postpartum adaptations and nursing care

involution of the uterus

the first 6 weeks after the birth of an infant is known as the postpartum period, or puerperium

body working to return to non pregnancy state

uterine involutions involves 3 processes
1. contraction of muscle fibers
2. catabolism: decrease in size of uterine cells
3. regeneration of uterine epithelium

involution begins immediately after delivery of the placenta

decent of uterine fundus

fundus involute each day by 1 fingerbreath

immediately after delivery: fundus can be palpated midway between symphysis pubis and umbilicus and in midline of abdomen

subinvolution: involution doesn’t occur properly, can cause PPH

after pains

source of discomfort for many women

intermittent uterine contractions, cramping

common, normal occurence

pain increased with: multiparas, women who are breastfeeding bc of oxytocin

nsg interventions: analgesics, positioning/heat packs

lochia

shows if involution is occurring properly

day 1-3: lochia rubra

day 4-10: lochia serosa

day 11-21: lochia alba

teach that it should get lighter in color and amount

cervix

immediately after childbirth: dilated, edematous, bruised. internal os closes, external stays open and changed

rapid healing takes place

internal os closes, but shape of external is is permanently changed. remains slightly open, appears slit-like and round

vagina

vaginal walls: edematous, lacerations may be present

very few rugae; reappears 3-4 weeks postpartum

vaginal dryness: low estrogen levels and progesterone, dyspareunia: discomfort during intercourse

perinuem

lots of pelvic floor stretching during second stage (pushing): bruising, edema

healing:
lacerations: heal 2-3 weeks, complete healing 4-6 months. may occur during birth
episiotomy: take longer to heal than natural tearing. surgical incision of there perineal area

nsg interventions: ice packs, sitz bath, frequent pad changes, use of peribottle, topical anesthetics (witch hazel), medications (oral and topical spray, dermaplast)

resuming ovulation and menstruation

may resume before postpartum follow up appointment

consideration of contraceptive measures

non nursing: usually resume in 6-10 weeks

nursing/breastfeeding: commonly delayed bc of prolactin increase, usually resumes between 10 weeks and 6 months

cardiovascular system

transient increase in maternal cardiac output after birth
-volume increase in central circulation from placenta and uterus
-increased blood return to heart from decreased pressure on vena cava
-fluid shifts from tissues into central circulation
-cardiac output returns to prepregnancy levels by 6-12 weeks postpartum

plasma volume
-diuresis; voiding
-diaphoresis; sweating due to hormone changed. showers, dry clothing, void every 2 hours, teach normal

hematologic system

physiologic leukocytosis
-due to inflammation, pain and stress with birth
-WBC count can increase as high as 30,000
-look for other signs to rule out infection
-falls to normal values within 1-2 weeks postpartum

hemoglobin and hematocrit
-difficult interpretation due to fluid shifting and rapid excretion of excess body fluid

coagulation
-increases risk for DVT
-elevations in clotting factors up to 4-6 weeks
-early ambulation/compression stockings

GI system

lots of energy expended in labor; mom typically hungry and thirsty

constipation: common, progesterone slows motility. decreased food and fluid intake during labor, perineal trauma/episiotomy/hemorrhoids cause further discomfort
nsg interventions stool softener, fiber, fluids, ambulation

urinary system

decreased sensitivity to fluid pressure: stretching of tissues/edema associated with delivery, anesthesia, pregnancy changes cause increased capacity and less tone

overdistension of bladder and urinary retention: increased risk for UTI, postpartum bleeding

stress incontinence; kegel exercises

abdominal wall

abdomen- diminished tone: weakened muscles, soft, flabby

diastasis recti: separation of longitudinal muscles
interventions: gentle exercises to strengthen, usually returns to normal position by 6 weeks postpartum, potential surgery

integumentary system

pigment changes reverse

striae gravidarum (stretch marks)

postpartum hair loss: normal response to hormonal changes, begins at 4-20 weeks after delivery

neurologic system

fatigue common: lack of sleep, afterpains, incisional discomfort, breast engorgement

safety is priority: prevent injury from falling/fainting due to dizziness

headaches: consider characteristics. frontal and bilateral common in the first week postpartum bc of hormone changes. severe headaches not common and prompt further evaluation; blurred vision, light sensitivity, abdominal pain

rhogam

may be necessary if mom is Rh- and newborn is Rh+ and the mother is not already sensitized

should be administered within 72 hours after childbirth

rubella

administer prior to discharge to prevent from acquiring during subsequent pregnancies

okay to administer if breastfeeding

pertussis

part of Tdap

recommended in all adults in contact with infants

varicella

recommended

administer prior to discharge

postpartum assessment

important to know normal so can identify abnormal

BUBBLE HEEL

cesarean section

fundal assessment: same technique as vaginal delivery, begin anterior and deepen, mindful of where incision is placed

post operative care: incision, respiratory assessment (narcotics can decrease consciousness), assessing for DVT, IV patency, flow

teaching

handwashing every time before touching baby, bathroom

breast care:
no soaps if breastfeeding, supporting bra (no underwire), breast pads (for leaking. change often)
not breastfeeing: firm, compression bra; prevent stimulation

peri care: peribottle after each void, tucks pads, patting dry, ice packs in 1st 24 hours

when to call the doctor: fever, foul smelling lochia, large blood clots, saturating pad in 1 hour, discharge or severe pain, hot/red/painful areas on breast and legs, bleeding/severe pain in nipples, severe HA/blurred vision, chest pain/dyspnea, frequent, painful urination, signs of depression

exercise and resuming sexual activity

exercise routines may be resumed gradually as mother gains strength; pelvic tilts, walking, kegels

consideration of where mother is in healing process

sex: fatigue, pain, fear of pregnancy, feeling unattractive
individual decision
recommended to wait until follow up visit postpartum (6-8 weeks)
at least wait for no pain/bleeding/infection

psychosocial adaptations

major shifts in the family’s structure and function:

mother/father/partner: focusing on recovery and bonding with newborn and adjusting to new roles

siblings: learn to adapt; depends on age/development

the fourth trimester: first 12 weeks as the family makes the transition to parenthood and adapts to changes in the family structure

bonding

rapid, initial attraction felt by parents for their infant

unidirectional (from parent to child)

nsg interventions: encourage early touch and interaction, skin to skin contact, delay weight, measurements, medications and full assessment

attachment

process by which an enduring bond between a parent and child is developed through pleasurable, satisfying interaction

develops over time

reciprocal between parent and infant

develops with consistent caregiving, touch, skin to skin, latching during breastfeeding

nsg interventions: latching, ability to comfort, newborn’s eyes gazing and tacking parents, grasp reflex

maternal touch and behaviors

maternal touch: fingertips to entire hand, en face: eye contact; being on same level

verbal: high pitched voice, use baby’s name

nsg interventions: teach and model interactions, offer praise, identify/point out similarities

puerperal phase: taking in

mother focused on own need for fluid, food, and sleep, shares experience of birth, lasts 1-2 days

puerperal phase taking hold

mother becomes more independent, assumes her care

extends over several days

teachable

puerperal phase letting go

time of relinquishment of previous lifestyle

relinquish differences in fantasy vs reality

maternal role attainment: anticipatory stage

begins in pregnancy

involves choosing OB provider, attendance at prenatal classes, looks to other mothers

maternal role attainment: formal stage

begins at birth and lasts up to 6 weeks

guided by advice from others

gets to know newborn cues

maternal role attainment: informal stage

overlaps with formal stage-mother learns cues and then responds

more comfortable, confident, competent

maternal role attainment: personal stage

accepts role of parent; feels comfortable/confident/competent

timing varies by experience, preparation, age, knowledge, involvement of support system, delivery complications

maternal adaptations

redefined roles in family structure: communication is key

role conflict: when a person’s perception of role responsibilities differs from reality; going back to work

body image: safe weight loss; realistic expectations (should be gradual), 1 lb per week. exercise

postpartum blues

common

begins in 1st week postpartum, no longer than 2 weeks

irritability, fatigue, tearfulness, mood swings, anxiety

cause is unknown; thought to be from sleep deprivation, hormonal changes

does not affect ability to care for self or baby

nsg interventions: educate, active listening, empathy, rest, support, share feelings

process of family adaptation

partner/father: sensitive to exclusion; be sure to include in teachings. engrossment: intense fascination with baby

sibling adaption: varies by age, all need attention and love
toddlers: view as competition, may regress, fear replacement
preschool: look more than touch; talks about baby
older: adaptation is generally easier

grandparents: roles vary. proximity; how close they live. role expectations: want to be involved vs “already raised children” mentality

factors that affect family adaptation

pain and discomfort

chronic fatigue due to interrupted sleep; improves as newborn sleeps longer stretches

knowledge of infant needs; confidence with consoling, diapering, etc

availability of support system for role modeling, encouragement

expectations of newborn

prior experience with babies

infant temperament; some require more attention than others (colic)

culture

mom’s age

recent stressors (life events, family illness, multiples)