Postpartum Assessment and Nursing Care

Postpartum Assessment and Nursing Care
Chapter 12 Postpartum Assessment and Nursing Care Review chapter objectives. Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

Objectives Define key terms listed. Describe the postpartum period. Explain the involution of the uterus and describe changes in the fundal position. Explain the cause of afterpains. Distinguish among the characteristics of lochia rubra, lochia serosa, and lochia alba. Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

Objectives (cont.) Explain how to assess the postpartum woman’s perineum. Describe two ways in which the fluid accumulated during pregnancy is eliminated during the postpartum period. Explain the importance of monitoring the vital signs during the first 24 hours postpartum. List three factors that influence urinary retention after delivery. Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

Postpartum Period Also called puerperium Six-week interval from childbirth to the return of the uterus and other organs to a prepregnant state Immediate postpartum: first 24 hours Early postpartum: first week Late postpartum: second to sixth weeks Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

Goals of Postpartum Care
Assist and support the woman’s recovery to the prepregnant state and identify deviations from the norm Educate the mother about her own self-care and newborn feeding and care Promote bonding between newborn and family Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

Dangers in Immediate Postpartum
Hemorrhage Hypovolemic shock Infection Uterine cavity easily accessible to microorganisms from exterior Placental attachment site is like an open wound Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

Clinical Pathway in Postpartum Period
Nursing assessments Teaching Medical and nursing interventions Discharge Follow-up care for woman Review Clinical Pathway 12-1 (p. 225). Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

Involution of the Uterus
Begins after expulsion of placenta Placental site contracts to a size less than half of its original size immediately after birth Contractions cause uterine muscles to act like “living ligatures” and compress blood vessels Caused by sudden withdrawal of estrogen and progesterone Refer to Figure 12-1 (p. 226). Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

Involution of the Uterus (cont.)
Release of proteolytic enzymes into endometrium Causes protein material within endometrial cells to break down into substances that are excreted in the urine Number of muscle cells does not change, only their size Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

Exfoliation Unique healing process that allows healing of placental site without scarring Necrotic tissue is sloughed off Reparative process ensures future fertilized ova will implant in an unscarred uterus Endometrial regeneration is complete within 16 days postpartum Placental regeneration is complete at 6 weeks postpartum Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

Uterus Immediately after birth weighs about 1000 g (2.2 lbs) Decreases to 500 g (1.1 lb) during first week postpartum By second week postpartum, weighs around 340 g (12 oz) Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

Factors That Can Slow Involution
Prolonged labor Incomplete expulsion of placenta and membranes Anesthesia Previous labors Distended (full) bladder Blood clots Boggy uterus Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

Factors That Can Enhance Involution
Uncomplicated labor and birth Breastfeeding Early, frequent ambulation Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

Cervix After birth it is soft By 18 hours postpartum, has regained its usual form Gradually closes around 2 weeks postpartum Never regains original appearance After pregnancy, os looks like a slit instead of a circle or dot Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

Descent of Uterine Fundus
Usual progression of uterine descent into pelvis at about 1 cm/day Immediately after delivery, fundus typically at umbilicus or just below it By 10 days postpartum, uterus should not be abdominally palpable Review Skill 12-1 (p. 227). Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

Subinvolution of the Uterus
Failure of the uterus to return to the prepregnant state Most common cause is retained placental fragments Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

Afterpains Intermittent uterine contractions Occur for the first 2 to 3 days postpartum Hormone oxytocin Strengthens uterine contractions Compresses blood vessels Infant suckling can cause afterpains Ibuprofen can be given Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

Lochia Postpartum vaginal discharge Contains Blood from placental site Particles of necrotic decidua Mucus Normally fleshy odor similar to menstrual flow See Table 12-1 (p. 228). Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

Lochia Rubra Heaviest during first 1 to 2 hours after delivery Initially bright red (lochia rubra) Lasts 1 to 3 days May contain small clots Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

Lochia Serosa Vaginal flow pales Becomes pink to brown after about 3 days Should not contain clots and can last up to 27 days in some women Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

Lochia Alba Typically by 10 days postpartum, vaginal discharge becomes yellow to white May continue on average to the 6th week postpartum Review Table 12-1 (p. 228). Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

Estimating Lochial Flow
Count number of pads being changed per hour Pads can be weighed (1 g = 1 mL blood) Check fundal firmness Document per facility protocol See Skill (p. 229). Why is it important to know what the peripads are made with? Answer: because the different brands may have a different rate of absorption. Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

Lochial Flow Teach mother that she may see an increase in lochia on rising due to pooling of fluids within the vagina Excessive lochia rubra early in postpartum may suggest bleeding due to retained placental fragments Recurrence of bleeding in 7 to 10 days suggests bleeding from placenta site but could also be normal sloughing Refer to Skill 12-2 (p. 229). Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

Lochial Flow (cont.) After 3 to 4 weeks, late bleeding may be caused by infection or subinvolution Continued lochia serosa or alba suggests infection (endometritis) and may also indicate fever, pain, or abdominal tenderness Lochia will have an offensive odor if infection is present Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

Vagina Appears edematous and bruised By week 3, resumes prepregnant appearance Rugae begin to reappear By week 6, has almost regained prepregnant form May notice dryness, which usually disappears when ovulation and menstruation return Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

Perineum Often edematous and bruised from delivery Assess for type and amount of vaginal discharge, unusual swelling, discoloration, healing of tissues, discomfort Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

Assessing Episiotomy Site
REEDA scale Redness Edema Ecchymosis (bruising) Discharge Approximation of wound Healing overall takes around 6 weeks Nurse would also assess hemorrhoids, if present. Discuss the benefits of sitz baths, peri bottles, cold applications, and medications to treat the perineal area in the postpartum period. Refer to Skill 12-3 (p. 230) and Skill 12-4 (p. 230). Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

Changes in the Musculoskeletal System
Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

Muscles and Joints Relaxin hormone decreases Ligaments and cartilage of pelvis begin to return to prepregnant state Progesterone hormone decreases Muscle tone improves Woman can develop diastasis recti Refer to Kegel exercises in Chapter 5. Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

Changes in the Cardiovascular System
Women lose at least 200 to 500 mL of blood during vaginal delivery Twice as much during cesarean birth Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

Rapid Changes in Blood Volume
Prevent hypovolemia Changes include Elimination of placenta Rapid reduction of size of uterus Increase of blood flow to vena cava Mobilization of body fluids accumulated during pregnancy Elimination of placenta diverts 500 to 750 mL of blood flow into maternal systemic circulation. Reduction of size of uterus puts more blood in systemic circulation. Blood flow to vena cava increases due to elimination of gravid uterus compressing it. Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

Excess Fluid Disposed of two ways Diuresis (increased excretion of urine) Woman may have urinary output as high as 3000 mL/day Diaphoresis (profuse perspiration) Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

Blood Values First 72 hours, greater loss of plasma volume than RBCs Temporary rise in hematocrit and hemoglobin Normal levels return in 2 to 4 weeks postpartum Leukocytosis (WBC can be as high as 15,000/mm3 or higher) without infection Normal levels return within 10 days postpartum Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

Blood Coagulation Increased during pregnancy Fibrinogen levels return to normal within 2 weeks postpartum Increases risk of thrombosis formation Risk can be decreased by early and frequent ambulation Dyspnea and tachypnea hallmark signs of pulmonary embolus Varicose veins diminish What causes the varicose veins to diminish? Answer: venous stasis that was caused by the gravid uterine compression decreases. The progesterone level declines, which leads to a decrease in smooth muscle tone during pregnancy but lessens in the early postpartum period. Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

Orthostatic Hypotension
Pelvic blood flow resistance decreases after delivery Woman’s blood pressure falls May complain of lightheadedness or dizziness or may even faint (pass out) Instruct woman to rise slowly to prevent this from occurring Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

Postpartum Diaphoresis
Elimination of excess fluid through the skin Body’s way of getting rid of excess fluid accumulated during pregnancy Profuse diaphoresis occurs most often at night Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

Temperature First 24 hours after delivery, temperature may rise to 38° C (100.4° F) Result of dehydration and exertion of labor Thereafter temperature should be in normal range If temperature still elevated, infection may have developed and should be reported Breast engorgement can cause a short-term elevation in temperature Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

Pulse In first 6 to 8 days Decreases to a rate of 50 to 60 beats/minute Elevated rate may indicate undue blood loss, infection, pain, anxiety, or cardiac disease Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

Blood Pressure Should remain stable after birth Decrease may indicate blood loss Elevation with a headache may indicate gestational hypertension that still needs to resolve in the postpartum period Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

Changes in the Urinary System
Loss of muscle tone in the bladder During labor and delivery, urethra, bladder, and surrounding tissue may become edematous or traumatized Urination can be impeded by anesthetic agents Urinary output in the early postpartum period can be significantly high Close observation of I&O is essential Glomerular filtration rate can remain high for up to 8 weeks postpartum. Costovertebral angle (CVA) tenderness, fever, urinary retention, and dysuria may indicate potential urinary tract infection and should be investigated. Refer to Safety Alert—Signs of a Distended Bladder (p. 232). Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

Urine Composition Mild proteinuria as result of uterine cell breakdown May test positive for acetone or ketones Lactosuria may occur in breastfeeding women Normal status returns about 4 weeks postpartum What measures can the nurse assist with in helping the postpartum woman void? Answers: 1. Provide privacy; 2. run water in the sink; 3. have woman use peri bottle to squirt warm water over perineal area (aids relaxation of sphincter). Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

Audience Response System Question 1
Glomerular filtration rate can remain high in the postpartum phase for up to: 2 weeks 4 weeks 6 weeks 8 weeks Answer: D. Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

Physiological Changes Postpartum

Objectives Discuss three factors that contribute to postpartum constipation. List two significant events that occur as a result of changes in the endocrine system. Explain the factors involved in the woman’s weight loss after birth. Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

Changes in the GI System
May have constipation postpartum due to Decreased peristalsis Stretched abdominal muscles Limited food or fluid intake Soreness and swelling of perineum or hemorrhoids Fear of pain Woman should have a bowel movement within 3 days postpartum What causes the decreased peristalsis? Answer: lingering relaxing effects of progesterone. Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

Fluid and Nutrition in Postpartum Period
Eat three balanced meals a day Maintain adequate calcium and phosphorus intake If breastfeeding, high fluid and high fiber intake to reduce risk of constipation Increase calories by 500 per day if breastfeeding Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

Changes in the Nervous System
Carpal tunnel syndrome may be lessened due to diuresis that occurs in postpartum period Headaches may continue for a while in women who experienced gestational hypertension Should be investigated Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

Changes in the Integumentary System
Melanocyte-stimulating hormone (which causes hyperpigmentation) decreases rapidly after delivery Chloasma (mask of pregnancy) and linea nigra fade Spider nevi and palmar erythema due to increased estrogen levels disappear Striae gravidarum (stretch marks) gradually fade, but do not totally disappear Hair growth slows; may experience some hair loss Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

Changes in the Endocrine System
Estrogen and progesterone levels decrease after expulsion of placenta Prepregnant levels If bottle-feeding, returns in about 3 weeks If breastfeeding, normal levels take longer First menses is usually anovulatory, but birth control should still be used Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

Prolactin and Oxytocin
Prolactin promotes milk production and ejection Stimulates alveolar cells of breast Oxytocin triggers milk ejection when infant sucks on nipple Also stimulates uterine contractions Day 3 postpartum, breast engorgement can occur If woman chooses not to breastfeed, she should be instructed to avoid any breast stimulation. Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

Breast Engorgement Primarily caused by temporary congestion of veins and lymphatics, not milk accumulation Spontaneously resolves within 24 to 36 hours Supportive bra should be worn for 72 hours; ice packs and mild analgesics may be used Milk production ceases within a few days to a week Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

Resumption of Ovulation and Menstruation
Nonlactating woman Ovulation may return within 1 month Menstruation usually resumes within 3 months Lactating woman Menstruation usually resumes within 6 months Menstruation may be heavy initially Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

Weight Loss Immediately after delivery weight decreases by 4.5 to 5.4 kg (10 to 12 lbs) Accounts for loss of fetus, placenta, and amniotic fluid Additional loss of 2.3 kg (5 lbs) due to diuresis and diaphoresis 2.3 to 3.2 kg (5 to 7 lbs) of fat stored during pregnancy for lactation Takes about 6 months to use if breastfeeding Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

Psychological Changes and Nursing Interventions
Mood swings common Related to rapid decline of estrogen and progesterone Maternal role and personal insecurity may also contribute Maternal adaptation takes place in phases Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

Taking-In Phase Begins immediately after birth and lasts up to 2 days postpartum Passive, dependent behavior Focuses on her own needs and health of newborn Repeatedly reviews labor and delivery experience Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

Taking-Hold Phase Ready to assert independence Initiates independent care of her newborn Often becomes exhausted in new role and verbalizes anxiety about it Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

Attainment of Maternal Role
Learns mothering behaviors Becomes comfortable with identity as mother Bond between newborn and mother forms Occurs in four stages Anticipatory Formal Informal Personal Anticipatory: occurs during pregnancy, looks to role models on how to be a mother. Formal: begins when newborn is born; mom still influenced by guidance of others. Informal: mother starts to make her own choices about mothering, finds own style. Personal: mom does what she is comfortable with in role of mother; occurs 3 to 10 months after delivery. Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

Interference with Maternal Role Attainment
Woman’s maturity level Minimum exposure of mother to baby in days after birth Lack of support system Ill health Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

Postpartum Blues 70% of women experience this Generally starts a few days after birth and lasts around 10 days Characterized by Tearfulness Insomnia Lack of appetite Feeling of being disappointed Psychological adjustments and hormonal factors thought to contribute; anxiety, discomfort, anger, and fatigue seem to play a role. Refer to Table 12-2 (pp ). Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

Teaching the Postpartum Woman
Relaxation techniques Increasing confidence in self-care and newborn care Promote communication between woman and partner Postpartum support group referral that may be in community Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

Audience Response System Question 2
Ovulation and menstruation typically resumes: Nonlactating woman Lactating woman Non-lactating: Ovulation may return within 1 month Menstruation usually resumes within 3 months Lactating Menstruation usually resumes within 6 months Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

Care Management After Delivery

Objectives Demonstrate three ways to prepare the sibling for the new family member. Present two ways to encourage parent-newborn attachment. Explain why early ambulation is encouraged. Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

Objectives (cont.) Review the importance of Kegel (perineal tightening) exercises. Describe five danger signs that the woman should report after discharge from the hospital. Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

Care Management After Delivery
Nursing assessment per facility protocol For mother, includes vital signs, fundal location and consistency, amount of bleeding Infant may be put to breast Infant is assessed on arrival in the newborn nursery Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

Care Plan Begins by using every contact with mother to fulfill teaching and learning goals Assist mother and family in learning about self-care and care of newborn Family and siblings can visit Mother encouraged to ask questions Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

Cultural Considerations
Rituals, taboos, and traditions need to be respected Birth control practices vary and must be considered when discussing family planning Review Nursing Care Plan 12-1 (pp ). Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

Postpartum Check: BUBBLE-HE
Breasts Uterus Bladder Bowel Lochia Episiotomy (perineum) Homans’ sign Emotions (psyche) Before and during assessment, explain to woman what you are looking for. Nurse teaches woman how to assess height and firmness of uterus. Teach woman to not push too hard because it could cause overstimulation, leading to uterine atony and hemorrhage. Refer to Table 12-3 (p. 239). Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

Ambulation Early and often Reduces risk of thrombus formation and infection Advise woman to ask nurse for assistance when she is first getting out of bed May experience orthostatic hypotension Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

Postpartum Chill Uncontrollable, usually after birth Cause is unknown May be related to nervous response or to vasomotor changes If chill is without fever, there is no clinical significance (i.e., infection) Cover woman with warm blankets Reassure woman that this is a normal response Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

Nursing Interventions
Application of cold or heat to the perineum Sitz bath—provides comfort, promotes healing, reduces incidence of infection Should not last longer than 20 minutes Topical anesthetic application Wait to apply peripad for 1 to 2 minutes to prevent medication from being absorbed into pad Nursing interventions should reduce the discomforts, allowing woman to care for herself and her baby. Review Skill 12-5 (p. 241). Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

Family Adjustment and Development of Attachment

Partner Bonding Partner should be included in all teaching sessions involving newborn care and feeding Bonding begins prenatally when father or partner feels fetus move or hears the heartbeat Engrossment is shown by holding, studying, and touching infant Adjustment and transition occur when partner is able to increase interaction with newborn and understands that time will be set aside for partner interaction See Figure 12-4 (p. 242). Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

Sibling Adjustment Depends on age and development Younger siblings may consider newborn as competition May see behaviors such as Regression Jealousy Frustration Special time should be set aside for parents to give to older siblings See Figure 12-5 (p. 242) and Box 12-2 (p. 242). Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

Grandparent Involvement
Level of involvement depends on proximity Parenting practices change from one generation to next May bring conflict in child-rearing between parents and grandparents Attending grandparenting classes is encouraged See Figure 12-6 (p. 243). Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

Promoting Parent-Newborn Bonding
Bonding and attachment processes produce affectionate and emotional commitment between two individuals Touch Voice pitch (a high pitch causes infant to become more alert and turn toward voice) Progresses over time Refer to Evidence-Based Practice—Signs of Positive Parent-Newborn Attachment (p. 243) and Box 12-3 (p. 243). Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

Early Discharge Planning and Health Promotion
Greatest need is education Mother must know How to prevent infection Danger signs to report for herself and her newborn Nurse provides education on how to care for newborn and then observes parents to see if additional education is needed See Table 12-5 (p. 244) and Patient Teaching—Postpartum Danger Signs (p. 243). Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

Discharge Teaching Can be provided through Video/DVD Pamphlets Return demonstrations Consultants, such as La Leche League for breastfeeding Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

Resumption of Normal Activity
Increase activities gradually and avoid fatigue Most can resume all activities within 4 to 5 weeks postpartum Cultural factors also determine when normal activities can be resumed Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

Resumption of Sexual Intercourse
Can be safely resumed when lochia has ceased, episiotomy has healed, and woman feels ready Usually takes 2 to 6 weeks First intercourse may be uncomfortable Partly attributed to vaginal dryness and diminished vaginal lubrication Breastfeeding woman may have milk spurts during orgasm due to release of oxytocin Breastfeeding infant before intercourse may lessen the risk of milk spurting from breasts. Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

Postpartum Fatigue Overwhelming sustained sense of exhaustion and decreased capacity for physical and mental work May persist for more than a year after delivery Early postpartum fatigue may be due to labor, hormone changes, wound healing, establishment of breast milk Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

Postpartum Fatigue (cont.)
Factors contributing to continued fatigue Continuing sleep difficulties Child care responsibilities Lack of assistance Nurse should provide anticipatory guidance to woman and her partner on how to lessen some of these factors Assessment for fatigue should occur at each postpartum office visit and well-baby clinic visit. Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

Family Planning Provide couple with options (see Chapter 19) Stress that ovulation often resumes before first menses, and pregnancy can occur Oral contraceptives can be started 2 to 3 weeks after delivery if not breastfeeding Progestin-only for birth control Enhances quality and duration of lactation Hispanic women should not take progestin-only birth control if they have had gestational diabetes. It increases risk of developing diabetes mellitus type 2. Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

Postpartum Exercises Hormonal effects on connective tissue are not reversed until ~6 weeks postpartum Risk of injury still present until after this time frame With normal, uneventful delivery, on first or second day, woman can Deep breathe Perform abdominal exercises, Kegel exercises, pelvic tilts Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

Kegel Exercises Strengthen and tone muscles of pelvic floor May help Decrease stress incontinence Speed recovery Increase sexual response Advised to do throughout life Review how to perform Kegel exercises with class. Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

Pelvic Tilt Assists with postural alignment and relieves strain on lower back Review and demonstrate how to perform this with class. Refer to Chapter 5 as well. Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

Rubella Vaccine Woman with a serum titer of 1:10 or less is given rubella vaccine in the postpartum period Stress with woman that she is not to become pregnant for at least 3 months after the vaccine has been given Can cause birth defects Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

RHo(D) Immune Globulin (RhoGAM)
Given to women who are Rh negative and meet specific criteria Should receive within 72 hours after delivery Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

Signs of a Distended Bladder
Discuss the signs of a distended bladder in a postpartum woman: Fundus: ____________ Bladder: ____________ Voiding: ____________ Fundus above umbilicus or above baseline level; fundus to the side or displaced from midline; bulge of bladder above symphysis pubis; excessive lochia; tenderness over bladder area; frequent voiding of less than 150 mL of urine, indicating urinary retention overflow. Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

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