Assessment and Care of the Newly Delivered Mother

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 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

LOCHIARubraSerosaAlba Normal Color RedPink, brown tinged Yellowish- white Normal Duration 1-3 days3-10 days10-14 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 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

Perineum Perineal lacerations –1ºskin & superficial structures –2ºreaches into perineal muscle –3ºextends into anal sphincter muscle –4ºinvolves anterior rectal wall

Perineum 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 & 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 1 st week –Cervical edema may last several months

Vagina 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 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 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 Ovulation

Family 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, (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 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 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 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 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 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 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

Musculoskeletal 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

Neurologic DTR’s remain normal Multiple sources of discomfort –Fatigue, afterpains, incisions, muscle aches, breast engorgement or sore nipples, headaches Sleep disturbances r/t hormones

Endocrine 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 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 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 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 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 Incisions Assessment of incisions –REEDA scale (Redness, Edema, Ecchymosis, Discharge, Approximation) Healing –Stitches absorb (10 days)

Interventions for Incisions Episiotomy (perineal) –Wash hands before and after pad change, ice pack 1 st 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.)

Incisions 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 Considerations Recovery from anesthesia Auscultate bowel sounds q. 4 hours Observe for bladder distension, adequate urinary output Auscultate lung sounds Ambulate early & often!

Pain Control Perineal pain –Ice, topical anesthetics, Tucks, whirlpool Oral medications Protective positioning, splinting (C/S)

Other 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 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 1 st 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 Issues Providing alternative support services –Postpartum follow-up clinic/phone calls –Lactation services –Support groups –Home visits –Early parenting education

Questions???