“Postpartum Care and Postpartum Complications”
Nursing Process
Initial Assessment
o Physical – body Systems and lab work
CBC and lab work can show how much blood she has lost.
o Psychosocial
Development of Nursing Care Plan – physical and educational needs
Nursing Diagnoses
o Risk for bleeding / Risk for fluid volume deficit
o Risk for impaired CO / Risk for decreased tissue perfusion
o Risk for infection
o Acute pain
o Knowledge deficit R/T self-care, newborn care, or breastfeeding
o Breastfeeding, ineffective or interrupted
o Alteration in bowel or urinary elimination
o Risk for impaired attachment or impaired parenting
o Disturbed sleep patterns
Expected Outcomes
o Involution and return to pre-pregnancy state will be accomplished without complications
o Parental roles will be successfully assumed
o New baby will be successfully integrated into family structure
o Successful infant feeding patterns will be established
Plan of Care
o Orientation to the unit
o Prevention of excessive bleeding
Maintenance of uterine tone
Prevention of bladder distention
o Prevention of infection
o Promotion of comfort, rest, ambulation, and exercise
o Patient teaching:
Self-care
Newborn feeding and care
Interventions
o Lab work: CBC, Rubella titer
o Medications:
Iron/prenatal vitamins
Analgesics
RhoGAM administration (if Rh negative)
Rubella Titer (if not immune) – 1:8 = immune
Vaccines: Varicella, Tdap
Depo-Provera or other contraceptives
Evaluation of Outcomes
o Involution successfully initiated and progressing without complication
Uterus returning back to its pre-pregnant state.
o Parents begin to assume new role behaviors and identities
o Beginning integration of newborn into family structure; bonding established
o Infant feeding techniques mastered
o Parents comfortable with infant care
Postpartum Assessment:
Six B’s: Bleeding, Breasts, Bladder, Bowels, Bottom, Bonding
BUBBLEHE
o Breasts
o Uterus
o Bladder
o Bowel
o Lochia
o Episiotomy
o High risk clots
o Emotional
Postpartum Period:
, Six-week period following birth in which the mother’s body undergoes anatomic and physiologic changes to reverse pregnancy changes;
body systems return to (nearly) nonpregnant state.
o Begins at the fourth stage of labor (the first 1-2 hours after birth)
o Puerperium – 6-week period in which the mother’s body undergoes anatomic and physiologic changes to reverse pregnancy changes
o Body systems return to (nearly) non-pregnant state
o May or may not include the return of the ovulatory/menstrual cycle
Reproductive System and Associated Structures:
Uterus
o Involution Process
Involution – the return of the uterus to a non-pregnant state – begins immediately after delivery of placents with contractions of
smooth muscle of uterus
Subinvolution – failure of uterus to return to non-pregnant state
Most common cause: retained placental fragments and infection
Approximately the size of a grapefruit – varies with parity, size of baby and mother
Autolysis of hypertrophied tissue
Estrogen and progesterone stimulated massive growth of uterus during pregnancy
After birth the decrease in these hormones causes autolysis of hypertrophied tissue
Additional cells laid down during pregnancy remain; hence uterus never truly returns to non-pregnant size and accounts for slight
increase in size with each pregnancy
o Contractions
Uterine contractions compress the intramyometrial blood vessels to stop bleeding at placental site (as opposed to platelet
aggregation and clot formation)
Oxytocin strengthens and coordinates these contractions
Pitocin – IM or IV after expulsion of placent; can be given IU with C/Section
Afterpains – uncomfortable cramping caused by contraction of the uterus; resolves in 3-7 days
Increased with breastfeeding, multiparity, multiple fetuses, or conditions that causes uterine over-distention
Also called afterbirth pains
Breastfeeding (nipple stimulation) helps uterus to contract
o Assessment
Fundus – assess firmness and location; should be midline and at or below the umbilicus
Evaluate with bladder empty and woman lying supine with head slightly raised
If displaced to the side or above the umbilicus, indicates full bladder which can cause uterine atony
Descends 1-2 cm per day
By day 12 it returns as a pelvic organ
After 2 weeks it is non-palpable
Document:
Fundal height
Firm or boggy
o If boggy then massage
Complaints of afterpains
o Placental Site
Placental site becomes an irregular nodular elevated area due to vascular constriction and thromboses
Upward growth of the endometrium causes sloughing of necrotic tissue and prevents scar formation
Permits implantation for future pregnancies
Complete by the 16th day postpartum, except at the placental site which is healed by 6 weeks
o Lochia
Vaginal discharge during the puerperium consisting of blood, endometrial tissue and mucus
Color
Days 1-4: Lochia Rubra – dark red
o Consisting mainly of blood and debris
Days 4-10 Lochia Serosa – serous, pink/brownish
o Consisting of old blood, serum, leukocytes, and tissue debris
Starts on day 10-14 and lasting 4-8 weeks’ post-birth: Lochia Alba - thin, yellowish to white discharge
o Consisting of leukocytes, decidua, epithelial cells, mucus, serum, and bacteria
Amount
Scant, light, moderate, or heavy
Should not have clots larger than a dime
Anticipate increased flow the first time the woman ambulates or breastfeeds; may feel a gush – do not confuse with a
hemorrhage
The amount may increase upon standing after sleeping, due to pooling in the vagina/uterus
Large or excessive clots indicates possible uterine atony and hemorrhage
The amount may be less in C/S mothers, but the stages remain the same (rubra serosa alba)
May feel gush with breastfeeding
, Total amount: 240-270 cc
Normal odor is the same as menstrual flow – call MD if odor becomes foul smelling
DANGER SIGNS:
Reappearance of bright red blood after rubra has stopped
Persistence of lochia rubra – possible retained placental fragments or membranes
Sudden, but brief, increase in bleeding 7-14 days after birth can occur due to sloughing of eschar over placental site
Notify provider if does not subside within 1-2 hours
10%-15% women have normal lochia serosa at 6 week visit
Continued flow of serosa or alba by 3-4 weeks postpartum can indicate endometritis, especially with fever, pain or
abdominal tenderness
Not all vaginal bleeding is lochia!! Differentiate between lochia and vaginal, cervical or uterine tear that needs repair
Box 20-1 Lochial and Nonlochial Bleeding
Lochial:
o Lochia usually trickles from the vaginal opening, with the steady flow increasing as the uterus contracts
o A gush of lochia can appear as the uterus is massaged
o If it is dark in color, it has been pooled in the relaxed vagina
o Amount soon lessens to a trickle of bright red lochia (in the early puerperium)
Nonlochial:
o If the blood discharge spurts from the vagina, and the uterus is firmly contracted, there can be cervical or vaginal tears
in addition to the normal lochia
o If the amount of bleeding continues to be excessive and bright red, a tear can be the source
Uterus and Lochia Assessment
Uterine and lochia assessment is ALWAYS assessed together
Consider parity, size of baby and gestational age, size of mother, length of labor, use of oxytocin, bladder status
Differentiate between lochial and non-lochial bleeding – is there a tear or laceration?
Cervix
o Immediately after birth:
Spongy, flabby, bruised, with small lacerations – risk for infection!
Over the next 12-18 hours, it shortens and becomes firmer
o Closes slowly – admits 1 fingertip by 1 week postpartum
o Shape of the cervical os does not return to normal round dimple, but instead changes to a slit
Vagina
o Edematous and bruised with superficial lacerations
o Not all lacerations sutures
o Rugae is obliterated – vaginal wall with be smooth for 3-4 weeks
Rugae will reappear, although not as prominent as pre-pregnant
o Hypoestrogenic until ovulation and menstruation resume
Estrogen deprivation responsible for the thinnest of the vaginal mucosa and absence of rugae
Perineum
o Perineal lacerations
1st degree – skin & superficial tissue
2nd degree – extends through muscles
3rd degree – continues through anal sphincter muscle
4th degree – involves anterior rectal wall
Nursing interventions:
o Assess site, keep clean, ice packs, analgesics
o Teach pt comfort measures, high fiber diet, stool softeners, increased fluids (3 rd/4th degree)
o Episiotomy
o Hemorrhoids
o Hematoma
o Perineal Comfort Measures
Ovulation and Menstruation
o Non-lactating Mothers:
Period returns as early as 27 days after birth
Mean length of time is 70-75 days
Many women ovulate before the return of menses
Ovulation may occur one month after childbirth
o Lactating Mothers:
Prolactin level remains elevated
Mean length of time until initial ovulation is 6 months
Dependent on the duration of each feeding, the frequency, and the amount of supplemental feedings
Not a reliable method of birth control
Nursing Interventions for Reproductive System
o Cervical and Vaginal Changes
, Assess for s/s of abnormal bleeding
Report abnormal findings
Teach Kegel exercises (pg. 92)
Use of water-soluble lubricant when resuming sexual relations
o Episiotomy
Document if midline or mediolateral (right or left)
Assess episiotomy for REEDA-D
Redness
Edema
Ecchymosis
Approximation
Discharge
Assess for tears or lacerations
Teach mother that healing takes about 2 weeks
If perineum is intact – assess for ecchymosis and edema
o Comfort Measures for “Bottom”
Ice packs for the first 24 hours
Analgesia:
Oral meds and/or topical meds (foam or spray)
Perineal care performed with peri-bottle and water with blot drying from front to back each time woman voids or stools
Positioning:
Crawl into bed
Perform Kegel before sitting
Lie on side
Take stool softener
Tucks – also helps with hemorrhoids
Sitz bath (after first 24 hours)
Hospital gown should be worn at least for the first day
o Pharmacologic Pain Relief
Opioids: Percocet, Meperidine, Morphine
A PCA pump is often ordered for C/S patients
NSAIDs: Naproxen Sodium
Toradol or Ketorolac for C/S moms
Topical antiseptic, anesthetic spray or ointment for pain
o Postpartum Sexual Activity
Follow primary HCP orders
Pelvic rest for 6 weeks****
Can increase risk for intrauterine infection because placental site doesn’t heal for 6 weeks
Abstain until episiotomy has healed, lochial flow has stopped, and there is no vaginal discharge
If there is a vaginal discharge, they should remain from having sex
Use an additional lubricant (dryness is a result of hormonal deficit)
Contraceptive/family planning should be considered
Body image concerns; breastfeeding; exhaustion
Consider different positions for comfort; encourage creativity! J
Musculoskeletal System
Abdomen
o Abdominal muscles are relaxed for the first 2 weeks after birth and the return of pre-pregnancy muscle tone takes about 6 weeks
o Diastasis recti abdominis – condition where the abdominal wall muscles separate with large fetus or multifetal pregnancy
Becomes less apparent with time
o The abdomen may still appear pregnant
o Joints stabilize by 6-8 weeks
o Feet may permanently remain a larger shoe size
o Do postpartal exercises
Integumentary System
Most skin changes during pregnancy resolve following pregnancy
Melasma (chloasma)-persists in 30% women
Hyperpigmentation of areola & linea nigra
Striae gravidarum – lighten, regress in size
Spider angiomas (nevi) – may persist
Palmar erythema regresses
Hair loss; fine hair from pregnancy disappears
Nails return to prepregnant status
Nursing Process
Initial Assessment
o Physical – body Systems and lab work
CBC and lab work can show how much blood she has lost.
o Psychosocial
Development of Nursing Care Plan – physical and educational needs
Nursing Diagnoses
o Risk for bleeding / Risk for fluid volume deficit
o Risk for impaired CO / Risk for decreased tissue perfusion
o Risk for infection
o Acute pain
o Knowledge deficit R/T self-care, newborn care, or breastfeeding
o Breastfeeding, ineffective or interrupted
o Alteration in bowel or urinary elimination
o Risk for impaired attachment or impaired parenting
o Disturbed sleep patterns
Expected Outcomes
o Involution and return to pre-pregnancy state will be accomplished without complications
o Parental roles will be successfully assumed
o New baby will be successfully integrated into family structure
o Successful infant feeding patterns will be established
Plan of Care
o Orientation to the unit
o Prevention of excessive bleeding
Maintenance of uterine tone
Prevention of bladder distention
o Prevention of infection
o Promotion of comfort, rest, ambulation, and exercise
o Patient teaching:
Self-care
Newborn feeding and care
Interventions
o Lab work: CBC, Rubella titer
o Medications:
Iron/prenatal vitamins
Analgesics
RhoGAM administration (if Rh negative)
Rubella Titer (if not immune) – 1:8 = immune
Vaccines: Varicella, Tdap
Depo-Provera or other contraceptives
Evaluation of Outcomes
o Involution successfully initiated and progressing without complication
Uterus returning back to its pre-pregnant state.
o Parents begin to assume new role behaviors and identities
o Beginning integration of newborn into family structure; bonding established
o Infant feeding techniques mastered
o Parents comfortable with infant care
Postpartum Assessment:
Six B’s: Bleeding, Breasts, Bladder, Bowels, Bottom, Bonding
BUBBLEHE
o Breasts
o Uterus
o Bladder
o Bowel
o Lochia
o Episiotomy
o High risk clots
o Emotional
Postpartum Period:
, Six-week period following birth in which the mother’s body undergoes anatomic and physiologic changes to reverse pregnancy changes;
body systems return to (nearly) nonpregnant state.
o Begins at the fourth stage of labor (the first 1-2 hours after birth)
o Puerperium – 6-week period in which the mother’s body undergoes anatomic and physiologic changes to reverse pregnancy changes
o Body systems return to (nearly) non-pregnant state
o May or may not include the return of the ovulatory/menstrual cycle
Reproductive System and Associated Structures:
Uterus
o Involution Process
Involution – the return of the uterus to a non-pregnant state – begins immediately after delivery of placents with contractions of
smooth muscle of uterus
Subinvolution – failure of uterus to return to non-pregnant state
Most common cause: retained placental fragments and infection
Approximately the size of a grapefruit – varies with parity, size of baby and mother
Autolysis of hypertrophied tissue
Estrogen and progesterone stimulated massive growth of uterus during pregnancy
After birth the decrease in these hormones causes autolysis of hypertrophied tissue
Additional cells laid down during pregnancy remain; hence uterus never truly returns to non-pregnant size and accounts for slight
increase in size with each pregnancy
o Contractions
Uterine contractions compress the intramyometrial blood vessels to stop bleeding at placental site (as opposed to platelet
aggregation and clot formation)
Oxytocin strengthens and coordinates these contractions
Pitocin – IM or IV after expulsion of placent; can be given IU with C/Section
Afterpains – uncomfortable cramping caused by contraction of the uterus; resolves in 3-7 days
Increased with breastfeeding, multiparity, multiple fetuses, or conditions that causes uterine over-distention
Also called afterbirth pains
Breastfeeding (nipple stimulation) helps uterus to contract
o Assessment
Fundus – assess firmness and location; should be midline and at or below the umbilicus
Evaluate with bladder empty and woman lying supine with head slightly raised
If displaced to the side or above the umbilicus, indicates full bladder which can cause uterine atony
Descends 1-2 cm per day
By day 12 it returns as a pelvic organ
After 2 weeks it is non-palpable
Document:
Fundal height
Firm or boggy
o If boggy then massage
Complaints of afterpains
o Placental Site
Placental site becomes an irregular nodular elevated area due to vascular constriction and thromboses
Upward growth of the endometrium causes sloughing of necrotic tissue and prevents scar formation
Permits implantation for future pregnancies
Complete by the 16th day postpartum, except at the placental site which is healed by 6 weeks
o Lochia
Vaginal discharge during the puerperium consisting of blood, endometrial tissue and mucus
Color
Days 1-4: Lochia Rubra – dark red
o Consisting mainly of blood and debris
Days 4-10 Lochia Serosa – serous, pink/brownish
o Consisting of old blood, serum, leukocytes, and tissue debris
Starts on day 10-14 and lasting 4-8 weeks’ post-birth: Lochia Alba - thin, yellowish to white discharge
o Consisting of leukocytes, decidua, epithelial cells, mucus, serum, and bacteria
Amount
Scant, light, moderate, or heavy
Should not have clots larger than a dime
Anticipate increased flow the first time the woman ambulates or breastfeeds; may feel a gush – do not confuse with a
hemorrhage
The amount may increase upon standing after sleeping, due to pooling in the vagina/uterus
Large or excessive clots indicates possible uterine atony and hemorrhage
The amount may be less in C/S mothers, but the stages remain the same (rubra serosa alba)
May feel gush with breastfeeding
, Total amount: 240-270 cc
Normal odor is the same as menstrual flow – call MD if odor becomes foul smelling
DANGER SIGNS:
Reappearance of bright red blood after rubra has stopped
Persistence of lochia rubra – possible retained placental fragments or membranes
Sudden, but brief, increase in bleeding 7-14 days after birth can occur due to sloughing of eschar over placental site
Notify provider if does not subside within 1-2 hours
10%-15% women have normal lochia serosa at 6 week visit
Continued flow of serosa or alba by 3-4 weeks postpartum can indicate endometritis, especially with fever, pain or
abdominal tenderness
Not all vaginal bleeding is lochia!! Differentiate between lochia and vaginal, cervical or uterine tear that needs repair
Box 20-1 Lochial and Nonlochial Bleeding
Lochial:
o Lochia usually trickles from the vaginal opening, with the steady flow increasing as the uterus contracts
o A gush of lochia can appear as the uterus is massaged
o If it is dark in color, it has been pooled in the relaxed vagina
o Amount soon lessens to a trickle of bright red lochia (in the early puerperium)
Nonlochial:
o If the blood discharge spurts from the vagina, and the uterus is firmly contracted, there can be cervical or vaginal tears
in addition to the normal lochia
o If the amount of bleeding continues to be excessive and bright red, a tear can be the source
Uterus and Lochia Assessment
Uterine and lochia assessment is ALWAYS assessed together
Consider parity, size of baby and gestational age, size of mother, length of labor, use of oxytocin, bladder status
Differentiate between lochial and non-lochial bleeding – is there a tear or laceration?
Cervix
o Immediately after birth:
Spongy, flabby, bruised, with small lacerations – risk for infection!
Over the next 12-18 hours, it shortens and becomes firmer
o Closes slowly – admits 1 fingertip by 1 week postpartum
o Shape of the cervical os does not return to normal round dimple, but instead changes to a slit
Vagina
o Edematous and bruised with superficial lacerations
o Not all lacerations sutures
o Rugae is obliterated – vaginal wall with be smooth for 3-4 weeks
Rugae will reappear, although not as prominent as pre-pregnant
o Hypoestrogenic until ovulation and menstruation resume
Estrogen deprivation responsible for the thinnest of the vaginal mucosa and absence of rugae
Perineum
o Perineal lacerations
1st degree – skin & superficial tissue
2nd degree – extends through muscles
3rd degree – continues through anal sphincter muscle
4th degree – involves anterior rectal wall
Nursing interventions:
o Assess site, keep clean, ice packs, analgesics
o Teach pt comfort measures, high fiber diet, stool softeners, increased fluids (3 rd/4th degree)
o Episiotomy
o Hemorrhoids
o Hematoma
o Perineal Comfort Measures
Ovulation and Menstruation
o Non-lactating Mothers:
Period returns as early as 27 days after birth
Mean length of time is 70-75 days
Many women ovulate before the return of menses
Ovulation may occur one month after childbirth
o Lactating Mothers:
Prolactin level remains elevated
Mean length of time until initial ovulation is 6 months
Dependent on the duration of each feeding, the frequency, and the amount of supplemental feedings
Not a reliable method of birth control
Nursing Interventions for Reproductive System
o Cervical and Vaginal Changes
, Assess for s/s of abnormal bleeding
Report abnormal findings
Teach Kegel exercises (pg. 92)
Use of water-soluble lubricant when resuming sexual relations
o Episiotomy
Document if midline or mediolateral (right or left)
Assess episiotomy for REEDA-D
Redness
Edema
Ecchymosis
Approximation
Discharge
Assess for tears or lacerations
Teach mother that healing takes about 2 weeks
If perineum is intact – assess for ecchymosis and edema
o Comfort Measures for “Bottom”
Ice packs for the first 24 hours
Analgesia:
Oral meds and/or topical meds (foam or spray)
Perineal care performed with peri-bottle and water with blot drying from front to back each time woman voids or stools
Positioning:
Crawl into bed
Perform Kegel before sitting
Lie on side
Take stool softener
Tucks – also helps with hemorrhoids
Sitz bath (after first 24 hours)
Hospital gown should be worn at least for the first day
o Pharmacologic Pain Relief
Opioids: Percocet, Meperidine, Morphine
A PCA pump is often ordered for C/S patients
NSAIDs: Naproxen Sodium
Toradol or Ketorolac for C/S moms
Topical antiseptic, anesthetic spray or ointment for pain
o Postpartum Sexual Activity
Follow primary HCP orders
Pelvic rest for 6 weeks****
Can increase risk for intrauterine infection because placental site doesn’t heal for 6 weeks
Abstain until episiotomy has healed, lochial flow has stopped, and there is no vaginal discharge
If there is a vaginal discharge, they should remain from having sex
Use an additional lubricant (dryness is a result of hormonal deficit)
Contraceptive/family planning should be considered
Body image concerns; breastfeeding; exhaustion
Consider different positions for comfort; encourage creativity! J
Musculoskeletal System
Abdomen
o Abdominal muscles are relaxed for the first 2 weeks after birth and the return of pre-pregnancy muscle tone takes about 6 weeks
o Diastasis recti abdominis – condition where the abdominal wall muscles separate with large fetus or multifetal pregnancy
Becomes less apparent with time
o The abdomen may still appear pregnant
o Joints stabilize by 6-8 weeks
o Feet may permanently remain a larger shoe size
o Do postpartal exercises
Integumentary System
Most skin changes during pregnancy resolve following pregnancy
Melasma (chloasma)-persists in 30% women
Hyperpigmentation of areola & linea nigra
Striae gravidarum – lighten, regress in size
Spider angiomas (nevi) – may persist
Palmar erythema regresses
Hair loss; fine hair from pregnancy disappears
Nails return to prepregnant status
