Exercises Progression after Vaginal & Cesarean Deliveries You may add on to the following exercises listed below

as tolerated. Be sure to check with your doctor before starting more vigorous exercises. Pelvic Tilt: While lying on your back with your knees bent, tilt your pelvis backward as you tighten your abs and exhale. Try to bring your belly button to your backbone as you push your low back into the mattress/floor. Hold for 5 seconds, inhale, and relax. Stretch out the kinks: Lie on your back with arms and legs out straight, palms up. Bend at the ankles so toes are aiming for the ceiling, tighten thigh muscles and push knees into the bed. Pull your abdominal muscles in and flatten your back. Squeeze your shoulder blades together and elongate your neck. Press your hands back into the bed and hold this for a few seconds, then relax. This allows your muscles to contract isometrically (without changing length), which is safe on the body and provides an easy readjustment to normal posture after birth. Active posture check: Standing - tuck your chin in to elongate the neck, pull your shoulders down and back, tighten your abdominal muscles while pulling your belly into your backbone, tighten your pelvic floor, keep knees soft, and increase the arch in your foot. Bridges: Lying on your back with knees bent, contract your abdominal, buttock, and pelvic floor muscles, and raise hips up off the floor. Hold for 5 seconds and relax down slowly. The farther your feet are from your buttocks the more challenging it will be. Bridging can also be progressed by lifting one leg while up in bridge position - but you must be able to keep hips level to do this. Heel Sliding: Lying on your back, tighten your abdominal muscles and do a pelvic tilt. Slowly slide out one leg at a time while trying to maintain your pelvic tilt. You can progress to sliding both legs out together as long as you can keep the pelvic tilt and not allow the back to arch. Always bring legs back one at a time. Arm exercises: Use a light weight (typically three to five pound dumbbells) for lateral raises, bicep curls, triceps exercises, and push up on your knees or against the wall. You can find several demonstrations of these exercises here. Abdominal Exercises It is helpful to check for diastasis recti (a separation in the connective tissue between the rectus abdominus abdominal muscles) before beginning any abdominal exercises. Click here for detailed instructions and a visual of this test. A diastasis recti is a normal response of your body to make room for a growing baby, and can take up to a year to return to pre-pregnancy width. In addition, current research

on diastasis recti has suggested that the degree of separation does not correlate with abdominal protrusion (some women with a wide diastasis had very little abdominal wall protrusion postpartum, whereas others with a small diastasis recti width had greater abdominal wall protrusion). It is helpful to determine how wide your diastasis is at the start of your exercise program so you can monitor your progress. If your width is more than 2 1/2 fingers, start with the simplest exercises first, and slowly work up to more difficult levels as you gain strength.

BreastFeeding
Research has shown that breastfeeding suppresses fertility. Yet many women know someone who became pregnant when breastfeeding -- or became pregnant themselves during breastfeeding. Service providers are sometimes reluctant to allow women to rely on breastfeeding for pregnancy protection, and have in certain settings discouraged breastfeeding in favor of initiating a modern method of contraception. In 1988, a group of scientists met in Bellagio, Italy to define a set of guidelines that a woman could use to predict her return to fertility during breastfeeding. The scientists reviewed data from studies regarding return to fertility and determined that breastfeeding can provide up to 98% effective contraception if three criteria are met:

The mother has not experienced the return of her menstrual periods (bleeding up to the 56th postpartum day is considered part of the postpartum recovery process and is not counted as menstrual bleeding); The mother is fully or nearly fully breastfeeding; and The baby is less than six months old.

These guidelines later defined a new method of family planning called the Lactational Amenorrhea Method or LAM. Clinical trials have shown that LAM is at least as effective as the Bellagio scientists predicted it would be. Fewer than 1% of LAM users in three clinical trials became pregnant when all the three LAM criteria were met.

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Of the three LAM criteria, the return of menses is the most important indicator of fertility. The studies conducted by Family Health International in Pakistan and the Philippines have shown that pregnancy is rare even beyond six months and the end of full breastfeeding among women who do not experience vaginal bleeding. Only 1.1% of the women in Pakistan and 2.6% of the women in the Philippines conceived during 12 months of lactational amenorrhea. The pattern of breastfeeding exerts a strong effect on the resumption of menstruation and fertility. However, defining what is meant by "full" breastfeeding can be difficult. The following definitions are currently being used by family planning counselors who are teaching LAM:

does not resemble her regular menses.

If she starts to give the infant any food or drink on a regular basis or experiences disruptions in her breastfeeding routine, such as returning to work or ceasing to breastfeed at night, she is no longer protected from pregnancy. Once the infant is older than six months, the chance of becoming pregnant, even before her periods return, is increased.

Full breastfeeding can be exclusive (no other liquid or solid is given to the infant) or almost exclusive (vitamins, water, juice or ritualistic feeds are given infrequently to the infant). Nearly full breastfeeding means that the vast majority of feeds (at least 85%) are breastfeeds. There can be some supplementation with another liquid or food, but supplementation never replaces or delays a breastfeed.

If any of these changes occur, a woman should choose another contraceptive method if she wants to be protected from pregnancy. There is no need to discontinue breastfeeding, however. Family planning methods that are recommended for breastfeeding women include barrier methods, IUDs, male or female sterilization, and hormonal methods that contain only progestin, such as progestin-only pills ("minipills"), injectables and Norplant. Contraceptive pills containing both estrogen and progestin (the most common kind of birth control pill) have been associated with reduced breastmilk production and should be considered a last-choice method. Optimal Breastfeeding Behaviors for Child Health and Child Spacing

A mother can maximize the contraceptive effect she receives from breastfeeding by following the guidelines for optimal breastfeeding behaviors. The Lactational Amenorrhea Method is, however, a temporary method of family planning. To continue effective pregnancy protection, a woman who uses LAM must be ready to switch to another family planning method when any one of the LAM criteria changes. She should be made aware that:

Begin breastfeeding as soon as possible after the child is born. Breastfeed exclusively for the first six months. After the first six months, when supplemental foods are introduced, breastfeeding should precede supplemental feedings. Breastfeed frequently, whenever the infant is hungry, day and night. Continue breastfeeding even if the mother or the baby become ill. Avoid using a bottle, pacifiers or other artificial nipples. Continue to breastfeed up to two years and beyond. Eat and drink sufficient quantities to satisfy the mother's hunger.

Once her periods return, breastfeeding will no longer protect her from a new pregnancy. She should consider any vaginal bleeding (after the 56th postpartum day) to be a warning that her fertility is returning, even if that bleeding

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Conclusions Breastfeeding is best for both mothers and babies and should be encouraged. Breastfeeding can also provide natural, safe, effective contraceptive protection, if certain conditions are met, for up to six months postpartum. Women who are interested in using the natural protection of breastfeeding should have access to information about LAM and about other available family planning methods suitable for breastfeeding women. Source 1. Labbok M, Cooney K, Coly S. Guidelines: Breastfeeding, Family Planning and the Lactational Amenorrhea MethodLAM. Washington, DC: Institute for Reproductive Health. 1994.

Signs of infection During the healing process, it's normal to see a little crust or dried blood near the stump. Contact your baby's doctor if your baby develops a fever or if the umbilical area:

Appears red and swollen around the cord Continues to bleed Oozes yellowish pus Produces a foul-smelling discharge If your baby has an umbilical cord infection, prompt treatment can stop the infection from spreading.

Taking care of the stump LOCHIA Your baby's umbilical cord stump will change from yellowish green to brown to black as it dries out and eventually falls off usually within about two weeks after birth. In the meantime, treat the area gently: In the field of obstetrics, lochia is the vaginal discharge for the first fortnight of puerperium (after birth), containing blood, mucus, and placental tissue. Lochia discharge typically continues for 4 to 6 weeks after childbirth.[1] It progresses through three stages:[2]

Keep the stump clean. Parents were once instructed to swab the stump with rubbing alcohol after every diaper change. Researchers now say the stump might heal faster if left alone. If the stump becomes dirty or sticky, clean it with plain water then dry it by holding a clean, absorbent cloth around the stump or fanning it with a piece of paper. Keep the stump dry. Expose the stump to air to help dry out the base. Keep the front of your baby's diaper folded down to avoid covering the stump. In warm weather, dress your baby in a diaper and Tshirt to improve air circulation. Stick with sponge baths. Sponge baths might be most practical during the healing process. When the stump falls off, you can bathe your baby in a baby tub or sink. Let the stump fall off on its own. Resist the temptation to pull off the stump yourself, even if it's hanging on by only a thread.

Lochia rubra (or cruenta) is the first discharge, red in color because of the large amount of blood it contains. It typically lasts no longer than 3 to 5 days after birth. Lochia serosa is the term for lochia that has thinned and turned brownish or pink in color. It contains serous exudate, erythrocytes, leukocytes, and cervical mucus. This stage continues until around the tenth day after delivery. Lochia serosa which persists to some weeks after birth can indicate late postpartum haemorrhaging, and should be reported to a physician. Lochia alba (or purulenta) is the name for lochia once it has turned whitish or yellowishwhite. It typically lasts from the second through the third to sixth weeks after delivery. It contains fewerred blood cells and is mainly made up of leukocytes, epithelial cells, cholesterol, fat, and mucus. Continuation

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beyond a few weeks can indicate a genital lesion, which should be reported to a physician. In general, lochia has an odor similar to that of normal menstrual fluid. Any offensive odor indicates contamination by saprophytic organisms and should be reported to a healthcare provider. Lochia that is retained within the uterus is known as lochiostasis[3] or lochioschesis, and can result in lochiometra[4] (distention of the uterus - pushing it out of shape). Lochiorrhea[5] describes an excessive flow of lochia and can indicate infection.

Endocrine System With the sharp decrease of estrogen and progesterone levels following delivery of the placenta, lactation begins and menstruation returns. Estrogen is a prolactin-inhibiting hormone. When clients choose to bottlefeed, prolactin levels diminish and estrogen levels begin to rise. Menstruation returns in approximately 6 to 8 weeks for these clients. However, ovulation can return within 4 weeks. When clients breastfeed, prolactin levels increase as breastfeeding continues. Therefore, menstruation does not return until 12 weeks or later. Because ovulation can return prior to menses, it is important for healthcare providers to discuss family planning with clients during the early postpartum period in order to prevent undesired pregnancies. Gastrointestinal System Clients are generally hungry and thirsty after delivery due to the amount of energy expended during labor. Food and fluid intake is usually restricted during labor, and many clients may not have eaten for a number of hours prior to delivery. The diaphoresis that occurs during the postpartum period may also lead to increased thirst. It is important for nurses to provide nourishment and hydration upon delivery. Many clients experience constipation from the lack of fluid and food intake during labor. Furthermore, bowel tone is sluggish as a result of elevated progesterone levels. Often clients are hesitant to have a bowel movement in the postpartum period due to pain in the perineal area resulting from an episiotomy, lacerations, or hemorrhoids. Some clients are also fearful that they will rip their stitches should they have a bowel movement. Healthcare providers may prescribe stool softeners and/or laxatives to treat constipation and provide perineal comfort during defecation.

BREASTS After delivery there is a significant decrease in estrogen and progesterone levels. Before milk production begins, the breasts secrete colostrum, a thin, yellowish fluid that helps maintain the blood glucose level in the breastfeeding infant. Nipple stimulation by the infant causes the release of the hormone oxytocin from the posterior pituitary gland, which triggers the release of the hormone prolactin from the anterior pituitary. Prolactin initiates milk production, and the breasts become full (engorged), as well as warm and tender, between postpartum days 3 and 4. Clients often refer to this as having their milk come in. There may be a slight elevation in body temperature during this time. Clients who choose not to breastfeed will also experience their milk coming in; however, lactation can be suppressed through the use of a well-fitted bra. Nonbreastfeeding clients should also avoid any type of nipple stimulation or heat to the breasts, such as warm or hot showers in which the water is allowed to run continuously over the breasts. These clients can use ice packs or cool cabbage leaves to ease breast discomfort until milk production ceases. It generally takes 5 to 7 days for the breasts to stop producing milk. Healthcare providers may consider prescribing mild analgesics if a client has significant discomfort.

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Urinary System The bladder, urethra, and urinary meatus are edematous after delivery as a result of the fetal head passing through the birth canal. Bladder tone is diminished, and many clients are unable to feel the need to void, despite the rapid diuresis that occurs following delivery. In this situation, the bladder can become distended and displace the uterus upward and to the side, which prevents the uterine muscles from contracting properly and can lead to a postpartum hemorrhage. Therefore, healthcare providers must carefully monitor bladder distention, the firmness of the fundus, and bleeding during the postpartum period. Urinary retention as a result of decreased bladder tone and emptying can lead to urinary tract infections (UTIs). It is imperative that nurses monitor postpartum clients for signs of urinary tract infection, including tenderness over the costovertebral angle, fever, urinary frequency and/or urgency, and difficult or painful urination. According to Varney and colleagues (2004), 40% of postpartum clients have protein in their urine that can be noted up to the second postpartum day. Proteinuria during this time is considered benign unless there are signs of a urinary tract infection or preeclampsia.

1. Early labor Your cervix opens to 4 centimeters. You will probably spend most of early labor at home. Try to keep doing your usual activities. Relax, rest, drink clear fluids, eat light meals if you want to, and keep track of your contractions. Contractions may go away if you change activity, but over time they'll get stronger. When you notice a clear change in how frequent, how strong, and how long your contractions are, and when you can no longer talk during a contraction, you are probably moving into active labor. 2. Active labor Your cervix opens from 4 to 7 centimeters. This is when you should head to the hospital. When you have contractions every 3 to 4 minutes and they each last about 60 seconds, it often means that your cervix is opening faster (about 1 centimeter per hour). You may not want to talk as you become more involved in dealing with your contractions. As your labor progresses, your bag of waters may break, causing a gush of fluid. After the bag of waters breaks, you can expect your contractions to speed up. Slow, easy breathing is usually helpful at this time. Focusing on positive, relaxing images or music may also be helpful. Changing positions, massage, and hot or cold compresses can help you feel better. Walking, standing, or sitting upright will help labor progress. Relaxing during and between contractions saves your energy and helps the cervix to open. Many hospitals have whirlpool or soaking tubs that may help you relax and ease discomfort. 3. Transition to second stage Your cervix opens from 7 to 10 centimeters. For most women, this is the hardest or most painful part of labor. This is when your cervix opens to its fullest. Contractions last about 60 to 90 seconds and come every 2 to 3 minutes. There is very little time to rest and you may feel overwhelmed by the strength of the contractions. You may feel tired, frustrated, or irritated, and may not want to be touched. You may feel sweaty, sick to your stomach, shaky, hot, or cold. Although you may find slow, easy breathing to be most effective throughout labor, you may also find an uneven breathing pattern most helpful at this time. Second Stage of Labor Your baby moves through the birth canal The second stage of labor begins when the cervix is completely dilated (open), and ends with the birth of your baby. Contractions push the baby down the birth canal, and you may feel intense pressure, similar to an urge to have a bowel movement. Your health care provider may ask you to push with each contraction. The contractions continue to be

First Stage of Labor Thinning (effacement) and opening (dilation) of the cervix During the first stage of labor, contractions help your cervix to thin and begin to open. This is called effacement and dilation. As your cervix dilates, your health care provider will measure the opening in centimeters. One centimeter is a little less than half an inch. During this stage, your cervix will widen to about 10 centimeters. This first stage of labor usually lasts about 12 to 13 hours for a first baby, and 7 to 8 hours for a second child. The first stage of labor has three parts:

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strong, but they may spread out a bit and give you time to rest. The length of the second stage depends on whether or not you've given birth before and how many times, and the position and size of the baby. The intensity at the end of the first stage of labor will continue in this pushing phase. You may be irritable during a contraction and alternate between wanting to be touched and talked to, and wanting to be left alone. It isn't unusual for a woman to grunt or moan when the contractions reach their peak. Third Stage of Labor Afterbirth After the birth of your baby, your uterus continues to contract to push out the placenta (afterbirth). The placenta usually delivers about 5 to 15 minutes after the baby arrives. Fourth Stage of Labor Recovery Your baby is born, the placenta has delivered, and you and your partner will probably feel joy, relief, and fatigue. Most babies are ready to nurse within a short period after birth. Others wait a little longer. If you are planning to breastfeed, we strongly encourage you to try to nurse as soon as possible after your baby is born. Nursing right after birth will help your uterus to contract and will decrease the amount of bleeding.

1. 2. 3. 4. 5. 6.

monitor V/S and FHR every 15 mins bed rest for ruptured membrane empty the bladder pain relief teach breathing techniques maintain safety

2. Second Stage of Labor - from full dilation to delivery of the fetus (30-60 mins for primigravida and 20 mins for multipara)

Phase One - station is 0 to +2; contraction is 2 to 3 mins apart Phase Two - station is +2 to +4; contraction is 2 to 2.5 mins apart with urgency to bear down Phase Three - station is +4 to birth; contraction is 1 to 2 mins apart;fetal head visible, increased urgency to bear down Nursing Care for Second Stage of Labor

1.

transfer to delivery room for 8-9 cm dilation for multigravidas and full dilation for primiparas

2. 3. 4. 5.

monitor V/S and FHR prepare perineal area encourage pushing with contractions immediate newborn care

The Stages of Labor are: 1. First Stage - onset of regular contraction to full dilation

3. Third Stage of Labor - from delivery of infant to delivery of placenta

5 - 30 mins sudden gush of blood lengthening of the cord rising of the fundus globular uterus

Phase

One

(LATENT) -

dilatation

is 0

cm; duration is 10 - 30 sec; interval is 5 - 30 mins; intensity ismild to moderate

Phase

Two

(ACTIVE) -

dilatation

is 4

cm; duration is 30 - 40 sec; interval is 3 -5 mins; intensity ismoderate to strong

Phase Three (TRANSITION) - dilatation is 8 - 10 cm; duration is 45 - 90 sec; interval is 2 - 3 mins; intensity is strong Nursing Care for First Stage of Labor

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Nursing Care for Third Stage of Labor

1. 2. 3. 4. 5. 6. 7.

assess for placental separation inspection of placenta monitor V/S initiate breastfeeding administer oxytoxin and antilactation agents as ordered sending cord blood to laboratory if mother is O-positive or Rh-negative allow bonding

4. Fourth Stage of Labor - time from delivery of placenta to homeostasis (first 4 hours after delivery of the placenta) Nursing Care for Fourth Stage of Labor

1. 2. 3. 4. 5. 6.

monitor V/S every 15 mins take fundal height, position and consistency assess for lochia check perineum perform perineal care from front to back post partum care

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