POSTPARTUM PERIOD Postpartal Puerperium PUER- Latin means CHILD PAPARE---- to bring forth refers to the 6 week period

d after birth time of maternal changes that are retrogressive ( Involution of the uterus and the vagina ) and progressive ( production of milk for lactation, restoration of the normal menstrual cycle and beginning of a parenting role popularly known as the fourth trimester of pregnancy TRANSITION a movement or passage from one position or concept to another. a pause between what was and what is to be or the internal process experience by people when change occurs CLASSICAL PRESENTATION Change is something that happens to people and transition is how they respond to change. POSTPARTUM PERIOD a time of transition during which the couple gives up concepts such as CHILDLESS OR PARENTS OF ONE and moves to the new beginning of parenthood. Phases of the Puerperium 1. Taking in phase --A time of reflection for a woman. She is passive (dependent) due partly to her physical discomfort from possible perineal stitches, after pains and extreme exhaustion. 2. Taking hold phase Woman begins to initiate action. Prefers to get her own washcloth and to make her own decisions. 3. Letting go phase The woman finally redefines her new role. She gives up the fantasized image of her child and accepts the real one. ROOMING IN Bringing the infant to the mothers room and stays with the mother. Two types of Rooming In 1. Complete - implies that the mother and child are together 24 hours a day 2. Partial ------ infant remains in the mothers room for part of time, perhaps from 10 am to 9 pm, after which he or she is taken to a small nursery near the mothers room or return to a central nursery at night. MATERNAL CONCERNS and FEELINGS 1. Abandonment Feeling of being abandoned and less important after birth. 2. Disappointment Expectation about the baby (chubby cheek) 3. Postpartum blues As many as 50 % of women experience some feelings of overwhelming sadness for which they cannot account. They burst into tears easily or may feel let down or be irritable. This temporary feeling after birth is known as Baby Blues. Maybe due to hormonal changes. Decrease in estrogen and progesterone that occurs with the delivery of the placenta.

Reproductive Changes Involution---- process whereby the reproductive organs return to their non pregnant state. Danger of hemorrhage from the uterus until involution is complete. Involution of the uterus involves two main process 1. The area where the placenta is planted is sealed off preventing bleeding. 2. The organ is reduced to its appropriate pre- gestational size. Note: First hour postpartum is dangerous time for women. If the uterus should become relaxed (uterine atony) the woman will loose blood very rapidly, coz no permanent thrombi have yet formed at the placental site. Lochia - Uterine flow consisting of blood, fragments of deciduas, white blood cells and some bacteria. Types: 1. Lochia Rubra 1 3 days and consist almost entirely of blood , with only small particles of deciduas and mucus. 2. Lochia Serosa 4th day flow, pink or brownish in color. 3. Lochia Alba ----10th day and flow becomes colorless or white and this is present until the third day after birth. Effects of Retrogressive Changes 1. Exhaustion 2. Weight loss Progressive changes or the building of new tissue: 1. Lactation formation of breast milk is initiated in women whether or not she plans to breastfeed. > Due to the increase estrogen level produced by the placenta stimulate the growth of milk glands and growth in breast size. > Little change in the breast occurs during the first two days. > On the third day, the breast become full and feel tense or tender as milk forms within breast ducts. Primary Engorgement > Feeling of tension in the breast on the third or fourth day postpartum > fades as the infant begins effective sucking and empties the Breast of milk 2. Return of menstrual flow > 6 to 10 weeks after birth to woman who is not breast feeding > 3 or 4 mos. With breastfeeding woman and for some, the entire period of lactation. Striae or Diastasis - A slightly indented, bluish - tinged groove in the midline of the abdomen. Procedure in palpating the uterus: 1. Place hand on the base of the uterus above the symphysis pubis and the other at the umbilicus. 2. Press in and downward with the hand on the umbilicus until you bump against a firm globular mass in the abdomen. Note: First hour after birth, height of the fundus is at the umbilicus or even slightly

above it. NOTE: > If the uterus is not firm on palpation, massage it gently with the examining hand this causes the uterus to contract and become firm immediately. > Gentle rotating motion of the hand not hard or forceful Episiotomy Cutting of the perineum during delivery Types: 1. Midline 2. Mediolateral ---- 1 or 2 inches long Laceration a tear of the perineum during delivery Nursing Intervention 1. Provide pain relief for after pains 2. Relieve muscular aches 3. Give episiotomy care 4. Promote perineal exercises : contract and relax the muscles of the perineum five to ten times in succession 3 to 4 times a day. 5. Administer hot and cold compress 6. Administer hot sitz bath 7. Promote perineal self- care 8. Promote rest in the early postpartal period 9. Promote adequate fluid intake Breastfeeding > Breast milk is the preferred method of feeding a newborn because it provides numerous health benefit to both the mother and the infant. > Remains the ideal nutritional source for infants through the first year of life. Colostrum > A thin, watery, yellow fluid composed of protein, sugar, fat, water, mineral, vitamins and maternal antibodies, secreted by the acinar breast cells starting in the 4th month of pregnancy. > For the 3 to 4 days after birth, colostrums production continues. > Because it is increase in protein and fairly low in sugar and fat, colostrums is easily digested. > provides totally adequate nutrition for the newborn until it is replace by transitional breast milk on the 2nd to 4th day. > True or mature breast milk is produce by the 10th day. BENEFITS FOR THE INFANTS Greater immune health: During breastfeeding, antibodies pass to the baby. This is one of the most important features of colostrum, the breast milk created for newborns. Breast milk contains several anti-infective factors such as bile salt stimulated lipase (protecting against amoebic infections), lactoferrin (which binds to iron and inhibits the growth of intestinal bacteria) and immunoglobulin A protecting against microorganisms. Fewer infections Among the studies showing that breastfed infants have a lower risk of infection than non-breastfed infants are:

In a 1993 University of Texas Medical Branch study, a longer period of breastfeeding was associated with a shorter duration of some middle ear infections (otitis media with effusion) in the first two years of life.

A 1995 study of 87 infants found that breastfed babies had half the incidence of diarrheal illness, 19% fewer cases of any otitis media infection, and 80% fewer prolonged cases of otitis media than formula fed babies in the first twelve months of life. Breastfeeding appeared to reduce symptoms of upper respiratory tract infections in premature infants up to seven months after release from hospital in a 2002 study of 39 infants. A 2004 case-control study found that breastfeeding reduced the risk of acquiring urinary tract infections in infants up to seven months of age, with the protection strongest immediately after birth. The 2007 review found that breastfeeding reduced the risk of acute otitis media, nonspecific gastroenteritis, and severe lower respiratory tract infections.

Protection from SIDS Breastfed babies have better arousal from sleep at 23 months. This coincides with the peak incidence of sudden infant death syndrome. A study conducted at the University of Mnster found that breastfeeding halved the risk of sudden infant death syndrome in children up to the age of 1. Higher intelligence

Studies have examined whether breastfeeding in infants is associated with higher intelligence later in life.

Less diabetes Infants exclusively breastfed have less chance of developing diabetes mellitus type 1 than peers with a shorter duration of breastfeeding and an earlier exposure to cow milk and solid foods. Breastfeeding also appears to protect against diabetes mellitus type 2, at least in part due to its effects on the child's weight. Less childhood obesity Breastfeeding appears to reduce the risk of extreme obesity in children aged 39 to 42 months. The protective effect of breastfeeding against obesity is consistent, though small, across many studies, and appears to increase with the duration of breastfeeding. Less tendency to develop allergic diseases (atopy) In children who are at risk for developing allergic diseases (defined as at least one parent or sibling having atopy), atopic syndrome can be prevented or delayed through exclusive breastfeeding for four months, though these benefits may not be present after four months of age. However, the key factor may be the age at which non-breastmilk is introduced rather than duration of breastfeeding. Atopic dermatitis, the most common form of eczema, can be reduced through exclusive breastfeeding beyond 12 weeks in individuals with a family history of atopy, but when breastfeeding beyond 12 weeks is combined with other foods incidents of eczema rise irrespective of family history.

Less necrotizing enterocolitis in premature infants Necrotizing enterocolitis (NEC) is an acute inflammatory disease in the intestines of infants. Necrosis or death of intestinal tissue may follow. It is mainly found in premature births.

Other long term health effects: In one study, breastfeeding did not appear to offer protection against allergies. However, another study showed breastfeeding to have lowered the risk of asthma, protect against allergies, and provide improved protection for babies against respiratory and intestinal infections. Less overweight: Doctors have long known that breast-fed infants are less likely to become overweight. A study in Today's Pediatrics associates solid food given too early to Formulafed babies before 4 months old will make them 6 times as likely to become obese by age 3. It does not happen if the babies were given solid foods with breast feeding. BENEFITS FOR THE MOTHERS Breastfeeding is a cost effective way of feeding an infant, providing nourishment for a child at a small cost to the mother. Frequent and exclusive breastfeeding can delay the return of fertility through lactational amenorrhea, though breastfeeding is an imperfect means of birth control. During breastfeeding beneficial hormones are released into the mother's body and the maternal bond can be strengthened. Breastfeeding is possible throughout pregnancy, but generally milk production will be reduced at some point. Bonding: Hormones released during breastfeeding help to strengthen the maternal bond. Teaching partners how to manage common difficulties is associated with higher breastfeeding rates. Support for a mother while breastfeeding can assist in familial bonds and help build a paternal bond between father and child. If the mother is away, an alternative caregiver may be able to feed the baby with expressed breast milk. The various breast pumps available for sale and rent help working mothers to feed their babies breast milk for as long as they want. To be successful, the mother must produce and store enough milk to feed the child for the time she is away, and the feeding caregiver must be comfortable in handling breast milk. Hormone release Breastfeeding releases oxytocin and prolactin, hormones that relax the mother and make her feel more nurturing toward her baby. Breastfeeding soon after giving birth increases the mother's oxytocin levels, making her uterus contract more quickly and reducing bleeding. Pitocin, a synthetic hormone used to make the uterus contract during and after labour, is structurally modelled on oxytocin. Syntocinon, another synthetic oxytocic, is commonly used in Australia and the UK rather than Pitocin. Weight loss As the fat accumulated during pregnancy is used to produce milk, extended breastfeedingat least 6 monthscan help mothers lose weight. However, weight loss is highly variable among lactating women; monitoring the diet and increasing the amount/intensity of exercise are more reliable ways of losing weight. Natural postpartum infertility Breastfeeding may delay the return to fertility for some women by suppressing ovulation. A breastfeeding woman may not ovulate, or have regular periods, during the entire lactation period. The period in which ovulation is absent differs for each woman. This lactational amenorrhea has been used as an imperfect form of natural contraception, with greater than 98% effectiveness during the first six months after birth if specific nursing behaviors are followed. It is possible for women to ovulate within two months after birth while fully breastfeeding and get pregnant again.

Long-term health effects For breastfeeding women, long-term health benefits include:

Less risk of breast cancer, ovarian cancer, and endometrial cancer. A 2009 study indicated that lactation for at least 24 months is associated with a 23% lower risk of coronary heart disease. Although the 2007 review for the AHRQ found "no relationship between a history of lactation and the risk of osteoporosis", mothers who breastfeed longer than eight months benefit from bone re-mineralisation. Breastfeeding diabetic mothers require less insulin. Reduced risk of metabolic syndrome. Reduced risk of post-partum bleeding. According to a Malm University study published in 2009, women who breast fed for a longer duration have a lower risk for contracting rheumatoid arthritis than women who breast fed for a shorter duration or who had never breast fed.

Advantage of breast feeding for the mother: 1. Serve as protective function in preventing breast cancer 2. Release of oxytocin from the posterior pituitary gland and in uterine involution 3. Can have an empowering effect because it is a skill only women can master. 4. Reduces the cost of feeding and preparation time 5. Provides the best opportunity to enhance the formation of a true symbiotic bond with their child 6. The presence of lactobacillus bifidus in breast milk interferes with the colonization of pathogenic bacteria in the gastrointestinal tract, reducing the incidence of diarrhea. 7. Breast milk contain anti-infective properties an ideal electrolyte and mineral composition for human infant growth MASSAGE >aids the ability of the body to heal itself and is aimed in achieving or increasing health and wellbeing. >A skilled massage therapist not only stretches and loosens muscles and connective tissue, but also greatly improves blood flow and the movements of lymph fluids throughout the body. > massage speeds the removal of metabolic waste products resulting from exercise or inactivity, allowing more nutrients and oxygen to reach the cells and tissues > the release of muscular tension also helps to unblock and balance the overall flow of life energy throughout the body. Physical Level Massage relieves muscle tension, reduces muscle spasm, improves muscle flexibility and range of motion, improves posture, lower blood pressure , slows heart rate, promotes deeper and easier breathing, and improves the health of the skin. Mental Level massage induces a relaxed state of alertness, reduces mental stress, and increases the capacity for clearer thinking. Emotional Level >massage satisfies the need for caring and nurturing touch, increases feelings of well- being, decreases mild depression, enhances self image, reduces level of anxiety, and increases awareness and body connection. EFFLEURAGE a type of massage consisting of long, slow, gliding strokes.

 Can enhance client comfort and relaxation and have a positive effect on cardiovascular parameters such as blood pressure heart rate and respiratory rate. Purposes >To relieve muscle tension > To decrease pain intensity > To promote physical and mental relaxation. EXPECTED OUTCOMES DURING THE POSTPARTAL PERIOD The woman will: Undergo a normal involution process with normal lochia discharge Remain comfortable and injury free Demonstrate normal bladder and bowel function Demonstrate knowledge of breast care Demonstrate knowledge of infant safety, infantcare activities, and infant feeding Integrate the newborn into the family ASSESSMENT SPECIFIC TO POSTPARTUM ADAPTATION Vital signs (q 4-8 hrs) Breasts/breastfeeding Uterus Bladder & bowel function Bonding & attachment process Lochia/perineum Edema, Homans sign Teaching/learning/referral needs assessment ASSESSMENT OF BREASTS & BREASTFEEDING Breasts soft & non-tender; nipples everted Begin by asking how feedings are going. Ask if patient feels lumps in breasts, or has redness, soreness, or blisters on nipples. Observe for signs that might indicate incorrect latch LATCH score NURSING DIAGNOSES RELATED TO BREASTS & BREASTFEEDING Pain r/t improper positioning, engorged breasts Ineffective breastfeeding r/t maternal discomfort, improper infant positioning Knowledge deficit r/t normal physiologic changes, breastfeeding Infection r/t improper breastfeeding techniques, improper breast care ASSESSMENT OF THE UTERUS Uterus midline, FF @ U/U or below following the first12-24 hrs after birth Rising uterus, displaced to side -- full bladder? Boggy uterus sub involution? Lochia: scant-moderate, rubra-serosa Perineal lacerations/episiotomy well-approximated, no signs of infection C/S dressing: REEDA (Redness, Edema, Ecchymosis, Discharge, Approximation) Patient should be educated about normal and abnormal changes, what to report, and when to ask for help. NURSING INTERVENTIONS Ice packs 24 hrs

Sitz bath 3-4x/day 20 mins warm H2O Dry heat (lamp, hot packs) Change pad frequently Pericare after each void Topical medication

PAD COUNT: LOCHIA Scant: 1-inch stain on pad in 1 hour Light/small: 4 inches in 1 hour Moderate: 6 inches in 1 hour Heavy/large: Pad saturated in 1 hour Excessive: Pad saturated in 15 min Can estimate blood loss by weighing pads 500 mL= 1 lb. or 454 g LOCHIA AMOUNTS

ASSESSMENT OF BOWEL &BLADDER FUNCTION Void without difficulty/pain, urine may be blood-tinged from lochia Possible diagnosis: Urinary retention or constipation r/t post childbirth discomfort or tissue trauma Expected outcome: Return to normal bowel and bladder habits, void at least 240mL in 8 hrs, bowel movement in 3 days without pain. Nursing interventions: Assist to the bathroom. Use measures to encourage voiding (privacy). Measure1st 2 voids after SVD or Foley catheter removed. Encourage use of peribottle with warm water, fluids, fiber, frequent ambulation, stool softeners; teach effects of pain medication. ASSESSMENT OF EDEMA & HOMANS SIGN Assess legs for presence and degree of edema; may have dependent edema in feet and legs (facial and hand edema may indicate preeclampsia) Assess for Homans sign (thromboembolism); should be negative Obtain lab values: 8-hr post-delivery hemogram, urinalysis/C&S, blood type/Rh status CHECKING HOMANS SIGN