The Postpartum Period

1. The Postpartum Period • Puerperium = fourth trimester of pregnancy- the 6-week interval between the birth of the newborn and the return of the reproductive organs to their normal nonpregnant state

2. Uterine Involution • Uterine Involution: • return of the uterus to its pre-pregnancy size and condition, which begins immediately after expulsion of the placenta with contraction of the uterine smooth muscle • Uterine fundal descent: • immediately after birth uterus is in the midline approximately 2 cm below the level of the umbilicus, size of grapefruit (like 16 weeks of gestation), weighs approximately 1000 g. • Within 12 hours the fundus may be approximately 1 cm above the umbilicus • During next few days the fundus descends 1 to 2 cm (fingerbreadth) every 24 hours. • By the sixth postpartum day the fundus is normally located halfway between the umbilicus and the symphysis pubis. • A week after birth the uterus once again lies in the true pelvis. • After the ninth postpartum day the uterus should not be palpable abdominally.

3. Uterine Involution • Increased estrogen and progesterone levels are responsible for stimulating the massive growth of the uterus during pregnancy. Prenatal uterine growth results from both hyperplasia, an increase in the number of muscle cells, and from hypertrophy, an enlargement of the existing cells. Postpartally, the decrease in these hormones causes autolysis, the self-destruction of excess hypertrophied tissue. The additional cells laid down during pregnancy remain and account for the slight increase in uterine size after each pregnancy. • Subinvolution is the failure of the uterus to return to a nonpregnant state. The most common causes of subinvolution are retained placental fragments and infection.

4. Lochia Assessment • Lochia–vaginal discharge after childbirth. • It takes 6 weeks for the vagina to regain its pre-pregnancy contour. • For the first 2 hours after birth the amount of uterine discharge should be approximately that of a heavy menstrual period. After that time, the lochia flow should steadily decrease. • Lochia: rubra, serosa or alba • Assessment of lochia includes noting color, presence and size of clots and foul odor. • Day 1- 3 - lochia rubra (blood with small pieces of decidua and mucus)   • Day 4-10-22-27 – lochia serosa (pink or pinkish brown serous exudate with old blood, cervical mucus, erythrocytes and leukocytes, tissue debris) • Day 11- 21 - lochia alba (yellowish white discharge with leucocytes, decidua, epithelian cells, mucus, serum, bacteria) • The amount of lochia is usually less after cesarean births. Flow of lochia usually increases with ambulation and breastfeeding and receives an oxytocin medication

5. LOCHIAL AND NONLOCHIAL BLEEDINGLOCHIAL BLEEDINGNONLOCHIAL BLEEDING Lochia • Lochia usually trickles from the vaginal opening. The steady flow is greater as the uterus contracts • A gush of lochia may result as the uterus is massaged. If it is dark in color, it has been pooled in the relaxed vagina, and the amount soon lessens to a trickle of bright red lochia (in the early puerperium). Bleeding • If the bloody discharge spurts from the vagina, there may be cervical or vaginal tears in addition to the normal lochia. • If the amount of bleeding continues to be excessive and bright red, a tear may be the source.

6. Cervix • The cervix is soft immediately after birth. • By 18 hours postpartum it has shortened, become firm, and regained its form. • The cervix up to the lower uterine segment remains edematous, thin, and fragile for several days after birth. • The ectocervix (portion of the cervix that protrudes into the vagina) appears bruised and has some small lacerations—optimal conditions for the development of infection. • The cervical os, which dilated to 10 cm during labor, closes gradually. • Two fingers may still be introduced into the cervical os for the first 4 to 6 days postpartum; however, only the smallest curette can be introduced by the end of 2 weeks. • The external cervical os never regains its prepregnant appearance; it is no longer shaped like a circle but appears as a jagged slit that is often described as a "fishmouth." • Lactation delays the production of cervical and other estrogen-influenced mucus and mucosal characteristics.

7. VAGINA AND PERINEUM • Vagina • vaginal mucosa is thin, atrophic, with decrease amount of lubrication and without rugae as a result of estrogen deprivation which lead to coital discomfort (dyspareunia) until ovarian function returns and menstruation resumes. • The greatly distended, smooth-walled vagina gradually returns to its prepregnancy size by 6 to 8 weeks after childbirth. Rugae reappear by approximately the fourth week, but they are never as prominent as they are in the nulliparous woman. Most rugae are permanently flattened. • Perineum • the introitus is erythematous and edematous, especially in the area of the episiotomy or laceration repair. It is barely distinguishable from that of a nulliparous woman • Episiotomy. Most episiotomies are visible only if the woman is lying on her side with her upper buttock raised or if she is placed in the lithotomy position. • Hemorrhoids (anal varicosities) are commonly seen. Internal hemorrhoids may evert while the woman is pushing during birth. Women often experience associated symptoms such as itching, discomfort, and bright red bleeding with defecation. Hemorrhoids usually decrease in size within 6 weeks of childbirth.

8. Endocrine System • Placental hormones (human chorionic somatomammotropin, estrogens, cortisol, and the placental enzyme insulinase) • dramatically decrease and reverse the diabetogenic effects of pregnancy, resulting in significantly lower blood sugar levels in the immediate puerperium. • Estrogen and progesterone levels drop markedly after expulsion of the placenta and reach their lowest levels 1 week postpartum. Decreased estrogen levels are associated with breast engorgement and with the diuresis of excess extracellular fluid accumulated during pregnancy. • In nonlactating women, estrogen levels begin to rise by 2 weeks after birth and by postpartum day 17 are higher than in women who breastfeed • β-Human chorionic gonadotropin disappears from maternal circulation in 14 days

9. Endocrine System • Pituitary hormones and ovarian function • The persistence of elevated serum prolactin levels in breastfeeding women appears to be responsible for suppressing ovulation. Because levels of follicle-stimulating hormone (FSH) have been shown to be identical in lactating and nonlactating women, it is thought that the ovulation is suppressed in lactating women because the ovary does not respond to FSH stimulation when increased prolactin levels are present • Prolactin levels in blood rise progressively throughout pregnancy. • In nonlactating women, prolactin levels decline after birth and reach the prepregnant range in 4 to 6 weeks • In breastfeeding woman prolactin levels remain elevated into the sixth week after birth, and influence by the frequency of breastfeeding, the duration of each feeding, and the degree to which supplementary feedings are used. • Ovulation occurs as early as 27 days after birth in nonlactating women, with a mean time of 70 to 75 days. Approximately 70% of nonbreastfeeding women resume menstruating by 3 months after birth. • In women who breastfeed, the mean length of time to initial ovulation is 17 weeks. In lactating women, both resumption of ovulation and return of menses are determined in large part by breastfeeding patterns. Many women ovulate before their first postpartum menstrual period occurs; thus there is need to discuss contraceptive options early in the puerperium. • The first menstrual flow after childbirth is usually heavier than normal. Within three to four cycles the amount of menstrual flow returns to the woman's prepregnancy volume

10. BREASTS • Promptly after birth, there is a decrease in the concentrations of hormones (i.e., estrogen, progesterone, hCG, prolactin, cortisol, and insulin) that stimulated breast development during pregnancy. The time it takes for these hormones to return to prepregnancy levels is determined in part by whether the mother breastfeeds her infant. • BREASTFEEDING MOTHERS • As lactation is established, a mass (lump) may be felt in the breast. Unlike the lumps associated with fibrocystic breast disease or cancer (which may be consistently palpated in the same location), a filled milk sac shifts position from day to day. Before lactation begins, the breasts feel soft and a yellowish fluid, colostrum, can be expressed from the nipples. After lactation begins, the breasts feel warm and firm. Tenderness may persist for approximately 48 hours after the start of lactation. Bluish-white milk with a skim-milk appearance (true milk) can be expressed from the nipples. The nipples are examined for erectility and signs of irritation such as cracks, blisters, or reddening. • NONBREASTFEEDING MOTHERS • The breasts generally feel nodular in contrast to the granular feel of breasts in nonpregnant women. The nodularity is bilateral and diffuse. Prolactin levels drop rapidly. Colostrum is present for the first few days after childbirth. Palpation of the breast on the second or third day, as milk production begins, may reveal tissue tenderness in some women. On the third or fourth postpartum day, engorgement may occur. The breasts are distended (swollen), firm, tender, and warm to the touch (because of vasocongestion). Breast distention is caused primarily by the temporary congestion of veins and lymphatics rather than by an accumulation of milk. Milk is present but should not be expressed. Axillary breast tissue (the tail of Spence) and any accessory breast or nipple tissue along the milk line may be involved. Engorgement resolves spontaneously, and discomfort decreases usually within 24 to 36 hours. A breast binder or tight bra, ice packs, or mild analgesics may be used to relieve discomfort. Nipple stimulation is avoided. If suckling is never begun (or is discontinued), lactation ceases within a few days to a week.

11. Fourth Stage of Labor • Goal of nursing care is to assist woman and their partners during their initial transition to parenting • Nursing's role is to monitor the recovery of the new mother and infant, to identify and manage promptly any deviations from the normal processes that may occur, and to promote and support parent-infant attachment

12. Fourth Stage of Labor • First 1 to 2 hours after birth • During this time, maternal organs undergo their initial readjustment to the nonpregnant state and the functions of body systems begin to stabilize. • Meanwhile, the newborn continues the transition from intrauterine to extrauterine existence • Excellent time to begin Breastfeeding • Encouraging of the mother • Colostrum prompting elimination of meconium

13. Care in the Immediate Postpartum Period • Assessment • During first hour every 15 minutes • During second hours every 30 minutes • VS (Ps, BP, T) • fundal height and firmness • bladder distension • amount of lochia • presence of edema • status of perineum, • Postanesthesia recovery (every 15 min) • Activity • Respiration • BP • Level of cosciousness • Color • general anesthesia • Awake, alert, orient to time, place, and person, respiratory rate, oxygen saturation levels at least 95%, as measured by a pulse oximeter • epidural or spinal anesthesia • should be able to raise her legs, extended at the knees, off the bed, or to flex her knees, place her feet flat on the bed, and raise her buttocks well off the bed. The numb or tingling, prickly sensation should be entirely gone from her legs. Often, it takes 1.5 to 2 hours for these anesthetic effects to disappear. • Providing comfort measures • Analgesics • Promoting bladder elimination • Providing fluid and food

14. Nursing Care After Cesarean Birth Same as with normal vaginal delivery except Postanesthesia recovery Monitoring of abdominal dressing Urinary catheter Respiratory care Prevention of thrombophlebitis Interventions for pain Slide 14

15. Postpartum Physical Assessment • B - breast • U - uterus • B - bowels • B - bladder • L - lochia • E - episiotomy

16. General Assessment • Enter the room quietly, speak quietly. • Wash hands and provide for privacy. • Inform patient before turning on lights. • Note LOC, activity level, position, color, general demeanor. • Take note of the total environment: • Safety/patient considerations • Note equipment and medical devices

17. Breast Assessment • Breasts: Soft, engorged, filling, swelling, redness, tenderness. • Nipples: Inverted, everted, cracked, bleeding, bruised, presence of colostrum or breastmilk. • Colostrum–yellowish fluid rich in antibodies and high in protein. • Engorgement occurs by day 3 or 4. Due to vasoconstriction as milk production begins • Lactation ceases within a week if breastfeeding is never begun or is stopped.

18. Nipple soreness is a portal of entry for bacteria - breast infection (Mastitis). • Maternal after pains: may be due to breastfeeding and multiparity • Always stay with the client when getting out of bed for the first time – hypotension effect and excess bleeding • When assessing fundal height, if you notice any discrepancies in fundal height have patient void and then reassess.

19. Assessing Uterine Fundus • Location in relation to umbilicus • Degree of firmness • Is it at Midline or deviated to one side? • Bladder Full? • A boggy uterus may indicate uterine atony or retained placental fragments. • Boggy refers to being inadequately contracted and having a spongy rather than firm feeling.

20. Massaging the Fundus • Every 15 mins during the 1st hr, every 30 mins during the next hr, and then, every hr until the patient is ready for transfer. • Document fundal height. • Evaluate from the umbilicus using fingerbreadths. • This is recorded as 2 fingers below the umbilicus (U/2), one finger above the umbilicus (1/U), and so forth. • The fundus should remain in the midline. If it deviates from the middle- distended bladder.

21. Uterine Atony • Lack of muscle tone in the cervix. • Uterus feels soft and boggy • The bladder has increased capacity and decreased muscle tone.  • This leads to over-distension of the bladder, incomplete emptying of bladder, retention of residual urine and increased risk of UTI and postpartum hemorrhage.

22. Bowels & Bladder • When was the patients last bowel movement? • Is she passing flatus? (gas) • Assess for bowel sounds • Voiding pattern - without difficulty/pain, urine may be blood tinged from lochia • Nursing interventions: Assist to the bathroom. Use measures to encourage voiding (privacy). Encourage use of peri-bottle with warm water, fluids, fiber, frequent ambulation, stool softeners; teach effects of pain medication.

23. Urinary System A full bladder can displace the uterus and lead to postpartum hemorrhage In the woman who voids frequently, small amounts of urine may have increased residual urine because her bladder does not empty completely Residual urine in the bladder may promote the growth of microorganisms Slide 23

24. Lochia: Pad Count • Scant: 1-inch stain on pad in 1 hour • Light/small: 4 inches in 1 hour • Moderate: 6 inches in 1 hour • Heavy/large: Pad saturated in 1 hour • Excessive: Pad saturated in 15 min • Can estimate blood loss by weighing pads: • 500 mL = 1 lb. or 454 g

25. Episiotomy/Perineal Assessment • Patient in lateral Sims (side lying) position. • Use the acronym REEDA • Redness, Edema, Ecchymosis, Discharge, Approximation of suture lines “edges of episiotomy”) to guide assessment. • Even if there is no episiotomy, the perineum should still be assessed. • Nursing care and patient teaching • Cold packs • Topical and systemic medications • Nonpharmacologic pain relief methods • Unusual perineal discomfort may be a symptom of impending infection or hematoma.Hemorrhoids ?

26. Episiotomy Pain Relief • Instruct Mother: • Tighten her buttocks and perineum before sitting to prevent pulling on the episiotomy and perineal area and to release tightening after being seated. • Rest several times a day with feet elevated. • Practice Kegel exercise many times a day to increase circulation to the perineal area and to strengthen the perineal muscles.

27. Postpartum Physical Assessment • B - breast • U - uterus • B - bowels • B - bladder • L - lochia • E - episiotomy

28. Routine care for the postpartum woman: Educate about danger signs (1) • Vaginal bleeding: • More than 2 or 3 pads soaked in 20-30 minutes after delivery, OR • Bleeding increases rather than decreases after delivery

29. Routine care for the postpartum woman: Educate about danger signs (2) Fever and too weak to get out of bed Severe abdominal pain

30. Routine care for the postpartum woman: Educate about danger signs (3) • Fast or difficult breathing • Severe headache, blurred vision • Convulsions

31. Routine care for the postpartum woman: Educate about danger signs (4) • Pain in the perineum or draining pus • Foul-smelling lochia Dribbling of urine or pain on micturition

32. Routine care for the postpartum woman: Educate about danger signs (5) The woman doesn’t feel well. Breasts swollen, red or tender breasts, or sore nipples

33. Postpartum Hemorrhage (PPH) Definition and incidence PPH traditionally defined as loss of more than: 500 ml of blood after vaginal birth 1000 ml after cesarean birth Cause of maternal morbidity and mortality Life-threatening with little warning Often unrecognized until profound symptoms

34. Etiology of PPH The causes of postpartum hemorrhage can be thought of as the four Ts: • tone, • tissue, • trauma, • thrombin

35. Postpartum Hemorrhage Etiology and risk factors (1) Uterine atony Marked hypotonia of uterus Leading cause of PPH, complicating approximately 1 in 20 births Brisk venous bleeding with impaired coagulation until the uterine muscle contracts 35 of 34

36. Postpartum Hemorrhage Etiology and risk factors (1) Uterine atony • Multiple gestation, • high parity, • prolonged labor • chorioamnionitis, • augmented labor, • tocolytic agents

37. Management of uterine atony • Explore the uterine cavity. • Inspect vagina and cervix for lacerations. • If the cavity is empty, Massage and give methylergonovine 0.2 mg, the dose can be repeated every 2 to 4 hours. • Rectal 800mcg. Misoprostol is beneficial.

38. Management of uterine atony During the administration of uterotonic agents, bimanual compression may control hemorrhage. The physician places his or her fist in the vagina and presses on the anterior surface of the uterus while an abdominal hand placed above the fundus presses on the posterior wall. This while the Blood for transfusion made available.

39. Complications of Puerperium • Uterine Atony (Cont’d) • Treatment • Uterine compression • Oxytocics • Early suckling causes endogenous release of oxytocin • Oxytocin IV/IM 10 units • Methylergonovine • Methyl prostoglandin F

40. Postpartum Hemorrhage Etiology and risk factors (2) • Lacerations of genital tract • Should be suspected if bleeding continues with a firm, contracted fundus • Includes perineal and cervical lacerations as well as pelvic hematomas 40 of 34

41. Postpartum Hemorrhage Etiology and risk factors (2) Lacerations and trauma • Unplanned • Vaginal/cervical tear, • surgical trauma •  Planned • Cesarean section, • episiotomy

42. Postpartum Hemorrhage Genital tract lacerations Management Genital trauma always must be eliminated first if the uterus is firm.

43. Postpartum Hemorrhage Etiology and risk factors (2)UTERINE RUPTURE Rupture of the uterus is described ascompleteor incompleteand should bedifferentiated fromdehiscenceof a cesarean section scar.

44. Postpartum Hemorrhage Etiology and risk factors (2)UTERINE RUPTURE The reported incidence for allpregnanciesis 0.05%, After one previous lower segment cesarean section 0.8% After two previous lower segment cesarean section is 5% all pregnancies following myomectomy may be complicated by uterine rupture.

45. Postpartum Hemorrhage Etiology and risk factors (2)UTERINE RUPTURE Complete rupture describes a full-thickness defect of the uterine wall and serosa resulting in direct communication between the uterine cavity and the peritoneal cavity.

46. Postpartum Hemorrhage Etiology and risk factors (2)UTERINE RUPTURE Incomplete rupture describes a defect of the uterine wall that is contained by the visceral peritoneum or broad ligament. In patients with prior cesarean section,

47. Postpartum Hemorrhage Etiology and risk factors (2)UTERINE RUPTURE dehiscence describes partial separation of the scar with minimal bleeding, with the peritoneum and fetal membranes remaining intact.

48. Management of Rupture Uterus The identification or suspicion of uterine rupture must be followed by an immediate and simultaneous response from the obstetric team. Surgery should not be delayed owing to hypovolemic shock because it may not be easily reversible until the hemorrhage is controlled.

49. Management of Rupture Uterus • Upon entering the abdomen, aortic compression can be applied to decrease bleeding. • Oxytocin should be administered to effect uterine contraction to assist in vessel constriction and to decrease bleeding. • Hemostasis can then be achieved by ligation of the hypogastric artery, uterine artery, or ovarian arteries.

50. Management of Rupture Uterus • At this point, a decision must be made to perform hysterectomy or to repair the rupture site. In most cases, hysterectomy should be performed. • In selected cases, repair of the rupture can be attempted. When rupture occurs in the body of the uterus, • bladder rupture must be ruled out by clearly mobilizing and inspecting the bladder to ensure that it is intact. This avoids injury on repair of the defect as well.