Uterine Growth during Pregnancy
Palpable above symphysis pubis at 10 weeks.
Midway between symphysis pubis and umbilicus at 16 weeks.
At umbilicus at 20 weeks.
Increase of 1 cm/week thereafter.
Lightening- engagement into the pelvis at 38 plus weeks.
Involution by Days
*Picture Slide
Fundal height at delivery - at umbilicus
Day 5 - Midway
Day 9 - Cannot feel anymore
Uterus decreases 1 finger breath per day
Involution
Autolysis - self destruction of hypertrophied tissue of uterus.
Uterine contraction (bladder must be emptied for contraction)
Placental site heals by exfoliation (open wound)
Lochia reflects healing of placental site
Involution complete in 5 to 6 weeks
Subinvolution - Factors that enhance it
Breastfeeding
Empty bladder - very important
Fundal massage - have to teach patients
Oxytocic medication
Early ambulation
Subinvolution - Factors that inhibit
Prolonged/ Difficult labor of birth
Excessive anesthesia/ analgesia
Grand multiparity
Atonic bladder
Retained membranes or placental fragments
Infection/ endometritis
Checking the Fundus
Always support from below to prevent inversion of the uterus
Assessment: Uterine Tone, Height, Position
Tone - Firm or boggy
Height - U= at umbilicus, 1/U = 1 cm above umbilicus, U/1= 1 cm below the umbilicus.
Position- ML, R or L, Full bladder will displace uterus from ML
* 1st thing is to massage if you can't feel uterus, helps contract and stop bleeding.
Maternal & Fetal Circulations
DO NOT MIX
Placental Separation
Placental separation occurs because of the disproportion between size of the placenta and the decreased size of the implantation site (contracted empty uterus).
*Continued bleeding with contraction uterus could be placental fragments retained.
Assessment - Lochia
Type: Rubra- 1 to 3 days, Serosa - 4 to 9 days light red/pinkish, Alba - 10-14 days colorless discharge
Amount (per hour): Scant - < 1 inch stain on pad, Light/Small - < 4 inch stain on pad, Moderate - < 6 inch stain on pad, Heavy- Saturated pad
*Keep up
Lochia
Clots - Press clots out to distinguish from placental tissue (spongy material)
Retained Placental Fragments - Will cause continued hemorrhage, will lead to endometritis (infection).
Odor- Foul odor can indicate endometritis
*Lochia DOES NOT smell foul
*Lo
Afterpains/ Uterine Contractions
Contraction of atonic uterus
More pronounced in first 2-3 days
More common with: multigravidas, overdistention of uterus - macrosomnia, multiple birth, polyhydramnios, retained placental fragments, latch-on in breastfeeders (oxytocin, contractions)
Massag
Cervical Changes
Slowly closes (still 1 cm dilated at 1 week)
Cervical permanently changed
Vaginal Changes
Hymen heals irregularly
Vaginal rugae return by 3 weeks
Complete healing by 6 weeks
Hormones cause vaginal dryness/dysparunia (prolonged in breastfeeders)
*Resume sexual activity when no discharge = placental site healed.
Perineal Muscles
Tone and contractility of perineal muscles are enhanced by Kegal's exercises.
*stimulates circulation in that area, decreases swelling.
Abdomen
Toned abdominal muscles - Give better support during pregnancy, regain tone sooner postpartum
Initially stretched and flabby
Responds to exercise by 2 to 3 months
Abdominal Changes
Diastasis recti - separation of abdominal muslces (improved with exercise)
Stretch marks - fade and shrink with time.
Gastrointestinal System
Immediately hungry and thirsty.
Bowel sluggish from progesterone
Fear of pain with defecation may delay it and cause constipation (laceration, C/S)
Stool softeners reduce fear and strain
C sections can have regular diet once bowel sounds are active.
Early
Assessment: Bowels
Auscultate bowel sounds
Assess abdominal distention
Encourage : Ambulation, increased roughage/fiber, increased fluids.
Stool softeners ( 3rd and 4th degree episiotomies and lacerations)
Hemorrhoids
Avoid prolonged sitting (main thing)
Side lying with hips elevated
Kegal's exercises
Sitz baths (after lay on side, do kegels)
Ice packs
Analgesic ointments
Fluids, stool softeners
*Ambulate, pressure from baby dilates anal sphincter and engorge, pillow u
Urinary Tract
May have : increased bladder capacity, decreased sensation of bladder filling, swelling/bruising around urethra.
Diuresis causes rapid bladder filling
Full bladder>uterine relaxation>hemorrhage
*Empty bladder at regular intervals (example before breastfee
Assessment: Bladder
Distention
Emptying
Discomfort (burning, urgency, frequency)
Intake & Output
Diaphoresis
Profuse sweating
Night sweats
Recommend cotton on flannel gowns and sheets
Assessments : Breasts
Firmness/Consistency : Soft, filling, firm, engorged (day 3-4)
Nipple Structure: everted, flat, inverted (compression pinch test)
Nipple integrity: Redness, soreness, bruising, cracks/fissures, bleeding (not latching on correctly)
Nipple Discharge: Colost
Vital Signs
Postpartum chill - nervous response or vasomotor changes. Later = infection.
Fever (up to 100.4) - due to exertion and dehydration of labor. Higher = Infection.
Bradycardia- (50-70) in first week (r/t increase in blood volume)
Tachycardia- hemorrhage or i
Assessment of Vital Signs
Temperature q4h (if under 100.4)
BP, P, R - q 15 mins x4, q 30 mins x2, q4h
Watch for: hypotension/tachycardia (shock), Hypertension (PIH), Fever (dehydration or infection)
Assessments BUBBLE
Breasts
Uterus
Bowel
Bladder
Lochia
Episiotomy
Ovulation/Menstruation/Contraception
May ovulate by 27 days
Menstruation resumes in 2-6 months in non-nursing mothers
Menstruation delayed in nursing mothers IF prolactin level is kept high
Hormonal contraception approved by AAP after lactation is well established. Can suppress hormones for
Blood Values
Activation of coagulation factors (an immobility) predisposed to thromboembolism.
Leukocytosis WBC 20-25,000 (normal 5-10,000) is normal and may mask infection.
H&H values should approximate or exceed pre-labor values within 2-6 weeks.
Weight Loss
Lose 10-12 pounds immediately from infant, placenta, amniotic fluid
Lose another 5 pounds with diuresis
Breastfeeders lose more weight (difference more pronounced after 3 months)
Rubella Vaccine ( or MMR)
Given to non-immune mothers before discharge
Attenuated virus is safe for breastfeeding mothers
Vaccine may be teratogenic for 2-3 months - Contraceptive teaching, informed consent
RhoGam (Rh Immune Globulin)
Given to prevent Rh isoimmunization: Rh - mother, Rh + baby, Coombs negative ( non-sensitized)
Uterine Atony/ Hypotonia Causes
High parity
Polyhydramnios
Macrosomic fetus
Multi-fetal gestation
Rapid or prolonged labor
Chorioamnionitis/ Endometritis
Couvelaire uterus (after central placental abruption)
Presentation: boggy uterus, hemorrhage
Uterina Atony/ Hypotonia Need to
Promote uterine contraction: Urinate frequently, massage fundus, breastfeeding releases oxytocin, pitocin (synthetic oxytocin)
Assess blood loss: weigh peripads & underpads, press out clots to detect placental fragments.
Episiotomies
Location: Midline (ML)(no muscles) and Mediolateral (RML or LML)( have to cut muscles, more pain, blood loss)
Degree: 1st- skin and mucous membranes, 2nd + muscles, 3rd + rectal sphincter, 4th + rectal wall.
*Exercise will help not tear, keep muscles in g
Lacerations
Types: cervix, vaginal, perineum
Degrees: Same as episiotomies
Laceration Causes
Operative or precipitate birth (forceps or vacuum)
Abnormal size, presentation, position (breech)
Vulvar, perineal, or vaginal varicosities
Presentation: slow trickle or oozing of blood
Treatment: sutures, pressure/ice packs
*Slow, controlled delivery of
Assessment: Episiotomy/Lacerations
Assess: Approximated edges, edema, pain, redness, bruising,hematoma
Episiotomy Complications: Edema/ Pain
Treatment: Ice packs (first day) PREVENT edema & pain, warm sitz bath (after first day), Avoid dependent position, Kegel's exercises, local analgesic preparations, oral analgesics ( in therapeutic doses, are safe for milk)
*edema causes the pain, stitches
Episiotomy/Laceration Complications
For 3rd and 4th degree episiotomies or lacerations:
No rectal suppositories
No enemas
Stool softeners
Hematomas
Hematomas - Vulvar, Vaginal, Retroperitoneal
Presentation - Pain/burning/pressure, purplish, shiny bulge
Prevention/ Treatment - Ice packs, sutures
*Swelling causes burning and pressure
Retained Placenta : Non-Adherent
Non-adherent- endometrium
Presentation - Boggy uterus (or alternate cramping), hemorrhage
Treatment- Manual exploration of uterus, manual removal, dilitation and curretage
Retained Placenta: Adherent
Adherent:
Placenta accreta - superficial in myometrium
Placenta increta - deep in myometrium
Placenta percreta - perforation of uterus
Treatment - Laceration or perforation of uterus may occur with surgical removal, hysterectomy
Inversion of the Uterus
Presentation: red, round, bleeding mass
Prevention: Do NOT pull on cord before placental separation. Do NOT push on relaxed fundus.
Treatment for inverted uterus: Gently replace with fist, bi-manual massage, hysterectomy
*Do not confuse with prolapsed ute
Post Partum Hemorrhage Monitoring
Monitor for : vital signs, bleeding (may need to weigh peripads & underpads), Clots (press out clots), Uterine tone
Fluid/blood replacement
Oxygen
Medications: Oxytocin (pitocin), Methylergonovine (methergine, do not give if increased BP), Prostagladin F2
Post Partum Infection - Endometritis
Most common cause of PP infection- localized at placental site, spread to entire endometrium.
Causes: operative birth, prolonged labor or prolonged ROM, internal monitoring.
Presentation: Fever, chills, Tachycardia. Pelvic pain, uterina tenderness, crampi
Post Partum Infection - Episiotomy/Lacerations
Presentation: Erythema, warmth, tenderness, seropurulent discharge, wound separation.
Pericare: soap and water at shower, peri bottle cleansing front to back (external), frequent change of pad.
PP Infection - Cesarean Incision
Presentation: Erythema, warmth, tenderness, seropurulent discharge- do NOT remove staples, wound separation.
PP Infection - UTI
Risk factors: catherization (most common cause), pelvic exams, epidural anesthesia/overdistention of bladder, birth trauma, cesarean birth.
Presentation: Dysuria, frequency, urgency, retention, low grade fever, hematuria, pyruia.
Postpartum Infection
Treatment: Cultures before starting antibiotics, antibiotics
Assessment: Pain
Perineum (laceration or episiotomy)
Hemorrhoids
C-Section incision
Gas pain
Afterpains
Sore nipples
Breast engorgement
Thromboembolic Disease Superficial & Deep Vein Thrombosis
Presentation - Superficial Vein Thrombosis : Warmth, redness, enlarged hardened vein
Presentation- Deep vein thrombosis: unilateral leg pain, calf tenderness, swelling, + Homan's sign.
Superficial & DVT Prevention
EARLY AMBULATION
Assessment: peripheral pulses, + Homan's sign, Leg circumference.
Treatment: Rest, elevation of leg/warm packs, elastic stockings, anticoagulants, analgesics.
Thromboembolic Disease- Pulmonary Embolism
Presentation & Assessment: Dyspnea & tachypnea, apprehension, cough/ hemoptysis, tachycardia, elevated temperature, chest pain.
Sore Nipples Risk Factors
Improper position or latch on
Sustained negative pressure ( not swallowing)
Moisture
Inadequate milk production or letdown
Sore Nipples Prevention/Treatment
Proper position & latch
Rotate nursing positions
Avoid non-nutritive sucking
Avoid non-physiologic pumps
Colostrum is healing*
Air dry after feeds
Change breast pads frequently
Promote milk supply and letdown
Cracks/ Fissure
Improper latch on
Fix latch BEFORE this occurs
Thrush
Previous candidiasis in family
Previous infection requiring antibiotics
Predisposing conditions - immunosuppression, diabetes
Family health and hygiene habits
Prevention/Treatment of Thrush
Wash hands after tolieting or changing diapers and before touching breasts or breastfeeding.
Wash towels and bras in hot, soapy water.
Boil items that come in contact with baby's mouth or mother's breasts.
Rinse breast after feeding.
Air dry
Expose to sun
Engorgement- Physiologic
Presentation: swelling and fullness on day 3-4, Normal stage of lactogenesis.
Treatment: Early & frequent emptying (q 2-3 h) to prevent pathological engorgement. Feeding, pumping & manual expression.
Engorgement Pathologic
Presentation: swelling around glands & ducts, accumulation of milk in glands and ducts, Pressure involution ( milk supply "dries up")
Treatment: manual expression/ pumping to soften, regular nursing to empty breasts, cold cabbage compresses, support bra,
Pressure involution
Milk pressure within alveoli
Swelling around alveoli
Damage milk producing cells.
Milk "dries up
Lactation Suppression
No nipple stimulation
No breast emptying (feeding, pumping or manual expression)
Same treatment as engorgement - Cold cabbage compresses, support bra.
Plugged ducts Risk Factors
Risk factors: thickening of milk in ducts, constriction across duct (elastic or underwire bra), milk stasis.
Presentation: red, hot, tender lump.
Plugged duct/ Milk bleb Prevention
Prevention/Treatment: Avoid constrictions, warm, moist compresses, massage toward nipple, regular emptying, be alert for mastitis.
Mastitis Risk Factors
Plugged ducts # 1 cause
Nipple cracks/ Fissures
Milk stasis : Engorgement, poor let down, irregular or skipped feeding/ pumping
Mastitis Presentation
Chills/Fever
Flu-like symptoms
Localized or generalized - tenderness/pain, redness/ swelling.
Treatment: rest, warm compresses, frequent thorough emptying, antibiotics
*Heat, rest, and empty breast
*Milk is still safe for baby
*Flu-like symptoms in a lact
Breast Abscess
May need incision & drainage
Continue nursing/pumping to ensure good emptying
Frequent change of dressings
Insufficient Milk Syndrome
Signs of an adequate milk supply:
Feeds at physiologic intervals ( q2-3h) round the clock
Nutritive sucking with audible swallowing
6-8 wet diapers/day
Mulitple YELLOW stools/day ( after day 5)
Satisfied & sleeps between feedings
Starts gaining weight by
Insufficient Milk Syndrome Risk Factors
Delayed/ irregular/ short feedings (baby doesn't set the pace)
Inadequate emptying (baby falls asleep)
Prevention/Treatment: early & frequent feedings/ pumping/ expression. Adequate emptying, promote letdown ( milk ejection reflex)
Psychologic Adaptation after birth
Must adjust to: reality of end of pregnancy, reality of birth, new baby, changed body image, changing family relationships, changing family roles.
Challenges to Adjustment
Fatigue/sleep deprivation
Discomfort
Feelings of: incompetence, overwhelming responsibility, lack of freedom, lack of privacy.
Mother-Infant Attachment
Is she attracted to her newborn?
Is she pleased with baby's sex, size, appearance?
Does she seek information about the baby?
Is she sensitive to her baby's needs?
Does she respond to those needs consistently?
Does she speak affectionately to/about the bab
Transistion to Parenthood
Taking- in: Focus on self & own needs, passive, excited/talkative, need to review birth experience
Taking-hold: Focus on infant care & mothering, desire to take charge.
Letting go: Focus on partner and family, role transistion.
Post Partum "Blues
Emotionally labile (adjustment of hormones)
Peak by 5th day, subside by 10th day
Depression/ let down feeling
Restlessness
Fatigue/exhaustion/insomnia
Anxiety/sadness/anger
Overwhelmed by mothering responsibilities
Coping Mechanisms: rest, selfcare, get h
Post Partum Depression Risk Factors
Prenatal anxiety or depression
Low self-esteem
stress of child care
life stress
lack of social support
marital relationship problems/ single status
"Difficult" infant temperament
Low SES
Unplanned/unwanted pregnancy
Post Partum Depression Presentation/ Treatment
Intense & pervasive sadness
severe and labile mood swings
intense fears, anger, anxiety, despondency
persistence of symptoms beyond first few weeks
irritability/violent outbursts
Obsessive thoughts of harming infant
Guilt over negative feelings towards in
Postpartum Psychosis Presentation/ Treatment
Presentation: depression, thoughts of harming infant or self, suspiciousness, confusion, incoherence, irrational statements, obsessive concerns about the baby's health, delusions/hallucinations.
*mentally ill before
Treatment: psychiatric emergency/hospit