What physiologic changes are occurring in the postpartum woman?

Weight loss of 15-17 lbs. 10-12 lbs baby, placenta, amniotic fluid Weight loss of 15-17 lbs 10-12 lbs baby, placenta, amniotic fluid 5 lbs excess fluid through diuresis 500 cc + from blood loss [for every 500cc blood loss Hct falls 3-5%] Elevated temp up to 100.4oF from muscular exertion, dehydration, hormonal changes [epidural also increases T]-afebrile after 24 hrs Shaking chills and/or diaphoresis due to vasomotor instability

Increased blood clotting mechanisms are activated postpartum  increased risk of thromboembolism Trauma to the bladder during birth can  urinary incompetence for the first few days and overdistention and incomplete emptying Diuresis begins within 24 hours Diaphoresis [‘Hot flashes’] are another mechanism of fluid reduction as hormonal levels return to pre-pregnant levels Involution [return of uterus to pre-pregnant state] begins immediately and is complete by ~ 6 weeks postbirth

The sudden, significant weight loss and fluid shifts that occur in women in the postpartum period would typically result in shock and profound deleterious physiologic effects in other less healthy and resilient individuals.

Gastrointestinal system Cardiovascular system Urinary tract Fundus Location Consistency Cramping [increases with each successive birth] Cervix Dilation Vagina Abdomen Gastrointestinal system Cardiovascular system Urinary tract Decreased sensation of bladder filling Diaphoresis Breasts

What is included in the assessment of the postpartum client?

Postpartum Assessment Monitor vital signs Q 15 minutes for the first hour postbirth Q 30 minutes for the second hour postbirth Q 1 hour for 2 hours or until stable BID through discharge All assessments should be more frequent if there are any abnormal assessment findings Always follow institutional protocols Include BP, HR, RR, Temp [q 4 hours], location and consistency of fundus, amount and color of lochia [note any abnormal smell which might indicate infection], perineal status [intact, edematous, etc.], bladder status [location of bladder/document voiding and amount and whether bladder was emptied], comfort level, status of abdominal dressing if cesarean birth

Figure 30. 1 Involution of the uterus Figure 30.1 Involution of the uterus. A, Immediately after delivery of the placenta, the top of the fundus is in the midline and approximately halfway between the symphysis pubis and the umbilicus. About 6 to 12 hours after birth, the fundus is at the level of the umbilicus. B, The height of the fundus then decreases about one finger breadth (approximately 1 cm) each day.

Correct position for assessing the fundus Correct position for assessing the fundus. Woman should be supine and flat or almost flat. Place the nonpalpating hand just above the symphysis to prevent inversion or prolapse of the uterus. Palpate gently, but firmly. Slowly remove your palpating hand to reduce discomfort, especially with a surgical abdomen.

Correct position for assessing the fundus Correct position for assessing the fundus. Woman should be supine and flat or almost flat. Place the nonpalpating hand just above the symphysis to prevent inversion or prolapse of the uterus. Palpate gently, but firmly. Slowly remove your palpating hand to reduce discomfort, especially with a surgical abdomen.

A full bladder will push the uterus up and [usually] toward the woman’s right side. Observing from the side, you might see what appears to be ‘camel humps’: the lower hump is the bladder and the upper hump is the uterus.

Transition of Lochia Lochia Rubra Lochia Serosa Lochia Alba Red First 1-3 days postbirth Dark red or brownish with clots; fleshy odor, increased flow on standing or with breastfeeding or during physical activity; contains blood and tissue fragments Lochia Serosa Pink, brown-tinged 3-10 days Serosanguinous consistency; contains a smaller amount of blood, erythrocytes, leukocytes, leukocytes, mucus, decidua; fleshy odor Lochia Alba Yellowish-white 10-14 days, but may last longer Contains mostly leukocytes as well as decidua, mucus, bacteria, and endothelial cells; no strong odor

Transition of Lochia Abnormal findings Foul smelling lochia Numerous or large clots Quickly saturated peri pad Lochia serosa or alba that returns to a more bloody appearance usually indicates the mother is too active-this is an excellent guide to activity postbirth Lochial flow usually ends by 6 weeks postbirth-abnormal vaginal discharge beyond this time should be evaluated

Classification of Lacerations First degree Limited to the perineal skin and vaginal mucous membrane Second degree Includes the fascia and perineal muscles Third degree Extends into the rectal sphincter muscle Fourth degree Extends through the anterior rectal mucosa, exposing the rectal lumen Lacerations heal better than episiotomies Complete healing may take up to 6 months Severe damage to the vagina may result in fistula formation

Lacerations What is most important is to understand the potential impact on Comfort level The more severe the laceration and extensive the repair, the more likely there is to be more discomfort and need for pain medication Discomfort will impact mobility Healing Concern about return of bowel function

What is included in the nursing care of the postpartum client?

Promote Comfort Care of the perineum Apply ice packs for comfort and to reduce swelling for first 24 hours After 24 hours encourage mom to sit in warm bath for 15-20 mins 2-3 times per day Have mom use squirt bottle to spray water during urination to reduce the burning from urine flow Have mom use water from squirt bottle to cleanse perineum after urination or bowel movement

Promote Comfort Care of the perineum Apply clean peri pad as needed Apply tucks pads Apply analgesic ointment Have mom put a pillow under one buttock cheek to tip her off the perineum when sitting or lying down [alternate sides] These interventions also relieve discomfort from hemorrhoids

Promote Comfort Managing general body ache Women often experience extensive body aches following the exertion of labor and birth and the muscle strain during pushing Exacerbated by positioning by others following an epidural [such as traction on legs] Massage is a wonderful intervention if available Warm tub bath Application of warm packs to most affected areas

Promote Comfort Managing backache following an epidural Application of hot pack or K pad May alternate with cold/ice pack as desired by mom Administer analgesics to relieve any and all discomforts Match the benefits of a particular medication to the specific discomfort

Promote Comfort Preventing constipation Women are very fearful of having a bowel movement following birth related to perineal discomfort or surgical incision in abdomen Encourage water drinking for hydration Administer docusate sodium for stool softening Administer senna as a gentle laxative to stimulate a sluggish bowel following pregnancy, birth, gut manipulation during cesarean birth

Promote Comfort Preventing constipation Remember the constipating effects of many analgesics Encourage mobility Getting out of bed Walking in hallway This will also help relieve bloating and gas following cesarean birth, which can exacerbate incisional pain and general discomfort

Promote Comfort If mom has had a cesarean birth, teach her how to get in and out of bed Raise the head of the bed Turn to side Use elbow to push up Then swing out legs Reverse process to get into bed Teach her how to get in and out of bed when she gets home—hands and knees

Promote Sleep and Rest Promoting comfort and sleep and rest are complementary—discomfort prevents sleep and rest/sleep and rest promote comfort Create a comfortable physical environment Temperature Light Sound [use white noise from something like a fan if necessary]

Promote Sleep and Rest Control visitors as needed Parents often want to see visitors, but don’t understand how exhausting they are Help reduce further exhaustion by working with mom to set limits on visitor number and length of visits Put a ‘Sleeping: Do Not Disturb’ sign on the door as needed Cluster care to minimize family disruption

Promote Parenting Reinforce to parents that this is their baby and encourage them to assume responsibility for care Guide parents in basic baby care Guide parents through initial baby bath if one is given Keeping baby warm with hat and blankets and human contact ‘Back to sleep’ unless baby is on a person Correct swaddling technique

Promote Parenting Prevent chilling baby Diaper changing Prevent chilling baby Use wet wash clothes to remove meconium Boys Cover penis while changing diaper to keep from getting peed on ‘Hose to toes’—point penis down so diaper will absorb urine Girls Wipe front to back

Promote Parenting Cover with blankets Put baby inside a belly band Encourage skin-to-skin contact Cover with blankets Put baby inside a belly band Use both parents Give lots of encouragement and positive reinforcement Teach infant cues and the meaning of crying Put parents’ questions and issues FIRST

Promote Parenting If this is a subsequent child, parents can reduce sibling rivalry by

Postpartum Teaching Use teachable moments Ask open ended questions Don’t ‘talk at’ parents or ‘information dump’ Ask follow up questions to evaluate actual learning Have parents provide return demonstrations of skills Focus first on the parents’ issues/questions Discharge teaching begins at admission Postpartum teaching should begin during pregnancy during prenatal visits

Care during labor, birth, and the postpartum period is not a medical procedure, it is growing a family.