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

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.

Reproductive System Changes Discuss BUBBLE

Physiological Changes

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

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

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

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.

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

Nursing Care 9

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

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

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.

Lochia Assess Type Assess Amount Assess Odor Rubra -- 1 - 3 days; dark red; consists mainly of blood Serosa -- 3 - 10 days; pinkish serum with tissue and debris Alba -- 10 - 14 days; creamy yellowish, brownish Assess Amount When was pad last changed? Assess Odor Fleshy, not foul smelling Lochia

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

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. .

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

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

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

Match the Lochia A. Pinkish serum with mucus and debris. Usually occurs on day 3 - 10. B. Creamy yellowish brownish. Occurs after day 10 to 2weeks. C. Dark Red and consists mainly of blood. Occurs day 1 - 3. Lochia rubra Lochia serosa Lochia alba

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 ___________.

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.

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

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

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 6 - 10 diapers / day and stooling, then must be getting enough to eat

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

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.

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.

Elimination Changes Urinary System Assess and measure first two voidings post-delivery. Important to attempt to void every 3 - 4 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

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?

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.

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.

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.

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

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

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 24-48 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.

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 6 - 8 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

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?

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 33-39% RT hemodilution. If drops below 32- 35% = anemia

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?

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

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?

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.

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

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!

Postpartum Phases by Rubin Taking - in Occurs during day 1 - 3 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

Tailoring teaching to individual Learning Styles Demonstrations Group Classes Videotapes

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

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

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

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”

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

The End