Ch 15: Postpartum Adaptations

puerperium/pp period

from the delivery of placenta till about 6-8 weeks & includes the changes that occur in all aspects of birthing

attachment

emotional bond between parent & newborn within weeks & months after birth

engorgement

temporary painful swelling of breasts caused by increased milk production, blood, & lymph fluid

cervix changes pp

extends into vagina & is bruised, edematous, & shapeless right after birth

when does the cervix return to normal?

6 wks

how is the os affected during birth?

the external os turns jagged & slit-like instead of an O -> never returns to normal

uterine involution

retrogressive changes that return uterus to pre-pregnancy size & weight

how can you tell if uterine involution is progressing?

noted by firm fundus along midline upon palpation

what level is the fundus at within 12 hours PP?

lined up w umbilicus

uterine descent timeline (3)

1. descends from umbilicus at 1 cm/day

2. halfway descent at 6 days

3. complete descent into true pelvis at day 10

1st retrogressive process of uterine involution

contraction of muscle fibers to decrease stretch

2nd retrogressive process of uterine involution

catabolism -> shrinks enlarged myometrial cells

3rd retrogressive process of uterine involution

regeneration of uterine epithelium from lower layer as upper layers are sloughed off during lochial discharge

subinvolution

failure of uterus to return to non-pregnant state caused by ineffective uterine contractions

*generally responsive to early dx & tx

most common causes of sub-involution (4)

- retained placental fragments*

- PP inf (endometriosis)*

- uterine atony

- prolonged labor

uterine atony

soft boggy uterus & inhibits involution of BV at placental site -> no contractions causing bleeding

afterpains

constriction of myometrial BV, impeding BF & causing uterine contractions -> prevents hemorrhage

what can uterine atony lead to?

PP hemorrhage

pain management for afterpains

oral analgesics -> ibuprofen & acetaminophen

what can worsen afterpains? (3)

- multiparous

- breastfeeding

- adm of exogenous oxytocin

lochia

vaginal discharge that occurs after birth for 4-6 weeks -> blood, mucus, & uterine tissue

how does lochia present?

progressive lightening of color & amt -> reflects good progress

1st phase of lochia

lochia rubra -> bright red & days 1-3 PP

2nd stage of lochia

lochia serosa -> pinkish brownish & days 4-10 PP

3rd stage lochia

lochia alba -> whiteish yellow & days 10-14 till 3-6 weeks

why does lochia color change?

results from changing composition of tissue sloughed off in endometrial restoration

how does lochia differ in c/s?

usually have less bc uterine debris is manually removed

lochia smell

fleshy

- if has offensive odor can indicate inf

signs of lochial bleeding (3)

- trickle from vagina

- possible gush during uterine massage

- dark color suggests pooling

signs of non-lochial bleeding (2)

- bleeding from vagina when uterus is contracted

- excessive & bright red

vaginal changes PP

endematous, relaxed, thin, & dry -> ovulation triggers mucus production

when does the vagina return to normal?

returns to approximate size around 6-8 wks & rugae return to normal thickness at 2 wks

perineum changes PP (6)

- edematous & bruised 1st few days

- hemorrhoids

- episiotomies/lacerations

- pelvic floor dys

- stretched

- typically suffers the worse

how long does it take for the perineum to fully heal?

4-6 months

how long does it take for lacerations/episiotomies to heal?

4-6 months

kegel exercises

tightening & releasing of pelvic floor muscles -> support bladder, control bowel fxn, & strengthen pelvic organs

why don't pregnant women produce breast milk during pregnancy?

high levels of progesterone & estrogen prevent production, instead makes colostrum

how does lactation work?

newborn sucking stimulates pituitary gland to release prolactin & oxytocin

prolaction fxn

causes the synthesis & release of breast milk in the breast

oxytocin fxn

causes contraction of smooth muscle around the alveoli cells in the breast -> milk ejection

what is colostrum made of?

protein & carbs

when does breast milk start being produced?

4-5 days PP

what is the golden standard to initiate breastfeeding?

skin to skin contact

what occurs if breastfeeding is not attempted after birth?

milk production subsides within days

engorgement risk factors (4)

- delayed breast feeding

- poor attachment

- overabundant milk supply

- infrequent feedings

* risk for mastitis

breastfeeding support interventions (4)

- tight bra

- ice

- warm shower

- avoid stimulation

cardiovascular signs of PP hemorrhage

decreased BP & tachycardia

cardiovascular changes PP (8)

- high CO gradually decreases

- varicosities regress

- HGB/HCT stable but can increase then decrease

- WBC remain elevated for 4-6 days

- high clotting factors

- BV rapidly decrease

- BP decrease then increase

- bradycardia

urinary system changes PP

GFR & renal plasma flow increase

immediate risks after birth regarding urinary sys (4)

- incomplete emptying

- bladder distension

- difficulty voiding

- urinary retention

factors that can impede urination PP (3)

- prolonged labor

- swelling & bruising of perineum

- lacerations/episiotomy

what can urinary retention PP lead to?

uterine atony which can cause excessive bleeding

postpartum diuresis

increased urination beginning within 12 hours of PP & lasts through 1 wk

postpartum diuresis cause

increased ANP which promotes urinary sodium excretion by inhibiting aldosterone & vasopressin actions

GI problem PP

constipation

what causes constipation in PP? (4)

- analgesics

- intra abdomina pressure

- diminished muscle tone

- pain from lacerations

what is prescribed to tx constipation during PP?

stool softner

musculoskeletal changes PP

joints return to pre-pregnancy size expect for feet -> flattened arch or increased shoe size

how can you education PP women regarding activity? (2)

- correct positioning & good body mechanisms prevent back & joint pain

- specific exercises can help regain muscle tone

integumentary changes PP (4)

- hyperpigmentation fades

- PP hair loss

- stretch marks -> silvery lines

- sweating

when does PP hair loss return to normal?

around 6-15 months PP

why do PP women sweat so much?

bodys mechanism to decrease fluids retained during pregnancy

endocrine changes PP (3)

- estrogen & progesterone drop quickly

- placental hormones decline

- prolactin levels decline within 2 weeks if not breastfeeding

when do non-lactating women usually get their menstruation?

7-9 weeks

when do lactating women usually get their menstruation?

3 months

what is important to note for the return of menstruation during PP?

ovulation may occur before menstruation -> breastfeeding is not a reliable method of contraception

what might the first cycle of menstruation be during PP?

anovulatory

VS alterations PP (4)

- HR decreases to normal range

- BP WNL or orthostatic

- RR WNL

- slight temp elevation in 1st 24 hrs

rubin nursing theory: maternal role attainment (MRA)

3 phases mom goes through to adjust to new role -> used to monitor progress of adjustments

3 MRA interventions to improve PP mom experience

- care instructions are more effective when focused on particular infant

- parents prefer live classes -> ask ?s

- identify barriers of skin to skin or parent infant contact

3 MRA phases

1. taking in

2. taking hold

3. letting go

taking in phase of MRA

time immediately after birth when client needs others to meet her needs & relives birthing process

*not good time to instruct infant care

taking hold phase of MRA

caring for themselves & learning to care for newborn but still need assurance -> interest in infant care

*good time to teach infant care

letting go phase of MRA

reestablishes her relationship w others while taking care of newborn w confidence

how can nurses help partners adapt to new changes?

promote involvement & encourage active participation

engrossment

partners developing time w newborn -> intense absorption, preoccupation, & interest

3 stages of partner role development

1. expectations

2. reality

3. transition to mastery

expectations phase of partner role development

partner has preconceptions abt what home life will be like

reality phase of partner role development

expectations from stage 1 are not in line w reality -> wish to be more involved or frustrated

transition to mastery phase of partner role development

partner takes control and wants to be at center of newborns life