Chapter 20: Postpartum Adaptations

Question 1

Postpartum period or puerperium

Answer 1

First 6 weeks after the birth

Question 2

Retrogressive changes

Answer 2

Occur in the body systems during pregnancy and are reversed as the body returns to a non pregnant state

These account for many postpartum physiologic changes

Question 3

Progressive changes

Answer 3

Less likely to occur than retrogressive but do occur

Ex: initiation of lactation

Question 4

Involution

Answer 4

Changes of the reproductive system (esp. the uterus) after childbirth so the mother returns to their nonpregnant size and condition

Entails 3 processes: contraction of muscle fibers, catabolism (converting cells into simpler compounds), and regeneration of the uterine epithelium.

Question 5

When does involution occur

Answer 5

Immediately after driver of the placenta, when uterine muscle fibers contract firmly around maternal blood vessels at the area where the placenta was attached. This contraction controls bleeding from the area left denuded when the placenta separates

The uterus becomes smaller as the muscle fibers (which have been stretched for many months) contract and gradually regain their former contour and size

Question 6

How is the enlarged uterine muscle cells affected?

Answer 6

By catabolic changes in protein cytoplasm that cause a reduction in individual cell size.

The products of the catabolic changes are absorbed by the bloodstream and excreted in the urine as nitrogenous waste

Question 7

When does regeneration of the uterine epithelial lining occur?

Answer 7

Soon after childbirth. The outer portion of the endometrial layer is expelled with the placenta

Within 2-3 days, the remaining decidua (endometrium during pregnancy) separates in 2 layers

Question 8

What are the 2 layers of the decidua?

Answer 8

The first layer is superficial and is shed in lochia

The basal layer remains to provide the source of new endometrium

Regeneration of the endometrium (except at the site of placental attachment) occurs by day 16 after birth

Question 9

What occurs with the placental site?

Answer 9

It is about 8-10 cm (3-4 inches) in diameter and heals by process of exfoliation (scaling off dead tissue)

A new endometrium is generated from glands and tissue that remain in the lower layer of the decidua after separation from the placenta

This process leaves the uterine lining free of scar tissue which may interfere with implantation of future pregnancies

Healing the placenta takes about 6 weeks

Question 10

Descent of the uterine fundus (top of the uterus above the openings of the Fallopian tubes)

Answer 10

Helps determine the involution process. Immediately after birth, the uterus is about 1000g (2.2 lbs) and the fundus can be palpated between the symphysis pubis and the umbilicus. Within 12 hours, the fundus rises to the level of the umbilicus. The fundus descends by about 1 finger/ 1cm per day. By the 14th day, it’s in the pelvic cavity and cannot be palpated abdominally.

Descent is documented in relation to the umbilicus. Ex: U - 1 or (down arrow) 1 means the fundus is palpable 1cm below the umbilicus. Within 1 week, the uterus weighs 500g (1 lb) and at 4 weeks, it weighs 100g (3.5oz) or less

Question 11

Other findings of descent of the uterine fundus

Answer 11

The fundus may be slightly higher in multiparas or women who had an overdistended uterus

When involution doesn’t occur properly, sub involution may occur which can lead to postpartum hemorrhage

Question 12

Etiology of after pains (intermittent contractions)

Answer 12

This discomfort is more acute for multiparas due to repeated stretching of muscle fibers which leads to loss of muscle tone that causes alternate contraction and relaxation of the uterus. The uterus of a primipara tends to remain contracted- she may still experience severe after pains if the uterus has become over-distended by multifetal pregnancy, a large infant, hydramnios, or if retained blood clots are present. Oxytocin released from the posterior pituitary during breastfeeding may cause strong contractions of the uterine muscles. After pains usually decrease to mild discomfort by the 3rd day after birth.

Question 13

Nursing interventions for after pains (intermittent contractions)

Answer 13

Analgesics are frequently used for short-term pain relief without harm to the infant

Lying in prone position with a small pillow or folded blanket under the abdomen helps keep the uterus contracted and provides relief

These pains are self-limited and decrease rapidly after 48 hours

Question 14

Benefits of pain relief (usually outweigh the small effects of the med on the infant)

Answer 14

Comfort and relaxation/ pain relief

Milk-ejection reflex/ letdown reflex

The release of milk from the alveoli into the ducts

Question 15

Lochia: color changes

Answer 15

First 3 days after childbirth: lochia consists of blood with small particles of decidua and mucus. Reddish/brown color is referred to as lochia rubra.

Amount of blood decreases by day 4 and changes from red to pink or brown-tinged known as lochia serosa composed of serous exudate, erythrocytes, leukocytes, and cervical mucous.

By day 11, erythrocytes decrease and is now known as lochia alba which consists of leukocytes, decidual cells, epithelial cells, fat, cervical mucous, and bacteria. This is present usually until the 3rd week but can last to the 6th week

Question 16

Lochia: amount

Answer 16

Scant: less than a 2.5 cm (1”) stain on the perineal pad

Light: 2.5-10 cm (1-4”) stain

Moderate: 10-15 cm (4-6”) stain

Heavy: saturated perineal pad

Excessive: saturated peripad in 15 minutes

Understand that what appears to be a light flow may be a moderate flow of the peripad has been in use less than an hour

Women who have cesarean births will go through the same lochia phases as the women who have vaginal births, but the amount will be less.

Lochia is often heavier when getting out of bed because blood that has pooled in the vagina gravitates to flow freely when standing

Question 17

Days 1-3: lochia rubra

Answer 17

Normal discharge: bloody, small clots, fleshy, earthy odor, red or red/brown

Abnormal discharge: large clots, saturated perineal pads, foul odor

Question 18

Days 4-10: lochia serosa

Answer 18

Normal discharge: decreased amount, serosanguineous, pink or brown-tinged

Abnormal discharge: excessive amount, foul smell, continued or recurrent reddish color

Question 19

Days 11-21: lochia alba (may last until 6th week postpartum)

Answer 19

Normal discharge: further decreased amounts, white, cream, or light yellow

Abnormal discharge: persistent lochia serosa, return to lochia rubra, foul odor, discharge continuing

Question 23

The cervix after childbirth

Answer 23

Immediately after childbirth, the cervix is formless, flabby, and open wide; small tears or lacerations may be present; often edematous

Healing occurs rapidly and by the end of the 1st week, the cervix feels firm, and the external os is dilated 1 cm. The shape of this os is permanently changed: remains slightly open and appears slit-like rather than round, as in the nulliparous woman

The internal os closes as before pregnancy

Question 24

The vagina after childbirth

Answer 24

Vaginal walls appear edematous, and multiple small lacerations may be present, few vaginal rugae (folds) are present. The hymen is permanently torn and heals with small, irregular tags of tissue visible at the vaginal introitus

Rugae are regained by 3-4 weeks. It takes 6-10 weeks for the vagina to complete involution and regain size and contour it had before pregnancy. It doesn’t regain entire nulliparous size

Vaginal mucosa becomes atrophic and don’t regain thickness until estrogen production by the ovaries is reestablished

Because ovarian function & estrogen production is not well established during lactation, breastfeeding mothers are likely to experience vaginal dryness and possibly dyspareunia (discomfort during intercourse)

Question 25

The perineum after childbirth

Answer 25

Muscles of pelvic floor stretch significantly during second stage of labor due to fetal head. May be edematous and bruised after childbirth. Some women have a episiotomy (surgical incisions of perineal area) to enlarge opening for birth. Healing of this site begins in 2-3 weeks but complete healing can take 4-6 months

Lacerations of the perineum may occur during delivery. Lacerations and episiotomies are classified according to the tissue involved.

Question 26

Lacerations of the birth canal: perineum

Answer 26

Classified in degrees to describe the amount of tissue involved. Also may be used to describe the extent of midline episiotomies.

First-degree: involves superficial vaginal mucosa or perineal skin

Second-degree: involves the vaginal mucosa, perineal skin, and deeper tissues, which may include fascia and muscles of the perineum

Third-degree: same as second-degree but involves the anal sphincter

Fourth-degree: extends through the anal sphincter into the rectal mucosa

Question 27

Lacerations of the birth canal: Periurethral area

Answer 27

A laceration in the area of the urethra may cause women difficulty urinating after birth. Am I dwelling catheter may be necessary for a day or two.

Question 28

Lacerations of the birth canal: vaginal wall

Answer 28

A laceration involving the mucosa of the vaginal wall

Question 29

Lacerations of the birth canal: cervix

Answer 29

Tears in the cervix may be a source of significant bleeding after birth

Question 30

Discomfort

Answer 30

Episiotomies are relatively small; however, the perineal muscles are involved in many activities (e.g., walking, sitting, stooping, squatting, bending, urinating, and defecating)

An incision here can cause great discomfort

Many pregnant women are affected by hemorrhoids (distended rectal veins) which are pushed out of the rectum during the second stage of labor

Question 31

Nursing considerations

Answer 31

Hemorrhoids, perineal trauma, episiotomy, or lacerations can make physical activity or bowel elimination difficult postpartum.

Relief of this discomfort includes teaching self-care measures such as applying ice, performing perineal care, use of topical anesthetics, and taking ordered analgesics

Question 32

CV changes

Answer 32

Hypervolemia occurs: 45% increase in blood volume occurs at term allowing the female to tolerate substantial blood loss during birth without falling ill

Average of 500 mL of blood loss occurs with vaginal delivery

Average of 1000 mL of blood loss occurs with cesarean births

Question 33

CV changes: cardiac output

Answer 33

There is a transient increase in maternal CO after childbirth cause by 1.) an increase flow of blood back to the ❤️ when blood from the urethroplacental unit returns to central circulation, 2.) decrease pressure from the uterus on the vessels, 3.) mobilization of excess extra cellular fluid into the vascular compartment

CO returns to prelabor values within an hour after delivery

Gradually, CO decreased and returns to prepregnancy levels by 6-12 weeks after birth

Question 34

CV changes: plasma volume

Answer 34

The body rids excess plasma volume needed for delivery by diuresis and diaphoresis

Question 35

Diuresis (increased excretion of urine)

Answer 35

Facilitated by a decline in the adrenal hormone aldosterone, which increases during pregnancy to counteract the salt-wasting effect of progesterone

As aldosterone production decreases, sodium retention declines and fluid excretion accelerates

A decrease in oxytocin (which promotes reabsorption of fluid) contributes to diuresis

Urinary output of 3000 mL/day is common esp. on days 2-5 during postpartum

Question 36

Diaphoresis (profuse perspiration/sweating)

Answer 36

Rids the body of excess fluids

Can be uncomfortable and unsettling

Explanations of the cause and provision of comfort measures, such as showers and dry clothing

Question 37

CV changes: blood values

Answer 37

Leukocytosis occurs with the WBC count increasing to up to 30,000/mm3 during labor and immediately postpartum. WBCs fall to normal by day 6 after birth

The hematocrit is low when plasma increases and diluted the concentration of blood cells and other substances carried by the plasma. As excess fluid is excreted, the dilution is gradually reduced. Hematocrit returns to normal within 4-6 weeks postpartum unless excessive blood loss occurs

Question 38

CV changes: coagulation

Answer 38

During pregnancy, plasma fibrinogen and other coagulation factors increase. Result: mother’s body has greater ability to form clots to prevent excessive bleeding.

Fibrinolytic activity (ability to break down clots) is decreased during pregnancy. Fibrinolysis increases shortly after delivery and continues for several days, increasing the risk for thrombus formation

It takes 4-6 weeks before hemostasis returns to normal and thrombophlebitis risks declines however is still prevalent. Those who have varicose veins, Hx of thrombophlebitis, or cesarean births are at higher risk.

Lower extremities should be monitored. Pneumatic compression devices should be applied before cesarean delivery for those not already receiving anticoagulants

Question 39

GI changes

Answer 39

Soon after childbirth, the digestive system reactivates and hunger occurs due to expended energy from labor

Excessive thrust occurs due to decreased intake and early diaphoresis

Constipation is common postpartum due to bowel tone and intestinal motility, which were diminished during pregnancy from progesterone, remain sluggish for several days. Abdominal musclulature is relaxed. Decreased food and fluids may result in small, hard stools. Perineal trauma, episiotomy, and hemorrhoids interfere with effective bowel elimination. Some women anticipate pain with defecation and avoid this.

Temporary constipation isn’t harmful but may cause full feeling and flatulence. Stool softeners and laxatives are used to prevent or treat this. The first stool usually occurs within 2-3 days postpartum. Normal bowel patterns usually resume by 8-14 days postpartum

Question 40

Urinary system changes

Answer 40

Trauma to the perineal area often results in sensitivity to fluid pressure and many have no sensation of needing to void even when the bladder is distended.

Postpartum, the mother is at risk for overdistention of the bladder, incomplete emptying, and retention of residual urine. Those who have received regional anesthesia are at risk for distinction and difficult voiding until feeling returns.

Retention and overdistention may cause UTI (occurs when urinary stasis allows for bacteria to accumulate) and increased postpartum bleeding (due to uterine ligament-stretched during pregnancy- allows the uterus to be displaced upward and laterally due to the full bladder; result: decreased uterine muscle contraction or uterine atony- a primary cause of excessive bleeding)

Stress incontinence may begin and improves within 3 months after birth. Pelvic floor exercises and time for healing helps. Some women may have continued problems.

Dilation of the ureters and kidney pelvis improves by the end of the first week. Usually regain normal state 2-8 weeks postpartum. Protein and acetone may be present in urine for first few weeks postpartum. Acetone suggests dehydration (may occur from exertion of labor) and mild proteinuria is usually the result of the catabolic processes involved in uterine involution

Question 41

Musculoskeletal system changes: muscles and joints

Answer 41

In the first 1-2 days postpartum, muscle fatigue and aches are common esp. in the shoulders, neck, and arms due to effort of labor. Warmth and gentle massage increase circulation to the area and provide comfort/relaxation

First few days: level of relaxin hormone gradually subside, ligaments and cartilage of the pelvis begin returning to prepregnancy positions which can cause hip or joint pain that interferes with ambulation/exercise. Teach that this is temporary. Correct posture and good body mechanics are important to prevent low back pain and injury to joints

Question 42

Musculoskeletal system changes: abdominal wall

Answer 42

Abdominal wall stretches and muscle tone is diminished during pregnancy. Immediately after childbirth, abdominal muscles remain weak, soft, and flabby

Longitudinal muscles of the abdomen may separate (diastasis recti) during pregnancy which may be minimal or severe. The mother may benefit from gentle exercises to strengthen the abdominal wall and usually resolved within 6 weeks

Exercise for diastasis recti: laying down, the woman inhaled and supports the abdominal wall firmly with hands; exhaling, the woman raises her head while pulling the abdominal muscles together

Question 43

Integumentary system changes

Answer 43

Many skin changes are due to an increase in hormones. After birth, hormone levels decline and the skin reverts to prepregnancy state. EX: estrogen, progesterone, and melanocyte-stimulating hormone (caused hyperpigmentation during pregnancy) decrease rapidly after childbirth and pigmentation begins to recede which is noticeable when melasma (mask of pregnancy) and linea nigra fade and disappear.

Striae gravidarum (stretch marks) from connective tissues being stretched, gradually fade to silvery lines but do not disappear. Loss of hair is a normal response due to hormonal changes and begins at 4-20 weeks postpartum and is regrown in 4-6 months for 2/3s or women and by 15 months for the rest

Question 44

Neurological system changes

Answer 44

Discomfort, fatigue, and inability to sleep postpartum may be seen with after pains, episiotomies, lacerations, incisions, muscle aches, and breast engorgement (swelling from increased blood flow, edema, and presence of milk)

Anesthesia or analgesia may result in lack of feeling in the legs and dizziness. Prevent injuries r/t falling.

HAs require careful assessment. Bilateral and frontal are common in 1st week postpartum and may be a result of F&E changes. Spinal HAs after spinal anesthesia may occur and may be more severe with woman in upright- relieved with supine position. They should be reported to HCW (usually anesthesiologist). HA, proteinuria, blurry vision, photophobia, and abd pain may indicate development or worsening of preeclampsia

Pain continues after being discharged and some report that pain interferes with self care and ability to care for infant

Question 45

Endocrine system changes

Answer 45

Rapid decline occurs in placental hormones (e.g., estrogen, progesterone, and human placental lactogen) after expulsion of the placenta

Human chorionic gonadotropin is present for 3-4 weeks

If mom is not breastfeeding, prolactin (pituitary hormone that stimulates milk secretion) returns to nonpregnant levels in 14 days

Question 46

Endocrine system changes: Resumption of ovulation and menstruation

Answer 46

The first few cycles for lactating and non-lactating women are often anovulatory, ovulation may occur before the first menses. For some, ovulation resumes as early as 3 weeks postpartum. Contraceptives are important for sexual activity for lactating and non-lactating women.

~40-45% of non-nursing moms resume menstruation 6-8 weeks postpartum, 75% by 12 weeks, and all within 6 months. Menses while lactating may resume as early as 8 weeks or as late as 18 months. Frequent breastfeeding with no supplements is more likely to delay menses. Yet, menses and ovulation are increasingly likely after the infant is 6 months old

Question 47

Endocrine system changes: lactation

Answer 47

During pregnancy, estrogen and progesterone prepare the breasts for lactation. Prolactin also rises. Lactation is inhibited by high level of estrogen and progesterone. After expulsion of the placenta, estrogen and progesterone decline rapidly, and prolactin initiates milk production within 2-3 days postpartum. Once milk is established, it continues due to frequent removal of milk from the breast.

Oxytocin is necessary for milk ejection, or “letdown”. Oxytocin causes milk to be expressed from the alveoli into the lactiferous ducts during suckling

Question 48

Endocrine system changes: weight loss

Answer 48

~5.5 kg (12lbs) is lost during birth from the weight of the fetus, placenta, amniotic fluid, and blood loss. An additional 4 kg (9lbs) are lost over the first 2 weeks postpartum and another 2.5 kg (5.5lbs) are lost by 6 months postpartum. Adipose tissue gained during pregnancy to meet energy requirements for labor and breastfeeding isn’t loss right away and the usual rate of loss is slow. Younger women with lower prepregnancy weight and lower parity lose weight sooner and faster.

Many women don’t lose all the weight gained and retain an average of 1kg (2.2lbs) per pregnancy. Often get frustrated because of this- provide info about diet and exercise to produce acceptable weight loss but doesn’t deplete energy or impair moms health

Question 49

Postpartum assessments

Answer 49

Provide essential, cost-effective postpartum care

Most women stay in the birth facility for 48 hours after vaginal birth and 96 hours after cesarean birth. Some may choose to go home earlier.

Question 50

Postpartum assessments: clinical pathways

Answer 50

Also known as critical pathways, care maps, care paths, or multidisciplinary action plans

Guide necessary care while reducing the length of stay. Identify expected outcomes and establish time frame for specific assessments and interventions to prepare the mother and infant for discharge.

It is a guideline and documentation tool

Question 51

Postpartum assessments: initial assessments

Answer 51

The nurse faces a high risk of contact with body fluids (colostrum, breast milk, lochia from mother, urine, stool, and blood from child). Follow CDC guidelines for standard blood and body fluid precautions.

Postpartum assessments begin during 4th stage of labor (1st 1-2 hours after delivery). Mom is examined to determine if she’s physically stable. VSs, skin color, location and firmness of fundus, amount and color of lochia, perineum (edema, episiotomy, lacerations, hematoma), presence/degree/location of pain, IV infusion (type of fluid, rate, type and amount of added meds, patency of IV line, redness/pain/edema of site, urine output (time and amount of last void or catheter, color and character of urine, status of abd incision and dressing if present, level of feeling and ability to move if regional anesthesia is present

Question 52

Postpartum assessments: chart review

Answer 52

Review the chart after assessments suggest mom is stable. Obtain PT info and if there’s factors that increase risk for complications postpartum. Relevant info: gravida/para, time and type of delivery (use of vacuum extractor, forceps), presence and degree of episiotomy or lacerations, anesthesia or meds administered, significant medical and surgical history (e.g., diabetes, HTN, or ❤️ disease, meds given during labor and delivery or routinely taken and reasons for their use, food and drug allergies, chosen method of infant feeding, condition of the baby.

Examine labs esp. the prenatal hemoglobin and hematocrit levels, blood type and Rh factors, hepatitis B surface antigen, rubella immune status, syphilis screen, and group B streptococcus status

Question 53

Need for Rh 0 (D) immune globulin

Answer 53

Prenatal and neonatal records are checked to determine if this should be administered. It may be necessary if the mother is Rh negative and the newborn is positive and the mother is not already sensitized.

To prevent the development of maternal antibodies that would affect subsequent pregnancies, this should be administered within 72 hours after childbirth

Question 54

Need for vaccines: rubella

Answer 54

A prenatal rubella antibody screen is performed on each pregnant women to determine if she is immune. If not, rubella vaccine is recommended after birth to prevent her from acquiring rubella with subsequent pregnancies which can cause serious anomalies. There is a theoretical risk of fetal defects because the vaccine contains a live virus; however, there is no evidence of damage when the vaccine is inadvertently given to pregnant women. Therefore, women are advised not to become pregnant for at least 28 days after receiving the vaccine. Women need to sign a statement that they accept the vaccine and understand the risks if she were to become pregnant too soon after. If statement isn’t required, document that risks have been explained and the woman has verbalized understanding.

Question 55

Need for vaccines: pertussis vaccine

Answer 55

Outbreaks have had serious effects in infants and young children. Although most adults have been vaccinated as children, effectiveness fades with time. Full protection doesn’t occur until entire series is completed.

CDC recommends that adults in contact with infants and young children get a booster dose.

The vaccine may be offered to women before hospital discharge after childbirth.

Question 56

Rubella vaccine drug guide info

Answer 56

Class: attenuated live virus vaccine

Action: produces a modified rubella (German measles) infection that’s not communicable, causing the formation of antibodies against the rubella virus

Indications: administered at least 1 month before pregnancy or after birth or abortion to women whose antibody screen shows they’re not immune to rubella. It prevents rubella infection and possible severe congenital defects in the fetus during a subsequent pregnancy.

Dose and route: 0.5 mL subcutaneously

Absorption: well absorbed

Contraindications and precautions: women who are immunosuppressive, pregnant, or sensitive to the vaccine components or have a mod-severe illness. The attenuated virus may appear in breast milk and some infants may develop a rash but this is not a contraindication for lactating women. Can be given near the time of Rh 0 (D). Should be tested for immune status 6-8 weeks to be sure they are immune.

Side effects: transient stinging at site, fever, lymphadenopathy, arthralgia, and transient arthritis are most common

NRSG implications: vials should be refrigerated. Reconstitute only with diluent supplies with vial. Used immediately after reconstituted or discard 8 hours after. Protect from light. Check with HCP before giving near admin time of Rh 0 (D). Birth of infants with congenital rubella syndrome has not been documented when the vaccine has been given inadvertently during pregnancy- yet women are advised to avoid pregnancy for at least 4 weeks after vaccination

Question 57

Two most common complications of the puerperium

Answer 57

Hemorrhage and infection

Question 58

Postpartum risk factor: hemorrhage

Answer 58

Grand multiparity (5+)

Overdistention of the uterus (large baby, twins, hydramnios)

Rapid or prolonged labor

Retained placenta

Placenta previa or previous placenta accreta or abruptio placentae

Drugs (tocolytics, magnesium sulfate, general anesthesia, prolonged use of oxytocin)

Operative procedures (cesarean birth, vacuum extraction, forceps)

Uterine fibroids

History of postpartum hemorrhage

Preeclampsia

Coagulation defects

Question 59

Postpartum risk factor: infection

Answer 59

Operative procedures (cesarean birth, vacuum extraction, forceps)

Multiple vertical exams

Prolonged labor

Prolonged rupture of membranes

Manual extraction of placenta or retained fragments

Diabetes

Catheterization

Bacterial colonization of lower genital tract

Question 60

Focused assessments after vaginal birth

Answer 60

Per facility protocol, assessments may be required every 15 minutes for the first hour, every half hour for the next hour, every 4 hours for the first 24 hours, and every 8 hours thereafter.

Focused assessments per vaginal birth generally includes VSs, fundus, lochia, perineum, bladder elimination, breasts, and lower extremities

Question 61

Focused assessments after vaginal birth: Vital Signs

Blood pressure

Answer 61

Varies with position and arm used

Measure on the same arm and in the same position each time

Compare postpartum to predelivery period so deviations from what is normal

An increase from baseline may be caused by anxiety or pain

140/90+ may indicate preeclampsia

A decrease may indicate dehydration or hypovolemia resulting from excessive bleeding

Question 62

Focused assessments after vaginal birth: Vital Signs

Orthostatic hypotension

Answer 62

After delivery, a rapid decrease in intraabdominal pressure results in dilation of blood vessels supplying the viscera. Resulting engorgement of these vessels contributes to a rapid fall in BP of 15-20 when moving from a recumbent to a sitting position. This causes feeling of dizziness or lightheaded ness or possible faint upon standing.

Risk for injury applies to this.

This may indicate hypovolemia

Assess for hemorrhage (location and firmness of the fundus, amount of lochia, pulse rate for tachycardia) if the BP is significantly less than the prenatal baseline BP

Question 63

Focused assessments after vaginal birth: Vital Signs

Pulse

Answer 63

Bradycardia (40-50 bpm): the lower pulse may reflect the large amount of blood returns to the central circulation after placental delivery. Increase in central circulation results in increased stroke volume and allows a slower heart rate to provide adequate maternal circulation.

Tachycardia may indicate pain, excitement, fatigue, dehydration, hypovolemia, anemia, or infection. Assess BP, location and firmness of uterus, amount of lochia, estimated blood loss from delivery, hemoglobin and hematocrit. Objective of additional assessments: to rule out excessive bleeding and to intervene if hemorrhage is suspected

Question 64

Focused assessments after vaginal birth: Vital Signs

Respirations

Answer 64

A normal rate of 12-20 should be maintained.

Especially important to assess in mothers with cesarean birth, smokers (history), a history of frequent or recent upper respiratory infections or asthma, and for those receiving magnesium sulfate

Question 65

Focused assessments after vaginal birth: Vital Signs

Temperature

Answer 65

A temp of up to 38 C (100.4 F) is common first 24 hours after birth and may be cause by dehydration or normal postpartum leukocytosis

If elevated temperature lasts longer than 24 hours or exceeds 38 C (100.4 F) or the mom shows other signs of infection, report to the physician or nurse midwife

Question 66

Focused assessments after vaginal birth: Vital Signs

Pain

Answer 66

The fifth vital sign

Determine location, type, and severity on a pain scale (COLDSPA)

Be alert to signs off after pain, perineal discomfort, and breast tenderness

Nonspecific signs of discomfort: inability to relax or sleep, change in VSs, restlessness, irritability, and facial grimaces

Encourage moms to take prescribed meds as needed and evaluate the effectiveness of pain-relief measures

Question 67

Focused assessments after vaginal birth: the fundus

Answer 67

Assess for consistency and location. It should be firmly contracted and at or near the level of the umbilicus

Bladder may be distended if uterus is above expected level or shifted- usually to the right- from the middle of abdomen (midline position). Recheck after bladder is emptied.

If difficult to locate or is soft or “boggy”, stimulate uterine muscle to contract by massaging the uterus. Not necessary if the uterus is firmly contracted. Use nondominant hand to support and anchor the lower uterine segment if necessary to massage an uncontracted uterus.

The uterus can contract only if it’s free of intrauterine clots. Massage the fundus until firmly contracted. Supporting the lower uterine segment prevents inversion of the uterus (turning inside out) when applying form pressure downward toward the vagina to express collected clots. Observe the perineum for number and size of expelled clots.

If lochia is excessive or clots present, weigh to estimate amount.

Drugs are sometimes needed to maintain contraction of the uterus and prevent postpartum hemorrhage. The most common is oxytocin (Pitocin).

Question 68

Observations of the uterine fundus and nursing actions:

nL find: fundus firmly contracted

Answer 68

Abnormal find: fundus is soft, “boggy”, uncontracted, or difficult to locate

Action: support lower uterine segment. Massage until firm

Question 69

Observations of the uterine fundus and nursing actions:

nL find: fundus remains contracted when massage is discontinued

Answer 69

Abnormal find: fundus becomes soft and uncontracted when massage is stopped

Action: continue to support lower uterine segment. Massage fundus until firm, then apply pressure to express clots that may be accumulating in uterus. Notify health care provider and begin oxytocin administration, as prescribed, to maintain a firm fundus

Question 70

Observations of the uterine fundus and nursing actions:

nL finds: fundus located at level of umbilicus and midline

Answer 70

Abnormal find: fundus above umbilicus and/or displaced from midline

Action: assess bladder elimination. Assist mother in urinating or catheterization, if necessary. Recheck the position and consistency of fundus after bladder is empty.