Care of the Postpartum Client

Romamea Magdayao Ana Marie Lopez Rowena Jenniesa Labordo Hanna Mae Magtoles BSN2BSN2-C

Postpartum Physical Adaptations

(pg. 906-929) 906-

Uterine Involution Fundal position changes: Boggy Lochia: Rubra, Serosa, Alba Cervical changes Vaginal changes Perineal changes Recurrence of ovulation and menustration

Lactation Gastrointestinal System Urinary tract Vital signs Weight loss Postpartum chill Postpartal diaphoresis Afterpains or Afterbirth pains

Uterine Involution
The rapid reduction in size of the uterus and its return to a condition similar to its preprepregnancy state. The uterus remains slightly larger than it was before the first pregnancy. Process is complete at 3 weeks except at the placental site (6 to 7 weeks) Subinvolution may be caused by an infection or retained placenta fragments.

WEIGHT OF THE UTERUS

Right after delivery: 1000 grams 1 week after :500 grams 2 weeks after : 300 grams 6 weeks after : 50 60 grams

Fundal Position Changes After birth :

 1st day: one fingerbreadth below umbilicus  2nd day: two fingerbreadths below umbilicus  9th to 10th day: cannot be palpated abdominallyThe first postpartum day it is located 1 cm or fingerbreadth below the umbilicus.

Fundal Position Changes

May be displaced to the left or right by a distended bladder. Becomes boggy with uterine atony

 Boggy Uterus
Massage the uterus Place infant on mothers breast Administer oxytocin
 Check BP  Do not give if BP > 140/90

UTERINE CONTRACTIONS
Prevent bleeding Afterpains uncomfortable cramps
Common in multipara Oxytocin treated Breastfeeding mothers

 2 3 days

NURSING MEASURES
Explain the cause and purpose of afterpains Keep bladder empty Prone position to lessen discomfort Gentle massage Administer analgesics

VAGINAL DISCHARGE
LOCHIA
 Uterine discharge after delivery  Blood, mucus, epithelial cells, leukocytes and bacteria

COLOR AND PATTERN

Rubra:
 dark red in color  present the first 2-3 days 2postpartum  few small clots

Serosa:
 pinkish to brownish  4th to the 10th day

Alba:
 creamy or yellowish  persists for a week or two after serosa, may be later in

breastfeeding clients.

SIGNS OF ABNORMAL LOCHIA

SIGNS FOUL SMELL LARGE CLOTS EXCESSIVE AMOUNT POSSIBLE CAUSE INFECTION RETAINED FRAGMENTS LACERATION OF BIRTH CANAL

RETURN TO RETAINED FRAGMENTS RUBRIA AFTER INFECTION SEROSA OR ALBA BLEEDING AFTER 6 WEEKS SUBINVOLUTION OF THE UTERUS

CERVICAL CHANGES Spongy, flabby, formless and bruised. Original form is regained in a few hours The shape is permanently changed by the first childbearing. Goes from dimple like to a lateral slit (fish mouth)

VAGINAL CHANGES Edematous and bruised Small superficial lacerations may be present Laceration and episiotomy heals after 2 weeks Size and rugae return to pre pregnancy in 3 weeks By 6 weeks appears normal

PERINEAL CHANGES edematous with some bruising Episiotomy edges should be approximated Ecchymosis may occur and delay healing Suture: 7 to 10 days Perineal muscle tone regained : 6th weeks

PERINEAL CARE
Flush with warm water Pat dry from front to back Change pad frequently Observe signs of infection Reduce hemorrhoids

PERINEAL CARE
ICE PACKS SITZ BATH
 PROMOTE CIRCULATION  20 MINUTES

PERINEAL LAMP
    Promote vasodilation 25 to 40 watts light 12 -18 inches away 20 minutes 3x a day

Recurrence of Ovulation and Menustration

Variable Generally returns to non-nursing mothers nonbetween 7 and 9 weeks after birth The first cycle is non-ovulatory nonBreastfeeding clients may experience menstruation and ovulation based on the amount of time nursingmay occur from 2nd to 18th month

LACTATION During pregnancy, the breasts develop in preparation for lactation as a result of both estrogen and progesterone. After birth, the interplay of maternal hormones leads to the establishment of milk production.

GASTROINTESTINAL May have a regular diet

 High in protein, iron and vitamins

Bowels tend to be sluggish Episiotomy clients may delay bowel movement for fear of pain Cesarean birth clients may receive clear liquids and progress to a regular diet Stool softeners may be used

URINARY TRACT
increased bladder capacity, swelling and bruising of tissue, decreased sensitivity to fluid pressure, and decreased sensation of bladder filling. At risk for over-distention, incomplete emptying, and overbuildup of residual urine. Urinary output increases 1rst 24 hours post delivery (puerperal diuresis) diuresis) Urine specimens should be obtained as a catheterized specimen.

CARDIOVACULAR  Blood loss: NSD: 300 to 500 ml CS: 500 to 1000 ml reduction in blood volume  40% increase of maternal blood volume after delivery of the placenta  Return of cardiac output to pregnant state takes about 2- 3 weeks from delivery 2 Hemoconcentration in the first 3 to 7 days  Leukocytosis in the first 12 days  Elevated fibrinogen levels up to the third weeks  Physiologic bradycardia during the first 24 hours  Orthostatic hypotension in the first 24 hours

INTEGUMENTARY
 Disappearance of skin changes (6 weeks) except for striae and diastisis recti  Areolar hyperpigmentation may not disappear completely

Vital Signs afebrile after the first 24 hours. BP WNL, a decrease may occur. An occur. BP may indicate toxemia, PIH. Pulse rate may decrease to 50-70. 50Tachycardia should alert the nurse to blood loss/difficult birth. birth.

Blood Values
Blood values should return to the prepregnant state by the end of the postpartum period. Leukocytosis with white blood cell (WBC) counts up to 30,000 per mL may occur early postpartum. Convenient rule of thumb is a 2 point drop in hematocrit equals a blood loss of 500 mL.

Weight Loss An initial weight loss of 10 to 12 lbs occurs as a result of the birth of the infant, placenta and amniotic fluid. Puerperal diuresis accounts for loss of an additional 5 lbs during the early postpartum period. Normally return to pre-pregnant preweight by 6 weeks postpartum.

Postpartum Chill and Postpartal Diaphoresis

Most clients experience a shaking chill or tremor after delivery.
 Warm blankets usually relieve this tremor or chill.

Chills and fever late in the postpartum period may indicate sepsis. Diaphoretic episodes may occur at night, a normal occurrence as the body rids itself of waste products.

AMBULATION
NSD : 4 8 hours ANESTHESIA : 8 hours ADVANTAGES:
 Prevent constipation  Prevent circulatory problems, urinary problems  Promote recovery  Hasten drainage of lochia

EXERCISE
Purpose
 Prevent complications  Psychological well being  Strengthen muscles of back, pelvic floor and abdomen

EXERCISE
POSTPARTUM EXERCISE
     Abdominal breathing Kegel exercise: tighten perineal muscle Arm Raising Leg Raising SitSit-ups

REST AND SLEEP

At least 8 hours Avoid heavy lifting Light housekeeping: 2 weeks Normal activities: 4 6 weeks

RESUMPTION OF SEX
VAGINAL DELIVERY: 3 4 WEEKS CS: 2 WEEKS

Discharge
 Primiparas : 2 to 3 days Multipara: 1 to 2 days CS: 3 to 4 days  Discharge IE is done before leaving  Follow up: 4 to 6 weeks after delivery

Postpartum Psychological Adaptations

Postpartum Psychological Adaptations

Postpartum blues Development of Parent-Infant Parentattachment Initial attachment Behavior FatherFather-Infant Interactions Cultural Influences

RUBINS POSTPARTUM PHASE

TAKINGTAKING-IN PHASE
 1st 2- 3 days postpartum  Need for sleep and rest  Dependence on other

TAKINGTAKING-HOLD PHASE
 Transition phase  3rd day to 2 weeks postpartum  Control body function

TAKINGTAKING-HOLD PHASE
 Ability to assume the mother role

LETTINGLETTING-GO PHASE
 Realize that the infant is a separate individual and not a part of herself  Feeling of loss  Adjustment phase

Postpartum blues
Transient period of depression : 1 - 2 weeks after birth. Manifested by mood swings, anger, weepiness, anorexia, difficulty sleeping, and a feeling of letdown. CAUSE: Hormonal changes and psychological adjustments

Postpartum blues

Resolve naturally in 2 to 3 weeks with support and reassurance. If symptoms persist, the client should be evaluated for postpartum depression.

Development of Parent-Infant Parentattachment

Level of trust Level of self-esteem selfCapacity for enjoying herself Interest in and adequacy of knowledge about childbearing and childrearing Clients prevailing mood or usual feeling tone Reactions to the present pregnancy

Initial attachment Behavior

Progression of touching activities En face position dominates Relies heavily on senses of sight, touch, hearing in getting to know the baby Some negative feelings may occur; be understanding not condescending Reciprocity is an interactional cycle that occurs simultaneously between mother and infant. (mutual cueing behaviors, expectancy, delight in each others company when synchronous)

FatherFather-Infant Interactions Primary role has been supporting role Engrossment (the characteristic sense of absorption, preoccupation, and interest in the infant demonstrated by fathers during early contact with the newborn.

Cultural Influences
Postpartum care my be affected by cultural beliefs: No shower, no breastfeeding for the first three days, hot and cold foods Do not make generalizations Extended family may play an important role in care

Postpartum Assessment
Vital signs: BP should remain consistent with baseline BP during pregnancy. Pulse 50 -90, respirations 16-24, temp 981698100.4 Breasts: Smooth, even pigmentation, soft, filling, full, engorged Abdomen: soft, fundus firm, midline and at/or below umbilicus, may be tender on palpation Lochia: rubra, scant to moderate, no clots, rubra to

Postpartum Assessment
Perineum: Slight edema, no bruising, episiotomy without redness, swelling or drainage, hemorrhoids (none or small) Lower extremities: No pain with palpation, negative Homans sign Elimination: voiding 4-6 hrs, no 4bladder distention noted, normal bowel movement by the 2nd to 3rd day post delivery Psychological adaptation: cultural assessment, bonding, holding en face, attachment behaviors

Postpartum Assessment

Dysfunctions of the Postpartum Period

Postpartal Uterine Infection: Endometritis, Pelvic Cellulitis Perineal Wound Infection Cesarean Wound Infection Urinary Tract Infection (UTI) Mastitis Thromboembolitic Disease: Superficial Leg Vein Disease, Deep Vein Thrombosis, Septic Pelvic Thrombophlebitis Postpartum Psychiatric Disorder: baby blues, Postpartum Psychosis, Postpartum Major Mood Disorder

Two methods of milk suppression a. mechanical (tight bras, avoiding nipple stimulation, ice packs) b. pharmacologic (bromocriptine)