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Postpartum Period
-Puerperium (from the Latin word puer”child: and parere”to bring forth” Or Postpartal Period, is when the woman
adjust physically and psychologically to the process of childbirth
-Begins immediately after birth and continues for approximately
Retrogressive Phase
-Uterus
-Involves 2 main Processes
*The area where the placenta was implanted sealed off to prevent bleeding.
*The organ is reduced to its approximate pregestational size.
Retrogressive Phase
*At 6 weeks it weights 50 grams(uterus)
*Feel “Boggy” and “Spongy” suspect bleeding or hemorrhage, uterine “automy?”
*Subinvolved Uterus is a big uterus and vaginal bleeding with clots
*After pains/after birth pains –strong uterine contractions felt more particularly by MULTI’s, those who delivered
large babies or wins and those who BREADTFEED.
Management:
-Never apply heat on the abdomen
-give analgesic as prescribed.
-Explain that it is normal and rarely lasts for more than 3 days,
Factors that slow uterine involution include the following
-birth of multiple fetuses
-hydramnios
-prolonged labor or difficult labor
-physiologic effects or excessive analgesia
-grand multiparity
-a full bladder
-incomplete expulsion of all the placenta or fragments of the membranes
-factors that enhance involution include the following
-an uncomplicated labor and birth
-complete expulsion of the placenta or membranes
-breastfeeding
-early ambulation
-Schultz=shiny uterus
Retrogressive Phase
-Oxytocin – hormone released from the pituitary gland which strengthen and coordinates the uterine contraction.
-Causes compression of blood vessels and aid in homeostasis
-1st 2 hours of POSTPARTUM – contraction usually subsides in intensity and becomes uncoordinated, MEthergin is
given to promote contraction.
Cervix
-After birth, the cervix is soft and malleable
-both internal and external OS are open
-By end of 7 days – external OS is narrowed to the size of a pencil opening
-Cervix is fuller firm and nongravid by end of 7 days
-external os will remain slightly open and appear SLITLIKE or STELLATE
Vagina
-often at birth – soft with few rugae
-takes about 6 weeks to return to its prepregnant state
-remain more slightly distended than before
-practice Kegel Exercise to increase strength and tone
-CARINCULAE MYSTIFORMESE – torn & jagged hymen tag.
Preineum
-still edematous with generalized tenderness due to pressure during child birth
-may show ECCHYMOSIS due to ruptured of surface capillaries
-Labia majora/minora – soft and never return to their prepregnant state
Breasts
-3 to 4 days after birth engorgement will start
-Engorge and warm
-just let the newborn suck to relieve engorgement
-sometimes mother experiences fever but will subside easily
Lochia
-Uterine discharges consisting blood, deciduas, WBC mucus and some bacteria
Lochia Rubra
-red
-1-3 days
-blood, fragments of deciduas and mucus
-moderate in amount
LOCHIA SEROSA
-pink
-3to 10 days
-blood, mucus, and invading leukocytes
-decreased in amount
LOCHIA ALBA
-white
-10-14 days (may last up to 6 weeks)
-largely mucus, leukocyte count is light
Cardivascular System
Heart rate
-during pregnancy, the distended uterus obstructs the amount of venous blood returning to the heart
-slightly slower than normal
-after birth, stroke volume increases to accommodate the increased blood volume returning to the heart
-the increased stroke volume reduces the rate between 60-70 bpm.
-a rapid and thread pulse is a possible sign of hemorrhage.
Blood Pressure
-should be monitored carefully because it can indicate bleeding
-always compare to the woman’s prepregnant BP
-140/90 mmHg above may indicate postpartum Pregnancy Induced Hypertension (PIH)
-Caution woman for possible OROTHOSTATIC HYPOTENSION or DIZZINESS due to lack of blood volume.
Blood Values
-30 to 50% increase in total cardiac volume during pregnancy will be reabsorbed in to the general circulation within
5-10 minutes after placental delivery.
IMPLICATIONS:
-the first 5 to 10 minutes after placental delivery is crucial to GRAVIDO CARDIACS because the weka heart may not
be able to handle much workload
-WBC increase to 20,000 – 30,000/mm3 cannot be used as indicator of postpartum infection
-There is extensive activation of the CLOTTING FACTORS which encourages THROMBOEMBOLIZATION
-Ambulation is recommended early, 4 to 8 hours in normal vaginal delivery
Exercise
-KEgel/Abdominal Breathing
*PPD(post partum day) 1
-Chin to chest
*PPD 2: firm abdominal muscles
Knee – To – Abdomen
-when perineum has healed – strengthen abdominal/gluteal muscles
-massage is contraindicated
-all blood values are back to prenatal level by the 3rd – 4th week postpartum.
-hematocrit levels – decrease 4 points
-hemoglobin levels – decrease by 1 gram with each 250 ml of blood loss
Respiratory Function
-without the presence of respiratory disease or medications, such as an epidural narcotic, the normal respiratory
rate should be 16 to 24 breaths per minute.
Gastrointestinal Function
-digestion and absorption begin to be active again soon after birth
-hungry due to glucose used during labor
-thirsty due to long periods of restricted fluid pus diaphoresis
-HEMORRHOIDS (distended rectal veins)
-pushed out from the rectum due to the effort of pelvic – stage pushing
-BOWEL SOUNDS – are active
-delay bowel evacuation may be due to:
*decreased muscle tones
*lack of food during labor
*dehydration
*fear of pain from perineal tenderness due to episiotomy, lacerations or hemorrhoids
Integumentary Function
-stretch marks (STRIAE GRAVIDARUM) still appear reddened
-this will fade to pale white over the next 3-6 months
-CHLOASMA barely detectable in 6 weeks
-LINEA NIGRA > Time
-DIASTASIS RECTI (overstretching and separation of the abdominal musculature) – slightly distended abdomen
-modified sit-ups can help strengthen the abdominal muscles.
-building of new tissues
LACTATION
-formation of breast milk is initiated in a woman whether or not she plans to breastfeed
Physiology of Breastmilk Production
-Decreased ESTROGEN and PROGESTERONE (after the delivery of placenta
-Stimulates ANTERIOR PITUATARY GLAND to produce PROLACTIN
-Acts on ACINAR CELLS to produce FOREMILK
-FOREMILK is stored in the COLLECTING TUBULES
-When Infants Suck…
-Posterior Pituitary Gland is stimulated to produce OXYTOCIN
-Causes contraction of SMOOTH MUSCLES of COLLECTEING TUBULES
-Milk is ejected forward
-LET DOWN or MILK EJECTION REFLEX is stimulated
-HINDMILK is produced
HYGIENE
-wash breast daily at bath or shower time
-soap or alcohol should never be used because dry and crack of nipples
-wash hands before and after feeding
-insert gauze in the brassiere to absorb moisture from breast discharges.
-RESUMPTION OF MENSTRUAL FLOW
*IF not breastfeeding – return of menstrual flow is expected within 6-10 weeks after delivery
*Is breastfeeding – menstrual return is expected 2 to 4 months
-in some women, no menstruation occurs during the entire lactation period
-IMPORTANT: AMENORRHEA during lactation is no guarantee that the woman will not become pregnant.
-POSTPARTUM CHECK UP: Should be done to assess involution.
Psychological Changes
Attachement – is the process of connecting with another human being.
-ideally, a mother’s attachment to her offspring is a strong bond that lasts a lifetime.
-begins during pregnancy and intensifies as the pregnancy progresses and a fantasy child is perceived.
-the postpartum period, the mother-infant acquaintance begins as the infant is compared to the child who was
perceived in the womb.
-“getting-to-know-you” period
-parents begin to identify with their newborn
Bonding Behavirors-describes initial mutual attraction between people. EX – parent and child at forst meeting
-CLAIMING PROCESS – period where families engage with the identification of the new baby
-IDENTIFICATION – first identified in terms of “likeness” to other family members, then in terms of “differences” and
in terms of “uniqueness.”
7/20/09
Psychological Changes
Helping Parents adjust to parenthood
-recognize that adjusting to parenthood takes time
-Discuss feelings with support persons
-obtain adequate rest and nutrition
-use community resources
-seek out support from family and friends
-understand postpartum and newborn care
-refer to written plans of care from postpartum and newborn care.
-keep postpartum and newborn follow-up appointments
Psychological Changes
Sibling Visitation Postpartum – early inclusion of older siblings helps to facilitate adaptation of older children to their
new role and promotes a sense of being family.
-promote early contact with the newborn to facilitate integration into the family unit.
-enhance the older sibling’s feeling of importance within the family as a “helper”
-include the sibling in a celebration party to promote a feeling of belonging.
-take precautions against cross-infection by questioning the parents to see if their older child has been exposed to
communicable diseases in the recent weeks or presently has symptoms of an infection, such as vomiting, coughing,
runny nose, fever, diarrhea or rash.
-educate parents regarding sibling hand washing to promote safe sibling contact with the newborn and facilitate
sibling attachment behavior.
Maternal Adjustment
-phases of puerperium where mother is experiencing changes:
-taking –in or dependent phase: period after birth characterized by woman’s dependency; maternal need is
dominant; talking about birth as an important tasks.
Taking-hold or the dependent-independent phase: the woman is more independent and more interested in learning
of the infant care skills with the supervision of experienced significant others.
-postpartum blues – “baby blues” an overwhelming feeling of sadness that cannot be accounted for.
-usually appear within 1-2 weeks after delivery
-may be observed at this period.
-could be due to hormonal changes, fatigue or feelings of inadequacy in taking care of a new baby.
-symptoms include: feeling of tiredness; mood swings; feeling of loss, frustration or anger; unexplained weeping,
irritability, inability to sleep.
-takes place within 6-8 weeks.
Letting Go-Phase: independent or interdependent phase – redefines her new role; gives up the fantasized image;
the woman and family moved forward as a system w/ interacting member.
-resuming of sexual act -3rd to 4th pp week.
Postpartum Assessment
-VS, amount of lochia, presence of edema, fundal height and firmness, status of perineum(check for bleeding,
infection, wound healing, foul order), bladder distension(would result in fundus to the right)
-1 to 2 hours after delivery: every 15 minutes
-if no problems every 8 hours
Perineum
-Patient in lateral Sims (side lying) position.
-use the acronym REEDA (redness, edema, ecchymosis, discharge, approximation of suture lines “edges of
episiotomy”) to guide assessment.
-even if there is no episiotomy, the perineum should still be assessed
-unusual perineal discomfort may be a symptom of impending infection or hematoma. Hemmorhoids?
-Episiotomy – usually sealed by 24 hours
Breast
-check if client is using bra – check if bra is adequate and comfortable
-check breast using inspection and palpation
*size
*shape
*color
-1 and 2nd day – soft
st
Elimination patterns
-marked DIURESIS within 12 hours
-postpartum to eliminate excess fluid accumulation during pregnancy.
-some may have “frequent” urination in small amounts – explain that it is due to urinary retention with overflow
-stimulate voiding – warm/cold water
-4 to 8 hours after birth bladder is already distended
-when was the patient’s last bowel movement
Assessment of Legs
-assess legs for presence and degree of edema; may have dependent edema in feet and legs
-assess for Homan’s sign(pain in the calf during dorsiflexion) – thrombophlebitis should be negative
-press down gently on the patient’s knee (legs extended flat on bed) ask her to flex her foot (dorsiflex)
Thromboembolic Conditions
-Thrombophlebitis(clot formation, inflammation of the veins?) the formation of a clot in an inflamed vein.
-risk factors include maternal age over 35, cesarean birth, prolonged time in stirrups, obesity, smoking, and history
of variscosities or venous thromboses.
-Prevention: client needs to ambulate early after delivery.
H – Homan’s Sign
E – Edema
Therapeutic Management:
-Attempt uterine massage to encourage contraction.
-If uterus cannot remain contracted, the physician or nurse-midwife probably will order a dilute intravenous infusion
of oxytocin to help the uterus tone. Intramuscular methylergonovine (Methergine), an ergot compound is a second
possibility.
-Offer a bedpan or assist the woman with ambulating to the bathroom at least every 4 hours to keep bladder
empty.
-Obtain vital signs frequently and make sure to interpret them accurately, loking for trends.
-Blood transfusion may be necessary
-In the rare instances of extreme uterine atony, litigation of the uterine arteries or hystectomy may be necessary.
Done as a last resort.
Management:
-repair of the cervical laceration
-regional anesthetic may be necessary to relax the uterine muscle to prevent pain.
-Vaginal Laceration are rare. Easier to assess than cervical lacerations because they are easier to view.
Management:
-vagina may be packed to maintain pressure on the suture line.
-an indwelling urinary catheter (foley catheter) may be placed because packing can interfere with voiding.
-Perineal Lacerations usually occurs when women are placed in a lithotomy position for birth, because this position
increases tension on the perineum.
Management:
-they are sutured and treated as episotomy repair
-make sure that the laceration is documented
-a diet high in fluid and a stool softener may be prescribed for the 1st week after birth to prevent constipation and
hard stools
-no enema or rectal suppository for a woman with 3rd or 4th degree laceration.
Retained Placental Fragments – occasionally a placenta does not deliver in its entirety, fragments of it separate and
are left behind
-the portion retained keeps the uterus from contracting fully.
Management:
-removal of the placental fragments is necessary to stop the bleeding.
-a dilation and curettage (D&C) is performed to remove the placental fragments.
Disseminated Intraaasclar Coagulation (DIC) is a deficiency in clotting ability caused by vascular injury.
-usually associated with premature separation of the placenta, a missed early miscarriage, or fetal death in utero.
Management
-the underlying insult that began the phenomenon must be halted, premature separation of the placenta – ending
pregnancy by delivering the fetus and placenta.
-Marked coagulation must be stopped so that coagulation factors can be freed and restore normal clotting function.
Heparin must be given cautiously close to birth or postpartum hemorrhage could occur from poor clotting after
delivery of the placenta.
-antithrombin III factor, fibrinogen, or cryoprecipitate (which contains fibrinogen) can all be used to restore blood
clotting, fresh-frozen plasma or platelets, can also aid in the restoring in the clotting function.
Management
-bed rest with the affected leg elevated.
-anticoagulatnts – Heparin – to prevent further clot formation
-analgesics
Subinvolution – is incomplete return of the uterus to its prepregnant size and shape
-signs and symptoms – 4 to 6 week postpartal visit, the uterus is still enlarged and soft
Management
-oral administration of methergine, 0.2 mg four times daily
-oral antibiotics may also be prescribed.
Management
-oxytocin
-fowler’s position to drain out lochia and prevent pooling of infected discharges.
Management:
-resuturing
-hot sitz bath
-heat lamp treatment
-antibiotic
Management:
-antibiotic
-ice compress
-proper breast support
-discontinued breastfeeding on the affected breast.