1. POST PARTUM
Lecture 8 1

2. Puerperium: “to bring forth” 6 wk > childbirth.
“4th trimester” - transition for woman/family (pregnancy ends/parenting role begins)
I. Physiological Changes of Post Partum Period
A. Reproductive System Changes:
UTERUS: contx’s begin > birth & delivery of placenta
1. placental site seals
2. Entire uterus contracts & reduces gradually for days. “INVOLUTION”. Pt. in danger of hemorrhage uterus until involution is complete.
Oxytocin released > uterine contx’s. 2

3. Fundus: assess for firmness. Palpate > delivery.
umbilicus X 24 hrs. Soft aka “boggy” - danger of hemorrhage.
Massage uterus!
Uterus descends one finger breadth every day.
Delivery day, umbilicus
1st day PP uterus 1 FB ↓ Umbilicus
2nd day PP uterus 2 FB ″ and so forth.
Support lower segment of uterus when palpating to prevent uterine eversion. 3

4. Full bladder raises fundal height, gives false reading.
By day 10, uterus almost back to pre-pregnant size & position in pelvic cavity. [1000 grams→ 50 grams] No longer palpated in abdomen.
Full bladder raises fundal height, gives false reading.
Natural oxytocin released with breast feeding. ^ contractions . 2FB ↓ umb. on 1st day PP.
Breast fdg.offers little protection against hemorr. 4

5. Delay in uterine involution: retained placenta/clots -
effective contraction of uterus not possible. Risk of PP Hemorr.
Delay also with:
multiparous pt. [grand multip ]
exhaustion
multi-fetuses.
C/S involutes slower; d/t surgery & less initiation of breast feeding > delivery.
After-birth pains = cramping caused by contractions
more in multi-parous women than in primips .
With Br. Fdg. because of release of oxytocin. 5

6. Placenta separates from spongy layer of uterus - decidua BASALIS.
2. LOCHIA
Placenta separates from spongy layer of uterus - decidua BASALIS.
Inner layer of decidua remains & forms new layer of endometrium . Outer becomes necrotic & sheds.
Consists of blood, fragments of decidua, mucus, bacteria.
1st 3 days = rubra =”red” [blood]
>3 days = serosa = “pink”
10th day – alba - “white” [up to 3 wks]
Total flow lasts about 4-5 wks
Should not be bright red; could be PP hemorrhage. 6

7. Neck; remains slightly opened & contracts > delivery.
3. CERVIX
Neck; remains slightly opened & contracts > delivery.
In 7 days, opening narrow as pencil. Os remains slit-like .
4. VAGINA
Slightly distended after birth. Kegel exercises ^muscle tone and strength. Important for lacerations.
5. PERINEUM
Can be edematous/ecchymotic
Ice x 24 hrs. then heat [Sitz]
Topical anesthetics creams/sprays apply for comfort.
Perineal massage relaxes perineum before delivery.
May prevent episiotomy/laceration.
Teach Kegels - tightening & releasing of perineal muscles. Improves circulation & healing of epis/lac. 7

8. Complications of Perineum: Hematomas [blood from bleeding vessel]
Area of swelling on one side of perineum.
If small, absorbs in few days; apply ice & give analgesics.
If large bleed, to OR for evacuation & vaginal packing.
Common - forceps deliveries
Perineal Care - use warm water; wipe from front to back. 8

9. size of baby, timing of delivery, tension on perineum.
Laceration
size of baby, timing of delivery, tension on perineum.
Sutured & treated as episiotomies.
Analgesics, ice, topical creams, Sitz bath.
1st degree = from base of vagina to base of labia minora.
2nd “ = from base of vagina to mid perineum
3rd = entire perineum to anal sphincter
4th = entire perineum through anal sphincter & some rectal tissue.
Nothing into rectum - no rectal temps., suppositories, or enemas with 4th degree to avoid further damage.
Colace TID, ^ po fluids to promote BM. Ice X 24 hrs., Sitz baths TID; topicals. KEGELS! 9

10. SYSTEMIC CHANGES - Body returns to pre-pregnant state by 6 wks.
Hormonal System:
Pregnancy hormones decrease w. delivery of placenta.
HCG & HPL disappear by 24 hrs. FSH rises
12 days - to begin new menstrual cycle. Menses resumes by 4-5 wks. if not Br. Fdg. 10

11. ↓ bladder sensitivity - ↑ risk for bladder infection - urinary stasis.
The Urinary System:
Loss of bladder tone d/t swelling & anesthesia ; urinating difficult. May not feel urge to void.
Hydronephrosis [enlargement of ureters] occurs after delivery & to 4 wks. PP. DIURESIS!
↓ bladder sensitivity - ↑ risk for bladder infection - urinary stasis.
Avoid bladder damage - assess bladder q 1-2 hrs.til voids qs. Teach voiding q 2 – 3 hours.
Palpate abdomen gently, note location of fundus.
When do you suspect full bladder?
During preg., ml. of fluid accumulates in body - Client loses lbs. of water weight in 1st wk.
How?
Diaphoresis & diuresis…. 11

12. Circulatory System: Blood volume ^ 30 – 50% in pregnancy.
With diuresis & blood delivery, blood volume
returns to normal in 1-2 wks.
Blood loss for NSVD = 300 cc. & C/S = 500 cc.
Non pregnant: HCT= % & HGB= g/dL
Pregnant: HCT= % & HGB = 11.5 – 14g/dL
HCT drops by 4 pts. & HGB drops by 1 g. for every 250cc. of blood client loses.
Patient should not be anemic entering delivery
Possible blood transfusion with large blood loss.
Average blood volume: pre-pregnant = 4000cc;
pregnant state = 5250cc. 12

13. Can cause ^ thrombus formation.
^ Blood volume: provides adequate exchange of nutrients in placenta & compensates for blood loss during delivery.
HR remains ^ x hrs. PP
With diuresis, HCT levels rise [^ hemoconcentration] reach pre-preg level by 6 wks.
Plasma fibrinogen ^^ 50% during pregnancy & remains elevated 6 wks. PP. [^ estrogen levels] WHY?
Can cause ^ thrombus formation.
Assess pts. legs/calves for s/s thrombus.
Rise in leukocytes; WBC ^ protective measure to prepare for stress of delivery. As high as 20-25,000.
To prevent hemorrhage. 13

14. Gastrointestinal System: NSVD: bowels sounds. Eat right away.
C/S: bowel sounds hypoactive 1st 8 hrs.
Epidural/spinal: po clears after delivery, advance diet if +BS.
General anesthesia: usually NPO for ~ 6-8 hrs.
Duramorph/astromorph can cause N/V up to 12 hrs.
antiemetic meds. [Reglan/Zofran] .
BM - difficult/painful d/t lacerations/hemmorhoids.
C/S - BM 3rd - 4th day. GI activity slowed d/t surgery.
Can go home without BM if + flatus. 14

15. Integumentary System: Stretch marks
[striae gravidarum] appear reddened on
abdomen. Fade by 3-6 months;
Pearly white marks may remain in lighter
skinned pts. & darker marks in darker skinned pts.
Modified sit-ups strengthen abdomen 15

16. T = 100.4 or > PP infection suspected.
VITAL SIGNS PP
Temperature: slightly ^ - dehydration during labor 1st 24 hrs. Returns to normal within 24 hrs.
T = or > PP infection suspected.
Temp. also rises 3rd - 4th day with filling of breast milk
Observe for s/s infection - nurse usually 1st to detect ↑ temp. [universal sign of infection x 2 readings, on days 2-10 PP]
Pulse: HR ^ slightly x 1st hr.
Stroke volume & cardiac output also ^ x 1st hr. then decreases
8-10 wks.,returns to pre-pregnant state.
Rapid, thready pulse- sign of PP hemorrhage, infection 16

17. Blood Pressure - Monitor carefully. 1st trimester
Heart works faster to handle ^ volume. BP remains same.
2nd trimester
BP drops slightly d/t lowered peripheral resistance in blood
vessels as placenta expands rapidly. Heart beats faster,
more efficiently d/t ^ blood volume.
Pre-pregnant BP 120/80. Pregnant BP 114/65.
3rd trimester
BP back to pre-pregnant value.
REVIEW: 17

18. BP Complications
↓ BP
[90/60 or less] with dizziness is “Orthostatic hypotension”; could signify hemorrhage.
Take BP/pulse lying/sitting/standing. Compare values.
Orthostatic: If BP drops mmHg and pulse increases 20 bpm or more. Caution for falls.
Needs IV fluids. Take VS. Report to MD > order for CBC.
↑ BP
[140/90 or >] could signify PP pre-eclampsia.
Notify MD. Could develop into serious complication.
Oxytocic meds [Pitocin] > delivery could ^ BP 18

19. RN coordinates nursing care & infant feeding times
Other Changes
Exhaustion:
Common
Frequent rest periods
RN coordinates nursing care & infant feeding times
provide maximum rest time.
Weight Loss:
Average wt. loss 12 lb. [infant & placenta]
5 lbs. - diuresis & diaphoresis in wk. that follows.
Lochial flow lbs.
Total = approx lbs. {depends on total wt. gain}
At 6 wks. wt. may still be above pre-preg. weight.
Return of Menses: > delivery FSH levels rise causing ovulation
No Br. Fdg.- menses resumes ~ 6 wks.
Lactation delays menses for several months (6 mos) 19

20. PSYCHOLOGICAL CHANGES OF POST PARTUM PERIOD: ADJUSTMENTS
Taking-In Phase:
time of reflection for client regarding new role
may be passive or excited
talks at length about birth experience
on phone with family/friends recounting birth experience.
Usually lasts 1-2 days.
Delayed d/t pain r/t vaginal or C/S.
Taking-Hold Phase:
woman makes own decisions regarding self & infant care.
Usually day Occur on day 1 esp. if woman is multip.
Can occur later, depends on recovery process or cultural beliefs. 20

21. Woman gives up fantasy image of baby and accepts
Letting Go Phase:
Woman gives up fantasy image of baby and accepts
real child.
Occurs within few weeks of getting home
Needs time to adjust to new experience.
Bonding:
Expressing maternal love & attachment toward new baby. Develops gradually.
Enface position: close eye contact with infant.
Healthy bonding - kissing, touching, counting fingers & toes, cooing, etc.
Factors Interfering with Bonding: difficult labor, birth (NICU) 21

22. Other Maternal Feelings of Post Partum Period
Abandonment: feelings that occur > birth of child; woman no longer center of attention.
Disappointment: infant does not meet expectations of mother/father. Eg. eye color; sex .
Post Partum Blues: d/t normal hormonal changes;
Drop in estrogen/progesterone; lasts 1st few days of
PP period. Occurs in 50% of women. 22

23. PP Depression: 30% of women exp. this.
Therapy & medication may be necessary.
Hx of depression & anxiety prior to pregnancy puts higher risk for developing this.
Can manifest itself up to 1 year > birth.
Screening tool: Edinburgh PP depression tool
Always refer to social worker to assess for degree of depression.
Ask: is mother able to take infant home without danger to self or baby?
Studies show breast feeding helps reduce symptoms d/t oxytocin “feel good” effect 23

24. MANIFESTATIONS OF POSTPARTUM DEPRESSION
 interest in surroundings
 interest in food
unable to feel pleasure
fatigue
health c/o
sleep disturbance
panic attacks
obsessive thinking
 hygiene
 ability to concentrate
odd food cravings
irritability
rejection of infant 24

25. frequent contact with other adults Resource:
PPD: Teaching
relaxation therapy
rest & nutrition
frequent contact with other adults
Resource:
The Post Partum Resource Center of New York, Inc.
MANIFESTATIONS OF POSTPARTUM PSYCHOSIS
s/s depression
s/s manic
auditory hallucinations
delusions
guilt
worthlessness 25

26. Development of Parental Love & Positive Family Relationships:
Rooming In: most hospitals offer this; infant stays in room with mom 24hrs. (partial or complete)
Sibling Visitation: encourage siblings to visit to promote family togetherness. 26

27. LACTATION & BREAST FEEDING
Lactation starts regardless if pt. is breastfeeding or not.
Entirely up to mother
Must feel comfortable doing so.
Advantages to Breast Feeding:
Promotes bonding between mother & baby.
High nutritional value for infant.
Promotes uterine involution thru release of
oxytocin from posterior pituitary.
Reduces cost of feeding & preparation time. 27

28. Nurse has major role as educator of benefits & methods of
breast feeding.
Ways to teach new moms about lactation:
videos
handouts
hands on demo
lactation specialist [in clinical settings]
Offer support
Contraindications to Breast Feeding:
Mom receiving meds not appropriate for Br. fdg. [Lithium]
Exposure to radioactive compounds [thyroid testing]; pump & dump breast milk x 48 hrs. Flush in toilet.
Breast Cancer; HIV 28

29. Physiology of Lactation
Body prepares for lactation during pregnancy; stores fat
& nutrients; provide energy, vitamins, minerals in breast milk.
Early pregnancy, ↑ estrogen (placenta) stimulates growth of milk glands & size of breasts.
Colostrum: middle of pregnancy & day 1-3 PP,
Thin, watery pre-lactation secretion. Rich in antibodies; passes to baby in 1-3 days.
Breasts begin to get tender; fill up w. milk.
Breast milk by 3rd to 4th day in response to:
falling levels of estrogen & progesterone > delivery of placenta.
^ production of prolactin by anterior pituitary
Milk ducts become distended & fluid turns bluish-white 29

30. Physiology cont.
Infant suckling on breast produces more prolactin, which in turn stimulates more milk production.
Finally, oxytocin released > delivery of placenta causing mammary glands to send milk to nipples [let down reflex].
Progesterone levels drop after delivery which leads to ↑ milk production. 30

31. Anatomy of Lactation
Colostrum: protein, sugar, fat, water, minerals, vitamins, maternal antibodies.
Provides total nutrition for infant
Transitional breast milk by 3 – 4th day.
Mature breast milk by 10th day.
Each breast lobes of glandular tissue -alveoli.
Acinar or alveolar cells of glands form milk.
Each alveolus ends in a ductule.
Each alveoli produces milk, ejects it into ductules aka let down reflex; milk transported to lactiferous sinus and ejected into infant’s mouth. 31

32. Pathway of Droplet of Milk:
Milk → mammary ducts → reservoirs behind nipples [lactiferous sinuses] → infant’s mouth
Foremilk: constantly accumulating.
“Let-down reflex” –lets foremilk be available right away.
Triggered by sound of baby crying
Hind milk: forms after let-down reflex. Has most calories;
Feed until breast empty.
Breast Milk: Provides complete nutrition for 1st 6 mos of life.
> 6 months, iron-fortified cereal.
Breast milk easier to digest than formula.
Iron in breast milk absorbed better than iron in formula. 32

33. Supply & Demand Response - Every time woman breast
feeds, more prolactin produced which then produces ^milk.
Time Interval to ↑ milk volume. It takes approx min. to fill up breast after nursing.
Assessment: Antepartum Changes
Breasts enlarge [each breast gains ~ lb. or more]
Glands enlarge
Increased blood flow to breasts, causing blood vessels to enlarge & become more visible.
Areola [dark circle around nipple] enlarges and darkens
Small bumps on areola [Montgomery’s tubercles] enlarge and produce oils to soften nipples and keep them clean.
Teach moms no soap on nipples;may ^ irritation.
Lanolin; tea bags [wet] [tanic acid] on sore nipples. 33

34. Engorgement : milk enters on 3rd - 4th day; C/S - prior to D/C
Common Problems:
Engorgement : milk enters on 3rd - 4th day; C/S - prior to D/C
breasts hard, painful to touch.
Warm soaks, hot showers, express milk manually, breast feed q 2-3
Pumping produces more milk. Cabbage leaves; diuretic property.
nursing bra.
tight bra and ice packs x hrs– why?
Analgesics [Tylenol 650 mg. q hrs.prn]
Sore/Cracked/Bleeding Nipples
Common - from improper positioning or not enough areola in infant’s mouth; may continue to feed; up to mom. Reposition infant. Reattempt nursing.
Rest the nipple; apply lanolin ointment prn.
Apply tea bag [tanic acid] natural healing property.
Constrict ducts & stop flow & production of breast milk. 34

35. Plugged Duct Mastitis –
firm nodule under arm; temporarily blocked duct; relieved by infant sucking. Evaluate carefully since may be malignant growth. Warm compresses prn.
Mastitis –
“inflammation”; milk duct/gland becomes infected. Poss. antibiotic therapy. Manual expression, continue to breast feed, frequent warm compresses. 35

36. Nursing Care : Promote successful breast feeding:
Encourage first feeding [L&D, PP; establish pt’s.
desire to breast feed]
Emptying of breasts ~ 20 minutes
Teach: start on breast where she left off - maintains good supply.
Rest, relaxation, ↑ fluids by four 8 oz glasses/day.
Not enough fluids, ^ anxiety may lower milk production.
Nutritional Counseling: ^ 500 calories/day. 36

37. Health Teaching Rooting – sign of hunger
Breast feed q 2-3 hrs. for minutes
Teach “latching”: nipple and part of areola to prevent nipple irritation. Listen for swallowing.
Nursing Bra
Feeding & Burping [bottle fed infants] upright position
Nipple care: no soap; nipple creams -Lansinoh
Avoid drugs, alcohol, smoking 37

38. Position upright position- support head and shoulders]
FORMULA FEEDING
Feeding Skills
Position upright position- support head and shoulders]
Formula [Similac, Enfamil, Isomil; all have iron]
milk or soy based
Burp
Safety Tips
never prop bottle; choking or ear infection.
^ amt. ½-3/4 oz./day; feed q 3 – 4 hrs. x 24 hrs.
Discharge Follow up:
Telephone calls & home visits [if needed]
Help line; Support groups [La Leche] 38

39. NURSING MANAGEMENT OF POST PARTUM CLIENT
Assessment – minimum of twice daily
Vital signs
Emotional Status
Breasts
Fundus, lochia, & perineum
Voiding & bowel function - flatus, BM
Legs [+ Homan’s sign, ankle edema ]
S/S complications [PP hemorrhage, infection, ↑ BP ]
Nursing Care
Safety
Prevent hemorrhage- massage uterus on admission and q 4 for first 8 hrs.
Prevent falls – assess when getting out of bed for 1st 8 hrs. Assist when necessary. Check labs for low H&H. 39

40. Bowel function (1-3 days to resume).
Stool softeners, as ordered [Colace]
Encourage ambulation
Increase dietary fiber
Provide adequate fluid intake
Health teaching & discharge planning
Reinforce self care -hand washing, peri care,
Self-breast exam q month; S/S PPD
Comfort Measures
Ice , Sitz Baths, Topical Anesthetics
Analgesia, Kegels for NSVD; modified sit-ups for
NSVD & C/S, Breast Care 40

41. Family Planning options [condoms, depo, OC’s, IUD] Exercises
Birth Control Plans
Family Planning options [condoms, depo, OC’s, IUD]
Exercises
Keep 6 week PP appt.
Maternal Warning Signs to Report
a) Heavy Vaginal Discharge [poss. hemorrhage]
b) Pelvic or perineal pain [traveling clot]
c) Fever [temp or greater = infection]
d) Burning sensation during urination [UTI]
e) Swollen area on leg ; painful, red, or hot
f) Breast: painful, red, hot area [mastitis] 41

42. a] Bathing, cord care, circumcision care, diapering
Infant care
a] Bathing, cord care, circumcision care, diapering
b] Feeding, burping, scheduling feedings [mom can keep chart]
c] Temperature, skin color [dusky], newborn rash, jaundice
d] Stool & voiding [BM’s ; 6 or more voids/day]
e] Back to Sleep [SIDS]
Newborn warning signs:
1. Diarrhea, constipation
2. Colic, repeated vomiting esp. projectile vomiting
3. Fever [temp Rectal or greater]
4. S/S inflammation/ cord stump [yellow drng.]
5. circumcision site
6. Rash, jaundice
7. Deviation from normal patterns [long period of sleep >5 hrs.; projectile
vomiting, etc. R/O sepsis; intestinal obstruction] 42