1. Normal Postpartum Revised 1/31/11 Debbie Perez RN, MSN, CNS

2. Normal Puerperium/Postpartum
It is the period of recovery that occurs from childbirth and extends for 6 weeks after delivery
It is a complex state of the childbearing experience during which the physical and psychological work of gestation and delivery become final
It is a period of INVOLUTION -- process by which the reproductive organs return to their normal size or pre-pregnant state and functions.

3. Reproductive System Changes
Discuss BUBBLE

4. Physiological Changes

5. The Uterus Contraction of the Uterus Autolysis / Catabolism
The uterus needs to return to its pre-
pregnant state. This occurs by:
Contraction of the Uterus
Autolysis / Catabolism
Regeneration of the
Endometrium 8

6. Contraction of the Uterus
Muscle fibers become shorter controlling the bleeding by compressing and sealing off blood vessels

7. Autolysis / Catabolism
Release of a proteolytic enzyme into the endometrium and myometrium.
This breaks down the protein material in the hypertrophied cells causing the uterine muscle cells to decrease in size

8. Regeneration of the Endometrium
the placenta site heals in about 6 weeks, the remainder of the endometrium surface heals in approx 3 weeks.
Healing takes place by exfoliation rather than by forming scar tissue.

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

10. Nursing Care 9

11. Assessment of the Uterus
Placement and Size (location)
Tone
Lochia

12. Nursing Care of Uterine Changes
Assessment of the Uterus
Placement and size -- should be level with the umbilicus after delivery. The uterus then should decrease 1 FB / day. Should also be midline and the size of a grapefruit

13. Nursing Care of Uterine Changes
Tone -- should be firm. Assess by supporting lower portion with one hand and palpate fundus with other.
If found boggy, then massage. Do not overmassage.

14. Lochia Assess Type Assess Amount Assess Odor
Rubra days; dark red; consists mainly of blood
Serosa days; pinkish serum with tissue and debris
Alba days; creamy yellowish, brownish
Assess Amount
When was pad last changed?
Assess Odor
Fleshy, not foul smelling Lochia

15. Characteristics of Lochia
Should not be excessive in amount
Should not have an offensive odor
Should not contain large pieces of tissue or blood clots
Should not be absent during the first 3 weeks
Should proceed from rubra -- serosa -- alba

16. Cervix
Remains soft and flabby, appears bruised and may have lacerations from delivery
Pre-pregnant appearance is a dimpled area in the center -- post-pregnancy appears as a jagged slit. .

17. Vagina May be edematous and bruised.
Rugae begin to appear when ovarian function returns.
May teach the mom to do Kegels exercises

18. Perineum May have tears, lacerations, or an episiotomy
Assessment Procedure:
Turn patient to side-lying / sims position
Gently spread buttocks apart inspect with
penlight
Assessment:
Episiotomy/lacerations/edema/hemorrhoids
Assess for complications/hematoma
Interventions:
Hygiene/ Peri-bottle filled with warm water
Wipe front to back; change pads frequently/snug fit
Use Tucks and Dermaplast Spray as needed
Sitz bath 3-4 x day

19. What are treatment measures to teach the mom in caring for her perineum? Why is perineal care important?

20. Match the Lochia
A. Pinkish serum with mucus and debris. Usually occurs on day
B. Creamy yellowish brownish. Occurs after day 10 to 2weeks.
C. Dark Red and consists mainly of blood. Occurs day
Lochia rubra
Lochia serosa
Lochia alba

21. 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 ___________.

22. 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.

23. Breasts
Teach to assess her own breasts -- similar to doing a self-breast exam (SBE)
Assessment:
Breasts- nodules, lumps
Nipples - assess for eversion, flat, inverted, cracking, bleeding, pain, blisters
Individualize teaching for breasts for breastfeeding and non-breastfeeding moms

24. 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

25. 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 and stooling, then must be getting enough to eat

26. Suppression of Lactation
Key: teach measures to decrease stimulation of the breasts
Tight-fitting bra or binder
Do not express milk from the breasts
Take shower with back to the warm water
Ice packs/cabbage leaves

27. 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.

28. 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.

29. Elimination Changes Urinary System
Assess and measure first two voidings post-delivery.
Important to attempt to void every hours. If unable to void– catheterize based on assessment
Diuresis is common -- loss of fluid of pregnancy
Mild proteinuria is normal.
Most common problem is urinary retention RT:
loss of elasticity and diminished bladder tone
loss of sensation from trauma, drugs, anesthesia
urethra edematous
Interventions: sitz baths,Tucks

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

31. Elimination Changes Gastrointestinal Tract
Most common problem is constipation RT:
decrease muscle tone and intra-abdominal pressure
Pre-labor diarrhea and decrease peristalsis
pre- delivery enema (not common)
dehydration
perineal tenderness, hemorrhoids and episiotomy
FEAR of pain
Patient Teaching:
increase fluids, fiber, and activity
stool softeners, anesthetic sprays, Tucks
**Do NOT give an enema or suppository to a person who has a 3rd or 4th degree laceration.

32. Regulatory Changes
Most common problem is Sleep deprivation -- the excitement and exhilaration following the birth may make it difficult to sleep.
Exercise – Should be individualized per patient. Use caution until involution is complete.

33. Postpartum Pain
Perineal pain – result of trauma during delivery-episiotomy/lacerations/hemorrhoids. Interventions: Comfort measures: sitz, Tucks, sprays / Foams, oral analgesics.
Afterbirth pain -- more common in multigravidas and breastfeeding moms. Interventions; Treat with mild analgesics (NSAIDS, Acetomenophen) heating pad, lie on abdomen, discontinue use of oxytocins, Norco for severe pain
Breast engorgement -- warm or cold packs, cabbage leaves, increase feedings if breastfeeding, decrease stimulation if not breastfeeding. Breast binder.
Gas distention -- no ice chips or cold liquids, provide warm / hot fluids, increase walking, rocking chair, Simethicone.

34. Integumentary Changes
Skin -- pigment changes will begin to disappear; diaphoresis is normal
Striae - May have stretch marks over abdomen and legs
diastasis recti- Can occur with overdistention of the uterus, caution with exercise
Episiotomy/lacerations – Important to treat as any other incision and maintain cleanliness
C/S Incision – Maintain pressure dressing for 24 hours and then open to air, closure with staples/ steri strips/dermabond. Document and assess approximation, and signs of infection

35. Safety Concerns
Safety for the new mom and baby is addressed on admission to postpartum
Should be aware of the effects of pain medication during handling of infant and during ambulation
First time OOB need to assist mom to BR for both C/S and vaginal deliveries
Administer RhoGam for Rh- mom and Rh+ baby

36. Oxygenation Alterations Cardiovascular System Changes
Plasma volume – body rids itself of excess by:
Diuresis – urinary output of 3000 cc / day is common
Diaphoresis
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.

37. Oxygenation Vital Signs
Temperature -- may see a SLIGHT ~100. rise in temperature because of dehydration and exertion of labor in first 24 hrs
Pulse -- Bradycardia is common for days postpartally. RT vagal response to increased sympathetic nervous system stimulation during labor and increase in stroke volume.
Respirations –begin to fall to normal pre-birth range.
B/P -- should remain steady. Not elevated or decreased

38. Critical Thinking The client’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?

39. Oxygenation – Lab Assessment
Post Partum
WBC – leukocytosis is common with values of 20,000 – 30,000 RT increassed neutrophils
RBC – return to normal
Hgb. – normal to see a drop of about 1 gram
Hct – normal to see a drop of about 4 points and then a rise RT > loss of plasma than RBC death
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

40. Assess for Thromboembolism
During pregnancy, plasma fibrinogen (coagulation) increases to prepare for delivery and prevention of excess blood loss
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?

41. Assess for Hemorrhage -- related to uterine atony
Normal for loss of up to 500 cc during vaginal delivery and 1000 cc in cesarean delivery.
Assessment of lochia: should be scant to small with no large clots.
Assessment of fundus: tone, location
If excess bleeding and decreased tone may administer Methergine. Assess B/P prior to giving--hold the dose if elevated >140 / 90. Other drugs to contract uterus: Hemabate, oxytocin and cytotec

42. Decision Making
During your shift assessment of the post partum mom’s peri pad, you observe that it is saturated with lochia rubra (large amount).
What is your priority nursing
intervention?

43. Nutritional Alterations
Most moms are hungry and eager to eat. Progress slowly to avoid nausea and vomiting.
Diet should include:
High in Protein, vitamin C, and fiber
Increase in fluids
Lactating moms need about 500 extra calories for milk production
Prenatal vitamins and iron supplements are often continued in the postpartum period.

44. Psychological Adaptation
The responses of the mother to the birth of her infant are influenced by many factors:
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

45. 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!

46. 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

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

48. 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

49. Attachment
Bond that endures over time. Contact should occur as early as possible and as frequently as possible.
Allow time for attachment to occur with all members of the family

50. Attachment Process 1. En Face position -- eye-to-eye contact
2. Explore with finger-tips
Hand and Palmar contact
Whole arms --enfolds whole baby
close to body

51. 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”

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

53. The End