Professional Documents
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POSTPARTUM
The postpartum period, or puerperium, refers to the 6-to-8-week period after delivery during which the
mother’s body returns to its prepregnant state. Some people refer to this period as the fourth trimester of
pregnancy. Many physiologic and psychological changes occur in the mother during this time. Nursing care
should focus on helping the mother and her family adjust to these changes and on easing the transition to the
parenting role.
Known as the 5th stages labor.
Physiologic changes: Two types of physiologic changes occur during the postpartum period: retrogressive and
progressive changes.
Getting back to normal: Retrogressive changes involve returning the body to its prepregnant state. Retrogressive
changes include:
• Shrinkage and descent of the uterus into its prepregnancy position in the pelvis
• Sloughing of the uterine lining and development of lochia
• Contraction of the cervix & vagina
• Recovery of vaginal and pelvic floor muscle tone.
Postpartum care should respond to the special needs of the mother and baby and should include
• Prevention and early detection and treatment of complications and disease.
• Provision of advice and services on breastfeeding, birth spacing, immunization and maternal
nutrition.
a. Taking in phase – dependent phase (1st 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.
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Because of the tendency of the woman to overwork herself, fatigue and exhaustion is common at this
stage.
HT:
- 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
CARDIOVASCULAR SYSTEM – 1st or 2nd week postpartum, the blood volume has returned to its
normal pre-pregnancy level.
Blood Volume
Hemorrhage – bleeding of > 500cc
CS – 600 – 800 cc normal NSD 500 cc
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Early postpartum hemorrhage– bleeding within 1st 24 hrs. Baggy or relaxed uterus & profuse bleeding –
uterine atony. Complications: hypovolemic shock.
Mgt:
Blood Components
Hct rises in the first 3 to 7 days due to hemoconcentration caused by excretion of large amounts of fluids
in the urine (diuresis during the first few days after delivery). Hct level returns to normal on the fourth to
fifth postpartum week.
Leukocytosis of 20,000 to 30,000 (normal is 5000 to 10000) during the first 12 days characterized by
increased neutrophils and easinophils and decreased lymphocytes.
Fibrinogen and thromboplastin remains elevated until the 3rd postpartum week.
Increased leukocyte sedimentation rate.
INTEGUMENTARY SYSTEM
-Chloasma, palmar erythema, linea nigra and other skin changes during pregnancy gradually disappear
during the postpartum period.
-Striae gravidarum do not disappear and assumes a silvery white appearance.
-Hyperpigmentation of the areola may not disappear completely. Some women are left with a wider and
darker areola after pregnancy.
Linea nigra will be barely detectable in 6 weeks time
GASTROINTESTINAL SYSTEM
Many women are hungry after delivery because of foods and fluids restriction during labor, diaphoresis
and the strenuous labor they just went through.
Bowel movement maybe delayed for days after delivery resulting in constipation. This is caused by:
Decreased muscle tone during labor and puerperium
Lack of food during labor
Dehydration
Perineal pain caused by episiotomy, hemorrhage,laceration
Bowel sounds are active, but passage of stool through the bowel may be slow
URINARY SYSTEM
o VOIDING is difficult because of the pressure on the bladder and urethra making it edematous
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o To prevent permanent damage to the bladder from over distention, assess the woman’s abdomen
frequently in the immediate postpartum period
o Increase daily output
o From 1500ml/day to 3000ml/day during the second to fifth day after birth
oDiuresis begins 12 hour after delivery and extends up to the 5th day as the body gets rid of extracellular
fluid accumulated during pregnancy. The woman loses up to 9 lbs. weight from the excretion of these
fluids and electrolytes.
o Acetone in the urine right after labor and lactosuria during the first week is normal.
o The bladder and urethra are traumatized by the pressure exerted by the fetal head as it passes through
the birth canal. Trauma to bladder results in loss of bladder tone, edema and hyperemia. As a result,
the woman experiences ↓ bladder tone that results in ↑ bladder capacity. Decreased bladder tone
causes decreased sensation to the filling and distention of the bladder, the woman may not experience
the urge to void even if her bladder is already distended with urine w/c predisposes to infection.
When catheterization of postpartum patient with urinary retention:
Use straight catheter if one hour catheterization is ordered; use foley for 24 hours catheterization
Maitain aseptic technique.
Provide gentle touch as the area is sore.
When amount of urine reaches 900-1000 cc, clamp catheter to prevent rapid decompression in
the abdomen w/c can cause hypotension
Check vital signs after catheterization.
Unclamp after 1 hour to drain urine.
HORMONAL SYSTEM
HCG & HPL almost negligible by 24 hours
Progestin, Estrone & Estradiol are at pre-pregnant level by 7th day
FSH remains low for about 12 days, then begins to rise to initiate a new menstrual cycle
Pregnancy hormones begin to decrease as soon as the placenta is no longer present.
REPRODUCTIVE SYSTEM
Uterus
INVOLUTION – a process whereby the reproductive organs return to their non-pregnant state.
2 main processes of involution of the uterus:
The area where the placenta was implanted is sealed off, preventing bleeding
Organ is reduced to its approximate pregestational size
Promotion of Uterine Involution : (well-nourished, ambulates early after birth,breastfeeding)
24 hours after birth the uterus is at the level of umbilicus.
CERVIX
Immediately after birth, the cervix is soft and malleable
Both the internal and external os are open
By the end of 7 days the external os is narrowed to the size of a pencil opening and the cervix feels firm
and nongravid again
Does not return exactly to its prepregnant state
External will usually remain slightly open
Cervical os appears slitlike or stellate (star shaped)
VAGINA
After a vaginal birth, the vagina is soft with few rugae
Hymen is permanently torn and heals with small separate tags of tissue
Gradually turns to its approximate prepregnant state
Outlet will remain slightly more distended than before.
AMBULATION
Advantages of early ambulation
Prevent constipation
Prevent thrombophlebitis
Prevent urinary problems
Promote rapid recovery and return of woman’s strength
Hastens drainage of lochia
Improves GIT & GUT function
Provides a sense of well-being
REST & SLEEP
The woman should rest & sleep as much as needed during the early postpartum period to overcome
fatigue, excitement, anxiety & discomfort associated with long & exhausting labor & delivery. Sleep and
rest promote healing by reducing BMR and allowing O2 & nutrients to be utilized for tissue growth,
healing & regeneration.
Instruct the mother to avoid heavy lifting and strenous activity after discharge
The woman may resume light housekeeping on the second week and can go back to normal activities by
4 to 6 weeks.
Resumption of Sex
Sexual intercourse can be resumed 3 to 4 weeks after vaginal delivery if bleeding has stopped,
perineum is healed and if does not cause pain to the woman.
DISCHARGE
The newly delivered mother is ready to go out of the health care facility 24-48 hours after NSD
Primiparas may leave after 2-3 days and multiparas after 1-2 days if they are recovering normally.
After a CS, a woman maybe discharged on the 3rd or 4th day.
Before leaving, she should be insructed re: schedule of follow-up clinic visit and to report immediately
to the doctor if the ff. signs & symptoms appear:
Heavy vaginal bleeding or bright red vaginal discharge
Fever
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BENEFITS OF BREASTFEEDING
POSTPARTAL HEMORRHAGE
Assess Any blood loss from the uterus greater than 500 ml within 24 hour period.
EARLY POSTPARTUM HEMORRHAGE
>500mL in first 24 hrs (blood loss often underestimated)
• LATE POSTPARTUM HEMORRHAGE
>500mL after first 24 hrs
Acreta – attached placenta to myometrium.
Increta – deeper attachment of placenta to myometrium hysterectomy
Percreta – invasion of placenta to perimetrium
SYMPTOMS OF POSTPARTUM HEMORRHAGE
uncontrolled bleeding (>2pads/30min)
decreased blood pressure
increased heart rate
decrease in the red blood cell count (hematocrit)
swelling and pain in tissues in the vaginal and perineal area
Light headedness, nausea and visual disturbances
Anxiety, pale and clammy skin
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TYPES OF LACERATIONS
CERVICAL LACERATION
- Arterial Bleeding (Bright red)
-Usually on the sides of the cervix, near the branches of the uterine artery.
VAGINAL LACERATION
Easier to assess but harder to repair
Vaginal tissue is friable so lacerations are harder to repair.
PERINEAL LACERATION
Occurs when woman is placed on lithotomy position during delivery (increase tension on the perineum).
CLASSIFICATIONS OF PERINEAL LACERATIONS
Classification Description of Involvement
First Degree Vaginal mucus membrane & skin of the perineum to the fourchette
Second Degree Vagina,perineal skin,fascia,levator ani muscles,& perineal body
Third Degree Entire perineum,& reaches the external sphincter of the rectum
Fourth Degree Entire perineum, rectal sphincter,and some of the mucus membrane of the rectum
NURSING MANAGEMENT
Repair as episiorrhapy.
document degree of laceration.
Provide increase fluid and stool softener for 1 week.
For 3rd and 4th degree: no enema, suppository or rectal temperature.
DISSEMINATED INTRAVASCULAR COAGULATION
A deficiency in clotting ability caused by vascular injury an emergency.
Hypofibrinogenemia
May occur in any postpartal woman
CAUSES: Premature separation of the placenta (abruptio placenta); Missed abortion ; Fetal death in
utero.
NURSING MANAGEMENT
Start IV Heparin as ordered.
Prepare blood replacement blood typing.
SUBINVOLUTION
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Distension
Nausea and vomiting
NURSING MANAGEMENT
Insertion of NGT (Nasogastric tube) -to prevent vomiting & rest bowel
IVF or Total Parenteral Nutrition
Analgesics and antibiotics as ordered.
THROMBOPLEBITIS
Inflammation with formation of blood clots, usually extension of endometritis
Classified as superficial vein disease (SVD) or deep vein thrombosis (DVT)
ETIOLOGIES: Increased in blood clotting factors; postpartal thrombocytosis (Increased Platelets)
Thromboplastin release (placenta, amnion)
Increased fibrinolysin and fibrinogen inhibitors.
SUPERFICIAL VEIN DISEASE (SVD)
- SYMPTOMS: tenderness, heat, redness, low grade fever, (+) Homan’s Sign and tachycardia
PELVIC THROMBOPLEBITIS
Involves the ovarian, uterine, or hypogastric veins.
It occurs later than femoral thrombophlebitis , often around 14th or 15th day of the puerperium.
NURSING MANAGEMENT
Total bed rest
Administer antibiotics and anticoagulants
Teach woman preventive measures:
- avoid constrictive clothing
- rest with feet elevated
- ambulate daily during pregnancy
PULMONARY EMBOLUS
Obstruction of Pulmonary Artery with blood clot.
SIGNS AND SYMPTOMS: Sudden, sharp chest pain, Tachypnea, Tachycardia, Orthopnea and Cyanosis
( blood clot is obstructing the pulmonary artery obstructing blood flow to the lungs and return to the
heart
Urinary retention
Implies inadequate bladder emptying
It occurs following childbirth because of decrease bladder sensation for voiding due to edema of the
bladder from the pressure of birth.
Unable to empty, the bladder fills to overdistention
A urine culture (clean catch) or catheterized urine specimen may be performed to determine the type of
bacteria in the urine and the appropriate antibiotic for treatment.
Treatment
Because of the risk of the infection spreading to the kidneys (complicated UTI) and due to the high
complication rate in the elderly population and in diabetics, prompt treatment is almost always
recommended.
Anti biotic
Prevention
Keeping the genital area clean and remembering to wipe from front to back may reduce the chance of
introducing bacteria from the rectal area to the urethra.
Increase fluid intake.
SALPHINGITIS
In contrast, salpingitis only refers to infection and inflammation in the fallopian tubes.
Causes and pathophysiology
The infection usually has its origin in the vagina, and ascends to the fallopian tube from there.
Because the infection can spread via the lymph vessels, infection in one fallopian tube usually leads to
infection of the other.
Treatment
Salpingitis is most commonly treated with antibiotics
Diagnosis
By Pelvic examination, blood tests and mucus swab a doctor can diagnose salpingitis.
Oophoritis is an inflammation of the ovaries.
It is often seen in combination with salpingitis (inflammation of the fallopian tubes).
PYELONEPHRITIS
Kidney infection, usually of the R. kidney
Ascends from bladder
SYMPTOMS: elevated temperature, chills, flank pain, CVA pain, Nausea and vomiting, history of asymptomatic bacteruria
or pyelonephritis
Urgency, frequency, dysuria
Back pain
PREVENTION AND TREATMENT
Increased Fluid Intake
Ensure complete emptying of the bladder
Sterile technique for catheterization
Good perineal care
PP Blues PP Depression PP Psychosis
onset 1-10 days after birth 1-12 months after birth Within first month after birth