POST PARTUM
Lecture 8
Puerperium: “to bring forth” 6 wk > childbirth.
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“4th trimester” - transition for woman/family
(pregnancy ends/parenting role begins)
I. Physiological Changes of Post Partum Period
A. Reproductive System Changes:
UTERUS: contx’s begin > birth & delivery of placenta
1. placental site seals
2. Entire uterus contracts & reduces gradually for 8-10
days. “INVOLUTION”. Pt. in danger of hemorrhage
uterus until involution is complete.
Oxytocin released > uterine contx’s.
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Fundus: assess for firmness. Palpate > delivery.
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Remains @ umbilicus X 24 hrs. Soft aka “boggy” danger of hemorrhage.
Massage uterus!
Uterus descends one finger breadth every day.
 Delivery day, uterus @ umbilicus
 1st day PP uterus 1 FB ↓ Umbilicus
 2nd day PP uterus 2 FB ″ and so forth.
 Support lower segment of uterus when palpating
to prevent uterine eversion.
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By day 10, uterus almost back to pre-pregnant
size & position in pelvic cavity. [1000 grams→ 50
grams] No longer palpated in abdomen.
Full bladder raises fundal height, gives false
reading.
Natural oxytocin released with breast feeding. ^
contractions . 2FB ↓ umb. on 1st day PP.
Breast fdg.offers little protection against hemorr.
Delay in uterine involution: retained placenta/clots effective contraction of uterus not possible. Risk of PP
Hemorr.
Delay also with:
 multiparous pt. [grand multip ]
 exhaustion
 multi-fetuses.
 C/S involutes slower; d/t surgery & less initiation of
breast feeding > delivery.
After-birth pains = cramping caused by contractions
 more in multi-parous women than in primips .
 With Br. Fdg. because of release of oxytocin.
2. LOCHIA
 Placenta separates from spongy layer of uterus decidua BASALIS.
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Inner layer of decidua remains & forms new layer of
endometrium . Outer becomes necrotic & sheds.
Consists of blood, fragments of decidua, mucus,
bacteria.
1st 3 days = rubra =”red” [blood]
>3 days = serosa = “pink”
10th day – alba - “white” [up to 3 wks]
Total flow lasts about 4-5 wks
Should not be bright red; could be PP hemorrhage.
3. CERVIX
 Neck; remains slightly opened & contracts > delivery.
 In 7 days, opening narrow as pencil. Os remains slit-like .
4. VAGINA
 Slightly distended after birth. Kegel exercises ^muscle
tone and strength. Important for lacerations.
5. PERINEUM
 Can be edematous/ecchymotic
 Ice x 24 hrs. then heat [Sitz]
 Topical anesthetics creams/sprays apply for comfort.
 Perineal massage relaxes perineum before delivery.
May prevent episiotomy/laceration.
Teach Kegels - tightening & releasing of perineal muscles.
Improves circulation & healing of epis/lac.
Complications of Perineum:
 Hematomas [blood from bleeding vessel]
 Area of swelling on one side of perineum.
 If small, absorbs in few days; apply ice &
give analgesics.
 If large bleed, to OR for evacuation &
vaginal packing.
 Common - forceps deliveries
 Perineal Care - use warm water; wipe
from front to back.
Laceration
 size of baby, timing of delivery, tension on perineum.
 Sutured & treated as episiotomies.
 Analgesics, ice, topical creams, Sitz bath.
 1st degree = from base of vagina to base of labia
minora.
 2nd “ = from base of vagina to mid perineum
 3rd = entire perineum to anal sphincter
 4th = entire perineum through anal sphincter & some
rectal tissue.
 Nothing into rectum - no rectal temps., suppositories, or
enemas with 4th degree to avoid further damage.
 Colace TID, ^ po fluids to promote BM. Ice X 24 hrs.,
Sitz baths TID; topicals. KEGELS!
SYSTEMIC CHANGES - Body returns to
pre-pregnant state by 6 wks.
Hormonal System:
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Pregnancy hormones decrease w. delivery of
placenta.
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HCG & HPL disappear by 24 hrs. FSH rises
12 days - to begin new menstrual cycle.
Menses resumes by 4-5 wks. if not Br. Fdg.
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The Urinary System:
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Loss of bladder tone d/t swelling & anesthesia ;
urinating difficult. May not feel urge to void.
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Hydronephrosis [enlargement of ureters] occurs after
delivery & to 4 wks. PP. DIURESIS!
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↓ bladder sensitivity - ↑ risk for bladder infection urinary stasis.
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Avoid bladder damage - assess bladder q 1-2 hrs.til
voids qs. Teach voiding q 2 – 3 hours.
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Palpate abdomen gently, note location of fundus.
When do you suspect full bladder?
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During preg., 2000-3000 ml. of fluid accumulates in
body - Client loses 5- 10 lbs. of water weight in 1st
wk.
How?
Circulatory System: Blood volume ^ 30 – 50% in
pregnancy.
With diuresis & blood loss @ delivery, blood volume
returns to normal in 1-2 wks.
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Blood loss for NSVD = 300 cc. & C/S = 500 cc.
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Non pregnant: HCT=37 - 47% & HGB=12 - 16g/dL
Pregnant: HCT=32 -42 % & HGB = 11.5 – 14g/dL
HCT drops by 4 pts. & HGB drops by 1 g. for every 250cc.
of blood client loses.
Patient should not be anemic entering delivery
Possible blood transfusion with large blood loss.
Average blood volume: pre-pregnant = 4000cc;
pregnant state = 5250cc.
^ Blood volume: provides adequate exchange of
nutrients in placenta & compensates for blood loss
during delivery.
 HR remains ^ x 24-48 hrs. PP
 With diuresis, HCT levels rise [^ hemoconcentration]
reach pre-preg level by 6 wks.
Plasma fibrinogen ^^ 50% during pregnancy & remains
elevated 6 wks. PP. [^ estrogen levels] WHY?
Can cause ^ thrombus formation.
 Assess pts. legs/calves for s/s thrombus.
 Rise in leukocytes; WBC ^ protective measure to
prepare for stress of delivery. As high as 20-25,000.
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Gastrointestinal System:
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NSVD: bowels sounds. Eat right away.
C/S: bowel sounds hypoactive 1st 8 hrs.
Epidural/spinal: po clears after delivery, advance diet if
+BS.
General anesthesia: usually NPO for ~ 6-8 hrs.
Duramorph/astromorph can cause N/V up to 12 hrs.
antiemetic meds. [Reglan/Zofran] .
BM - difficult/painful d/t lacerations/hemmorhoids.
C/S - BM 3rd - 4th day. GI activity slowed d/t surgery.
Can go home without BM if + flatus.
Integumentary System: Stretch marks
[striae gravidarum] appear reddened on
abdomen. Fade by 3-6 months;
Pearly white marks may remain in lighter
skinned pts. & darker marks in darker
skinned pts.
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Modified sit-ups strengthen abdomen
VITAL SIGNS PP
Temperature: slightly ^ - dehydration during labor 1st 24
hrs. Returns to normal within 24 hrs.
 T = 100.4 or > PP infection suspected.
 Temp. also rises 3rd - 4th day with filling of breast milk
 Observe for s/s infection - nurse usually 1st to detect ↑
temp. [universal sign of infection 100.4 x 2 readings, on
days 2-10 PP]
Pulse: HR ^ slightly x 1st hr.
 Stroke volume & cardiac output also ^ x 1st hr. then
decreases
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8-10 wks.,returns to pre-pregnant state.
Rapid, thready pulse- sign of PP hemorrhage, infection
Blood Pressure - Monitor carefully.
1st trimester
Heart works faster to handle ^ volume. BP remains same.
2nd trimester
BP drops slightly d/t lowered peripheral resistance in blood
vessels as placenta expands rapidly. Heart beats faster,
more efficiently d/t ^ blood volume.
Pre-pregnant BP 120/80. Pregnant BP 114/65.
3rd trimester
BP back to pre-pregnant value.
BP Complications
↓ BP
[90/60 or less] with dizziness is “Orthostatic hypotension”;
could signify hemorrhage.
 Take BP/pulse lying/sitting/standing. Compare values.
 Orthostatic: If BP drops 15-20 mmHg and pulse increases 20
bpm or more. Caution for falls.
 Needs IV fluids. Take VS. Report to MD > order for CBC.
↑ BP
[140/90 or >] could signify PP pre-eclampsia.
 Notify MD. Could develop into serious complication.
 Oxytocic meds [Pitocin] > delivery could ^ BP
Other Changes
Exhaustion:
 Common
 Frequent rest periods
 RN coordinates nursing care & infant feeding times
 provide maximum rest time.
Weight Loss:
 Average wt. loss 12 lb. [infant & placenta]
 5 lbs. - diuresis & diaphoresis in wk. that follows.
 Lochial flow - 2-3 lbs.
 Total = approx. 19-20 lbs. {depends on total wt. gain}
 At 6 wks. wt. may still be above pre-preg. weight.
Return of Menses: > delivery FSH levels rise causing ovulation
 No Br. Fdg.- menses resumes ~ 6 wks.
 Lactation delays menses for several months (6 mos)
PSYCHOLOGICAL CHANGES OF POST PARTUM PERIOD:
ADJUSTMENTS
Taking-In Phase:
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time of reflection for client regarding new role
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may be passive or excited
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talks at length about birth experience
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on phone with family/friends recounting birth
experience.
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Usually lasts 1-2 days.
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Delayed d/t pain r/t vaginal or C/S.
Taking-Hold Phase:
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woman makes own decisions regarding self & infant
care.
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Usually day 2 - 3. Occur on day 1 esp. if woman is
multip.
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Can occur later, depends on recovery process or
cultural beliefs.
Letting Go Phase:
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Woman gives up fantasy image of baby and accepts
real child.
Occurs within few weeks of getting home
Needs time to adjust to new experience.
Bonding:
 Expressing maternal love & attachment toward new
baby. Develops gradually.
 Enface position: close eye contact with infant.
 Healthy bonding - kissing, touching, counting fingers &
toes, cooing, etc.
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Factors Interfering with Bonding: difficult labor,
separation @ birth (NICU)
Other Maternal Feelings of Post Partum Period
Abandonment: feelings that occur > birth of child;
woman no longer center of attention.
 Disappointment: infant does not meet
expectations of mother/father. Eg. eye color; sex .
 Post Partum Blues: d/t normal hormonal changes;
Drop in estrogen/progesterone; lasts 1st few days of
PP period. Occurs in 50% of women.
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PP Depression: 30% of women exp. this.
 Therapy & medication may be necessary.
 Hx of depression & anxiety prior to pregnancy
puts mother @ higher risk for developing this.
 Can manifest itself up to 1 year > birth.
 Screening tool: Edinburgh PP depression tool
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Always refer to social worker to assess for degree of
depression.
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Ask: is mother able to take infant home without danger
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to self or baby?
Studies show breast feeding helps reduce symptoms d/t
oxytocin “feel good” effect
MANIFESTATIONS OF POSTPARTUM
DEPRESSION
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 interest in surroundings
 interest in food
unable to feel pleasure
fatigue
health c/o
sleep disturbance
panic attacks
obsessive thinking
 hygiene
 ability to concentrate
odd food cravings
irritability
rejection of infant
PPD: Teaching
 relaxation therapy
 rest & nutrition
 frequent contact with other adults
Resource:
The Post Partum Resource Center of New York, Inc.
631-422-2255 www.postpartumNY.org
MANIFESTATIONS OF POSTPARTUM PSYCHOSIS
 s/s depression
 s/s manic
 auditory hallucinations
 delusions
 guilt
 worthlessness
Development of Parental Love & Positive
Family Relationships:
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Rooming In: most hospitals offer this; infant stays in
room with mom 24hrs. (partial or complete)
Sibling Visitation: encourage siblings to visit to promote
family togetherness.
LACTATION & BREAST FEEDING
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Lactation starts regardless if pt. is
breastfeeding or not.
Entirely up to mother
Must feel comfortable doing so.
Advantages to Breast Feeding:
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Promotes bonding between mother & baby.
High nutritional value for infant.
Promotes uterine involution thru release of
oxytocin from posterior pituitary.
Reduces cost of feeding & preparation time.
Nurse has major role as educator of benefits & methods of
breast feeding.
Ways to teach new moms about lactation:
videos
handouts
hands on demo
lactation specialist [in clinical settings]
Offer support
Contraindications to Breast Feeding:
 Mom receiving meds not appropriate for Br. fdg.
[Lithium]
 Exposure to radioactive compounds [thyroid testing];
pump & dump breast milk x 48 hrs. Flush in toilet.
 Breast Cancer; HIV
Physiology of Lactation
Body prepares for lactation during pregnancy; stores fat
& nutrients; provide energy, vitamins, minerals in breast milk.
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Early pregnancy, ↑ estrogen (placenta) stimulates growth
of milk glands & size of breasts.
Colostrum: middle of pregnancy & day 1-3 PP,
Thin, watery pre-lactation secretion. Rich in antibodies;
passes to baby in 1-3 days.
Breasts begin to get tender; fill up w. milk.
Breast milk by 3rd to 4th day in response to:
 falling levels of estrogen & progesterone > delivery of
placenta.
 ^ production of prolactin by anterior pituitary
 Milk ducts become distended & fluid turns bluish-white
Physiology cont.
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Infant suckling on breast produces more
prolactin, which in turn stimulates more milk
production.
Finally, oxytocin released > delivery of
placenta causing mammary glands to send
milk to nipples [let down reflex].
Progesterone levels drop after delivery which
leads to ↑ milk production.
Anatomy of Lactation
Colostrum: protein, sugar, fat, water, minerals,
vitamins, maternal antibodies.
 Provides total nutrition for infant
 Transitional breast milk by 3 – 4th day.
 Mature breast milk by 10th day.
 Each breast - 15-20 lobes of glandular tissue -alveoli.
 Acinar or alveolar cells of glands form milk.
 Each alveolus ends in a ductule.
 Each alveoli produces milk, ejects it into ductules aka
let down reflex; milk transported to lactiferous sinus
and ejected into infant’s mouth.
Pathway of Droplet of Milk:
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Milk → mammary ducts → reservoirs behind nipples
[lactiferous sinuses] → infant’s mouth
Foremilk: constantly accumulating.
“Let-down reflex” –lets foremilk be available right away.
 Triggered by sound of baby crying
Hind milk: forms after let-down reflex. Has most calories;
Feed until breast empty.
Breast Milk: Provides complete nutrition for 1st 6 mos of life.
 > 6 months, iron-fortified cereal.
 Breast milk easier to digest than formula.
 Iron in breast milk absorbed better than iron in formula.
Supply & Demand Response - Every time woman breast
feeds, more prolactin produced which then produces ^milk.
 Time Interval to ↑ milk volume. It takes approx. 30-60
min. to fill up breast after nursing.
Assessment: Antepartum Changes
 Breasts enlarge [each breast gains ~ 0.5 - 0.9 lb. or
more]
 Glands enlarge
 Increased blood flow to breasts, causing blood vessels to
enlarge & become more visible.
 Areola [dark circle around nipple] enlarges and darkens
 Small bumps on areola [Montgomery’s tubercles] enlarge
and produce oils to soften nipples and keep them clean.
 Teach moms no soap on nipples;may ^ irritation.
 Lanolin; tea bags [wet] [tanic acid] on sore nipples.
Common Problems:
Engorgement : milk enters on 3rd - 4th day; C/S - prior to D/C
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breasts hard, painful to touch.
Warm soaks, hot showers, express milk manually, breast feed q 2-3
Pumping produces more milk. Cabbage leaves; diuretic property.
nursing bra.
tight bra and ice packs x 24-36 hrs– why?
Analgesics [Tylenol 650 mg. q 4 - 6 hrs.prn]
Sore/Cracked/Bleeding Nipples
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Common - from improper positioning or not enough areola in
infant’s mouth; may continue to feed; up to mom. Reposition infant.
Reattempt nursing.
Rest the nipple; apply lanolin ointment prn.
Apply tea bag [tanic acid] natural healing property.
Plugged Duct
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firm nodule under arm; temporarily blocked
duct; relieved by infant sucking. Evaluate
carefully since may be malignant growth. Warm
compresses prn.
Mastitis –
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“inflammation”; milk duct/gland becomes
infected. Poss. antibiotic therapy. Manual
expression, continue to breast feed, frequent
warm compresses.
Nursing Care : Promote successful breast feeding:
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Encourage first feeding [L&D, PP; establish pt’s.
desire to breast feed]
Emptying of breasts ~ 20 minutes
Teach: start on breast where she left off - maintains
good supply.
Rest, relaxation, ↑ fluids by four 8 oz glasses/day.
Not enough fluids, ^ anxiety may lower milk production.
Nutritional Counseling: ^ 500 calories/day.
Health Teaching
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Rooting – sign of hunger
Breast feed q 2-3 hrs. for 20-30 minutes
Teach “latching”: nipple and part of areola to prevent
nipple irritation. Listen for swallowing.
Nursing Bra
Feeding & Burping [bottle fed infants] upright position
Nipple care: no soap; nipple creams -Lansinoh
Avoid drugs, alcohol, smoking
FORMULA FEEDING
Feeding Skills
 Position upright position- support head and shoulders]
 Formula [Similac, Enfamil, Isomil; all have iron]
 milk or soy based
 Burp
Safety Tips
 never prop bottle; choking or ear infection.
 ^ amt. ½-3/4 oz./day; feed q 3 – 4 hrs. x 24 hrs.
Discharge Follow up:
 Telephone calls & home visits [if needed]
 Help line; Support groups [La Leche]
NURSING MANAGEMENT OF POST PARTUM CLIENT
Assessment – minimum of twice daily
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Vital signs
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Emotional Status
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Breasts
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Fundus, lochia, & perineum
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Voiding & bowel function - flatus, BM
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Legs [+ Homan’s sign, ankle edema ]
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S/S complications [PP hemorrhage, infection, ↑ BP ]
Nursing Care
Safety
 Prevent hemorrhage- massage uterus on admission and q 4 for first
8 hrs.
 Prevent falls – assess when getting out of bed for 1st 8 hrs. Assist
when necessary. Check labs for low H&H.
Bowel function (1-3 days to resume).
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Stool softeners, as ordered [Colace]
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Encourage ambulation
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Increase dietary fiber
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Provide adequate fluid intake
Health teaching & discharge planning
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Reinforce self care -hand washing, peri care,
Self-breast exam q month; S/S PPD
Comfort Measures
Ice , Sitz Baths, Topical Anesthetics
Analgesia, Kegels for NSVD; modified sit-ups for
NSVD & C/S, Breast Care
Birth Control Plans
Family Planning options [condoms, depo, OC’s, IUD]
Exercises
Keep 6 week PP appt.
Maternal Warning Signs to Report
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a) Heavy Vaginal Discharge [poss. hemorrhage]
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b) Pelvic or perineal pain [traveling clot]
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c) Fever [temp 100.4 or greater = infection]
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d) Burning sensation during urination [UTI]
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e) Swollen area on leg ; painful, red, or hot
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f) Breast: painful, red, hot area [mastitis]
Infant care
a]
b]
c]
d]
e]
Bathing, cord care, circumcision care, diapering
Feeding, burping, scheduling feedings [mom can keep chart]
Temperature, skin color [dusky], newborn rash, jaundice
Stool & voiding [BM’s ; 6 or more voids/day]
Back to Sleep [SIDS]
Newborn warning signs:
1. Diarrhea, constipation
2. Colic, repeated vomiting esp. projectile vomiting
3. Fever [temp. 100.0 Rectal or greater]
4. S/S inflammation/ infection @ cord stump [yellow drng.]
5. Bleeding @ circumcision site
6. Rash, jaundice
7. Deviation from normal patterns [long period of sleep >5 hrs.; projectile
vomiting, etc. R/O sepsis; intestinal obstruction]