Post on 17-Jan-2016
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Physiologic Adaptations to Postpartum
“Making the decision to have a child – it’s momentous. It is to decide forever to have your heart go walking around outside your body.”
– Elizabeth Stone
Postpartum or Puerperium
First six weeks after delivery during which the reproductive system and the body returns to normal.
Although changes are normal, in no other period of life is there such marked and rapid physiological catabolism.
Changes in the following:
Cardiovascular Blood Vital Signs Abdominal
musculature Sleeping Psychological
Uterus Breasts Perineum Vagina Bowel Bladder Endocrine
Postpartum Assessment“BUBBLE-HE”
Breasts Uterus Bladder Bowel Lochia Episiotomy Homan Sign Emotion
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
Assessment- Engorgement, nipple cracks, soreness, or discomfort while breastfeeding
Uterine Changes
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
Assessment- palpate fundus at frequent intervals for position and firmness (ALWAYS support with two hands).
Bladder Changes
Bladder Changes– edema and hyperemia,extravasation– increased capacity, decreased sensitivity– overdistension with incomplete emptying– urethral trauma may cause dysuria– transient glycosuria, proteinuria, and keytonuria
are normal in immediate postpartum
Assessment- Dysuria, fullness, tone (ability to empty), placement, amount, frequency
Bowel Changes
decreased peristalisis decreased intra abdominal pressure hemorrhoidal discomfort perineal discomfort
Increase roughage and fluids, laxatives and suppositories--bowels normal by 1wk pp
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
Assessment- color, amount, odor, & clots
Episiotomy
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
Assessment-
Redness, Edema, Ecchymosis, Drainage, Approximation
Episiotomy
First Degree
Second Degree
Third Degree
Fourth Degree
Vaginal membranes
above include fascia
above, include anal sphincter
above, include anal canal
Homan’s Sign
Pregnancy and immediate pp is a hypercoagulable period placing a woman at risk for DVT.– Elevated clotting factors and fibrinogen
Assessment- Dorsiflexing the foot to assess calf for pain. Observe for redness, swelling, pain, or heat at site.
Emotion
Taking In
Taking Hold
Letting Go Giving up previous role See self as separate from infant Give up fantasy delivery and baby Readjustment Depression and grief work from 1wk
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
Focused on self (not infant) dependent on others for help in care decision making difficult comfort-rest-food needs paramount relives delivery experience may last for several hours or days
Can you tell the difference?
Maternity Blues Postpartum Depression 13-20% of new mothers little interest or pleasure in
doing things feeling down, depressed, or
hopeless disturbed sleep patterns not wanting to socialize or “join
in”
50% to 80% of new mothers first few days- 2 weeks after
delivery mood swings feeling sad, anxious, or
overwhelmed crying spells loss of appetite trouble sleeping
The nurse becomes very frustrated with Maggie on day one, when she refuses to participate in the care of
her baby.
“All the patient wants to do is talk about how out of
shape she is.”
Endocrine Changes
Placental estrogen and progesterone removed
Prolactin increases, esp in breastfeeding women
Estrogen begins to increase to follicular levels at 3-4 wks after delivery
Menstruation returns--6 wks not breastfeeding, 2-18 mos breastfeeding
Vital Signs Change
BP first then – increases during uterine massage/pain– if PIH may stay elevated– orthostatic hypotension common
Temp first then P-- R--
Cardiovascular Changes
Blood volume goes rapidly from hypervolemia to hypovolemia– blood loss 400-500cc vaginal delivery
700-1000 cc C-section
Blood Changes
HCT (down 16% → in transient anemia) Leukocytes (20,000 to 25,000 mm3 for 10-12
days) Lymphocytes Fibrinogen--risk of thrombophlebitis Erythrocyte Sedimentation Rate (ESR)
Other Changes
Postpartum Chill
Shaking chill due to vasomotor instability
Postpartum diaphoresis
night sweats and increased odor
Maggie, 32 y/o G4 T2 P1A0 L3, delivered her infant son one hour ago
• Normal Vaginal Delivery• 3rd degree episiotomy• Catheterized just prior to delivery (200cc)• Epidural anesthesia
• Fundus @ the umbilicus• Lochia, moderate, Rubra with tissue debris• VSS• Bonding with newborn
QuestionA nurse is assessing the vital signs on a postpartum client who delivered vaginally 10 hours earlier. Findings indicate a temperature of 100º, pulse 76 beats/minute, respirations 18/min, and blood pressure 124/70 mmHg. The client reports feeling sweaty and having to urinate frequently but is otherwise comfortable. How should the nurse interpret these findings?
a. The client is demonstrating signs and symptoms of hypovolemic shock indicated by her slow pulse and diaphoresis.
b. The client's elevated temperature and diaphoresis are an indication of puerperal infection and need to be addressed.
c. The client is bradycardic and the primary care provider should be notified for further assessment.
d. The client's vital signs and reports of feeling sweaty are normal and there is no need for intervention at this time.
Question
The nurse knows that subinvolution is most often the result of:
a. premature separation of the placenta
b. retained placental fragments and infection
c. self-destruction of excess hypertrophied tissue
d. velamentous insertion of the umbilical cord.
Essential Data
Blood Type Rh Status Rubella Status Infant Feeding Support System
Additional Assessment Data
• Blood type= O• Rh= Negative• Rubella titer= 1:4• Indirect Coombs= negative• Direct Coombs= negative• Infant Blood Type=O• Breastfeeding• Spouse and extended family in room
Rh Disease
• Affects mother’s with “negative Rh factor”• Fetal blood crosses placental barrier• Sensitization occurs• Administer Rhogam
• 28 weeks• within 72 hours after delivery
Rh -
48 hours post delivery
• Uterus @ 2cm below the umbilicus
• Lochia, rubra, large amount
• Diaphoretic
• Breasts- “filling”
• Last BM prior to delivery
• Voiding frequent small amounts
• Vital signs stable
Maggie calls the nurse to the room and she is crying. She tells the
nurse….“I can’t breastfeed…my stomach is
hurting all of the time.”
Lillian, a 22 y/o multipara, admitted from the L&D, 2 hours following vaginal birth of an 8
lb. 10 oz. girl
• Fundus is displaced to the right
• Perineal pads saturated
Four hours after delivery, a primipara c/o severe perineal pain.
i Second stage of labor lasted 2 1/2 hours
• Third degree extension of midline episiotomy
• Marked edema and bruising of perineum
A patient’s spouse rushes to the nurse for “HELP”…states “my
wife just passed out while walking to the bathroom.”
• Nursing Considerations
A patient asks the following questions during discharge
teaching:“When can I...
• Take a bath?• Return to work?• Resume sexual intercourse?• Stop talking my vitamins and iron?• Resume exercise?