The Postpartum Period Postpartal Adaptation and Nursing Assessment Chapter 21 Maternal-Newborn & Child Nursing London, Ladewig, Ball, & Bindler Prepared by Mary Ann Gagen Professor of Nursing

Postpartal Adaptation and Nursing Assessment Physical adaptations Reproductive Abdomen Lactation GI Urinary tract Vital signs Blood values Weight loss Postpartal chill Postpartal diaphoresis Afterpains Chapter 21: p 446

Reproductive System Involution Fundal position Lochia Cervical changes Rubra Serosa alba Cervical changes Vaginal changes Perineal changes Recurrence of ovulation and menstruation Reproductive: Involution – rapid ↓ in size of uterus to nonpregnant state. Decidua sheds as lochia; placental site is exfoliated. Cells grow smaller, reversing the uterine hyperplasia. Factors slowing down process: prolonged labor, anesthesia or excessive analgesia, difficult birth, full bladder, multiparity, incomplete expulsion of the placenta or membrane fragments. Factors enhancing involution: breastfeeding, early ambulation, & uncomplicated birth. Changes in fundal position: /p placental delivery: uterus grapefruit-size. Fundus midline; at level of umbilicus at 6 -12 hrs /p. Boggy uterus: blood & clots collect, uterus rises, contractions interrupted; moves to R side: suspect distended bladder. PP day #1: 1 cm ↓ umbilicus; descends 1 fingerbreath/day. Breastfeeding → pitocin → faster; nonpregnant size @ 5-6wks Lochia: uterine debris /p birth. rubra – 3-4 days – dark red, bloody, fleshy, musty, stale non-offensive odor; clots < nickle; composition: blood /c sm amts mucus, shreds of diciua, epithelial cells, leukocytes; may contain fetal meconium, lanugo, or vernix caseosa serosa – 4 – 10 days – pink,or brownish; watery; odorless. Composition: serum, erythrocytes, shreds of degenerating decidua, leukocytes, cervical mucus, numerours bacteria alba – 11 – 21 days; u/t 6 wks if lactating – yellow to white, possible stale odor. Composition: leukocytes, decidual cells, epithelial cells, fat, cervical mucus, cholesterol, bacteria Cervical changes: soft, irregular, edematous; bruised-looking /c multiple small lacerations; closes to 2 -3 cm /p few days; admits fingertip /p 1 wk; permanent change to os /p 1st delivery to slit-like Vaginal changes: smooth walls, edematous, multiple small lacerations; perineal pain d/c /p 2 wks; ↓ PP estrogen → ↓ vaginal lubrication & vasoconstricition 6 – 10 wks → painful intercourse. Chp 9, Figure 9-9, p 197 : Perineal muscle tightening, also called Kegel exercises strengthen the pubococcygeus muscle, which improves support to the pelvic organs. p 195: how to teach: compare to elevator, 1-4 floors; properly done, does not contract the buttocks & thighs; done any time Perineal: bruising; episiotomy edges together; separation Recurrence of ovulation & menstruation: nonlactating: 6-8 wks; 1st cycle usually anovulatory; breastfeeding: delayed, but not reliable form of birth control. Exclusive breastfeeding → wider spacing of pregnancies

Postpartal Adaptations, cont’d Abdominal wall Cardiovascular/blood values GI Urinary Afterpains Abdominal: soft, flabby; striae or stretch marks; diastisis recti, separation of rectus muscle, may improve PP r/t woman’s physical condition, gravidity, exercise Cardiovascular/blood values: returns to prepreg. Within 2 wks; 40% inc in blood volume eliminated through diuresis; 1st 48 hrs greatest risk for PP hemorrhage; BP - baseline; Inc in fibrinogen → ↑ risk of thrombophlebitis; inc WBCs 25-30,000/mm3 - nonpathologic leukocytosis; an ↑ of > 30% in 6 hrs indicate pathology GI: hunger & thirst common; risk for constipation ↑ d/t ↓ peristatlsis, narcotics, dehydration & ↓ mobility; risk for hemorrhoids ↑ d/t pressure of pushing Urinary: inc bladder capacity & ↓ bladder tone → ↓sensation & ↑ risk of urinary retention & UTI; PP diuresis 1st 12-24 hrs of 2,000 – 3,000 ml urine; 5 lb loss; full bladder displaces uterus, usually R side; fluids lost through diaphoresis, esp at night Endocirine: estrogen & progesterone drop rapidly; Lactation: nipple stimulation → pitocin release → release of prolactin → milk production & let-down reflex & release of milk by contractions of alveoli of breast; colostrum - 1st milk, rich in protein & immunoglobulins; engorgement occurs 2nd/3rd day; usually 2-5 days; mature milk produced after 2 weeks Afterpains: intermittent uterine contractions; > common in multigrav than primi (“rubber band”), esp when breastfeeding

Postpartal Psychosocial Adaptations Phases of maternal adjustment Taking-in Taking-hold Letting-go Maternal role attainment Postpartum blues Bonding Taking-in: 1st PP day or 2 ; preoccupied /c own needs; tells her story; passive, independent; touches & explores infant Taking-hold: 2nd or 3rd day ready to resume control; obsessed with body functions; anticipatory guidance most effective; rapid mood swings Taking-hold – in other texts: mothering functioning established; sees infant as unique person Your text: Maternal role attainment: takes abour 3 – 10 months Anticipatory stage during pregnancy; role model Formal stage – birth of child; influenced by others; tries to please everybody Informal – mother begins making own decisions Personal stage – final; comfortable with her concept of maternal role Challenges: finding time for self; feelings of incompetence; fatigue from sleep deprivation; loss of freedom/added responsibility; challenge caring for active baby. Nurses can give anticipatory guidance Postpartum blues: transient depression 1st few days &/or within 1st 2 wks, manifested by mood swings, anger, tearfulness, felling let-down, anorexia, & insomnia; usually resolves spontaneously; evaluation necessary if persistent Bonding: also known as attachment: process by which parents form emotional relationship with infant over time; influenced by many factors: family, stability of home environment, nurturing she received as child. Certain characteristics important: level of trust, level of self esteem, reactions to present pregnancy; interest in child rearing. Initial attachment behavior: mother explores infant with fingertips, then palms, & then enfolding newborn with whole hands & arms; holds infant in en face position, face-to-face position about 20cm , same plane; mother uses soft, high-pitched voice; engrossment - father’s absorption, preoccupation, & interest in infant; stimulated by active participation in the birth Cultural influences: remember that mother’s expectations may be different from what the nurse or physician expect; foods, hygiene practices, support from family members vary

Postpartal Nursing Assessment Risk Factors: table 21-1, p 453 Assessment Guide, Postpartal – First 24 Hours After Birth, pp 454 - 455

Physical Assessment: “BUBBLE-HE” Breasts Uterus Bladder Bowel Lochia Episiotomy Homan’s sign Emotional status Breasts: breast or bottle? Palpate for engorgement; inspect nipples for redness, cracks, erectility, if nursing Uterus: fundal height, firmness, position r/t abdominal midline; fundal location r/t expected descent’ inspect abdominal incisions, c-sec, or BTL for REEDA: redness, edema, ecchymosis, discharge, & approximation of skin edges Bladder: void within 6 - 8hrs of delivery; assess frequency , burning, urgency (UTI); retention, distension Bowel: passage of flatus; signs of distension Lochia: type, quantity, amount, & presence of odor; expected findings? C-sec pts may have < bleeding; refer to Figure 21-6, p 457 Episiotomy: inspect perineum for REEDA; hemorrhoids Assess for lacerations: 1. 1st degree: ; limited to perineal skin & vaginal mucous membrane2. 2nd degree: involves perineal skin, vaginal mucous membrane, underlying fascia, & muscles; 3. 3rd degree: through perineal skin, vaginal mucous membrane, involves anal sphincter, possibly anterior wall of rectum 4. 4th degree: same as 3rd but extends through rectal mucosa to lumen of rectum Homan’s sign: pain in calf upon dorsiflexion of foot – possible thrombophlebitis; pedal edema/pedal pulse Emotional Status: appropriate for situation; phase of psychological adjustment; “postpartum blues” Bonding: interactions with infant