Care of the Postpartum Client

Marlo V. Abella

Postpartum Physical Adaptations
(pg. 906-929) 906- 

     

Uterine Involution Fundal position changes: ³Boggy´ Lochia: Rubra, Serosa, Alba Cervical changes Vaginal changes Perineal changes Recurrence of ovulation and menustration 

      

Lactation Gastrointestinal System Urinary tract Vital signs Weight loss Postpartum chill Postpartal diaphoresis Afterpains or Afterbirth pains

Uterine Involution    

The rapid reduction in size of the uterus and it¶s return to a condition similar to its pre-pregnancy state. preThe uterus remains slightly larger than it was before the first pregnancy. Process is complete at 3 weeks except at the placental site (6 to 7 weeks) Subinvolution may be caused by an infection or retained placenta fragments.

WEIGHT OF THE UTERUS 
  

Right after delivery: 1000 grams 1 week after :500 grams 2 weeks after : 300 grams 6 weeks after : 50 ± 60 grams

Fundal Position Changes  After birth : 1st day: one fingerbreadth below umbilicus  2nd day: two fingerbreadths below umbilicus  9th to 10th day: cannot be palpated abdominallyThe first postpartum day it is located 1 cm or fingerbreadth below the umbilicus.  .

Becomes ³boggy´ with uterine atony .Fundal Position Changes   May be displaced to the left or right by a distended bladder.

³ Boggy Uterus ´    Massage the uterus Place infant on mother¶s breast Administer oxytocin Check BP  Do not give if BP > 140/90  .

UTERINE CONTRACTIONS   Prevent bleeding Afterpains ± uncomfortable cramps Common in multipara  Oxytocin treated  Breastfeeding mothers   2 ± 3 days .

NURSING MEASURES      Explain the cause and purpose of afterpains Keep bladder empty Prone position to lessen discomfort Gentle massage Administer analgesics .

epithelial cells. leukocytes and bacteria  .VAGINAL DISCHARGE  LOCHIA Uterine discharge after delivery  Blood. mucus.

 Serosa:    Alba:   . may be later in breastfeeding clients.COLOR AND PATTERN  Rubra:    dark red in color present the first 2-3 days postpartum 2few small clots pinkish to brownish 4th to the 10th day creamy or yellowish persists for a week or two after serosa.

SIGNS OF ABNORMAL LOCHIA SIGNS FOUL SMELL LARGE CLOTS EXCESSIVE AMOUNT RETURN TO RUBRIA AFTER SEROSA OR ALBA POSSIBLE CAUSE INFECTION RETAINED FRAGMENTS LACERATION OF BIRTH CANAL RETAINED FRAGMENTS INFECTION BLEEDING SUBINVOLUTION OF AFTER 6 WEEKS THE UTERUS .

Goes from dimple like to a lateral slit (fish mouth) . formless and bruised. flabby.CERVICAL CHANGES     Spongy. Original form is regained in a few hours The shape is permanently changed by the first childbearing.

VAGINAL CHANGES      Edematous and bruised Small superficial lacerations may be present Laceration and episiotomy heals after 2 weeks Size and rugae return to pre pregnancy in 3 weeks By 6 weeks appears normal .

PERINEAL CHANGES      edematous with some bruising Episiotomy edges should be approximated Ecchymosis may occur and delay healing Suture: 7 to 10 days Perineal muscle tone regained : 6th weeks .

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PERINEAL CARE Flush with warm water  Pat dry from front to back  Change pad frequently  Observe signs of infection  Reduce hemorrhoids  .

PERINEAL CARE   ICE PACKS SITZ BATH PROMOTE CIRCULATION  20 MINUTES   PERINEAL LAMP Promote vasodilation  25 to 40 watts light  12 -18 inches away  20 minutes 3x a day  .

Recurrence of Ovulation and Menustration     Variable Generally returns to non-nursing nonmothers between 7 and 9 weeks after birth The first cycle is non-ovulatory nonBreastfeeding clients may experience menstruation and ovulation based on the amount of time nursing«may occur from 2nd to 18th month .

the interplay of maternal hormones leads to the establishment of milk production.LACTATION  During pregnancy. . After birth. the breasts develop in preparation for lactation as a result of both estrogen and progesterone.

GASTROINTESTINAL     May have a regular diet  High in protein. iron and vitamins  Bowels tend to be sluggish Episiotomy clients may delay bowel movement for fear of pain Cesarean birth clients may receive clear liquids and progress to a regular diet Stool softeners may be used .

swelling and bruising of tissue.URINARY TRACT     increased bladder capacity. incomplete overemptying. . and buildup of residual urine. Urinary output increases 1rst 24 hours post delivery (puerperal diuresis) (puerperal diuresis) Urine specimens should be obtained as a catheterized specimen. and decreased sensation of bladder filling. At risk for over-distention. decreased sensitivity to fluid pressure.

3 weeks from delivery 2Hemoconcentration in the first 3 to 7 days Leukocytosis in the first 12 days Elevated fibrinogen levels up to the third weeks Physiologic bradycardia during the first 24 hours Orthostatic hypotension in the first 24 hours . CARDIOVACULAR         Blood loss: NSD: 300 to 500 ml CS: 500 to 1000 ml reduction in blood volume 40% increase of maternal blood volume after delivery of the placenta Return of cardiac output to pregnant state takes about 2.

 INTEGUMENTARY Disappearance of skin changes (6 weeks) except for striae and diastisis recti  Areolar hyperpigmentation may not disappear completely  .

birth. a decrease may occur. BP WNL. PIH. An BP may indicate toxemia. . Pulse rate may decrease to 505070. Tachycardia should alert the nurse to blood loss/difficult birth.Vital Signs    afebrile after the first 24 hours. occur.

Leukocytosis with white blood cell (WBC) counts up to 30. Convenient rule of thumb is a 2 point drop in hematocrit equals a blood loss of 500 mL.000 per mL may occur early postpartum.Blood Values    Blood values should return to the prepregnant state by the end of the postpartum period. .

placenta and amniotic fluid. Puerperal diuresis accounts for loss of an additional 5 lbs during the early postpartum period. Normally return to pre-pregnant preweight by 6 weeks postpartum.Weight Loss    An initial weight loss of 10 to 12 lbs occurs as a result of the birth of the infant. .

Diaphoretic episodes may occur at night. a normal occurrence as the body rids itself of waste products.Postpartum Chill and Postpartal Diaphoresis  Most clients experience a shaking chill or tremor after delivery.   Chills and fever late in the postpartum period may indicate sepsis. .  Warm blankets usually relieve this tremor or chill.

urinary problems  Promote recovery  Hasten drainage of lochia  .AMBULATION    NSD : 4 ± 8 hours ANESTHESIA : 8 hours ADVANTAGES: Prevent constipation  Prevent circulatory problems.

pelvic floor and abdomen  .EXERCISE  Purpose Prevent complications  Psychological well being  Strengthen muscles of back.

EXERCISE  POSTPARTUM EXERCISE Abdominal breathing  Kegel exercise: tighten perineal muscle  Arm Raising  Leg Raising  Sit-ups Sit .

REST AND SLEEP     At least 8 hours Avoid heavy lifting Light housekeeping: 2 weeks Normal activities: 4 ± 6 weeks .

RESUMPTION OF SEX   VAGINAL DELIVERY: 3 ± 4 WEEKS CS: 2 WEEKS .

 Discharge Primiparas : 2 to 3 days Multipara: 1 to 2 days CS: 3 to 4 days  Discharge IE is done before leaving  Follow up: 4 to 6 weeks after delivery  .

Postpartum Psychological Adaptations .

Postpartum Psychological Adaptations      Postpartum blues Development of Parent-Infant Parentattachment Initial attachment Behavior FatherFather-Infant Interactions Cultural Influences .

3 days postpartum  Need for sleep and rest  Dependence on other   TAKINGTAKING-HOLD PHASE Transition phase  3rd day to 2 weeks postpartum  Control body function  .RUBIN¶S POSTPARTUM PHASE  TAKINGTAKING-IN PHASE 1st 2.

 TAKINGTAKING-HOLD PHASE  Ability to assume the mother role  LETTINGLETTING-GO PHASE Realize that the infant is a separate individual and not a part of herself  Feeling of loss  Adjustment phase  .

anger. Manifested by mood swings. weepiness. CAUSE: Hormonal changes and psychological adjustments . difficulty sleeping.2 weeks after birth.Postpartum blues    Transient period of depression : 1 . anorexia. and a feeling of letdown.

 If symptoms persist. the client should be evaluated for postpartum depression. .Postpartum blues  Resolve naturally in 2 to 3 weeks with support and reassurance.

Development of Parent-Infant Parentattachment       Level of trust Level of self-esteem selfCapacity for enjoying herself Interest in and adequacy of knowledge about childbearing and childrearing Client¶s prevailing mood or usual feeling tone Reactions to the present pregnancy .

expectancy. touch. delight in each others company when synchronous) . (mutual cueing behaviors. be understanding not condescending Reciprocity is an interactional cycle that occurs simultaneously between mother and infant.Initial attachment Behavior      Progression of touching activities En face position dominates Relies heavily on senses of sight. hearing in getting to know the baby Some negative feelings may occur.

preoccupation.FatherFather-Infant Interactions Primary role has been supporting role  Engrossment (the characteristic sense of absorption. and interest in the infant demonstrated by fathers during early contact with the newborn.  .

³hot´ and ³cold´ foods Do not make generalizations Extended family may play an important role in care . no breastfeeding for the first three days.Cultural Influences    Postpartum care my be affected by cultural beliefs: No shower.

4 1698Breasts: Smooth. rubra to serosa to alba . even pigmentation. temp 98-100.Postpartum Assessment     Vital signs: BP should remain consistent with baseline BP during pregnancy. respirations 16-24. Pulse 50 -90. no clots. scant to moderate. fundus firm. midline and at/or below umbilicus. filling. soft. engorged Abdomen: soft. may be tender on palpation Lochia: rubra. full.

no 4bladder distention noted. holding en face. hemorrhoids (none or small) Lower extremities: No pain with palpation. negative Homan¶s sign Elimination: voiding 4-6 hrs. bonding. episiotomy without redness.Postpartum Assessment     Perineum: Slight edema. swelling or drainage. normal bowel movement by the 2nd to 3rd day post delivery Psychological adaptation: cultural assessment. no bruising. attachment behaviors .

Postpartum Assessment .

Postpartum Major Mood Disorder . Postpartum Psychosis. Pelvic Cellulitis Perineal Wound Infection Cesarean Wound Infection Urinary Tract Infection (UTI) Mastitis Thromboembolitic Disease: Superficial Leg Vein Disease.Dysfunctions of the Postpartum Period        Postpartal Uterine Infection: Endometritis. Deep Vein Thrombosis. Septic Pelvic Thrombophlebitis Postpartum Psychiatric Disorder: ³baby blues´.

 Two methods of milk suppression a. mechanical (tight bras. ice packs) b. avoiding nipple stimulation. pharmacologic (bromocriptine) .

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