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ATI Chapter 17: Postpartum Physiological Adaptations  Fourth stage of labor o Starts with delivery of the placenta o Includes at least first 2 hours after birth o Newborn-parent boding should begin to occur  Main goal during immediate postpartum period is to prevent postpartum hemorrhage  Postpartum period  puerperium o Period between birth and the return of the reproductive organs to their nonpregnant state o Lasts around 6 weeks  Physical changes o Physiological changes consist of  Involution  Lochia flow  Cervical involution  Decrease in vaginal distention  Alteration in ovarian function and menstruation o Greatest risks during this period is hemorrhage, shock and infection o Oxytocin coordinates and strengthens uterine contractions  Breast feeding stimulates release of oxytocin  Oxytocin can be administered to improve the quality of uterine contractions  Firm contracted uterus prevents excessive bleeding o After delivery of the placenta, hormones (estrogen, progesterone, and placental enzymes insulinase) decrease, thus resulting in decrease blood glucose, estrogen, and progesterone levels  Decreased estrogen is associated with breast engouement, diaphoresis, and diuresis  Removes extracellular fluid accumulated during pregnancy  Decreased estrogen diminished vaginal lubrication  Decreased progesterone results in an increase in muscle tone throught the body o Lactatin and nonlactating clients differ in the timing of first ovulation  Lactating clients, the blood prolactin levels remain elevated and suppress ovulation  Influenced by breastfeeding frequency, length of each feeding, and use of supplementation  6 months first postpartum ovulation  Nonlactating clients, prolactin declines and reached the prepregnant level by the third week  Ovulation occurs 7 to 9 weeks after birth  Menses resume by 12 weeks  Assessment o Immediately following delivery

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Vital signs, uterine firmness, location in relation to umbilicus, uterine position in relation to the midline of abdomen, and amount of vaginal bleeding o BP and pulse be assessed at least every 15 min for the first 2 hours o Temp should be assessed every 4 hours for the first 8 then at least every 8 o Focused postpartum physical assessment should include:  B: Breast  U: Uterus (Fundal height, uterine placement, and consistency)  B: Bowel and GI function  B: Bladder  L: Lochia (color, odor, consistency, and Amount (COCA))  E: Episiotomy (edema, Ecchymosis, approximation)  Vital Signs + Pain  Teaching Needs Lab Tests o Urinalysis and CBC  Hgb, Hct, WBC and platelet  If rubella and RH status are unknown, tests should be performed Uterus o Involution occurs with contractions of the uterine smooth muscle o Decreases in size from 1000g to 60-80g at 6 weeks postpartum o Fundal height decreases o At the end of the third stage of labor, the uterus should be palpable at midline and 2 cm below the umbilicus o 1 hr after delivery, the fundus should rise to the level of the umbilicus o Every 24hr the fundus should descend approx. 1-2 cm o After about 2 weeks, the uterus should lie within the true pelvis and should not be palpable o Assessment  Assess the fundal height, uterine placement and uterine consistency at least every 8hr after recovery period has ended  Pt supine with knees slightly flexed  Never palpate the fundus without cupping the uterus  Determine fundal height by placing fingers on the abdomen and measuring how many fingerbreadths (cm) fit between the fundus and the umbilicus above, below, or at the umbilical level  Determine whether the fundus is firm or boggy  If boggy lightly massage the fundus in circular motion  Determine whether the fundus is midline in the pelvis or displaced laterally  Caused by a full bladder  Document the position and location of the uterus by the number of fingerbreadths  If above the umbilicus document as +1, U+1, 1/U  If below the umbilicus document as -1, U-1, U/1

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o Patient Centered Care  Monitor for adverse effects of medications  Oxytocin and misoprostol can cause hypotension  Methylergonovine, ergonovine, and carboprost can cause hypertension  Encourage emptying the bladder to prevent possible uterine displacement and atony Lochia o Post-birth uterine discharge that contains blood, mucus and uterine tissue o Three stages  Lochia Rubra: Dark red color, bloody consistency, fleshy odor, can contain small clots  Lasts 1 to 3 days after delivery  Lochia Serosa: Pinkish brown color and serosanguineous consistency; can contain small clots and leukocytes.  Lasts approx. day 4 to day 10  Lochia Alba: yellowish white creamy color, fleshy odor; can consist of mucus and leukocytes  Lasts day 10 up to 8 weeks postpartum o Assessment  Assessed by the quantity of saturation on the perineal pad  Scant: less than 2.5 cm  Light: 2.5 to 10 cm  Moderate: More than 10cm  Heavy: One pad saturated within 2 hours  Excessive blood loss: one pad saturated in 15 min or less, pooling of blood under buttocks  Assess for normal color, amount, odor, and consistency  Check frequency at least every 15 min for the first hour then every hours for the next 4 hr and then every 4 to 8 hours  Massaging the uterus or ambulation can result in a gush of lochia but should soon decrease back to a trickle when in early postpartum  If c section was perform, the amount of bleeding will be decreased because the provider cleans out the uterus after surgery.  Patient Centered care  Manifestations of abnormal lochia o Excessive spurting of bright red blood possibly indicating a cervical or vaginal tear o Numerous large clots and excessive blood loss can indicate hemorrhage o Foul odor, suggestive of infection o Persistent heavy lochia in early postpartum beyond day 3 can indicate retained placental fragments

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o Continued flow of serous or alba beyond normal length can indicate endometritis  Client education  Change pads frequently  Perform hand hygiene after peri care  Do not use tampons due to increased risk of infection Cervix, Vagina, and Perineum o Physical Changes  Cervix is softly directly after birth and can be edematous, bruised, and have small lacerations.  Within 2 to 3 days, it shortens, regains form, and becomes firm, os gradually closing  The vagina (which has distended) gradually returns to its pregnancy size with the reappearance of rugae and a thickening of vaginal mucosa  Muscle tone is never restored completely  Breastfeeding increases the incidence of vaginal dryness and atrophy o Assessment  Initial healing occurs in 2 to 3 weeks, and complete healing occurs within 4 to 6 months  A bright red trickle of blood from the episiotomy site in the early postpartum period is a normal finding o Patient Centered Care  Perineal tenderness, laceration and episiotomy  Promote measures to help soften the client’s stools  Comfort measures o Apply ice/cool packs to perineum for first 24 hours to reduce edema and provide anesthetic effect o Heat therapies (hot packs), moist heat and sitz bath can be used to increase circulation and promote healing and comfort o Administer analgesics o Administer topical anesthetics  Educate about proper cleansing to prevent infection  Education  Squeeze bottle filled with warm water or antiseptic solution after each void to cleanse the area  Blot the perineal area to clean it after toilet, starting from front to back Breasts o Assessment  Colostrum transitions to mature milk by 72 to 96 hours after birth  Transition is referred to as milk coming in  Engorgement (fullness) is a result of lymphatic circulation, milk production, and temporary vein congestion.

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Breast will appear tight, tender, warm, and full Resolves on its own, but breast binders, icepacks, or cabbage leaves can be applied  Frequent feeding will prevent/manage this  Observe for cracked nipples, breast tenderness, and indications of mastitis (infection in a milk duct)  Ensure newborn has latched on correctly to prevent sore nipples  Ineffective newborn feeding patterns are related to maternal dehydration, maternal discomfort, newborn positioning, or difficulty with the newborn latching o Patient Centered Care  Promote early breastfeeding w/ in the first 1 to 2 hours after birth  Encourage early demand feeding for clients who choose to breast feed  This will also stimulate the production of natural oxytocin and help prevent uterine hemorrhage  Assist client into comfortable position, and have them try various positions during breastfeeding  Teach importance of proper latch techniques to prevent nipple soreness  Inform client that breast feeding releases oxytocin which causes uterine contractions  This is normal and beneficial to uterine tone  Advise clients who do not plan to breastfeed to not stimulate the breast or express breast milk Cardiovascular System and Fluid and Hematologic Status o Physical changes  Decrease in blood volume during postpartum period related to  Blood loss during childbirth (average BL is 200 to 500mL 10% vaginal, 500 to 1000 c-section)  Diaphoresis and diuresis occur within the first 2 to 5 days after delivery and rid the body of the excess fluid accumulated during the last part of pregnancy  Weight loss (due to lochia, delivery, and diuresis of about 19lb during the first 5 days after delivery  Hypovolemic shock does not usually occur in response to the normal blood loss because of expanded blood volume of pregnancy and the readjustment in the maternal vasculature  Elimination of the placenta  Rapid reduction in the size of the uterus,  In blood vessels, coagulation factors, and fibrinogen levels during the puerperium  Hematocrit levels drop moderately for 3 to 4 days then being to increase and reach nonpregnant levels by 8 weeks postpartum  During the first 4 to 7 days after birth, WBC values between 20,000 and 25,000 are common.

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o Postpartum leukocytosis  how body prevents infections and aids in healing Coagulation factors and fibrinogen levels increase during pregnancy and remain elevated in the immediate postpartum period o Hypercoagulability predisposes the client to thrombus formation and thromboembolism

Vital Sign Changes o Significant BP decrease from baseline could indicate bleeding o Significant BP increase could indicate postpartum hypertension o Possible orthostatic hypotension within the first 48 hours can occur immediately after standing up o Elevation of pulse, stroke volume and cardiac output for the first hour postpartum occurs and then gradually decreases to baseline by 6 to 8 weeks  Puerperal bradycardia  common finding,  Results from elevations in stroke volume during first 2 days after delivery  HR can be as low as 40/min o Elevation of temperature (100.4F) resulting from dehydration after labor during the first 24 hours can occur but should return to normal during the first 24 hours  Elevation after 24 hours or that persists after 2 days could indicate infections o Patient Centered Care  Encourage adequate fluid intake  Encourage early ambulation to prevent venous stasis and thrombosis  Apply antiembolism stockings if client is at high risk GI and Bowel function o Physical changes  Increased appetite following delivery  Constipation  Hemorrhoids o Assessment  Assess the urinary system and bladder function  Assess ability to void  Assess bladder elimination patter  Excessive urine diuresis (more than 3000mL/day) is normal within the first 2 to 3 days after delivery  Assess for evidence of a distended bladder  Fundal height above the umbilicus or baseline level  Fundus displaced from the midline over to the side  Bladder bulges above the symphysis pubis  Excessive lochia  Tenderness over the bladder area

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Frequent voiding less than 150mL is indicative of urinary retention with overflow o Patient Centered Care  Assess client to void every 6 to 8 hr after delivery  Encourage pt to empty their bladder frequently to prevent possible displacement of the uterus and atony  Measure the client’s first few voids after delivery to asses for bladder emptying  Increase oral intake Musculoskeletal o By 6 to 8 weeks:  Joints return to their prepregnant state are completely restabilized  Muscle tone begins to be restored throughout the body with the removal of progesterone’s effect following delivery of the placenta o Assessment  Assess for changes  Assess abdominal wall for diastasis recti (separation of the rectus muscle)  Usually resolved within 6 weeks o Education  Strengthen muscles by performing exercises  Following C-section postpone abdominal exercises until about 4 to 6 wks  Use good body mechanics  Ambulate soon after delivery  Perform Kegel exercises Immune System o Rh: all negative clients who have newborns who are Rh Positive must be given Rho(D) immune globuling IM within 72 hours of the newborn being born to suppress antibody formation in the mother o

Chapter 18: baby-Friendly Care  Can be promoted by delaying nursing procedures during the first hour after birth and through the first attempt of the client to breastfeed to allow for immediate parent-infant contact  Psychosocial and Maternal Adaptation o Beings during pregnancy as the client goes through commitment, attachment and preparation for the birth of newborn  During the first 2 to 6 weeks after birth, the client does through a period of acquaintance with the newborn, as well as physical restoration  During this time the client also focuses on competently caring for the newborn  Act of achieving maternal identity is accomplished around 4 months following birth

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These stages can overlap, and vary based on maternal, infant and environmental factors Phases of Maternal Role Attainment o Dependent: taking- in phase  First 24 to 48 hours  Focus on meeting personal needs  Rely on others for assistance  Excited, talkative  Need to review birth experience to others o Dependent- Independent: taking-hold phase  Being on day 2 or 3  Lasts 10 days to several weeks  Focus on baby care and improving caregiving competency  Want to take charge but need acceptance from others  Want to learn and practice  Dealing with psychical and emotional discomforts can experience “baby blues” o Interdependent: Letting-go phase  Focus on family as a unit  Resumption of role (intimate partner, individual) Assessment o Noting client’s condition after birth, observing the maternal adaptation process, assessing maternal emotional readiness to care for the infant, and assessing how comfortable the client appears in providing infant care  Assess for behaviors that facilitate and indicate parent-infant bonding  Considers the infant a family member  Hold the infant face-to-face maintaining eye contact  Assigns meaning to the infant’s behavior and view this positively  Identifies the infant’s unique characteristics and relates them to those of other family members  name the infant, indicating bonding is occurring  Touches the infant and maintains close physical contact  Provides physical care for the infant  Responds to infant’s cries  Smiles at, talks to and signs to infant  Assess for behaviors that impair and indicate a lack of parent-infant bonding  Apathy when the infant cries  Disgust when the infant voids, stools, or spits up  Expresses disappointment in the infant  Turns away from the infant  Does not seek close physical proximity to the infant  Does not talk about the infants unique features  Handles infant roughly  Ignores the infant completely

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 Does not include infant in family context  Perceives infant behavior as uncooperative  Assess for manifestations of mood swings, conflict about maternal role, or personal insecurity  Feelings of being “down”, inadequate, anxiety,  Emotional lability with frequent crying  Flat affect and being withdrawn  Feeling unable to care for the infant o Nursing Actions  Facilitate the bonding process by placing the infant skin to skin or in en face position w/ client  Promote rooming-in as a quiet and private environment that enhances the family bonding process  Promote early inhiation of breast feeding and encourage to recognize readiness cues  Teach about infant care to facilitate bonding as the client’s confidence improves  Encourage parent bonding- cuddling, bathing, feeding, diapering, watching the infant  Encourage parents to express feelings, fears, and anxieties about caring for the infant Co-Parent Adaptation o Occurs through bonding with the infant through the following behaviors  Using skin to skin contact, holding the infant, and engaging in eye to eye contact with the infant  Observing the infant for similarities to the parent’s own features  Talking, singing and reading to the infant o Transition (to fatherhood)  Expectations and intentions:  Desires to be deeply and emotionally connected with the infant  Confronting reality:  Understands that reality does not always meet expectations.  Commonly expressed emotions include o Feeling sad o Frustrated o Jealous  Feel like they are unable to talk to the other parent, who is consumed with infant caregiving and their own transitioning into parenthood  Creating the role of the involved father  Decides to become actively involved in the care of the infant  Reaping rewards:  Rewards include infant smiles and a sense of completeness and meaning

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o Assessment  Nursing Actions  Provide education about infant care with each parent and encourage hands on approach  Assist the co-parent to transition to the paternal role by providing guidance and encouraging equal participation in infant care  Encouraging parents to verbalize concerns and expectations related to infant care Sibling Adaptation o Addition of an infant into the family unit affects everyone in the family o Assessment  Assess for positive responses from the sibling  Interest and concern for the infant  Increased independence  Assess for adverse responses from the sibling  Indication of sibling rivalry and jealousy  Regression in toileting and sleep habits  Aggression toward the infant  Increased attention-seeking behaviors and whining o Nursing Actions  Take sibling on the tour of the unit  Encourage the parents to do the following  Let the sibling be one of the first ro see the infant  Provide a gift from the infant to give the sibling  Arrange for one parent to spend time with the sibling while the other parent is caring for the infant  Allow older siblings to help provide care for the infant  Provide preschool-aged sibling with a doll to care for. Complications o Nursing Actions  Emphasize verbal and nonverbal communication skills between the client, caregiver, and the infant  Provide continued assessment of the client’s parent abilities as well as other caregivers for the infant  Encourage continued support of grandparents and other family members  Provide home visits and group sessions for discussion regarding infant care and parent problems  Give the client and caregiver information about social networks that provide support system where they can seek assistance  Notify programs that provide prompt and effective community interventions to prevent more serious problems from occurring

Chapter 19: Client Education and Discharge Teaching  Return demonstrations are important to ensure that adequate learning has taken place

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Assessing a Client’s Knowledge of Post-Partum Care o Inquire about the client’s current knowledge regarding self-care o Assess the client’s home support system and who will be there to assist  Include these people in the educational process o Determining the client’s readiness for learning and their ability to verbalize or demonstrate the information that has been given Nursing Interventions for Postpartum Care o Perineal care  Cleanse the peri area from front to back with warm water after voiding and BM  Blot perineal area from front to back  Remove and apply perineal pads from front to bac...