Chapter 12 The Postpartum Woman

Maternal Adaptation during the Postpartum Period Physiologic adaptation Reproductive system Uterus Uterine contraction and involution Uterine contraction leads to involution Measured by assessing fundal height Involutes one fingerbreadth per day Factors promote, inhibit involution

Maternal Adaptation during the Postpartum Period (cont.) Uterus (cont.) Afterpains Lochia Rubra Serosa Alba Ovaries Ovulation can occur as soon as three weeks postdelivery

Maternal Adaptation during the Postpartum Period (cont.) Reproductive system (cont.) Cervix Vagina, perineum Never fully return to pregravid state; Kegel exercises Lactation can lead to vaginal dryness, dyspareunia Breasts Colostrum; prolactin

Maternal Adaptation during the Postpartum Period (cont.) Physiologic adaptation (cont.) Cardiovascular system High plasma fibrinogen levels and other coagulation factors mark postpartum period Vital signs Temperature may be slightly elevated first 24 hours Slow pulse WNL first week postdelivery Blood pressure should not be elevated

Maternal Adaptation during the Postpartum Period (cont.) Physiologic adaptation (cont.) Musculoskeletal system: Abdomen is soft, sagging immediately postpartum Gastrointestinal system: Very hungry; constipation Urinary system: Transient glycosuria, proteinuria, and ketonuria are normal immediately postpartum Voiding issues Integumentary system: Copious diaphoresis common Striae (stretch marks) on abdomen and breasts

Maternal Adaptation during the Postpartum Period (cont.) Physiologic adaptation (cont.) Weight loss Immediate 12 to 14 lb = baby, placenta, and amniotic fluid 5 to 15 lb (early postpartum) = fluid loss from diaphoresis, urinary excretion Return to prepregnant weight six months after childbirth (if within recommended weight gain range)

Question A 26-year-old G1P1 has delivered a healthy baby girl. You are providing patient teaching. One of the subjects you know to cover is the restarting of ovulation and menstrual cycles. One point you need to stress is a. Lactating women may not restart their menses for more than 24 months b. Menses always begins before ovulation c. You can’t get pregnant as long as you are breast-feeding d. You can conceive even if your periods have not restarted

d. You can conceive even if your periods have not restarted Answer d. You can conceive even if your periods have not restarted Rationale: Return of ovulation and menstrual bleeding do not always occur together. Explain to the woman that she may be able to conceive even if her menses do not resume immediately.

Maternal Adaptation during the Postpartum Period (cont.) Psychological adaptation Becoming a mother: Begin role change in pregnancy Two critical elements: Development of love; attachment to and engagement with the child Four developmental, overlapping stages: Beginning attachment (during pregnancy) Increasing attachment (early postpartum) Moving toward normal (in the first four months) Achieving maternal identity (around four months)

Maternal Adaptation during the Postpartum Period (cont.) Psychological adaptation (cont.) Development of positive family relationships Attachment: Enduring emotional bond that develops between parent and infant; not automatic Bonding: How new mother and father become acquainted with their newborn En face position: Mother interacts face to face with newborn Naming newborn; calling newborn by name; maintaining eye contact and talking to newborn

Maternal Adaptation during the Postpartum Period (cont.) Psychological adaptation (cont.) Development of positive family relationships (cont.) Signs of problematic attachment development Turning away from newborn Refusing to name newborn Refusing or neglecting care of newborn Disengagement from newborn Absence of pattern of touching

Maternal Adaptation during the Postpartum Period (cont.) Psychological adaptation (cont.) Postpartum blues: Temporary condition (usually begins on third day) lasting for two to three days Rapid mood swings; irritability Anxiety; decreased concentration Possible difficulty sleeping and eating Contributing factors Psychological adjustment; hormonal impact Too much activity; fatigue Disturbed sleep patterns Discomfort may contribute

Question When providing care to a postpartum patient it is important to assess the new mother’s psychological adaptation to the infant. You know that there are two critical elements to becoming a mother. What is one of these elements? a. Learning to care for the infant b. Engagement with the child c. Redevelopment of love and attachment to significant other d. Moving toward a new normal

b. Engagement with the child Answer b. Engagement with the child Rationale: The two critical elements of becoming a mother are development of love and attachment to the child and engagement with the child. Engagement includes all the activities of care giving as the child grows and changes.

The Nurse’s Role in Postpartum Care Nursing process for early postpartum period Assessment Data collection Initial assessment and prenatal history Initial physical assessment in first hour following delivery Early data from L&D nurse Report from L&D nurse to postpartum nurse upon transfer

The Nurse’s Role in Postpartum Care (cont.) Assessment (cont.) Complete postpartum physical assessment Performed at least once per shift Assess following areas Breasts, uterus Lochia Bladder, bowel Perineum Lower extremities Pain

The Nurse’s Role in Postpartum Care (cont.) Assessment (cont.) Complete postpartum physical assessment (cont.) Assess following areas (cont.) Laboratory studies Maternal–newborn bonding Maternal emotional status Selected nursing diagnoses Outcome identification and planning

The Nurse’s Role in Postpartum Care (cont.) Nursing process for early postpartum period Implementation Promoting hemostasis Providing pain management Breast pain; afterpains Perineal pain Preventing infection Preventing injury from falls

The Nurse’s Role in Postpartum Care (cont.) Nursing process for early postpartum period (cont.) Implementation (cont.) Promoting urinary and bowel elimination Preventing injury from thrombus formation Promoting restful sleep Promoting parent–newborn attachment Evaluation: Goals and expected outcomes

The Nurse’s Role in Postpartum Care (cont.) Nursing process for postpartum care after cesarean birth Assessment Primary causes of maternal mortality postcesarean Anesthesia complications Postpartum infection Hemorrhage Thromboembolism

The Nurse’s Role in Postpartum Care (cont.) Nursing process for postpartum care after cesarean birth (cont.) Assessment (cont.) Monitor Lungs; signs of respiratory depression IV for rate (flow, correct solution) Sources of pain, discomfort Incision; bowel sounds; urinary output Signs of thrombus formation

The Nurse’s Role in Postpartum Care (cont.) Nursing process for postpartum care after cesarean birth (cont.) Selected nursing diagnoses Outcome identification and planning Implementation Monitoring for adequate respiratory pattern Preventing injury from hemorrhage Preventing infection; providing pain management Preventing injury from thrombus formation Evaluation: Goals and expected outcomes

The Nurse’s Role in Postpartum Care (cont.) Nursing process for preparing the postpartum woman for discharge Assessment Observe parental interaction Observe interactions between other family members Selected nursing diagnoses Outcome identification and planning

The Nurse’s Role in Postpartum Care (cont.) Nursing process for preparing the postpartum woman for discharge (cont.) Implementation Supporting health-seeking behaviors Reinforce positive family behaviors Anticipatory guidance: Sibling involvement Preventing injury from Rh-negative blood type or nonimmunity to rubella Is the woman a candidate for Rho(D) immune globulin (RhoGAM)

The Nurse’s Role in Postpartum Care (cont.) Implementation (cont.) Providing patient teaching Breast care; fundal massage Perineum and vaginal care Pain management Nutrition; constipation Proper rest Stress import of prioritizing self-care Evaluation: Goals and expected outcomes

Question Tell whether the following statement is true or false. RhoGAM (Rho(D) immune globulin) is given to an Rh- negative mother who delivers an Rh-positive infant to prevent the formation of antibodies that may attack future fetuses.

Answer True Rationale: If the woman is Rh-negative and the baby is Rh- positive, the woman will need an injection of RhoGAM to prevent the development of antibodies to Rh-positive blood. The woman must receive the RhoGAM within 72 hours of delivery to be most effective.