Cervix, Vagina, and Perineum

The cervix appears edematous, with bruising. The external cervical os has a ragged, slit-like appearance instead of a round shape as seen in the nulliparous woman. The vaginal walls are thin and dry, with an absence of rugae. Vaginal mucus production returns with the return of estrogen production. Rugae reappear in 4 weeks.

Bruising and edema of the perineum is common. The episiotomy (if present) should be free of erythema,

Table 27-1 Lochia and Nonlochia Bleeding

with the edges well approximated and without discharge. It should heal in 2 to 3 weeks. Sutures that are used are absorbed by the woman’s body. Lacerations of the perineum are classified from first to fourth degree, depending on depth of involvement. The repaired laceration should also have well-approximated edges and no drainage. Healing time depends on laceration depth. Return of these areas to the nonpregnant state should be complete in 6 to 8 weeks.

Lacerations of the genital tract.

Lacerations of the cervix, the vagina, and the perineum are also causes of postpartum hemorrhage. Hemorrhage related to lacerations should be suspected if bleeding continues despite a firm, contracted uterine fundus. This bleeding can be a slow trickle, an oozing, or frank hemorrhage.

Factors that can lead to obstetric lacerations of the lower genital tract include operative birth, precipitous birth, congenital abnormalities of the maternal soft parts (vulva perineum), and a contracted pelvis. Other causes include size, abnormal presentation, and position of the fetus; relative size of the presenting part to the size of the birth canal; scarring from prior vaginal infections, injury, or surgery; and vulvar, perineal, and vaginal varicosities. Extreme vascularity in the labia and periclitoral area often results in profuse bleeding if laceration occurs. Pelvic hematomas (i.e., a collection of blood in the connective tissue) may be vulvar, vaginal, or retroperitoneal in origin. Vulvar hematomas are the most common. They usually are visible and painful. Vaginal hematomas are typically associated with a forceps-assisted birth, episiotomy, or primigravidity. Retroperitoneal hematomas are the least common, but they are life threatening. They are caused by laceration of one of the vessels attached to the hypogastric artery, usually because of the rupture of a cesarean scar during labor.

Most acute injuries and lacerations of the perineum, the vagina, the uterus, and their support tissues occur

Box 27-1 Hypovolemic Shock

Signs and Symptoms

• • Woman has persistent significant bleeding (perineal pad soaked within 15 minutes); this bleeding may not be accompanied by a change in vital signs or maternal color or behavior.
• • Woman states she feels weak, lightheaded, “funny,” or “sick to my stomach” or she “sees stars.”
• • Woman begins to act anxious or exhibits air hunger.
• • Skin turns ashen or grayish.
• • Skin feels cool and clammy.
• • Pulse rate increases.
• • Blood pressure declines.

Interventions

• • Notify primary health care provider.
• • If uterus is atonic, massage gently and expel clots to cause uterus to contract; compress uterus manually, as needed, with two hands. Add oxytocic agent to IV drip, as ordered.
• • Give oxygen via face mask or nasal prongs at 8 to 10 L/min.
• • Tilt the woman to her side or elevate the right hip; elevate her legs to at least a 30-degree angle.
• • Provide additional or maintain existing IV infusion of lactated Ringer’s solution or normal saline solution to restore circulatory volume.
• • Administer blood or blood products, as ordered.
• • Monitor vital signs.
• • Insert an indwelling urinary catheter to monitor perfusion of kidneys.
• • Administer emergency drugs, as ordered.
• • Prepare for possible surgery or other emergency treatments or procedures.
• • Chart incident, medical and nursing interventions instituted, and results of treatments.

during childbirth. Ideally, injuries are repaired at the time of delivery, which facilitates healing, limits residual damage, and reduces the incidence of infection. Future gynecologic problems, including pelvic relaxation, uterine prolapse, cystocele, and rectocele, may be attributed to childbirth.

The tendency to sustain lacerations varies with each woman; in some women, the soft tissue may be less distensible. Heredity may be a factor in this. For example, the tissue of light-skinned women, especially those with reddish hair, is not as readily distensible as that of darker-skinned women, and healing may be less efficient.

Perineal lacerations.

Perineal lacerations are the most common of all injuries in the lower genital tract. They usually occur when the fetal head is being born. The extent of the laceration is defined in terms of its depth:

• •First-degree: Laceration extends through the skin and structures superficial to muscles.
• •Second-degree: Laceration extends through muscles of perineal body.
• •Third-degree: Laceration continues through the sphincter muscle.
• •Fourth-degree: Laceration also involves the anterior rectal wall.

Perineal injury is often accompanied by small lacerations on the medial surfaces of the labia minora below the pubic rami and to the sides of the urethra and the clitoris. Lacerations in this vascular area often result in profuse bleeding and necessitate repair with absorbable sutures.

When caring for the woman with a third-degree or fourth-degree laceration, the nurse must assess the bowel habits. Assessment of fecal continence should be included. The initial stool after delivery may be uncomfortable, and measures to promote soft stools should be implemented. Some health care providers may prescribe stool softeners. Additional measures include promoting fluid intake and encouraging increased dietary fiber and activity such as walking. Rectal treatments such as enemas or suppositories are contraindicated for women who have third-degree or fourth-degree lacerations. Antimicrobial therapy may be used in some cases.

Vaginal and urethral lacerations.

Vaginal lacerations often occur in conjunction with perineal lacerations. Vaginal lacerations tend to extend up the lateral walls (sulci) and, if deep enough, involve the levator ani muscle. Additional injury may occur high in the vaginal vault near the level of the ischial spines. Vaginal vault lacerations may be circular and may result from forceps rotation, especially in cases of cephalopelvic disproportion, rapid fetal descent, and precipitous birth. Lacerations can also occur around the urethra (periurethral) and in the area of the clitoris.

Cervical injuries.

Cervical injuries occur when the cervix retracts over the advancing fetal head. These cervical lacerations occur at the lateral angles of the external os; most are shallow, and bleeding is minimal. Larger lacerations may extend to the vaginal vault or beyond the vault into the lower uterine segment; serious bleeding may occur. Extensive lacerations may follow if the woman is allowed to push before full cervical dilation is achieved. Injuries to the cervix can impact pregnancies and childbirths.

Nursing interventions for episiotomy, lacerations, and hemorrhoids are listed in Box 27-2.

Breasts

Breast changes begin early in pregnancy. Increased amounts of estrogen stimulate enlargement of breast size by increasing adipose tissue and fluid retention. Estrogen also stimulates the growth of the milk ducts to prepare for lactation (function of secreting milk or period during which milk is secreted).

The first secretion produced by the breast is colostrum. This precursor to milk is thin, watery, and slightly yellow. It is rich in protein, calories, antibodies, and lymphocytes. Colostrum production begins in the second trimester. Expectant mothers begin to leak colostrum in the later weeks of the third trimester. Its production continues for about 2 days after delivery, when true milk production begins.

Lactation is a combination of hormonal, neurologic, and psychological responses. After delivery, estrogen and progesterone levels diminish rapidly. As they drop, the level of prolactin increases. Prolactin, a hormone secreted by the anterior pituitary gland, is responsible for stimulating milk production in the mammary alveolar cells. Stimulation of the nipples, particularly by the infant’s sucking, causes the release of oxytocin from the posterior pituitary gland. Oxytocin stimulates contraction of the mammary ducts, and milk is ejected from the breast. This cycle is called the let-down reflex.