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

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

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

Uterus Involution: return of uterus to prepregnancy state; subinvolution Location Delivery: located @ 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

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

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

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"

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

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

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 24-36 hours

Immune System No Changes Determine need for Rubella Rhogam

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

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 10-12 days Clotting factors and fibrinogen elevated in early PP Temp elevation to 100.4 F (38.0C) first 24 hours

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

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

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

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

Postpartal Nursing Care Assessment BUBBLEHE REEDA Care Discharge Teaching Potential Complications

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

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

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

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

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

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

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