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Flashcards in Postpartum Care Deck (35)
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Postpartum: delivery through 6 weeks
“4th trimester”
AKA “puerperium”, from the Greek “puerperos”, meaning “to bear young”
Puerperal = postpartal
Key task: involution



Uterus returns to its normal position, shape, size

Position: pelvic organ

Shape: upside-down pear

Size: fruit-basket pear


Uterus Decreases in Size

1. Uterine contractions

2. Autolysis
- Catabolic process
- Muscle fibers get smaller
- Protein from myometrial cells reabsorbed


Endometrial Changes

1.Uterine contractions decrease placental site to ½ predelivery size
2. Blood loss controlled
- Compression of blood vessels that supply decidual sinuses
- Compression of sinuses themselves
- Clot formation in vessels that supply decidua - endometrium 



Infiltrate placental site, blood vessels, and surrounding tissues
Necrosis begins
3 weeks total for decidual necrosis/regeneration
3 weeks for placental site necrosis/regeneration


Lochia (Postdelivery Flow)

After delivery, almost entirely blood
As sinuses compressed, clots form, less blood
1. Rubra (red)
2. Serosa (pink)
3. Alba (yellowish-white) 


Lochia Rubra: 2-3 Days

Blood + mucus + decidual particles + cellular debris from placental site
Endometrial cavity sterile initially, then bacterial growth + WBCs contribute to lochia


Lochia Serosa: At 3-4 Days

Less oozing blood, more watery (serous)
Pinkish-tan color

Involution of placental site continues: blood decreases, WBC + cellular debris


Lochia Alba: By Day 10

Yellowish-white to white in color
Gone by end of 3rd PP week or brownish mucoid discharge few days


Peripad Assessment (1 Hour)

Scant; Light; Moderate; Heavy saturated 


PPH (Postpartum Hemorrhage)

Early PPH
Within first 24 hours

Uterine atony #1 ( uterus without tone, not contracting) , also genital tract lacerations and retained placenta
Late PPH
After first 24 hours

Retained placenta


Fundal Height 

Fundus ( top portion of the uterus ) - at or below the level of umbilicus 

Empty bladder - two-handed approach - palpate the abdoemn gently feeling for the top of the uterus while the other hand is placed on the lower segment of the uterus to stabilize it. 

* By the 10th day PP, uterus is no longer palpable abdominally 

if it is palpable - subinvolution  due to retained placenta 


Fundal Characteristics

Should be firm, in the midline

Reference position to the umbilicus
FF U/0 (at the level of umbilicus) , FF U/1 (1 cm below) , etc. !!!!!!
FF ( fundus firm)  1/U ( 1 cm above) , FF 2/U ( 2 cm above) , etc.


Boggy Uterus

Uterus not firm? Massage & reassess.
Support base of uterus
 Massage fundus straight down towards patient’s spine
Note passage of clots, retained placenta, pieces of amniotic sac


Full Bladder

Too high? Over to right side? Probably full bladder. Have patient void & reassess.


Medications: Promote Uterine Tone

1. Pitocin (oxytocin)
10 units (1 ml) IM
Vastus lateralis or directly into myometrium if C/S patient
Up to 30 units (3 ml) into 1000 cc bag of an electrolyte solution
Titrate rate to keep uterus firm, bleeding minimal
2.  Methergine (methylergonovine)
O.2 mg IM or IV
Note patient’s BP before administering
IV carries more risk of complications (HPN, CVA)


Bimanual Compression

Used for severe cases of uterine atony
Combined with use of oxytocic medications
1 hand in vagina; other on abdomen


Bakri Tamponade Balloon

Into uterus - fill with saline - leave - direct pressure on wound - stop bleeding 



Primipara: uterus contracts & stays contracted
Multipara: intermittent uterine contractions
Worse with breastfeeding (oxytocin) !!! - lets milk down + uterus contractions 

Problems maintaining contraction

- Uterus overdistended
- Clots or retained placenta
- Use of pitocin during labor



Cx & lower uterine segment thin & collapsed; poor tone
Cx soft, edematous, many small lacerations
External os gradually closes & thickens 



1. Damage to soft tissues & support structures
- Small tears in fascia & musculature
2. Vagina: smooth, swollen, poor tone
- Tone restored, but rarely like nullipara’s
- Rugae reappear after 3 weeks; many not as thick as before
- Estrogen deficiency by 3-4 weeks = atrophy of epithelial cells (vaginal tissue)
- Poor lubrication, vasocongestion, sexual response
- Estrogen normal level 6-10 weeks - no intercoarse until 6 weeks post 


Introitus ( vaginal opening ) 

Red & swollen, especially if episiotomy or lacerations
Heals by 2 weeks PP if no infections or hematomas
Free of perineal pain
Extensive lacerations or poor repair = relaxed perineal floor - urine and fecal incontinence 


Layers of Tissue in Perineum


1st: perineal skin + subcutaneous layer
2nd: addition of perineal muscles
3rd: addition of rectal sphincter
4th: addition of rectal mucosa
Episiotomies cut through 2nd degree
Lacerations (tears) usually 1st & 2nd degree
Periurethral lacerations

                       - Midline (median)
                        - Mediolateral

                                       Right or left


Pericare (Perineal Care)

1. Ice packs x 24 hours - reduce swelling ( 20 min on ; 20 min off) 
2. Sitz baths ( 2/ day , 10 min ) - warmth brings blood flow to the area - WBC ( healing) + RBC
3. Peribottle
4. Topical lidocaine ( allergic to novocaine) 
5. Tucks (witch hazel) pads


Special Considerations: 3rd & 4th Degree Lacerations

Nothing per rectum
Emphasize dietary changes
Increase fluids
Increase intake of fruits/vegetables
Encourage ambulation
Stool softeners

* occur with midline episiotomie 




* Blue+black dime or smaller - ice for an hour; bigger - call doctor - hematoma - up to 1000 cc blood loss 


Fallopian Tubes

Respond to low estrogen level
Transient, non-bacterial inflammation by PPD #4
Gone once estrogen levels are restored to normal


Hormonal Changes

Decreased estrogen & progesterone reactivates hypothalamic-pituitary-ovarian feedback
FSH & LH rise gradually
Lower level than normal menstrual cycle
Breastfeeding governs if normal ovarian function, ovulation, menstruation returns


Bottlefeeding or Breastfeeding < 28 Days

FSH & estrogen levels rise to follicular phase concentration by 3rd week PP
Menses can occur 6-8 weeks PP
Menses before 6 weeks usually anovulatory
Initial ovulation usually about 10 weeks PP
By 12 weeks PP, 70% have first menses



Associated with delayed ovulation
 Menses return more gradually
12 weeks PP: 45% have menses
36 weeks PP: 55-75% have menses
First 1-2 cycles usually anovulatory
Unclear why delay in menses: possible influence of prolactin