Medicine

UNIT TEST IV

UNIT TEST IV

Prepared by assistant professor N.Petrenko, MD, PhD

LEARNING OBJECTIVES

Summarize knowledge about normal and abnormal postpartum period

 

The postpartum period is the 6-week interval between the birth of the newborn and the return of the reproductive organs to their normal nonpregnant state. This period is sometimes referred to as the puerperium, or fourth trimester of pregnancy. The physiologic changes that occur during the reversal of the processes of pregnancy, though distinctive, are normal. To provide care during the recovery period that is beneficial to the mother, her infant, and her family, the nurse must synthesize knowledge of maternal anatomy and physiology of the recovery period, the newborn's physical and behavioral characteristics, infant care activities, and family response to the birth of the infant. This chapter focuses on anatomic and physiologic changes that occur in the mother during the postpartum period.

 

REPRODUCTIVE SYSTEM AND ASSOCIATED STRUCTURES

UTERUS

Involution process

The return of the uterus to a nonpregnant state following birth is known as involution. This process begins immediately after expulsion of the placenta with contraction of the uterine smooth muscle.

At the end of the third stage of labor the uterus is in the midline, approximately 2 cm below the level of the umbilicus, with the fundus resting on the sacral promontory. At this time, the uterus is approximately the size it was at 16 weeks of gestation (about the size of a grapefruit) and weighs approximately 1000 g.

 

Fig. 1 Assessment of involution of uterus after childbirth. A, Normal progress, days 1 through 9. B, Size and position of uterus 2 hours after childbirth. C, Two days after childbirth. D, Four days after childbirth. (B, C, D, Courtesy Marjorie Pyle, RNC, Lifecircle, Costa Mesa, CA.)

 

Within 12 hours the fundus may be approximately 1 cm above the umbilicus (Fig. 1). Involution progresses rapidly during the next few days. The fundus descends 1 to 2 cm every 24 hours. By the sixth postpartum day the fundus is normally located halfway between the umbilicus and the symphysis pubis. A week after birth the uterus once again lies in the true pelvis. The uterus should not be palpable abdominally after the ninth postpartum day.

The uterus, which at full term weighs approximately 11 times its prepregnancy weight, involutes to approximately 500 g by 1 week after birth and to 350 g by 2 weeks after birth. At 6 weeks it weighs 50 to 60 g (see Fig. 1).

Increased estrogen and progesterone levels are responsible for stimulating the massive growth of the uterus during pregnancy. Prenatal uterine growth results from both hyperplasia, an increase in the number of muscle cells, and from hypertrophy, an enlargement of the existing cells. Postpartally, the decrease in these hormones causes autolysis, the self-destruction of excess hypertrophied tissue. The additional cells laid down during pregnancy remain and account for the slight increase in uterine size after each pregnancy.

Subinvolution is the failure of the uterus to return to a nonpregnant state. The most common causes of subinvolution are retained placental fragments and infection.

 

Contractions

Postpartum hemostasis is achieved primarily by compression of intramyometrial blood vessels as the uterine muscle contracts rather than by platelet aggregation and clot formation. The hormone oxytocin, released from the pituitary gland, strengthens and coordinates these uterine contractions, which compress blood vessels and promote hemostasis. During the first 1 to 2 postpartum hours, uterine contractions may decrease in intensity and become uncoordinated. Because it is vital that the uterus remain firm and well contracted, exogenous oxytocin (Pitocin) is usually administered intravenously or intramuscularly immediately after expulsion of the placenta. Mothers who plan to breastfeed may also be encouraged to put the baby to breast immediately after birth because suckling stimulates oxytocin release from the posterior pituitary gland.

 

Afterains

In first-time mothers, uterine tone is good, the fundus generally remains firm, and the mother does not perceive uterine cramping. Periodic relaxation and vigorous contraction are more common in subsequent pregnancies and may cause uncomfortable cramping called afterbirth pains (afterpains), which persist throughout the early puerperium. Afterpains are more noticeable after births in which the uterus was overdistended (e.g., large baby, multifetal gestation, polyhydramnios). Breastfeeding and exogenous oxytocic medication usually intensify these afterpains because both stimulate uterine contractions.

 

Placental site

Immediately after the placenta and membranes are expelled, vascular constriction and thromboses reduce the placental site to an irregular nodular and elevated area. Upward growth of the endometrium causes sloughing of necrotic tissue and prevents the scar formation that is characteristic of normal wound healing. This unique healing process enables the endometrium to resume its usual cycle of changes and to permit implantation and placentation in future pregnancies. Endometrial regeneration is completed by the end of the third postpartum week, except at the placental site. Regeneration at the placental site usually is not complete until 6 weeks after birth.

 

Lochia

Postchildbirth uterine discharge, commonly called lochia, initially is bright red and changes later to a pinkish red or reddish brown. It may contain small clots. For the first 2 hours after birth the amount of uterine discharge should be approximately that of a heavy menstrual period. After that time, the lochia flow should steadily decrease.

Lochia rubra consists mainly of blood and decidual and trophoblastic debris. The flow pales, becoming pink or brown (lochia serosa) after 3 to 4 days. Lochia serosa consists of old blood, serum, leukocytes, and tissue debris. Approximately 10 days after childbirth the drainage becomes yellow to white (lochia alba). Lochia alba consists of leukocytes, decidua, epithelial cells, mucus, serum, and bacteria. Lochia alba may continue for 2 to 6 weeks after the birth.

If the woman receives an oxytocic medication, the flow of lochia is usually scant until the effects of the medication wear off. The amount of lochia is usually less after cesarean births. Flow of lochia usually increases with ambulation and breastfeeding. Lochia tends to pool in the vagina when the woman is lying in bed; the woman then may experience a gush of blood when she stands. This gush should not be confused with hemorrhage.

Persistence of lochia rubra early in the postpartum period suggests continued bleeding as a result of retained fragments of the placenta or membranes. Recurrence of bleeding approximately 10 days after birth is from the healing placental site. However, any bleeding occurring 3 to 4 weeks after birth may be caused by infection or subinvolution. Continued flow of lochia serosa or lochia alba may indicate endometritis, particularly if fever, pain, or abdominal tenderness is associated with the discharge. Lochia should smell like normal menstrual flow; an offensive odor usually indicates infection.

Not all postpartal vaginal bleeding is lochia; vaginal bleeding after birth may be due to unrepaired vaginal or cervical lacerations. Table 1 distinguishes between lochial and nonlochial bleeding.

 

TABLE 1 LOCHIAL AND NONLOCHIAL BLEEDING

LOCHIAL BLEEDING

NONLOCHIAL BLEEDING

Lochia usually trickles from the vaginal opening. The steady flow is greater as the uterus contracts

If the bloody discharge spurts from the vagina, there may be cervical or vaginal tears in addition to the normal lochia.

A gush of lochia may result as the uterus is massaged. If it is dark in color, it has been pooled in the relaxed vagina, and the amount soon lessens to a trickle of bright red lochia (in the early puerperium).

If the amount of bleeding continues to be excessive and bright red, a tear may be the source.

 

CERVIX

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

 

VAGINA AND PERINEUM

Postpartum estrogen deprivation is responsible for the thinness of the vaginal mucosa and the absence of rugae. The greatly distended, smooth-walled vagina gradually returns to its prepregnancy size by 6 to 8 weeks after childbirth. Rugae reappear by approximately the fourth week, but they are never as prominent as they are in the nulliparous woman. Most rugae are permanently flattened. The mucosa remains atrophic in the lactating woman, at least until menstruation resumes. Thickening of the vaginal mucosa occurs with the return of ovarian function. Estrogen deficiency is also responsible for a decreased amount of vaginal lubrication. Localized dryness and coital discomfort (dyspareunia) may persist until ovarian function returns and menstruation resumes. The use of a water-soluble lubricant during sexual intercourse is usually recommended.

Initially, the introitus is erythematous and edematous, especially in the area of the episiotomy or laceration repair. It is barely distinguishable from that of a nulliparous woman if lacerations and an episiotomy have been carefully repaired, hematomas are prevented or treated early, and the woman observes good hygiene during the first 2 weeks after birth.

Most episiotomies are visible only if the woman is lying on her side with her upper buttock raised or if she is placed in the lithotomy position. A good light source is essential for visualization of some episiotomies. Healing of an episiotomy is the same as any surgical incision. Signs of infection (pain, redness, warmth, swelling, or discharge) or loss of approximation (separation of the edges of the incision) may occur. Healing should occur within 2 to 3 weeks.

Hemorrhoids (anal varicosities) are commonly seen. Internal hemorrhoids may evert while the woman is pushing during birth. Women often experience associated symptoms such as itching, discomfort, and bright red bleeding with defecation. Hemorrhoids usually decrease in size within 6 weeks of childbirth.

 

Pelvic muscular support

The supporting structure of the uterus and vagina may be injured during childbirth and may contribute to later gynecologic problems. Supportive tissues of the pelvic floor that are torn or stretched during childbirth may require up to 6 months to regain tone. Kegel exercises, which help to strengthen perineal muscles and encourage healing, are recommended after childbirth. Later in life, women can experience pelvic relaxation, the lengthening and weakening of the fascial supports of pelvic structures. These structures include the uterus, upper posterior vaginal wall, urethra, bladder, and rectum.

 

ENDOCRINE SYSTEM

PLACENTAL HORMONES

Significant hormonal changes occur during the postpartal period. Expulsion of the placenta results in dramatic decreases of the hormones produced by that organ. Decreases in human chorionic somatomammotropin, estrogens, cortisol, and the placental enzyme insulinase reverse the diabetogenic effects of pregnancy, resulting in significantly lower blood sugar levels in the immediate puerperium. Mothers with type 1 diabetes will be likely to require much less insulin for several days after birth. Because these normal hormonal changes make the puerperium a transitional period for carbohydrate metabolism, it is more difficult to interpret glucose tolerance tests.

Estrogen and progesterone levels drop markedly after expulsion of the placenta and reach their lowest levels 1 week postpartum. Decreased estrogen levels are associated with breast engorgement and with the diuresis of excess extracellular fluid accumulated during pregnancy. In nonlactating women, estrogen levels begin to rise by 2 weeks after birth and by postpartum day 17 are higher than in women who breastfeed (Bowes & Katz, 2002).

β-Human chorionic gonadotropin (/3-hCG) disappears from maternal circulation in 14 days (Resnik, 1999).

 

PITUITARY HORMONES AND OVARIAN FUNCTION

Lactating and nonlactating women differ considerably in the time when the first ovulation occurs and when menstruation resumes. The persistence of elevated serum prolactin levels in breastfeeding women appears to be responsible for suppressing ovulation. Because levels of follicle-stimulating hormone (FSH) have been shown to be identical in lactating and nonlactating women, it is thought that the ovulation is suppressed in lactating women because the ovary does not respond to FSH stimulation when increased prolactin levels are present (Resnik, 1999).

Prolactin levels in blood rise progressively throughout pregnancy. In women who breastfeed, prolactin levels remain elevated into the sixth week after birth (Rebar, 1999). Serum prolactin levels are influenced by the frequency of breastfeeding, the duration of each feeding, and the degree to which supplementary feedings are used. Individual differences in the strength of an infant's sucking stimulus probably also affect prolactin levels. In nonlactating women, prolactin levels decline after birth and reach the prepregnant range in 4 to 6 weeks (Rebar, 1999).

Ovulation occurs as early as 27 days after birth in nonlactating women, with a mean time of 70 to 75 days. Approximately 70% of nonbreastfeeding women resume menstruating by 3 months after birth. In women who breastfeed, the mean length of time to initial ovulation is 17 weeks. In lactating women, both resumption of ovulation and return of menses are determined in large part by breastfeeding patterns (Resnik, 1999). Many women ovulate before their first postpartum menstrual period occurs; thus there is need to discuss contraceptive options early in the puerperium (Rebar, 1999).

The first menstrual flow after childbirth is usually heavier than normal. Within three to four cycles the amount of menstrual flow returns to the woman's prepregnancy volume.

 

ABDOMEN

When the woman stands up during the first days after birth, her abdomen protrudes and gives her a still-pregnant appearance. During the first 2 weeks after birth the abdominal wall is relaxed. It takes approximately 6 weeks for the abdominal wall to return almost to its nonpregnancy state. The skin regains most of its previous elasticity, but some striae may persist. The return of muscle tone depends on previous tone, proper exercise, and the amount of adipose tissue. Occasionally, with or without overdistention because of a large fetus or multiple fetuses, the abdominal wall muscles separate, a condition termed diastasis recti abdominis (see Fig. 8-13). Persistence of this defect may be disturbing to the woman, but surgical correction rarely is necessary. With time, the defect becomes less apparent.

 

URINARY SYSTEM

The hormonal changes of pregnancy (i.e., high steroid levels) contribute to an increase in renal function; diminishing steroid levels after childbirth may partly explain the reduced renal function that occurs during the puerperium. Kidney function returns to normal within 1 month after birth. From 2 to 8 weeks are required for the pregnancy-induced hypotonia and dilation of the ureters and renal pelves to return to the nonpregnant state (Resnik, 1999). In a small percentage of women, dilation of the urinary tract may persist for 3 months, which increases the chance of developing a urinary tract infection.

 

URINE COMPONENTS

The renal glycosuria induced by pregnancy disappears, but lactosuria may occur in lactating women. The blood urea nitrogen increases during the puerperium as autolysis of the involuting uterus occurs. This breakdown of excess protein in the uterine muscle cells also results in a mild (+1) proteinuria for 1 to 2 days after childbirth in approximately 50% of women (Simpson & Creehan, 2001). Ketonuria may occur in women with an uncomplicated birth or after a prolonged labor with dehydration.

 

POSTPARTAL DIURESIS

Within 12 hours of birth, women begin to lose excess tissue fluid accumulated during pregnancy. Profuse diaphoresis often occurs, especially at night, for the first 2 or 3 days after childbirth. Postpartal diuresis, caused by decreased estrogen levels, removal of increased venous pressure in the lower extremities, and loss of the remaining pregnancy-induced increase in blood volume, also aids the body to rid itself of excess fluid. Fluid loss through perspiration and increased urinary output accounts for a weight loss of approximately 2.25 kg during the puerperium.

 

URETHRA AND BLADDER

Birth-induced trauma, increased bladder capacity following childbirth, and the effects of conduction anesthesia combine to cause a decreased urge to void. In addition, pelvic soreness caused by the forces of labor, vaginal lacerations, or the episiotomy reduces or alters the voiding reflex. Decreased voiding combined with postpartal diuresis may result in bladder distention. Immediately after birth, excessive bleeding can occur if the bladder becomes distended because it pushes the uterus up and to the side and prevents the uterus from contracting firmly. Later in the puerperium overdistention can make the bladder more susceptible to infection and impede the resumption of normal voiding (Resnik, 1999). With adequate emptying of the bladder, bladder tone is usually restored 5 to 7 days after childbirth.

 

GASTROINTESTINAL SYSTEM

APPETITE

The mother usually is hungry shortly after the birth and can tolerate a light diet. Most new mothers are very hungry after full recovery from analgesia, anesthesia, and fatigue. Requests for double portions of food and frequent snacks are not uncommon (see Research box).

 

RESEARCH

Weight and Fat Gain During Pregnancy and Postpartum

Obesity is a risk factor for a variety of diseases. Its prevalence is increasing in the United States and at earlier ages. Central obesity, or abdominal fat, as demonstrated by a greater waist-to-hip ratio, is the most valuable predictor of disordered glucose tolerance, which predisposes the patient to diabetes and gestational diabetes. Many women trace weight gain to their pregnancies. Previous studies have documented that most women in developed countries accumulate subcutaneous fat during pregnancy, affecting postpartum weight retention with only minimal effects on infant birth weight.

To assess whether patterns of weight and fat gain during pregnancy differed by body mass index (BMI), researchers studied 77 United Kingdom women during pregnancy and 47 of them to 6 months postpartum. The following BMI categories were used: underweight, BMI < 19.8; normal, 19.8 > BMI < 26; overweight, 26 > BMI £ 29; obese, BMI > 29. The BMI in early pregnancy was the baseline. Weight and skinfold thickness at five sites (triceps, biceps, subscapular, suprailiac, and midthigh) were measured at 13, 25, and 36 weeks of gestation and at 6 weeks and 6 months postpartum.

Overall, weight gain was not significant from 13 weeks of gestation to 6 months postpartum, but fat gain was significant. Normal-weight women had little variance in their gain and loss curves. Overweight women had the most dramatic weight gains and weight losses. Obese women showed the highest values for fat mass at 6 months. Whereas other groups lost fat during the postpartum, obese women gained fat.

IMPLICATIONS FOR PRACTICE

In preconception counseling, nurses can advise women why it is important to attain normal body weight before getting pregnant. In prenatal counseling, obese women can be encouraged to try to limit pregnancy weight gain to 15 pounds. After the birth, nurses can offer suggestions and support to postpartum patients, especially those who are obese, about ways to increase exercise and decrease fat intake to lose weight sensibly and safely. Referrals to weight loss programs and support groups may be important interventions to help the woman continue to be successful after the postpartum period.

 

BOWEL EVACUATION

A spontaneous bowel evacuation may not occur for 2 to 3 days after childbirth. This delay can be explained by decreased muscle tone in the intestines during labor and the immediate puerperium, prelabor diarrhea, lack of food, or dehydration. The mother often anticipates discomfort during the bowel movement because of perineal tenderness as a result of episiotomy, lacerations, or hemorrhoids and resists the urge to defecate. Regular bowel habits should be reestablished when bowel tone returns.

Obstetric trauma (e.g., direct injury to the sphincter muscle, damage to the innervation of the pelvic floor) is perhaps the leading cause of anal incontinence in otherwise healthy women (Toglia, 1996). Women should be taught during pregnancy about episiotomy and its possible sequelae. Pelvic floor (Kegel) exercises should be encouraged.

 

BREASTS

Promptly after birth, there is a decrease in the concentrations of hormones (i.e., estrogen, progesterone, hCG, prolactin, cortisol, and insulin) that stimulated breast development during pregnancy. The time it takes for these hormones to return to prepregnancy levels is determined in part by whether the mother breastfeeds her infant.

 

BREASTFEEDING MOTHERS

As lactation is established, a mass (lump) may be felt in the breast. Unlike the lumps associated with fibrocystic breast disease or cancer (which may be consistently palpated in the same location), a filled milk sac shifts position from day to day. Before lactation begins, the breasts feel soft and a yellowish fluid, colostrum, can be expressed from the nipples. After lactation begins, the breasts feel warm and firm. Tenderness may persist for approximately 48 hours after the start of lactation. Bluish-white milk with a skim-milk appearance (true milk) can be expressed from the nipples. The nipples are examined for erectility and signs of irritation such as cracks, blisters, or reddening.

 

NONBREASTFEEDING MOTHERS

The breasts generally feel nodular in contrast to the granular feel of breasts in nonpregnant women. The nodularity is bilateral and diffuse. Prolactin levels drop rapidly. Colostrum is present for the first few days after childbirth. Palpation of the breast on the second or third day, as milk production begins, may reveal tissue tenderness in some women. On the third or fourth postpartum day, engorgement may occur. The breasts are distended (swollen), firm, tender, and warm to the touch (because of vasocongestion). Breast distention is caused primarily by the temporary congestion of veins and lymphatics rather than by an accumulation of milk. Milk is present but should not be expressed. Axillary breast tissue (the tail of Spence) and any accessory breast or nipple tissue along the milk line may be involved. Engorgement resolves spontaneously, and discomfort decreases usually within 24 to 36 hours. A breast binder or tight bra, ice packs, or mild analgesics may be used to relieve discomfort. Nipple stimulation is avoided. If suckling is never begun (or is discontinued), lactation ceases within a few days to a week.

 

CARDIOVASCULAR SYSTEM

BLOOD VOLUME

Changes in blood volume after birth depend on several factors, such as blood loss during childbirth and the amount of extravascular water (physiologic edema) mobilized and excreted. Blood loss results in an immediate but limited decrease in total blood volume. Thereafter, most of the blood volume increase during pregnancy (1000 to 1500 ml) is eliminated within the first 2 weeks after birth, with return to nonpregnancy values by 6 weeks postpartum (Simpson & Creehan, 2001).

Pregnancy-induced hypervolemia (an increase in blood volume of at least 40% more than prepregnancy values near term) allows most women to tolerate considerable blood loss during childbirth. Many women lose approximately 300 to 400 ml of blood during vaginal birth of a single fetus and approximately twice this much during cesarean birth.

Readjustments in the maternal vasculature after childbirth are dramatic and rapid. The woman's response to blood loss during the early puerperium differs from that in a nonpregnant woman. Three postpartal physiologic changes protect the woman by increasing the blood volume: (1) elimination of uteroplacental circulation reduces the size of the maternal vascular bed by 10% to 15%, (2) loss of placental endocrine function removes the stimulus for vasodilation, and (3) mobilization of extravascular water stored during pregnancy occurs. Thus hypovolemic shock usually does not occur in women who experience a normal blood loss.

 

CARDIAC OUTPUT

Pulse rate, stroke volume, and cardiac output increase throughout pregnancy. Immediately after the birth they remain elevated or rise even higher for 30 to 60 minutes as the blood that was shunted through the uteroplacental circuit suddenly returns to the maternal systemic venous circulation. Data regarding the exact time of return of cardiac hemodynamic levels to normal are not available, but cardiac output values remain elevated for at least 48 hours after birth, decrease rapidly in the first 2 weeks postpartum, and return to prepregnancy level by 24 weeks postpartum. Stroke volume, cardiac output, end-diastolic volume, and systemic vascular resistance values have been shown to remain greatly elevated for as long as 12 weeks postpartum (Resnik, 1999).

 

VITAL SIGNS

Few alterations in vital signs are seen under normal circumstances. There may be a small, transient rise in both systolic and diastolic blood pressure that lasts approximately 4 days after the birth (Table 2). Respiratory function returns to nonpregnant levels by 6 to 8 weeks after birth. After the uterus is emptied, the diaphragm descends, the normal cardiac axis is restored, and the point of maximal impulse and the electrocardiogram are normalized.

 

TABLE 2 Vital Signs After Childbirth

NORMAL FINDINGS

DEVIATIONS FROM NORMAL FINDINGS AND PROBABLE CAUSES

TEMPERATURE

During first 24 hours may rise to 38° C as a result of dehydrating effects of labor. After 24 hours the woman should be afebrile.

 

A diagnosis of puerperal sepsis is suggested if a rise in maternal temperature to 38° C is noted after the first 24 hours after childbirth and recurs or persists for 2 days. Other possibilities are mastitis, endometritis, urinary tract infections, and other systemic infections.

PULSE

Pulse, along with stroke volume and cardiac output, remains elevated for the first hour or so after childbirth. It then begins to decrease. By 8 to 10 weeks after childbirth, the pulse has returned to a nonpregnant rate.

 

A rapid pulse rate or one that is increasing may indicate hypovolemia as a result of hemorrhage.

RESPIRATIONS

Respirations should decrease to within the woman's normal prebirth range by 6 to 8 weeks after birth.

 

Hypoventilation may follow an unusually high subarachnoid (spinal) block or epidural narcotic after a cesarean birth.

BLOOD PRESSURE

Blood pressure is altered slightly if at all. Orthostatic hypotension, as indicated by feelings of faintness or dizziness immediately after standing up, can develop in the first 48 hours as a result of the splanchnic engorgement that may occur after birth.

 

A low or decreasing blood pressure may reflect hypovolemia secondary to hemorrhage. However, it is a late sign, and other symptoms of hemorrhage usually alert the staff. An increased reading may result from excessive use of vasopressor or oxytocic medications. Because pregnancyinduced hypertension can persist into or occur first in the postpartum period, routine evaluation of blood pressure is needed. If a woman complains of headache, hypertension must be ruled out as a cause before analgesics are administered.

 

BLOOD COMPONENTS

Hematocrit and hemoglobin

During the first 72 hours after childbirth, there is a greater loss of plasma volume than in the number of blood cells. This results in a rise in hematocrit and hemoglobin levels by the seventh day after the birth. There is no increased red blood cell (RBC) destruction during the puerperium, but any excess will disappear gradually in accordance with the life span of the RBC. The exact time at which RBC volume returns to prepregnancy values is not known, but it is within normal limits when measured 8 weeks after childbirth (Bowes & Katz, 2002).

 

White blood cell count

Normal leukocytosis of pregnancy averages approximately 12,000/mm3. During the first 10 to 12 days after childbirth, values between 20,000 and 25,000/mm3 are common. Neutrophils are the most numerous white blood cells. Leukocytosis coupled with the normal increase in erythrocyte sedimentation rate that occurs may obscure the diagnosis of acute infections at this time.

 

Coagulation factors

Clotting factors and fibrinogen are normally increased during pregnancy and remain elevated in the immediate puerperium. When combined with vessel damage and immobility, this hypercoagulable state causes an increased risk of thromboembolism, especially after a cesarean birth. Fibrinolytic activity also increases during the first few days after childbirth (Bowes & Katz, 2002). Factors I, II, VIII, IX, and X decrease within a few days to nonpregnant levels. Fibrin split products, probably released from the placental site, can also be found in maternal blood.

 

VARICOSITIES

Varicosities (varices) of the legs and around the anus (hemorrhoids) are common during pregnancy. Varices, even the less common vulvar varices, regress (empty) rapidly immediately after childbirth. Surgical repair of varicosities is not considered during pregnancy. Total or nearly total regression of varicosities is expected after childbirth.

 

NEUROLOGIC SYSTEM

Neurologic changes during the puerperium are those that result from a reversal of maternal adaptations to pregnancy and those resulting from trauma during labor and childbirth.

Pregnancy-induced neurologic discomforts abate after birth. Elimination of physiologic edema through the diuresis that follows childbirth relieves carpal tunnel syndrome by easing compression of the median nerve. The periodic numbness and tingling of fingers that afflicts 5% of pregnant women usually disappears after the birth unless lifting and carrying the baby aggravates the condition. Headache requires careful assessment. Postpartum headaches may be caused by various conditions, including pregnancy-induced hypertension, stress, and leakage of cerebrospinal fluid into the extradural space during placement of the needle for epidural or spinal anesthesia. Depending on the cause and effectiveness of the treatment, the duration of the headaches can vary from 1 to 3 days to several weeks.

 

MUSCULOSKELETAL SYSTEM

Adaptations of the mother's musculoskeletal system that occur during pregnancy are reversed in the puerperium. These adaptations include the relaxation and subsequent hypermobility of the joints and the change in the mother's center of gravity in response to the enlarging uterus. The joints are completely stabilized by 6 to 8 weeks after birth. However, although all other joints return to their normal prepregnancy state, those in the parous woman's feet do not. The new mother may notice a permanent increase in her shoe size.

 

INTEGUMENTARY SYSTEM

Chloasma of pregnancy usually disappears at the end of pregnancy. Hyperpigmentation of the areolae and linea nigra may not regress completely after childbirth. Some women will have permanent darker pigmentation of those areas. Striae gravidarum (stretch marks) on the breasts, abdomen, and thighs may fade but usually do not disappear.

Vascular abnormalities such as spider angiomas (nevi), palmar erythema, and epulis generally regress in response to the rapid decline in estrogens after the end of pregnancy. For some woman, spider nevi persist indefinitely.

The abundance of fine hair seen during pregnancy usually disappears after giving birth; however, any coarse or bristly hair that appears during pregnancy usually remains. Fingernails return to their prepregnancy consistency and strength.

Profuse diaphoresis that occurs in the immediate postpartum period is the most noticeable change in the integumentary system.

 

IMMUNE SYSTEM

No significant changes in the maternal immune system occur during the postpartum period. The mother's need for a rubella vaccination or for prevention of Rh isoimmunization is determined.

 

Nursing Care During the Fourth Trimester

The goal of nursing care in the immediate postpartum period is to assist women and their partners during their initial transition to parenting. The approach to the care of women after birth has changed from one modeled on sick care to one that is wellness-oriented. Consequently, in the United States most women remain hospitalized no more than 1 or 2 days after giving birth and some for as few as 6 hours. Because there is so much important information to be shared with these women in a very short time, it is vital that their care be thoughtfully planned and provided. Care is focused on the woman's physiologic recovery, her psychologic well-being, and her ability to care for herself and her new baby, and includes other family members.

 

FOURTH STAGE OF LABOR

The first 1 to 2 hours after birth, sometimes called the fourth stage of labor, is a crucial time for mother and newborn. Both are not only recovering from the physical process of birth but are also becoming acquainted with each other and additional family members. During this time, maternal organs undergo their initial readjustment to the nonpregnant state and the functions of body systems begin to stabilize. Meanwhile, the newborn continues the transition from intrauterine to extrauterine existence.

The fourth stage of labor is an excellent time to begin breastfeeding because the infant is in an alert state and ready to nurse. Breastfeeding at this time also aids in the contraction of the uterus and the prevention of maternal hemorrhage. In most centers the mother remains in the labor and birth area during this recovery time. In an institution where labor, delivery, and recovery (LDR) rooms are used, the woman stays in the same room where she gave birth. In traditional settings, women are taken from the delivery room to a separate recovery area for observation. Arrangements for care of the newborn vary during the fourth stage of labor. In many settings, the baby remains at the mother's bedside and the labor/birth nurse cares for both of them. In other institutions the baby is taken to the nursery for several hours of observation after an initial bonding period with the parents (Fig. 1).

 

Fig. 1 Mother and father get acquainted with their newborn. (Courtesy Michael S. Clement, MD, Mesa, AZ.)

 

ASSESSMENT

If the recovery nurse has not previously cared for the new mother, her assessment begins with an oral report from the nurse who attended the woman during labor and birth and a review of the prenatal, labor, and birth records. Of primary importance are conditions that could predispose the mother to hemorrhage, such as precipitous labor, large baby, grand multiparity (i.e., having given birth to six or more viable infants), or induced labor. For healthy women, hemorrhage is probably the most dangerous potential complication during the fourth stage of labor.

During the first hour in the recovery room, physical assessments of the mother are frequent. All factors except temperature are assessed every 15 minutes for 1 hour. Temperature is assessed at the beginning and end of the recovery period. After the fourth 15-minute assessment, if all parameters have stabilized within the normal range, the process is usually repeated once in the second hour. Box 1 and Fig. 2 describe the physical assessment of the mother during the fourth stage of labor. Fig. 3 demonstrates an easy to-use flow sheet that combines the essential immediate postpartum and anesthesia recovery assessments.

 

BOX 1 Assessment During Fourth Stage of Labor

Before beginning the assessment, wash hands thoroughly, assemble necessary equipment, and explain the procedure to the patient.

BLOOD PRESSURE

Measure blood pressure per assessment schedule.

PULSE

Assess rate and regularity.

TEMPERATURE

Determine temperature.

FUNDUS

Put on clean examination gloves.

Position woman with knees flexed and head flat.

Just below umbilicus, cup hand and press firmly into abdomen. At the same time, stabilize the uterus at the symphysis with the opposite hand.

If fundus is firm (and bladder is empty), with uterus in midline, measure its position relative to woman's umbilicus. Lay fingers flat on abdomen under umbilicus; measure how many fingerbreadths (fb) or centimeters (cm) fit between umbilicus and top of fundus. If the fundus is above the umbilicus, this is recorded as plus fb or cm; if below, as minus fb or cm.

If fundus is not firm, massage it gently to contract and expel any clots before measuring distance from umbilicus.

Place hands appropriately; massage gently only until firm.

Expel clots while keeping hands placed as in Fig. 2. With upper hand, firmly apply pressure downward toward vagina; observe perineum for amount and size of expelled clots.

BLADDER

Assess distention by noting location and firmness of uterine fundus and by observing and palpating bladder. Distended bladder is seen as a suprapubic rounded bulge that is dull to percussion and fluctuates like a waterfilled balloon. When the bladder is distended, the uterus is usually boggy in consistency, well above the umbilicus, and to the woman's right side.

Assist woman to void spontaneously. Measure amount of urine voided.

Catheterize as necessary.

Reassess after voiding or catheterization to make sure the bladder is not palpable and the fundus is firm and in the midline.

LOCHIA

Observe lochia on perineal pads and on linen under the mother's buttocks. Determine amount and color, note size and number of clots; note odor.

Observe perineum for source of bleeding (e.g., episiotomy, lacerations).

PERINEUM

Ask or assist woman to turn on her side and flex upper leg on hip.

Lift upper buttock.

Observe perineum in good lighting.

Assess episiotomy site or laceration repair for intactness, hematoma, edema, bruising, redness, and drainage.

Assess for presence of hemorrhoids.

 

Fig. 2 Palpating fundus of uterus during the fourth stage of labor. Note that upper hand is cupped over fundus; lower hand dips in above symphysis pubis and supports uterus while it is massaged gently.

 

Fig. 3 An example of a maternity recovery room record. (Courtesy The Regional Medical Center at Memphis [The Med], Memphis, TN.)

 

During the fourth stage of labor, intense tremors that resemble shivering from a chill are commonly seen; they are not related to infection. Several theories have been offered to explain these tremors or shivering, such as their being the result of a sudden release of pressure on pelvic nerves after birth, a response to a fetus-to-mother transfusion that occurred during placental separation, a reaction to maternal adrenaline production during labor and birth, or a reaction to epidural anesthesia. Warm blankets and reassurance that the chills or tremors are common, self-limiting, and last only a short while are useful interventions.

The nutritional status of the woman is assessed. Restriction of food and fluid intake and the loss of fluids (blood, perspiration, or emesis) during labor cause many women to express a strong desire to eat or drink soon after birth. In the absence of complications, a woman who has given birth vaginally; has recovered from the effects of the anesthetic; and has stable vital signs, a firm uterus, and small to moderate lochial flow may have fluids and a regular diet as desired (American Academy of Pediatrics & American College of Obstetricians and Gynecologists, 1997).

 

POSTANESTHESIA RECOVERY

The woman who has given birth by cesarean or has received regional anesthesia for a vaginal birth requires special attention during the recovery period. Recovery from anesthesia requires that cardiopulmonary support and emergency supplies (e.g., resuscitation bag, face mask) be available (Johnson & Johnson, 1996). A postanesthesia recovery (PAR) score is determined for each patient on arrival and updated as part of every 15-minute assessment. Components of the PAR score include activity, respirations, blood pressure, level of consciousness, and color.

 

NURSE ALERT Regardless of her obstetric status, no woman should be discharged from the recovery area until she has completely recovered from the effects of anesthesia.

 

If the woman received general anesthesia, she should be awake and alert and oriented to time, place, and person. Her respiratory rate should be within normal limits, and her oxygen saturation levels at least 95%, as measured by a pulse oximeter. If the woman received epidural or spinal anesthesia, she should be able to raise her legs, extended at the knees, off the bed, or to flex her knees, place her feet flat on the bed, and raise her buttocks well off the bed. The numb or tingling, prickly sensation should be entirely gone from her legs. Often, it takes 1.5 to 2 hours for these anesthetic effects to disappear.

 

TRANSFER FROM THE RECOVERY AREA

After the initial recovery period of 1 to 2 hours has been completed, he woman may be transferred to a postpartum room in the same or another nursing unit. In facilities with labor, delivery, recovery, postpartum (LDRP) rooms, the nurse who provides care during the recovery period usually continues caring for the woman. Women who have received general or regional anesthesia must be cleared for transfer from the recovery area by a member of the anesthesia care team.

In preparing the transfer report, the recovery nurse uses information from the records of admission, birth, and recovery. Information that must be communicated to the postpartum nurse includes identity of the health care provider; gravidity and parity; age; anesthetic used; any medications given; duration of labor and time of rapture of membranes; oxytocin induction or augmentation; type of birth and repair; blood type and Rh status; group B streptococci status; status of rubella immunity; syphilis and hepatitis serology test results; intravenous infusion of any fluids; physiologic status since birth; description of fundus, lochia, bladder, and perineum; sex and weight of infant; time of birth; name of pediatrician or pediatric nurse practitioner; chosen method of feeding; any abnormalities noted; and assessment of initial parent-infant interaction.

Most of this information is also documented for the nursing staff in the newborn nursery. In addition, specific information should be provided regarding the infant's Apgar scores, weight, voiding, stooling, and whether fed since birth. Nursing interventions that have been completed (e.g., eye prophylaxis, vitamin K injection) must also be recorded.

Women who give birth in birthing centers may go home within a few hours, after the woman's and infant's conditions are stable.

 

DISCHARGE—BEFORE 24 HOURS AND AFTER 48 HOURS

Early postparturn discharge, shortened hospital stay, and 1-day maternity stay are all terms for the decreasing length of hospital stays of mothers and their babies after a low risk birth. The trend of shortened hospital stays is based largely on efforts to reduce health care costs coupled with consumer demands to have less medical intervention and more family-focused experiences (Ferguson & Englehard, 1997; Wilkerson, 1996).

 

LAWS RELATING TO DISCHARGE

Health care providers have expressed concern with shortened stays because some medical problems do not show up in the first 24 hours after birth and new mothers have not had sufficient time to learn how to care for their newborns and identify newborn health problems such as jaundice and dehydration related to breastfeeding difficulties (Havens & Hannan, 1996).

The concern for the potential increase in adverse maternalinfant outcomes from hospital early discharge practices led the American College of Obstetricians and Gynecologists, the American Academy of Pediatrics, and other professional health care organizations to promote the enactment of federal and state maternity length-of-stay bills to ensure adequate care for both the mother and the newborn. The passage of the Newborns' and Mothers' Health Protection Act of 1996 provides minimum federal standards for health plan coverage for mothers and their newborns (Ferguson & Engelhard, 1997). Under the Newborns' and Mothers' Health Protection Act, all health plans are required to allow the new mother and newborn to remain in the hospital for a minimum of 48 hours after a normal vaginal birth and for 96 hours after a cesarean birth unless the attending provider, in consultation with the mother, decides on early discharge.

 

CRITERIA FOR DISCHARGE

Early discharge with postpartum home care can be a safe and satisfying option for women and their families when it is comprehensive and based on individual needs (Wilkerson, 1996). Hospital stays must be long enough to identify problems and to ensure that the woman is sufficiently recovered and prepared to care for herself and the baby at home.

It is essential that nurses consider the medical needs of the woman and her baby and provide care that is coordinated to meet those needs in order to provide timely physiologic interventions and treatment to prevent morbidity and hospital readmission. With predetermined criteria for identifying low risk in the mothers and newborns (Box 2), the length of hospitalization can be based on medical need for care in an acute care setting or in consideration of the ongoing care needed in the home environment (American Academy of Pediatrics & American College of Obstetricians and Gynecologists, 1997; Weekly & Neumann, 1997).

 

BOX 2 Criteria for Early Discharge

MOTHER

Uncomplicated pregnancy, labor, vaginal birth, and postpartum course

No evidence of premature rupture of membranes

Blood pressure, temperature stable and within normal limits

Ambulating unassisted

Voiding adequate amounts without difficulty

Hemoglobin >10 g

No significant vaginal bleeding; perineum intact or no more than second-degree episiotomy or laceration repair; uterus is firm

Received instructions on postpartum self-care

INFANT

Term infant (38 to 42 weeks) with weight appropriate for gestational age

Normal findings on physical assessment

Temperature, respirations, and heart rate within normal limits and stable for the 12 hours preceding discharge

At least two successful feedings completed (normal sucking and swallowing)

Urination and stooling have occurred at least once

No evidence of significant jaundice in the first 24 hours after the birth

No excessive bleeding at the circumcision site for at least 2 hours

Screening tests performed according to state regulations; tests to be repeated at follow-up visit if done before the infant is 24 hours old

Initial hepatitis B vaccine given or scheduled for first follow-up visit

Laboratory data reviewed: maternal syphilis and hepatitis B status; infant or cord blood type and Coombs test results if indicated

GENERAL

No social, family, or environmental risk factors identified

Family or support person available to assist mother and infant at home

Follow-up scheduled within 1 week if discharged before 48 hours after the birth

Documentation of skill of mother in feeding (breast or bottle), cord care, skin care, perineal care, infant safety (use of car seat, sleeping positions), and recognizing signs of illness and common infant problems

 

Care paths provide the nurse with an organize

d approach toward meeting essential maternal-newborn care and teaching goals within a limited time frame (see Care Path). Care paths can be developed for vaginal or cesarean births. Other methods such as postpartum order sets and maternal-newborn teaching checklists (Fig. 4) can be used to accomplish patient care and educational outcomes.

 

CARE PATH 24-Hour Vaginal Birth Without Complications

Date of Birth: ____________________

Hour of Birth: ____________________

The uncomplicated vaginal birth patient's admission/discharge is based on a 24-hour length of stay postbirth based on individual needs.

Time: __________________________

PULMONARY PHYSIOLOGIC FOCUS

RECOVERY

ADM. TO PP UNIT—8 HOUR

9-16 HOURS

17-24 HOURS/DISCHARGE

Woman will have normal vital signs (VS) as documented on flowsheet

NA MET VARIANCE

Woman will have normal VS and moderate lochia rubra

 

NA MET VARIANCE

Woman will have normal VS and minimal lochia rubra

 

NA MET VARIANCE

Woman will have normal VS and minimal lochia rubra

 

 

NA MET VARIANCE

Vital signs every 15 min x 1 hour, then hourly Assess perineum/episiotomy Ice pack prn Assess lochia

 

 

RECOVERY

Vital signs every 4 hours

Assess perineum/episiotomy

Ice pack prn

Assess lochia

 

ADM. TO PP UNIT—8 HOURS

Vital signs every shift

Assess perineum/episiotomy

Ice pack prn

Assess lochia

 

 

 

9-16 HOURS

Vital signs every shift

Assess perineum/episiotomy

Ice pack prn

Assess lochia

 

17-24 HOURS/DISCHARGE

IVs/LABWORK/MEDICATIONS

Woman will have appropriate lab work done and medication given by time of transfer to mother/baby unit

NA MET VARIANCE

Woman will begin to verbalize understanding of hepatitis status and medication requirements

 

 

 

NA MET VARIANCE

Woman will have appropriate lab work done by 16 hours PP

 

 

 

 

NA MET VARIANCE

Woman will have appropriate lab work done and appropriate meds initiated

NA MET VARIANCE

CBC, if not done before birth Urine drug screen if ordered U/A—dipstick (Send to lab, if abnormal)

RECOVERY

Review hepatitis B status

Medication regimen initiated

 

 

 

 

ADM. TO PP UNIT—8 HOURS

CBC

Review rubella status

Review Hgb and Hct

 

 

 

 

9-16 HOURS

FeTab

Prenatal vitamin

Rubella vaccine, if appropriate

RhoGAM, if indicated

 

 

17-24 HOURS/DISCHARGE

NUTRITION/ELIMINATIONJ

Parent will be up to bathroom before transfer

 

 

NA MET VARIANCE

Woman will resume normal nutritional status and bladder function

NA MET VARIANCE

Woman will resume normal nutritional status

and bladder function

NA MET VARIANCE

Woman will have normal bowel and bladder function

 

 

NA MET VARIANCE

Assess bladder fullness

Assist to bathroom

Assess for tolerance of PO intake

 

 

 

 

 

 

RECOVERY

Encourage ambulation

Encourage PO fluids

Assist to bathroom as needed

Assess bladder function

Encourage PO intake

ADM. TO PP UNIT—8 HOURS

Encourage ambulation

Encourage PO fluids

Assist to bathroom as needed

Assess bladder function

Encourage PO intake

 

 

9-16 HOURS

Encourage ambulation

Encourage PO fluids

Assist to bathroom as needed

 

 

 

 

 

 

17-24 HOURS/DISCHARGE

PSYCHOSOCAL

Woman/family will begin attachment behaviors with newborn

NA MET VARIANCE

Woman/family will demonstrate appropriate attachment behaviors

NA MET VARIANCE

Family will verbalize comfort with new infant

NA MET VARIANCE

Family will verbalize comfort with new infant

NA MET VARIANCE

Encourage mother/family members to hold and touch infant

Provide skin-to-skin contact of mother/infant

Provide mother the opportunity to breastfeed, if

applicable

Offer flexible rooming-in with infant

Allow for verbalization of woman's feelings

Assess discharge needs and need for Social

Service consult

Reinforce interventions

Reinforce interventions

Completion of birth certificate

Arrange for home visit

SELF-CARE ACTIVITY

Woman will begin self-care activities as tolerated

NA MET VARIANCE

Woman will be up to bathroom/shower with assistance

NA MET VARIANCE

Woman will be up to bathroom/shower independently

NA MET VARIANCE

Woman will be up to bathroom/shower independently

 

NA MET VARIANCE

Instruct woman in pericare and pad changes

 

 

 

 

 

RECOVERY

Reinforce proper pericare

Instruct on use of sitz bath

Encourage woman to shower

ADM. TO PP UNIT—8 HOURS

Reinforce proper pericare

Reinforce use of sitz bath

 

 

 

 

9-16 HOURS

Reinforce proper pericare

Reinforce use of sitz bath

 

 

17-24 HOURS/DISCHARGE

Woman will begin to verbalize and/or demonstrate self-care and infant care activities

NA MET VARIANCE

Woman will begin to verbalize and/or demonstrate infant and selfcare activities

 

 

NA MET VARIANCE

Woman/family will demonstrate appropriate infant care activities

 

 

 

 

NA MET VARIANCE

Woman/family will demonstrate appropriate infant care activities

 

 

 

 

NA MET VARIANCE

TEACHING/DISCHARGE PLANNING

Date:

Initials:

Teaching to include:

Breastfeeding latch-on and positioning, if applicable

Appropriate handwashing techniques

Cough and deep breathing exercises

Instruct in pain relief techniques/medication

Teaching to include:

Breastfeeding/formula initial feeding information

Breast care

Perineal care

Proper nutrition

Safety issues reviewed

Teaching to include:

Attendance at mother/baby care class

Breast care or formula information

Newborn channel

Lactation consult prn

Appropriate handwashing techniques

Teaching to include:

Reinforcement of teaching from mother/baby class

Plans for self/infant follow-up

Review IHSP*

Review Baby Net program

Telephone number for follow-up questions

Home-going meds and purposes

 

Variance Documentation:

 

 

 

 

Fig. 4 Self/family learning checklist. (Copyright Abbott Northwestern Hospital of Allina Health System, Minneapolis and St. Paul, MN.)

 

Hospital-based maternity nurses continue to play invaluable roles as caregivers, teachers, and patient and family advocates in developing and implementing effective home care strategies. The nurse participates in the determination of whether the mother and newborn meet the criteria for early discharge.

 

LEGAL TIP Early Discharge

Whether or not the woman and her family have chosen early discharge, the nurse and the primary health care provider are held responsible if the woman is discharged before her condition has stabilized within normal limits. If complications occur, the medical and nursing staff could be sued for abandonment.

 

CARE MANAGEMENT—PHYSICAL NEEDS

Assessment and Nursing Diagnoses

A complete physical assessment, including measurement of vital signs, is performed on admission to the postpartum unit. If the woman's vital signs are within normal limits, they are usually assessed every 4 to 8 hours for the remainder of her hospitalization. Other components of the initial assessment include the mother's emotional status, energy level, degree of physical discomfort, hunger, and thirst. Intake and output assessments should always be included if an intravenous infusion or a urinary catheter is in place. If the woman gave birth by cesarean, her incisional dressing should also be assessed. To some degree, her knowledge level concerning self-care and infant care can also be determined at this time.

 

Ongoing physical assessment

The new mother should be evaluated thoroughly each shift throughout hospitalization. Physical assessments include evaluation of the breasts, uterine fundus, lochia, perineum, bladder and bowel function, vital signs, and legs. If a woman has an intravenous line in place, her fluid and hematologic status should be evaluated before it is removed. Signs of potential problems that may be identified during the assessment process are listed in the Signs of Potential Complications box.

 

SIGNS OF POTENTIAL COMPLICATIONS

PHYSIOLOGIC PROBLEMS

Temperature

More than 38° C after the first 24 hr

Pulse

Tachycardia or marked bradycardia

Blood Pressure

Hypotension or hypertension

Energy Level

Lethargy, extreme fatigue

Uterus

Deviated from the midline, boggy consistency, remains above the umbilicus after 24 hr

Lochia

Heavy, foul odor, bright red bleeding that is not lochia

Perineum

Pronounced edema, not intact, signs of infection, marked discomfort

Legs

Homans sign positive; painful, reddened area; warmth on posterior aspect of calf

Breasts

Redness, heat, pain, cracked and fissured nipples, inverted nipples, palpable mass

Appetite

Lack of appetite

Elimination

Urine: inability to void, urgency, frequency, dysuria; bowel; constipation, diarrhea

Rest

Inability to rest or sleep

 

Routine laboratory tests

Several laboratory tests may be performed in the immediate postpartum period. Hemoglobin and hematocrit values are often evaluated on the first postpartum day to assess blood loss during childbirth, especially after cesarean birth. In some hospitals a clean-catch or catheterized urine specimen may be obtained and sent for routine urinalysis or culture and sensitivity, especially if an indwelling urinary catheter was inserted during the intrapartum period. In addition, if the woman's rubella and Rh status are unknown, tests to determine her status and need for possible treatment should be performed at this time.

 

Nursing diagnoses

Although all women experience similar physiologic changes during the postpartum period, certain factors act to make each woman's experience unique. From a physiologic standpoint the length and difficulty of the labor, type of birth (i.e., vaginal or cesarean), presence of episiotomy or lacerations, parity, and whether the mother plans to breastfeed or bottle-feed are factors to be considered with each woman. After analyzing the data obtained during the assessment process, the nurse establishes nursing diagnoses that will provide a guide for planning care. Examples of nursing diagnoses commonly established for the postpartum patient include the following:

Risk for deficient fluid volume (hemorrhage) related to

-uterine atony after childbirth

Urinary retention or constipation related to

-postchildbirth discomfort

-childbirth trauma to tissues

Acute pain related to

-uterine involution

-trauma to perineum

-episiotomy

-hemorrhoids

-engorged breasts

Disturbed sleep pattern related to

-discomforts of postpartum period

-long labor process

-infant care and hospital routine

Ineffective breastfeeding related to

-maternal discomfort

-infant positioning

 

Expected Outcomes of Care

The nursing plan of care includes both the postpartum woman and her infant, even if the nursery nurse retains primary responsibility for the infant. In many hospitals, couplet care (also called mother-baby care or single-room maternity care) is practiced. Nurses in these settings have been educated in both mother and infant care and function as primary nurses for both mother and infant, even if the infant is kept in the nursery. This approach is a variation of rooming-in, in which the mother and infant room together and mother and nurse share the care of the infant. The organization of the mother's care must take the newborn into consideration. The day actually revolves around the baby's feeding and care times.

Once the nursing diagnoses are formulated, the nurse plans with the woman what nursing measures are appropriate and which are to be given priority.

The nursing plan of care includes periodic assessments to detect deviations from normal physical changes, measures to relieve discomfort or pain, safety measures to prevent injury or infection, and teaching and counseling measures designed to promote the woman's feelings of competence in self-care and baby care. Family members are included in the teaching. The nurse evaluates continuously and is ready to change the plan if indicated. Almost all hospitals use standardized care plans or care paths as a basis for planning. The nurse's adaptation of the standardized plan to specific medical and nursing diagnoses results in individualized patient care.

Expected outcomes for the postpartum period are based on the nursing diagnoses identified for the individual patient. Examples of common expected outcomes for physiologic needs are that the woman will do the following:

• Demonstrate normal involution and lochial characteristics

• Remain comfortable and injury free

• Demonstrate normal bladder and bowel patterns

• Demonstrate knowledge of breast care, whether breastfeeding or bottle-feeding

• Integrate the newborn into the family

 

Plan of Care and Interventions

Nurses assume many roles while implementing the nursing care plan. They provide direct physical care, teach motherbaby care, and provide anticipatory guidance and counseling. Perhaps most important of all, they nurture the woman by providing encouragement and support as the woman begins to assume the many tasks of motherhood. Nurses who take the time to "mother the mother" do much to increase feelings of self-confidence in new mothers.

The first step in providing individualized care is to confirm the woman's identity by checking her wristband. At the same time the infant's identification number is matched with the corresponding band on the mother's wrist and, in some instances, the father's wrist. The nurse determines how the mother wishes to be addressed and then notes her preference in her record and in her nursing care plan.

The woman and her family are oriented to their surroundings. Familiarity with the unit, routines, resources, and personnel reduces one potential source of anxiety—the unknown. The mother is reassured through knowing whom and how she can call for assistance and what she can expect in the way of supplies and services. If the woman's usual daily routine before admission differs from the facility's routine, the nurse works with the woman to develop a mutually acceptable routine.

Infant abduction from hospitals in the United States has increased over the past few years. The mother should be taught to check the identity of any person who comes to remove the baby from her room. Hospital personnel usually wear picture identification badges. On some units, all staff members wear matching scrubs or special badges. Other units use closed-circuit television, computer monitoring systems, or fingerprint identification pads. As a rule, the baby is never carried in a staff member's arms between the mother's room and the nursery but is always wheeled in a bassinet, which also contains baby care supplies. Patients and nurses must work together to ensure the safety of newborns in the hospital environment (see Plan of Care).

 

PLAN OF CARE POSTPARTUM CARE—VAGINAL BIRTH

NURSING DIAGNOSIS Risk for deficient fluid volume related to uterine atony/hemorrhage

Expected Outcomes Fundus is firm, lochia is moderate, and there is no evidence of hemorrhage.

Nursing Interventions/Rat/onates

Monitor lochia (color, amount, consistency) and count and weigh sanitary pads if lochia is heavy to evaluate amount of bleeding.

Monitor and palpate fundus for location and tone to determine status of uterus and dictate further interventions because atonic uterus is most common cause of postpartum hemorrhage.

Monitor intake and output, assess for bladder fullness, and encourage voiding because a full bladder interferes with involution of the uterus.

Monitor vital signs (increased pulse and respirations, decreased blood pressure) and skin temperature and color to detect signs of hemorrhage/shock.

Monitor postpartum hematology studies to assess effects of blood loss.

If fundus is boggy, apply gentle massage and assess tone response to promote uterine contractions and increase uterine tone. (Do not overstimulate because doing so can cause fundal relaxation.)

Express uterine clots to promote uterine contraction.

Explain to the woman the process of involution and teach her to assess and massage the fundus and to report any persistent bogginess to involve her in self-care and increase sense of self-control.

Administer oxytocic agents per physician/nurse-midwife order and evaluate effectiveness to promote continuing uterine contraction.

Administer fluids, blood, blood products, or plasma expanders as ordered to replace lost fluid and lost blood volume.

 

NURSING DIAGNOSIS Acute pain related to postpartum physiologic changes (hemorrhoids, episiotomy, breast engorgement, cracked/sore nipples)

Expected Outcome Patient exhibits signs of decreased discomfort.

Nursing Interventions/Rationales

Assess location, type, and quality of pain to direct intervention.

Explain to the woman the source and reasons for the pain, its expected duration, and treatments to decrease anxiety and increase sense of control.

Administer prescribed pain medications to provide pain relief.

If pain is perineal (episiotomy, hemorrhoids), apply ice packs in the first 24 hours to reduce edema and vulvar irritation and reduce discomfort; encourage sitz baths using cool water first 24 hours to reduce edema and warm water thereafter to promote circulation; apply witch hazel compresses to reduce edema; teach woman to use prescribed perineal creams, sprays, or ointments to depress response of peripheral nerves; teach woman to tighten buttocks before sitting and to sit on flat, hard surfaces to compress buttocks and reduce pressure on the perineum. (Avoid donuts and soft pillows as they separate the buttocks and decrease venous blood flow, increasing pain.)

If pain is from breasts and woman is breastfeeding, encourage use of a supportive bra to increase comfort; ascertain that infant has latched on correctly to prevent sore nipples; vary infant position during feeding to prevent sore nipples.

If breasts are engorged, have woman use warm compresses or take a warm shower before breastfeeding to stimulate milk flow and relieve stasis.

If nipples are sore, have woman air-dry nipples after feeding to toughen nipples, apply breast creams as prescribed to soften nipples and relieve irritation and wear breast shields in her bra to relieve irritation.

If pain is from breast and woman is not breastfeeding, encourage use of a tight supportive bra or breast binder and application of ice packs to reduce lactation and decrease heaviness

.

NURSING DIAGNOSIS Disturbed sleep pattern related to excitement, discomfort, and environmental interruptions

Expected Outcome Patient sleeps for uninterrupted periods of time and feels rested after waking.

Nursing lnterventions/Rationales

Establish woman's routine sleep patterns and compare with current sleep pattern, exploring things that interfere with sleep, to determine scope of problem and direct interventions.

Individualize nursing routines to fit woman's natural body rhythms (i.e., wake/sleep cycles), provide a sleep-promoting environment (i.e., darkness, quiet, adequate ventilation, appropriate room temperature), prepare for sleep using woman's usual routines (i.e., back rub, soothing music, warm milk), teach use of guided imagery and relaxation techniques to promote optimum conditions for sleep.

Avoid things or routines (i.e., caffeine, foods that induce heartburn, fluids, strenuous mental/physical activity) that may interfere with sleep.

Administer sedation or pain medication as prescribed to enhance quality of sleep.

Advise woman/partner to limit visitors and activities to avoid further taxation and fatigue.

Teach woman to use infant nap time as a time for her also to nap and replenish energy and decrease fatigue.

 

Prevention of infection

One important means of preventing infection is maintenance of a clean environment. Bed linens should be changed as needed. Disposable pads and draw sheets may need to be changed frequently. By not walking about bare foot, women avoid contaminating the linens when they return to bed. A sitz bath or heat lamp used in common must be scrubbed after each woman's use. Personnel must be conscientious about their handwashing techniques to prevent cross-infection. Standard Precautions must be practiced. Staff members with colds, coughs, or skin infections (e.g., a cold sore on the lips [herpes simplex virus type 1]) must follow hospital protocol when in contact with postpartum patients. In many hospitals, staff members with open herpetic lesions, strep throat, conjunctivitis, upper respiratory infections, or diarrhea are encouraged to avoid contact with mothers and infants by staying home until the condition is no longer contagious.

Proper care of the episiotomy site and any perineal lacerations prevents infection in the genitourinary area and aids the healing process. Educating the woman to wipe from front to back (urethra to anus) after voiding or defecating is a simple first step. In many hospitals a squeeze bottle filled with warm water or an antiseptic solution is used after each voiding to cleanse the perineal area (Box 3). The woman should change her perineal pad from front to back each time she voids or defecates and wash her hands thoroughly before and after doing so.

 

BOX 3 Interventions for Episiotomy, Lacerations, and Hemorrhoids

Explain both procedure and rationale before implementation.

CLEANSING

Wash hands before and after cleansing perineum and changing pads.

Wash perineum with mild soap and warm water at least once daily.

Cleanse from symphysis pubis to anal area.

Apply peripad from front to back, protecting inner surface of pad from contamination.

Wrap soiled pad and place in covered waste container.

Change pad with each void or defecation or at least 4 times per day.

Assess amount and character of lochia with each pad change.

ICE PACK

Apply a covered ice pack to perineum from front to back

1. During first 2 hours to decrease edema formation and increase comfort

2. After the first 2 hours following the birth to provide anesthetic effect

SQUEEZE BOTTLE

Demonstrate for and assist woman; explain rationale.

Fill bottle with tap water warmed to approximately 38° C (comfortably warm on the wrist).

Instruct woman to position nozzle between her legs so that squirts of water reach perineum as she sits on toilet seat.

Explain that it will take whole bottle of water to cleanse perineum.

Remind her to blot dry with toilet paper or clean wipes.

Remind her to avoid contamination from anal area.

Apply clean pad.

SITZ BATH

Built-in Type

Prepare bath by thoroughly scrubbing with cleaning agent and rinsing.

Pad with towel before filling.

Fill one-half to one-third full with water of correct temperature 38° to 40.6° C. Some women prefer cool sitz baths.

Ice is added to water to lower the temperature to the level comfortable for the woman.

Encourage woman to use at least twice a day for 20 minutes.

Place call bell within easy reach.

Teach woman to enter bath by tightening gluteal muscles and keeping them tightened and then relaxing them after she is in the bath.

Place dry towels within reach.

Ensure privacy.

Check woman in 15 minutes; assess pulse as needed.

Disposable Type

Clamp tubing and fill bag with warm water.

Raise toilet seat, place bath in bowl with overflow opening directed toward back of toilet.

Place container above toilet bowl.

Attach tube into groove at front of bath.

Loosen tube clamp to regulate rate of flow: fill bath to about one-half full; continue as above for built-in sitz bath.

SURGI-GATOR

Assemble Surgi-Gator (see Fig. 6).

Instruct woman regarding use and rationale.

Follow package directions.

Instruct woman to sit on toilet with legs apart and to put nozzle so tip is just past the perineum, adjusting placement as needed.

Remind her to return her applicator to her bedside stand.

DRY HEAT

Inspect lamp for defects.

Cover lamp with towels.

Position lamp 50 cm from perineum; use 3 times a day for 20-minute periods.

Teach regarding use of 40-W bulb at home.

Provide draping over woman.

If same lamp is being used by several women, clean it carefully between uses.

TOPICAL APPLICATIONS

Apply anesthetic cream or spray: use sparingly 3 to 4 times per day.

Offer witch hazel pads (Tucks) after voiding or defecating; woman pats perineum dry from front to back, then applies witch hazel pads.

 

Prevention of excessive bleeding

The most common cause of excessive bleeding following birth is uterine atony, failure of the uterine muscle to contract firmly. The two most important interventions for preventing excessive bleeding are maintaining good uterine tone and preventing bladder distention.

If uterine atony occurs, the relaxed uterus distends with blood and clots, blood vessels in the placental site are not clamped off, and excessive bleeding results.

Excessive blood loss following childbirth may also be caused by vaginal or vulvar hematomas, unrepaired lacerations of the vagina or cervix, and retained placental fragments.

 

NURSE ALERT A perineal pad saturated in 15 minutes or less and pooling of blood under the buttocks are indications of excessive blood loss, requiring immediate assessment, intervention, and notification of the physician or nurse-midwife.

 

Accurate visual estimation of blood loss is an important nursing responsibility. Blood loss is usually described subjectively as scant, light, moderate, or heavy (profuse). Fig. 5 shows examples of perineal pad saturation corresponding to each of these descriptions.

 

Fig. 5 Blood loss after birth is assessed by the extent of perineal pad saturation as (from left to right) scant (<2.5 cm), light (<10 cm), moderate (>10 cm), or heavy (one pad saturated within 2 hours).

 

It is difficult to judge the amount of lochial flow based only on observation of perineal pads. Postpartal blood loss may be estimated by observing the amount of staining on a perineal pad. More objective estimates of blood loss include weighing blood clots and items saturated with blood (1 ml equals 1 g); using devices that catch and measure blood flowing from the vagina; and establishing how many milliliters it takes to saturate perineal pads being used (Johnson &Johnson, 1996; Luegenbiehl, 1997); however, these methods are not common in practice.

Any estimation of lochial flow is inaccurate and incomplete without consideration of the time factor. The woman who saturates a perineal pad in 1 hour or less is bleeding much more than the woman who saturates one perineal pad in 8 hours.

Luegenbiehl (1997) found that nurses in general tend to overestimate, rather than underestimate, blood loss. Different brands of perineal pads vary in their saturation volume and soaking appearance. For example, blood placed on some brands tends to soak down into the pad, whereas on other brands it tends to spread outward. Nurses should determine saturation volume and soaking appearance for the brands used in their institution so that they may improve accuracy of blood loss estimation.

Blood pressure is not a reliable indicator of impending shock from early hemorrhage. More sensitive means of identifying shock are provided by respirations, pulse, skin condition, urinary output, and level of consciousness. The frequent physical assessments performed during the fourth stage of labor are designed to provide prompt identification of excessive bleeding (see Emergency box).

 

EMERGENCY HYPOVOLEMIC SHOCK

Signs and Symptoms

Persistent significant bleeding —perineal pad soaked within 15 minutes; may not be accompanied by a change in vital signs or maternal color or behavior.

Woman states she feels weak, light-headed, "funny," "sick to my stomach," or "sees stars."

Woman begins to act anxious or exhibits air hunger.

Woman's skin turns ashen or grayish.

Skin feels cool and clammy.

Pulse rate increases.

Blood pressure declines.

Interventions

Notify primary health care provider.

If uterus is atonic, massage gently and expel clots to cause uterus to contract; compress uterus manually, as needed, using two hands. Add oxytocic agent to IV drip, as ordered.

Give oxygen by face mask or nasal prongs at 8 to 10 L/min.

Tilt the woman to her side or elevate the right hip; elevate her legs to at least a 30-degree angle.

Provide additional or maintain existing IV infusion of lactated Ringer's solution or normal saline solution to restore circulatory volume.

Administer blood or blood products, as ordered.

Monitor vital signs.

Insert an indwelling urinary catheter to monitor perfusion of kidneys.

Administer emergency drugs, as ordered.

Prepare for possible surgery or other emergency treatments or procedures.

Chart incident, medical and nursing interventions instituted, and results of treatments.

 

MAINTENANCE OF UTERINE TONE

A major intervention to restore good tone is stimulation by gently massaging the uterine fundus until firm (see Fig. 2). Fundal massage may cause a temporary increase in the amount of vaginal bleeding seen as pooled blood leaves the uterus. Clots may also be expelled. The uterus may remain boggy even after massage and expulsion of clots.

Fundal massage can be a very uncomfortable procedure. Understanding the causes and dangers of uterine atony and the purpose of fundal massage can help the woman to be more cooperative. Teaching the patient to massage her own fundus enables her to maintain some control and decreases her anxiety.

Additional interventions likely to be used are administration of intravenous fluids and oxytocic medications (drugs that stimulate contraction of the uterine smooth muscle).

Prevention of bladder distention. A full bladder causes the uterus to be displaced above the umbilicus and well to one side of midline in the abdomen. It also prevents the uterus from contracting normally. Nursing interventions focus on helping the woman to empty her bladder spontaneously as soon as possible. The first priority is to assist the woman to the bathroom or onto a bedpan if she is unable to ambulate. Having the woman listen to running water, placing her hands in warm water, or pouring water from a squeeze bottle over her perineum may stimulate voiding. Other techniques include assisting the woman into the shower or sitz bath and encouraging her to void, or placing oil of peppermint in a bedpan under the woman (the vapors may relax the urinary meatus and trigger spontaneous voiding). Administering analgesics, if ordered, may be indicated because some women may fear voiding because of anticipated pain. If these measures are unsuccessful, a sterile catheter may be inserted to drain the urine.

 

Promotion of comfort, rest, ambulation, and exercise

Comfort. Most women experience some degree of discomfort during the postpartum period. Common causes of discomfort include afterbirth pains (afterpains), episiotomy or perineal lacerations, hemorrhoids, and breast engorgement. The woman's description of the type and everity of her pain is the best guide in choosing an appropriate intervention. To confirm the location and extent of discomfort, the nurse inspects and palpates areas of pain as appropriate for redness, swelling, discharge, and heat and observes for body tension, guarded movements, and facial tension. Blood pressure, pulse, and respirations may be elevated in response to acute pain. Diaphoresis may accompany severe pain. A lack of objective signs does not necessarily mean there is no pain, because there may also be a cultural component to the expression of pain. Nursing interventions are intended to eliminate the pain sensation entirely or reduce it to a tolerable level that allows the woman to care for herself and her baby. Nurses may use both nonpharmacologic and pharmacologic interventions to promote comfort. Pain relief is enhanced by using more than one method or route.

Nonpharmacologic interventions. Warmth, distraction, imagery, therapeutic touch, relaxation, and interaction with the infant may decrease the discomfort associated with afterbirth pain. Simple interventions that can decrease the discomfort associated with an episiotomy or perineal lacerations include encouraging the woman to lie on her side whenever possible and to use a pillow when sitting. Other interventions include application of an ice pack; topical application (if ordered); dry heat; cleansing with a squeeze bottle; and a cleansing shower, tub bath, or sitz bath (Fig. 6). Many of these interventions are also effective for hemorrhoids, especially ice packs, sitz baths, and topical applications (such as witch hazel pads). Box 3 gives more specific information about these interventions.

 

 

Fig, 6 Hygienic sitz bath (Surgi-Gator) for perineal care. (Courtesy Andermac, Inc., Yuba City, CA.)

 

The discomfort associated with engorged breasts may be lessened by applying either ice, heat, or cabbage leaves to the breasts and wearing a well-fitted support bra. Decisions about specific interventions for engorgement are based on whether the woman chooses breastfeeding or bottle-feeding .

Pharmacologic interventions. Most health care  providers routinely order a variety of analgesics to be administered as needed, including both narcotic and nonnarcotic (nonsteroidal antiinflammatory medications) choices, with their dosage and time frequency ranges. Topical application of antiseptic or anesthetic ointment or spray is a common pharmacologic intervention for perineal pain. Patient-controlled analgesia pumps and epidural analgesia are technologies commonly used to provide pain relief after cesarean birth.

 

NURSE ALERT The nurse should carefully monitor all women receiving opioids because respiratory depression and decreased intestinal motility are side effects.

 

Many women want to participate in decisions about analgesia. Severe pain, however, may interfere with active participation in choosing pain relief measures. If an analgesic is to be given, the nurse must make a clinical judgment of the type, dosage, and frequency from the medications ordered. The woman is informed of the prescribed analgesic and its common side effects; this teaching is documented.

Breastfeeding mothers often have concerns about the effects of an analgesic on the infant. Although nearly all drugs present in maternal circulation are also found in breast milk, many analgesics commonly used during the postpartum period are considered relatively safe for breastfeeding mothers. Often, the timing of medications can be adjusted to minimize infant exposure. A mother may be given pain medication immediately after breastfeeding so that the interval between medication administration and the next nursing period is as long as possible. The decision to administer medications of any type to a breastfeeding mother must always be made by carefully weighing the woman's need against actual or potential risks to the infant.

If acceptable pain relief has not been obtained in 1 hour and there has been no change in the initial assessment, the nurse may need to contact the primary care provider for additional pain relief orders or further directions. Unrelieved pain results in fatigue, anxiety, and a worsening perception of the pain. It might also indicate the presence of a previously unidentified or untreated problem.

Rest. The excitement and exhilaration experienced after the birth of the infant may make rest difficult. The new mother, who is often anxious about her ability to care for her infant or is uncomfortable, may also have difficulty sleeping. The demands of the infant, the hospital environment and routines, and the presence of frequent visitors contribute to alterations in her sleep pattern.

Fatigue. Fatigue is common in the postpartum period (Pugh et al., 1999) and involves both physiologic components, associated with long labors, cesarean birth, anemia, and breastfeeding, and psychologic components, related to depression and anxiety. Infant behavior may also contribute to fatigue, particularly for mothers of more difficult infants.

Interventions must be planned to meet the woman's individual needs for sleep and rest. Back rubs, other comfort measures, and medication for sleep for the first few nights may be necessary. The side-lying position for breastfeeding minimizes fatigue in nursing mothers (Milligan, Flenniken, & Pugh, 1996). Support and encouragement in mothering behaviors help reduce anxiety. Hospital and nursing routines may be adjusted to meet individual needs. In addition, the nurse can help the family limit visitors and provide a comfortable chair or bed for the partner.

Ambulation. Early ambulation is successful in reducing the incidence of thromboembolism and in promoting the woman's more rapid recovery of strength. Free movement is encouraged once anesthesia wears off unless an analgesic has been administered. After the initial recovery period is over, the mother is encouraged to ambulate frequently.

 

NURSE ALERT Having a hospital staff or family member present the first time the woman gets out of bed after birth is wise because she may feel weak, dizzy, faint, or light-headed.

 

The rapid decrease in intraabdominal pressure after birth results in a dilation of blood vessels supplying the intestines (splanchnic engorgement) and causes blood to pool m the viscera. This condition contributes to the development of orthostatic hypotension when the woman who has recently given birth sits or stands up, first ambulates, or takes a warm shower or sitz bath. The nurse also needs to consider the baseline blood pressure; amount of blood loss; and type, amount, and timing of analgesic or anesthetic medications administered when assisting a woman to ambulate.

Prevention of clot formation is important. Women who must remain in bed after giving birth are at increased risk for the development of a thrombus. If a woman remains in bed longer than 8 hours (e.g., for postpartum MgSO4 therapy for preeclampsia), exercise to promote circulation in the legs is indicated using the following routine:

• Alternate flexion and extension of feet.

• Rotate ankle in circular motion.

• Alternate flexion and extension of legs.

• Press back of knee to bed surface; relax.

If the woman is susceptible to thromboembolism, she is encouraged to walk about actively for true ambulation and is discouraged from sitting immobile in a chair. Women with varicosities are advised to wear support hose. If a thrombus is suspected, as evidenced by complaint of pain in calf muscles, or warmth, redness, or tenderness in the suspected leg (positive Homans sign), the primary health care provider should be notified immediately; meanwhile the woman should be confined to bed, with the affected limb elevated on pillows.

Exercise. Most women who have just given birth are extremely interested in regaining their nonpregnant figures. Postpartum exercise can begin soon after birth, although the woman should be encouraged to start with simple exercises and gradually progress to more strenuous ones. Fig. 7 illustrates a number of exercises appropriate for the new mother. Abdominal exercises are postponed until approximately 4 weeks after cesarean birth.

 

 

Fig. 7 Postpartum exercise should begin as soon as possible. The woman should start with simple exercises and gradually progress to more strenuous ones

 

Kegel exercises to strengthen pelvic muscle tone are extremely important, particularly after vaginal birth. Kegel exercises help women regain the muscle tone that is often lost as pelvic tissues are stretched and torn during pregnancy and birth. Women who maintain muscle strength may benefit years later by maintaining urinary continence. It is essential that women learn to perform Kegel exercises correctly. Approximately one fourth of all women who learn Kegel exercises do them incorrectly and may increase their risk of incontinence (Sampselle & Miller, 1996). This may occur when women inadvertently bear down on the pelvic floor muscles, thrusting the perineum outward. The woman's technique can be assessed during the pelvic examination at the 6-week checkup by inserting two fingers intravaginally and checking whether the pelvic floor muscles correctly contract and relax.

 

Promotion of nutrition

During the hospital stay, most women display a good appetite and eat well; nutritious snacks are usually welcomed. Women may request that family members bring to the hospital favorite or culturally appropriate foods (Fig. 8). Cultural dietary preferences must be respected. This interest in food presents an ideal opportunity for nutritional counseling on dietary needs after pregnancy, such as for breastfeeding, preventing constipation and anemia, promoting weight loss, and promoting healing and well-being. Prenatal vitamins and iron supplements are often continued until 6 weeks postpartum or until the ordered supply has been used.

 

 

Fig. 8 Special foods are considered essential for recovery in the Asian culture. (Courtesy Concept Media, Irvine, CA.)

 

Promotion of normal bladder and bowel patterns

Bladder function. After giving birth the mother should void spontaneously within 6 to 8 hours. The first several voidings should be measured to document adequate emptying of the bladder. A volume of at least 150 ml is expected for each voiding. Some women experience difficulty in emptying the bladder, possibly a result of diminished bladder tone, edema from trauma, or fear of discomfort.

Bowel function. Interventions to promote normal bowel elimination include educating the woman about measures to avoid constipation, such as ensuring adequate roughage and fluid intake and promoting exercise. Alerting the woman to side effects of medications such as narcotic analgesics (e.g., decreased gastrointestinal tract motility) may encourage her to implement measures to reduce the risk of constipation. Stool softeners or laxatives may be necessary during the early postpartum period. With early discharge a new mother may be home before having a bowel movement. Some mothers experience gas pains. Antigas medications may be ordered. Ambulation or rocking in a rocking chair may stimulate passage of flatus and relief of discomfort.

 

Breastfeeding promotion and lactation suppression

Breastfeeding promotion. The first 2 hours after childbirth are an excellent time to encourage the mother to breastfeed. The infant is in an alert state and ready to breastfeed. Breastfeeding aids in the contraction of the uterus and prevention of maternal hemorrhage. This is an opportune time to instruct the mother in breastfeeding and to assess the physical appearance of the breasts.

Lactation suppression. Suppression of lactation is necessary when the woman has decided not to breastfeed or in the case of neonatal death. Wearing a well-fitted support bra or breast binder continuously for at least the first 72 hours after giving birth is important. Women should avoid breast stimulation, including running warm water over the breasts, newborn suckling, or pumping of the breasts. A few nonbreastfeeding mothers experience severe breast engorgement (swelling of breast tissue caused by increased blood and lymph supply to the breasts preceding lactation). If breast engorgement occurs, it can usually be managed satisfactorily with nonpharmacologic interventions.

Ice packs to the breasts are helpful in decreasing the discomfort associated with engorgement. The woman should use a 15 minutes on-45 minutes off schedule (to prevent the rebound swelling that can occur if ice is used continuously), or she can place fresh cabbage leaves inside her bra. Cabbage leaves have been used to treat swelling in other cultures for years (Roberts, 1995). The exact mechanism of action is not known, but it is thought that naturally occurring plant estrogens or salicylates may be responsible for the effects. The leaves are replaced each time they wilt. A mild analgesic may also be necessary to help the mother through this uncomfortable time. Medications that were once prescribed for lactation suppression (e.g., estrogen, estrogen and testosterone, bromocriptine) are no longer used.

 

Health promotion of future pregnancies and children

Rubella vaccination. For women who have not had rubella (10% to 20% of all women) or women who are serologically not immune (titer of 1:8 or enzyme immunoassay level less than 0.8), a subcutaneous injection of rubella vaccine is recommended in the immediate postpartum period to prevent the possibility of contracting rubella in future pregnancies. Seroconversion occurs in approximately 90% of women vaccinated after birth. The live attenuated rubella virus is not communicable in breast milk; therefore breastfeeding mothers can be vaccinated. However, because the virus is shed in urine and other body fluids, the vaccine should not be given if the mother or other household members are immunocompromised. Rubella vaccine is made from duck eggs, so women who have allergies to these eggs may develop a hypersensitivity reaction to the vaccine, for which they will need adrenaline. A transient arthralgia or rash is common in vaccinated women but is benign. Because the vaccine may be teratogenic, women who receive the vaccine must be informed about this fact.

 

LEGAL TIP Rubella Vaccination informed consent for rubella vaccination in the postpartum period includes information about possible side effects and the risk of teratogenic effects. Women must understand that they must practice contraception to avoid pregnancy for 2 to 3 months after being vaccinated.

 

Prevention of Rh Isoimmunization. Injection of Rh immune globulin (a solution of gamma globulin that contains Rh antibodies) within 72 hours after birth prevents sensitization in the Rh-negative woman who has had a fetomaternal transfusion of Rh-positive fetal red blood cells (RBCs) (see Medication Guide). Rh immune globulin promotes lysis of fetal Rh-positive blood cells before the mother forms her own antibodies against them.

 

MEDICATION GUIDE

Rh Immune Globulin, RhoGAM, Gamulin Rh, HypRho-D

ACTION

Suppression of immune response in nonsensitized women with Rh-negative blood who receive Rhpositive blood cells because of fetomaternal hemorrhage, transfusion, or accident

INDICATIONS

Suppress antibody formation in women with Rh-negative blood after birth, miscarriage/pregnancy termination, abdominal trauma, ectopic pregnancy, amniocentesis, version, or chorionic villi sampling

DOSAGE/ROUTE

Standard dose 1 vial (300 jjig) IM in deltoid or gluteal muscle; microdose 1 vial (50 ^g) IM in deltoid muscle

ADVERSE EFFECTS

Myalgia, lethargy, localized tenderness and stiffness at injection site, possible allergic response

NURSING CONSIDERATIONS

• Give standard dose to mother within 72 hours after birth if baby is Rh positive, at 28 weeks of gestation as prophylaxis, or after an incident or exposure risk that occurs after 28 weeks of gestation (e.g., amniocentesis, second trimester miscarriage or abortion, after version).

• Give microdose for first trimester miscarriage or abortion, ectopic pregnancy, chorionic villi sampling.

• Verify that the woman is Rh negative and has not been sensitized, that Coombs' test is negative, and that baby is Rh positive. Provide explanation to the woman about procedure, including the purpose, possible side effects, and effect on future pregnancies. Have the woman sign a consent form if required by agency. Verify correct dosage and confirm lot number and woman's identity before giving injection (verify with another RN or other procedure per agency policy); document administration per agency policy.

 

NURSE ALERT After birth, Rh immune globulin is administered to all Rh-negative, antibody (Coombs'jnegative women who give birth to Rh-positive infants. Rh immune globulin is administered to the mother intramuscularly. It should never be given to an infant.

 

The administration of 300 /j,g (1 vial) of Rh immune globulin is usually sufficient to prevent maternal sensitization. If a large fetomaternal transfusion is suspected, however, the dosage needed should be determined by performing a Kleihauer-Betke test, which detects the amount of fetal blood in the maternal circulation. If more than 15 ml of fetal blood is present in maternal circulation, the dosage of Rh immune globulin must be increased.

A 1:1000 dilution of Rh immune globulin is crossmatched to the mother's RBCs to ensure compatibility. Because Rh immune globulin is usually considered a blood product, precautions similar to those used for transfusing blood are necessary when it is given. The identification number on the patient's hospital wristband should correspond to the identification number found on the laboratory slip. The nurse must also check to see that the lot number of the laboratory slip corresponds to the lot number on the vial. Finally, the expiration date on the vial should be checked to ensure a usable product.

Rh immune globulin suppresses the immune response. Therefore the woman who receives both Rh immune globulin and rubella vaccine must be tested at 3 months to see if she has developed rubella immunity. If not, the woman will need another dose of rubella vaccine.

There is some disagreement about whether Rh immune globulin should be considered a blood product. Health care providers need to discuss the most current information about this issue with women whose religious beliefs conflict with having blood products administered to them.

 

Evaluation

The nurse can be reasonably assured that care was effective when the expected outcomes of care for physical needs have been achieved.

 

CARE MANAGEMENT—PSYCHOSOCIAL NEEDS

Meeting the psychosocial needs of new mothers involves assessing the parents' reactions to the birth experience, feelings about themselves, and interactions with the new baby and other family members (Fig. 9). Specific inter ventions are then planned to increase the parents' knowledge and self-confidence as they assume the care and responsibility of the new baby and integrate a new member into their existing family structure in a way that meets their cultural expectations.

 

 

Fig. 9 Bonding and attachment begun early after birth are fostered in the postpartum period. (Courtesy Marjorie Pyle, RNC, Lifecircle, Costa Mesa, CA.)

 

Assessment and Nursing Diagnoses

Impact of the birth experience

Many women indicate a need to examine the birth process itself and look at their own intrapartal behavior in retrospect. Their partners may express similar desires. If their birth experience was different from that included in their birth plan (e.g., induction, epidural anesthesia, cesarean birth), both partners may need to mourn the loss of their expectations before they can adjust to the reality of their birth experience. Inviting them to review the events and describe how they feel helps the nurse assess how well they understand what happened and how well they have been able to put their childbirth experience into perspective.

Maternal self-image

An important assessment concerns the woman's selfconcept, body image, and sexuality. How this new mother feels about herself and her body during the puerperium may affect her behavior and adaptation to parenting. The woman's self-concept and body image may also affect her sexuality. Overweight women experience depressive and anxiety symptoms up to 14 months postpartum (Carter, Baker, & Brownell, 2000).

Feelings related to sexual adjustment after childbirth are often a cause of concern for new parents. Women who have recently given birth may be reluctant to resume sexual intercourse for fear of pain or may worry that coitus could damage healing perineal tissue. Because many new parents are anxious for information but reluctant to bring up the subject, postpartum nurses should matter-of-factly include the topic of postpartum sexuality during their routine physical assessment. While examining the episiotomy site, for example, the nurse can say, "I know you're sore right now, but it probably won't be long until you (or you and your partner) are ready to make love again. Have you thought about what that might be like? Would you like to ask me questions?" This approach assures the woman and her partner that resuming sexual activity is a legitimate concern for new parents and indicates the nurse's willingness to answer questions and share information.

Adaptation to parenthood/parent-infant interactions

The psychosocial assessment also includes evaluating adaptation to parenthood, as evidenced by mother's and father's reactions to and interactions with the new baby. Clues indicating successful adaptation begin to appear early in the postbirth period as parents react positively to the newborn infant and continue the process of establishing a relationship with him or her.

Parents are adapting well to their new role when they exhibit a realistic perception and acceptance of their newborn's needs and his or her limited abilities, immature social responses, and helplessness. Examples of positive parent-infant interactions include taking pleasure in their infant and in the tasks done for and with her or him, understanding their infant's emotional states and providing comfort, and reading their infant's cues for new experiences and sensing the infant's fatigue level.

Family structure and functioning

A woman's adjustment to her role as mother is affected greatly by her relationships with her partner, her mother and other relatives, and any other children. Nurses can help ease the new mother's return home by identifying possible conflicts among family members and helping the woman plan strategies for dealing with these problems before discharge. Such a conflict could arise when couples have very different ideas about parenting. Dealing with the stresses of sibling rivalry and unsolicited grandparent advice can also affect the woman's transition to motherhood. Only by asking about other nuclear and extended family members can the nurse discover potential problems in such relationships and help plan workable solutions for them.

Impact of cultural diversity

The final component of a complete psychosocial assessment is the woman's cultural beliefs and values. Much of a woman's behavior during the postpartum period is strongly influenced by her cultural background. Nurses are likely to come into contact with women from many different countries and cultures. All cultures have developed safe and satisfying methods of caring for new mothers and babies. Only by understanding and respecting the values and beliefs of each woman can the nurse design a plan of care to meet their individual needs.

Sometimes the psychosocial assessment indicates serious actual or potential problems that must be addressed. The Signs of Potential Complications box lists several psychosocial needs that, at a minimum, warrant ongoing evaluation following hospital discharge. Patients exhibiting these needs should be referred to appropriate community resources for assessment and management.

 

SIGN OF NOTENTIAL COMPLICATIONS

PSYCHOSOCIAL NEEDS

Unable or unwilling to discuss labor and birth experience.

Refers to self as ugly and useless.

Excessively preoccupied with self (body image).

Markedly depressed.

Lacks a support system.

Partner or other family members react negatively to the baby.

Refuses to interact with or care for baby. For example, does not name baby, does not want to hold or feed baby, is upset by vomiting and wet or dirty diapers. (Cultural appropriateness of actions needs to be considered.)

Expresses disappointment over baby's sex.

Sees baby as messy or unattractive.

Baby reminds mother of family member or friend she does not like.

 

After analyzing the data obtained during the assessment process, the nurse establishes nursing diagnoses to provide a guide for planning care. Nursing diagnoses related to psychosocial issues that are frequently established for the postpartum patient include the following:

Interrupted family processes related to

-unexpected birth of twins

Impaired verbal communication related to

-patient's hearing impairment

-nurse's language not the same as patient's

Impaired parenting related to

-long, difficult labor

-unmet expectations of labor and birth

Anxiety related to

-newness of parenting role, sibling rivalry, or response of grandparent

Risk for situational low self-esteem related to

-body image changes

 

Expected Outcomes of Care

Expected psychosocial outcomes during the postpartum period are based on the nursing diagnoses identified for the individual woman and her family. Examples of common expected outcomes include that the woman (family) will do the following:

• Identify measures that promote a healthy personal adjustment in the postpartum period

• Maintain healthy family functioning based on cultural norms and personal expectations

 

Plan of Care and Interventions

The nurse functions in the roles of teacher, encourager, and supporter rather than doer while implementing the psychosocial plan of care for a postpartum woman. Implementation of the psychosocial care plan involves carrying out specific activities to achieve the expected outcome of care planned for each individual woman. Topics that should be included in the psychosocial plan of care include promotion of parenting skills and family member adjustment to the newest member.

Cultural issues must also be considered when planning care. There are many traditional health beliefs and practices among the different cultures within the American population. Traditional health practices that are used to maintain health or to avoid illnesses deal with the whole person (i.e., body, mind, and spirit) and tend to be culturally based.

Women from various cultures may view health as a balance between opposing forces (e.g., yin versus yang), being in harmony with nature, or just "feeling good." Traditional practices may include the observance of certain dietary restrictions, clothing, or taboos for balancing the body; participation in certain activities such as sports and art for maintaining mental health; and use of silence, prayer, or meditation for developing spiritually. Practices (e.g., using religious objects or eating garlic) are used to protect oneself from illness and may involve avoiding people who are believed to create hexes, spells, or who have an "evil eye." Restoration of health may involve a person taking folk medicines (e.g., herbs, animal substances) or using a traditional healer.

Childbirth occurs within this sociocultural context. Rest, seclusion, dietary restraints, and ceremonies honoring the mother are all common traditional practices that are followed for the promotion of the health and well-being of the mother and baby.

There are several common traditional health practices used and beliefs held by women and their families during the postpartum period. In Asia, for example, pregnancy is considered to be a hot (yang) condition, and childbirth results in a sudden loss of yang forces (Mattson, 1995). Therefore balance must be restored by increasing the return of yang forces present physically or symbolically in hot food, hot water, and warm air.

Another common belief is that the mother and baby remain in a weak and vulnerable state for a period of several weeks following birth. During this time the mother may remain in a passive role, take no baths or showers, and stay in bed to prevent cold air from entering her body.

Women who have immigrated to the United States or other Western nations without their extended families may not have much help at home, making it difficult for them to observe these activity restrictions. The Cultural Considerations box lists some common cultural beliefs about the postpartum period and family planning.

 

CULTURAL CONSIDERATIONS

Postpartum Period and Family Planning

POSTPARTUM CARE

Chinese, Mexican, Korean, and Southeast Asian women may wish to eat only warm foods and drink hot drinks to replace blood loss and to restore the balance of hot and cold in their bodies. These women may also wish to stay warm and avoid bathing, exercises, and hair washing for 7 to 30 days after childbirth. Self-care may not be a priority; care by family members is preferred. The woman has respect for elders and authority. These woman may wear abdominal binders. They may prefer not to give their babies colostrum.

Haitian women may request to take the placenta home to bury or burn.

Muslim women follow strict religious laws on modesty and diet. A Muslim woman must keep her hair, body, arms to the wrist, and legs to the ankles covered  at all times. She cannot be alone in the presence of a man other than her husband or a male relative. Observant Muslims will not eat pork or pork products and are obligated to eat meat slaughtered according to Islamic laws (halal meat). If halal meat is not available, kosher meat, seafood, or a vegetarian diet is usually accepted.

FAMILY PLANNING

Birth control is government mandated in mainland China. Most Chinese women will have an IUD inserted after the birth of their first child. Women do not want hormonal methods of contraception because they fear putting these medications in their bodies.

Hispanic women will likely choose the rhythm method because most are Catholic.

(East) Indian men are encouraged to have voluntary sterilization by vasectomy.

Muslim couples may practice contraception by mutual consent as long as its use is not harmful to the woman. Acceptable contraceptive methods include foam and condoms, the diaphragm, and natural family planning.

Hmong women highly value and desire large families, which limits birth control practices.

 

It is important that nurses consider all cultural aspects when planning care and not use their own cultural beliefs as the framework for that care. Although the beliefs and behaviors of other cultures may seem different or strange, they should be encouraged as long as the mother wants to conform to them and she and the baby suffer no ill effects. The nurse needs to determine whether a woman is using any folk medicine during the postpartum period because active ingredients in folk medicine may have adverse physiologic effects on the woman when ingested with prescribed medicines. The nurse should not assume that a mother desires to use traditional health practices that represent a particular cultural group merely because she is a member of that culture. Many young women who are first or second-generation Americans follow their cultural traditions only when older family members are present or not at all.

 

Evaluation

The nurse can be reasonably assured that care was effective if expected outcomes of care for psychosocial needs have been met.

 

DISCHARGE TEACHING

SELF-CARE, SIGNS OF COMPLICATIONS

Discharge planning begins at the time of admission to the unit and should be reflected in the plan of care developed for each individual woman. For example, a great deal of time during the hospital stay is usually spent in teaching about maternal and newborn care, because all women must be capable of providing basic care for themselves and their infants at the time of discharge. It is also crucial that every woman be taught to recognize the physical signs and symptoms that might indicate problems and how to obtain advice and assistance quickly if these signs appear. Before discharge, women need basic instruction regarding the resumption of sexual intercourse, prescribed medications, routine mother-baby checkups, and contraception.

Just before the time of discharge the nurse reviews the woman's chart to see that laboratory reports, medications, signatures, and other items are in order. Some hospitals have a checklist to use before the woman's discharge. The nurse verifies that medications, if ordered, have arrived on the unit; that any valuables kept secured during the woman's stay have been returned to her and that she has signed a receipt for them; and that the infant is ready to be discharged.

No medication that would make the mother sleepy should be administered if she is the one who will be holding the baby on the way out of the hospital. In most instances the woman is seated in a wheelchair and is given the baby to hold. Some families leave unescorted and ambulatory, depending on hospital protocol. The woman's possessions are gathered and taken out with her and her family. The woman's and the baby's identification bands are carefully checked. Babies must be secured in a car seat for the drive home.

 

SEXUAL ACTIVITY/CONTRACEPTION

Many couples resume sexual activity before the traditional postpartum checkup 6 weeks after childbirth. Risk of hemorrhage and infection are minimal by approximately 2 weeks postpartum. Couples may be anxious about the topic but uncomfortable and unwilling to bring it up. It is important that the nurse discuss the physical and psychologic effects that giving birth can have on sexual activity (see Self-Care box). Contraceptive options should also be discussed with women (and their partners if present) be fore discharge so that they can make informed decisions about fertility management before resuming sexual activity. Waiting to discuss contraception at the 6-week checkup may be too late. It is possible, particularly in women who bottle-feed, for ovulation to occur as soon as 1 month after birth. A woman who engages in unprotected sex risks becoming pregnant. Current contraceptive options are discussed in detail in Chapter 6. Women who are undecided about contraception at the time of discharge need information about using condoms with foam or creams until the first postpartum checkup.

 

Patient Instructions for Self-Care

Resumption of Sexual Intercourse

You can safely resume sexual intercourse by the second to fourth week after birth when bleeding has stopped and the episiotomy has healed. For the first 6 weeks to 6 months, the vagina does not lubricate well.

Your physiologic reactions to sexual stimulation for the first 3 months after birth will be slower and less intense. The strength of the orgasm is reduced.

A water-soluble gel, cocoa butter, or a contraceptive cream or jelly might be recommended for lubrication. If some vaginal tenderness is present, your partner can be instructed to insert one or more clean, lubricated fingers into the vagina and rotate them within the vagina to help relax it and to identify possible areas of discomfort. A position in which you have control of the depth of the insertion of the penis also is useful. The side-by-side or female-on-top position may be more comfortable.

The presence of the baby influences postbirth lovemaking. Parents hear every sound made by the baby; conversely you may be concerned that the baby hears every sound you make. In either case, any phase of the sexual response cycle may be interrupted by hearing the baby cry or move, leaving both of you frustrated and unsatisfied. In addition, the amount of psychologic energy expended by you in child care activities may lead to fatigue. Newborns require a great deal of attention and time.

Some women have reported feeling sexual stimulation and orgasms when breastfeeding their babies. Breastfeeding mothers often are interested in returning to sexual activity before nonbreastfeeding mothers.

You should be instructed to correctly perform the Kegel exercises to strengthen your pubococcygeal muscle. This muscle is associated with bowel and bladder function and with vaginal feeling during intercourse.

 

PRESCRIBED MEDICATIONS

Women routinely continue to take their prenatal vitamins and iron during the postpartum period. It is especially important that women who are breastfeeding or who are discharged with a lower than normal hematocrit take these medications as prescribed. Women with extensive episiotomies or vaginal lacerations (third or fourth degree) are usually prescribed stool softeners to take at home. Pain relief medications (analgesics or nonsteroidal anti-inflammatory medications) may be prescribed, especially for women who had cesarean birth. The nurse should make certain that the woman knows the route, dosage, frequency, and common side effects of all ordered medications.

 

ROUTINE MOTHER AND BABY CHECKUPS

Women who have experienced uncomplicated vaginal births are still commonly scheduled for the traditional 6-week postpartum examination. Women who have had a cesarean birth are often seen in the physician's or nursemidwife's office or clinic 2 weeks after hospital discharge. The date and time for the follow-up appointment should be included in the discharge instructions. If an appointment has not been made before the woman leaves the hospital, she should be encouraged to call the physician's or nurse-midwife's office or clinic and schedule an appointment.

Parents who have not already done so need to make plans for newborn follow-up at the time of discharge. Most offices and clinics like to see newborns for an initial examination within the first week or by 2 weeks of age. If an appointment for a specific date and time was not made for the infant before leaving the hospital, the parents should be encouraged to call the office or clinic right away.

 

FOLLOW-UP AFTER DISCHARGE

Home visits

Home visits to new mothers and babies within a few days of discharge can help bridge the gap between hospital care and routine visits to health care providers. Nurses are able to assess the mother, infant, and home environment; answer questions and provide education; and make referrals to community resources if necessary. Home visits may also help reduce the need for more expensive health care, such as nonroutine health care visits and rehospitalization, and decrease stress in new families (Brown & Johnson, 1998). Immediate follow-up contact and home visits ideally are available 7 days a week.

Home nursing care many not be available even if needed because there are no agencies providing the service or there is no coverage for payment by third-party payers. If care is available, a referral form containing information about both mother and baby should be completed at hospital discharge and sent immediately to the home care agency. Fig. 10 is an example of such a referral form.

 

 

Fig. 10 Referral form. (Courtesy OB Homecare of Allina Hospitals and Clinics, Minneapolis, MN.)

 

The home visit is most commonly scheduled on the  woman's second day home from the hospital, but it may be scheduled on any of the first 4 days at home, depending on the individual family's situation and needs. Additional visits are planned throughout the first week, as needed. The home visits may be extended beyond that time if the family's needs warrant it and if a home visit is the most appropriate option for carrying out the follow-up care required to meet the specific needs identified.

During the home visit the nurse conducts a systematic assessment of mother and newborn to determine physiologic adjustment, identify any existing complications, and answer any questions the mother has for herself and the mother or family has about the newborn or newborn care. Conducting the assessment in a separate room provides private time for the mother to ask questions on topics such as breast care, family planning, and constipation. The assessment focuses on the mother's emotional adjustment and her knowledge of self-care and infant care.

During the newborn assessment, the nurse can demonstrate and explain normal newborn behavior and capabilities and encourage the mother and family to ask questions or express concerns they may have. The home care nurse must verify if the newborn screen for phenylketonuria and other inborn errors of metabolism has been drawn. If the baby was discharged from the hospital before 24 hours of age, the newborn screen may be done by the home care nurse or the family will need to take the infant to the clinic or physician's office.

 

Telephone follow-up

As part of the routine follow-up of a woman and her infant after discharge from the hospital, many providers are implementing one or more postpartum telephone followup calls to their patients for assessment, health teaching, identification of complications to effect timely intervention, and referrals. Telephone follow-up may be part of the services offered by the hospital, private physician or clinic, or a private agency; it may be either a separate service, or combined with other strategies for extending postpartum care. Telephonic nursing assessments are frequently used after a postpartum home care visit to reassess a woman's knowledge about the signs and symptoms of adequate hydration in breastfeeding or, after initiating home phototherapy, to assess the caregiver's knowledge regarding equipment complications.

The "warm line" is another type of telephone link between the new family and concerned caregivers or experienced parent volunteers. A warm line is a help line or consultation service, not a crisis intervention line. The warm line is appropriately used for dealing with less extreme concerns that may seem urgent at the time the call is placed but are not actual emergencies. Calls to warm lines commonly relate to infant feeding, prolonged crying, or sibling rivalry. Warm line services may extend beyond the fourth trimester. Families need to call when concerns arise and be given phone numbers for easy access to answers to their questions.

 

Support groups

A special group experience is sometimes sought by the woman adjusting to motherhood. On occasion, postpartum women who have met earlier in prenatal clinics or on the hospital unit may begin to associate for mutual support. Members of childbirth classes who attend a postpartum reunion may decide to extend their relationship during the fourth trimester.

A postpartum support group enables mothers and fathers to share with and support each other as they adjust to parenting. Many new parents find it reassuring to discover that they are not alone in their feelings of confusion and uncertainty. An experienced parent can often impart concrete information that can be valuable to other members in a postpartum support group. Inexperienced parents may find themselves imitating the behavior of others in the group whom they perceive as particularly capable.

 

Referral to community resources

To develop an effective referral system, it is important that the nurse have an understanding of the needs of the woman and family and of the organization and community resources available for meeting those needs. Locating and compiling information about available community services contributes to the development of a referral system. It is important for the nurse to develop his or her own resource file of local and national services that are used commonly by health care providers (see Resources at the end of this chapter).

 

 

POSTPARTUM HEMORRHAGE

DEFINITION AND INCIDENCE

Postpartum hemorrhage (PPH) continues to be a leading cause of maternal morbidity and death in the United States today. It is a life-threatening event that can occur with littie warning and is often unrecognized until the mother has profound symptoms (Norris, 1997). PPH has been traditionally defined as the loss of greater than 500 ml of blood after vaginal birth and 1000 ml after cesarean birth. A 10% change in hematocrit between admission for labor and postpartum or the need for erythrocyte transfusion also has been used to define PPH (American College of Obstetricians and Gynecologists [ACOG], 1998). However, defining PPH is not a clear-cut issue. The ACOG states that hemorrhage is difficult to define clinically (ACOG, 1998). Diagnosis is often based on subjective observations, with blood loss often being underestimated by as much as 50%.

Traditionally, PPH has been classified as early or late with respect to the birth. Early, acute, or primary PPH occurs within 24 hours of the birth. Late or secondary PPH occurs more than 24 hours but less than 6 weeks postpartum (ACOG, 1998). Today's health care environment encourages shortened stays after birth, thereby increasing the potential for acute episodes of PPH to occur outside the traditional hospital or birth center setting.

 

ETIOLOGY AND RISK FACTORS

The most common cause of PPH is uterine atony, which complicates approximately 1 in 20 births (Gonik, 1999). Less common causes include retained placenta, placenta accreta, cervical or vaginal lacerations, uterine rupture or inversion, lower genital tract lacerations and hematomas, infection, and coagulopathies (ACOG, 1998; Varner,

 

BOX 1 Risk Factors for Postpartum Hemorrhage

Uterine atony

• Overdistended uterus

-Large fetus

-Multiple fetuses

-Hydramnios

-Distention with clots

• Anesthesia and analgesia

-Conduction anesthesia

• Previous history of uterine atony

• High parity

• Prolonged labor, oxytocin-induced labor

• Trauma during labor and birth

-Forceps birth

-Vacuum-assisted birth

-Cesarean birth

Retained placental fragments

Lacerations of the birth canal

Ruptured uterus

Inversion of the uterus

Placenta accreta

Placental abruption

Placenta previa

Coagulation disorders

Manual removal of a retained placenta

Magnesium sulfate administration during labor or postpartum

Endometritis

Uterine subinvolution

 

It is helpful to consider the problem of excessive bleeding with reference to the stages of labor. From birth of the infant until separation of the placenta, the character and quantity of blood passed may suggest excessive bleeding. For example, dark blood is probably of venous origin, perhaps from varices or superficial lacerations of the birth canal. Bright blood is arterial and may indicate deep lacerations of the cervix. Spurts of blood with clots may indicate partial placental separation. Failure of blood to clot or remain clotted indicates a pathologic condition or coagulopathy such as disseminated intravascular coagulation.

Excessive bleeding may occur during the period from the separation of the placenta to its expulsion or removal. Commonly, such excessive bleeding is the result of incomplete placental separation, undue manipulation of the fundus, or excessive traction on the cord. After the placenta has been expelled or removed, persistent or excessive blood loss usually is the result of atony of the uterus (failure to contract well or maintain contraction) or prolapse of the uterus into the vagina. Late PPH may be the result of subinvolution of the uterus, endometritis, or retained placental fragments (ACOG, 1998).

 

UTERINE ATONY

Uterine atony is marked hypotonia of the uterus. Normally, placental separation and expulsion are facilitated by contraction of the uterus, which also prevents hemorrhage from the placental site. The corpus is in essence a basket weave of strong, interlacing smooth muscle bundles through which many large maternal blood vessels pass. If the uterus is flaccid after detachment of all or part of the placenta, brisk venous bleeding occurs and normal coagulation of the open vasculature is impaired and continues until the uterine muscle is contracted.

Uterine atony accounts for more than 90% of all cases of PPH (Norris, 1997). It is associated with high parity, hydramnios, a macrosomic fetus, and multifetal gestation. In such conditions the uterus is "overstretched" and contracts poorly after the birth. Other causes of atony include traumatic birth, use of halogenated anesthesia (e.g., halothane) or magnesium sulfate, rapid or prolonged labor, chorioamnionitis, and use of oxytocin for labor induction or augmentation (ACOG, 1998; Varner, 1998).

 

LACERATIONS OF THE GENITAL TRACT

Lacerations of the cervix, vagina, and perineum are also causes of PPH. Hemorrhage related to lacerations should be suspected if bleeding continues despite a firm, contracted uterine fundus. This bleeding can be a slow trickle, an oozing, or frank hemorrhage. Factors that influence the causes and incidence of obstetric lacerations of the lower genital tract include operative birth, precipitous birth, congenital abnormalities of the maternal soft parts, and contracted pelvis. Size, abnormal presentation, and position of the fetus; relative size of the presenting part and the birth canal; previous scarring from infection, injury, or operation; and vulvar, perineal, and vaginal varicosities can also cause lacerations.

Extreme vascularity in the labial and periclitoral areas often results in profuse bleeding if laceration occurs. Hematomas may also be present.

Lacerations of the perineum are the most common of all injuries in the lower portion of the genital tract. These are classified as first, second, third, and fourth degree. An episiotomy may extend to become either third- or fourth-degree laceration.

Prolonged pressure of the fetal head on the vaginal mucosa ultimately interferes with the circulation and may produce ischemic or pressure necrosis. The state of the tissues in combination with the type of birth may result in deep vaginal lacerations, with consequent predisposition toward vaginal hematomas.

A pelvic hematoma may be vulvar, vaginal, or retroperitoneal in origin. Vulvar hematomas are the most common. Pain is the most common symptom, and most vulvar hematomas are visible. Vaginal hematomas occur more commonly in association with a forceps-assisted birth, an episiotomy, or primigravidity (Ridgeway, 1995). During the postpartum period, if the woman reports a persistent perineal or rectal pain or a feeling of pressure in the vagina, a careful examination is performed. However, a subperitoneal hematoma may cause minimal pain, and the initial symptoms may be signs of shock (Ridgeway, 1995).

Cervical lacerations usually occur at the lateral angles of the external os. Most are shallow, and bleeding is minimal. More extensive lacerations may extend into the vaginal vault or into the lower uterine segment.

 

RETAINED PLACENTA

Nonadherent retained placenta

Retained placenta may result from partial separation of a normal placenta, entrapment of the partially or completely separated placenta by an hourglass constriction ring of the uterus, mismanagement of the third stage of labor, or abnormal adherence of the entire placenta or a portion of the placenta to the uterine wall. Placental retention because of poor separation is common in very preterm births (20 to 24 weeks of gestation).

Management of nonadherent retained placenta is by manual separation and removal by the primary health care provider. Supplementary anesthesia is not usually needed for women who have had regional anesthesia for birth. For other women, administration of light nitrous oxide and oxygen inhalation anesthesia or intravenous (IV) thiopental facilitates uterine exploration and placental removal. After this removal, the woman is at continued risk for PPH or for infection.

 

Adherent retained placenta

Abnormal adherence of the placenta occurs for reasons unknown, but it is thought to result from zygotic implantation in an area of defective endometrium so that there is no zone of separation between the placenta and the decidua. Attempts to remove the placenta in the usual manner are unsuccessful, and laceration or perforation of the uterine wall may result, putting the woman at great risk for severe PPH and infection (Cunningham et al., 2001).

Unusual placental adherence may be partial or complete. The following degrees of attachment are recognized:

Placenta accreta, slight penetration of myometrium by placental trophoblast

Placenta increta, deep penetration of myometrium by placenta

Placenta percreta, perforation of uterus by placenta

Bleeding with complete or total placenta accreta may not occur unless separation of the placenta is attempted. With more extensive involvement, bleeding will become profuse when delivery of the placenta is attempted. Treatment includes blood component replacement therapy, and hysterectomy may be indicated (Clark, 1999).

 

INVERSION OF THE UTERUS

Inversion of the uterus after birth is a potentially life-threatening complication. The incidence of uterine inversion is approximately 1 in 2000 to 2500 births (ACOG, 1998) and may recur with a subsequent birth. Uterine inversion may be partial or complete. Complete inversion of the uterus is obvious; a large, red, rounded mass (perhaps with the placenta attached) protrudes 20 to 30 cm outside the introitus. Incomplete inversion cannot be seen but must be felt; a smooth mass will be palpated through the dilated cervix. Contributing factors to uterine inversion include fundal implantation of the placenta, vigorous fundal pressure, excessive traction applied to the cord, uterine atony, leiomyomas, and abnormally adherent placental tissue (Bowes, 1999). Uterine inversion occurs most often in multiparous women and with placenta accreta or increta. The primary presenting signs of uterine inversion are hemorrhage, shock, and pain.

Prevention—always the easiest, cheapest, and most effective therapy-is especially appropriate for uterine inversion. The umbilical cord should not be pulled on strongly unless the placenta has definitely separated.

 

SUBINVOLUTION OF THE UTERUS

Late postpartum bleeding may occur as a result of subinvolution of the uterus. Recognized causes of subinvolution include retained placental fragments and pelvic infection. Signs and symptoms include prolonged lochial discharge, irregular or excessive bleeding, and sometimes he morrhage. A pelvic examination usually reveals a uterus that is larger than normal and one that may be boggy.

 

CARE MANAGEMENT

Assessment and Nursing Diagnoses

Fig. 1 Nursing assessments for postpartum bleeding. CBC, Complete blood count; IV, intravenous; s/s, signs and symptoms.

 

BOX 2 Noninvasive Assessments of Cardiac Output in Postpartum Patients Who Are Bleeding

Palpation of pulses (rate, quality, equality)

• Arterial

• Blood pressure

Auscultation

• Heart sounds/murmurs

• Breath sounds

Inspection

• Skin color, temperature, turgor

• Level of consciousness

• Capillary refill

• Urinary output

• Neck veins

• Pulse oximetry

• Mucous membranes

Presence or absence of anxiety, apprehension, restlessness, disorientation

 

PPH may be sudden and even exsanguinating. The nurse must therefore be alert to the symptoms of hemorrhage and hypovolemic shock and be prepared to act quickly to minimize blood loss (Fig. 1 and Box 2).

The woman's history should be reviewed for factors that cause predisposition to PPH (see Box 25-1). The fundus is assessed to determine whether it is firmly contracted at or near the level of the umbilicus. Bleeding should be assessed for color and amount. The perineum is inspected for signs of lacerations or hematomas to determine the possible source of bleeding.

Vital signs may not be reliable indicators of shock immediately postpartum because of the physiologic adaptations of this period. However, frequent vital sign measure ments during the first 2 hours after birth may identify trends related to blood loss (e.g., tachycardia, tachypnea, falling blood pressure).

Assessment for bladder distention is important because a distended bladder can displace the uterus and prevent contraction. The skin is assessed for warmth and dryness; nail beds are checked for color and promptness of capillary refill. Laboratory studies include evaluation of hemoglobin and hematocrit levels.

Late PPH may develop 24 hours after birth or later in the postpartum period. The woman may be at home when the symptoms occur. Discharge teaching should emphasize the signs of normal involution, as well as potential complications. Nursing diagnoses for women experiencing

PPH include the following:

Deficient fluid volume related to

-excessive blood loss secondary to uterine atony, lacerations, or uterine inversion

Risk for imbalancedfluid volume related to

-blood and fluid volume replacement therapy

Risk for infection related to

-excessive blood loss or exposed placental attachment site

Risk for injury (maternal) related to

-attempted manual removal of retained placenta

-administration of blood products

-operative procedures

Fear/anxiety related to

-threat to self

-knowledge deficit regarding procedures and operative management

Ineffective peripheral tissue perfusion related to

-excessive blood loss and shunting of blood to central circulation

 

Expected Outcomes of Care

Expected outcomes of care for the woman experiencing PPH may include that the woman will do the following:

• Identify and use available support systems

• Maintain normal vital signs and laboratory values

• Develop no complications related to excessive bleeding

• Express understanding of her condition, its management, and discharge instructions

 

Plan of Care and Interventions

Medical management

Early recognition and acknowledgment of the diagnosis of PPH are critical to care management. The first step is to evaluate the contractility of the uterus. If the uterus is hypotonic, management is directed toward increasing contractility and minimizing blood loss.

The initial management of excessive postpartum bleeding is firm massage of the uterine fundus, expression of any clots in the uterus, eliminating any bladder distention, and continuous IV infusion of 10 to 40 units of oxytocin added to 1000 ml of lactated Ringer's or normal saline solution. If the uterus fails to respond to oxytocin, a 0.2 mg dose of ergonovine (Ergotrate) or methylergonovine (Methergine) may be given intramuscularly to produce sustained uterine contractions. If these first-line drugs are not effective, a derivative of prostaglandin F2a (carboprost tromethamine, 0.25 mg) is given intramuscularly. It can also be given intramyometrially at cesarean birth or intraabdominally after vaginal birth. Most hemorrhage can be controlled after one or two injections of 0.25 mg intramuscularly (ACOG, 1998). See Table 1 for a comparison of drugs used to manage PPH. In addition to the medications used to contract the uterus, rapid administration of crystalloid solutions or blood is needed to restore the woman's intravascular volume.

 

TABLE 1 Drug Used to Manage Postpartum Hemorrhage

 

OXYTOCIN (PITOCIN)

METHYLERGONOVINE (METHERGINE)

PROSTAGLANDIN F2α

(PROSTIN/15M; HEMABATE)

Action

Contraction of uterus; decreases bleeding

Contraction of uterus

Contraction of uterus

Side effect

Infrequent; water intoxication; nausea and vomiting

Hypertension, nausea, vomiting, headache

Headache, nausea, vomiting, fever

Contraindications

None forPPH

Hypertension, cardiac disease

Asthma, hypersensitivity

Dosage; route

10-40 U/L diluted in lactated Ringer's solution or normal saline at 125-200 mU/min IV or 10-20 U IM

0.2 mg IM every 2-4 hr up to 5 doses; 0.2 mg IV only for emergency

0.25 mg IM or intramyometrially every 15 min up to 5 doses

Nursing considerations

Continue to monitor vaginal bleeding and uterine tone

Check blood pressure before

giving and do not give if >140/90 mm Hg; continue monitoring vaginal bleeding and uterine tone

Continue to monitor vaginal bleeding and uterine tone

 

NURSE ALERT Use of ergonovine or methylergonovine is contraindicated in the presence of hypertension or cardiovascular disease. Prostaglandin F2l, should be used cautiously in women with cardiovascular disease or asthma (Bowes, 1999).

 

Hypotonic uterus. Oxygen can be given to enhance oxygen delivery to the cells. A urinary catheter is usually inserted to monitor urine output as a measure of intravascular volume. Laboratory studies usually include a complete blood count with platelet count, fibrinogen, fibrin split products, prothrombin time, and partial thromboplastin time. Blood type and antibody screen are done if not previously performed (ACOG, 1998).

If bleeding persists, bimanual compression may be considered by the obstetrician or nurse-midwife. This procedure involves inserting a fist into the vagina and pressing the knuckles against the anterior side of the uterus, then placing the other hand on the abdomen and massaging the posterior uterus with it. If the uterus still does not become firm, manual exploration of the uterine cavity for retained placental fragments is implemented. If the preceding procedures are ineffective, surgical management may be the only alternative. Surgical management options include vessel ligation (uteroovarian, uterine, hypogastric), angiographic embolization, and hysterectomy (ACOG, 1998).

Bleeding with a contracted uterus. If the uterus is firmly contracted and bleeding continues, the source of bleeding still must be identified and treated. Assessment may include visual or manual inspection of the perineum, vagina, uterus, cervix, or rectum and laboratory studies (e.g., hemoglobin, hematocrit, coagulation studies, platelet count) (ACOG, 1998). Treatment depends on the source of the bleeding. Lacerations are usually sutured. Hematomas may be managed with observation, cold therapy, ligation of the bleeding vessel, or evacuation. Fluids or blood replacement may be needed (Roberts, 1995).

Uterine inversion. Uterine inversion is an emergency situation requiring immediate recognition, replacement of the uterus within the pelvic cavity, and correction of associated clinical conditions. Medical management of this condition includes treating shock, repositioning the uterus, giving oxytocic agents after the uterus is repositioned, and initiating broad-spectrum antibiotics (Benedetti, 2002; Bowes, 1999).

Subinvolution. Treatment of subinvolution depends on the cause. Ergonovine or methylergonovine (0.2 mg every 4 hours for 2 or 3 days) and antibiotic therapy are the most common medications used (Cunningham et al., 2001). Dilation and curettage may be needed to remove retained placental fragments or to debride the placental site.

 

Herbal remedies

BOX 3 Herbal Remedies for Postpartum Hemorrhage

HERBS

ACTION

Witch hazel

Hemostatic

Lady's mantle

Hemostatic

Blue cohosh

Oxytocic

Cotton root bark

Oxytocic

Motherwort

Promotes uterine contraction; vasoconstrictive

Shepherd's purse

Promotes uterine contraction

Alfalfa leaf

Increases availability of vitamin K; increases hemoglobin

Nettle

Increases availability of vitamin K; increases hemoglobin

 

Herbal remedies have been used with some success to control PPH in some settings. Some herbs have homeostatic actions; others work as oxytocic agents to contract the uterus (Beal, 1998; Schirmer, 1998). Box 25-3 lists herbs that have been used and their actions. However, published evidence of the safety and efficacy of herbal therapy is lacking. Evidence from well-controlled studies is needed before recommendation for practice should be made (Enkin et al., 1995).

 

Nursing interventions

Immediate nursing care of the woman with PPH includes assessment of vital signs and uterine consistency and administration of oxytocin or other drugs to stimulate uterine contraction according to standing orders or protocols. The primary health care provider is notified if not present.

The woman and her family will be anxious about her condition. The nurse can intervene by calmly providing explanations about interventions being performed and the need to act quickly.

After the bleeding has been controlled, the care of the woman with lacerations of the perineum is similar to that for women with episiotomies (analgesia as needed for pain and hot or cold applications as necessary). The need for increased roughage in the diet and increased intake of fluids is emphasized. Stool softeners may be used to assist the woman in reestablishing bowel habits without straining and putting stress on the suture lines.

 

NURSE ALERT TO prevent injury to the suture line, a woman with third- or fourth-degree lacerations is not given rectal suppositories or enemas.

 

The care of the woman who has experienced an inversion of the uterus focuses on immediate stabilization of hemodynamic status. This requires close observation of her response to treatment to prevent shock or fluid overload. If the uterus has been repositioned manually, care must be taken to avoid aggressive fundal massage.

Discharge instructions for the woman who has had PPH are similar to those for any postpartum woman. In addition, she should be told that she will probably feel fatigue, even exhaustion, and will need to limit her physical activities to conserve her strength. She may need instructions in increasing her dietary iron and protein intake and iron supplementation to rebuild lost red cell volume. She may need assistance with infant care and household activities until she has regained strength. Some women have problems with delayed or insufficient lactation and postpartum depression. Referrals for home care follow-up or to community resources may be needed (see Plan of Care).

 

Evaluation

The nurse can be reasonably assured that care was effective to the extent that the expected outcomes were achieved.

 

PLAN OF CARE Postpartum Hemorrhage

NURSING DIAGNOSIS Deficient fluid volume related to postpartum hemorrhage

Expected Outcome Patient will demonstrate fluid balance as evidenced by stable vital signs, prompt capillary refill time, and balanced intake and output.

 

Nursing Interventions/Rationales

Monitor vital signs, oxygen saturation, urine specific gravity, and capillary refill to provide baseline data.

Measure and record amount and type of bleeding by weighing and counting saturated pads. If woman is at home, teach her to count pads and save any clots or tissue. If woman is admitted to hospital, save any clots and tissue for further examination to estimate type and amount of blood loss for fluid replacement.

Provide quiet environment to promote rest and decrease metabolic demands.

Give explanation of all procedures to reduce anxiety.

Begin IV access with 18-gauge or larger needle for infusion of isotonic solution as ordered to provide fluid or blood replacement.

Administer medications as ordered, such as oxytocin, Methergine, or Prostin, to increase contractility of the uterus.

Insert indwelling urinary catheterr to provide most accurate assessment of renal function and hypovolemia.

Prepare for surgical intervention as needed to stop the source of bleeding.

 

NURSING DIAGNOSIS Ineffective tissue perfusion related to hypovolemia

Expected Outcome Woman will have stable vital signs, oxygen saturation, arterial blood gases, and adequate hematocrit and hemoglobin.

Nursing Interventions/Rationales

Monitor vital signs, oxygen saturation, arterial blood gases, and hematocrit and hemoglobin to assess for hypovolemic shock and decreased tissue perfusion.

Assess for any changes in level of consciousness to assess for evidence of hypoxia.

Assess capillary refill, mucous membranes, skin temperature to note indicators of vasoconstriction.

Give supplementary oxygen as ordered to provide additional oxygenation to tissues.

Suction as needed, insert oral airway, to maintain clear, open airway for oxygenation.

Monitor arterial blood gases to provide information about acidosis or hypoxia.

Administer sodium bicarbonate if ordered to reverse metabolic acidosis.

 

NURSING DIAGNOSIS Anxiety related to sudden change in heaith status

Expected Outcome Woman will verbalize the anxious feelings are diminished.

Nursing Interventions/Rationales

Using therapeutic communication, evaluate woman's understanding of events to provide clarification of any misconceptions.

Provide calm, competent attitude and environment to aid in decreasing anxiety.

Explain all procedures to decrease anxiety about the unknown.

Allow woman to verbalize feelings to permit clarification of information and promote trust.

Continue to assess vital signs or other clinical indicators of hypovolemic shock to evaluate if psychologic response of anxiety intensifies physiologic indicators.

 

HEMORRHAGIC (HYPOVOLEMIC) SHOCK

Hemorrhage may result in hemorrhagic (hypovolemic) shock. Shock is an emergency situation in which the per fusion of body organs may become severely compromised and death may occur. Physiologic compensatory mechanisms are activated in response to hemorrhage. The adrenal glands release catecholamines, causing arterioles and venules in the skin, lungs, gastrointestinal tract, liver, and kidneys to constrict. The available blood flow is diverted to the brain and heart and away from other organs, including the uterus. If shock is prolonged, the continued reduction in cellular oxygenation results in an accumulation of lactic acid and acidosis (from anaerobic glucose metabolism). Acidosis (lowered serum pH) causes arteriolar vasodilation; venule vasoconstriction persists. A circular pattern is established; that is, decreased perfusion, increased tissue anoxia and acidosis, edema formation, and pooling of blood further decrease the perfusion. Cellular death occurs. See the Emergency box for assessments and interventions for hemorrhagic shock.

 

EMERGENCY Hemorragic Shock

ASSESSMENTS

CHARACTERISTICS

Respirations

Rapid and shallow

Pulse

Rapid, weak, irregular

Blood pressure

Decreasing (late sign)

Skin

Cool, pale, clammy

Urinary output

Decreasing

Level of consciousness

Lethargy -> coma

Mental status

Anxiety —> coma

Central venous pressure

Decreased

INTERVENTION

 

Summon assistance and equipment

 

Start IV infusion per standing orders

 

Ensure patent airway; administer oxygen

 

Continue to monitor status

 

 

MEDICAL MANAGEMENT

Vigorous treatment is necessary to prevent adverse sequelae. Medical management of hypovolemic shock involves restoring circulating blood volume and treating the cause of the hemorrhage (e.g., lacerations, uterine atony or inversion). To restore circulating blood volume, a rapid IV infusion of crystalloid solution is given at a rate of 3 ml infused for every 1 ml of estimated blood loss (e.g., 3000 ml infused for 1000 ml of blood loss). Packed red blood cells are usually infused if the woman is still actively bleeding and no improvement in her condition is noted after the initial crystalloid infusion. Infusion of fresh frozen plasma may be needed if clotting factors and platelet counts are below normal values (Cunningham et al., 2001).

 

NURSING INTERVENTIONS

Hemorrhagic shock can occur rapidly, but the classic signs of shock may not appear until the postpartum woman has lost 30% to 40% of blood volume. The nurse needs to continue to reassess the woman's condition, as evidenced by the degree of measurable and anticipated blood loss, and mobilize appropriate resources.

Most interventions are instituted to improve or monitor tissue perfusion. The nurse continues to monitor the woman's pulse and blood pressure. If invasive hemodynamic monitoring is ordered, the nurse may assist with the placement of the central venous pressure (CVP) or pulmonary artery (Swan-Ganz) catheter and monitor CVP, pulmonary artery pressure, or pulmonary artery wedge pressure as ordered (White & Poole, 1996).

Additional assessments to be made include evaluation of skin temperature, color, and turgor, as well as assessment of the woman's mucous membranes. Breath sounds should be auscultated before fluid volume replacement, if possible, to provide a baseline for future assessment. Inspection for oozing at the sites of incisions or injections and assessment of the presence of petechiae or ecchymosis in areas not associated with surgery or trauma are critical in the evaluation for disseminated intravascular coagulopathy.

Oxygen is administered, preferably by nonrebreathing face mask, at 10 to 12 L/min to maintain oxygen saturation. Oxygen saturation should be monitored with a pulse oximeter, although measurements may not always be accurate in a patient with hypovolemia or decreased perfusion. Level of consciousness is assessed frequently and provides additional indications of blood volume and oxygen saturation. In early stages of decreased blood flow, the woman may report "seeing stars" or feeling dizzy or nauseated. She may become restless and orthopneic. As cerebral hypoxia increases, she may become confused and react slowly or not at all to stimuli. Some women complain of headaches. An improved sensorium is an indicator of improved perfusion.

Continuous electrocardiographic monitoring may be indicated for the woman who is hypotensive or tachycardic, continues to bleed profusely, or is in shock. A Foley catheter with a urometer is inserted to allow hourly assessment of urinary output. The most objective and least invasive assessment of adequate organ perfusion and oxygenation is urinary output of at least 30 ml/hr (White & Poole, 1996). Blood may need to be drawn and sent to the laboratory for studies that include hemoglobin and hematocrit levels, platelet count, and coagulation profile.

 

FLUID OR BLOOD REPLACEMENT THERAPY

Critical to successful management of the woman with a hemorrhagic complication is establishment of venous access, preferably with a large-bore IV catheter. The establishment of two IV lines facilitates fluid resuscitation. Vigorous fluid resuscitation includes the administration of crystalloids (lactated Ringer's, normal saline solutions), colloids (albumin), blood, and blood components. Fluid resuscitation must be carefully monitored because fluid overload may occur. Intravascular fluid overload occurs more frequently with colloid therapy. Transfusion reactions may follow administration of blood or blood components, including cryoprecipitates. Even in an emergency, each unit should be checked per hospital protocol. Complications of fluid or blood replacement therapy include hemolytic reactions, febrile reactions, allergic reactions, circulatory overload, and air embolism.

 

LEGAL TIP Standard of Care for Bleeding Emergencies

The standard of care for obstetric emergency situations such as postpartum hemorrhage or hypovolemic shock is that provision should be made for the nurse to implement actions independently. Policies, procedures, standing orders or protocols, and clinical guides should be established by each health care facility in which births occur and should be agreed on by health care providers involved in the care of obstetric patients.

 

COAGULOPATHIES

When bleeding is continuous and there is no identifiable source, a coagulopathy may be the cause. The woman's coagulation status must be assessed quickly and continuously. The nurse may draw and send blood to the laboratory for studies. Abnormal results depend on the cause and may include increased prothrombin time, increased partial prothrombin time, decreased platelets, decreased fibrinogen level, increased fibrin degradation products, and prolonged bleeding time. Causes of coagulopathies may be pregnancy complications such as idiopathic thrombocytopenic purpura or von Willebrand disease.

 

IDIOPATHIC THROMBOCYTOPENIC PURPURA

Idiopathic or immune thrombocytopenic purpura (ITP) is an autoimmune disorder in which antiplatelet antibodies decrease the life span of the platelets. Thrombocytopenia, capillary fragility, and increased bleeding time are diagnostic findings. ITP may cause severe hemorrhage after cesarean birth or from cervical or vaginal lacerations. Incidences of postpartum uterine bleeding and vaginal hematomas are also increased.

Medical management focuses on control of platelet stability. If ITP was diagnosed during pregnancy, the woman probably was treated with corticosteroids or IV immunoglobulin. Platelet transfusions are usually given when there is significant bleeding. A splenectomy may be needed if the ITP does not respond to medical management. Neonatal thrombocytopenia, a result of the maternal disease process, occurs in approximately 50% of cases and is associated with a high mortality rate (Kilpatrick & Laros, 1999).

 

VON WILLEBRAND DISEASE

Von Willebrand disease, a type of hemophilia, is probably the most common of all hereditary bleeding disorders (Kleinert et al., 1997). Although von Willebrand disease is rare, it is among the most common congenital clotting defects in American women of childbearing age. It results from a factor VIII deficiency and platelet dysfunction that is transmitted as an incomplete autosomal dominant trait to both sexes. Symptoms include a familial bleeding tendency, previous bleeding episodes, prolonged bleeding time (the most important test), factor VIII deficiency (mild to moderate), and bleeding from mucous membranes. Factor VIII increases during pregnancy, and this increase may be sufficient to offset danger from hemorrhage during childbirth. However, the woman's condition should be observed for at least 1 week after childbirth. Treatment of von Willebrand disease may include replacement of factor VIII if it is at less than 30% of normal levels and administration of cryoprecipitate or fresh frozen plasma.

 

DISSEMINATED INTRAVASCULAR COAGULATION

Disseminated intravascular coagulation (DIC) is a pathologic form of clotting that is diffuse and consumes large amounts of clotting factors, including platelets, fibrinogen, prothrombin, and factors V and VII. Widespread external bleeding, internal bleeding, or both can result. DIC also causes vascular occlusion of small vessels resulting from small clots forming in the microcirculation. In the obstetric population, DIC may occur as a result of abruption placentae, amniotic fluid embolism, dead fetus syndrome (fetus has died but is retained in utero for at least 6 weeks), severe preeclampsia, septicemia, cardiopulmonary arrest, and hemorrhage.

The diagnosis of DIC is made according to clinical findings and laboratory markers. Physical examination reveals unusual bleeding; spontaneous bleeding from the woman's gums or nose may be noted. Petechiae may appear around a blood pressure cuff placed on the woman's arm. Excessive bleeding may occur from the site of a slight trauma (e.g., venipuncture sites, intramuscular or subcutaneous injection sites, nicks from shaving of perineum or abdomen, and injury from insertion of a urinary catheter). Symptoms may also include tachycardia and diaphoresis. Laboratory tests reveal decreased levels of platelets, fibrinogen, proaccelerin, antihemophiliac factor, and prothrombin (the factors consumed during coagulation). Fibrinolysis is increased at first but is later severely depressed. Degradation of fibrin leads to the accumulation of fibrin split products in the blood; these have anticoagulant properties and prolong the prothrombin time. Bleeding time is normal, coagulation time shows no clot, clot retraction time shows no clot, and partial thromboplastin time is increased. DIC must be distinguished from other clotting disorders before therapy is initiated.

Primary medical management in all cases of DIC involves correction of the underlying cause (e.g., removal of the dead fetus, treatment of existing infection or of preeclampsia or eclampsia, or removal of a placental abruption). Volume replacement, blood component therapy, optimization of oxygenation and perfusion status, and continued reassessment of laboratory parameters are the usual forms of treatment. Plasma levels usually return to normal within 24 hours after birth. Platelet counts usually return to normal within 7 days (Kilpatrick & Laros, 1999).

Nursing interventions include assessment for signs of bleeding and signs of complications from the administration of blood and blood products, administering fluid or blood replacement as ordered, and protecting from injury. Because renal failure is one consequence of DIC, urinary output is monitored, usually by insertion of an indwelling urinary catheter. Urinary output must be maintained at more than 30 ml/hr.

The woman and her family will be anxious or concerned about her condition and prognosis. The nurse offers explanations about care and provides emotional support to the woman and her family through this critical time.

 

THROMBOEMBOLIC DISEASE

A thrombosis is the formation of a blood clot or clots inside a blood vessel and is caused by inflammation (thrombophlebitis) or partial obstruction of the vessel. Three thromboembolic conditions are of concern in the postpartum period:

Superficial venous thrombosis: involvement of the superficial saphenous venous system

Deep venous thrombosis: involvement varies but can extend from the foot to the iliofemoral region

Pulmonary embolism: complication of deep venous thrombosis occurring when part of a blood clot dislodges and is carried to the pulmonary artery where it occludes the vessel and obstructs blood flow to the lungs

 

INCIDENCE AND ETIOLOGY

The incidence of thromboembolic disease in the postpartum period varies from approximately 0.5 to 3 per 1000 women (Laros, 1999). The incidence has declined in the last 20 years because early ambulation after childbirth has become standard practice. The major causes of thromboembolic disease are venous stasis and hypercoagulation, both of which are present in pregnancy and continue into the postpartum period. Other risk factors include cesarean birth, history of venous thrombosis or varicosities, obesity, maternal age greater than 35, multiparity, and smoking (Falter, 1997).

 

CLINICAL MANIFESTATIONS

 

Fig. 2 Deep vein thrombophlebitis. (Courtesy Julie L. Perry.)

 

Superficial venous thrombosis is the most frequent form of postpartum thrombophlebitis. It is characterized by pain and tenderness in the lower extremity. Physical examination may reveal warmth; redness; and an enlarged, hardened vein over the site of the thrombosis. Deep vein thrombosis is more common in pregnancy and is characterized by unilateral leg pain, calf tenderness, and swelling (Fig. 2). Physical examination may reveal redness and warmth, but the woman may also have a large amount of clot and have few symptoms (Stenchever et al., 2001). A positive Homans' sign may be present, but further evaluation is needed because the calf pain may be attributed to other causes such as a strained muscle resulting from the birthing position. Pulmonary embolism is characterized by dyspnea and tachypnea. Other signs and symptoms frequently seen include apprehension, cough, tachycardia, hemoptysis, elevated temperature, and pleuritic chest pain (Laros, 1999).

Physical examination is not a sensitive diagnostic indicator for thrombosis. Venography is the most accurate method for diagnosing deep venous thrombosis; however, it is an invasive procedure that exposes the woman and fetus to ionizing radiation and is associated with serious complications. Noninvasive diagnostic methods are more commonly used; these include real-time and color Doppler ultrasound. Cardiac auscultation may reveal murmurs with pulmonary embolism. Electrocardiograms are usually normal. Arterial Po2 may be lower than normal. A ventilation/perfusion scan, Doppler ultrasound, and pulmonary arteriogram may be used for diagnosis (Laros, 1999).

 

MEDICAL MANAGEMENT

Superficial venous thrombosis is treated with analgesia (nonsteroidal antiinflammatory agents), rest with elevation of the affected leg, and elastic stockings (Falter, 1997). Local application of heat may also be used. Deep venous thrombosis is initially treated with anticoagulant (usually continuous IV heparin) therapy, bed rest with the affected leg elevated, and analgesia. After the symptoms have decreased, the woman may be fitted with elastic stockings to use when she is allowed to ambulate. IV heparin therapy continues for 5 to 7 days. Oral anticoagulant therapy (warfarin) is started during this time and will be continued for approximately 3 months. Continuous IV heparin therapy is used for pulmonary embolism until symptoms have resolved. Intermittent subcutaneous heparin or oral anticoagulant therapy is usually continued for 6 months.

 

NURSING INTERVENTIONS

In the hospital setting nursing care of the woman with a thrombosis consists of continued assessments: inspection and palpation of the affected area; palpation of peripheral pulses; checking Homans' sign; measurement and comparison of leg circumferences; inspection for signs of bleeding; monitoring for signs of pulmonary embolism, including chest pain, coughing, dyspnea, and tachypnea; and respiratory status for presence of crackles. Laboratory reports are monitored for prothrombin or partial prothrombin times. The woman and her family are assessed for their level of understanding about the diagnosis and their ability to cope during the unexpected extended period of recovery.

Interventions include explanations and education about the diagnosis and the treatment. The woman will need assistance with personal care as long as she is on bed rest; the family should be encouraged to participate in the care if that is what they wish. While the woman is on bed rest, she should be encouraged to change positions frequently, but not to place the knees in a sharply flexed position that could cause pooling of blood in the lower extremities. She should also be cautioned not to rub the affected area because this action could cause the clot to dislodge. Once the woman is allowed to ambulate, she is taught how to prevent venous congestion by putting on the elastic stockings before getting out of bed.

Heparin and warfarin are administered as ordered, and the physician is notified if clotting times are outside the therapeutic level. If the woman is breastfeeding, she is assured that neither heparin nor warfarin is excreted in significant quantities in breast milk. If the infant has been discharged, the family is encouraged to bring the infant for feedings as permitted by hospital policy; the mother can also express milk to be sent home.

Pain can be managed with a variety of measures. Position changes, elevating the leg, and application of moist warm heat may decrease discomfort. Administration of analgesics and antiinflammatory medications may be needed.

 

NURSE ALERT Medications containing aspirin are not given to women on anticoagulant therapy because aspirin inhibits synthesis of clotting factors and can lead to prolonged clotting time and increased risk of bleeding.

 

The woman is usually discharged home on oral anticoagulants and will need explanations about the treatment schedule and possible side effects. If subcutaneous injections are to be given, the woman and family are taught how to administer the medication and about site rotation. The woman and her family should also be given information about safe care practices to prevent bleeding and injury while she is on anticoagulant therapy, such as using a soft toothbrush and using an electric razor. She will also need information about the need for follow-up with her health care provider to monitor clotting times and to make sure the correct dose of anticoagulant therapy is maintained (Lowdermilk & Grohar, 1998). The woman should also use a reliable method of contraception if taking warfarin because this medication is considered teratogenic (Toglia & Nolan, 1997).

 

POSTPARTUM INFECTIONS

Postpartum infection, or puerperal infection, is any clinical infection of the genital canal that occurs within 28 days after miscarriage, induced abortion, or childbirth. The first symptom of postpartum infection is usually a fever of 38° C or more on 2 successive days of the first 10 postpartum days (not counting the first 24 hours after birth) (Cunningham et al., 2001). Puerperal infection is probably the major cause of maternal morbidity and death throughout the world; however, it occurs after only 6% of births in the United States (3% after vaginal births; 5 to 10 times higher after cesarean births) (Gibbs & Sweet, 1999). Common postpartum infections include endometritis, wound infections, mastitis, urinary tract infections, and respiratory tract infections.

The most common infecting organisms are the numerous streptococcal and anaerobic organisms. Staphylococcus aureus, gonococci, coliform bacteria, and clostridia are less common but serious pathogenic organisms that also cause puerperal infection. Postpartum infections are more common in women who have concurrent medical or immunosuppressive conditions or who had a cesarean or other operative birth. Intrapartal factors such as prolonged rupture of membranes, prolonged labor, and internal maternal or fetal monitoring also increase the risk of infection (Varner, 1998). Factors that predispose the woman to postpartum infection are listed in Box 4.

 

BOX 4 Predisposing Factors for Postpartum Infection

PRECONCEPTION OR ANTEPARTUM FACTORS

History of previous venous thrombosis, urinary tract infection, mastitis, pneumonia

Diabetes mellitus

Alcoholism

Drug abuse

Immunosuppression

Anemia

Malnutrition

INTRAPARTUM FACTORS

Cesarean birth

Prolonged rupture of membranes

Chorioamnionitis

Prolonged labor

Bladder catheterization

Internal fetal/uterine pressure monitoring

Multiple vaginal examinations after the rupture of membranes

Epidural anesthesia

Retained placental fragments

Postpartum hemorrhage

Episiotomy or lacerations

Hematomas

 

ENDOMETRITIS

Endometritis is the most common cause of postpartum infection. It usually begins as a localized infection at the placental site (Fig. 3) but can spread to involve the entire endometrium. Incidence is higher after cesarean birth. Assessment for signs of endometritis may reveal a fever (usually greater than 38° C); increased pulse; chills; anorexia; nausea; fatigue and lethargy; pelvic pain; uterine tenderness; or foul-smelling, profuse lochia (Calhoun & Brost, 1995). Leukocytosis and a markedly increased red blood cell sedimentation rate are typical laboratory findings of postpartum infections. Anemia may also be present. Blood cultures or intracervical or intrauterine bacterial cultures (aerobic and anaerobic) should reveal the offending pathogens within 36 to 48 hours.

 

 

Fig. 3 Postpartum infection—endometritis.

 

WOUND INFECTIONS

Wound infections are also common postpartum infections but often develop after the woman is at home. Sites of infection include the cesarean incision and the episiotomy or repaired laceration site. Predisposing factors are similar to those for endometritis (see Box 4). Signs of wound infection include erythema, edema, warmth, tenderness, seropurulent drainage, and wound separation. Fever and pain may also be present.

 

URINARY TRACT INFECTIONS

Urinary tract infections (UTIs) occur in 2% to 4% of postpartum women. Risk factors include urinary catheterization, frequent pelvic examinations, epidural anesthesia, genital tract injury, history of UTI, and cesarean birth. Signs and symptoms include dysuria, frequency and urgency, low-grade fever, urinary retention, hematuria, and pyuria. Costovertebral angle tenderness or flank pain may indicate upper UTI. Urinalysis results may reveal Escherichia coli, although other gram-negative aerobic bacilli may also cause UTIs.

 

MASTITIS

 

Fig. 4 Mastitis.

 

Mastitis affects approximately 1% of women soon after childbirth, most of whom are first-time mothers who are breastfeeding. Mastitis almost always is unilateral and develops well after the flow of milk has been established (Fig. 4). The infecting organism generally is the hemolytic S. aureus. An infected nipple fissure usually is the initial lesion, but the ductal system is involved next. Inflammatory edema and engorgement of the breast soon obstruct the flow of milk in a lobe; regional, then generalized, mastitis follows. If treatment is not prompt, mastitis may progress to a breast abscess. Symptoms rarely appear before the end of the first postpartum week and are more common in the second to fourth weeks. Chills, fever, malaise, and local breast tenderness are noted first. Localized breast tenderness, pain, swelling, redness, and axillary adenopathy may also occur. Antibiotics are prescribed. Lactation can be maintained by emptying the breasts every 2 to 4 hours by breastfeeding, manual expression, or breast pump.

 

CARE MANAGEMENT

Prenatal and intrapartal factors that can predispose a woman to postpartum infection are listed in Box 4. Signs and symptoms associated with postpartum infection have been discussed with each infection. Laboratory tests usually performed include a complete blood count, venous blood cultures, and uterine tissue cultures. Nursing diagnoses for women experiencing postpartum infection include the following:

Deficient knowledge related to

-etiology, management, course of infection

-transmission and prevention of infection

Impaired tissue integrity related to

-effects of infection process

Acute pain related to

-mastitis

-puerperal infection

-urinary tract infection

Interrupted family processes related to

-unexpected complication to expected postpartum recovery

-possible separation from newborn

-interruption in process of realigning relationships after the addition of the new family member

Risk for impaired parenting related to

-fear of spread of infection to newborn

 

The most effective and least expensive treatment of postpartum infection is prevention. Preventive measures include good prenatal nutrition to control anemia and intrapartal hemorrhage. Good maternal perineal hygiene is emphasized. Strict adherence by all health care personnel to aseptic techniques during childbirth and the postpartum period is important.

Management of endometritis consists of IV broadspectrum antibiotic therapy (cephalosporins, penicillins, or clindamycin and gentamicin) and supportive care, including hydration, rest, and pain relief. Antibiotic therapy is usually discontinued 24 hours after the woman is asymptomatic (Gibbs & Sweet, 1999). Assessments of lochia, vital signs, and changes in the woman's condition continue during treatment. Comfort measures depend on the symptoms and may include cool compresses, warm blankets, perineal care, and sitz baths. Teaching should include side effects of therapy, prevention of spread of infection, signs and symptoms of worsening condition, and adherence to the treatment plan and the need for followup care. Women may need to be encouraged or assisted to maintain mother-infant interactions and breastfeeding (if allowed during treatment).

Postpartum women are usually discharged to home by 48 hours after birth. This is often before signs of infection are evident. Nurses in birth centers and hospital settings need to be able to identify women at risk for postpartum infection and to provide anticipatory teaching and counseling before discharge. After discharge, telephone followup, hot lines, support groups, lactation counselors, home visits by nurses, and teaching materials (videos, written materials) are all interventions that can be implemented to decrease the risk of postpartum infections. Home care nurses need to be able to recognize signs and symptoms of postpartum infection so that the woman can contact her primary health care provider. These nurses must also be able to provide the appropriate nursing care for women who need follow-up home care.

Treatment of wound infections may combine antibiotic therapy with wound debridement. Wounds may be opened and drained. Nursing care includes frequent wound and vital sign assessments and wound care. Comfort measures include sitz baths, warm compresses, and perineal care. Teaching includes good hygiene techniques (i.e., changing perineal pads front to back, handwashing before and after perineal care), self-care measures, and signs of worsening conditions to report to the health care provider. The woman is usually discharged to home for self-care or home nursing care after treatment is initiated in the inpatient setting.

Medical management for UTIs consists of antibiotic therapy, analgesia, and hydration. Postpartum women are usually treated on an outpatient basis; therefore teaching should include instructions on how to monitor temperature, bladder function, and appearance of urine. The woman should also be taught about signs of potential complications and the importance of taking all antibiotics as prescribed. Other suggestions for prevention of UTIs include proper perineal care, wiping from front to back after urinating or having a bowel movement, and increasing fluid intake.

Because mastitis rarely occurs before the postpartum woman is discharged, teaching should include warning signs of mastitis and counseling about prevention of cracked nipples. Management includes intensive antibiotic therapy (e.g., cephalosporins and vancomycin, which are particularly useful in staphylococcal infections), support of breasts, local heat (or cold), adequate hydration, and analgesics.

Almost all instances of acute mastitis can be avoided by proper breastfeeding technique to prevent cracked nipples. Missed feedings, waiting too long between feedings, and abrupt weaning may lead to clogged nipples and mastitis. Cleanliness practiced by all who have contact with the newborn and new mother also reduces the incidence of mastitis. See Chapter 20 for further information.