Postpartal Period• Puerperium- “puer”- child, “parere” –to bring forth• 6-weeks period after childbirth• Retrogressive- involution of the uterus and vagina• Progressive- production of milk for lactation, restoration of the normal menstrual cycle, and beginning of a parenting role
PHASES OF PUERPERIUMTaking-In Phase • 2- to 3-day period, a woman is largely passive • woman usually wants to talk about her pregnancy, especially about her labor and birth• ***Main nursing is to listen and help the mother interpret events of the delivery to make them more meaningful and clarify and misconceptions
PHASES OF PUERPERIUMTaking-Hold Phase – Occurs during day 1 - 3 following delivery. – Marked by a period of being dependent and passive behavior. – Mother’s primary needs are her own -- food and sleep – Mother is talkative about her labor and delivery experience***It is the best time for teaching!
PHASES OF PUERPERIUMLetting-Go Phase• woman finally redefines her new role• She gives up the fantasized image of her child and accepts the real one; she gives up her old role of being childless or the mother of only one or two
Development of Parental Love and Positive Family Relationship1. En Face position -- eye-to-eye contact 2. Explore with finger-tips3. Hand and Palmar contact4. Whole arms --enfolds whole baby close to body
DPLPFR• Claiming or BondingThe Claiming ProcessIncludes the identificationOf the baby’s specificFeatures, relating themTo other family members “Those long toes are just like his Dad’s”
Rooming-In• Infant stays in the room rather than in the nursery.• She can become better acquainted with her child and begin to feel more confident in her ability to care
Postpartal Blues• 50% of women experience some feeling of overwhelming sadness for which they cannot account• Hormonal changes- dec progesterone and estrogen• Response to dependence and low self esteem caused by exhaustion, being away from home, physical discomfort and tension
Postpartal Blues• Fearfulness, feeling of inadequacy, mood lability, anorexia and sleep disturbance• Assurance and support
Physiologic Changes of the Postpartal Period• Involution – Reproductive organs return to their normal state
Physiologic Changes of the Postpartal Period• Uterus• 2 process 1.The area where the placenta is sealed off – Accomplished by rapid contraction of the uterus after the delivery of the placenta – Muscle fibers become shorter controlling the bleeding by compressing and sealing off blood vessels
2. The organ is reduced to its pregestational size through– Autolytic process • Few cells of the uterine wall are broken down into their protein component which is then absorbed in the blood stream and excreted in the urine.– Contraction- Immediately after birth – 1000g- At the end of 1st wk- 500g- 6wks – 50g
Physiologic Changes of the Postpartal Period- After placental delivery the uterus may be palpated through the abdominal wall halfway bet the umbilicus and the symphysis pubis- 1hr after- level of umbilicus- Decrease 1 fingerbreath per day
Assessment of the Uterus • Placement and Size (location) • Tone • Lochia
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
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.
Lochia TYPE COLOR DURATION COMPOSITI ONLochia Rubra Red 1-3 days Blood, fragments of decidua, mucus Lochia Pink 3-10 days Blood, Serosa mucus and leukocytesLochia Alba White 10-14 days Largely mucus
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
Physiologic Changes of the Postpartal Period• Cervix – After birth- soft and malleable, internal and external os is open – Pre-pregnant appearance is a dimpled area in the center -- post-pregnancy appears as a jagged slit.
Physiologic Changes of the Postpartal Period• Vagina – May be edematous and bruised. – Rugae begin to appear when ovarian function returns. – May teach the mom to do Kegels exercises
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 – Sitz bath 3-4 x day
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
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
Process of Lactation– 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
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”
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
Elimination Changes Urinary 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.
Elimination Changes Urinary System• 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.
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.
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
Postpartum 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.
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
Integumentary Changes• 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
Oxygenation Alterations Cardiovascular 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.
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
Oxygenation – Lab Assessment Pregnancy Post PartumWBC – elevated slightly to about 12,000 WBC – leukocytosis is common with values of 20,000 – 30,000 RT increassed neutrophilsRBC – increase slightly to about 10 milion. RBC – return to normalHemoglobin – stays about normal at ~ 12 Hgb. – normal to see a drop of about 1g. Below 10 g = anemia gramHemotocrit – lowers 33-39% RT Hct – normal to see a drop of about 4hemodilution. If drops below 32- 35% = points and then a rise RT > loss of plasmaanemia than RBC death
• 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 homan’s sign?
– 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 >140 / 90. Other drugs to contract uterus
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.
“ Because the more a mother is cared for, the more easily she can care for her baby.” - Shivam Rachana