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Home , Areola, Childbirth, Fissure of the nipple, Involution (medicine), Lochia, Orthostatic hypotension

3/21/2018

Starting at her head

“Are you Postpartum Physiology, experiencing a “Any visual headache?” changes… such what’s normal? as blurry vision/ seeing spots?” Let’s go over a head to toe maternal “I am going to be your postpartum assessment together temperature. When you are at home if you have an She may have temperature of 100.4 questions about or greater you need to contact your her , the provider” possible changes

Neurologic Changes/Conditions Postdural puncture headache (spinal headache) • Headache • Leaking of cerebrospinal fluid from the site of a – Most common neurologic symptom puncture of the dura mater –Can occur from • Most common when dura is accidently punctured during epidural placement • Fluid shifts • Assuming an upright triggers a change in • Stress volume of CSF and leaking • Spinal headache – Intensifies headache – • Fluid and Electrolyte imbalance Auditory problems – Visual problems • Preeclampsia • begin within 2 days and may persist for days or weeks

Postdural puncture headache Temperature

• Nursing Care If in the first 10 days postpartum (excluding – Administration of oral and methylxanthines the first 24 hours post delivery) if mom has: ( or theophylline) – Remain laying as position change precipitates the fluid • Oral temperature of >100.4 degrees Fahrenheit shift on two occasions that are 6 hours apart think – Epidural patch possible puerperal • 20 ml of the patient’s blood is injected slowly into the lumbar area of the epidural space. – Cardinal symptoms of postpartum infection include an • This creates a blood clot that patches the dura mater elevated temperature, , and pain. • Most rapid and beneficial relief method

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Vital signs What is a puerperal infection? Normal Findings Deviations From Normal Findings with probable causes • An infection of the reproductive tract associated Temperature: Temperature: Slight increase in the first 24 hours to 38 degrees C (100.4 greater than 38 degrees C (100.4 degrees F) after 24 hours with , which may occur anytime up to degrees F) due to . Afebrile after 24 hours can be indicative of infection (, , , other systemic ) six weeks post delivery Pulse: Pulse: • Most common puerperal infection is Slight elevation in first hour after that gradually Rapid or increasing pulse rate can indicate declines over 48 hours. Puerperal bradycardia of 40-50 bpm endometritis is common • A mom may be discharged prior to symptoms of a Respirations: Respirations: Return to pre- rate soon after birth Hypoventilation can be a result of an unusually high spinal puerperal infection becoming apparent, proper block or epidural medication after a cesarean section

discharge teaching is necessary. About 84% of : Blood Pressure: Slight transient return of approx. 5% increase over the first can indicate hypovolemia (late sign), manifest after discharge few days to weeks after delivery. can be caused by excessive use of may be a result of splenic engorgement after birth vasopressor or . may from the . continue for weeks after delivery, assess for corresponding signs of preeclampsia

Integumentary Changes How often to complete a • Cholasma (mask of pregnancy) comprehensive maternal assessment? – Usually disappears in the postpartum . May persist in First Hour Second Hour First 12-24 Hours about 30% of women • Hyperpigmentation of areola and linea negra may not Every 15 Minutes Every 30 Minutes Every 4 hours completely regress • Striae gravidarum () on , abdomen, and • Follow your facility’s protocols thighs may fade but usually do not disappear completely • This is a guide, may need to be done more frequently • Spider angiomas and palmer usually regresses • To promote maternal safety and optimal outcomes there rapidly due to decreased have not been clinical trials to state exactly how often to – Spider angiomas may persist indefinitely in some women assess during the : guidelines state • may occur as the rapid growth associated with what to assess but don’t states exactly how often pregnancy ends • Except temperature, 2008 ACOG and AAP state at least • Hair and nail strength return to pre-pregnancy states every 4 hours during the immediate postpartum period AWHONN Perinatal Nursing 2014

Maternal Blood Pressure Maternal Blood Pressure If there is a rise in blood pressure • Many women have a rise in blood pressure • Continue to closely observe blood pressure right after delivery readings. If the reading is 140/90 mm Hg on two or • This is a transient increase in both the systolic more occasion at least 6 hours apart (AWHON 2014) and diastolic • Or this patient is having headaches/visual changes • This will spontaneously return to the pre- the health care provider needs to be aware (AWHON 2014) pregnancy baseline over the next few days

Be aware that preeclampsia can persist into or occur for the first time in postpartum

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Nursing Care

• Orthostatic hypotension may happen in the first 48 hours post delivery – May be due to the decrease in intrapelvic pressure – She may feel dizziness right after moving to a standing position

Maternal Blood Pressure • How should BP be taken? Let’s Discuss – See resources section under Hypertension for full hand out on how to properly measure a Cardiovascular blood pressure Changes

Decreased Rate Elevated Heart Rate

• Bradycardia is common during the first 6-10 • Tachycardia needs to be evaluated, may be days after delivery due to: • The heart rate is 50-70 beats per minute – Blood loss possibly related to: – Temperature elevation – Decreased cardiac strain – Infection – Decreased blood volume following placental – separation – Fear – Increased volume – Pain

3 3/21/2018

Cardiovascular Changes Cardiovascular Changes

• Immediately following birth, • This will create an increased stroke volume (the autotransfusion occurs amount of blood pumped with one contraction) which will increase the • So the 500-700 mL per minute of blood flow that • Which is what? was going to the uteroplacental unit is now in just the maternal systemic venous circulation right after delivery • It means that the blood that was going

through the stops, creating more blood circulating in just the maternal system

Cardiovascular Cardiac output

• Changes in blood volume is dependent on 10-15 minutes post delivery – Blood loss during birth cardiac output is at the highest – Amount of extravascular fluid that is excreted One hour post • Average blood loss delivery cardiac – Vaginal deliveries 300-500mL output reaches pre labor value By 6-12 weeks – Cesarean section deliveries 500-000 mL postpartum the cardiac output Delivery reaches prepregnant levels Declines by 30% in the first 2 weeks

Cardiovascular Peripartum Cardiomyopathy

• Maternal Physiological changes that allow the Defined as: new to accommodate for changes in “a weakness of the heart muscle that by definition blood volume include: begins sometime during the final month of – Elimination of utero-placental circulation • Reduces vascular bed by 10-15% pregnancy through about five months after – Loss of placental endocrine function delivery, without any other known cause.” • Removes the stimulus for • Dr. Lili Barouch, Assistant Professor of , Division – Mobilization of extravascular fluid of , Johns Hopkins School of Medicine • Movement of fluid from extravascular spacing to vasculature happens by 3rd day postpartum

4 3/21/2018

Peripartum Cardiomyopathy Signs and Symptoms

• Actual cause is unknown Present with signs and symptoms of pulmonary • May be associated with nutritional and immunologic mechanisms – Dyspnea- difficult or labored breathing • Higher Incidence in: – Cough – Older gravidas – Orthopnea- sensation of breathlessness in the – Multiparas recumbent position, relieved by sitting or standing. – African-Americans – Tachycardia – Multiple – Occasional hemoptysis- coughing up blood or blood – Patients with preeclampsia tinged mucous

Evaluation of Respiratory Changes Respirations

• Should remain within the normal range of 12- 20 breaths per minute

• Variations to this may be: – pain, fear, excitement,

• Immediate attention is needed if she also has shortness of breath, chest pain, , restlessness…. could be a pulmonary emboli

Pulmonary Normal Respiratory Changes Most common signs: Most serious signs • Tachpnea (>20 • Sudden breaths/min) collapse/ After delivery the reduction in the • Tachycardia (>100 • Cyanosis intra abdominal pressure allows for beats/min) • Hypotention increased expansion of the diaphragm. • Dyspnea-labored breathing, • Presyncope Mom feels like she can take that deep shortness of breath breath again! • Chest pain • Hemoptysis- coughing up of blood or bloody sputum • Abdominal pain

5 3/21/2018

Respiratory Respiratory • When you let your breath out there is remaining air in your , this is called residual volume

• This too will normalize for mom soon after the baby is delivered

• Everyone take a deep breath in….. Let that breath out

• The volume of air you just inhaled and exhaled is called tidal volume

• Tidal volume normalizes for mom soon after birth

• To help prevent a mom from getting into a shallow Postpartum Neuraxial breathing pattern we should teach patients how to perform pulmonary exercises Who is a candidate? – Place her in a high fowler’s position, use a pillow to support her incision and instruct her to take a deep • cesarean deliveries • extensive ,3rd or 4th degree lacerations breath and cough. – If available utilized respiratory therapists to assist in the Effective pain relief? patient education – Administering pain medication prior to pulmonary • Yes, when compared to IV administration of medication it: exercise may be beneficial • Provides better pain control in the first 24 hours – Explained that these exercises will help reduce the following delivery chance of and by promoting • Earlier ambulation • Earlier bowel function in postoperative cesarean adequate function patient

Neuraxial Morphine Postpartum Neuraxial Morphine • Nursing Care Early-onset respiratory depression – Monitor Level of Consciousness 30-90 minutes after administration – Respiratory Rate every hours if epidural morphine administered for 12-24 hours Late-onset respiratory depression • Notify if respiratory rate is <10 or other specified criteria 6-18 hours after administration – If the patient received EREM (Depodur) a sustained release formulation Women at an increased risk for respiratory • Assess respiratory status for 48 hours depression – Pulse oximetry 12-24 hours post epidural morphine administration • Notify anesthesia if O2 saturation <90% • Morbidly Obese • Pulse oximetry is not sensitive to hypercarbia or hypoventilation • Concurrently receiving magnesium sulfate – Narcan (Naloxone 0.1 mg IV push at the bedside in case of • History of obstructive sleep apnea respiratory depression

6 3/21/2018

Breasts Nursing Care: If , assess for:

• Size and shape of the breasts • Any abnormalities, reddened areas, or engorgement • Palpate for softness, slight firmness associated with filling, or firmness associated with engorgement • Warmth • Tenderness

Nursing Care: Breasts Explain the difference to patients

Breast Fullness Engorgement If breastfeeding, assess for: • transitional fullness will • overfilling and swelling of the usually last about 24 hours breast and/or areola • Fissures • the breast will still be soft • typically be painful, warm to enough for the baby to nurse the touch, skin will appear • Cracks shiny and taut • Typically no pain, but a sense • Soreness • engorgement can occur at any of fullness to the breast time • Inversion • will occur about the 3-5th day • initiation of breastfeeding post delivery soon after delivery, and • breast fullness is normal and offering frequent feedings will will resolve reduce the chances of engorgement

Nursing Care: Breasts Nursing Care: Breasts

If bottlefeeding, assess breasts for: Bottlefeeding mother

• Size • No evidence currently exists to show that • Shape nonpharmacologic approaches to suppress • Tenderness are more effective than no treatment Oladapo & Fawole, 2009 • Color • In the United States medication to suppress lactation is no longer given

7 3/21/2018

Nursing Care: Breasts Nursing Care: Breasts

Bottlefeeding mother The goals of breast care are prevention of • Bathe breasts during daily shower, but inform infection, adequate breast support, and her to allow the warm water to run over her maternal comfort shoulder instead of directly at her breasts • Avoiding breast and stimulation is recommended • Breast Binding is no longer recommended

Uterus Uterine Changes

B) 6-12 Hours Postpartum

A) Immediately Postpartum

As the nurse We need to understand Involution: the return of the uterus to a • the expected involution process of the nonpregnant state after birth uterus to know if there is a need for • Reduction in size occurs over 6 weeks intervention • Fundus will go through involution at a rate of • palpate the fundus, where is it located and 1 finger breadth (1 cm) per day how does it feel? • Decreased estrogen and • a boggy uterus, a uterine height higher contribute to uterine cell and than normal, or a uterus that is displaced autolysis (self destruction of excess from midline needs to be investigated hypertrophied tissue). Cell number remains the same.

8 3/21/2018

Uterine Involution Assessing the Uterus • Have the woman void prior to assessment, a • Factors that enhance involution distended bladder may cause the uterus to deviate, typically to the right • Uncomplicated labor & birth • Make sure the woman is in a supine position • Complete expulsion of amniotic membranes • The clinician should have one hand at the level of the and placenta umbilicus and the other hand right about the symphysis pubis to stabilize the uterus. The support • Breastfeeding is need to help prevent and • Manual removal of the placenta during prolapse • The hand at the umbilicus will push down and in to cesarean section feel the fundus • Early ambulation • The fundus is the part of the uterus above the insertion of the fallopian tubes

Uterine Subinvolution

• Subinvolution: failure of the uterus to complete the process of involution

Perinatal Nursing, AWOHNN 2014

Factors That Slow Uterine Involution Factors That Slow Uterine Involution Factor Rationale Factor Rationale Full Bladder Interferes with effective uterine Prolonged Labor Muscles relax because of contractions prolonged time of contraction during labor Incomplete Expulsion of Placenta Interferes with ability of uterus to

or Membranes remain firmly contracted Anesthesia Muscles relax

Infection interferes with Difficult Birth Excessive manipulation of the uterus’ ability to contract

uterus effectively

Grandmultiparity Diminished uterine tone and Over distention of Uterus Overstretching from multiple muscles relaxation from repeated , hydramnios, or large baby

9 3/21/2018

What is ? In the case of subinvolution • Lack of • Is the leading cause of early postpartum postpartum • The doesn’t typically progress like it is hemorrhage (50% off PPH cases) suppose to • Subinvolution is most commonly diagnosed • If the uterus is not contracting and putting during her follow up exam in the clinic pressure on these vessels: • Treatment depends on the reason the uterus is – the uterus will fill with blood and clots not going through the involution process – Not Good! – this will lead to hemorrhage

– frequent uterine assessment is necessary

Placental Site Vaginal Changes

• After delivery the placenta should separate • may appear edematous, gaping, and/ spontaneously or bruised • The placental site heals by exfoliation • Vaginal mucosa might appear pale and • Tell patients they may have an increase in without rugae around postpartum day 7-14 • The post-delivery hymen has characteristic • This is due to the placental site sloughing off, small skin tags at its edges but this bleeding should only last a few hours • The labia majora and the labia minora are looser

Uterine Contractions Afterbirth pains comfort measures • Compression of the intramyometrial blood vessels • Pain Medications by contraction of the uterine muscle is the primary – (24 hour maximum dosage 3200mg) or source of postpartum homeostasis. Acetaminophen (24 hour maximum dosage 4000mg) • Afterbirth pains – Narcotic analgesics as prescribed (with attention to – Strong of the involuing uterus medications containing Acetaminophen) – Caused by oxytocin release from the posterior pituitary • Take pain medications approximately 1 hour prior to • May be more severe with breastfeeding nursing • May be accompanied by an increase of lochia • Prone position with small pillow under abdomen – More common in multipara women, women with an – The position applies pressure to uterus and stimulates overdistended uterus, or if clots or retained placental contraction. The constant contraction eases the after birth fragments remain in uterus. pain. – Usually lasts 2-3 days • Warm compress or water bottle to lower abdomen

10 3/21/2018

Bladder Changes • Transient loss of bladder tone or decreased bladder tone is expected during pregnancy due to the effect that progesterone has on • The fetal head pressing on the bladder during labor may have caused some trauma/edema • This may cause a decreased sensation making voiding difficult

• Diuresis occurs due to: Nursing Care: Urinary System – Decrease in estrogen which stimulated fluid retention during pregnancy • Assess for bladder distention and encourage the – Decrease in residual hypervolemia, or fluid woman to empty her bladder regularly overload • Stimulate voiding by running tap water or pouring – Reduction in venous pressure in the lower half of warm water over the the body • Uterine atony that can be caused by bladder – Profound diuresis can begin immediately after distention delivery and spontaneous voiding usually returns • C-Section patients should have I/O documented until within 6-8 hours post delivery spontaneous voiding after removal – Bladder fills rapidly after delivery due to the • Patient should void spontaneously by 6-8 hours after marked increase in urine production birth – Urine volume should return to pre-pregnant levels • Expected volume is 150 ml for each void by 2-3 days after delivery • (Simpson and Creehan, 2014)

Nursing Care: Urinary System Perfect environment for a UTI…

• Catheterize if bladder is distended and patient A bladder that experienced trauma from is unable to void delivery, bacteria that may have been – Avoid Rapid Emptying introduced during catheterization, and retention – Do not remove more than 800 ml at one time of residual urine give way to an environment to – This prevents a precipitous drop in intraabdominal develop cystitis pressure and splenic engorgement and Typically symptoms of cystitis happen around 2- hypotension 3 days post delivery

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Make Sure Patient’s Know the Signs of If cystitis is suspected… a UTI • Urinary frequency • The nurse may need to assist the postpartum • Dysuria women with obtaining a urine sample. In • Urgency order to not contaminate the sample it needs • Hesitancy to be obtained during midstream to avoid • Dribbling getting lochia in the sample • Nocturia • Then the sample is sent for microscopic • Suprapubic pain examination, culture, and sensitivity tests. • May have gross hematuria • Odor

Transient Stress Incontinence Discuss

Causes? • Explaining that proper perineum care is essential • Conflicting evidence to support if pregnancy during this healing process. predisposes women for and • A reminder to use the peri bottle, hands or if it is after a certain before and after peri care, wipe from front to number of vaginal increases the risk of developing urinary incontinence and pelvic organ back, change the peri pad often. prolapse • Once the lochia has stopped the is closed • Factors that influence it and the chance of infection ascending from the – Length of second stage of labor vagina to the uterus reduces. – ’s head size – Infant’s –

Urine components Urine components • Plasma Creatinine (Creatinine is a waste product produced by • Renal glycosuria (simple sugar glucose is excreted in the muscles from the breakdown of a compound called creatine. Almost urine despite normal or low blood glucose levels) all creatinine is filtered from the blood by the kidneys and released – Induced by pregnancy, usually disappears by 1 week postpartum into the urine, so blood levels are usually a good indicator of how well the kidneys are working.) • Lactosuria (abnormal amount of lactose in the urine) – Return to normal by 6 weeks – Occurs in lactating women • (presence of excess proteins in the urine) • Blood Urea Nitrogen (medical test that measures the – Resolves by 6 weeks amount of urea nitrogen found in blood. The • Ketonuria (ketone bodies are present in the urine, the body produces urea in the urea cycle as a waste product of the produces excess ketones as an indication that it is using an alternative digestion of protein.) source of energy. It is seen during starvation or more commonly in – Increases during postpartum as autolysis as uterine involution type I mellitus.) occurs – Occurs with dehydration in women with uncomplicated births or prolonged labor

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Bowels Gastrointestinal System Changes Gastrointestinal System • Bowels sluggish after birth due to • Bowel movement may not happen for 2-3 days

– lingering effects of progesterone – decreased abdominal and intestinal muscle tone – the peptide depresses bowel motility

http://www.thevisualmd.com/panel/?c=564.00

To Facilitate Normal Bowel Function Cesarean Deliveries

• After a cesarean delivery moms may start with • Drink water clear liquids • Eat a high fiber diet • Typically once bowel sounds are present the diet • Don’t ignore it can advance to solids • Ambulate early! • Avoid Straining • Gas build up can occur following a cesarean birth • Ambulate because of the anesthesia and intestinal • Stool Softeners manipulation, moving will help expel some of the gas • Medication • Stool softeners and other medications are available

Nursing Care: Nutrition Gastrointestinal

• Assess the woman’s appetite Assess for • Most women are hungry and thirsty post • Antiemetic medications include –Ondasetron (Zofran) • Provide the woman with a menu to select –Promethazine (Phenergan) meals that appeal to her appetite –Metoclopromide (Reglan) • Make snacks readily available • Encourage foods high in protein, roughage, vitamins and minerals

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Nursing Care: Gastrointestinal Abdominal Incision • Gas pains • The nurse needs to include assessing the – Ambulation incision, looking for: – Rocking in a rocking chair – Approximation of the edges – Avoiding gas-forming food – Is there any: Redness, Discoloration, – Avoiding carbonated beverages Warmth, Edema, Unusual Tenderness, or Drainage

Microsoft Clip Art

Wound infections from cesarean section or Abdominal Incision dehiscence – Elevated temperature on 3rd or 4th post Teach the signs of infection and proper care for the delivery day, can be masked by early area. postoperative • If she notices foul odor, fever, redness around the – Presence of incision, discharge from the incision, or the – Redness, indurated (hardened), and incision appears open she needs to call right away. inflamed appearance around the • She can shower as usual and just pat the area repaired edges around the incision dry. – Discharge from the incision, such as pus or blood • Remind her if there are steri-strips that they will – Incision appears open and abdominal fall off and not to pull them. contents are exposed to air – Often associated with endometritis

Postpartum Endometritis (metritis)

• An infection of the uterine lining • Postpartum endometritis happens in 1-3% of vaginal births and about 10 times more common for cesarean deliveries • Administration of prior to cesarean delivery can decrease the incidence of endometritis • Findings in the first 24-36 hours post delivery tend to be related to group B (GBS). Late- onset is more commonly associated with genital and trachomatis

14 3/21/2018

Symptoms for Endometritis (metritis) Treatment

• Foul smelling lochia • Typically treated with IV antibiotics, • Fever (typically between 101-104 degrees cephalosporins or penicillin Fahrenheit) • Mom typically will improve within a few days of • Uterine tenderness on palpation initiated treatment • Lower abdominal pain • Treatment is typically continued until mom is • Tachycardia afebrile and for 24 hours • • Chills If a fever continues at the 48 hour mark after antibiotics then additional investigating is needed to check for refractory pelvic infection

Be aware of the risk factors for Be aware of the risk factors for Postpartum Uterine Infection Postpartum Uterine Infection • • Manual removal of the • Cesarean Delivery (single • Multiple vaginal (infection of the placenta, most significant risk) examination during labor placenta or uterine , and ) exploration after delivery • Prolonged premature • Compromised health rupture of the amniotic status (low socioeconomic • Pre-existing bacterial • Retained placental membranes status, , obesity, vaginosis or Chlamydia fragments • Prolonged labor preceding smoking, use of illicit trachomatis infection • Lapses in aseptic cesarean birth drugs or alcohol, poor • Instrument assisted technique by surgical staff nutritional state) • Obstetric trauma childbirth (vacuum or • Diabetes mellitus (episiotomy, laceration of • Use of fetal scalp forceps) perineum, vagina, or electrode or intrauterine • Immunocompromised cervix pressure catheter status

What about Postoperative Prevention for DVT’s? May have questions about Changes Even if a mom is at a low risk for thrombogenic thrombophilias she needs postoperative Stretch marks prophylaxis. Treatment is aimed at preventing VTE (Venous Thromboembolism) • Common on breasts, abdomen, hips, and thighs fade, but usually do not disappear • Nonpharmacolgic Interventions • It is caused by the stretching of the skin and – Graduated elastic softening and relaxing of the dermal collagenous – Pneumatic compression devices and elastic tissues

15 3/21/2018

We are going to talk Episiotomy about ways to care Episiotomy for your perineum, including hygiene and also pain • Surgical enlargement of the vagina management • Incision to the perineum, completed in the last part of the second stage of labor

Monitoring for • Based on 2012 hospital discharge date about infection is 12% of vaginal births had an episiotomy important let’s talk about the • Compared to 1992’s data which stated about signs and 54% symptoms you need to know about for when

you go home (Ward & Hisley, 2016 p 456)

Perineal Lacerations Perineal Lacerations • First Degree • With a vaginal delivery around 53-79% of women – Laceration that extends through the skin and structures superficial to the muscle will have some type of laceration – Perineal skin and mucous membranes • Most common are 1st and 2nd degree lacerations • Second Degree – Laceration that extends through muscles of the perineal body • Occur as the fetal head is being born – Skin and mucous membranes plus fascia and muscles of perineum • • Third Degree Repairs should be attended to quickly to promote – Laceration that continues through the anal sphincter muscle healing, and limit the damage – Skin, mucous membranes, muscle of the perineum, extends into rectal sphincter • If mom has an operative assisted delivery or • Forth Degree precipitous labor she is at an increased risk – Laceration that also involves the anterior rectal wall – Extends into rectal mucosa to expose

Perineal Lacerations Severe Perineal Lacerations • Bleeding from the laceration is one of the most • Mother may get a single dose of antibiotic common complications during the repair • Observe for hematoma formation • Monitor to evaluate would healing • If the laceration extends into or through the • Some Expert Opinion Suggestions for OASIS: anal sphincter complex it may be referred to as – Stool softeners and oral Obstetric Anal Sphincter Injuries (OASIS) – Instruct patient on how to avoid • These need additional teaching and – Early and consistent follow up care education geared toward healing

16 3/21/2018

Let Your Patients Know… Nursing Care: Pelvic Muscular Support

• After delivery the soft tissue in and around the • Instruct the mother that Kegel exercises can perineum may be swollen and bruised improve the tone and contractibility of the vaginal opening • Initial healing of the episiotomy occurs within

2 to 3 weeks • Can be started soon after delivery • Supportive tissue of the is stretched and during birth and complete • Kegel exercises can help to maintain perineal healing may take 4 to 6 months muscle tone and help prevent urinary leakage

Kegel Exercises Nursing Care: Perineum

• Contracting the muscles of the perineum with • Assess perineum with the mother laying in a Sims’ enough force to stop a stream of urine position and the buttock is lifted to show the • The contraction is held for about 5 seconds and perineum and anus. then released • Use the acronym REEDA as a guide • This exercise is repeated 4 to 5 times in a row • Redness • Then work up to keeping the muscles tightened • Ecchymosis/bruising (purplish color) for 10 seconds at a time, then relaxing for 10 • Edema (swelling) of the perineum seconds. Goal is to complete 3 sets of 10 • Discharge from the episiotomy repetitions a day • Approximation of the skin edges

Nursing Care: General Perineum Nursing Care: General Perineum Sitz Bath • Provide comfort measures for perineal/rectal pain: • A portable basin that will fit in the toilet, the water will sooth the tissue and reduce inflammation by promoting – Ice packs vasodilation

– Sitz baths • Offer either cool or warm water and allow woman to chose – Peri bottle which temperature she wants

– Anesthetic sprays • She should utilize the sitz bath for 20 minutes at a time, three to four times daily – Topical creams – Witch hazel pads (to reduce edema) • This can be initiated 24 hours or more post delivery

17 3/21/2018

Nursing Care: Perineum Nursing Care: Perineum

• Be sure to consider cultural norms before Peri bottle application. • Intended use of peri bottle is to squirt warm • Some cultural groups considered blood “hot” water toward the front of the perineum and and when she looses blood she is now in a let it run from the front to the back. This can “cold” state. To avoid illness the mother needs relieve discomfort and keep the area clean. to return back to a hot state.

Signs of infection of the episiotomy or General Prevention of Postpartum repaired laceration of the perineum Infection may include: • Proper , by everyone • Adequate nutrition, fluids, and rest • Redness • Encourage complete emptying of her bladder • Warmth • Proper breast and perineal hygiene • Edema • Breastfeeding support, to help minimize nipple • Purulent drainage trauma and ensure breast emptying • Gaping of the previously approximated • Education to non-breastfeeding moms to minimize breast stimulation • Local pain

Quick Chart for Infections Postpartum Could be a result from: C/S, PROM, multiple vaginal exams, Endometritis fetal scalp electrode, forceps/vacuum, pre-existing vaginal May fear first bowel movement (metritis) infection, lack of aseptic technique. May also be due to maternal behaviors: drug use, smoking , poor nutrition. Signs: may have foul/scant lochia, uterine tenderness, elevated • The woman with an episiotomy or temperatures, tachycardia, chills. Parametritis (Pelvic Could be a result from: bacteria getting into a cervical may fear the her first Cellulitis) laceration or pelvic . Signs: may appear, may have chills, high fever, abdominal pain, uterine bowel movement due to anticipated subinvolution, local and rebound tenderness, tachycardia, abdominal distention, nausea, vomiting. pain, thus she tries to delay it

Urinary Could be a result from: , urinary retention, contamination from a catheter Signs: dysuria, fever, urinary retention

Wound Could be a result from: contamination of laceration, episiotomy, c/s incision Signs: erythema, local pain, purulent discharge, edema, possibly dehiscence

18 3/21/2018

Nursing Care: Hemorrhoids Nursing Care: Hemorrhoids

• Hemorrhoids, distended rectal , may • Teaching to mother: become larger in the second stage of labor due – Sit on flat, hard surfaces – Avoid soft surfaces to the pressure on the lower bowel • Why? • However, after delivery the hemorrhoids reduce – Soft surfaces separate the buttocks and decrease the in size and can be manually inserted into the venous flow, and intensifies the pain rectum if needed – Tighten buttocks before sitting – Lay on her side instead • Educate her on the suggestions to facilitate • Provide comfort measures: normal bowel function to help ease her mind – Ice Packs about the potential pain with the first bowel – Anesthetic sprays or ointments – Cool witch hazel pads movement

Cervix • Immediately following birth, the cervix and lower Lochia uterine segment are thin and flaccid • The external cervical os never regains its pre-pregnant appearance When to call • The cervix may appear: spongy, flabby, formless, and/or your provider bruised • Over next 12-18 hours the Cervix shortens and What the expected becomes firmer progression of vaginal • Within 2-3 days should be – Cervix has shortened, firmed and regained its form – Os will close to 1 cm by one week after birth – Appearance will no longer have circular shape but rather a jagged slit “fish mouth”

Lochia Lochia Lochia Color Time Frame Constituents • Lochia occurs in 3 stages and is classified Rubra Dark red First 1-3 Epithelial cells, blood, blood clots, according to its appearance and contents days fragments of , and – Lochia Rubra – Lochia Serosa Serosa Pink or Days 3-10 Blood, mucus, and invading leukocytes – Lochia Alba brown

Largely mucus, Alba White Days 10-14 The total amount of lochia varies by person, leukocyte count up to 6 weeks the average volume is 150 -400 mL (creamy or high yellowish)

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Things to tell your patient… Lochia Amount

• This discharge normally has a musty, stale Amount Description odor that is not offensive Scant amount Blood only on tissue when wiped or less than 1 inch stain on peripad within 1 • Any foul odor is suggestive of infection and hour they should call their health care provider Light amount Less than 4-inch stain on peripad within • Lochia is heavier in the morning than at night, 1 hour there is pooling in the vagina and uterus when Moderate Less than 6-inch stain on peripad within the she is in a lying position amount 1 hour • The amount of lochia may also be increased Heavy amount Saturated peripad within 1 hour by exertion or breastfeeding From Davidson, London, & Ladewig (2012, p. 1011).suggested guidelines for assessing lochia volume

Less than 4-inch stain on peripad Visual verses Measuring Scant amount within 1 hour • A visual account of blood loss can vary person less than 1 inch stain on peripad within 1 hour Light amount to person • Weighing the pads is more accurate Less than 6-inch stain on peripad within 1 Heavy amount hour • You must know the dry weight of the pad • Peripads can be weighed if needed: Moderate amount Saturated peripad within 1 hour 1 gram = 1 ml of blood

From Littleton & Engebretson (2002). Maternal, Neonatal, and Women’s Health Nursing. Albany, NY: Delmar, p. 892

• To help mothers endure the blood loss at delivery the body will have a 30-45% increase in the blood Things to tell your patient volume at term. • What the expected progression of lochia • The body typically holds about 5 Liters of should be blood, depending on the size of the person. • Notify her health care provider if: – Bright-red lochia returns after lochia has stopped • Blood loss for an uncomplicated vaginal delivery – Persistent discharge of lochia rubra or a return to lochia rubra can indicate subinvolution or – 500 ml postpartum hemorrhage – An offensive odor, may suggest infection • Blood loss after cesarean – 1000 ml or more

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Homans Sign (Legs) How Many Assess for Homans sign? Some don’t conduct a Homans sign during the assessment • Stating it is not diagnostic and may lead to an embolus if the clot becomes loose while the nurse is assessing • The other hand is that there are no published reports of an embolus occurring due to conducing a Homans sign • How it is performed: The nurse will abruptly and with force dorsiflex the ankle while observing for

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Break this down…you need to remember

Postpartum mothers are at more of a risk for Mom has a high-volume, high-flow, and low- resistance uteroplacental circulation that is meant –Thrombophelbitis to support fetal development so she has measures in place to prevent maternal hemorrhage… such as –Thrombus formation increase in concentration of coagulation factors and –Inflammation involving a vein fibrinogen. The down side… now mom is at an increased risk venous and pulmonary embolus.

Deep vein thrombosis (DVT) Assessment & Education about DVT’s Physical Findings: is important • Pain/tenderness • • Tenderness with palpation More common in the postpartum period • Change in surface temperature between days 10-20 • Edema (usually one is larger) • About 90% of Pulmonary (PE) • Erythema (red/patchy skin color) come from lower extremity DVT’s! • Mottled appearance (discolored/patchy skin color) • Difference in leg circumference of each leg

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Thromboembolic Evaluation of Neuromuscular System Changes Postpartum measures to decrease the risk: – Early ambulation – Leg exercises in bed and turning frequently, every two hours – Use of antiembolism stockings for those woman at risk – Avoid pressure behind knees & crossing the legs – Avoid sitting for extended periods of time – Promote elevation of the legs while sitting – Avoid dehydration, promote fluids – Encourage the woman not to smoke

Nursing Care: Neuromuscular Postpartum Chill

• Observe for return of full sensory • Right after delivery some may have intense tremors/shivering • Assist with ambulation mother may not have • As long as there is no fever present this is not a all her sensation yet or could be dizzy due to threat to mother orthostatic hypotension • Comfort measures to help can include a warm blanket, warm drink, reassuring her that it is • Have mom sit on the side of the bed, wait, common and will dissipate and gradually go to a standing position

Integumentary

• During first postpartum week profuse afebrile diaphoresis is common, especially at night, as a mechanism to secrete excess accumulation of fluid • Nursing Care Immune System – Instruct woman that excessive sweating is normal – Change the bed linens and provide a clean gown as needed – Observe for itching from epidural morphine • Medications to ease itching include – Diphenhydromine (Benadryl) 25 mg IV or oral every 6 hours PRN, itching – Narcan drip – Nubain • Offer cool washcloth and provide cool environment

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Postpartum Physiologic Changes Rhogam

Rhogam causes lysis of any fetal red blood cells The white blood cell count is increased that might have entered the maternal circulation post delivery. By the end of the first (fetomaternal transfusion) before the mother has week postpartum it will return to a time to build up against foreign normal level. protein.

In the United States most of the population is Rh Lukocytes return to nonpregnant level positive. by six weeks post delivery.

Rhogam Vaccine • Rubella Vaccine Women that are RhO(D) negative and have a baby that is RhO(D) positive should receive –If rubella titer is 1:18 or less or equivocal the mother should get the RhoGAM or a similar formulation within 72 rubella vaccine, and advised against hours post delivery to prevent sensitization pregnancy for the next 28 days. from a fetomaternal transfusion of Rh- –If Rhogam and a live virus vaccine positive fetal red blood cells (such as measles or rubella) is administered during postpartum, the mother needs to get a post- vaccination serology test in three months to check immunity.

Davidson,M., London, M., & Ladewig, P. (2016).

Vaccines Lab values will be off..

Breastfeeding mothers can be vaccinated,

inactivated and live viruses can be given to a breastfeeding mother, with the exception of the smallpox vaccine.

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After Delivery Return to Normal Value After Delivery Return to Normal Value Platelets Decrease right after delivery Begin to increase by day 3-4 due to the placental post delivery separation Return to normal levels by 6 WBC’s Average increase of 14- Decreases to normal values weeks post delivery 16,000/mm3 by day six postpartum May increase to 30,000/mm3 Coagulation Factors Plasma fibrinogen will Return to nonpregnant level during labor and right after typically remain elevated for around 3-4 weeks post delivery a few weeks after delivery. delivery This offers protection to the Hematocrit Lower post delivery, drops in Return to normal range mother from hemorrhage. the third trimester of within 4-8 weeks But it may also increase her pregnancy. Increase in postpartum. Exception if risk of thrombus formation. hematocrit is seen between there was excessive blood day 3 and 7 due to the loss plasma volume decrease being greater than the loss Blood volume Blood volume decreases 16% Total blood volume decreases of red blood cells after from peak pregnancy levels to nearly prepregnant levels delivery on the third day postpartum 1 to 2 weeks postpartum

After Delivery Return to Normal Function Immunosuppression is a With in 4-6 weeks post normal physiologic result delivery of pregnancy. Increased risk of transient autoimmune thyroiditis to develop

Glucose Levels Lower glucose levels for Gestational Diabetic moms during moms typically have postpartum. May need normal glucose levels less insulin requirements right after delivery. for insulin-dependent diabetic women.

Endocrine system Endocrine • Placental • Pituitary Hormones – Estrogen and Progesterone decrease markedly with – expulsion of the placenta • Prolactin levels increase after birth – Reach lowest levels by 1 week postpartum • Highest in the first month for breastfeeding mothers and remain elevated while lactation occurs – Estrogen • Return to pre-pregnant levels by 3 weeks in non-lactating • Decreases also associated with diuresis of excess women extracellular fluid accumulated in pregnancy – Oxytocin – Progesterone • Released from posterior pituitary in response to suckling – Human chorionic gonadotropin (hCG) infant • Disappears fairly quickly from circulation,

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Emotions How is Mom feeling?? We will cover this more in the section about Perinatal Mood Disorders

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Energy Level Nursing Care: Energy Level

• Ranges from high energy to extreme fatigue We can help by: and sleepiness, this is individual • Organize nursing activities to avoid frequent • Moms will often feel physical fatigue, and interruptions fatigue is common • Schedule nap time to encourage and promote • This should resolve over the first few weeks rest postpartum • Someone there to watch the infant so mom can rest peacefully knowing her baby is cared for

Nursing Care: Resumption of Sexual Activity Resumption of Sexual Activity When can couples safely resume intercourse?

• Current recommendations are that couples may resume intercourse once the perineum is healed and the lochia has stopped • Average time for this is 3-6 weeks • The risk of infection and hemorrhage are minimal after about two weeks post delivery

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Nursing Care: Resumption of Sexual Activity Nursing Care: and • Reasons couples may wait due to: – Mom is tired • Instruct women about when ovulation and – Decreased libido menstruation can be expected to return based – Hormonal alterations may impact mom’s upon whether the woman is breastfeeding or physiologic response to sexual stimulation for bottle feeding months • The first is typically – Baby’s needs anovulatory, but some (about 25%) may – Vaginal dryness ovulate before menstruation.

Menstruation Return Ovulation

• Nonlactating Women: • Ovulation suppression is due to high prolactin • Between 7-12 weeks levels • Lactating Women: • Nonlactating women • If breastfeeds for one month or shorter: • Mean time is about 70-75 days return will be similar to a non lactating • Lactating women women. • Delayed ovulation for lactating women, mean • If exclusively breastfeeding: return will be time is around 4-6 months. delayed, it varies greatly between women. (Mattson & Smith, 2016)

References: • Davidson,M., London, M., & Ladewig, P. (2016). Olds Maternal- Newborn Nursing & Women’s Health Across the Lifespan, 10th ed. Boston: Pearson Education, Inc. • Mattson, S. & Smith, J.E. (2014). Core Curriculum for Maternal- Newborn Nursing, 5th ed., AWHONN. St. Louis, MO: Elsevier • Simpson, K.R. & Creehan, P.A. (2014). AWHONN Perinatal Nursing, 4th ed. Philadelphia: Wolters Kluwer/Lippincott Williams & Wilkins • The American College of Obstetricians and Gynecologists, Practice bulletin: July 2016. Prevention and management of obstetric lacerations at vaginal delivery • Ward, S. & Shelton, H. (2016). Maternal- Nursing Care Optimizing Outcomes for Mothers, Children, & Families, 2nd ed. Philadelphia: F.A. Davis Company

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