Normal Postpartum Chapters 15 16 Study Guide 06092021 PDF

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Puerperium: period begins after placenta delivery and lasts 6 weeks (fourth trimester.) The true postpartum period last 9-12 months. Postpartum physiologic adaptations: (1) Uterus: (a) Involution-the uterus returns to the normal size in a three retrogressive progress. (1) contraction of the muscle fibers to reduce those previously stretched during pregnancy; (2) catabolism, which shrinks enlarged individual myometrial cells; (3) regeneration of uterine epithelium from the lower layer of the decidua after the upper layers have been sloughed off and shed during lochia discharge. Uterus goes from 1000 g to 60-80 g at 6 weeks PP. Fundal height descends into the pelvis 1 cm per day. 1 hr. post-delivery, the fundus should rise to the level of the umbilicus. During the first 12 hours PP, the fundus is at the level of the umbilicus. Every 24 hours, fundus descents 1-2 cm, and by sixth day PP, the fundus is halfway between the symphysis pubis and the umbilicus. 2 weeks PP, uterus lies within true pelvis & not palpable. After 1 week decreased by 50% & weights 500 g (1 lbs.). Palpate fundus for location & tone at least every 8-hour PP. Oxytocic’s like oxytocin, methylergonovine, and carboprost, and misoprostol are administered to promote uterine contractions. Oxytocin & misoprostol cause hypotension; methylergonovine, ergonovine, and carboprost cause HTN. (b) Lochia-vaginal discharge that contains blood, mucus, & uterine tissue and can continue 4-8 weeks PP. Three stages of lochia: (1) lochia rubra-dark red, bloody, fleshy odor, small slots, transient flow increases during breastfeeding & upon rising. Last 1-3 days post-delivery. (2) lochia serosa-pinkish brown and is expelled 4-10 days after delivery. Serosanguineous, small clots, and leukocytes. (3) lochia alba-creamy white or light brown discharge/yellow, fleshy odor. Mucus & leukocytes. Lasts 10 days up to 8 weeks PP. Check lochia every 15 min for the 1st hour then every hour next four hours then 4-8 hours. Bleeding greater than 1 pad/hr. is too much. (c) Afterpains-uterine cramps PP can be caused by pituitary release of oxytocin, uterine cramping due to myometrial cx, and breastfeeding. Afterpains respond to oral analgesics. (2) Cervix/vagina/Perineum: The cervix is soft and within 2-3 days PP shortens and regains form with the os gradually closing. External os will no longer have round-dimple shape and will now have a slit-like appearance. The cervix returns to pre-pregnant state by week 6. Internal cervical OS returns to normal by 2 weeks PP. The vagina muscle tone is never fully restored, and breastfeeding increases vaginal dryness and atrophy. Mucosa thickens and rugae return 3 weeks PP. Vagina returns to pre-pregnant size by 6-8 weeks. The perineum can be erythematous and edematous with hematomas or hemorrhoids. Pelvic floor is weak and overstretched. Healing 2-3 weeks and complete healing in 4-6 months. Apply ice/cold back to the first 24 hours (do not apply directly to the perineum.) Heat therapy, moist heat, and sitz baths increase circulation and promote healing/comfort. Analgesics help oral and topical. (3) Vital signs- BP may have some changes but significant decrease indicates bleeding and significant increase indicates PP HTN. Orthostatic hypotension can occur within first 48 hours. Pulse, SV, and CO increase first hour PP then decrease to baseline by 6-8 weeks. Increase in SV during the first 2 days PP, the HR can be as low as 40/min and is known as puerperal bradycardia and is common. Temperate of 38 C/100.4 F can occur during the first 24 hours but after 24 hours may indicate infection. Pulse can be 4080 (may see bradycardia for 2 weeks pp); respirations 16-20 per minute, blood pressure orthostatic hypotension possible, temp above 100.4 F may indicate infection. CO returns to normal 3 months PP. (4) Cardiac and hematologic: Blood volume decreases in the PP period due to blood loss during birth; diaphoresis and diuresis; and weight loss. Average blood loss is 300-500 mL and 500-1,000 mL for cesarean. Weight loss during the first 5 days after delivery about 19 lbs. Hematocrit levels drop 3-4 days PP and go back to normal 8 weeks PP. First 4-7 days PP, WBC values 20,000-25,000 common (leukocytosis) and prevents infection and aids in healing. Coagulation & fibrinogen levels increase. Tachycardia may indicate hypovolemia, dehydration, or hemorrhage. BP falls most within first 2 days then increases by days 3-7 and back to pregnancy by week 6.

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(5) Urinary system-urinary retention secondary to loss of bladder elasticity and tone and/or loss of bladder sensation resulting from trauma, medications, or anesthesia. Distended bladder can cause infection, uterine atony, and displacement. Urine retention can cause uterine displacement to the right and above the umbilicus, first ask mom to empty bladder. Diuresis begins within 12 hours post-delivery. Excessive urination about 3,000 mL a day is normal within the first 2-3 days PP. Voiding less than 150 mL frequently may indicate urinary retention with overflow. Assist with voiding within 6-8 hrs. after birth. PP diuresis is a result of large amounts of IV given during labor, decreased antidiuretic effect of oxytocin as levels declines, buildup and retention of extra fluids during pregnancy, and decreased production of aldosterone (decreases sodium retention and increases urine production.) (6) GI system: Anal incontinence can last 6 months. Changes in GI include increased appetite, constipation, and hemorrhoids. Spontaneous BM may not occur for 2-3 days PP. Initially GI motility remains decreased so Colace is often prescribed and often women with episiotomy can be fearful of having BM movements. (7) MS system: by 6-8 weeks after birth, joints return to pre-pregnant size, but feet can remain increased in size. Muscle tone begins to restore. Diastasis recti can resolve in 6 weeks. Following c-section, avoid abdominal exercise until 4-6 weeks after delivery or instructions by provider. Perform Kegel exercises and ambulate soon after birth. (8) Skin- decrease in estrogen and progesterone causes Linea nigra, melasma, and stretch marks to diminish. (9) Respiratory System-16-20 per minute and pulse 40-80 with bradycardia 2 weeks PP. Back to pre-pregnancy in 1 weeks and diaphragm is back in place so less SOB. (10) Endocrine system: Post placenta delivery, estrogen, progesterone, and placental enzyme insulinase decreases and this results in decrease blood glucose, estrogen, and progesterone. Decreased estrogen causes breast engorgement, diaphoresis, and diuresis. Decreased estrogen causes vaginal dryness. Decreased progesterone results in increase in muscle tone. Decreased placental enzyme insulinase lowers blood glucose levels. hCG can be detected up to 4 weeks PP. Lactating moms have elevated prolactin levels and this can suppress ovulation. PP ovulation in lactating clients is approx. 6 months. In nonlactating, ovulation occurs by weeks 7-9 and menses resumes by 12 weeks. Oxytocin and prolactin released post-delivery & increased with breastfeeding. (11) Immune system: If a client is nonimmune to rubella, administer SubQ rubella or MMR (do not get pregnant 1 month post vaccination). All Rh-negative patients who have newborns that are positive will receive Rho(D) administered IM within 72 hours of the newborn being born to suppress antibody formation in the mother. If client is not immune to varicella and TDaP, administer vaccine. Hormones of Lactation Prolactin and Oxytocin-are produced by the pituitary in response to suckling. Estrogen and progesterone levels decrease after the placenta is delivered. Prolactin stimulates the production of milk/initiates milk production; and Oxytocin is responsible for ejection of milk/milk letdown. During pregnancy, prolactin, estrogen, and progesterone cause synthesis and secretion of colostrum (protein & carbs, no milk fat.) Prolactin & Oxytocin result in milk production if stimulated by sucking.

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Summarize some cultural considerations for the postpartum time period : African American-mother shares care of infant with extended family, experiences of older women influence care, mothers protect newborns from strangers for several weeks, mothers may not bathe newborns for first weeks, silver dollars may be tapped over infants’ umbilical cord, and sleeping with parents is a common practice. Amish- women consider childbearing their primary role in society, oppose birth control, pregnancy and childbirth are considered private, and women do not respond favorably when hurried to complete selfcare task. Appalachian- infant colic is treated by passing newborn through a leather horse’s collar or administered weak catnip tea, an asafetida bag is tied around neck to ward off disease, women may avoid eye contact, women typically avoid asking questions, and the grandmother may rear the infant for the mother. Filipino American- grandparents often assist in the care of their grandchildren, breastfeeding is encouraged and often may up to 2 years, women may feel comfortable discussing birth control and sexual matters, strong religious beliefs, and families are close-knit. Japanese American-cleanliness and protection from cold are essential (bathe infant daily), newborns are not routinely taken outside home and are kept warm inside, breast-feeding is primary method of feeding, women stay home from 12 months PP, and bathing infant is a center family activity. Mexican American- newborn’s grandmother lives with mother for several weeks PP, many women will breast-feed for more than 1 year and infant is carried in a rebozo to allow access for breast-feeding, may avoid eye contact, and some may bring religious icons. Muslim- modesty is primary concern, Muslims will not eat pork, muscles may prefer same-sex health provider, a muscle often stays in the house 40 days after birth, most will breast-feed, women are exempt from prayer with lochia present, and extended family is likely to be present during hospital stay. Native American- women may be secretive about pregnancies, touching is not a typical female behavior and eye contact is brief, resent being hurried and need time for sitting and talking, mother mothers breast-feed and practice birth control. Psychosocial adaptations: parental attachment and bonding: formation of a relationship between a parent & a newborn through a process of physical & emotional interactions. Attachment beings before birth. Oxytocin is essential for bonding and its effects are enhanced by skin-to-skin contact, breastfeeding; eye contact; social vocalizations; maternal and milk odors, which are soothing for newborn; and newborn massage during the first PP hour. Early and sustained contact between newborns and parents is vital. Encourage skin-to-skin contact (kangaroo care) by placing infant onto bare chest of mom and partner to enhance newborn attachment. Encourage breast-feeding. Encourage touching, talking, singing, comforting, changing diapers, feeding and participation in newborn care. Bonding is the close emotional attraction to a newborn by parents during the first 30-60 min after birth. Attachment three stages are proximity, reciprocity, and commitment. (1) Proximity has three dimensions the contact, emotional state, and individualization. (2) Reciprocity is the process by which the infant’s abilities and behaviors elicit parental response and this involves complementary behavior and sensitivity. (3) Commitment refers to the enduring nature of the relationship which includes centrality and parent role exploration. Three phases of Rubin’s theory on a woman’s adjustment to her new maternal role: (1) Taking-in phase (dependent phase)-Phase can 1-2 days (24-48 hr.) and is the time immediately after birth when the client needs sleep, depends on others, and relives events surrounding birth process. Focus on meeting personal needs, excited and talkative, and needs to review birth experience with others. (2) Taking-hold phase (Dependent-independent phase)- Begins on day 2-3 and lasts 10 days to several weeks. Focus is on the baby and improving caregiving competency; want to take charge but need acceptance from others; want to learn and practice; dealing with physical and emotional discomforts, can experience baby-blues. (3) Letting-go phase- reestablishes relationships with others, focus is the family as a unit and resumption of role (intimate partner, individual.)

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Summarize the frequency of assessments for a woman who has just given birth: During the first hour the nurse will check the following every 15 min-BP, pulse, respiratory status, fundus, lochia, abdominal dressing, episiotomy (check at least once in 1st hour), assess bladder, and check temperature. During the second hour, assessment every 30 min. During the first 24 hours, assessment every 4 hours . After 24 hours, every 8 hours. Interventions a nurse can provide to promote: (1) Comfort-assess pain related to episiotomy, lacerations, incisions, afterpains, and sore nipples and intervene. Administer pain medications. Teach nonpharmacological methods like distraction, imagery, heating pads, position changes, cold packs. (2) Rest- teach client how to perform pelvic tilt exercises to strength back muscles and relieve strain on the lower back and teach client to perform Kegel’s. Begin simple exercise soon after birth and progress. Follow vaginal birth, limit stair climbing for the first few weeks PP. Following c-section, postpone abdominal exercises for 4-6 weeks and postpone strenuous exercise for 4-6 weeks until follow up visit. Do not climb more than one flight of stairs per day and do not lift more than 10 lbs. first 2 weeks. Plan at least one daily rest period; rest when infant does. (3) Nutrition- non-lactating clients consume 1,800 to 2,200 kcal/day. Lactating clients should increase intake to an additional 450-500 calories/day. Continue taking prenatal 6 weeks PP. (4) Self-care- can resume intercourse 2nd-4th week after birth, when bleeding stopped and perineum healing. Physiological reactions to sex may be less intense for the first 3 months. List the postpartum danger signs: fever more than 100.4; foul-smelling lochia or an unexpected change in amount or color; large blood clots, or bleeding that saturates a peri-pad in an hour; severe headaches or blurred vision; visual changes such as blurred vision or spots or headaches; calf pain with dorsiflexion of the foot; swelling, redness, or discharge at the episiotomy, epidural, or abdominal sites; dysuria, burning, or incomplete emptying of the bladder; SOB or difficulty breathing without exertion; and depression or extreme mood swings. What factors would place a woman at increased risk for pp complications? Operative procedure, history of diabetes, prolonged labor, use of indwelling catheter, anemia (hemoglobin less than 10.5 mg/dL), multiple vaginal exams during labor, prolonged rupture of membranes (less than 24 hours), manual extraction of placenta, and compromised immune system. Precipitous labor, uterine atony, placenta previa or abruptio placenta, labor induction or augmentation, operative procedures, prolonged third stage of labor (more than 30 min.), multiparity, and uterine overdistention. Summarize the basic teaching the nurse can provide a breastfeeding mother/family: (1) Hunger cues- Woman may report tingling sensation in both breasts called the ‘let-down reflex’ and it occurs before or during breast-feeding. (2) Frequency of feedings-Allow infant to nurse on demand, about 8-12 times in 24 hours. Allow infant to feed until breast softens. Offer the second breast to infant before completing feeding and start each feeding with different breast. (3) Latch on and positioningFour traditional positions for breastfeeding are the football hold (under the arm), cradle, across the lap, and side-lying. The infant should take in part of the areola and nipple, not just the tip. The newborn is latched on correctly when the nose, cheeks, and chin touch the breast. (4) Length of feedings-Breastfeed at least 15-20 min per breast. 8-12 times in a 24-hour period. (5) Preventing engorgement-engorgement peaks in 3-5 days PP and subsides within 24-36 hours. It can occur from infrequency feeding or ineffective emptying of the breasts and can last 24 hours. Frequent emptying to minimize discomfort and resolve engorgement. Stand in warm shower or apply warm compresses immediately before feedings to help soften breasts and nipples to allow newborn to latch easily. Heat/cold applications, cabbage leaf compresses, breast massage and milk expression, ultrasound, breast pumping, and anti-inflammatory agents.

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(6) Breast discomfort/sore nipples-To relieve breast engorgement, take warm shower and apply warm compress before breastfeeding to promote letdown and milk flow. Empty each breast after feeding and use pump as needed to finish emptying. Apply cool compress after feeding. Apply breast creams as prescribed and wear breast shells to soften nipples if irritated or cracked. For flat or inverted nipples, use breast shell between feedings. For sore nipples, apply a small amount of breast milk to the nipple to allow it to air dry after breastfeeding. Drink fluids. What teaching can the nurse provide to the bottle-feeding mother/family? Newborns need about 100 to 110 cal/kg or 650 cal/day. Infant will need 2-4 oz each feeding to feel satisfied at each feeding and until 4 months, need six feedings a day. Summarize the criteria that must be met in order for a mother/newborn to be discharged “early”: Mother is afebrile and vital signs are normal, lochia is appropriate amount and color for stage of recovery, hemoglobin and hematocrit values normal, fundus is firm and urinary output is adequate, ABO blood groups and RhD status are known and anti-D immunoglobulin administered if needed, surgical wounds healing and no signs of infection, mother is able to ambulate without difficulty, foods and fluids are taken without difficulty, self-care and infant care are understood and demonstrated, family or other support system is available, and mother aware of complications. Postpartum Assessment: During the first hour, every 15 min. During the second hour, every 30 minutes. During the first 24 hours, every 4 hours. After 24 hours, every 8 hours.

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