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 hrsearly--first weeklate--2nd to 6th week

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:

UterusBreastsPerineumVaginaElimination

urinary bowels

Endocrine

ReproductiveCardiovascularBlood ChangesVital SignsAbd. musculatureSleeping and restPsychological

Uterine Involution

Blood vessels contract, uterus shrinks

Involutes at 1cm/day 1cm=1fingerbreadth

Below the symphysis by 10-12 daysProcess for involution=autolysis of

protein 1000gm at delivery, 60gm at 6 wks pp

Autolysis

Outer decidua and autolysed protein excreted in lochia

Inner decidua forms new endometriumEntire endometrium restored in 3 wk,

except for placental siteLarge bld vess. degenerate, replaced by

smaller ones.Cervix never returns to nulliparous state

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 firmDeviation and above umb. may

signal full bladder

LochiaVaginal 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”

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 ChangesColostrum secreted from third tri. until

lactation beginsMilk--lactation 3rd pp dayEngorgement from increased vascular

and lymphatic circulationDecreased/absent placental hormones

cause prolactin to be secreted=lactationCheck breasts for engorgement, nipple

cracks, soreness

Suppression of Lactation

Avoid breast stimulationIceTight braDo not pump or express milkHomonal suppression (rarely)

Perineal Changes

Episiotomy--subcuticular suturesPain 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

RednessEdemaEcchymosisDrainageApproximation

Vaginal Changes

rugae absent--return in 3 wksedematous--venous congestion for 3 daysdistention--decreases but never back to

nulliparous statelacerationshymenal tagslabia flabby, improve but never back to

nulliparous state

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

DysuriaIV fluids cause bladder fullnessregional anesthesia and decreased

abdominal pressure=pt unaware of full bladder

Nursing Care

Check bladder frequently post deliveryFull bladder can inhibit uterine

contraction=bleedingSigns of full postpartum bladder=uterus

high and displaced to side (usually R)If no void in 4-6hrs, catheterizeCheck amount of voiding (retention

with overflow possible)

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

Constipation r/tdecreased peristalisisdecreased intra abdominal pressurehemorrhoidal discomfortperineal discomfortIncrease roughage and fluids, laxatives

and suppositories--bowels normal by 1wk pp

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

Blood volume goes rapidly from hypervolemia to hypovolemia blood loss 400-500cc vaginal

delivery 700-1000 cc Csection

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

BP first then increases during uterine massage/pain if PIH may stay elevated orthostatic hypotension common

Temp first then P-- R--

Other changes

Postpartum ChillShaking chill due to vasomotor instability

Postpartum diaphoresisnight sweats and increased odor

Abdominal Musculature

muscle tone--soft, weak, flabbydiastasis recti remainsMay 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 disrupted during thrird trimester and continue to be disrupted during pp period excitement anxiety discomfort baby feedings

Psychological Changes

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

Reva Rubins three stages of the postpartum

Taking inTaking holdLetting go (taking over)

Taking in phase

Focused on self (not infant)dependent on others for help in careneeds assistancedecision making difficultcomfort-rest-food needs paramountrelives delivery experienceMay last for several hours or days

Taking hold phase

Moving from dependence to independence

energy level focus on infantself care, focus on bowels, bladder,

brfeedresponds to instruction, praiseLasts from 2days to 1wk

Letting go phase

Giving up previous roleSee self as separate from infantGive up fantasy delivery and babyReadjustment Depression and grief workfrom 1wk

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

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