Post-Partum adaptations

Assessment & Management of the Postpartal Period

POSTPARTAL PHYSIOLOGY

UNIT VIII

### NUR 158

Objectives

Ricci Ch. 15 & 16

Upon completion of these assignments and with consideration of the PN and ADN dimensions of practice, the student will:

1. Relate pertinent assessment data to the pathophysiology of the following postpartum physical changes:
      - Uterine involution
      - Lochia progression
      - Lactation/breastfeeding
      - Cardiovascular changes
      - GI/GU changes
      - Integumentary changes
      - Musculoskeletal changes
      - Endocrine system changes
      - Psychosocial changes:
        - Bonding—parent/infant attachment
        - Postpartum blues
        - Taking-in, Taking-hold/Maternal role-attainment

2. Discuss medications commonly used in the care of postpartal childbearing women, including:
      - Oxytocic drugs
      - Stool softeners
      - Non-steroidal anti-inflammatory drugs (NSAIDs)
        - (Refer to the list of commonly used medications in Clinical Resources section in D2L)

3. Relate the concepts of evidence-based nursing practice, patient and family preferences and values, and quality improvement to the delivery of optimal health care in planning care for postpartal childbearing women and their families.

4. Discuss nursing interventions that promote safety in planning care for postpartal childbearing women and their families.

5. Differentiate between effective and ineffective verbal and non-verbal communication by the nurse as a health team member when planning care and discharge teaching for postpartal childbearing women and their families.

6. Investigate the concepts of caring, physical and mental health promotion, nursing process, and diversity as they relate to patient-centered nursing care of postpartal childbearing families.

7. Examine the importance of teamwork and collaboration in the nursing care of postpartal childbearing women and their families.

8. Discuss the nurse’s professional responsibility to identify legal standards and ethical frameworks relating to the care of postpartal childbearing women and their families.

Puerperium

• Also referred to as "The 4th trimester"

• Defined as the first 6 weeks after delivery

- Involves physiological and psychological adjustments

Involution

Definition

• Involution is the progressive changes observed in the uterus after delivery.

Process

- The uterus begins decreasing in size after delivery and will typically return to its pre-pregnant size at a rate of approximately one fingerbreadth per day for about 10 days.

Assessing the Fundus

- The fundus is assessed to evaluate the status of uterine involution.

Involution of the Uterus

Features of Involution

• Involution describes the rapid reduction in the size of the uterus and its return to the pre-pregnant state.

• Exfoliation allows healing of the placental site, which is a vital part of the involution process.

• Involution is enhanced by:
    - Uncomplicated labor and birth
    - Complete expulsion of placenta or membranes
    - Breastfeeding

  - Early ambulation

Lochia

Definition

• Lochia refers to the discharge from the uterus that occurs during the first three weeks after delivery.

Types

1. Lochia rubra:
      - Dark red discharge for the first 2-3 days.

2. Lochia serosa:
      - Pink to brownish in color, typically from 3 to 10 days postpartum.

3. Lochia alba:
      - Colorless to creamy white, usually from 10 days to 3 weeks after delivery, indicating a decrease in red blood cells.

Lochia Progression

• Lochia progression is a significant sign of healing and should decrease each day.

• Normal characteristics include:
    - A fleshy/musty odor that is not foul.
    - Lochia may be heavier in the morning and after breastfeeding or prolonged sitting.

  - Increased lochia could indicate uterine atony or cervical lacerations.

Assessing Lochia Output

• Lochia output can be categorized as follows:
     - Scant amount: Blood only on tissue when wiped, with less than a 1-inch (2.5 cm) stain on the peripad.
     - Light amount: Less than a 4-inch (10 cm) stain on peripad.

   - Heavy amount: Saturated peripad (15.2 cm).

Condition of Cervix After Delivery

• The cervix is often observed to be:
    - Spongy, flabby, formless, and bruised.
    - Changes to a thicker, firmer condition over time.
    - By the end of the first postpartal week, it remains dilated to 1 cm.

  - The shape of the cervical os changes permanently from round to elongated following childbirth.

Condition of Vagina After Delivery

• The vagina appears to be smooth and swollen with poor tone.

• Initial loss of rugae is noted and typically returns by 3 weeks postpartum.

• The labia may be looser and flabbier following childbearing.

- Kegel exercises are recommended to help improve tone by promoting contraction and relaxation of the perineum.

Perineum After Delivery

• Commonly edematous and bruised following delivery.

• May have episiotomy or lacerations.

• Recommended interventions include:

  - Application of ICE for the first 24 hours to numb the area and decrease swelling, followed by the application of heat to increase circulation and encourage healing.

Abdomen

Assessment Findings

• The abdominal area is typically round, and broad ligaments are stretched.

• The abdominal wall appears loose and flabby after delivery.

Interventions

• Postpartal exercises are advised to improve tone in the abdominal area.

• Striae may remain but can take on a silvery-white appearance, eventually fading.

Diastasis Recti

• Diastasis recti describes the separation of abdominal recti muscles (the vertical muscle along the median line) due to the enlarging uterus.

• More likely to occur in women with poor muscle tone.

- If muscle tone is not regained, it can lead to inadequate muscle support in future pregnancies, possibly resulting in backache, abdominal pain, or a pendulous abdomen.

Assessing Diastasis Recti

• To assess for diastasis recti, instruct the woman to raise her head from the bed while lying flat, which will reveal muscle separation.

- Encourage exercises to regain tone as this condition responds well to physical activity.

Breasts

Postpartum Changes

• Breasts may appear soft and non-tender initially and will secrete colostrum, which is thicker than milk and contains high protein, fat-soluble vitamins, minerals, and antibodies.

• Engorgement typically occurs 3-4 days after delivery as lactation is established, resulting in larger and firmer breasts.

Hormonal Changes

• There is a rapid decrease in estrogen and progesterone levels postpartum.

• Prolactin and oxytocin levels increase, where:
    - Sucking stimulates the hypothalamus to release prolactin for milk production.
    - Sucking also triggers the posterior pituitary to release oxytocin for milk release (the let-down reflex) and uterine contractions.

Supportive Measures

• Wearing a supportive bra is recommended.

• To stimulate lactation, encourage infant sucking; a warm shower may facilitate the let-down reflex.

- To suppress lactation, suggest avoiding breast stimulation and using a breast binder; ice application may alleviate discomfort associated with engorgement.

Fun Fact about Breastmilk

• The average milk production increases over time as follows:
    - 1st week: 6 to 10 oz.
    - 1-4 weeks: 20 oz.

  - After 4 weeks: 30 oz. (based on the infant’s needs and growth spurts).

Ovulation and Menstruation

Effects of Hormonal Changes

• The return of ovulation and menstruation varies among postpartal women due to decreased estrogen and progesterone levels after delivery.

• Menstruation typically returns between 6 and 10 weeks for non-lactating mothers, with ovulation resuming within 6 months.

- For breastfeeding mothers, the return of menstruation and ovulation is prolonged, which correlates to the duration of breastfeeding and the frequency of daily feedings.

GI System/Elimination

Postpartum Effects

• The intestines may be sluggish due to lingering effects of progesterone and decreased muscle tone, leading to potential delays in spontaneous bowel movements for several days postpartum.

• Mothers may experience discomfort associated with perineal tenderness or fear of tearing from an episiotomy.

• Stool softeners are commonly prescribed to prevent constipation following delivery.

C-Section Patients

• Clear liquids are administered initially and advanced as tolerated, dependent upon positive bowel sounds.

• Assessment for abdominal distension is critical as gas may cause pain; anti-flatulent medications may be provided.

- Patients should avoid using straws and chewing gum.

Urinary System

Common Postpartum Concerns

• Overdistention of the bladder is common due to increased capacity, swelling, bruising around the urethra, and decreased sensation of pressure.

• Increased output is expected (diuresis and diaphoresis) for the first 24 hours postpartum.

- A full bladder can displace the uterus, potentially leading to urinary retention and increasing the risk of postpartal hemorrhage.

Musculoskeletal System

Importance of Activity

• Early ambulation is encouraged to prevent thromboembolic issues and to promote uterine involution.

• Warning signs to monitor include:
    - Tightness or aching in lower extremities that is relieved by rest and elevation.
    - Edema in affected legs.
    - Warmth or tenderness in legs.

  - Presence of low-grade fever.

Integumentary System

• Gradual decrease in melanin levels occurs, leading to a reduction in hyperpigmentation.

- Visible vascular changes diminishes as estrogen levels decrease.

Cardiovascular System

Expectations After Delivery

• Transient bradycardia (40-70 bpm) is expected within the first 24-48 hours postpartum.

• Normal pulse rates during the first week can range from 60-80 bpm.

• Blood volume decreases toward pre-pregnant state.

- Blood pressure should be compared with the usual baseline; typically remains consistent with levels noted during labor.

Blood Values

• White blood cell count may elevate post-delivery (leukocytosis), ranging from 15,000 to 20,000.

• Activation of clotting factors can predispose women to thrombus formation, with risk lasting about 6 weeks post-delivery.

- The hemostatic system typically returns to a non-pregnant state within 3 to 4 weeks postpartum.

Vital Signs

Clinical Importance

• Temperature: A reading of 100.4 or higher on any two of the first 10 postpartum days (not necessarily consecutive) following the first 24 hours can indicate infection.

• Blood Pressure: Assess against patient’s normal ranges (85/60—140/90 as min/max).
    - Report any elevation from normal range (may signal gestational hypertension).
    - Report any decrease from normal range (may indicate blood loss, dehydration, or orthostatic hypotension).

- Pulse may be slow (40-70 bpm is common) due to decreased vascularity, diminished cardiac strain, and increased stroke volume.

Expected Blood Loss

Delivery Types

• Vaginal delivery: 200-500 mL

• Cesarean delivery: 500-1000 mL

- It is critical that all blood loss is quantified (measured) within the first 24 hours postpartum.

Shaking/Chills Post-delivery

Common Causes

• Shaking or chills in the immediate postpartum period may arise from vasomotor changes or neurological reactions, provided they are not accompanied by fever.

- Offer a warm blanket and reassure the patient that this response is temporary.

Afterpains

Description and Management

• Afterpains are painful uterine contractions, usually related to oxytocin.

• They may be more intense in multiparas (due to an overdistended uterus) and breastfeeding women (oxytocin release).

• Treatment options include:
    - Oral analgesics (NSAIDs) post assessment of uterine firmness.

  - Rocking or similar activities may also provide relief.

Care after Surgical Delivery (Cesarean Birth)

Assessment and Nursing Care Post-op

1. Assess uterine tone and lochia flow every 15 minutes for the first hour, then every 30 minutes for the next hour, and finally every 4 hours once stable.

2. Encourage deep breathing exercises using the incentive spirometer.

3. Assist with and teach perineal care.

4. Inspect abdominal dressing and document any drainage.

5. Check patency of IV line and ensure rate of infusion is correct.

6. For regional anesthesia, assess the return of sensation to the lower extremities.

7. Monitor urine output for consistency, amount, and color, as well as bowel sounds.

Preventing Complications

Nursing Strategies

• Promote venous return by encouraging early ambulation; sequential compression devices should be removed when the patient begins ambulating.

• Early ambulation, with assistance, should begin once the patient regains sensation.
    - This practice promotes peristalsis and prevents respiratory and cardiovascular complications.

• Comfort Measures:
    - Ensure effective pain management, teach splinting of the incision, and encourage prompt reporting of pain.

  - Auscultate for bowel sounds and assess for abdominal distension.

The Critical First Hour After Delivery

Assessment Focus

1. Check the fundus.

2. Inspect the perineum for visible bleeding.

3. Monitor vital signs closely, observing symptoms of hemorrhagic shock as hemorrhage is often most prevalent within the first hour post-delivery.

Postpartum Assessment

“BUBBLE-EE” Framework

• Breasts

• Uterus

• Bowels/Bladder

• Lochia

• Episiotomy/Perineum/Epidural

• Extremities

- Emotional Status

Breast and Uterus Assessment

Procedure

• For breasts:
    - Assess whether the mother is breast or bottle feeding.
    - Inspect nipples and palpate for engorgement or tenderness.

• For the uterus:
    - Determine the firmness of the fundus and ascertain its position.

  - Correlate the fundus position with the expected descent of approximately 1 cm per day.

Bowel, Bladder, Perineum, and Extremities Assessment

Procedure

1. Assess for frequency, burning, or urgency of urination.
      - Palpate for bladder distention or monitor Foley output for cesarean sections.

2. For bowel, assess bowel sounds, flatus, and abdominal distension.

3. Inspect the perineum for REEDA (Redness, Edema, Ecchymosis, Drainage, Approximation).

4. For cesarean sections, inspect abdominal incisions for REEDA.

5. Assess for hemorrhoids in the perineal area.

6. Extremities:
      - Evaluate for edema, redness, and warmth.
      - Check Homan’s sign per hospital protocol.

   - Apply sequential compression devices post-operatively until the patient is ambulatory to prevent venous stasis.

Emotional Status Assessment

Important Observations

• Observe how the mother interacts with her newborn and family members/support persons.

• Assess bonding behaviors:
    - Facilitating close contact (skin-to-skin) should be promoted immediately after delivery, regardless of delivery type.

  - Encourage and foster attachment between the infant and parent(s).

Common Questions from Postpartum Mothers

Typical Concerns

• Questions may include:
    - “Why do I have a gush of blood the first time I get up in the morning?”
    - “Is it normal to pass blood clots?”
    - “Why do I have night sweats?”
    - “I am cramping like when I have a period. Is this ‘afterpains’?”

  - “Why is my stomach still large? Will I lose all this baby weight?”

Concerns and Explanations

Possible Explanations