3/21/2018

Starting at her head

Postpartum Physiology, “Are you
experiencing a “Any visual
changes… such
what’s normal? headache?”
as blurry
vision/ seeing
spots?”
Let’s go over a head to toe maternal “I am going to be
monitoring your
postpartum assessment together temperature. When
you are at home if
you have an She may have
temperature of 100.4 questions about
or greater you need
to contact your
her skin, the
health care provider” possible
changes

Neurologic Changes/Conditions Postdural puncture headache

(spinal headache)
• Headache • Leaking of cerebrospinal fluid from the site of a
– Most common neurologic symptom puncture of the dura mater
– Can occur from • Most common when dura is accidently punctured
during epidural placement
• Fluid shifts
• Assuming an upright position triggers a change in
• Stress volume of CSF and leaking
• Spinal headache – Intensifies headache
– Auditory problems
• Fluid and Electrolyte imbalance
– Visual problems
• Preeclampsia • Signs and symptoms begin within 2 days and may
persist for days or weeks

Postdural puncture headache Temperature

• Nursing Care If in the first 10 days postpartum (excluding
– Administration of oral analgesics and methylxanthines
(caffeine or theophylline)
the first 24 hours post delivery) if mom has:
– Remain laying as position change precipitates the fluid • Oral temperature of >100.4 degrees Fahrenheit
shift on two occasions that are 6 hours apart think
– Epidural blood patch possible puerperal infection
• 20 ml of the patient’s blood is injected slowly into the
lumbar area of the epidural space.
– Cardinal symptoms of postpartum infection include an
• This creates a blood clot that patches the dura mater
elevated temperature, tachycardia, and pain.
• Most rapid and beneficial relief method

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Vital signs
What is a puerperal infection? Normal Findings Deviations From Normal Findings with
probable causes
• An infection of the reproductive tract associated Temperature:
Slight increase in the first 24 hours to 38 degrees C (100.4
Temperature:
greater than 38 degrees C (100.4 degrees F) after 24 hours
with childbirth, which may occur anytime up to degrees F) due to dehydration. Afebrile after 24 hours can be indicative of infection (mastitis, endometritis,
urinary tract infection, other systemic infections)
six weeks post delivery
• Most common puerperal infection is Pulse:
Slight elevation in first hour after birth that gradually
Pulse:
Rapid or increasing pulse rate can indicate hypovolemia

endometritis declines over 48 hours. Puerperal bradycardia of 40-50 bpm

is common

• A mom may be discharged prior to symptoms of a Respirations:

Return to pre-pregnancy rate soon after birth
Respirations:
Hypoventilation can be a result of an unusually high spinal
puerperal infection becoming apparent, proper block or epidural medication after a cesarean section

discharge teaching is necessary. About 84% of Blood Pressure : Blood Pressure:

postpartum infections manifest after discharge Slight transient return of approx. 5% increase over the first
few days to weeks after delivery. Orthostatic hypotension
Hypotension can indicate hypovolemia (late sign),
Hypertension can be caused by excessive use of
from the hospital. may be a result of splenic engorgement after birth vasopressor or oxytocin. Gestational hypertension may
continue for weeks after delivery, assess for corresponding
signs of preeclampsia

Integumentary Changes How often to complete a

• Cholasma (mask of pregnancy) comprehensive maternal assessment?
– Usually disappears in the postpartum woman. May persist in First Hour Second Hour First 12-24 Hours
about 30% of women
• Hyperpigmentation of areola and linea negra may not Every 15 Minutes Every 30 Minutes Every 4 hours
completely regress
• Striae gravidarum (stretch marks) on breast, abdomen, and • Follow your facility’s protocols
thighs may fade but usually do not disappear completely • This is a guide, may need to be done more frequently
• Spider angiomas and palmer erythema usually regresses • To promote maternal safety and optimal outcomes there
rapidly due to decreased estrogen have not been clinical trials to state exactly how often to
– Spider angiomas may persist indefinitely in some women assess during the postpartum period: guidelines state
• Hair loss may occur as the rapid growth associated with what to assess but don’t states exactly how often
pregnancy ends • Except temperature, 2008 ACOG and AAP state at least
• Hair and nail strength return to pre-pregnancy states every 4 hours during the immediate postpartum period
AWHONN Perinatal Nursing 2014

Maternal Blood Pressure

Maternal Blood Pressure
If there is a rise in blood pressure
• Many women have a rise in blood pressure
• Continue to closely observe blood pressure
right after delivery readings. If the reading is 140/90 mm Hg on two or
• This is a transient increase in both the systolic more occasion at least 6 hours apart (AWHON 2014)
and diastolic
• Or this patient is having headaches/visual changes
• This will spontaneously return to the pre- the health care provider needs to be aware (AWHON 2014)
pregnancy baseline over the next few days
Be aware that preeclampsia can persist into or occur
for the first time in postpartum

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Nursing Care

• Orthostatic hypotension may happen in the

first 48 hours post delivery
– May be due to the decrease in intrapelvic pressure
– She may feel dizziness right after moving to a
standing position

Maternal Blood Pressure

• How should BP be taken?
Let’s Discuss
– See resources section under Hypertension for
full hand out on how to properly measure a Cardiovascular
blood pressure Changes

Decreased Heart Rate Elevated Heart Rate

• Bradycardia is common during the first 6-10 • Tachycardia needs to be evaluated, may be
days after delivery due to:
• The heart rate is 50-70 beats per minute – Blood loss
possibly related to: – Temperature elevation
– Decreased cardiac strain – Infection
– Decreased blood volume following placental – Prolonged labor
separation – Fear
– Increased stroke volume – Pain

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Cardiovascular Changes Cardiovascular Changes

• Immediately following birth, • This will create an increased stroke volume (the
amount of blood pumped with one contraction)
autotransfusion occurs
which will increase the cardiac output
• So the 500-700 mL per minute of blood flow that
• Which is what? was going to the uteroplacental unit is now in just
the maternal systemic venous circulation right after
delivery
• It means that the blood that was going
through the placenta stops, creating more
blood circulating in just the maternal system

Cardiovascular Cardiac output

10-15 minutes
• Changes in blood volume is dependent on post delivery
cardiac output
– Blood loss during birth is at the highest
– Amount of extravascular fluid that is excreted
One hour post
• Average blood loss delivery cardiac
output reaches
– Vaginal deliveries 300-500mL pre labor value By 6-12 weeks
– Cesarean section deliveries 500-000 mL postpartum the
cardiac output
Delivery reaches
prepregnant levels
Declines by
30% in the first
2 weeks

Cardiovascular Peripartum Cardiomyopathy

• Maternal Physiological changes that allow the Defined as:
new mother to accommodate for changes in “a weakness of the heart muscle that by definition
blood volume include:
begins sometime during the final month of
– Elimination of utero-placental circulation
• Reduces vascular bed by 10-15%
pregnancy through about five months after
– Loss of placental endocrine function delivery, without any other known cause.”
• Removes the stimulus for vasodilation • Dr. Lili Barouch, Assistant Professor of Medicine, Division
of Cardiology, Johns Hopkins School of Medicine
– Mobilization of extravascular fluid
• Movement of fluid from extravascular spacing to
vasculature happens by 3rd day postpartum

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Peripartum Cardiomyopathy Signs and Symptoms

• Actual cause is unknown Present with signs and symptoms of pulmonary
• May be associated with nutritional and edema
immunologic mechanisms – Dyspnea- difficult or labored breathing
• Higher Incidence in: – Cough
– Older gravidas – Orthopnea- sensation of breathlessness in the
– Multiparas recumbent position, relieved by sitting or standing.
– African-Americans – Tachycardia
– Multiple gestations – Occasional hemoptysis- coughing up blood or blood
– Patients with preeclampsia tinged mucous

Evaluation of Respiratory Changes Respirations

• Should remain within the normal range of 12-
20 breaths per minute

• Variations to this may be:

– pain, fear, excitement, exertion

• Immediate attention is needed if she also has

shortness of breath, chest pain, anxiety,
restlessness…. could be a pulmonary emboli

Pulmonary Embolism
Normal Respiratory Changes
Most common signs: Most serious signs
• Tachpnea (>20 • Sudden
breaths/min) collapse/Syncope After delivery the reduction in the
• Tachycardia (>100 • Cyanosis intra abdominal pressure allows for
beats/min) • Hypotention increased expansion of the diaphragm.
• Dyspnea-labored breathing, • Presyncope Mom feels like she can take that deep
shortness of breath breath again!
• Chest pain
• Hemoptysis- coughing up of
blood or bloody sputum
• Abdominal pain

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Respiratory Respiratory
• When you let your breath out there is remaining air in your
lungs, this is called residual volume

• This too will normalize for mom soon after the baby is
delivered

• Everyone take a deep breath in….. Let that breath out

• The volume of air you just inhaled and exhaled is called

tidal volume

• Tidal volume normalizes for mom soon after birth

• To help prevent a mom from getting into a shallow Postpartum Neuraxial Morphine
breathing pattern we should teach patients how to
perform pulmonary exercises Who is a candidate?
– Place her in a high fowler’s position, use a pillow to
support her incision and instruct her to take a deep • cesarean deliveries
• extensive episiotomies,3rd or 4th degree lacerations
breath and cough.
– If available utilized respiratory therapists to assist in the Effective pain relief?
patient education
– Administering pain medication prior to pulmonary • Yes, when compared to IV administration of medication
exercise may be beneficial
it:
• Provides better pain control in the first 24 hours
– Explained that these exercises will help reduce the following delivery
chance of atelectasis and pneumonia by promoting • Earlier ambulation
adequate lung function
• Earlier bowel function in postoperative cesarean
patient

Neuraxial Morphine Postpartum Neuraxial Morphine

• Nursing Care Early-onset respiratory depression
– Monitor Level of Consciousness 30-90 minutes after administration
– Respiratory Rate every hours if epidural morphine
administered for 12-24 hours Late-onset respiratory depression
• Notify anesthesia if respiratory rate is <10 or other specified criteria
6-18 hours after administration
– If the patient received EREM (Depodur) a sustained release
formulation
• Assess respiratory status for 48 hours Women at an increased risk for respiratory
depression
– Pulse oximetry 12-24 hours post epidural morphine
administration
• Notify anesthesia if O2 saturation <90% • Morbidly Obese
• Pulse oximetry is not sensitive to hypercarbia or hypoventilation • Concurrently receiving magnesium sulfate
– Narcan (Naloxone 0.1 mg IV push at the bedside in case of • History of obstructive sleep apnea
respiratory depression

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Breasts Nursing Care: Breasts

If breastfeeding, assess for:

• Size and shape of the breasts

• Any abnormalities, reddened areas, or
engorgement
• Palpate for softness, slight firmness associated
with filling, or firmness associated with
engorgement
• Warmth
• Tenderness

Nursing Care: Breasts Explain the difference to patients

Breast Fullness Engorgement
If breastfeeding, assess nipples for:
• transitional fullness will • overfilling and swelling of the
usually last about 24 hours breast and/or areola
• Fissures • the breast will still be soft • typically be painful, warm to
the touch, skin will appear
• Cracks enough for the baby to nurse
shiny and taut
• Typically no pain, but a sense • engorgement can occur at any
• Soreness of fullness to the breast time
• Inversion • will occur about the 3-5th day • initiation of breastfeeding
post delivery soon after delivery, and
• breast fullness is normal and offering frequent feedings will
will resolve reduce the chances of
engorgement

Nursing Care: Breasts Nursing Care: Breasts

If bottlefeeding, assess breasts for: Bottlefeeding mother

• Size • No evidence currently exists to show that

• Shape nonpharmacologic approaches to suppress
• Tenderness lactation are more effective than no treatment
Oladapo & Fawole, 2009
• Color • In the United States medication to suppress
lactation is no longer given

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Nursing Care: Breasts Nursing Care: Breasts

Bottlefeeding mother
The goals of breast care are prevention of
• Bathe breasts during daily shower, but inform infection, adequate breast support, and
her to allow the warm water to run over her maternal comfort
shoulder instead of directly at her breasts
• Avoiding breast and nipple stimulation is
recommended
• Breast Binding is no longer recommended

Uterus Uterine Changes

B) 6-12 Hours
Postpartum

A) Immediately
Postpartum

As the nurse Uterus

We need to understand Involution: the return of the uterus to a
• the expected involution process of the nonpregnant state after birth
uterus to know if there is a need for • Reduction in size occurs over 6 weeks
intervention • Fundus will go through involution at a rate of
• palpate the fundus, where is it located and 1 finger breadth (1 cm) per day
how does it feel? • Decreased estrogen and progesterone
• a boggy uterus, a uterine height higher contribute to uterine cell atrophy and
than normal, or a uterus that is displaced autolysis (self destruction of excess
from midline needs to be investigated hypertrophied tissue). Cell number remains
the same.

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Uterine Involution Assessing the Uterus

• Have the woman void prior to assessment, a
• Factors that enhance involution distended bladder may cause the uterus to deviate,
typically to the right
• Uncomplicated labor & birth • Make sure the woman is in a supine position
• Complete expulsion of amniotic membranes • The clinician should have one hand at the level of the
and placenta umbilicus and the other hand right about the
symphysis pubis to stabilize the uterus. The support
• Breastfeeding is need to help prevent uterine inversion and
prolapse
• Manual removal of the placenta during
• The hand at the umbilicus will push down and in to
cesarean section feel the fundus
• Early ambulation • The fundus is the part of the uterus above the
insertion of the fallopian tubes

Uterine Subinvolution
• Subinvolution: failure of the uterus
to complete the process of involution

Perinatal Nursing, AWOHNN 2014

Factors That Slow Uterine Involution

Factors That Slow Uterine Involution
Factor Rationale
Factor Rationale
Full Bladder Interferes with effective uterine
Prolonged Labor Muscles relax because of contractions
prolonged time of contraction
during labor Incomplete Expulsion of Placenta Interferes with ability of uterus to
or Membranes remain firmly contracted
Anesthesia Muscles relax
Infection Inflammation interferes with
Difficult Birth Excessive manipulation of the uterus’ ability to contract
uterus effectively

Grandmultiparity Diminished uterine tone and Over distention of Uterus Overstretching from multiple
muscles relaxation from repeated gestation, hydramnios, or large
pregnancies baby

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What is Uterine Atony?

In the case of subinvolution
• Lack of muscle tone
• Is the leading cause of early postpartum postpartum • The lochia doesn’t typically progress like it is
hemorrhage (50% off PPH cases) suppose to
• Subinvolution is most commonly diagnosed
• If the uterus is not contracting and putting during her follow up exam in the clinic
pressure on these vessels: • Treatment depends on the reason the uterus is
– the uterus will fill with blood and clots not going through the involution process
– Not Good!
– this will lead to hemorrhage
– frequent uterine assessment is necessary

Placental Site Vaginal Changes

• After delivery the placenta should separate • Vagina may appear edematous, gaping, and/
spontaneously or bruised
• The placental site heals by exfoliation • Vaginal mucosa might appear pale and
• Tell patients they may have an increase in without rugae
bleeding around postpartum day 7-14 • The post-delivery hymen has characteristic
• This is due to the placental site sloughing off, small skin tags at its edges
but this bleeding should only last a few hours • The labia majora and the labia minora are
looser

Uterine Contractions Afterbirth pains comfort measures

• Compression of the intramyometrial blood vessels • Pain Medications
by contraction of the uterine muscle is the primary – Ibuprofen (24 hour maximum dosage 3200mg) or
source of postpartum homeostasis. Acetaminophen (24 hour maximum dosage 4000mg)
• Afterbirth pains – Narcotic analgesics as prescribed (with attention to
– Strong uterine contraction of the involuing uterus medications containing Acetaminophen)
– Caused by oxytocin release from the posterior pituitary • Take pain medications approximately 1 hour prior to
• May be more severe with breastfeeding
nursing
• May be accompanied by an increase of lochia • Prone position with small pillow under abdomen
– More common in multipara women, women with an – The position applies pressure to uterus and stimulates
overdistended uterus, or if clots or retained placental contraction. The constant contraction eases the after birth
fragments remain in uterus. pain.
– Usually lasts 2-3 days • Warm compress or water bottle to lower abdomen

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Bladder Urinary System Changes

• Transient loss of bladder tone or decreased
bladder tone is expected during pregnancy
due to the effect that progesterone has on
smooth muscle
• The fetal head pressing on the bladder during
labor may have caused some trauma/edema
• This may cause a decreased sensation making
voiding difficult

• Diuresis occurs due to:

– Decrease in estrogen which stimulated fluid
Nursing Care: Urinary System
retention during pregnancy • Assess for bladder distention and encourage the
– Decrease in residual hypervolemia, or fluid woman to empty her bladder regularly
overload • Stimulate voiding by running tap water or pouring
– Reduction in venous pressure in the lower half of warm water over the perineum
the body • Uterine atony that can be caused by bladder
– Profound diuresis can begin immediately after distention
delivery and spontaneous voiding usually returns • C-Section patients should have I/O documented until
within 6-8 hours post delivery spontaneous voiding after catheter removal
– Bladder fills rapidly after delivery due to the • Patient should void spontaneously by 6-8 hours after
marked increase in urine production birth
– Urine volume should return to pre-pregnant levels • Expected volume is 150 ml for each void
by 2-3 days after delivery • (Simpson and Creehan, 2014)

Nursing Care: Urinary System Perfect environment for a UTI…

• Catheterize if bladder is distended and patient A bladder that experienced trauma from
is unable to void delivery, bacteria that may have been
– Avoid Rapid Emptying introduced during catheterization, and retention
– Do not remove more than 800 ml at one time of residual urine give way to an environment to
– This prevents a precipitous drop in intraabdominal develop cystitis
pressure and splenic engorgement and Typically symptoms of cystitis happen around 2-
hypotension 3 days post delivery

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Make Sure Patient’s Know the Signs of

If cystitis is suspected…
a UTI
• Urinary frequency • The nurse may need to assist the postpartum
• Dysuria women with obtaining a urine sample. In
• Urgency order to not contaminate the sample it needs
• Hesitancy to be obtained during midstream to avoid
• Dribbling getting lochia in the sample
• Nocturia • Then the sample is sent for microscopic
• Suprapubic pain examination, culture, and sensitivity tests.
• May have gross hematuria
• Odor

Transient Stress Incontinence

Discuss Hygiene
Causes?
• Explaining that proper perineum care is essential • Conflicting evidence to support if pregnancy
during this healing process. predisposes women for urinary incontinence and
• A reminder to use the peri bottle, wash hands pelvic organ prolapse or if it is after a certain
number of vaginal births increases the risk of
before and after peri care, wipe from front to
developing urinary incontinence and pelvic organ
back, change the peri pad often. prolapse
• Once the lochia has stopped the cervix is closed • Factors that influence it
and the chance of infection ascending from the – Length of second stage of labor
vagina to the uterus reduces. – Infant’s head size
– Infant’s birth weight
– Episiotomy

Urine components Urine components

• Plasma Creatinine (Creatinine is a waste product produced by
• Renal glycosuria (simple sugar glucose is excreted in the muscles from the breakdown of a compound called creatine. Almost
urine despite normal or low blood glucose levels) all creatinine is filtered from the blood by the kidneys and released
– Induced by pregnancy, usually disappears by 1 week postpartum into the urine, so blood levels are usually a good indicator of how
well the kidneys are working.)
• Lactosuria (abnormal amount of lactose in the urine) – Return to normal by 6 weeks
– Occurs in lactating women
• Proteinuria (presence of excess proteins in the urine)
• Blood Urea Nitrogen (medical test that measures the – Resolves by 6 weeks
amount of urea nitrogen found in blood. The liver
• Ketonuria (ketone bodies are present in the urine, the body
produces urea in the urea cycle as a waste product of the
produces excess ketones as an indication that it is using an alternative
digestion of protein.) source of energy. It is seen during starvation or more commonly in
– Increases during postpartum as autolysis as uterine involution type I diabetes mellitus.)
occurs – Occurs with dehydration in women with uncomplicated births or
prolonged labor

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Bowels Gastrointestinal System Changes

Gastrointestinal System
• Bowels sluggish after birth due to
• Bowel movement may not happen for 2-3 days

– lingering effects of progesterone

– decreased abdominal and intestinal muscle
tone
– the peptide hormone relaxin depresses bowel
motility
http://www.thevisualmd.com/panel/?c=564.00

To Facilitate Normal Bowel Function

Cesarean Deliveries
• After a cesarean delivery moms may start with
• Drink water clear liquids
• Eat a high fiber diet • Typically once bowel sounds are present the diet
• Don’t ignore it can advance to solids
• Ambulate early!
• Avoid Straining
• Gas build up can occur following a cesarean birth
• Ambulate because of the anesthesia and intestinal
• Stool Softeners manipulation, moving will help expel some of the
gas
• Medication
• Stool softeners and other medications are
available

Nursing Care: Nutrition Gastrointestinal

• Assess the woman’s appetite Assess for nausea
• Most women are hungry and thirsty post • Antiemetic medications include
vaginal delivery –Ondasetron (Zofran)
• Provide the woman with a menu to select –Promethazine (Phenergan)
meals that appeal to her appetite –Metoclopromide (Reglan)
• Make snacks readily available
• Encourage foods high in protein, roughage,
vitamins and minerals

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Nursing Care: Gastrointestinal Abdominal Incision

• Gas pains • The nurse needs to include assessing the
– Ambulation incision, looking for:
– Rocking in a rocking chair – Approximation of the edges
– Avoiding gas-forming food – Is there any: Redness, Discoloration,
– Avoiding carbonated beverages Warmth, Edema, Unusual Tenderness, or
Drainage

Microsoft Clip Art

Wound infections from cesarean section or

Abdominal Incision dehiscence
– Elevated temperature on 3rd or 4th post
Teach the signs of infection and proper care for the delivery day, can be masked by early
area. postoperative fever
• If she notices foul odor, fever, redness around the – Presence of cellulitis
incision, discharge from the incision, or the – Redness, indurated (hardened), and
incision appears open she needs to call right away. inflamed appearance around the
repaired edges
• She can shower as usual and just pat the area
around the incision dry. – Discharge from the incision, such as pus
or blood
• Remind her if there are steri-strips that they will – Incision appears open and abdominal
fall off and not to pull them. contents are exposed to air
– Often associated with endometritis

Postpartum Endometritis (metritis)

• An infection of the uterine lining
• Postpartum endometritis happens in 1-3% of
vaginal births and about 10 times more common for
cesarean deliveries
• Administration of antibiotics prior to cesarean
delivery can decrease the incidence of endometritis
• Findings in the first 24-36 hours post delivery tend
to be related to group B Streptococcus (GBS). Late-
onset is more commonly associated with genital
mycoplasmas and Chlamydia trachomatis

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Symptoms for Endometritis (metritis) Treatment

• Foul smelling lochia • Typically treated with IV antibiotics,
• Fever (typically between 101-104 degrees cephalosporins or penicillin
Fahrenheit) • Mom typically will improve within a few days of
• Uterine tenderness on palpation initiated antibiotic treatment
• Lower abdominal pain • Treatment is typically continued until mom is
• Tachycardia afebrile and asymptomatic for 24 hours
• Chills • If a fever continues at the 48 hour mark after
antibiotics then additional investigating is
needed to check for refractory pelvic infection

Be aware of the risk factors for

Be aware of the risk factors for
Postpartum Uterine Infection
Postpartum Uterine Infection
• Chorioamnionitis • Manual removal of the
• Cesarean Delivery (single • Multiple vaginal (infection of the placenta,
most significant risk) examination during labor placenta or uterine
chorion, and amnion) exploration after delivery
• Prolonged premature • Compromised health
rupture of the amniotic status (low socioeconomic • Pre-existing bacterial • Retained placental
membranes status, anemia, obesity, vaginosis or Chlamydia fragments
• Prolonged labor preceding smoking, use of illicit trachomatis infection • Lapses in aseptic
cesarean birth drugs or alcohol, poor • Instrument assisted technique by surgical staff
• Obstetric trauma nutritional state) childbirth (vacuum or • Diabetes mellitus
(episiotomy, laceration of • Use of fetal scalp forceps)
perineum, vagina, or electrode or intrauterine • Immunocompromised
cervix pressure catheter status

What about Postoperative Prevention for DVT’s? May have questions about
Integumentary System Changes
Even if a mom is at a low risk for thrombogenic
thrombophilias she needs postoperative Stretch marks
prophylaxis. Treatment is aimed at preventing VTE
(Venous Thromboembolism)
• Common on breasts, abdomen, hips, and thighs
fade, but usually do not disappear
• Nonpharmacolgic Interventions
• It is caused by the stretching of the skin and
– Graduated elastic compression stockings
softening and relaxing of the dermal collagenous
– Pneumatic compression devices
and elastic tissues

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We are going to talk

about ways to care
Episiotomy Episiotomy
for your perineum,
including hygiene
and also pain • Surgical enlargement of the vagina
management
• Incision to the perineum, completed in the last
part of the second stage of labor
Monitoring for • Based on 2012 hospital discharge date about
infection is 12% of vaginal births had an episiotomy
important let’s
talk about the • Compared to 1992’s data which stated about
signs and 54%
symptoms you
need to know
about for when
you go home (Ward & Hisley, 2016 p 456)

Perineal Lacerations Perineal Lacerations

• First Degree
• With a vaginal delivery around 53-79% of women – Laceration that extends through the skin and structures superficial to
the muscle
will have some type of laceration – Perineal skin and mucous membranes
• Most common are 1st and 2nd degree lacerations • Second Degree
– Laceration that extends through muscles of the perineal body
• Occur as the fetal head is being born – Skin and mucous membranes plus fascia and muscles of perineum
• Third Degree
• Repairs should be attended to quickly to promote – Laceration that continues through the anal sphincter muscle
healing, and limit the damage – Skin, mucous membranes, muscle of the perineum, extends into
rectal sphincter
• If mom has an operative assisted delivery or • Forth Degree
precipitous labor she is at an increased risk – Laceration that also involves the anterior rectal wall
– Extends into rectal mucosa to expose rectum

Perineal Lacerations Severe Perineal Lacerations

• Bleeding from the laceration is one of the most • Mother may get a single dose of antibiotic
common complications during the repair
• Observe for hematoma formation • Monitor to evaluate would healing
• If the laceration extends into or through the • Some Expert Opinion Suggestions for OASIS:
anal sphincter complex it may be referred to as – Stool softeners and oral laxative
Obstetric Anal Sphincter Injuries (OASIS) – Instruct patient on how to avoid constipation
• These mothers need additional teaching and – Early and consistent follow up care
education geared toward healing

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Let Your Patients Know… Nursing Care: Pelvic Muscular Support

• After delivery the soft tissue in and around the • Instruct the mother that Kegel exercises can
perineum may be swollen and bruised improve the tone and contractibility of the vaginal
opening
• Initial healing of the episiotomy occurs within
2 to 3 weeks
• Can be started soon after delivery
• Supportive tissue of the pelvic floor is
stretched and during birth and complete • Kegel exercises can help to maintain perineal
healing may take 4 to 6 months muscle tone and help prevent urinary leakage

Kegel Exercises Nursing Care: Perineum

• Contracting the muscles of the perineum with • Assess perineum with the mother laying in a Sims’
enough force to stop a stream of urine position and the buttock is lifted to show the
• The contraction is held for about 5 seconds and perineum and anus.
then released • Use the acronym REEDA as a guide
• This exercise is repeated 4 to 5 times in a row • Redness
• Then work up to keeping the muscles tightened • Ecchymosis/bruising (purplish color)
for 10 seconds at a time, then relaxing for 10 • Edema (swelling) of the perineum
seconds. Goal is to complete 3 sets of 10
• Discharge from the episiotomy
repetitions a day
• Approximation of the skin edges

Nursing Care: General Perineum Nursing Care: General Perineum

Sitz Bath
• Provide comfort measures for
perineal/rectal pain: • A portable basin that will fit in the toilet, the water will sooth
the tissue and reduce inflammation by promoting
– Ice packs vasodilation

– Sitz baths • Offer either cool or warm water and allow woman to chose
which temperature she wants
– Peri bottle
– Anesthetic sprays • She should utilize the sitz bath for 20 minutes at a time, three
to four times daily
– Topical creams
– Witch hazel pads (to reduce edema) • This can be initiated 24 hours or more post delivery

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Nursing Care: Perineum Nursing Care: Perineum

• Be sure to consider cultural norms before Peri bottle
application. • Intended use of peri bottle is to squirt warm
• Some cultural groups considered blood “hot” water toward the front of the perineum and
and when she looses blood she is now in a let it run from the front to the back. This can
“cold” state. To avoid illness the mother needs relieve discomfort and keep the area clean.
to return back to a hot state.

Signs of infection of the episiotomy or General Prevention of Postpartum

repaired laceration of the perineum Infection
may include: • Proper hand washing, by everyone
• Adequate nutrition, fluids, and rest
• Redness
• Encourage complete emptying of her bladder
• Warmth • Proper breast and perineal hygiene
• Edema • Breastfeeding support, to help minimize nipple
• Purulent drainage trauma and ensure breast emptying
• Gaping of the previously approximated • Education to non-breastfeeding moms to
wound minimize breast stimulation

• Local pain

Quick Chart for Infections

Postpartum
Endometritis
Could be a result from: C/S, PROM, multiple vaginal exams,
fetal scalp electrode, forceps/vacuum, pre-existing vaginal
May fear first bowel movement
(metritis) infection, lack of aseptic technique. May also be due to
maternal behaviors: drug use, smoking , poor nutrition. Signs:
may have foul/scant lochia, uterine tenderness, elevated • The woman with an episiotomy or
temperatures, tachycardia, chills.
Parametritis (Pelvic Could be a result from: bacteria getting into a cervical hemorrhoids may fear the her first
Cellulitis) laceration or pelvic vein thrombophlebitis. Signs: abscess may
appear, may have chills, high fever, abdominal pain, uterine bowel movement due to anticipated
subinvolution, local and rebound tenderness, tachycardia,
abdominal distention, nausea, vomiting. pain, thus she tries to delay it
Urinary Could be a result from: birth trauma, urinary retention,
contamination from a catheter Signs: dysuria, fever, urinary
retention

Wound Could be a result from: contamination of laceration,

episiotomy, c/s incision Signs: erythema, local pain, purulent
discharge, edema, possibly dehiscence

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Nursing Care: Hemorrhoids Nursing Care: Hemorrhoids

• Hemorrhoids, distended rectal veins, may • Teaching to mother:
become larger in the second stage of labor due – Sit on flat, hard surfaces
– Avoid soft surfaces
to the pressure on the lower bowel • Why?
• However, after delivery the hemorrhoids reduce – Soft surfaces separate the buttocks and decrease the
in size and can be manually inserted into the venous flow, and intensifies the pain
rectum if needed – Tighten buttocks before sitting
– Lay on her side instead
• Educate her on the suggestions to facilitate • Provide comfort measures:
normal bowel function to help ease her mind – Ice Packs
about the potential pain with the first bowel – Anesthetic sprays or ointments
– Cool witch hazel pads
movement

Cervix
• Immediately following birth, the cervix and lower
Lochia
uterine segment are thin and flaccid
• The external cervical os never regains its pre-pregnant
appearance When to call
• The cervix may appear: spongy, flabby, formless, and/or your provider
bruised
• Over next 12-18 hours the Cervix shortens and What the expected
becomes firmer progression of vaginal
• Within 2-3 days postpartum
bleeding should be
– Cervix has shortened, firmed and regained its form
– Os will close to 1 cm by one week after birth
– Appearance will no longer have circular shape but rather a
jagged slit “fish mouth”

Lochia
Lochia Lochia Color Time Frame Constituents

• Lochia occurs in 3 stages and is classified Epithelial cells,

Rubra Dark red First 1-3
according to its appearance and contents days
blood, blood clots,
fragments of
– Lochia Rubra decidua, and
mucus

– Lochia Serosa Serosa Pink or Days 3-10 Blood, mucus, and

invading leukocytes
– Lochia Alba brown

Largely mucus,
The total amount of lochia varies by person, Alba White Days 10-14 leukocyte count
(creamy or up to 6 weeks high
the average volume is 150 -400 mL
yellowish)

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Things to tell your patient… Lochia Amount

• This discharge normally has a musty, stale Amount Description
odor that is not offensive Scant amount Blood only on tissue when wiped or less
than 1 inch stain on peripad within 1
• Any foul odor is suggestive of infection and hour
they should call their health care provider Less than 4-inch stain on peripad within
Light amount
• Lochia is heavier in the morning than at night, 1 hour
there is pooling in the vagina and uterus when Moderate Less than 6-inch stain on peripad within
the she is in a lying position amount 1 hour

• The amount of lochia may also be increased Heavy amount Saturated peripad within 1 hour
by exertion or breastfeeding
From Davidson, London, & Ladewig (2012, p. 1011).suggested guidelines for assessing lochia volume

Scant amount
Less than 4-inch stain on peripad Visual verses Measuring
within 1 hour

• A visual account of blood loss can vary person

less than 1 inch stain on peripad within 1 hour Light amount to person
• Weighing the pads is more accurate
Less than 6-inch stain on peripad within 1 Heavy amount
hour • You must know the dry weight of the pad
• Peripads can be weighed if needed:
Moderate amount
Saturated peripad within 1 hour 1 gram = 1 ml of blood

From Littleton & Engebretson (2002). Maternal, Neonatal, and Women’s Health
Nursing. Albany, NY: Delmar, p. 892

• To help mothers endure the blood loss at delivery

the body will have a 30-45% increase in the blood Things to tell your patient
volume at term.
• What the expected progression of lochia
• The human body typically holds about 5 Liters of should be
blood, depending on the size of the person. • Notify her health care provider if:
– Bright-red lochia returns after lochia has stopped
• Blood loss for an uncomplicated vaginal delivery – Persistent discharge of lochia rubra or a return to
lochia rubra can indicate subinvolution or
– 500 ml
postpartum hemorrhage
– An offensive odor, may suggest infection
• Blood loss after cesarean
– 1000 ml or more

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Homans Sign (Legs) How Many Assess for Homans sign?

Some hospitals don’t conduct a Homans sign during
the assessment
• Stating it is not diagnostic and may lead to an
embolus if the clot becomes loose while the nurse
is assessing
• The other hand is that there are no published
reports of an embolus occurring due to conducing a
Homans sign
• How it is performed: The nurse will abruptly and
with force dorsiflex the ankle while observing for
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pain in the calf and popliteal area

Break this down…you need to

remember
Postpartum mothers are at more of a risk for Mom has a high-volume, high-flow, and low-
resistance uteroplacental circulation that is meant
to support fetal development so she has measures
–Thrombophelbitis
in place to prevent maternal hemorrhage… such as
–Thrombus formation increase in concentration of coagulation factors and
–Inflammation involving a vein fibrinogen. The down side… now mom is at an
increased risk venous thrombosis and pulmonary
embolus.

Deep vein thrombosis (DVT) Assessment & Education about DVT’s

Physical Findings: is important
• Pain/tenderness
• Tenderness with palpation
• More common in the postpartum period
• Change in surface temperature between days 10-20
• Edema (usually one is larger) • About 90% of Pulmonary Embolisms (PE)
• Erythema (red/patchy skin color) come from lower extremity DVT’s!
• Mottled appearance
(discolored/patchy skin color)
• Difference in leg circumference of
each leg
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Thromboembolic Disease Evaluation of Neuromuscular System

Changes
Postpartum measures to decrease the risk:
– Early ambulation
– Leg exercises in bed and turning frequently,
every two hours
– Use of antiembolism stockings for those woman
at risk
– Avoid pressure behind knees & crossing the legs
– Avoid sitting for extended periods of time
– Promote elevation of the legs while sitting
– Avoid dehydration, promote fluids
– Encourage the woman not to smoke

Nursing Care: Neuromuscular Postpartum Chill

• Observe for return of full sensory
• Right after delivery some may have intense
tremors/shivering
• Assist with ambulation mother may not have • As long as there is no fever present this is not a
all her sensation yet or could be dizzy due to threat to mother
orthostatic hypotension • Comfort measures to help can include a warm
blanket, warm drink, reassuring her that it is
• Have mom sit on the side of the bed, wait, common and will dissipate
and gradually go to a standing position

Integumentary
• During first postpartum week profuse afebrile
diaphoresis is common, especially at night, as a
mechanism to secrete excess accumulation of fluid
• Nursing Care Immune System
– Instruct woman that excessive sweating is normal
– Change the bed linens and provide a clean gown as needed
– Observe for itching from epidural morphine
• Medications to ease itching include
– Diphenhydromine (Benadryl) 25 mg IV or oral every 6 hours PRN, itching
– Narcan drip
– Nubain
• Offer cool washcloth and provide cool environment

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Postpartum Physiologic Changes Rhogam

Rhogam causes lysis of any fetal red blood cells

The white blood cell count is increased that might have entered the maternal circulation
post delivery. By the end of the first (fetomaternal transfusion) before the mother has
week postpartum it will return to a time to build up antibodies against foreign
normal level. protein.

In the United States most of the population is Rh

Lukocytes return to nonpregnant level positive.
by six weeks post delivery.

Rubella Vaccine
Rhogam
• Rubella Vaccine
Women that are RhO(D) negative and have a
baby that is Rh (D) positive should receive
O –If rubella titer is 1:18 or less or
equivocal the mother should get the
RhoGAM or a similar formulation within 72 rubella vaccine, and advised against
hours post delivery to prevent sensitization pregnancy for the next 28 days.
from a fetomaternal transfusion of Rh- –If Rhogam and a live virus vaccine
positive fetal red blood cells (such as measles or rubella) is
administered during postpartum, the
mother needs to get a post-
vaccination serology test in three
months to check immunity.
Davidson,M., London, M., & Ladewig, P. (2016).

Vaccines
Lab values will be off..

Breastfeeding mothers can be vaccinated,

inactivated and live viruses can be given
to a breastfeeding mother, with the
exception of the smallpox vaccine.

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After Delivery Return to Normal Value

After Delivery Return to Normal Value
Platelets Decrease right after delivery Begin to increase by day 3-4
due to the placental post delivery
separation Return to normal levels by 6 WBC’s Average increase of 14- Decreases to normal values
weeks post delivery 16,000/mm3 by day six postpartum
May increase to 30,000/mm3
Coagulation Factors Plasma fibrinogen will Return to nonpregnant level during labor and right after
typically remain elevated for around 3-4 weeks post delivery
a few weeks after delivery. delivery
This offers protection to the Hematocrit Lower post delivery, drops in Return to normal range
mother from hemorrhage. the third trimester of within 4-8 weeks
But it may also increase her pregnancy. Increase in postpartum. Exception if
risk of thrombus formation. hematocrit is seen between there was excessive blood
day 3 and 7 due to the loss
plasma volume decrease
being greater than the loss
Blood volume Blood volume decreases 16% Total blood volume decreases of red blood cells after
from peak pregnancy levels to nearly prepregnant levels delivery
on the third day postpartum 1 to 2 weeks postpartum

After Delivery Return to Normal

Thyroid Function Immunosuppression is a With in 4-6 weeks post
normal physiologic result delivery
of pregnancy. Increased
risk of transient
autoimmune thyroiditis
to develop

Glucose Levels Lower glucose levels for Gestational Diabetic

moms during moms typically have
postpartum. May need normal glucose levels
less insulin requirements right after delivery.
for insulin-dependent
diabetic women.

Endocrine system Endocrine

• Placental Hormones • Pituitary Hormones
– Estrogen and Progesterone decrease markedly with – Prolactin
expulsion of the placenta • Prolactin levels increase after birth
– Reach lowest levels by 1 week postpartum • Highest in the first month for breastfeeding mothers and
remain elevated while lactation occurs
– Estrogen
• Return to pre-pregnant levels by 3 weeks in non-lactating
• Decreases also associated with diuresis of excess
women
extracellular fluid accumulated in pregnancy
– Oxytocin
– Progesterone
• Released from posterior pituitary in response to suckling
– Human chorionic gonadotropin (hCG) infant
• Disappears fairly quickly from circulation,

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Emotions How is Mom feeling??

We will cover this more in the
section about Perinatal Mood
Disorders

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Energy Level Nursing Care: Energy Level

• Ranges from high energy to extreme fatigue We can help by:

and sleepiness, this is individual
• Organize nursing activities to avoid frequent
• Moms will often feel physical fatigue, and interruptions
fatigue is common
• Schedule nap time to encourage and promote
• This should resolve over the first few weeks rest
postpartum
• Someone there to watch the infant so mom can
rest peacefully knowing her baby is cared for

Nursing Care:
Resumption of Sexual Activity
Resumption of Sexual Activity
When can couples safely resume intercourse?

• Current recommendations are that couples may resume

intercourse once the perineum is healed and the lochia has
stopped
• Average time for this is 3-6 weeks
• The risk of infection and hemorrhage are minimal after
about two weeks post delivery

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Nursing Care:
Resumption of Sexual Activity Nursing Care: Ovulation and Menstruation
• Reasons couples may wait due to:
– Mom is tired • Instruct women about when ovulation and
– Decreased libido menstruation can be expected to return based
– Hormonal alterations may impact mom’s upon whether the woman is breastfeeding or
physiologic response to sexual stimulation for bottle feeding
months • The first menstrual cycle is typically
– Baby’s needs anovulatory, but some (about 25%) may
– Vaginal dryness ovulate before menstruation.

Menstruation Return Ovulation

• Nonlactating Women: • Ovulation suppression is due to high prolactin

• Between 7-12 weeks levels
• Lactating Women: • Nonlactating women
• If breastfeeds for one month or shorter: • Mean time is about 70-75 days
return will be similar to a non lactating • Lactating women
women. • Delayed ovulation for lactating women, mean
• If exclusively breastfeeding: return will be time is around 4-6 months.
delayed, it varies greatly between women.
(Mattson & Smith, 2016)

References:
• Davidson,M., London, M., & Ladewig, P. (2016). Olds Maternal-
Newborn Nursing & Women’s Health Across the Lifespan, 10th ed.
Boston: Pearson Education, Inc.
• Mattson, S. & Smith, J.E. (2014). Core Curriculum for Maternal-
Newborn Nursing, 5th ed., AWHONN. St. Louis, MO: Elsevier
• Simpson, K.R. & Creehan, P.A. (2014). AWHONN Perinatal Nursing, 4th
ed. Philadelphia: Wolters Kluwer/Lippincott Williams & Wilkins
• The American College of Obstetricians and Gynecologists, Practice
bulletin: July 2016. Prevention and management of obstetric
lacerations at vaginal delivery
• Ward, S. & Shelton, H. (2016). Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families, 2nd ed.
Philadelphia: F.A. Davis Company

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