Maternal Physiologic Changes
- 1. What is involution?
- 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.
- Most common cause is retained placental fragments and infection.
- 2. What is lochia?
- 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
- Blood and decidual debris becomes pale and then pink or brown (lochia serosa) after 3-4 days.
iv. Lochia Serosa
- Old blood, serum, leukocytes, tissue debris
- Duration of 22-27 days
v. Lochia Alba
- Yellow to white discharge 10 days after childbirth
- 10-14 days
- Oxytocin will delay flow until it wears off, increases with ambulation and breastfeeding, less after c section.
- 3. The loss of which two hormones after the expulsion of the placenta account for most of the changes during the postpartum period?
- Estrogen and progesterone drop after expulsion of placenta.
i. Decreased estrogen associated engorgement of breasts and diuresis
- 4. How does a full bladder effect the uterus placement?
- a. If the bladder becomes distended it pushes the uterus up and to the side and prevents the uterus from contracting.
- 5. What is the cause of diuresis after delivery?
- Decrease in estrogen levels, decrease in venous pressure in lower extremities, loss of blood volume all contribute to post partum dieresis.
- 6. Why are women prone to have a decreased sensation of the need to void after delivery?
- Birth induced trauma
- Increased bladder capacity
- Effects of anesthesia
- Reduced voiding reflex
- 7. Is it normal for a woman to have increased WBC’s for the first week or so after delivery?
- WBC can be elevated for the first 72 hours post partum. Values between 20,000 to 25,000 is normal.
- 8. Will non-breastfeeding woman experience engorgement?
- 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. What are the warning signs that the woman needs to be taught before she is discharged:
- 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)
- Dark brown to red to pink
- 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
- 4 servings bread, fruit/vegetables, molk
- 2 servings of meat
- 8 glasses of fluid
xi. Call doctor for:
- Increased vaginal bleeding
- Painful or burning urination
- Foul smelling discharge
- Increased swelling
- Draining or separation of incision
- b. about her infant
- 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?
- 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.
- 3. When is the rubella vaccine given during the postpartum stay? Why?
- Women with a negative titer, have not had rubella.
i. Prevents possibility of contracting rubella during future pregnancy.
- 4. What nursing interventions can help a woman who is having problems voiding after delivery?
- a. Listen to running water
- b. Place hands under running water
- c. Pouring water over perineum
- d. Assist woman into sitz bath
- e. Oil of peppermint in bed pan
- f. Possible administration of anesthetic
- g. Straight cath
- 5. Why is breastfeeding initiated during the fourth stage of labor?
- a. Aids in the contraction of the uterus
- b. Infant is alert and ready to feed
- 6. What should a woman be taught to reduce her chance of infection?
- Wiping from front to back
- Use clean antiseptic solution when voiding to cleanse
- Change perineal pad each time you void or defecate
- Wash hands
- 7. What two interventions are the most important in preventing excessive postpartum bleeding?
- Maintain good uterine tone
- Prevent bladder distention
i. Perineal pad saturation in 15 minutes or less or pooling of blood under the buttocks indicates excessive blood loss
- 8. What criteria should the mother and baby meet before they are discharged from the hospital?
- 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
- 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
- c. General
i. No social risk factors
ii. Family or support person available
iii. Follow-up scheduled
Transition to Parenthood
- What is the difference between attachment and bonding?
- Understand the facilitating and inhibiting behaviors that promote infant attachment.
- Understand Rubin’s three phases of becoming a mother: see box on pate 424.
- Look at nursing care plan on page 426 for appropriate ND and interventions for the postpartum family.
- Look at table on page 427: what is the development of the father role?
- What actions promote sibling adaptation?
- 1. What are the risk factors for a postpartum hemorrhage?
- Uterine atony
i. Overdistended uterus
- Large uterus
- Multiple fetuses
- Distention with clots
ii. Anesthesia and analgesia
iii. High parity
iv. Prolonged labor, oxytocin induced labor
v. Trauma during labor and birth
- Lacerations of the birth canal
- Retained placental fragments
- Ruptured uterus
- Placenta accrete
- Coagulation disorders
- Placenta abruption
- Placenta previa
- Manual removal of a retained placenta
- Mag sulfate administration
- Uterine subinvolution
- 2. What is the first nursing intervention with a hypotonic when the bladder is not distended uterus?
- Increase contractility and decrease blood loss
i. Firm massage of the fundus, expression of clots, infuse oxytocin
- 3. What medication, that can be given for postpartum hemorrhage is contraindicated with hypertension?
- Ergonovine or methylergonovine
- 4. Name three medications that can be given for uterine atony?
- Same as medications for post partum hemorrhage – uterine stimulates
- If a woman has a third or fourth degree episiotomy, what would be contraindicated?
- What are the nursing assessments of a patient who is experiencing hemorrhagic shock?
- What is critical to managing a woman with hemorrhagic shock?
- 8. What puts a postpartum woman at risk for a DVT?
- Venous stasis and hypercoagulation
- C section, hx of varicosities, obesity, maternal age, multiparity, smoking
- 9. What are interventions that need to be done to decrease the chance of a DVT?
- Movement – early and frequent post partum
- Change position – do not cross legs, elevate legs when sitting
- Do not place knees in sharply flexed position
- Fluid intake of 2 – 3L
- Measure extremities
- 10. What assessment is done to evaluate for a DVT?
- Homans sign
- Pain and tenderness in lower extremity
- Warmth, redness, enlarged, hard vein
- Unilateral pain, calf tenderness, swelling
- Cough, tachy, hemoptysis, elevated temp, chest painj
i. Real time color Doppler ultrasound
- Cardiac auscultation
- PO2 may be low
- 11. What are the signs and symptoms of a wound infection?
- Erythema, edema, warmth, tenderness, seropurulent drainage, wound separation, fever, pain
- 12. What are the signs and symptoms of a UTI?
- a. Risk factors
ii. Frequent pelvic exams
iii. Epidural anesthesia
iv. Genital tract infection
v. Hx of UTI
vi. C section
- b. Signs
ii. Frequency and urgency
iii. Low-grade fever
iv. Urinary retention
vii. Costovertebral or flank pain indicate upper UTI
viii. E. coli most common
- 13. What are the signs and symptoms of mastitis?
- Local breast tenderness
- Swelling redness
- Axillary adenopathy
- Empty the breast every 2 to 4 hours manually or with pump
- 14. What is the most effective treatment for postpartum infection? How can the nurse facilitate this?
i. Good nutrition
iii. Aseptic technique by providers
- Broad spectrum antibiotics