Maternal and Child Nursing PDF

Maternal and Child Nursing Chapter 16  The Assessment of Uterine Contractions Depending on the hospital or birthing center policy, most women are monitored by an external contraction monitor for about 20 minutes in early labor. The monitor is then removed, and contractions are assessed...

Maternal and Child Nursing Chapter 16  The Assessment of Uterine Contractions Depending on the hospital or birthing center policy, most women are monitored by an external contraction monitor for about 20 minutes in early labor. The monitor is then removed, and contractions are assessed intermittently by Doppler. The use of internal fetal monitoring is reserved for high-risk pregnancies. Length of Contractions To determine the beginning of a contraction, rest a hand on a woman’s abdomen at the fundus of the uterus very gently until you sense the gradual tensing and upward rising of the fundus that accompanies a contraction. Time the duration of the contraction from the moment the uterus first tenses until it has relaxed again. It is possible to palpate this tensing approximately 5 seconds before the woman is able to feel the contraction because contractions become palpable when the intrauterine pressure reaches approximately 20 mmHg. Intensity of Contractions The intensity of a contraction refers to its strength. On a monitor, this is the height of the waveform. If you are assessing manually, rate a contraction according to: Mild, if the uterus does not feel more than minimally tense Moderate, if the uterus feels firm Strong, if the uterus feels as hard as a wooden board or you are unable to indent  At the conclusion of the contraction to be certain it does relax and becomes soft to the touch again. This demonstrates that the uterus is not in continuous contraction but is providing a relaxation time, during which placental blood vessels can fill to supply the fetus with adequate oxygen. Interval of Contractions Lastly, time the interval of contractions or how often they are occurring. Interval is timed from the beginning of one contraction to the beginning of the next. Use as light a touch as possible on a woman’s abdomen while evaluating contractions or estimating their strength manually. Otherwise, the uterine fundus can become tender if it has to push against the extra weight of a hand with each contraction, creating unnecessary discomfort for a woman in labor. THE INITIAL FETAL ASSESSMENT Fetal heart sounds are transmitted best through the convex portion of a fetus because that is the part that lies in closest contact with the uterine wall.  Determine the FHR every 30 minutes during beginning latent labor, every 15 minutes during active first stage labor, and every 5 minutes during the second stage of labor. This can be done by inspecting an FHR monitoring strip or by periodic auscultation by a fetoscope (a modified stethoscope attached to a headpiece), a Pinard stethoscope (a hollow tube that directs sound into the ear), or a Doppler unit (which uses ultrasound waves that bounce off the fetal heart to produce echoes or clicking noises, which reflect the fetal heartbeat as labor progresses. ELECTRONIC MONITORING Electronic monitoring is noninvasive, easily applied, and does not require cervical dilatation or fetal descent before it can be used, so it can be introduced at any time during labor. The presence and duration of uterine contractions is gained by means of a pressure transducer or tocodynamometer (toko is Greek for “contraction”) strapped to the woman’s abdomen or held in place by stockinette  Place the transducer snugly over the uterine fundus or the area where contractions are most easily felt. The transducer works to convert the pressure originated by the contraction into an electronic signal that is then recorded on graph paper. The FHR is monitored with the use of an ultrasonic sensor or monitor also strapped against a woman’s abdomen at the level of the fetal chest. The small Doppler unit converts fetal heart movements into audible beeping sounds and also records them on graph paper. FETAL HEART RATE AND UTERINE CONTRACTION RECORDS Labor monitors trace both the FHR and the duration and interval of uterine contractions onto an oscilloscope screen and produce a permanent record on paper rolls 2 column = 1min/60 secs (Other strips- 1 column=1min) The Baseline Fetal Heart Rate A baseline FHR is determined by analyzing the pace of fetal heartbeats recorded in a minimum of 2 minutes obtained between contractions. A normal rate is 120 to 160bpm Variability FHR variability or the difference between the highest and lowest heart rates shown on a strip is one of the most reliable indicators of fetal well-being. Variability is reflected on an FHR tracing as a slight irregularity or “jitter” to the wave. The degree of baseline variability increases (5 to 15 beats/min) when a fetus moves; it slows if a fetus sleeps. If no variability is present, it indicates the natural pacemaker activity of the fetal heart (effects of the sympathetic and parasympathetic nervous systems) may be affected. This may occur as a response to narcotics or barbiturates administered to a woman in labor, but the possibility of fetal hypoxia and acidosis must also be considered and investigated. Very immature fetuses show diminished baseline variability because of a reduced nervous system response to stimulation and immature cardiac node function. Variability should be recorded as: Absent: No amplitude range is detectable. Minimal: Amplitude range is detectable but is 5 beats/min or fewer. Moderate (normal): Amplitude range is 6 to 25 beats/min. Marked: Amplitude range is greater than 25 beats/min. Other patterns in the baseline rate that can be detected include fetal bradycardia (FHR is lower than 110 beats/min for 10 minutes) and fetal tachycardia (FHR is faster than 160 beats/min for a 10-minute period). Periodic Changes Periodic changes or fluctuations in FHR occur in response to contractions and fetal movement and are described in terms of accelerations or decelerations. Periodic changes are short-term changes in rate other than baseline; they last from a few seconds to 1 or 2 minutes. Accelerations Nonperiodic accelerations are temporary normal increases in FHR caused by fetal movement, a change in maternal position, or administration of an analgesic. An acceleration is a visually apparent abrupt increase (onset to peak in less than 30 seconds) in the FHR. At 32 weeks of gestation and beyond, an acceleration has a peak of 15 beats/min or more above baseline with a duration of 15 seconds or more but less than 2 minutes from onset to return. Before 32 weeks of gestation, an acceleration has a peak of 10 beats/min or more above baseline, with a duration of 10 seconds or more but less than 2 minutes from onset to return. Prolonged acceleration lasts 2 minutes or more but less than 10 minutes in duration. If an acceleration lasts 10 minutes or longer, it is a baseline change or a new baseline is established. Decelerations Decelerations are visually apparent, usually symmetrical, periodic decreases in FHR resulting from pressure on the fetal head during contractions as parasympathetic stimulation in response to vagal nerve compression brings about a slowing of FHR. Early deceleration follows the pattern of the contraction, beginning when the contraction begins and ending when the contraction ends. (Mirror image) Decelerations are an abrupt decrease in the baseline fetal heart rate of greater than 15 bpm for greater than 15 seconds Early decelerations normally occur late in labor, when the head has descended fairly low; they are viewed as innocent. If they occur early in labor, before the head has fully descended, the head compression causing the waveform change could be the result of cephalopelvic disproportion and is a cause to investigate. Late decelerations Are those in which the onset, nadir, and recovery of the deceleration occur after the beginning, peak, and ending of the contraction, respectively. This is an ominous pattern in labor because it suggests uteroplacental insufficiency or decreased blood flow through the intervillous spaces of the uterus during uterine contractions. This pattern may occur with marked hypertonia or increased uterine tone. Immediately change the woman’s position from supine if she is lying down to lateral to relieve pressure on the vena cava and supply more blood to the uterus and fetus. Intravenous fluid or oxygen may be prescribed. Prepare for a prompt cesarean birth of the infant if the late decelerations persist or if FHR variability becomes abnormal (absent or decreased). Late Deceleration Variable Decelerations The pattern of variable decelerations refers to decelerations that occur at unpredictable times in relation to contractions. They may indicate compression of the cord, which can be an ominous development in terms of fetal well-being. Cord compression may be occurring because of a prolapsed cord, but it most often occurs because the fetus is simply lying on the cord. It tends to occur more frequently after rupture of the membranes than when membranes are intact, or with oligohydramnios (the presence of less than a normal amount of amniotic fluid), such as occurs in post term pregnancy or with intrauterine growth restriction (IUGR). As a first step, change the woman’s position from supine to lateral if she is not already lying on her side. If a prolapsed cord is diagnosed as the cause of the variable decelerations, oxygen will be prescribed as well as changing her position to a knee-to-chest one to help relieve pressure on the cord. Because a prolapsed cord is a potential serious complication of labor.  The Care of a Woman During the First Stage of Labor The Care of a Woman During the Second Stage of Labor PREPARING THE PLACE OF BIRTH POSITIONING FOR BIRTH PROMOTING EFFECTIVE SECOND-STAGE PUSHING PERINEAL CLEANING AND MASSAGE THE BIRTH As soon as the head of a fetus is prominent at the vaginal opening, one technique to help the fetus achieve extension and allow the smallest head diameter to present is for the care provider to place a sterile towel over the rectum and press forward on the fetal chin while the other hand presses downward on the occiput (a Ritgen maneuver). This maneuver, however, is often unnecessary as babies tend to be born easily without this assistance. Pressure should never be applied to the fundus of the uterus to effect birth because uterine rupture could occur.  The woman is asked to continue pushing until the occiput of the fetal head is firmly at the pubic arch. The head is then gently born between contractions if possible. This helps to prevent the head from being expelled too rapidly, creating a major pressure change in the skull, which might then rupture cerebral blood vessels. It also reduces the possibility of a perineal tear. A woman who has not had anesthesia experiences the birth of the head as a flash of pain or a burning sensation, as if someone had momentarily poured hot water on her perineum.  Immediately after birth of the baby’s head, the primary care provider passes his or her fingers around the newborn’s neck to determine whether a loop of umbilical cord is encircling the neck. It is not uncommon for a single loop of cord to be positioned this way (termed a nuchal cord). If such a loop is felt, it is gently loosened and drawn down over the fetal head. If it is too tightly coiled to allow this, it is clamped and cut before the shoulders are born. Otherwise, it could tear and interfere with the fetal oxygen supply. CUTTING AND CLAMPING THE CORD Cutting the cord is part of the stimulus that initiates a first breath or marks the newborn’s most important transition into the outside world, the establishment of independent respirations. The umbilical cord continues to pulsate for a few minutes after birth and then the pulsation ceases. Delaying cutting (also called physiologic clamping) until pulsation ceases and maintaining the infant at a uterine level allows as much as 100 ml more of blood to pass from the placenta into the fetus than if the infant were held in a superior position or the cord was immediately cut. Delaying cutting, therefore, helps ensure an adequate red blood cell and white cell count in the newborn.  The timing of cord clamping, however, is individualized because late clamping of the cord this way could cause over infusion with placental blood and the possibility of polycythemia and hyperbilirubinemia in a susceptible newborn, a particular concern if the infant is preterm. Before cutting, the cord is clamped with cord clamp and one hemostats placed 2 and 5 in. from the infant’s umbilicus. Blood may also be taken for cord blood banking so the family has stem cells available if needed in the future. The vessels in the cord are then counted to be certain three are present. Some umbilical clamps in hospitals have an alarm attached that will ring if the infant is taken further than set hospital boundaries, a precaution against newborn abduction. INTRODUCING THE INFANT After the cord is cut, it is time for the new parents to spend quality time with their newborn. The infant can remain on the mother’s abdomen for skin-to-skin contact. If the woman’s partner or support person wants to hold the infant, dry the infant well with a warmed towel, wrap him or her in a sterile blanket, and cover the head with a wrapped towel or cap. Be certain to handle newborns gently but firmly as they are slippery from amniotic fluid and vernix. Most newborns receive prophylactic eye ointment against the possibility of a chlamydia infection. Don’t administer this until after the parents have had this chance to see their infant for the first time (and the infant has had a chance to see them). This initial contact is also the optimal time for a mother to begin breastfeeding because an infant seems to be hungry at birth and sucking at the breasts stimulates the release of endogenous oxytocin, encouraging uterine contraction and involution, or the return of the uterus to its prepregnant state. The Care of a Woman During the Third and Fourth Stages of Labor The third stage of labor is the time from the birth of the baby until the placenta is delivered. For most women, this is a time of great excitement because the infant has been born, but this can also be a time of feeling anticlimactic because the infant has finally arrived after being anticipated for so long a time. THE DELIVERY OF THE PLACENTA Placenta should be delivered within 15-30 minutes. After delivery, inspect number of cotyledons. Normally, a placenta is one sixth the weight of the infant. If it is unusually large or small, you may be asked to weigh it. After the placenta inspection, if the mother’s uterus has not contracted firmly on its own, the primary care provider will massage the fundus to urge it to contract. Oxytocin (Pitocin 10 units) may be prescribed to be administered intramuscularly (IM) or per 1,000 ml fluid intravenously (IV) to also help contraction.  If excessive bleeding with poor uterine contraction remains, an injection of carboprost tromethamine (Hemabate) or methylergonovine maleate (Methergine) is yet another solution to increase uterine contraction and to guard against hemorrhage. It is important to know prior to the second stage whether a woman has a contraindication to either of these drugs such as asthma or hypertension. The administration of these drugs is a nursing responsibility in most healthcare facilities. The fourth stage of labor includes the first few hours after birth. It signals the beginning of dramatic changes because it marks the beginning of both a new life and a new family. THE PERINEAL INSPECTION To be certain a woman’s perineum did not tear from the pressure of the fetal head, the perineum is carefully inspected after birth. About 3% of women do have a small tear extending backward from the vagina. Perineal tears are rated grade 1 to grade 4, grade 1 being minimal and grade 4 extending to and including the rectum. THE IMMEDIATE POSTPARTUM ASSESSMENT AND NURSING CARE Obtain vital signs (pulse, respirations, and blood pressure) every 15 minutes for the first hour and then according to agency policy or the woman’s condition. Pulse and respirations may be fairly rapid immediately after birth (80 to 90 beats/min and 20 to 24 breaths/min), and blood pressure may be slightly elevated due to exertion and excitement of the moment or recent oxytocin administration. Palpate a woman’s fundus for size, consistency, and position and observe the amount and characteristics of lochia each time you record vital signs. THE IMMEDIATE POSTPARTUM ASSESSMENT AND NURSING CARE Offer a clean gown and a warmed blanket because a woman often experiences chills and a shaking sensation 10 to 15 minutes after birth. This may be due to the low temperature of a birthing room but may also be a result of the sudden release of pressure on pelvic nerves or of excess epinephrine production during labor. In any event, it is a normal phenomenon but can be frightening to the mother if she associates the chills with fever or infection and worry she will be ill at a time when she most wants to be well to care for her new child. You can reassure her this is a transitory sensation, is very common, and passes quickly. Nursing Care of a Post partal Family Chapter 17 Psychological Changes of the Postpartal Period BEHAVIORAL ADJUSTMENT: PHASES OF THE PUERPERIUM In her classic work on maternal behavior, Reva Rubin, a nurse, divided the puerperium into three separate phases. Taking-in phase Taking-hold Letting-go phases Taking-In Phase The taking-in phase is largely a time of reflection. 1- to 3-day period, (woman is largely passive) She prefers having a nurse attend to her needs and make decisions for her rather than do these things herself. This dependence results from her physical discomfort because of afterpains or hemorrhoids, partly from her uncertainty in caring for her newborn, and partly from the exhaustion that follows childbirth. As part of thinking and pondering about her new role, the woman usually wants to talk about her pregnancy, especially about her labor and birth. She holds her new child with a sense of wonder and asks: Is birth really over? Could this child really have been inside me? She wants to rest to regain her physical strength and experience a calm atmosphere around her to quiet and contain her swirling thoughts. Encouraging her to talk about the birth is an important way to help her integrate the experience into her total life experiences. Taking-Hold Phase After a time of passive dependence, a woman begins to initiate action (the taking-hold phase). She prefers to get her own washcloth or to make her own decisions. Women who give birth without any anesthesia may reach this second phase in a matter of hours after birth. She begins to take a stronger interest in her infant and begins maternal role behaviors. As a rule, it is usually best to give a woman a brief demonstration of baby care and then allow her to care for her child herself—with watchful guidance—as she enters this phase. She often still feels insecure about her ability to care for her new child. She needs praise for the things she does well, such as supporting the baby’s head or beginning breastfeeding, to give her confidence. This positive reinforcement begins in the healthcare facility and continues after discharge, at home and at postpartum and well- baby visits.  Do not rush a woman through the phase of taking-in or prevent her from taking hold when she reaches this point. For many young mothers, learning to make decisions about their child’s welfare is one of the most difficult phases of motherhood. It helps if a woman has practice in making such decisions in a sheltered setting, such as a hospital, rather than first taking on that level of responsibility after she is home alone. First-time mothers may need additional guidance and time during this phase compared to multigravida moms, but not always, as in the case of a multigravida mom who is learning to care for twins. Letting-Go Phase A woman finally redefines her new role. She gives up the fantasized image of her child and accepts the real one; she gives up her old role of being childless or the mother of only one or two (or however many children she had before this birth). This process requires some grief work and readjustment of relationships, similar to what occurred during pregnancy. It is extended and continues during the child’s growing years. A woman who has reached this phase is well into her new role. DEVELOPMENT OF PARENTAL ATTACHMENT, BONDING, AND POSITIVE FAMILY RELATIONSHIPS During pregnancy – woman is worries about her ability to be a “good” mother After birth – some women recognize newborns needs (adjustment period) - Some infants are calm and others are easily excitable. “Learning the infant’s cues and personality takes time and patience. This is because parental love is only partly instinctive. ” A major portion develops gradually, in stages such as planning the pregnancy, hearing the pregnancy confirmed, feeling the child move in utero, birthing, touching the baby, and, finally, giving total care to the child.  Attachment or Bonding - When a woman has successfully linked with her newborn, Although a woman carried the child inside her for 9 months She often approaches her newborn not as someone she loves but more as she would approach a stranger. The first time she holds the infant, she may touch only the blanket. If she unfolds the blanket to examine the baby or count the fingers or toes, she may use only her fingertips for touch. Skin-to-skin contact soon after birth facilitates the early attachment and binding phase. This should ideally occur within the first hour of any birth, even cesarean deliveries, as soon as the mother and baby are stable and last until completion of the first breastfeeding  Gradually, as a woman holds her child more, she begins to express more warmth, touching the child with the palm of her hand rather than with her fingertips, smoothes the baby’s hair, brushes a cheek, plays with toes, and lets the baby’s fingers clasp hers, feels comfortable enough to press her cheek against the baby’s or kiss the infant’s nose; she has successfully bonded or become a mother tending to her child. Looking directly at her newborn’s face, with direct eye contact (termed an en face position), is a sign a woman is beginning effective attachment. Rooming-In The more time a woman has to spend with her baby, the sooner she can become better acquainted with her child, feel more confident in her ability to care for her baby, and more likely form a sound mother–child relationship. In order to qualify as “baby friendly,” a hospital must provide “rooming-in,” or space to keep the infant with the parents. Rooming-in occurs when the infant remains in the woman’s room and the mother and child are together 23 out of 24 hours a day. With both complete and partial rooming-in (infant spends time in newborn nursery), the father and siblings can hold the infant when they visit. In many settings, the father can stay overnight in the mother’s room. MATERNAL CONCERNS AND FEELINGS IN THE POSTPARTAL PERIOD Typical issues identified by postpartal women that they would like to hear discussed are breast soreness; regaining their figure; regulating the demands of a job, housework, their partner, and their children; coping with emotional tension and sibling jealousy; and how to combat fatigue. MATERNAL CONCERNS AND FEELINGS IN THE POSTPARTAL PERIOD Abandonment Many mothers, admit to feeling abandoned and less important after giving birth than they did during pregnancy or labor. Only hours before, after all, they were the center of attention, with everyone asking about their health and well- being. Now, suddenly, the baby is everyone’s chief interest. Help a woman move past these feelings by verbalizing the problem: “How things have changed! Everyone’s asking about the baby today and not about you, aren’t they?” These are reassuring words for a woman and help her realize that, although uncomfortable, the feeling she is experiencing is normal. When a newborn comes home, a father or partner may express much the same feelings as he or she feels resentful of the time the mother spends with the infant. Examination of these competitive feelings can help a couple realize that parenthood involves some compromise in favor of the baby’s interests. Making infant care a shared responsibility can help alleviate these feelings and make both partners feel equally involved in the baby’s care. You can help parents or partners move past this competitive stage by pointing out positive parenting behaviors, positive self-care behaviors, and the warm infant response to their behaviors.  Disappointment Another common feeling parents or partners may experience is disappointment in the baby. All during pregnancy, they pictured a chubby-cheeked, curly-haired, smiling girl or boy. They may have instead a thinner baby, without any hair, who seems to cry constantly, or may have a congenital condition. This can make it difficult to feel positive immediately toward a child who does not meet their expectations. It can cause parents to remember their adolescence, when they felt gangly and unattractive, or to experience feelings of inadequacy all over again. You can never change the sex, size, or look of a child, but in the short time you care for a postpartal family, it is possible for a key person such as a nurse to tip a scale toward acceptance or at least help a person involved to take a clearer look at his or her situation and begin to cope with the new circumstances. As an example, handle the child warmly, to show you find the infant satisfactory or even special. Comment on the child’s good points, such as long fingers, lovely eyes, and healthy appetite. Be aware, however, that, culturally, some groups are fearful for the baby if these types of comments are made because they could draw evil influences toward the child. Postpartal Blues During the postpartal period, as many as 50% of women experience some feelings of overwhelming sadness or “baby blues” They may burst into tears easily or feel let down and irritable. Caused by hormonal changes, particularly the decrease in estrogen and progesterone that occurred with delivery of the placenta. Breastfeeding has been shown to help elevate baby blues and counteract the effects of the hormonal drop that occurs after childbirth. For some women, it may be a response to dependence and low self-esteem caused by exhaustion, being away from home, physical discomfort, and the tension engendered by assuming a new role, especially if a woman is not receiving support from her partner. In addition to crying, the syndrome is evidenced by feelings of inadequacy, mood lability, anorexia, and sleep disturbance.  Anticipatory guidance and individualized support from healthcare personnel are important to help the parents understand that this unexpected response is normal. Give the woman a chance to verbalize her feelings and make as many decisions as she wants to help her gain a sense of control and move past this strange postpartal emotion. Most people experience baby blues 2 to 3 days after the baby is born. They can last up to 2 weeks. Physiologic Changes of the Postpartal Period REPRODUCTIVE SYSTEM CHANGES Involution is the process whereby the reproductive organs return to their nonpregnant state. A woman is in danger of hemorrhage from the denuded surface of the uterus until involution is complete. The Uterus Involution of the uterus involves two processes. First, the area where the placenta was implanted is sealed off to prevent bleeding. Second, the organ is reduced to its approximate pregestational size. The sealing of the placenta site is accomplished by rapid contraction of the uterus immediately after delivery of the placenta. This contraction pinches the blood vessels entering the 7-cm-wide area left denuded by the placenta and halts bleeding. With time, thrombi form within the uterine sinuses and permanently seal the area. Eventually, endometrial tissue undermines the site and obliterates the organized thrombi, covering and healing the area so completely the process leaves no scar tissue within the uterus so does not compromise future implantation sites.  Immediately after birth, the uterus weighs about 1,000 g. At the end of the first week, it weighs 500 g. By the time involution is complete (6 weeks), it weighs approximately 50 g, similar to its prepregnancy weight. Uterine contraction begins immediately after placental delivery, The fundus of the uterus is palpable through the abdominal wall, halfway between the umbilicus and the symphysis pubis, within a few minutes after birth. One hour later, it will rise to the level of the umbilicus, where it remains for approximately the next 24 hours. From then on, it decreases by one fingerbreadth, or 1 cm, per day; for example, on the first postpartal day, it will be palpable 1 cm below the umbilicus. In the average woman, by the ninth or tenth day, the uterus will have contracted so much that it is withdrawn into the pelvis and can no longer be detected by abdominal palpation.  The uterus of a breastfeeding mother may contract even more quickly because oxytocin, which is released with breastfeeding, stimulates uterine contractions. Breastfeeding alone, however, is not sufficient to protect against postpartum hemorrhage. The fundus is normally located in the midline of the abdomen. Occasionally, it can be felt slightly to the right because the bulk of the sigmoid colon forced it to that side during pregnancy and it tends to remain in that position. Assess fundal height shortly after a woman has emptied her bladder for most accurate results because a full bladder can keep the uterus from contracting, pushing it upward and increasing the risk of excess bleeding and blood clot formation in the uterus. Involution will occur most dependably in a woman who is well nourished and who ambulates early after birth as gravity may play a role. Involution may be delayed by a condition such as the birth of multiple fetuses, hydramnios, exhaustion from prolonged labor, grand multiparity, or physiologic effects of excessive analgesia. Contraction may be ineffective if there is retained placenta or membranes.  The first hour after birth is potentially the most dangerous time for a woman. If her uterus should become relaxed during this time (uterine atony), she will lose blood very rapidly because no permanent thrombi have yet formed at the placental site. In some women, contraction of the uterus after birth causes intermittent cramping termed afterpains, similar to that accompanying a menstrual period. Afterpains tend to be noticed most by multiparas than by primiparas and by women who have given birth to large babies or multiple births. In these situations, the uterus must contract more forcefully to regain its prepregnancy size. These sensations are noticed most intensely with breastfeeding, when the infant’s sucking causes a release of oxytocin from the posterior pituitary, increasing the strength of the contractions. Lochia The separation of the placenta and membranes occurs in the spongy layer or outer portion of the decidua basalis of the uterus. By the second day after birth, the layer of decidua remaining under the placental site (an area 7 cm wide) and throughout the uterus differentiates into two distinct layers. The inner layer attached to the muscular wall of the uterus remains, serving as the foundation from which a new layer of endometrium will be formed. The layer adjacent to the uterine cavity becomes necrotic and is cast off as a vaginal discharge similar to a menstrual flow. This flow, consisting of blood, fragments of decidua, white blood cells, mucus, and some bacteria, is termed lochia.  The portion of the uterus where the placenta was not attached is so fully cleansed by this sloughing process it will be in a reproductive state in about 3 weeks’ time; it takes approximately 6 weeks (the entire postpartal period) for the placental implantation site to be healed. For the first 3 days after birth, a lochia discharge consists almost entirely of blood, with only small particles of decidua and mucus. Because of its mainly red color, it is termed lochia rubra. As the amount of blood involved in the cast-off tissue decreases (about the fourth day) and leukocytes begin to invade the area, as they do with any healing surface, the flow becomes pink or brownish (lochia serosa). On about the 10th day, the amount of the flow decreases and becomes colorless or white with streaks of brownish mucus (lochia alba). Lochia alba is present in most women until the third week after birth, although it is not unusual for a lochia flow to last the entire 6 weeks of the puerperium. Type of Lochia Color Post-Partal Day Composition Lochia Rubra Red 1-3 Blood, fragments of decidua, and mucus Lochia Serosa Pink 3-10 Blood, mucus and invading leukocytes Lochia Alba White 10-14 (may last to 6 Largely mucus, weeks) leukocyte count high Evaluating Lochia Flow Amount Varies greatly from woman to woman. Breastfeeding Mothers tend to have less lochial discharge than those who do not because the natural release of the hormone oxytocin during breastfeeding strengthens uterine contractions. Lochial flow increases on exertion, especially the first few times a woman is out of bed but decreases again with rest. Saturating a perineal pad in less than 1 hour is considered an abnormally heavy flow and should be reported. Don’t use tampons to halt the flow or this could lead to infection. Consistency: Lochia should contain no exceedingly large clots as these may indicate a portion of the placenta has been retained and is preventing closure of the maternal uterine blood sinuses. In any event, large clots denote poor uterine contraction, which needs to be corrected. Evaluating Lochia Flow Pattern: Lochia is red for the first 1 to 3 days (lochia rubra), pinkish-brown from days 4 to 10 (lochia serosa), and then white (lochia alba) for as long as 6 weeks after birth. The pattern of lochia (rubra to serosa to alba) should not reverse as this suggests a placental fragment has been retained or uterine contraction is decreasing and new bleeding is beginning. Odor: Lochia should not have an offensive odor as this suggests the uterus has become infected. Immediate intervention is needed to halt postpartal infection. Absence: Lochia should never be absent during the first 1 to 3 weeks as absence of lochia, like presence of an offensive odor, may indicate postpartal infection. Lochia may be scant in amount after cesarean delivery, but it is never altogether absent. The Cervix Immediately after birth, a uterine cervix feels soft and malleable to palpation. Both the internal and external os are open. Like contraction of the uterus, contraction of the cervix toward its prepregnant state begins at once. By the end of 7 days, the external os has narrowed to the size of a pencil opening; the cervix feels firm and nongravid again. In contrast to the process of uterine involution, in which the changes consist primarily of old cells being returned to their former position by contraction, the process in the cervix does involve the formation of new muscle cells. Because of this, the cervix does not return exactly to its prepregnancy state. The internal os closes as before, but after a vaginal birth, the external os usually remains slightly open and appears slit-like or stellate (star shaped), whereas previously, it was round. Finding this pattern on pelvic examination suggests that childbearing has taken place. The Vagina After a vaginal birth, the vagina feels soft, with few rugae, and its diameter is considerably greater than normal. The hymen is permanently torn and heals with small, separate tags of tissue. It takes the entire postpartal period for the vagina to involute (by contraction, as with the uterus) until it gradually returns to its approximate prepregnancy state. Thickening of the walls appears to depend on renewed estrogen stimulation from the ovaries. Because a woman who is breastfeeding may have delayed ovulation, she may continue to have thin-walled or fragile vaginal cells that cause slight vaginal bleeding during sexual intercourse until about 6 weeks’ time. If a woman practices Kegel exercises, the strength and tone of the vagina will increase more rapidly. This may be important for the sexual enjoyment of both a woman and her partner. The Perineum Because of the great amount of pressure experienced during birth, the perineum is edematous and tender immediately after birth. Ecchymosis patches from ruptured capillaries may show on the surface. The labia majora and labia minora typically remain atrophic and softened after birth, never returning to their prepregnancy state. Mothers may experience various levels of tenderness in the perineum area. Suggesting nonpharmacologic comfort measures such as ice or warm packs or a gentle pillow or doughnut pad to sit on will be much appreciated by the mother. Nurses should discuss with the mother’s provider available pharmacologic pain relievers, such as acetaminophen or ibuprofen, and administer according to the prescription orders when deemed necessary or by maternal request. SYSTEMIC CHANGES The Hormonal System Pregnancy hormones begin to decrease as soon as the placenta is no longer present. Levels of hCG and human placental lactogen hPL are almost negligible by 24 hours. By week 1, progestin, estrogen, and estradiol are all at prepregnancy levels (estriol may take an additional week before it reaches prepregnancy levels). Follicle-stimulating hormone (FSH) remains low for about 12 days and then begins to rise as a new menstrual cycle is initiated. The Urinary System During pregnancy, as much as 2,000 to 3,000 ml of excess fluid accumulates in the body so extensive diaphoresis (excessive sweating) and diuresis (excess urine production) begin almost immediately after birth to rid the body of this fluid. This easily increases the daily urine output of a postpartal woman from a normal level of 1,500 ml to as much as 3,000 ml/day during the second to fifth day after birth. This marked increase in urine production causes the bladder to fill rapidly. Reassure the mother that this is normal and she still needs to continue drinking a healthy amount of fluids daily, especially if she is breastfeeding. To prevent permanent damage to the bladder from overdistention, assess a woman’s abdomen frequently in the immediate postpartal period. As the bladder fills, it displaces the uterus; uterine position and lack of contraction are therefore a second good gauge of whether a bladder is full or empty.. The Circulatory System The diuresis that is evident between the second and fifth days after birth, as well as the blood loss at birth, acts to reduce the added blood volume a woman accumulated during pregnancy. This reduction occurs so rapidly, in fact, that the blood volume returns to its normal prepregnancy level by the first or second week after birth. The usual blood loss with a vaginal birth is 300 to 500 ml. With a cesarean delivery, it is 500 to 1,000 ml. There is also an increase in the number of leukocytes in the blood. The white blood cell count may be as high as 30,000 cells/mm3 (mainly granulocytes) compared to a normal level of 5,000 to 10,000 cells/mm3, particularly if labor was long or difficult. This, too, is part of the body’s defense system, a defense against infection and an aid to healing. Any varicosities that are present from pregnancy will recede, but they rarely return to a completely prepregnant appearance. Although vascular blemishes, such as spider angiomas, fade slightly, they may not disappear completely either. Bilateral ankle edema is not uncommon but should not progress above the knees. This decreases over time as fluid shifts and returns to the circulatory system. The Gastrointestinal System Digestion and absorption begin to be active again soon after birth unless a woman has had a cesarean delivery. Almost immediately, the woman feels hungry and thirsty, and she can eat without difficulty from nausea or vomiting during this time. Bowel sounds are active, but passage of stool through the bowel may be slow because of the still-present effect of relaxin (a hormone which softens and lengthens the cervix and pubic symphysis for preparation of the infant’s birth during pregnancy) on the bowel. Bowel evacuation may be difficult because of pain if a woman has episiotomy sutures or from hemorrhoids. Encouraging the mother to eat produce and soluble fiber foods, especially fruits, will help keep her stools naturally soft and ease in her bowel movements. The Integumentary System After birth, the stretch marks on a woman’s abdomen (striae gravidarum) still appear reddened and may be even more prominent than during pregnancy, when they were tightly stretched. Excessive pigment on the face and neck (chloasma) and on the abdomen (linea nigra) will become barely detectable by 6 weeks’ time. If diastasis recti (overstretching and separation of the abdominal musculature) occurred, the area will appear as a slightly indented bluish streak in the abdominal midline. Modified sit-ups help to strengthen abdominal muscles and return abdominal support to its prepregnant level. Diastasis recti, however, may require surgery to correct. Lactation The early lactation process, which is driven by hormones from the hypothalamus to the pituitary gland in order to secrete the lactation hormones, is identified by four phases of lactogenesis (human milk production). Prolactin hormone is responsible for milk production, and oxytocin is responsible for the let-down reflex arch. A retrained placenta can inhibit this process by causing continual circulation of progesterone, which inhibits prolactin and thus milk production. The lactogenesis I (milk synthesis) process begins around 16 weeks gestation as the glandular luminal cells in the breast begin secreting colostrum, a thin, watery prelactation secretion.  Lactogenesis II is triggered at birth by the delivery of the placenta, when the progesterone hormone (prolactin is no longer inhibited) and other circulating pregnancy hormones suddenly decrease and oxytocin sharply increases as a result of the infant suckling. Lactogenesis II is often when mothers feel that their “milk has come in” (engorgement) and occurs from birth to 5 to 10 days postpartum; this is often termed “transitional milk.” Lactogenesis III can occur from day 10 until weaning postpartum, when the “mature milk” supply is now driven by the circulating lactation hormones oxytocin and progesterone. Lactogenesis IV occurs after complete weaning and the breasts involute to their prelactation state. Other hormones are associated with breastfeeding, such as endorphins and oxytocin, and may help to mitigate and reduce the risk of developing postpartum depression.  Early in pregnancy, the increased estrogen level produced by the placenta stimulated the growth of milk glands; breasts increased in size because of these larger glands, accumulated fluid, and some extra adipose tissue. For the first 2 days after birth, an average woman notices little change in her breasts from the way they were during pregnancy because, since midway through pregnancy, she has been secreting colostrum. On the third day after birth, her breasts become full and feel tense or tender as milk forms within breast ducts and replaces colostrum. Breast milk forms in response to the decrease in estrogen and progesterone levels that follows delivery of the placenta (which stimulates prolactin production and, consequently, milk production) and an increase in prolactin and oxytocin. A woman’s breasts become fuller, larger, and firmer as blood and lymph enter the area to contribute fluid to the formation of milk. In many women, breast distention/engorgement is accompanied by a feeling of heat or tenderness.  Whether milk production (lactogenesis) continues will depend on an infant’s successful latch, ability to suck, and transfer milk effectively, as this releases oxytocin and prolactin which promotes the lactogenesis process. Mothers who are primigravida tend to have a longer initial lactogenesis phase and may not have an abundance of milk until the fourth to sixth day postpartum. This is normal and does not indicate that a mother cannot breastfeed. Multigravida mothers’ breast milk often “arrives” quickly within the first few days and their milk volume tends to be fuller earlier. First-time mothers may need additional breastfeeding support and lots of encouragement and assurance to continue efforts to breastfeed. Whether women continue to breastfeed after hospital discharge is influenced by such factors as lactation support, latch, milk supply, employment, personal habits, and how important they view breastfeeding to be for themselves and their newborn. Ten steps to successful breastfeeding WHO and UNICEF launched the Baby-friendly Hospital Initiative (BFHI) in 1991 to help motivate facilities providing maternity and newborn services worldwide to implement the Ten Steps to Successful Breastfeeding. The Ten Steps summarize a package of policies and procedures that facilities providing maternity and newborn services should implement to support breastfeeding. WHO has called upon all facilities providing maternity and newborn services worldwide to implement the Ten Steps. The implementation guidance for BFHI focuses on integrating the program across healthcare systems to facilitate universal coverage and ensure sustainability over time.