1. Chapter 12 The Postpartum Woman

2. 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

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

4. 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

5. 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

6. 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

7. 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)

8. 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

9. 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.

10. 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)

11. 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

12. 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

13. 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

14. 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

15. 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.

16. 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

17. 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

18. 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

19. 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

20. 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

21. 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

22. 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

23. 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

24. 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

25. 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)

26. 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

27. 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.

28. 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.