"4th trimester"

A term used to describe the postpartum period through the 6 weeks following delivery.

Maternal Adaptation

Involution

Process of the uterus, cervix, and vagina returning to normal, non-pregnant size.

Uterus contracts inward following delivery of placenta to seal off opening of vessels to prevent hemmorhage.

The large vessels degenerate and are replaced by smaller vessels.

The decidua (lining of uterus) sheds and the placental area heals.

As soon as you deliver!

Fundus should be:

Midline, firm, halfway b/w symphisis pubis and umbilicus.

Uterus should feel like a grapefruit.

Reported in fingerbreadths relative to umbilicus.

1hour post partum, uterus should be at umbilicus.

Uterus contracts vigorously

1hr post partum uterus comes up a little.

Then moves down in the pelvis.

Breastfeeding-stimulates oxytocin causing the uterus to contract

Oxytocin Admin-Given pitocin to help stimulate contactions

Normal Ambulation & Proper Nutrition

Keeping The Bladder Empty-When the bladders full it displaces the uterus & doesn't allow it to contract. It pushes it to the side. Should empty it q2h.

Full Bladder

Overdistention of the Uterus During Pregnancy-Too much amniotic fluid (polyhydramnios), multiples, body has to work extra hard to contract.

Maternal Muscle Exhaustion-Prolonged labor or induction. Uterus is exhausted and doesn't want to work. (kinda like all of us now!)

Excessive Analgesia-Uterus is too relaxed to contract.

Retained placental fragments-Can cause hemmorhage.

Grand Multiparity-5+ babies. Stretched too many times.

Infection.

A uterus which is not well contracted and that feels mushy and soft rather than firm. Can cause hemmorhage if not corrected!

Can usually be corrected with fundal massage and pitocin. Also used hemabate and methergine IM.

Blood clots form inside. Need to empty bladder. If can't get to contract and slow bleeding then to perform DNC.

Postpartum Bleeding

Lochia

Blood, tissue, mucous, and WBCs, which are expelled from the uterus.

Continues for 2-3wks post partum. Can last up to 6wks.

3 stages of lochia (rubra, serosa, alba)

Rubra:  3-4 days, bright red, small-mod amt, fleshy odor. Shouldn't saturate more than 1 pad/1hr. Otherwise it's a problem.

Serosa: 4-10 days, small amt, brownish/pink.

Alba: After day 10, white/pale yellow, mostly WBCs.

Large clots

Reversal of progression (ex: from serosa-rubra)

Increase of amt of bleeding

Foul odor

Most Likely to occur within first 24hours!

GREATEST RISK 1ST HOUR AFTER DELIVERY!

Early detection and prompt intervention!!!

Fundal checks must be done at least q15min for the first hour after delivery.

Note firmness, postion (midline & how far away from umbilicus), and bleeding amt.

Postpartum hemmorhage is fast and furious (like the movie!)

Causes:

Early in postpartum: d/t uterine atony, muscles don't want to contract. Or a laceration or hematoma, which won't have apparent bleeding.

Late:Retained placenta fragment or subinvolution (uterus is not contracting back to normal state)

S/SX of hypovolemic shock: Decrease in BP, weak, thready, rapid pulse, clammy skin, change in level of consciousness.

Labs: Increase in clotting times, decrease in Hct, decrease in platlets.

Atony S/SX: boggy uterus, difficult to palpate, mod-heavy bleeding, passing dark red clots.

Laceration S/SX: bright red, firm uterus

Hematoma S/SX: blood vessels leaking into tissue. No apparent bleeding. Change in labs. Can form deep in pelvis. One sided pain and swelling.

Correct the underlying cause and prevent bleeding.

Prevent shock.

TX: IV fluids, blood transfusion, O2, freq vitals

Atony tx: massage uterus, get clots out, empty bladder, pitocin, hemabate, methergin, DNC if necessary and possible hysterectomy if all else fails.

Laceration tx: find and repair

Hematoma tx: small one use ice and pain meds. Large one surgicially incise and drain and cauterize the vessels.

History and risk factors:what was the labor like? Pain meds (was there excess analegesia?) How much pitocin was given? Was it a long labor?

Description of Lochia: Color, amt of bleeding

Fundus: is it midline? Firm?

Bladder: Is it emptying?

Perineum: Is it intact? Lacertations? Or episiotomy?

Vital Signs, Peri Pad and Pain

Vulval structures may appear bruised and swollen following delivery.

if an episiotomy was done or a tear occurred there will be suturing on the perineum.

You must assess suturing for infection and approximation.

Post Partum Assessments

Homan Signs

At an increased risk for DVTs.

Losing extra blood volume becomes hemoconcentration. They lose blood in delivery and have diaphoresis because of exrection of urine and sweat.

This can lead to hypercoaguable state, which predisposes to DVTs.

Do homan's sign.

Dehydration and immobility increases the risk.

They'll have an elevated WBC count, but if it's over 30,000 can indicate infection.

Shivering is a hormonal response. Take temp. If above 100.4 can indicate infection. Otherwise cover them with warm blanket.

Diaphoresis-rid of excesss volume. Night sweats.

Urinary retention-can have trauma to urethra. Lots of edema. Loose bladder tone. Encourage voiding q2h.

Stretch marks/striae-red/purple then fade to silvery/gray.

Abdomen will be soft, mushy, saggy.

Fundus should be firm.

Muscle tone can return with exercise.

Predisposed to lack of muscle tone: obesity, overdistention during pregnancy, multiples, grandmultiparas.

Causes:

Decreased intrabdominal pressure

Decreased persitalsis from pain meds

Hormones, anesthia, fear of pain of defecating b/c of lacerations/episiotomy.

TX: ambulation, high fiber diets, lots of fluids, stool softeners until back to normal bowel habits.

Women lose 12-14lbs in placenta and baby right off the bat!

5-15lbs is usually lost in water weight due to diaphoresis and urinary excretion.

Breastfeeding promotes weight loss. It increases caloric demand.

On average, will be pre-pregnant weight 6months following delivery.

Taking In-passivity and dependence. Concerned with own needs. Difficulty making decisions. Request help caring for newborn. Relieve experience. Can last hours to days. Not a good time to teach.

Taking Hold-Increasing independence and receptive to infant. Wants to learn, wants reassurance & encouragement. Responds well to praise. Last couple days to weeks.

Letting go-Later in puerpurium. Ideals of motherhood are released and reality of motherhood set in. Explore self and baby. Many emotions experienced. See baby as separate from self. Family relationships are built and tested. Technically ends at 1st year. Adjustments never end.

Postpartum Psyche

Baby Blues

50-70% of women experience.

Lasts about 2-3days following delivery. Moodiness, weepy, difficulty eating and sleeping. Normal phase.

Tearful psychological adjustment to new role.

Physiological decrease in estrogen and progesterone.

Fatigue & discomfort. Need to get help if it lasts longer than 2-3 days.

Post partum Psyche

Depression

May begin within first 6 months after delivery. Strong feelings of sadness and irritability. 

lack of interest in the baby. Obessive thinking.

Mood disorder. Lasts a year or longer. Problems with eating & sleeping. Lack of sex drive.

Insecure & indecisive.

Post Partum Psyche

Psychosis

1 in 500 births. Delusions. Distorted reality. Voices telling her to injure self, baby, or others. Requires immediate tx.

Rare. Mimics severe bipolar disorder. 2-3 weeks after delivery. Hallucinations Severe agitation, hyperactivity, poor judgment, confusion.

TX: antidepressants, and antipsychotics, suicide precautions

Head to toe Post partum assessment

Recovery Period

Recovery Period: q15m for 1st hour check fundus, bladder, perineum and do vital signs

Then q30min for 2nd hour.

Then q4hr for 1st 24hours (if stable).

Report temp above 100.4 and bleeding more than 1pad/more.

Check LOC and VS (including respirations) and listen to lung sounds (b/c pulmonary edema can occur)

Inspect nipples for S/SX of infection and palpate uterus. Should be firm and midline.

Note lochia. The amt, color, character, odor. Do pad counts & weigh them.

Less than 100cc voided could be urinary retention.

Listen to bowel sounds (especially after C section) and assess perineum.(Sims position) Palpate it for hematoma.

Lower extremities:check for edema, equal pulses, cap refill & homans sign.

Pain:type, source, how severe, interventions? did they work?

Labs: H&H It's the 1st indication of hemorrhage. Rhogham workup and rubella status.

Newborn interaction:bonding well? breastfeeding? Social support? Emotional status?

C section: assess incision for s/sx of infection.

Given if mom is rh(-) and baby is Rh(+).

Exchange of blood during delivery.

Must be given within 72 hours.

Can develop antibodies and can hurt subsequent children.

If mother is non-immune she must be immunized before she is discharged.

No pregnancy for 3 months following vaccine.

Fever over 100.4

Shaking/chills +temp

Reddened, painful area on breast (mastitis)

Frequency, urgency, and painful urination (UTI)

SOB/chest pain

Severe abdominal/back pain

Foul smelling lochia or passing clots.

Increased lochia or reversal of pattern.

Severe pain in perineal or abdominal incision.

Swollen, reddened, painful area on the calf.

Prolonged/severe depression (longer than 2-3days)

Thoughts of harming the baby/self.

Newborn Adaptations: flattened nose to help breathe while feeding. Rooting & sucking reflex.

Breast Adaptations: Very vascular. Rich with lymphatic supply. Milk producing alveoli. Surrounded by smooth muscle. Helps eject milk. Has physical control. Breast responds to empty breast by replenishing of it. Each feeding you should empty at least one breast.

Hormonal Control: Anterior pituitary realease prolactin which causes milk production and oxytocin which contracts smooth muscle.

Sensory Stimulation: Just from touching, visualizing, and smell and sound can cause/aide in letdown reflex. Even from other people's babies.

Colostrum: initial breast milk. lower in fat, higher in protein. anti-body rich, yellowish. Appears last few weeks of pregnancy and first post partum days.

Breast milk comes in around 3rd post partum day.

Foremilk: mature breastmilk watery thin blueish tint. Comes in first.

Hindmilk: Mature breastmilk. Thicker, whiter, fat and colorie content. Satiates them longer. Makes them feel fuller longer.

Rapid involution (uterine contracts) = less bleeding

Quicker wt less (increase caloric demands)

Decreased risk for reproductive cancer

Increased newborn immunity

Maternal-newborn bonding.

Decreased risk of overfeeding.

Lower rate of ear infection, diarrhea, respiratory infection. SIDS, diabetes mellitus, allergies.

Enhanced cognitive development. Economical.

Convienent? Decreased healthcare costs.

Illegal Drug Use

Active, untreated TB

HIV, Chemotherapy

Herpetic lesions on breast

Galactosemia in infant (error in metabolism needs special formula)

PKU

Lack of knowledge regarding benefits.

Lack of role model.

Viewing breasts as sexual/dirty.

Intimidated by the process.

Difficulty breastfeeding previously.

Need to return to work immediately.