Postpartum Uterine Involution

Involution of the Uterus

• Normal process where the uterus returns to its nonpregnant size occurs after birth, beginning immediately after the placenta is expelled
• Contraction of the uterine smooth muscle contributes to involution

Location and size changes

• At the end of the third stage of labor, the uterus is midline, 2 cm below the umbilicus
• Within 12 hours postpartum, the fundus rises to 1 cm above the umbilicus
• By 24 hours after birth, the uterus' size is roughly the size it was at 20 weeks of gestation
• Involution progresses with the fundus descending 1 to 2 cm every 24 hours
• By the sixth postpartum day, the fundus is halfway between the umbilicus and the symphysis pubis
• The uterus should not be palpable abdominally after 2 weeks and should return to its nonpregnant location by 6 weeks postpartum

Subinvolution of the uterus

• A failure of the uterus to return to its nonpregnant state at the expected rate.
• A cause of late postpartum bleeding
• Most common causes are retained placental fragments and pelvic infection
• Signs and symptoms include prolonged lochial discharge, irregular or excessive bleeding, and sometimes hemorrhage
• A pelvic exam reveals a larger-than-normal uterus that can be boggy

Treatment for subinvolution of the uterus

• Treatment depends on cause
• Ergonovine (Ergotrate) or methylergonovine (Methergine) may be prescribed to promote uterine contractions
• Dilation and curettage (D&C) might be necessary to remove retained placental fragments or debride the placental site
• If infection is the cause, antibiotic therapy is required

Inversion of the uterus

• Rare, potentially life-threatening complication
• The fundus collapses into the uterine cavity, turning the uterus inside out after birth
• Incidence varies, ranging from 1 in 2000 to 1 in 20,000 vaginal births, depending on risk factors

Inversion types

• Incomplete: Mass is palpable through the cervix, but not visible
• Complete: The lining of the fundus crosses the cervical os and forms a vaginal mass
• Prolapsed: A large, red, rounded mass (possibly with the placenta attached) protrudes 20-30 cm outside the introitus

Etiology and risk factors

• Excessive umbilical cord traction when the placenta is attached high in the uterus
• Fundal pressure when the uterus is not well contracted
• Risk factors for postpartum hemorrhage, such as uterine atony, are also relevant

Inversion: Primary presenting signs

• Sudden hemorrhage
• Shock
• Pain
• The uterus is not palpable abdominally

Inversion: Management

• Obstetric emergency, immediate interventions required
• Fluid resuscitation
• Replacement of the uterus within the pelvic cavity
• Correction of associated clinical conditions (like shock)
• Tocolytics or halogenated anesthetics may be given to relax the uterus before attempting replacement
• Oxytocic agents are administered after the uterus is repositioned
• Broad-spectrum antibiotics are initiated
• Closely monitor the woman's response to treatment to prevent shock or fluid overload
• If the uterus has been repositioned manually, take care to avoid subsequent aggressive fundal massage

Afterpains

• Known as afterbirth pains
• Uncomfortable uterine cramping in the postpartum period

Afterpains: Characteristics

• Periodic relaxation
• Vigorous contractions of the uterus

Afterpains: Prevalence

• More prevalent/noticeable in subsequent pregnancies (multiparous women)
• Less prevalent in first pregnancies (primiparous women), where uterine tone is generally good and cramping is mild

Afterpains: Causes and intensifying factors

• More likely/intense after births in which the uterus was overdistended, such as with a large infant, multifetal gestation, or polyhydramnios
• Breastfeeding and exogenous oxytocic medication intensify afterpains because both stimulate uterine contractions

Afterpains: Duration

• Typically resolves within 3 to 7 days

Afterpains: Management

• Nonpharmacologic interventions, including application of warmth or lying prone
• Interaction with the infant can provide distraction and decrease discomfort
• Plan interventions for afterpains because more severe during/after breastfeeding to be effective
• Pharmacologic interventions, including nonopioid analgesics like ibuprofen or naproxen, provide better relief than acetaminophen

Lochia

• Postbirth uterine discharge
• Most women experience lochia for 4 to 6 weeks postpartum
• During the first 2 hours postpartum, the amount should be about that of a heavy menstrual period, with a few small clots typical
• After that, lochial flow steadily decreases in amount and appearance changes

Lochia flow

• Lochia flow is often scant until the effects wear off if the woman receives an oxytocic medication
• Usually less after cesarean birth due to suctioning of the uterus
• Flow increases with ambulation and breastfeeding
• Lochia tends to pool in the vagina when lying in bed, resulting in a gush of blood when she stands

Lochia rubra

• Appearance: Bright red
• Timing after birth: 1-3 days
• Contents: Blood from the placental site; trophoblastic tissue debris, vernix, lanugo, meconium

Lochia serosa

• Appearance: Pinkish-brown
• Timing after birth: 4-10 days
• Contents: Blood, wound exudate, RBCs, WBCs, trophoblastic tissue debris, cervical mucus, microorganisms

Lochia alba

• Appearance: Whitish-yellow
• Timing after birth: 10-14 days, can last 3-6 weeks
• Contents: WBCs, trophoblastic tissue debris

Lochia characteristics indicating complications

• Persistence of rubra beyond 3 days suggests continued bleeding, possibly due to retained pieces of placenta
• Common for a sudden, but brief (1-2 hours), increase in bleeding 7 to 14 days after birth when sloughing of eschar over the placental site occurs
• Continued lochia serosa or alba by 3 to 4 weeks can indicate endometritis
• A large amount of lochia or the passage of large clots may indicate uterine atony or vaginal or cervical laceration
• Lochia should smell like normal menstrual flow; an offensive odor usually indicates infection

Assessing lochial flow

• Crucial to consider the time factor and not just the appearance on the perineal pad
• Check for blood under the mother's buttocks as blood can flow there even if the amount on the pad appears small

Lacerations of the genital tract

• Lacerations of the cervix, vagina, and perineum are causes of postpartum hemorrhage (PPH)
• Hemorrhage related to lacerations should be suspected if bleeding continues despite a firm, contracted uterine fundus
• Causes/incidence of obstetric lacerations includes: operative birth (forceps-assisted or vacuum-assisted), precipitous birth, congenital abnormalities of maternal soft tissue, and contracted pelvis
• Other possible causes are increased size; abnormal presentation/position of the fetus; relative size of the presenting part/birth canal; previous scarring from infection/injury/surgery; and vulvar/perineal/vaginal varicosities

Perineal lacerations and episiotomies

• Lacerations of the perineum are the most common injuries in the lower portion of the genital tract
• Classified as first, second, third, and fourth degree

Episiotomy extension

• An episiotomy can extend to become either a third- or fourth-degree laceration

Prolonged fetal head pressure

• Can interfere with circulation
• May produce ischemic or pressure necrosis
• Potentially leading to deep vaginal lacerations and a predisposition to vaginal hematomas

Introitus after vaginal birth

• Erythematous and edematous immediately

Cervical and vaginal lacerations

• Most cervical lacerations are shallow, and bleeding is minimal
• If bloody discharge spurts from the vagina, and uterus is firmly contracted, there can be cervical or vaginal tears

Assessment and care of lacerations and episiotomies

• Identified and sutured immediately after birth
• Care includes position changes, analgesia for pain, warm/cold applications after bleeding is controlled
• Chemical ice packs are commonly applied to the perineum for the first 24 hours following a vaginal birth
• The need for increased fiber/fluids is emphasized to reduce constipation
• Stool softeners may be used to assist with bowel habits without straining the sutures
• Rectal suppositories/enemas are not given for third/fourth degree lacerations to avoid injury to healing tissues
• Perineal care helps to prevent infection and aids healing with wiping from front to back, a squeeze bottle with warm water/antiseptic solution after voiding, frequent perineal pad changing, and thorough hand hygiene
• Ice packs can be applied during the first 24 hours to decrease edema/increase comfort and after for an anesthetic effect
• Topical anesthetic creams/sprays or witch hazel pads can also be used
• Healing is similar to a surgical incision; signs of infection include pain, redness, warmth, swelling, or discharge, with initial healing within 2-3 weeks, but complete in 4-6 months
• Women should be taught hygienic care techniques, self-care measures, and signs of worsening conditions to report
• Nonpharmacologic measures include side-lying, ice packs, squeeze bottle cleansing, and sitz baths with analgesics
• If extreme perineal pain continues after pain meds, assess the perineum for hematoma or perineal infection

Hematomas

• Pelvic hematomas: Collections of blood in the connective tissue, either vulvar, vaginal, or retroperitoneal
• Vulvar hematomas are the most common
• Retroperitoneal hematomas are least common

Retroperitoneal hematomas

• Life-threatening and caused by laceration of vessels attached to the hypogastric artery
• Often associated with rupture of a cesarean scar during labor
• Possible minimal initial pain, with signs of shock being the first symptoms

Hematoma hemorrhage

• Should be suspected if excessive vaginal bleeding occurs in a firmly contracted uterine fundus
• Generally surgically evacuated

Postpartum hormones

• The rapid decrease in estrogen and progesterone levels after expulsion of the placenta triggers many anatomical/physiological changes

Estrogen and progesterone

• Levels drop markedly after birth, reaching their lowest levels 1 week after birth
• During pregnancy, increased estrogen/progesterone stimulate massive uterus growth through both hyperplasia (↑ # cells) and hypertrophy (↑ of cells)
• After birth, the decrease causes autolysis, the self-destruction of excess uterine tissue
• Decreased estrogen levels cause the diuresis of excess extracellular fluid, thin vaginal mucosa and absence of rugae, a decrease in vaginal lubrication, and regression of vascular abnormalities
• Lactation delays production of cervical and other estrogen-influenced mucus

Human chorionic gonadotropin

• Levels decrease rapidly after birth
• Can still be detected in the maternal system for 3-4 weeks after birth

Prolactin

• Decreased progesterone triggers an increase in prolactin by the anterior pituitary to stimulate milk production
• Highest during the first month after birth, gradually decreasing after 6 weeks but remaining elevated as long as breastfeeding
• Influenced by infant suckling, nipple stimulation, the frequency, duration of breastfeeding, and supplementary feedings
• Elevated prolactin levels in lactating women suppresses ovulation
• Nonbreastfeeding levels decline after birth, reaching the nonpregnant range by the third postpartum week

Oxytocin

• The posterior pituitary gland releases hormone to strengthen/coordinate uterine contractions
• Breastfeeding immediately after birth and in the early days increases release
• The uterus is very sensitive during the first week or so after birth
• Oxytocin triggers the milk ejection or let-down reflex in response to infant suckling/nipple stimulation

Human placental lactogen, cortisol and insulinase

• Decreases reverse the diabetogenic effects of pregnancy
• Resulting in significantly lower blood glucose levels in the immediate postpartum period

Insulin

• Type 1 diabetics likely require much less insulin for several days after birth (especially when breastfeeding) due to the reversal of the diabetogenic effects of pregnancy

EBL and QBL

• Quantitative measurement of blood loss (QBL) is the recommended standard for accurate assessment/management of postpartum hemorrhage

Postpartum hemorrhage

• Postpartum hemorrhage is cumulative blood loss ≥1000 mL or bleeding associated with signs/symptoms of hypovolemia within 24 hours of the birth process (regardless of type of birth)

Calculating for vaginal birth QBL

• Should begin immediately after the birth of the neonate, before the delivery of the placenta, using a calibrated under-buttocks drape and weighing all blood-soaked items

Calculating for a cesarean birth QBL

• Begins when the membranes are ruptured or after the birth of the neonate, by measuring fluids in suction canisters (subtracting irrigation fluid) and weighing all blood-soaked materials/clots

Estimated blood loss

• American College of Obstetricians and Gynecologists (ACOG) revised its definition due to inaccuracy in relying solely on visual estimation

Breastfeeding initiation

• Ideal time is within 1 to 2 hours after birth
• The newborn should be placed in skin-to-skin contact with mom and remain there for at least 1 hour
• Encourage the mother to observe for signs that the baby is ready to breastfeed and assist as needed
• Most newborns are alert and ready to nurse during this first hour
• Breastfeeding aids in contracting the uterus and preventing maternal hemorrhage
• Initial session allows assessment of basic knowledge of breastfeeding and the physical appearance of the breasts and nipples

Benefits of breastfeeding

• Human milk is the best source of nutrition for both term and preterm infants
• Increases the release of oxytocin, which promotes uterine contractions, therefore decreasing blood loss and reducing the risk for postpartum hemorrhage
• Fewer oxygen desaturations, no bradycardia, warmer skin temperature, and improved coordination of sucking, swallowing, and breathing seen in preterm infants
• Provides protective mechanisms with Colostrum contains IgA, offers protection against infection in the GI tract, contains iron- binding protein that exerts a bacteriostatic effect on E. coli and macrophages and lymphocytes
• Reduces vulnerability of infants to common mucosal pathogens such as RSV with maternal immunity found in colostrum
• A protective effect against the development of necrotizing enterocolitis (NEC) and includes antioxidant properties and inhibits bacteria
• Provides welfare of infant leading mother to feel like they are contributing uniquely

Breast changes in the postpartum period

• Little change first 24 hours and colostrum is expressed
• As colostrum transitions to mature milk by 72 to 96 hours after delivery breasts become fuller and heavier in lactogenesis II
• Breast engorgement causes discomfort and fullness, heat, and pain
• Nipples should be assessed for skin intactness, and reported soreness and redness, bruising, cracks, fissures, abrasions, and blisters

Management for breastfeeding-related issues

• Provide education and assistance, and referrals to lactation consultants as needed
• Sore nipples are likely related to ineffective latch technique
• Topical preparations or hydrogel pads help provide sore nipple comfort
• Frequent feeding, hand expression or a breast pump are useful for breast engorgement

Management of breast engorgement for non-breastfeeding mothers for lactation suppression

• Supportive bra for at least 72 hours continuously
• Avoid breast stimulation including running warm water, suckling or expressing milk
• Ice packs can help decrease the discomfort of engorgement
• Used of fresh cabbage leaves or a mild analgesic or antiinflammatory medication
• The use of estrogen, estrogen and testosterone, and bromocriptine is not generally recommended

Breastfeeding and Medication

• Opioids transfer through milk, so use with caution and observation to avoid sedation and or respiratory depression
• Analgesics during the postpartum period are relatively safe, and timing of medication can minimize infant exposure
• Women with chronic HTN can breastfeed and diuretic use may lower milk production although Labetalol is safe for lactating mothers
• Street drugs prohibit breastfeeding, and treatment should be provided with Candida

Anticoagulant and breastfeeding

• Either avoid breastfeeding or use an alternative anticoagulant, because of the potential for newborn harm

Support and Resources for Breastfeeding

• Nurses provide information about breastfeeding support groups
• Exploration of online support groups with hospitals and health departments recommended
• Home visitation and referrals to lactation recommended
• HUG is a program to understand newborns and prevent problems related to crying, sleeping, eating, attachments, and bonding

Cultural Considerations for Breastfeeding

• Asians and seaweed soup thought to help with milk production
• Breastfeeding encouraged with cultural dietary preferences

Maternal Health

• Delayed Lactogenesis can be caused by postpartum hemorrhage
• Bereavement post loss can benefit from breastfeeding consultant visits

Considerations for Preterm Infants

• 32 to 36 week newborn breastfeeding encouraged if adequate sucking and swallowing reflexes
• Human milk feeding until breastfeeding with electric pumps recommended

Considerations for Contraception

• Exclusive breastfeeding is not considered reliable due to production interference with hormones unless other methods are used
• Baby Cuddling
• Positive associations and skin to skin contact with cuddling is great for infant soothing

General Breastfeeding Recommendations

• Assess lactation and weigh both before for optimal intake

Disseminated Intravascular Coagulation

• Disseminated Intravascular Coagulation an acquired is acquired syndrome with widespread intravascular coagulation with excessive hemorrhaging.
• DIC is never a primary diagnosis as it results from triggered coagulation.
• DIC in OB commonly from placental disruptions
• Other causes include the following preeclampsia or eclampsia/HELLP syndrome, amniotic fluid embolism, postpartum hemorrhage, sepsis, acute fatty liver of pregnancy, and retained IUFD.
• Watch for peripheral cyanosis and bleeding, nosebleeds, venupuncture site oozing, and tachycardia.

Testing DIC

• Decreased platelets, prolonged Prothrombin and thromboplastin times, and increased D-dimer and FDP.

DIC Medical Management

• Correction of underlying issue including rapid volume expanders with blood. MOnitor intake and output, administer recombinant factors, and monitor the results

Nursing with DIC

• Monitoring blood products or administering fluids, protect the client, and if there is vaginal bleeding, place in tilt.

Idiopathic Thrombyctopenia

• Idiopathic Thrombyctopenia is an autoimmune disorder where platelets reduce the lifespan of the bodies plates
• Leads to cesarean and/or vaginal lacerations
• May treat with immunoglobulin or corticosteroids

Considerations for Thrombosis

• Thrombosis requires initial heparin IV or IV antibiotics and is hard to distinguish from pregnancy,

Prevention and Treatment for thrombosis

• Clients may receive heparin for prevention
• Treated with warfarin or aspirin

Nursing with Thrombosis -

• Monitor swelling, pulses, and PE

Infant Senses on Assessment

• Infant Sight is generally underdeveloped with blurry senses. Clear vision is within one foot, and pupils react to light. Eye contact is encouraged with dimming lights and delay Ointment use.

Infant Hearing

• Hearing is immediate, infants turn to locate sound. Integrate bonding with heartbeat, and ensure the volume in environment is as low as possible.

Infant Smell

• Smell integrated at birth to help infant identify caregiver

Infant Touch

• Infants must be touched appropriately and require early skin to skin. Soothe with rubbing

Newborn Transition

• Transition or life stabilization is in neonatal period that stabilizes vitals up to 8 hours after birth in 28 days. Ensure temperature is monitored with this

Adaptation for behavior

• Newborns undertake to monitor stimuli and regulate behavioral tempo through organizing and socializing.

Factors in Behavioral Adaptions

• Maturity by gestation to monitor organ immaturity
• Monitor medication maternal conditions impact newborns

Nursing During Transition

• Perform assessments to look for trauma/distress, perform V/S and score systems needed. Preterm are a primary focus.
• Comfort the infant with warmth, stimulate the baby, manage termorature via warmers.
• Educate on care, teach families with care opportunities, and provide bereavement counseling in certain situations

Newborn adaption Vitals

• Thermal control must be maintained in neonatal
• Medulla factors influence breathing and rates

Thermoregulation of infants

• Infants are at risk for temperature changes and must maintain NTE without overheating.
• Loss is increased, resulting in glucose consumption

Renal adaptions

• Decreased concentrate ability for kidneys to maintain

Gasteronal adaptations

• Requires coordination to develop with geststional maturity

Neuromuscular adaptations. -

• Must maintain reflexes and flexation

Metabolic adaptation

• May be risk for hypoglycemia

New Born Vitals & Respiration

• Term Heart Rates in newborns can range from 120-160, sleeping is 80. Monitor tachycardia or Persistent bradycardia. Respiration is caused by mechanical, thermal and sensory factors which result in a drop of oxygen

Trouble Signs For Newborn

• Flaring Nares, retractions, grunting, hypo or tachypnea, and ausculations
• Premature infants may have trouble

Thermo for Newborns

• Heat must be maintained with low surface area, conduction, Evaporation, radiation, and convection. Check Temp
• Non Shivering responses metabolizes. Glucose and hypoglycemia increase
• Preterm require humidity controlled and radiation warmers.

Kernicterus -

• Acute bilirubin encephalopathy can lead to toxicity. Can be diagnosed with bilirubin levels above 25.
• Causes include high bilirubin and immature livers or bruising causing production

Kernicturus Process

• Lack of production causes binding in brain, causing lethargy, hypertonia, coma, and/or death

Skin on Newborns

• All structures present at birth
• Skin has 35 weeks of caseosa to help with epidermis
• Red for a few hours and often blotchy
• Creases more, maturation more

Common skin changes

• Neuvias marks, Milia, Stork bites and pigmentations
• Hydorcles may resolve on there own
• Close Observation with temp and bathing recommended

HTN or pre-eclampsia

• HTN develop after 20 weeks of pregnancy in mothers with normal B/P of 140 or more systolic and diastolic
• GHTN resolves after birth in 6-12 months after birth
• 50% progress to serve cases
• Requires creatine, liver enzyme assessment. Monitor BP after checking post delivery and 7-10 day post

Preeclampsia

• HTN and proteinuria or can include thrombocytopenia with insufficient kidney activity. risk includes BMI, Multi parity history, lupus, assisted tech
• Severe is frontal pain, gastric pain, visual distubrances,

Risk for Mothers

• Complications: Anxiety, injury, and coping issues
• *Fetal: growth failure and preterm risks
• Care involves magnesium and antihypertensives but monitoring is vital

HELLP

• HELLP a variant with high maternal risks, DIC, Renal, HTM, and hemorrhage

Magnesium

• Seziures and HTM tx
• Administer always via IV and has low effects on BP
• Watch out for DTRS, and output

Magnesium -

• A high alert to prevent harm and monitor

Miscarriage

• SAB: a spontaneous abortion
• 20 weeks before gestation is a SAB. Weight may play a role
• 10% clinically see it
• Common 12 weeks

Miscarriage Causes

• Half is chromosomes, medicals cause etc,
• Reccuent is 2X
• Signs are Uterus Pain and heavy bleeding with threatening
• Common problems include anxiety
• Can be surgical with management
• After oxytocin can help bleeding with RhoGAM, check it and monitor

Ineatable bleeding

• High amounts with low dilation
• Missed bleeding - needs evacuation

Cullen

• Cullen is a blue discoloration in the umbilicus and should not be pushed away as a non event

Ectopic pregnancies. -

• Ectopic: fertilized egg outside that uterus and most causes

• Is at end of Fallopian or cervix and scar

• Causes - art history, smoking, ab, and infections

• Pain or bleeding is common with referral to shoulder

• Check BHG is a rapid divider

• Mangement and check to ensure the tissue doesnt return

Molar Pregnancies

• Tumors of trophy and should be rapidly removed to prevent metastasis and issues as followups

Postpartums Hemorrhages. And related interventions +

• Greater than 1000 mL blood loss, with 15 in peripal pads is heavy with inversion , shock, and pain being primary issues.
• To fix assess uterus firmness.
• Initial intervention with assessment to prevent shock. Give fluid, oxygen at a 4l and watch Output.

More PPH

• Meds with miso, methylergovonine( contra with bp 140/90mcarb ( cautiosly with asthma, htn, heart issues) and TXA
• With TXA Check Labs
• Tamponade can work,

Uterine Artery and Atong -

• Urentie artery not able to contract
• Give to tx and then help contract when the placenta is not at delivery to decrease risk

Management & and Atonry -

• Massage and find all clots and distention or fluid build up
• Always mainitinf good tone
• Crapmping caused PPH.

Apnea - Infant

• Monitor breathing cessations for 20 seconds
• Note periods of regularity, causes can be from premurtity

• Treat as appropriate

Birth Injuries : Risk Factors -

• Under 17 or over 35
• Long labor
• CPD ( Infant doesn’t fit )
• Fetal and Intrauteran Events that will hurt: Macrosomia, distress

Common Birth Injury -

• Caput common and heals itself
• Ceph not crosses
• Subgaleal causes serious issue in general
• Fractures clavicals are most common, move them and heal

Common Peripheral Injury -

• Bracial Plexus: caused by high weight so use erb deuchene testing