the post-partum period revised by prof. unn hidle updated spring 2010

The Post-Partum PeriodRevised by

Prof. Unn Hidle

Updated Spring 2010

Third Stage of Labor

• Delivery of placenta• Usually about 20-30 minutes after delivery• If >30 minutes = retained placenta• The placenta should be delivered

spontaneously• Never “pull” / “tug” on the umbilical cord• DO NOT MASSAGE if placenta is in place• Fundal height:

– Should be between symphysis pubis and umbilicus immediately after delivery

– Feels more boggy immediately, but firms up quickly

– Bimanual massage once placenta is delivered (in most cases)

D

• Separation of the placenta from uterus is evident when:– There is a rise in the uterus with firm and

globular appearance in the abdomen– The cord protrudes from the vagina– There is a “gush”, “spurt” or “trickle” of blood

from the vagina– The shape of the uterus changes from a disk to

a probe

• Instruct the mother to bear down to deliver the placenta UPON A CONTRACTION

• If the uterus is not contracted, the uterus may turn inside-out in attempted delivery

• Important to note the TIME of the placental delivery

Dirty Duncan vs. Shiny ShultzCareful with terminology!

• “DIRTY DUNCAN”– Separation from the outer

margin inward and rolling up

– Maternal side first• “SHINY SHULTZ”

– Separation from inside to the outer margins

– Fetal side first

Dirty Duncan

Shiny Shultz

VARIATIONS IN PLACENTA

WHY SHOULD WE KNOW THIS ???

Succenturiate placenta

Placenta circumvallatate

MATERNITY NURSING: The Postpartum Period

Battledore placenta

Velamentous placenta

Post-placental delivery

• Note TIME of placental delivery in nurse’s notes

• Inspect the placental membranes to make sure they are intact (no residual placenta)

• Inspect for all the cotyledons (mass of villi, fetal vessel and intervillous space)

• If a part is missing, manual uterine exam is necessary

REVIEW OF OXYTOCIN/PITOCIN

Remember, the post-partum use of Pitocin is

different than for induction!

OXYTOCIN (PITOCIN)

• Pitocin is the synthetic for of Oxytocin• Natural release of Oxytocin i.e. with BF• Administered DIRECTLY upon delivery

of the placenta• To contract the uterus and therefore

minimize bleeding• Standard drip:

– (10)-20 units in 1000cc LR @ 125cc/h– Know your drip factor!

• Well, actually we’re using more and more IV pumps (ml/hr)

• Side effects:– Water intoxification = HYPERHYDRATION

• Nausea / Vomiting

• Hypotension

• Tachycardia

• Cardiac arrhythimas secondary to electrolyte imbalance (hyponatremia)

– Urinary retention– Hypotension

• With rapid IV bolus administration

• IMPORTANT:– Literature states Pitocin can result in EITHER

hypotension (rapid infusion) or hypertension (contractility = increased BP)

• Started in the delivery room: 2 bags– First bag: “poured” in, wide open in

Delivery Room– Second bag: given @ 125cc/h X 8

hours• Pitocin may also be given IM or SLOW

IV push• Alternative: Methylergonivine maleate

(Metergine) 0.2 mg IM

Methylergonovine maleate

(Methergine)

Methylergonovine maleate (Methergine)

• Ergot alkaloid• Stimulates smooth muscle tissue =

vasoconstriction• Uterus very sensitive to the drug• Used in PP to stimulate the uterus to

contract in order to decrease blood loss by clamping off uterine blood flow (promote involution)

• Vasoconstriction may result in HYPERTENSION (be aware in case of PIH)

• Dose:– 0.2 – 0.4 mg IM (may be given PO

later) after delivery– May be given IV but more side

effects– Can be given Q2-Q4 hours

• Contraindication:– Pregnancy….. Fetal trauma or death– Hepatic, renal or cardiac disease– Hypertension– Caution with lactation

• Side Effects:– Hypertension– Nausea and vomiting– Bradycardia– Dizziness– Tinnitus– Abdominal cramps– Palpitations– Dyspnea– Chest pain

• Methergine has a long duration (3 hours) and can cause tetanic contractions.

• Therefore, NEVER use DURING pregnancy or labor as it may cause sustained uterine contractions (result = amniotic fluid embolism – entry of amniotic fluid under the edge of the placenta and then into the maternal circulatory system )

Cytotec (Misoprostol)

• Dual action!• Prostaglandin analog• Causes uterine contractions• Labor induction:

– “Cervical ripening”– Very potent– May cause uterine rupture

• Post-Partum hemorrhage:– Prevention or treatment of post-partum

hemorrhage in the presence of uterine atony

• Termination of pregnancy

LACERATIONS

LACERATIONS

• High risk:– Young mothers– Nullipara– Large fetus– Epidural (decreased sensation and

unable to push exactly with contractions)

– Forceps assisted birth– Previous episiotomies– Has not done perineal massage or

preparation during pregnancy

Categories of lacerations

• First Degree– Limited to the fourchette, perineal skin and

vaginal mucous membrane

• Second Degree– Perineal skin (1st degree) + underlying fascia

and muscles of perineal body on one or both sides of the vagina

• Third Degree– All of 2nd degree + involvement of anal sphincter

• Fourth Degree– Same as 3rd degree + extension through the

rectal mucosa to the lumen of the rectum. It is also called “3rd degree laceration with a rectal wall extension.”

2nd Degree Laceration

4th Degree Laceration

EPISIOTOMY

• Surgical incision of the perineal body that is done DURING CROWNING to protect the perineum, the anal sphincter, and the rectum from laceration during birth

• Also helps “shorten” the 2nds stage of labor

• Use scissors (or sharp scalpel)

• Some research suggest that instead of protecting the perineum, the episiotomy makes a woman more prone to lacerations in subsequent pregnancies (weakened tissue)

• CULTURAL

• Complications:– Infection– Blood loss– Pain– Dyspariumia (painful intercourse)

• Two types:

– Mediolateral: 45 degree angle to the right or the left of the perineum• “Larger” opening with smaller incision• Increase risk for blood loss• Increased pain

– Midline: Extends down through perineal body• Preferred because of decreased blood

loss• Incision easier to repair• Heals with less discomfort

• Done DURING A CONTRACTION when crowning causes distension (also numbing of the perineum????????)

• Usually regional or local anesthesia (1% or 2% lidocaine), but sometimes without anything

• Episiorrhaphy = repair of the episiotomy:– Done during the period between

birth of the neonate and BEFORE the expulsion or AFTER expulsion of the placenta

Episiotomy

Medical and Nursing Care

• Inspect Q15minutes X 1st hour• Assess for redness, swelling, tenderness and

hematomas• PAIN management IMMEDIATELY!

– Ice pack X 12-24 hours: Leave on for 20-30 minutes and remove X 20 minutes in order to avoid burns

– Ice will: decrease the inflammatory process, vasoconstrict and numb the area

– Careful baseline assessment: Use pain scale

– After 24 hours: Warm sitz baths to increase circulation

– Mild local anesthetic spray (Dermaplast, Americaine) may be used

• Hygiene is essential: touch minimally to prevent transmission of any organisms (i.e. don’t touch directly with fingers)

• Use peri-bottle front-to-back and pat dry

• There may be pain for a prolonged period of time (>8 weeks), which may interfere with:– Breast feeding– Sexual intercourse– ADL– Depression

4th STAGE OF LABOR

POSTPARTUM PERIOD

• Fourth Stage of Labor– Begins with placental delivery– Ends 1-4 hours postpartum when

the mother is stable

• Post-Partum Period (overall):– Period when the reproductive tract

returns to the normal non-pregnant state

– Starts immediately after delivery and is completed usually by week 6 following delivery

POSTPARTUM IMPLEMENTATION

• Assessment– Monitor vital signs (fever >101 and BP)– Low grade fever is acceptable in 1st 12-24H– Assess height, consistency, and location of the

fundus– Monitor color, amount, and odor of lochia– Assess breasts for engorgement– Monitor perineum for swelling or discoloration– Monitor episiotomy for healing– Assess incisions or dressings of cesarean birth

client– Monitor bowel status– Monitor I&O– Encourage frequent voiding– Encourage ambulation


– Monitor lab values (CBC)– Administer RhoGAM as prescribed

within 72 hours postpartum to the Rh-negative client who is not sensitized• RhoGam 300 mcg IM after every

pregnancy• RhoGam 50 mcg after other

causes (amniocentesis, abortion, ectopic pregnancy)

A word on Rh factor:

Detect sensitization (if mother is Rh -):– Indirect Coombs test: done on the mother’s blood to

measure the number of Rh+ antibodies– Direct Coombs test: done on the infant’s blood (after

birth) to detect antibody-coated Rh+ RBCs

• Based on the results:– If mother’s Indirect Coombs is negative and the

infant’s direct Coombs is negative, GIVE RhoGAM within 72 hours to prevent harm in next pregnancy (of note, if Rh factor is NEGATIVE in both mother and infant, NO NEED FOR RHOGAM)

– Usually if the Indirect Coombs test is negative in a Rh- mother, the Direct Coombs test is not done since RhGAM is given anyway

– If mother’s Indirect Coombs is positive and her Rh+ infant has a direct Coombs that is positive, SENSITIZATION has occurred and RhoGAM is not given, but infant is watched for s/s of hemolytic disease

• Administer RhoGAM accordingly

– Determine need for Rubella vaccine • Titer < or = 1:10 (no immunity) – for example, 1:8 is a

clear indicator there is no immunity – see website: http://www.healthatoz.com/healthatoz/Atoz/common/standard/transform.jsp?requestURI=/healthatoz/Atoz/ency/rubella_test.jsp or

• Test antibody negative on the ELISA (enzyme-linked immunosorbent assay)

• Safe of nursing moms

• Should not get pregnant for next 2-3 months

• Precautions if allergic to egg whites (???)

– Assess bonding with the newborn infant

– Assess emotional status

PHYSIOLOGICAL MATERNAL CHANGES

• Involution– Description

• The rapid decrease in the size of the uterus as it returns to the non-pregnant state

• Clients who breast-feed may experience a more rapid involution

– Assessment• Weight of the uterus decreases from 2 lb to 2 oz

in 6 weeks; endometrium regenerates• Fundus steadily descends into pelvis• Fundal height decreases about one

fingerbreadth (1 cm) per day• A flaccid fundus indicates uterine atony and

should be massaged until firm• A tender fundus indicates an infection• By 10 days postpartum, uterus cannot be

palpated abdominally

• Factors enhancing involution:– Uncomplicated L&D– Complete expulsion of the placenta

or membranes– Breastfeeding– Early ambulation

Post-partum implementation

• If uterus boggy / lateral displacement, have pt void and/or reposition to get better body alignment

• If no void >6-8 hours, possible catheterization:– Atony of the bladder = decrease

tone due to:• Hormones• Trauma to urethra and bladder• Anesthesia• Pitocin also decreases chance of

urination

• Firm fundus, but still bleeding – suspect laceration

• If fundus unable to contract or sustained contraction, possible retained placental fragment

• Teach appropriate peri-care (as previous) --- PERI-BOTTLE!

• Lochia– Description

• Discharge from the uterus that consists of blood from the vessels of the placental site and debris from the decidua


– Assessment• Rubra: Bright red discharge which

occurs from delivery day to day 3– 2 pad checks 15 minutes apart =

hemorrhage (or =>8 pads/24H)• Serosa: Brownish pink discharge which

occurs from days 3 to 10• Alba: White discharge, which occurs

from days 10 to 14• Normally, the discharge has a fleshy

odor. Should not be foul = infection

• No clots (NOT larger than a QUARTER)• Discharge decreases daily in amount• Discharge increases with ambulation

POST PARTUM PHYSIOLOGICAL MATERNAL CHANGES• Cervix

– Soft, open and edematous– Many lacerations– Two fingers can be inserted following delivery– One week later, only one finger can be inserted– Cervical involution and after 1 week the muscle

begins to regenerate– KEGAL EXERCISE!

• Vagina – Bruises– Normal rugea – returns after 3 weeks– Poor tone– Vaginal distention decreases although muscle

tone is never restored completely to the pregravida state


• Ovarian Function and Menstruation

– Ovarian function depends on the rapidity with which the pituitary function is restored

– Menstrual flow resumes within 8 weeks in nonbreast-feeding mothers

– Menstrual flow usually resumes within 3 to 4 months in breast-feeding mothers

– Breast-feeding mothers may experience amenorrhea during the entire period of lactation

– NOT A CONTRACEPTIVE!

– Woman may ovulate without menstruating, so breast-feeding should not be considered a form of birth control


• Breasts

– Influenced by HPL during pregnancy

– Influenced by LH, FSH, Prolactin, ACTH, TSH to produce milk

– After placenta is delivered = decrease in estrogen and progesteron: Prolactin increases

– Oxytocin for letdown reflex

– Breasts continue to secrete colostrum

– Breasts become distended with milk on the third day

– Breast-feeding will relieve engorgement

– Engorgement occurs in 48 to 72 hours in non-breast-feeding mothers

• Urinary Tract

– May have urinary retention due to loss of elasticity and tone and loss of sensation in the bladder from trauma, medications, anesthesia, and lack of privacy

– Diuresis usually begins within first 12 hours after delivery and they may diurese more than normal (may be 1-2 liters/hour immediately)

– Should normalize within 6 weeks

• Gastrointestinal Tract

– Women are usually very hungry after delivery ?– Constipation can occur– Hemorrhoids are common


• Blood volume– Pre-pregnancy level returns rapidly

– Normalized by the 4th week PP = 4 liters

• HCT– Decreased 1 day PP (500 – 1000cc EBL)

– Increased cardiac output to get extra blood to kidneys

• Vital Signs– Temperature may be elevated during the first 24

hours due to dehydration, inflammation, trauma

– Note any “abnormal” temperature elevations

– Bradycardia is common during the first week with a range of 50 to 70 beats per minute

– Blood pressure slightly elevated initially, but then returns to baseline


• Client Teaching– Demonstrate newborn care skills as necessary

– Provide the opportunity for the mother to bathe the newborn

– Instruct on feeding technique

– Instruct mother to avoid heavy lifting for at least 3 weeks

– Instruct mother to plan at least one rest period per day

– Instruct mother that contraception should begin after delivery or with the initiation of coitus

– Instruct mother on the importance of follow-up which should be scheduled at 4 to 6 weeks

– Instruct mother to report any signs of chills, fever, increased lochia, or depressed feelings to the physician immediately

POSTPARTUM DISCOMFORTS

• Afterbirth Pains– Occur due to contractions of the uterus

– Are more common in multiparas, breast-feeding mothers, clients treated with oxytocin (Pitocin), and clients who had an overdistended uterus during pregnancy

• Episiotomy– Instruct client to administer perineal care after

each voiding

– Encourage the use of analgesic spray as prescribed

– Administer analgesic as prescribed if comfort measures are unsuccessful

POSTPARTUM BLUES

• Condition is caused by physiological and emotional stress

• The mother may feel upset and depressed at times

• Verbalization should be encouraged

• Postpartum blues may progress to postpartum depression if unresolved

• Breast Discomfort from Engorgement

– Encourage wearing a support bra at all times, even while sleeping

– Encourage the use of ice packs if not breast-feeding

– Encourage the use of warm soaks before feeding for breast-feeding mother

– Administer analgesics as prescribed if comfort measures are unsuccessful

RUBIN’S POSTPARTUM PHASES OF REGENERATION

• Taking-In Phase

– First 3 days– Mother focuses on her own primary

needs such as sleep and food Important for nurse to listen and help mother interpret the events of delivery to make them more meaningful

– Not an optimum time to teach the mother about baby care

RUBIN’S POSTPARTUM PHASES OF REGENERATION

• Taking Hold Phase

– Days 3-10 – Autonomy and independence– More in control but yet fatigue and

exhaustion– Begins to assume the tasks of mothering– An optimum time to teach the mother

about baby care– Despair if she cannot handle mothering– DANGER SIGNS: Mother is distancing

herself from infant, i.e. not responding to infant’s needs. Intervene IMMEDIATELY!

• Letting Go Phase

– Mother may feel deep loss over separation of the baby from part of the body and may grieve over the loss

– Mother may be caught in a dependent/independent role, wanting to feel safe and secure yet wanting to make decisions

– Teenage mothers need special consideration because of the conflict taking place within them as part of adolescence

NUTRITIONAL COUNSELING

• Discuss caloric intake for breast-feeding and non breast-feeding mothers

• Nutritional needs depend on pre-pregnancy weight, ideal weight for height, and whether the mother is breast-feeding

• If the mother is breast-feeding:– Increase diet with 500 kcal per day– Increased fluids– Continue prenatal vitamins and minerals

TRANSITION TO PARENTHOOD

• ANTICIPATORY– Division of labor needs to be decided during

pregnancy. Expectations, decision and changing roles. Plans who will work, when, change shifts, etc

• HONEYMOON– Attachment phase between parents and baby– EXPLORING the baby (10 fingers/10 toes, etc)

• BONDING & ATTACHMENT– Initial attraction and desire to make it with another

person; work to keep the relationship going

• RELATING– “He looks like……..”

• INTERPRETING– Meaning given to infant’s actions and perceived

needs, i.e. screaming baby: mother interprets the baby will be a “terror”

LATER POST-PARTUM PERIOD

HOME CARE

OVERVIEWThere are three aspects to the home care

of postpartum women:

1) Care of the mother

2) Care of the infant

3) Care of the family

Each piece is integral in the overall wellness of the family unit.

Initial Post-partum Period:Physical and Developmental tasks:

• Restoring physical condition• Developing competence in caring

for an meeting the needs of her infant

• Establishing a relationship with her new child

• Adapting to altered lifestyles and family structure with the addition of a new baby

REST

• Rest and sleep is critical in the immediate postpartum period.

• The new mother, especially when nursing, should prioritize rest:– Take naps when the baby naps– Pump breast-milk so that another family

member can assist with one of the night-feeds

ACTIVITY

• Provide information regarding appropriate exercise programs

• Exercise depends on the pre-pregnancy & pregnancy exercise levels

• Introduce an exercise program slowly

EXERCISES: 1st week

• KEGAL exercises:– Strengthens the muscles of the

pelvic floor

• ABDOMINAL BREATHING:

Before advancing …….

• Check for extensive separation of the abdominal muscles:– Lie on your back and bend your knees, feet flat on the

floor.– Slowly put your chin to your chest and raise your

head and shoulders until your neck is six to eight inches off the floor.

– Hold one arm out in front of you.– With the other hand, check for a gap or a bulge in the

middle of your abdomen. • If there is a gap wider than the width of two fingers, avoid

further separation by:– Drossing your hands over the abdominal area to

support and bring together the muscles.– Exhale as you lift your head = decreases strain on

abdomen– Tighten abdominal muscles when lifting

• If you become dizzy, excessively tired, or begin bright red bleeding, STOP IMMEDIATELY.

• Consult your health care provider for his/her recommendations.

EXERCISES: After 1st week

• PELVIC TILT

– Lie on your back, with your knees bent.– Tighten your stomach and buttock

muscles.– Allow your pelvis to tilt upward.– Flatten the small of your back against the

floor as you inhale.– Hold for a count of five.– Relax and exhale.– Repeat three to five times.

• Straight Curl-up

• Sit-ups

BREAST-FEEDING

• General Principles and Considerations

– Put baby to breast as soon as mother and baby's conditions are stable; on delivery table if possible (remember the 30min window)

– Stay with the client while nursing until she feels confident

– Explain uterine cramping from oxytocin release Use general hygiene and wash the breast once daily

– Hygiene:

• Gently clean with warm water after feedings

• Do not use soap as it tends to remove natural oils and increases the chances of cracking


BREAST-FEEDING

• General Principles and Considerations – Bra should be well fitted and supporting– Breasts may leak between feedings or

during coitus; place breast pad in bra– Baby's stools will be light yellow, watery,

and frequent– Medications should be avoided unless

prescribed– Gas producing foods and caffeine should

be avoided– Baby will develop own feeding schedule


BREAST-FEEDING: Procedure

• Start with the breast that the last feeding ended with

• Stimulate Rooting Reflex• Guide nipple and surrounding areola into

baby's mouth• After baby has nursed, release suction by

depressing the newborn infant’s chin or inserting clean finger into the baby's mouth

• Burp baby after first breast• Repeat procedure on the second breast until

the baby stops nursing• Burp baby again• Instruct mother to listen for audible sucking

and swallowing


LATCHING

• L = Latching on

• A = Audible swallowing

• T = Type of nipple

• C = Comfort

• H = Hold

SPECIFIC BREASTFEEDING ISSUES

NIPPLE SORENESS

• Peaks between the 3rd and 6th day and then recedes

• Nipple soreness can be painful and discouraging– May cause mom to stop breastfeeding causing

• Factors contributing to nipple soreness include: – The baby’s position at the breast– Poor sucking habits (only sucking on nipple)– Continuous negative pressure (infant falls asleep

while feeding) – Other reasons:

• Overly eager to nurse• Dry colostrum/milk on nipple• Moist nipples• Improper use of breast shield• Lotions or other products on nipples

NIPPLE SORENESS INTERVENTIONS

• Encouraging the mother to rotate position when feeding the infant.

• Ice may be applied BRIEFLY to the areola pre-nursing to promote nipple erectness and numb the tissue (prolonged ice may stop milk production)

• Wash the nipples with water immediately after feeding and let them air-dry

• Nipples can be left open to air or exposed to sunlight or UV light. – Even drying nipples with hair dryer on low heat.

CRACKED NIPPLES

• Nipple soreness is often coupled with cracked nipples …… may lead to fissures

CRACKED NIPPLES: Possible Outcomes

NIPPLE SHIELD

BREAST ENGORGEMENT

• Distinguish between breast fullness and engorgement (FULLNESS & TENDERNESS in breast 3-4 days post-partum = normal)

• Engorged breasts are hard, painful, warm and appear taut and shiny

BREAST ENGORGEMENT: Interventions

Makes sure the infant suck for an average of 15 min/feeding

Infant should feed at least 8 times/24 hours

Mother may express milk manually or pump if breasts are not emptied

Warm compresses before nursing stimulate letdown and soften the breast

Use of fresh green cabbage leaves placed inside the bra (home remedy) works by decreasing edema -- unknown etiology

Analgesics (i.e. acetaminophen, codeine) may be helpful if taken immediately prior to nursing

BREAST ENGORGEMENT

PLUGGED DUCTS: May lead to mastitis if not treated

• Usually follows engorgement • May be referred to as “caked

breasts”• Area of tenderness or lumpiness• Blister on the nipple is often

associated with a plugged duct

PLUGGED DUCTS: Interventions

• May be relieved by:

– Increase nursing on the affected breast

– Massaging toward the nipple while nursing

– Heat q4h prn to site

MASTITIS

PLUGGED DUCTS

BREAST FEEDING & RETURN TO WORK

• Key: Frequent breastfeeding to maintain breastmilk

• Continue to take prenatal vitamins • Increase 500 Kcal/day (increased protein) • Adequate fluid intake: >2000cc/day• Breast milk production: supply & demand

demand • Options for milk expression include:

• Electrical breast pump (single or double)

• Manual breast pump• Manual expression with use of hands• Arranging schedule so that breast-

feeding infant is possible i.e. during lunch hour

WEANING

• WHEN (WHAT AGE) IS IT APPROPRIATE TO WEAN?

• Decision to wean is based on:– Family/personal reasons– Cultural influences– Changes in the home situation– Pressure from the woman’s partner

• Weaning is a time of emotional separation for mother and baby

• It may be difficult for them to give up the closeness of their nursing sessions

LATE Post-partum WARNING SIGNS

• Fevers – signs of infection• Mastitis – redness, marked tenderness, or even

abscess formation• Cesarean incision – drainage, redness, tenderness,

pain, edema• Urinary incontinence – urethral trauma, cystocele• UTI – pain or burning with voiding, urgency &/or

frequency, pus (WBC) in urine• Trauma or hemorrhoids – sever constipation or

pain when defecating• Fecal incontinence or constipation – rectocele• Lochia – excess amounts (non-firm uterus); foul

odor (infection)• Episiotomy or laceration healing – evidence of

redness, tenderness, poor tissue approximation in episiotomy and/or laceration may indicate wound infection

• Emotional state - “blues”; lack of caring for infant• Inadequate knowledge of self-care

HOME-VISIT Follow-Ups• Should ideally occur within 24-48 hours post-

discharge:– RN experienced in postpartal and newborn

care – Not usually the case (insurance issues)

• Home visits done to assess for any postpartum complications (including infant)

• Reality:– Infant follow up:

• 1-2 days of age for breastfed infant• 2-3 days of age for formula-fed infant

– Maternal follow-up:• 6 weeks post-partum

THE END!

the post-partum period revised by prof. unn hidle updated spring 2010

Documents

battledore placenta

velamentous placenta

placenta circumvallatate

succenturiate placenta

im slide

placental delivery slide

necessary slide

dirty duncan slide