1
MATERNAL HEALTH → EXAM 3
(11) Caring for the Postpartal Woman and Her Family
Puerperium → Postpartum care → Immediately AFTER childbirth → 6 weeks
● “Fourth-Trimester”
● Constant Changes
● Nursing assessments: Mother + Newborn + Family
ENSURING SAFETY FOR THE MOTHER + INFANT
Protecting the Infant from Abduction ↴
● Infant Transport → ONLY in BASSINETS
○ Parents = Prohibited from carrying infant in halls
● Identification Bracelets
○ Matched before giving to mother
● Patient Education
○ Release infant to properly identified hospital personnel
● Umbilical Cord Clamp → Embedded security alarm
○ Clamp remains in place until discharge
○ Set off when infant is removed from the unit / device = damaged
● Infant Electronic Radio Transmitter Tag
○ Matches mothers
● Similar last names
○ Cribs + Charts → Mother’s FIRST name + bear “NAME ALERT” label
● Multiple births → Cribs labeled (infant’s) FIRST name + Letter of alphabet (A, B, C, or D)
○ Bands can be color-coded
● Hospital personnel
○ Photo identification required
● Visitors
○ Identification Badges + Pictures taken
● Hospital-Unit Based Drills
○ Code “Pink” → Hospital-wide security + Employee response to child abduction
● ALWAYS question suspicious activity * (Large bags/Questions about feeding times/Exits)
, 2
EARLY MATERNAL ASSESSMENT
Vital Signs → Reflection of body’s attempt to return to → PREPREGNANT state
Vaginal Birth Monitoring Cesarean Birth Monitoring
Every 15 minutes → First 2 hours Every 30 minutes x 4 hours
Every 4 hours → First 8 hours Every hour x 3 hours
Every 8 hours → Stable (Discharge) Every 4-8 hours
● Temperature (98.6℉ - 100.4℉)
○ First 2 hours → Postpartal CHILLS + Uncontrollable SHAKING
■ Normal Physiological Response
■ Provide Warm Blankets
○ First 24 hours → Increased Body Temperature (100.4℉)
■ Exertion
■ Dehydration
■ Increase fluids → Return Temperature → Normal Range
○ Increased Breast Vascularity → Transient Increase in Temperature
○ Post 24 hours → PATIENT SHOULD BE AFEBRILE *
＞
■ Temperture 100.4℉ = INFECTION ex.) 101 ℉ ↗
● Pulse (50-90 bpm)
○ HR 50-70 beats per minute (Bradycardia) = COMMON → First 6-10 days
■ Increased Intravascular Volume / Stroke volume → Decreased HR
○ Postpartal Tachycardia → Prolonged Labor, Blood Loss, Temperature Elevation,
Hemorrhage, Infection [INDICATIVE of COMPLICATIONS]
● Blood Pressure (SHOULD BE Consistent w/ Baseline → FIRST trimester)
○ Cause of Decreased → Decreased Intrapelvic Pressure OR UTERINE HEMORRHAGE
○ Uncomplicated Pregnancies → Can develop Postpartum PRE-ECLAMPSIA
■ ↑ Systolic BP 30 mmHg
■ ↑ Diastolic BP 15 mmHg
■ ≥ 140/80 + Edema, Headaches, Visual changes → PRE-ECLAMPSIA
○ Plasma Renin + Angiotensin II Levels Regulate → Decreased vascular resistance
○ ORTHOSTATIC HYPOTENSION may occur → Supine to Sitting
○ MATERNAL BLOOD PRESSURE SHOULD REMAIN STABLE *
● Respirations (12-20 respirations per minute)
○ SHOULD REMAIN NORMAL ⇈
○ Slower Rate → OPIOID effect + Further monitoring
○ Slightly Elevated → Pain + Fear + Excitement + Exertion + EXCESSIVE BLOOD LOSS
(ASSESS)
■ SUDDEN ONSET OF TACHYPNEA + ABNORMAL LUNG SOUNDS + SHORTNESS OF
BREATH + CHEST PAIN + ANXIETY + RESTLESSNESS → ABNORMAL FINDINGS! →
REPORT THESE IMMEDIATELY!
● Indicative of PULMONARY EDEMA/EMBOLI
, 3
● Pain
○ Afterpains → Intermittent UTERINE contractions → Process of Involution (Similar to
Menstrual Cramps)
■ Primiparous → MILD (Maintained Contracted State)
■ Multiparas + Uterine Overdistention (Multiparity, Large baby, Hydramnios) →
MORE LIKELY (Continuous pattern of Uterine RELAXATION + Vigorous
CONTRACTIONS)
○ Breastfeeding + Administration of exogenous OXYTOCIN → Afterpains (Both → Powerful
Uterine Contractions → Both INVOLVE Oxytocin)
○ Afterbirth Pain = SEVERE → 2-3 days postpartum
○ Uterus MAINTAINS → CONSTANT CONTRACTION → Afterpains CEASE
○ Nursing Interventions (Discomfort)↴
■ Assist → Prone position + Small pillow UNDER Abdomen
■ Sitz baths (Warmth)
■ Encouraging Ambulation
■ Administration of MILD Analgesics
○ Failure to manage pain is associated with prolonged recovery, increased length of stay,
depression, anxiety, poor coping, & altered sleeping patterns
Medications to Manage Pain (Puerperium)
● Analgesics→ Ibuprofen (Advil/Motrin) or Naproxen (Aleve/Anaprox) → Lessen the discomforts
of AFTERPAINS
○ Breastfeeding women → Pain medication → 30 MINUTES BEFORE → Nursing baby →
MAXIMUM pain relief
, 4
Postpartum Hemorrhage (PPH) → BLOOD LOSS
● Leading cause of maternal MORBIDITY + MORTALITY
● Vaginal: > 500 mL
● Cesarean: ≥ 1000 mL
● Hematocrit (Hct) ↓ DECREASE by 10% compared to Pre Birth Values
● Need for RBC transfusion → Anemia/Hemodynamic Instability
● 50% of PPH = Preventable
Early Postpartum Hemorrhage (EPPH) (1°) Late Postpartum Hemorrhage (LPPH) (2°)
24 hours postpartum AFTER 24 hours postpartum
Greatest Likelihood: 1%-2% Of All Childbearing Women
FIRST 4 hours
Most Common Cause: Most Common Cause:
Uterine Atony Retained placental fragments
(Lack of contraction + retraction)
Blood flow to Uterus: Other Causes:
500-800 mL/minute Subinvolution (failure of uterus to return to normal
size), Uterine infection, Inherited coagulation defects →
von Willebrand (vW) disease (less common)
Placental site:
Multiple EXPOSED VENOUS AREAS + LOW resistance
Misc: Check for the presence of FRAGMENTS in LOCHIAL
● Most practitioners do not accurately estimate TISSUE
blood loss
● 4 T’s: Tone, Trauma, Tissue, Thrombin
● Early Signs: Tachycardia, 15% drop (BP), <95%
SPO2%
Unrepaired Lacerations → Monitor for CONTINUOUS trickle of BRIGHT RED BLOOD
Hematomas → Unrelieved pain/Pressure/ May not be able to see/ Can be caused by Forceps Delivery
Risk Factors : Macrosomia, Multiple gestation, Polyhydramnios, Chorioamnionitis, Prolonged Labor, Use of Oxytocin
(Pitocin)
● Medications for PPH
○ Oxytocin (Pitocin)10-40 U / 1000 mL Lacted Ringers (or Normal Saline) (IV)
○ Methylergonovine maleate (Methergine) 0.1-0.2 mg (IM) Q2-Q4 hours
■ Followed by 0.2 mg (PO) Q4-Q6 hours x 24 hours
■ CHECK BLOOD PRESSURE DO NOT GIVE IF HYPERTENSIVE
○ Prostaglandins:
■ Carboprost tromethamine (Hemabate) 0.25 mg (250 mcg) IM/Directly into
uterus (MD) // DO NOT GIVE TO ASTHMATICS
● Q15-90 minutes // 8 DOSES MAXIMUM!
■ Misoprostol (Cytotec) 800 - 1000 mcg rectally / 600 mg orally / 800 mg
sublingually
■ Dinoprostone (Prostin E2) 20 mg suppository vaginally / rectally Q2 hours
○ Side Effects: Nausea, Vomiting, Diarrhea
, 5
BUBBLE-HE(b) Assessment → Reminds the nurse to assess the BREASTS, UTERUS, BLADDER, BOWEL,
LOCHIA, & EPISIOTOMY (perineum), Homan’s sign/Deep venous thrombosis (DVTs) and EMOTIONS
(Bonding)
● Breasts
○ Pathophysiology / A&P
■ Breast size does NOT impact the ability to nourish a child
■ Glandular + Connective + Fatty tissues
■ Lactating breast → Alveoli (House milk) + Fatty tissue + Ducts → Main duct
● Ducts collect milk from alveoli → Transport → Nipple
● Cooper’s Ligaments + Adipose tissue → Support ductal system
■ Areola (15-16 mm) DARKENS + ENGLARGES with pregnancy
● Montgomery tubules ENLARGE → Secrete waxy substance → Lubricant
+ Anti-infective properties (Protection)
○ Lactation = Established → ALL postpartum women (Regardless of breast/bottle
feeding)
○ Temperature/Color
○ Nipple Inspection
■ Flat, Everted, Inverted
■ Intact vs. Cracked
, 6
○ Breast Tissue
■ Soft (FIRST 2 days)
■ Filling (3rd day) → FIRM + WARM
■ Firm (4-5 days) → FIRM BEFORE feeding + SOFT AFTER feeding
● ENGORGEMENT occurs on the 4th day
■ TENSE + PAINFUL Breasts → POOR TRANSFER OF MILK to infant
● Follow with → Breastfeeding Assessment + Lactation Consultant (IBCLC)
○ Bottle Feeding Mothers
■ Encouragement of BINDING Breasts Tightly DO NOT SQUEEZE MILK OUT OF
BREASTS
■ Ice packs can be helpful
○ Breast Feeding Mothers
■ SUPPORTIVE BRA → Worn CONSISTENTLY
● Uterus (Fundus)
○ Involution → Uterus returns → Nonpregnant state
■ Dramatic reduction in size; Will remain slightly larger compared to first
pregnancy
■ UTERUS = MUSCLE + Myometrium + Serosa
○ Involution results from → DECREASE in SIZE of MYOMETRIAL CELLS → Myometrial
THICKENING + ISCHEMIA (Reduced blood flow → Contracted uterus)
○ Rapid UTERINE CONTRACTIONS SEAL OFF placental site → Pinching off blood vessels
previously attached to the placenta (Post spontaneous expulsion → 20 minutes)
■ Original site → HEALS → 6-7 weeks (Exfoliation: Scaling off of dead tissue)
● New endometrial tissue = generated
● Result → Scar tissue (Could impede implantation in the future)
■ Regeneration = Complete → 16th postpartum day (Minus placental site)
■ PLACENTAL SITE regeneration = Complete → 6 weeks after childbirth
○ Within a few minutes after birth → FIRMLY CONTRACTED UTERUS → PALPABLE →
Abdominal wall (HALFWAY → Umbilicus + Symphysis pubis// MIDDLE)
○ 1 hour later → FUNDUS → UMBILICUS → Remains for 24 hours
○ Fundus → DESCENDS → ONE FINGERBREADTH (1cm) → per DAY in size
○ FUNDUS, LOCHIA (puerperal discharge of blood, mucus, and tissue), and PERINEUM →
NEED TO BE ASSESSED x 15 MINUTES → IMMEDIATE POSTPARTUM PERIOD
, 7
○ How to Perform Assessment:
■ Patient assisted to SUPINE position
■ Abdomen observed for CONTOUR (distention) + STRIAE
■ Uterine fundus → Palpated → One hand immediately ABOVE symphysis pubis
(stabilize uterus) + Other hand at the level of the umbilicus
● FIRM, GLOBULAR mass felt at or slightly above umbilicus (first hour)
● UTERINE FUNDUS → ALWAYS MIDLINE (OVERDISTENDED BLADDER may
push uterus to the RIGHT)
● Within 1 hour → Uterus settles MIDLINE at the level → Umbilicus
● Uterus descends → Pelvis → 1cm/day
● After 10 days → UTERUS → PELVIS → NOT PALPABLE
● Assess → Consistency (firm, soft, boggy), Location, (midline), & Height
(measured in fingerbreadths)
● NON-CONTRACTED UTERUS → BOGGY → RISK FOR INCREASED BLEEDING
● Bladder
○ Spontaneous Voiding → 6-8 hours
■ Straight cath → Prevent DISTENTION
○ First two voiding amounts SHOULD be monitored
○ Urinary output → MINIMUM 150 mL/hr → Avoid urinary retention/stasis
○ Generalized edema → Early puerperium → Fluid accumulation + IV fluids + Birth
○ Maternal diuresis → IMMEDIATELY after birth → Urinary output = 3,000 mL/day (2-5 days
postpartum)
○ Decreased bladder tone = Normal (Progesterone/Edema/Mucosal hyperemia)
■ Prolonged labor, Forceps delivery, Analgesia, & Anesthesia → May intensify
■ Epidurals may delay sensation of needing to urinate
○ Pressure from fetal head → Trauma/Transient loss of bladder sensation → Incomplete
bladder emptying + Overdistention
○ Urine volume + Flow time → RETURN to prepregnant levels → 2-3 days
○ Increased risk of Urinary Retention → Epidural anesthesia, Catheterization, Instrument
facilitated birth
○ Urinary Retention → Bladder Hypotonia → Gravid uterus no longer limits bladder
capacity
○ OVERDISTENDED BLADDER → DISPLACES UTERUS → ABOVE + RIGHT of UMBILICUS →
UTERINE ATONY → HEMORRHAGE
○ Other assessment findings:
■ Presence of BLADDER (hard/firm area) ABOVE symphysis pubis
■ Urinary OUTPUT disproportionate → Fluid INTAKE
■ Bladder percussion
● FULL bladder → RESONATE sound
● EMPTY bladder → DULL, THUDDING sound
○ Nursing Interventions:
■ Assisting patient to toilet
■ Providing privacy
■ Unhurried environment
■ Turning on lavatory faucet
■ Assisting patient → Sitz bath
, 8
● Bowel
○ G.I. system → MORE ACTIVE soon AFTER childbirth (Giving birth usually clears stool)
○ HUNGRY + THIRSTY → Food/Fluid restrictions
○ Peptide hormone Relaxin → Depresses bowel motility (during pregnancy)
○ Continued effects of PROGESTERONE → CONSTIPATION (early puerperium)
○ Bowel movements = DELAYED → 2-3 puerperal days
○ Hemorrhoids (distended rectal veins), Perineal trauma, Episiotomy → PAINFUL
DEFECATION
○ Prevent Constipation :
■ EARLY Ambulation
■ Abundant FLUIDS
■ HIGH-FIBER diet
■ Stool softeners
● Lochia → Separation of PLACENTA + MEMBRANES → Spongy/Outer layer (Decidua basalis)
○ SUPERFICIAL LAYER of the ENDOMETRIUM sloughs off → Uterine discharge
○ HOW LONG HAVE YOU BEEN WEARING THAT PAD GURL
○ Composed of → Erythrocutes + Epithelial cells + Blood + Fragments of decidua + Mucus + Bacteria
○ INDICATIVE OF WOMAN’S STATUS → PROCESS of INVOLUTION
Postpartum Lochia Characteristics
Lochia Rubra Lochia Serosa Lochia Alba
1-3 days Day 4 10-14 days
BLOOD + RED PINKISH/BROWN WHITE/YELLOW/THICK
FLESHY ODOR ↓ DECREASED DISCHARGE +
LEUKOCYTES
Blood, Wound exudate,
Amnion, Chorion, Decidua, Vernix Erythrocytes, Leukocytes, Cervical Decidua cells + Mucus + Bacteria +
lanugo, & Meconium mucosa Epithelial cells
Present UNTIL WEEK 3 / May persist
→ 8 WEEKS
○ Pattern of lochia flow → LOCHIA RUBRA → SEROSA → ALBA → SHOULD NOT REVERSE!
○ RETURNED LOCHIA RUBRA → PLACENTAL FRAGMENTS/DECREASED UTERINE CONTRACTIONS + NEW
BLEEDING → CONTACT PCP *
○ Should NOT contain LARGE clots → Prevent closure of maternal uterine blood sinuses
○ Odor → Similar to menstrual blood
○ OFFENSIVE ODOR → INFECTION
○ Documented → Amount (Scant, Light, Moderate, or Heavy)
○ Amount of vaginal discharge IS NOT a true indicator of FLOW unless time is considered
○ Detail what KIND of PERIPAD is used as they are all different
○ Methods to more ACCURATELY quantify blood loss:
■ Weigh linens + pads // Scoop blood + clots → Measuring jugs
, 9
● Episiotomy(Midline/Mediolateral) / Incision (Perineal Assessment)
○ Assess → VAGINA + PERINEUM + RECTUM
■ Swelling, bruising, healing of injuries/episiotomy sustained during delivery
■ SWELLING + BRUISING (Hematoma) (Early postpartum) →
HEMORRHAGE/INFECTION → CALL PCP *
○ ALL lacerations → Assessed for healing/complications that require intervention
■ Often require sutures → Sutures intact?
○ Episiotomy edges = SEALED/FUSED → First 24 hours after birth
○ Carefully assess EPISIOSTOMY/VAGINAL/PERINEAL tears → Redness, Edema,
Ecchymosis, Discharge, & Approximation (REEDA) → Document
○ Hemorrhoids → Distended rectal veins
■ Present before pregnancy/ Develop during → Pressure → Lower bowel
(Second Stage)
■ Relieve Discomfort:
● Application of ICE PACKS (24 hours) → HEAT (Cover with cloth cover)
● Pharmaceutical preparations → Topical anesthetic ointments
● Witch Hazel pads
● Assist patient to SIDE-LYING position
● Educate patient → Sitting on FLAT + HARD surfaces + TIGHTEN BUTTOCKS
before sitting
● AVOID DONUT RINGS/SOFT PILLOWS → Separate buttocks + Decrease
venous flow → Intensifies pain
● SEVERE HEMORRHOIDS → Manually reposition → Rectum
○ Hemorrhoids generally disappear within a few weeks
○ Extending → Rectal SPHINCTER → 3rd DEGREE
○ Extending → Rectal WALL/MUCOSA → 4th DEGREE
, 10
● Homan’s Sign → Assessment for (Legs)
DVT
○ Performing Screening Assessment :
■ Patient’s legs → Extended + Relaxed + Knees flexed
■ Examiner grasps foot → Sharply dorsiflexes it
■ POSITIVE = RESISTANCE/DISCOMFORT in CALF/POPLITEAL region
■ Pain occurs from INFLAMMATION of BLOOD VESSELS → Associated w/THROMBOSIS
■ Negative Homan’s sign DOES NOT rule out DVT
○ Clinical Signs:
■ PAIN → CALF
■ ERYTHEMA
■ WARMTH greater in one calf vs. the other
■ UNEQUAL calf circumference
○ Diagnostic Procedures:
■ Venography
■ Real-time/Color Doppler ultrasound
○ Powerpoint:
■ Variscocities
■ Pulses (Pedal pulses)
■ Pain
■ Warmth
■ Edema (Swelling)
■ Discoloration in calves
■ Sensation
MATERNAL HEALTH → EXAM 3
(11) Caring for the Postpartal Woman and Her Family
Puerperium → Postpartum care → Immediately AFTER childbirth → 6 weeks
● “Fourth-Trimester”
● Constant Changes
● Nursing assessments: Mother + Newborn + Family
ENSURING SAFETY FOR THE MOTHER + INFANT
Protecting the Infant from Abduction ↴
● Infant Transport → ONLY in BASSINETS
○ Parents = Prohibited from carrying infant in halls
● Identification Bracelets
○ Matched before giving to mother
● Patient Education
○ Release infant to properly identified hospital personnel
● Umbilical Cord Clamp → Embedded security alarm
○ Clamp remains in place until discharge
○ Set off when infant is removed from the unit / device = damaged
● Infant Electronic Radio Transmitter Tag
○ Matches mothers
● Similar last names
○ Cribs + Charts → Mother’s FIRST name + bear “NAME ALERT” label
● Multiple births → Cribs labeled (infant’s) FIRST name + Letter of alphabet (A, B, C, or D)
○ Bands can be color-coded
● Hospital personnel
○ Photo identification required
● Visitors
○ Identification Badges + Pictures taken
● Hospital-Unit Based Drills
○ Code “Pink” → Hospital-wide security + Employee response to child abduction
● ALWAYS question suspicious activity * (Large bags/Questions about feeding times/Exits)
, 2
EARLY MATERNAL ASSESSMENT
Vital Signs → Reflection of body’s attempt to return to → PREPREGNANT state
Vaginal Birth Monitoring Cesarean Birth Monitoring
Every 15 minutes → First 2 hours Every 30 minutes x 4 hours
Every 4 hours → First 8 hours Every hour x 3 hours
Every 8 hours → Stable (Discharge) Every 4-8 hours
● Temperature (98.6℉ - 100.4℉)
○ First 2 hours → Postpartal CHILLS + Uncontrollable SHAKING
■ Normal Physiological Response
■ Provide Warm Blankets
○ First 24 hours → Increased Body Temperature (100.4℉)
■ Exertion
■ Dehydration
■ Increase fluids → Return Temperature → Normal Range
○ Increased Breast Vascularity → Transient Increase in Temperature
○ Post 24 hours → PATIENT SHOULD BE AFEBRILE *
＞
■ Temperture 100.4℉ = INFECTION ex.) 101 ℉ ↗
● Pulse (50-90 bpm)
○ HR 50-70 beats per minute (Bradycardia) = COMMON → First 6-10 days
■ Increased Intravascular Volume / Stroke volume → Decreased HR
○ Postpartal Tachycardia → Prolonged Labor, Blood Loss, Temperature Elevation,
Hemorrhage, Infection [INDICATIVE of COMPLICATIONS]
● Blood Pressure (SHOULD BE Consistent w/ Baseline → FIRST trimester)
○ Cause of Decreased → Decreased Intrapelvic Pressure OR UTERINE HEMORRHAGE
○ Uncomplicated Pregnancies → Can develop Postpartum PRE-ECLAMPSIA
■ ↑ Systolic BP 30 mmHg
■ ↑ Diastolic BP 15 mmHg
■ ≥ 140/80 + Edema, Headaches, Visual changes → PRE-ECLAMPSIA
○ Plasma Renin + Angiotensin II Levels Regulate → Decreased vascular resistance
○ ORTHOSTATIC HYPOTENSION may occur → Supine to Sitting
○ MATERNAL BLOOD PRESSURE SHOULD REMAIN STABLE *
● Respirations (12-20 respirations per minute)
○ SHOULD REMAIN NORMAL ⇈
○ Slower Rate → OPIOID effect + Further monitoring
○ Slightly Elevated → Pain + Fear + Excitement + Exertion + EXCESSIVE BLOOD LOSS
(ASSESS)
■ SUDDEN ONSET OF TACHYPNEA + ABNORMAL LUNG SOUNDS + SHORTNESS OF
BREATH + CHEST PAIN + ANXIETY + RESTLESSNESS → ABNORMAL FINDINGS! →
REPORT THESE IMMEDIATELY!
● Indicative of PULMONARY EDEMA/EMBOLI
, 3
● Pain
○ Afterpains → Intermittent UTERINE contractions → Process of Involution (Similar to
Menstrual Cramps)
■ Primiparous → MILD (Maintained Contracted State)
■ Multiparas + Uterine Overdistention (Multiparity, Large baby, Hydramnios) →
MORE LIKELY (Continuous pattern of Uterine RELAXATION + Vigorous
CONTRACTIONS)
○ Breastfeeding + Administration of exogenous OXYTOCIN → Afterpains (Both → Powerful
Uterine Contractions → Both INVOLVE Oxytocin)
○ Afterbirth Pain = SEVERE → 2-3 days postpartum
○ Uterus MAINTAINS → CONSTANT CONTRACTION → Afterpains CEASE
○ Nursing Interventions (Discomfort)↴
■ Assist → Prone position + Small pillow UNDER Abdomen
■ Sitz baths (Warmth)
■ Encouraging Ambulation
■ Administration of MILD Analgesics
○ Failure to manage pain is associated with prolonged recovery, increased length of stay,
depression, anxiety, poor coping, & altered sleeping patterns
Medications to Manage Pain (Puerperium)
● Analgesics→ Ibuprofen (Advil/Motrin) or Naproxen (Aleve/Anaprox) → Lessen the discomforts
of AFTERPAINS
○ Breastfeeding women → Pain medication → 30 MINUTES BEFORE → Nursing baby →
MAXIMUM pain relief
, 4
Postpartum Hemorrhage (PPH) → BLOOD LOSS
● Leading cause of maternal MORBIDITY + MORTALITY
● Vaginal: > 500 mL
● Cesarean: ≥ 1000 mL
● Hematocrit (Hct) ↓ DECREASE by 10% compared to Pre Birth Values
● Need for RBC transfusion → Anemia/Hemodynamic Instability
● 50% of PPH = Preventable
Early Postpartum Hemorrhage (EPPH) (1°) Late Postpartum Hemorrhage (LPPH) (2°)
24 hours postpartum AFTER 24 hours postpartum
Greatest Likelihood: 1%-2% Of All Childbearing Women
FIRST 4 hours
Most Common Cause: Most Common Cause:
Uterine Atony Retained placental fragments
(Lack of contraction + retraction)
Blood flow to Uterus: Other Causes:
500-800 mL/minute Subinvolution (failure of uterus to return to normal
size), Uterine infection, Inherited coagulation defects →
von Willebrand (vW) disease (less common)
Placental site:
Multiple EXPOSED VENOUS AREAS + LOW resistance
Misc: Check for the presence of FRAGMENTS in LOCHIAL
● Most practitioners do not accurately estimate TISSUE
blood loss
● 4 T’s: Tone, Trauma, Tissue, Thrombin
● Early Signs: Tachycardia, 15% drop (BP), <95%
SPO2%
Unrepaired Lacerations → Monitor for CONTINUOUS trickle of BRIGHT RED BLOOD
Hematomas → Unrelieved pain/Pressure/ May not be able to see/ Can be caused by Forceps Delivery
Risk Factors : Macrosomia, Multiple gestation, Polyhydramnios, Chorioamnionitis, Prolonged Labor, Use of Oxytocin
(Pitocin)
● Medications for PPH
○ Oxytocin (Pitocin)10-40 U / 1000 mL Lacted Ringers (or Normal Saline) (IV)
○ Methylergonovine maleate (Methergine) 0.1-0.2 mg (IM) Q2-Q4 hours
■ Followed by 0.2 mg (PO) Q4-Q6 hours x 24 hours
■ CHECK BLOOD PRESSURE DO NOT GIVE IF HYPERTENSIVE
○ Prostaglandins:
■ Carboprost tromethamine (Hemabate) 0.25 mg (250 mcg) IM/Directly into
uterus (MD) // DO NOT GIVE TO ASTHMATICS
● Q15-90 minutes // 8 DOSES MAXIMUM!
■ Misoprostol (Cytotec) 800 - 1000 mcg rectally / 600 mg orally / 800 mg
sublingually
■ Dinoprostone (Prostin E2) 20 mg suppository vaginally / rectally Q2 hours
○ Side Effects: Nausea, Vomiting, Diarrhea
, 5
BUBBLE-HE(b) Assessment → Reminds the nurse to assess the BREASTS, UTERUS, BLADDER, BOWEL,
LOCHIA, & EPISIOTOMY (perineum), Homan’s sign/Deep venous thrombosis (DVTs) and EMOTIONS
(Bonding)
● Breasts
○ Pathophysiology / A&P
■ Breast size does NOT impact the ability to nourish a child
■ Glandular + Connective + Fatty tissues
■ Lactating breast → Alveoli (House milk) + Fatty tissue + Ducts → Main duct
● Ducts collect milk from alveoli → Transport → Nipple
● Cooper’s Ligaments + Adipose tissue → Support ductal system
■ Areola (15-16 mm) DARKENS + ENGLARGES with pregnancy
● Montgomery tubules ENLARGE → Secrete waxy substance → Lubricant
+ Anti-infective properties (Protection)
○ Lactation = Established → ALL postpartum women (Regardless of breast/bottle
feeding)
○ Temperature/Color
○ Nipple Inspection
■ Flat, Everted, Inverted
■ Intact vs. Cracked
, 6
○ Breast Tissue
■ Soft (FIRST 2 days)
■ Filling (3rd day) → FIRM + WARM
■ Firm (4-5 days) → FIRM BEFORE feeding + SOFT AFTER feeding
● ENGORGEMENT occurs on the 4th day
■ TENSE + PAINFUL Breasts → POOR TRANSFER OF MILK to infant
● Follow with → Breastfeeding Assessment + Lactation Consultant (IBCLC)
○ Bottle Feeding Mothers
■ Encouragement of BINDING Breasts Tightly DO NOT SQUEEZE MILK OUT OF
BREASTS
■ Ice packs can be helpful
○ Breast Feeding Mothers
■ SUPPORTIVE BRA → Worn CONSISTENTLY
● Uterus (Fundus)
○ Involution → Uterus returns → Nonpregnant state
■ Dramatic reduction in size; Will remain slightly larger compared to first
pregnancy
■ UTERUS = MUSCLE + Myometrium + Serosa
○ Involution results from → DECREASE in SIZE of MYOMETRIAL CELLS → Myometrial
THICKENING + ISCHEMIA (Reduced blood flow → Contracted uterus)
○ Rapid UTERINE CONTRACTIONS SEAL OFF placental site → Pinching off blood vessels
previously attached to the placenta (Post spontaneous expulsion → 20 minutes)
■ Original site → HEALS → 6-7 weeks (Exfoliation: Scaling off of dead tissue)
● New endometrial tissue = generated
● Result → Scar tissue (Could impede implantation in the future)
■ Regeneration = Complete → 16th postpartum day (Minus placental site)
■ PLACENTAL SITE regeneration = Complete → 6 weeks after childbirth
○ Within a few minutes after birth → FIRMLY CONTRACTED UTERUS → PALPABLE →
Abdominal wall (HALFWAY → Umbilicus + Symphysis pubis// MIDDLE)
○ 1 hour later → FUNDUS → UMBILICUS → Remains for 24 hours
○ Fundus → DESCENDS → ONE FINGERBREADTH (1cm) → per DAY in size
○ FUNDUS, LOCHIA (puerperal discharge of blood, mucus, and tissue), and PERINEUM →
NEED TO BE ASSESSED x 15 MINUTES → IMMEDIATE POSTPARTUM PERIOD
, 7
○ How to Perform Assessment:
■ Patient assisted to SUPINE position
■ Abdomen observed for CONTOUR (distention) + STRIAE
■ Uterine fundus → Palpated → One hand immediately ABOVE symphysis pubis
(stabilize uterus) + Other hand at the level of the umbilicus
● FIRM, GLOBULAR mass felt at or slightly above umbilicus (first hour)
● UTERINE FUNDUS → ALWAYS MIDLINE (OVERDISTENDED BLADDER may
push uterus to the RIGHT)
● Within 1 hour → Uterus settles MIDLINE at the level → Umbilicus
● Uterus descends → Pelvis → 1cm/day
● After 10 days → UTERUS → PELVIS → NOT PALPABLE
● Assess → Consistency (firm, soft, boggy), Location, (midline), & Height
(measured in fingerbreadths)
● NON-CONTRACTED UTERUS → BOGGY → RISK FOR INCREASED BLEEDING
● Bladder
○ Spontaneous Voiding → 6-8 hours
■ Straight cath → Prevent DISTENTION
○ First two voiding amounts SHOULD be monitored
○ Urinary output → MINIMUM 150 mL/hr → Avoid urinary retention/stasis
○ Generalized edema → Early puerperium → Fluid accumulation + IV fluids + Birth
○ Maternal diuresis → IMMEDIATELY after birth → Urinary output = 3,000 mL/day (2-5 days
postpartum)
○ Decreased bladder tone = Normal (Progesterone/Edema/Mucosal hyperemia)
■ Prolonged labor, Forceps delivery, Analgesia, & Anesthesia → May intensify
■ Epidurals may delay sensation of needing to urinate
○ Pressure from fetal head → Trauma/Transient loss of bladder sensation → Incomplete
bladder emptying + Overdistention
○ Urine volume + Flow time → RETURN to prepregnant levels → 2-3 days
○ Increased risk of Urinary Retention → Epidural anesthesia, Catheterization, Instrument
facilitated birth
○ Urinary Retention → Bladder Hypotonia → Gravid uterus no longer limits bladder
capacity
○ OVERDISTENDED BLADDER → DISPLACES UTERUS → ABOVE + RIGHT of UMBILICUS →
UTERINE ATONY → HEMORRHAGE
○ Other assessment findings:
■ Presence of BLADDER (hard/firm area) ABOVE symphysis pubis
■ Urinary OUTPUT disproportionate → Fluid INTAKE
■ Bladder percussion
● FULL bladder → RESONATE sound
● EMPTY bladder → DULL, THUDDING sound
○ Nursing Interventions:
■ Assisting patient to toilet
■ Providing privacy
■ Unhurried environment
■ Turning on lavatory faucet
■ Assisting patient → Sitz bath
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● Bowel
○ G.I. system → MORE ACTIVE soon AFTER childbirth (Giving birth usually clears stool)
○ HUNGRY + THIRSTY → Food/Fluid restrictions
○ Peptide hormone Relaxin → Depresses bowel motility (during pregnancy)
○ Continued effects of PROGESTERONE → CONSTIPATION (early puerperium)
○ Bowel movements = DELAYED → 2-3 puerperal days
○ Hemorrhoids (distended rectal veins), Perineal trauma, Episiotomy → PAINFUL
DEFECATION
○ Prevent Constipation :
■ EARLY Ambulation
■ Abundant FLUIDS
■ HIGH-FIBER diet
■ Stool softeners
● Lochia → Separation of PLACENTA + MEMBRANES → Spongy/Outer layer (Decidua basalis)
○ SUPERFICIAL LAYER of the ENDOMETRIUM sloughs off → Uterine discharge
○ HOW LONG HAVE YOU BEEN WEARING THAT PAD GURL
○ Composed of → Erythrocutes + Epithelial cells + Blood + Fragments of decidua + Mucus + Bacteria
○ INDICATIVE OF WOMAN’S STATUS → PROCESS of INVOLUTION
Postpartum Lochia Characteristics
Lochia Rubra Lochia Serosa Lochia Alba
1-3 days Day 4 10-14 days
BLOOD + RED PINKISH/BROWN WHITE/YELLOW/THICK
FLESHY ODOR ↓ DECREASED DISCHARGE +
LEUKOCYTES
Blood, Wound exudate,
Amnion, Chorion, Decidua, Vernix Erythrocytes, Leukocytes, Cervical Decidua cells + Mucus + Bacteria +
lanugo, & Meconium mucosa Epithelial cells
Present UNTIL WEEK 3 / May persist
→ 8 WEEKS
○ Pattern of lochia flow → LOCHIA RUBRA → SEROSA → ALBA → SHOULD NOT REVERSE!
○ RETURNED LOCHIA RUBRA → PLACENTAL FRAGMENTS/DECREASED UTERINE CONTRACTIONS + NEW
BLEEDING → CONTACT PCP *
○ Should NOT contain LARGE clots → Prevent closure of maternal uterine blood sinuses
○ Odor → Similar to menstrual blood
○ OFFENSIVE ODOR → INFECTION
○ Documented → Amount (Scant, Light, Moderate, or Heavy)
○ Amount of vaginal discharge IS NOT a true indicator of FLOW unless time is considered
○ Detail what KIND of PERIPAD is used as they are all different
○ Methods to more ACCURATELY quantify blood loss:
■ Weigh linens + pads // Scoop blood + clots → Measuring jugs
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● Episiotomy(Midline/Mediolateral) / Incision (Perineal Assessment)
○ Assess → VAGINA + PERINEUM + RECTUM
■ Swelling, bruising, healing of injuries/episiotomy sustained during delivery
■ SWELLING + BRUISING (Hematoma) (Early postpartum) →
HEMORRHAGE/INFECTION → CALL PCP *
○ ALL lacerations → Assessed for healing/complications that require intervention
■ Often require sutures → Sutures intact?
○ Episiotomy edges = SEALED/FUSED → First 24 hours after birth
○ Carefully assess EPISIOSTOMY/VAGINAL/PERINEAL tears → Redness, Edema,
Ecchymosis, Discharge, & Approximation (REEDA) → Document
○ Hemorrhoids → Distended rectal veins
■ Present before pregnancy/ Develop during → Pressure → Lower bowel
(Second Stage)
■ Relieve Discomfort:
● Application of ICE PACKS (24 hours) → HEAT (Cover with cloth cover)
● Pharmaceutical preparations → Topical anesthetic ointments
● Witch Hazel pads
● Assist patient to SIDE-LYING position
● Educate patient → Sitting on FLAT + HARD surfaces + TIGHTEN BUTTOCKS
before sitting
● AVOID DONUT RINGS/SOFT PILLOWS → Separate buttocks + Decrease
venous flow → Intensifies pain
● SEVERE HEMORRHOIDS → Manually reposition → Rectum
○ Hemorrhoids generally disappear within a few weeks
○ Extending → Rectal SPHINCTER → 3rd DEGREE
○ Extending → Rectal WALL/MUCOSA → 4th DEGREE
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● Homan’s Sign → Assessment for (Legs)
DVT
○ Performing Screening Assessment :
■ Patient’s legs → Extended + Relaxed + Knees flexed
■ Examiner grasps foot → Sharply dorsiflexes it
■ POSITIVE = RESISTANCE/DISCOMFORT in CALF/POPLITEAL region
■ Pain occurs from INFLAMMATION of BLOOD VESSELS → Associated w/THROMBOSIS
■ Negative Homan’s sign DOES NOT rule out DVT
○ Clinical Signs:
■ PAIN → CALF
■ ERYTHEMA
■ WARMTH greater in one calf vs. the other
■ UNEQUAL calf circumference
○ Diagnostic Procedures:
■ Venography
■ Real-time/Color Doppler ultrasound
○ Powerpoint:
■ Variscocities
■ Pulses (Pedal pulses)
■ Pain
■ Warmth
■ Edema (Swelling)
■ Discoloration in calves
■ Sensation
