Chapter 20 – Postpartum Adaptations C. Lutkenhaus, MSN,RNC-OB, C- EFM Updated 8/2015

Reproductive System Uterus Cervix Vagina Perineum Involution After-pains – worse in multiparous women, increased with breast stimulation/feeding. Lochia (rubra, serosa, alba) Cervix Vagina Perineum All can take 6 weeks to return to pre- pregnant size

Cardiovascular System Blood from the uterus and placenta returns to the central circulation. Extracellular fluid moves into the vascular compartment. Cardiac output increases, and excess fluid is excreted by diuresis and diaphoresis. Increased clotting factors predispose the postpartum woman to clot formation.

Urinary System Increased bladder capacity and decreased sense to fluid pressure may result in urinary retention. Stasis of urine allows time for bacteria to grow and can lead to urinary tract infection. The distended bladder displaces the uterus and can interfere with uterine contraction and cause excessive bleeding.

Signs of Bladder Distention Location of fundus above baseline level (determine with empty bladder) Fundus displaced from midline Excessive lochia Bladder discomfort Bulge of bladder above symphysis Frequent voidings of less than 150 mL each time

Musculoskeletal System Muscles and joints First 1-2 days after childbirth, muscle fatigue and aches Abdominal wall Diastasis recti Reduction in musculoskeletal discomfort Exercises to strengthen the abdominal muscles Good posture Body mechanics

Neurologic System Endocrine System Assess c/o headache May result from epidural or spinal Headaches, vision changes, photophobia, abdominal pain can be indicative of worsening gestational hypertension Pain continues, but becomes less Endocrine System Ovulation resumes Can become pregnant during breastfeeding even with no menses Lactation occurs Prolactin produces milk Oxytocin lets milk out Weight loss 12-13 pounds from fetus, fluid, blood, and placenta 9 pounds from diaphoresis, diuresis, and involution Pre-pregnant weight by 6 months www.e-forwards.com

Postpartum Assessments 5 B’s Breasts Engorgement before feeding, soften after feeding Belly (Fundus) Massage if boggy Blood (Lochia) Continuous trickle is laceration Hemorrhage saturates one pad in one hour or less May be scant after cesarean Bladder Bottom Perineum Clean, dry, intact No hematomas Rectal area Hemorrhoids VS, orthostatic hypotension, Pain? Homan’s Sign DTR Edema

Care in the Immediate Postpartum Care after Cesarean First 24 hrs VS Pain relief TCDB ROM Comfort and hygiene After 24 hrs Promote voiding Assist ambulation Assist infant feeding/care Prevent ABD distention Teaching Comfort measures after Vag Del Ice to perineum ICE is NICE! X 24 hrs Sitz bath after first 24 hrs Prn pain meds Local Anesthetic Spray Promote urination Cath prn Provide food and fluids Prevent clots Early ambulation dermoplast.com mancpubs.info

Attachment- rarely instantaneous Maternal touch Becoming acquainted Bonding- initial Attachment- rarely instantaneous Maternal touch Maternal role adaptation Taking-in- her own needs Taking hold- assumes responsibility for her own care Letting go to father Other Maternal Concerns & Feelings during Postpartum: ABANDONMENT – During labor they were the center of attention, with everyone asking them. Now suddenly, the baby is the main interest. Sharing responsibility for infant care can help to make both partners feel equally involved in the baby’s care. DISAPPOINTMENT - It can be difficult for parents to feel positive immediately about a child who may not have met their expectations. Comment on the child good points. POSTPARTUM BLUES (Baby blues)- 50% of women experience some feelings of overwhelming sadness. The mother burst into tears easily or may feel let down or be irritable. Likely due to (decrease estrogen & progesterone), but also worsened by low self-esteem, exhaustion and pain. A woman needs assurance that sudden crying episodes are normal. Allow to Verbalize feelings. Discuss when she needs to seek help. BODY IMAGE keishaksp.wordpress.com Rubin’s Postpartum phase Psychological Responses: a. Taking in phase  – dependent phase (first three days) mom – passive, cant make decisions, activity is to tell child birth experiences. During this time, the woman’s attention is focused on her own needs for sleep, rest and she is dependent on others. Nursing Care: - proper hygiene b. Taking hold phase  – dependent to independent phase (4 to 7 days). Mom is active, can make decisions. The concern of the mother at this time is focused on her ability to control body function and her ability to assume the mothering role. She prefers to do things by herself. As she is not yet completely recovered, she feels impatient that she’s not strong enough to do everything she wishes to accomplish Because of the tendency of the woman to overwork herself, fatigue and exhaustion is common at this stage. Begins to take a strong interest for her child- Give the woman brief demonstration of baby care- Allow her to care for the child herself with watchful guidance common post partum blues/ baby blues present 4 – 5 days 50-80% moms – overwhelming feeling of depression characterized by crying, despondence- inability to sleep & lack of appetite. – let mom cry – therapeutic. c. Letting go  – interdependent phase – 7 days & above. Mom - redefines new roles may extend until child grows. Letting-Go –  the act of ending old ways of thinking or believing- The woman finally redefines her new role- Gives up fantasized image of her child and accepts the real one- Gives up her old role of being childless or the mother of only one or two- Extended and continues during the child’s growing years