1. Nursing 471 Postpartal Anatomic & Physiologic Changes And Care
Dr. Jeannie Harper, PhD, RN

2. Objectives
Describe the anatomical and physiological changes that occur during the postpartal period
Identify psychological and cultural needs during the postpartal period
Relate the complications that can occur in the postpartal period
Discuss nursing interventions for the postpartal woman

3. Postpartum Nursing Diagnoses
Risk for fluid volume deficit
Acute pain
Risk for infection
Risk for altered bowel elimination
Risk for altered urinary elimination
Risk for disturbed sleep pattern
Potential knowledge deficit

4. Uterus
Involution: return of uterus to prepregnancy state; subinvolution
Location
Delivery: midline, approx. 2 cm below umbilicus
12 hours postpartum may be 1-2 cm above umbilicus
Fundus descends 1-2 cm every 24 hours
Contractions make uterus firm & prevent bleeding

5. Uterus continued Lochia Lochial flow
Rubra: Delivery > 3 days (dark red)
Serosa: > 10 days (pinkish)
Alba: 2-6wks (white)
Lochial flow
Scant < 2.5 cm (1 inch)
Light < 10 cm (4 inches)
Moderate < 15 cm (6 inches)
Heavy- Saturated pad in 2 hours

6. Vagina and Perineum Low estrogen causes thin mucosa & dryness
Prepregnant size after 8 weeks
Thicker mucosa (ruggae)after ovarian function returns
Introitus edematous, erythmatous

7. Endocrine System Sudden drop in placental hormones
Estrogen, cortisol, insulinase
Decrease in estrogen leads to
Breast engorgement
Diuresis of extracellular fluid
Decreased insulin requirements; lower BG
Breastfeeding leads to increased prolactin levels which suppress ovulation, not a reliable method of birth control
Serum prolactin levels vary with frequency & duration of breast feeding and intensity of sucking
Ovulation can occur as early as 27 days, mostly by 3 mos
Postpartal "blues" or "baby blues"

8. Urinary System Traumatized during delivery
Edematous & hyperemic urethra
Decreased urge to void
Bladder distention can lead to decreased uterine ctxs which can lead to postpartal hemorrhage
Profuse diuresis & diaphoresis
Mild proteinuria x 1-2 days

9. GI System Anesthesia & analgesic may delay return of gastric motility
Delayed BM (dehydration, prelabor diarrhea, discomfort, anesthesia, analgesia)
Hemorrhoids
Increased appetite

10. Breasts Breastfeeding mom Nonbreastfeeding moms
Soft to palpation before lactation begins & may be tender, warm and firm up to 48 hours with beginning milk production
Colostrum excreted first (yellowish color), then milk (bluish white color) by 2-3 days
Nonbreastfeeding moms
Engorgement from congestion of veins & lymphatics causes breasts to be swollen, firm, tender, warm on 3rd to 4th
Resolves spontaneously within hours

11. Immune System
No Changes
Determine need for
Rubella
Rhogam

12. Neurological, Musculoskeletal and Integumentary Systems
Carpal tunnel syndrome reverses
Musculoskeletal changes reverse (except shoe size may increase)
Some skin changes may remain
Linea nigra
Pigmentation of areolae
Striae gravidarum

13. Cardiovascular System/VS
Blood loss of ~ 500 ml-100ml tolerated well usually
Pulse & resp rate decline after ~ 1-24 hrs
B/P remains stable or slight decrease
Decreased plasma volume leads to increase in HCT and HGB by day 7
WBC's increased X days
Clotting factors and fibrinogen elevated in early PP
Temp elevation to F (38.0C) first 24 hours

14. Psychological Adjustments
Mother
Reva Rubin's three phases of the puerperium
Taking-in (dependent) first 1-2 days; mother is passive, dependent; reflective; talks about birth experience
Taking-hold (dependent/independent) mother becomes active in own & baby's care; lasts up to 10 days
Letting-go (interdependent) woman redefines her role; accepts real child, not fantasy image; involves some grief work, may continue a while

15. Psychological Adjustments
Attachment/bonding
Claiming
En face
Reciprocity/mutuality
See pp. 606, signs of potential psychocial complications, and 654, assessment of attachment behaviors

16. Psychological Adjustments
Father
Engrossment
Stages
Stage 1-Expectations
Stage 2-Reality
Stage 3-Transition to mastery
Siblings-must be included!!
Grandparents

17. Fourth Stage of Labor See p. 586, Box 23-1 1-2 hours after birth
Assess q 15 min X 1 hour, then q 30min X 1 hour
BP, P, R, Fundus/Lochia
Assess perineum; bladder ; activity level; LOC; tremors; temp q 1 hour
See p. 586, Box 23-1

18. Postpartal Nursing Care
Assessment
BUBBLEHE
REEDA
Care
Discharge Teaching
Potential Complications

19. Assessment BUBBLEHE B - breasts U – uterus B – bladder B – bowel
L – lochia
E – episiotomy
H – Homan’s sign
E – emotional state

20. Assessment REEDA R – redress E – ecchymosis E – edema D – discharge
A – approximation

21. Care Breasts – engorgement, bra, ice, nipples
Uterus – location, firmness, massage, c/s
Bladder – voiding, cath prn, I&O, infection
Bowel – sounds, flatus, BM, hemorrhoids
Lochia – type, amount, odor, clots
Episiotomy – REEDA, peri-care, infection
Homan’s sign - assess
Emotional state – see later slide

22. Care continued Fluids/Nutrition Comfort level Feeding Method Fatigue
IV, I&O, appetite
Comfort level
Comfort measures
Pain medication (Duramorph, analgesics. Ibuprofen)
Feeding Method
Fatigue
Ambulation/orthostatic hypertension
Rubella/Rhogam (see p. 604)
Kleihauer-Betke test
Teaching – Ongoing/Discharge

23. Emotional State Stages Bonding/attachment Cultural-p. 607
Social services
Blues/Depression
Teens
Family

24. Discharge teaching Signs/sxs complications Rest, diet, elimination
Vagina and Perineum
Pelvic rest for 2-4 weeks
Birth control if requested
Kegel exercises
Appt for 6 week pp checkup

25. Potential Complications
Hemorrhage
Causes-uterine atony; lacerations; retained placental fragments
Infection
Thrombus; thrombophlebitis
Hematoma
Preeclampsia