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

2. 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

3. 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.

4. 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.

5. 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

6. 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

7. 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

8. 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

9. 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
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12. 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
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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