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Chapter 21

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Normal Puerperium

It is the period of recovery that occurs fromchildbirth and extends for 6 weeks after delivery

What is involution?

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Reproductive System

Changes

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The Uterus

What are the three ways that

the uterus involutes?

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Contraction of the Uterus

Muscle fibers become shorter

controlling the bleeding by

compressing and sealing off bloodvessels

Acting as the living ligature

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Protein Material Catabolism

Release of a proteolytic enzyme into theendometrium and myometrium.

This enzyme breaks down the proteinmaterial in the hypertrophied cells causingthe uterine muscle cells to decrease in size

The uterus gradually decreases in size as thecells grow smaller

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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 formingscar tissue.

The endometrium grows from the margins ofthe placental site and from the fundi of the

endometrial glands left in the basal layer of

the placental site

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Critical Thinking

Why does the uterus heal by

Exfoliation

and not by

primary intention?

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Uterine Changes

Placement and size Where is the normal placement of the

uterus immediately after birth, 12 hours

later?

What is the size of the uterus?

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Uterus

What nursing intervention

should the nurse encourage

PRIOR to

assessing the fundus?

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Uterine Changes

What is the normal tone of the uterus?

What is the technique used to assess the

uterus?

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Uterine Involution

What is the PRIORITY intervention when

the uterus is found to be boggy?

Why is it important not to over-stimulate

the uterus?

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Uterus

What interventions

must the nurse

include if theuterus is found

deviated from

midline?

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Short Answers

The nurse is going to assess the uterus. The 3main assessments include:

1.

2.

3.

The normal height of a first day postpartumwoman is ________________. It should decrease_____fingerbreadth per _______.

The tone should be __________. If found boggy,the nurse would ___________ the uterus.

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Lochia What are the three types of lochia?

What is a normal amount?

What question is important to ask

the woman when assessing amount?

What is normal odor of Lochia?

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Characteristics of Lochia

Should not be excessive in amount

Should never have an offensive odor

Should not contain large pieces oftissue

Should not be absent during the first3 weeks

Should proceed from rubra -- serosa-- alba

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Match the Lochia

Lochia rubra

Lochia serosa

Lochia alba

A. Pinkish serum with mucus

and debris usually occurs

on day 3 - 10.

B. Creamy yellowishbrownish. Occurs after day

10

C. Dark Red and consists

mainly of blood. Occurs

day 1 - 3.

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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

___________.

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Cervix

Remains soft and flabby, appears bruisedand may have some lacerations

No longer does the external os have thepre-pregnant appearance -- now appears

as a jagged slit not a circle.

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Vagina

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

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Perineum

Assess:

the episiotomy the same as with any incision.

R redness

E edema or swelling

E ecchymosis or bruising

D drainage

A approximated

How should the nurse assessthe perineum?

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What are measures toteach the mom in

caring for theperineum?

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Comfort Measures

Relief of Perineal Discomfort Ice packs

Topical agents

Perineal care

Sitz bath

Relief of hemorrhoidal discomfort

may include Sitz baths

Topical anesthetic ointments

Witch hazel pads

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Ovulation and Menstruation

When does Menstruation generally

return?

Return is prolonged for the

breastfeeding mom because of

alterations in the gonadotropin-releasing

hormone production.

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Ovulation and Menstruation

Nurses need to teach moms that

breastfeeding is NOT a reliable

means of contraception.

WHY

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Breasts

Allow the mother to assess her own breasts --similar to doing a self-breast exam

ask if feels any nodules, lumps

ask if nipples are sore, reddened, blisters,

cracks Assess nipples for everted, flat, inverted

Teach to care for breasts according to whetherthey are breastfeeding or bottle feeding.

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Process of Lactation

Sucking of infant stimulates the nervesbeneath skin of the areola to transmitmessages to the hypothalamus

Hypothalamus sends messages to thepituitary gland

Anterior pituitary -- stimulatesProlactin to be released which is the

ultimate stimulation for milkproduction

Posterior pituitary -- releasesOxytocin which stimulates thecontraction of the cells around thealveoli in the mammary glands. Thiscauses milk to be propelled throughthe duct system to the infant. This isthe LET-DOWN reflex. Felt as atingling sensation

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Breastfeeding Care

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

No timing

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

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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 Ice packs

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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.

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Short Answers What are four important interventions to teach a

mom who is bottle feeding to decrease

stimulation of the breasts.

1.

2.

3.

4.

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Cardiovascular System Changes How does the body rid itself of excess Plasma

volume?

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 thevascular system / intravascular

Leads to increased cardiac output mainly RT increase

stroke volume.

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Blood Values

Pregnancy

WBC elevated slightly to about12,000

RBC increase slightly to about 10

milion.

Hemoglobin stays about normalat ~ 12 g. Below 10 g = anemia

Hemotocrit lowers 33-39% RT

hemodilution. If drops below 32-35% = anemia

Post Partum

WBC leukocytosis is common withvalues of 25,000 30,000 RTincreased neutrophils

RBC return to normal

Hgb. normal to see a drop of about1 gram

Hct normal to see a drop of about2- 4 points and then a rise RT >loss of plasma than RBC death

Platelets drop and gradually rise

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Assess for Thromboembolism

During pregnancy, plasma fibrinogen(coagulation) increases, Mothers body

has the ability to form clots and prevent

excessive bleeding.

Plasminogen (lysis of clots) does not

rise

Hypercoagulable state and the woman

is at a greater risk for thrombusformation.

assess for homans sign

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Vital Signs Temperature

A slight elevation of up to 100.40

may occur related todehydration and increase basal body metabolism from

exertion of labor and delivery.

After 24 hours, the temperature should be normal

A temperature greater than 100.40 suggests infection.

Blood Pressure

Should remain stable Hypovolemia can indicate postpartum hemorrhage

Hypervolemia could indicate preeclampsia

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Vital Signs

Pulse Bradycardia of 50 70 bpm is Normal

Tachcardia is not considered a normal occurrence and

may indicate excessive blood loss

Respirations

Should remain stable and within normal range

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Critical Thinking

The womans 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?

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Gastrointestinal Tract

The most common GI problemduring postpartum is constipation

EXPLAIN.

What teaching is important to assist

in decreasing constipation?

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Urinary System

What is the most common problemassociated with the urinary system?

Why be concerned?

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Critical Thinking

A primigravida delivered 2 hoursago. The woman states she would

like to go to the bathroom. What

should the nurse do?

The woman is unable to void. Whatshould the nurse do next?

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AfterpainsWho is more likely to experience afterbirth

pains? Explain.

Relief of after pains Positioning (prone position)

Analgesia administered an hour before

breastfeeding

Encourage early ambulation - monitor for

dizziness and weakness

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Rest and Activity

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.

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Resumption of Activities

New mother should gradually increase activities and

ambulation after birth

She should avoid heavy lifting, excessive stair

climbing, strenuous activity

Resume light housekeeping by second week at

home

Delay returning to work until after 6-week

postpartum examination

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Exercises

Recommend exercise to provide health benefits to

new mother

Nurse should encourage client to begin simple

exercises while on nursing unit

Inform her that increased lochia and pain may

necessitate a change in her activity

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PainPerineal 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),heatingpad, lie on abdomen, discontinue use of

oxytocins,

Breast engorgement -- warm or cold packs,

increase feedings, decrease stimulation. Bindbreasts.

Gas distention -- no ice, increase warm / hot

fluids, increase walking, rocking chair, antiflatus

drugs.

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Decision Making

During shift assessment of the post

partum moms peri pad, the nurse

found it saturated with lochia rubra.

What would be the priority nursing

intervention?

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The Nutrition Need

Most moms are hungry and eager to eat. Start offslowly 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.

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Psychological Adjustment

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

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Postpartum Blues

Transient period of depression

Occurs first few days after delivery

Mother may experience tearfulness,

anorexia, difficulty sleeping, feeling ofletdown

Usually resolves in 10 to 14 days

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Bonding

Initial attraction felt by parents

Contact should occur as early as possibleand as frequently as possible.

Allow time for attachment to occur with all

members of the family

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Attachment

Bond that endures over time

Occurs through mutually satisfying experiences

Reciprocity - Mutually gratifying interaction amongmother, infant, father

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Attachment Process

Enface - infants face on samevertical plane as parent. Mutualgazing

Explore with finger-tips

Hand and Palmar contact

Whole arms --enfolds wholebaby close to body

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Claiming

The Claiming Process

Includes the identification

Of the babys specific

Features, relating them

To other family members

Those long toes are

just like his Dads

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The Steps in Attachment are:

1.

2.

3.

4.

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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 -- foodand 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

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Postpartum Phases by Rubin

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!

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Tailoring teaching to individual

Learning Styles

Demonstrations

Group Classes

Videotapes

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Postpartum Phases by Rubin

Letting Go Phase

occurs after about 2 weeks

Mother may feel a deep loss over theseparation of the baby from part of her

body and may grieve over this loss.

Common for Postpartum Blues to occur

during this time

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Father-Infant Interaction

Engrossment

Sense of absorption

Preoccupation -

Interest in infant

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Discharge Preparation for discharge should begin when

expectant mother enters birthing unit

Mother needs to be aware of signs of postpartumcomplications and should be aware of her self-care

needs

Nurses should begin first by assessing knowledgeand expectations of new mother and family

Nurse should be available to answer questions andprovide support to parents

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Discharge

Printed Information Nurse should review with new mother any

information she has received regarding postpartum

exercises, prevent of fatigue, sitz bath and perineal

care, etc. - nurse should spend time with parent to

determine if they have any last-minute questionsbefore discharge

Printed information about local agencies and

support groups should be given to new family

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The End