Postpartum Adaptations

Christine Dunn

Healthy People 2020

Increase the proportion of mothers who breast-feed.

Ever breast feeding to one year.Exclusively up to 6 months.

Reproductive System

Uterine involution- umbilicus, 24 hours 1cm.Descent of the uterine fundusAfter painsLochiaCervixVaginaPerineum- edematous and bruised.

Involution Factors which facilitate

involution include complete expulsion of amniotic membranes and placenta at birth, breast-feeding, and early ambulation.

Inhibit involution- Prolonged labor and difficult birth, incomplete expulsion of amniotic membranes and placenta, uterine infection, overdistention of uterine muscles, full bladder, anesthesia, close childbirth spacing (decreased tone, thus muscular relaxation). This is termed subinvolution.

Postpartum phase

Lochia- Postchildbirth uterine discharge. Initially bright red, then changes to pinkish red or reddish brown. Small clots normal. Immediatley after birth is bright red (fibrinous products decidual cells, red and white blood cells)

Rubra- Blood, and trophoblastic debris(tissue from implantation, deep red, 3-4 days after birth)

Serosa- Pink or brown color, old blood, serum and leukocytes, and tissue debris. 3-10 days after birth

Alba- Leukocytes, epithelial cells, mucus, serum and bacteria. White light brown 10 days to 6 week

Nursing interventions (discharge instructions)

Cardiovascular System Adaptations

Blood volume-Pulse and blood pressure- Brady, Tachy?CoagulationWBC

Urinary System

Profound effects can occur6 weeks GFR and renal plasma flow back to pre

pregnancy.Risk for several manifestations:

Full bladder can lead to uterine atony which leads to what?

Postpartum diuresis will occur, thus sweating, voiding more than her usual.

Can be for 4 weeks.

Lactation

EstrogenProgesteroneProlactinOxytocinSkin to skin contactBreast milk production summary/ Physiology of

lactationSee text

Culture and postpartum

How a woman perceives childbirth and the postpartum period is culturally defined.

Thus know the culture if necessary; ask.Hot and coldMay need creative strategies.

Psychological Adaptations

Attachment- formation of a relationship between a parent and his or her newborn through a process of physical and emotional interactions.

Early and sustained contact between newborns and their parents is vital for initiating their relationship.

Nurses role if vital: assist in the attachment process by promoting early parent-newborn interactions. Example?

Attachment is complex influenced by: environment, newborn’s health, quality of nursing care.

Provide clear communication encourage skin to skin, breast feeding and rooming in.

Postpartum Mood disorders

Baby blues- 60-80% Transient last no longer than 2 weeks. Mom wants to care for herself and her newborn.

Postpartum depression- 15% Sad, overwhelmed, hopeless, guilty. Does not want to care for newborn or herself.

Postpartum psychosis- psychiatric emergency. Delusional thoughts. Harm herself or newborn.

Nursing interventions: Educate prior to discharge, know risk factors and intervene as necessary.

Maternal Role Development TheoriesReva Rubin

Phases a mother goes through to adjust to her new maternal role.

Taking-in Phase- Dependent behaviors during the first 24-48 hours or so. Longer for primapara.

Taking-Hold Phase- starts second to third day after delivery and continues for several weeks. Concerned about her health and the newborn’s condition and her ability to care for the newborn. Masters her own body functions along with a desire to take charge with support from others.

Letting –Go Phase- Her lifestyle now includes the infant. More confident in her role as a mother.

By discharge: Taking Hold. How can we get her there?

Nursing management during postpartum

Physical assessment and care important during PP; she needs a strong social support to help her integrate the baby into the family.

Family may not live close by, thus the nurse must be a resource by mentoring, teaching , provide emotional support.

Postpartum AssessmentsChart Review

Vitals- Pulse, Temperature? 100.4?, BP.Gravada, Para.Type of deliveryEpisiotomy/laceration?/ Fundus location, firm?Anesthesia or medicationsSignificant medical/surgical historyHome medicationsAllergiesLabsEBL, Lochia amount? Color, Clots? (Handout)

Focused Assessments

HemorrhageInfectionOrthostatic HypotensionBladder DistentionPerineum

Nursing Care

Promoting Bladder EliminationAnalgesicsPrivacyRunning WaterProviding fluids Catheterize if unable to void

Preventing Abdominal Distention

Encourage early and frequent ambulationAbdominal exercisesAvoid carbonated beveragesSimethiconeRectal suppositoriesAnalgesics

Teaching Self Care

Hand washingBreastfeedingIncision carePerineal careKegel exercises

Promote sleep/restNutritionGood body mechanicsCounseling about

sexual activity

Psychosocial Assessment

Focus on emotional status and bonding or attachment with the newborn.

How does she interact with her family, independent?Energy level, eye contactAlert for : mood swings, irritability, crying episodes.

Bonding is a continuation of the relationship that began during pregnancy. Can be affected by family hx, role models, support system, culture, birth experience.

Attachment- strong affection between infant and other

Psychosocial attachment

Assessment for attachment: by observing the interaction

Touching, kissing, cuddling, en face position, expressing pride in Newborn.

Bonding is a vital component of the attachment process and is necessary in establishing parent-infant attachment and a healthy, loving relationship.

Attachment is a process, does not occur instantaneously.

Factors affecting attachment see text.

Episiotomy

Surgical incision made in the perineum to enlarge the vaginal outlet.

Types: RML. LMLML

Use is declining in the US.Can lead to 4 th degree laceration and large

amounts of pain during the postpartum period.

Lacerations

Occur as the fetal head is being born. The extent of the laceration is defined in terms of its depth.

1. First degree- Extends through the skin and structures superficial to muscles.

2. Second degree Through muscles of the perineal body.

3. Third degree- Continues through the anal sphincter muscle

4. Fourth degree- Involves anterior rectal wall

EpisiotomyCare- After delivery

interventions stem around pain control with ice, tucks pads, or oral medications (Colace). Education on proper perineal hygiene (sitz) to prevent infection of the episiotomy. Washing of the perineal area with water after voiding or defecation is important to emphasize to the patient.

Lacerations

Vaginal- With perineal lacerations. Lateral walls of the vagina, and vaginal muscles(levator ani)

Urethral- Lacerated bilateral sides of the urethra.( precipitus birth)

Cervical- Pushing before completely dilated.

Type of feeding

Support her decision of feeding.Lactation nursesHow to make bottles at home

Discharge

Immunizations:1. Rubella2. Rh negative; check newborn blood type.See textbook about Rhogam.3. Tdap- CDC recommendation.

Home follow-up: phone call.

Nursing Diagnosis

Primary postpartum:How do you prioritize? By what?

Risk for bleeding related to uterine atony.Stg- soak no more than one pad per hour on

my shiftLtg- patient will understand s&s of bleeding by

DC.Interventions:First?Evaluations:

NR Diagnosis

Risk for infection related to birth process or labor process.

Stg-Ltg-Interventions:Evaluation:Risk for injury?Acute pain related to what?Impaired tissue integrity related to surgical incisionRisk for ineffective coping related to mood

alteration/pain.

NCLEX

Six hours after delivery, the nurse notes that a woman’s fundus is two cm above the umbilicus and deviated to the right of the midline. What is the most likely cause of this finding?

A. Retained placental fragmentsB. Bladder distentionC. Normal involutionD. Second-degree uterine atony

NCLEX

Which area of health teaching will a new mother be most responsive to during the taking in phase of the postpartum period?

A. family planningB. newborn careC. community support groupsD. Perineal care

NCLEX

The nurse is caring for several immediate postpartum women. Which client should the nurse attend to first?

A. A woman who had a cesarean delivery asks for something for pain.

B. A woman who had a vaginal delivery says she needs to urinate.

C. A woman who infant is nursing says her uterus hurts.

D. A woman says her bed suddenly feels wet beneath her bottom.