1. Highlights of Chapter Nine
The Family After Birth

2. Changes in the uterus; page 200
Involution
Returning to pre pregnancy size and condition
Descent of Uterine Fundus
Once centimeter a day and tucked back in the pelvis by day ten
Afterpains
Intermittent uterine contractions
Occur more often in multiparas or women whose uterus was overly distended
Lochia
Rubra, serosa, alba. Page 201

4. Make note of on Page 201!!
Summary of Post Partum Assessment on page 201
Nursing tips regarding:
Massaging a soft uterus properly
Assessing the uterus each shift
Teaching mother to assess and massage the uterus
See Observing and Massaging the Uterine Fundus
Page 2o3

6. Assessment of amount of lochia
Heavier when the mother ambulates because of pooled lochia
Small clots normal, large clots need to be reported
Women with C section will bleed less
Absence of lochia is NOT normal
See 9-1 page 202 for estimating the volume of lochia.

7. Nursing Care Related to the Fundus and Bleeding.
Should be assessed once a shift (once recovery period is complete) more often for mothers at high risk for post partum hemorrhage
If Mom is bed ridden make sure you roll her over and check her under pad too.
Massage a poorly contracted uterus
Make sure mom’s bladder stays empty
Medication may be necessary to stimulate uterine contractions: Oxytocin or Methergine
An infant sucking at the breast assists with contractions

8. Report any of the following:
Fouls smelling lochia
Lochia rubra that persists beyond the third day
Unusually heavy flow of lochia
Lochia that returns to red after it has progressed to serosa or alba

9. The Cervix
The most important thing to remember is that if there is a constant trickle of bright red lochia it probably isn’t lochia but is bleeding from a laceration of the cervix of vagina, particularly if the fundus remains firm.

10. Vagina Safe to resume sexual intercourse when Bleeding has stopped
Episiotomy has healed.
Vagina does not lubricate well first 6 weeks after child birth
Many health care providers continue to recommend waiting for intercourse for six weeks

11. Assess the Episiotomy
Redness
Edema
Ecchymosis
Drainage
Approximation

12. Nursing Care of the Episiotomy
Ice Pack first hours
CLEAN TECHNIQUE in preparing the ice pack
After 24 hours: warmth to episiotomy
Perineal care
Pads removed in front to back direction
Topicals: Epifoam, Benzocaine
Witch hazel pads
Squeeze buttocks when she sits down.
Squeezing the cheeks together before she sits down will protect her episiotomy or lacerated perineum from stretching once she sits.

13. Ovulation and Menstruation
Resumes in 6-8 weeks if not breastfeeding
Delayed in breast feeding mother.
You may ovulate before your first period
Breastfeeding is not considered an adequate form of birth control

14. BREASTS Milk comes in by the third day (after 48 hours)
Engorgement may occur due to
Abundance of milk
Increased circulation
Edema
Wear a supportive bra
Avoid soap to the nipples
Most sore nipples due to poor position of infant on the breast.

15. Cardiovascular; Output and Blood Volume
Blood loss
500 ml in vaginal
1000 ml in c section
However still a temporary increase in blood volume due to fluid shift from tissues as well as extra volume needed when pregnant
Temporary increase in stroke volume= bradycardia
Body rids itself of fluid
Diuresis
diaphoresis

16. Blood Coagulation Blood clotting factors are higher
Blood clot break down remains the same
Prone to blood clot formation
Thrombophlebitis
Pulmonary embolism
Check for both in your assessment

17. Blood Values Hemodilution of pregnancy continues Hematocrit 33-46%
Return to normal by 8 weeks pp (36- 48%)
Elevated white blood count is normal
12,000-20,000

18. "Chills" Sudden release of pressure on the pelvic nerves
Vasomotor response involving epinephrine
Reassurance and a warm blanket

19. Orthostatic Hypotension
Resistance to blood flow in pelvis drops
Blood pressure falls when she sits or stands
Careful when getting up.

20. Assessment/care related to Cardiovascular
High pulse must be taken seriously due to expected bradycardia
Shock
Infection
Edema of lower extremities common
Edema of upper extremities may be related to pregnancy induced hypertension
Check for evidence of thrombosis

21. Urinary System
Mothers may have difficulty with emptying their bladders due to
Epidural
Birth trauma
Keep ahead of distension of the bladder
Contributes to uterine atony
Residual urine may promote growth of organisms
Measure the first two or three voids after birth
Should be able to void at least 150 mls; some resources state that under 300 suggest urinary retention and I agree that 150 is too low

22. Gastrointestinal System
Constipation is a problem due to :
Medications
Stretched abdominal muscles
Soreness and swelling of perineum
Hemorrhoids
Dehydration
Encourage Mom to:
Drink a lot of fluid
Add fiber to her diet
Ambulate
Take stool softeners/laxatives

23. Immunity for Mothers
RhoGAM for RH negative mothers who have had an RH positive baby
Rubella (German measles) immunization for non immune mothers.

24. Cesarean Section Care. Uterus Lochia Dressing Urinary Catheter
Respiratory
Thrombophlebitis
Pain management

25. Rubin's Psychological Changes
Taking in
Taking hold
Letting go

26. Grieving Parents Grieving can even happen when the baby is healthy
Grieving can happen when a baby has a birth defect
Grieving will happen with a still born
Shock and disbelief
Anger
Guilt
Sadness and Depression
Gradual resolution

27. What nurses can do for grieving parents
Listen
Provide privacy
Make sure support systems are in place
Assist with rituals
Memory packet
Code on the door

28. See danger signs of pregnancy page 233
Post Partum Discharge
Follow up at 2 and 6 weeks
Hygiene
Intercourse
See danger signs of pregnancy page 233