Post C-Section

Clinical Practice Guideline:
POSTPARTUM FOLLOWING CESAREAN DELIVERY

Type: Medical Diagnosis/Treatment/Procedure
Target Population: Adolescent/Adult
PROFESSIONAL PROCESS
GOALS/OUTCOMES:
A.
B.
Signs and symptoms of listed potential problems will be absent or manageable.

1. Bleeding/Hemorrhage
2. Acute Pain
3. Infection leading to Sepsis
4. Embolism leading to Tissue Ischemia/Infarction
5. Voiding Dysfunction
6. Postoperative Ileus
7. Constipation
8. Postpartum Thyroid Dysfunction
9. Postpartum Mood and Anxiety Disorders
10. Situational Response
Patient/family/significant other (S.O.)/caregiver will verbalize and/or demonstrate an understanding of teaching/learning goals listed below: (Refer to
Education Outcome Record)
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Physiology of returning reproductive status, plan for contraception and resuming normal sexual activity.
Personal hygiene recommendations (e.g., breasts, episiotomy/incision care, lochia).
Expected weight loss pattern and recommended nutritional needs during the lactation and postpartum periods.
Breastfeeding techniques and normal course of lactation.
Potential stressors, emotional responses and role changes as related to parenting, family relationships and depression/blues.
Potential problems: signs/symptoms, prevention, follow-up strategy.
Lifestyle alterations, present and future (e.g., physical activity, lifting, driving, sexuality, integration of parenting role, returning to
work).
General Goals (room/unit routine, pain, medication, diagnostic tests/procedures, dietary modifications, hygiene, infection
prevention, rehabilitation, medical equipment/supplies, tobacco cessation, resources for support).
ASSESSMENT/INTERVENTIONS/CLINICAL REASONING/DECISION-MAKING:
A. Assess and document readiness and ability to learn, learning needs and preferences. (Refer to Pre-Teaching Assessment on Education
Outcome Record)
B. Collaborate with interdisciplinary resources related to significant changes in patient status and for the continuum of care (e.g.,
Physician, Nursing, Social Work/Services, Dietitian/Nutrition Services, Pastoral Care, Pharmacy, Respiratory Therapy, Occupational
Therapy, Physical Therapy, Child Life, Speech Language Pathology, Home Care Services).
C. Assess, Monitor, and Detect:
The impact of other pre-existing health problems.
The impact on psychosocial, cultural, sexual, developmental and spiritual well-being.
The impact of common diagnostic studies/laboratory values [e.g., CBC with differential, urinalysis, urine culture and sensitivity, blood cultures,
thyroid studies, D-dimer, positive ventilation perfusion scan (VQ Scan), coagulation studies, venous ultrasound, pulmonary angiography,
positive helical computer tomography scan, Bladder Scan, echocardiogram (ECG), breast ultrasound, chest x-ray (CXR), drug screen].
Baseline vital signs and trends.
Risks to safety.
D. Assess, Monitor, Detect, Prevent and/or Modify the listed potential problems and implement interventions as appropriate:
Bleeding/Hemorrhage AEB (As Evidenced By):
General signs/symptoms: painful/painless bright red vaginal bleeding; symptoms of hypovolemic shock when blood loss is substantial
(approximately 10 percent or more of blood volume) [e.g., increased heart rate (HR) and respiratory rate (RR), cool clammy skin,
diaphoresis, change in mental status, restlessness, agitation, confusion, decreased BP, shortness of breath, decreased urinary output,
decreased pulmonary artery wedge pressure, decreased central venous pressure, decreased cardiac output/cardiac index]; decrease in
hemoglobin, hematocrit, platelets; decrease percent arterial oxygen (O2) saturation hemoglobin (SaO2); change in prothrombin time/partial
thromboplastin time (PTT); fatigue
Coagulation defects/Disseminated intravascular coagulation/Consumptive coagulopathy (DIC): bleeding/oozing from injection and
incision sites; rapid, weak, thready pulse; sudden drop in BP; urine output less than 30 mL/hour; pale, cool clammy skin; change in mental
status; epistaxis; bleeding gums; purpura and petechiae; increased pro-time/PTT; decreased fibrinogen; decreased platelets; increased
fibrin split products; decrease in D-dimer
Retained placenta: failure of placental delivery within 30 minutes after birth of baby; atypical uterine firmness or bogginess; bleeding.
Copyright 2010, CPM Resource Center, an Elsevier business. All rights reserved.
Postpartum C-Section; Spring release 2010
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14.
Abnormal placental implantation/placenta accreta: entire placenta is adherent to myometrium, excessive bleeding during surgery
(100)
Hematoma: skin discoloration; tight, full-feeling and painful to touch (88); difficulty/inability to void; signs and symptoms of hypovolemia in
large hematomas (one or more liters of blood)
Uterine atony: failure of the uterus to contract following delivery (72); marked uterine hypotonia accompanied by blood loss (100)
Genital tract lacerations: firm uterine fundus accompanied by continuous/steady bleeding; complaints of severe pain (e.g., pelvic or
localized) (100)
Correlate blood loss, including amount lost in delivery and current bleeding [e.g., perineal pad counts/weight of pads or chux
(1 gram=1mL blood) and characteristics (e.g., color, odor, clots, rate of loss) to normal bleeding patterns, vital signs (VS), SaO2,
intake and output, skin color, laboratory values (e.g., type and cross, CBC, pro-time/PTT, fibrinogen), blood replacement therapy
and baseline assessment data. (100; 109) {Grade C}
Notify physician and request additional professional assistance. (100) {Grade C}
Anticipate need for O2 therapy. (100) {Grade C}
Ensure patency or establish IV access; anticipating the need for a second IV line. (5; 41; 100) {Grade C}
Anticipate use of oxytocin, methylergonovine or 15-methyl-prostaglandin-F2, prostaglandin E2, misoprostol. (50; 52; 100)
{Grade C}
Anticipate the need for type and cross match and blood replacement therapy. (100) {Grade C}
Evaluate firmness and position of uterus; massage or compress fundus until firm if uterus is soft and/or relaxed expelling blood
and clots. (5; 41; 56; 100) {Grade C}
Palpate bladder to assess for distension. (100) {Grade C}
Anticipate need for indwelling catheter insertion. Note: Urine output should be at least 30 mL/hour to ensure adequate renal
perfusion. (41; 100) {Grade C}
Position patient to maximize venous return; placing wedge beneath hip or elevating legs 20 to 30 degrees. (52; 100) {Grade C}
Anticipate use of uterine tamponade (e.g., uterine packing, tamponade-balloon) for uncontrolled bleeding; pay careful attention
to VS and laboratory values to minimize unrecognized continued bleeding. (50) {Grade C}
Anticipate emergency surgery (e.g., hysterectomy, artery ligation) with uncontrolled postpartum bleeding. (100) {Grade C}
Address concerns, provide education, offer reassurance and provide support for patient and family. (52) {Grade C}
Anticipate use of prenatal vitamin/mineral and additional iron supplement once patient is stable in order to restore red blood cell
mass. (56; 100) {Grade B}
Note: Due to the increased blood volume in pregnancy, signs and symptoms of hypovolemic shock may not appear until the
amount of blood loss is significant.
Acute Pain AEB: (29)

Patient may have nociceptive, neuropathic or a combination of both types of pain:
Nociceptive (somatic): recent onset; well-localized; sharp, pin-prick, aching, stabbing or throbbing
Nociceptive (visceral): poorly localized; diffuse with vague complaints such as generalized ache or pressure; may be referred to sites
remote from the primary injury. Autonomic symptoms include nausea/vomiting (N/V), hypotension, bradycardia, sweating.
Neuropathic: radiating or specific burning, electric-like, shooting, tingling or lancinating (stabbing, piercing) pain. Physical exam may
reveal allodynia (pain on light touch), hypoalgesia or hyperalgesia (relatively decreased or increased perception of noxious stimulus) or
hyperpathia (exaggerated pain response). Symptoms usually are experienced distal to the site of injury.
Breast engorgement: painful, warm breasts; feeling of fullness, tautness in breasts
Cracked/Sore nipples related to breastfeeding: nipple soreness; visible fissures or cracks in nipples; bleeding; blister formation
Uterine contractions ("after pain"): complaints of uterine cramping, especially during/after breastfeeding
Hemorrhoids: visualization of swollen, reddened mass in anorectal area; complaints of anal burning and/or itching
Incision: holding incisional site; discomfort with movement; swelling; redness; ecchymosis; drainage from site
15. Evaluate pain using identified tool/self-report description [e.g., onset, location, radiation frequency/duration, intensity/severity at
rest and with activity, aggravating/relieving factors (medications, positioning, treatment devices), exacerbation], physiologic and
behavioral indicators [e.g., moaning, rubbing a particular area, guarding, facial expression (brow lowering, orbital tightening,
levator contraction, eyelid closing), decreased attention span, agitation, inability to rest/sleep, inability to alleviate distress],
patients stated perception of pain tolerance and correlate to VS, type of procedure/ treatment/disease process, expected pain
progression, cultural factors that may influence pain perception and baseline assessment data. (13; 27; 29; 53; 60) {Grade B}
16. Correlate intensity of uterine contractions to voiding patterns, bladder status, breastfeeding schedule and activity tolerance.
(41; 100) {Grade C}
17. Correlate wound discomfort to activity patterns, positioning, appearance of incisional site, wound care techniques and baseline
assessment data. (100) {Grade C}
18. Establish with patient what level of discomfort is acceptable that will allow for maximal function with basic/instrumental activities
of daily living (BADL/IADL). (29; 60) {Grade B}
19. Mutually develop plan for pharmacologic/nonpharmacologic comfort measures as appropriate [e.g., medications (appropriate to
type of pain reported), procedures (neuraxial or sympathetic blocks), adjuvants such as complementary and alternative therapies
(massage, touch, back rub, counterpresure, movement and positioning, ice to incision first 24 hours, hydrotherapy, hypnosis,
acupuncture, music, relaxation and distraction), psychological interventions (behavioral therapy, biofeedback, cognitive
behavioral therapy, counseling, relaxation)]. (29; 60; 100) {Grade B}
20. Account for the possibility of acute pain in the presence of pre-existing chronic pain syndrome and adjust medications
appropriately (e.g., use patients prehospital basal rate plus adjustment for acute pain). Collaborate with patient on what has
worked best for her in the past. (29; 43) {Grade B}
21. Initiate pain management plan that includes scheduled around-the-clock pain medication dosing with PRN breakthrough
medications as prescribed if pain is present the majority of a 24-hour time span. (13; 29; 60) {Grade B}
22. Provide individualized pain management measures prior to procedure(s)/planned activities (e.g., turning, suctioning, wound
care/drain removal). (60; 96) {Grade B}
23. Anticipate need for management of drug-induced side effects. For opioids: N/V, constipation, itching, myoclonus and respiratory
depression. For nonsteroidal anti-inflammatory drugs (NSAIDs): dyspepsia, prolonged bleeding times, renal dysfunction, urinary
retention, hypertension. (13; 14; 29; 60) {Grade B}
24. Assist patient in proper breastfeeding techniques and hygiene (e.g., correct positioning and latch on; nipple/breast care
following feeding). (82) {Grade A}
25. Acknowledge the difficulties that may be involved in successful breastfeeding and facilitate referral to lactation consultants or
breastfeeding counselors. (4) {Grade A}
26. Encourage fluids and high-fiber foods to minimize constipation; promote use of warm or cold sitz baths and/or topical
anesthetics for hemorrhoid pain. (100) {Grade C}
Infection leading to Sepsis AEB:
Infection: fever; pain/tenderness; localized swelling, redness, heat; changed bowel/bladder function; delayed wound healing; purulent
drainage; abscess; positive cultures
Sepsis: fever or hypothermia; decreased BP; oliguria; increased HR; increased RR; decreased partial pressure of carbon dioxide (PCO2);
change in white blood cell count (WBCs); increased bands
Mastitis: pain in breast unilateral or bilateral; usually appears between the third and fourth week postpartum, warmth, redness and
swelling of breast tissue; localized tenderness, malaise; headache; fever; chills; history of recently missed feedings
Breast abscess: unresolved mastitis; fever and chills; tachycardia; palpable mass; localized tenderness
Urinary tract infection: may be asymptomatic (e.g., bacteriuria) or symptomatic (e.g., cystitis, acute pyelonephritis) with urinary
frequency, urgency, dysuria; complaints of suprapubic abdominal/flank pain; cloudy/bloody/foul smelling urine; hematuria, positive urine
cultures; increased WBC in urine; fever; chills; tachycardia; N/V
Endometritis: temperature elevation around the third postpartum day; tachycardia; malaise; lower abdominal pain or uterine tenderness
upon palpation; slight abdominal distension; foul-smelling lochia may or may not be present (present if organism is anaerobic)
Wound infection: wound erythema; swelling; tenderness and purulent discharge, localized pain, low grade temperature elevation (101
degrees Fahrenheit or 38.3 degrees Celsius) or spike in temperature to 104 degrees Fahrenheit or 40 degrees Celsius; chills; tachycardia
27. Correlate clinical status with age, VS, signs of local/systemic infection, exposures, medications, procedures/ treatments/surgery,
immunologic status and baseline assessment data. (59; 78; 105) {Grade B}
28. Implement precautions to prevent transmission of infectious agents in the healthcare environment (e.g., hand hygiene, standard
precautions, monitor visitors, barrier precautions, transmission-based precautions, surgical asepsis). (8; 78; 105) {Grade B}
29. Identify conditions, treatments, diet and medications that may lower resistance to infection; promote changes/additions that
increase resistance and/or reduce recurrent infection. (45; 47; 67; 73) {Grade A}
30. For noncritically ill patients, evaluate and monitor blood glucose levels (e.g., premeal blood glucose goal less than 140 mg/dL;
random blood glucose goal less than 180 mg/dL), advocate for appropriate treatment [e.g., individualize blood glucose targets
based on previous diagnosis of diabetes and/or control and/or medical status (end of life, brittle diabetes), anticipate use of
scheduled subcutaneous administration of insulin with basal, nutritional and correction doses, ongoing blood sugar monitoring
and assessment to prevent over/undertreatment]. (81) {Grade C}
31. Assess for signs of localized infection (e.g., invasive lines, urinary tract, GI tract, respiratory tract, surgical sites). (59; 78; 105)
{Grade B}
32. Evaluate/anticipate need for cultures (e.g., blood, urine, stool, wound, cerebrospinal fluid, respiratory, drainage, invasive
devices, indwelling lines) before antimicrobial therapy is initiated. (10; 31; 44; 79; 115) {Grade B}
33. Provide comfort/fever-reduction measures (e.g., medications, cool cloths, lightweight clothing/covers, change room temperature,
decrease stimulation, change ventilator/aerosol temperature). (97) {Grade C}
34. Promote wound healing (e.g., cleanse with minimal chemical/mechanical trauma, cold/warm compresses, adequate hydration,
manage fecal/urinary incontinence, prevent hypothermia). (8; 92; 95; 104; 107; 112; 115) {Grade B}
35. Promote patient/family behaviors that reduce endogenous flora and enhance host defenses (e.g., hand hygiene, pulmonary
hygiene, personal hygiene, diet/hydration, safe sex practices, mouth/dental care, diabetic foot care). (49; 78; 79; 90) {Grade B}
36. Facilitate briefest possible hospital stay. (18; 78) {Grade B}
37. Evaluate/anticipate need for medications (e.g., uroseptic, antibiotic, probiotic, antiviral, antifungal, antipyretic, immune globulin,
interferon, steroid). (10; 31-34; 36; 42; 79; 95; 115) {Grade B}
38. Evaluate/anticipate need for surgical treatment (e.g., wound biopsy, incision/drainage, irrigation/debridement, amputation).
(10; 95; 115) {Grade B}
39. Assist with measures to diagnose/treat early sepsis (e.g., two or more blood cultures, percutaneous blood culture, blood culture
from each vascular access device, imaging studies to confirm source of infection, early IV antibiotic therapy, remove infected IV
access devices, volume resuscitation to restore normal perfusion pressure and hemodynamic function, protect the airway,
ventilation, oxygenation, monitor potential nephrotoxic medication). (44; 93; 106) {Grade C}
40. Initiate strategies to prevent/treat endometritis:
Correlate laboratory values [e.g., white blood count, blood cultures, endometrial cultures (if patient doesnt respond to initial
antibiotic therapy)] and baseline assessment data. (100) {Grade C}
Anticipate use of parenteral broad spectrum antibiotic until afebrile for 48 hours. (100; 108) {Grade C}
Encourage fluid intake to maintain hydration (1500 to 2000 mL of oral fluids) and adequate nutrition 1500 calories/day (1800
to 2000 if lactating). (100) {Grade C}
Initiate intake and output measurement. (100) {Grade C}
41. Initiate strategies to prevent/treat urinary tract infection (UTI):
Correlate characteristics of urine to voiding patterns, VS, pain, indwelling drainage devices, laboratory values, personal
hygiene practices, hydration status, medications/infusions, procedure/treatment/surgery and baseline assessment data.
(36; 54; 114) {Grade C}
Ensure proper personal hygiene (e.g., clean/wipe perineum front to back, hand hygiene, change perineal pads). (36; 54)
{Grade C}
Promote sterility of urinary tract (e.g., avoid unnecessary catheterization, insert catheter aseptically and remove when no
longer needed, closed drainage system, drainage bag below bladder level, unobstructed urine flow, closed technique for
specimen collection, secure tubing). (76) {Grade C}
Ensure adequate fluid intake of 2,000 to 2,500 mL daily, unless contraindicated. (36; 54) {Grade C}
Encourage acidifying fluids (e.g., citrus juice, cranberry juice, pineapple juice) to decrease bacterial count in urine and
discourage adherence of bacteria to bladder wall. (36; 54; 80) {Grade C}
Encourage frequent bladder emptying (every two hours while awake). (36) {Grade C}
Provide approaches that enhance ability to void by relaxing urinary sphincter [e.g., accessible facilities (bathroom/bedside
commode/urinal, hand sanitizer), calm/private atmosphere, comfortable position (upright if possible), running water, warm
water to perineum]. (100) {Grade C}
Perform intermittent catheterization every 4 to 6 hours to keep bladder volume less than 400 mL in the case of urinary
retention. (41; 100) {Grade C}
Evaluate/anticipate need for urine cultures before antimicrobial therapy is initiated. (36; 54) {Grade C}
Evaluate/anticipate need for medications (e.g., uroseptic, antibiotic, probiotic). (36; 42; 54) {Grade C}
42. Initiate strategies to prevent/treat surgical site/episiotomy infection:
Correlate appearance of wound/incision(s) to dressings, drainage, hydration/nutritional status, wound classification,
expected patterns of wound healing, age, medications, comorbidity and baseline assessment data. (59; 78) {Grade C}
Anticipate risk by correlating intended surgical procedure to known/suspected infectious disease, expected wound
classification, degree of trauma and transfusion potential. (61; 78) {Grade C}
Advocate for surgical antimicrobial prophylaxis (e.g., bowel preparation, vaginal douche, IV antibiotic) as indicated, using
agent consistent with national guidelines (e.g., Centers for Disease Control). (61; 78) {Grade B}
Administer IV antimicrobial prophylaxis within one hour prior to incision (except Vancomycin within two hours prior to
incision). Redose every half-life of the antibiotic (usually every three hours) while the incision remains open. (41; 61; 78)
{Grade A}
Reduce skin microbial count prior to surgery [e.g., preoperative shower(s), avoid hair removal or use of clipping/depilatory
methods, antiseptic skin preparation]. (6; 61; 78) {Grade B}
Maintain normothermia [core temperature 36 degrees to 38 degrees Celsius (96.8 degrees to 100.4 degrees Fahrenheit)]
using active measures (e.g., forced warm air, fluid warmer). (3; 6; 20; 24; 61; 69; 77; 78; 89; 104) {Grade A}
Prevent contamination and/or irritation of incision using principles of surgical asepsis [e.g., barrier methods (gloves), gentle
handling of tissues, closed drainage systems, sterile dressing for 24 to 48 hours, protect from secretions/excretions]. (6; 78)
{Grade B}
Control serum glucose levels to less than 140 mg/dL (less than 110 mg/dL for cardiac surgery/critical care) in diabetic
patients. (61; 78) {Grade A}
Implement postoperative measures to prevent sepsis (e.g., hand hygiene, rest, avoid cross contamination, pulmonary
hygiene, personal hygiene, adequate diet/hydration, wound care techniques). (78) {Grade B}
Facilitate briefest possible hospital stay. (61; 78) {Grade B}
43. Evaluate/anticipate need for cultures (e.g., wound, drainage, indwelling lines) before antimicrobial therapy is initiated: (106; 115)
{Grade C}
Evaluate/anticipate need for medications (e.g., antibiotic, antifungal). (95; 115) {Grade B}
Evaluate/anticipate need for surgical treatment (e.g., wound biopsy, incision/drainage, irrigation/debridement). (95; 115)
{Grade B}
44. Initiate strategies to prevent mastitis:

Encourage maternal/infant skin-to-skin contact as early as possible and also as often as possible and for as long as
possible each time, at least during the entire postpartum stay. (82) Grade A
Assess for signs and symptoms of mastitis and correlate with baseline assessment data. (100) {Grade C}
Provide education about preventive measures (e.g., hand hygiene, breast cleanliness, frequent breast pad changes,
exposure of nipples to the air, correct latch-on and removal from breast). (100) {Grade C}
Anticipate use of antibiotic therapy. (100) {Grade C}
Provide comfort measures including warm or cold compresses, wearing a supportive bra and analgesia as ordered. (100)
{Grade C}
Assist with the use of a breast pump or manual expression; massage and position infant in the direction of the site and
encourage frequent breast feeding or pumping. (100) {Grade C}
Embolism leading to Tissue Ischemia/Infarction AEB:
pain; sudden/temporary decreased organ function; tissue necrosis (51)
Deep vein thrombosis (DVT) leading to venous thromboembolism (VTE): redness, warmth, tenderness, edema of affected area;
increased temperature; impaired neurovascular status; apprehension; restlessness; venous congestion; deep/local muscle pain; size
asymmetry, color change; palpable cord along vein; abnormal D-dimer level; positive venous ultrasonography (26; 94)
Septic pelvic thrombophlebitis: fever; tachycardia; abdominal and flank pain (100)
Arterial embolus: muscle pain, muscle spasm; numbness, tingling; pallor/cyanosis of affected area; decreased or absent pulse; cold to
touch; lack of movement/weakness; blisters, skin erosion; tissue necrosis; sloughing of skin; blue toe syndrome (22; 51; 58)
Pulmonary embolus: sudden cardiovascular instability/respiratory distress; cough; decreased end-tidal carbon dioxide (EtCO2); increased
RR; marked decrease in SaO2, changed arterial blood gases; hypoxemia; thoracic/upper abdominal pain; tachycardia; petechiae; pulmonary
infiltrates; positive D-dimer level; positive ventilation perfusion scan; positive pulmonary angiography or positive computed tomography scan
(CT scan) (22; 26; 94)
45. Correlate cardiorespiratory and neurovascular status to identified risk factors, hydration status, medications, laboratory values,
bleeding patterns, diet, activity level, location/intensity of pain, procedures performed and baseline assessment data. (62)
{Grade C}
46. Correlate and symptoms of pain and tenderness, swelling, warmth, reddening or discoloration in each extremity. (57) (Grade C)
47. Evaluate/anticipate need for measurements of extremities to compare size and symmetry. (100) {Grade C}
48. Initiate strategies to prevent/treat DVT/VTE:
Prevent venous stasis/pooling of blood in extremities [e.g., compression stockings, prevent pressure/constriction, frequent
position change, avoid compression of vena cava, ankle dorsoplantar exercises, avoid crossing legs, intermittent pneumatic
compression, neutral position, head of bed (HOB) elevated less than 30 degrees]. (2; 8; 25; 62; 83) {Grade A}
Promote early and frequent ambulation. (26; 62) {Grade B}
Advocate for VTE prophylactic medication. (7; 62-64) {Grade B}
49. Monitor for bleeding and correlate laboratory results to dose of antithrombotic medications. (25; 62) {Grade B}
50. Avoid deep/vigorous massage when suspected signs and symptoms of DVT or receiving antithrombotic therapy. (39; 46)
{Grade C}
51. Evaluate/anticipate need for diagnostic studies (e.g., D-dimer level, ventilation perfusion scan, ultrasound, echocardiography,
venography, arteriography). (22; 51; 62; 100) {Grade B}
52. Anticipate need for emergent/urgent procedures (e.g., thrombolysis, embolectomy/thrombectomy, vena cava filter). (51; 62)
{Grade B}
53. Anticipate bedrest with involved extremity elevated; encourage ambulation as soon as symptoms allow. (100) {Grade C}
54. Evaluate/anticipate need for postdischarge anticoagulation. (62) {Grade B}
Voiding Dysfunction AEB:
Urinary Retention: inability to void; change in urination pattern; frequent small voiding; abdominal discomfort/pressure; urgency; suprapubic
distension; uterine displacement above and to right of umbilicus; bladder distension; incomplete emptying (residual urine per catheter or
Bladder Scan of greater than 100 mL for adults); restlessness; increased BP; increased HR; anxiety; increased lochia; decreased urine
output compared to oral and IV intake
55. Correlate voiding pattern (e.g., frequency, amount) to VS, laboratory values, medications, types of infusions (e.g., narcotics,
epidural anesthesia/analgesia, blood components, volume expanders), by mouth fluid intake, expected patterns and baseline
assessment data. (100) {Grade C}
56. Encourage patient to void as soon as possible after removal of indwelling catheter to avoid bladder overfilling. (100) {Grade C}
57. Provide approaches that enhance ability to void [e.g., calm/private atmosphere, comfortable position (upright if possible), running
water, blow bubbles with straw, warm water to perineum). (100) {Grade C}
58. Ensure adequate fluid intake (e.g., 2,000 to 2,500 mL daily for an adult). (41; 100) {Grade C}
59. Offer assistance to bathroom/commode every two hours while awake. (100) {Grade C}
60. Anticipate need for intermittent catheterization to empty bladder; avoid rapid emptying (no more than 800 mL of urine at each
time). (100) {Grade C}.
61. Anticipate need to reinsert indwelling catheter if inability to void continues. (41) Grade C
62. Evaluate for signs of urinary tract infection; correlate characteristics of urine to voiding patterns, VS, pain, indwelling drainage
devices, laboratory values, personal hygiene practices, hydration status, medications/infusions, procedure/treatment/surgery and
baseline assessment data. (36; 54; 114) {Grade C}
Postoperative Ileus AEB:
abdominal distension; diffuse abdominal pain; N/V; hypoactive or absent bowel sounds; delayed passage or absence of flatus/bowel
movements; increased nasogastric tube output; increased residual contents prior to gastric feedings; evidence noted on abdominal
radiographs, contrast studies or computed tomography (CT) scan
63. Correlate GI status to type of surgery/procedure/injury, medications (e.g., opioids), inflammation/infection, metabolic
disturbances (e.g., hypokalemia) and baseline assessment data. (74; 103) {Grade C}
64. Adjust diet. Initially provide bowel rest: nothing by mouth other than sips as tolerated. As motility indicators return, start
patient on a liquid diet and advance as tolerated. (74) {Grade C}
65. Provide comfort measures related to N/V including pharmacological (e.g., antiemetics) and nonpharmacological (e.g.,
nasogastric tube) modalities. (74) {Grade C}
66. Evaluate pain (including aggravating and relieving factors) and mutually develop plan for comfort measures including
pharmacologic (e.g., using opioids sparingly and supplementing with nonsteroidal anti-inflammatory drugs (NSAIDs) and
nonpharmacologic (e.g., nasogastric tube, relaxation, ambulation, adjust environment) modalities. (48; 68; 74) {Grade C}
67. Assist in maintaining fluid and electrolyte balance [e.g., evaluate/anticipate need for IV fluid replacement when there is a large
volume of emesis or drainage from a nasogastric tube (one or more liters per day)]. (48; 74) {Grade C}
Constipation AEB:
incomplete/decreased frequency of bowel movements; dry, hard, formed stool; difficulty in passing stool (e.g., straining, pushing for greater
than 10 minutes, pain with defecation); decreased volume of stool; abdominal distension/firmness; feeling of fullness in lower abdomen/
rectum; radiographic confirmation of stool in colon (9)
68. Correlate stool elimination status to normal bowel patterns/habits/programs, diet, hydration, medications, activity/mobility,
factors contributing to decreased gastric motility (e.g., surgery, chronic diseases/conditions) mental/behavioral/psychosocial/
cultural factors and baseline assessment data. (19; 113) {Grade C}
69. Facilitate defecation to baseline elimination pattern [e.g., prompt assistance, convenient access (bedside commode), appropriate
position (upright squatting; if bed-bound, left-side lying, bending knees/legs toward abdomen), visual and auditory privacy,
support of usual bowel program/routine, medications (bulk-forming laxatives, stool softeners, stimulants, lubricants, osmotic
agents), digital stimulation]. (19; 99; 113) {Grade C}
70. Advocate for pharmacological and nonpharmacological interventions that counter the effect of constipating medications
(e.g., opioids, antidepressants, iron supplements, diuretics). (19) {Grade C}
71. Assess current fluid intake and prevent dehydration (e.g., fluids per patient preference). (28; 99; 113) {Grade C}
72. Promote prompt patient response to defecation urge and consistent time for bowel elimination (e.g., follow normal home toileting
routine; 30 minutes after a meal, particularly in the morning or based on patients triggering meal). (28; 99; 113) {Grade C}
73. Evaluate and adjust diet (e.g., promote high-fiber choices, cautiously add/increase fiber in small amounts). (19; 28; 99; 113)
{Grade C}
74. Evaluate psychosocial and/or cultural impact on elimination pattern [e.g., anxiety, unwillingness to use public facilities,
unfamiliar toileting facilities (commode, bedpan), need for privacy]. (9) {Grade C}
Postpartum Thyroid Dysfunction AEB:
Thyrotoxicosis: possible goiter development; fatigue; palpitations (72)
Hypothyroidism: mild dysphoria; goiter; fatigue; depression; difficulty concentrating (50; 72)
75. Assess VS/laboratory values and correlate to patients signs and symptoms (e.g., postpartum depression versus postpartum
thyroid dysfunction) and baseline assessment data. (38; 50) {Grade C}
76. Provide education on disorder. (41) {Grade C}
77. Emphasize the need for follow-up laboratory tests and physician visits. (72) {Grade C}
78. Mutually develop plan for treatment and follow-up. (41) {Grade C}
79. Provide reassurance to assist with alleviation of patients anxiety. (41) {Grade C}
Postpartum Mood and Anxiety Disorders AEB:

Maternity blues (Baby Blues): (15) episodes of tearfulness; complaints of being unable to sleep; expression of feeling overwhelmed
and insecure in mothering role
Postpartum depression: (15)complaints of feeling depressed most of the time; loss of interest in daily activities; change in appetite;
feelings of worthlessness; fatigue; restlessness
Postpartum psychosis: (15; 50)mood fluctuation; agitation; exhilaration; inability to concentrate, eat or sleep; hallucinations, delusions,
disorganized behavior and thought processes, thoughts of harming self and/or baby
Postpartum panic disorder: (15)characterized by feelings of choking, dizziness and shortness of breath; complaints of chest pain and
palpitations; visual disturbances; sweating; heightened awareness of sounds; nausea; numbness/tingling; exhaustion; fear of losing control
and dying; sweating; hot flashes; poor self-esteem
Obsessive compulsive disorder with postpartum onset: (15)persistent and repetitive thoughts and behaviors that can significantly
interfere with normal activities; repetitive thoughts about harming the baby leading to avoidance of contact; feelings of guilt, shame, fear
Post-traumatic stress disorder related to childbirth: (15)recurrent thoughts and/or dreams related to past traumatic event (e.g.,
negative memories regarding a previous delivery, history of psychologic disorder); exaggerated response to cues or stimuli that act as
reminders of the event; social withdrawal; inability to concentrate; emotionally distanced from others; sleep disturbances; irritability;
emotional outbursts; compelling need to continuously discuss labor and delivery process; need to continually relive delivery experience;
flashbacks of the event; nightmares
80. Anticipate the need to discuss with patient, the potential mood changes that can occur during in the postpartum period. (70)
{Grade C}
81. Assess changes in mood or behavior that can indicate the development of a serious postpartum mood disorder; consider using
a standardized, reliable assessment tool such as the Edinburgh Postnatal Depression Scale. (50; 52) {Grade C}
82. Encourage verbalization of feelings, thoughts, concerns and fears by new mother concerning her maternal role and the impact
on her lifestyle and relationships. (70; 100) {Grade C}
83. Encourage patient to engage in early and prolonged maternal-infant contact activities that enhance attachment (e.g., rooming-in,
becoming involved in the medical examination of baby); realize that effective attachment behaviors differ culturally and do not
necessarily indicate maladaptive parenting behaviors. (50; 88) {Grade C}
84. Assist mother in attachment process by establishing a responsive, nurturing environment and assisting the mother to
understand and respond to the newborns behavioral cues. (100) {Grade C}
85. Provide education on hormonal changes following delivery and their potential impact on emotions and behavior (e.g., mood
changes, tearfulness), as well as signs and symptoms of more serious disorders. (52) {Grade C}
86. Anticipate need for Psychiatry to become involved for possible medication evaluation. (70; 88) {Grade C}
87. Supply information and contact numbers for resources and support groups that are available in the community. (52; 70; 100)
{Grade C}
Situational Response AEB:
expression of anxiety, fear, anger, guilt, frustration, grief/loss (e.g., loss of control, loss of previous role, loss of child); sadness, depression;
boredom; increase stress; (e.g., financial, relationships, roles, responsibilities) (38; 71; 88; 101)
88. Develop trust relationship/rapport through therapeutic presence, active/empathic listening and sensitivity to nonverbal
communication; allow patient to retell birth experience to assist with the takingin process. (101; 110) {Grade C}
89. Correlate patient/support system response to pregnancy/complications with ability and/or readiness to comprehend information,
past experiences/history (including mental health), current situation, developmental stage, medications/substance use and
baseline assessment data. (88) {Grade C}
90. Encourage verbalization of feelings regarding current situation. (101) {Grade C}
91. Support coping by recognizing current strategies and developing new strategies (e.g., journaling, relaxation techniques, guided
imagery, problem solving). (101) {Grade C}
92. Evaluate the need for anticipatory guidance (e.g., provide information on realistic expectations, education/resources) and
encourage patient/support system to ask questions regarding treatment/procedures. (88) {Grade C}
93. Facilitate the presence of/private time with the patient support system (e.g., partner, family members, children, friend). (88)
{Grade C}
94. Address concerns, offer reassurance and provide support for patient/support system. (88) {Grade C}
95. Acknowledge cognitive difficulties that may occur following delivery and facilitate postpartum education by following inpatient
education with written material for review at home. (50) {Grade C}
96. Encourage patient to have newborn at bedside as much as she desires to promote attachment. (110) {Grade C}
97. Provide reassurance to mother while she provides care to infant regardless of how awkward her skills seem; positively reinforce
tasks, coach and role-model skills, avoid criticism. (110) {Grade C}
Clinical Practice Guidelines represent a consistent/standardized approach to the care of patients with specific diagnoses. Care should always be individualized by adding
patient specific information to the Plan of Care.
Guidelines
GENERAL INFORMATION: POSTPARTUM FOLLOWING CESAREAN DELIVERY

A. CLINICAL DESCRIPTION: The postpartum period begins with delivery of the infant and lasts approximately 6 weeks and is characterized by rapid
physical and psychosocial changes. The postpartum period is a time of transition involving physiologic changes, adaption to the maternal role and
changes to the family system with addition of the new baby. Significant anatomic and physiologic changes occur during the postpartum period; a
thorough knowledge of them will assist practitioners in planning comprehensive care for new mothers.
B. PATHOPHYSIOLOGY/ETIOLOGY/RISK FACTORS FOR POTENTIAL PROBLEMS:
1. Bleeding/Hemorrhage:
a. Definitions:
Hemorrhage: loss of blood from the vascular space.
Hemorrhagic shock: a form of hypovolemic shock that is due to loss of one fifth or more of normal circulating blood volume.
Hypovolemic shock: an emergency situation in which low blood volume prevents the heart from pumping enough blood to meet body
tissue demands. Shock may lead to organ failure and death. (93)
Shock Index: correlation of HR and systolic BP (HR sBP; normal range 0.5 to 0.7) is demonstrated to be an effective indicator of
shock despite stable VS. SI that persists at a ratio at or greater than one indicates bleeding that requires acute medical intervention.
(21)
b. Postpartum hemorrhage: the loss of greater than 500 mL of blood following a vaginal delivery and 1000 mL of blood following a caesarean
delivery. Postpartum hemorrhage can occur within the first 24 hours following delivery (early) or after the first 24 hours up to 14 days
postpartum (late). The leading causes of postpartum hemorrhage include uterine atony, retained placenta (including placenta accreta) and
genital tract lacerations. (41) Due to the normal pregnancy-induced hypervolemia (1 to 2 liters of blood) signs and symptoms of
hypovolemic shock may not appear until the amount of blood loss is significant. One of the most important risk factors for postpartum
hemorrhage is a prior postpartum hemorrhage. (5; 66)
c. Causes include:
DIC/Consumptive coagulopathy: Syndrome produced as part of an underlying disease that in some way leads to the initiation of the
clotting mechanism. This leads to consumption of plasma, clotting factors and production of anticoagulants. (40)
Risk factors: placental abruption, hemorrhage, preeclampsia, eclampsia, amniotic fluid embolism, pregnancy termination, sepsis,
cardiopulmonary arrest, massive transfusion therapy. (100)
Retained placenta: A potential cause of late postpartum hemorrhage. Placental fragment(s) remain in the uterus following delivery.
This hinders normal uterine involution leading to increased bleeding. It is recommended that the placenta be inspected following
delivery. If fragments are missing, uterine exploration is recommended.(72) The major complication of placenta accreta is massive
postpartum hemorrhage that occurs when attempting to remove the placenta. The hemorrhage is usually so profuse, even lifethreatening, that massive blood transfusions and emergency hysterectomy are needed to control bleeding and save the mothers life.
Conservative management can be considered in selected cases of women without massive postpartum hemorrhage who want to
preserve fertility. In general, a conservative strategy leaves the placenta in situ without forced removal during delivery. Sometimes
additional treatments are given, including methotrexate, uterine artery embolization or sulprostone. Prophylactic antibiotics are usually
used to prevent infection. The benefits of conservative treatment include less postpartum hemorrhage, decreasing the need for blood
transfusion or hysterectomy and preservation of the uterus and further fertility. However, the outcome of conservative treatment is not
always satisfactory. The disadvantages include postpartum infection, treatment failure, frequent follow-up and even further surgical
intervention such as hysterectomy. (37)
Risk factors: previous cesarean delivery, uterine leiomyomas, prior uterine curettage, succenturiate placental lobe (16)
Hematoma: postpartal bleeding into perineal tissue due to undiagnosed lacerated artery/vein, with complaints of extreme
perineal/pelvic pain typically not relieved by analgesics. May require incision and drainage with ligation of the lacerated vessel.
Risk factors: nulliparity, episiotomy, forceps delivery. (41)
Uterine atony: Marked hypotonia of the uterus, (100) failure of the uterus to contract following delivery. (41) The most common cause
of postpartum hemorrhage.(16) Uterine atony may respond to fundal massage or further treatment with oxytocin, ergot derivatives
(e.g., Methergine) and prostaglandins (e.g., Hemabate, Cytotec).
Risk factors: polyhydramnios, multiple gestation, precipitous delivery, large fetus, use of oxytocin (augmentation/induction), use of
tocolytics, placenta previa, multiparity, rapid or prolonged labor, halogenated anesthesia, chorioamnionitis, difficult delivery. (50;
100)
Birth canal lacerations: Lacerations of the birth canal following delivery, including vaginal, cervical, labial, perineal. More commonly
seen following an operative delivery (e.g., use of forceps, vacuum assist).(100) Characteristically, uterus is firm but heavy bleeding
continues.
Risk factors: operative vaginal delivery, malpresentation, macrosomia, manipulative delivery (e.g., breech extraction), episiotomy,
precipitous delivery. (100)
d. Management:
Uterine massage technique: Place one hand pointing toward the womans head with thumb resting on one side of the uterus and
fingers along the other side. Use other hand to massage using only the force needed to effect contraction or expulsion of clots. Over
aggressive uterine massage may tire muscle fibers and contribute to continued atony.(100)
Drug
2.
3.
Medical Management of Postpartum Hemorrhage

Dose/Route
Frequency
Comment
Oxytocin (Pitocin)
IV: 10 to 40 units in 1 L normal

saline or lactated Ringers solution
Intramuscular: 10 units
Continuous
Avoid undiluted rapid IV infusion

which causes hypotension
Methylergonovine (Methergine)
15-methyl PGF2 (Carboprost)
(Hemabate)
Intramuscular: 0.2 mg
Intramuscular: 0.25 mg
Every 2 to 4 hours
Every 15 to 90 minutes
8 doses maximum
Dinoprostone
(Prostin E2)
20 mg, Suppository: vaginal or

rectal
Every 2 hours
Avoid if patient is hypertensive

Avoid in asthmatic patients;
relative contraindication if
hepatic, renal, and cardiac
disease is present. Diarrhea, fever,
tachycardia can occur
Avoid if patient is hypotensive.
Fever is common. Stored frozen, it
must be thawed to room
temperature.
Misoprostol
(Cytotec, PGE1)
800 to 1,000 mcg
Abbreviations: IV, intravenously; PG, prostaglandin.

*All agents can cause N/V.
Modified from ACOG Practice Guideline (56) (Permission pending)
Uterine tamponade: (50)
Uterine packing may be used to control post partum hemorrhage by providing tamponade (constriction of blood vessels by an outside force)
to the bleeding uterine surface. Packing is usually done with long, continuous gauze (e.g., Kerlex) rather than multiple sponges. Placement
begins at the fundus and progresses downward to avoid dead space that allows for blood accumulation. A foley catheter is generally
inserted and antibiotics administered to prevent urinary retention and infection. Packing should be removed within 12 to 24 hours. Close
attention should be paid to VS and laboratory values to minimize unrecognized continued bleeding. A tamponade balloon (Bakri
Tamponade Balloon) has been developed as an alternative to packing. The catheter balloon is inserted into the uterus and inflated with
saline providing a tamponade to the uterine surface while the catheter allows for drainage of blood.
Acute Pain: is a symptom versus a diagnosis. Pain is subjective. Acute pain is usually related to an injury, trauma or surgery, thus is
protective, acting as an early warning sign that tissue damage is about to occur or is occurring. The patient expects to recover following the
delivery process and any surgical wounds are expected to heal. (29; 43; 53)
In labor acute pain is caused by anoxia of compressed muscle cells of the uterus, nerve ganglia compression in cervix and lower uterine
segment during contractions, cervical stretching during dilation and effacement, perineal stretching and displacement as fetus descends.
Cesarean delivery following a period of labor may contribute to fatigue and decreased pain tolerance.
Acute-on-chronic pain: person suffering from chronic pain (e.g., cancer or neuropathy) who is admitted to an acute care setting in labor.
Both types of pain must be treated. (27)
Adequate pain management can reduce complications [e.g., poor sleep patterns, depression, anxiety, atelectasis, pneumonia, DVT] and
shorten recovery time and length of hospital stay.
Surgical incision, breast engorgement, sore/cracked nipples, hemorrhoids and afterpains can be a source of pain/discomfort.
If spinal or epidural anesthesia is used for the cesarean delivery addition of opioids to the local anesthetic solution will provide excellent
postoperative analgesia.
Fentanyl or sufentanil provide fast onset with fewer side effects but have a duration of only 2 to 4 hours. Morphine has a duration of up to
24 hours but it has a long onset time and more side effects. Side effects include itching and nausea; rarely respiratory depression.
If general anesthesia was used or the spinal or epidural analgesia provides inadequate pain control, an intravenous PCA (Patient controlled
analgesia) can be used. Morphine, Dilaudid (hydromorphone) and fentanyl have all been used with success. Using PCA provides better
patient satisfaction because it allows the patient to control her pain medication. PCA morphine has been found to be superior to
intramuscular meperidine for pain control and breast feeding success.
The addition of nonsteroidal anti-inflammatory agents (NSAIDS) significantly improve pain scores with spinal or epidural morphine and
reduces PCA opioid use.
Other comfort measures include:
position changes (e.g., sidelying, HOB elevation, knees bent)
hydrotherapy
music
imagery
Infection leading to Sepsis:
a. Definitions:
Infection: invasion of body tissues with pathogenic agents.
Healthcare-associated infection: infection acquired in a hospital setting. (105)
Sepsis: a whole-body inflammatory state caused by infection originating anywhere in the body; also may be called systemic
inflammatory response syndrome (SIRS). (104)
b.
4.
Etiology: infection occurs when microorganisms invade healthy tissue and proliferate to the point of overwhelming the hosts immune
response. Transmission of infection requires three elements: 1) a source of infectious agents; 2) a susceptible host with a portal of entry
receptive to the agent and 3) a mode of transmission of the infectious agent. Host factors that increase susceptibility to healthcareassociated infection include: extreme age, underlying conditions (e.g., diabetes, malnutrition), immunodeficiency, malignancy and
transplants. Whole body infection (sepsis) may result from the spread of local infections. Multidrug-Resistant Organisms (MDRO) have
significant healthcare-associated infection potential. (44; 78; 95; 104; 105)
c. Postpartum Infections:
Three categories of the most common postpartum infections include reproductive/genital tract, urinary tract and breasts. The most
common causative organisms include anaerobic streptococcus, clostridium, group A or B hemolytic streptococcus, E. coli, Klebsiella,
Gardnerella vaginalis, Chlamydia trachomatis. Endometritis constitutes the most common febrile complication after delivery, being
more frequent and severe after cesarean delivery, where its incidence ranges between 5 and 85 percent.(35) Infection most often
occurs after the third or fourth postpartum day and must be differentiated from other causes of increased temperature (e.g.,
dehydration, postoperative elevation, breast engorgement).
Risk factors: history of long labor, postpartum hemorrhage, anemia, premature rupture of membranes, malnutrition, diabetes, breaks
in aseptic technique, frequent vaginal exams in labor, chorioamnionitis, prolonged rupture of membranes, poor hygiene, intrauterine
monitoring
Endometritis: occurs when pathogens are introduced into the uterus during birth process. Uterine tenderness and fever are the
associated symptoms and may or may not be accompanied by foul lochial odor depending on causative organism. Rupture of
membranes prior to onset of delivery increases the risk. A cesarean delivery with premature rupture of membranes carries a high risk of
endometritis. Prophylactic administration of antibiotics during the intrapartum period has been associated with a decrease in rate of
endometritis following a cesarean section delivery. Laboratory tests may not be helpful in diagnosing endometritis, as the changes that
take place after delivery may affect results (e.g., white blood cell count). The clinical picture may be the more reliable way to diagnose
the infection. Causative organisms can be either aerobic or anaerobic. IV antibiotics are the treatment of choice until mother is afebrile
for 24 to 36 hours, which may or may not be followed by an oral course of antibiotics.
Wound infection: The cascade of events leading to wound infection is initiated by changes in blood volume occurring during cesarean
delivery that create a transient hyperperfusion in subcutaneous vessels where development of hematomas occur that may easily
become infected. Gestational diabetes mellitus and history of previous cesarean deliveries were found to be significantly associated to
wound infection. (35)
Urinary tract infection: can occur due to incomplete emptying of bladder, overdistention of bladder, indwelling or frequent intermittent
catheterizations.
Mastitis: may occur from incomplete emptying, milk stasis, cracked nipples and presence of bacteria in infant's oral mucosa. Causative
organisms can include staphylococcus aureus (40 percent) or E. coli. Community-acquired Methicillin resistant staph aureus (MRSA)
is an increasingly common pathogen in spontaneous cases of postpartum mastitis. (98) Treatment should include antibiotics. Notify
Pediatrician if mother is placed on an antibiotic. Usually, breastfeeding does not need to cease during treatment. Mom should wear a
well-fitting, supportive bra. Medications to cause cessation of lactation are not recommended.
Breast abscess: can result from unresolved mastitis. Ultrasound can localize the area of abscess. Treatment may be aspiration or
surgical incision/drainage.
Embolism leading to Tissue Ischemia/Infarction:
a. Definitions:
Embolus (plural emboli): a plug, composed of a detached thrombus or vegetation, mass of bacteria or other foreign body occluding a
vessel.
Ischemia: inadequate blood supply due to blockage of the blood vessels to the area.
Infarction: sudden insufficiency of arterial or venous blood supply due to emboli, thrombi, mechanical factors or pressure that produces
a macroscopic area of necrosis. Any organ can be affected. The six weeks of postpartum and particularly the several days surrounding
delivery are times of increased risk for ischemic stroke.
Thrombus: A clot in the cardiovascular system formed during life from constituents of blood; it may be occlusive or attached to the
vessel or heart wall without obstructing the lumen (mural thrombus).
b. Pathophysiology:
DVT/VTE: Immobility leads to venous stasis thereby facilitating coagulation cascade in large veins. DVT causes less inflammation than
thrombophlebitis. Lack of inflammation increases the risk that portions of clot may break off and travel through the vascular system as
VTE. (7; 17) A DVT formed in the leg is not life-threatening, but if the clot breaks loose and moves to the lungs, a life-threatening PE
can result. Pulmonary embolism is a medical emergency affecting both the cardiovascular and respiratory systems and has mortality
rates that may be as high as 25 percent. (7) Deep vein thrombosis may develop as late as 7 to 10 days postoperatively in vessels of
pelvis and lower extremities. Venous thromboembolism prophylaxis should begin for surgical cases between 24 hours prior to surgical
incision and 24 hours after surgery end time. (63)
c. Etiology: A mobilized blood clot, mass of bacteria, vascular plaque, liquid fat, bone marrow or air in the arterial system obstructs
circulation/respiration; may manifest as arterial occlusion in extremity, pulmonary embolus, myocardial infarction or ischemic stroke. Less
commonly, emboli may affect intestine, kidney or eye. (51)
10
d.
5.
6.
Risk factors:
VTE: more common in Blacks than Caucasians/Asians. Risk factors include: history of past VTE; pregnancy postpartum, current
estrogen use recent trauma/surgery, immobilization; tobacco use, trauma, presence of cancer; airline flight longer than 8 hours; obesity,
fractures of hip/pelvis/lower extremity, central venous catheter, diabetes, hyperlipidemia, hyperuricemia, cardiovascular disease (e.g.,
hypertension, varicose veins, atrial fibrillation, angina, myocardial infarction, valvular disease), pulmonary hypertension, history of
ischemic stroke. Eclampsia is the single most important risk factor for stroke during pregnancy and the postpartum period. (1; 12; 22; 26;
57; 87)
VTE prophylaxis: indicated for vascular, urologic, cardiac, orthopaedic, intracranial neurologic or multiple trauma surgeries. General
Surgery procedures are graded (e.g., low, moderate, high, very high risk) based on patient age/risk factors/duration of surgery.
Voiding Dysfunction:
a. Urinary retention: inability to void voluntarily, results in painful or nonpainful distension. Acute urinary retention can lead to acute renal failure
or bladder rupture if the bladder is not emptied by catheterization. Labor may result in displacement of the bladder. The effects of anesthesia
and temporary neural dysfunction of the bladder contribute to voiding difficulties and incomplete emptying of the bladder. This needs to be
delineated from anuria and oliguria and urine production from the kidneys versus voiding dysfunction. May be associated with positioning,
pain, use of bedpan.
b. Postpartum: A major diuresis in immediate postpartum period causes excretion of 2000 to 3000 mL of extracellular fluid by the kidneys.
Bladder distension can impede accurate assessment of fundal height and increase the risk of postpartum bleeding. Overdistention coupled
with improper perineal cleansing may lead to urinary tract infection. Indwelling catheter is placed in bladder prior to cesarean delivery and
discontinued 6 to 8 hours after delivery or when sensation to the lower extremities returns.
c. Urinary retention after Foley catheter removed:
May occur secondary to surgical procedure decreasing neural stimulation to the bladder.
May be secondary to inadequate pain control or overmedication, anesthetic effects on urinary meatus, tissue trauma associated with
labor/delivery/surgery.
Presurgical assessment should include urinary tract function/infection history and individualized strategy to minimize risk of urinary tract
infection (UTI).
Catheterize patient according to physician order or every four hours. Do not wait 6 to 8 hours. Bladder Scan can be used to
determine retention.
Anxiety and restlessness are seen in patients who are afraid of being unable to empty their bladder. The more anxious and restless a
patient, the more difficult it will be to successfully empty the bladder.
Postoperative Ileus:
a. Definitions:
An ileus is the slowing/failure of passage of intestinal contents caused by a nonmechanical insult that disrupts the normal coordinated
propulsive motor activity of the GI tract. (48)
Primary or postoperative ileus: expected after abdominal or nonabdominal surgery and resolves within 2 to 4 days. Generally gastric
and small intestinal activity return within hours of surgery and colonic activity returns a day or two thereafter. (68; 74)
Secondary or paralytic ileus: associated with a delay in the expected return of bowel function following surgery or precipitating insult.
(68; 84)
b. Etiology/Pathophysiology: The most common cause of an ileus is the temporary paralysis of the intestines following abdominal surgery,
related to pain activating a spinal reflex that inhibits GI motility, sympathetic hyperactivity and surgical manipulation of bowel, viscera and
irritation of peritoneum. Other derangements that may cause or prolong an ileus include neurogenic factors (e.g., alteration in sympathetic
nerve fibers innervating GI tract), metabolic/electrolyte imbalance (e.g., hypokalemia), pharmacologic effects [e.g., analgesics (particularly
opioids)], inflammation/infection (e.g., systemic sepsis), injury/trauma, intestinal ischemia, kidney or thoracic disease. (48; 68; 111)
c. Risk factors: The period of normal postoperative ileus (primary ileus) and the risk of a prolonged postoperative ileus (secondary ileus) can
be decreased by minimizing trauma to tissues, using proper technique in the operating room, minimizing use of opioids and supplementing
with nonsteroidal anti-inflammatory drugs (NSAIDs) for analgesia, early feeding, correcting any electrolyte or metabolic imbalances and
early recognition of septic complications. (68; 74)
d. Treatment considerations: Contrary to popular belief, supportive therapy with nasogastric tube and early mobilization do not shorten primary
(postoperative) ileus. (74; 84) Management of secondary ileus is directed at identifying and correcting reversible factors contributing to ileus
and excluding other disorders. Supportive care for secondary ileus includes bowel rest, IV fluids, minimizing opioid use, selective placement
of a nasogastric tube and close monitoring (including diagnostic imaging studies). Generally, oral feeding is delayed until a secondary ileus
resolves clinically, but the presence of secondary ileus does not preclude enteral feeding. (84; 103) Investigational agents (e.g.,
Alvimopan) that inhibit peripheral opioid receptors have been effective in abolishing the adverse GI effects of opioids without impairing the
analgesic effects of such drugs. (84) Differential diagnosis should include the possibility of mechanical obstruction from early postoperative
adhesions as treatment is completely different. (68; 74)
e. Related diagnoses: Acute pseudo-obstruction of the colon (Ogilvie syndrome) is a distinct type of paralytic ileus limited to the colon alone.
(84) Possible causes include severe blunt trauma, orthopaedic trauma or procedures, acute cardiac events or coronary bypass surgery,
acute neurological events or neurosurgical procedures and acute metabolic derangements. (103) Usually, acute colonic pseudo-obstruction
will resolve in 3 days. Medical management may include correction of any underlying metabolic or electrolyte imbalances, various
procedures (e.g., colonoscopy) and pharmacological treatments (e.g., neostigmine). When bowel ischemia is suspected, surgery is
indicated. (103)
11
7.
8.
9.
Constipation:
a. Definition: (9; 28)
constipation is defined as decreased frequency of/incomplete bowel movements; dry, hard, formed stool; decreased volume of stool;
difficulty in passing stools. There are 2 types of constipation, idiopathic and functional.
Idiopathic constipation: origin not known, does not respond to standard treatment
Functional constipation: the bowel is healthy, however, is not working properly
b. Etiology/Pathology:
constipation occurs when the colon absorbs too much water or if the colons muscle contractions are slow or sluggish, causing the stool
to move through the colon too slowly. As a result, stools can become hard and dry. (28) It may result from a poor diet, poor bowel
habits or problems in elimination of stool, whether physical, functional or voluntary. (9)
Risk factors: (9; 19; 28) medications (e.g., opioids, antidepressants, diuretics, iron supplements, antacids) may contribute to
constipation. It may be secondary to neurological (e.g., stroke, spinal cord injury), endocrine (e.g., diabetes, hypothyroidism),
metabolic/electrolyte (e.g., hypokalemia), connective tissue (e.g., scleroderma) or psychiatric (e.g., depression) disorders. It may be
related to irritable bowel syndrome, mechanical obstruction of large intestine, decreased intestinal motility or pelvic floor dysfunction.
Factors such as stress, pregnancy, anesthesia or hemorrhoids may contribute to constipation. Most cases of serious constipation have
multifactorial causes. Though usually not serious, constipation may impair quality of life, lead to complications or signal a serious
underlying disorder (e.g., cancer).
c. Other treatment considerations:
Fiber: for many patients dietary fiber and bulk laxatives, together with adequate fluids, are the most physiologic and effective approach
to constipation. However, increasing dietary fiber intake may worsen symptoms for patients with more severe constipation(85),
decreased intestinal motility or opiate-induced constipation. (19)
Laxatives: patients who respond poorly to or who do not tolerate fiber may require laxatives other than the bulk-forming agents.
Categories of nonbulk-forming laxatives include stool softeners, osmotic, stimulants, lubricants and saline laxatives. (28) Some
laxatives have not been well-studied but have been used extensively. Choosing among them can be based on costs, ease of use,
patient preference and results of empiric trials. (113) Patients receiving regular doses of opioids should be offered a stimulant laxative.
(19)
Postpartum Thyroid Dysfunction:
a. Definitions:
Postpartum thyroid dysfunction: Transient postpartum thyroid dysfunction may be experienced following some pregnancies. It may
be due to an autoimmune response. Initially there may be a period of hyperthyroidism (lasting approximately 2 to 4 months following
delivery), followed by a period of hypothyroidism. Incidence peaks at two to five months postpartum. Return to normal thyroid function
usually occurs by 12 months following delivery. Some women will experience only one of these periods and some will develop
permanent hypothyroidism.(100) Major depressive episodes in the postpartum period may have an insidious onset and come to clinical
attention 4 to 6 months postpartum, which correlates with the peak incidence of postpartum hypothyroidism. Thyroid dysfunction is
often implicated in depression in women. (23; 38)
Postpartum Mood and Anxiety Disorders: Approximately 13 percent of mothers experience postnatal depression. It occurs at a crucial time in
a mothers life, can persist for long periods and can have adverse effects on partners and on the emotional and cognitive development of infants
and children. (70)
a. Maternity blues (Baby Blues): (15) Usually a temporary condition occurring after delivery, attributed to the hormonal changes that take
place following the delivery of the placenta. It typically lasts days to weeks and can sometimes develop into postpartum depression.
b. Postpartum depression: (15) Peak incidence of postpartum depression can occur at approximately three months after delivery, but
symptoms can surface anytime during the first year (or longer) following delivery. This disorder is characterized by a maternal sense of
feeling out of control. Beck et.al have identified a process called Teetering on the Edge (referring to the fine line between sanity and
insanity) that included the following stages:
Encountering Terror: This is the stage when the depression hits the mother. She experiences anxiety attacks, obsessive thoughts
and a mental fogginess and inability to concentrate.
Dying of Self: This stage is characterized by maternal feelings of isolation, an unreal quality to life and suicidal ideation.
Struggling to Survive: Mothers battle the system to find help for their condition, they may use prayer as a way to obtain help and
they make seek assistance from support groups.
Regaining Control: This is considered the road to recovery, which may be very slow. There may be regrets at the amount of time
lost during the depressive episode. The mother will become more like herself.
c. Postpartum psychosis: (15; 50) Considered to be the most severe of the Postpartum Mood and Anxiety disorders, psychosis usually
appears shortly after delivery and is characterized by high incidence of maternal suicide and infanticide. This episode may follow a
previously undiagnosed mood disorder .This disorder is considered a psychiatric emergency and the mother should be hospitalized. The
mother should not be left alone with the infant.
d. Postpartum panic disorder: (15) Postpartum is a time when a panic disorder may first be diagnosed or when a pre-existing panic disorder
worsens. This may be due to hormonal changes or other medical conditions that need to be ruled out (e.g., hyperthyroidism, mitral valve
prolapse).
e. Obsessive compulsive disorder with postpartum onset: (15) Pregnancy and the postpartum period are times that can render a woman more
vulnerable to either develop obsessive-compulsive disorder (OCD) or manifest OCD tendencies that may have already existed. Cause is
unknown, but may be related to hormonal changes affecting serotonin levels. An increase in anxiety and depression can coexist with an
OCD disorder. Recurrence with future pregnancies may be seen.
12
f.
Post-traumatic stress disorder related to childbirth: (15) Contributing factors may include history of psychological disorder, negative
memories associated with previous deliveries, first baby, experiencing of extreme pain, long labor, lack of information regarding process,
feeling powerless, fear for own life and/or that of unborn child, unpleasant interactions with staff in the Labor and Delivery unit, induction of
labor, highly interventional labor and delivery care, perceptions of receiving poor care, cesarean delivery, differences between actual
delivery experience and planned delivery experience, feelings of being violated during the delivery experience. There is a heightened trio of
emotions that accompany this disorder: anger (rage), anxiety (panic attacks) and depression (suicidal ideation). Feelings of isolation can
negatively impact relationships, including the relationship with her infant.
10. Situational Response:
a. Psychological defenses allow us to cope with our day-to-day life. Increased stress leads to less effective psychological defenses, therefore,
our typically well-managed emotions (e.g., anger, sadness, anxiety, frustration) become less well-managed leading to emotional instability,
interpersonal conflict and diminished social/occupational functioning in many persons. (38)
b. The family unit is a system based on interdependency between members and patterns that provides structure and support. A medical
condition (e.g., pregnancy, complication of pregnancy) may disrupt these relationships and patterns. (30)
c. Mothers report feeling overwhelmed, frightened or weak after giving birth and describe struggles to receive their preferred care or treatment
that violated their wishes (e.g. breast fed infants receiving supplements in the nursery, lack of collaborative decision making). (102)
d. Individual differences need to be considered regarding response/reaction to medical condition (e.g., pregnancy, complication of pregnancy)
and support provided to patient/support system. Gender and/or cultural differences may influence response/reaction as well as attitudes
and beliefs about support. (75)
e. Healthcare practitioners may hesitate to ask questions related to a patient/support system emotional/mental status, for fear of not feeling
prepared to deal with the response. Failure to address this area of patient/support system health can result in suboptimal care. For this
reason, it is essential to refer to someone on the healthcare team that is knowledgeable, competent and comfortable in assisting the patient/
support system in this area. (38)
f. Normal, pregnant women may temporarily develop mild cognitive defects during labor and after birth when compared with nonpregnant
women. Women report problems with attention, concentration and memory throughout pregnancy and in the early postpartum period. (55)
Changes may be attributable to increased levels of pregnenolone and allopregnanolone that are correlated with negative effects on memory,
as well as increased levels of cortisol which impacts hippocampal integrity and memory. (50)
g. Community and web-based support groups/programs are often an effective way for patients/support systems to enhance/assist with coping
skills. (101)
h. Definition: A phase in ones life during which normal ways of dealing with the world are suddenly interrupted due to pregnancy and/or a
complication of pregnancy. (71; 101)
i. Risk factors: Adjustments to parenting, under any circumstances, are necessary and normal. (88) A history of chronic mental health issues,
substance use/abuse, poor coping abilities/strategies, past experience of trauma/abuse (both personal and professional), lack of support
and low self-esteem contribute to an inability to deal with trauma (e.g., pregnancy, complication of pregnancy). (65)
C. ADDITIONAL INFORMATION:
1. Cesarean delivery:
a. Incidence: From 1965 through 1988, the cesarean delivery rate in the United States rose progressively from only 4.5 percent of all deliveries
to almost 25 percent. Most of this increase took place in the 1970s and early 1980s and occurred throughout the western world. Between
1989 and 1996 the annual rate of cesarean delivery decreased in the United States. This was due in large part to an increased rate of
vaginal birth after cesarean (VBAC) and to a lesser extent, a small decrease in the primary cesarean rate. Since 1996, however, the total
cesarean rate has increased every year and in 2002 it was 26.1 percent, the highest rate ever recorded in the United States. The reasons
why the cesarean rate quadrupled between 1965 and 1988 and its continued rise are not completely understood but some explanations
include the following:
Women are having fewer children, thus a greater percentage of births are among nulliparas who are at increased risk for cesarean
delivery.
The average maternal age is rising and older women, especially nulliparas, are at increased risk of cesarean delivery.
The use of electronic fetal monitoring is widespread. This technique is associated with an increased cesarean delivery rate compared
with intermittent FHR auscultation. Cesarean delivery performed primarily for Category III FHR tracing comprises only a minority of all
such procedures. In many more cases the concern for an abnormal or Category III FHR tracing lowers the threshold for cesarean
deliveries performed for abnormal progress of labor.
The vast majority of fetuses presenting as breech are now delivered by cesarean.
The incidence of midpelvic forceps and vacuum deliveries has decreased.
Rates of labor induction continue to rise and induced labor, especially among nulliparas, increases the risk of cesarean delivery.
The prevalence of obesity has risen dramatically and obesity also increases the risk of cesarean delivery.
Concern for malpractice litigation has contributed significantly to the present cesarean delivery rate. More than a decade ago, it was
reported that failure to perform a cesarean delivery and thus avoid adverse neonatal neurological outcome or cerebral palsy was the
dominant obstetrical claim in the United States. Although more recent data are aggregated differently, they suggest that this picture
has changed little. Specifically, in 2001 a brain-damaged infant was the claim responsible for 40 percent of all medicolegal indemnity
paid by obstetricians-gynecologists. This reality is especially troubling in view of the well-documented lack of association between
cesarean delivery and any reduction in childhood neurological problems.
Some elective cesarean deliveries are now performed due to concern over pelvic floor injury associated with vaginal birth. Indications
include: prior cesarean delivery, dystocia, Category III FHR tracing, malpresentation.
Incision: Usually either a midline vertical or a suprapubic transverse incision is used.(41)
13
2.
3.
4.
5.
Expected biophysical changes following delivery: (41; 100)

a. VS:
Temperature: May be elevated during the first 24 hours due to dehydration and postoperative state. Continued temperature elevation
can be an indication of infection.
BP: BP should remain stable in the postpartum period; however, lowered vascular resistance in the pelvis may result in orthostatic
hypotension when a patient moves to a sitting or standing position. An increase in BP, especially if accompanied by headache or
visual changes, may indicate the onset of postpartum preeclampsia or be related to pain or anxiety. A decrease may be an indication
of bleeding or hemorrhage.
Respirations: Normal range is 16 to 24 per minute, but may be decreased related to narcotic analgesia, magnesium sulfate toxicity,
anesthesia and/or medications.
Pulse: remains stable or decreases slightly after birth. The presence of tachycardia can be an indication of bleeding/hemorrhage or
infection. Some women display a pulse rate of 40 to 50 beats per minute; the cause of this transient bradycardia in uncertain.
Breasts: Engorgement occurs approximately the second or third postpartum day due to increased levels of prolactin; no engorgement is a sign
of a problem that requires close follow-up. It may be as a result of retained placental tissue or minimal breast tissue growth during pregnancy.
For the breastfeeding mother: Suckling by infant stimulates milk production; 24-hour rooming in supports breastfeeding and is an integral part of
family-centered care.
a. Colostrum: present at delivery; thick and yellow in appearance; high in protein, lower in fat and sugar, amount produced may vary.
b. Transitional milk: follows colostrum and is present up to two weeks postpartum. Not as yellow as colostrum; lower in protein and higher in
fat, lactose and calories.
c. Mature milk: follows transitional milk; thinner and whiter in appearance. Composed of foremilk (milk initially taken in by the infant and
satisfies thirst) and hind milk (the milk received later in the feeding that has a higher fat content, satisfies infant hunger and increases infant
weight gain).
d. If a mother is not breastfeeding: milk leakage and discomfort from engorgement begins one to four days after birth. Considerable pain
may be experienced. Wearing a well-fitting bra, ice packs, analgesics and avoiding nipple stimulation will provide relief. Tenderness
decreases within 48 to 72 hours after engorgement occurs. Breast changes experienced during pregnancy will subside within the first three
weeks postpartum.
Uterus: Involution results from a decrease in the size of myometrial cells, not in the number. This decrease is a result of ischemia, autolysis and
phagocytosis. Immediately after birth the uterine fundus can be palpated midway between the umbilicus and symphysis pubis. During the first
12 hours after birth, the muscles relax slightly and the fundus returns to the level of the umbilicus. Within 24 hours the uterus is approximately
the size it was at 20 week s gestation. Beginning on postpartum day two or three, the usual progression of involutions one centimeter per day.
Multiparity, multiple gestation, polyhydramnios and bladder dysfunction can influence uterine size and the progress of involution. (100)
Lochia: The placenta separates from the uterus within 15 minutes of birth in 90 percent of women and within three minutes for 95 percent of
women. Separation of the placenta and membranes includes the spongy layer of the endometrium, leaving the deciduas basalis in the uterus.
The remaining layer reorganizes into basal and superficial layers. The superficial layer becomes necrotic and sloughs off as lochia. The basal
layers become the beginning of the new endometrium. Although lochia varies in amount, the total volume lost is usually 150 to 400 mL. At 7 to
14 days postpartum the superficial tissue over the placental site sheds. There may be an increase in vaginal bleeding at this time; bleeding
lasting more than one to two hours should be evaluated. Although the amount of lochia lost following a cesarean delivery may be less than
following a vaginal delivery, the stages (rubra, serosa and alba) remain the same for both delivery methods.
a. Rubra:
Normal color: red
Normal duration: one to three days
Normal discharge: bloody with clots; fleshy odor, increased flow on standing, with breastfeeding or during physical activity
Abnormal discharge: Foul smell, numerous and/or large clots, quickly (within 15 minutes) saturates perineal pad
b. Serosa:
Normal color: pink, brown tinged
Normal duration: 3 to 10 days
Normal discharge: Serosanguineous (blood and mucus) consistency, fleshy odor
Abnormal discharge: foul smell, quickly saturates perineal pad
c. Alba:
Normal color: yellowish-white
Normal duration: 10 to 14 days (not abnormal to last longer)
Normal discharge: mostly mucus, no strong odor
Abnormal discharge: foul smell, saturates perineal pad, reappearance of pink or red lochia, discharge lasts longer than four weeks
d. Return of menses: although the return of ovulation and menses may vary, the first menstrual cycle usually occurs in 7 to 9 weeks for nonnursing mothers. There are wide variations in the return of menses for nursing mothers due to depressed estrogen levels. Menses usually
resumes between months 2 and 18. The first menstrual cycle is usually anovulatory but up to 25 percent of mothers may ovulate prior to
their first cycle. The average return of ovulation is 10 weeks for non-nursing mothers and 17 weeks for nursing mothers. Preferred method
of contraception should be discussed and implemented prior to resumption of sexual intercourse.
14
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
Cervix: The cervix and lower uterine segment are thin and flaccid immediately following delivery. Cervical lacerations may have occurred during
birth especially for patients with precipitous labor and operative procedures such as a cervical cerclage. At two to three days postpartum the
cervix resumes its usual appearance but is dilated two to three centimeters. If the mother experienced labor prior to a cesarean delivery, the
internal os returns to a normal state within the first two weeks postpartum. Refitting of diaphragm birth control devices is recommended following
each delivery.
Vagina: The vagina and vaginal outlet are smooth-walled and may appear bruised in the early postpartum period. The voluntary muscles and
supports of the pelvic floor regain tone during the first six weeks postpartum. Kegel exercises may improve vaginal tone. In lactating women,
lowered estrogen levels may cause the vagina to look pale and without rugae; this may cause painful intercourse. Mucus production will return
when the mother ovulates.
Endocrine/Hormones: Estrogen and progesterone levels decrease with placental delivery stimulating the anterior pituitary to produce prolactin.
Between the third and fourth weeks postpartum prolactin levels return to normal in non-nursing mothers. For nursing mothers, prolactin levels
increase with each breastfeeding episode. Thyroid function returns to nonpregnant levels within four to six weeks after birth. Immunosuppression is a normal physiologic response of pregnancy; there is a slightly increased risk of recurrence of hypothyroidism postpartum.
Decreased levels of placental lactogen, estrogen, cortisol, growth hormone and the enzyme insulinase reduce their anti-insulin effect during the
postpartum period. This causes lower glucose levels and a reduction in insulin need for insulin-dependant diabetic mothers.
Cardiovascular: Changes occur early in the postpartum period with baseline levels resumed 6 to 12 week after delivery. Blood volume
changes rapidly. Autotransfusion occurs when blood flow is eliminated to the placenta. Blood loss with an uncomplicated vaginal birth is 500 to
1000 mL, more with a cesarean delivery. Blood volume returns to normal levels by three to four weeks postpartum. Hematocrit levels decrease
after delivery due to lower blood volume and dehydration. Hemoglobin levels reflect the amount of blood loss experienced at delivery and
immediately postpartum. Both levels should return to normal levels within several weeks postpartum. Plasma volume is diminished as a result of
blood loss and diuresis returning to normal levels one to two weeks postpartum. Cardiac output depends on the use and choice of anesthesia
and analgesia, mode of delivery, blood loss and maternal positioning. After reaching a maximum at 10 to 15 minutes after delivery, cardiac
output begins to decline reaching prepregnancy levels by two to three weeks after birth.
Respiratory: The respiratory system quickly resumes in a nonpregnant state following birth. These changes occur as a result of a decrease in
progesterone levels, a decrease in intra-abdominal pressure and the return to normal diaphragmatic movement. Vital capacity, inspiratory
capacity and maximum breathing capacity decrease after birth; the patients tolerance for exercise may be affected in the first postpartum weeks.
Basal metabolic rate can remain elevated for the first two postpartum weeks and is attributable to mild anemia, lactation and psychologic factors.
Acid-base balance returns to normal by three weeks postpartum.
GI: After birth, a decrease in GI muscle tone and motility occurs. When this is coupled with relaxation of the abdominal muscles, gaseous
distension, constipation and ileus can occur. Constipation may also result from hemorrhoids, perineal trauma, dehydration, pain, fear of having a
bowel movement, immobility and medication (e.g. magnesium sulfate, iron, codeine, anesthetics during surgery).
Urinary system: Labor may result in displacement of the bladder and stretching of the urethra and anesthesia and temporary neural dysfunction
of a traumatized bladder following a cesarean section may interfere with normal urinary process. Decreased sensitivity may result in
overdistention and incomplete emptying. Postpartum diuresis, which usually begins within five hours of birth, combined with an often large
amount of IV fluids administered during labor or surgery can result in a full bladder in a relatively short time. Urine output may be 3000 mL or
more per day. The first void after delivery should occur within the first six to eight hours and voiding amounts should be at least 150 to 200 mL.
Normal bladder tone usually resumes five to seven days postpartum. A uterus that is assessed to be above the umbilicus and/or displaced to the
right side can be an indication of urinary retention. Mild proteinuria (1+) may occur for one to two days postpartum in approximately half of all
women. If a urine specimen is necessary it should be obtained by catheterization or a clean-catch midstream to avoid protein-laden lochia.
Stress incontinence may appear transiently during the first six weeks postpartum.
Musculoskeletal system: Diastasis of the rectus muscles is common and usually resolves in the late postpartum period. Joints that have been
loosened during pregnancy should stabilize by the sixth postpartum week.
Skin: Discoloration that occurred during pregnancy should slowly fade following delivery. Diaphoresis, sometimes profuse, can occur as a part of
the diuresis process. Striae ("stretch marks") are red to purple at delivery. They are caused by hormonal changes or rupture of elastic fibers of
the stretching skin from over distension of the abdominal wall and can also appear on the breasts, buttocks and thighs. Striae gradually fade and
will eventually appear as irregular white lines maternal age and weight gain contribute to the appearance of striae. (91)
Immune system: For Rh negative mothers, with Rh positive infants, anti-RhD immunoglobulin should be given within the first 72 hours following
delivery to prevent maternal sensitization. If a mother has a rubella titer that is 18 or less, a rubella vaccine should be administered during the
postpartum period. Mothers should be cautioned to avoid pregnancy for a 3-month time period following administration of rubella vaccine. When
indicated a diphtheria-tetanus-pertussis booster may be given prior to discharge. (41; 86)
Nervous system: Neurologic changes related to anesthesia and analgesia are transient. If present, they require attention to safety during
ambulation. Headaches may result from fluid shifts in the first postpartum week, leakage of cerebrospinal fluid during spinal anesthesia, fluid and
electrolyte imbalance, gestational hypertension or stress. Postpartum eclampsia is often preceded by severe headache and visual changes.
Hematologic changes: An increase in hematocrit is noted between postpartum days three and seven and returns to normal four to eight weeks
later as red blood cells reach the end of their life span. A 1 to 1.5 gram decrease in hemoglobin or two to three point rise in hematocrit is
reflective of a 500 mL blood loss. Elevated WBC count is seen as a result of the stress from labor and birth. A nonpathologic WBC count may
rise to 25,000/ L to 30,000/L. Infection should be suspected when the WBCs rises 30 percent over a six hour period.
Weight loss: average weight loss at birth is 12 pounds (5.5 kg). Additional weight loss occurs between two and six months postpartum,
especially if the patient is breastfeeding. Continued catabolism returns patient to prepregnant weight in 6 to 8 weeks if average weight gain was
25 to 30 pounds. Women who choose formula feeding have an average weight loss of one to two pounds (.5 to 1 kg) per week if eating a wellbalanced diet and slightly fewer calories than their usual daily calorie use. Weight loss occurs more rapidly in women of lower parity, age and
prepregnancy weight.
15
D. PATIENT/FAMILY RESOURCES:
1. Sidelines http://www.sidelines.org/
2. CaringBridge http://www.caringbridge.org/
3. March of Dimes http://www.marchofdimes.com/
4. LaLeche League International http://www.llli.org/ or local La Leche League groups
5. Maternal-child home visiting programs contact local health department
6. 150 Tips and Tricks for New Moms: From those Frantic First Days to Baby's First Birthday - Everything You Need to Know to Enjoy Your New
Addition by Robin Elise Weiss
7. Being Dad: Inspiration and Information for Dads-To-Be by 40 New Dads
E.
SAFETY CONSIDERATIONS AND INITIATIVES:

1. Advances in medical care have led to increasing numbers of complex, high-risk obstetric patients.
2. A sound knowledge of normal maternal physiology are essential to optimize outcomes.
3. To reduce errors and improve outcomes in the overall health of the population, meaningful, reliable, reproducible quality outcome measures must
be used.
4. Outcome measures should have five characteristics: association with meaningful maternal and neonatal outcomes, relation to outcomes that are
influenced by physician/health system behaviors, affordability for application on a large scale basis, acceptability to practicing obstetricians as a
meaningful marker of quality and reliability/reproducibility. (11)
5. The concept of quality of care may encompass not only the technical quality of the care provided but also how the patient perceives their health
care experience and whether the care was cost-effective.
6. There are currently no uniformly accepted measures of obstetrical quality. Many traditional measures of obstetrical quality are flawed and newer
measures are still undergoing necessary validation.
7. The Weighted Adverse Outcome Index may offer a useful model for how to establish such valid measures, although further testing and validation
needs to be done on a more comprehensive basis before it can be accepted as a standard.
8. The OB Safety Reporting System (OBSRS) is designed for all health care personnel involved in maternity care, including nurses, secretaries,
laboratory personnel, anesthesiologists, obstetricians, family medicine doctors and midwives. The system can be accessed by any of these
individuals via the Web site. The purpose of OBSRS is to promote maternal and infant safety during childbirth through an international forum for
the collection and dissemination of safety concerns in OB and maternal/newborn care. https://www.obsafety.org/
9. Compared with planned vaginal delivery at term, elective low-risk cesarean delivery poses higher risks of severe maternal morbidity. Pregnant
women and physicians should be aware of these potential risks when contemplating an elective cesarean delivery, and their decisions should be
based on the risks and benefits for mother and infant alike.
10. Pain:
The Joint Commission 2010 Hospital Accreditation Standards:
Provision of Care: Standard PC.01.02.07: The hospital assesses and manages the patients pain.
Standard PC.02.03.01: The hospital provides patient education and training based on each patients needs and abilities.
Rights and Responsibilities of the Individual: Standard RI.01.01.01: The hospital respects patient rights
The Joint Commission International Accreditation Standards for Hospitals, 3rd ed:
Patient and Family Rights: Standard PFR.2.4: The organization supports the patients right to appropriate assessment and management of
pain.
Assessment of Patients: Standard AOP.1.8.2: All patients are screened for pain and assessed when pain is present.
Patient and Family Education: Standard PFE.4: Patient and family education include the following topics, as appropriate to the patients
care: the safe use of medications, the safe use of medical equipment, potential interactions between medications and food, nutritional
guidance, pain management and rehabilitation techniques.
Institute for Clinical Systems Improvement (ICSI). Pain, Acute, Assessment and Management of (Guideline). Last Updated 3/2008.
Available at: http://www.icsi.org/guidelines_and_more/gl_os_prot/musculo-skeletal/pain_acute/pain__acute__assessment_and_management_of__2.html
11. Infection
Reduce the risk of healthcare-associated infections:
The Joint Commission 2010 Hospital Accreditation Standards, National Patient Safety Goal 7: Reduce the risk of healthcare-associated
infections.
The Joint Commission International Accreditation Standards for Hospitals, 3rd ed., International Patient Safety Goal 5: Reduce the risk of
health care-associated infections
National Quality Forum Safe Practices for Better Healthcare 2009 Update, Safe Practice 19, Hand Hygiene: Comply with current Centers
for Disease Control and Prevention Hand Hygiene Guidelines
National Quality Forum Safe Practices for Better Healthcare 2009 Update, Safe Practice 24 Multidrug-Resistant Organism Prevention:
Implement a systematic multidrug-resistant organism (MDRO) eradication program built upon the fundamental elements of infection control,
an evidence-based approach, assurance of the hospital staff and independent practitioner readiness, and a re-engineered identification and
care process for those patients with or at risk for MDRO infections.
Note: This practice applies to, but is not limited to, epidemiologically important organisms such as methicillin-resistant Staphylococcus aureus,
vancomycin-resistant enterococci, and Clostridium difficile. Multidrug-resistant gram-negative bacilli, such as Enterobacter species, Klebsiella
species, Pseudomonas species and Escherichia coli, and vancomycin-resistant Staphylococcus aureus, should be evaluated for inclusion on a
local system level based on organizational risk assessments.
Accreditation Canada. Patient Safety Goals: Infection Control: Reduce the risk of health service organization-acquired infections, and their
impact across the continuum of care/service. Available at: http://www.accreditation.ca/knowledge-exchange/patient-safety/goals/
16
Safer Healthcare Now! Getting Started Kit: Antibiotic Resistant Organisms: MRSA, How to Guide. Last updated 2/2009. Available at:
http://www.saferhealthcarenow.ca/EN/Interventions/aro_mrsa/Documents/ARO%20MRSA%20Getting%20Started%20Kit.pdf
Surgical-Site Infection Prevention:
Joint Commission Hospital Accreditation Standards, 2010 National Patient Safety Goal 7, NPSG.07.05.01: Implement evidence-based
practices for preventing surgical site infections.
National Quality Forum Safe Practices for Better Healthcare 2009 Update, Safe Practice 22, Surgical-Site Infection Prevention: Take
actions to prevent surgical-site infections by implementing evidence-based intervention practices
National Hospital Inpatient Quality Measures, Specification Manual: Surgical Care Improvement Project (SCIP) National Quality Measures:
Infections Measures
Institute for Healthcare Improvement, Protecting 5 Million Patients from Harm. Getting Started Kit: Preventing Surgical Site Infections: How
to Guide. Last updated October 1, 2008. Available at: http://www.ihi.org/nr/rdonlyres/c54b5133-f4bb-4360-a3e42952c08c9b59/0/ssihowtoguide.doc
Pediatric Affinity Group. How to Guide, Pediatric Supplement, Surgical Site Infections. n.d. Available at:
http://www.nichq.org/pdf/SurgicalSiteInfections.pdf
Safer Healthcare Now! Getting Started Kit: Prevent Surgical Site Infections, How to Guide. Last updated 5/2007. Available at
http://www.saferhealthcarenow.ca/EN/Interventions/SSI/Documents/SSI%20Getting%20Started%20Kit.pdf
Catheter-Associated Urinary Tract Infection Prevention:
National Quality Forum Safe Practices for Better Healthcare 2009 Update, Safe Practice 25, Catheter-Associated Urinary Tract Infection
Prevention: Take actions to prevent catheter-associated urinary tract infection by implementing evidence-based intervention practices
National Voluntary Consensus Standards for Nursing-Sensitive Care Performance Measures, Urinary Catheter-Associated Urinary Tract
Infections (UTI) for Intensive Care Unit (ICU) Patients: The rate of CAUTIs by ICU location.
Institute for Healthcare Improvement, Improvement Map. Getting Started Kit. Preventing Catheter-Associated Urinary Tract Infections:
How to Guide. Last updated 2/2009. Available at: http://www.ihi.org/nr/rdonlyres/4e9f3ce4-4841-4e48-bfee371fe6baac10/0/cautihowtoguide.doc
Centers for Medicare & Medicaid Services. Hospital-Acquired Conditions: Catheter-Associated Urinary Tract Infection
Glycemic Control:
National Quality Forum Safe Practices for Better Healthcare 2009 Update, Safe Practice 32, Glycemic Control: Take actions to improve
glycemic control by implementing evidence-based intervention practices that prevent hypoglycemia and optimize the care of patients with
hyperglycemia and diabetes.
Centers for Medicare & Medicaid Services. Hospital-Acquired Conditions: Manifestations of Poor Glycemic Control
12. Venous Thromboembolism:
Venous Thromboembolism Prevention:
The Joint Commission. Performance Measurement. Core Measure Set: Venous Thromboembolism (VTE) Measures. Last updated
4/2009. Available at: http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/VTE.htm
The Joint Commission Hospital Accreditation Standards. 2010 National Patient Safety Goal 3: Improve the safety of using medications.
NPSG.03.05.01: Reduce the likelihood of patient harm associated with the use of anticoagulant therapy.
National Quality Forum Safe Practices for Better Healthcare 2009 Update, Safe Practice 28 Venous Thromboembolism Prevention:
Evaluate each patient upon admission, and regularly thereafter, for the risk of developing venous thromboembolism. Utilize clinically
appropriate, evidence-based methods of thromboprophylaxis.
National Quality Forum Safe Practices for Better Healthcare 2009 Update, Safe Practice 29 Anticoagulation Therapy. Organizations
should implement practices to prevent patient harm due to anticoagulant therapy.
National Hospital Inpatient Quality Measures, Specification Manual: Surgical Care Improvement Project (SCIP) National Quality Measures:
VTE Measures
Safer Healthcare Now! Getting Started Kit: Venous Thromboembolism Prevention, How to Guide. Last updated May 2008. Available at
http://www.saferhealthcarenow.ca/EN/Interventions/vte/Documents/VTE%20Getting%20Started%20Kit.pdf
Agency for Healthcare Quality and Research. VTE Safety Toolkit. Last updated 2007. Available at: http://vte.son.washington.edu/
U.S. Department of Health and Human Services. The Surgeon Generals Call to Action to Prevent Deep Vein Thrombosis and Pulmonary
Embolism. Last updated 2008. Available at: http://www.surgeongeneral.gov/topics/deepvein/calltoaction/call-to-action-on-dvt-2008.pdf
13. Safe Surgery:
World Health Organization. WHO Guidelines for Safe Surgery 2009. Available at:
http://whqlibdoc.who.int/publications/2009/9789241598552_eng.pdf
The Joint Commission Hospital Accreditation Standards. 2010 National Patient Safety Goals: The Universal Protocol
Standard UP.01.01.01: Conduct a preprocedure verification process
Standard UP.01.02.01: Mark the procedure site
Standard UP.01.03.01: A time-out is performed immediately prior to starting procedures
The Joint Commission International Accreditation Standards for Hospitals, 3rd ed., International Patient Safety Goals, Goal 4: Ensure
Correct-Site, Correct-Procedure, Correct-Patient Surgery.
National Quality Forum Safe Practices for Better Healthcare 2009 Update, Safe Practice 26, Wrong-Site, Wrong-Procedure, WrongPerson Surgery Prevention: Implement the universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery for all
invasive procedures
17
F.
Institute for Healthcare Improvement, Protecting 5 Million Patients from Harm. Getting Started Kit: Reduce Surgical Complications: How to
Guide. Last updated 10/2008. Available at: http://www.ihi.org/nr/rdonlyres/ac9aaeed-7516-4371-88108bf45b8ce9c2/0/sciphowtoguide.doc
Pediatric Affinity Group. How to Guide, Pediatric Supplement: Surgical Site Infection. n.d., Available at:
http://www.nichq.org/pdf/SurgicalSiteInfections.pdf
Refer to the Breastfeeding Clinical Practice Guideline.
18
References
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3 American Society of PeriAnesthesia Nurses (ASPAN). (2001). Clinical guideline for the prevention of unplanned perioperative hypothermia. Journal of
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4 Amir, L. H., & Lumley, J. (2006). Women's experience of lactational mastitis. "I have never felt worse". Australian Family Physician, 35(9), 745 - 747.
5 Anderson, J. M., & Etches, D. (2007). Prevention and management of postpartum hemorrhage. American Family Physician, 75, 875 - 882.
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Clinical Practice Guideline:

POSTPARTUM FOLLOWING CESAREAN DELIVERY

Signs and symptoms of listed potential problems will be absent or manageable.

Acute Pain AEB: (29)

44. Initiate strategies to prevent mastitis:

Postpartum Mood and Anxiety Disorders AEB:

GENERAL INFORMATION: POSTPARTUM FOLLOWING CESAREAN DELIVERY

Medical Management of Postpartum Hemorrhage

IV: 10 to 40 units in 1 L normal

Avoid undiluted rapid IV infusion

20 mg, Suppository: vaginal or

Avoid if patient is hypertensive

800 to 1,000 mcg

Abbreviations: IV, intravenously; PG, prostaglandin.

Expected biophysical changes following delivery: (41; 100)

SAFETY CONSIDERATIONS AND INITIATIVES:

Refer to the Breastfeeding Clinical Practice Guideline.

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