Lecture 7

Postpartum
Ch 20, 21, & 23
Lynne Rhodes, MSN, APRN, FNP-C

POSTPARTUM PERIOD
Think Safety!!
What can go wrong?
What is normal/abnormal?
What will be my first action if abnormal
findings occur?

Reproductive System:
Uterus

Involution: return of uterus to a

nonpregnant state following birth
Fundus

descends 1 to 2 cm every 24 hours

2 weeks after childbirth, uterus lies in true
pelvis

Subinvolution: failure of uterus to return

to nonpregnant state
Common

causes are retained placental

fragments and infection

Involution
The fundus will be at about 1 cm or fingerbreadth above the
umbilicus for the 1st 12-24 hours after delivery, then begins a slow
descent into the pelvis. Most important in checking the fundus
IT SHOULD NEVER MOVE UPWARDS OR DEVIATE FROM THE
MIDLINE!!

Reproductive System: Cervix

Soft immediately after birth
Within 2 to 3 postpartum days it has shortened,
become firm, and regained form
Ectocervix appears bruised and has small
lacerations

Optimal

conditions to develop infection

Cervical os, dilated to 10 cm during labor,

closes gradually
KAPLAN HINT: If patient has signs/symptoms
of postpartum infection, what should the nurse
do?

Reproductive System: Vagina

Vagina gradually returns to prepregnancy size by 6 to 10

weeks after childbirth
Pelvic muscular support (Kegel exercises)
Thickening of vaginal mucosa occurs with return of
ovarian function
Dryness and coital discomfort, dyspareunia, may persist
until return of ovarian function
Introitus is erythematous and edematous
Episiotomies heal within 2 to 3 weeks
Hemorrhoids and anal varicosities are common and
decrease within 6 weeks of childbirth
Internal hemorrhoids may evert while woman is
pushing during birth

Cardiovascular System

Blood volume
Blood

volume increase eliminated within first 2

weeks after birth, with return to nonpregnancy
values by 6 months postpartum
Readjustments in maternal vasculature after
childbirth dramatic and rapid. Pulse may decrease
to 50 (which could identify shivering in patient).

Cardiovascular System

Cardiac output
Remains

increased for 48 hours after birth

Decreases by 30% by 2 weeks postpartum
Stroke volume, cardiac output, end-diastolic
volume, and systemic vascular resistance remain
elevated for 12 weeks postpartum
Left ventricular volume and cardiac output remain
elevated for 1 year postpartum

Hematologic system

Blood components
Hgb/Hct

rise due to sudden decrease in plasma

volume, UNLESS patient has excessive blood loss
White blood cell count is elevated (making it difficult to
use WBC to determine infection
Coagulation factors elevated, increasing the risk for
thromboembolism.
Varicosities
Regress rapidly immediately after childbirth
Total or nearly total regression of varicosities is
expected after childbirth

Endocrine System

Placental hormones
Expulsion

of placenta results in dramatic

decreases of placental-produced hormones
Decreases in chorionic somatomammotropin
(hCS), estrogens, cortisol, and placental enzyme
insulinase reverse effects of pregnancy
Estrogen and progesterone levels drop markedly

Urinary System
Diuresis occurs; woman excretes up to
3000ml/day of urine.
Bladder distention and incomplete emptying
are common.
Persistent dilatation of ureter and renal
pelvis increase risk for UTI.
Urine glucose, creatinine, and BUN levels
are normal after 7 days.

Gastrointestinal System

Appetite
Most

new mothers very hungry after recovery

from analgesia, anesthesia, and fatigue

Bowel evacuation
Excess

analgesia and anesthesia may

decrease peristalsis.
Spontaneous bowel evacuation may not occur
for 2 to 3 days after childbirth

Musculoskeletal System

Reversal of pregnancy adaptations

Pelvis

muscles regain tone in 3 to 6 weeks.

Abdominal muscles regain tone in 6 weeks
unless diastasis recti (seperation of rectus
abdominis muscles) occur.

New mother may notice permanent increase in shoe

size

Neurologic System
Pregnancy-induced neurologic
discomforts abate after birth
Headache requires careful assessment
Postpartum headaches may be caused by
gestational hypertension, stress, and
leakage of cerebrospinal fluid into the
extradural space during placement of
needle for epidural or spinal anesthesia

Integumentary System

Chloasma of pregnancy usually disappears at end

of pregnancy
Hyperpigmentation of areolae and linea nigra may
not regress completely after childbirth
Some

women will have permanent darker pigmentation

of those areas
Stretch marks on breasts, abdomen, and thighs may
fade but not disappear

Integumentary System

Vascular abnormalities, spider angiomas, palmar

erythema, and epulis regress with rapid decline
in estrogens
Spider nevi persist indefinitely for some
Hair

growth slows during postpartum period

Abundance of fine hair during pregnancy usually

disappears after birth
Coarse

or bristly hair that appears during pregnancy

usually remains

Integumentary System
Profuse diaphoresis in immediate
postpartum period is most noticeable
change in integumentary system
Mostly occurs at night
Body is losing excess tissue fluid
accumulated during pregnancy
Occurs due to loss of the increased
blood volume of pregnancy

Immune System
No significant changes in maternal immune
system occur during postpartum period
Mothers need for rubella vaccination or for
Rho (D) immune globulin for prevention of
Rh isoimmunization is determined

REMEMBER:

RhoGam is given to mothers who are Rhnegative when fetus is Rh-positive and has a
negative direct Coombs test. If the mother has a
positive Coombs test, there is no need to give
RhoGAM, but if the Coombs is negative
RhoGAM must be given within 72 hours of
delivery
The MMR vaccine is given to mothers who are
not rubella-immune. THEY SHOULD BE
INFORMED NOT TO GET PREGNANT FOR AT
LEAST 3 MONTHS AFTER THE VACCINE!

Chapter 21
Nursing Care during the
Fourth Trimester

Fourth Stage of Labor

First 1 to 2 hours after birth
Breastfeeding is recommended to begin
Postanesthesia recovery

Regardless

of obstetric status, no woman

should be discharged from recovery area until
completely recovered from anesthesia.
When the mother feels ready to stand, the
nurse should always stay with her the first time
up!!

Vital Signs/Lab

Vitals
1st

Hour q15min
2nd Hour q 30 min
Q hour thereafter
Once discharged q 48hrs

Lab
H/H

to assess blood

loss
Urinalysis
Rubella and Rh

Vital Sign

Description

Temperature

May rise to 100.4 due to dehydrating

effects of labor. Any higher elevation
may be due to infection and must be
reported

Pulse

May decrease to 50 (normal puerperal

bradycardia). Pulse >100 may indicate
excessive blood loss or infection.

Blood Pressure

Should be normal. Suspect

hypovolemia if it decreases,
preeclampsia if it increases.

Respirations

Rarely change. If respirations increase

significantly, suspect pulmonary
embolism, uterine atony, or
hemorrhage.

For slight elevation in body temperature, increase fluid intake.

Lowered heart rate may lead to shivering.
Pain is usually the priority nursing diagnosis if no excessive bleeding.

Postpartum Assessment
B = Breasts
U = Uterus (Fundus)
B = Bladder
B = Bowel
L = Lochia
E = Episiotomy

H = Homans Sign
E = Emotions

BREASTS

Engorgement
48-72

hrs after delivery

Inspect for nipple inversion, cracks,

blisters, fissures and tenderness

Breasts
Non-lactating women
Breast binding with an Ace bandage
Ice packs for 30-60 min. Off 1 hour
Support bra not loose fitting.
No Breast stimulation do NOT
express milk!
Cold cabbage leaves
leave

Tylenol

on until wilted

Breasts
Lactating women

Teach proper technique, holding infant, latch

on, when to switch breasts. Important to help
prevent engorgement and mastitis.
Lanolin after each feeding; no need to cleanse
prior to feeding
Support and encouragement, breastfeeding is
learned skill for mother and infant
Breast milk bluish in color and thin; reassure
this is normal
Report pain, swelling, redness immediately,
especially if only one breast affected!!

UTERINE INVOLUTION

Monitor by assessing:
Uterine

size and location

Uterine tone
boggy vs. firm

Administering Pitocin after delivery of

placenta stimulates uterine involution.
Usually

will be 20-40 units Pitocin in 1 liter fluid.

Afterpains or afterbirth pains

Caused

by contractions of the uterus as it goes

through involution.
Increased by breastfeeding and/or Pitocin
infusion.
Treatment give pain medication.

Fundal Massage
#1 Nursing Action for postpartum bleeding!!!!!

UTERINE SUBINVOLUTION
Failure of uterus to return to non-pregnant
state
Most common causes

Infection
Retained

placental fragments

Prevention of Excessive Bleeding

Uterine Atony- failure of muscles to

contract firmly. It is the most frequent
cause of excessive bleeding
Nurse

must!!!

Maintain uterine tone MASSAGE!!!!

Prevent OR correct bladder distention

BOWEL
Usually become hungry 1-2 hrs after
delivery
Bowel movements occur 2-3 days pp
Narcotics will depress bowel motility
Stool softeners routinely given pp
(Dulcolax/ Colace)

Bowel
May have hemorrhoids
Ice pack application immediately after
delivery and for first 24 hours

Hemorrhoids common pp especially in

prolonged labor or with prolonged
pushing

witch hazel and topical anesthetics

routinely ordered pp

BLADDER

Effects of anesthesia may last several

hours.
need

staff assistance when ambulating to

bathroom for first time or for first several
times in order to prevent falls. STAY WITH
PATIENT FIRST TIME OUT OF BED!!
Make sure you educate your patient to call
nurse when needing to void.

Remember . . .

Client should void within 4 hours of

delivery. Monitor client closely for urine
retention. Suspect retention if voiding is
frequent and <100ml per voiding. Also
suspect retention if uterus is boggy, above
the umbilicus, and deviated from the
midline!

Uterine Displacement

If at any time the top of fundus is moving

above the umbilicus and deviated from
midline-usually to the right, think full
bladder or uterine distention from
blood or clots.

If the uterus is boggy and does not firm

with massage, have the patient void, if
received anesthesia may need bedpan, or
I/O cath.

Bladder Distention

Risk Factors:
Episiotomy
Perineal

edema / tenderness
Long labor
Assisted delivery

forceps, vacuum suction

Lacerations
Previous

catheterizations
Anesthesia

Lochia
Rubra (bright red)
Lasts 2-3 days
Chart large, moderate, small, scant
amount
Saturation of a pad in 15-30 min may
indicate hemorrhage
If heavy bleeding persists despite a firm
uterus think laceration

Lochia
Serosa
(watery pink or brown
tinged)
Alba
(white-yellow, creamy)

4-10 days after

delivery
Lighter in amount that
rubra

Days 10-17

UTERINE ATONY:
CONTRIBUTING FACTORS

Uterine over
distention- multiple
gestation,
hydramnios,
macrosomia
Dysfunctional/
prolonged labor
Oxytocin
augmentation
Grandmultiparity
Placenta previa

Anesthesia
Prolonged 3rd stage of
labor
>30

min

Preeclampsia
Asian or Hispanic
ethnicity
Operative birth
Retained placental
fragments

Early Post-Partal Hemorrhage

Other causes of P.P. hemorrhage:
Lacerations
Retained placental fragments
Hemotomas
Coagulation disorders

Late Post-Partal Hemorrhage

After the first postpartum day, the most
common cause of uterine atony is retained
placental fragments.
The nurse must check for the presence of
fragments in lochia tissue.

Hemorrhage

Blood pressure and pulse may NOT change until

significant blood loss has occurred d/t extra
blood volume of pregnancy they are a late sign
of shock in the postpartum woman!!
exception

is preeclamptic women; they do not have

hypervolemia of pregnancy

Post-Partum Hemorrhage
Management
Massage

Options

fundus !!!!!!!!!!!!!
Check for bladder
distention/voiding
Quantify blood loss
Watch vital signs
Notify provider

Hypovolemic Shock
Skin cool and clammy
Pulse rate increases
BP declines
Skin ashen or grayish
Women acts anxious
What are your nursing interventions?

Nursing Interventions for Hypovolemic

Shock
MASSAGE THE FUNDUS!!!!
Notify physician
8/10L O2 via face mask
Tilt pt. to left side and raise legs.
IV fluids
Blood products if ordered
Monitor VS
Insert foley catheter
Administer emergency drugs if ordered
Prepare for possible surgery
Document! Document! Document!

EPISIOTOMY
To assess, have patient lay on her
side, flexing her upper leg toward the
hip or place in lithotomy position
Signs of infection-pain, redness,
warmth, swelling, discharge or loss of
approximation
Episiotomy will heal within 2-3 wks

Pericare
Peri-bottle, pads, Dermoplast, Tucks to
keep at bedside
Use peri-bottle to cleanse perineum after
each urination and bowel movement

daily

washing with warm water and mild soap

wipe front to back
change peri-pad frequently
good hand washing

Pericare

Warm therapies after first 24 hours

Warm

Sitz baths will aide in easing episiotomy

discomfort
Heat lamp for 20 minutes 2-3 times a day

Teach Kegels

Perineum

Inspect episiotomy for hematoma

extremely

painful
unable to void
mass palpated or observed

HOMANS SIGN

DVT assessment and prevention Homans

sign, redness, pain
Also assess:
Extremities:

Assess for sensation and mobility when epidural or spinal

anesthesia
Should be able to move toes and lift buttocks off bed within
2-4 hours after discontinuation of anesthesia

Dependent

edema is common
Assess for edema: pitting vs. non-pitting

EMOTIONS
Attachment
Process by which parents come to love and
accept a child and a child loves and accepts
a parent
Bonding
Sensitive time immediately after birth when
parents must have close contact with their
infant in order for later development to be
normal-Klaus & Kennell-1976
These terms are used interchangeably

3 Phases of Psychological
Adaptation

Taking in: dependency behaviors for 24-48hrs.

Taking hold: less focus on physical discomforts,
beginning confidence with infant care taking.
Letting go: total separation of NB from self;
confident in care taking activities of self and NB.
If adaption does not occur, why? Are mother and
infant safe???

Care Management: Physical

Needs

Comfort usually #1
Nonpharmacologic

interventions
Pharmacologic interventions

Rest, fatigue, ambulation, and exercise

Cultural Awareness nurses role is to
support unless the activity, food, etc. is
harmful.

Discharge Teaching

Teaching for self-care: signs of complications

Sexual activity/contraception
KAPLAN HINT: Remember ovulation will
occur before first period!!
Prescribed medications
Routine mother and baby checkups
Dealing with activities of daily life at home
Dealing with visitors

Discharge Teaching

Follow-up after discharge

Home

visits
Telephone follow-up
Warm lines
Support groups
Referral to community resources

Remember . . .

Client and family teaching is a common

subject of NCLEX-RN questions.
Remember that when teaching, the first
step is to assess the clients level of
knowledge and to identify their readiness
to learn. Client teaching regarding lochia
changes, perineal care, breastfeeding,
and sore nipples are subjects that are
commonly tested.

Chapter 23
Postpartum Complications

Postpartum Hemorrhage

Definition and incidence

PPH

traditionally defined as loss of more

than:
500 ml of blood after vaginal birth
1000 ml after cesarean birth

Cause

of maternal morbidity and mortality

Life-threatening with little warning
Often unrecognized until profound symptoms

Postpartum Hemorrhage

Etiology and risk factors

Uterine

atony

Marked hypotonia of uterus

Leading cause of PPH, complicating
approximately 1 in 20 births

Lacerations

of genital tract
Retained placenta
Nondherent retained placenta
Adherent retained placenta

Care Management

Assessment
Bleeding

assessed for color and amount

Perineum inspected for signs of lacerations or
hematomas to determine source of bleeding
Vital signs may not be reliable indicators because of
postpartum adaptations

Measurements during first 2 hours may identify trends

related to blood loss (tachycardia, tachypnea, decreasing bp)

Laboratory

studies of hemoglobin and hematocrit

levels
Most objective, least invasive assessment of
adequate organ perfusion and oxygenation is UO of >
or = 30ml/hour!!!

Care Management

Plan of care and implementation

Medical

management

Hypotonic uterus
Bleeding with a contracted uterus
Uterine inversion
Subinvolution

Herbal

remedies

Care Management

Plan of care and implementation

Nursing

interventions

Providing explanations about interventions and

need to act quickly
Instructions in increasing dietary iron, protein
intake, and iron supplementation
May need assistance with infant care and
household activities until strength regained

Hemorrhagic (Hypovolemic)
Shock

Medical management
Nursing interventions
Fluid or blood replacement therapy

Coagulopathies

Idiopathic thrombocytopenic purpura (ITP)

von Willebrand diseasetype of hemophilia
Disseminated intravascular coagulation (DIC)
Pathologic

clotting
Correction of underlying cause

Removal of fetus
Treatment for infection
Preeclampsia or eclampsia
Removal of placental abruption

Thromboembolic Disease (DVT)

Results from blood clot caused by inflammation or

partial obstruction of vessel
Incidence and etiology
Venous stasis
Hypercoagulation
Clinical manifestations
+Homans sign, redness, swelling, pain
Medical management
Nursing interventions
PREVENTION:
Use of TED hose or ICD device
Early ambulation

Postpartum Infections

Puerperal sepsis: any infection of genital canal within

28 days after abortion or birth
Most common infecting agents are numerous
streptococcal and anaerobic organisms
Endometritis
Urinary tract infections
Mastitis
C/section incision red, edematous, tender, purulent
drainage
Management notify MD
Prevention HANDWASHING!!

Sequelae of Childbirth Trauma

Disorders of uterus and vagina related to
pelvic relaxation and urinary incontinence,
are often result of childbearing
Uterine displacement and prolapse

Posterior

displacement, or retroversion
Retroflexion and anteflexion
Prolapse a more serious displacement

Cervix and body of uterus protrude through vagina

and vagina is inverted

Sequelae of Childbirth Trauma

Cystocele and rectocele

Cystocele:

protrusion of bladder downward

into vagina when support structures in
vesicovaginal septum are injured
Rectocele is herniation of anterior rectal wall
through relaxed or ruptured vaginal fascia and
rectovaginal septum

Urinary incontinence

Sequelae of Childbirth Trauma

Genital fistulas
May

result from congenital anomaly,

gynecologic surgery, obstetric trauma, cancer,
radiation therapy, gynecologic trauma, or
infection
Vesicovaginal: between bladder and genital tract
Urethrovaginal: between urethra and vagina
Rectovaginal: between rectum or sigmoid colon
and vagina

Postpartum Psychologic
Complications

Mental health disorders in postpartum

period have implications for mother,
newborn, and entire family
Interfere

with attachment to newborn and

family integration
May threaten safety and well-being of
mother, newborn, and other children

Postpartum Psychologic
Complications

Postpartum depression without psychotic features

PPD: an intense and pervasive sadness with severe
and labile mood swings
Disappointment with outcome of pregnancy
Treatment options
Antidepressants, anxiolytic agents, and
electroconvulsive therapy
Psychotherapy focuses fears and concerns of new
responsibilities and roles, and monitoring for
suicidal or homicidal thoughts
KAPLAN HINT: Encourage mother to talk and
provide support.

Postpartum Psychologic Complications

Postpartum depression with psychotic

features
Postpartum

psychosis: syndrome
characterized by depression, delusions, and
thoughts of harming either infant or herself

SAFETY!!

Psychiatric

emergency, and may require

psychiatric hospitalization
Antipsychotics and mood stabilizers such as
lithium are treatments of choice

Loss and Grief

Losses of what was hoped for, dreamed
about, and/or planned
Any perception of loss of control during
the birthing experience
Birth of a child with handicap
Maternal death
Fetal or neonatal death

Loss and Grief

Conceptual model of parental grief

Acute

distress
Intense grief
Reorganization

Anticipatory grief

Loss and Grief

Plan of care and implementation

Communicating

and care techniques

Actualize the loss

Provide time to grieve
Interpret normal feelings
Allow for individual differences
Cultural and spiritual needs of parents
Physical comfort

Loss and Grief

Plan of care and implementation

Options

for parents

Seeing and holding

Bathing and dressing
Privacy
Visitations: other family members or
friends
Religious rituals/funeral arrangements
Special memories
Pictures

Maternal Death
Rare for woman to die in childbirth
Families are at risk for developing
complicated bereavement and altered
parenting of surviving baby and other
children in family
Referral to social services can help
combat potential problems before they
develop