Week 1 - Postpartum assessment & Newborn assessment and care

Info that must be communicated to postpartum nurse

-woman's name - age - hc provider - gravidity (# of times woman has been pregnant) & parity(# of times she has given birth to fetus with a gestational age of 24 wks+ - anesthetic used - any meds given - duration of labor & time of rupture of membranes - whether labor was induced or augmented - mode of birth (vaginal or cesarean) - perineal repair or type of cesarean incision - blood type and Rh status - group B streptococcus (GBS) status - status of rubella immunity - HIV, hep B, & syphilis serology test results - other infections identified during pregnancy (e.g., gonorrhea, chlamydia) & whether these were treated - type & amt of IV fluids - physiologic status since birth - description of fundus, lochia, bladder, & perineum - sex & weight of infant - time of birth - name of pediatric care provider - chosen method of feeding - any abnormalities - assessment of initial parent-infant interaction Specific info should be provided regarding newborn's Apgar scores), weight, voiding, stooling, feeding since birth, eye prophylaxis, & vit K injection.

Medication order for the postpartum woman is Nubain 0.1 mg/kg IM not to exceed 10 mg per dose. The patient weighs 132 lb. The ampule of Nubain is labeled 10 mg/mL.How many mL will the nurse adminster?

0.6mL

Normal newborn apical pulse is between ___ to ___ per minute.

120, 160

Respirations Normal Findings

16-20 breaths/min

To administer the IM vitamin K injection to the newborn which size needle willl the nurse choose? 18 gauge / 1 inch 30 gauge / 1/2 inch 22 gauge/ 1 1/2 inch 25 gauge/ 5/8 inch

25 gauge/ 5/8 inch

Normal newborn respiratory rate is between ____ to ____ per minute

30, 60

Temp Normal Findings

36.2°-38° C (97.2°-100.4° F)

Nonpharmacologic pain interventions

Distraction, imagery, therapeutic touch, relaxation, acupressure, aromatherapy, hydrotherapy, massage therapy, music therapy, & transcutaneous electrical nerve stimulation (TENS).

Pulse Normal Findings

50-90 beats/min

NO FC's FOR:

54 -557; 571 - 573; 582 - 583 and 585 - 586 including Medication Guides on p. 586

Family structure & functioning

A woman's adjustment to her role as mother is affected greatly by relationships with her partner, mother, other relatives, & other children. Nurses can help ease new mother's return home by identifying possible conflicts among family members & by helping woman plan strategies for dealing with these problems before discharge. Such a conflict can arise when couples have very different ideas about parenting. Dealing with stresses of sibling rivalry & unsolicited grandparent advice also can affect woman's transition to motherhood. Only by asking about other nuclear & extended family members can nurse discover potential problems in such relationships & help plan workable solutions for them.

Bladder Normal Findings

Able to void spontaneously; no distention; able to empty completely; no dysuria Diuresis begins ≈12 hours after birth; can void 3000 mL/day

Vagina & Perineum - Hemorrhoids

Hemorrhoids (anal varicosities) are commonly seen. Hemorrhoids often develop during pregnancy, & internal hemorrhoids can evert while woman is pushing during birth. Women often experience associated symptoms such as itching, discomfort, & bright red bleeding with defecation. Hemorrhoids usually decrease in size within 6 wks of birth & eventually regress.

Abdomen & Bowels Normal Findings

Abdomen soft, active bowel sounds in all quadrants Bowel movement by day 2 or 3 after birth Cesarean: incision dressing clean and dry; suture line intact

Energy Level Normal Findings

Able to care for self and infant; able to sleep

Visual estimation of blood loss

Accurate visual estimation of blood loss is an important nursing responsibility. Blood loss is usually described subjectively as scant, light, moderate, or heavy Although postpartum blood loss can be estimated by observing amt of drainage on perineal pad, judging amount of lochia is difficult if based only on observation of perineal pads. Quantification of blood loss by weighing clots & items saturated with blood (1 mL equals 1 g) is recommended as most accurate way to determine blood loss. Any estimation of lochial flow is inaccurate & incomplete without considering time factor. Woman who saturates a perineal pad in 1 hr or less is bleeding much more heavily than woman who saturates one perineal pad in 8 hrs. When assessing blood loss, nurse asks woman how long it has been since her perineal pad was changed. Nurses tend to overestimate rather than underestimate blood loss. Different brands of perineal pads vary in their saturation volume & soaking appearance. For example, blood placed on some brands tends to soak down into pad, whereas on other brands it tends to spreads outward. Nurses should determine saturation volume and soaking appearance for brands used in their institution so that they can improve accuracy of blood loss estimation.

Rh Immune Globulin (RhoGAM)

Action: Suppression of immune response in nonsensitized women with Rh-negative blood who receive Rh-positive blood cells because of fetomaternal hemorrhage, transfusion, or accident

Chemical factors

Activation of chemoreceptors in carotid arteries & aorta results from relative state of hypoxia associated with labor. With each labor contraction there is a temp decrease in uterine blood flow & transplacental gas exchange, resulting in transient fetal hypoxia & hypercarbia. Although fetus able to recover between contractions, cumulative effect that results in progressive decline in PO2, increased PCO2, & lowered blood pH. Decreased levels of O2 & ^ levels of CO2 seem to have cumulative effect involved in initiating neonatal breathing by stimulating respiratory center in medulla. Another chemical factor may also play role; thought that as a result of clamping cord, there is drop in levels of a prostaglandin that can inhibit respirations.

Autolysis

After birth, decrease in est & prog causes autolysis (self-destruction of excess hypertrophied tissue). The additional cells laid down during pregnancy remain & account for slight increase in uterine size after each pregnancy.

Bowel function

After birth, women can be at risk for constipation related to side effects of meds (opioid analgesics, iron supplements, magnesium sulfate), dehydration, immobility, or presence of episiotomy, perineal lacerations, or hemorrhoids. Woman can be fearful of pain with first bowel movement. Nursing interventions to promote normal bowel elimination include educating woman about measures to prevent constipation, such as ambulation & increasing intake of fluids & fiber. Alerting woman to SE's of meds such as opioid analgesics (e.g., decreased gastrointestinal tract motility) can encourage to implement measures to reduce the risk for constipation. Stool softeners or laxatives may be necessary during early postpartum period. Used only at direction of hc provider.

Which of the following steps are included in assessing the fundus of the postpartum patient after a vaginal birth? ( Select all that apply) A) Help patient to empty bladder unless has recently voided. B) Postion patient lying on back with knees slightly bent. C) Place one hand above pubic symphysis to support lower uterine segment. D) Palpate abdomen to locate fundus.

All

Surfactant

Alveoli of the term infant's lungs are lined with surfactant, a protein manufactured in type II lung cells. Lung expansion depends largely on chest wall contraction and adequate surfactant secretion. Surfactant lowers surface tension, reducing pressure required to keep alveoli open with inspiration, and prevents total alveolar collapse on exhalation, maintaining alveolar stability. Decreased surface tension results in increased lung compliance, helping to establish functional residual capacity of the lungs. With absent or decreased surfactant, more pressure must be generated for inspiration, which can soon tire or exhaust preterm or sick term infants.

Apnea & Tachypnea

Apneic episodes can be related to events such as rapid increase in body temp, hypothermia, hypoglycemia, or sepsis that require thorough eval. Tachypnea can result from inadequate clearance of lung fluid, or it can be an indication of newborn respiratory distress syndrome (RDS). Tachypnea can be the first sign of respiratory, cardiac, metabolic, or infectious illnesses.

Newborn respiratory system

As infant emerges from intrauterine envt & umbilical cord is clamped & severed, profound adaptations are necessary for survival. Most critical of these is establishment of effective respirations. Most newborns breathe spontaneously after birth & are able to maintain adequate oxygenation. Preterm infants often encounter respiratory difficulties related to immature lungs.

More on follow ups

As many as 40% of new mothers forego postpartum visit. Reasons include thinking they feel fine & do not need to follow-up, believing that maternity care was already completed, difficulty getting to appt, & lack of insurance. In effort to increase compliance with postpartum visits, discussions related to discharge planning should begin during pregnancy with providers & nurses talking with expectant parents about importance of follow-up care. A postpartum plan of care can be developed during pregnancy in collab with woman & partner, considering mother's physical & mental health, individual & family needs & desires, support system, & available resources. Plan of care should be reviewed after birth, prior to hospital discharge, & revised as needed at postpartum follow-up visit. An interprofessional team for postpartum care may include the obstetric & pediatric hc providers, lactation consultants, home visitation nurses or peer counselors, public health nurses, nutritionists, mental health care providers, & other specialists based on the specific needs of mother and infant.

Promoting rest - Follow up care

Because postpartum fatigue can be debilitating, follow-up after discharge is important. Assessment for fatigue can be done with nurse-initiated telephone call at 2 wks, & at routine 6-wk postpartum visit with hc provider. Nurses in pediatric care provider's office or clinic should also be alert for signs of maternal fatigue. Infant will be seen within first few days after birth—before woman sees obstetric care provider.

Discharge planning - self mgmt

Begins upon admission to facility Before discharge, women need basic instruction regarding a variety of self-management topics such as nutrition, exercise, family planning, the resumption of sexual intercourse, prescribed medications, and routine mother-baby follow-up care. Just before time of discharge, nurse reviews woman's records to see that lab reports, meds, signatures, and other items are in order. Some facilities have a checklist to use before discharge. Nurse verifies that meds, if ordered, have arrived on unit; any valuables kept secured during woman's stay have been returned and that she has signed a receipt for them; and that infant is ready to be discharged. Woman's & baby's id bands are checked carefully.

Promoting Ambulation - Preventing VTE (venous thromboembolism)

Blood is hypercoagulable in postpartum period, esp during first 48 hrs after birth. Women who must remain in bed after giving birth are at ^ risk for complication. Antiembolic stockings (TED hose) or a sequential compression device (SCD boots) may be ordered prophylactically. If a woman remains in bed longer than 8 hrs, exercise to promote circulation in legs is indicated, using following routine: • Alternate flexion and extension of feet. • Rotate ankles in a circular motion. • Alternate flexion and extension of legs. • Press back of knees to the bed surface; relax. If woman is susceptible to VTE, encouraged to walk about actively for true ambulation & discouraged from sitting immobile in a chair. Women with varicosities encouraged to wear support hose. If thrombus suspected, (warmth, redness, or tenderness in suspected leg), primary hc provider should be notified. Meanwhile woman should be confined to bed, with affected limb elevated on pillows.

Nonpharmacological treatments for breast engorgement pain

Breast engorgement can occur whether woman is breastfeeding or formula feeding. Discomfort associated with engorged breasts may be reduced by applying ice packs or cabbage leaves (or both) to breasts, & wearing well-fitted support bra. Antiinflammatory medications such as ibuprofen can also be helpful in relieving some discomfort. Decisions about specific interventions for engorgement are based on whether woman chooses breastfeeding or formula feeding. Breastfeeding mothers can feed frequently and use hand expression or a breast pump to reduce engorgement and promote comfort

Pharmacologic interventions - Breastfeeding mothers

Breastfeeding mothers often have concerns about effects of an analgesic on infant. Although nearly all drugs present in maternal circulation are also found in breast milk, many analgesics commonly used during postpartum period are considered relatively safe for breastfeeding mothers & infants. Often timing of meds can be adjusted to minimize infant exposure. Mother may be given pain med immediately after breastfeeding so that interval between med admin & next breastfeeding session is as long as possible. Decision to admin meds of any kind to a breastfeeding mother must always be made by carefully weighing woman's need against actual or potential risks to infant. Resources are readily accessible for nurses & hc providers to examine safety of meds for breastfeeding mothers If acceptable pain relief not obtained in 1 hr & there is no change in initial assessment, nurse may need to contact obstetric care provider for additional pain relief orders or further directions. Unrelieved pain results in fatigue, anxiety, & a worsening perception of pain. It might also indicate presence of a previously unidentified or untreated problem.

Breathing mvmts

Breathing movements that began in utero as intermittent become continuous after birth, although mechanism for this is not well understood. Once respirations are established, breaths are shallow and irregular, ranging from 30 to 60 breaths/minute, with periods of breathing that include pauses in respirations lasting <20 secs. These episodes of periodic breathing occur most often during active REM & decrease in frequency & duration with age. Apneic periods >20 secs are abnormal & should be evaluated. Newborn infants are by preference nose breathers. The reflex response to nasal obstruction is to open mouth to maintain an airway. This response not present in most infants until 3 wks after birth; therefore cyanosis or asphyxia can occur with nasal blockage.

CV system of newborn

CV system changes significantly after birth. Infant's first breaths, combined with increased alveolar capillary distention, inflate lungs and reduce pulmonary vascular resistance to pulmonary blood flow from pulmonary arteries. Pulmonary artery pressure drops, and pressure in the right atrium declines. ^ pulmonary blood flow from left side of the heart increases pressure in the left atrium, which causes a functional closure of the foramen ovale. During first few days of life, crying can temporarily reverse flow through foramen ovale and lead to mild cyanosis. Soon after birth, cardiac output nearly doubles and blood flow increases to the lungs, heart, kidneys, and gastrointestinal (GI) tract (Hillman et al., 2012). In utero fetal PO2 is 20 to 30 mm Hg. After birth, when the PO2 level in the arterial blood approximates 50 mm Hg, the ductus arteriosus constricts in response to increased oxygenation. Circulating prostaglandin E (PGE2) levels also have an important role in closing the ductus arteriosus. In term infants, it functionally closes within the first 24 hours after birth; permanent (anatomic) closure usually occurs within 3 to 4 weeks, and the ductus arteriosus becomes a ligament. The ductus arteriosus can open in response to low oxygen levels in association with hypoxia, asphyxia, or prematurity. With auscultation of the chest, a patent ductus arteriosus can be detected as a heart murmur. When the cord is clamped and severed, the umbilical arteries, the umbilical vein, and the ductus venosus are functionally closed; they are converted into ligaments within 2 to 3 months. The hypogastric arteries also occlude and become ligaments.

CV System - Blood Volume

Changes in bv after birth depend on several factors, such as blood loss during birth & amount of extravascular water (physiologic edema) mobilized & excreted. Pregnancy-induced hypervolemia (an increase in blood volume to 40% to 45% above nonpregnancy levels) allows most women to tolerate considerable blood loss during birth. Avg blood loss for vaginal birth of single fetus ranges from 300-500 mL (10% of bv). Typical blood loss for women who give birth by cesarean is 500-1000 mL (15%-30% of bv). During first few days after birth, plasma vol decreases further as a result of diuresis. Maternal physiologic changes in puerperium enable woman to cope with blood loss that normally occurs during birth by increasing her circulating bv. These changes are: (1) elimination of uteroplacental circulation that reduces size of maternal vascular bed by 10% to 15%; (2) loss of placental endocrine function that removes stimulus for vasodilation; (3) mobilization of extravascular water stored during pregnancy. By third postpartum day, plasma volume has been replenished as extravascular fluid returns to intravascular space

Color

Changes in the infant's color can indicate respiratory distress. Acrocyanosis, the bluish discoloration of hands and feet, is a normal finding in the first 24 hours after birth. Transient periods of duskiness while crying are common immediately after birth; however, central cyanosis is abnormal and signifies hypoxemia. With central cyanosis, the lips and mucous membranes are bluish (circumoral cyanosis). It can be the result of inadequate delivery of oxygen to the alveoli, poor perfusion of the lungs that inhibits gas exchange, or cardiac dysfunction. Because central cyanosis is a late sign of distress, newborns usually have significant hypoxemia when cyanosis appears.

Breath Sounds Normal Findings

Clear to auscultation

Coagulation factors

Clotting factors & fibrinogen are normally ^ during pregnancy &remain elevated in immediate puerperium. When combined with vessel damage & immobility, this hypercoagulable state causes an increased risk for venous thromboembolism, esp after a cesarean birth. Fibrinolytic activity also increases during first few days after birth. Factors I, II, VIII, IX, and X decrease to nonpregnant levels within few days. Fibrin split products, prob released from placental site, can be found in maternal blood.

Pharmacologic interventions

Commonly used to relieve or reduce postpartum discomfort. Most hc providers routinely order a variety of analgesics to be admin'ed as needed, including both opioid & nonopioid. NSAIDs commonly used are ibuprofen or naproxen. These meds provide better relief from uterine cramping & perineal pain than acetaminophen or propoxyphene. Ibuprofen is preferred for breastfeeding women because it has low milk/maternal plasma drug concentration ratio & a short-half life. In some hospitals, NSAIDs are administered on a scheduled basis, esp if woman had peri repair. Topical application of antiseptic or anesthetic ointment or spray can be used for peri pain. PCA pumps & epidural analgesia are commonly used to provide pain relief after cesarean birth.

Cultural considerations

Conduct a cultural assessment. Accomplished most easily through conversation with mother & her partner. Components of the cultural assessment include ability to read and write English, primary language spoken, family involvement and support, dietary preferences, infant care, attachment, religious or cultural beliefs, folk medicine practices, nonverbal communication, and personal space preferences. Postpartum care occurs within a sociocultural context. Rest, seclusion, dietary constraints, & ceremonies honoring mother are common traditional practices that are followed for promotion of health & well-being of mother and baby. In some cultures, postpartum period is considered a time of increased vulnerability for mother. To protect her, restrictions on activity, diet, bathing, & infant caretaking. Postpartum period is seen by some cultures as a time of impurity for mother. For as many days or weeks as she has lochial flow, she is considered "impure" & has limited contact with others. Sexual activity prohibited during this time. In many Asian cultures, balance between yin and yang (cold and hot) is necessary for balance and harmony with environment. Postpartum practices focus on helping mother achieve this balance. Pregnancy is considered a "hot" condition. Believed that birth depletes mother's body of heat through loss of blood and inner energy; this places her in a "cold" state for about 40 days until her womb is healed. Woman consumes only "hot" foods & beverages. Examples of foods that are considered "hot" include rice, eggs, beef, & chicken soup. Seaweed soup consumed by postpartum women for purpose of increasing milk prod & helping to rid body of lochia. Family members often bring in foods from home. To help prevent loss of heat from body, mother may be discouraged from showering or bathing for days or weeks; however, there is attention to perineal care & hygiene. Temp of hospital room is warmer than usual. Mother likely spends most of time in bed to prevent cold air from entering body, & has minimal contact with infant. Family members provide care for mother and newborn. For example, in Korean culture, mother-in-law is charged with caring for daughter-in-law & newly born grandchild during postpartum period

Lung fluid

Sensory stimulation occurs in a variety of ways with birth. Some of these include handling by obstetric hc provider, suctioning mouth & nose, & drying by nurses. Environmental factors (lights, sounds, smells) stimulate respiratory center. At term lungs hold approximately 20 mL fluid/kg. Air must be substituted for fluid that filled fetal respiratory tract.

The nurse will administer the IM Vitamin K injection for the newborn in the: A) deltoid B) ventrogluteal C) dorsogluteal D) vastus lateralis

D

Breasts Normal Findings

Days 1-2: soft Days 2-3: filling Days 3-5: full, soften with breastfeeding (milk is "in")

Lochia Normal Findings

Days 1-3: rubra (dark red) Days 4-10: serosa (brownish red or pink) After 10 days: alba (yellowish white) Amount: scant to moderate Few clots Fleshy odor

Metabolic changes

Decreases in human chorionic somatomammotropin, estrogens, cortisol, & placental enzyme insulinase reverse diabetogenic effects of pregnancy, resulting in significantly lower BG levels in immediate puerperium. Mothers with type 1 dm require much less insulin for several days after birth, esp if breastfeeding. Because these normal hormonal changes make puerperium a transitional period for carbohydrate metabolism, more difficult to interpret results of glucose tolerance tests at this time. Thyroid vol returns to normal by 3 mos after birth. Thyroxine & triiodothyronine lvls decrease to prepregnant levels within 4 wks. There is ^ risk for transient autoimmune thyroiditis in the postpartum period. The BMR remains elevated for first 1-2 wks after birth. It gradually returns to prepregnancy levels.

3 Stages of Newborn Transition

Desmond, Rudolph, and Phitaksphraiwan (1966) proposed 3 stages of newborn transition. Stage 1 - First Period of Reactivity: - Lasts up to 30 mins after birth - HR increases to 160-180 b/min but gradually falls after 30 mins or so to a baseline rate of 100-120 b/min. - Respirations are irregular, 60-80 breaths/min. - Fine crackles can be present on auscultation. - Audible grunting, nasal flaring, & retractions of chest also can be present, but these should cease within first hr of birth. - Infant is alert & may have spontaneous startles, tremors, crying, & head mvmt side to side. - Bowel sounds audible, & meconium may be passed. Stage 2 - After first period of reactivity, newborn either sleeps or has a marked decrease in motor activity: - Lasts from 60-100 mins. - Infant is pink - Respirations are rapid (up to 60 breaths/min) & shallow but unlabored. - Bowel sounds are audible, & peristaltic waves may be noted over the rounded abdomen. Stage 3 - Second Period of Reactivity: - occurs 2- 8 hrs after birth & lasts 10 mins to several hours. - Brief periods of tachycardia & tachypnea occur, associated with increased muscle tone, changes in skin color, & mucus production. - Meconium is commonly passed at this time. - Most healthy newborns experience this transition, regardless of gestational age or type of birth; very preterm infants do not

Sexual activity & contraception

Discussing sexual activity with women & partners before leave hospital is important because many couples resume sex before traditional postpartum follow-up visit with hc provider 6 wks after birth. For most women, risk for hemorrhage or infection is minimal by approximately 2 wks postpartum. Couples may be anxious about topic but uncomfortable & unwilling to bring it up. TNurse needs to discuss physical and psychologic effects that giving birth can have on sexual activity

Promoting nutrition

During hospital stay, most women have good appetite & eat well. May request that family members bring favorite or culturally appropriate foods. Cultural dietary preferences must be respected. This interest in food presents an ideal opportunity for nutritional counseling on dietary needs after pregnancy, with specific info related to breastfeeding, preventing constipation and anemia, promoting weight loss, & promoting healing & well-being. Well-balanced diet helps promote healing & health in postpartum period. Recommended caloric intake for mod active, nonlactating postpartum woman is 1800-2200 kcal/day. Lactating women need an additional 450-500 kcal/day, which can usually be met with simple adjustments in a normally balanced diet. Women who are underweight, exercise excessively, or are breastfeeding more than one infant need additional calories. Dietary intake for lactating women should include 200-300 mg of omega-3 long-chain polyunsaturated fatty acids ([DHA]) so that there is adequate DHA in breast milk. Addition of 1 or 2 portions of fish with low mercury content provides additional DHA. Women on selected vegan diets & those poorly nourished may need to take DHA & multivitamin supplements. Prenatal vitamins may be continued until 6 wks after birth or until supply has been used. Iron supplements may be prescribed for women with low hemoglobin and hematocrit levels.

Initiation of breathing

During intrauterine life, oxygenation of fetus occurs through transplacental gas exchange. At birth, lungs must be established as site of gas exchange. In utero fetal blood was shunted away from lungs, but when birth occurs, pulmonary vasculature must be fully perfused for this purpose. Clamping umbilical cord causes a rise in bp, which increases circulation & lung perfusion. No single trigger for newborn resp function. Initiation of respirations in neonate is result of a combination of chemical, mechanical, thermal, & sensory factors

Home care - infant

During newborn assessment, nurse can demonstrate and explain normal newborn behavior and capabilities and encourage mother and family to ask questions or express concerns they have. Home care nurse verifies if blood sample for newborn screening has been drawn. If baby was discharged from hospital before 24 hrs of age, a blood sample for newborn screen may be drawn by home care nurse, or family will need to take infant to health care provider's office or clinic to have blood sample drawn.

Promoting ambulation - early ambulation

Early ambulation is associated with reduced incidence of venous thromboembolism (VTE) Promotes return of strength. Free movement is encouraged once anesthesia wears off unless opioid analgesic was administered. After initial recovery period, mother encouraged to ambulate frequently.

Emotional Status Normal Findings

Excited, happy, interested or involved in infant care

Portpartum sexuality

Feelings related to sexual adjustment after birth are often a cause of concern for new parents. Women who have recently given birth can be reluctant to resume sex for fear of pain or may worry that coitus (sex) will damage healing perineal tissue. Because many new parents are anxious for info but reluctant to bring up subject, postpartum nurses can matter-of-factly include the topic of postpartum sexuality during their routine physical assessment and teaching. Partners often have questions and concerns as well; it is helpful to include them in teaching sessions or discussions regarding sexuality in the postpartum period.

CV System - Vital Signs

Few alterations in vital signs are seen under normal circumstances (Table 18.1). Heart rate is increased immediately after birth and can remain elevated for the first hour. Puerperal bradycardia is common, with heart rate decreasing to 40 to 50 beats/minute Transient ^ in bp of 5% during first few days after birth. Can take wks or months for pulse and BP to return to prepregnancy levels. ^ in BP >140/90 when measured on 2+ occasions at least 6 hrs apart can indicate preeclampsia. Resp function rapidly returns to nonpregnant levels after birth. After uterus emptied, diaphragm descends, normal cardiac axis is restored, and PMI & ECG are normalized. Low grade fever not uncommon during first 24 hrs after birth. However, temp elevation of 38° C (100.4° F) or higher during first 10 days postpartum can indicate infection & should be evaluated. Up to 50% of women experience shivering episodes during first few minutes up to first hour after birth. Cause is unknown, & usually no treatment is needed; if shivering is related to effects of anesthesia, pharmacologic treatment may be needed

Uterus (Fundus) Normal Findings

Firm, midline; first 24 hours at level of umbilicus; involutes ≈1 cm/day

Postpartum period to 4th trimester

First 3mo after birth

Nonpharmacologic pain interventions related to uterine contractions

For women experiencing discomfort associated with uterine contractions, application of warmth or lying prone can be helpful. Interaction with infant can also provide distraction and decrease discomfort. Because afterpains are more severe during & after breastfeeding, interventions are planned to provide most timely & effective relief.

Rubella vaccination

For women who have not had rubella (type of measles) or who are serologically non-immune (titer of 1 : 8 or less or enzyme immunoassay level <0.8), a subcut injection of rubella vaccine recommended in postpartum period prior to hospital discharge to prevent possibility of contracting rubella in future pregnancies; given as measles, mumps, rubella (MMR) vaccine. Women cautioned to avoid becoming pregnant 28 days after receiving rubella vaccine- potential teratogenic risk to fetus. Live attenuated rubella virus (vaccine) is not communicable in breast milk, so breastfeeding mothers can be vaccinated. However, because virus is shed in urine & other body fluids, vaccine should not be given if mother or other household members are immunocompromised. Fever, transient arthralgia, rash, & lymphadenopathy are common SE's of rubella vaccine

Hispanic postpartum cultural practices

Hispanic & Latino women who have immigrated to US often observe period of 40 days (6 weeks) after birth as la cuarentena. During this time, woman's body is perceived to be "open" & vulnerable to drafts; la cuarentena is about "closing the body." Traditional practices associated with la cuarentena include a liquid diet of nutritious drinks, soups, and broths in early postpartum period; binding abdomen; avoiding cool air; & maintaining sexual abstinence. Activity is restricted, and the mother stays home. Common concern of Hispanic & Latino women is "evil eye" or mal de ojo. Believe if someone admires or covets infant but does not touch him or her, it can cause bad luck, illness, or even death. In an attempt to ward off evil eye, some mothers place a bracelet with a black onyx hand, la manita de azabache, on or near newborn

Home visits

Home nursing care may not be available, even if needed, because no agencies are available to provide service or no coverage is in place for payment by third-party payers. If care is available, a referral form containing infoabout mother and baby should be completed at discharge from birthing facility & sent immediately to home care agency. Home visit is most commonly scheduled on woman's second day home from hospital, but can be scheduled on any of first 4 days at home, depending on individual family's situation & needs. Additional visits are planned throughout first week, as needed. Home visits may be extended beyond that time if family's needs warrant it & home visit is most appropriate option for carrying out follow-up care required to meet specific needs identified. During home visit, nurse conducts a systematic assessment of mother & newborn to determine physiologic adjustment & identify any existing complications. Assessment also focuses on mother's emotional adjustment & knowledge of self-mgmt and infant care. Conducting assessment in a private area of home provides an opportunity for mother to ask questions on potentially sensitive topics such as breast care, constipation, sexual activity, or family planning. Nurse assesses family adjustment to newborn and addresses any concerns during home visit.

Promoting breastfeeding

Ideal time to initiate breastfeeding is within first 1-2 hrs after birth. Newborns should be placed in skin-to-skin contact with mothers asap after birth &remain there for at least 1 hr. Nurses can encourage mothers to observe their babies for signs they are ready to breastfeed & assist mothers as needed to initiate breastfeeding. During first hour, most infants alert & ready to nurse. Breastfeeding aids in contracting uterus & preventing maternal hemorrhage. Initial breastfeeding session allows nurse to assess mother's basic knowledge of breastfeeding & physical appearance of breasts & nipples. Throughout hospital stay, nurses provide education & assistance for breastfeeding mother, making appropriate referrals to lactation consultants as needed. Nurses also provide info about community breastfeeding support groups

Vagina & Perineum - Forceps-assisted birth

If forceps used for the birth, woman may have experienced vaginal or cervical lacerations; hematomas of the pelvic soft tissues can also occur with forceps-assisted birth

Follow up care after discharge

Important components of postpartum visit are review of: - woman's postpartum concerns; - routine screening for PPD; - review of labor and birth experience and any complications that occurred; - counseling for women with ongoing health concerns such as diabetes; - contraceptive planning; - anticipatory guidance related to return to employment, weight loss, and so on; - planning for ongoing care under the supervision of a primary health care provider

Promoting ambulation - dizziness

In early postpartum period, some women feel lightheaded or dizzy when standing. Rapid decrease in intraabdominal pressure after birth results in a dilation of bv's supplying intestines (splanchnic engorgement) & causes blood to pool in viscera. This condition contributes to development of orthostatic hypotension when woman who has recently given birth sits or stands up, first ambulates, or takes a warm shower or sitz bath. When assisting a woman to ambulate, nurse needs to consider baseline bp; amt of blood loss; & type, amount, & timing of analgesic or anesthetic medications administered

More chest mvmt

In most newborns, auscultation of chest reveals loud, clear breath sounds that seem very near because little chest tissue intervenes. Breath sounds should be clear & equal bilaterally, although fine rales for first few hrs not unusual. Ribs of infant articulate with spine at a horizontal rather than a downward slope; consequently rib cage cannot expand with inspiration as readily as that of an adult. Because neonatal resp function is largely a matter of diaphragmatic contraction, abdominal breathing is characteristic of newborns. The newborn infant's chest and abdomen rise simultaneously with inspiration.

Serious respiratory issues

In neonates with more serious resp probs, symptoms of distress more pronounced & tend to last beyond first 2 hrs after birth. RRs can exceed 120 breaths/min. Moderate to severe retractions, grunting, pallor, and central cyanosis can occur. Resp symptoms can be accompanied by hypotension, temperature instability, hypoglycemia, acidosis, and signs of cardiac problems. Common respiratory complications affecting neonates include RDS, meconium aspiration, pneumonia, & persistent pulmonary hypertension of newborn (PPHN). Congenital defects such as anomalies of great vessels, diaphragmatic hernia, or chest wall defects can cause severe resp problems. Blood incompatibilities such as hydrops fetalis can result in respiratory compromise

Mild TTN

Infants who experience mild TTN often have signs of respiratory distress during the first 1 to 2 hours after birth as they transition to extrauterine life. Tachypnea with rates up to 100 breaths/minute can be present along with intermittent grunting, nasal flaring, and mild retractions. Supplemental oxygen may be needed. TTN usually resolves in 24 to 48 hours

legal tip for rubella & varicella vaccination

Informed consent for rubella & varicella vaccination in postpartum period includes info about possible side effects & risk for teratogenic effects on fetus. Women must understand that they should not become pregnant for 28 days after being vaccinated

Preventing Rh Isoimmunization

Injection of Rh immune globulin within 72 hrs after birth prevents sensitization in Rh-negative woman who has had a fetomaternal transfusion of Rh-positive fetal RBCs. Rh immune globulin promotes lysis of fetal Rh-positive blood cells before mother forms her own antibodies against them. Admin of Rh immune globulin is intended to prevent problems in future pregnancies should the Rh negative woman have an Rh positive fetus.

Postpartum period (puerperium)

Interval between birth & the return of reproductive organs to normal nonpregnant state 4th trimester Traditionally considered to last 6 wks, but time varies.

Neonatal adjustment tasks

Neonatal period: birth-day 28 of life. Physiologic & behavioral adaptations to extrauterine life. Physiologic adjustment tasks are those that involve: (1) establishing & maintaining respirations; (2) adjusting to circulatory changes; (3) regulating temperature; (4) ingesting, retaining, and digesting nutrients; (5) eliminating waste; (6) regulating weight. Behavioral tasks include: (1) establishing regulated behavioral tempo independent of mother, which involves self-regulating arousal, self-monitoring changes in state, & patterning sleep; (2) processing, storing, and organizing multiple stimuli (3) establishing a relationship with caregivers and the environment.

Lochial vs. Nonlochial bleeding

Lochial Bleeding • Lochia usually trickles from vaginal opening. Steady flow is greater as uterus contracts. • Gush of lochia can appear as uterus massaged. If dark color, has been pooled in relaxed vagina, & amt soon lessens to trickle of bright red (in early puerperium). Nonlochial Bleeding • If bloody discharge spurts from vagina, and uterus is firmly contracted, there can be cervical or vaginal tears in addition to normal lochia. • If amount of bleeding continues to be excessive and bright red, a tear can be source.

Adaptation

Major adaptations associated with transition from intrauterine to extrauterine life occur during first 6-8 hrs after birth. Predictable series of events during transition are mediated by SNS & result in changes in HR, respirations, temp, & GI function. This transition period represents a time of vulnerability for neonate & warrants careful observation. To detect disorders in adaptation soon after birth, nurses must be aware of normal features of transition period. In their classic work on newborn adaptation to extrauterine life.

Timing & quality of sexual activity after birth

Many factors can influence timing & quality of sexual activity after birth. Postpartum perineal pain & dyspareunia are common among women with perineal lacerations or episiotomy. Some women who had an episiotomy report discomfort with intercourse for months after birth. Discomfort is more severe and lasts longer with third- and fourth-degree lacerations. Breastfeeding mothers often experience vaginal dryness related to high prolactin levels and low estrogen levels. Changes in family structure and altered sleep patterns can make it difficult for a couple to find time for privacy and intimacy. PPD is associated with decreased sexual desire; medication used to treat PPD can reduce sexual desire and inhibit orgasm.

Effect of the birth experience

Many women need to review & reflect on labor & birth & to look retrospectively at own intrapartal behavior. Their partners can have similar needs. If their birth experience was different from their birth plan (e.g., induction, epidural anesthesia, cesarean birth), both partners may need to mourn loss of expectations before they can adjust to reality of their actual birth experience. Inviting them to review events & describe how they feel helps nurse assess how well they understand what happened & how well they have been able to put their birth experience into perspective.

Endocrine System

Placental Hormones Metabolic Changes Pituitary & Ovarian Functions

Perineum Normal Findings

Minimal edema Laceration or episiotomy: edges approximated Pain minimal to moderate: controlled by analgesics, nonpharmacologic techniques, or both

Bladder functions

Mother should void spontaneously 6-8 hrs after birth. First several voidings should be measured to doc adequate emptying of bladder. A vol of at least 150 mL is expected for each voiding. Some women experience difficulty in emptying bladder, possibly as a result of diminished bladder tone, edema from trauma, or fear of discomfort. Nursing interventions for inability to void & bladder distention are discussed in "Preventing Bladder Distention" section earlier in chapter. UI is not uncommon, esp if was significant perineal trauma with birth. Pelvic floor muscle training, (Kegels), helps to strengthen muscle tone, esp after vaginal birth. Kegel exercises help women regain muscle tone lost as pelvic tissues stretched & torn during pregnancy & birth. Women who maintain muscle strength benefit years later by retaining urinary continence. Some women perform kegel exercises incorrectly & can increase risk for incontinence, which can occur when inadvertently bearing down on pelvic floor muscles, thrusting perineum outward. The hc provider can assess woman's technique during the pelvic examination at her follow-up visit by inserting two fingers intravaginally & noting whether the pelvic floor muscles correctly contract & relax.

Signs of respiratory distress

Nasal flaring, intercostal or subcostal retractions (in-drawing of tissue between the ribs or below the rib cage), or grunting with respirations. Suprasternal or subclavicular retractions with stridor or gasping most often represent an upper airway obstruction. Seesaw or paradoxical respirations (exaggerated rise in abdomen with respiration as the chest falls) instead of abdominal respirations are abnormal and should be reported. RR < 30 or greater than 60 breaths/min with infant at rest must be evaluated. RR of infant can be slowed, depressed, or absent as a result of effects of analgesics or anesthetics administered to mother during labor and birth.

Lactation Suppression

Necessary when woman has decided not to breastfeed or in case of neonatal death. Woman wears well-fitted support bra continuously for at least first 72 hrs after birth. Should avoid breast stimulation, including running warm water over breasts, newborn suckling, or expressing milk. Some nonbreastfeeding mothers experience severe breast engorgement which can be managed satisfactorily with nonpharmacologic interventions. Periodic application of ice packs to breasts can help decrease discomfort associated with engorgement. Lack of scientific evidence to support effectiveness, but cabbage leaves often recommended; formula-feeding mothers may be told to place fresh green cabbage leaves over breasts & replace leaves when wilted. Mild analgesic or antiinflammatory med can reduce discomfort associated w/ engorgement. Meds once prescribed for lactation suppression are no longer used.

Rh factor

Presence or lack of antigens on the surface of red blood cells, which causes a reaction between Rh-positive blood and Rh-negative blood

Safety Alert - Discharge

No med that can cause drowsiness should be administered to mother before discharge if she is one who will be holding baby when they leave hospital. In most instances, woman is seated in a wheelchair and given baby to hold. Some families leave unescorted & ambulatory, depending on hospital protocol. Newborn must be secured in a car seat for the drive home.

Contraceptive use postpartum

Ovulation can occur as soon as 1 mo after birth, particularly in women who formula-feed their infants. Breastfeeding mothers should be informed that breastfeeding is not a reliable means of contraception & that other methods should be used; nonhormonal methods are best because oral contraceptives can interfere with milk production. Women who are undecided about contraception at time of discharge need info about using condoms with spermicidal foam or creams until first postpartum checkup.

Postpartum fatigue - Nursing interventions

Planned to meet woman's individual needs for sleep & rest while she is in hospital. Comfort measures & meds to promote sleep may be necessary. Side-lying position for breastfeeding minimizes fatigue in nursing mothers. Support & encouragement of mothering behaviors help reduce anxiety. Hospital & nursing routines can be adjusted to meet needs of individuals. Nurse can help family limit visitors & provide comfortable chair or bed for partner or other family who is staying with new mother.

Promoting exercise

Postpartum exercise can begin soon after birth, although woman should be encouraged to start with simple exercises & gradually progress to more strenuous ones. Abdominal exercises are postponed until approximately 4-6 wks after cesarean birth.

Psychosocial care needs

Postpartum support likely an ongoing concern after discharge when woman is providing care for newborn, herself, & other fam members. Esp beneficial to at-risk populations such as low-income primiparas, those at risk for fam dysfunction & child abuse, & those at risk for PPD. Home visitation programs for postpartum women & families promote better outcomes. Sometimes psychosocial assessment indicates serious actual or potential problems that must be addressed. Women exhibiting these needs should be referred to appropriate community resources for assessment and management: • 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/other family members react negatively to 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

Discharge gifts

Prepackaged formula should not be given to mothers who are breastfeeding. Such "gifts" are associated with earlier cessation of breastfeeding.

Infant follow uo

Prior to discharge from birthing facility, nurse emphasizes need for follow-up care for newborn. Breastfeeding infants are routinely seen by pediatric hc provider or clinic within 3-5 days after birth or 48-72 hrs after hospital discharge & again at 2 wks of age. Formula-feeding infants may be seen for first time at 2 weeks of age. If appt was not scheduled for infant's follow-up visit before leaving hospital, parents should be encouraged to call office or clinic soon after arrival home. This visit is essential for evaluating status of infant, & provides an opportunity for assessing mother for PPD, even before she returns to obstetric hc provider.

Pituitary Hormons & Ovarian Function

Prolactin levels in blood rise progressively throughout pregnancy. After birth, as levels of progesterone decrease, prolactin levels ^. In woman who breastfeeds, prolactin levels highest during first month after birth & remain elevated above nonpregnant levels as long as breastfeeding. Serum prolactin levels influenced by frequency of breastfeeding, duration of each feeding, & use of supplementary feedings. Individual differences in strength of an infant's sucking stimulus affect prolactin levels. In nonlactating women, prolactin levels decline after birth & reach prepregnant range by third postpartum week. Lactating and nonlactating women differ considerably in timing of first ovulation & when menstruation resumes. Ovulation occurs early as 27 days after birth in nonlactating women, with mean time of 7-9 wks. 70% of nonbreastfeeding women resume menstruating by 12 wks after birth. Mean time to ovulation in women who breastfeed is 6 months. Persistence of elevated serum prolactin levels in breastfeeding women appears to be responsible for suppressing ovulation. In lactating women, both resumption of ovulation and return of menses are determined in large part by breastfeeding patterns. For example, ovulation is delayed longer in women who breastfeed exclusively compared with women who breastfeed & offer supplemental infant formula to their infants. Because of uncertainty about return of ovulation & menstruation, discussion of contraceptive options early in postpartum period is necessary. First menstrual flow after birth is usually heavier than normal. Within three or four cycles, amt of menstrual flow returns to prepregnancy volume.

Breasts

Promptly after birth, decrease occurs in concentrations of hormones that stimulated breast development during pregnancy. (i.e., estrogen, progesterone, hCG, prolactin, cortisol, and insulin) Time required for these hormones to return to prepregnancy levels is determined in part by whether or not mother breastfeeds her infant.

Bowel function - Safety Alert

Rectal suppositories & enemas should not be admin'ed to women with 3rd- or 4th-degree perineal lacerations. These measures to treat constipation can be very uncomfortable & cause hemorrhage or damage to suture line. Can predispose woman to infection

Promoting ambulation - anesthesia

Regional (epidural or spinal) anesthesia can cause slow return of sensory & motor function in lower extremities, increasing risk for falls with early ambulation. Careful assessment by postpartum nurse can prevent falls. Factors that nurse should consider are time lapse since epidural or spinal med was given; woman's ability to bend both knees, place both feet flat on bed, & lift buttocks off bed without assistance; meds since birth; vitals; & estimated blood loss with birth. Before allowing woman to ambulate, nurse assesses ability of woman to stand unassisted beside her bed, simultaneously bending both knees slightly, & then standing with knees locked. If woman is unable to balance herself, can be safely eased back into bed without injury

Urine components

Renal glycosuria induced by pregnancy disappears by 1 wk postpartum, but lactosuria can occur in lactating women. BUN increases during puerperium as autolysis of involuting uterus occurs. Plasma creatinine levels return to normal by 6 wks postpartum. Pregnancy-associated proteinuria resolves by 6 wks after birth. Ketonuria can occur in women with uncomplicated birth or after prolonged labor with dehydration.

Mechanical factors

Respirations in newborn can be stimulated by changes in intrathoracic pressure resulting from compression of chest during vaginal birth. As infant passes through birth canal, chest is compressed. With birth this pressure on chest is released, and negative intrathoracic pressure helps draw air into lungs. Crying increases distribution of air in lungs and promotes expansion of alveoli. Positive pressure created by crying helps keep the alveoli open.

Fluid retention

Retention of lung fluid can interfere with infant's ability to maintain adequate oxygenation, especially if other factors that compromise respirations (e.g., meconium aspiration, congenital diaphragmatic hernia, esophageal atresia with fistula, choanal atresia, congenital cardiac defect, immature alveoli) are present. Infants born by cesarean in which labor did not occur before birth can experience some lung fluid retention, although it typically clears without harmful effects on infant. These infants are also more likely to develop transient tachypnea of the newborn (TTN)

Involution process

Return of uterus to a nonpregnant state after birth Begins immediately after expulsion of placenta with contraction of uterine smooth muscle. Increased estrogen & progesterone levels are responsible for stimulating massive growth of uterus during pregnancy. Prenatal uterine growth results from both: - hyperplasia (increase in # of muscle cells) - hypertrophy (increase in size of existing cells)

RhoGAM safety alert

Rh immune globulin suppresses immune response. Therefore, woman who receives both Rh immune globulin & a live virus immunization such as rubella must be tested in 3 mos to see if she has developed rubella immunity. If not, will need another dose of vaccine.

PPD Screening

Screening for PPD through use of simple tool such as the Edinburgh Postnatal Depression Scale (EPDS) can be done before hospital discharge. Screening for PPD should also be done after discharge. The AAP recommends pediatric care providers routinely perform maternal screening for PPD during infant follow-up visits at 1, 2, & 4 months

Bowel function - Gas pains

Some mothers experience gas pains; more common following cesarean birth. Ambulation or rocking in a rocking chair can stimulate passage of flatus & provide relief. Antiflatulent meds may be ordered. Mother can avoid foods (e.g., legumes, beans, broccoli) that tend to produce gas.

Tetanus-Diphtheria-Acellular Pertussis Vaccine (Tdap)

Tetanus-diphtheria-acellular pertussis (Tdap) vaccine is recommended for postpartum women who have not previously received the vaccine; given before discharge from hospital or as early as possible in postpartum period to protect women from pertussis & decrease risk for infant exposure to pertussis. Women should be advised that other adults & children who will be around newborn should be vaccinated with Tdap if have not previously received vaccine. Women who receive vaccine can continue to breastfeed

Varicella virus

The CDC recommends that varicella vaccine be administered before discharge in postpartum women who have no immunity. A second dose is given at postpartum follow-up visit (4-8 wks after first dose)

Subinvolution

The failure of the uterus to return to a nonpregnant state. Most common causes of subinvolution are retained placental fragments and infection

HR and sounds of newborn

The heart rate for a term newborn ranges from 120 to 160 beats/minute, with brief fluctuations greater and less than these values usually noted during sleeping and waking states. The range of the heart rate in the term infant is about 80 to 100 beats/minute during deep sleep and can increase to 180 beats/min or higher when the infant cries. A heart rate that is either high (more than 160 beats/minute) or low (fewer than 100 beats/minute) should be reevaluated within 30 minutes to 1 hour or when the activity of the infant changes. The apical impulse (point of maximal impulse [PMI]) in the newborn is at the fourth intercostal space and to the left of the midclavicular line. The PMI is often visible and easily palpable because of the thin chest wall; this is also called precordial activity. Irregular heart rate or sinus dysrhythmia is common in the first few hours of life but thereafter may need to be evaluated. Heart sounds during the neonatal period are of higher pitch, shorter duration, and greater intensity than during adult life. The first sound (S1) is typically louder and duller than the second sound (S2), which is sharp. The third and fourth heart sounds are not audible in newborns. Most heart murmurs heard during the neonatal period have no pathologic significance, and more than one-half of the murmurs disappear by 6 months of age. However, the presence of a murmur and accompanying signs such as poor feeding, apnea, cyanosis, or pallor is considered abnormal and should be investigated. There can be significant cardiac defects without a murmur or other symptoms (Smith, 2012). This reinforces the importance of ongoing assessment.

Rh immune globulin (RhoGAM) as a blood product

There is some disagreement about whether Rh immune globulin should be considered a blood product. Health care providers need to discuss most current info about this issue with women whose religious beliefs conflict with having blood products administered to them

Safety Alert - Promoting Ambulation

To promote safety and prevent injury, it is important to have hospital personnel present first time woman gets out of bed after birth because she can feel weak, dizzy, faint, or lightheaded. Nurse instructs woman to call for assistance before getting out of bed first time & any time thereafter if feels dizzy or weak. Partner or family members who are present are instructed as well.

Thoracic squeeze

Traditionally thought that thoracic squeeze occurring during normal vaginal birth resulted in significant clearance of lung fluid. However, this event plays minor role. In days preceding labor, reduced production of fetal lung fluid and concomitant decreased alveolar fluid volume. Shortly before onset of labor, catecholamine surge that seems to promote fluid clearance from lungs, which continues during labor. Mvmt of lung fluid from air spaces occurs through active transport into interstitium, with drainage occurring through pulmonary circulation and lymphatic system.

Medications

Women routinely continue to take prenatal vitamins during the postpartum period. Breastfeeding mothers may continue prenatal vitamins for duration of breastfeeding. Supplemental iron may be prescribed for mothers with lower than normal hemoglobin levels. Women with extensive episiotomies or perineal lacerations (third or fourth degree) are usually prescribed stool softeners to take at home. Pain meds (opioid and nonopioid) may be prescribed, esp for women who had cesarean births. Nurse should make certain that woman knows route, dosage, frequency, and common SEs of all meds that she will be taking at home. Written info about meds is usually included in discharge instructions.

BP

Values for newborn blood pressure vary with gestational age, weight, state of alertness, and cuff size. The term newborn infant's average systolic BP is 60 to 80 mm Hg, and average diastolic BP is 40 to 50 mm Hg. The mean arterial pressure (MAP) should be equivalent to the weeks of gestation. For example, an infant born at 40 weeks of gestation should have a MAP of at least 40. The BP increases by the second day of life, with minor variations noted during the first month of life. A drop in systolic BP (about 15 mm Hg) in the first hour of life is common. Crying and movement usually cause increases in the systolic BP.

Thermal factors

With birth, newborn enters extrauterine environment, in which temperature is significantly lower. Profound change in environmental temp stimulates receptors in skin, resulting in stimulation of respiratory center in medulla.

Follow up appts

Women who have experienced uncomplicated vaginal births are commonly scheduled for traditional 6-wk postpartum exam. Women who have had a cesarean birth are usually seen in hc provider's office or clinic within 2 wks after hospital discharge. Early follow-up is warranted for women who experienced complications such as hypertensive disorders of pregnancy, those with chronic health conditions, women at high risk for depression, and breastfeeding mothers who are experiencing lactation problems. Date & time for follow-up appt should be included in discharge instructions. If an appointment has not been made before woman leaves hospital, she should be encouraged to call hc provider's office or clinic to schedule one. Nurse should explain importance of postpartum follow-up care and encourage new mother to be compliant.

Other forms of postpartum follow ups

postpartum telephone follow-up calls are sometimes used for assessment, health teaching, and identification of complications to facilitate timely intervention and referrals The warm line is another type of telephone link between the new family and concerned caregivers or experienced parent volunteers. A warm line is a help line or consultation service. Calls commonly relate to infant feeding, prolonged crying, or sibling rivalry. Families are encouraged to call when concerns arise. Support groups are available for mothers and their partners in person or online Nurse should provide local and national resources to mother prior to discharge, depending on individual needs. Nurse should compile frequently used lists.

Patient teaching - resuming sexual activity after giving birth

• Unless hc provider indicates otherwise, you can safely resume sexual activity (intercourse) by second to fourth week after birth, when bleeding has stopped & perineum is healed. Most women resume sexual activity by 5-6 wks after birth, although this varies & is often related to perineal discomfort. Perineal lacerations or episiotomy increase chances of discomfort with intercourse. For first 6 wks to 6 mos, vaginal lubrication might be decreased, especially among breastfeeding women. Your physiologic reactions to sexual stimulation for first 3 months after birth may be slower & less intense. Strength of orgasm may be reduced. • Water-soluble gel or contraceptive cream or jelly might be recommended for lubrication. If some vaginal tenderness is present, your partner can be instructed to insert one or more clean, lubricated fingers into vagina and rotate them to help the vagina relax and identify possible areas of discomfort. A position in which you have control of depth of insertion of penis also is useful. Side-by-side or female-on-top position may be most comfortable. • Presence of baby influences sexual activity & enjoyment. Parents hear every sound made by baby; conversely you may be concerned that baby hears every sound you make. In either case, any phase of sexual response cycle can be interrupted by hearing baby cry or move, leaving both of you frustrated and unsatisfied. In addition, amt of psychologic energy expended in child-care activities can lead to fatigue. Newborns require great deal of attention & time. • Some women have reported feeling sexual stimulation & orgasms when breastfeeding their babies. This is not abnormal. Breastfeeding mothers often are interested in returning to sexual activity before nonbreastfeeding mothers. • You should be instructed to perform Kegel exercises correctly to strengthen your pubococcygeal muscle. This muscle is associated with bowel & bladder function & vaginal feeling during intercourse.

Routine lab tests

Several lab tests may be performed in immediate postpartum period. Hemoglobin & hematocrit values often evaluated on first postpartum day to assess blood loss during birth, esp after cesarean birth. In some hospitals, a clean-catch or catheterized urine specimen is obtained & sent for routine urinalysis or culture & sensitivity, esp if an indwelling urinary catheter was inserted during intrapartum period. If woman's rubella immunity & Rh status unknown, tests to determine status & need for possible trtmt should be performed.

Transfer from the recovery area

After initial recovery period completed, woman may be transferred to postpartum room in same or another nursing unit. In facilities with labor, delivery, recovery, postpartum (LDRP) rooms, woman not moved & nurse who provides care during recovery period usually continues caring for woman. In many settings, women who have received general or regional anesthesia must be cleared for transfer from recovery area by member of anesthesia care team. In other settings, nurse makes determination. In preparing transfer report or "hand-off," labor & delivery or postanesthesia care nurse uses info from records of admission, birth, & recovery.

Nursing interventions

Based on available data (med record) & assessment findings, nurse plans with woman which nursing measures are appropriate & which are to be given priority. Nursing care plan includes periodic assessments to detect deviations from normal physical changes, measures to relieve discomfort or pain, safety measures to prevent injury & infection, & education & counseling measures designed to promote woman's feelings of competence in self-mgmt & infant care. Nurse evaluates continually & is ready to change plan if indicated. Almost all hospitals use standardized care plans as a base. Nurses individualize care of postpartum woman & neonate according to specific needs.

Urethra & Bladder - Post-birth

Birth-induced trauma, ^ bladder capacity after birth, & effects of conduction anesthesia can result in decreased urge to void. Pelvic soreness caused by forces of labor, vaginal or perineal lacerations, or episiotomy can reduce or alter voiding reflex. Decreased voiding combined with postpartal diuresis can result in bladder distention. Immediately after birth, excessive bleeding can occur if bladder becomes distended because it pushes uterus up & to side & prevents it from contracting firmly. Later in puerperium, overdistention can make bladder more susceptible to infection & impede resumption of normal voiding. With adequate bladder emptying, bladder tone usually restored by 5-7 days after birth.

Breasts of non-breastfeeding mothers

Breasts generally feel nodular in contrast to granular feel of breasts in nonpregnant women. Nodularity is bilateral & diffuse. Prolactin levels drop rapidly. Colostrum present for first few days after birth. Palpation of breasts on second or third day as milk prod begins can reveal tissue tenderness. On third or fourth postpartum day, engorgement can occur. Breasts are distended (swollen), firm, tender, & warm to touch. Breast distention caused primarily by temporary congestion of veins & lymphatics rather than by an accumulation of milk. Milk is present but should not be expressed. Axillary breast tissue (the tail of Spence) & any accessory breast or nipple tissue along milk line can be involved. Engorgement resolves spontaneously, and discomfort decreases usually within 24-36 hrs. A breast binder or well-fitted supportive bra, ice packs, fresh cabbage leaves, and/or mild analgesics may relieve discomfort. Nipple stimulation is avoided. If suckling or milk expression is never begun (or is discontinued), lactation ceases within a few days to 1 week.

BP Normal findings

Consistent with BP baseline during pregnancy; transient increase of 5% first few days after birth; can have orthostatic hypotension for 48 hours

Worsening fatigue

Fatigue likely to worsen over first 6 wks after birth, often because of situational factors. After discharge from hospital, fatigue ^ as woman provides care & feeding for newborn in combination with other family & household responsibilities. Many women have partners, family members, or friends to provide assistance, whereas others can be without help. Nurse needs to inquire about resources available to woman after discharge & help plan accordingly. Important to remember that partner is also prone to fatigue if helping new mother with infant care & attending to other children or tasks.

Legs Normal Findings

Deep tendon reflexes (DTRs) 1+ to 2+ Peripheral edema possibly present Homan sign* negative

Breasts of breastfeeding mothers

During first 24 hrs after birth, little if any change in breast tissue. *Colostrum*, or early milk, a clear yellow fluid, can be expressed from breasts. Breasts gradually become fuller & heavier as colostrum transitions to mature milk by about 72-96 hrs after birth; this is often referred to as the "milk coming in," or lactogenesis II. Breasts can feel warm, firm, & somewhat tender. Bluish white milk with a skim-milk appearance (true milk) can be expressed from nipples. As milk glands & ducts fill with milk, breast tissue can feel somewhat nodular or lumpy. Unlike lumps associated with fibrocystic breast changes or cancer (which can be palpated consistently in the same location), nodularity associated with milk production tends to shift in position. Some women experience engorgement at this time due to ^ in blood & lymphatic fluid as milk production increases. Engorged breasts are hard & uncomfortable; fullness of nipple tissue can make it difficult for infant to latch on & feed. With frequent breastfeeding & proper care, engorgement is a temporary condition (24-48 hrs)

Vagina & Perineum - Dryness

Estrogen deficiency is responsible for a decreased amt of vaginal lubrication; vaginal dryness more prevalent among breastfeeding mothers. Localized dryness & coital discomfort (dyspareunia) can persist until ovarian function returns & menstruation resumes. Use of water-soluble lube during sex is recommended.

Other causes

Excessive blood loss after birth can also be caused by vaginal or vulvar hematomas or unrepaired lacerations of the vagina or cervix. These potential sources might be suspected if excessive vaginal bleeding occurs in presence of a firmly contracted uterine fundus. A perineal pad saturated in 15 mins or less & pooling of blood under buttocks are indications of excessive blood loss, requiring immediate assessment, intervention, & notification of the primary hc provider.

Newborns' and Mothers' Health Protection Act of 1996

Provided minimum federal standards for health plan coverage for mothers & newborns. All health plans required to allow new mother & newborn to remain in hospital for a min of: - 48 hrs after uncomplicated vaginal birth - 96 hrs after a cesarean (unless attending provider in consultation with mother decides on early discharge)

Placental hormones

Expulsion of placenta results in dramatic decreases in hormones produced by that organ. Estrogen & progesterone levels drop after birth & reach lowest levels 1 wk after birth. Decreased estrogen levels are associated with diuresis of excess ECF accumulated during pregnancy. In nonlactating women, estrogen levels begin to ^ by 2 wks after birth, & by postpartum day 17 they are higher than in women who breastfeed. Human chorionic gonadotropin (hCG) disappears quickly from maternal circulation. But because removing hCG from extravascular and intracellular spaces takes time, hormone can be detected in maternal system for 3-4 wks after birth

Nonpharmacologic pain interventions assoc with episiotomy or perineal lacerations

Simple intervention that can decrease discomfort associated with episiotomy or perineal lacerations is to encourage woman to lie on side whenever possible. Other interventions include application of ice pack; topical application of anesthetic spray or cream; cleansing with water from a squeeze bottle; & cleansing shower, tub bath, or sitz bath. Many of these interventions also effective for hemorrhoids, esp ice packs, sitz baths, & topical applications (such as witch hazel pads).

Family-centered maternity care

Family-centered maternity care important in postpartum period. Care is provided in context of family unit & focuses on assessment & support of woman's physiologic & emotional adaptation after birth. During early postpartum period, components of nursing care include: - assisting with rest & recovery from labor & birth - assessing physiologic & psychologic adaptation after birth - preventing complications - educating regarding self-management and infant care - supporting mother and partner during initial transition to parenthood. - considering needs of family members & strategies in care plan to assist family in adjusting to new baby. In US, most women remain hospitalized 1 or 2 days after vaginal birth, & some only 6 hrs. Discharge planning & education begins during pregnancy

Nipples Normal FIndings

Skin intact; no soreness reported

Patient-Centered Care

First step in pt-centered care is to confirm woman's identity by checking wristband. At same time, infant's identification number is matched with corresponding band on mother's wrist & in some instances father's or partner's wrist. Nurse determines how mother wishes to be addressed & notes preference in medical record & nursing care plan. Nurse orients woman & family to surroundings. Familiarity with unit, routines, resources, & personnel reduces potential source of anxiety—unknown. Mother reassured through knowing whom & how she can call for assistance & what can expect in way of supplies & services. If woman's usual daily routine before admission differs from routine of facility, nurse works with woman to develop mutually acceptable routine. Nurses discuss infant security precautions with mother & family

Planning for discharge

From initial contact with postpartum woman, nurses prepare new mother for return home. Planning for discharge begins with first interaction among nurse, woman, & family & continues until they leave facility. Length of hospital stay after birth depends on: - physical condition of mother and newborn - mental and emotional status of mother - social support at home - pt ed needs for self-care & infant care, & financial constraints. Women who give birth in birthing centers may be discharged within a few hrs, after woman's & infant's conditions are stable. Mothers & newborns at low risk for complications may be discharged within 24-36 hrs after vaginal birth. This short time frame is often called "early postpartum discharge", "shortened hospital stay", and "1-day maternity stay".

Urinary system

Hormonal changes of pregnancy (i.e., high steroid levels) contribute to ^ in renal function; diminishing steroid levels after birth may partly explain reduced renal function that occurs during puerperium. Kidney function returns to normal by 8 wks after birth. About 6 wks are required for pregnancy-induced hypotonia & dilation of ureters & renal pelves to return to nonpregnant state In a small % of women, dilation of urinary tract can persist for 3 mos+, increasing risk for developing UTI Urine Components Fluid Loss Urethra & Bladder

Safety Alert - Pain

If postpartum woman complains of extreme perineal pain, esp after having received pain med, first action by nurse should be to assess perineum. May be a hematoma or perineal infection causing pain. Although rare, inordinate degree of pain can be sign of serious complications incl. perineal cellulitis, necrotizing fasciitis, or angioedema

Vagina & Perineum - Episiostomy & Laceration

Immediately after birth, introitus (opening) is erythematous & edematous, esp in area of an episiotomy (surgical cut made at opening of vagina) or laceration repair. Barely distinguishable from that of a nulliparous woman if lacerations or an episiotomy have been carefully repaired, hematomas are prevented or treated early, and woman practices good hygiene during first 2 wks after birth. Most episiotomies & laceration repairs are visible only if woman is lying on side with upper buttock raised or if placed in lithotomy position. Good light source is essential for visualization of some repairs. Healing of episiotomy or laceration is same as any surgical incision. Signs of infection (pain, redness, warmth, swelling, or discharge) or lack of approximation (separation of the edges of the incision) can occur. Initial healing occurs within 2-3 wks, but 4-6 mos can be required for repair to heal completely.

Placental site

Immediately after placenta & membranes expelled, vascular const. & thromboses reduce placental site to an irregular nodular & elevated area. Upward growth of endometrium causes sloughing of necrotic tissue & prevents scar formation characteristic of normal wound healing. This unique healing process enables endometrium to resume its usual cycle of changes & permit implantation & placentation in future pregnancies. Endometrial regeneration is completed by postpartum day 16, except at placental site. Regeneration at placental site usually not complete until 6wks after birth

Immune System

In postpartum period, woman's immune (lymphoreticular) system, which was mildly suppressed during pregnancy, gradually returns to prepregnant state, although the exact timeline is unclear. This rebound of immune system can trigger "flare-ups" of autoimmune conditions such as MS or lupus erythematosus

Hematocrit & Hgb

In women with avg blood loss during birth, hematocrit level drops moderately for 3-4 days, then begins to ^, & reaches nonpregnant levels by 8 wks postpartum. A postpartum hematocrit can be lower than normal if blood loss was increased or if hypervolemia of pregnancy was less than normal

CV System - Cardiac Output

Pulse rate, stroke volume, & cardiac output ^ throughout pregnancy. Dramatic changes in maternal hemodynamic status occur with birth & delivery of placenta. Immediate blood loss reduces plasma vol without reducing cardiac output. This is due to compensatory influx of nearly 500 mL of blood into maternal system from uteroplacental bed, a rapid decrease in uterine blood flow, & mobilization of ECF. Typically cardiac output is ^ immediately after birth by 60%-80% over prelabor values; it returns to prelabor values within 1 hour. By 2 wks after birth, cardiac output decreases by 30% & gradually decreases to prepregnant levels by 6-8 wks postpartum in majority of women

Promoting rest - Lack of sleep

Lack of sleep & fatigue are common complaints of new parents. Sleep loss, feeling stressed, & physical exhaustion have been reported as top 3 problems women experience within first 2 months after birth. Early postpartum period is time that new parents experience greatest disruption to lives as try to adjust to nearly constant demands of newborn. Other factors contribute to physical fatigue or exhaustion such as long labor or cesarean birth, hospital routines that interrupt periods of sleep & rest, physical discomfort, & visitors. Fatigue can also be associated with anemia, infection, or thyroid dysfunction. Excitement & exhilaration experienced after birth of infant makes resting difficult. Disrupted sleep & fatigue in postpartum woman contribute to development of postpartum depressive symptoms & ^ risk for postpartum depression (PPD)

Maintaining uterine tone

Major intervention to alleviate uterine atony & restore uterine muscle tone is stimulation by gently massaging the fundus until firm. Fundal massage can cause a temp ^ in amt of vaginal bleeding seen as pooled blood leaves uterus. Clots can also be expelled. Uterus can remain boggy even after massage & clot expulsion. Fundal massage can be uncomfortable. If nurse explains purpose of fundal massage as well as causes & dangers of uterine atony, woman will likely be more cooperative. Teaching woman to massage her own fundus enables her to maintain some control & decreases anxiety. When uterine atony & excessive bleeding occur, additional interventions likely to be used are admin of IV fluids &oxytocic meds (drugs that stimulate contraction of the uterine smooth muscle)

Bedside reporting

Many inpatient nursing units, including perinatal care areas, have a bedside report. Increasingly being used instead of traditional report given at nurses' station. Shown to improve pt safety & pt satisfaction. Pts feel more involved in their plan of care, which increases satisfaction. Holding report at bedside has enabled nurses to both visualize & communicate with pt at time of report, which improves pt safety

Pharmacologic interventions - Active participation

Many women want to participate in decisions about analgesia. Severe pain, however, can interfere with active participation in choosing pain relief measures. If an analgesic is to be given, the nurse must make a clinical judgment of the type, appropriate dosage, and frequency from the medications ordered. The woman is informed of the prescribed analgesic and its common side effects; this teaching is documented.

Integumentary System

Melasma (chloasma or "mask of pregnancy") usually disappears in postpartum period but persists in about 30% of women. Hyperpigmentation of areolae & linea nigra may not regress completely after birth. Some women will have permanent darker pigmentation of those areas. Striae gravidarum (stretch marks) on breasts, abdomen, hips, & thighs may fade but usually do not disappear completely. Vascular abnormalities such as angiomatas (vascular spiders) & palmar erythema generally regress in response to rapid decline in estrogens after birth. For some women, vascular spiders persist indefinitely. For first 3 months after birth, women often report hair loss when brush or comb hair. Abundance of fine hair seen during pregnancy usually disappears after giving birth; however, any coarse or bristly hair that appears during pregnancy usually remains. Fingernails return to their prepregnancy consistency and strength.

GI System

Most new mothers very hungry after full recovery from analgesia, anesthesia, & fatigue. Requests for extra portions of food & frequent snacks common. Spontaneous bowel evacuation may not occur for 2-3 days after birth. Delay explained by slowed peristalsis related to decreased muscle tone in intestines during labor and immediate postpartum period, prelabor diarrhea, lack of food, or dehydration. Mother often anticipates discomfort during bowel movement because of perineal tenderness as result of an episiotomy, lacerations, or hemorrhoids & resists urge to defecate. Regular bowel habits should be reestablished when bowel tone returns. Third- & fourth-degree perineal lacerations that involve anal sphincter are associated with increased risk for postpartum anal incontinence. Women with this problem more often incontinent of flatus than stool. If anal incontinence lasts more than 6 mos, studies conducted to determine specific cause & treatment

Promoting comfort

Most women experience some degree of discomfort during postpartum period. Common causes include pain from uterine contractions (afterpains), perineal lacerations or episiotomy, hemorrhoids, sore nipples, and breast engorgement. Woman's description of location, type, & severity of pain is best guide in choosing appropriate interventions. To confirm location & extent of discomfort, nurse inspects & palpates areas of pain as appropriate for redness, swelling, discharge, & heat, & observes for body tension, guarded movements, & facial tension. BP, pulse, & respirations can ^ in response to acute pain. Diaphoresis can accompany severe pain. Lack of objective signs does not necessarily mean is no pain because can be cultural component to expression of pain. Nursing interventions intended to eliminate pain sensation entirely or reduce to a tolerable level that allows woman to care for herself & newborn. Nurses may use nonpharmacologic & pharmacologic interventions to promote comfort. Pain relief is enhanced by using more than one method or route.

Neurologic system

Neurologic changes during puerperium result from a reversal of maternal adaptations to pregnancy & from trauma during labor & birth. Pregnancy-induced neurologic discomforts disappear after birth. Elimination of physiologic edema through diuresis that follows birth relieves carpal tunnel syndrome by easing compression of median nerve. Periodic numbness & tingling of fingers usually disappear after birth unless lifting & carrying baby aggravate condition. Nasal stuffiness, tinnitus, & laryngeal changes resolve within few days postpartum. Headaches common in first postpartum week; usually bilateral & frontal. Requires careful assessment. Can be caused by various conditions, including postpartum-onset preeclampsia, stress, & leakage of cerebrospinal fluid into extradural space during placement of needle for admin of epidural or spinal anesthesia.

Rectal Area Normal Findings

No hemorrhoids; if hemorrhoids are present, soft and pink

WBC count

Normal leukocytosis of pregnancy ranges from 5,000-15,000/mm3. During & after labor WBC count may rise to 30,000/mm3. Leukocytosis, coupled with ^ in erythrocyte sedimentation rate that normally occurs, can obscure diagnosis of acute infection

Safety Alert

Nurse always checks for blood under mother's buttocks as well as on perineal pad. Although amount on perineal pad can appear small, blood can flow between buttocks onto linens under mother. When this happens, excessive bleeding can go undetected.

Pharmacologic interventions Safety Alert!

Nurse should carefully monitor women receiving opioids because respiratory depression & decreased intestinal motility are side effects.

Preventing infection

Nurses in postpartum setting are acutely aware of importance of preventing infection. One important means of preventing infection is by maintaining a clean envmt. Bed linens should be changed as needed. Disposable pads & drawsheets changed frequently. Women should wear slippers when walking to prevent contamination of linens when return to bed. Personnel must be conscientious about hand hygiene to prevent cross-infection. Standard Precautions must be practiced. Staff members with colds, coughs, or skin infections (cold sores) must follow hospital protocol when in contact with postpartum women. In many hospitals, staff members with open herpetic lesions, strep throat, conjunctivitis, upper respiratory infections, or diarrhea are encouraged to avoid contact with mothers & infants by staying home until condition is no longer contagious. Visitors with signs of illness not permitted to enter postpartum unit. Perineal lacerations & episiotomies can increase risk for infection as a result of interruption in skin integrity. Proper peri care helps prevent infection in genitourinary area & aids healing process. Educating woman to wipe front to back after voiding or defecating is a simple first step. In many hospitals, a squeeze bottle filled with warm water or an antiseptic solution is used after each voiding to cleanse perineal area. Woman should change her perineal pad from front to back each time she voids or defecates and wash her hands thoroughly before & after

Care Plan

Nurses provide direct physical care, educate new mothers / families, & provide anticipatory guidance & counseling. Nurture woman by providing encouragement & support as begins to assume tasks of motherhood. Nurses who take time to "mother the mother" increase self-confidence in new mothers. Nurses are careful to include woman's spouse or partner & other primary support persons in education & counseling.

Ongoing physical assessment

Ongoing assessments performed throughout hospitalization. In addition to vitals, physical assessment of postpartum woman focuses on evaluation of breasts, uterine fundus, lochia, perineum, bladder & bowel function, & lower extremities

Lochial abnormalities

Persistence of lochia rubra in postpartum period suggests continued bleeding as result of retained fragments of placenta or membranes. Not uncommon for women to experience sudden, brief increase in bleeding 7-14 days after birth when sloughing of eschar over placental site occurs. If this does not subside within 1-2 hrs, the woman needs to be evaluated for possible retained placental fragments. 10% to 15% of women still have normal lochia serosa discharge at their 6-wk postpartum exam. Continued flow of lochia serosa or lochia alba by 3-4 wks after birth can indicate endometritis, particularly if the woman has fever, pain, or abdominal tenderness. Lochia should smell like normal menstrual flow; an offensive odor usually indicates infection. Not all postpartal vaginal bleeding is lochia; vaginal bleeding after birth can be caused by unrepaired vaginal or cervical lacerations.

Care Mgmt: Physical needs

Plan of care includes postpartum woman, newborn, & family. Most birth facilities use th couplet or mother/baby model of care Nurses in these settings have been educated in both mother & infant care & function as primary nurses for both mother & infant, even if infant is kept in nursery. This approach is a variation of rooming-in, in which mother & infant room together & mother & nurse share in infant's care. Organization of mother's care must take newborn's feeding & care needs into consideration.

Lochia

Postbirth uterine discharge Initially bright red (lochia rubra) & may contain small clots. For first 2 hrs after birth, amt of uterine discharge should be that of a heavy menstrual period. After that, lochial flow steadily decreases. Lochia rubra is bright red & consists mainly of blood & decidual & trophoblastic debris. Flow pales, becoming pink or brown (lochia serosa) after 3-4 days. Lochia serosa consists of old blood, serum, leukocytes, & tissue debris. About 10-14 days after birth the drainage becomes yellow to white (lochia alba). Lochia alba consists of leukocytes, decidua, epithelial cells, mucus, serum, & bacteria. Lochia can persist up to 4-8 weeks after birth. If woman receives an oxytocic med, regardless of route of admin, flow of lochia often scant until effects of med wear off. Amount of lochia usually less after a cesarean birth because surgeon suctions blood & fluids from uterus or wipes uterine lining before closing incision. Flow of lochia usually increases with ambulation & breastfeeding. Lochia tends to pool in vagina when woman is lying in bed; woman can experience gush of blood when stands. Should not be confused with hemorrhage.

Vagina & Perineum - Mucosa & Rugae

Postpartum estrogen deprivation is responsible for thinness of vaginal mucosa & absence of rugae (folds). Smooth-walled vagina that was greatly distended during birth gradually decreases in size & regains tone, but never completely returns to prepregnancy state. Rugae reappear within 3 wks, but they never as prominent as in nulliparous woman. Most rugae permanently flattened. Mucosa remains atrophic in lactating woman until menstruation resumes. Thickening of vaginal mucosa occurs with return of ovarian function.

Uterine Contractions

Postpartum hemostasis achieved primarily by compression of intramyometrial bv's as uterine muscle contracts (rather than by platelet aggregation & clot formation). Oxytocin (from pituitary gland) strengthens & coordinates contractions, which compress bv's & promote hemostasis. During first 1-2 postpartum hrs, contractions can decrease in intensity & become uncoordinated. Because vital that uterus remains firm & well contracted, exogenous oxytocin (Pitocin) is usually admin'd IV or IM immediately after expulsion of placenta. Uterus is very sensitive to oxytocin during first week or so after birth. Breastfeeding immediately after birth & in early days postpartum increases release of oxytocin, which promotes uterine contractions, therefore, decreasing blood loss & reducing the risk for postpartum hemorrhage. In primiparous (1st time preg) women, uterine tone is good, fundus generally remains firm, and woman usually perceives only mild uterine cramping. Periodic relaxation & vigorous contractions are more common in subsequent pregnancies & can cause uncomfortable cramping called *afterpains* (afterbirth pains), which typically resolve in 3-7 days. Afterpains more noticeable after births in which uterus was overdistended. Breastfeeding & exogenous oxytocic meds usually intensify afterpains because both stimulate uterine contractions.

Cervix

Soft immediately after birth. Ectocervix: portion of cervix that protrudes into vagina. - It does appear bruised & has small lacerations, creating optimal condition for development of infection - Over next 12-18 hrs, shortens & becomes firmer Cervical os: portion in lower part of uterus - Dilated to 10cm during labor & closes gradually - Within 2-3 days postpartum, it has shortened, become firm, & regained form. Cervix up to lower uterine segment remains edematous, thin, & fragile for several days after birth. By second or third postpartum day, cervical dilation has decreased to 2-3 cm, & by 1 week after birth, it is approximately 1cm dilated. External cervical os never regains prepregnancy appearance; no longer has circular shape but, instead, appears as a jagged slit often described as a "fish mouth". Lactation delays production of cervical & other estrogen-influenced mucus & affects mucosal characteristics.

Urethra & Bladder - Stress Incontinence

Some women experience stress incontinence during postpartum period. More likely to occur after vaginal than cesarean birth. SI can be related to tissue trauma to pelvic floor occurring with maternal expulsive efforts & increased size of neonate. Coached pushing versus uncoached (non-Valsalva) pushing can increase risk for damage to pelvic floor & subsequent SI.

Nonpharmacologic treatments for sore nipples

Sore nipples in breastfeeding mothers are most likely related to ineffective latch technique. Assessment and assistance with feeding can help alleviate the cause. To ease discomfort associated with sore nipples, mother may apply topical preparations such as purified lanolin or hydrogel pads.

Pelvic muscular support

Supporting structure (muscles & ligaments) of uterus & vagina can be injured during birth; can contribute to later problems. Supportive tissues of pelvic floor that are torn or stretched during birth can require up to 6 mos to regain tone. Kegel exercises, which help strengthen perineal muscles & encourage healing, recommended after birth Later in life, women can experience pelvic relaxation—lengthening & weakening of fascial supports of pelvic structures. Structures include uterus, upper posterior vaginal wall, urethra, bladder, & rectum. Relaxation can occur in any woman, but commonly a direct but delayed complication of birth.

In the postpartum woman, a full bladder may displace the uterus and prevent it from contracting properly. True False

T

Vitals with blood loss

When excessive bleeding occurs, vitals monitored closely. BP is not reliable indicator of impending shock from early postpartum hemorrhage because compensatory mechanisms prevent a significant drop in bp until woman has lost 30% -40% of blood volume. Respirations, pulse, skin condition, urinary output, & LOC are more sensitive means of identifying hypovolemic shock. Frequent physical assessments performed during fourth stage of labor are designed to provide prompt identification of excessive bleeding. Nurses maintain vigilance for excessive bleeding throughout hospital stay as perform periodic assessment of uterine fundus & lochia.

Criteria for discharge

The American Academy of Pediatrics (AAP, 2015): recommends hospital stay for mother with healthy term newborn should be of sufficient length to identify early problems & determine that mother & family are prepared & able to care for neonate at home. Health of mother & newborn should be stable, mother should be able & confident to provide care for her infant, & there should be adequate support systems in place & access to follow-up care. Essential that nurses consider individual needs of woman and newborn and provide care that is intentionally planned to meet needs. Hospital-based maternity nurses continue to play key roles as caregivers, teachers, & advocates for mothers, newborns, & families in developing & implementing effective home-care strategies. Postpartum order sets & maternal-newborn teaching checklists that address mother's learning needs can be used to accomplish pt care tasks & educational outcomes.

Preventing bladder distension

Uterine atony & excessive bleeding after birth can be result of bladder distention. A full bladder causes uterus to be displaced above umbilicus & well to one side of midline in abdomen. Also prevents uterus from contracting normally. Women can be at risk for bladder distention resulting from urinary retention based on intrapartum factors including: - epidural anesthesia - episiotomy - extensive vaginal or perineal lacerations - instrument-assisted birth - prolonged labor. Women who have had indwelling catheters, such as with cesarean birth, can experience some difficulty as they initially attempt to void after the catheter is removed. Nurses aware of these risk factors can be proactive in preventing complications. Nursing interventions for postpartum woman focus on helping woman empty bladder spontaneously as soon as possible. First priority is to assist woman to bathroom or onto bedpan if unable to ambulate. Having woman listen to running water, placing hands in warm water, or pouring water from a squeeze bottle over perineum may stimulate voiding. Other techniques include assisting woman into shower or sitz bath & encouraging her to void; relaxation techniques can also be helpful. Administering analgesics, if ordered, may be indicated because some women fear voiding because of anticipated pain. If these measures are unsuccessful, a sterile catheter may be inserted to drain urine.

Reproductive system & associated structures

Uterus - Involution process - Contractions - Placental site - Lochia Cervix Vagina & Perineum Pelvic Muscular Support

Varicosities

Varicosities (varices) of legs and around anus (hemorrhoids) are common during pregnancy. All varices, even less common vulvar varices, regress (empty) rapidly immediately after birth. Total or nearly total regression of varicosities is expected in postpartum period.

Respiratory system

When birth occurs, immediate decrease in intraabdominal pressure, which allows greater excursion of diaphragm. With decreased pressure on diaphragm & reduced pulm blood flow, chest wall compliance ^. Rib cage elasticity can take months to return to a prepregnancy state. Costal angle that was increased during pregnancy may not completely return to prepregnancy level. Decline in progesterone that occurs with loss of placenta causes PaCO2 levels to rise

MS System - Abdomen

When woman stands during first days after birth, abdomen protrudes & gives still-pregnant appearance. During first 2 wks after birth, abdominal wall is relaxed. Takes about 6 wks for abdominal wall to return almost to prepregnancy state. Rreturn of muscle tone depends on previous tone, proper exercise, and amount of adipose tissue. Occasionally, with or without overdistention because of a large fetus or multiple fetuses, abdominal wall muscles separate, a condition termed diastasis recti abdominis. Persistence of this separation can be disturbing to woman, but surgical correction rarely necessary. With time, separation becomes less apparent. Other adaptations of mother's ms system that occur during pregnancy are reversed in puerperium. These adaptations include relaxation & subsequent hypermobility of joints and change in mother's center of gravity in response to enlarging uterus. Joints are completely stabilized by 6-8 wks after birth. Although all other joints return to their normal prepregnancy state, those in parous woman's feet do not. New mother may notice a permanent increase in her shoe size. Back pain resolves in a few weeks or months following birth.

Fluid Loss

Within 12 hrs of birth, women begin to lose excess tissue fluid accumulated during pregnancy. Postpartal diuresis, caused by decreased estrogen levels, removal of increased venous pressure in lower extremities, & loss of remaining pregnancy-induced increase in bv aids body in ridding itself of excess fluid. Urine output of 3000 mL+ each day during first 2-3 days is common. Profuse diaphoresis often occurs, esp at night, for first 2-3 days after birth. Fluid loss through perspiration & increased urinary output accounts for a weight loss of 2-3 kg (5 to 6.6 lb) during early puerperium

Excessive bleeding

Women who have given birth at risk for excessive bleeding that can progress to postpartum hemorrhage. Most frequent cause is uterine atony (failure of uterine muscle to contract firmly). Two most important interventions for preventing excessive bleeding are maintaining good uterine tone & preventing bladder distention. If uterine atony occurs, relaxed uterus distends with blood & clots, bvs in placental site are not clamped off, & excessive bleeding results. Although cause of uterine atony not always clear, often results from retained placental fragments.