Postpartum

THE POSTPARTAL FAMILY

Maybelle B. Animas

Postpartal Period

• Puerperium- “puer”- child, “parere” –to bring

forth

• 6-weeks period after childbirth

• Retrogressive- involution of the uterus

and vagina

• Progressive- production of milk for lactation,

restoration of the normal menstrual cycle,

and beginning of a parenting role

Psychological Changes of the

Postpartal Period

PHASES OF PUERPERIUM

Taking-In Phase

• 2- to 3-day period, a woman is largely

passive

• woman usually wants to talk about her

pregnancy, especially about her labor

and birth

• ***Main nursing is to listen and help the mother interpret

events of the delivery to make them more meaningful and

clarify and misconceptions


Taking-Hold Phase – 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

***It is the best time for teaching!


Letting-Go Phase

• woman finally redefines her new role

• She gives up the fantasized image of her

child and accepts the real one; she gives

up her old role of being childless or the

mother of only one or two

Development of Parental Love and

Positive Family Relationship

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

DPLPFR

• Claiming or Bonding

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”

Rooming-In

• Infant stays in the room rather than in the

nursery.

• She can become better acquainted with

her child and begin to feel more confident

in her ability to care

Postpartal Blues

• 50% of women experience some feeling of

overwhelming sadness for which they

cannot account

• Hormonal changes- dec progesterone and

estrogen

• Response to dependence and low self

esteem caused by exhaustion, being away

from home, physical discomfort and

tension

Postpartal Blues

• Fearfulness, feeling of inadequacy, mood

lability, anorexia and sleep disturbance

• Assurance and support

Physiologic Changes of the Postpartal Period

• Involution

– Reproductive organs return to their normal state


• Uterus

• 2 process

1.The area where the placenta is sealed off

– Accomplished by rapid contraction of the uterus after the delivery of the placenta

– Muscle fibers become shorter controlling the bleeding by compressing and sealing off blood vessels

2. The organ is reduced to its pregestational size through

– Autolytic process

• Few cells of the uterine wall are broken down into their protein component which is then absorbed in the blood stream and excreted in the urine.

– Contraction

- Immediately after birth – 1000g

- At the end of 1st wk- 500g

- 6wks – 50g


- After placental delivery the uterus may be palpated through the abdominal wall halfway bet the umbilicus and the symphysis pubis

- 1hr after- level of umbilicus

- Decrease 1 fingerbreath per day

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

TYPE COLOR DURATION COMPOSITION

Lochia Rubra Red 1-3 days Blood, fragments of

decidua, mucus

Lochia Serosa

Pink 3-10 days Blood, mucus and leukocytes

Lochia Alba White 10-14 days Largely mucus

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

Physiologic Changes of the

Postpartal Period • Cervix

– After birth- soft and

malleable, internal and

external os is open

– Pre-pregnant appearance

is a dimpled area in the

center -- post-pregnancy

appears as a jagged slit.

Physiologic Changes of the

Postpartal Period

• 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

– Sitz bath 3-4 x day

• 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

Breasts

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

Process of Lactation

– 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”

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

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.

Elimination Changes Urinary System

• 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

Postpartum 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

Integumentary Changes

• 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

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

Oxygenation – Lab Assessment

Pregnancy Post Partum

WBC – elevated slightly to about 12,000 WBC – leukocytosis is common with values of 20,000 – 30,000 RT increassed neutrophils

RBC – increase slightly to about 10 milion.

RBC – return to normal

Hemoglobin – stays about normal at ~ 12 g. Below 10 g = anemia

Hgb. – normal to see a drop of about 1 gram

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

Hct – normal to see a drop of about 4 points and then a rise RT > loss of plasma than RBC death

• 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

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.

“ Because the more a mother is cared for, the more easily she can care for her baby.”

- Shivam Rachana

Health & Medicine

Postpartum