I.

Physical Changes during Postpartal Period (Puerperium).

A. Reproductive 1. Involution: the reduction in the size of the uterus after delivery to the pre pregnant size caused by uterine contractions that constrict and occlude underlying blood vessels at the placental site. Factors that Enhance Involution uncomplicated labor and delivery Breastfeeding Early ambulation Complete expulsion of placenta and membranes Factors that Slow Involution Prolonged labor and difficult delivery Anesthesia Grand Multiparity Full urinary bladder infection Over distention of the uterus

2. Fundus: the top portion of the uterus; a palpable indicator of involution; if contractions of the uterine muscle are interrupted, a boggy uterus, one that is soft, relaxed, and likely to cause hemorrhage results Location of the Fundus after Delivery: Few minutes after delivery: halfway between the umbilicus and the symphysis pubis One hour after delivery: at the level of the umbilicus 1st post partal day: one fingerbreadth below the umbilicus 2nd post partal day: two fingerbreadth below the umbilicus 9th or 10th post partal day: withdrawn into the pelvis that it can no longer be detected by abdominal palpation 3. Lochia is the discharge of blood, fragments of deciduas, white blood cells, mucus, and some bacteria following delivery; types include Lochia rubra, Lochia serosa, and Lochia alba a. Should not contain large clots b. Total volume is 240-270 ml, and daily volume gradually decreases. c. Amount may be increased by exertion or breast-feeding. d. Pooling in the uterus or vagina may occur while reclining with increased bleeding upon arising. e. Unexplained increase in amount or reappearance of lochia rubra is abnormal. Type Lochia Rubra Duration (Day) 1-3 Appearance Dark red, bloody; fleshy, musty, stale odor that is nonoffensive; may have clots smaller than a nickel Pink or Brownish; watery; odorless 10-14 (may last for weeks) Composition Blood with small amounts of mucus, shreds of deciduas, epithelial cells, leukocytes; may contain fetal meconium, lanugo, or vernix caseosa Serum, erythrocytes, shreds of degenerating deciduas, leukocytes, cervical mucus, numerous bacteria Leukocytes, decidual cells, epithelial cells, fat, cervical mucus, cholesterol, bacteria

3-10 Lochia serosa

Lochia alba

Yellow to white; may have slightly stale odor

4. Afterpains a. Caused by intermittent uterine contractions following delivery b. Occur in all women but are more painful in multiparous and breastfeeding women

5. Cervix a. Soft, malleable, irregular, and edematous; may appear bruised with multiple small lacerations b. Closes to 2 to 3 cm after several days; by the end of 7 days external os is narrowed to the size of a pencil opening and cervix feels firm and non gravid again c. Shape permanently changes after the first delivery from the round, dimple-like external os of the nullipara to the lateral, slightly open, slit-like or stellate external os of the multiparous women 6. Vagina a. Soft with few rugae, diameter considerably greater that normal, smooth walls, edematous with multiple small lacerations, hymen permanently torn b. Client should be free from perineal pain within 2 weeks c. Low estrogen levels postpartum leads to decreased vaginal lubrication and vasocongestion for 6 to 10 weeks, which can result to painful intercourse 7. Perineum a. Develops edema and generalized tenderness after birth b. Portions may show ecchymosis c. Labia majora and minora remain atrophic and softened and never return to pre pregnant state B. Abdominal Wall 1. Soft and flabby with decreased muscle tone 2. Striae, or stretch marks, that were red during pregnancy will fade to silver or white in Caucasian women; darker-skinned women will have darker striae that remain darker 3. Diastisis recti, separation of the rectus muscles of the abdomen, may improve postpartally depending on the womans physical condition, number of pregnancies, and type and amount of exercise. C. Cardiovascular 1. Returns to pre pregnant state within 2 weeks 2. The increase in blood volume by 40 percent during pregnancy is eliminated primarily by dieresis between 2nd and 5th post partum days 3. The first 48 hours postpartum are the time of greatest risk of complications for clients with heart disease 4. Blood pressure should remain consistent with pregnancy baseline 5. Bradycardia of 50 to 70 beats per minute is common during the first 6 to10 days; tachycardia is related to increased blood loss, temperature elevation, or difficult, prolonged labor and birth 6. Increased fibrinogen continues for 1 week resulting in increased sedimentation rate(protective measure against hemorrhage) and risk for thrombophlebitis 7. Increased white blood cells up to 30,000/mm3 does not necessarily mean infection or may mask signs of infection; an increase of >30 percent in 6 hours indicates pathology 8. Decreased hemoglobin is related to the amount of blood loss during delivery (1 g/250 ml of blood loss); should return to pre-labor value in 2 to 6 weeks depending on degree of decrease

9. A 4 point decrease in hematocrit on the first post partal day. Hematocrit increases by 3rd to 5th day postpartum related to diuresis; a drop indicates abnormal blood loss 10. Usual blood loss with a vaginal birth: 300-500ml, with a cesarean birth: 500-1000ml 11. Varicosities recede; vascular blemishes (spider angiomas) fade slightly D. Urinary 1. Increased bladder capacity and decreased bladder tone lead to decreased sensation and increased risk of urinary retention and infection 2. Postpartal diuresis of 2,000 to 3,000 ml increases the output in the first 12 to 24 after delivery and accounts for a 5-pound weight loss (urine volume:1500-3000 ml 2nd-5th day after delivery) 3. Increased glomerular filtration rate assists in diuresis 4. A full bladder displaces the uterus, increasing the risk of uterine atony and postpartal hemorrhage 5. Fluids are also lost through diaphoresis with increased perspiration most commonly occurring at night 6. Hydronephrosis (increased size of ureters) present for about 4 weeks post partum increasing possibility of urinary stasis and UTI E. Gastrointestinal 1. Hunger (from glucose used during labor) and thirst (from long period of restricted fluid and beginning diaphoresis) are common following after birth 2. Risk for constipation increases because of decreased peristalsis (effect of relaxin), use of narcotic analgesics, dehydration and decreased mobility during labor, and fear of pain from having bowel movement (episiotomy sutures or hemorrhoids) 3. Risk for hemorrhoids increases because of pressure from pushing during the second stage of labor F. Endocrine 1. Estrogen and progesterone level drop rapidly after delivery of the placenta 2. Progestin, Estrone, and Estradiol level at pre pregnancy levels by 1 week; FSH low for about 12 days then begins to rise to initiate a new menstrual cycle 3. Menstruation usually resumes at 6 to 10 weeks for non-lactating women with 90 percent experiencing a menstrual period by 12 weeks; the first cycle is usually anovulatory 4. Ovulation and menstruation return time is prolonged in lactating women and affected by the length of time the woman breast-feeds and whether formula supplements are used; may vary from 3 or 4 months or for the entire lactation period 5. Lactation a. Nipple stimulation leads to release of oxytocin from the pituitary gland; that stimulates the release of prolactin from the pituitary gland, which causes production of milk and the let-down reflex, release of milk by contractions of alveoli of the breast b. Colostrum is the first milk secreted and is rich in protein and immunoglobulins secreted midway through pregnancy to the first 2 days postpartum c. Primary engorgement occurs on the second or third day as the supply of the blood and lymph in the breast is increased and transitional milk is produced

d. Mature milk is produced after 2 weeks and appears watery and slightly bluish in color, similar to skim milk. II. Psychosocial Changes During the Postpartal period A. Phases of maternal adjustment 1. Taking-in phase a. First 3 days postpartum b. Preoccupied with own needs c. Passive and dependent d. Touches and explores infant e. Needs to discuss labor and delivery 2. Taking-hold phase a. Lasts from the 3rd to 10th day postpartum b. Obsessed with body functions c. Rapid mood swings d. Anticipatory guidance most effective now 3. Letting-go phase a. Lasts from 1o days to 6 weeks postpartum b. Mothering functions established c. Sees infant as a unique person B. Bonding (also known as attachment): the process by which form an emotional relationship with their infant over time 1. Mother explores the infant with fingertips, then palms, and finally enfolding the newborn with the whole arms and hands 2. Holds infant in en face position, face-to-face position about 20 centimeters apart and on the same plane 3. Uses a soft, high-pitched tone voice 4. Engrossed is the fathers absorption, preoccupation, and interest in infant shortly after birth, which can be stimulated by witnessing the birth C. Postpartum blues: a maternal adjustment reaction 1. Transient depression usually occurs between the second and third postpartum days and/or within the first 2 weeks postpartum 2. Probably related to changes in hormone levels (decrease in estrogen and progesterone), fatigue, and physiological stress related to infant dependency 3. Experienced to some degree by a majority of women 4. Characterized by mood swings, anger, tearfulness, feeling let-down, anorexia, and insomnia 5. Usually resolves spontaneously, may need evaluation for postpartum depression if symptoms persist and or are severe III. Nursing Care of the Postpartal Client A. General considerations with postpartal assessment 1. 2. 3. 4. Evaluate prenatal and intrapartal history for risk factors Provide privacy and encourage client to void prior assessment Position client in bed with head flat for most accurate findings Proceed in a head-to-toe direction

5. Vitals signs are most accurate with woman at rest, will determine the need or priority for other assessments a. Temperature 1.) Above 100.4F (38 degree Celsius) after first 24 hours may indicate an infection 2.) May be elevated initially after delivery related to dehydration b. Pulse 1.) Normal range postpartum is 50 to 80 beats per minute 2.) Pulse greater than 100 beats per minute should be reported to the healthcare provider c. Respirations: normal range is 16 to 24 breaths per minute d. Blood pressure 1.) Assess for orthostatic hypotension 2.) Monitor more closely if client has a history of preeclampsia 6. Women who experience operative procedures, caesarean delivery, or tubal ligation have postpartal needs similar to those of women who gave birth vaginally and the needs of postoperative clients; monitor breath sounds and have the client cough and take deep breaths B. Postpartum assessment: the mneumonic BUBBLE-HEB aids the nurse in remembering the components of the assessment 1. Breasts a. Determine if mother is breast- or bottle- feeding b. Palpate for engorgement or tenderness c. Inspect the nipples for redness, cracks, and erectility, if nursing 2. Uterus a. Gently place the nondominant hand on the lower uterine segment just above the symphysis pubis; the dominant hand palpates the top of the fundus b. Determine the uterine firmness, height of the fundus, and ascertain the position of the fundus in relation to the midline of the abdomen c. Correlate fundal location with expected descent of 1 centimeter each postpartal day d. Inspect any abdominal incisions, cesarean delivery, or tubal ligation, for REEDA: redness, edema, ecchymosis, discharge, and approximation of the skin edges. 3. Bladder a. The client should void 6 to 8 hours after delivery b. Assess frequency, burning, or urgency which could indicate a urinary tract infection c. Evaluate the ability to completely empty the bladder d. Palpate for bladder distention, if unable to void or complete emptying is in question 4. Bowel a. Assess for passage of flatus b. Inspect for signs of distention c. Auscultate bowel sounds in all four quadrants for postoperative clients 5. Lochia a. Inspect type, quantity, amount , and odor b. Correlate findings with expected findings of bleeding c. Cesarean-delivered women may have less lochia

6. Episiotomy or perineal lacerations a. Inspect the perineum for REEDA b. Inspect for hemorrhoids 7. Homans sign a. Pain in the calf upon dorsiflexion of the foot is recorded as a positive sign and indicate thrombophlebitis b. Inspect for pedal edema, redness, or warmth; if abnormal changes are present, assess pedal pulse 8. Emotional status a. Assess if the clients emotions are appropriate for the situation b. Determine the clients phase of postpartal psychological adjustment c. Assess for signs of postpartum blues 9. Bonding: describe how the parents interact with the infant C. Priority nursing diagnoses 1. 2. 3. 4. 5. 6. 7. Deficient fluid volume Impaired urinary elimination Risk of infection Pain Risk for constipation Interrupted family processes Deficient knowledge

D. Implementation 1. Prevent hemorrhage a. Assess for risk factors b. Keep bladder empty c. Gently massage fundus, if boggy; teach self-massage of uterus d. Administer oxytocic medications, if ordered; oxytocin (Pitocin), methylergonovine maleate (Methergine), ergonovine maleate (Ergotrate) e. Monitor for side effects of oxytocics, if administered; hypotension with rapid IV bolus of Pitocin, hypertension with Methergine and Ergotrate 2. Promote comfort a. Apply ice to perineum 20 minutes/10 minutes off for first 24 hours b. Encourage sitz bath, warm or cool, tid and prn after first 12 to 24 hours c. Teach client perineal care to be used after every elimination 1.) Squirt or pour warm water over the perineum 2.) Blot dry from front to back to prevent tissue trauma and contamination from anal are 3.) Apply clean perineal pad from front to back without touching the surface that will be next to client d. Teach client to tighten buttocks, then sit and relax muscles e. Apply topical anesthetics (Dermaplast or Americaine spray) or witch hazel compresses (Tucks) f. Administer analgesics; acetaminophen (Tylenol), non-steroidal antiinflammatory agents (ibuprofen) , narcotics (codeine, hydrocodone, oxycodone) g. Utilized patient-controlled analgesia (PCA pump) or morphine epidural for cesarean deliveries

h. Monitor for side effects of morphine epidural, if administered; lateonset respiratory depression (8 to 12 hours), nausea and vomiting (4 to 7 hours), itching (within 3 up to 10 hours), urinary retention, and somnolence 3. Promote bowel elimination a. Encourage early and frequent ambulation b. Encourage increased fluids and fiber c. Administer stool softeners, as ordered; suppositories are contraindicated if the client has a third- or fourth- degree perineal laceration involving the rectum d. Teach client to avoid straining; normal bowel pattern returns in 2 to 3 weeks

4. Urinary elimination a. Encourage voiding every 2 to 3 hours even if no urge is felt b. Catheterize, as ordered, for urinary retention; Foley catheter for 12 to 24 hours after cesarean delivery 5. Promote successful infant feeding patterns a. Suppression of lactation and successful bottle-feeding 1.) Utilize snug bra or breast binder continuously for 5 to 7 days to prevent engorgement 2.) Avoid heat and stimulation of the breast 3.) Apply ice packs for 20 minutes qid, if engorgement occur 4.) Encourage demand feedings every 3 to 4 hours, awakening during the day and allowing to sleep at night b. Establishment of lactation and successful breast-feeding 1.) Utilize a well-fitting bra for continuous support of the breast 2.) Teach breast care including no use of soap and air drying nipples after feeding 3.) Encourage nursing on demand every 2 to 4 hours, awakening during the day and allowing to sleep at night 4.) Advise the mother to nurse 10 to 15 minutes on first breast and until the baby lets go of the second; alternate the breast used first and rotate positions 5.) Suggest football hold or side-lying position for mothers with cesarean delivery or tubal ligation to avoid discomfort caused by the weight of the baby on the abdominal incision 6.) Provide help with positioning, latching in, and breaking suction when done nursing for women nursing multiple births c. Explore the impact of culture on feeding practices and support family choices 1.) Amount of contact and degree of closeness between mother and newborn is often culturally determined 2.) Culture may influence how long breast-feeding continues 3.) Feeding practices vary across cultures 6. Promotes rest and gradual return to activity a. Organize nursing care to avoid frequent interruptions b. Plan maternal rest periods when the baby is expected to sleep c. Teach the woman to resume activity gradually over 4 to 5 weeks; avoid lifting, stair-climbing, and strenuous activity d. Simple postpartal exercises should be started, per orders; encourage the client to strengthen muscles affected by childbearing; Kegel exercises tighten the perineum by repeatedly attempting to stop the flow of urine and then relaxing; raising the

chin to the chest, knee rolls, and buttocks lifts strengthen the abdomen e. Increased lochia or pain indicates overexertion; modify exercise plan 7. Promote adequate nutritional intake a. Encourage lactating mothers to add 500 kcal/day to the prepregnancy diet; bottle-feeding mothers should return to the prepregnancy diet b. Encourage fluid intake of 2,000 ml/day c. Continue administration of prenatal vitamins and iron, as ordered; iron is best absorbed in the presence of vitamin C and may increase constipation 8. Promote psychological well-being a. Plan nursing care based on the clients phase of psychological adjustment and degree of dependence/independence; provide choices whenever possible b. Encourage and support expression of feelings, positive and negative, without guilt c. Encourage the client to tell the story of her labor to integrate expectations and fantasies with reality d. Provide recognition and praise for self- and infant-care activities 9. Promote family well-being a. Provide an environment that supports family unity and promotes attachment to the newborn b. Encourage rooming-in, presence of family members c. Assist parents in preparing siblings with realistic expectations of the newborn, involve siblings in infant care d. Teach parents that sibling regression is common e. Advise the couple to resume sexual activity after the episiotomy has healed and the lochia has stopped, about 3 weeks after delivery; the level of sexual interest and activity may vary, additional water-soluble lubrication may be needed and breast milk may be released with orgasm

f. Counsel couples regarding contraception before discharge, assist the couple to select a method compatible with health needs and individual preferences; a diaphragm or cervical cap will need to be refitted following delivery; oral contraceptives containing estrogens may interfere lactation 10.Promote maternal safety a. Give Rho (D) gamma globulin (Rhogam, RhIG, Gamulin) if needed t prevent Rh sensitization and future hemolytic disease of the newborn 1.) Confirm the woman is a candidate: Rh-negative mother not sensitized (negative indirect Coombs test), Rh-positive newborn not sensitized (negative direct Coombs test), and no known maternal allergy to globulin preparations 2.) Administer 300 g IM within 72 hours of delivery b. Give rubella vaccine to provide activity immunity for mother and avoid fetal malformations if the disease is contacted during a future pregnancy

1.) Confirm the woman is a candidate: titer of < 1:8 (not immune); no known allergy to neomycin 2.) Administer 0.5 ml SC prior to discharge 3.) If mother is a candidate for both Rhogam and rubella vaccine, delay the rubella vaccine at least 6 weeks, and preferably 3 months, to avoid drug interaction and reduced rubella immunity 4.) Teach the client to avoid pregnancy for at least 3 months following vaccination; vaccine contains live virus and can adversely affect the fetus; side effects include burning and stinging at the injection site, warmth and redness, mild symptoms of the disease c. Teach the client postpartum warning signs to be reported 1.) Bright red bleeding saturating more than 1 pad/hour or passing large clots 2.) Temperature greater than 100.4F 3.) Chills 4.) Excessive pain 5.) Reddened or warm areas of the breast 6.) Reddened or gaping episiotomy, foul-smelling lochia 7.) Inability to urinate; burning, frequency, or urgency with urination 8.) Calf pain, tenderness, redness or swelling E. Evaluation 1. Assessment findings remains normal 2. Maternal physical and psychological well-being is maintained 3. Client verbalizes/demonstrate techniques of self-and infant-care 4. Parents demonstrate positive signs of attachment with their infant Cultural Group North American and European Hmong (southeast Asian) Mexican American, Filipino, Navajo, Vietnamese African-American Muslim Infant feeding practice Exposing the breast is indecent; weaning is a sign of infant development Breast- and bottle-feeding may be combined; expressing or pumping breast milk is unacceptable Colostrum is not offered to the newborn Plentiful feeding is emphasized; solids are introduced early Breast-feeding is encouraged to 2 years of age