Chapter 21
Normal Puerperium

It is the period of recovery that occurs from
childbirth and extends for 6 weeks after delivery
What is involution?
Reproductive System
Changes
The Uterus

What are the three ways that
the uterus involutes?
Contraction of the Uterus
Muscle
fibers become shorter
controlling the bleeding by
compressing and sealing off blood
vessels –
Acting as “the living ligature”
Protein Material Catabolism
 Release
of a proteolytic enzyme into the
endometrium and myometrium.

This enzyme breaks down the protein
material in the hypertrophied cells causing
the uterine muscle cells to decrease in size

The uterus gradually decreases in size as the
cells grow smaller
Regeneration of the Endometrium
– the placenta site heals in about 6 weeks with
the other part healing in 3 weeks.
– Heals by exfoliation rather than by forming
scar tissue.
– The endometrium grows from the margins of
the placental site and from the fundi of the
endometrial glands left in the basal layer of
the placental site
Critical Thinking
Why does the uterus heal by
Exfoliation
and not by
primary intention?
Uterine Changes
Placement and size
– Where is the normal placement of the
uterus immediately after birth, 12 hours
later?
– What is the size of the uterus?
Uterus
What nursing intervention
should the nurse encourage
PRIOR to
assessing the fundus?
Uterine Changes
 What
 What
is the normal tone of the uterus?
is the technique used to assess the
uterus?
Uterine Involution
 What
is the PRIORITY intervention when
the uterus is found to be boggy?
 Why
is it important not to over-stimulate
the uterus?
Uterus
What
interventions
must the nurse
include if the
uterus is found
deviated from
midline?
Short Answers

The nurse is going to assess the uterus. The 3
main assessments include:
1.
2.
3.

The normal height of a first day postpartum
woman is ________________. It should decrease
_____fingerbreadth per _______.

The tone should be __________. If found boggy,
the nurse would ___________ the uterus.
Lochia

What are the three types of lochia?

What is a normal amount?

What question is important to ask
the woman when assessing amount?

What is normal odor of Lochia?
Characteristics of Lochia
 Should
not be excessive in amount
 Should never have an offensive odor
 Should not contain large pieces of
tissue
 Should not be absent during the first
3 weeks
 Should proceed from rubra -- serosa
-- alba
Match the Lochia

Lochia rubra

Lochia serosa

Lochia alba
A. Pinkish serum with mucus
and debris usually occurs
on day 3 - 10.
B. Creamy yellowish
brownish. Occurs after day
10
C. Dark Red and consists
mainly of blood. Occurs
day 1 - 3.
Fill in the Blank

Lochia should never be ______________ in amount.

Lochia should never have an ______________odor.

Lochia should not contain __________ _________ of tissue

Lochia should not be _____________ during the first ________
weeks

Lochia should proceed from _________ to _________ to
___________.
Cervix
 Remains
soft and flabby, appears bruised
and may have some lacerations
 No
longer does the external os have the
pre-pregnant appearance -- now appears
as a jagged slit not a circle.
Vagina
 May
be edematous and bruised.
 Rugae begin to appear when ovarian
function returns.
 May teach the mom to do Kegels
exercises to increase the blood flow to the
area and aid in healing
Perineum

Assess:
the episiotomy the same as with any incision.
–
–
–
–
–
R – redness
E – edema or swelling
E – ecchymosis or bruising
D – drainage
A – approximated
How should the nurse assess
the perineum?
What are measures to
teach the mom in
caring for the
perineum?
Comfort Measures
 Relief
–
–
–
–
of Perineal Discomfort
Ice packs
Topical agents
Perineal care
Sitz bath
 Relief
of hemorrhoidal discomfort
may include
– Sitz baths
– Topical anesthetic ointments
– Witch hazel pads
Ovulation and Menstruation
 When
does Menstruation generally
return?
 Return
is prolonged for the
breastfeeding mom because of
alterations in the gonadotropin-releasing
hormone production.
Ovulation and Menstruation
Nurses
need to teach moms that
breastfeeding is NOT a reliable
means of contraception.
WHY
Breasts

Allow the mother to assess her own breasts -similar to doing a self-breast exam
– ask if feels any nodules, lumps
– ask if nipples are sore, reddened, blisters,
cracks
– Assess nipples for everted, flat, inverted

Teach to care for breasts according to whether
they are breastfeeding or bottle feeding.
Process of Lactation


Sucking of infant stimulates the nerves
beneath skin of the areola to transmit
messages to the hypothalamus
Hypothalamus sends messages to the
pituitary gland
– Anterior pituitary -- stimulates
Prolactin to be released which is the
ultimate stimulation for milk
production
– Posterior pituitary -- releases
Oxytocin which stimulates the
contraction of the cells around the
alveoli in the mammary glands. This
causes milk to be propelled through
the duct system to the infant. This is
the “LET-DOWN” reflex. Felt as a
tingling sensation
Breastfeeding Care



No soap on the nipples, wash in water
wear supportive bra
Breastfeeding tips:
– Most important is the “latch-on” Teach measures to
assist with the infant getting the nipple and areola in the
mouth
– Teach different positions to hold the baby
– No timing
– Relax to allow for “let-down”
– express colostrum on the nipples after feeding
– remember drops of colostrum are the same as ounces
of milk -- if wetting 6 - 10 diapers / day, then must be
getting enough to eat
Suppression of Lactation
 Key
is to teach the mother measures
to decrease stimulation of the
breasts
– Wear a tight-fitting bra or binder
– Do not express milk from the breasts
– Take shower with back to the warm
water
– Ice packs
Fill in the Blank

The Anterior pituitary stimulates the release of
___________________ which is responsible for
_________ _____________________.

The posterior pituitary gland releases
___________ which is responsible for the
______-__________ reflex.
Short Answers

What are four important interventions to teach a
mom who is bottle feeding to decrease
stimulation of the breasts.
1.
2.
3.
4.
Cardiovascular System Changes

How does the body rid itself of excess Plasma
volume?

Blood Volume
– Increase for about 24-48 hours after delivery
– Increase in blood flow back to the heart when blood
from the placenta unit returns to central circulation
– Extravascular interstitial fluid is moved into the
vascular system / intravascular
– Leads to increased cardiac output mainly RT increase
stroke volume.
Blood Values
Pregnancy
Post Partum
WBC – elevated slightly to about
12,000
WBC – leukocytosis is common with
values of 25,000 – 30,000 RT
increased neutrophils
RBC – increase slightly to about 10
milion.
RBC – return to normal
Hemoglobin – stays about normal
at ~ 12 g. Below 10 g = anemia
Hemotocrit – lowers 33-39% RT
hemodilution. If drops below 3235% = anemia
Hgb. – normal to see a drop of about
1 gram
Hct – normal to see a drop of about
2- 4 points and then a rise RT >
loss of plasma than RBC death
Platelets – drop and gradually rise
 Assess
for Thromboembolism
– During pregnancy, plasma fibrinogen
(coagulation) increases, Mother’s body
has the ability to form clots and prevent
excessive bleeding.
– Plasminogen (lysis of clots) does not
rise
– Hypercoagulable state and the woman
is at a greater risk for thrombus
formation.
– assess for homan’s sign
Vital Signs

Temperature
– A slight elevation of up to 100.40 may occur related to
dehydration and increase basal body metabolism from
exertion of labor and delivery.
– After 24 hours, the temperature should be normal
– A temperature greater than 100.40 suggests infection.

Blood Pressure
– Should remain stable
– Hypovolemia can indicate postpartum hemorrhage
– Hypervolemia could indicate preeclampsia
Vital Signs

Pulse
– Bradycardia of 50 – 70 bpm is Normal
– Tachcardia is not considered a normal occurrence and
may indicate excessive blood loss

Respirations
– Should remain stable and within normal range
Critical Thinking
 The
woman’s vital signs are:
T.100.8, P- 56, R – 16, B/P – 110/65.
How would the nurse interpret these
findings? What interventions are
indicated?
Gastrointestinal Tract
 The
most common GI problem
during postpartum is constipation
– EXPLAIN.
 What
teaching is important to assist
in decreasing constipation?
Urinary System
 What
is the most common problem
associated with the urinary system?
Why be concerned?
Critical Thinking
A
primigravida delivered 2 hours
ago. The woman states she would
like to go to the bathroom. What
should the nurse do?
 The
woman is unable to void. What
should the nurse do next?
Afterpains
 Who
is more likely to experience afterbirth
pains? Explain.
 Relief
of after pains
– Positioning (prone position)
– Analgesia administered an hour before
breastfeeding
– Encourage early ambulation - monitor for
dizziness and weakness
Rest and Activity

Most common problem is Sleep -- the excitement
and exhilaration experienced by birth my make it
difficult to sleep. They are tired and need rest.
Allow for times of uninterrupted sleep.

Exercises -- have the patient to ask her own
doctor for specific exercises. Usually walking is
safe. May eventually do postpartum exercises.
Just need to allow the body to return to its prepregnant state before straining it.
Resumption of Activities




New mother should gradually increase activities and
ambulation after birth
She should avoid heavy lifting, excessive stair
climbing, strenuous activity
Resume light housekeeping by second week at
home
Delay returning to work until after 6-week
postpartum examination
Exercises



Recommend exercise to provide health benefits to
new mother
Nurse should encourage client to begin simple
exercises while on nursing unit
Inform her that increased lochia and pain may
necessitate a change in her activity
Pain
 Perineal pain -- caused from trauma during
delivery, episiotomy, hemorrhoids. Provide
comfort measures such as: sitz baths, Tucks,
Sprays / Foams, oral analgesics.
 Afterbirth pain -- more common in multigravidas
and breastfeeding moms. Treat with * mild
analgesics (NSAIDS, Acetamenaphen),heating
pad, lie on abdomen, discontinue use of
oxytocins,
 Breast engorgement -- warm or cold packs,
increase feedings, decrease stimulation. Bind
breasts.
 Gas distention -- no ice, increase warm / hot
fluids, increase walking, rocking chair, antiflatus
drugs.
Decision Making
 During
shift assessment of the post
partum mom’s peri pad, the nurse
found it saturated with lochia rubra.

What would be the priority nursing
intervention?
The Nutrition Need

Most moms are hungry and eager to eat. Start off
slowly to avoid nausea and vomiting.

Diet should include:
– High in Protein, vitamin C, and fiber
– Increase in fluids

Lactating moms need about 700 extra calories for
milk production

Prenatal vitamins and iron supplements are often
continued in the postpartum period.
Psychological Adjustment

The responses of the mother to the birth of her
infant are influenced by many factors such as:
– Her parents own birth -- parenting and nurturing
– Cultural background -- only by understanding and
respecting the values and beliefs of each woman
can the nurse plan and meet the patient’s needs
– Readiness for parenthood -- emotional maturity,
pregnancy planned or unplanned, financial status,
job status
– Freedom from discomfort -- physical condition
– Health of her newborn -- physical condition,
prematurity, congenital defects
– Opportunities for parent- infant interactions
Postpartum Blues
 Transient
period of depression
– Occurs first few days after delivery
– Mother may experience tearfulness,
anorexia, difficulty sleeping, feeling of
letdown
 Usually
resolves in 10 to 14 days
Bonding
 Initial
attraction felt by parents
 Contact
should occur as early as possible
and as frequently as possible.
 Allow
time for attachment to occur with all
members of the family
Attachment

Bond that endures over time

Occurs through mutually satisfying experiences

Reciprocity - Mutually gratifying interaction among
mother, infant, father
Attachment Process
Enface - infants face on same
vertical plane as parent. Mutual
gazing
Explore with finger-tips
Hand and Palmar contact
Whole arms --enfolds whole
baby close to body
Claiming
The Claiming Process
Includes the identification
Of the baby’s specific
Features, relating them
To other family members
“Those long toes are
just like his Dad’s”
The Steps in Attachment are:
1.
2.
3.
4.
Postpartum Phases by Rubin

Taking - in
– Occurs during day 1 - 3 following delivery.
– Marked by a period of being dependent and
passive behavior.
– Mother’s primary needs are her own -- food
and sleep
– Mother is talkative about her labor and delivery
experience
***Main nursing is to listen and help the mother
interpret events of the delivery to make them
more meaningful and clarify and misconceptions
Postpartum Phases by Rubin

Taking - Hold
– Occurs during day 3 to about 2 weeks
postpartum
– Ready to deal with the present
– More in control . Begins to take
hold of the task of “mothering”
***It is the best time for teaching!
 Tailoring
teaching to individual
Learning Styles
– Demonstrations
– Group Classes
– Videotapes
Postpartum Phases by Rubin
 Letting
Go Phase
– occurs after about 2 weeks
– Mother may feel a deep loss over the
separation of the baby from part of her
body and may grieve over this loss.
– Common for Postpartum Blues to occur
during this time
Father-Infant Interaction

Engrossment
– Sense of absorption
– Preoccupation Interest in infant
Discharge

Preparation for discharge should begin when
expectant mother enters birthing unit

Mother needs to be aware of signs of postpartum
complications and should be aware of her self-care
needs

Nurses should begin first by assessing knowledge
and expectations of new mother and family

Nurse should be available to answer questions and
provide support to parents
Discharge
Printed Information


Nurse should review with new mother any
information she has received regarding postpartum
exercises, prevent of fatigue, sitz bath and perineal
care, etc. - nurse should spend time with parent to
determine if they have any last-minute questions
before discharge
Printed information about local agencies and
support groups should be given to new family
The End