Normal Postpartum

1
Normal Postpartum
Chapter 21
2
Normal Puerperium

• It is the period of recovery that occurs from
  childbirth and extends for 6 weeks after delivery
• What is involution?

3
Postpartal Physical Adaptations
4
Reproductive System Changes
5
The Uterus

• What are the three ways that the uterus
  involutes?

6
Contraction of the Uterus

• Muscle fibers become shorter controlling the
  bleeding by compressing and sealing off blood
  vessels
• Acting as the living ligature

7
Protein Material Catabolism

• Release of a proteolytic enzyme into the
  endometrium and myometrium.
• This enzyme breaks down the protein material in
  the hypertrophied cells causing the uterine
  muscle cells to decrease in size
• The uterus gradually decreases in size as the
  cells grow smaller

8
Regeneration of the Endometrium

• the placenta site heals in about 6 weeks with the
  other part healing in 3 weeks.
• Heals by exfoliation rather than by forming scar
  tissue.
• The endometrium grows from the margins of the
  placental site and from the fundi of the
  endometrial glands left in the basal layer of the
  placental site

9
Critical Thinking
Why does the uterus heal by Exfoliation and
not by primary intention?
10
Uterine Changes

• Placement and size
• Where is the normal placement of the uterus
  immediately after birth, 12 hours later?
• What is the size of the uterus?

11
Uterus
What nursing intervention should the nurse
encourage PRIOR to assessing the fundus?
12
Uterine Changes

• What is the normal tone of the uterus?
• What is the technique used to assess the uterus?

13
Uterine Involution

• What is the PRIORITY intervention when the uterus
  is found to be boggy?
• Why is it important not to over-stimulate the
  uterus?

14
Uterus

• What interventions must the nurse include if the
  uterus is found deviated from midline?

15
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.

16
Lochia

• What are the three types of lochia?
• What is a normal amount?
• What question is important to ask
• the woman when assessing amount?
• What is normal odor of Lochia?

17
Characteristics of Lochia

• Should not be excessive in amount
• Should never have an offensive odor
• Should not contain large pieces of tissue
• Should not be absent during the first 3 weeks
• Should proceed from rubra -- serosa -- alba

18
Match the Lochia

• A. Pinkish serum with mucus and debris usually
  occurs on day 3 - 10.
• B. Creamy yellowish brownish. Occurs after day
  10
• C. Dark Red and consists mainly of blood.
  Occurs day 1 - 3.

• Lochia rubra
• Lochia serosa
• Lochia alba

19
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 ___________.

20
Cervix

• Remains soft and flabby, appears bruised and may
  have some lacerations
• No longer does the external os have the
  pre-pregnant appearance -- now appears as a
  jagged slit not a circle.

21
Vagina

• May be edematous and bruised.
• Rugae begin to appear when ovarian function
  returns.
• May teach the mom to do Kegels exercises to
  increase the blood flow to the area and aid in
  healing

22
Perineum

• Assess
• the episiotomy the same as with any incision.
• R redness
• E edema or swelling
• E ecchymosis or bruising
• D drainage
• A approximated
• How should the nurse assess
• the perineum?

23
What are measures to teach the mom in caring for
the perineum?
24
Comfort Measures

• Relief of Perineal Discomfort
• Ice packs
• Topical agents
• Perineal care
• Sitz bath
• Relief of hemorrhoidal discomfort may include
• Sitz baths
• Topical anesthetic ointments
• Witch hazel pads

25
Ovulation and Menstruation

• When does Menstruation generally return?
• Return is prolonged for the breastfeeding mom
  because of alterations in the gonadotropin-releasi
  ng hormone production.

26
Ovulation and Menstruation

• Nurses need to teach moms that breastfeeding is
  NOT a reliable means of contraception.
• WHY

27
Breasts

• Allow the mother to assess her own breasts --
  similar to doing a self-breast exam
• ask if feels any nodules, lumps
• ask if nipples are sore, reddened, blisters,
  cracks
• Assess nipples for everted, flat, inverted
• Teach to care for breasts according to whether
  they are breastfeeding or bottle feeding.

28
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

29
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, then must be getting enough to eat

30
Suppression of Lactation

• Key is to teach the mother measures to decrease
  stimulation of the breasts
• Wear a tight-fitting bra or binder
• Do not express milk from the breasts
• Take shower with back to the warm water
• Ice packs

31
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.

32
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.

33
Cardiovascular System
34
Cardiovascular System Changes

• How does the body rid itself of excess Plasma
  volume?
• 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.

35
Blood Values

• Post Partum
• WBC leukocytosis is common with values of
  25,000 30,000 RT increased neutrophils
• RBC return to normal
• Hgb. normal to see a drop of about 1 gram
• Hct normal to see a drop of about 2- 4 points
  and then a rise RT gt loss of plasma than RBC
  death
• Platelets drop and gradually rise

• 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

36

• Assess for Thromboembolism
• During pregnancy, plasma fibrinogen (coagulation)
  increases, Mothers body has the ability to form
  clots and prevent excessive bleeding.
• Plasminogen (lysis of clots) does not rise
• Hypercoagulable state and the woman is at a
  greater risk for thrombus formation.
• assess for homans sign

37
Vital Signs

• Temperature
• A slight elevation of up to 100.40 may occur
  related to dehydration and increase basal body
  metabolism from exertion of labor and delivery.
• After 24 hours, the temperature should be normal
• A temperature greater than 100.40 suggests
  infection.
• Blood Pressure
• Should remain stable
• Hypovolemia can indicate postpartum hemorrhage
• Hypervolemia could indicate preeclampsia

38
Vital Signs

• Pulse
• Bradycardia of 50 70 bpm is Normal
• Tachcardia is not considered a normal occurrence
  and may indicate excessive blood loss
• Respirations
• Should remain stable and within normal range

39
Critical Thinking

• The womans 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?

40
Gastrointestinal Tract

• The most common GI problem during postpartum is
  constipation EXPLAIN.
• What teaching is important to assist in
  decreasing constipation?

41
Urinary System

• What is the most common problem associated with
  the urinary system?
• Why be concerned?

42
Critical Thinking

• A primigravida delivered 2 hours ago. The woman
  states she would like to go to the bathroom.
  What should the nurse do?
• The woman is unable to void. What should the
  nurse do next?

43
Afterpains

• Who is more likely to experience afterbirth
  pains? Explain.
• Relief of after pains
• Positioning (prone position)
• Analgesia administered an hour before
  breastfeeding
• Encourage early ambulation - monitor for
  dizziness and weakness

44
Rest and Activity

• Most common problem is Sleep -- the excitement
  and exhilaration experienced by birth my make it
  difficult to sleep. They are tired and need
  rest. Allow for times of uninterrupted sleep.
• Exercises -- have the patient to ask her own
  doctor for specific exercises. Usually walking
  is safe. May eventually do postpartum exercises.
  Just need to allow the body to return to its
  pre-pregnant state before straining it.

45
Resumption of Activities

• New mother should gradually increase activities
  and ambulation after birth
• She should avoid heavy lifting, excessive stair
  climbing, strenuous activity
• Resume light housekeeping by second week at home
• Delay returning to work until after 6-week
  postpartum examination

46
Exercises

• Recommend exercise to provide health benefits to
  new mother
• Nurse should encourage client to begin simple
  exercises while on nursing unit
• Inform her that increased lochia and pain may
  necessitate a change in her activity

47
Pain

• Perineal pain -- caused from trauma during
  delivery, episiotomy, hemorrhoids. Provide
  comfort measures such as sitz baths, Tucks,
  Sprays / Foams, oral analgesics.
• Afterbirth pain -- more common in multigravidas
  and breastfeeding moms. Treat with mild
  analgesics (NSAIDS, Acetamenaphen),heating pad,
  lie on abdomen, discontinue use of oxytocins,
• Breast engorgement -- warm or cold packs,
  increase feedings, decrease stimulation. Bind
  breasts.
• Gas distention -- no ice, increase warm / hot
  fluids, increase walking, rocking chair,
  antiflatus drugs.

48
Decision Making

• During shift assessment of the post partum moms
  peri pad, the nurse found it saturated with
  lochia rubra.
• What would be the priority nursing
• intervention?

49
The Nutrition Need

• Most moms are hungry and eager to eat. Start off
  slowly to avoid nausea and vomiting.
• Diet should include
• High in Protein, vitamin C, and fiber
• Increase in fluids
• Lactating moms need about 700 extra calories for
  milk production
• Prenatal vitamins and iron supplements are often
  continued in the postpartum period.

50
Psychological Adjustment

• The responses of the mother to the birth of her
  infant are influenced by many factors such as
• Her 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

51
Postpartum Blues

• Transient period of depression
• Occurs first few days after delivery
• Mother may experience tearfulness, anorexia,
  difficulty sleeping, feeling of letdown
• Usually resolves in 10 to 14 days

52
The Process of Becoming Acquainted
53
Bonding

• Initial attraction felt by parents
• Contact should occur as early as possible and as
  frequently as possible.
• Allow time for attachment to occur with all
  members of the family

54
Attachment

• Bond that endures over time
• Occurs through mutually satisfying experiences
• Reciprocity - Mutually gratifying interaction
  among mother, infant, father

55
Attachment Process
56
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
57
The Steps in Attachment are
1. 2.
3.

4.

58
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

59
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!

60

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

61
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

62
Father-Infant Interaction

• Engrossment
• Sense of absorption
• Preoccupation - Interest in infant

63
Discharge

• Preparation for discharge should begin when
  expectant mother enters birthing unit
• Mother needs to be aware of signs of postpartum
  complications and should be aware of her
  self-care needs
• Nurses should begin first by assessing knowledge
  and expectations of new mother and family
• Nurse should be available to answer questions and
  provide support to parents

64
DischargePrinted Information

• Nurse should review with new mother any
  information she has received regarding postpartum
  exercises, prevent of fatigue, sitz bath and
  perineal care, etc. - nurse should spend time
  with parent to determine if they have any
  last-minute questions before discharge
• Printed information about local agencies and
  support groups should be given to new family

65
The End