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Postpartum Care & Cesarean Birth

OB Exam #4
Care in the Postpartum Period (Puerperium)
Definition: Interval between the birth and return of reproductive system to
nonpregnant state (6 weeks)
Postpartum Physiologic Changes in Maternal Body Systems
Cardiovascular
o Blood volume
Diuresis plasma volume
Diaphoresis, sweating (especially in the first couple days)
o Immediate hemodilution hemoconcentration (Hct immediate
postpartum)
o Hct returns to normal pre pregnant value in 4-5 weeks
o Cardiac output and stroke volume
Initially increased; decreased after third week
o Heart returns to normal position
o Vital sign changes
Initial slight HR, then transient bradycardia x24-48 hours (may
last 6-8 days)
HR returns to pre pregnant rate by 3 mos PP
BP stable
Slight temperature rise in 1st 24 hours
o Blood clotting factors
Extensive activation after birth; normal by 3rd week
o White blood cells
Leukocytosis (20,000-25,000 wbc/ml) x several day
Normal level by 2nd week
Respiratory
o Respiratory rate normal by 6-8 weeks
o Pulmonary functions return to pre pregnant status within 6 months
Reproductive Changes
o Uterus
Involution
Progesterone production stops
Afterpains (uterine contractions)
Placental attachment site
Healing in 6-7 weeks
Endometrial regeneration in 6 weeks
Postpartum hemorrhage-leading cause of maternal
morbidity and mortality
o Cervix
Os closes
Permanent alteration in external os
o Lochia

Definition: discharge from uterus 3 weeks after birth


Composition: endometrial tissue, blood, lymph
Types:
Lochia rubra: 1-3 days
Lochia serosa 3-10 days
Lochia alba 10-21 days

o Vagina
Rugae reappear in 3-4 weeks
Pre pregnant size by 6-8 postpartum
o Perineum
Most healing within 2 weeks
Perineal Lacerations
First degree- skin and structures superficial to muscles
Second degree- extends through perineal muscles
Third degree- continues through anal sphincter muscle
Fourth degree- continues through anterior rectal wall
Also may be cervical, vaginal, labial, urethral, or clitoral
o Gastrointestinal Changes
Thirst and hunger
GI motility and tone
Bowel function
Hemorrhoids
Return to pre pregnant weight
6-8 weeks with normal pregnant weight gain
Average weight loss at birth =12 lb
Another 5 lbs during first week
o Genitourinary Changes
Urinary output
Bladder
Over distension ( capacity, swelling, bruising, sensation
to increased pressure)
Bladder emptying (should resume 5-7 days after swelling
goes down)
Uteters and renal pelvis
o Nonpregnant state within 6-10 weeks
Proteinuria
o Endocrine Changes
estrogen and progesterone
Prolactin level
Ovulation/return of menses depends on whether breastfeeding
Lactating: 45% of women have 1st period by 12 weeks;
many not for 12-16 months
Not lactating: ovulation within 10-12 weeks

thyroid function
o Breast Changes
Pregnancy changes regress in 1-2 weeks if not lactating
Prolactin secretion
Due to rapid drop in estrogen, progesterone
Increase vascularity and swelling
Lactation
Oxytocin released with infant suckling
Colostrum present at birth
Breast milk produced 2-3 days postpartum
Engorgement 2-3 days pp; lasts 24-48 hours
o Musculoskeletal Changes
Abdominal muscles
Relaxed
Diastasis recti
o Separation of rectus muscle
o Usually 2-4 cm
Joints
Stabilize 6-8 weeks post partum
o Integumentary Changes
Decreased melanin
Results in gradual decrease in hyperpigmentation
Decreased estrogen
Visible vascular changes of pregnancy disappear
Striae do not disappear; change to silver color

Postpartum Care: Nursing Interventions


Vital Signs
o Frequency
Vaginal birth
Q 15 minutes x 4, Q 30 minutes x 2; Q 4 hours x1; then Q 8
hours
Cesarean birth
Q 15 minutes x8, Q 30 min x2, every hour x4, Q 4 hours x
24 hours
Postpartum Changes
o Temperature
May be increased due to dehydration, lactation, or increased
WBCs
>100.4 F is considered elevated
o Hypotension/orthostatic hypotension
Common
Rapid, thready pulse and decrease in BP-hemorrhage/shock

o Hypertension
May be associated with preeclampsia
Postpartum Assessment
1. Breasts
Soft/firm, tenderness, warmth
Nipples: erectness, cracks, bleeding
2. Fundus
a. Firmness, location, height, size
b. Accurate with empty bladder
c. ~cm below fundus (FFU/3) by 3rd ppd
3. Lochia/Bleeding
a. Characteristics/Amount/Odor/Presence of clots
b. Vaginal pooling
c. Danger sign: increased bright, red bleeding after initial decrease
d. Cesarean delivery: may be decreased
e. Subinvolution

4. Perineum
a. Assess Q shift (condition/state of healing, sutures, if any)
b. REEDA
i. Redness, edema, ecchymosis, discharge, approximation
c. Hemorrhoids/fissures

5. Elimination
a. Bladder
i. Assess degree of distention and/or pain
ii. Monitor urine output; should void within 6 hours
1. Should void Q 2-3 hours
iii. Pain medication
iv. Foley or straight catheter x 24 hours PRN
b. Bowel
i. Assess frequency
ii. Hemorrhoidal care
iii. Nothing done rectally if has 4th degree laceration
6. Peripheral Circulation
a. Assesss Q shift
b. Abnormalities:
i. Varicosities, edema, asymmetry of size/shape, temperature, color,
ROM
ii. Signs of thrombophlebitis
1. + Homans sign
a. Pointing toes upward, dorsiflexion, pain in calf with
that motion, may indicate DVT
7. Psychological Issues
a. S/S of postpartum blues, anxiety depression, poor concentration
b. Nutritional status, loss of appetite
c. Difficulty sleeping
d. Attachment of newborn with mother

Postpartum Teaching: Maternal Self Care


Breast Care
o Bathe normally, wash breasts 1st, no soap on nipples if BF
o Well fitting bra; 24/7 after milk comes in
o Wear tight bra 24/7 for at least 72 hours
o Medications to suppress lactation not recommended
o Cool pack to breasts
o Milk analgesic
o Cold cabbage leaves
o Avoid breast stimulation (including hot water in the shower)
Breastfeeding mothers
o Use breast pads
o Ice packs between feedings for engorgement
Fresh cabbage leaves are helpful for engorgement
symptoms
o Heat and massage immediately prior to feedings
o Review self breast exam
Perineal care

o
o
o
o
o
o
o
o

Ice x12-24 hours; then heat (baths)


Cleansing (use of peri bottle)
Change pads frequently; apply front to back
Proper hygiene (cleansing from front to back), pat dry, hand-washing
Medications (topical anesthetic creams/sprays, tuck pads, po analgesia
Review signs and symptoms of ---Perineum should be healed in ---Posture/exercise
Discuss sitting properly
Use of side-lying position/changing positions
Use of Kegel exercises (pelvic floor exercises)
Use of donut is controversial

Pelvic Floor Muscle Training


How to contract the pelvic floor muscles
1. The first thing to do is to correctly identify the muscles that need to be exercised.
2. Sit or lie down comfortably with the muscles of your thighs, buttocks & abdomen
relaxed
3. Tighten the ring of muscle around the back passage as if you are trying to control
diarrhea or flatus. Relax it. Practice this movement several times until you are
sure you are exercising the correct muscle. Try not to squeeze your buttocks.
4. When you are passing urine, try to stop the flow mid-stream, then restart it. Only
do this to learn which muscles are the correct ones to use & then do it no more
than once/week to cheek your progress, as this may interfere with normal bladder
emptying.
5. If you are unable to feel a definite squeeze & lift action of your pelvic floor
muscles or are unable to even slow the stream of urine as described in point 3,
you should seek professional help to get your pelvic floor muscles working

correctly. Even women with very weak pelvic floor muscles can be taught these
exercises by a physiotherapist with expertise in this area.
Doing Pelvic Floor Exercises
If you can feel the muscles working, exercise them by:
Tightening and drawing in around the anus, the vagina & the urethra all at once, lifting
them UP inside. Try to hold this contraction strongly as you count to 5 then release &
relax. You should have a definite feeling of 'letting go'.
Repeat ('squeeze and lift') & relax. It is important to rest for about 10 seconds in
between each contraction. If you find it easy to hold for a count of 5, try to hold for
longer - up to 10 seconds.
Repeat these as many times as you are able up to a maximum of 8-10 squeezes.
Now do 5-10 short, fast, but strong contractions.
Do this whole exercise routine at least 4-5 times everyday
Points to Remember:
o DO NOT hold your breath
o DO NOT push down instead of squeezing and lifting up
o DO NOT tighten your tummy, buttocks, of thighs
o Do your exercises well- the quality if important. Fewer good exercises will
be more beneficial than many half hearted ones
o Once you have learned how to do these exercises, they should be done
regularly, giving each set your full attention.
o It might be helpful to have at least 5 regular times during the day for doing
the exercises.
o For example, after going to the toilet, when having a drink, when lying in
bed.
Other things you can do to help your pelvic floor muscles:
Share the lifting of heavy loads;
Avoid constipation and prevent any straining during a bowel movement;
Seek medical advice for hay-fever, asthma and bronchitis to reduce sneezing and
coughing; and
Keep your weight within the right range for your height and age

Sexual Activity
o Resumption of sexual activity
Can resume in 3-4 weeks, as long as episiotomy is healed and no
longer vaginal discharge
o Contraception
Set up plan before leaves hospital with HCP; address in discharge
instructions
o Vaginal lubrication
Will be decreased for 6 mos or longer; longer if breast feeding
Nutrition and Weight Loss
o Weight loss
10-12 lbs after birth
Additional 5 lbs during 1st weeks

Return to pre pregnancy weight by ~6-8 weeks (if pregnancy


weight gain within normal limits)
No weight loss diets first month!
o Nutrients needed
Increase protein and calories
Iron intake
o Nutrient/Caloric increases for breast feeding mothers
Increase calories by 200 calories over pregnancy requirement
=2400 calories
Increase calcium = 1200 mg
Adequate vitamin C
Fluid intake
o Activity and Exercise
Increase abdominal muscle tone within 2-3 mos
Exercises after first couple of weeks
Starts with head raises, abdominal tightening
Pelvic rocking
Add crunches, leg lifts gradually
Avoid constricting clothing
Warning sign: Increased bleeding, especially bright red
bleeding
Emotional Changes

Postpartum Blues
o Within 2-3 days after birth, resolving within 1-2 weeks
o 50-70% of women
o Coincides with normal drop in estrogen and progesterone
o S/S: irritability, restlessness, crying spells, sleeplessness, anger towards
family, anxiety
Postpartum Depression
o Occurs after 1-2 weeks
o ~10-20% of women
o Change in mood, eating, sleep patterns, concentration, or libido
o Body preoccupation, phobias
o Loss of interest in activities
o Irritability
Postpartum Psychosis
o Break with reality
o Delusions, hallucinations
o Plans to harm self or baby
Assess support system and encourage support
Postpartum Danger signs
o Pain
o Temperature >100.4
o Resumption of bright, red bleeding after lochia disappeared; clots, or foul
odor of vaginal discharge
o Leg edema
o Burning on urination, inability to urinate
o Severe HA, visual probs (could be a sign of proclapsia)
o Severe mood swings, thoughts of harming herself or her baby
Postpartum Attachment
o Definition: Enduring emotional bond between parent (both mother and
father) and infant
o Maternal Infant bonding
Maternal contributions
Strong prenatal attachment correlates with increased risk
of PTSD
Newborn contributions
o Maternal Non Attachment Behaviors
Prenatally
Excessive mood swings
Emotional withdrawal
Excessive preoccupation with appearance
Numerous physical complaints
Postnatally
Negative comments about infants appearance

Disappointment about infants sex


Failure to look at or touch infant
Failure to respond to infants signaling behaviors
Failure to name infant
Limited handling of infant
Failure to meet infants physical needs
3 Tasks of Mothering (Reva Rubin)
o Identifying new child
o Determining ones relationship to new child
o Guiding and reconstructing the family constellation to include a new
family member
Phases of Psychological Adjustment
o Taking in Phase (1st 1-2 days after birth)
Passive, dependent, directing energy toward herself instead of
infant
Reliving labor/birth to integrate the process
Decision-making may be difficult
Wants to eat and sleep
Many questions
May only explore infant with her fingertips
o Taking Hold Phase (~10 days4-5 weeks)
Increase in energy
Independence/initiation of self care activities
Accepts increasing responsibility for newborn
May verbalize lack of confidence with infant care/needs
reassurance
Begins to touch infant with whole hand, then enfolds infant
Often concerned about her bodily functions
Wants to be independent again
High Fatigue
o Letting go Phase (by the end of the 1st week)
Reorganization of family ties
Mother assumes responsibility for her dependent newborn
Recognizes infant as separate from self
Relinquishes the fantasy infant
Feelings of are common
Fathers
o Dads more involved in preg and present at birth - + better attachment
o Engrossment- fathers behavior at birth
Siblings
Grandparents and other family members

Cesarean Birth (C-Section)


Decreased risk of c-section if have a support person
Increase in mortality/morbidity:
o Hemorrhage
o Infection
o Anesthesia complications
o Blood clots

Indications for Cesarean Section

1. Malpresentations
2. Placenta Problems

3.
4.
5.
6.

Cephalopelvic disproportion (CPD)


Non reassuring fetal heart rate
Prior Cesarean delivery
Others:
a. Active herpes
b. Fetal Macrosomia
c. Fetal disease/anomaly

Trial of Labor after Cesarean (TOLAC)


Vaginal Birth After Cesarean (VBAC)

Advantages of VBAC
o Shorter hospital stay and recovery
o Decrease need for blood transfusion (decrease in blood loss)
o Decrease risk of infection
o Lower risk than C-section
o 6080% of women with TOLAC have VBAC
Advantages of repeat C-section
o Possibility of uterine rupture with TOLAC (<1%)
Contraindications for TOLAC
o History of high vertical or T incision
o Small pelvis and large baby
o Medical/OB problems (placenta previa or abruption)
o Multiple births
o Breech
Lack of facility for monitoring and emergency C/S
Rising C-section rate myths
o More women asking for C/S with no medical rationale
o The number of women who genuinely need a cesarean is increasing
Reasons for Rising C/S rate:
1. Low priority of enhancing womens own abilities to give birth
2. Side effects of common labor interventions
3. Vaginal birth is not offered to women with previous C/S
4. Casual attitudes about surgery and C/S in particular
5. Limited awareness of risks associated with C/S
6. Providers fears of malpractice claims and lawsuits
7. Incentives to practice in a manner that is efficient for providers
Anesthesia Choices for C/S
o Epidural
o Spinal
Lasts 25-30 minutes
Used a majority of the time in C/S bc safer for fetus
o General
Preoperative Preparation

o
o
o
o
o
o
o
o
o

NPO
Antacids
Abdominal shave/clip
Foley
Lab work
IV
Consent
Fetal lung maturity
Gestational age assessment
Skin Incisions

Nursing Care
Support/Inform
Presence of support person
Pictures
Post birth contact
Breastfeeding in recovery room
Evaluate response to C/S birth
o Relief, fear, helplessness, disappointment
Postoperative Care
Pain
o PCA (patient controlled analgesia) PO meds
o Pain sources: incisional pain, gas pain, referred shoulder pain, periodic
uterine contractions, and pain from voiding, defecation or constipation
o Pain meds also enable mobility and recovery
o Positioning
TCDB leg exrcises ambulation
Foley x12-24 hours
Diet (NPO ice chips C.L FL Gen)
Incision Care
Increased need for rest
Limit stair climbing, driving
Need help at home
Cesarean Birth Postpartum Care
Postpartum assessment, including:
o TCDB/Leg exercises/ambulation
o Intake/output (Foley)
o Assess
o Assess incision/dressing (---)
o Assess pains/need for meds
o Psychological responses