Postpartum newborn

• Involution


  Changes that the reproductive organs, particularly the uterus, undergo after birth to return them to their prepregnancy size and condition
• Subinvolution


  The failure of the uterus to return to the prepregnant state after 6 weeks
• Involution


  1. Descent of the uterine fundus

  2. The uterine fundus (the upper portion of the body of the uterus) descends at a predictable rate as the muscle cells contract to control bleeding at the placental insertion site and as the size of each muscle cell decreases

  3. Immediately after the placenta is expelled, the uterine fundus can be felt midline, at or below the level of the umbilicus, as a firm mass

  4. After 24 hours the fundus begins to descent about 1 cm (1 finger's width) each day

  5. By 10 days postpartum, it should no longer be palpable
• A full bladder


  Interferes with uterine contraction, because it pushes the fundus up and causes it to deviate to one side, usually to the right side
• Lochia


  Vaginal discharge after delivery, composed of endometrial tissue, blood, and lymph
• Types of lochia


  • Lochia rubra (red, composed mostly of blood, lasts for about 3 days after birth)
  • Lochia serosa (pinkish, lasts from about the 3rd through the 10th day after birth)
  • Lochia alba (mostly mucus, clear and colorless or white, lasts from the 10th day through the 21st day after birth)
• Lochia has a characteristic fleshy menstrual odor; it should not have a foul odor
• Boggy uterus


  A poorly contracted (soft or boggy) uterus
• A boggy uterus should be massaged until firm to prevent hemorrhage
• The perineum is often edematous, tender and bruised
• An episiotomy (incision to enlarge the vaginal opening) may have been performed, or a perineal laceration may have occurred
• BUBBLE - Postpartum assessment

  • Breast (assess for red tender areas, education about breastfeeding and or pumping every 2-3 hours, if mom is not breastfeeding, education about how to stop milk production-tight fitting bra, standing with back to the shower water, cabbage leaves)
  • Uterus (check the fundus, is it boggy? If it is, massage and pay close attention as this can cause maternal hemorrhage. Uterus should go down 1 fingerbreath per day after delivery until you can no longer feel it by day 10)
  • Bladder (is she voiding? Is she having burning, irritation, redness. Is she emptying her bladder all the way? This can also affect the way the uterus feels and will shift fundus to the right)
  • Bowel (are you passing gas? Educate mom to eat more fiber, ambulate (walk around), and drink more water)
  • Lochia (discharge - Lochia Rubra: bright red blood til day 3, Lochia Serosa: pink discharge day 4-10, Lochia Alba: white discharge day 10-21, report bleeding that is soaking more than 1 pad an hour)
  • Episiotomy (check the site to make sure its healing well, document REEDA)
  • Emotions (how is she feeling? Educate on depression and what that looks like and REPORT to doctor)
  • Clonus (check for clonus! She can still be pre-eclamptic after birth!)
  • Deep tendon reflex (CHECK! On both legs)
• Danger signs for the mother to report

  • Fever higher than 100.4 ⸰F
  • Persistent lochia rubra or lochia that has a foul odor
  • Bright red bleeding, especially if the bleeding has changed to serosa or alba
  • Prolonged afterpains, pelvic or abdominal pain, or a constant backache
  • Signs of a urinary tract infection
  • Pain, redness, or tenderness in the calf
  • Localized breast tenderness or redness
  • Discharge, pain, redness, or separation of any suture line (cesarean, perineal laceration or episiotomy)
  • Prolonged and pervasive feelings of depression or being let down; generally not enjoying life
• Postpartum Blues


  Mom may feel let down, still finds joy, self limiting
• Postpartum Depression


  Persistent mood of unhappiness, needs treatment
• Postpartum Psychosis


  Impaired sense of reality, can be fatal for both mom and infant, emergent treatment needed
• Postpartum hemorrhage


  Blood loss greater than 500 mL after vaginal birth or 1000 mL after cesarean birth, resulting in signs or symptoms of hypovolemia
• A woman can have a postpartum hemorrhage even weeks after she has delivered her baby
• Causes of early (primary) postpartum hemorrhage

  • Uterine Atony (the most common cause)
  • Lacerations (tears) of the reproductive tract
  • Hematomas in the reproductive tract
• A full bladder interferes with the ability of the uterus to contract and, if not corrected, eventually leads to uterine atony
• The nurse should catheterize the woman if she cannot urinate on the toilet or in a bedpan
• Causes of late postpartum hemorrhage


  • Retention of placental fragments
  • Subinvolution of the uterus
• Estimation of blood loss

  To best determine blood loss, weigh perineal pads before and after applying them: 1 g in weight equals about 1 mL in volume of blood lost
• Medications that may be given to stimulate uterine contraction

  • Oxytocin (Pitocin), often routinely given in an IV infusion after birth
  • Methylergonovine (Methergine), given intramuscularly or orally
• A newborn suckling at the breast has a similar effect, because natural oxytocin release stimulates contractions
• REEDA - Signs to assess for normal perineal healing


  • Redness (redness without excessive tenderness is probably normal inflammation associated with healing, but pain with redness is more likely to indicate infection)
  • Edema (mild edema is common, but severe edema interferes with healing)
  • Ecchymosis (bruising) (a few small superficial bruises are common)
  • Discharge (no discharge from the perineal suture line should be present)
  • Approximation (the suture line should not be separated)
• A cold baby is a dead baby
• Mechanisms of heat loss and related interventions

  1. Evaporation: dry newborn quickly, dry and cover head of newborn

  2. Conduction: prewarm radiant warmer and stethoscope before use, place scale paper, and place warm blanket on other surfaces

  3. Convection: place crib away from windows and vents

  4. Radiation: place crib away from cold walls, wrap newborn warmly
• Newborn vital signs


  • Respiratory rate 30 to 60 breaths per minute
  • Heart rate 110 to 160 beats per minute
  • Temp 97.7 to 99F (36.5-37.2C)
• Vitamin K


  Newborns need Vitamin K to assist in blood clotting, one single dose of vitamin K (AquaMEPHYTON) is injected into the vastus lateralis muscle (thigh) before the infant leaves the delivery room, usually at one hour of age
• Hypoglycemia


  A blood glucose lower than 45 mg/dL 2 hours after birth
• Signs of hypoglycemia in the newborn

  • Jitteriness
  • Poor muscle tone
  • Respiratory difficulty
  • Low temperature (which can also cause hypoglycemia)
  • Poor suck
  • High-pitched cry
  • Lethargy
  • Seizures
  • Sweating
• Signs of respiratory distress in the infant

  • Persistent cyanosis (other than hands and feet)
  • Grunting respirations
  • Flaring of the nostrils
  • Retractions under the sternum or between the ribs
  • Sustained respiratory rate higher than 60 breaths/min
  • Sustained heart rate greater than 160 beats/min or less than 110 beats/min
  • Temp below 97.1F or above 99.8F
• Head lag


  When the infant is lifted from the bed, the head will fall back, because the newborn cannot maintain neutral position of the head
• Moro reflex


  If the crib is jarred, infants draw their legs up and the arms fan out and then come toward midline in an embrace position
• Rooting reflex


  Causes the infant to turn in the direction of anything that touches the cheek
• Signs of respiratory distress in the infant

  • Persistent cyanosis (other than hands and feet)
  • Grunting respirations
  • Flaring of the nostrils
  • Retractions under the sternum or between the ribs
  • Sustained respiratory rate higher than 60 breaths/min
  • Sustained heart rate greater than 160 beats/min or less than 110 beats/min
  • Temp below 97.1F or above 99.8F
• Rooting reflex


  Causes the infant to turn in the direction of anything that touches the cheek, in anticipation of food (seen within 24 hours of birth)
• Tonic neck reflex


  A postural reflex that is sometimes assumed by sleeping infants. The head is turned to one side, the arm and leg are extended on the same side, and the opposite arm and leg are flexed in a "fencing" position
• Palmar grasp reflex


  When the examiner places an object in the hand of the newborn, he/she will grasp it tightly