Chapter 18 4th stage of labour begins after the delivery of the placenta, lasting 1 hour postpartum (following childbirth).

- puerperium/postpartum: 42 days (6 weeks) after childbirth; Physiological Changes After several weeks months, the client s body will return to their nonpregnant state following the 4th stage of labour. Weight The reduction of uterine contents and blood contribute to the 5-6 kg that clients lose. By 6-18 months postpartum, women weight about 3.6 kg more than they did before pregnanc on average - excess weight regarding diet during pregnancy, smoking cessation, reduced physical activity, any lifestyle changes that may influence health and diet (weight gain during pregnancy).

CVS Postpartum; the maternal body begin to return to its pre-pregnant state. The blood flow that was once directed to the uteroplacental (increased during pregnancy), is now diverted back to the maternal circulation immediately. - vaginal birth: 500 mL loss of blood - caesarean birth: 1000 mL > loss of blood overall loss of blood volume in postpartum client, due to blood loss during birth and dieresis during the first postpartum week. * normal blood volumes return by approximately 1 week postpartum CO (increased by as much as 40% during pregnancy), may remain elevated to about 48 hours postpartum, perhaps due to an increase in stroke volume and venous return. - CO should return back to normal stats by 1~3 weeks postpartum. Heart rate should remain stable or slowly decrease following birth - should it rise to 100 beats/min, it may indicate postpartum hemorrhage or an infection Blood pressure may remain elevated (6mm S/4mm D) up to 4 days postpartum - this is quite common in women who are hypertensive, or late onset pre-eclampsia Possible correlation between an increased risk of thromboembolism with increased blood coagulability

Iron Most women regain normal serum iron levels by 2nd week postpartum, but it also depends on whether the mother had adequate iron stores to begin with. - women are at risk of postpartum anemia if they are iron deficient or experience hemorrhage - if some women took iron supplements because they have iron-deficiency anemia, they should continue to take it.

WBC Leukocytosis is quite common during the postpartum period (25,000 ~ 30,000). - although quite common, a 30% increase in WBC count over a 6-hour period would require further investigation of a possible infection.

Respiratory System Changes in respiratory system return quickly to pre-pregnant state and breathing becomes much easier (when clients begin to expel uterine contents).

Gastrointestinal System Abdominal muscles that were stretched during pregnancy remain relaxed. Clients may experience gaseous distention because of decreased gastrointestinal motility. - especially women who underwent a caesarean birth. Clients are given only clear fluids until bowel sounds are present, followed by solid foods. - heartburns that some clients may be experiencing should be resolved by approx. 6 weeks postpartum (decrease in pressure on esophageal sphincter and stomach). Some women may experience constipation during postpartum period - fear of pain (tearing of sutures) - dehydration - immotility - medications (iron preparations, codeine) - haemorrhoids Normal bowel movements should return to normal by 2 weeks postpartum

Integumentary System Stretch marks will begin to fade into a silvery white shade Abdominal muscle distention may continue to persist after birth, but with proper exercise and limited stress placed on the abs, they should heal and reapproximate by late postpartum period. Chloasma (dark spots that develop during pregnancy) usually fade within a few months following birth, when hormones levels return to normal levels (decreased melanin as a result). - extra sun exposure of contraceptives could lead to chloasma to return

Endocrine System Prolactin levels (from ant.pit) promotes milk secretion and will being to rise in the 5th week of pregnancy until birth. [estrogen and progesterone] levels will sharply decrease after the delivery of the placenta. - this decrease will allow the client to lactate as high levels of estrogen and progesterone inhibit secretion of milk Glucose level often fall after the delivery of the placenta and may require insulin medication - breastfeeding may contribute to hypoglycaemia Reproductive System Uterus The uterine cavity will begin to collapse following birth (newborn and placenta). As the uterus contract, it will begin to shrink. - involution: the processes of the uterus contracting and shrinking following birth (fig. 18.1), leading to a vaginal discharge known as lochia. Immediately after birth, the uterine fundus is palpable which is slightly below the level of the umbilicus (and it starts to descent into the pelvis after 2 days). Multiparas -given birth 2 or more times -vigorous, periodic contractions that cause cramps afterpains

Primiparas -first pregnancy; first child -tonic contractions (continuos) - some may experience afterpain -

Some women may feel afterpains during breastfeeding, because it stimulates the release of oxytocin from the posterior pit. gland

Lochia also known as the vaginal discharge during postpartum. Lochia is the superficial layer that gets sloughed off, which contain blood, mucous, placental tissue, epithelial cells, bacteria. It continues 4-6 weeks after childbirth. Its progressiveness may increase while breastfeeding due to the secretion of oxytocin in the process, stimulating uterine contraction. Lochia Serosa Days 4-5 -paler in red (less blood) and thinner in size Lochia Alba Day 10 -white/yellowish white with increased WBC, fats, cholesterol, and less fluid content

Lochia Rubra days 3-4 -dark red due to RBC

- if involution is prolonged or arrested, the site may not heal properly leading to postpartum hemorrhage or subinvolution, because the uterus fails to contract effectively - irregular or excessive bleeding

Cervix -

Subinvolution may also lead to what s known as the boggy uterus.

Women who experienced precipitous labour (sudden + dramatic) or with an instrument-assisted birth are at greater risk for cervical lacerations. Following birth, the cervix will widen compared to before and it will not return to its original state.

Ovaries Vagina Breasts Recall that prolactin gets secreted when there s a decrease in progesterone and estrogen, which stimulates the posterior pituitary. Postpartum changes with regards to changes in the breasts will depend on the client s decision to breastfeed her child. - repeated suckling will stimulate the release of prolactin, affecting the duration of lactation. - [prolactin] are high for the P10, slowly declining over the next 6 months. Faster and full emptying of the breasts will result in quicker milk synthesis with higher fat contents. - if however, the client does not wish to breastfeed, she may experience discomfort, leakage and engorgement (P3-5). Following birth, the vaginal walls and the vagina itself may appear smooth yet bruised early on during the postpartum period Reguae (series of ridges as a result of folding) may appear 3weeks postpartum. Menstruation usually returns approximately 6-10 weeks postpartum (nonlactating clients) - 8 weeks 18 months; lactating and breastfeeding clients Gonadotropin activities are minimal for the first several weeks postpartum

Urinary System Diuresis occurs between P2-P5, and often the bladder has an increased capacity and decreased sensation to fluid pressure. This may possibly lead to urinary retention and distention. - similar symptoms may be due to the use of anaesthesia during labour and birth Episiotomy: surgically planned incision on the perineum and posterior vaginal wall during 2nd stage of labour. The incision may be performed midline or at an angle w.r.t. the midline under local anaesthesia, and is sutured after delivery. - clients who underwent an episiotomy may have impaired muscle function around the urethra

Family centred maternity and newborn care This mode provides the mother and her significant others with time to interact with the infant. It s also a period where she is becoming attuned to her schedules and habits. Mothers and infants are cared for as a unit and are only separated if it is absolutely necessary. 2 types of models of care for labour through postpartum: LDRP (labour, delivery, recovery, postpartum) - Client remains in the same room throughout all 4 phases Second model Room 1 labour, childbirth, recovery Room 2 postpartum stay (or diff. unit)

Maternal assessment 4th stage of labour We need to conduct a focused assessment from the delivery of the placenta until 1 hour after birth

Vital Signs (table 18.1) Pulse and BP require an assessment every 15 min / hr following the delivery of the placenta Temperature should be assessed at least once in this first hour - we may find that the client may exhibit signs as if they were cold (teeth chattering and shaking), but this response is normal due to stress of labour and birth. - we should provide our clients a warmed blanket to provide comfort Clients who underwent a caesarean birth with anaesthesia should have her vital signs taken with an evaluation of her respiratory rate BUBBLES Ongoing assessment postpartum (table 18.2) Vital Signs Vital signs are crucial and must be performed for the first 24hr postpartum because clients are at greatest risk for hemorrhage - ex: vital signs, 30m/hr. every 4-6 hrs for the remaining 24 hrs. Temperature; every 4-6hrs postpartum. It may rise minimally in the first 24hrs due to dehydration that is accompanied with prolonged labour. * the client is to report any elevation in her temperature if above 38oC, when she is at home. This may indicate possible postpartum infections, especially within the first 10 days.

Breasts Assess for symmetry, consistency, and lumps. Breastfeeding clients: the breasts are soft for about the first 48-72 hrs. After this, milk production starts and beings to fill the breasts. They become more full and firmer. We ll also see veins that become more prominent, while some clients may feel engorgement in their breast and nipples. - incorrect positioning of the infant s mouth to the nipple may result in redness, bruising, or cracking of the area around the nipple. formula feeding: assess nipples for any discharge and breasts for lumps or hardness. The client may experience some sense of fullness and leakiness P1-P4.

Uterus Assess fundal height and tone by checking the position of the fundus in relation to the umbilicus - by 12 hours postpartum, the fundus should be around the level of the umbilicus and decreases by 1 fingerbreadth / day - tell the client to void before palpating the fundus

Bladder The bladder should be assessed for the amount, voiding frequency, and any difficulties initating or emptying. Some women experience problems with retention, either the inability to void at all or retaining some residual urine

Bowel Function Auscultate the client s abdomen for any bowel sounds, especially clients who underwent a caesarean birth. Abdominal contents may cause an increase in the potential for an ileus (obstruction in the small intestines). Ask the client whether she had a bowel movement or any complications associated with it, while listening in all 4 abdominal quadrants. It s important to let the client know that any concerns or fears associated with the discomfort or pain of bowel movements may lead to further complications of elimination retaining feces will promote harder feces that are more difficult to expel.

Lochia Important qualities to assess are: - colour (rubra serosa alba) via perineal pads as an example - odour - amount - clots (presence/absence) Ask the client to refrain from discarding the pad in the garbage and to leave in the bathroom for further assessment, or ask her to describe her flow. During the client s first hour postpartum, she should not saturate more than 2 pads. * it s important to look for clots (size + consistency). Clots are usually easily separated using gloved hands or tongue depressors. Materials that are difficult to separate is likely the presence of tissue. * if we find tissues in the pad, it should be sent to the lab for histologic examinations

Perineum Episiotomy Midline: ask client to lie on the side that has the incision. RML right side, LML left side. Laceration ask client to assume a sidelying position on bed. Intact perineum assess for edema and bruising, associated with prolonged pushing. Usage of ice packs are most effective in reducing edemas with a barrier (no direct skin-skin contact). Warmth would be better after 24hr, like a sitz bath. Lift the client s upper buttock cheek for adequate light and visualization REEDA (redness, edema, ecchymosis, discharge, approximation). * also check that the sutures are intact

GTPAL Gravida is the number of times you have been pregnant, Term is the number of birthsborn full term, preterm is the number of births before 37 weeks, abortions refers to the number of elective or spontaneous abortions (before 20 weeks) and living is the number of children that are currently alive. You might see something like G2P1 21001 That means gravida 2 para 1 (para meaning the number of times the woman gave birth) and the 21001 is the GTPAL. In this scenario, the woman has been pregnant 2 times, gave birth once, at term, had no preterm babies, no abortions, and one living child.