Maternal Physiologic Changes

  1. 1.      What is involution?
    1. The return of the uterus to a nonpregnant state after birth.

i.      Uterus is located approximately 2cm below umbilicus at end of third stage of labor.

ii.      Within 12 hours fundus raises to 1 cm above umbilicus.

iii.      By 24 hours uterus is about same size as it was at 20 weeks gestation.

iv.      Fundus descends about 1-2cm every day.

v.      Uterus should not be palpable after 2 weeks post partum.

vi.      Subinvolution is the failure of the uterus to return to nonpregnant state.

  1. Most common cause is retained placental fragments and infection.
  2. 2.      What is lochia?
    1. Discharge post childbirth

i.      Initially it is bright red and may contain small clots.

ii.      First 2 hours should be amount of heavy period then decrease.

iii.      Lochia Rubra

  1. Blood and decidual debris becomes pale and then pink or brown (lochia serosa) after 3-4 days.

iv.      Lochia Serosa

  1. Old blood, serum, leukocytes, tissue debris
  2. Duration of 22-27 days

v.      Lochia Alba

  1. Yellow to white discharge 10 days after childbirth
  2. 10-14 days
  3. Oxytocin will delay flow until it wears off, increases with ambulation and breastfeeding, less after c section.
  4. 3.      The loss of which two hormones after the expulsion of the placenta account for most of the changes during the postpartum period?
    1. Estrogen and progesterone drop after expulsion of placenta.

i.      Decreased estrogen associated engorgement of breasts and diuresis

  1. 4.      How does a full bladder effect the uterus placement?
    1. a.      If the bladder becomes distended it pushes the uterus up and to the side and prevents the uterus from contracting.
    2. 5.      What is the cause of diuresis after delivery?
      1. Decrease in estrogen levels, decrease in venous pressure in lower extremities, loss of blood volume all contribute to post partum dieresis.
      2. 6.      Why are women prone to have a decreased sensation of the need to void after delivery?
        1. Birth induced trauma
        2. Increased bladder capacity
        3. Effects of anesthesia
        4. Reduced voiding reflex
        5. 7.      Is it normal for a woman to have increased WBC’s for the first week or so after delivery?
          1. WBC can be elevated for the first 72 hours post partum.  Values between 20,000 to 25,000 is normal.
          2. 8.      Will non-breastfeeding woman experience engorgement?
            1. Non breastfeeding mothers may feel engorgement on the third or fourth day post partum.  Lactation will cease within a few days to a week.  Engorgement will resolve spontaneously, and discomfort decreases within 24-36 hours.

Nursing Care of the Family during the Fourth Trimester

  1. 1.      What are the warning signs that the woman needs to be taught before she is discharged:
    1. a.      about herself

i.      Always wipe front to back

ii.      Sit in a warm bath to relieve discomfort

iii.      Moderate amount of vaginal discharge is normal (4-6 wks)

  1. Dark brown to red to pink
  2. May contain clots

iv.      Use a sanitary pad instead of a tampon

v.      Menstrual period will not resume for 4-6 weeks

vi.      Avoid sexual relations for 2-4 weeks

vii.      Gradually increase activity

viii.      Do kegel exercises

ix.      Do not lift over 10 pounds

x.      Eat daily

  1. 4 servings bread, fruit/vegetables, molk
  2. 2 servings of meat
  3. 8 glasses of fluid

xi.      Call doctor for:

  1. Fever
  2. Increased vaginal bleeding
  3. Chills
  4. Painful or burning urination
  5. Foul smelling discharge
  6. Increased swelling
  7. Draining or separation of incision
  8. b.      about her infant


  1. 2.      What is significant about a woman’s blood type if it is negative? What medication needs to be given after delivery? How soon? In what circumstances?
    1. The mother will need to receive Rh immune globulin with 72 hours after birth.

i.      Promotes lysis of fetal Rh-positive blood cells before mother can form her own antibodies.

  1. 3.      When is the rubella vaccine given during the postpartum stay? Why?
    1. Women with a negative titer, have not had rubella.

i.      Prevents possibility of contracting rubella during future pregnancy.

  1. 4.      What nursing interventions can help a woman who is having problems voiding after delivery?
    1. a.      Listen to running water
    2. b.      Place hands under running water
    3. c.       Pouring water over perineum
    4. d.      Assist woman into sitz bath
    5. e.       Oil of peppermint in bed pan
    6. f.       Possible administration of anesthetic
    7. g.      Straight cath
    8. 5.      Why is breastfeeding initiated during the fourth stage of labor?
      1. a.      Aids in the contraction of the uterus
      2. b.      Infant is alert and ready to feed
      3. 6.      What should a woman be taught to reduce her chance of infection?
        1. Wiping from front to back
        2. Use clean antiseptic solution when voiding to cleanse
        3. Change perineal pad each time you void or defecate
        4. Wash hands
        5. 7.      What two interventions are the most important in preventing excessive postpartum bleeding?
          1. Maintain good uterine tone
          2. Prevent bladder distention

i.      Perineal pad saturation in 15 minutes or less or pooling of blood under the buttocks indicates excessive blood loss

  1. 8.      What criteria should the mother and baby meet before they are discharged from the hospital?
    1. a.      Mother

i.      Uncomplicated pregnancy

ii.      No evidence of PROM

iii.      BP and temp WNL

iv.      Ambulating unassisted

v.      Voiding adequate amounts

vi.      Hemoglobin >10 g

vii.      No significant vaginal bleeding, perineum intact or no more than second degree episiotomy or laceration repair, uterus firm

viii.      Received instruction on postpartum self-care

  1. b.      Infant

i.      Term (38-40 weeks) weight appropriate for GA

ii.      Normal findings on physical assessment

iii.      Temp, resp, HR WNL and stable for 12 hours

iv.      2 successful feedings completed

v.      Urination and stool at least once

vi.      No evidence of significant jaundice

vii.      No excessive bleeding at circumcision site for at least 2 hours

viii.      State screenings performed

ix.      Initial Hep B vaccine

x.      Lab data reviewed

  1. c.       General

i.      No social risk factors

ii.      Family or support person available

iii.      Follow-up scheduled

iv.      documentation

Transition to Parenthood

  1. What is the difference between attachment and bonding?
  2. Understand the facilitating and inhibiting behaviors that promote infant attachment.
  3. Understand Rubin’s three phases of becoming a mother: see box on pate 424.
  4. Look at nursing care plan on page 426 for appropriate ND and interventions for the postpartum family.
  5. Look at table on page 427: what is the development of the father role?
  6. What actions promote sibling adaptation?

Postpartum Complications

  1. 1.      What are the risk factors for a postpartum hemorrhage?
    1. Uterine atony

i.      Overdistended uterus

  1. Large uterus
  2. Multiple fetuses
  3. Hydramnios
  4. Distention with clots

ii.      Anesthesia and analgesia

iii.      High parity

iv.      Prolonged labor, oxytocin induced labor

v.      Trauma during labor and birth

  1. Lacerations of the birth canal
  2. Retained placental fragments
  3. Ruptured uterus
  4. Placenta accrete
  5. Coagulation disorders
  6. Placenta abruption
  7. Placenta previa
  8. Manual removal of a retained placenta
  9. Mag sulfate administration
  10. Endometritis
  11. Uterine subinvolution
  12. 2.      What is the first nursing intervention with a hypotonic when the bladder is not distended uterus?
    1. Increase contractility and decrease blood loss

i.      Firm massage of the fundus, expression of clots, infuse oxytocin

  1. 3.      What medication, that can be given for postpartum hemorrhage is contraindicated with hypertension?
    1. Ergonovine or methylergonovine
    2. 4.      Name three medications that can be given for uterine atony?
      1. Oxytocin
      2. Hemabate
      3. Cytotec
      4. Methergin
      5. Same as medications for post partum hemorrhage – uterine stimulates
      6. If a woman has a third or fourth degree episiotomy, what would be contraindicated?
      7. What are the nursing assessments of a patient who is experiencing hemorrhagic shock?
      8. What is critical to managing a woman with hemorrhagic shock?
      9. 8.      What puts a postpartum woman at risk for a DVT?
        1. Venous stasis and hypercoagulation
        2. C section, hx of varicosities, obesity, maternal age, multiparity, smoking
        3. 9.      What are interventions that need to be done to decrease the chance of a DVT?
          1. Movement – early and frequent post partum
          2. Change position – do not cross legs, elevate legs when sitting
          3. Do not place knees in sharply flexed position
          4. Fluid intake of 2 – 3L
          5. Measure extremities
          6. 10.  What assessment is done to evaluate for a DVT?
            1. Homans sign
            2. Pain and tenderness in lower extremity
            3. Warmth, redness, enlarged, hard vein
            4. Unilateral pain, calf tenderness, swelling
            5. Cough, tachy, hemoptysis, elevated temp, chest painj
            6. Venography

i.      Real time color Doppler ultrasound

  1. Cardiac auscultation
  2. ECG
  3. PO2 may be low
  4. 11.  What are the signs and symptoms of a wound infection?
    1. Erythema, edema, warmth, tenderness, seropurulent drainage, wound separation, fever, pain
    2. 12.  What are the signs and symptoms of a UTI?
      1. a.      Risk factors

i.      Catheterization

ii.      Frequent pelvic exams

iii.      Epidural anesthesia

iv.      Genital tract infection

v.      Hx of UTI

vi.      C section

  1. b.      Signs

i.      Dysuria

ii.      Frequency and urgency

iii.      Low-grade fever

iv.      Urinary retention

v.      Hematuria

vi.      Pyuria

vii.      Costovertebral or flank pain indicate upper UTI

                                                      viii.      E. coli most common

  1. 13.  What are the signs and symptoms of mastitis?
    1. Chills
    2. Fever
    3. Malaise
    4. Local breast tenderness
    5. Pain
    6. Swelling redness
    7. Axillary adenopathy
    8. Empty the breast every 2 to 4 hours manually or with pump
    9. 14.  What is the most effective treatment for postpartum infection? How can the nurse facilitate this?
      1. Prevention

i.      Good nutrition

ii.      Hygiene

iii.      Aseptic technique by providers

  1. Broad spectrum antibiotics