1. What physiologic changes are occurring in the postpartum woman?

2. Weight loss of 15-17 lbs. 10-12 lbs baby, placenta, amniotic fluid
Weight loss of lbs lbs baby, placenta, amniotic fluid 5 lbs excess fluid through diuresis 500 cc + from blood loss [for every 500cc blood loss Hct falls 3-5%] Elevated temp up to 100.4oF from muscular exertion, dehydration, hormonal changes [epidural also increases T]-afebrile after 24 hrs Shaking chills and/or diaphoresis due to vasomotor instability

3. Increased blood clotting mechanisms are activated postpartum  increased risk of thromboembolism Trauma to the bladder during birth can  urinary incompetence for the first few days and overdistention and incomplete emptying Diuresis begins within 24 hours Diaphoresis [‘Hot flashes’] are another mechanism of fluid reduction as hormonal levels return to pre-pregnant levels Involution [return of uterus to pre-pregnant state] begins immediately and is complete by ~ 6 weeks postbirth

4. The sudden, significant weight loss and fluid shifts that occur in women in the postpartum period would typically result in shock and profound deleterious physiologic effects in other less healthy and resilient individuals.

5. Gastrointestinal system Cardiovascular system Urinary tract
Fundus
Location
Consistency
Cramping [increases with each successive birth]
Cervix
Dilation
Vagina
Abdomen
Gastrointestinal system
Cardiovascular system
Urinary tract
Decreased sensation of bladder filling
Diaphoresis
Breasts

6. What is included in the assessment of the postpartum client?

7. Postpartum Assessment
Monitor vital signs
Q 15 minutes for the first hour postbirth
Q 30 minutes for the second hour postbirth
Q 1 hour for 2 hours or until stable
BID through discharge
All assessments should be more frequent if there are any abnormal assessment findings
Always follow institutional protocols
Include BP, HR, RR, Temp [q 4 hours], location and consistency of fundus, amount and color of lochia [note any abnormal smell which might indicate infection], perineal status [intact, edematous, etc.], bladder status [location of bladder/document voiding and amount and whether bladder was emptied], comfort level, status of abdominal dressing if cesarean birth

9. Figure 30. 1 Involution of the uterus
Figure Involution of the uterus. A, Immediately after delivery of the placenta, the top of the fundus is in the midline and approximately halfway between the symphysis pubis and the umbilicus. About 6 to 12 hours after birth, the fundus is at the level of the umbilicus. B, The height of the fundus then decreases about one finger breadth (approximately 1 cm) each day.

10. Correct position for assessing the fundus
Correct position for assessing the fundus. Woman should be supine and flat or almost flat. Place the nonpalpating hand just above the symphysis to prevent inversion or prolapse of the uterus. Palpate gently, but firmly. Slowly remove your palpating hand to reduce discomfort, especially with a surgical abdomen.

11. Correct position for assessing the fundus
Correct position for assessing the fundus. Woman should be supine and flat or almost flat. Place the nonpalpating hand just above the symphysis to prevent inversion or prolapse of the uterus. Palpate gently, but firmly. Slowly remove your palpating hand to reduce discomfort, especially with a surgical abdomen.

13. A full bladder will push the uterus up and [usually] toward the woman’s right side. Observing from the side, you might see what appears to be ‘camel humps’: the lower hump is the bladder and the upper hump is the uterus.

15. Transition of Lochia Lochia Rubra Lochia Serosa Lochia Alba Red
First 1-3 days postbirth
Dark red or brownish with clots; fleshy odor, increased flow on standing or with breastfeeding or during physical activity; contains blood and tissue fragments
Lochia Serosa
Pink, brown-tinged
3-10 days
Serosanguinous consistency; contains a smaller amount of blood, erythrocytes, leukocytes, leukocytes, mucus, decidua; fleshy odor
Lochia Alba
Yellowish-white
10-14 days, but may last longer
Contains mostly leukocytes as well as decidua, mucus, bacteria, and endothelial cells; no strong odor

16. Transition of Lochia Abnormal findings
Foul smelling lochia
Numerous or large clots
Quickly saturated peri pad
Lochia serosa or alba that returns to a more bloody appearance usually indicates the mother is too active-this is an excellent guide to activity postbirth
Lochial flow usually ends by 6 weeks postbirth-abnormal vaginal discharge beyond this time should be evaluated

21. Classification of Lacerations
First degree
Limited to the perineal skin and vaginal mucous membrane
Second degree
Includes the fascia and perineal muscles
Third degree
Extends into the rectal sphincter muscle
Fourth degree
Extends through the anterior rectal mucosa, exposing the rectal lumen
Lacerations heal better than episiotomies
Complete healing may take up to 6 months
Severe damage to the vagina may result in fistula formation

22. Lacerations
What is most important is to understand the potential impact on
Comfort level
The more severe the laceration and extensive the repair, the more likely there is to be more discomfort and need for pain medication
Discomfort will impact mobility
Healing
Concern about return of bowel function

23. What is included in the nursing care of the postpartum client?

24. Promote Comfort Care of the perineum
Apply ice packs for comfort and to reduce swelling for first 24 hours
After 24 hours encourage mom to sit in warm bath for mins 2-3 times per day
Have mom use squirt bottle to spray water during urination to reduce the burning from urine flow
Have mom use water from squirt bottle to cleanse perineum after urination or bowel movement

25. Promote Comfort Care of the perineum Apply clean peri pad as needed
Apply tucks pads
Apply analgesic ointment
Have mom put a pillow under one buttock cheek to tip her off the perineum when sitting or lying down [alternate sides]
These interventions also relieve discomfort from hemorrhoids

26. Promote Comfort Managing general body ache
Women often experience extensive body aches following the exertion of labor and birth and the muscle strain during pushing
Exacerbated by positioning by others following an epidural [such as traction on legs]
Massage is a wonderful intervention if available
Warm tub bath
Application of warm packs to most affected areas

27. Promote Comfort Managing backache following an epidural
Application of hot pack or K pad
May alternate with cold/ice pack as desired by mom
Administer analgesics to relieve any and all discomforts
Match the benefits of a particular medication to the specific discomfort

28. Promote Comfort Preventing constipation
Women are very fearful of having a bowel movement following birth related to perineal discomfort or surgical incision in abdomen
Encourage water drinking for hydration
Administer docusate sodium for stool softening
Administer senna as a gentle laxative to stimulate a sluggish bowel following pregnancy, birth, gut manipulation during cesarean birth

29. Promote Comfort Preventing constipation
Remember the constipating effects of many analgesics
Encourage mobility
Getting out of bed
Walking in hallway
This will also help relieve bloating and gas following cesarean birth, which can exacerbate incisional pain and general discomfort

30. Promote Comfort
If mom has had a cesarean birth, teach her how to get in and out of bed
Raise the head of the bed
Turn to side
Use elbow to push up
Then swing out legs
Reverse process to get into bed
Teach her how to get in and out of bed when she gets home—hands and knees

31. Promote Sleep and Rest
Promoting comfort and sleep and rest are complementary—discomfort prevents sleep and rest/sleep and rest promote comfort
Create a comfortable physical environment
Temperature
Light
Sound [use white noise from something like a fan if necessary]

32. Promote Sleep and Rest Control visitors as needed
Parents often want to see visitors, but don’t understand how exhausting they are
Help reduce further exhaustion by working with mom to set limits on visitor number and length of visits
Put a ‘Sleeping: Do Not Disturb’ sign on the door as needed
Cluster care to minimize family disruption

33. Promote Parenting
Reinforce to parents that this is their baby and encourage them to assume responsibility for care
Guide parents in basic baby care
Guide parents through initial baby bath if one is given
Keeping baby warm with hat and blankets and human contact
‘Back to sleep’ unless baby is on a person
Correct swaddling technique

34. Promote Parenting Prevent chilling baby
Diaper changing
Prevent chilling baby
Use wet wash clothes to remove meconium
Boys
Cover penis while changing diaper to keep from getting peed on
‘Hose to toes’—point penis down so diaper will absorb urine
Girls
Wipe front to back

35. Promote Parenting Cover with blankets Put baby inside a belly band
Encourage skin-to-skin contact
Cover with blankets
Put baby inside a belly band
Use both parents
Give lots of encouragement and positive reinforcement
Teach infant cues and the meaning of crying
Put parents’ questions and issues FIRST

36. Promote Parenting
If this is a subsequent child, parents can reduce sibling rivalry by

37. Postpartum Teaching Use teachable moments Ask open ended questions
Don’t ‘talk at’ parents or ‘information dump’
Ask follow up questions to evaluate actual learning
Have parents provide return demonstrations of skills
Focus first on the parents’ issues/questions
Discharge teaching begins at admission
Postpartum teaching should begin during pregnancy during prenatal visits

43. Care during labor, birth, and the postpartum period is not a medical procedure, it is growing a family.