingectomy- decreases risk for ovarian cancer by 50%.

• Risk of adverse effects with hormonal contraceptives: thromboembolism; doesn’t prevent STI.

Essential Discharge Teaching

• Focus teaching based on patient’s education level, health literacy, and language.

• INCLUDE Teaching on:

  • Pain and discomfort, Immunizations, Nutrition, Activity and exercise.

  • Infant Care, Lactation, Sex and contraception, Follow up.

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Postpartum Assessment (BUBBLES)

• B - Breasts: Soft, filling, engorged; colostrum or true milk; nipple structure, pain, damage. Action: Teach breast care, supportive bra, avoid soap on nipples.

• U - Uterus: Fundus – firm, firm with massage, or boggy; Vertical position in relation to umbilicus; Midline or shifted to right or left. Action: Teach self-palpation and massage.

• B - Bowel: Bowel sounds; Abdomen soft, distended-soft, distended-firm; Tympany; Flatus/BMs. Action: Teach fiber/fluids/ambulation, peribottle for cleansing.

• B - Bladder: Is it full? Palpable? Emptying? Measure first 3 voids >150cc; Urine quantity, color, clarity; Dysuria. Action: Teach diuresis, peribottle.

• L - Lochia: Color, amount, odor consistency; Scant, Light, Moderate, Heavy, Excessive; Clots; Odor. Action: Teach pad changes, peribottle, amount for concern.

• E - Episiotomy/Laceration/Incision: REEDA, hemorrhoids, hematomas, cesarean incision. Action: Teach Peribottle, changing pad, Sitz bath, dermaplast.

• E - Extremities: Edema, DVT signs.

• E - Emotional Status: Assess mood, bonding.

Anatomic and Physiologic Changes

• Uterus: Involution (contraction), fundus descends 1-2 cm every 24 hours, returns to pre-pregnancy size by 6 weeks. 

  • Involution - contraction of smooth muscle to facilitate the uterus returning to its pre-pregnancy size

  • Returns to 16- week size (grapefruit) immediately after delivery

    • Fundus @ umbilicus

  • After first 24 hours, descends 1-2 cm every 24 hours

  • 6 days - halfway between symphysis and umbilicus

  • 2 weeks - not palpable abdominally

• 

• Lochia: Rubra, serosa, alba.

• Endocrine: Estrogen and progesterone drop, prolactin increases with breastfeeding.

• Urinary: Diuresis, diaphoresis.

• Cardiovascular: Blood volume decreases, cardiac output returns to normal by 6-8 weeks.

• GI: Bowel tone reduced.

Normal vs. Abnormal Findings

• Uterine Involution:

  • Normal: Firm fundus, descends daily.

  • Abnormal: Boggy uterus, subinvolution (caused by retained placenta, infection, overdistention).

• Lochia Flow:

  • Normal: Rubra (3-4 days), serosa (up to 27 days), alba (10-14 days).

  • Abnormal: Heavy bleeding (saturating pad in 1 hour), large clots, foul odor.

• Voiding/Stooling:

  • Normal: Diuresis, spontaneous bowel movement by day 2-3.

  • Abnormal: Urinary retention, constipation.

• Vital Signs:

  • Normal: Temp up to 100.4F in first 24 hours, HR returns to pre-pregnant levels.

  • Abnormal: Fever after 24 hours, elevated BP, signs of DVT.

Laceration Degrees

• 1st Degree: Skin and superficial structures.

• 2nd Degree: Through muscles of the perineal body.

• 3rd Degree: Through anal sphincter muscle.

• 4th Degree: Through anterior rectal wall.

Systematic Assessment Sequence

1. Vital signs.

2. Breasts.

3. Uterus (fundal height, placement, consistency).

4. Bowel.

5. Bladder.

6. Lochia.

7. Episiotomy/laceration/incision (REEDA).

8. Extremities.

9. Emotional status.

Key Teaching Opportunities

• Self-Care: Perineal care, hygiene, nutrition, rest.

• Newborn Care: Feeding, diapering, cord care, safe sleep.

• Complications: Signs of infection, PPH, DVT, mood disorders.

• Follow-Up: Appointments for mom and baby.

Maternal, Paternal, and Sibling Adaptation

• Maternal:

  • Taking-in: Focused on self, reviewing birth experience.

  • Taking-hold: Concerned about self and infant care, mood swings.

  • Letting-go: Reestablishes relationships, focuses on family unit.

• Paternal: Engrossment (intense interest in the newborn).

• Sibling: Adjustment to new family member.

Factors Affecting Attachment

• Parent: Emotional well-being, support system, previous experiences.

• Infant: Temperament, health status.

• Interventions: Skin-to-skin, rooming-in, teaching newborn care.

Contraception

• Risks: Thromboembolism (hormonal methods), infection (IUD).

• Benefits: Prevents unwanted pregnancy, spacing births.

• Teaching: Proper use, side effects, contraindications.

Postpartum Complications

Causes of Deviations

• Vaginal Delivery: Lacerations, hematomas, infection.

• C-Section: Infection, hemorrhage, thromboembolism.

Common Complications

• PPH: Risk factors (uterine atony, lacerations), assessment (fundal height, lochia), prevention (uterine massage, oxytocin), management (medications, transfusion).

• Infection: Risk factors (C-section, PROM), assessment (fever, wound assessment), prevention (hand hygiene, perineal care), management (antibiotics).

• Thromboembolic Disorders: Risk factors (immobility, hypercoagulability), assessment (leg pain, edema), prevention (ambulation, SCDs), management (anticoagulants).

Postpartum Hemorrhage

• Early PPH: Uterine atony, lacerations, retained placental fragments.

• Late PPH: Subinvolution, infection.

• Uterine Atony: Boggy uterus, massage and oxytocics.

• Bleeding Lacerations: Firm fundus, bright red bleeding, surgical repair.

Immediate/Urgent Actions for PPH

• Massage uterus.

• Empty bladder.

• Administer oxygen.

• Establish IV access.

• Administer medications (oxytocin, misoprostol, etc.).

• Call for help.

Pharmacologic Agents

• Oxytocin: First-line, contracts uterus.

• Methylergonovine: Contraindicated in HTN.

• Misoprostol: Off-label use, contracts uterus.

• Tranexamic Acid (TXA): stops the breakdown of fibrinogen and fibrin clots. Given with trauma.

Postpartum Infections

• Assessment: Fever, wound assessment, lochia assessment.

• Laboratory Data: Elevated WBCs.

• Treatment: Antibiotics.

Thromboembolic Disorders

• Risk Factors: Hypercoagulability, immobility, C-section.

• Treatment: Anticoagulants, compression stockings.

Postpartum Mood Disorders

• Baby Blues: Transient sadness, resolves within 2 weeks.

• Postpartum Depression: Persistent sadness, anxiety, interferes with ADLs, treat with therapy and/or medication.

• Postpartum Psychosis: Hallucinations, delusions, risk of harm to self or infant, requires hospitalization.