C.

POSTPARTUM CARE Puerperium/Postpartum Period Refers to the six (6) weeks peri od after delivery of the baby Time of maternal changes that are both o Retrogres sive (involution of uterus and vagina) o Progressive (production of milk for lac tation, restoration of normal menstrual cycle, and beginning parenting role)

*Involution- return of the reproductive organs to their pre-pregnant state (6 we eks) Postpartum Care & Assessment (mnemonic: BUBBLE-HE) BREASTS UTERUS BLAD OWELS LOCHIA EPISIOTOMY HOMANS SIGN EMOTIONAL STATUS A. IMMEDIATE NURSING CARE 1. Vital signs Assess q 15 min x 4; then q 30 min x2; the n q 4 hrs for the first 24 hrs (if stable) then q 8 hrs BP should be WNL for pat ient Pulse- 50-90 bpm Temp- 98-100.4 degree F (36.6-38 degree C): normal for the 1st 24 hrs due to DHN during labor Resp- 16-24 cpm o Increase in body temperatu re during the first 24 hours is not necessarily a sign of postpartum infection. Any mother whose temperature reaches 38 degree C in any two consecutive 24 hrs p eriod during the first 10 postpartum days may suggest infection. o Bradycardia (heart rate of 50-7- bpm) is common for (24-48 hrs) and persist 6-8 days postpartum. Returns to non-pregnant rate by 3 months postpartum

2. Breast hether trogen ulates Prolactin- hormone for production of breast milk Oxytocin- hormone for excretion /ejection of milk Colostrum is present at the time of delivery; BM is produced b y the 3rd and 4th postpartum day; yellow sticky fluid; more protein, less sugar, less fat than mature milk. Engorgement_ the feeling of tension (heat or throbbing pain) in the breast as br east distention becomes marked (fuller, larger, firmer); occurs on the 3rd -4th day o o o Due to expanding veins and pressure of new breast milk contained with them There may be a slight elevation of body temperature during this time Conges tion subsides in 1 or 2 days In breast, prolactin stimulates alveolar cells to produce milk. Sucking of the n ewborn triggers a release of oxytocin and contractility of the myoepithelial cel ls, which stimulate milk flow; this is known as the let down reflex. The average amount of milk produced in 24 hours increases with time: o o o First week- 6-10 oz 1-4 weeks- 20 oz After 4 weeks- 30 oz Mature milk Foremilk-watery milk comin g from full breast (low in fat, high in carbohydrates) Hindmilk- creamy milk com ing from a nearly empty breast Amount of supply depends on how often the mother nurse or pumps ( the more the m other nurses, the more milk is produced) For those who choose not to breastfeed, lactation can be suppressed through: o o Use a well-fitting bra Avoid any type of nipple stimulation or heat to the breasts (such as warm/hot showers) May use ice packs or cold cabbages leaves to east breast discomfort until milk productio n ceases (it generally takes 5-7 days) o Lacatation- formation of breast milk (BM); begins in a postpartal woman w or not she plans to breast-feed. o BM forms in response to decrease in es and progesterone levels that follows delivery of the placenta (which stim prolactin production)

o Mild analgesics as prescribed 3.

Uterus After delivery of the newborn, involution of the uterus must occur; 2 mai n processes: o o Area where placenta is implanted is sealed off to prevent bleed ing Uterus reduced to its pregestational size (grapefruit) Firm, midline, reduc d in its size Soft & boggy, displaced (hemorrhage risk) Few minutes after birth, fundus halfway between umbilicus and symphysis pubis On e hour later, rise to the level of umbilicus and it remains for the next 24 hour s First postpartal day (day 1)- one fingerbreadth below umbilicus Day 2- 2 finng erbreadth below and so forth until day 10, it can no longer be palpated because it is already behind symphysis pubis At 10-14 postpartum days, the uterus cannot be palpated abdominally o Subinvoluted Uterus Uterus larger than normal and vaginal bleeding with clots. S ince blood clots are good media for bacteria; it is therefore as sign of puerper al sepsis To encourage return of the uterus to its usual anteflexed position, PR ONE and KNEE CHEST positions are advised. Fundal massage, ice pack over hypogast rium, IV oxytocin, nipple stimulation (breastfeeding) o Afterpains/afterbirth pains Strong uterine contractions felt more particularly b y multis, those who delivered larger babies or twins and those who breastfeed. I t is normal and rarely last for more than 3 days. Menstruation o o If not breastfeeding- return in 6-8 weeks after birth If breast feeding, in 3-4 months (lactational amenorrhea) or entire lactation period Thoug h does not guarantee that woman will not conceive because she may ovulate well b efore menstruation returns

4. Bladder Elimination Marked dieresis to eliminate excess fluid (as much as 2000-3 000ml accumulates in the body during pregnancy) o Urine output from 1500ml/day to as much as 3000ml/day 2nd-5th after birth May complain of frequent urination in small amounts: explain that this is due to urinary retention with overflow May have difficulty voiding because of abdomina l pressure or trauma to the trigone of the bladder Assess hypogastric area for o verdistention of bladder: o o Palpation: hard or firm just above symphysis pubis Percussion: resonant Voiding may be initiated by: o o o o Pouring warm and cool water alternately ove r the vulva Encourage the client to go to the comfort room Let her listen to the sound of running water If these measures fail, catheterization, done gently and aseptically, is the last resort on doctors order. (if there is resistance to the catheter when it reaches the internal sphincter, ask patient to breathe through the mouth while rotating the catheter before moving it inward again.) 5. Bowel Elimination Full diet (unless GA) Constipation: delayed bowel evacuation p ostpartally may be due to: o o o o Decrease muscle tone Lack of food and enema d uring labor Dehydration Fear of pain from perineal tenderness due to episiotomy, lacerations or hemorrhoids 6. Lochial discharge ( during the 1st 3 weeks after delivery)- uterine discharge co nsisting of blood, deciduas, WBC, mucus and some bacteria It should approximate menstrual flow. It increases with activity and decreases with breastfeeding. Typ es of lochia:

o Lochia rubra Dark red in color within first 2-3 days Contains epithelial cells, erythrocytes, leukocytes, and deciduas and has a characteristic human odor. o Lochia alba Pinkish to brownish discharge It is a serosanguineous discharge cont aining erythrocytes, leukocytes, cervical mucus and microorganism It has a stron g odor o Lochia serosa Almost colorless to creamy yellowish discharge occurring from 10 d ays to 3 weeks after delivery. It contains leukocytes, deciduas, epithelial cell s, fat, cervical mucus, cholesterol crystals and bacteria Odorless

7. Episiotomy/Perineum Appears edematous and bruised after delivery caused by episi otomy (if performed) and some degree of laceration Assess s/s of infection and i nflammation: o REEDA (redness, edema, ecchymosis, discharge, approximation of su tures) Assess for lacerations: o o o o 1st degree- lacerations extend through the skin and superficial layers of the pe rineum 2nd degree- through perineal muscles 3rd degree- through anal sphincters 4th degree- through the anterior rectal wall and can be damaging to the perineum Prevention of lacerations: o o o o Massage Warm compress Manual support (Ritgens maneuver) Birthing in a lateral position

 To relieve pain: o o Sims position- minimizes strain on the suture line Perineal heat lamp or warm sitz baths twice a day- vasodilation increases blood supply an d therefore, promotes healing Apply ice or cold therapy to the episiotomy or lac eration immediately after delivery to decrease edema and provide anesthesia; the reafter apply moist or dry heat therapy to promote comfort and healing Applicati on of topical analgesics or administration of mild oral analgesics as ordered. o o 8. Homans sign/Legs Relative inactivity/prolonged time in stirrups leads to stasis o f blood and promotes clotting of blood in the lower extremities Assess s/s of DV T o o Redness, warmth, tenderness, Homans sign (pain upon dorsiflexion of foot) I t is also important to note that a DVT may be present despite a negative Homans s ign Early ambulation Avoid crossing of legs, constrictive clothings/undergarments 9. Emotions: Psychological Adaptation (Reva Rubin): ESSENTIAL CONCEPTS The postpart um period represents a time to emotional stress for the new mother, made even mo re difficult by the tremendous physiologic changes that occur Factors influencin g successful transition to parenthood during the postpartum period include: o o o o Response and support of family and friends Relationship of the birthing expe rience to expectations and aspirations Previous childbearing and childrearing ex periences Cultural influences Rubin (1997) describes this period as occurring in three stages: taking-in, taki ng-hold and letting-go o TAKING-IN PERIOD Occurring 1-2 days after delivery, the new mother typically is passive and dependent Energies are focused on bodily co ncerns

She may review her labor and delivery frequently Uninterrupted sleep is importan t if the mother is to avoid the effects of sleep deprivation, which include fati gue, irritability, and interference with normal restorative process Additional n ourishment may be needed because the mothers appetite unusually increased; poor a ppetite may be a clue that the restorative process is not progressing normally E ncourage her to talk about the birth will her integrate it into her life experie nces

o TAKING-HOLD PERIOD 2-4 days after delivery Mother becomes concerned with her abi lity to parent successfully and accepts increasing responsibilities for her newb orn Woman begins to initiate action; she prefer to get her own wash cloth and ma ke her own decisions Mother focuses on regaining control over her bodily functio ns: bowel and bladder function, strength and endurance The mother strives to mas ter newborn care skills (holding, breastfeeding, or bottlefeeding, bathing and d iapering) She may be sensitive to feelings of inadequacy The nurse should take t his into instructions and emotional support, Provide praises account when provid ing

o LETTING-GO PERIOD Redefines her new role Generally occurs after the new mother r eturns home. It involves a time of family reorganization Mother assumes responsi bility for newborn care; she must adapt to demands of the newborns dependency and to her decreased autonomy, independence and social interaction She gives up the fantasized image of her child and accepts the real one.

ATTACHMENT o Refers to the emotional connection between a patient and her infant Behaviors indicating a positive attachment include:

 Touching Holding Kissing Cuddling Talking and singing Choosing the en face positio n Expressing pride in the infant Mal-attachment behaviors vary, but can include: Refusing to look at the infant R efusing to touch or hold the infant Refusing to name the infant Negative comment s about the infant Refusing to respond or responding negatively to infant cues ( crying, smiling) POSTPARTUM BLUES baby blues; normal part of postpartum experience but only for a f ew days Tearfulness, irritability, sometimes insomnia Causes: hormonal fluctuati ons, physical exhaustion, maternal role adjustment o o Reassure that this is nor mal Anticipatory guidance and individualized support from health care personnel are important to help the parents understand Keeping lines of communication open Allow her to make as many decision as possible can help give her sense of contr ol over her life Allow her to verbalize her feelings and concerns o o o POSTPARTUM DEPRESSION A serious & debilitating depression, occurring within firs t 9 months after delivery, often within the initial weeks or months Sadness, cry ing, insomnia, decreased appetite, withdrawal and sometimes suicidal ideation or the desire to harm the infant Somatic symptoms: headaches, diarrhea, constipati on, severe anxiety, feeling as though they are jumping out of their skinm and/or just not feeling like themselves Management: o Assessment tools:

o o Edinburg Postnatal Depression Scale (EPDS) Postpartum Depression Screening Scale (PDSS) Refer to doctor; counseling and medication Help patient and family to understand this condition and assist to explore spiritual aspect of care Additional physiologic adaptations after delivery: 1. Cardiovascular system 30-5 0% increase in total cardiac volume during pregnancy will be reabsorbed into the general circulation within 5-10 minutes after placental delivery Blood loss: va ginal birth- 300-500 ml; cesarean birth- 500-1000ml Blood volume decrease to non pregnant levels by fourth week after delivery Hematocrit rises by the 3rd-7th p ostpartum day WBC increases to 20000-30000/mm3 o o o Cannot be used as an indica tor or signs of postpartum infection Part of bodys defense system against infecti on Aid to healing Extensive activation of the clotting factors which encourages thromboembolizatio n: o Ambulation is done early 4-8hours after normal vaginal delivery When ambula ting the newly-delivered patient for the first time, the nurse should hold on to the patients arm. o Massage is contraindicated. All blood values are back to prenatal levels by the 3rd-4th week postpartum 2. Reproductive system (Vagina) Smooth and swollen with poor tone after delivery Ru gae reappears by 3-4 postpartum weeks Diameter is greater than normal. Hymen is permanently torn. The estrogen index returns in 6-10 weeks. Vaginal dryness and painful intercourse (dyspareunia) may be noted during the postpartum period due to decreased estrogen levels. 3. Integumentary system

 Mask of pregnancy (chloasma) usually disappears, while stretch marks (striae gra vidarum) and linea negra fade but generally do not disappear 4. Endocrine system Estrogen and progesterone level decreases as soon as the placen ta is no longer present HPL and HCG are almost negligible by 24 hours FSH remain s low for about 12 days and begins to rise as new menstrual cycle is initiated. Menstruation return in approximately 6-8 weeks; ovulation cam return within 4 we eks. 5. Musculoskeletal system Relaxin is the hormone responsible for the relaxation of the pelvic ligaments and joints during pregnancy. After delivery, relaxin level subsides and the pelvic ligaments and joints return to their pre pregnant state. However, the joints of the feet remain altered and many patients notice a perma nent increase in shoe size. Abdominal wall is weakened and the muscle tone of th e abdomen is diminished after pregnancy. Some patients have a separation between the abdominal wall muscles, called diastasis recti. This separation can ofte be corrected with certain abdominal exercises (sit ups) performed during the postp artum period. 6. Urinary changes Extensive diuresi begins to take place almost immediately after birth to rid the boyd of fluid Increases the daily output a postpartal woman fro m a 1500- 3000 ml/day during the 2nd-5th day after birth Contain more nitrogen t han normal (due to breakdown of protein in a portion of uterine muscle) Urinary retention as a result of decreased bladder tone and emptying can lead to urinary tract infections PATIENT TEACHING: Self-care guidelines to the mother Instruct the client on sitt ing properly to relieve pain (squeeze the buttocks together and contract pelvic floor muscles before sitting) Instruct to wear perineal pads loosely and to lie in sims position Demonstrate how to clean the perineum after each voiding and def ecation (wiping form front to back), washing the hands and applying a perineal p ad from front to back Teach the importance of adequate fluid intake, exercise, p roper diet and a regular defecation time Instruct to avoid garters or constricti ng clothing that can impair circulation

 Encourage client to shower as soon as she can ambulate and to take tub baths if desired after two weeks. Recommended daily shower to promote comfort and a sense of well-being/ Provide adequate dietary fiber and fluids to promote bowel movem ents; if necessary administer stool softeners, laxatives, suppositories or enema Demonstrate newborn care and safery measures Recommended exercise: o o o Kegels and abdominal breathing on postpartum day one Chin-to-chest on postpartum day 2 to tighten and firm up abdominal muscles Knee-to-abdomen when perineum has heale d, to strengthen abdominal and gluteal muscles Sexual activity o o o o Resume by the 3rd-4th week postpartum Bleeding has stopped Espisiprrhaphy has he aled ( usually 1 week after delivery) Lochia has turned to alba. Decreased physi ologic reactions to sexual stimulation are expected for the 1st 3 months postpar tum because of hormonal changes and emotional factors. o o She should be protected against subsequent pregnancy by observing a method of co ntraception, except the PILLS. Postpartum check up- 4-6 weeks after birth. Woman should return to her physician for an examination (visit is important to ensure that involution is complete an d reproductive planning is desired and may be discussed further.) BREASTFEEDING Feed newborn per demand (breastfeeding or bottlefeeding) or at lea st every two hours and intervals should not exceed 5 hours If breastfeeding o o o From birth to at least 2 years and should continue as long as the mother and c hild wish Exclusive breastfeeding until 6 months of age (when solid are graduall y introduced) Correct latching on ( to prevent nipple sores and allow baby to ge t enough milk) Large part of the breast and areola need to enter the babys mouth Nipple should be at the back of the babys throat with the babys tongue lying flat in its mouth o 10-20 minutes each breast

o Cradling position Storage of expressed breastmilk o Hard sided containers with airtight seals Place of storage In a room Insulated thermal bag with ice packs In a refrigerato r Freezer compartment inside a refrigerator A combined refrigerator and freezer with separate doors Chest or upright manual defrost deep freezer Temperature 25 degree C Maximum storage time 6-8 hours Up to 24 hours 4 degree C -15 degree C -18 degree C Up to 5 days 2 weeks 3-6 months -20 degree C 6-12 months Oral contraceptives are contraindicated in lactating mothers because they contai n estrogen and progesterone derivatives, thereby decreasing milk supply BREAST CARE: Wash breast daily at bath or shower time Soap or alcohol should nev er be used on the breast as they tend to dry and crack the nipples and cause sor e nipples Wash hands before and after every feeding Insert clean OS squares or p iece of cloth in the brassiere to absorb moisture when there is considerable bre ast discharges. Engorgement managemet: o Nurse often (not going more than 3 hour s without nursing and not skipping night feedings) Well-fitted bra Warm compress /shower Chilled cabbage leaves (placed on breast with nipple exposed) Acetaminop hen or ibuprofen for pain Pumping or manually expressing breast milk o o o o o How to Manually Express Breastmilk - The Marmet Technique Draining the Milk Rese rvoirs

1. Position the thumb (above the nipple) and first two fingers (below the nipple ) about 1 to 11/2 from the nipple, though not necessarily at the outer edges of the areola. Use this measurement as a guide, since breasts and areolas vary in size from one woman to another. Be sure the hand forms the letter C and the finger pad s are at 6 and 12 oclock in line with the nipple. Note the fingers are positioned so that the milk reservoirs lie beneath them. Avoid cupping the breast 2. Push straight into the chest wall Avoid spreading the fingers apart. For large breasts, first lift and then push i nto the chest wall 3. Roll thumb and fingers forward at the same time. This roll ing motion compresses and empties milk reservoirs without injuring sensitive bre ast tissue. Note the position of thumb and fingernails during the finish roll as shown in the illustration. 4. Repeat rhythmically to completely drain reservoir s. Position, push, roll... Position, push, roll... 5. Rotate the thumb and finge rs to milk other reservoirs, using both hands on each breast. Avoid These Motion s 1. Do not squeeze the breast, as this can cause bruising. 2. Sliding hands ove r the breast may cause painful skin burns. 3. Avoid pulling the nipple which may result in tissue damage