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Chapter 21
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Normal Puerperium
It is the period of recovery that occurs fromchildbirth and extends for 6 weeks after delivery
What is involution?
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Reproductive System
Changes
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The Uterus
What are the three ways that
the uterus involutes?
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Contraction of the Uterus
Muscle fibers become shorter
controlling the bleeding by
compressing and sealing off bloodvessels
Acting as the living ligature
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Protein Material Catabolism
Release of a proteolytic enzyme into theendometrium and myometrium.
This enzyme breaks down the proteinmaterial in the hypertrophied cells causingthe uterine muscle cells to decrease in size
The uterus gradually decreases in size as thecells grow smaller
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Regeneration of the Endometrium
the placenta site heals in about 6 weeks with
the other part healing in 3 weeks.
Heals by exfoliation rather than by formingscar tissue.
The endometrium grows from the margins ofthe placental site and from the fundi of the
endometrial glands left in the basal layer of
the placental site
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Critical Thinking
Why does the uterus heal by
Exfoliation
and not by
primary intention?
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Uterine Changes
Placement and size Where is the normal placement of the
uterus immediately after birth, 12 hours
later?
What is the size of the uterus?
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Uterus
What nursing intervention
should the nurse encourage
PRIOR to
assessing the fundus?
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Uterine Changes
What is the normal tone of the uterus?
What is the technique used to assess the
uterus?
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Uterine Involution
What is the PRIORITY intervention when
the uterus is found to be boggy?
Why is it important not to over-stimulate
the uterus?
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Uterus
What interventions
must the nurse
include if theuterus is found
deviated from
midline?
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Short Answers
The nurse is going to assess the uterus. The 3main assessments include:
1.
2.
3.
The normal height of a first day postpartumwoman is ________________. It should decrease_____fingerbreadth per _______.
The tone should be __________. If found boggy,the nurse would ___________ the uterus.
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Lochia What are the three types of lochia?
What is a normal amount?
What question is important to ask
the woman when assessing amount?
What is normal odor of Lochia?
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Characteristics of Lochia
Should not be excessive in amount
Should never have an offensive odor
Should not contain large pieces oftissue
Should not be absent during the first3 weeks
Should proceed from rubra -- serosa-- alba
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Match the Lochia
Lochia rubra
Lochia serosa
Lochia alba
A. Pinkish serum with mucus
and debris usually occurs
on day 3 - 10.
B. Creamy yellowishbrownish. Occurs after day
10
C. Dark Red and consists
mainly of blood. Occurs
day 1 - 3.
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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
___________.
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Cervix
Remains soft and flabby, appears bruisedand may have some lacerations
No longer does the external os have thepre-pregnant appearance -- now appears
as a jagged slit not a circle.
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Vagina
May be edematous and bruised.
Rugae begin to appear when ovarian
function returns.May teach the mom to do Kegels
exercises to increase the blood flow to the
area and aid in healing
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Perineum
Assess:
the episiotomy the same as with any incision.
R redness
E edema or swelling
E ecchymosis or bruising
D drainage
A approximated
How should the nurse assessthe perineum?
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What are measures toteach the mom in
caring for theperineum?
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Comfort Measures
Relief of Perineal Discomfort Ice packs
Topical agents
Perineal care
Sitz bath
Relief of hemorrhoidal discomfort
may include Sitz baths
Topical anesthetic ointments
Witch hazel pads
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Ovulation and Menstruation
When does Menstruation generally
return?
Return is prolonged for the
breastfeeding mom because of
alterations in the gonadotropin-releasing
hormone production.
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Ovulation and Menstruation
Nurses need to teach moms that
breastfeeding is NOT a reliable
means of contraception.
WHY
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Breasts
Allow the mother to assess her own breasts --similar to doing a self-breast exam
ask if feels any nodules, lumps
ask if nipples are sore, reddened, blisters,
cracks Assess nipples for everted, flat, inverted
Teach to care for breasts according to whetherthey are breastfeeding or bottle feeding.
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Process of Lactation
Sucking of infant stimulates the nervesbeneath skin of the areola to transmitmessages to the hypothalamus
Hypothalamus sends messages to thepituitary gland
Anterior pituitary -- stimulatesProlactin to be released which is the
ultimate stimulation for milkproduction
Posterior pituitary -- releasesOxytocin which stimulates thecontraction of the cells around thealveoli in the mammary glands. Thiscauses milk to be propelled throughthe duct system to the infant. This isthe LET-DOWN reflex. Felt as atingling sensation
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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, then must be
getting enough to eat
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Suppression of Lactation
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
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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.
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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.
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Cardiovascular System Changes How does the body rid itself of excess Plasma
volume?
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 thevascular system / intravascular
Leads to increased cardiac output mainly RT increase
stroke volume.
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Blood Values
Pregnancy
WBC elevated slightly to about12,000
RBC increase slightly to about 10
milion.
Hemoglobin stays about normalat ~ 12 g. Below 10 g = anemia
Hemotocrit lowers 33-39% RT
hemodilution. If drops below 32-35% = anemia
Post Partum
WBC leukocytosis is common withvalues of 25,000 30,000 RTincreased neutrophils
RBC return to normal
Hgb. normal to see a drop of about1 gram
Hct normal to see a drop of about2- 4 points and then a rise RT >loss of plasma than RBC death
Platelets drop and gradually rise
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Assess for Thromboembolism
During pregnancy, plasma fibrinogen(coagulation) increases, Mothers body
has the ability to form clots and prevent
excessive bleeding.
Plasminogen (lysis of clots) does not
rise
Hypercoagulable state and the woman
is at a greater risk for thrombusformation.
assess for homans sign
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Vital Signs Temperature
A slight elevation of up to 100.40
may occur related todehydration and increase basal body metabolism from
exertion of labor and delivery.
After 24 hours, the temperature should be normal
A temperature greater than 100.40 suggests infection.
Blood Pressure
Should remain stable Hypovolemia can indicate postpartum hemorrhage
Hypervolemia could indicate preeclampsia
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Vital Signs
Pulse Bradycardia of 50 70 bpm is Normal
Tachcardia is not considered a normal occurrence and
may indicate excessive blood loss
Respirations
Should remain stable and within normal range
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Critical Thinking
The womans 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?
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Gastrointestinal Tract
The most common GI problemduring postpartum is constipation
EXPLAIN.
What teaching is important to assist
in decreasing constipation?
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Urinary System
What is the most common problemassociated with the urinary system?
Why be concerned?
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Critical Thinking
A primigravida delivered 2 hoursago. The woman states she would
like to go to the bathroom. What
should the nurse do?
The woman is unable to void. Whatshould the nurse do next?
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AfterpainsWho is more likely to experience afterbirth
pains? Explain.
Relief of after pains Positioning (prone position)
Analgesia administered an hour before
breastfeeding
Encourage early ambulation - monitor for
dizziness and weakness
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Rest and Activity
Most common problem is Sleep -- the excitement
and exhilaration experienced by birth my make it
difficult to sleep. They are tired and need rest.
Allow for times of uninterrupted sleep.
Exercises -- have the patient to ask her own
doctor for specific exercises. Usually walking is
safe. May eventually do postpartum exercises.Just need to allow the body to return to its pre-
pregnant state before straining it.
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Resumption of Activities
New mother should gradually increase activities and
ambulation after birth
She should avoid heavy lifting, excessive stair
climbing, strenuous activity
Resume light housekeeping by second week at
home
Delay returning to work until after 6-week
postpartum examination
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Exercises
Recommend exercise to provide health benefits to
new mother
Nurse should encourage client to begin simple
exercises while on nursing unit
Inform her that increased lochia and pain may
necessitate a change in her activity
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PainPerineal pain -- caused from trauma during
delivery, episiotomy, hemorrhoids. Provide
comfort measures such as: sitz baths, Tucks,Sprays / Foams, oral analgesics.
Afterbirth pain -- more common in multigravidas
and breastfeeding moms. Treat with * mild
analgesics (NSAIDS, Acetamenaphen),heatingpad, lie on abdomen, discontinue use of
oxytocins,
Breast engorgement -- warm or cold packs,
increase feedings, decrease stimulation. Bindbreasts.
Gas distention -- no ice, increase warm / hot
fluids, increase walking, rocking chair, antiflatus
drugs.
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Decision Making
During shift assessment of the post
partum moms peri pad, the nurse
found it saturated with lochia rubra.
What would be the priority nursing
intervention?
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The Nutrition Need
Most moms are hungry and eager to eat. Start offslowly to avoid nausea and vomiting.
Diet should include:
High in Protein, vitamin C, and fiber Increase in fluids
Lactating moms need about 700 extra calories for
milk production
Prenatal vitamins and iron supplements are often
continued in the postpartum period.
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Psychological Adjustment
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 patients 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
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Postpartum Blues
Transient period of depression
Occurs first few days after delivery
Mother may experience tearfulness,
anorexia, difficulty sleeping, feeling ofletdown
Usually resolves in 10 to 14 days
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Bonding
Initial attraction felt by parents
Contact should occur as early as possibleand as frequently as possible.
Allow time for attachment to occur with all
members of the family
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Attachment
Bond that endures over time
Occurs through mutually satisfying experiences
Reciprocity - Mutually gratifying interaction amongmother, infant, father
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Attachment Process
Enface - infants face on samevertical plane as parent. Mutualgazing
Explore with finger-tips
Hand and Palmar contact
Whole arms --enfolds wholebaby close to body
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Claiming
The Claiming Process
Includes the identification
Of the babys specific
Features, relating them
To other family members
Those long toes are
just like his Dads
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The Steps in Attachment are:
1.
2.
3.
4.
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Postpartum Phases by Rubin
Taking - in
Occurs during day 1 - 3 following delivery.
Marked by a period of being dependent and
passive behavior.
Mothers primary needs are her own -- foodand 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
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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!
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Tailoring teaching to individual
Learning Styles
Demonstrations
Group Classes
Videotapes
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Postpartum Phases by Rubin
Letting Go Phase
occurs after about 2 weeks
Mother may feel a deep loss over theseparation of the baby from part of her
body and may grieve over this loss.
Common for Postpartum Blues to occur
during this time
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Father-Infant Interaction
Engrossment
Sense of absorption
Preoccupation -
Interest in infant
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Discharge Preparation for discharge should begin when
expectant mother enters birthing unit
Mother needs to be aware of signs of postpartumcomplications and should be aware of her self-care
needs
Nurses should begin first by assessing knowledgeand expectations of new mother and family
Nurse should be available to answer questions andprovide support to parents
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Discharge
Printed Information Nurse should review with new mother any
information she has received regarding postpartum
exercises, prevent of fatigue, sitz bath and perineal
care, etc. - nurse should spend time with parent to
determine if they have any last-minute questionsbefore discharge
Printed information about local agencies and
support groups should be given to new family
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The End