1. Normal Postpartum Revised 9/7/08 Debbie Perez RN, MSN, CNS

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

3. The “P” Need u The responses of the mother to the birth of her infant are influenced by many factors such as: –Her 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

4. Bonding

5. Postpartum Phases by Rubin u 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

6. Postpartum Phases by Rubin u 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!

7. u Tailoring teaching to individual Learning Styles –Demonstrations –Group Classes –Videotapes

8. Postpartum Phases by Rubin u 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

9. Reproductive System Changes

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

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

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

14. 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.

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

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

18. Nursing Assessment u 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

19. Nursing Assessment of Uterine Changes u 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. Causes relaxation and more bleeding.

20. Lochia u Assess Type –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 u Assess Amount –When did you last change your pad u Assess Odor –Fleshy, not foul smelling Lochia

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

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

23. Vagina u May be edematous and bruised. u Rugae begin to appear when ovarian function returns. u May teach the mom to do Kegels exercises to increase the blood flow to the area and aid in healing

24. Perineum u May have tears, lacerations, or an episiotomy u Assessment Procedure: –Turn patient to side-lying / sims position –Gently spread buttocks apart inspect with penlight Assess: –episiotomy is a an incision –Assess for hematoma, most common labial u Teach hygiene measures to aid in healing –Use Peri-bottle with each trip to the bathroom –Wipe front to back; change pads frequently –Use Tucks and Spray as needed –Sitz bath 3-4 x day

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

26. Match the Lochia u Lochia rubra u Lochia serosa u Lochia alba 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.

27. Fill in the Blank u Lochia should never be ______________ in amount. u Lochia should never have an ______________odor. u Lochia should not contain __________ _________ of tissue u Lochia should not be _____________ during the first ________ weeks u Lochia should proceed from _________ to _________ to ___________.

28. Short Answers u The nurse is going to assess the uterus. The 3 main assessments include: 1. 2. 3. u The normal height of a first day postpartum woman is ________________. It should decrease _____fingerbreadth per _______. u The tone should be __________. If found boggy, the nurse would ___________ the uterus.

29. Breasts u Teach the mother to assess her own breasts -- similar to doing a self-breast exam –ask if she feels any nodules, lumps –Assess for soreness, redness, blisters, cracks –Assessment of nipples: everted, flat, inverted u Teaching depends on whether client is breast for bottle feeding

30. Process of Lactation u Sucking of infant stimulates the nerves beneath skin of the areola to transmit messages to the hypothalamus u 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

31. Breastfeeding Care u No soap on the nipples, wash in water u Wear supportive bra u Breastfeeding tips: –Most important for successful breastfeeding 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 –Feed as long a client and baby desires –Relaxation important 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, this is validation of adequate intake

32. Suppression of Lactation for Bottle Feeding Moms u Key is to teach the mother measures to decrease stimulation of the breasts –Wear a tight-fitting bra or binder –Do not express milk from the breasts –Take shower with back to the warm water –Ice packs and cabbage leaves

33. Fill in the Blank u The Anterior pituitary stimulates the release of ___________________ which is responsible for _________ _____________________. u The posterior pituitary gland releases ___________ which is responsible for the ______-__________ reflex.

34. Short Answers u What are four important interventions to teach a mom who is bottle feeding to decrease stimulation of the breasts. 1. 2. 3. 4.

35. The Elimination Need Urinary System u Assess voiding carefully. Important to empty bladder each time. u Diuresis is common -- loss of excess volume of pregnancy (no longer needed) u Mild Proteinuria – Why? u Most common problem is urinary retention RT: –loss of elasticity and diminished bladder tone –loss of sensation from trauma, drugs, anesthesia –urethral edema u Interventions: sitz baths,Tucks to decrease swelling, topical spray

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

37. The Elimination Need Gastrointestinal Tract u 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 u Interventions and teaching: –Increase fluids, fiber, and activity –Stool softeners, anesthetic sprays, Tucks –**Do NOT give an enema or suppository to a person who has a 4th degree laceration.

38. The “R” Need u Most common problem is Sleep deprivation –due to excitement and exhilaration following the birth. Rest is needed for healing and recovery. Cluster care. u Exercise – Should be individualized per patient. Walking is safe (limit stair climbing). Caution until involution is complete.

39. The “S” Need u Pain –Perineal pain -- caused from trauma during delivery, episiotomy, hemorrhoids. Interventions: sitz baths, Tucks, Sprays / Foams, oral analgesics. –Afterbirth pain -- more common in multigravidas and breastfeeding moms. Why? Interventions: * mild analgesics (NSAIDS, Acetamenophen) heating pad, lie on abdomen, discontinue use of oxytocins, –Breast engorgement – Interventions: warm or cold packs, increase feedings, decrease stimulation. Bind breasts, apply cabbage leaves. –Abdominal distention – Interventions: no ice, increase warm / hot fluids, increase walking, rocking chair, antiflatus drugs (Simethicone).

40. “S” Need u Skin -- pigment changes will begin to disappear; diaphoresis is normal u Striae - May have stretch marks over abdomen and legs u diastasis recti- Can occur with overdistension of the uterus, caution with exercise, Why? u Episiotomy – Important to treat as any other incision and maintain cleanliness. Intervention: Peri bottle u C/S Incision – Maintain pressure dressing for 24 hours and then open to air, closure with staples. Monitor for approximation and signs of infection

41. “S” Need u Safety for mom and baby is addressed on admission to postpartum u Should be aware of the effects of pain medication during handling of infant and during ambulation u First time OOB need to assist mom to BR for both C/S and vaginal deliveries, Why? u Administer RhoGam for Rh- mom and Rh+ baby

42. Oxygenation Need Cardiovascular System Changes u Plasma volume – body rids itself of excess by: –Diuresis – urinary output of 3000 cc / day is common –Diaphoresis – Assess need for frequent gown change u Blood Volume –Increase for about 24-48 hours after delivery, Why? –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.

43. The Oxygenation Need u Vital Signs –Temperature -- may see a SLIGHT ~100. rise in temperature due to dehydration and exertion of labor in first 24 hrs –Pulse -- Bradycardia is common for 6 - 8 days postpartum. 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. Why? –B/P -- should remain steady. Not elevated or decreased unless PIH

44. Critical Thinking u 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?

45. O Need – Lab Data 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 Hematocrit – lowers 33-39% RT hemodilution. If drops below 32- 35% = anemia 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

46. u Assess for Thromboembolism –During pregnancy, plasma fibrinogen (coagulation) increases, Mother’s body has the ability to form clots and prevent excessive bleeding. –Plasminogen (lysis of clots) does not rise –Hypercoagulable state increasing the risk for thrombus formation. –Assess for homan’s sign.

47. –Assess for Hemorrhage -- RT uterine atony t Average estimated blood loss (EBL) up to 500 cc during vaginal delivery and 1000 cc during cesarean delivery. Assess for excess bleeding. Fundus assessment: firm, midline, and small amt. lochia rubra, no large clots. For Excess Bleeding: t May be treated with Methergine. Assess BP prior to giving--hold the dose if elevated >140 / 90

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

49. The Nutrition Need u Most moms are hungry and eager to eat. Start slowly to avoid nausea and vomiting. u Diet: –Increase Protein, vitamin C, and fiber, Why? –Increase fluids u Lactating moms need about 500 extra calories for milk production u Prenatal vitamins and iron supplements are often continued in the postpartum period. Why?

50. Attachment

51. u Bond that endures over time. Encourage mom and baby contact as early as possible and as frequently as possible. u Allow time for attachment to occur with all members of the family (siblings, grandparents).

53. Attachment Process 1. En Face position -- eye-to-eye contact 2. Explore with finger-tips 3.Hand and palmar contact 4.Whole arms --enfolds whole baby close to body

54. Claiming The Claiming Process: includes identification of the baby’s specific features, relating them to other family members “Those long toes are just like his Dad’s”

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

56. The End