Postpartum~ Physiology and Nursing Care

1. Postpartum~ Physiology and Nursing Care

2. Puerperium • A Latin term for the period of involution when the mother’s body returns to its pre-pregnant state. • Involution is the rapid reduction in size of the uterus • Also referred to as the postpartum period of 6 weeks after birth of the baby. • Let’s look at how the systems change

3. The Uterus • Physical changes • After pregnancy estrogen and progesterone decrease which causes autolysis destruction of tissue, the layers of the lining are shed in the form of lochia • The placenta site heals thru exfoliation rather than scar tissue formation allowing future pregnancies • By 24 hours postpartum the uterus is the same size it is at 20 weeks gestation • The fundus (top of uterus) descends 1-2 cm or 1-2 finger breaths every 24hours. • By 2 weeks postpartum the uterus has descended into the true pelvis

4. The Uterus • What to assess/what to expect • Height • Where is the top of the fundus located in relationship to the umbilicus (below, at the level of or above) • The fundus is measured in fingerbreadths above or below the umbilicus • Documentation of findings • If the fundus is 1 fingerbreadth above the umbilicus it is documented as 1/u meaning 1 fingerbreadth above the umbilicus • If the fundus is 2 fingerbreadths below the umbilicus it is documented as u/2 meaning 2 fingerbreadths below umbilicus • If the fundus is at the level of the umbilicus then it is documented as u/u meaning the fundus is at the level of the umbilicus

5. The Uterus • What to assess/what to expect • Firmness • Palpate the fundus, what does it feel like? • The fundus should be firm and hard  • If fundus is found to be soft and mushy (boggy), or gets firmer or harder when massaged interventions are indicated • Centeredness • Where is the fundus located? • The fundus should be located midline to the umbilicus • If the fundus is to the left or right of umbilicus pt. will need to void then be reassessed for placement • Afterpains • Cramping caused by involution of the uterus • Increased with greater number of pregnancies • Breastfeeding also increases afterpains

6. The Uterus • What to teach • Encourage pts. to empty bladder every two hours to aide involution and decrease bladder distention • Encourage pts. to breastfeed (causes the release of oxytocin) helps the uterus contract to promote involution • Encourage pts. to massage own uterus

7. Let’s practice! • If the mom is 2 days postpartum, a primigravida who had a normal vaginal delivery of a 7 lb 8 oz baby girl, and you assess her fundus, you would expect to find it where? • How would you record this in your nurse’s notes?

8. Lochia • Lochia determines state of healing of the placenta site, it should steadily decrease every day • Rubra • Bright red for 2-3 days post delivery, contains blood and decidual trophoblatic debris, small nickel size clots are common • Serosa • Pink or brown after 3-4 days postpartum consists of old blood serum, leukocytes, tissue debris, last 10 days • Alba • Yellow to white, consists of leukocytes decidua, epithelial cells, mucus serum bacteria, lasts 2-6 weeks after birth

9. Lochia • What to assess/what to expect • Assessment is needed in order to determine stage of healing of uterus • Color-rubra, serosa, alba • Amount-scant<2.5 cm, light <10 cm, mod >10 cm, heavy one pad an hour (check vs, skin color, urinary outpt, r/t pp hemorrhage) • Presence of clots-nothing greater than half dollar size • Odor-foul odor indicates infection • What to teach • Sequence of changes (rubra, serosa, to alba) • Report large clots half dollar size or plum size • Bleeding should decrease daily • Will increase with activity (encourage to rest then reassess) • Soaking through a pad an hour is too much bleeding and should notify nurse or physican ASAP

10. Lochia-how to guesstimate amounts

11. Cervix • How does it change after delivery? • Soft and flabby becomes firm after 2 days pp • What to assess • Cervical os no longer appears as circle shaped but as jagged slit • What to teach • Due to changes in cervix diaphragm and cervical caps need to be refitted for proper contraception . - Prepregant Postpartum

12. Vagina & Perineum • What to assess • Episiotomy • Type • Midline • Mediolateral • Degree of episiotomy • REEDA • Redness • Edema • Ecchymosis • Discharge • approximation • Lacerations • Type and degree of extension • 1st, 2nd, vaginal, periurethral, cervical • Hemorrhoids • Assess presence and swelling • What to teach • Link to handout on Kegels • Sitz bath to promote healing of tissues, hygiene from front to back, hand washing, use of peribottle

13. Abdominal Wall • What to assess? • Diastisis Recti • Abdominal wall separates during pregnancy • Have pt. do mini sit up and will palpate and visually inspect abdomen • Diastisis recti can be seen as a little hill in the center of the abdomen and with palpation will feel separated • Measured in fingerbreadths of separation • What to teach? • Importance of pp exercise—one link • Responds to exercise within 2-3 months • Chin lifts • Separation of diastisis recti becomes less apparent with time

14. Endocrine System and Ovarian Function • Onset of first menses • Breastfeeding mom • Breastfeeding suppresses ovulation due to the increase in serum prolactin • Breastfeeding longer than one month menstruation delayed for 3 months • Bottlefeeding mom • 1st cycle anovulatory typically menstruation begins 6-10weeks, 90% resumed by 12 weeks. • What to teach • Educate pts. on the importance of using contraceptive methods, they may be fertile before first period

15. Urinary System • What to assess? What to expect • Bladder function/output • May be decreased due to trauma or edema • Anesthesia can decrease urge to void • Output increases during early post partal period • Bladder distension • Assess for bladder distension by palpating bladder and fundus, if bladder is full fundus will be off to right or left of umbilicus • 20% of women experience incomplete emptying after delivery • Bladder distension causes increased susceptibility to infection and pp hemorrhage • Kidney function • Reduces in post partum b/c of decreased steroid levels, returns to normal within 1 month • Diuresis in the postpartum period • With in 12 hours loss of excess fluid begins, profuse diaphoresis occurs at noc first 2-3 days post partum

16. Cardiovascular System • Vital Sign Changes—know this! • Pulse— decreases to rate of 50-70 first 6-10 days, returns to normal by 8-10 weeks (watch pulse > 100 can indicate infection, hypovolemia) • Respirations— decrease to within normal prebirth by 6-8 weeks • Blood Pressure— small transient rise last 4 days of postpartum, watch for orthostatic hypotension 1st. 48 hours as a result of abdominal engorgement also could be late sign of pp hemorrhage • Temperature—1st 24 hours may increase to 38 degrees as a result of dehydration, after 24 hours should be afebrile • Blood Volume—decreases within 1st 2 weeks return to non pregnant values by 6 months • Homan’s Sign—why assess? • Needs to be assessed due to increase amount of blood volume during pregnancy, and the activation of blood clotting factors after delivery • What to teach • Encourage ambulation to decrease risk for thrombophlebitis • Educate pts. on signs to look for, warm, tender, reddened areas on legs.

17. Gastrointestinal System • What to assess • Bowel sounds-gastric motility is decreased during labor, sluggish after b/c of lingering progesterone • Last BM? What is there normal pattern, okay not to have BM before leaving hospital • Fear-anticipation of discomfort can decrease return to normal bowel habits in reestablishing bowel tone • What to teach • Early ambulation • Increase fluid intake • Increase fiber • Stool softener/laxative

18. Blood Components • Hemoglobin/Hematocritdrop in values by 2% equals 500cc blood loss, expected loss for vag delivery 250-500cc, c-section 700-1000cc. • H & H increases by 7th day pp • WBC-25000-30000 early pp period, an increase by 30% in 6 hours indicative of pathology, note s/s infection • Clotting Factors-remain elevated for 6 weeks • Fibrinogen level increases after delivery 

19. Psychological Adaptation—Maternal and Paternal Adjustment • Maternal Adjustment (Reva Rubin, 1961)—know these characteristics that you will see in the mother. • Taking In Phase—dependent phase • 1st 24 hours range 1-2 days, focus on self and meeting basic needs, reliance on others to meet needs of comfort, rest, closeness, nourishment, relives birth, excited and talkative • Taking Hold Phase—dependent/independent phase • Starts end of 3rd day pp, last for 10 days to several weeks, focuses on care of baby, desire to take charge, still need nurturing and acceptance by others, eagerness to learn (period to teach most receptive time to learn), possible experience pp “blues” • Letting Go Phase—interdependent phase • Focuses on forward mov’t of family as unit with interacting members, reassertion of relationship with partner, resumption of sexual intimacy, resolution of individual roles.

20. Postpartum Blues— Postpartum blues are considered a transient period of depression, occurs 1st few days of puerperium • What to assess? • 70% of women experience baby blues • Changing hormone levels affect blues • Common symptoms • labile, crying, mood swings, anger, depression, let down feelings, fatigue, headaches, anxiety, • resolves 10-14 days • What to teach • Educate parents on normal newborn behaviors and growth and development • Encourage rest and to accept help from others • Educate mothers of symptoms and if they last longer than 2 weeks, or feel they cannot care for their self or baby contact physician.

21. Weight Loss in postpartum • Fetus, placenta, amniotic fluid, & blood loss at delivery (largely determined by weight of baby and amt of AF)=12-13 lbs. • Perspiration and diuresis in 1st week pp (affected by the amt of edema in mother)= 5-8 lbs. • Uterine involution/lochia over 6 wk period= 2-4 lbs • Total wt loss= 19-25 lbs • http://womenshealth.gov/pregnancy/childbirth-beyond/recovering-from-birth.html#b

22. Developing Attachment • Initial attachment behavior • Mothers begin with finger-tip touching of baby’s face and body and proceeds to palmar contact • Higher-pitched voice • En face positioning • Comments on child’s appearance • The ‘wonder of it all’!

23. Enface Positioning Note direct eye-to eye contact between parent and child

24. Paternal Attachment Behaviors • Engrossment—key term used in relation to dads. • See handout on Engrossment and Attachment Characteristics.

25. Role Adjustments • Sibling Adaptation • Social Networks • Altered Body Image • Relationship with significant other • Resumption of intimacy

26. PP Nursing Care • Maintain physiologic integrity—assess vitals signs, fundal height and firmness, lochia color and amt, etc. using BUBBLEHED assessment technique. • Nurture the Mother—essential nursing role is to help her transition to motherhood smoothly • Comfort & Rest— • Perineal care—careful hygiene, use of sitz bath, use of anesthetic spray and witch hazel pads, use of donut pillow prn

27. Comfort measures (cont’d) • Hemorrhoids—use of topical cream prn, sitz bath, donut ring prn, avoid straining with BM, avoid sitting up for long periods. • Afterpains—encourage massage of uterus, use of relaxation and breathing techniques, anticipatory analgesic management based on assessed pt. status. Know side effects of analgesics and teach as needed. • Rest—organize care to allow for rest periods. Encourage mom to sleep when baby sleeps and limit visitors. Don’t lift anything heavier than baby.

28. Immunizations • Rubella Vaccine should be administered to postpartum mom prior to discharge from hospital. • Instruct to avoid pregnancy for at least 3 months to prevent possible injury to fetus from live-attenuated vaccine.

29. Immunizations • T dap • http://www.cdc.gov/vaccines/hcp/vis/vis-statements/tdap.html • Pregnant women should get a dose of Tdap during every pregnancy, to protect the newborn from pertussis • Recommended for pregnant women to get in the 3rd trimester for best protection. Takes two weeks for passive immunity to occur for newborn.

30. Other Education topics • Perineal care • Bowel and bladder function • Nutrition—no fad diets, prenatal vitamins daily esp. if breastfeeding, 6-8 glasses of water/day • Early ambulation • Bathing—showers only, start with breasts, no soap, then shower as usual cleansing perineum last with clean washcloth. Use peri-shower if available • Exercise—see earlier link • Breast care (will be discussed later)

31. Anticipatory Guidance • Postpartum follow-up visits—4-6 wks for vaginal delivery, 1 wks for C/S • Infant development and care • Physical recovery • Sexuality and contraception • Role changes

32. Danger signs in the Post Partum Period • Return of vaginal bleeding esp. > 1 pad/hour or large clots • Fever >38C with or without chills after 1st 24 hours • Increased vaginal discharge, especially if foul-smelling • Swollen, red area on leg (thrombophlebitis) • Swollen, red, tender area on breast (mastitis) • Dysuria, increased frequency and pressure with urination (UTI) • Persistent perineal or pelvic pain (chorioamnionitis)

33. Cultural Influences • See handout • Refer to pp. 21-32 in Olds 10th ed