Postpartum~ Physiology and Nursing

Care

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

uterusAlso referred to as the postpartum period of

6 weeks after birth of the baby.Let’s look at how the systems change

The Uterus

Physical changes 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

The Uterus

What to assess/what to expect 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

The Uterus

What to assess/what to expect Firmness

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 indicated 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

The Uterus

What to teach Encourage pts. to empty 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

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?

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 daysAlba

Yellow to white, consists of leukocytes decidua, epithelial cells, mucus serum bacteria, lasts 2-6 weeks after birth

What to assess/what to expect Assessment is needed in order to determine stage of healing

of uterus Color-rubra, serosa, alba Amount-scant<2.5 cm, light <10 cm, mod >10 cm, heavy one pad

an hour (check vs, skin color, urinary outpt, r/t pp hemorrhage) Presence of clots-nothing greater than half dollar size Odor-foul odor indicates infection

What to teach Sequence of changes (rubra, serosa, to alba) Report large clots half dollar size or plum size Bleeding should decrease daily Will increase with activity (encourage to rest then reassess) Soaking through a pad an hour is too much bleeding and should

notify nurse or physican ASAP

Lochia

Lochia-how to guesstimate amounts

Cervix 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

Vagina & Perineum

What to assess Episiotomy

Type Midline Mediolateral Degree of episiotomy

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

Abdominal Wall

What to assess? 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

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

1st 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

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 post partal period

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 b/c of decreased steroid levels, returns to normal

within 1 month

Diuresis in the postpartum period With in 12 hours loss of excess fluid begins, profuse diaphoresis occurs at

noc first 2-3 days post partum

Cardiovascular System

Vital Sign Changes—know this! Pulse— decreases to rate of 50-70 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—1st 24 hours may increase to 38 degrees as a result of dehydration, after 24 hours should be afebrile

Blood Volume—decreases within 1st 2 weeks return to non pregnant values by 6 months

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.

Gastrointestinal System

What to assess Bowel sounds-gastric motility is decreased during

labor, sluggish after b/c 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 toneWhat to teach

Early ambulation Increase fluid intake Increase fiber Stool softener/laxative

Blood Components

Hemoglobin/Hematocritdrop in values by 2% equals 500cc blood loss, expected loss for vag delivery 250-500cc, c-section 700-1000cc. H & H increases by 7th day pp

WBC-25000-30000 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

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 mov’t of family as unit with interacting

members, reassertion of relationship with partner, resumption of sexual intimacy, resolution of individual roles.

Postpartum Blues— Postpartum blues are considered a transient period

of depression, occurs 1st few days of puerperium

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 10-14 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.

Weight Loss in postpartum

Fetus, placenta, amniotic fluid, & blood loss at delivery (largely determined by weight of baby and amt of AF)= 12-13 lbs.

Perspiration and diuresis in 1st week pp (affected by the amt of edema in mother)= 5-8 lbs.

Uterine involution/lochia over 6 wk period= 2-4 lbs

Total wt loss= 19-25 lbshttp://womenshealth.gov/pregnancy/childbirth-

beyond/recovering-from-birth.html#b

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’!

Enface Positioning

Note direct eye-to eye contact between parent and child

Paternal Attachment Behaviors

Engrossment—key term used in relation to dads.

See handout on Engrossment and Attachment Characteristics.

Role Adjustments

Sibling Adaptation

Social Networks

Altered Body Image

Relationship with significant other Resumption of intimacy

PP 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

Comfort measures (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.

Immunizations

Rubella Vaccine should be administered to postpartum mom prior to discharge from hospital.

Instruct to avoid pregnancy for at least 3 months to prevent possible injury to fetus from live-attenuated vaccine.

Immunizations

T daphttp://www.cdc.gov/vaccines/hcp/vis/vis-

statements/tdap.htmlPregnant 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.

Other Education topics

Perineal careBowel and bladder functionNutrition—no fad diets, prenatal vitamins daily

esp. if breastfeeding, 6-8 glasses of water/dayEarly ambulationBathing—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 linkBreast care (will be discussed later)

Anticipatory Guidance

Postpartum follow-up visits—4-6 wks for vaginal delivery, 1 wks for C/S

Infant development and carePhysical recoverySexuality and contraceptionRole changes

Danger signs in the Post Partum Period

•Return of vaginal bleeding esp. > 1 pad/hour or large clots•Fever >38C with or without chills after 1st 24 hours

•Increased 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 (chorioamnionitis)

Cultural Influences

See handout Refer to pp. 21-32 in Olds 10th ed