The Postpartal Woman

1
The Postpartal Woman

• Postpartal period refers to the 6 week period
  after childbirth.
• Fourth trimester of pregnancy.
• Maternal changes-involution of the uterus and
  vagina.
• Production of milk for lactation.
• Restoration of the normal menstrual cycle.
• Parenting role.
• Physical and emotional care.

2
The Postpartal Woman

• Nursing Process
• Assessment
• Outcome Identification and Planning
• Implementation
• Outcome Evaluation
• Woman and baby are safe
• Parents make one positive comment about the baby
  before D/C
• Pt. states she will be able to manage newborn
  care.

3
The Postpartal Woman

• Lochia flow is 1 pad (50ml) every 3 hours.

4
Psychological Changes

• 3 Phases of the Puerperium
• Taking-In-Phase
• Time of reflection, passive, wants to talk about
  her labor and birth.
• Needs time to rest, holds child with sense of
  wonder.
• Taking-Hold Phase
• Begins to initiate action, strong independence
• Feels insecure about her ability to care for her
  new child.

5
Psychological Changes

• Give praise, support and positive reinforcement.
• Letting-Go Phase
• Redefines her new role
• Development of Relationships
• May not experience feelings for their infant
  until days or weeks
• Fathers may have difficulty bonding until 3
  months.
• Physical contact, holds blanket.

6
Psychological Changes

• Claiming or bonding
• Identification process-gradually holding infant,
  touch with palms, smooths babys hair, brushes
  cheek, plays with toes, kiss.
• En face position-looking directly at her
  newborns face, with direct eye contact.
• Engrossment-staring at newborn for long
  intervals.
• Rooming-in
• Partial in nursery at night
• Complete 24 hours

7
Psychological Changes

• Sibling Visitation
• Free of disease.
• May have a different picture of the baby via
  phone.
• Maternal Concerns and Feelings
• Focus on care of infant, bathing, breast feeding
  and soreness, regaining figure, housework,
  children, tension, fatigue, partners, sibling
  jealousy.

8
Maternal Concerns and Feelings

• Abandonment
• No longer the center of attention
• Disappointment
• Child does not meet their expectations.
• Postpartal Blues
• 50 will experience some sadness
• Hormonal changes-decreased estrogen and
  progesterone
• 30 experience this, 12 receive treatment.

9
Physiologic Changes

• Retrogressive physiologic changes related to the
  reproductive system and other systemic changes.
• Reproductive System Changes
• Involution-process of returning to their
  nonpregnant state.
• Danger of hemorrhage until involution is
  complete.
• Uterus
• 1. Area where placenta was implanted

10
Reproductive System Changes

• is sealed off, preventing bleeding.
• 2. Organ is reduced to its approximate
  pregestational size.
• Accomplished by rapid contraction of the uterus
  immediately after delivery.
• Thrombi form within the uterine sinuses.
• Eventually endometrial tissue undermines the site
  and obliterates the area.
• The process leaves no scar tissue within the
  uterus and implantation sites are unharmed.

11
Reproductive System Changes

• Same contractions reduce the bulk of the uterus.
• Uterus thickens and contracts to the size of a
  grapefruit. Never completely returns to
  prepregnancy state.
• At birth 1000 g., 1 week 500 g., 6 wks.50 g.
• After delivery fundus is halfway between the
  umbilicus and symphysis pubis.
• 1 hour later-it has risen to the umbilicus and
  remains for next 24 hours.(figure 22.4)
• Will decrease 1 cm/day (day 9-10 in pelvis)

12
Reproductive System Changes

• Oxytocin is released with breast feeding and may
  contract more quickly.
• Fundus feel firm, if boggy will lose blood very
  fast because no permanent thrombi have formed.
  1st hour is most dangerous.
• Afterpains-contraction of uterus after birth
  causes intermittent cramping.
• Lochia
• Layer adjacent to the uterine cavity will become
  necrotic and cast off as discharge.
• This flow consists of blood, fragments of

13
Reproductive System Changes

• decidua, WBC, mucus, and bacteria.
• Lochia rubra-red color blood for 1st 3 days
• Lochia serose-pink or brownish color, amount of
  blood decreases and leukocytes invade the area
  and healing begins.
• Lochia alba-10th day amount of flow decreases and
  becomes colorless or white. Remains until 3rd to
  6th week after birth.
• Table 22.1

14
Reproductive System Changes

• Cervix
• Immediately after birth, soft and malleable.
• Internal and external os are open.
• Contraction of cervix begins at once and by the
  end of 7 days is the size of pencil opening and
  feels firm and nongravid.
• Os remains slightly open, slitlike or stellate
  (star shaped).
• Vagina
• Soft with few rugae. Takes 6 wks. to return.

15
Reproductive System Changes

• Thickening of walls depends on renewed estrogen
  stimulation from the ovaries.
• Kegel exercises strengthen and tone the vagina.
• Perineum
• Edema and tenderness due to the birth. Ecchymosis
  from rupture of capillaries.
• Labia majora and minora remain atrophic and
  softened never returning to prepregnant state.

16
Systemic Changes

• Hormonal System
• HCG and hPI-negligible by 24 hours.
• Week 1-progestin, estrone, estradiol.
• Estradiol may be elevated for 1 additional wk.
• FSH-remains low for 12 days then rises to
  initiate a new menstrual cycle.
• Urinary System
• Due to trauma at birth, loss of tone and edema at
  urethra.
• No sensation to void, bladder fills unable to
  void.

17
Systemic Changes

• Possibility of stasis and UTI.
• Extensive diuresis immediately after birth to rid
  body of excess fluids. 3000mL/day during 2nd to
  5th day.
• Increased nitrogen due to increased muscle
  activity during labor and protein breakdown.
• Increased diaphoresis(sweating) to get rid of
  excess fluids.

18
Systemic Changes

• Circulatory System
• Blood volume returns to normal within 1 to 2
  weeks.
• Usual blood loss-vaginal-300 to 500 mL
• Cesarean-500 to 1000 mL
• Hematocrit - 4 point decrease
• Hemoglobin 1g decrease with each 250 mL of
  blood lost.
• Plasma fibrinogen-high-protects against
  hemorrhage increases thrombus formation.

19
Systemic Changes

• Leukocytes-increased-WBC 30,000/mm
• Granulocytes
• Varicosities recede, will fade.
• Gastrointestinal System
• Feels hungry immediately from glucose used during
  labor and thirst due to restricted fluids and
  diaphoresis.
• Passage of stool through mat be slowed because of
  effects of relaxin on the bowel.
• BM difficult due to pain of episotomy.

20
Systemic Changes

• Integumentary System
• Stretch marks on abdomen more reddened. Will fade
  to pale white over 3 to 6 months.
• Coloasma and linea nigra-barely detectable in 6
  weeks.
• Diastasis recti- slightly indented if large will
  be bluish at abdominal midline.
• Sit ups will help.
• Effects of Retrogressive Changes
• Exhaustion sleep hunger

21
Retrogressive Changes

• Weight Loss rapid diuresis 5 lb wt. loss over
  12 lb loss at birth.
• 2 to 3 lbs lochia flow
• Total 19 lbs. the weight at 6 weeks will be her
  baseline postpartal weight.
• Vital Signs
• Temperature-slight increase during first 24
  hours. If 100.4 afterwards monitor for infection.
• Pulse-slightly slower then normal (60 to 70)
  returns within 1 week.

22
Retrogressive Changes

• B/P-above140 mm Hg systolic or 90 mm Hg diastolic
  may be postpartal hypertension (oxytocin
  increases B/P)
• Orthostatic hypotension due to blood loss.
• Check B/P and pulse supine then raise head of bed
  upright wait 2 to 3 min. recheck. If pulse
  increased by 20 bpm and B/P is 15 to 20 mm Hg
  lower she may have dizziness.
• Have her walk with assist, dangle first.

23
Progressive Changes

• Lactation formation of breast milk
• Colostrum thin, watery, pre-lactation secretion
  since midway through pregnancy.
• 3rd day breasts become full and feel tense or
  tender as milk forms within the breast ducts.
• Breast milk forms due to fall in estrogen and
  progresterone levels that follows delivery of the
  placenta(which increases prolactin and stimulates
  milk production.
• Milk is bluish white color.

24
Progressive Changes

• Primary engorgement-feeling of tension on day
  3-4. Will fade as the infant begins sucking and
  empties the breasts of milk.
• Return of Menstrual flow
• When placenta is delivered the production of
  estrogen and progesterone are no longer
  available. This increases FSH by the pituitary
  and returns ovulation.
• If not breast feeding menstrual flow returns in 6
  to 10 weeks after birth.

25
Progressive Changes

• If breast feeding menstrual flow may not return
  for 3 to 4 months, sometimes for the entire
  lactation period.
• She may ovulate well before menstruation returns.
• Nursing Care in the First 24 Hours
• Usually remain in a birthing room or recovery for
  the 1st hour postpartum for careful assessment.
• After 1st hour she showers and is taught
  perineal care.

26
Nursing Care

• Assessment
• Health History
• Family Profile
• Pregnancy History
• Labor and Birth History
• Infant Data
• Postpartal Course
• Laboratory Data

27
Nursing Care

• Physical Assessment
• Estimation of nutrition and fluid state, energy
  level, presence or absence of pain, breast
  health, fundal height and consistency, lochia
  amount and character, perineal integrity, and
  circulatory adequacy are required.
• General Appearance
• Hair
• Face
• Eyes
• Breasts

28
Physical Assessment

• Uterus
• Lochia
• Perineum
• Provide Pain Relief for Afterpains
• Relieve Muscular Aches
• Give Episiotomy Care
• Promote Perineal Exercises
• Administer Cold and Hot Therapy
• Administer Sitz Baths
• Provide Pain Management

29
Physical Assessment

• Provide Perineal Care
• Promote Perineal Self-Care
• Promote Rest in the Early Postpartal Period
• Promote Rest Throughout the Puerperium
• Promote Adequate Fluid Intake
• Promote Urinary Elimination
• Prevent Constipation
• Prevent Development of Hemorrhoids
• Assess Peripheral Circulation

30
Physical Assessment

• Promote Breast Hygiene
• Teach Methods to Promote Uterine Involution

31
Preparation For Discharge

• Education to prepare her to care for herself and
  her newborn at home.
• To prevent infection
• Danger signs to look for
• Who to call
• Observation of parent-child interaction
• Teaching and re-teaching
• Taking hold period
• Group classes
• Bathing infants

32
Preparation For Discharge

• Preparing formula
• Breastfeeding techniques
• Minimizing jealousy in siblings
• Maintaining health of newborn
• Individual Instruction
• Rooming in is the ideal setup for observation and
  teaching.
• Discharge Planning
• Instructions verbally (table 22.3 p. 622) and in
  writing.
• Must return for an exam in 4 to 6 weeks

33
Preparation For Discharge

• Schedule an appointment for baby in 4 to 6 weeks.
• Rubella immunization if needed.
• Answer questions.
• Community liaison calling in 2 to 7 days.
• After Discharge
• Postpartal Home Visit
• Postpartal Examination

34
Unique Needs

• Woman Who Chooses Not to Keep Her Child
• Numerous reasons
• May feel confused
• Every woman has a right to see, hold and feed her
  child if she wishes.
• Offer nonjudgmental support, be aware of your
  feelings to avoid influencing her.
• Grief reaction
• Family counseling

35
Unique Needs

• Woman Who is Discharged But Whose Child Remains
  Hospitalized
• Ill infants are transported to a regional center
  or neonatal intensive care.
• Leave a photograph of the baby with the mother
  with a telephone number and name of a nurse or
  doctor to contact for questions or information.
• The team may call her when they arrive.
• Encourage them to call once a day.

36
Unique Needs

• Assist mother to visit the infant if in the same
  hospital.
• Family Who is Adopting a Child
• May come to the hospital to meet the new infant.
• Teach them the same as a biologic parent.