Chapter 12: Postpartum Physiological Assessments and Nursing Care

Lactating Women

Prolactin levels increase in response to the infant's suckling. Lactation suppresses menses. Return of menses depends on the length and amount of breastfeeding. Ovulation is suppressed longer for lactating women than for non lactating.

Perineum Assessment

Redness Edema Ecchymosis Discharge Approximation

Rh Isoimmunization

Rho immune globulin is given to Rh-negative women at 28 weeks' gestation. Rh negative women who gave birth to a Rh-positive neonate are screened for anti-Rh antibodies. A second injection of Rho immune globulin is given to the woman if she is Coombs' negative.

Lochia

Scant- 1 to 2 inches Light- 4 inches Moderate- less than 6 inches Heavy- saturated

Kliehaur Betke Screening

Screening to determine how much of the fetus' RBCs are in the mother's circulation. Determines how much RhoGAM to give.

Diastasis recti abdominis

Some women experience a separation of the rectus muscle. This separation becomes less apparent as the body return's to a pre-pregnancy state.

Assessing Postpartum Uterus

Support the lower uterine segment to prevent uterine inversion

Requirements for Rh Isoimmunization

The fetus is Rh positive and mother is Rh negative Significant amounts of fetal RBCs to get into mom's bloodstream (0.4 mLs) Mom has to have ability to have antibodies directed against the D antigens

Involution

Uterine contractions, atrophy of the uterine muscle, and a decrease in the size of uterine cells allow the uterus to return to a pre-preganant size, shape, and location; and the placental site heals.

Constipation

Women are at risk for constipation due to: Decreased GI motility due to the effects of progesterone. Decreased physical activity. Dehydration and fluid loss from labor. Fear of having a bowel movement after perineal lacerations or episiotomy. Perineal pain and trauma.

Appetite

Women are hungry after the birthing process and can be given a regular diet, unless they are on a prescribed diet, such as for diabetes. Women are exceptionally hungry during the first few postpartum days and may require snacks.

Immunizations

Women can receive MMR, Tdap, hepatitis B, varicella, and influenza if needed.

Rh D Immun Globulin [RhoGAM]

Wraps around the RBCs in the mother's circulation. Contains plasma

Lochia Alba [Day 10]

Yellow to white in color, scant amount, fleshy odor

Cardiac Output

returns to pre-pregnancy levels within 48 hours.

Postpartum

6 weeks after delivery

Non-lactating Women

Prolactin levels continue to decline throughout the first 3 postpartum weeks. Menses begins 7-9 weeks post-birth. The first menses is usually anovulatory. Ovulation usually occurs by the fourth cycle.

Colostrum

A clear, yellowish fluid, precedes milk production. It is higher in protein and lower in carbohydrates than breast milk. It contains IgG and IgA to provide protection to the infant in the early weeks of life.

Orthostatic Hypotension

A sudden drop in BP when the woman stands up, which is due to decreased vascular resistance in her pelvis.

Elevated temperatures

A temperature greater than 100.4 F (38 C) after the first 24 hours of birth on two separate occasions may be indicative of postpartum infection and requires further evaluation.

Fundus Location

After birth: midway between umbilicus and symphysis pubis Within 12 hours of birth and placenta: level of umbilicus or 1 cm below umbilicus and is firm and midline 24 hours: 1 cm below umbilicus and is firm and midline The uterus descends 1 cm per day. By day 14, the fundus has descended into the pelvis and is not palpable.

Primary Engorgement

An increase in the vascular and lymphatic system of the breasts, precedes the initiation of milk production. The woman's breasts may become larger, firm, warm, and tender, and the woman may feel throbbing pain in the breast. Usually subsides in 24-48 hours.

Metritis

An infection of the endometrial tissue

Perineum Comfort Measures

Apply ice, cold sitz baths, lie on her side, tighten gluteal muscles, wear snug pads, analgesia, topical anesthetic

GI Assessment

Assess bowel sounds, ask about constipation, and give increased fluids.

Cystitis

Bladder inflammation/infection Frequency, urgency, pain/burning on urination, and malaise Antibiotic therapy, increased hydration, rest

Lochia Rubra [Day 1-3]

Bloody with small clots, Moderate to scant amount, increased flow on standing or breastfeeding, fleshy odor

Effects of Epidural

Cannot get up until gets full feeling back in her legs. Might not have the urge to void so make sure she does not have a distended bladder or boggy uterus. Lower body nerve sensation may be diminished. Assess for headache and increased BP

Bladder Distention

Common during first few days post-birth due to decreased sensation of the urge to void and/or edema around the urethra.

Subsequent Engorgement

Distension of milk glands that is relived by having the baby suckle or by expressing milk.

Urination

Encourage woman to void within 6 hours of birth and be tracking I&O for 24 hours. Minimum of 8 glasses of water a day.

Uterus Assessment Frequency

Every 15 minutes for the first hour Every 30 minutes for the second hour Ever 4 hours for the next 24 hours Every shift for the first 24 hours

Assessment of BP, Pulse, Respiratory Rate, Temperature

First hour: every 15 minutes Second hour: every 30 minutes Next 22 hours: every 4 hours First 24 hours: every shift

Complete Blood Count [CBC]

Hematocrit and hemoglobin are assessed in cases where excessive blood loss has occurred.

Venous Thrombosis

Increased coagulability associated with pregnancy continues into the post-delivery period. Additionally, venous stasis may occur when there is limited mobility in the immediate postpartum period. These factors lead to an increased risk of venous thrombosis. Assess Homan's sign and leg and calf tenderness, edema, and sensation of warmth.

Boggy Uterus

Indicates that the uterus is not contracting and places the woman at risk for excessive blood loss. Massage the fundus, give oxytocin, and notify the HCP.

Temperature

It is common for the postpartum woman to experience mild temperature elevations during the first 24 hours post-birth related to muscular exertion, exhaustion, dehydration, or hormonal changes.

Hemorrhoids

It is common for women to develop hemorrhoids during pregnancy and/or the birthing process. Hemorrhoids will slowly resolve but can be painful.

Uterus Assessment

Location, position, and tone of the fundus.

Signs and Symptoms of Possible Complications

Look for foul smelling lochia, burning or pain upon urination, and breast pain or engorgement.

Afterpains

Moderate to severe cramp-like pains that are related to the uterus worker harder to remain contracted and/or to the increase of oxytocin that is released in response to infant suckling.

Weight Loss

Most women will experience a significant weight loss during the first 2-3 weeks postpartum. Usually back to pre-pregnancy weight at the end of the 6 weeks.

Health Promotion

Nutrition and fluids Activity and exercise Rest and comfort Contraception Sexual activity Prescribed medications

Diaphoresis

Occurs during the first few weeks postpartum in response to the deceased estrogen levels.

Diuresis

Occurs within 12 hours post-birth and aids in the elimination of excess tissue fluid caused by decreased oxytocin and estrogen levels.

Postpartum Chills

Phenomenon of feeling cold and shaking during the first few hours following birth related to vascular instability.

Lochia Serosa [Day4-10]

Pink or brown color, scant amount, increased flow during physical activity, fleshy odor

Mastitis

Plugged milk ducts are associated with emptying of the breast, wearing overly tight bras, and/or failure to change the infant into different feeding positions.