Title: Normal Postpartum Revised 1/31/11 Debbie Perez RN, MSN, CNS
1Normal PostpartumRevised 1/31/11Debbie Perez
RN, MSN, CNS
2Normal Puerperium/Postpartum
- It is the period of recovery that occurs from
childbirth and extends for 6 weeks after delivery - It is a complex state of the childbearing
experience during which the physical and
psychological work of gestation and delivery
become final - It is a period of INVOLUTION -- process by which
the reproductive organs return to their normal
size or pre-pregnant state and functions.
3Reproductive System Changes
4Physiological Changes
5 The Uterus
- The uterus needs to return to its pre-
- pregnant state. This occurs by
Contraction of the Uterus
Autolysis / Catabolism
Regeneration of the Endometrium
6 Contraction of the Uterus
- Muscle fibers become shorter controlling the
bleeding by compressing and sealing off blood
vessels
7 Autolysis / Catabolism
- Release of a proteolytic enzyme into the
endometrium and myometrium. - This breaks down the protein material in the
hypertrophied cells causing the uterine muscle
cells to decrease in size
8 Regeneration of
the Endometrium
- the placenta site heals in about 6 weeks, the
remainder of the endometrium surface heals in
approx 3 weeks. - Healing takes place by exfoliation rather than
by forming scar tissue.
9 Critical Thinking
- Why does the uterus heal by exfoliation and not
by primary intention?
10 Nursing Care
11 Assessment of the Uterus
- Placement and Size (location)
- Tone
- Lochia
12Nursing 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
13Nursing 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.
14Lochia
- Assess Type
- Rubra -- 1 - 3 days dark red consists mainly of
blood - Serosa -- 3 - 10 days pinkish serum with tissue
and debris - Alba -- 10 - 14 days creamy yellowish, brownish
- Assess Amount
- When was pad last changed?
- Assess Odor
- Fleshy, not foul smelling Lochia
15Characteristics 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
16Cervix
- Remains soft and flabby, appears bruised and may
have lacerations from delivery - Pre-pregnant appearance is a dimpled area in the
center -- post-pregnancy appears as a jagged
slit.
17Vagina
- May be edematous and bruised.
- Rugae begin to appear when ovarian function
returns. - May teach the mom to do Kegels exercises
18Perineum
- 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 - Use Tucks and Dermaplast Spray as needed
- Sitz bath 3-4 x day
19What are treatment measures to teach the mom in
caring for her perineum?Why is perineal care
important?
20Match the Lochia
- A. Pinkish serum with mucus and debris. Usually
occurs on day 3 - 10. - B. Creamy yellowish brownish. Occurs after day
10 to 2weeks. - C. Dark Red and consists mainly of blood.
Occurs day 1 - 3. -
- Lochia rubra
- Lochia serosa
- Lochia alba
21Fill 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 ___________.
22Short Answers
- The nurse is going to assess the uterus. The 3
main assessments include - 1.
- 2.
- 3.
- The normal height of a first day postpartum woman
is ________________. It should decrease
_____fingerbreadth per _______. - The tone should be __________. If found boggy,
the nurse would ___________ the uterus.
23Breasts
- 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
24Process 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 - 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
25Breastfeeding 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
and stooling, then must be getting enough to eat
26Suppression 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/cabbage leaves
27Fill 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.
28Short Answers
- What are four important interventions to teach a
mom who is bottle feeding to decrease stimulation
of the breasts. - 1.
- 2.
- 3.
- 4.
29Elimination ChangesUrinary 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.
- Most common problem is urinary retention RT
- loss of elasticity and diminished bladder tone
- loss of sensation from trauma, drugs, anesthesia
- urethra edematous
- Interventions sitz baths,Tucks
30Critical Thinking
- A primigravida delivered 2 hours ago. The client
states she would like to go to the bathroom.
What should the nurse do? - The client is unable to void. What should the
nurse do next?
31Elimination ChangesGastrointestinal Tract
- Most common problem is constipation RT
- decrease muscle tone and intra-abdominal pressure
- Pre-labor diarrhea and decrease peristalsis
- pre- delivery enema (not common)
- dehydration
- perineal tenderness, hemorrhoids and episiotomy
- FEAR of pain
- 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.
32Regulatory 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.
33Postpartum 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 - 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.
34Integumentary 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 - 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
35Safety Concerns
- Safety for the new mom and baby is addressed on
admission to postpartum - Should be aware of the effects of pain medication
during handling of infant and during ambulation - First time OOB need to assist mom to BR for both
C/S and vaginal deliveries - Administer RhoGam for Rh- mom and Rh baby
36Oxygenation AlterationsCardiovascular 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.
37Oxygenation
- 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
38Critical Thinking
- The clients 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?
39Oxygenation Lab Assessment
- Post Partum
- WBC leukocytosis is common with values of
20,000 30,000 RT increassed neutrophils - RBC return to normal
- Hgb. normal to see a drop of about 1 gram
- Hct normal to see a drop of about 4 points and
then a rise RT gt loss of plasma than RBC death
- Pregnancy
- WBC elevated slightly to about 12,000
- RBC increase slightly to about 10 milion.
- Hemoglobin stays about normal at 12 g. Below
10 g anemia - Hemotocrit lowers 33-39 RT hemodilution. If
drops below 32- 35 anemia
40- 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 homans sign?
41- 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 gt140 / 90.
Other drugs to contract uterus Hemabate,
oxytocin and cytotec
42Decision Making
- During your shift assessment of the post partum
moms peri pad, you observe that it is saturated
with lochia rubra (large amount). - What is your priority nursing
- intervention?
43Nutritional 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.
44Psychological Adaptation
- The responses of the mother to the birth of her
infant are influenced by many factors - 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
45Postpartum 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!
46Postpartum 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 -- food
- and 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
47 - Tailoring teaching to individual Learning Styles
- Demonstrations
- Group Classes
- Videotapes
48Postpartum Phases by Rubin
- Letting Go Phase
- occurs after about 2 weeks
- Mother may feel a deep loss over the separation
of the baby from part of her body and may grieve
over this loss. - Common for Postpartum Blues to occur during this
time
49Attachment
- Bond that endures over time. Contact should
occur as early as possible and as frequently as
possible. - Allow time for attachment to occur with all
members of the family
50Attachment Process
- 1. En Face position -- eye-to-eye contact
- 2. Explore with
finger-tips - Hand and Palmar contact
- Whole arms --enfolds whole baby
- close to body
51Claiming
- 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
52The Steps in Attachment are
1. 2.
3.
4.
53The End