2. Involution: uterine reduction; 1 cm/day (from 1 above umbilicus at 12 h) Contractions: oxytocin; decrease bleeding After pains: associated with multiparas, distended uterus, breastfeeding and uterotonic medications Placental site: regenerates by 6 wks Lochia: uterine discharge lasting 3-6 wks – Rubra: reddish brown; 3-4 days – Serosa: pinkish brown; 4-10 days – Alba: yellow-white, up to 6 wks) Cervix: bruising & small lacerations common

3. Vagina  Thin, smooth walls; rugae reappear by wk 4  Dryness associated with low estrogen levels and dyspareunia (pain with sexual intercourse) Perineum  Edema, erythema and pain common  Episiotomy/laceration should heal by 2 wks Pelvic floor muscles  May be stretched or torn; Kegal exercises help to regain tone

4.  Estrogen/progesterone levels drop, associated with breast engorgement & diuresis  Nonlactating: estrogen level rise in 2 wks; with menstruation & ovulation 4-12 weeks  Lactating: estrogen rise & menses delayed (2-18 months; affected by supplementation & breastfeeding duration)  Prolactin: infant sucking stimulates production remains elevated in lactating women; drops in nonlactating women; suppresses ovulation

5. Abdomen: decreased muscle tone for 6 wks Bladder:  Increased capacity & decreased tone increases risk of retention & infection  If full, will displace uterus, causing uterine atony Postpartal diuresis  2000 to 3000 ml in first 12-24 hours  Profuse diaphoresis occurs commonly at night

6.  Hunger & thirst common following birth  Increased risk of hemorrhoids from pushing  Increased risk for constipation associated with decreased peristalsis, narcotic analgesics, dehydration, decreased mobility & fear of pain with bowel movement  Injury to anal sphincter associated with forceps or episiotomy can cause bowel incontinence

7.  Colostrum: first milk secreted, rich in protein & immunoglobulins  Milk production begins day 3 or 4  Engorgement may occur when milk comes in; breasts swollen, firm, warm & tender – Lactating: breastfeed/pump breasts, ice packs to axillary area and well-fitted bra – Nonlactating: ice packs, breast binder; do not express milk  Nipples: erythema, blisters & fissures can result from poor positioning

8.  Cardiac output: remains elevated for 48 hours until diuresis reduces blood volume; this is riskiest time if woman has cardiac disease  Hgb & Hct: depends on prenatal values, amount of blood loss during birth (300 - 400 ml normal)  WBCs (up to 25,000/mm3) normal  Hypercoagulable state increases thrombus risk  Temp 100.4º F (38 º C) normal in first 24 hrs  Varicosities regress after birth

9. Frequency: Q 15 min x 4, Q 30 min x 2, Q 1 h x 1 BP, pulse, resp rate, (temperature x 1) Fundus: palpate for height, position & firmness Bladder: assess for distension Lochia: amount, color & odor. Note number and size of any clots. Weigh pads if > 1 pad/h Perineum: assess for edema, hemorrhoids & hematoma. If incision, for REEDA (redness, edema, ecchymosis, discharge & approximation of skin edges)

10. Should void within 6 to 8 hours of delivery Fundus will usually be displaced to the right if bladder full Encourage voiding – Running water in sink – Hand in warm water – Low, open vocalizations Straight catheterize as ordered if bladder filling and unable to void

11. Post op: auscultate BS, assess for flatus & distension (avoid ice, sodas or apple juice) Promote bowel elimination: – Hot tea & frequent ambulation – Fluids and fibers – Stool softeners/suppositories – Teach to obey urge to defecate & push normally but avoid straining

12. Perineum: Ice pack x 6 hrs (or as ordered) Sits bath x 20 min tid (need MD order) Perineal care after each elimination: squirt warm water over perineum, blot dry & apply peripad front to back Apply topical anesthetics or Tucks Afterpains: Warm blanket to abdomen Relaxation breathing Administer analgesics as ordered

13. Process when parents form emotional relationship with their infant over time Mother explores first with fingertips, then palms, then with hands and arms Holds infant in face position about 20 cm apart and on same plane Uses soft, high pitched tone of voice Engrossment: father’s absorption & interest in infant; can be stimulated by witnessing birth

14. Rooming in Pain relief for mother Baby with parents/family after birth Father sleep in room with mom Teach parents infant comforting techniques – Swaddling – Rhythmic motion (rocking or chicken walk) – Holding with pressure on tummy Observe, listen and support

15. RhoGAM if needed – If Rh- mom with Rh+ father – 300 mcg IM by 72 hrs

16. General Instructions for Comfort and Activity  Rest for about half waking hours, alternating brief periods of activity with rest for a week.  Nap when the baby naps.  After the first week, take an afternoon rest of 1-2 hours each day.  Shower or bathe freely.  Eat three balanced meals a day.

17.  For painful stitches, soak in the tub (sitz bath) for 15 minutes, three times a day. Apply anesthetic spray or ointment as needed.  For hemorrhoids, use 15 minute sitz baths several times a day. Keep stool soft by drinking plenty of fluids and eating fruits and vegetables. You may use stool softeners, mineral oil, Tucks or suppositories as prescribed by your doctor.  For constipation, increase fluid intake, use mineral oil

18.  Do not douche, use tampons or vaginal suppositories for 6 weeks.  Do not engage in sexual intercourse for 6 weeks.  Climb whatever stairs are necessary.  Avoid strenuous physical activity, including exercise workouts, for 6 weeks following the delivery

19.  Eat a well balanced diet including lean meats, fish, fresh fruit or juice, fresh vegetables, and dairy products.  Breast feeding burns about 300 calories per day. This will help you return to prepregnancy weight faster.  Drink eight to ten (8-10) glasses of fluid each day. Have a glass of water, juice, or low-fat milk each time you feed your baby.

20.  Continue a daily multivitamin for as long as breastfeed.  If needed, doctor will order additional iron pills  You may safely use acetaminaphen, ibuprofen, or any other medication

21. May experience blood tinged or brownish discharge for 3 to 6 weeks.  The first menstrual period may occur from four to eight weeks after delivery, longer if breastfeeding.  The first period may be heavier than usual.

22.  Call at the first sign of a breast infection (pain, redness or fever).  If not breastfeeding, use a tight, supportive bra for five days after discharge, avoid breast stimulation, and use ice packs to help with engorgement.  If breastfeeding, keep the breasts clean with frequent warm water rinses to clear dried milk from the nipples. It is generally better to avoid the use of soap on the breasts.

23.  Continuous abdominal pain  Bad smelling vaginal discharge  Heavy bleeding (a full sanitary napkin in an hour)  Pain or redness in the leg  Difficulty urinating  Temperature greater than 38 degrees  Tenderness or localized redness of the breasts