1. Postpartum~ Physiology and Nursing Care

2. Puerperium
A Latin term for the period of involution when the mother’s body returns to its pre-pregnant state.
Involution is the rapid reduction in size of the uterus
Also referred to as the postpartum period of 6 weeks after birth of the baby.
Let’s look at how the systems change

3. The Physical Changes of the Uterus
After pregnancy estrogen and progesterone decrease which causes autolysis destruction of tissue, the layers of the lining are shed in the form of lochia
The placenta site heals thru exfoliation rather than scar tissue formation allowing future pregnancies
By 24 hours postpartum the uterus is the same size it is at 20 weeks gestation
The fundus (top of uterus) descends 1-2 cm or 1-2 finger breaths every 24hours.
By 2 weeks postpartum the uterus has descended into the true pelvis

4. What to Assess and What to Expect: Uterus
Height
Where is the top of the fundus located in relationship to the umbilicus (below, at the level of or above)
The fundus is measured in fingerbreadths above or below the umbilicus
Documentation of findings
If the fundus is 1 fingerbreadth above the umbilicus it is documented as 1/u meaning 1 fingerbreadth above the umbilicus
If the fundus is 2 fingerbreadths below the umbilicus it is documented as u/2 meaning 2 fingerbreadths below umbilicus
If the fundus is at the level of the umbilicus then it is documented as u/u meaning the fundus is at the level of the umbilicus

5. Assessment: Uterus Firmness Centeredness Afterpains
Palpate the fundus, what does it feel like?
The fundus should be firm and hard 
If fundus is found to be soft and mushy (boggy), or gets firmer or harder when massaged interventions are indicate
Centeredness
Where is the fundus located?
The fundus should be located midline to the umbilicus
If the fundus is to the left or right of umbilicus pt. will need to void then be reassessed for placement
Afterpains
Cramping caused by involution of the uterus
Increased with greater number of pregnancies
Breastfeeding also increases afterpains

6. Patient Education: The Uterus
Encourage
Encourage the patient to empty her bladder every two hours to aide involution and decrease bladder distention
Encourage pts. to breastfeed (causes the release of oxytocin) helps the uterus contract to promote involution
Encourage pts. to massage own uterus. Show the new mother how to find the top of her uterus and explain how it will decrease in size.

7. Let’s practice!
If the mom is 2 days postpartum, a primigravida who had a normal vaginal delivery of a 7 lb 8 oz baby girl, and you assess her fundus, you would expect to find it where?
How would you record this in your nurse’s notes?

8. Lochia
Lochia determines state of healing of the placenta site, it should steadily decrease every day
Rubra
Bright red for 2-3 days post delivery, contains blood and decidual trophoblatic debris, small nickel size clots are common
Serosa
Pink or brown after 3-4 days postpartum consists of old blood serum, leukocytes, tissue debris, last 10 days
Alba
Yellow to white, consists of leukocytes decidua, epithelial cells, mucus serum bacteria, lasts 2-6 weeks after birth

9. Lochia-how to guesstimate amounts

10. Patient Education Sequence of changes (rubra, serosa, to alba)
What to teach
Sequence of changes (rubra, serosa, to alba)
Report large clots that are larger than a half dollar size or plum size
Bleeding should decrease daily
Bleeding will increase with activity (encourage to rest then reassess)
Soaking through a pad an hour is too much bleeding and should notify nurse or physician ASAP
Report a foul odor which can indicate infection

11. . - Cervix Prepregant Postpartum How does it change after delivery?
Soft and flabby becomes firm after 2 days pp
What to assess
Cervical os no longer appears as circle shaped but as jagged slit
What to teach
Due to changes in cervix diaphragm and cervical caps need to be refitted for proper contraception . -
Prepregant
Postpartum

12. Vagina & Perineum What to assess Episiotomy Type Midline Mediolateral
Degree of episiotomy
Degree of tear
REEDA
Redness
Edema
Ecchymosis
Discharge
approximation
Lacerations
Type and degree of extension
1st, 2nd, vaginal, periurethral, cervical
Hemorrhoids
Assess presence and swelling
What to teach
Link to handout on Kegels
Sitz bath to promote healing of tissues, hygiene from front to back, hand washing, use of peribottle

13. Abdominal Wall What to assess? What to teach? Diastisis Recti
Abdominal wall separates during pregnancy
Have pt. do mini sit up and will palpate and visually inspect abdomen
Diastisis recti can be seen as a little hill in the center of the abdomen and with palpation will feel separated
Measured in fingerbreadths of separation
What to teach?
Importance of pp exercise—one link
Responds to exercise within 2-3 months
Chin lifts
Separation of diastisis recti becomes less apparent with time

14. Endocrine System and Ovarian Function
Onset of first menses
Breastfeeding mom
Breastfeeding suppresses ovulation due to the increase in serum prolactin
Breastfeeding longer than one month menstruation delayed for 3 months
Bottlefeeding mom
First cycle anovulatory typically menstruation begins 6-10weeks, 90% resumed by 12 weeks.
What to teach
Educate pts. on the importance of using contraceptive methods, they may be fertile before first period

15. Urinary System What to assess? What to expect Bladder function/output
May be decreased due to trauma or edema
Anesthesia can decrease urge to void
Output increases during early postpartum period (first hours)
Bladder distension
Assess for bladder distension by palpating bladder and fundus, if bladder is full fundus will be off to right or left of umbilicus
20% of women experience incomplete emptying after delivery
Bladder distension causes increased susceptibility to infection and pp hemorrhage
Kidney function
Reduces in post partum because of decreased steroid levels, returns to normal within month
Diuresis in the postpartum period
With in 12 hours loss of excess fluid begins,
profuse diaphoresis occurs at night first 2-3 days post partum
Output increases in first hours, body is eliminating 2000 to 3000 cc of fluid

16. Cardiovascular System
Vital Sign Changes—know this!
Pulse— decreases to rate of first 6-10 days, returns to normal by 8-10 weeks (watch pulse > 100 can indicate infection, hypovolemia)
Respirations— decrease to within normal prebirth by 6-8 weeks
Blood Pressure— small transient rise last 4 days of postpartum, watch for orthostatic hypotension 1st. 48 hours as a result of abdominal engorgement also could be late sign of pp hemorrhage
Temperature—First 24 hours may increase to 38 degrees as a result of dehydration, after 24 hours should be afebrile

17. Cardiovascular (continued)
Blood Volume— Initially hypervolemic then cardiac output decreases 30% in the first 2 weeks return to normal levels in 6 to 12 weeks.
Homan’s Sign—why assess?
Needs to be assessed due to increase amount of blood volume during pregnancy, and the activation of blood clotting factors after delivery
What to teach
Encourage ambulation to decrease risk for thrombophlebitis
Educate pts. on signs to look for, warm, tender, reddened areas on legs.

18. Gastrointestinal System
What to assess
Bowel sounds-gastric motility is decreased during labor, sluggish after birth because of lingering progesterone
Last BM? What is there normal pattern, okay not to have BM before leaving hospital
Fear-anticipation of discomfort can decrease return to normal bowel habits in reestablishing bowel tone
What to teach
Early ambulation
Increase fluid intake
Increase fiber
Stool softener/laxative

19. Blood Components
Hemoglobin/Hematocrit drop in values by 2% equals 500cc blood loss, expected loss for vag delivery cc, c-section cc.
H & H increases by 7th day post partum
WBC early pp period, an increase by 30% in 6 hours indicative of pathology, note s/s infection
Clotting Factors-remain elevated for 6 weeks
Fibrinogen level increases after delivery 

20. Psychological Adaptation Maternal and Paternal Adjustment
Maternal Adjustment (Reva Rubin, 1961)—know these characteristics that you will see in the mother.
Taking In Phase—dependent phase
1st 24 hours range 1-2 days, focus on self and meeting basic needs, reliance on others to meet needs of comfort, rest, closeness, nourishment, relives birth, excited and talkative
Taking Hold Phase—dependent/independent phase
Starts end of 3rd day pp, last for 10 days to several weeks, focuses on care of baby, desire to take charge, still need nurturing and acceptance by others, eagerness to learn (period to teach most receptive time to learn), possible experience pp “blues”
Letting Go Phase—interdependent phase
Focuses on forward movement of family as unit with interacting members, reassertion of relationship with partner, resumption of sexual intimacy, resolution of individual roles.

21. Transient Period of Depression
Post Partum Blues
Transient Period of Depression
What to assess
70% of women experience baby blues
Changing hormone levels affect blues
Common symptoms
labile, crying, mood swings, anger, depression, let down feelings, fatigue, headaches, anxiety,
resolves days
What to teach
Educate parents on normal newborn behaviors and growth and development
Encourage rest and to accept help from others
Educate mothers of symptoms and if they last longer than 2 weeks, or feel they cannot care for their self or baby contact physician.

22. Weight Loss in Postpartum
Fetus, placenta, amniotic fluid, & blood loss at delivery (largely determined by weight of baby and amt of AF)= lbs.
Perspiration and diuresis in 1st week pp (affected by the amt of edema in mother)= lbs.
Uterine involution/lochia over 6 wk period= lbs
Total wt loss= lbs

23. Developing Attachment
Initial attachment behavior
Mothers begin with finger-tip touching of baby’s face and body and proceeds to palmar contact
Higher-pitched voice
En face positioning
Comments on child’s appearance
The ‘wonder of it all’!

24. Enface Positioning
Note direct eye-to eye contact between parent and child

25. Paternal Attachment Behaviors
Engrossment—key term used in relation to dads.
P. 285 in Hockenberry has some good descriptions

26. Role Adjustments Sibling Adaptation Social Networks Altered Body Image
Relationship with significant other
Resumption of intimacy

27. Post Partum Nursing Care
Maintain physiologic integrity—assess vitals signs, fundal height and firmness, lochia color and amt, etc. using BUBBLEHED assessment technique.
Nurture the Mother—essential nursing role is to help her transition to motherhood smoothly
Comfort & Rest—
Perineal care—careful hygiene, use of sitz bath, use of anesthetic spray and witch hazel pads, use of donut pillow prn

28. Comfort Measures (Post Partum Nursing Care cont’d)
Hemorrhoids—use of topical cream prn, sitz bath, donut ring prn, avoid straining with BM, avoid sitting up for long periods.
Afterpains—encourage massage of uterus, use of relaxation and breathing techniques, anticipatory analgesic management based on assessed pt. status. Know side effects of analgesics and teach as needed.
Rest—organize care to allow for rest periods. Encourage mom to sleep when baby sleeps and limit visitors. Don’t lift anything heavier than baby.

29. Immunizations
Rubella Vaccine should be administered to postpartum mom prior to discharge from hospital. (MMR has rubella in it)
Instruct to avoid pregnancy for at least 3 months to prevent possible injury to fetus from live-attenuated vaccine.

30. Immunizations
T dap
Pregnant women should get a dose of Tdap during every pregnancy, to protect the newborn from pertussis
Recommended for pregnant women to get in the 3rd trimester for best protection. Takes two weeks for passive immunity to occur for newborn.

31. Patient Education Topics
Perineal care
Bowel and bladder function
Nutrition—no fad diets, prenatal vitamins daily esp. if breastfeeding, 6-8 glasses of water/day
Early ambulation
Bathing—showers only, start with breasts, no soap, then shower as usual cleansing perineum last with clean washcloth. Use peri-shower if available
Exercise—see earlier link
Breast care (will be discussed later)

32. Anticipatory Guidance
Postpartum follow-up visits—4-6 weeks for vaginal delivery, 1 weeks and 6 weeks for C/S
Infant development and care
Physical recovery
Sexuality and contraception
Role changes

33. Danger signs in the Post Partum Period
Return of Vaginal bleeding (one pad in an hour or large clots)
Fever >38C with or without chills after the first 24 hours
Increase in vaginal discharge especially if foul smelling
Swollen red area on leg (thrombophlebitis)
Swollen red tender area on breast (mastitis)
Dysuria, increased frequency and pressure with urination (UTI)
Persistent perineal or pelvic pain (chorioamniotis)

34. Cultural Influences
See handout
Refer to pp in Olds 10th ed