:The postpartal period, or puerperium: 6-8 week period after childbirth.

Its time of maternal change

retrogressive (involution uterus,vagina)-
progressive (production milk for lactation, restoration menstrual cycle, begin parent role)-
.The period is popularly termed the fourth trimester of pregnancy
Phases of the Puerperium
.Taking-In Phase, the first phase experienced, is time of reflection. During this 2-3day, woman is largely passive.1
She prefer having nurse minister (bringing bath towel, clean nightgown) make decision, rather than do these herself
.Taking-Hold Phase, after time of passive dependence, woman begins to initiate action.2
She prefers to get her own washcloth and to make her own decisions. Women who give birth without anesthesia:
reach second phase in matter of hours after birth. Now, she begin to take strong interest
.Letting-Go Phase, in the third phase, woman finally redefines her new role.3
She giveup fantasized image and accept the real one, she give up her old role of being childless or mother of only one
DEVELOPMENT OF PARENTAL LOVE AND POSITIVE FAMILY RELATIONSHIPS
.Because of mixed feelings, parents may not show real warmth the first time they hold their infant
.The first time she holds infant, she may touch only blanket and never make close physical contact
.If she unfolds the blanket to examine the baby or count the fingers or toes, she may use only her fingertips for touch
.gradually, as woman hold her child more, begin to express more warmth, touch child with palm rather than fingertip
soon, she feel comfortable to press her cheek against baby, kiss nose or mouth, she become mother tending to her
child
.This identification process is termed: claiming or bonding
en face position: look direct at her newborn face, with direct eye contact, sign woman beginning effective interaction
MATERNAL CONCERNS AND FEELINGS IN THE POSTPARTAL PERIOD
Abandonment mother admit to feel neglected and less important after birth than they did during pregnancy or .1
.labor Only hours before, they were center of attention, with everyone asking about their health and well-being
.Now, suddenly, the baby seems to be everyone’s chief interest
Disappointment all during pregnancy pictured chubby-cheeked, curly-haired, smiling girl or boy. instead, skinny, .2
.without hair, cry constantly. Its difficult for parent to feel positive immediately about child who not meet expectation
.Postpartal Blues as many as 50% of women experience some feeling of great sadness .3
.They may burst into tears easily, feel let down, irritable. This feeling after birth is known as: baby blues
Cause by: hormonal change, particularly decrease in estrogen and progesterone that occur with delivery of placenta
The syndrome is evidenced by tearfulness, feelings of inadequacy, mood lability change, anorexia, sleep disturbance
You can assure woman sudden crying episodes may occur; otherwise, she may have dibculty understand what is
.happening to her. Her support person also needs assurance
.Thirty percent 30% of women experience more serious level of sadness after birth or postpartal depression
.Serious depression requiring: formal counseling or psychiatric care also can occur in women during this time
Physiologic change occur during postpartal period includ those related specifically to reproductive system as well
other systemic: hunger, thirst - breast filling - colostrum secretion - uterine involution - afterpains - diuresis - locia
transient loss of bladder tone - constipation – closure of cervical os - decrease Hpl, estrogen, progesteron, hCG
prolactin increases to initiate breastmilk - labile mood
REPRODUCTIVE SYSTEM CHANGES
Involution: reproductive organ return to their nonpregnant state. woman in danger of hemorrhage from denuded -
:surface of uterus until involution is complete. Involution of uterus involve two main processes
First, area where placenta was implanted sealed of to prevent bleed
Second, organ reduced to approximate pregestational size
.Immediately after birth, uterus weighs 1000g. At the end of the first week, weighs 500g
.By the time involution is complete (6 weeks), it weighs approximately 50g, similar to its prepregnancy weight
.After 10 day it recedes under pubic bone and no longer palpable
.Uters the first hour after birth is potentially the most dangerous time for woman-
If her uterus should become relaxed during this time (uterine atony), she will lose blood very rapidly, because no
.permanent thrombi have yet formed at the placental site
.Afterpains: contraction of uterus after birth cause intermitient cramp, similar to that associat with menstrual period
Lochia: the layer adjacent to uterine cavity become necrotic and cast of as uterine discharg similar to menstrual flow -
.This uterine flow, consisting of blood, fragments of decidua, white blood cell, mucus, some bacteria, known as lochia

.Cervix Immediately after birth, uterine cervix soft. Both internal and external os open-
 .Like contraction of uterus, contraction of cervix toward its prepregnant state begin at once
.By end of 7day, external os narrowed to size of pencil open, cervix feel firm, nongravid again
.After vaginal birth, the vagina is soft, with few rugae, its diameter is considerably greater than normal-
.Perineum because of great amount of pressure experienced during birth, perineum feels edematous and tender-
.Ecchymosis from ruptured capillaries may show on the surface
.Urinary system during pregnancy, as much as 2000-3000mL excess fluid accumulates in body-
Extensive diuresis begin immediately after birth to rid body of fluid. increase daily output of postpartal woman from
.normal level of 1500mL to 3000mL during 2-5day after birth
.This marked increase in urine production causes bladder to fill rapidly
.As bladder fills it displaces uterus, uterine position is a good gauge of whether a bladder is full or empty
.If uterus become uncontracted or feel soft on palpation and pushed to the side, the usual cause overfilled bladder
During the entire postpartal period, urine contain more nitrogen than normal. increase muscle activity during labor
.and breakdown of protein in portion of uterine muscle during involution
Circulatory system diuresis that is evident between 2-5days after birth, as well as blood loss at birth, acts to reduce -
.the added blood volume a woman accumulated during pregnancy
.This reduction occur rapidly, blood volume return to normal prepregnancy level by first or second week after birth
Gastrointestinal system digestion and absorption begin to be active again soon after birth unless a woman has had -
cesarean birth. immediately, woman feel hungry and thirsty and can eat without diffculty from nausea or vomiting
.Hemorrhoids (distended rectal veins) - Bowel evacuation dibcult because pain of episiotomy suture or hemorrhoids
Integumentary system after birth, stretch marks on woman’s abdomen (striae gravidarum) still appear reddened -
.and may be more prominent than during pregnancy, when they were tightly stretched
.Typically, these will fade to pale white over next 3-6 month, or remain as areas of slightly darker pigment

.The overall effects of postpartal retrogressive changes are exhaustion and weight loss
.Two physiologic changes that occur during the puerperium: progressive changes - building of new tissue
Progressive changes
Lactation formation of breast milk (lactation) begins in postpartal woman whether or not she plans to breastfeed. -
.Primary engorgement: feeling of tension in breasts on third or fourth day after birth
.Return of menstrual flow with the delivery of placenta, the production of placental estrogen and progesterone end-

.Abdominal breathing may be started on first day after birth, because it is a relatively easy exercise
.Lying flat on back or sitting, breathe slowly and deeply in and out 5 times, using abdominal muscles
Check by watching her abdominal wall rise that she is actually using these muscles
Chin-to-chest is excellent for second day. Lying on her back with no pillow, raises her head and bends her chin
forward on her chest without moving any other part of her body while exhaling. She should start this gradually,
.repeating it no more than 5 times the first time and then increasing to 10-15 times in succession
.The exercise can be done 3-4time day. She will feel her abdominal muscles pull and tighten if she is doing it correctly
Perineal contraction If a woman is not already using this exercise as a means of alleviating perineal discomfort, it is a
good one to add on the third day. She should tighten and relax her perineal muscles 10-25 times in succession as if
.she were trying to stop voiding (Kegel exercises). She will feel her perineal muscles working if she is doing it correctly
.Arm raising helps both breasts and abdomen return to good tone and is good exercise to add on fourth day
Lying on back, arms at sides, a woman moves her arms out from her sides until they are perpendicular to her body.
then raises them over her body until her hands touch and lowers them slowly to her side. She should rest a moment,
.then repeat the exercise 5 times
Abdominal crunches Its advisable to wait until 10th or 12th day after birth before attempting abdominal crunches.
.Lying flat on back with knees bent, woman folds her arms across her chest and raises herself to a sitting position
.This exercise expend great deal of effort and tires a postpartal woman easily
Caution her to begin very gradually and work up slowly to doing it 10 times in a row
.Postpartum period starts immediately after delivery and completed by week 6 following delivery
.PUER: for child - PARERE: for to bring forth. is popularly termed the fourth trimester of pregnancy
Period when the reproductive tract returns to the normal, nonpregnant state
:Maternal changes that are both
retrogressive (involution uterus,vagina) - progressive (production milk lactation, restoration menstrual, parent role)
Method of assessment during puerperium: health interview - physical examination - analysis of laboratory data
:Method of assessment during puerperium
.Uterine involution: occurring by evaluating uterine size, consistency, lochia flow amount-
Assess woman’s psychological adjustment begins with her reaction at birth-
?was she disappointed or happy with appearance of her baby
?Is she glad to be through with pregnancy or still longing to be back in it
?Assess the extent and quality of woman’s interaction with child: Does she hold the infant and talk to him or her-
?Her overall mood: Do you observe her crying? Does she have long periods of staring into space or not talking-
.Her ability to begin infant care-
.Observe also for self-care-
woman who feel good about herself, even though exhausted from childbirth, usually will try to maintain appearance.
.If she depressed, she probably has little energy to do things such as comb her hair or worry about her appearance
:NURSING DIAGNOSIS
Health Seeking Behavior related to care of newborn 4.Risk for deficient fluid volume r/t postpartal hemorrhage .1
Risk for impaired parenting r/t disappointment in sex of child 3.Fear r/t lack of preparation for child care.2
IMPLEMENTATION, Considerations: Family centered to enhance family functioning and bonding
Increase woman selfestem and allow herself to view herself new mother - Explore what they know about child care -
EXPECTED OUTCOME: Client states that she is tired but feels able to manage her newborn and family care
.Client states that she believes she will be able to manage newborn care with the support of the significant others -
Client’s lochia flow is no more than one saturated perineal pad (50ml) every 3hours-
Postpartum blues: anger - anxiety - cry easily for no apparent reason - emotionally labile - expresses let down feeling
Fatigue - Headache - Insomnia - Restlessness – Sadness
Postpartum depression: guilt - anxiety - cry,sadness - difficult concentrat or make decision - loss pleasure in activity
suicidal thought - fatigue,unable to sleep – Irritation,agitation - less responsiv to infant - lack energy - appetite chang
Postpartum psychosis: Break with reality – Confusion – Delirium – Delusions – Hallucinations – panic
when assessing a maternity patient, you complete a regular head-to-toe assessment (cardiac, resp, GI,) but then
make it maternity-focused. That means you add the elements covered under BUBBLE-HE
BUBBLE HE: Breasts/nipples - Uterus - Bladder - Bowels - Lochia - Episiotomy - Homan's Sign - Emotional/bonding
Breasts and Nipples-
Bottle-feeding or nursing? bottle have patient wear supportiv bra 24/7 to prevent milk from coming in engorgement
Assess breasts: Soft, engorged, filling, tender/non-tender, any tissue breakdown, blood blisters
Uterus: tone: firm or boggy (squishy/spongy)-
?Location: Is the fundus midline or does it deviate to the right or left (due to a full bladder)
Where is fundus in relation to umbilicus? ff @u (fundus firm @ umbilicus) - ff u/2 (2cm below) - ff 1/u (1cm above)
- Bladder: Able to void spontaneously within 6-8 hours of vaginal birth? Epidurals commonly cause urinary retention
Assess for frequency, burning or urgency (UTI?)
Bladder distention: full bladder displace uterus, prevent involution (contraction of uterus), great risk for hemorrhage
May require catheterization
Bowel: active bowel sound in all four quadrant - movement - flatus in C-section patient - assess C-section incision site-
REEDA: Redness - Edema or swelling - Ecchymosis or bruising - Drainage - Approximation of wound edges
Lochia: color (rubra,serosa,alba) Rubra dark red,sanginous - Serosa pink,sero-sanginous - Alba creamy,yellowish-
Amount (scant, light, moderate, heavy) - Odor: infection - C-section patient have less lochia: normal
C-section fundal assessments are gentle. Otherwise very painful for the patient
Episiotomy: assess entire perineum from open of vagina to rectum - Perineum intact, lacerated, require episiotomy -
REEDA: redness - Edema or swelling - Ecchymosis or bruising Drainage - approximation of laceration/episiotomy
,Homan's Sign: Dorsiflex foot - Assess for sharp, knife-like pain in calf - If present, assess pedal pulses, diameter-
.edema, warmth, redness and inflammation - Advise patient not to get out of bed; report to attending physician
Anticipate orders (ultrasound/MRI/CT/venography)
Emotional: determin emotion status: normal baby blue - Bonding: Interact appropriat with baby - Provid infant care -
Evidence of postpartum blues or depression? Report to MD and anticipate a referral to social work/psych