Postpartum 08

Care of the Postpartum Client

Postpartum Physical Adaptations (pg. 906-929)

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Uterine Involution Fundal position changes: “Boggy” Lochia: Rubra, Serosa, Alba Cervical changes Vaginal changes Perineal changes Recurrence of ovulation and menustration

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Lactation Gastrointestinal System Urinary tract Vital signs Weight loss Postpartum chill Postpartal diaphoresis Afterpains or Afterbirth pains

Uterine Involution 

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The rapid reduction in size of the uterus and it’s return to a condition similar to its pre-pregnancy state. The uterus remains slightly larger than it was before the first pregnancy. Process is complete at 3 weeks except at the placental site (6 to 7 weeks) Subinvolution may be caused by an infection or retained placenta fragments.

WEIGHT OF THE UTERUS    

Right after delivery: 1000 grams 1 week after :500 grams 2 weeks after : 300 grams 6 weeks after : 50 – 60 grams

Fundal Position Changes 

After birth :  1st

day: one fingerbreadth below umbilicus  2nd day: two fingerbreadths below umbilicus  9th to 10th day: cannot be palpated abdominallyThe first postpartum day it is located 1 cm or fingerbreadth below the umbilicus.

Fundal Position Changes 

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May be displaced to the left or right by a distended bladder. Becomes “boggy” with uterine atony

“ Boggy Uterus ”   

Massage the uterus Place infant on mother’s breast Administer oxytocin  Check

BP  Do not give if BP > 140/90

UTERINE CONTRACTIONS  

Prevent bleeding Afterpains – uncomfortable cramps Common in multipara  Oxytocin treated  Breastfeeding mothers 

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2 – 3 days

NURSING MEASURES 

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Explain the cause and purpose of afterpains Keep bladder empty Prone position to lessen discomfort Gentle massage Administer analgesics

VAGINAL DISCHARGE 

LOCHIA  Uterine

discharge after delivery  Blood, mucus, epithelial cells, leukocytes and bacteria

COLOR AND PATTERN 

Rubra: dark red in color  present the first 2-3 days postpartum  few small clots 

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Serosa: pinkish to brownish  4th to the 10th day 

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Alba: creamy or yellowish  persists for a week or two after serosa, may be later in breastfeeding clients. 

SIGNS OF ABNORMAL LOCHIA

SIGNS

POSSIBLE CAUSE

FOUL SMELL

INFECTION

LARGE CLOTS

RETAINED FRAGMENTS

EXCESSIVE AMOUNT

LACERATION OF BIRTH CANAL

RETURN TO RETAINED FRAGMENTS RUBRIA AFTER INFECTION SEROSA OR ALBA BLEEDING AFTER SUBINVOLUTION OF 6 WEEKS THE UTERUS

CERVICAL CHANGES 

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Spongy, flabby, formless and bruised. Original form is regained in a few hours The shape is permanently changed by the first childbearing. Goes from dimple like to a lateral slit (fish mouth)

VAGINAL CHANGES  

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Edematous and bruised Small superficial lacerations may be present Laceration and episiotomy heals after 2 weeks Size and rugae return to pre pregnancy in 3 weeks By 6 weeks appears normal

PERINEAL CHANGES  

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edematous with some bruising Episiotomy edges should be approximated Ecchymosis may occur and delay healing Suture: 7 to 10 days Perineal muscle tone regained : 6th weeks

PERINEAL CARE Flush with warm water  Pat dry from front to back  Change pead frequently  Observe signs of infection  Reduce hemorrhoids 

PERINEAL CARE  

ICE PACKS SITZ BATH  PROMOTE

CIRCULATION  20 MINUTES 

PERINEAL LAMP  Promote

vasodilation  25 to 40 watts light  12 -18 inches away  20 minutes 3x a day

Recurrence of Ovulation and Menustration  

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Variable Generally returns to non-nursing mothers between 7 and 9 weeks after birth The first cycle is non-ovulatory Breastfeeding clients may experience menstruation and ovulation based on the amount of time nursing…may occur from 2nd to 18th month

LACTATION 

During pregnancy, the breasts develop in preparation for lactation as a result of both estrogen and progesterone. After birth, the interplay of maternal hormones leads to the establishment of milk production.

GASTROINTESTINAL 

May have a regular diet  High

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in protein, iron and vitamins

Bowels tend to be sluggish Episiotomy clients may delay bowel movement for fear of pain Cesarean birth clients may receive clear liquids and progress to a regular diet Stool softeners may be used

URINARY TRACT 

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increased bladder capacity, swelling and bruising of tissue, decreased sensitivity to fluid pressure, and decreased sensation of bladder filling. At risk for over-distention, incomplete emptying, and buildup of residual urine. Urinary output increases 1rst 24 hours post delivery (puerperal diuresis) Urine specimens should be obtained as a catheterized specimen.

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CARDIOVACULAR        

Blood loss: NSD: 300 to 500 ml CS: 500 to 1000 ml reduction in blood volume 40% increase of maternal blood volume after delivery of the placenta Return of cardiac output to pregnant state takes about 2- 3 weeks from delivery Hemoconcentration in the first 3 to 7 days Leukocytosis in the first 12 days Elevated fibrinogen levels up to the third weeks Physiologic bradycardia during the first 24 hours Orthostatic hypotension in the first 24 hours

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INTEGUMENTARY Disappearance of skin changes (6 weeks) except for striae and diastisis recti  Areolar hyperpigmentation may not disappear completely 

Vital Signs  

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afebrile after the first 24 hours. BP WNL, a decrease may occur. An ↑BP may indicate toxemia, PIH. Pulse rate may decrease to 5070. Tachycardia should alert the nurse to blood loss/difficult birth.

Blood Values 

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Blood values should return to the prepregnant state by the end of the postpartum period. Leukocytosis with white blood cell (WBC) counts up to 30,000 per mL may occur early postpartum. Convenient rule of thumb is a 2 point drop in hematocrit equals a blood loss of 500 mL.

Weight Loss 

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An initial weight loss of 10 to 12 lbs occurs as a result of the birth of the infant, placenta and amniotic fluid. Puerperal diuresis accounts for loss of an additional 5 lbs during the early postpartum period. Normally return to pre-pregnant weight by 6 weeks postpartum.

Postpartum Chill and Postpartal Diaphoresis 

Most clients experience a shaking chill or tremor after delivery. 

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Warm blankets usually relieve this tremor or chill.

Chills and fever late in the postpartum period may indicate sepsis. Diaphoretic episodes may occur at night, a normal occurrence as the body rids itself of waste products.

AMBULATION   

NSD : 4 – 8 hours ANESTHESIA : 8 hours ADVANTAGES:  Prevent

constipation  Prevent circulatory problems, urinary problems  Promote recovery  Hasten drainage of lochia

EXERCISE 

Purpose  Prevent

complications  Psychological well being  Strengthen muscles of back, pelvic floor and abdomen

EXERCISE 

POSTPARTUM EXERCISE  Abdominal

breathing  Kegel exercise: tighten perineal muscle  Arm Raising  Leg Raising  Sit-ups

REST AND SLEEP    

At least 8 hours Avoid heavy lifting Light housekeeping: 2 weeks Normal activities: 4 – 6 weeks

RESUMPTION OF SEX 

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VAGINAL DELIVERY: 3 – 4 WEEKS CS: 2 WEEKS

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Discharge Primiparas : 2 to 3 days Multipara: 1 to 2 days CS: 3 to 4 days  Discharge IE is done before leaving  Follow up: 4 to 6 weeks after delivery 

Postpartum Psychological Adaptations

Postpartum Psychological Adaptations  

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Postpartum blues Development of Parent-Infant attachment Initial attachment Behavior Father-Infant Interactions Cultural Influences

RUBIN’S POSTPARTUM PHASE 

TAKING-IN PHASE  1st

2- 3 days postpartum  Need for sleep and rest  Dependence on other 

TAKING-HOLD PHASE  Transition

phase  3rd day to 2 weeks postpartu,m  Control body function

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TAKING-HOLD PHASE  Ability

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to assume the mother role

LETTING-GO PHASE  Realize

that the infant is a separate individual and not a part of herself  Feeling of loss  Adjustment phase

Postpartum blues  

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Transient period of depression : 1 - 2 weeks after birth. Manifested by mood swings, anger, weepiness, anorexia, difficulty sleeping, and a feeling of letdown. CAUSE: Hormonal changes and psychological adjustments

Postpartum blues  Resolve

naturally in 2 to 3 weeks with support and reassurance.  If symptoms persist, the client should be evaluated for postpartum depression.

Development of Parent-Infant attachment    

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Level of trust Level of self-esteem Capacity for enjoying herself Interest in and adequacy of knowledge about childbearing and childrearing Client’s prevailing mood or usual feeling tone Reactions to the present pregnancy

Initial attachment Behavior   

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Progression of touching activities En face position dominates Relies heavily on senses of sight, touch, hearing in getting to know the baby Some negative feelings may occur; be understanding not condescending Reciprocity is an interactional cycle that occurs simultaneously between mother and infant. (mutual cueing behaviors, expectancy, delight in each others company when synchronous)

Father-Infant Interactions Primary role has been supporting role  Engrossment (the characteristic sense of absorption, preoccupation, and interest in the infant demonstrated by fathers during early contact with the newborn. 

Cultural Influences 

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Postpartum care my be affected by cultural beliefs: No shower, no breastfeeding for the first three days, “hot” and “cold” foods Do not make generalizations Extended family may play an important role in care

Postpartum Assessment 

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Vital signs: BP should remain consistent with baseline BP during pregnancy. Pulse 50 -90, respirations 16-24, temp 98-100.4 Breasts: Smooth, even pigmentation, soft, filling, full, engorged Abdomen: soft, fundus firm, midline and at/or below umbilicus, may be tender on palpation Lochia: rubra, scant to moderate, no clots, rubra to serosa to alba

Postpartum Assessment 

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Perineum: Slight edema, no bruising, episiotomy without redness, swelling or drainage, hemorrhoids (none or small) Lower extremities: No pain with palpation, negative Homan’s sign Elimination: voiding 4-6 hrs, no bladder distention noted, normal bowel movement by the 2nd to 3rd day post delivery Psychological adaptation: cultural assessment, bonding, holding en face, attachment behaviors

Postpartum Assessment

Dysfunctions of the Postpartum Period      

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Postpartal Uterine Infection: Endometritis, Pelvic Cellulitis Perineal Wound Infection Cesarean Wound Infection Urinary Tract Infection (UTI) Mastitis Thromboembolitic Disease: Superficial Leg Vein Disease, Deep Vein Thrombosis, Septic Pelvic Thrombophlebitis Postpartum Psychiatric Disorder: “baby blues”, Postpartum Psychosis, Postpartum Major Mood Disorder

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Two methods of milk suppression a. mechanical (tight bras, avoiding nipple stimulation, ice packs) b. pharmacologic (bromocriptine)