N.I: N.I for discomfort include assisting the patient into a prone position with a small pillow placed under her abdomen, initiating sitz baths (for warmth), encouraging ambulation, and administrating mild analgesics. Breastfeeding the NB.
Breastfeeding women should take pain medication approximately 30 minutes before nursing the baby to achieve maximum pain relief.
· Normal/Abnormal findings
Redness, Edema, Ecchymosis, Discharge, Approximation
· Risks, Interventions, Medications, Education
Additional challenges faced by patients during recovery from a cesarean birth include recovery from the anesthesia, a need to cope with incisional and gas pain, and slow ambulation. Mother-infant bonding may be delayed, and patients are at an increased risk for hemorrhage, surgical wound infection, urinary tract infections (UTIs), and DVT.
Care of the patient after cesarean birth:
The nurse must complete the Breasts, Uterus, Bladder, Bowel, Lochia, and Episiotomy ( BUBBLE-HEB) Homan sign, Emotions, Bonding assessment.
· Recovery from anesthesia
· Abdominal Distension
· Urinary (retention/distension)
· Care of the cesarean Incision/Episiotomy
N.I: Perineal care. Clean, Front to back, Washing, Padding, Sitting, Change pad (3 to 4 hrs.) Ice Packs first 24 hrs. postpartum. Tucks, if Hemorrhoids. Sitz Baths relief pain and discomfort (24 to 48 hrs. postpartum) If bleeding occurs, notify the physician *PRIORYTY
Early Maternal Assessment:
Monitor for Infection/Hemorrhage
· Vital Signs: 1st 24hrs.
Temperature: 98.6 ~ 100.4 F
Pulse: 60~100 bpm Bradycardia is common
Blood Pressure: Consistent 120/80mmHg If High: Anxiety, HTN, Preeclampsia.
Respirations: 12~20 per minute
Pain: “The Fifth Vital Sign”
Stool softener, Laxative, Hemorrhoid Cream, NSAID.
Body system adaptations/physiological changes:
· Hematological and Metabolic System
500mL Blood Loss if Vaginal Childbirth 1gr / 1000mL Blood Loss if C/S 2gr
It is important for the nurse to remember that, as the body’s excess fluid is excreted, the hematocrit may rise because of hemoconcentration.
Maternal plasma volume decreases even further as a result of diuresis.
Circulating levels of estrogen and progesterone decrease dramatically after delivery of the placenta; human placental lactogen, cortisol, growth hormone, and insulinase, also fall.
Patients who received epidural or spinal anesthesia may experience headaches, especially when they assume an upright position. After spinal or epidural anesthesia, headaches may result from the leakage of cerebrospinal fluid into the extradural space.
Fatigue, Discomfort, OXYTOCIN causes sleepiness.
· Renal System, Fluids and Electrolytes
Urinary output 3000mL in 24 hrs. Diuresis occurs after birth.
· Respiratory System
Resp system goes back to normal non-pregnancy state. Progesterone levels drop.
The immediate decrease in intra-abdominal pressure associated with the birth of the baby allows for increased expansion of the diaphragm and relief from the dyspnea usually associated with pregnancy.
· Integumentary System
Changes related to major alterations in hormones, alterations in pigmentation, connective and cutaneous tissue, hair, nails, secretory glands, and pruritus. Most pregnancy-related skin changes disappear completely during the postpartum period, although some, such as striae gravidarum (stretch marks), fade but may remain permanently.
· Cardiovascular System
Maternal cardiac output is significantly elevated above pre-labor levels for 1 to 2 hours postpartum and remains high for 48 hours postpartum. Returns to normal within 2~4 weeks after childbirth.
· Immune System
WBC slightly increased (25.000 count) during labor and birth and remains elevated during the early postpartum period, gradually returning to normal values within 4 to 7 days after childbirth. Rubella shot (MMR if titters are not immune) RhoGAM If Mom (-) and child (+)
Menstruation usually resumes within 6 to 8 weeks after childbirth in women who are not breastfeeding.
Exclusively breastfeeding moms may not ovulate or menstruate for 3 or more months.
breastfeeding is not a reliable method of contraception.
· Gastrointestinal System
Bowels more active right after birth, mom may become hungry and thirsty . Constipation, a common nursing diagnosis for the postpartum patient, is associated with abdominal discomfort and decreased hunger.
· Musculoskeletal System
Diastasis recti abdominal: separation of the abdominal muscles. N.I Maintain correct posture when lifting, carrying and bathing the baby for at least 12 weeks after birth. Perform modified sit-ups to strength abdominal muscles.
UTERUS: Fundal Heigh- Uterine Placement/ Consistency (Boggy/ Firm)
BOWEL: Gas passing, Constipation, Air can engage in arm (Early Ambulation)
BLADDER: Assess Catheter/Remove Urine color and amount
LOCHIA: COCA Color, Odor, Consistency, Amount.
EPISISOTOMY: Perineum, Hemorrhoids
REEDA Redness, Edema, Ecchymosis, Discharge, Approximation.
Homans Sign: Calf + Pushing test
Emotions: Affect, family interactions, Baby Blues
Bonding: Gazing, Enfolding, Interaction with the Newborn.
Assessment of Lochia Flow:
Scant: 1 inch 2.5cm
Light: 4inch 10cm
Moderate: 6inch 15cm
Heavy: Per Pad Saturated within 1hr.
Lochia Rubra: 3-4 days postpartum Dark bright red/ Menstrual odor/ Decreasing
Lochia Serosa: Up to 14th day postpartum pink, old blood, decrease amount
Lochia Alba: Up to 6 weeks postpartum White yellow creamy/light
Phases associated with the Mothering Role:
Rubin (1975) described three distinct phases that are associated with the woman’s assuming the mothering role. She labeled these phases:
“Taking-hold,” (2nd and 3rd day) and
“Letting-go” (2-6 weeks postpartum)
“Taking-in,” her birth experience in the first day or two after birth.
“Taking -hold,” Mom assumes care for herself and her infant. signs of bonding
“Letting-go,” Starts to focus on issues directly with herself and her newborn
DVT Deep Vein Thrombosis
Common during pregnancy
S & S: Depend on size
Unilateral Leg Pain
Positive Homan’s Sign
Calf Tenderness / Warm / Inflamed
Swelling / Maybe asymptomatic 50%
Pedal Pulse at +2
Developmental of Collateral Circulation
Degree of Vessel Occlusion
• Medications/labs for meds
– Basic Chemistry test
– PT and PTT
Thrombophlebitis = Thrombus + Inflammation
Typically occurs in CALFS
Risk during postpartum
Superficial Venous Thrombosis
Deep Venous Thrombosis
Pulmonary Embolism Med: Warfarin/Heparin
Maintain antidotes on bedside (e.g., protamine sulfate for Heparin, Vitamin K for warfarin) to promptly treat drug overdose.
Specific diagnostic procedures (e.g., venography and real-time and color Doppler ultrasound)
Avoid massage when DVT is suspected
When you sit, elevate your legs and do not cross them.
Drink plenty of fluids (10–12 8-ounce glasses) to prevent dehydration.
Avoid sitting in one position or standing for a prolonged period of time.