1. Normal Postpartum
Chapter 21

2. What is involution? Normal Puerperium
It is the period of recovery that occurs from childbirth and extends for 6 weeks after delivery
What is involution?

3. Postpartal Physical
Adaptations

4. Reproductive System Changes

5. What are the three ways that the uterus involutes?8

6. Contraction of the Uterus
Muscle fibers become shorter controlling the bleeding by compressing and sealing off blood vessels –
Acting as “the living ligature”

7. Protein Material Catabolism
Release of a proteolytic enzyme into the endometrium and myometrium.
This enzyme breaks down the protein material in the hypertrophied cells causing the uterine muscle cells to decrease in size
The uterus gradually decreases in size as the cells grow smaller

8. Regeneration of the Endometrium
the placenta site heals in about 6 weeks with the other part healing in 3 weeks.
Heals by exfoliation rather than by forming scar tissue.
The endometrium grows from the margins of the placental site and from the fundi of the endometrial glands left in the basal layer of the placental site

9. Why does the uterus heal by
Critical Thinking
Why does the uterus heal by
Exfoliation
and not by
primary intention?

10. Uterine Changes
Placement and size
Where is the normal placement of the uterus immediately after birth, 12 hours later?
What is the size of the uterus?

11. What nursing intervention should the nurse encourage PRIOR to
Uterus
What nursing intervention should the nurse encourage PRIOR to
assessing the fundus?

12. Uterine Changes What is the normal tone of the uterus?
What is the technique used to assess the uterus?

13. Uterine Involution
What is the PRIORITY intervention when the uterus is found to be boggy?
Why is it important not to over-stimulate the uterus?

14. Uterus
What interventions must the nurse include if the uterus is found deviated from midline?

15. Short Answers
The nurse is going to assess the uterus. The 3 main assessments include: 1. 2. 3.
The normal height of a first day postpartum woman is ________________. It should decrease _____fingerbreadth per _______.
The tone should be __________. If found boggy, the nurse would ___________ the uterus.

16. Lochia What are the three types of lochia? What is a normal amount?
What question is important to ask
the woman when assessing amount?
What is normal odor of Lochia?

17. Characteristics of Lochia
Should not be excessive in amount
Should never have an offensive odor
Should not contain large pieces of tissue
Should not be absent during the first 3 weeks
Should proceed from rubra -- serosa -- alba

18. Match the Lochia
A. Pinkish serum with mucus and debris usually occurs on day
B. Creamy yellowish brownish. Occurs after day 10
C. Dark Red and consists mainly of blood. Occurs day
Lochia rubra
Lochia serosa
Lochia alba

19. Fill in the Blank Lochia should never be ______________ in amount.
Lochia should never have an ______________odor.
Lochia should not contain __________ _________ of tissue
Lochia should not be _____________ during the first ________ weeks
Lochia should proceed from _________ to _________ to ___________.

20. Cervix
Remains soft and flabby, appears bruised and may have some lacerations
No longer does the external os have the pre-pregnant appearance -- now appears as a jagged slit not a circle.

21. Vagina May be edematous and bruised.
Rugae begin to appear when ovarian function returns.
May teach the mom to do Kegels exercises to increase the blood flow to the area and aid in healing

22. Perineum How should the nurse assess the perineum? Assess: R – redness
the episiotomy the same as with any incision.
R – redness
E – edema or swelling
E – ecchymosis or bruising
D – drainage
A – approximated
How should the nurse assess
the perineum?

23. What are measures to teach the mom in caring for the perineum?

24. Comfort Measures Relief of Perineal Discomfort
Ice packs
Topical agents
Perineal care
Sitz bath
Relief of hemorrhoidal discomfort may include
Sitz baths
Topical anesthetic ointments
Witch hazel pads

25. Ovulation and Menstruation
When does Menstruation generally return?
Return is prolonged for the breastfeeding mom because of alterations in the gonadotropin-releasing hormone production.

26. Ovulation and Menstruation
Nurses need to teach moms that breastfeeding is NOT a reliable means of contraception.
WHY

27. Breasts
Allow the mother to assess her own breasts -- similar to doing a self-breast exam
ask if feels any nodules, lumps
ask if nipples are sore, reddened, blisters, cracks
Assess nipples for everted, flat, inverted
Teach to care for breasts according to whether they are breastfeeding or bottle feeding.

28. Process of Lactation
Sucking of infant stimulates the nerves beneath skin of the areola to transmit messages to the hypothalamus
Hypothalamus sends messages to the pituitary gland
Anterior pituitary -- stimulates Prolactin to be released which is the ultimate stimulation for milk production
Posterior pituitary -- releases Oxytocin which stimulates the contraction of the cells around the alveoli in the mammary glands. This causes milk to be propelled through the duct system to the infant. This is the “LET-DOWN” reflex. Felt as a tingling sensation

29. Breastfeeding Care No soap on the nipples, wash in water
wear supportive bra
Breastfeeding tips:
Most important is the “latch-on” Teach measures to assist with the infant getting the nipple and areola in the mouth
Teach different positions to hold the baby
No timing
Relax to allow for “let-down”
express colostrum on the nipples after feeding
remember drops of colostrum are the same as ounces of milk -- if wetting diapers / day, then must be getting enough to eat

30. Suppression of Lactation
Key is to teach the mother measures to decrease stimulation of the breasts
Wear a tight-fitting bra or binder
Do not express milk from the breasts
Take shower with back to the warm water
Ice packs

31. Fill in the Blank
The Anterior pituitary stimulates the release of ___________________ which is responsible for _________ _____________________.
The posterior pituitary gland releases ___________ which is responsible for the ______-__________ reflex.

32. Short Answers
What are four important interventions to teach a mom who is bottle feeding to decrease stimulation of the breasts. 1. 2. 3. 4.

33. Cardiovascular System

34. Cardiovascular System Changes
How does the body rid itself of excess Plasma volume?
Blood Volume
Increase for about hours after delivery
Increase in blood flow back to the heart when blood from the placenta unit returns to central circulation
Extravascular interstitial fluid is moved into the vascular system / intravascular
Leads to increased cardiac output mainly RT increase stroke volume.

35. Blood Values Post Partum Pregnancy
WBC – leukocytosis is common with values of 25,000 – 30,000 RT increased neutrophils
RBC – return to normal
Hgb. – normal to see a drop of about 1 gram
Hct – normal to see a drop of about 2- 4 points and then a rise RT > loss of plasma than RBC death
Platelets – drop and gradually rise
Pregnancy
WBC – elevated slightly to about 12,000
RBC – increase slightly to about 10 milion.
Hemoglobin – stays about normal at ~ 12 g. Below 10 g = anemia
Hemotocrit – lowers % RT hemodilution. If drops below % = anemia

36. Assess for Thromboembolism
During pregnancy, plasma fibrinogen (coagulation) increases, Mother’s body has the ability to form clots and prevent excessive bleeding.
Plasminogen (lysis of clots) does not rise
Hypercoagulable state and the woman is at a greater risk for thrombus formation.
assess for homan’s sign

37. Vital Signs Temperature Blood Pressure
A slight elevation of up to may occur related to dehydration and increase basal body metabolism from exertion of labor and delivery.
After 24 hours, the temperature should be normal
A temperature greater than suggests infection.
Blood Pressure
Should remain stable
Hypovolemia can indicate postpartum hemorrhage
Hypervolemia could indicate preeclampsia
What common changes in vital signs occur in the postpartum period?

38. Vital Signs Pulse Respirations Bradycardia of 50 – 70 bpm is Normal
Tachcardia is not considered a normal occurrence and may indicate excessive blood loss
Respirations
Should remain stable and within normal range

39. Critical Thinking The woman’s vital signs are:
T.100.8, P- 56, R – 16, B/P – 110/65.
How would the nurse interpret these findings? What interventions are indicated?

40. Gastrointestinal Tract
The most common GI problem during postpartum is constipation – EXPLAIN.
What teaching is important to assist in decreasing constipation?

41. What is the most common problem associated with the urinary system?
Why be concerned?

42. Critical Thinking
A primigravida delivered 2 hours ago. The woman states she would like to go to the bathroom. What should the nurse do?
The woman is unable to void. What should the nurse do next?

43. Afterpains Who is more likely to experience afterbirth pains? Explain.
Relief of after pains
Positioning (prone position)
Analgesia administered an hour before breastfeeding
Encourage early ambulation - monitor for dizziness and weakness

44. Rest and Activity
Most common problem is Sleep -- the excitement and exhilaration experienced by birth my make it difficult to sleep. They are tired and need rest. Allow for times of uninterrupted sleep.
Exercises -- have the patient to ask her own doctor for specific exercises. Usually walking is safe. May eventually do postpartum exercises. Just need to allow the body to return to its pre-pregnant state before straining it.

45. Resumption of Activities
New mother should gradually increase activities and ambulation after birth
She should avoid heavy lifting, excessive stair climbing, strenuous activity
Resume light housekeeping by second week at home
Delay returning to work until after 6-week postpartum examination

46. Exercises Recommend exercise to provide health benefits to new mother
Nurse should encourage client to begin simple exercises while on nursing unit
Inform her that increased lochia and pain may necessitate a change in her activity

47. Pain
Perineal pain -- caused from trauma during delivery, episiotomy, hemorrhoids. Provide comfort measures such as: sitz baths, Tucks, Sprays / Foams, oral analgesics.
Afterbirth pain -- more common in multigravidas and breastfeeding moms. Treat with * mild analgesics (NSAIDS, Acetamenaphen),heating pad, lie on abdomen, discontinue use of oxytocins,
Breast engorgement -- warm or cold packs, increase feedings, decrease stimulation. Bind breasts.
Gas distention -- no ice, increase warm / hot fluids, increase walking, rocking chair, antiflatus drugs.

48. Decision Making
During shift assessment of the post partum mom’s peri pad, the nurse found it saturated with lochia rubra.
What would be the priority nursing
intervention?

49. The Nutrition Need
Most moms are hungry and eager to eat. Start off slowly to avoid nausea and vomiting.
Diet should include:
High in Protein, vitamin C, and fiber
Increase in fluids
Lactating moms need about 700 extra calories for milk production
Prenatal vitamins and iron supplements are often continued in the postpartum period.

50. Psychological Adjustment
The responses of the mother to the birth of her infant are influenced by many factors such as:
Her parents own birth -- parenting and nurturing
Cultural background -- only by understanding and respecting the values and beliefs of each woman can the nurse plan and meet the patient’s needs
Readiness for parenthood -- emotional maturity, pregnancy planned or unplanned, financial status, job status
Freedom from discomfort -- physical condition
Health of her newborn -- physical condition, prematurity, congenital defects
Opportunities for parent- infant interactions

51. Postpartum Blues Transient period of depression
Occurs first few days after delivery
Mother may experience tearfulness, anorexia, difficulty sleeping, feeling of letdown
Usually resolves in 10 to 14 days

52. The Process of
Becoming Acquainted

53. Allow time for attachment to occur with all members of the family
Bonding
Initial attraction felt by parents
Contact should occur as early as possible and as frequently as possible.
Allow time for attachment to occur with all members of the family

54. Attachment Bond that endures over time
Occurs through mutually satisfying experiences
Reciprocity - Mutually gratifying interaction among mother, infant, father

55. Attachment Process
Enface - infants face on same vertical plane as parent. Mutual gazing
Explore with finger-tips
Hand and Palmar contact
Whole arms --enfolds whole baby close to body

56. Claiming “Those long toes are just like his Dad’s”
The Claiming Process
Includes the identification
Of the baby’s specific
Features, relating them
To other family members
“Those long toes are
just like his Dad’s”

57. The Steps in Attachment are:1. 2. 3. 4.

58. Postpartum Phases by Rubin
Taking - in
Occurs during day following delivery.
Marked by a period of being dependent and passive behavior.
Mother’s primary needs are her own -- food
and sleep
Mother is talkative about her labor and delivery experience
***Main nursing is to listen and help the mother interpret events of the delivery to make them more meaningful and clarify and misconceptions

59. Postpartum Phases by Rubin
Taking - Hold
Occurs during day 3 to about 2 weeks postpartum
Ready to deal with the present
More in control . Begins to take
hold of the task of “mothering”
***It is the best time for teaching!

60. Tailoring teaching to individual Learning Styles
Demonstrations
Group Classes
Videotapes

61. Postpartum Phases by Rubin
Letting Go Phase
occurs after about 2 weeks
Mother may feel a deep loss over the separation of the baby from part of her body and may grieve over this loss.
Common for Postpartum Blues to occur during this time

62. Father-Infant Interaction
Engrossment
Sense of absorption
Preoccupation - Interest in infant

63. Discharge
Preparation for discharge should begin when expectant mother enters birthing unit
Mother needs to be aware of signs of postpartum complications and should be aware of her self-care needs
Nurses should begin first by assessing knowledge and expectations of new mother and family
Nurse should be available to answer questions and provide support to parents

64. Discharge Printed Information
Nurse should review with new mother any information she has received regarding postpartum exercises, prevent of fatigue, sitz bath and perineal care, etc. - nurse should spend time with parent to determine if they have any last-minute questions before discharge
Printed information about local agencies and support groups should be given to new family

65. The End