Assessment and Care of the

Newly Delivered Mother

Assessment and Care of the

Newly Delivered Mother

Normal Postpartum Changes Uterus

Normal Postpartum Changes Uterus

•Rapid contraction of the uterine muscle and arteries

– compresses blood vessels– thrombi form–endometrium undermines

site, area heals

Normal Postpartum Changes Uterus

Normal Postpartum Changes Uterus

•Normal size decrease ~1 cm/day

•Weight from 1000g to ~50-100g

•Size affected by parity, multiple gestation, or bladder distension

•After-pains start to in frequency

LOCHIA Rubra Serosa Alba

Normal Color

Red Pink, brown tinged

Yellowish-

white

Normal Duration

1-3 days 3-10 days 10-14 days,

Can be longer

Normal

Discharge

Bloody w/ clots

Serosang.,

Fleshy odor

Mostly musus, no strong odor

Abnormal

Discharge

Foul smell; many lg. clots, saturate pad

Foul smell, quickly saturate pad

Foul smell, rubra or serosa flow; lasts > 4 wks

Factors Affecting LochiaFactors Affecting Lochia

• Factors:– Uterine atony, retained placental

fragments/membranes, activity, distended bladder

– Duration not affected by choice of feeding method or use of oral contraceptives

• Warning signs– Foul-smelling lochia, unusually

heavy flow, large clots, rubra continues by PPD4, saturates > 1pad/hr

• Final sloughing at 7-14 days

PerineumPerineum

•Perineal lacerations–1º skin & superficial structures–2º reaches into perineal muscle–3º extends into anal sphincter

muscle–4º involves anterior rectal wall

PerineumPerineum

• Comfort measures: warm or cool baths, ice packs, witch hazel pads, anesthetic sprays, po analgesics

• Report unusual discomfort, pain, drainage

• Continue perineal hygiene

Cervix, Vagina, & Pelvic Floor

Cervix, Vagina, & Pelvic Floor

• Cervix & lower uterine segment flaccid immediately PP

• Cervix – by 2-3 days has resumed its usual appearance but remains dilated 2-3 cm., 1 cm by end of 1st week– Cervical edema may last several

months

VaginaVagina• Vagina & vaginal outlet may appear

bruised early after delivery; caused by pelvic congestion, disappears quickly after birth

• Involutes by contraction– Walls become gradually thicker, rugae return

by ~ 3 weeks

• Pelvic floor tone regained during first 6 wks PP

Return of MensesReturn of Menses

•Menses – return varies–First menses usually occurs

within 7-9 wks PP if non-nursing

–Great variation in menses return if BF due to depressed estrogen levels. Usually returns between 2-18 months

• First menstrual cycle is usually anovulatory, but 25% may ovulate before menstruation

• Mean return of ovulation –~ 10 wks PP if non-nursing –~ 17 wks PP if breastfeeding

Return of OvulationReturn of Ovulation

Family PlanningFamily Planning

• Discuss family planning– Wait until bleeding stops & have

seen provider for 6 week follow-up appt.

– Discuss with provider at 6 wk. checkup

FertilityCare Program, 322-4434 (Creighton Model)

FertilityCare Program, 322-4434 (Creighton Model)

• 99.5% effective in spacing pregnancy• Can an infertile couple’s chance of

conceiving by 20-80%• Simple charting based on external exams• Can be used to treat GYN conditions:

– Infertility, menstrual cramps, PMS, ovarian cysts, abnormal bleeding, PCOS, repetitive miscarriage, PP depression, hormonal abnormalities, chronic discharge, pelvic pain

Normal Postpartum Changes Bladder

Normal Postpartum Changes Bladder

• Extensive diuresis to excrete excess fluid (2-3 L)

capacity, tone• Risk of over-distention and

incomplete emptying • Leakage, urinary frequency common• Mild proteinuria (1+) may exist for

1-2 days in ~ half of women

Normal Postpartum Changes Bladder

Normal Postpartum Changes Bladder

•Spontaneous voiding should occur by 6-8 hours PP; enc. Frequent voiding

• If cath’d, remove no more than 800 cc at one time

•Stress incontinence common

• Encourage Kegel exercises•Observe for s/s UTI

Hemodynamic/Hematologic

Hemodynamic/Hematologic

• Normal EBL up to 500 ml vaginal birth, up to 1000 ml cesarean birth

• By 3rd day PP plasma volume as fluid shifts from extracellular to intravascular

• Excess fluid by 2 wks PP by diuresis and diaphoresis

• Leukocytosis to 14-16,000 during labor (or higher): remains 2-3 days PP

Hemodynamic/Hematologic

Hemodynamic/Hematologic

• Cardiac output peaks immediately after birth (autotransfusion)

• Decreases to pre-labor by 1 hour, remains for 24 hours, then to normal levels by 2 weeks

• Clotting factors in preg. & early PP– Assess for thrombus formation

Gastrointestinal Gastrointestinal•Relaxin slows GI tract, delays

passage of stool

• Incontinence 6x more common w/ 3 and 4° lacerations

•Prevent constipation - should have BM by 2-3 days PP

•Hemorrhoids common

GI SystemGI System

•Encourage non-pharmacological methods (fiber, fluids, warm drinks in AM, walking, etc.)

•OTC stool softeners•Hemorrhoid OTC preparations•Use care w/suppositories if 3

or 4 lacerations

MusculoskeletalMusculoskeletal•Skin

– diaphoresis– stretch marks, pigmentation chg– varicosities, spider veins

•Stretched muscles and ligaments return to former state– Diastasis separation 2-3 fingerwidths;

lasts ~ 2 wks• Edema decreases 1-3 days PP•Hormonal effects regress over time

NeurologicNeurologic

•DTR’s remain normal

•Multiple sources of discomfort– Fatigue, afterpains, incisions,

muscle aches, breast engorgement or sore nipples, headaches

•Sleep disturbances r/t hormones

EndocrineEndocrine• Thyroid - risk of thyroiditis

– May develop during first month PP, most likely in weeks 3-4.

• Followed by thyroid storm– Life threatening emergency, caused by

excessive amounts of thyroid hormones– S/S: fever, marked weakness, extreme

restlessness w/wide emotional swings, confusion, psychosis, even coma

• Followed by hypothyroidism– Extreme lethargy, fatigue, weight loss

or later wt. gain, goiter formation

Endocrine: Glucose Metabolism

Endocrine: Glucose Metabolism

• Levels change r/t absence of pregnancy hormones –Decreased insulin needs if

diabetic–Gestational diabetics return to

normal–6 wk 75 gm glucose screen to

R/O Type 2 DM (fasting BG ok if no further pregnancies planned)

Initial Postpartum Assessment

Initial Postpartum Assessment

• Vital signs – Vag birth – q. 15 min. x 4, q. 30 min.

x 2, then 1 hour, then q. 12 hrs or more frequent if indicated

– C/birth – q. 15 min. in PAR; then q. 30 min. x 2, q. 1 hr x 4, then q. 4 hrs until 24 hour post-op; then QID

• Physical assessment• Emotional considerations

Vital SignsVital Signs

• Temp should be normal. Call if temp for 2 days (> 100.4° F)– Incisions, IV site, breasts, S/S UTI

•Pulse remains normal or decreases slightly after birth

•BP normal– Assess patients w/ DBP for HTN– Orthostatic BP common BP can be late sign of hemorrhage

Assessment: BUBBLE-HEAD

Assessment: BUBBLE-HEAD

• B Breasts• U Uterus• B Bladder• B Bowels• L Lochia/lungs• E Episiotomy/

lacerations

• H Homan’s sign

• E Edema• A Affect• D Discomfort

Monitoring of IncisionsMonitoring of Incisions

•Assessment of incisions–REEDA scale (Redness, Edema,

Ecchymosis, Discharge, Approximation)

•Healing–Stitches absorb (10 days)

Interventions for IncisionsInterventions for Incisions

• Episiotomy (perineal)– Wash hands before and after pad

change, ice pack 1st 24 hours, change pads frequently, peri bottle after voiding, wipe front to back, wash with soap & water daily, tub/sitz baths

– Stitches dissolve in about 10 days– Healing generally takes 4-6 weeks -

may take longer for “no pain” (type of epis, ability to heal, infections, etc.)

IncisionsIncisions

• Abdominal– Wash with soap & water daily,

rinse well; keep clean and dry, soft cloth to whisk away moisture, assess daily for healing, remove steri strips in 7-10 days

– Healing takes ~ 6 weeks

Cesarean ConsiderationsCesarean Considerations

• Recovery from anesthesia

• Auscultate bowel sounds q. 4 hours

• Observe for bladder distension, adequate urinary output

• Auscultate lung sounds

• Ambulate early & often!

Pain ControlPain Control

• Perineal pain– Ice, topical anesthetics, Tucks,

whirlpool

• Oral medications

• Protective positioning, splinting (C/S)

Other IssuesOther Issues

•Restructuring patient education– teaching in antepartum period

about self and baby care– age of informed consumer– intrapartum & PP notoriously poor

retention of teaching. Need time to rest and “practice” what has been learned earlier.

PP TeachingPP Teaching• PP women have transient deficits in

cognition, particularlyin memory function, the first day after giving birth (Rana, Lindheimer, Hibbard, & Pliskin, 2005).

• Verbal instruction immediately after birth or first PP day will be poorly remembered

• Need appropriate written materials• Priorities for most women in 1st 24 hrs PP are

rest, time to touch, hold, and get to know their baby, and an opportunity to review and discuss their L&D

Other IssuesOther Issues

• Providing alternative support services– Postpartum follow-up

clinic/phone calls– Lactation services– Support groups– Home visits– Early parenting education

Questions??? Questions???