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Postpartum Nursing. Postpartum or Puerperium. Period of 6 wks after delivery during which the reproductive system and the body returns to normal immediate--first 24 hrs early--first week late--2nd to 6th week. Dramatic Changes in every body system.

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postpartum or puerperium

Postpartum or Puerperium

Period of 6 wks after delivery during which the reproductive system and the body returns to normal

immediate--first 24 hrs

early--first week

late--2nd to 6th week

dramatic changes in every body system
Dramatic Changes in every body system
  • While Changes are normal, in no other period of life is there such marked and rapid catabolism
  • Wt. Loss ot 15-17 lbs. Possibly more if breastfeeding.
changes in the following
Uterus

Breasts

Perineum

Vagina

Elimination

urinary

bowels

Endocrine

Reproductive

Cardiovascular

Blood Changes

Vital Signs

Abd. musculature

Sleeping and rest

Psychological

Changes in the following:
uterine involution
Uterine Involution
  • Blood vessels contract, uterus shrinks
  • Involutes at 1cm/day 1cm=1fingerbreadth
  • Below the symphysis by 10-12 days
  • Process for involution=autolysis of protein
    • 1000gm at delivery, 60gm at 6 wks pp
autolysis
Autolysis
  • Outer decidua and autolysed protein excreted in lochia
  • Inner decidua forms new endometrium
  • Entire endometrium restored in 3 wk, except for placental site
  • Large bld vess. degenerate, replaced by smaller ones.
  • Cervix never returns to nulliparous state
nursing care r t uterine changes
Nursing care r/t uterine changes
  • Palpate fundus at frequent intervals
    • q. 15” X 1hr
    • q. 1hr X 2
    • q. 2hr X 2
    • q. 4 hrs up to 24-48 hrs. post delivery
  • Massage if not firm
  • Deviation and above umb. may signal full bladder
lochia
Lochia
  • Vaginal discharge after delivery,composed of leukocytes, epithelial cells, decidua, autolysed protein and bacteria.
    • Rubra--delivery to 3rd day
    • Serosa--days 4-10
    • Alba--10--several weeks post delivery

Assess color, amt, odor, clots

cramping or afterpains
Cramping or “Afterpains”
  • Primigravida--uterus tonically contracted unless clots or tissue remain in uterus.
  • Multipara--uterus contracts and relaxes at intervals causing “afterpains”.

More severe when breasfeeding in both primiparas and multiparas.

breast changes
Breast Changes
  • Colostrum secreted from third tri. until lactation begins
  • Milk--lactation 3rd pp day
  • Engorgement from increased vascular and lymphatic circulation
  • Decreased/absent placental hormones cause prolactin to be secreted=lactation

Check breasts for engorgement, nipple cracks, soreness

suppression of lactation
Suppression of Lactation
  • Avoid breast stimulation
  • Ice
  • Tight bra
  • Do not pump or express milk
  • Homonal suppression (rarely)
perineal changes
Perineal Changes
  • Episiotomy--subcuticular sutures
  • Pain for 24-48 hrs
    • ice for 24 hrs then heat (sitz baths)
    • Analgesics, systemic and topical
    • Sit properly
    • Keep clean--perineal care
evaluate episiotomy or perineal lac for reeda
Evaluate Episiotomy or Perineal lac. for REEDA
  • Redness
  • Edema
  • Ecchymosis
  • Drainage
  • Approximation
vaginal changes
Vaginal Changes
  • rugae absent--return in 3 wks
  • edematous--venous congestion for 3 days
  • distention--decreases but never back to nulliparous state
  • lacerations
  • hymenal tags
  • labia flabby, improve but never back to nulliparous state
urinary elimination
Urinary Elimination
  • Bladder Changes
    • edema and hyperemia,extravasation
    • increased capacity, decreased sensitivity
    • overdistension with incomplete emptying
    • urethral trauma may cause dysuria

Note, transient glycosuria, proteinuria, and keytonuria are normal in immediate pp. period.

problems with urinary elimination
Problems with urinary elimination
  • Dysuria
  • IV fluids cause bladder fullness
  • regional anesthesia and decreased abdominal pressure=pt unaware of full bladder
nursing care
Nursing Care
  • Check bladder frequently post delivery
  • Full bladder can inhibit uterine contraction=bleeding

Signs of full postpartum bladder=uterus high and displaced to side (usually R)

  • If no void in 4-6hrs, catheterize
  • Check amount of voiding (retention with overflow possible)
retention with overflow
Retention with overflow
  • When bladder is overdistended pt. will void small amouts without emptying bladder.
  • If catheterize for an overdistended bladder, remove only 1000cc and then clamp and consult MD
  • If unable to void after cathX2, Foley indicated
bowel elimination
Bowel Elimination

Constipation r/t

  • decreased peristalisis
  • decreased intra abdominal pressure
  • hemorrhoidal discomfort
  • perineal discomfort

Increase roughage and fluids, laxatives and suppositories--bowels normal by 1wk pp

endocrine changes
Endocrine Changes
  • Placental estrogen and progesterone removed
  • Prolactin increases, esp in breastfeeding women
  • Estrogen begins to increase to follicular levels at 3-4 wks p. Delivery
  • Menstruation returns--6 wks not breastfeeding, 2-18 mos breastfeeding
cardiovascular changes
Cardiovascular Changes
  • Blood volume goes rapidly from hypervolemia to hypovolemia
    • blood loss 400-500cc vaginal delivery

700-1000 cc Csection

blood components
Blood Components
  • HCT (down 4pts for each pt blood lost)
  •  Leucocytes(15,000 to 30,000 mm3)
  •  Lymphocytes
  •  Fibrinogen--risk of thrombophlebitis
  •  ESR
vital signs
Vital Signs
  • BP first  then 
    • increases during uterine massage/pain
    • if PIH may stay elevated
    • orthostatic hypotension common
  • Temp first  then 
  • P-- 
  • R-- 
other changes
Other changes

Postpartum Chill

Shaking chill due to vasomotor instability

Postpartum diaphoresis

night sweats and increased odor

abdominal musculature
Abdominal Musculature
  •  muscle tone--soft, weak, flabby
  • diastasis recti remains

May do head and shoulder raises and lie on abdomen--ask MD about resumption of more vigourous activity

(other muscles may be weak due to the exertion of delivery and lactic acidosis)

sleep and rest patterns
Sleep and Rest Patterns
  • Sleep and rest patterns disrupted during thrird trimester and continue to be disrupted during pp period
    • excitement
    • anxiety
    • discomfort
    • baby feedings
psychological changes
Psychological Changes

The new mother must move from dependent to independent in a short time

Reva Rubins three stages of the postpartum

  • Taking in
  • Taking hold
  • Letting go (taking over)
taking in phase
Taking in phase
  • Focused on self (not infant)
  • dependent on others for help in care
  • needs assistance
  • decision making difficult
  • comfort-rest-food needs paramount
  • relives delivery experience

May last for several hours or days

taking hold phase
Taking hold phase
  • Moving from dependence to independence
  •  energy level
  •  focus on infant
  • self care, focus on bowels, bladder, brfeed
  • responds to instruction, praise

Lasts from 2days to 1wk

letting go phase
Letting go phase
  • Giving up previous role
  • See self as separate from infant
  • Give up fantasy delivery and baby
  • Readjustment
  • Depression and grief work
  • from 1wk
postpartum blues
Postpartum blues
  • Reduction of progesterone, delayed prolactin release and changes in other placental hormones may trigger emotional instability
  • Body image changes and dependency needs may contribute
  • Overconcern re infant and self, and emotional lability are “normal” during the first 5-10 days after delivery
postpartum depression
Postpartum depression
  • Rejection of infant, or fears that she may harm infant call for immediate intervention.
  • Remind mom during postpartum teaching that these feelings sometimes occur and help is available