Chapter 15 and Chapter 16
• POST PARTUM ADAPTATIONS AND
NURSING MANAGEMENT DURING THE
POST PARTUM PERIOD.
Postpartum Period
• Critical transition period for woman, newborn, and
family physiologically and psychologically
• Puerperium: period after delivery of placenta, lasting for
6 weeks
• Possible definition: changes in all aspects of mother’s life
that occur during the first year following birth of child
• Maternal physiologic and psychological changes
• Mother and family adjustment to new family member
Reproductive System
Adaptations
• Uterus
• Involution: contraction of muscle fibers; catabolism;
regeneration of uterine epithelium
• Lochia: rubra, serosa, alba
• Afterpains
• Cervix: closure; now appearing as jagged slit-like opening. Vagina:
eventual thickening and return of rugae.
• Perineum
Typical Assessments in
Postpartum Period
• During the first hour: every 15 minutes
• During the second hour: every 30 minutes
• During the first 24 hours: every 4 hours
• After 24 hours: every 8 hours
Question
Is the following statement True or False?
After birth, the cervix returns to its prepregnant shape.
a. True
b. False
Answer
b. False
After delivery, the cervix closes but never regains its
prepregnant appearance. It is no longer circular but appears
as a jagged slit-like opening.
Cardiovascular System Adaptations
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Blood volume and cardiac output
Hematocrit level
Pulse rate and blood pressure
Coagulation factors
Red blood cell production
Physical Assessment
• Provide for Privacy
• Time for Teaching
• Have Woman Void Prior to Assessment
• Assess Psychosocial Status
• Perform General Postpartum Assessment –
BUBBLE-EEE
Physical Assessment: Postpartum
Period
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Breasts (size, contour, engorgement)
Uterus (height of fundus, firmness)
Bladder (voiding, bladder emptying)
Bowels (bowel sounds, distention)
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Lochia (amount, color, odor)
Episiotomy and perineum (lacerations, hematoma)
Extremities
Emotional status
Assessment of Uterine Fundus
• Flat Bed
• Place Hand Just Above
Symphysis Pubis
• Palpate by Placing Other
Hand At Level of Uterus
• Frequency of assessment
Nursing Care for Involutional Pain
• Medication
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Motrin (ibuprofen)
Percocet (oxycodone and acetominophen
Darvon (propoxphene)
Tylenol (acetominophen)
PCA
Pain: goal between 0 and 2 on pain scale
Vaginal Discharge
• Physiology of Lochia
• decidua basalis separates into 2 layers
• inner layer creates new endometrium
• outer layer becomes lochia
• Types of Lochia
• lochia
• lochia
• lochia
Evaluating Lochial Flow
• Assess character
• Assess amount
• Assess for clots
• Assess pattern
• Assess odor
• Teaching about lochia
Cervix and Vagina
• Cervix
• Vagina
Perineum
• Physiological Changes
• Assessment of the
Perineum
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intactness
episiotomy
lacerations
hemorrhoids
Classifications of Perineal Lacerations
• 1st degree laceration: involves only skin and
superficial structures above muscle.
• 2nd degree laceration: extends through perineal
muscles.
• 3rd degree laceration extends through anal sphincter
muscle
• 4th degree laceration: continues through anterior
rectal wall.
Nursing Care of the Perineum
• Changing Pads
• Hygienic Care with warm water-peri bottle
• Application of Ice
• Application of Warmth
• Protective Devices-anesthetic sprays
• Hemorrhoidal Care
• Sitz bathes
• Exercise program; recommended exercises; Kegel
exercises
Urinary System Adaptations
• Glomerular filtration rate and renal flow increase
• Voiding sensation affected by:
• Perineal lacerations
• Generalized swelling and bruising of the perineum and tissues
surrounding the urinary meatus
• Hematomas
• Decreased bladder tone due to regional anesthesia
• Diminished sensation of bladder pressure due to swelling,
poor bladder tone, and numbing effects of regional anesthesia
used during labor
Causes of Postpartum
Diuresis
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Large amounts of intravenous fluids given during labor
Decreasing antidiuretic effect of oxytocin as its level declines
Buildup and retention of extra fluids during pregnancy
Decreasing production of aldosterone—the hormone that
decreases sodium retention and increases urine production
GI System Adaptations
• The GI system quickly returns to normal
• Relief of pressure on organs
• Decreased bowel tones for several days
• Decreased peristalsis occurs
• Constipation is common due to fear of straining affecting the
perineum
• Hunger and thirst occur due to NPO status prior to delivery
Musculoskeletal System
Adaptations
• Joints return to prepregnant state except for feet
• Women commonly experience fatigue and activity intolerance for
weeks after giving birth
• Abdominal muscle tone is diminished after birth and special
exercises are needed to return to normal
Integumentary System Adaptations
• Pigmentation fades
• Stretch marks fade to silvery lines
• Diaphoresis is common for about a week postpartum
Respiratory and Endocrine System
Adaptations
• Respiratory system
• Tidal volume, minute volume, vital capacity, and functional
residual capacity return to prepregnant values within 1 to 3
weeks of birth
• Anatomic changes reside quickly
• Endocrine system
• Estrogen and progesterone levels drop quickly
• Placental hormones decline rapidly
• Prolactin levels decline within 2 weeks if not breast-feeding
Vital Signs Assessment
• Temperature: slight elevation during first 24 hours; normal
afterward
• Pulse: 40 to 80 bpm; puerperal bradycardia
• Respirations: 16 to 20 breaths per minute
• Blood pressure: within usual range
• Pain: goal between 0 and 2 on pain scale
Question
Is the following statement True or False?
During the first 24 hours postpartum, a slight elevation in
temperature is considered normal.
a. True
b. False
Answer
a. True
Some women experience a slight elevation in temperature during
the first 24 hours postpartum; this may be the result of
dehydration secondary to fluid loss during labor.
Physical Assessment: Postpartum
Period
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Breasts (size, contour, engorgement)
Uterus (height of fundus, firmness)
Bladder (voiding, bladder emptying)
Bowels (bowel sounds, distention)
Lochia (amount, color, odor)
Episiotomy and perineum (lacerations, hematoma)
Extremities
Emotional status
Breast feeding
• https://www.youtube.com/watch?v=b3oPb4WdycE&feature=youtu.b
e
Lactation
• Secretion of milk by the breasts
• Result of interaction of progesterone, estrogen, prolactin, and
oxytocin
• Typically appearing 4 to 5 days after childbirth
• “Breast crawl” process
Post Partum Breast Care for the Lactating woman
• Supportive bra
• Warm showers
• Correct position
• Correct latch-on technique
• Nipple/areolar inspection
• Exposure to air
• Frequent nursing
• Increased fluid intake
• Assess: soft, filling, engorged
Post Partum Breast Care for the Non-lactating
Woman
• Avoid stimulation
• Cold showers
• Supportive bra on for 24 hours
• Use ice pack or cabbage leaves for engorgement
• Avoid manually expressing milk from breast
• Take mild analgesic for discomfort
Engorgement
• Process of swelling of the breast tissue due to an increase in blood
and lymph supply as a precursor to lactation
• Relieved by frequent emptying, warm showers and compresses
before feeding, cold compresses between feedings, if breastfeeding
• Tight supportive bra, ice, avoidance of breast stimulation if not
breast-feeding
Comfort-Rest Status
• Need for Sleep in Puerperium
• Effects of Spinal Anesthesia
• Exhaustion
• Post-Partum Chill
Question
For the woman who is not breast-feeding her newborn, which
measure would be most appropriate to relieve engorgement?
a. Warm showers
b. Nipple stimulation
c. Ice to the breasts
d. Manually expressing milk
Answer
c. Ice to the breasts
For the woman who is not breast-feeding, measures to relieve
engorgement include applying ice to the breasts for 15 to 20
minutes every other hour. Warm showers promote the let-down
reflex are encouraged for the woman who is breast-feeding and
experiencing engorgement. Any stimulation of the breasts, such
as nipple stimulation or manual milk expression, is to be avoided
for the woman who is not breast-feeding.
Teaching Topics for Postpartum Period
• Pain and discomfort
• Immunizations
• Nutrition
• Activity and exercise
• Lactation
• Discharge teaching
• Sexuality and contraception
• Follow-up
Nursing Management in Postpartum
Period: Nursing Interventions
• Providing optimal cultural care (see Box 16.3)
• Promoting comfort
• Cold and heat applications
• Topical preparations
• Analgesics
• Assisting with elimination
• Promoting voiding
• Promoting bowel elimination
Nursing Management in Postpartum
Period: Nursing Interventions (cont.)
• Promoting activity, rest, and exercise
• Early ambulation
• Rest periods
• Exercise program; recommended exercises; Kegel exercises
• Assisting with self-care measures
• Ensuring safety
• Counseling about sexuality and contraception
Nursing Management in Postpartum
Period: Nursing Interventions (cont.)
• Promoting nutrition
• General recommendations (see Box 16.4)
• Needs for the breast-feeding woman
• Supporting choice of newborn feeding method
• Assistance with breast-feeding
• Assistance with bottle-feeding
Ensuring Safety During Ambulation
• Check blood pressure first
• Elevate head of bed for a few minutes before ambulating
• Have client sit on side of bed for a few moments first
• Help client stand up and stay with her
• Ambulate alongside client and provide support if needed
• Frequently ask client how her head feels
• Stay close by to assist if she feels lightheaded
Question
Is the following statement True or False?
A woman who is not breast-feeding should increase her daily
caloric intake by approximately 500 calories.
a. True
b. False
Answer
b. False
The breast-feeding woman should increase her daily caloric intake
by approximately 500 calories.
Ovulation and Return of
Menstruation
• Interplay of hormones: estrogen, progesterone, prolactin, and
oxytocin
• Nonlactating women: return of menstruation 7 to 9 weeks after
birth
• Lactating women: return dependent on breast-feeding frequency
and duration; anywhere from 2 to 18 months
Maternal Psychological Adaptation: Reva
Rubin’s Three Phases
• Taking-in phase: Time immediately after birth when the
client needs others to meet her needs and relives the birth
process
• Taking-hold phase: Second phase characterized by
dependent and independent maternal behavior
• Letting-go phase: Third phase in which woman reestablishes
relationships with others
Emotional Status Assessment:
Postpartum Period
• Interactions with family
• Level of independence
• Energy levels
• Eye contact with infant
• Posture and comfort level with infant
• Sleep and rest patterns
• Be alert for mood swings, irritability, or crying episodes
Nursing Management: Bonding and
Attachment
• Transition to parenthood
• Stages
• Factors affecting attachment: parent’s background, infant,
care practices
• Critical attributes of attachment: proximity, reciprocity,
commitment
• Positive and negative attachment behaviors (see Table 16.1)
Stages in the Transition to Parenthood
• Commitment, attachment, preparation for an infant
during pregnancy
• Acquaintance with and attachment to the infant,
learning how to care for the infant; physical restoration
in first weeks after birth
• Moving toward a new normal routine in the first 4
months after birth
• Achievement of a parenthood role around 4 months
Factors Affecting Attachment
• Parent’s background
• Infant temperament and health at birth
• Care practices
• Separation immediately after birth
• Policies discouraging exploring infant
• Intensive care environment
• Staff indifference or lack of support for parents
Maternal Psychological Adaptations
• Attachment: formation of a relationship between a parent and his
or her newborn through a process of physical and emotional
interactions
• Early and sustained contact between newborns and parents is
vital
• Nurses play a crucial role in assisting with this process of
attachment
• Factors influencing attachment include environmental
circumstances, newborn health, and quality of nursing care
Postpartum Mood
Disorders
• Baby blues
• Mild depressive symptoms, anxiety irritability, mood swings,
tearfulness, increased sensitivity, fatigue
• Usually peak at days 4 and 5 and resolve by day 10
• Postpartum depression and psychosis
• Symptoms last longer and are more severe and require
treatment
• May lead to poor bonding, alienation from loved ones, daily
dysfunction, and violent thoughts/actions
Teaching About Postpartum Blues
• Transient emotional disturbances
• Characterized by anxiety, irritability, insomnia, crying, loss of
appetite, and sadness (King et al., 2015)
• Symptoms usually begin 2 to 4 days after childbirth and
resolve by day 8
• Blues typically resolve with restorative sleep
• Postpartum depression and psychosis are more serious and
require professional referral
Variables Affecting Maternal Role
Attainment
• Maternal
• Confidence, age, relationship with father, socioeconomic
status, birth experience, stress, support system, personality
traits, self-concept, child-rearing attitudes, role strain, health
status, preparation during pregnancy, relationship with own
mother, depression, and anxiety
• Infant
• Appearance, responsiveness, temperament, health status
Four Stages of Becoming A
Mother (BAM)
• Commitment, attachment to unborn baby, preparation
for delivery and motherhood during pregnancy
• Acquaintance/attachment to infant, learning to care for
infant, and physical restoration 2 to 6 weeks postbirth
• Moving toward a new normal
• Achievement of a maternal identity through redefining
self to incorporate motherhood (around 4 months)
Engrossment: Partner Psychological
Adaptation
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Visual awareness of the newborn
Tactile awareness of the newborn
Perception of the newborn as perfect
Strong attraction to the newborn
Awareness of distinct features of the newborn
Extreme elation by the father
Increased sense of self-esteem
Engrossment: Partner Psychological
Adaptations (cont.)
• Three-stage role development process
• Expectations
• Reality
• Transition to mastery
Cultural Considerations
• Cultures vary in their postpartum beliefs, practices, and customs
• Nurses must be open, respectful, nonjudgmental, and willing to
learn about ethnically diverse populations
• Understanding various cultures’ views of the postnatal period
as it relates to their recovery and well-being after childbirth is
important for all nurses
Preparing for Discharge
• Preparing for discharge (criteria)
• Providing immunizations
• Ensuring follow-up care
• Telephone follow-up
• Outpatient follow-up
• Home visit follow-up