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Postphartum

Nathania . Chindy . Meyda

Postpartal Period
The postpartal period refers to the 6 week period after childbirth. This is time of maternal changes that retrogressive (the involution of the uterus and vagina)and progressive (the production of milk for lactation the restoration of the normal menstrual cycle and the beginning of the parenting role). This period is popularly termed the fourth trimester of pregnancy.

PSYCHOLOGICAL CHANGES OF THE POSTPARTAL PERIOD

The postpartum period is a time of transition during which the couple gives up concepts such as childless or parents of one and moves to the new beginning of parenthood.

Maternal Concerns and feelings in the postpartal period


Traditionally most of a womans concerns in the postpartal period have been assumed to be with care of the infant. A woman has come through a tremendous psychological experience during pregnancy and birth of a child. She has made a complete role change. Major issues identified by postpatrtum woman breast soreness regaining their figure regulating the demands of housework their paretner and their children coping with emotional tension and sibling jealously and fatigue.

Abandonment

If given opportunity admit to feeling abandoned and less important after birth.only hours before they were the center of attention. When a newborn comes home the father may have much the same feeling. He may become resentful of the time his wife spends with the infant.

Disappointment
Another common feeling parents may experience is disappointment in the baby. Its difficult for parents to feel positive immediately over a child who does not meet their expectation. Handle the child warmly to show that you find the infant satisfactory or even special. Comment on the child good points such as long fingers lovely eyes and good appetite . during periods of crisis like childbearing .

Postpartal Blues
During puerpenium as may as 80% of woman experience some feelings of overwhelming sadness that they cannot account for. They burst into tears easly or may feel let down or be irritable. This temporary feeling after birth has long been known as a baby blues .

This phenomenom may be due to hormonal changes particularly the decreases in estrogens and progesterone that occur with the delivery of the placenta. For some it may be a response of dependence and low self-esteem caused by exhaustion being away from home physical discomfort and the tension engendered by assuming new role

The syndrome is evidenced by tearsfullness feeling of inadequancy mood lability anorexia and sleep disturbance. Anticipatory guidance and individualized support from the nurse are important to help the parents understand what is happening and that the response is normal.

Its also important to giva a woman a chance to verbalize her feelings.

Phases of Puerperium
Taking in phase
The taking in phase is a time of reflection for a woman. During this period she is largely passive. Having a nurse minister to get her a bath towel or a clean nightgown and make decision for her rather than doing these things herself.
This dependence is due partly to her physical discomfort from possible perineal stitches afterpains or hemorrhoids partly to her uncertainty in caring for a newborn and partly from the extreme exhaustion that follows childbirth.

Taking hold phase


After the time of passive dependence a woman begins to initiate action. Women who give birth without any anesthesia may reach this second phase in a matter of hours after birth. Woman many have expressed little interest in caring for her child. Now she begins to take a strong interest.

Brief demonstration of baby care and then allow her to care for the child herself with watchful guidance.
Often still feels insecure about her ability to care for her new child. Do not rush a woman through the phase of taking in or prevent her from taking hold when she reaches that point. Learning to make decision about their childs welfare is one of the most difficult phases of motherhood.

Letting go phase
In the third phase called letting go the woman finally redefines her new role. She gives up the fantasized image of her child and accept the real one she gives up her old role of being childless or the mother of only one or two(or however many children she had before this birth). Requires some grief work and read justment of relationship similar to what occurred during pregnancy.

PHYSIOLOGIC CHANGES OF THE POSTPORTAL PERIOD


Reproductive system change

Involution is a process whereby the reproductive or gans return to their nan pregnant state. The woman is in danger of hemorrhage from the uterus until involution is complete.

The Uterus
Involution of the uterus invoves two main processes.
First the area where the placenta was implanted is sealed off and bleeding is thus prevented. Second the organ is reduce to its approximate pregestational size.

Immediately after birth the uterus weighs about 1000g . at the end of the first week it weighs 500g. By the time involution is complete (6 weeks) it will weigh approximately 50 g its prepregnant weight.
Uterine contraction begins immediately after placenta delivery. The fundus of the uterus may be palpated though the abdominal wall halfway between the umbilicus and the symphysis pubis within a few minutes after birth.

One hour later it has risen to the level of the umbilicus where it remains for approximately the next 24 hours.
From then on it will decrease one fingerbreadth (1 cm )a day in size. On the first postportal day the fundus of the uterus will be palpable one fingerbreadth below the umbilicus on the second two fingerbreadth below the umbilicus and so on. Because a fingerbreadth is about 1 cm this can be recorded as 1cm below the umbilicus 2cm below it and so forth.

The Lochia
By the second day after birth the layer of decidua remining under the placental site (an area 7cm wide) and through out the uterus differentiates into two distinct layers. The inner layer attached to the muscular wall of the uterus will remain and serve as the foundation from which a new layer of endometrium will be formed. The layer adjacent to the uterine cavity eill become necrotic and will be cast off as a uterine discharge similar to a menstrual flow.

This uterin flow consisting of blood fragments of deciduas white blood cells mucus and some bactria is known as LOCHIA.

For the first 3 days after birth a lochia discharge consist almost entirely of blood with only small particles of deciduas and mucus. Because of its re color it is termed lochia rubra.

As the amount of blood invoved in the cast off tissue decreases (about the 4th day) and leukocytes begin to invade the area as they do any healing surface the flow becomes pink or brownish in color(lochia serosa). On about the 10th day the amount of the flow decreases znd becomes colorless or white(lochia alba).

The Cervix
Immediately after birth the cervix is soft and malleable. Both the ineternal and external os are well open. Like contraction of the fundus of the uterus,contraction of the cervix begins at once. By the end of 7days the external os is narrowed to the size of a pencil opening and the cervix feels firm and nongravid again. The cervix does not return exactly to its prepregnant state. The internal os will close as before but assuming that the birth was vaginal os will usually remain slightly open and appear slitlike or stellate(star shaped)when previously.

The vagina
After the vaginal birth the vagina is soft with few rugae. Its diameter is considerably grether than normal. The hymen is permanently torn and heals with small separate tags of tissue. It takes the entire postpartal period for the vagina to involute (as in uterus by contraction)until it gradually return to its approximate prepregnant state.

Woman who is breastfeeding and in whom ovulatin is delayed may contine to have thin walled or fragile vaginal cells that cause vaginal slight bleeding during sexual intercourse until about 6 weeks time. Vaginal outlet will remain slightly more distended than before if the woman practices kegels exercise the strength and tone of the vagina will increase more rapidly

The Perineum
development of edema and generalized tenderness. Portions of the perineum may show ecchymosis from the rupture of surface capillaries. The labia manjora and labia minora typically remain atrophic and softened in a woman and never return to their prepregnant state.

Systemic Changes
The hormonal system Pregnancy hormones begin to decrease as soon as the placenta is no longer present. Levels of human chorionic gonadotropin and human placental lactogen(hPL) are almost negligible by 24 hours. By week 1 progestin estrone and estradiol are at prepregnancy levels. Estrol may be elevated for an addition al week before it reaches prepregnancy levels. Follicle stimulating hormone(FSH) remains low for about 12 days then begins to rise to initiate a new menstrual cycle

The Urinary System


During a agnal birth the fetal head exert a great deal of pressure on the bladder and urethra as it passed on the bladders underside. This pressure may leave the bladder with a transient loss of tone and edema surrounding the urethra makes voiding difficult.

Bladder fills rapidly and becomes distended the woman may leave no sensation of having to void.

The woman who has had an epidural a spinal or general anesthetic for birth can feel no sensation in the bladder area until the anesthetic has worn off. Assess the woman abdomen frequently in immediate postpartal period to see whether bladder distention developing . A full bladder is felt as a hard or firm area on palpation just above the symphysis pubis. Hydronephrosis or inceased size of ureters that occurred during pregnancy remains present for about 4 weeks postpartum. The inceased size of these structures inceases the possibility of urinary stasis and urinary tract infection in the postpartal period.

The Circulatory System


The dieresis evident between the 2nd and the 5th days postpartum plus the blood loss at birth act to reduce the added blood volume the woman accumulated during pregnancy. This reduction occurs so rapidly that by the 1st or 2nd week postpartum the blood volume has returned to its normal prepregnancy level. Usual blood loss is 300 ml to 500ml with a vaginal birth and 500ml to 1000ml with a cesarean birth. Woman generally continue to have the same high level of plasma fibrinogen during the first postpartal weeks as they did during pregnancy. Also increases the risk of thrombophlebitis an increase in the number of leukocytes of blood. The white blood cells count may be as high as 30.000 total (mainly granulocytes) particularly if the woman had a long or difficult labor.

The Gastrointestinal System


Digestion and absorbtion begin to be active again in the gastrointestinal system so after birth. Immediately hungry from the glucose used during labor and thirsty from the long period of restricted fluid plus the beginning diaphoresis. Hemorroids (distended rectal veins)that have been pushed out of the rectum due to the effort of pelvic stage pushing often are present. Bowel sounds are active but passage of stool through the bowel may be slow because of the still present effect of relaxin on the bowel, bowel evacuation may be difficult due to pain of episiotomy sutures or hemorrhoids.

The Integumentary System


After birth the stretch marks on the abdomen (striae gravidarum)still appear reddened and may be even more prominent than during pregnancy when they were tightly stretched. Caucasian woman these will fade to a pale white over the next 3 to 6 months in an African-american woman they will be revealed as only slightly darker pigment. Excessive pigment on the face and neck (chloasma) and on the abdomen (linea nigra)will be barely detectable in 6 weeks time. If diastasis recti (overstreching and separation of the abdominal musculature) is present the area will appear slightly indented.

Effects of retrogressive changes


Exhaustion As soon as birth is completed the woman experiences total exhaustion. Near the end of pregnancy she was unable to find a comfortable position in bed because of the fetus activity or the presence of back or leg pain.

Now she has sleep hunger which makes it difficult for her to cope with new experiences and stressful situations.

Weight loss The rapid dieresis and diaphoresis during the 2nd to 5th day postpartum will ordinarily result in a weight loss of an additional 5lb (2kg to 4kg) over the approximately 12lb (5,8kg) that the woman lost a birth. Lochia flow will cause an additional 2 to 3 lb (1kg)loss of about 19lb.

it is also influenced by factors such as nutrition exercise and breastfeeding. The weight a woman reaches at 6 weeks post birth will be her baseline postpartal weight.

Vital sign
Temperature .Slight increase in temperature during the first 24hours of the pueperium because of the period of dehydration she underwent during labor. Any woman whose oral temperature rissees above 38C (100.4f)

Excluding the first 24hours period is considered by criteria of the Joint Comission on Maternal Welfare to be febrile and a postpartal infection should be suspected.
On the 3rd or 4th day postpartum when the breasts fill with milk the woman temperature rises for a period of hours because of of the increases vascular activity involved. However infection is more likely reason for the fever.

Infection is a major cause of postpartal mortality and morbidity.

Pulse The pulse rate during the postpartal period is generally slightly slower than normal.
After delivery stroke volume increases to accommodate the increased blood volume returning to the heart. The increased stroke volume reduce the pulse rate to between 60 and 70 bpm. By the end of the 1st week the pulse rate has return to normal.

Blood pressure
A reading above 140 mmhg systolic or 90mmhg diastolic may indicate the development of postpartal pregnancy induced hypertension an unusual but serious complicsation of the pueperium. A major complication of acute blood loss is orthostatic hypotension or dizziness that occurs on standing because the vascular system does not have enough volume to maintain nourishment of brain cells. Caution her not attempt to walk carrying her newborn until her cardiovascular status adjusts better to her blood loss.

Progressive changes
Lactation The formation of breast milk(lacktation) is initiated in a woman whether or not she plans to breastfeed. For the 2 days postpartum the average woman noticed little change in her breasts from the way they were during pregnancy. Since midway through pregnancy she has been secreting colostrums a thin watery prelactation secretion. She continues to excrete this fluid the first 2 days postpartum. On 3rd day her breasts tend to become full and feel tense or tender as milk forms within breast ducts. Breast milk forms in response to the fall in estrogen and progesterone levels that follows delivery of the placenta.

Nipple secretion changes to bluish white the typical color of breast milk. The breasts become fuller larger and firmer. The distention is not limited to the milk ducts but occurs in the surrounding tissue as well because blood and lymph enter the area to contribute fluid to the formation of milk. This feeling of tension in the breasts on the 3rd or 4th day postpartum is termed primary engorgement. It fades as the infant begins effective sucking and empties the breasts of milk.

Return of menstrual flow


With the delivery of the placenta the production of placental estrogen and progesterone is no longer available to the womanthis decrease in hormones causes a rise in the production of FSH by the pituitary and therefore with only a slight delay the return ofovulation. This is initiateprepregnancy menstrual cycles. If the woman is not breast feeding menstrual flow to return within 6 or 10 weeks after birth. If she is breastfeeding menstrual flow may not return for 3 to 4 months or in some woman for the entire lactation period.

Physical assessment
Crucial assessment examinining particular aspects of the health such as : an estimation of nutrition fluid state energy level presence absence of painbreast health fundal height consistency lochia amount character perineal integrity circulatory adequancy are required.

General appearance. energy level self-esteem and whether she is moving into the taking-hold phase of recovery. cringing expression hand pressure against her abdomen that suggests pain on movement. Hair. Palpate her hair to determine its firmness and strength. When a diet is deficient in nutrients hair become listless and stringy. A woman who had good nutritional intake during pregnancy has firm crisp hair.

Face. Assess the woman face for devidence of edema. This is most apparent early in the morning because the woman has been lying supine with her head level during the night. Edema is manifested as puffy eyelids or a promonent fold of tissue inferior to the lower eyelid. Normally, this is negligible. Eyes. Inspect the color of the conjunctiva. Normally this should appear pink and moist. The conjunctiva of the woman who is anemic from poor pregnancy nutririon or excessive blood loss at birth will have a be alert to possible variation because of skin color. The conjunctiva always appears lightly the shaded in fair-skinned women.

Breasts.
Using a bra in the postpartal period offers support the breast tissue that has increased fluid accumulation in preparation for breastfeeding. Breast tissue increases in size as breast milk forms , so a bra that was adequate by the 2nd or 3rd postpartal day. Ask the woman to remove the bra and cover the breasts with a towel or folded sheet to protect modesty. Ask the woman to raise her hand over her head and tuck it under her head as this stretches and thins breast tissue. Inspect and than palpate for shape and color. Breast tissue feels soft on palpation the 1st and 2nd day. On the 3rd it feels firm and warm(describe filling). On the 3rd or 4th day breasts appear large and reddened,with taut shiny skin (engorgement). On palpation they feel hard tense and painful.

Uterus. Observe the woman abdomen for contour to detect distension and the appearance of striae or a diastasis measures the width and length by fingerbreadths. Palpate the fundus of the uterus by placing a hand on the base of the uterus just above the symphysis pubis and the other at the umbilicus . press in and downward with the hand on the umbilicus until you bump against a firm globular mass in the abdomen: the uterine fundus. By the 9th or 10th day postpartum the uterus will have become so small that it is so longer palpable above the symphisis pubis. Lochia. A woman can expect to have lochia for 2 to 6 weeks. Characteristics of normal lochia and the change in pattern from red to pink to white. During the 1st hours postpartum when the fundus is checked every 15 minutes the mothers perineal pad should be removed and the character amount color(rubra,serosa, or alba) odor and presence of any clots should be evaluated. Be certain the pad is not adhering to perineal stitches before removing. Perineum. At the time that lochia is evaluated the perineum also should be inspected. An episiotomy is usually 1 or 2 in long but if a laceration was involved stitches may extend from the vagina back to the rectum. Rarely they extend forward toward the urethra. An episiotomy incision is generally fused(edges sealed) by 24 hours after birth if it is a midline incision it may be almost invisible because the perineal fold obscures it.

Perineum.

At the time that lochia is evaluated the perineum also should be inspected. An episiotomy is usually 1 or 2 in long but if a laceration was involved stitches may extend from the vagina back to the rectum. Rarely they extend forward toward the urethra. An episiotomy incision is generally fused(edges sealed) by 24 hours after birth if it is a midline incision it may be almost invisible because the perineal fold obscures it.

Laboratory data

Women routinely have a hemoglobin and hematocrit level done 12 to 24 hours after birth to determine whether blood loss at birth has left them anemic.
If the hemoglobin is below 10g/100ml supplementary iron is usually prescribed.

Nursing Diagnosis And Related Interventions


Nursing diagnosis and related intervention Nursing diagnosis : risk for pain related to uterine cramping (afterpains) or perineal sutures Outcome identification : client will not experience pain above a tolerable level during postpartal period Outcome evaluation : client states that degree of pain is tolerable demonstrates knowledge of measures for adequate pain relief

Provide pain relief for afterpains. Woman can be assured that this is discomfot is normal and rarely last more than 3days. Either ibuprofen (motrin and others) an analgesic effective for relief for afterpains because of its anti-inflamatory properties or a common analgesic such as acetaminophen ( tylenol) can be taken for relief .

Relief muscular aches. Many woman feel sore and aching after labor and birth because of the excessive energy they used for pushing during the pelvic division of labor. A backrub is effective for relieving aching shoulders or back. Pain is calf of the leg on standing(a position dorsiflexes the foot) is a sign similar to a humans sign suggesting thrombophloebitis.

Give episiotonmy care.

Although the frequency of performing an eoisiotomy iss decreasing some woman may still require one. Although relatively small in size an episiostomy can caused considerable discomfort because the perineum is an extremely tender area. Most woman expect labor to ben painful. However they usually do not anticipate the pulliing pain from perineal stitches in the poatpartal period. This diacomfort interferes with their rest and sleep with eating and with being able to sit anf hold the baby comfortably. Does not usually last nmore than 5 to 6 days. Many physicians and nurse midwives order a soothing cream or anesthetic spray to be applied to a sutue line to reduce discomfort.

Promote perineal exercise.

Some woman find that carriying out perineal exercise 3 or 4 times a day greatly relieves episiotomy discomfort. The exercise consist of contracting and relaxing the muscles of the perineum five to ten times in succession as if you trying to stop voiding (kegels exercise). This impoves circulation to the area and so helps decreased edema. Kegels exercises help the woman regain her prepregnant muscle tone and form.

Administer cold and hot therapy. Applying an ice an icebag or cold pack to the perineum during the first 24 hours reduce perineal edema the possibility of hematoma formation and therefore reduce pain and promotes healing nad comfort. Dry heat in the form of a perineal hot pack or moist heat with a sitz bath is an effective way of increasing circulation to the perineum and providing comfort reducing edema and promoting healing. Administer sitz baths. A sitz bath is small portable basin that fits on a toilet seat. A reservoir filled with water provides a constant supply of the water to the basin in a swirling motion. The movement of water sootheshealing tissue decreases inflammation by vasodilatation to the area and therefore effectively reduce discomfort and promotes healing. Sitz baths usually use water that is maintained at 100F to 105(38C to 41C). a sitz bath should be used three to four times perday for a maximum of 20 minutes each time. Because of the soothing effect of the warm water and the sitting position the woman may feel extremely tired and unsteady on her feet after using a sitz bath and may need may help in getting back to bed.

Nursing diagnosis : risk for infection (uterine) related to lochia and episiotomy Outcome identification : client will remain free of any symptoms of infection during postpartal period. Outcome evaluation : clients temperature remains below 100.4F; no redness or abnormal discharge is present at an episiotomy line; lochia without foul odor.

Provide perineal care.


Every woman needs attention to perineal cleanliness in the postpartal period to prevent infection. Woman are particularly prone to this because lochia, allowed to dry and harden on the vulva and perineum,furnishes a bed or bacterial growth. Because the vagina lies in close proximity to the rectum there is also always the danger that bacteria will apread from the rectum to the vagina and cause uterine infection. Perineal care should be done as part of the daily bath and after each voiding or bowel movement. Before beginning perineal care wash your own hands and pull on clean gloves to prevent the risk of infection transmission. Place a plastic-covered pad under the womans buttocks to protect the bed during the procedure. With the woman lying in a supine position,remove the perineal pad from the front to back;the direction is important in preventing the portion to the pad that has touched the rectal area from sliding forward to contaminate the vaginal opening. A second common method is to spray the perineum with clear tap water from a spray bottle.

Nursing diagnosis : Risk for altered nutrition ,less than body requirements related to lack knowledge about postpartal needs Outcome identification : client will ingest an adequate diet during the postpartal period Outcome evaluation: client will ingest a 2200to 2700-kcal diet and drink 6 to 8 glasses of fluid daily.

Postpartal menu planning should include a diet of between 2200 and 2300 calories daily. Foods should be high in protein and the vitamins and minerals needed for good tissues repair. It should have an adequate supply of roughage to help restore the peristaltic action of the bowel. The woman who is breastfeeding needs an additional 500calories (a 2700-kcal diet) and an additional 500ml of fluid(these may be from the same source) in her diet to enchourage the production of highquality breast milk.

Promote adequate fluid intake The rapid dieresis and diaphoresis during the 2nd and 5th day postpartum will ordinarily result in a weight loss of an additional 5lb over the approximate 12lb the woman lost at birth. Some women need to be encouraged to drink adequate fluid in the first few days postpartum because they are restricting fluid in the hope of preventing their breasts from becoming engorged. The postpartal period is a time of rebuilding and readjusting for which a woman needs both ample nourishment and adequate fluid intake. For this reason she should drink at least three to four 8-oz glasses of fluid a day (six to eight if breastfeeding)

Nursing diagnosis : risk for altered elimination related to loss of bladder and bowel sensation after childbirth Outcome identification: client will remain free of any elimination problems during the postpartal period Outcome evaluation: client voids over 30ml/h without urinary retention brginning the hour after birth, and has a bowel movement by 4 days postpartum. No urinary incontinence noted.

Promote urinary elimination Because the diuresis of the postpartal period begins almost immediately after birth, the womans bladder begins filling almost immediately. A full bladder puts pressure on the uterus and may interfere with effective uterine contraction. An overdistended bladder may damage bladder function. Encourage the woman to walk to the woman to walk to the bathroom and void at the end of the 1st hour postpartum. Some women have too much perineal edema to be able to void this early. Women with episiotomies my be reluctant to void because they know that acid urine against the sutures will sting. If the womans bladder is distended and she is unable to void, she will need to be catherized. Most women however do not have this mmuch filling at this time. By 4 to 8 hours after birth, bladder distention usually is present. Because the perineum is edematous after birth, the vulvula in postpartal women appears out of proportion. It is usually difficult to locate the urinary urethra for catheterization.

Prevent constipation Many women have difficulty moving their bowels during the first week of the puerperium a condition that can be worrisome and uncomfortable. Constipation tends to occur because of relaxation of the abdominal wall and the intestine now that it is no longer compressed by the bulky uterus. For a bowel movement the abdominal wall must exert pressure. In its relaxed state the pressure is not strong enough to be effective. Also if hemorrhoids or perineal stitches are present the woman may decline to try to move her bowels for fear pain. Ducosate sodium prescribed, beginning with the 1st day after birth(see the drug highlight)

Nursing diagnosis : pain related to primary breast engorgement Outcome identification : client will experience pain that is at a tolerable level during postpartal period Outcome evaluation : client states pain from breast engorgement is at a tolerable level.

Prevent/ alleviate breast engoergement


If the woman is breastfeeding the sucking of the infant is the main treatment for relief of the tenderness and soreness of primary breast engorgement. Cold compresses,applied to the breast three or four times a day during the period of engorgement and /or an oral analgesic provide relief. Wearing a snug-fitting bra or a commercial breast binder and avoiding nipple stimulation may help. Restriction of fluid and pumping milk from the breasts are not effective measures and are to some degree harmful and so should be avoided.

Promote breast hygiene


Breast care during the postpartal period is directed toward cleanliness and support. Should wash her breasts daily at the time of her bath or shower. Soap should be avoided because soap tends to dry and crack nipples. This could lead to fissures and possible breast absences. It is not necessary for women to wash their breasts more often than this. A woman who has considerable discharge of colostrums or milk from her breast (whether breastfeeding or not) should insert clean gauze squares or commercial nursing pads in her bra to absorb the moistures. These should be changed as often as necessary to keep the nipples dry. If nipples remain wet for any length of time, fissures may form and lead to infection.

Nursing Care of the Woman and Family in preparation for discharge


Education to prepare her to care for herself and her newborn at home. Must know how to care for themselves to prevent introducing infection on the unhealed uterus or perineal suture line. Must be aware of danger signs to look for . Must understand safe baby care.

The postpartal period is a. Teaching b. Reteaching c. Offering anticipatory guidance to help in the situations the family can expect to arise when they go home.

Group Classes
Bathing infants Preparing formula Breastfeeding techniques Minimizing jealously in older children Maintaining health in the newborn can be helpful to mothers and fathers.

Individual Instruction
Rooming-in How to bath and feed the baby How to care for the infants cord and circumcision How much infants sleep during 24 hours How to fit a newborn into the familys pattern

Postpartal Discharge Instructions


Area Work Instructions All women should avoid heavy work ( lifting and straining ) for at least the first 3 weeks after birth. Rest Should plan at least one rest period a day and try to get a good nights sleep.

Exercise

Should limit the number of stairs she climbs to one flight/day


for the first week at home. Should continue with musclestrenghthening exercises, such as abdominal crunches.

Hygiene

May take either tub baths or showers. Should continue to apply any cream or ointment as ordered for the perineal are and cleanse her perineum from front to back

Area

Instructions

Coitus

Safe as soon as the womans lochia has turned to alba. If present the
epiostomy is healed ( thir week after delivery ). Vaginalcells may not be as thick as formely because prepregnancy hormone balance has not yet completely returned. Use a contraceptive foam or lubricating jell will aid comfort

Contraception

If desired, the woman should begin a contraception measure with the


initiation of coitus. IUD may be fitted immediately after delivery or at her first postpartal checkup. Oral contaceptive are begun about 2-3weeks after delivery. A diaphragm must be reffited at a 6 week check-up.

Follow-up

Delayed postpartal hemorrhage can occur in women who become extremely fatigued. Getting adequate rest during her first weeks at home. 4 to 6 weeks after birth, the woman should return to her physician for an eamintaion.

Six week Pysical Assessment


Area of assessment

History

Review of systems (urinary system for pain, frequency, stress


incontinence with gastrointestinal tract), assess maternal intake

Physical Assessment General appearance Weight Hair Eyes Breast feeding Alert, positive mood Achieved prepregnantweight Healthy, firm hair, excess loss of hair Pink and moist conjuctiva Full and firm to palpation, blue veins prominent under skin, only

slighty tender. No palpable nodules or lumps. If erythematous or


tender, mastitis may be present. If fissure on nipples are prsent, the woman may need to expose her nipples to air or to apply additional cream.

Area Abdomen Striae less prominent, line nigra fading, muscle tone improving, No constipation and retention Perineum and Uterus Lower extremities No lochia, cervix closed, Varicosities are barely noticeable

Rectum
Laboratory report Laboratiry values

Hemorrhoid have reeceded

Hct 37%, Hb 11-12mg/dl Rubella antibody titer 1: 8

Health belief & practices of different cultures in pregnancy


Birth

Many Chinese people believe that a woman should not cry out or
scream during labour. Women may prefer sitting or squatting to give birth. Ideally, the labouring womans mother or mother-in-law attends childbirth, rather than the father of the child. This practice varies among communities.

After birth Some women may observe a period of confinement after

birth, during which they rest, dress warmly, limit showers,


and eat only foods classed as hot. According to some customs in Guandong and Hong Kong, postpartum women may not eat with other family members for up to one month due to the notion of pollution linked to lochial discharge. For the same reason, postpartum women may abstain from sexual relations.

filipino
Birth The most common birthing position is to lie down. Some women may prefer a squatting position, believed that putting squash leaves on the abdomen of a labouring woman can facilitate labour. believe that drinking coconut water can facilitate a fast labour. Some fathers may prefer to be close to their labouring wife, so they can bury the placenta.

Indian
The mother and the child are usually isolated immediately after

delivery, due to beliefs about pollution and impurity linked to the


delivery process Some women may be required to follow a diet of puffed rice,

tea and hot water for the first three days after delivery.
The consumption of milk, butter, ghee and some types of fish is encouraged due to the belief that these foods will increase the quantity and quality of breast milk.

Postpartum women may consume a large quantity of garlic, to

aid in the contraction of the uterus or to dry the womb.


The placenta may be disposed of by burying it under the floor of the room where the birth occurred, or in the courtyard of the house. The placenta is buried to keep an enemy or evil spirit from seizing it and influencing the well-being and longevity of

the child.
Cold baths or showers are avoided.

Japan
Women in labour are encouraged to eat, as it is believed that food
will provide the strength and energy needed for effective pushing. Women are also encouraged not to cry during labour.

In Japan, women stay at their maternal home for


up to eight weeks after the baby is born. In Japan, showering or washing hair is prohibited until seven days after birth (including in hospitals)

Trends in maternal and child care


The woman who chooses not to keep her child The woman who is discharge but whose child remains hospitalized The family who is adopting a child

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