Normal Postpartum Revised 1/31/11 Debbie Perez RN, MSN, CNS

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Normal PostpartumRevised 1/31/11Debbie Perez
RN, MSN, CNS
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Normal 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.

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Reproductive System Changes
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Physiological Changes
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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
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Contraction of the Uterus

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

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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

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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.

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Critical Thinking

• Why does the uterus heal by exfoliation and not
  by primary intention?

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Nursing Care
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Assessment of the Uterus

• Placement and Size (location)
• Tone
• Lochia

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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

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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.

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Lochia

• 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

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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

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Cervix

• 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.

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Vagina

• May be edematous and bruised.
• Rugae begin to appear when ovarian function
  returns.
• May teach the mom to do Kegels exercises

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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
• Use Tucks and Dermaplast Spray as needed
• Sitz bath 3-4 x day

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What are treatment measures to teach the mom in
caring for her perineum?Why is perineal care
important?
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Match 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

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Fill 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 ___________.

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Short 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.

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Breasts

• 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

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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
• 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

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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
• 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

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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/cabbage leaves

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Fill 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.

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Short Answers

• What are four important interventions to teach a
  mom who is bottle feeding to decrease stimulation
  of the breasts.
• 1.
• 2.
• 3.
• 4.

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Elimination 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

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Critical 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?

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Elimination 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.

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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.

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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
• 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.

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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
• 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

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Safety 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

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Oxygenation 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.

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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

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Critical 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?

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Oxygenation 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

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• 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?

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• 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

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Decision 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?

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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.

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Psychological 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

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Postpartum 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!

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Postpartum 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

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• Tailoring teaching to individual Learning Styles
• Demonstrations
• Group Classes
• Videotapes

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Postpartum 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

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Attachment

• 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

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Attachment 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

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Claiming

• 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
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The Steps in Attachment are
1. 2.
3.

4.

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The End