Post-Partum Woman

Slide 1

Postpartum periodinterval between the birth of the newborn and the return of the
reproductive organs to their non-pregnant state.
Slide 3

Although changes are normal, in no other period of life is there such

marked and rapid physiological catabolism.

Slide 4

Uterus- Involution occurs immediately after explosion of the placenta.

At the end of the 3rd stage of labor the uterus is midline, aprrox 2cm
below the level of the umbilicus. After 12 hrs the fundus rises to
aprrox the level of the umbilicus. The fundus then descends 1-2 cm
every 24 hrs. Unable to palpates after 9th day PP.
Breasts- Colostrum or early milk is expressed from breasts after
birth. The breast gradually become fuller and heavier as the
colostrum transitions to mature milk by 72-96 hrs after birth. The
breast may feel warm, firm, and somewhat tender. As milk glands
and milk ducts fill with milk, breast tissue may fell somewhat nodular
or lumpy. Some women may experience engorement but with
frequent breast feeding and proper care this conditions is temporary
and last only 24-48 hrs. In non breast feeding mothers breast feel
nodular and its typically bilaterally and diffuse. Palpation of the breast
on the 2nd or 3rd day as milk production begins, may reveal tissue
tenderness, on the 3rd or 4th day engorgement may occur. The breast
are distended, firm, tender, and warm to touch because of
vasocongestation. Teach mother not to stimulate breasts in any way
-- warm water in shower, nipple stimulation, manual expression,
suckling. Will resolve spontaneously in 24 - 36 hours. Teach comfort
measures -- breast binder or tight bra, ice packs, mild analgesics.
Perineum- The greatly distended smooth-walled vagina gradually
decreases on size and regains tone but never completely return to its
prepregnancy state. Immeditaley after birth the introitus is
erythematous and edematous. Assess lacerations and episiotomies
with women lying on her side with her buttock raised or placed in
litthotomy. Assess for signs of infection, loss of approximation.
Assess for hemorrhoids.

Post-Partum Woman

Bowel- Woman may not have bowel movement for 2-3 days after
childbirth. Delay can be explained by decreased muscle tone in the
intestines and prelabor diarrhea, lack of food, or dehydration. Also
mom may resist the urge to defecate because of the anticipation of
pain from hemorrhoids, epis, or lacerations.
Bladder- Birth-induced trauma, increased bladder capacity after
childbirth, and effects of conduction anesthesia combine to cause a
decreased urge to void. You want to avoid bladder distention
because it can cause excessive bleeding by pushing the uterus up
and the side and preventing it from contracting firmly. With adequate
emptying of the bladder, bladder tome is usually restored 5-7 days
after birth.
Cardiovascular- Blood volume- Changes in blood volume depend on
several factors such as blood loss during childbirth and the amount
of extravascular water mobilized and excreted. Pregnancy-induced
hypervolemia (an increase in blood volume of at least 35% more
than prepregnancy values near term) allows most women to tolerate
considerable blood loss during childbirth. Average blood loss for
vaginal delivery ranges from 300 to 500ml (10% blood volume). Csection delivery is 500-100ml (15%-30% blood volume). During the
first few days after childbirth the plasma volume decreases further as
a result of diuresis. The womans response to blood loss after
delivery is different than when in nonpregnant state. Three pp
physiologic changes protect the woman by increasing circulating
blood volume: 1) elimination of uteroplacenatal circulation reduces
blood volume; 2) loss of placental endocrine function removes the
stimulus fro vasodilation, and 3) mobilization of extravascular water
stored during pregnancy occurs. By the 3rd pp day the plasma
volume has been replenished as extravascular fluid returns to the
intravascular space. Cardiac output- Pulse rate, stroke volume, and
cardiac output increase throughout pregnancy and remains
increased for first 48 hrs postpartum. CO decreases by 30% by 2
weeks after childbirth and then gradually decreases to nonpregnant
values by 6-12 weeks in most women.

Post-Partum Woman

Blood- Hct and HGB- After childbirth the total blood volume
decreases apprx 16% from its prebirth value, resulting in a transient
anemia. After 8 weeks the number of red blood cells has increased
and the majority of women have a normal hematocrit. WBC- During
first 10-12 days after childbirth, WBC values can be between 20,00025,000. This can obcure a dx of acute infection at this time.
Abdominal musculature- During the first days after birth, abdomen
still protrudes and gives her a still pregnant appearance. Approx 6
weeks is required for the abdominal wall to approximate its
prepregnancy state. The return of time depends on previous tone,
proper exercise, and the amount of adipose tissue present.
Slide 6

Breasts: [B]

Before lactation begins breasts are soft and colostrum, a yellow fluid, can
be expressed from the nipples. Colostrum is rich in antibodies and
protein.
After lactation begins [2nd or 3rd day] breasts are firm, warm and tender.
Tenderness lasts ~48 hours after lactation begins. Bluish white milk can
be expressed from the nipples.
Examine the nipples for erectility and signs of irritation -- cracks, blisters,
reddening. May feel a mass in breast that shifts position day to day -- fluid
filled milk sac. Observe for signs of redness and pain in breast that may
signal a clogged milk duct.
Engorgement -- occurs on 3rd or 4th day in women who choose not to
breastfeed. Breasts are swollen, firm, tender, warm. Teach mother not to
stimulate breasts in any way -- warm water in shower, nipple stimulation,
manual expression, suckling. Will resolve spontaneously in 24 - 36 hours.
Teach comfort measures -- breast binder or tight bra, ice packs, mild
analgesics

Post-Partum Woman
Slide 7

Uterus: [U]

Slide 8

Trauma and effects of anesthesia may cause a decrease in the urge to

void.
Decreased voiding along with postpartum diuresis may result in a
distended bladder.
Immediately, a distended bladder pushes the uterus up and to the side
preventing the uterus from firmly contracting. This results in excessive
bleeding.
Later, a distended bladder increases the risk for infection.
With adequate emptying of the bladder, tone is usually restored in 5 to 7
days after birth.
Teach methods to stimulate voiding -- early ambulation, listening to
running water, placing hands in warm water, warm water poured over
perineum. Catheterization may be necessary if efforts to stimulate voiding
are unsuccessful.

Bowels: [B]

Slide 10

Involution -- end of third stage uterus is at the midline and 2 cm below

umbilicus. By 12 hours uterus is at or 1 cm above the umbilicus. Fundus
will descend 1 to 2 cms each day. Unable to palpate after ninth
postpartum day. Uterus involutes because of hormone withdrawal
(estrogen and progesterone). Remains firm and contracted under the
influence of oxytocin from the posterior pituitary. Breastfeeding and fundal
massage facilitate involution. Suckling stimulates the release of oxytocin.
Subinvolution -- failure of uterus to involute. Most common causes are
retained placental fragments and infection.
Teach fundal massage.

Bladder: [B]

Slide 9

Spontaneous evacuation may be delayed until 2 to 3 days because of

decreased muscle tone in the intestines during labor, prelabor diarrhea,
lack of food or dehydration.
Mother may resist the urge to deficate because of anticpated discomfort
from episiotomy, lacerations, hemorrhoids.
Regular bowel habits need to be reestablished when bowel tone returns.
Medications may be given to assist -- stool softeners, laxatives, etc.
Teach importance of high fiber diet, plenty of fluids, and exercise.

Lochia:[L]

Color and Character

rubra -- red in color; mainly blood and decidual and trophoblastic debris;
lasts ~3 days
serosa -- pink in color; old blood, serum, leukocytes, tissue debris; lasts
until ~day 10
alba -- color is yellow/white; leukocytes, decidua, epithelial cells, mucus,

Post-Partum Woman

serum, and bacteria; lasts up to and beyond 6 weeks pp

Slide 11

Flow in women who have received an oxytocic is usually scant until

effects of medication wear off

less after cesarean birth

increases with ambulation and breastfeeding -- pools in vagina when

lying down then gushes upon standing

Teach color changes. Report any change in opposite direction. Green and
foul smelling is never normal. Rubra after alba may mean late PPH from
retained fragments or infection.

Episiotomy:

Slide 12

Amount: [see text fig. 23-5 page 597]

scant (<2.5 cm [1 inch] in 1 hr)
light (<10 cm [4 inches] in 1 hr.)
moderate (<15 cm [6 inches] in 1 hr)
heavy (saturated in 2 hours)
excessive (saturated in 15 minutes).

An incision made in the perineum to enlarge the vaginal outlet. Midline is

the most common type in the US.

Episiotomy:

An incision made in the perineum to enlarge the vaginal outlet. Midline is

the most common type in the US.
Types:
first degree -- extends through the skin and structure superficial to
muscles [vaginal membranes]
second degree -- extends through muscles of the perineal body
[vaginal membranes + fascia]
third degree -- extends through the anal sphincter muscle
[membranes + fascia + anal sphincter]
fourth degree -- involves anterior rectal wall [membranes + fascia +
anal sphicter + anal canal]
Most frequently used:
nulliparity
occiput posterior position
large infants
use of instruments to facilitate birth
prolonged second stage

Post-Partum Woman

Slide 14

Slide 15

fetal distress

Emotion: [E]

Baby blues are experienced by most women as a period of emotional

lability -- crying easily for no apparent reason. These feelings peak at
about day 5 and are gone by day 10.

Etiology is unknown but a let-down feeling, restlessness, fatigue,

insomnia, and anxiety contribute to feelings of depression. May be
overwhelmed by parental responsibilities, deprived of supportive care
experienced during pregnancy, fatigued from the round-the clock
demands of the new baby.

Teach: blues are normal. Get plenty of rest by napping when baby
naps, going to bed early, controlling visits from family and friends. Use
relaxation techniques. Do something special for yourself. Talk to your
partner about how you feel. Call provider if symptoms of depression
intensify or persist past the babys first few weeks. May be a sign of
postpartum depression that rarely disappears without outside help and
pharmacologic intervention. May develop into postpartum psychosis -- a
syndrome of depression, delusions, and suicide/infanticide ideation.

Dependent Phase [Taking In]:

first 24 to 48 hours after childbirth

mothers dependency needs predominate -- she needs mothering
herself to mother
Nurturing and protective care are required by the new mother
Mothers suspend their involvement in everyday responsibilities and rely
on others to satisfy their needs for comfort, rest, and nourishment.
Parents need to verbalize their experience of pregnancy and birth.
Focusing on, analyzing and accepting these experiences help the parents
move on to the next phase.

Post-Partum Woman

Dependent-Independent Phase [Taking Hold]:

occurs by 2nd or 3rd day and lasts ~10 days

desire for independent action reasserts itself
mother alternates between a need for nurturing and acceptance and the
desire to take charge once again.
Enthusiastic response to learning or carrying out baby care
Taking hold behaviors are enhanced by current OB practices -- childbirth
preparation classes, OB pain management, early contact with newborn,
rooming-in, early discharge
Mothers are discharged during this phase
Main concerns during this phase -- fatigue, loss of weight or figure, pain
from episiotomy or cesarean incision, sexual relations, hemorrhoids.
Baby Blues are a recurring emotional concern but feelings of depression
are transient (<1 week).

Interdependent Phase [Letting Go]:

Slide 17

Interdependent behavior reasserts itself, and the mother and her family
move forward as a unit with interacting members.
May be a time when new father feels alienated and jealous of the infant
A stressful period as the parental pair resolve issues of divergent interests
and needs. Partners are grappling with the effects on the relationship of
child rearing, homemaking and career demands.

You are the nursing supervisor when Maggies nurse makes this
complaint. How will you respond to this nurse?
Dependent Phase [Taking In]:

first 24 to 48 hours after childbirth

mothers dependency needs predominate -- she needs mothering
herself to mother
Nurturing and protective care are required by the new mother
Mothers suspend their involvement in everyday responsibilities and rely
on others to satisfy their needs for comfort, rest, and nourishment.
Parents need to verbalize their experience of pregnancy and birth.
Focusing on, analyzing and accepting these experiences help the parents
move on to the next phase.

Dependent-Independent Phase [Taking Hold]:

occurs by 2nd or 3rd day and lasts ~10 days

desire for independent action reasserts itself
mother alternates between a need for nurturing and acceptance and the
desire to take charge once again.
Enthusiastic response to learning or carrying out baby care
Taking hold behaviors are enhanced by current OB practices -- childbirth
preparation classes, OB pain management, early contact with newborn,
rooming-in, early discharge

Post-Partum Woman

Slide 23

Mothers are discharged during this phase

Main concerns during this phase -- fatigue, loss of weight or figure, pain
from episiotomy or cesarean incision, sexual relations, hemorrhoids.
Baby Blues are a recurring emotional concern but feelings of depression
are transient (<1 week).

Nursing Judgment:

Normal postpartum period

Fundus at the umbilicus
Normal involution

end of the 3rd stage- in the midline, approx 2 cm below, fundus resting
on the sacral promontory
within 12 hours- rises to umbilicus
Fundus descends 1 -2 cm every 24 hours

Moderate lochia rubra

VSS -- see table 21-2, pg 489
Temp increases in first 24 hours due to dehydration or epidural,
then afebrile
Heart rate and Pulse returns to non-pregnant value within a few
days

at risk for orthostatic hypotension within first 48 hours.

Bonding with newborn

Expect profuse diaphoresis within 12 hrs, especially at night for 2-3 days
-- loss of extra tissue fluid due to decrease in estrogen.

Risks for postpartum hemorrhage include:

high parity (G4) -- uterine atony
anesthesia -- uterine atony
bladder distention -- uterine atony
3rd degree episiotomy -- vaginal hematoma

Post-Partum Woman
Slide 26

Essential data in the postpartum period includes:

Slide 27

blood type and Rh factor

rubella status
infant feeding method
support system

The nurse gathers additional assessment data on Maggie:

What is the significance of these findings?

Mothers and babys blood type are both O -- no risk for ABO
incompatibility
Rh negative
Direct and indirect Coombs are negative

indirect tests mothers serum for antibodies to Rh antigen -- first penatal

visit, repeat at 28 weeks
direct test infants cord blood for antibodies to Rh antigen
Maggie has not been sensitized and is therefore a candidate for
Rhogam

Rubella status is non-immune

Rubella vaccine is recommended for women who have not had rubella
or are serologically negative in the immediate postpartum period.

Rubella titer is < 1:8. Therefore Maggie is non-immune and will require a
rubella vaccine prior to discharge. Since she will also be receiving
Rhogam that suppresses the immune response she may need to repeat
the Rubella titer in 3 months to see if she will need another dose of
vaccine.
Rubella vaccine is reconstituted with the diluent provided by the
manufacturer. A single does [,5 mL] is administered SC in the outer
aspect of the upper arm with a 25 gauge 5/8 in needle.

Rubella vaccine is a live attenuated virus that is not communicable

therefore breastfeeding women may receive it. However, it is shed in
urine and other body fluids and should not be given if mother or
household member is immuno-compromised. Vaccine is made from
duck eggs -- allergic reaction may require adrenaline.

Rubella vaccine is teratogenic -- requires informed consent and an

understanding that pregnancy must be avoided for 1 month following
vaccination.

Hospital is still teaching to avoid pregnancy for 3 months

Post-Partum Woman
Slide 28

Rh Disease:

Slide 29

10

Affects mothers with a negative Rh Factor when the baby is Rh positive

Fetal blood crosses the placental barrier and the mother develops
antibodies to the Rh antigen. This is referred to as maternal sensitization.
The first pregnancy in which sensitization occurs is not affected. In
subsequent pregnancies the maternal antibodies will attack and lyse fetal
red blood cells resulting in a severe fetal hemolytic anemia -erythroblastosis fetalis or hydrops fetalis.
Maternal sensitization can occur as the result of: previous pregnancy with
an Rh-pos fetus; transfusion with Rh-pos blood; spontaneous or elective
abortion after the eighth week of gestation [hematopoiesis begins in 8th
week]; amniocentesis; premature separation of the placenta, and trauma.
The nurse takes a history to determine if any of these events have
occurred. Then checks records to determine if Rhogam was administered.
Indirect Coombs test at first PNV and again at 28 weeks will
determine presence of antibodies.
Rhogam is a preparation of passive antibodies that bind with fetal
RBC antigens causing the cells to phagocytose before the womans
immune system is activated to produce antibodies.
Administered at 28 weeks and within 72 hours of birth
1 vial (300 ug) is usually sufficient -- handles 15 mL of fetal blood in
maternal circulation.
If large fetomaternal transfusion is suspected perform a KleihauerBetke test to detect the amount of fetal blood in maternal
circulation and adjust the Rhogam dose accordingly.
Treat Rhogam as a blood product -- identification, lot number,
expiration date, religious beliefs.

What needs intervention?

Voiding frequent small amounts -- should be 150 cc each voiding to be

adequate. Spontaneous voiding returns in 6-8 hours.
Last bowel movement prior to delivery -- expect return of normal function
by day 2 or 3. May administer a stool softener.

Post-Partum Woman
Slide 30

Slide 31

11

What is Maggie experiencing? Why?

Afterpains -- uncomfortable cramping more notable in multiparas than

primiparas. Maggie is a G4.

Breastfeeding and exogenous oxytocic medications intensify afterpains

since both stimulate uterine contractions. Maggie is breastfeeding.

Other risk factors for afterpains -- overdistended uterus from a large baby
or twin gestation.

What is wrong with Lillian?

Uterine Atony: -- Failure of the uterine muscle to contract firmly resulting

in marked hypotonia. It is the leading cause of PPH.
Risk factors:
overstretched uterus that contracts poorly after birth
grand multiparity
hydramnios
macrosomic or large fetus
multifetal gestation
traumatic birth
magnesium sulfate
rapid or prolonged labor
chorioamnionitis
pitocin induction or augmentation
Assessment: Figure 37-1 pg 978
Blood pressure is not a reliable indicator of impending shock from early
hemorrhage. Why? Volume expansion in pregnancy
Better assessment parameters include -- respirations, pulse, skin
condition, urinary output, level of consciousness.

Post-Partum Woman
Slide 32

Slide 33

12

What is the most likely cause of her severe pain?

Vaginal hematoma -- a collection of blood in the connective tissue

Risk factors -- forceps-assisted birth, episiotomy, primagravidy

Assess for hematoma if patient c/o persistent perineal or rectal pain or

feeling of pressure in the vagina

A subperitoneal hematoma may cause minimal pain. Initial symptoms

may be signs of shock.

Splanchnic Engorgement:

rapid decrease in intraabdominal pressure after birth results in a dilation

of blood vessels supplying the intestines
causes blood to pool in the viscera
contributes to the development of orthostatic hypotension
may occur when woman who recently gave birth sit or stands up, first
ambulates, or takes a warm shower or sitz bath.

Other considerations:

Slide 34

baseline blood pressure

amount of blood loss
type, amount, timing of analgesic or anesthetic medications

Bath -

may shower independently as early as 9 hours after birth

no scientific evidence that bath water in the vagina increases the risk of
infection
recommend showering until bleeding stops and episiotomy is healed -- 2
to 4 weeks.

Work -

return to occupational or educational settings depends on the nature of

the activity and the womans unique circumstances
healthy women who deliver vaginally safely return in 4 - 6 weeks
providing the planned activities are not too strenuous. Following
cesearean birth wait at least 6 - 8 weeks.

Sexual intercourse -

recommend waiting until after 6 week pp check-up

Post-Partum Woman

13

many couples will resume before 6 weeks -- safe after 2 - 4 weeks when
bleeding has stopped and episiotomy has healed.
risk of hemorrhage and infection are minimal after 2 weeks pp

Prenatal vitamins and iron -

continue until 6 weeks pp or current supply has been used

Exercise -

soon after birth

recommend starting with simple exercise and slowly progressing to more
strenuous [text - pg 602 exercises for new mother]
recommend Kegel exercises to strengthen muscle tone