1. Normal Postpartum Period

2. The Postpartum Period
Puerperium = fourth trimester of pregnancy - the 6-week interval between the birth of the newborn and the return of the reproductive organs to their normal nonpregnant state

3. Uterine Involution Uterine Involution: Uterine fundal descent:
return of the uterus to its pre-pregnancy size and condition, which begins immediately after expulsion of the placenta with contraction of the uterine smooth muscle
Uterine fundal descent:
immediately after birth uterus is in the midline approximately 2 cm below the level of the umbilicus, size of grapefruit (like 16 weeks of gestation), weighs approximately 1000 g.
Within 12 hours the fundus may be approximately 1 cm above the umbilicus
During next few days the fundus descends 1 to 2 cm (fingerbreadth) every 24 hours.
By the sixth postpartum day the fundus is normally located halfway between the umbilicus and the symphysis pubis.
A week after birth the uterus once again lies in the true pelvis.
After the ninth postpartum day the uterus should not be palpable abdominally.

4. Uterine Involution
Increased estrogen and progesterone levels are responsible for stimulating the massive growth of the uterus during pregnancy. Prenatal uterine growth results from both hyperplasia, an increase in the number of muscle cells, and from hypertrophy, an enlargement of the existing cells. Postpartally, the decrease in these hormones causes autolysis, the self-destruction of excess hypertrophied tissue. The additional cells laid down during pregnancy remain and account for the slight increase in uterine size after each pregnancy.
Subinvolution is the failure of the uterus to return to a nonpregnant state. The most common causes of subinvolution are retained placental fragments and infection.

5. Lochia Assessment Lochia–vaginal discharge after childbirth.
It takes 6 weeks for the vagina to regain its pre-pregnancy contour.
For the first 2 hours after birth the amount of uterine discharge should be approximately that of a heavy menstrual period. After that time, the lochia flow should steadily decrease.
Lochia: rubra, serosa or alba
Assessment of lochia includes noting color, presence and size of clots and foul odor.
Day lochia rubra (blood with small pieces of decidua and mucus)                               
Day – lochia serosa (pink or pinkish brown serous exudate with old blood, cervical mucus, erythrocytes and leukocytes, tissue debris)
Day lochia alba (yellowish white discharge with leucocytes, decidua, epithelian cells, mucus, serum, bacteria)
The amount of lochia is usually less after cesarean births. Flow of lochia usually increases with ambulation and breastfeeding and receives an oxytocin medication

6. LOCHIAL AND NONLOCHIAL BLEEDINGLOCHIAL BLEEDINGNONLOCHIAL BLEEDING
Lochia usually trickles from the vaginal opening. The steady flow is greater as the uterus contracts
A gush of lochia may result as the uterus is massaged. If it is dark in color, it has been pooled in the relaxed vagina, and the amount soon lessens to a trickle of bright red lochia (in the early puerperium).
Bleeding
If the bloody discharge spurts from the vagina, there may be cervical or vaginal tears in addition to the normal lochia.
If the amount of bleeding continues to be excessive and bright red, a tear may be the source.

7. Cervix The cervix is soft immediately after birth.
By 18 hours postpartum it has shortened, become firm, and regained its form.
The cervix up to the lower uterine segment remains edematous, thin, and fragile for several days after birth.
The ectocervix (portion of the cervix that protrudes into the vagina) appears bruised and has some small lacerations—optimal conditions for the development of infection.
The cervical os, which dilated to 10 cm during labor, closes gradually.
Two fingers may still be introduced into the cervical os for the first 4 to 6 days postpartum; however, only the smallest curette can be introduced by the end of 2 weeks.
The external cervical os never regains its prepregnant appearance; it is no longer shaped like a circle but appears as a jagged slit that is often described as a "fishmouth."
Lactation delays the production of cervical and other estrogen-influenced mucus and mucosal characteristics.

8. VAGINA AND PERINEUM Vagina Perineum
vaginal mucosa is thin, atrophic, with decrease amount of lubrication and without rugae as a result of estrogen deprivation which lead to coital discomfort (dyspareunia) until ovarian function returns and menstruation resumes.
The greatly distended, smooth-walled vagina gradually returns to its prepregnancy size by 6 to 8 weeks after childbirth. Rugae reappear by approximately the fourth week, but they are never as prominent as they are in the nulliparous woman. Most rugae are permanently flattened.
Perineum
the introitus is erythematous and edematous, especially in the area of the episiotomy or laceration repair. It is barely distinguishable from that of a nulliparous woman
Episiotomy. Most episiotomies are visible only if the woman is lying on her side with her upper buttock raised or if she is placed in the lithotomy position.
Hemorrhoids (anal varicosities) are commonly seen. Internal hemorrhoids may evert while the woman is pushing during birth. Women often experience associated symptoms such as itching, discomfort, and bright red bleeding with defecation. Hemorrhoids usually decrease in size within 6 weeks of childbirth.

9. Pelvic muscular support
The supporting structure of the uterus and vagina may be injured during childbirth and may contribute to later gynecologic problems.
Supportive tissues of the pelvic floor that are torn or stretched during childbirth may require up to 6 months to regain tone.
Kegel exercises, which help to strengthen perineal muscles and encourage healing, are recommended after childbirth.
Later in life, women can experience pelvic relaxation, the lengthening and weakening of the fascial supports of pelvic structures.
These structures include the uterus, upper posterior vaginal wall, urethra, bladder, and rectum.

10. Endocrine System
Placental hormones (human chorionic somatomammotropin, estrogens, cortisol, and the placental enzyme insulinase)
dramatically decrease and reverse the diabetogenic effects of pregnancy, resulting in significantly lower blood sugar levels in the immediate puerperium.
Estrogen and progesterone levels drop markedly after expulsion of the placenta and reach their lowest levels 1 week postpartum. Decreased estrogen levels are associated with breast engorgement and with the diuresis of excess extracellular fluid accumulated during pregnancy.
In nonlactating women, estrogen levels begin to rise by 2 weeks after birth and by postpartum day 17 are higher than in women who breastfeed
β-Human chorionic gonadotropin disappears from maternal circulation in 14 days

11. Endocrine System Pituitary hormones and ovarian function
The persistence of elevated serum prolactin levels in breastfeeding women appears to be responsible for suppressing ovulation. Because levels of follicle-stimulating hormone (FSH) have been shown to be identical in lactating and nonlactating women, it is thought that the ovulation is suppressed in lactating women because the ovary does not respond to FSH stimulation when increased prolactin levels are present
Prolactin levels in blood rise progressively throughout pregnancy.
In nonlactating women, prolactin levels decline after birth and reach the prepregnant range in 4 to 6 weeks
In breastfeeding woman prolactin levels remain elevated into the sixth week after birth, and influence by the frequency of breastfeeding, the duration of each feeding, and the degree to which supplementary feedings are used.
Ovulation occurs as early as 27 days after birth in nonlactating women, with a mean time of 70 to 75 days. Approximately 70% of nonbreastfeeding women resume menstruating by 3 months after birth.
In women who breastfeed, the mean length of time to initial ovulation is 17 weeks. In lactating women, both resumption of ovulation and return of menses are determined in large part by breastfeeding patterns. Many women ovulate before their first postpartum menstrual period occurs; thus there is need to discuss contraceptive options early in the puerperium.
The first menstrual flow after childbirth is usually heavier than normal. Within three to four cycles the amount of menstrual flow returns to the woman's prepregnancy volume

12. Abdomen
During the first 2 weeks after birth the abdominal wall is relaxed.
Returns to prepregnancy state 6 weeks after birth
The skin regains most of its previous elasticity, but some striae may persist.
The return of muscle tone depends on previous tone, proper exercise, and the amount of adipose tissue.
Occasionally, with or without overdistention because of a large fetus or multiple fetuses, the abdominal wall muscles separate, a condition termed diastasis recti abdominis. Persistence of this defect may be disturbing to the woman, but surgical correction rarely is necessary. With time, the defect becomes less apparent.

13. Urinary System
Renal function reduced as a result of diminishing steroid levels after childbirth
Kidney function returns to normal within 1 month after birth.
From 2 to 8 weeks are required for the pregnancy-induced hypotonia and dilation of the ureters and renal pelvis to return to the nonpregnant state.
In a small percentage of women, dilation of the urinary tract may persist for 3 months, which increases the chance of developing a urinary tract infection.
URINE COMPONENTS
renal glycosuria disappears,
but lactosuria may occur in lactating women.
The blood urea nitrogen increases during the puerperium as autolysis of the involuting uterus occurs. This breakdown of excess protein in the uterine muscle cells also results in a mild (+1) proteinuria for 1 to 2 days after childbirth in approximately 50% of women
Ketonuria may occur in women with an uncomplicated birth or after a prolonged labor with dehydration.

14. Urinary System POSTPARTAL DIURESIS URETHRA AND BLADDER
Within 12 hours of birth, women begin to lose excess tissue fluid accumulated during pregnancy.
Profuse diaphoresis often occurs, especially at night, for the first 2 or 3 days after childbirth.
Postpartal diuresis, caused by decreased estrogen levels, removal of increased venous pressure in the lower extremities, and loss of the remaining pregnancy-induced increase in blood volume, also aids the body to rid itself of excess fluid.
Fluid loss through perspiration and increased urinary output accounts for a weight loss of approximately 2.25 kg during the puerperium.
URETHRA AND BLADDER
Birth-induced trauma, increased bladder capacity following childbirth, and the effects of conduction anesthesia combine to cause a decreased urge to void.
In addition, pelvic soreness caused by the forces of labor, vaginal lacerations, or the episiotomy reduces or alters the voiding reflex.
Decreased voiding combined with postpartal diuresis may result in bladder distention. Immediately after birth, excessive bleeding can occur if the bladder becomes distended because it pushes the uterus up and to the side and prevents the uterus from contracting firmly.
Later in the puerperium overdistention can make the bladder more susceptible to infection and impede the resumption of normal voiding. With adequate emptying of the bladder, bladder tone is usually restored 5 to 7 days after childbirth.

15. GASTROINTESTINAL SYSTEM
APPETITE
The mother usually is hungry shortly after the birth and can tolerate a light diet.
Most new mothers are very hungry after full recovery from analgesia, anesthesia, and fatigue. Requests for double portions of food and frequent snacks are not uncommon
BOWEL EVACUATION
A spontaneous bowel evacuation may not occur for 2 to 3 days after childbirth. This delay can be explained by decreased muscle tone in the intestines during labor and the immediate puerperium, prelabor diarrhea, lack of food, or dehydration. The mother often anticipates discomfort during the bowel movement because of perineal tenderness as a result of episiotomy, lacerations, or hemorrhoids and resists the urge to defecate. Regular bowel habits should be reestablished when bowel tone returns.
Obstetric trauma (e.g., direct injury to the sphincter muscle, damage to the innervation of the pelvic floor) is perhaps the leading cause of anal incontinence in otherwise healthy women. Women should be taught during pregnancy about episiotomy and its possible sequelae. Pelvic floor (Kegel) exercises should be encouraged.

16. BREASTS
Promptly after birth, there is a decrease in the concentrations of hormones (i.e., estrogen, progesterone, hCG, prolactin, cortisol, and insulin) that stimulated breast development during pregnancy. The time it takes for these hormones to return to prepregnancy levels is determined in part by whether the mother breastfeeds her infant.
BREASTFEEDING MOTHERS
As lactation is established, a mass (lump) may be felt in the breast. Unlike the lumps associated with fibrocystic breast disease or cancer (which may be consistently palpated in the same location), a filled milk sac shifts position from day to day. Before lactation begins, the breasts feel soft and a yellowish fluid, colostrum, can be expressed from the nipples. After lactation begins, the breasts feel warm and firm. Tenderness may persist for approximately 48 hours after the start of lactation. Bluish-white milk with a skim-milk appearance (true milk) can be expressed from the nipples. The nipples are examined for erectility and signs of irritation such as cracks, blisters, or reddening.
NONBREASTFEEDING MOTHERS
The breasts generally feel nodular in contrast to the granular feel of breasts in nonpregnant women. The nodularity is bilateral and diffuse. Prolactin levels drop rapidly. Colostrum is present for the first few days after childbirth. Palpation of the breast on the second or third day, as milk production begins, may reveal tissue tenderness in some women. On the third or fourth postpartum day, engorgement may occur. The breasts are distended (swollen), firm, tender, and warm to the touch (because of vasocongestion). Breast distention is caused primarily by the temporary congestion of veins and lymphatics rather than by an accumulation of milk. Milk is present but should not be expressed. Axillary breast tissue (the tail of Spence) and any accessory breast or nipple tissue along the milk line may be involved. Engorgement resolves spontaneously, and discomfort decreases usually within 24 to 36 hours. A breast binder or tight bra, ice packs, or mild analgesics may be used to relieve discomfort. Nipple stimulation is avoided. If suckling is never begun (or is discontinued), lactation ceases within a few days to a week.

17. CARDIOVASCULAR SYSTEM
BLOOD VOLUME
Changes in blood volume after birth depend on several factors, such as blood loss during childbirth and the amount of extravascular water (physiologic edema) mobilized and excreted. Blood loss results in an immediate but limited decrease in total blood volume. Thereafter, most of the blood volume increase during pregnancy (1000 to 1500 ml) is eliminated within the first 2 weeks after birth, with return to nonpregnancy values by 6 weeks postpartum
Pregnancy-induced hypervolemia allows most women to tolerate considerable blood loss during childbirth. Many women lose approximately 300 to 400 ml of blood during vaginal birth of a single fetus and approximately twice this much during cesarean birth.
Readjustments in the maternal vasculature after childbirth are dramatic and rapid. The woman's response to blood loss during the early puerperium differs from that in a nonpregnant woman. Three postpartal physiologic changes protect the woman by increasing the blood volume:
elimination of uteroplacental circulation reduces the size of the maternal vascular bed by 10% to 15%,
loss of placental endocrine function removes the stimulus for vasodilation,
mobilization of extravascular water stored during pregnancy occurs. Thus hypovolemic shock usually does not occur in women who experience a normal blood loss.

18. CARDIOVASCULAR SYSTEM
CARDIAC OUTPUT
Pulse rate, stroke volume, and cardiac output increase throughout pregnancy. Immediately after the birth they remain elevated or rise even higher for 30 to 60 minutes as the blood that was shunted through the uteroplacental circuit suddenly returns to the maternal systemic venous circulation.
Data regarding the exact time of return of cardiac hemodynamic levels to normal are not available, but cardiac output values remain elevated for at least 48 hours after birth, decrease rapidly in the first 2 weeks postpartum, and return to prepregnancy level by 24 weeks postpartum.
Stroke volume, cardiac output, end-diastolic volume, and systemic vascular resistance values have been shown to remain greatly elevated for as long as 12 weeks postpartum
VITAL SIGNS
Few alterations in vital signs are seen under normal circumstances. There may be a small, transient rise in both systolic and diastolic blood pressure that lasts approximately 4 days after the birth
Respiratory function returns to nonpregnant levels by 6 to 8 weeks after birth. After the uterus is emptied, the diaphragm descends, the normal cardiac axis is restored, and the point of maximal impulse and the electrocardiogram are normalized.

19. CARDIOVASCULAR SYSTEM
BLOOD COMPONENTS
Hematocrit and hemoglobin
During the first 72 hours after childbirth, there is a greater loss of plasma volume than in the number of blood cells. This results in a rise in hematocrit and hemoglobin levels by the seventh day after the birth. There is no increased red blood cell (RBC) destruction during the puerperium, but any excess will disappear gradually in accordance with the life span of the RBC. The exact time at which RBC volume returns to prepregnancy values is not known, but it is within normal limits when measured 8 weeks after childbirth
White blood cell count
Normal leukocytosis of pregnancy averages approximately 12,000/mm3. During the first 10 to 12 days after childbirth, values between 20,000 and 25,000/mm3 are common. Neutrophils are the most numerous white blood cells. Leukocytosis coupled with the normal increase in erythrocyte sedimentation rate that occurs may obscure the diagnosis of acute infections at this time.
Coagulation factors
Clotting factors and fibrinogen are normally increased during pregnancy and remain elevated in the immediate puerperium. When combined with vessel damage and immobility, this hypercoagulable state causes an increased risk of thromboembolism, especially after a cesarean birth. Fibrinolytic activity also increases during the first few days after childbirth. Factors I, II, VIII, IX, and X decrease within a few days to nonpregnant levels. Fibrin split products, probably released from the placental site, can also be found in maternal blood.
VARICOSITIES
Varicosities (varices) of the legs and around the anus (hemorrhoids) are common during pregnancy. Varices, even the less common vulvar varices, regress (empty) rapidly immediately after childbirth. Surgical repair of varicosities is not considered during pregnancy. Total or nearly total regression of varicosities is expected after childbirth.

20. NEUROLOGIC SYSTEM
Neurologic changes during the puerperium are those that result from a reversal of maternal adaptations to pregnancy and those resulting from trauma during labor and childbirth.
Pregnancy-induced neurologic discomforts abate after birth. Elimination of physiologic edema through the diuresis that follows childbirth relieves carpal tunnel syndrome by easing compression of the median nerve.
The periodic numbness and tingling of fingers that afflicts 5% of pregnant women usually disappears after the birth unless lifting and carrying the baby aggravates the condition.
Headache requires careful assessment. Postpartum headaches may be caused by various conditions, including pregnancy-induced hypertension, stress, and leakage of cerebrospinal fluid into the extradural space during placement of the needle for epidural or spinal anesthesia.
Depending on the cause and effectiveness of the treatment, the duration of the headaches can vary from 1 to 3 days to several weeks.

21. Postpartum Depression
Postpartum depression is a nonpsychotic depressive episode that begins in the postpartum period due to decreased estrogen level
Symptoms: changes in appetite or weight, sleep, and psychomotor activity; decreased energy; feeling of worthlessness or guilt; difficulty thinking, concentrating or making decisions; or recurrent thoughts of death or suicidal ideation, plans, or attempts.

22. Postpartum Psychosis
A very serious type of PPD illness that can affect new mothers.
Begin 2-3 weeks post delivery
Fatigue, restlessness, insomnia, crying liable emotions, inability to move, irrationally statements incoherence confusion and obsessive concerns about the infant’s health
Psychiatric emergency

23. MUSCULOSKELETAL SYSTEM
Adaptations to pregnancy include the relaxation and subsequent hypermobility of the joints and the change in the mother's center of gravity in response to the enlarging uterus.
The joints are completely stabilized by 6 to 8 weeks after birth. However, although all other joints return to their normal prepregnancy state, those in the parous woman's feet do not.
The new mother may notice a permanent increase in her shoe size.

24. INTEGUMENTARY SYSTEM
Chloasma of pregnancy usually disappears at the end of pregnancy.
Hyperpigmentation of the areolae and linea nigra may not regress completely after childbirth. Some women will have permanent darker pigmentation of those areas.
Striae gravidarum (stretch marks) on the breasts, abdomen, and thighs may fade but usually do not disappear.
Vascular abnormalities such as spider angiomas (nevi), palmar erythema, and epulis generally regress in response to the rapid decline in estrogens after the end of pregnancy. For some woman, spider nevi persist indefinitely.
The abundance of fine hair seen during pregnancy usually disappears after giving birth; however, any coarse or bristly hair that appears during pregnancy usually remains. Fingernails return to their prepregnancy consistency and strength.
Profuse diaphoresis that occurs in the immediate postpartum period is the most noticeable change in the integumentary system.

25. IMMUNE SYSTEM
No significant changes in the maternal immune system occur during the postpartum period.
The mother's need for a rubella vaccination or for prevention of Rh isoimmunization is determined.

26. Nursing Care of the Postpartum Woman

27. Fourth Stage of Labor
Goal of nursing care is to assist woman and their partners during their initial transition to parenting
Nursing's role is to monitor the recovery of the new mother and infant, to identify and manage promptly any deviations from the normal processes that may occur, and to promote and support parent-infant attachment

28. Fourth Stage of Labor First 1 to 2 hours after birth
During this time, maternal organs undergo their initial readjustment to the nonpregnant state and the functions of body systems begin to stabilize.
Meanwhile, the newborn continues the transition from intrauterine to extrauterine existence
Excellent time to begin Breastfeeding
Encouraging of the mother
Colostrum prompting elimination of meconium

29. Care in the Immediate Postpartum Period
Assessment
During first hour every 15 minutes
During second hours every 30 minutes
VS (Ps, BP, T)
fundal height and firmness
bladder distension
amount of lochia
presence of edema
status of perineum,
Postanesthesia recovery (every 15 min)
Activity
Respiration BP
Level of cosciousness
Color
general anesthesia
Awake, alert, orient to time, place, and person, respiratory rate, oxygen saturation levels at least 95%, as measured by a pulse oximeter
epidural or spinal anesthesia
should be able to raise her legs, extended at the knees, off the bed, or to flex her knees, place her feet flat on the bed, and raise her buttocks well off the bed. The numb or tingling, prickly sensation should be entirely gone from her legs. Often, it takes 1.5 to 2 hours for these anesthetic effects to disappear.
Providing comfort measures
Analgesics
Promoting bladder elimination
Providing fluid and food

30. Nursing Care After Cesarean Birth
Same as with normal vaginal delivery except
Postanesthesia recovery
Monitoring of abdominal dressing
Urinary catheter
Respiratory care
Prevention of thrombophlebitis
Interventions for pain
Slide 30

31. Postpartum Physical Assessment
B - breast
U - uterus
B - bowels
B - bladder
L - lochia
E - episiotomy

32. General Assessment Enter the room quietly, speak quietly.
Wash hands and provide for privacy.
Inform patient before turning on lights.
Note LOC, activity level, position, color, general demeanor.
Take note of the total environment:
Safety/patient considerations
Note equipment and medical devices

33. Breast Assessment
Breasts: Soft, engorged, filling, swelling, redness, tenderness.
Nipples: Inverted, everted, cracked, bleeding, bruised, presence of colostrum or breastmilk.
Colostrum–yellowish fluid rich in antibodies and high in protein.
Engorgement occurs by day 3 or 4. Due to vasoconstriction as milk production begins
Lactation ceases within a week if breastfeeding is never begun or is stopped.

34. Nipple soreness is a portal of entry for bacteria - breast infection (Mastitis).
Maternal after pains: may be due to breastfeeding and multiparity
Always stay with the client when getting out of bed for the first time – hypotension effect and excess bleeding
When assessing fundal height, if you notice any discrepancies in fundal height have patient void and then reassess.

35. Nursing Diagnosis Related to Breasts and Breastfeeding
Pain r/t improper positioning, engorged breasts
Ineffective breastfeeding r/t maternal discomfort, improper infant positioning
Knowledge deficit r/t normal physiologic changes, breastfeeding
Infection r/t improper breastfeeding techniques, improper breast care

36. Assessing Uterine Fundus
Location in relation to umbilicus
Degree of firmness
Is it at Midline or deviated to one side?
Bladder Full?
A boggy uterus may indicate uterine atony or retained placental fragments.
Boggy refers to being inadequately contracted and having a spongy rather than firm feeling.

37. Massaging the Fundus
Every 15 mins during the 1st hr, every 30 mins during the next hr, and then, every hr until the patient is ready for transfer.
Document fundal height.
Evaluate from the umbilicus using fingerbreadths.
This is recorded as 2 fingers below the umbilicus (U/2), one finger above the umbilicus (1/U), and so forth.
The fundus should remain in the midline. If it deviates from the middle- distended bladder.

38. Uterine Atony Lack of muscle tone in the cervix.
Uterus feels soft and boggy
The bladder has increased capacity and decreased muscle tone. 
This leads to over-distension of the bladder, incomplete emptying of bladder, retention of residual urine and increased risk of UTI and postpartum hemorrhage.

39. Bowels & Bladder When was the patients last bowel movement?
Is she passing flatus? (gas)
Assess for bowel sounds
Voiding pattern - without difficulty/pain, urine may be blood tinged from lochia
Nursing interventions: Assist to the bathroom. Use measures to encourage voiding (privacy). Encourage use of peri-bottle with warm water, fluids, fiber, frequent ambulation, stool softeners; teach effects of pain medication.

40. Urinary System
A full bladder can displace the uterus and lead to postpartum hemorrhage
In the woman who voids frequently, small amounts of urine may have increased residual urine because her bladder does not empty completely
Residual urine in the bladder may promote the growth of microorganisms
Slide 40

41. Lochia: Pad Count Scant: 1-inch stain on pad in 1 hour
Light/small: 4 inches in 1 hour
Moderate: 6 inches in 1 hour
Heavy/large: Pad saturated in 1 hour
Excessive: Pad saturated in 15 min
Can estimate blood loss by weighing pads:
500 mL = 1 lb. or 454 g

42. Episiotomy/Perineal Assessment
Patient in lateral Sims (side lying) position.
Use the acronym REEDA
Redness, Edema, Ecchymosis, Discharge, Approximation of suture lines “edges of episiotomy”) to guide assessment.
Even if there is no episiotomy, the perineum should still be assessed.
Nursing care and patient teaching
Cold packs
Topical and systemic medications
Nonpharmacologic pain relief methods
Unusual perineal discomfort may be a symptom of impending infection or hematoma. Hemorrhoids ?

43. Episiotomy Pain Relief
Instruct Mother:
Tighten her buttocks and perineum before sitting to prevent pulling on the episiotomy and perineal area and to release tightening after being seated.
Rest several times a day with feet elevated.
Practice Kegel exercise many times a day to increase circulation to the perineal area and to strengthen the perineal muscles.

44. Discharge: Before 24 Hours and After 48 Hours
Terms for decreasing length of stay of mothers and newborns after a low risk birth
Early postpartum discharge
Shortened hospital stay
1-day maternity stay

45. Discharge: Before 24 Hours and After 48 Hours
Laws relating to discharge
Advantages and disadvantages of early postpartum discharge
Criteria for early discharge
Mother recovered and able to care for self and baby

46. RhoGAM
It is given to an Rh- mother within 72 hours after delivery of an Rh+ infant or if the Rh is unknown.
The dose must be repeated after each subsequent delivery. RhoGAM 300 mcg is the standard dose.

47. Rubella vaccination
For women who have not had rubella (10% to 20% of all women) or women who are serologically not immune (titer of 1:8 or enzyme immunoassay level less than 0.8), a subcutaneous injection of rubella vaccine is recommended in the immediate postpartum period to prevent the possibility of contracting rubella in future pregnancies.
The live attenuated rubella virus is not communicable in breast milk; therefore breastfeeding mothers can be vaccinated. However, because the virus is shed in urine and other body fluids, the vaccine should not be given if the mother or other household members are immunocompromised.

48. Discharge Teaching Teaching for self-care: signs of complications
Sexual activity/contraception
Prescribed medications
Routine mother and baby checkups

49. Discharge Teaching Follow-up after discharge Home visits
Telephone follow-up
Warm lines
Support groups
Referral to community resources

53. Process of Becoming Acquainted
Bonding
Attachment
Maternal touch
Verbal behaviors

54. Factors Affecting Family Adaptation
Parental fatigue
Previous experience with a newborn
Parental expectations of newborn
Knowledge of and confidence in providing for newborn needs
Temperament of the newborn
Temperament of parents
Age of parents
Available support system
Unexpected events

55. Cultural Influences on Adaptation
Provide care that is culture specific
Communication
Health beliefs
Dietary practices

56. The Process of Family Adaptation
Father
Siblings
Grandparents

57. Process of Maternal Adaptation
Maternal role attainment
Heading toward a new normal
Redefining roles
Role conflict
Major maternal concerns
Body image
Postpartum blues

58. Application of the Nursing Process: Maternal Adaptation
Assessment
Analysis
Planning
Interventions
Assist mother
Monitor and protect
Listen
Foster independence
Promote bonding
Involve parents in care
Evaluation

59. Fathers Engrossment Four phases of adjustment
Having expectations and personal intentions
Confronting reality and overcoming frustrations
Creating one’s own personal father role
Reaping rewards of fatherhood
Slide 59

60. Family Care Plan
Studying the family, as the patient can offer insight into community-based care
Slide 60

61. Data Collection for the Family Care Plan
Demographic information
Family composition
Occupation
Cultural group
Religious/spiritual affiliation
Developmental tasks
Health concerns
Communication patterns
Decision making
Family values
Socialization
Coping patterns
Housing
Cognitive abilities
Support system
Response to care
Slide 61

62. Key Points
Nurse provides teaching and counseling to promote the woman’s feelings of competence in self-care and baby care

63. Key Points Postpartum care is modeled on the concept of health
Cultural beliefs and practices affect the client’s response to the puerperium
Nursing plan of care includes:
Assessments to detect deviations from normal
Comfort measures to relieve discomfort or pain
Safety measures to prevent injury or infection

64. Key Points Common nursing interventions include:
Evaluating and treating the boggy uterus and the full urinary bladder
Providing for pharmacologic and nonpharmacologic relief of pain and discomfort associated with the episiotomy or lacerations
Instituting measures to promote or suppress lactation

65. Key Points
Effective means to prevent crisis and facilitate physiologic and psychologic adjustments used in combination include:
Home visits
Telephone follow-up
Warm lines
Support groups
Referral to community resources

66. Key Points
Short-stay option is safer when selection criteria are used to determine a woman’s eligibility for early discharge and when home care follow-up is available

67. Key Points
Early postpartum discharge will continue to be the trend as a result of:
Consumer demand
Medical necessity
Discharge criteria for low risk childbirth
Cost-containment measures

68. Key Points
Nurses promote the health of the woman’s future pregnancies by administering rubella vaccine and Rh immune globulin if indicated
Meeting psychosocial needs of new mothers involves planning care that considers the composition and functioning of the entire family

69. Key Points
Under normal circumstances, few alterations in vital signs are seen after childbirth
Activation of blood-clotting factors, immobility, and sepsis predispose woman to thromboembolism
Marked diuresis, decreased bladder sensitivity, and overdistention of bladder can lead to problems with urinary elimination

70. Дякую за увагу!

71. Assessment of Edema & Homan’s Sign
Assess legs for presence and degree of edema; may have dependent edema in feet and legs.
Assess for Homan’s sign- thromboembolism should be negative
Press down gently on the patient’s knee (legs extended flat on bed) ask her to flex her foot (dorsiflex)

72. Homan’s Sign

73. Thromboembolic Conditions
Thrombophlebitis–the formation of a clot in an inflamed vein.
Risk factors include maternal age over 35, cesarean birth, prolonged time in stirrups, obesity, smoking, and history of varicosities or venous thromboses.
Prevention: client needs to ambulate early after delivery.

74. Postpartum Cesarean Incision site…redness swelling, discharge. Intact?
Abdomen soft, distended? Bowel sounds heard all 4 quadrants
Flatus?
Lochia is less amount than in normal spontaneous vaginal delivery (NSVD) because uterus is wiped with sponges during c/section.
If lochia indicates excessive bleeding, combine palpation and pain management measures.
Auscultate breath sounds
Fluid intake and output
Pain?

75. Postpartum Disseminated Intravascular Coagulation
Abnormal stimulation of clotting mechanism.
Normally, the body forms a blood clot in reaction to an injury.
Small blood clots throughout the body, depleting the body of clotting factors and platelets. –Massive bleeding
Causes may include amniotic fluid clots, fetal demise, abruptio placenta. Eclampsia or Retained placenta
Symptoms: Sometimes severe bleeding and sudden bruising .

76. Postpartum Hemorrhage
Blood loss of more than 500 ml after vaginal birth or 1,000 ml after a cesarean birth.
Early hemorrhage –Cervical or vaginal tears, uterine atony, retained placental fragments, lacerations, hematomas.
Late hemorrhage –subinvolution, retained placental fragments.
Subinvolution: failure of the uterus to return to normal size.
Management may include CBC, sedimentation rate, type and cross, fluid resuscitation with normal saline and blood, vaginal examination, diagnosis, and correction of the underlying cause.

77. Interventions Prevention of Complications Reduce Discomfort ADL
Nutrition
Rest & Sleep
Ambulation
Bathing
Kegel Exercises

78. Process of Maternal Adaptation
Puerperal phases
Taking-in
Taking-hold
Letting-go
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