Transcript 9_Postpartum physiology

Normal Postpartum Period
The Postpartum Period
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Puerperium = fourth trimester of pregnancy
- the 6-week interval between the birth of
the newborn and the return of the
reproductive organs to their normal
nonpregnant state
Uterine Involution
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Uterine Involution:
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return of the uterus to its pre-pregnancy
size and condition, which begins
immediately after expulsion of the
placenta with contraction of the uterine
smooth muscle
Uterine fundal descent:
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immediately after birth uterus is in the
midline approximately 2 cm below the
level of the umbilicus, size of grapefruit
(like 16 weeks of gestation), weighs
approximately 1000 g.
Within 12 hours the fundus may be
approximately 1 cm above the umbilicus
During next few days the fundus
descends 1 to 2 cm (fingerbreadth)
every 24 hours.
By the sixth postpartum day the fundus
is normally located halfway between the
umbilicus and the symphysis pubis.
A week after birth the uterus once again
lies in the true pelvis.
After the ninth postpartum day the
uterus should not be palpable
abdominally.
Uterine Involution
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Increased estrogen and progesterone levels are responsible
for stimulating the massive growth of the uterus during
pregnancy. Prenatal uterine growth results from both
hyperplasia, an increase in the number of muscle cells, and
from hypertrophy, an enlargement of the existing cells.
Postpartally, the decrease in these hormones causes
autolysis, the self-destruction of excess hypertrophied
tissue. The additional cells laid down during pregnancy
remain and account for the slight increase in uterine size
after each pregnancy.
Subinvolution is the failure of the uterus to return to a
nonpregnant state. The most common causes of
subinvolution are retained placental fragments and infection.
Lochia Assessment
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Lochia–vaginal discharge after childbirth.
It takes 6 weeks for the vagina to regain its pre-pregnancy contour.
For the first 2 hours after birth the amount of uterine discharge
should be approximately that of a heavy menstrual period. After that
time, the lochia flow should steadily decrease.
Lochia: rubra, serosa or alba
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Assessment of lochia includes noting color, presence and size of clots and
foul odor.
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Day 1- 3 - lochia rubra (blood with small pieces of decidua and
mucus)
Day 4-10-22-27 – lochia serosa (pink or pinkish brown serous exudate with
old blood, cervical mucus, erythrocytes and leukocytes, tissue debris)
Day 11- 21 - lochia alba (yellowish white discharge with leucocytes, decidua,
epithelian cells, mucus, serum, bacteria)
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The amount of lochia is usually less after cesarean births. Flow of
lochia usually increases with ambulation and breastfeeding and
receives an oxytocin medication
LOCHIAL AND NONLOCHIAL
BLEEDINGLOCHIAL
BLEEDINGNONLOCHIAL BLEEDING
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Lochia
Lochia usually trickles from
the vaginal opening. The
steady flow is greater as
the uterus contracts
A gush of lochia may result
as the uterus is massaged.
If it is dark in color, it has
been pooled in the relaxed
vagina, and the amount
soon lessens to a trickle of
bright red lochia (in the
early puerperium).
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Bleeding
If the bloody discharge
spurts from the vagina,
there may be cervical or
vaginal tears in addition
to the normal lochia.
If the amount of
bleeding continues to be
excessive and bright red,
a tear may be the
source.
Cervix
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The cervix is soft immediately after birth.
By 18 hours postpartum it has shortened, become firm, and regained
its form.
The cervix up to the lower uterine segment remains edematous, thin,
and fragile for several days after birth.
The ectocervix (portion of the cervix that protrudes into the vagina)
appears bruised and has some small lacerations—optimal conditions for
the development of infection.
The cervical os, which dilated to 10 cm during labor, closes gradually.
Two fingers may still be introduced into the cervical os for the first 4 to
6 days postpartum; however, only the smallest curette can be
introduced by the end of 2 weeks.
The external cervical os never regains its prepregnant appearance; it is
no longer shaped like a circle but appears as a jagged slit that is often
described as a "fishmouth."
Lactation delays the production of cervical and other estrogeninfluenced mucus and mucosal characteristics.
VAGINA AND PERINEUM
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Vagina
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vaginal mucosa is thin, atrophic, with decrease amount of lubrication and without
rugae as a result of estrogen deprivation which lead to coital discomfort (dyspareunia)
until ovarian function returns and menstruation resumes.
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The greatly distended, smooth-walled vagina gradually returns to its prepregnancy
size by 6 to 8 weeks after childbirth. Rugae reappear by approximately the fourth
week, but they are never as prominent as they are in the nulliparous woman. Most
rugae are permanently flattened.
Perineum
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the introitus is erythematous and edematous, especially in the area of the episiotomy
or laceration repair. It is barely distinguishable from that of a nulliparous woman
Episiotomy. Most episiotomies are visible only if the woman is lying on her side with
her upper buttock raised or if she is placed in the lithotomy position.
Hemorrhoids (anal varicosities) are commonly seen. Internal hemorrhoids may evert
while the woman is pushing during birth. Women often experience associated
symptoms such as itching, discomfort, and bright red bleeding with defecation.
Hemorrhoids usually decrease in size within 6 weeks of childbirth.
Pelvic muscular support
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The supporting structure of the uterus and vagina may be
injured during childbirth and may contribute to later
gynecologic problems.
Supportive tissues of the pelvic floor that are torn or
stretched during childbirth may require up to 6 months to
regain tone.
Kegel exercises, which help to strengthen perineal
muscles and encourage healing, are recommended after
childbirth.
Later in life, women can experience pelvic relaxation, the
lengthening and weakening of the fascial supports of pelvic
structures.
These structures include the uterus, upper posterior vaginal
wall, urethra, bladder, and rectum.
Endocrine System
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Placental hormones (human chorionic somatomammotropin,
estrogens, cortisol, and the placental enzyme insulinase)
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dramatically decrease and reverse the diabetogenic effects of
pregnancy, resulting in significantly lower blood sugar levels in the
immediate puerperium.
Estrogen and progesterone levels drop markedly after expulsion of
the placenta and reach their lowest levels 1 week postpartum.
Decreased estrogen levels are associated with breast engorgement
and with the diuresis of excess extracellular fluid accumulated during
pregnancy.
In nonlactating women, estrogen levels begin to rise by 2 weeks
after birth and by postpartum day 17 are higher than in women who
breastfeed
β-Human chorionic gonadotropin disappears from maternal
circulation in 14 days
Endocrine System
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Pituitary hormones and ovarian function
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The persistence of elevated serum prolactin levels in breastfeeding women appears to
be responsible for suppressing ovulation. Because levels of follicle-stimulating
hormone (FSH) have been shown to be identical in lactating and nonlactating women,
it is thought that the ovulation is suppressed in lactating women because the ovary
does not respond to FSH stimulation when increased prolactin levels are present
Prolactin levels in blood rise progressively throughout pregnancy.
In nonlactating women, prolactin levels decline after birth and reach the prepregnant
range in 4 to 6 weeks
In breastfeeding woman prolactin levels remain elevated into the sixth week after
birth, and influence by the frequency of breastfeeding, the duration of each feeding,
and the degree to which supplementary feedings are used.
Ovulation occurs as early as 27 days after birth in nonlactating women, with a mean
time of 70 to 75 days. Approximately 70% of nonbreastfeeding women resume
menstruating by 3 months after birth.
In women who breastfeed, the mean length of time to initial ovulation is 17 weeks.
In lactating women, both resumption of ovulation and return of menses are
determined in large part by breastfeeding patterns. Many women ovulate before their
first postpartum menstrual period occurs; thus there is need to discuss contraceptive
options early in the puerperium.
The first menstrual flow after childbirth is usually heavier than normal. Within three to
four cycles the amount of menstrual flow returns to the woman's prepregnancy
volume
Abdomen
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During the first 2 weeks after birth the
abdominal wall is relaxed.
Returns to prepregnancy state 6 weeks after
birth
The skin regains most of its previous
elasticity, but some striae may persist.
The return of muscle tone depends on
previous tone, proper exercise, and the
amount of adipose tissue.
Occasionally, with or without overdistention
because of a large fetus or multiple fetuses,
the abdominal wall muscles separate, a
condition termed diastasis recti abdominis.
Persistence of this defect may be disturbing
to the woman, but surgical correction rarely is
necessary. With time, the defect becomes less
apparent.
Urinary System
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Renal function reduced as a result of diminishing steroid levels after
childbirth
Kidney function returns to normal within 1 month after birth.
From 2 to 8 weeks are required for the pregnancy-induced hypotonia
and dilation of the ureters and renal pelvis to return to the nonpregnant
state.
In a small percentage of women, dilation of the urinary tract may persist
for 3 months, which increases the chance of developing a urinary tract
infection.
URINE COMPONENTS
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renal glycosuria disappears,
but lactosuria may occur in lactating women.
The blood urea nitrogen increases during the puerperium as autolysis of the
involuting uterus occurs. This breakdown of excess protein in the uterine
muscle cells also results in a mild (+1) proteinuria for 1 to 2 days after
childbirth in approximately 50% of women
Ketonuria may occur in women with an uncomplicated birth or after a
prolonged labor with dehydration.
Urinary System
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POSTPARTAL DIURESIS
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Within 12 hours of birth, women begin to lose excess tissue fluid accumulated during
pregnancy.
Profuse diaphoresis often occurs, especially at night, for the first 2 or 3 days after
childbirth.
Postpartal diuresis, caused by decreased estrogen levels, removal of increased venous
pressure in the lower extremities, and loss of the remaining pregnancy-induced
increase in blood volume, also aids the body to rid itself of excess fluid.
Fluid loss through perspiration and increased urinary output accounts for a weight loss
of approximately 2.25 kg during the puerperium.
URETHRA AND BLADDER
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Birth-induced trauma, increased bladder capacity following childbirth, and the effects
of conduction anesthesia combine to cause a decreased urge to void.
In addition, pelvic soreness caused by the forces of labor, vaginal lacerations, or the
episiotomy reduces or alters the voiding reflex.
Decreased voiding combined with postpartal diuresis may result in bladder distention.
Immediately after birth, excessive bleeding can occur if the bladder becomes
distended because it pushes the uterus up and to the side and prevents the uterus
from contracting firmly.
Later in the puerperium overdistention can make the bladder more susceptible to
infection and impede the resumption of normal voiding. With adequate emptying of
the bladder, bladder tone is usually restored 5 to 7 days after childbirth.
GASTROINTESTINAL SYSTEM
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APPETITE
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The mother usually is hungry shortly after the birth and can tolerate a light
diet.
Most new mothers are very hungry after full recovery from analgesia,
anesthesia, and fatigue. Requests for double portions of food and frequent
snacks are not uncommon
BOWEL EVACUATION
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A spontaneous bowel evacuation may not occur for 2 to 3 days after
childbirth. This delay can be explained by decreased muscle tone in the
intestines during labor and the immediate puerperium, prelabor diarrhea,
lack of food, or dehydration. The mother often anticipates discomfort during
the bowel movement because of perineal tenderness as a result of
episiotomy, lacerations, or hemorrhoids and resists the urge to defecate.
Regular bowel habits should be reestablished when bowel tone returns.
Obstetric trauma (e.g., direct injury to the sphincter muscle, damage to the
innervation of the pelvic floor) is perhaps the leading cause of anal
incontinence in otherwise healthy women. Women should be taught during
pregnancy about episiotomy and its possible sequelae. Pelvic floor (Kegel)
exercises should be encouraged.
BREASTS
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Promptly after birth, there is a decrease in the concentrations of hormones (i.e., estrogen,
progesterone, hCG, prolactin, cortisol, and insulin) that stimulated breast development during
pregnancy. The time it takes for these hormones to return to prepregnancy levels is determined in part
by whether the mother breastfeeds her infant.
BREASTFEEDING MOTHERS
As lactation is established, a mass (lump) may be felt in the breast. Unlike the lumps associated with
fibrocystic breast disease or cancer (which may be consistently palpated in the same location), a filled
milk sac shifts position from day to day. Before lactation begins, the breasts feel soft and a yellowish
fluid, colostrum, can be expressed from the nipples. After lactation begins, the breasts feel warm and
firm. Tenderness may persist for approximately 48 hours after the start of lactation. Bluish-white milk
with a skim-milk appearance (true milk) can be expressed from the nipples. The nipples are examined
for erectility and signs of irritation such as cracks, blisters, or reddening.
NONBREASTFEEDING MOTHERS
The breasts generally feel nodular in contrast to the granular feel of breasts in nonpregnant women.
The nodularity is bilateral and diffuse. Prolactin levels drop rapidly. Colostrum is present for the first few
days after childbirth. Palpation of the breast on the second or third day, as milk production begins, may
reveal tissue tenderness in some women. On the third or fourth postpartum day, engorgement may
occur. The breasts are distended (swollen), firm, tender, and warm to the touch (because of
vasocongestion). Breast distention is caused primarily by the temporary congestion of veins and
lymphatics rather than by an accumulation of milk. Milk is present but should not be expressed. Axillary
breast tissue (the tail of Spence) and any accessory breast or nipple tissue along the milk line may be
involved. Engorgement resolves spontaneously, and discomfort decreases usually within 24 to 36 hours.
A breast binder or tight bra, ice packs, or mild analgesics may be used to relieve discomfort. Nipple
stimulation is avoided. If suckling is never begun (or is discontinued), lactation ceases within a few
days to a week.
CARDIOVASCULAR SYSTEM
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BLOOD VOLUME
Changes in blood volume after birth depend on several factors, such as blood
loss during childbirth and the amount of extravascular water (physiologic
edema) mobilized and excreted. Blood loss results in an immediate but limited
decrease in total blood volume. Thereafter, most of the blood volume increase
during pregnancy (1000 to 1500 ml) is eliminated within the first 2 weeks after
birth, with return to nonpregnancy values by 6 weeks postpartum
Pregnancy-induced hypervolemia allows most women to tolerate considerable
blood loss during childbirth. Many women lose approximately 300 to 400 ml of
blood during vaginal birth of a single fetus and approximately twice this much
during cesarean birth.
Readjustments in the maternal vasculature after childbirth are dramatic and
rapid. The woman's response to blood loss during the early puerperium differs
from that in a nonpregnant woman. Three postpartal physiologic changes
protect the woman by increasing the blood volume:
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elimination of uteroplacental circulation reduces the size of the maternal vascular bed
by 10% to 15%,
loss of placental endocrine function removes the stimulus for vasodilation,
mobilization of extravascular water stored during pregnancy occurs. Thus hypovolemic
shock usually does not occur in women who experience a normal blood loss.
CARDIOVASCULAR SYSTEM
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CARDIAC OUTPUT
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Pulse rate, stroke volume, and cardiac output increase throughout
pregnancy. Immediately after the birth they remain elevated or rise even
higher for 30 to 60 minutes as the blood that was shunted through the
uteroplacental circuit suddenly returns to the maternal systemic venous
circulation.
Data regarding the exact time of return of cardiac hemodynamic levels to
normal are not available, but cardiac output values remain elevated for at
least 48 hours after birth, decrease rapidly in the first 2 weeks postpartum,
and return to prepregnancy level by 24 weeks postpartum.
Stroke volume, cardiac output, end-diastolic volume, and systemic vascular
resistance values have been shown to remain greatly elevated for as long as
12 weeks postpartum
VITAL SIGNS
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Few alterations in vital signs are seen under normal circumstances. There
may be a small, transient rise in both systolic and diastolic blood pressure
that lasts approximately 4 days after the birth
Respiratory function returns to nonpregnant levels by 6 to 8 weeks after
birth. After the uterus is emptied, the diaphragm descends, the normal
cardiac axis is restored, and the point of maximal impulse and the
electrocardiogram are normalized.
CARDIOVASCULAR SYSTEM
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BLOOD COMPONENTS
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Hematocrit and hemoglobin
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White blood cell count
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Normal leukocytosis of pregnancy averages approximately 12,000/mm3. During the first 10
to 12 days after childbirth, values between 20,000 and 25,000/mm3 are common.
Neutrophils are the most numerous white blood cells. Leukocytosis coupled with the normal
increase in erythrocyte sedimentation rate that occurs may obscure the diagnosis of acute
infections at this time.
Coagulation factors
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During the first 72 hours after childbirth, there is a greater loss of plasma volume than in the
number of blood cells. This results in a rise in hematocrit and hemoglobin levels by the
seventh day after the birth. There is no increased red blood cell (RBC) destruction during the
puerperium, but any excess will disappear gradually in accordance with the life span of the
RBC. The exact time at which RBC volume returns to prepregnancy values is not known, but
it is within normal limits when measured 8 weeks after childbirth
Clotting factors and fibrinogen are normally increased during pregnancy and remain elevated
in the immediate puerperium. When combined with vessel damage and immobility, this
hypercoagulable state causes an increased risk of thromboembolism, especially after a
cesarean birth. Fibrinolytic activity also increases during the first few days after childbirth.
Factors I, II, VIII, IX, and X decrease within a few days to nonpregnant levels. Fibrin split
products, probably released from the placental site, can also be found in maternal blood.
VARICOSITIES
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Varicosities (varices) of the legs and around the anus (hemorrhoids) are common during
pregnancy. Varices, even the less common vulvar varices, regress (empty) rapidly
immediately after childbirth. Surgical repair of varicosities is not considered during pregnancy.
Total or nearly total regression of varicosities is expected after childbirth.
NEUROLOGIC SYSTEM
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Neurologic changes during the puerperium are those that result from a
reversal of maternal adaptations to pregnancy and those resulting from
trauma during labor and childbirth.
Pregnancy-induced neurologic discomforts abate after birth. Elimination
of physiologic edema through the diuresis that follows childbirth relieves
carpal tunnel syndrome by easing compression of the median nerve.
The periodic numbness and tingling of fingers that afflicts 5% of
pregnant women usually disappears after the birth unless lifting and
carrying the baby aggravates the condition.
Headache requires careful assessment. Postpartum headaches may be
caused by various conditions, including pregnancy-induced
hypertension, stress, and leakage of cerebrospinal fluid into the
extradural space during placement of the needle for epidural or spinal
anesthesia.
Depending on the cause and effectiveness of the treatment, the
duration of the headaches can vary from 1 to 3 days to several weeks.
Postpartum Depression
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Postpartum depression is a nonpsychotic
depressive episode that begins in the
postpartum period due to decreased
estrogen level
Symptoms: changes in appetite or weight,
sleep, and psychomotor activity; decreased
energy; feeling of worthlessness or guilt;
difficulty thinking, concentrating or making
decisions; or recurrent thoughts of death or
suicidal ideation, plans, or attempts.
Postpartum Psychosis
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A very serious type of PPD
illness that can affect new
mothers.
Begin 2-3 weeks post
delivery
Fatigue, restlessness,
insomnia, crying liable
emotions, inability to move,
irrationally statements
incoherence confusion and
obsessive concerns about
the infant’s health
Psychiatric emergency
MUSCULOSKELETAL SYSTEM
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Adaptations to pregnancy include the relaxation
and subsequent hypermobility of the joints and the
change in the mother's center of gravity in
response to the enlarging uterus.
The joints are completely stabilized by 6 to 8 weeks
after birth. However, although all other joints return
to their normal prepregnancy state, those in the
parous woman's feet do not.
The new mother may notice a permanent increase
in her shoe size.
INTEGUMENTARY SYSTEM
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Chloasma of pregnancy usually disappears at the end of pregnancy.
Hyperpigmentation of the areolae and linea nigra may not regress
completely after childbirth. Some women will have permanent darker
pigmentation of those areas.
Striae gravidarum (stretch marks) on the breasts, abdomen, and thighs
may fade but usually do not disappear.
Vascular abnormalities such as spider angiomas (nevi), palmar
erythema, and epulis generally regress in response to the rapid decline
in estrogens after the end of pregnancy. For some woman, spider nevi
persist indefinitely.
The abundance of fine hair seen during pregnancy usually disappears
after giving birth; however, any coarse or bristly hair that appears
during pregnancy usually remains. Fingernails return to their
prepregnancy consistency and strength.
Profuse diaphoresis that occurs in the immediate postpartum period is
the most noticeable change in the integumentary system.
IMMUNE SYSTEM
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No significant changes in the maternal
immune system occur during the postpartum
period.
The mother's need for a rubella vaccination
or for prevention of Rh isoimmunization is
determined.
Nursing Care
of the Postpartum Woman
Fourth Stage of Labor
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Goal of nursing care is to assist woman and
their partners during their initial transition to
parenting
Nursing's role is to monitor the recovery of
the new mother and infant, to identify and
manage promptly any deviations from the
normal processes that may occur, and to
promote and support parent-infant
attachment
Fourth Stage of Labor
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First 1 to 2 hours after birth
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During this time, maternal organs undergo their
initial readjustment to the nonpregnant state and
the functions of body systems begin to stabilize.
Meanwhile, the newborn continues the transition
from intrauterine to extrauterine existence
Excellent time to begin Breastfeeding
Encouraging of the mother
 Colostrum prompting elimination of meconium
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Care in the Immediate
Postpartum Period
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Assessment
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During first hour every 15 minutes
During second hours every 30 minutes
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Postanesthesia recovery (every 15 min)
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Activity
Respiration
BP
Level of cosciousness
Color
general anesthesia
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Awake, alert, orient to time, place, and person, respiratory rate, oxygen saturation levels at least 95%, as measured by a pulse
oximeter
epidural or spinal anesthesia
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VS (Ps, BP, T)
fundal height and firmness
bladder distension
amount of lochia
presence of edema
status of perineum,
should be able to raise her legs, extended at the knees, off the bed, or to flex her knees, place her feet flat on the bed, and raise
her buttocks well off the bed. The numb or tingling, prickly sensation should be entirely gone from her legs. Often, it takes 1.5 to
2 hours for these anesthetic effects to disappear.
Providing comfort measures
Analgesics
Promoting bladder elimination
Providing fluid and food
Nursing Care After Cesarean
Birth
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Same as with normal vaginal delivery except
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Postanesthesia recovery
Monitoring of abdominal dressing
Urinary catheter
Respiratory care
Prevention of thrombophlebitis
Interventions for pain
Slide 30
Postpartum Physical Assessment
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B - breast
U - uterus
B - bowels
B - bladder
L - lochia
E - episiotomy
General Assessment
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Enter the room quietly, speak quietly.
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Wash hands and provide for privacy.
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Inform patient before turning on lights.
Note LOC, activity level, position, color,
general demeanor.
Take note of the total environment:
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Safety/patient considerations
Note equipment and medical devices
Breast Assessment
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Breasts: Soft, engorged, filling, swelling,
redness, tenderness.
Nipples: Inverted, everted, cracked,
bleeding, bruised, presence of colostrum or
breastmilk.
Colostrum–yellowish fluid rich in antibodies
and high in protein.
Engorgement occurs by day 3 or 4. Due to
vasoconstriction as milk production begins
Lactation ceases within a week if
breastfeeding is never begun or is stopped.
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Nipple soreness is a portal of entry for
bacteria - breast infection (Mastitis).
Maternal after pains: may be due to
breastfeeding and multiparity
Always stay with the client when getting
out of bed for the first time – hypotension
effect and excess bleeding
When assessing fundal height, if you
notice any discrepancies in fundal height
have patient void and then reassess.
Nursing Diagnosis Related to Breasts and
Breastfeeding
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Pain r/t improper positioning, engorged
breasts
Ineffective breastfeeding r/t maternal
discomfort, improper infant positioning
Knowledge deficit r/t normal physiologic
changes, breastfeeding
Infection r/t improper breastfeeding
techniques, improper breast care
Assessing Uterine Fundus
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Location in relation to
umbilicus
Degree of firmness
Is it at Midline or deviated to
one side?
Bladder Full?
A boggy uterus may indicate
uterine atony or retained
placental fragments.
Boggy refers to being
inadequately contracted and
having a spongy rather than
firm feeling.
Massaging the Fundus
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Every 15 mins during the 1st hr,
every 30 mins during the next hr,
and then, every hr until the patient
is ready for transfer.
Document fundal height.
Evaluate from the umbilicus using
fingerbreadths.
This is recorded as 2 fingers
below the umbilicus (U/2), one
finger above the umbilicus (1/U),
and so forth.
The fundus should remain in the
midline. If it deviates from the
middle- distended bladder.
Uterine Atony
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Lack of muscle tone in the cervix.
Uterus feels soft and boggy
The bladder has increased capacity and
decreased muscle tone.
This leads to over-distension of the
bladder, incomplete emptying of bladder,
retention of residual urine and increased
risk of UTI and postpartum hemorrhage.
Bowels & Bladder
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When was the patients last bowel movement?
Is she passing flatus? (gas)
Assess for bowel sounds
Voiding pattern - without difficulty/pain, urine may
be blood tinged from lochia
Nursing interventions: Assist to the bathroom. Use
measures to encourage voiding (privacy).
Encourage use of peri-bottle with warm water,
fluids, fiber, frequent ambulation, stool softeners;
teach effects of pain medication.
Urinary System



A full bladder can displace the uterus and lead to
postpartum hemorrhage
In the woman who voids frequently, small amounts
of urine may have increased residual urine because
her bladder does not empty completely
Residual urine in the bladder may promote the
growth of microorganisms
Slide 40
Lochia: Pad Count
1.
2.
3.
4.



Scant: 1-inch stain on pad in 1 hour
Light/small: 4 inches in 1 hour
Moderate: 6 inches in 1 hour
Heavy/large: Pad saturated in 1 hour
Excessive: Pad saturated in 15 min
Can estimate blood loss by weighing pads:
500 mL = 1 lb. or 454 g
Episiotomy/Perineal Assessment


Patient in lateral Sims (side lying) position.
Use the acronym REEDA


Even if there is no episiotomy, the perineum
should still be assessed.


Redness, Edema, Ecchymosis, Discharge,
Approximation of suture lines “edges of episiotomy”) to
guide assessment.
Nursing care and patient teaching
 Cold packs
 Topical and systemic medications
 Nonpharmacologic pain relief methods
Unusual perineal discomfort may be a symptom of
impending infection or hematoma.
Hemorrhoids ?
Episiotomy Pain Relief




Instruct Mother:
Tighten her buttocks and perineum before
sitting to prevent pulling on the episiotomy
and perineal area and to release tightening
after being seated.
Rest several times a day with feet elevated.
Practice Kegel exercise many times a day to
increase circulation to the perineal area and
to strengthen the perineal muscles.
Discharge: Before 24 Hours and
After 48 Hours

Terms for decreasing length of stay of
mothers and newborns after a low risk birth



Early postpartum discharge
Shortened hospital stay
1-day maternity stay
Discharge: Before 24 Hours and
After 48 Hours

Laws relating to discharge


Advantages and disadvantages of early
postpartum discharge
Criteria for early discharge

Mother recovered and able to care for self and
baby
RhoGAM


It is given to an Rh- mother within 72
hours after delivery of an Rh+ infant or if
the Rh is unknown.
The dose must be repeated after each
subsequent delivery. RhoGAM 300 mcg is
the standard dose.
Rubella vaccination


For women who have not had rubella (10% to 20%
of all women) or women who are serologically not
immune (titer of 1:8 or enzyme immunoassay level
less than 0.8), a subcutaneous injection of rubella
vaccine is recommended in the immediate
postpartum period to prevent the possibility of
contracting rubella in future pregnancies.
The live attenuated rubella virus is not
communicable in breast milk; therefore
breastfeeding mothers can be vaccinated. However,
because the virus is shed in urine and other body
fluids, the vaccine should not be given if the
mother or other household members are
immunocompromised.
Discharge Teaching




Teaching for self-care: signs of complications
Sexual activity/contraception
Prescribed medications
Routine mother and baby checkups
Discharge Teaching

Follow-up after discharge





Home visits
Telephone follow-up
Warm lines
Support groups
Referral to community resources
Process of Becoming Acquainted




Bonding
Attachment
Maternal touch
Verbal behaviors
Factors Affecting Family Adaptation









Parental fatigue
Previous experience with a newborn
Parental expectations of newborn
Knowledge of and confidence in providing
for newborn needs
Temperament of the newborn
Temperament of parents
Age of parents
Available support system
Unexpected events
Cultural Influences on Adaptation




Provide care that is culture specific
Communication
Health beliefs
Dietary practices
The Process of Family Adaptation



Father
Siblings
Grandparents
Process of Maternal Adaptation







Maternal role attainment
Heading toward a new normal
Redefining roles
Role conflict
Major maternal concerns
Body image
Postpartum blues
Application of the Nursing Process:
Maternal Adaptation



Assessment
Analysis
Planning

Interventions







Assist mother
Monitor and protect
Listen
Foster independence
Promote bonding
Involve parents in care
Evaluation
Fathers


Engrossment
Four phases of adjustment
 Having expectations and personal intentions
 Confronting reality and overcoming frustrations
 Creating one’s own personal father role
 Reaping rewards of fatherhood
Slide 59
Family Care Plan

Studying the family, as the patient can offer insight
into community-based care
Slide 60
Data Collection for the
Family Care Plan








Demographic
information
Family composition
Occupation
Cultural group
Religious/spiritual
affiliation
Developmental tasks
Health concerns
Communication
patterns








Decision making
Family values
Socialization
Coping patterns
Housing
Cognitive abilities
Support system
Response to care
Slide 61
Key Points

Nurse provides teaching and counseling to
promote the woman’s feelings of
competence in self-care and baby care
Key Points



Postpartum care is modeled on the concept
of health
Cultural beliefs and practices affect the
client’s response to the puerperium
Nursing plan of care includes:



Assessments to detect deviations from normal
Comfort measures to relieve discomfort or pain
Safety measures to prevent injury or infection
Key Points

Common nursing interventions include:



Evaluating and treating the boggy uterus and the
full urinary bladder
Providing for pharmacologic and
nonpharmacologic relief of pain and discomfort
associated with the episiotomy or lacerations
Instituting measures to promote or suppress
lactation
Key Points

Effective means to prevent crisis and
facilitate physiologic and psychologic
adjustments used in combination include:





Home visits
Telephone follow-up
Warm lines
Support groups
Referral to community resources
Key Points

Short-stay option is safer when selection
criteria are used to determine a woman’s
eligibility for early discharge and when home
care follow-up is available
Key Points

Early postpartum discharge will continue to
be the trend as a result of:




Consumer demand
Medical necessity
Discharge criteria for low risk childbirth
Cost-containment measures
Key Points


Nurses promote the health of the woman’s
future pregnancies by administering rubella
vaccine and Rh immune globulin if indicated
Meeting psychosocial needs of new mothers
involves planning care that considers the
composition and functioning of the entire
family
Key Points



Under normal circumstances, few alterations
in vital signs are seen after childbirth
Activation of blood-clotting factors,
immobility, and sepsis predispose woman to
thromboembolism
Marked diuresis, decreased bladder
sensitivity, and overdistention of bladder can
lead to problems with urinary elimination
Дякую за увагу!
Assessment of Edema & Homan’s Sign



Assess legs for presence and degree of
edema; may have dependent edema in feet
and legs.
Assess for Homan’s sign- thromboembolism
should be negative
Press down gently on the patient’s knee
(legs extended flat on bed) ask her to flex
her foot (dorsiflex)
Homan’s Sign
Thromboembolic Conditions



Thrombophlebitis–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 varicosities
or venous thromboses.
Prevention: client needs to ambulate early
after delivery.
Postpartum Cesarean








Incision site…redness swelling, discharge. Intact?
Abdomen soft, distended? Bowel sounds heard all
4 quadrants
Flatus?
Lochia is less amount than in normal spontaneous
vaginal delivery (NSVD) because uterus is wiped
with sponges during c/section.
If lochia indicates excessive bleeding, combine
palpation and pain management measures.
Auscultate breath sounds
Fluid intake and output
Pain?
Postpartum Disseminated Intravascular Coagulation





Abnormal stimulation of clotting mechanism.
Normally, the body forms a blood clot in
reaction to an injury.
Small blood clots throughout the body,
depleting the body of clotting factors and
platelets. –Massive bleeding
Causes may include amniotic fluid clots, fetal
demise, abruptio placenta. Eclampsia or
Retained placenta
Symptoms: Sometimes severe bleeding and
sudden bruising .
Postpartum Hemorrhage





Blood loss of more than 500 ml after vaginal birth
or 1,000 ml after a cesarean birth.
Early hemorrhage –Cervical or vaginal tears,
uterine atony, retained placental fragments,
lacerations, hematomas.
Late hemorrhage –subinvolution, retained placental
fragments.
Subinvolution: failure of the uterus to return to
normal size.
Management may include CBC, sedimentation rate,
type and cross, fluid resuscitation with normal
saline and blood, vaginal examination, diagnosis,
and correction of the underlying cause.
Interventions



Prevention of Complications
Reduce Discomfort
ADL





Nutrition
Rest & Sleep
Ambulation
Bathing
Kegel Exercises
Process of Maternal Adaptation

Puerperal phases



Taking-in
Taking-hold
Letting-go
Elsevier items and derived items © 2006, 2002, 1998, 1994 by Elsevier, Inc