maternal adaptation during the postpartum period part 1

postpartum period (puerperium)

begins with delivery of placenta and lasts approx. 6 wks. all aspects of mother's life occurring during the 1st year.

reproductive system adaptations - uterus

contraction of muscle fibers to reduce those previously stretched during pregnancy. catabolism that reduces enlarged individual myometrial cells. regeneration of uterine epithelium from the lower layer of the decidua after upper layers have been sloughed off and shed in lochia.

involution

fairly rapid. wt of uterus decreases by 6 wks. endometrium is thin. descends 1cm/day.

day 10 involution

in true pelvis, cannot palpate (normal, good, healthy)

factors that facilitate uterine involution

complete expulsion of amniotic membranes and placenta at birth, a complication-free labor and birth process, breast-feeding, and early ambulation.

factors that inhibit involution

prolonged labor, difficult delivery, grand multiparity, full bladder, retained placenta/amniotic membrane, uterine infection

palpation of uterus

void before exam. note fundal relation to umbilicus. describe: firm, boggy, displaced to right or left usually bladder.

danger signs of uterus

boggy. uterus firm but lochia may be laceration or retained fragments. persistent lochia after 2 wks or return to pink/red discharge after it has cleared.

persistent lochia after 2 wks or return to pink/red discharge after it has cleared is indicative of what?

subinvolution of placental site or late pp hemorrhage

large clots

more concerned

dark clots

old clots

bright red clots

new clots

lochia

discharge occurs after birth. results from involution. superficial layer of decidua basalis necrosis, sloughs off. fleshy smell.

lochia should be equal to amt of...

heavy menstrual period

true or false: lochia is less in c/s d/t uterine debris being removed manually with placenta

true

offensive odor of lochia =

infection

lochia rubra (day 1-3/4 days)

deep red mixture of mucus, tissue debris, and blood

lochia serosa (3-10 days pp)

pink to brown in color; contains leukocytes, decidual tissue, RBC's and serous fluid

lochia alba (days 10-14, could last 3-6 wks)

creamy white or light brown in color; consists of leukocytes, decidual tissue, and reduced fluid contact

if lochia stages back track...

stop and rest immediately, do not lift anything heavier than baby. drink lots of fluids. if continued they can hemorrhage and die.

causes of postpartum hemorrhage

uterine atony, retained placental fragments, cervical/perineal lacerations, subinvolution (failure of uterus to return to normal size), bleeding d/o

management of postpartum hemorrhage

fundal massage. teach woman to massage own fundus and assess bleeding. monitor CBC.

meds to stimulate uterus to contract

oxytocin (pitocin); methylergonovine maleate (methergine); misoprostol (cytotec); prostaglandin (PGF2); carboprost (hemabate)

afterpains

painful UC's due to involution caused by UC's

afterpains in multips

overdistended uterus, retained clots/placenta fragments, prolonged, difficult labor (greater afterpains)

what are afterpains stronger with?

breastfeeding due to oxytocin (strengthens UC's)

cervix

by 6 wks prepregnant state. changes in appearance (slit). gradually closes.

vagina after delivery

edematous, bruised, small lacerations that are thin, few to no rugae

vagina 3wks after delivery

mucosa thickens, rugae, stays slightly larger than pre-preg.

mucosa production and thickening of vaginal mucosa begins with...

ovulation

when should period return with a non BF mom?

1 to 3 months

when should period return with a BF mom?

average 6 months

teaching point with menstrual cycle and postpartum women

make sure they know they can get pregnant due to ovulating before menses

vaginal dryness/discomfort

until menstruation can use water soluble lubricant

perineum

pressure of descending head stretches and thins the muscle of pelvic floor, edematous, bruised. hemorrhoid distended rectal veins are pushed out.

episiotomy

edges of the incision should be approximated, ecchymosis. inspection with sim's position. may take 4-6 months to heal with episiotomy/laceration

REEDA

redness, edematous, ecchymosis, discharge, approximate

perineum incision pain may persist as long as

5-6 wks to 4-6 months

edema in perineal area

may be present with or without episiotomy

kegel exercises with perineum importance

improve rectal tone, strengthen perineal muscles (if not urinary incontinence is possible later in life)

comfort measures

ice packs 24 hrs, wamr packs every 24 hrs. warm water over the area with peribottle. witch hazel pads. anesthetic sprays. sitz bath after 24 hrs (4x day). hydrocortisone cream.

witch hazel pads with hemorrhoids

can stay in place until she uses bathroom again and then remove. it shrinks them.

cardiac adaptations - CO

remains high for first few days pp, gradually decreases to nonpregnant values within 3 months of birth

cardiac adaptations - blood volume

increases substantially during pregnancy, drops rapidly following birth and returns to normal within 4 wks pp (also diuresis)

blood loss for vaginal delivery

500 ml

blood loss for c-section

1000 ml

the increase in cardiac output, diminishes after birth; this decrease is reflected in...

bradycardia (40 to 60 bpm) for first 2 wks.

if tachycardia noted consider...

hypovolemia, dehydration, hemorrhage

cardiac adaptations - BP

decreases first 2 days, then may have slight increase days 3-7, returns to pre-preg by 6 wks.

if elevated BP and H/A consider...

preeclampsia, which can still be present after birth

decreased BP

orthostatic hypotension or hemorrhage

cardiac adaptations - coagulation

clotting factors increase during pregnancy. elevated for 2-3 wks post partum.

coagulation combined with immobility, vessel damage during birth = risk for

thromboembolism

bladder

may be subjected to trauma that results in edema and diminished sensitivity to fluid pressure. can lead to over distention and emptying and incomplete emptying, may have difficulty voiding the first 2 days.

hematuria

early PP period reflects trauma, later may be UTI

acetone denotes...

dehydration after prolonged labor, decreased bladder capacity during pregnancy due to decreased muscle tone.

diuresis

usually begins within 12 hours after delivery which eliminates excess body fluid, continues for 1 wk. normal by 4 wks.

what decreases effects of diuresis?

oxytocin (antidiuretic effect)

GFR

renal plasma flow normal within 6 wks

factors impending urination in the postpartum women

perineal lacerations. generalized swelling and bruising of the perineum and tissues surrounding the urinary meatus. hematomas. decreased bladder tone d/t regional anesthesia. diminished sensation of bladder pressure d/t swelling, poor bladder tone, and numbing effects of regional anesthesia used during labor.

difficulty voiding - urinary retention

major cause of uterine atony, which causes excessive bleeding. frequent voids of small amts (<150 ml). cath may be needed.

difficulty voiding - bladder distention

inhibits UC. increased risk for pp hemorrhage.

management of difficulty voiding

early ambulation; void within 4-6 hrs after birth, using nursing tricks to stimulate voiding

gastrointestinal

normal bowel function is interrupted in first week d/t decreased mobility. pain meds, low fiber diet, fluid loss and perineal discomfort.

normal bowel function usually reestablished

by end of 1st wk as fluids increase, decreased progesterone and perineal discomfort decreases.

nursing measures for GI

appetite, bowel function, stool softeners, early OOB, dulcolax supp. or fleets enema if needed

appetite

early PP increased appetite, provide snacks and fluids as needed between meals

bowel function

listen BS q shift, ask about passing flatus. high fiber diet and 300 ml of fluid intake.

stool softeners

Docusate sodium (colace) to decrease discomfort. always offer, especially with lacerations.

musculoskeletal

hormones decrease (relaxin, estrogen, progesterone). all joints return to normal within 6-8 wks except feet. fatigue, activity intolerance, distorted body image. careful to prevent low back pain, joint injury until stabilized. may have separation of rectus abdominis muscle (diastasis recti, d/t stretching, loss of tone)

separation of rectus abdominis muscle (diastasis recti) can be corrected with...

exercise

true or false - there is a permanent increase in shoe size

true

integumentary system applications

darkened pigmentation on the abdomen (linea nigra), face (melasma), and nipple fades. some women experience hair loss during pregnancy and pp periods. stria gravidarum gradually fade to silvery lines. profuse diaphoresis is common.

profuse diaphoresis is seen especially

at night during first wk. it reduces fluid levels to pre-pregnancy state.

respiratory system

remain in normal range. anatomic changes back to pre-pregnancy state. SOB relieved.

neurological system

chills/tremors; self limiting and normal

quick drop of what hormones?

estrogen and progesterone, hCG, hPL

lower estrogen

breast engorgement

estrogen increases 2 wks after birth for non BF or BF moms?

non BF moms

estrogen with BF moms?

increases when frequency of feedings decrease

after first menses

progesterone production reestablished

prolactin

stays elevated BP, drop within 2 wks non BF mom

lactation

secretion of milk by the breast

causes of lactation

interaction of progesterone, estrogen, prolactin, and oxytocin

occurrence of lactation

typically appears 3 days after the childbirth experience

engorgement

process of swelling of breast tissue d/t an increase in blood and lymph supply as a precursor to lactation

colostrum (pre-milk)

thin, yellow color. easily digested. protein and carbohydrates. no milk fat.

breast milk

after estrogen/progesterone levels drop. 2-3 days after birth.

prolactin stimulates glandular cells to what?

secrete milk

oxytocin acts so milk is....

ejected from alveoli to nipple

what is breast milk stimulated by?

sucking (releases milk)

engorgement s/s

hard, tender to touch

engorgement management

frequent emptying of breasts, also helps with discomfort. warm shower and compresses.

maintain milk supply

nursing infant, breast pump, manual expression

is a low grade temp < 101 uncommon?

no (should not last more than 24 hours)

lactating women

menses developed on BF frequency and duration. 3-18 months after birth. depends on exclusive BF vs supplementation.

non-lactating women

Menstruation begins 7-9 weeks after birth but could take up to 3 months

first pp menses

usually heavier

can ovulation occur before menses?

yes

weight loss occurs d/t

rapid diuresis and lochia flow