Download Assessment and care of the newly delivered mother

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
LOCHIA
Rubra
Serosa
Alba
Normal
Color
Red
Pink, brown Yellowishtinged
white
Normal
Duration
1-3 days
3-10 days
Normal
Discharge
Bloody w/
clots
Abnormal
Discharge
Foul smell;
many lg.
clots,
saturate pad
10-14 days,
Can be
longer
Serosang., Mostly
Fleshy odor musus, no
strong odor
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
– 1º
– 2º
– 3º
– 4º
skin & superficial structures
reaches into perineal muscle
extends into anal sphincter muscle
involves 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 1st
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 218 months
Return of Ovulation
• 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
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, 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
• 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
• Skin
Musculoskeletal
– 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
U
B
B
L
E
Breasts
Uterus
Bladder
Bowels
Lochia/lungs
Episiotomy/
lacerations
•
•
•
•
H
E
A
D
Homan’s sign
Edema
Affect
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 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.)
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 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 Issues
• Providing alternative support
services
–
–
–
–
–
Postpartum follow-up clinic/phone calls
Lactation services
Support groups
Home visits
Early parenting education
Questions???