§ It is the period of recovery that occurs from childbirth and extends for 6 weeks after delivery
§ It is a period of INVOLUTION -- process by which the reproductive organs return to their normal size or pre-pregnant state and functions.
Mothers Responses to Birth
§ The responses of the mother to the birth of her infant are influenced by many factors such as:
Her parents own birth -- parenting and nurturing
Cultural background -- only by understanding and respecting the values and beliefs of each woman can the nurse plan and meet the patients needs
Readiness for parenthood -- emotional maturity, pregnancy planned or unplanned, financial status, job status
Freedom from discomfort -- physical condition
Health of her newborn -- physical condition, prematurity, congenital defects
Opportunities for parent- infant interactions
Postpartum Phases by Rubin
§ Taking - in
Occurs during day 1 - 3 following delivery.
Marked by a period of being dependent and passive behavior.
Mothers primary needs are her own -- food and sleep
Mother is talkative about her labor and delivery experience
***Main nursing is to listen and help the mother interpret events of the delivery to make them more meaningful and clarify and misconceptions
§ Taking - Hold
Occurs during day 3 to about 2 weeks postpartum
Ready to deal with the present
More in control . Begins to take hold of the task of mothering
***It is the best time for teaching! The nurse should
tailor teaching to individual Learning Styles:
Demonstrations; Group Classes; Videotapes
§ Letting Go Phase
occurs after about 2 weeks
Mother may feel a deep loss over the separation of the baby from part of her body and may grieve over this loss.
Common for Postpartum Blues to occur during this time
Reproductive System Changes
Involution of Uterus occurs by:
1. Contraction of the Uterus
2. Autolysis / Catabolism
-- Release of a proteolytic enzyme into the endometrium
and myometrium. This breaks down the protein
material in the hypertrophied cells causing the uterine
muscle cells to decrease in size
3. Regeneration of the Endometrium
the placenta site heals in about 6 weeks with the other part healing in 3 weeks.
Heals by exfoliation rather than by forming scar tissue.
§ Why does the uterus heal by exfoliation and not by primary intention?
§ Answer: so there is no scar tissue
Assessment and Nursing Care of Uterine Changes
§ Assessment of the Uterus
Placement and size -- should be level with the umbilicus after delivery. The uterus then should decrease 1 FB / day. Should also be midline and the size of a grapefruit
-Tone -- should be firm. Assess by supporting lower
portion with one hand and palpate fundus with other. If
found boggy, then massage. Do not overmassage.
causes relaxation and more bleeding.
§ Assess Type
Rubra -- 1 - 3 days; dark red; consists mainly of blood
Serosa -- 3 - 10 days; pinkish serum with tissue and debris
Alba -- 10 - 14 days; creamy yellowish, brownish
§ Assess Amount
Ask -- When did you last change your pad?
§ Assess Odor
Fleshy, not foul smelling Lochia
Characteristics of Lochia
1. Should not be excessive in amount
2. Should never have an offensive odor
3. Should not contain large pieces of tissue
4. Should not be absent during the first 3 weeks
5. Should proceed from rubra -- serosa alba
§ Remains soft and flabby, appears bruised and may have some lacerations
§ No longer does the external os have the pre-pregnant appearance -- now appears as a jagged slit not a circle.
§ May be edematous and bruised.
§ Rugae begin to appear when ovarian function returns.
§ May teach the mom to do Kegels exercises to increase the blood flow to the area and aid in healing
§ May have tears, laceratioins, or an episiotomy
§ Assessment Procedure:
Turn patient to side-lying / sims position
Gently spread buttocks apart and with penlight inspect
o the episiotomy the same as with any incision.
o Assess for hematoma
§ Teach hygiene measures to aid in healing
Use Peri-bottle each time to the bathroom
Wipe front to back; Change pads frequently
Use Tucks and Spray
Match the Lochia:
1. Lochia rubra a. Pinkish serum with mucus and
debris usually occurs on day 3 - 10.
2. Lochia serosa b. Creamy yellowish brownish.
Occurs after day 10
3. Lochia alba. C. Dark Red and consists mainly of
blood. Occurs day 1 - 3.
Fill in the Blank:
§ Lochia should never be ______________ in amount.
§ Lochia should never have an ______________odor.
§ Lochia should not contain ________ _______ of tissue.
§ Lochia should not be _____ during the first ____ weeks.
§ Lochia should proceed from _____ to ____ to ________.
The nurse is going to assess the uterus. The 3 main assessments include:
The normal height of a first day postpartum woman is ______. It
should decrease ___fingerbreadth per ___.
The tone should be __________. If found boggy, the nurse would ___________ the uterus.
§ Allow the mother to assess her own breasts -- similar to doing a self-breast exam
o ask if feels any nodules, lumps
o ask if nipples are sore, reddened, blisters, cracks
§ Assess nipples for everted, flat, inverted
§ Teach to care for breasts according to whether they are breastfeeding or bottle feeding.
Process of Lactation
§ Sucking of infant stimulates the nerves beneath skin of the areola to transmit messages to the hypothalamus
§ Hypothalamus sends messages to the pituitary gland
Anterior pituitary -- stimulates Prolactin to be released which is the ultimate stimulation for milk production
Posterior pituitary -- releases Oxytocin which stimulates the contraction of the cells around the alveoli in the mammary glands. This causes milk to be propelled through the duct system to the infant. This is the LET-DOWN reflex. Felt as a tingling sensation
§ No soap on the nipples, wash in water
§ wear supportive bra
§ Breastfeeding tips:
Most important is the latch-on Teach measures to assist with the infant getting the nipple and areola in the mouth
Teach different positions to hold the baby
Relax to allow for let-down
express colostrum on the nipples after feeding
remember drops of colostrum are the same as ounces of milk -- if wetting 6 - 10 diapers / day, then must be getting enough to eat
Suppression of Lactation
§ Key is to teach the mother measures to decrease stimulation of the breasts
Wear a tight-fitting bra or binder
Do not express milk from the breasts
Take shower with back to the warm water
Fill in the Blank
§ The Anterior pituitary stimulates the release of _______ which is responsible for ______ ___________.
§ The posterior pituitary gland releases ___________ which is responsible for the ______-________ reflex.
§ Short Answers
§ What are four important interventions to teach a mom who is bottle feeding to decrease stimulation of the breasts.
§ Assess voiding carefully. Make sure the patient is emptying her bladder. Must void every 3 - 4 hours. If unable to void-- catheterize
§ Diuresis is common -- loss of fluid of pregnancy
§ Mild Proteinuria release of proteolytic material
§ Most common problem is urinary retention RT:
loss of elasticity and diminished bladder tone
loss of sensation from trauma, drugs, anesthesia
§ Teach to do sitz baths, peri - lite, Tucks to decrease swelling
§ A primigravida delivered 2 hours ago. The client states she would like to go to the bathroom. What should the nurse do?
§ The client is unable to void. What should the nurse do next?
§ Most common problem is constipation RT:
decrease muscle tone and intraabdominal pressure
prelabor diarrhea and decrease peristalsis
pre- delivery enema
perineal tenderness, hemorrhoids and episiotomy
increase fluids, fiber, and activity
Stool softeners, anesthetic sprays, Tucks
**Do NOT give an enema or suppository to a person who has a 4th degree laceration.
Rest and Sleep
§ Most common problem is Sleep -- the excitement and exhilaration experienced by birth my make it difficult to sleep. They are tired and need rest. Allow for times of uninterrupted sleep.
§ Exercises -- have the patient to ask her own doctor for specific exercises. Usually walking is safe. May eventually do postpartum exercises. Just need to allow the body to return to its pre-pregnant state before straining it.
Perineal pain -- caused from trauma during delivery, episiotomy, hemorrhoids. Provide comfort measures such as: sitz baths, Tucks, Sprays / Foams, oral analgesics.
Afterbirth pain -- more common in multigravidas and breastfeeding moms. Treat with * mild analgesics (NSAIDS, Acetamenaphen),heating pad, lie on abdomen, discontinue use of oxytocins,
Breast engorgement -- warm or cold packs, increase feedings, decrease stimulation. Bind breasts.
Gas distention -- no ice, increase warm / hot fluids, increase walking, rocking chair, antiflatus drugs.
§ Skin -- pigment changes will begin to disappear; diaphorsis is normal; may have diastasis recti
Cardiovascular System Changes
§ Plasma volume body rids itself of excess by:
Diuresis urinary output of 3000 cc / day is common
§ Blood Volume
Increase for about 24-48 hours after delivery
Increase in blood flow back to the heart when blood from the placenta unit returns to central circulation
Extravascular interstitial fluid is moved into the vascular system / intravascular
Leads to increased cardiac output mainly RT increase stroke volume.
§ Vital Signs
Temperature -- may see a SLIGHT ~100. rise in temperature because of dehydration and exertion of labor in first 24 hrs
Pulse -- Bradycardia is common for 6 - 8 days postpartally. RT vagal response to increased sympathetic nervous system stimulation during labor and increase in stroke volume.
Respirations begin to fall to normal pre-birth range.
--B/P -- should remain steady. Not elevated or decreased
The clients vital signs are:
T.100.8, P- 56, R 16, B/P 110/65.
How would the nurse interpret these findings? What interventions are indicated?
WBC elevated slightly to about 12,000
RBC increase slightly to about 10 milion.
Hemoglobin stays about normal at ~ 12 g. Below 10 g = anemia
Hemotocrit lowers 33-39% RT hemodilution. If drops below 32- 35% = anemia
Normal Post Partum Results:
WBC leukocytosis is common with values of 20,000 30,000 RT increassed neutrophils
RBC return to normal
Hgb. normal to see a drop of about 1 gram
Hct normal to see a drop of about 4 points and then a rise RT > loss of plasma than RBC death
§ During your shift assessment of the post partum moms peri pad, you found it saturated with lochia rubra.
§ What would be your nursing interventions now?
§ Most moms are hungry and eager to eat. Start off slowly to avoid nausea and vomiting.
§ Diet should include:
High in Protein, vitamin C, and fiber
Increase in fluids
§ Lactating moms need about 700 extra calories for milk production
§ Prenatal vitamins and iron supplements are often continued in the postpartum period.
§ Bond that endures over time. Contact should occur as early as possible and as frequently as possible.
§ Allow time for attachment to occur with all members of the family
1. En Face position -- eye-to-eye contact
2. Explore with finger-tips
3. Hand and Palmar contact
4. Whole arms --enfolds whole baby close to body
The Claiming Process
- Includes the identification of the babys specific features, relating them to other family members