Chapter 17: Postpartum Physical Adjustment

Question 1

what is the puerperium?

Answer 1

• it is the first 6 weeks following births
  
  • sometimes called the “fourth trimester”
  • woman experiences physical and psychosocial changes
  • nurses role: assess the patient, implement care, teach the new family

Question 2

what is involution of the uterus?

Answer 2

• process of the uterus returning to its non-pregnant size and condition

Question 3

what are the 3 processes involved with uterine involution?

Answer 3

1. contraction of muscle fibers: uterine involution begins immediately after birth when uterine muscle fibers contract around blood vessels
   
   • decreases size of uterus
   • controls bleeding
2. catabolism: muscle cells of uterus shrink in size
   
   • byproducts are excreted in the urine–allows woman to get rid of extra fluid
3. regeneration of uterine epithelium
   
   • begins after childbirth
   • first layer of decidua shed in lochia
   • basal layer of decidua is source of new endometrium
     
     • regeneration of new endometrium occurs w/in 2-3 weeks except at site of placental attachment
   • healing at placental site takes place in 6 weeks

Question 4

what is a risk of getting pregnant during the period prior to the uterine epithelium completely healing?

Answer 4

placenta previa–b/c the placental attachment site is not healed before 6 weeks postpartum, so a new fetus cannot implant in the posterior fundus if it is not completely healed

Question 5

how to determine descent of uterine fundus

Answer 5

• Location of uterine fundus helps determine whether involution is occurring
  
  • Immediately after birth: fundus palpated halfway b/w pubic symphysis and umbilicus in midline of abdomen
  • w/in 12 hours: fundus rises to approximately the level of umbilicus
  • Fundus descends by approx 1 cm per day
    
    • By 14th day, it has descended into pelvic cavity and cannot be palpated

Question 6

factors that enhance uterine involution

Answer 6

• uncomplicated labor and delivery
• breastfeeding: stimulate oxytocin release–>cause uterine contraction
• early ambulation
• complete expulsion of placenta and membranes

Question 7

what are factors that slow descent of the uterine fundus?

Answer 7

• more than one fetus
• large fetus
• hydramnios

Question 8

what are factors that slow uterine involution?

Answer 8

• prolonged labor or difficult delivery
• anesthesia
• grand multiparity: b/c uterus is overdistended and doesn’t contract like it should
• retained placental fragments
• infection
• overdistention of the uterus: can be due to polyhydramnios
• full urinary bladder

Question 9

what is subinvolution? what does it increase risk of? what are the most common causes?

Answer 9

• subinvolution is a slower than expected return of the uterus to its nonpregnant size
• can cause postpartum hemorrhage
• most common causes:
  
  • retained placental fragments
  • pelvic infection

Question 10

what are the S/S of subinvolution?

Answer 10

• Prolonged discharge of lochia
• Irregular or excessive uterine bleeding
• Profuse hemorrhage
• Pelvic pain or feelings of pelvic heaviness
• Backache
• Fatigue
• Persistent malaise
• Uterus feels larger and softer

Question 11

subinvolution: treatment

Answer 11

• Methylergonovine: given PO
  
  • Provides long, sustained uterine contraction
• Infection responds to antimicrobial treatment

Question 12

subinvolution: nursing considerations

Answer 12

• Teach mom how to recognize subinvolution
• Demonstrate how to locate and palpate the fundus and estimate the fundal height in relation to the umbilicus
• Explain the progressive changes of lochia
• Instruct the mother to report any deviation from expected pattern or duration of lochia
• Report any signs of foul odor, pelvic/fundal pain, backache, feelings of pelvic pressure or fullness

Question 13

what are afterpains? what makes afterpains worse? what are nursing considerations for afterpains?

Answer 13

• Afterpains are intermittent uterine contractions
• More acute for multiparas b/c repeated stretching leads to loss of muscle tone
• Made worse by breastfeeding b/c oxytocin released from the posterior pituitary stimulates the milk ejection reflex and causes strong contractions of the uterus
• Nursing considerations:
  
  • Analgesics are common
  • Sometimes helps to lie in a prone position with a small pillow or folded blanket under the abdomen to keep the uterus contracted
  • Can tell woman that they are self-limiting and will subside by 3rd day

Question 14

lochia rubra

Answer 14

• days 1-3
• normal: bloody, small clots, fleshy/earthy odor, dark red or red brown
• abnormal: large clots, saturated perineal pads, foul odor

Question 15

lochia serosa

Answer 15

• days 3-10
• normal: decreased amount, serosanguinous, pink or brown tinged
• abnormal: excessive amount, foul smell, continued or recurrent reddish color

Question 16

lochia alba

Answer 16

• days 10-14
• normal: white, cream, or light yellow color; decreasing amounts
• abnormal: persistent lochia serosa, return to lochia rubra, foul odor, discharge continuing

Question 17

what is a concerning sign with lochia? what does it signify?

Answer 17

• concerned if pt progresses to alba then all the sudden goes back to rubra
  
  • usually signifies infection

Question 18

would vaginal or C/S delivery have more lochia? why?

Answer 18

• vaginal deliveries would result in more lochia
  
  • b/c in C/S: they clean out the uterus and get a lot of that out

Question 19

how to measure lochia

Answer 19

• Measure for one hour:
  
  • Scant: less than a 1 in stain on peripad
  • Light: less than a 4 in stain on pad
  • Moderate: less than a 6 in stain on pad
  • Heavy: saturated peripad in 1 hour
  • Excessive: saturated peripad in 15 min
• Sometimes bleeding can suddenly inc at 7-14 days postpartum due to the eschar over the placental site sloughing off
  
  • But if lasts longer than 1-2 hours, then call HCP

Question 20

postpartum cervix

Answer 20

• after birth, the cervix is dilated, edematous and bruised
  
  • may have small tears or lacerations
  • external os heals rapidly and is 1 cm by end of first week
    
    • but the shape is forever changed to slit-like appearance rather than round, dimple like os of nullipara
  • internal os returns to pre-pregnancy state

Question 21

postpartum vagina

Answer 21

• smooth walls due to lack of rugae
• rugae begin to reappear by 3-4 weeks
• edematous and has lacerations
• may be an area of hematoma formation which the woman describes as “pressure” pain and is unrelieved by medications
• During postpartum, vaginal mucosa atrophies and the vaginal walls do not regain thickness until estrogen production by the ovaries is reestablished
  
  • While breastfeeding, estrogen production is not well established, so vaginal dryness and dyspareunia are common

Question 22

what does it mean if there is inc lochia with a firm uterine fundus?

Answer 22

significant lacerations

Question 23

postpartum perineum

Answer 23

• may be edematous and bruised
• episiotomy takes 2-3 weeks to start to heal, but may take up to 4-6 mos to completely heal
• discomfort very common b/c muscles of perineum involved in everyday activities
  
  • hemorrhoids are common
• elimination may be difficult due to inc constipation after birth with an inc risk due to opioids

Question 24

nursing care for postpartum perineal discomfort

Answer 24

• clients should be free from perineal pain w/in 2 weeks
• relief of discomfort is a nursing priority:
  
  • apply ice (first 24 hours)
  • sitz baths (after 24 hours)
  • topical anesthetics and analgesics
  • perineal care

Question 25

postpartum cardiovascular system

Answer 25

• inc in pregnancy
• plasma volume: returns to pre-pregnant state w/in 2 weeks
• these are all methods that the body uses to get rid of extra fluid:
  
  • post partal diuresis (12 hours-5 days postpartum)
  • diaphoresis (hot flashes common)
  • coagulation (elevation of fibrinogen–up to 1 wk)
  • blood values: H&H (anemia or blood loss evaluation); WBCs (non-pathologic if inc up to 25-30000)
  • bradycardia (50-70 bpm)

Question 26

aldosterone after pregnancy

Answer 26

• inc during pregnancy
• decreases after pregnancy which allows new mom to drop off all the extra fluid through urination

Question 27

at what HR are we concerned about a postpartum mom? why?

Answer 27

• concerned if HR is over 100 b/c it can indicate a postpartum hemorrhage

Question 28

postpartum GI system

Answer 28

• hunger and thirst are common
• risk for constipation inc b/c of dec peristalsis and bowel tone from pregnancy, use of narcotics, dec mobility during labor, and fear of painful bowel movements
  
  • always administer stool softeners, and first stool is usually w/in 2-3 days postpartum
  • normal bowel elimination w/in 1-2 weeks
• pushing inc risk of hemorrhoids

Question 29

postpartum GU system

Answer 29

• inc bladder capacity and less awareness of bladder fullness can lead to incomplete emptying and excess residual volume
• stress incontinence occurs in many in the first 6 weeks
  
  • prone to this b/c of trauma and stretching to perineal area
• Kegal exercises help inc muscle tone

Question 30

urinary retention postpartum

Answer 30

• more common: after 1st vaginal delivery, regional anesthesia, and catheterization before delivery
• complications: UTI, inc postpartum bleeding b/c of stretched uterine ligaments which allow uterus to be displaced upward and laterally which results in dec contraction of uterine Ms–>bleeding
• inc risk for urinary retention b/c the bladder is less sensitive to fluid pressure, decreasing the urge to void even when bladder is distended

Question 31

postpartum musculoskeletal system

Answer 31

• Muscle fatigue and aches occur in first 1-2 days after childbirth
  
  • Warmth and massage help with this
• Hip and joint pain occur b/c the hormone relaxin dec in concentration and ligaments of the pelvis return to pre-pregnancy positions
  
  • Help mom to use good body mechanics and correct posture
• Abdominal muscle tone is diminished after pregnancy
  
  • Diastasis recti: may occur–longitudinal muscles of the abdomen may separate

Question 32

postpartum integumentary system

Answer 32

• skin is soft and flabby with dec muscle tone
• ruptured elastic fibers in the skin cause striae which are red during pregnancy but will fade to silver/white
• estrogen, progesterone, and melanocyte stimulating Hs decline after childbirth, and melasma and linea nigra fade and disappear

Question 33

postpartum neurologic system

Answer 33

• discomfort and fatigue are common
• analgesia and anesthesia may cause temporary neurologic changes such as a lack of feeling and dizziness
  
  • prevention of injury is PRIORITY
• HAs must be assessed

Question 34

postpartum HAs

Answer 34

• Frontal and bilateral: common in 1st week postpartum and may be a result of changes in fluids/electrolytes
• Severe HA: postdural puncture HA–from regional anesthesia
  
  • Most severe when woman is upright
• HA w/ blurred vision, photophobia, proteinuria, and abdominal pain: may indicate development or worsening of pre-eclampsia
  
  • in the frontal are, not relieved by analgesics, and does not change with position changes

Question 35

resumption of ovulation and menstruation for bottle feeding women

Answer 35

• menses returns w/in 6-8 weeks for 40% of women and 12 weeks for 75% of women, the rest of women have it return by 6 months
  
  • usually takes about 2 months

Question 36

resumption of ovulation and menstruation for breast feeding women

Answer 36

• delays the return of ovulation and menstruation, but it is not predictable so contraception is important!
• menses may return as early as 12 weeks or as late as 18 months during menstruation
  
  • If you breastfeed more often and use fewer supplements, likely to ovulate and menstruate later

Question 37

lactation

Answer 37

• During pregnancy, estrogen and progesterone prepare breasts for lactation
  
  • Prolactin also rises during pregnancy, but lactation inhibited at this time b/c estrogen and progesterone are so high
  • When placenta delivered, estrogen and progesterone drop and prolactin initiates milk production in 2-3 days
    
    • Once milk production is established, it continues b/c of frequent suckling by infant and removal of milk from the breast
• Oxytocin: necessary for milk ejection or “let down”

Question 38

postpartum thyroid

Answer 38

• thyroid levels return to normal in 4-6 weeks but there is a risk of transient autoimmune thyroiditis and hypothyroidism

Question 39

weight loss after childbirth

Answer 39

• Childbirth: Lose 4.5-5.8 kg (10-13 lb)
• Diuresis: lose 2.3-3.6 (5-8 lb)
• Involution and lochia: lose 0.9-1.4 kg (2-3 lb)
  
  • Total loss first week: 17-24 lbs
• Continues especially during the first 3 months
  
  • Most likely to lose all but about 1 kg (2.2 lb) w/in 1 year if follow a well balanced diet

Question 40

post partum physical adaptations: temp, BP, HR

Answer 40

• temp: expected temp elevation due to dehydration, epidural anesthesia, or breast engorgement
  
  • morbid temperature elevation over 100.4 deg F could indicate infection
• BP:
  
  • orthostatic hypoTN: fall precautions
  • decrease may also be due to dehydration or hypovolemia
  • elevations: possible pregnancy induced HTN (PIH)
    
    • if over 140/90: may indicate pre-eclampsia
• pulse:
  
  • bradycardia: acceptable first 6-10 days
  • tachycardia: over 100+ could be hemorrhage or infection

Question 41

REEDA Scale

Answer 41

• used when looking at incisions, lacerations
  
  • R: redness
  • E: edema
  • E: ecchymosis
  • D: discharge
  • A: approximation

Question 42

assessment of the postpartum woman

Answer 42

• BUBBLE-HE
  
  • B: Breast
    
    • assess stage of lactation, nipples
  • U: Uterus
  • B: Bladder
  • B: Bowel
  • L: Lochia
  • E: edema
  • H: Homan’s sign, hemorrhage
  • E: emotions

Question 43

comfort measures and analgesics to use in the immediate postpartum period

Answer 43

• comfort measures:
  
  • ice packs
  • perineal care: peribottle, pat dry but don’t wipe
  • topical meds: tucks, dermoplast
  • instruction on sitting: clamp buttocks as sitting to put less pressure on stitches
  • sitz baths
• analgesics:
  
  • NSAID: ibuprofen 600 mg Q6h
  • acetaminophen
  • narcotics: percocet (oxycodone w/ acetaminophen 5/325)

Question 44

rubella vaccine

Answer 44

• woman receives rubella antibody screen during prenatal period
• If she is not immune, she is given rubella vaccine to prevent her from acquiring rubella during subsequent pregnancies
• Should not become pregnant for 28 days after receiving vaccine
• refridgerate

Question 45

pertussis vaccine

Answer 45

• all adults in contact with infants should get a booster shot
• Vaccine may be offered during pregnancy or before discharge and is usually given with Tdap

Question 46

RhoGAM

Answer 46

• needed if mother is Rh neg, baby is Rh pos, and mother is NOT already sensitized (by a previous Rh + baby or previous RhoGAM)
• give w/in 72 hours to prevent Ab
• comes from blood bank
• IM, possible fever and pain at site
• blood consent

Question 47

risk factors for hemorrhage

Answer 47

• Grand multiparity (5 or more),
• overdistention of uterus,
• precipitous labor (less than 3 hours),
• prolonged labor,
• retained placenta,
• placenta previa,
• drugs,
• operative procedures

Question 48

risk factors for infection

Answer 48

• Operative procedures,
• multiple cervical exams,
• prolonged labor,
• prolonged ROM,
• manual extraction of placenta,
• diabetes,
• catheterization,
• bacterial colonization of lower genital tract

Question 49

what are signs of an empty bladder?

Answer 49

• firm fundus in midline
• nonpalpable bladder
• mother voiding at least 300-400 mL

Question 50

what are signs of bladder distention?

Answer 50

• obvious or palpable bulge that feels like a soft, moveable mass above the symphysis pubis
• Also will see upward and lateral displacement of the uterine fundus and inc lochia

Question 51

when to catheterize a woman?

Answer 51

• She is unable to void
• Amount voided is less than 150 mL and bladder can be palpated
• Fundus is elevated or displaced from midline

Question 52

how long does a woman usually stay in the hospital if she had a C/S?

Answer 52

72-96 hours

Question 53

respiratory assessment after a C/S

Answer 53

• Must assess frequently if mother is given narcotics
• Pulse ox is used for 18-24 hours–>should be documented hourly
• If woman has a RR of 12 or less or pulse ox shows persistent O2 sats of less than 95%, then:
  
  • Notify anesthesiologist
  • Elevate head of bed and instruct woman to breathe deeply
  • Administer O2
  • Administer narcotic antagonists
  • Observe for recurrence of respiratory depression b/c of duration of naloxone being only 30 min
  • Recognize that naloxone may reduce level of pain relief

Question 54

interventions for the first 24 hours after a C/S

Answer 54

• pain relief: determine need for pain relief on regular basis
  
  • PCA, duramorpha
• relaxation: breathing techniques
• ambulation:
  
  • help woman sit and dangle feet first
  • encourage her to do active ROM exercises
  • prevent secretions from pooling by turning, coughing, deep breathing, and using IS to expand lungs and prevent pneumonia
• IV: replenish fluids
• hydration: ice chips then clear fluids
• foley: observe I/O
• abdomen: check dressing, observe incision, check bowel sounds (may be hypoactive)
• DVT prevention: sequentials
• infant feeding: much assistance

Question 55

interventions after first 24 hours for C/S

Answer 55

• pain relief: oral pain meds
• ambulation: encourage walking
• diet: soft or regular diet when bowel sounds are audible
• hydration: encourage fluids
• IV: discontinue
• foley: remove
• abdomen: check dressing, check bowel sounds (should be normal and passing gas)
• infant feeding: less help needed

Question 56

preventing abdominal distention after C/S

Answer 56

• Early, frequent ambulation
• Tighten and relax abdominal muscle
• Avoid carbonated beverages and use of straws
• Pelvic lifts
• Simethicone: to disperse upper GI flatulence
• Rectal suppositories: to stimulate peristalsis

Question 57

breast care if lactating

Answer 57

• Instruct mom to avoid using soap on nipples b/c it will remove natural lubricant
• Keep nipple dry between feedings to prevent tissue damage
• Wear a good bra to provide support

Question 58

breast care to suppress lactation

Answer 58

• Wear a sports bra or well fitting bra 24 hours a day until the breasts become soft
• Manage breast discomfort with ice and analgesics
• Allow woman to avoid warm water falling directly onto breasts which stimulates milk production

Question 59

sexual activity

Answer 59

• May begin intercourse as early as 2 weeks after giving birth if desire and comfort allow
• Low estrogen levels during early postpartum period and during lactation may cause vaginal dryness, so may need water based lube

Question 60

follow up appointments

Answer 60

• Vaginal birth: 4-6 weeks
• Cesarean birth: 2 weeks

Question 61

warning signs to report

Answer 61

• Fever over 100.4 def F
• Localized area of redness, swelling, or pain in either breast
• Persistent abdominal tenderness
• Feelings of pelvic fullness or pelvic pressure
• Persistent perineal pain
• Frequency, urgency, or burning or urination
• Abnormal change in character of lochia
  
  • lochia alba/serosa back to rubra
  • odor
• Localized tenderness, redness, edema, or warmth of the legs
• redness separation or edema of, or foul drainage from incision