1
Nursing in the Normal Puerperium (the period of 42 days post
childbirth and expulsion of the placenta)
Lecture 6
I.
Physiology of the puerperium
A.
Alterations in the body systems as a result of the birth process
1.
Reproductive system
a.
involution of uterus-return to non-pregnant
state-caused by contractions of uterine
muscles (size of a grapefruit after 3rd stage)
b.
within 12 hours, fundus at U/U
c.
fundus descends 1-2 cm/24 hrs
d.
uterus not palpable after the 9th PP day
e.
↓ in estrogen/progesterone=autolysis
f.
subinvolution-failure of uterus to return to
non-pregnant state-usually involves retained
POC or infection
g.
outer decidua sloughs off as lochia, inner layer
becomes new endometrium
h.
oxytocin released from pituitary gland helps
uterus to contract-↑ with BF
i.
afterbirth pains ↑ in multiparas
j.
placental site regeneration complete at 6 wks
k.
change in lochia-rubra-1-3 days-bright red
serosa-3-10 days-pink, brown
alba-10 dys-2 wks-yellow, white
l.
cervix-bruised, soft, swollen-closes by 2 wks
-external os-appears as jagged slit
m.
vagina-returns to prepregnancy state by 6-8 wks
n.
perineum-healing start by 2-3 wks, complete
within 4-6 months
-Red
-Edema
-Ecchymosis
-Drainage
-Approximation
o.
6 months for return of pelvic musculature
2.
Cardiovascular
a.
CO remains elevated for 2 weeks-12 wks before
↓ to prepregnancy values
b.
EBL 300-500 ml-vaginal birth
500-1000ml –C/S
c.
blood volume increased by:
-elimination of uteroplacental circulation
-loss of placental endocrine function which
removes stimulus for vasodilatation
-mobilization of extravascular water stored
2
d.
e.
f.
g.
Vital signs:
-Temp-↑ to 380 C/1004 F R/T dehydration
-Pulse-↑ 1st hr-return to pre-preg. 8-10 wks
-Resp-↓ by 8-10 wks
-BP-may have orthostatic hypotension
Hgb/Hct:
-1st 72 hrs-↑ loss of plasma volume compared to
RBC’s
-↑ in H & H by day 7
WBC’s may ↑ to 25-30,000/mm3
Coag factors-hypercoagulable state may lead
to possible thromboembolism
3.
Gastrointestinal
a.
↑ appetite
b.
no BM for 2-4 days post delivery
-encourage ambulation
-hydration
-fiber
-medications, i.e.: stool softeners
c.
tx hemorrhoids-ice packs, tucks, crm
-no pr meds if 3rd-4th degree laceration
d.
Kegel exercises to strengthen pelvic floor
4.
Renal
a.
returns to normal function 1 month after birth
-bladder tone returned by 5-7 days
b.
diuresis-from fluid retention, pitocin, etc
c.
excessive vaginal bleeding may be noted if
bladder is allowed to get distended with urine
5.
Musculoskeletal
a.
joints stabilize 6-8 weeks post birth
b.
may have permanent increase in shoe size
c.
may have separation of symphysis pubis or
rectus abdominis
6.
Integumentary
a.
chloasma (mask of pregnancy) usually fades
by end of pregnancy
b.
hyperpigmentation of areolae and linea nigra
may continue
c.
may note perfuse diaphoresis post delivery
7.
Endocrine
a.
Expulsion of placenta=↓ in estrogen, cortisol
progesterone, and hPL (hCS)
[human placental lactogen/human chorionic
3
b.
8.
somatomammotropin]
-reverse diabetogenic effect-lower BS level
if BF-↑ prolactin levels for 6 weeks
if bottle-fed-↓
-usually means later ovulation in lactating women
Psychosocial
a.
parent’s acceptance of infant’s needs and
abilities
b.
need to learn cues, understand emotional
states
c.
bonding-proximity, touch, voice, interaction
d.
identify infant as an individual yet part of the
whole family
e.
mutuality-infant’s behaviors stimulate mom’s
f.
may feel attracted to alert, responsive infant
and repelled by irritable, disinterested infant
g.
attachment occurs more readily with the
infant whose temperament, social capabilities,
appearance, and sex fit parent’s expectations
h.
need to assess mother-infant communication
i.
behaviors
-entrainment-moving in time with adult speech
-biorhythmicity-soothed by mom’s heartbeat
-reciprocity-responds to cues
-synchrony-mutually rewarding
-engrossment-interest in baby by father
j.
maternal adjustments
-taking in-first 24 hrs-focus on self and basic need
Dependent, passive
-taking hold-last 10 days to several weeks-focus
on care of baby and competent
mothering-dependent
-letting go-focus on forward movement of
the family unit
k.
PP blues- 70% of women-mood swings, anger,
depression, letdown, fatigue, insomnia,
H/A’s, weepiness (resolves in 10-14 days)
l.
PP depression-7-30%-more severe syndrome
-depression, feeling of failure overwhelming
guilt, loneliness
4
II.
Nursing Process
A.
Data collection/Assessment
1.
Vital signs
2.
Fundus
a.
ck fundal location, tone, lochia
b.
have pt empty bladder before exam
3.
Bladder
a.
assess for distention
b.
measure first voids until 500 ml (voided out)
c.
catheterize if needed
4.
Perineum
a.
if repair done, assess site for intactness, edema,
hematomas, redness, or drainage (REEDA)
b.
assess for presence of hemorrhoids
5.
Breasts
a.
note if breast are filling-palpate
b.
note any redness, soreness, cracking of
nipples
B.
Nursing Diagnoses
1.
Risk for fluid volume deficit
2.
Alteration in urinary elimination
3.
Pain
4.
Fatigue
5.
Ineffective breast feeding
6.
Situational low self-esteem
7.
Anxiety due to lack of knowledge base
8.
etc.
C.
Interventions
1.
Safety
a.
infant ID bands
b.
orientation to unit
c.
staff picture ID’s
d.
move infant in crib
2.
Standard precautions
a.
wash hands before handling baby
b.
change linens
c.
proper hygiene
d.
use of squeeze bottle for peri care
e.
wiping front to back
f.
teach pt about fundal massage
g.
use of peppermint or running water to aid in
5
h.
i.
j.
k.
l.
m.
n.
o.
p.
q.
III.
IV.
voiding to prevent urinary retention
use of ice packs for the first 12 hours post
repair of peri then instruct on use of sitz bath
squeeze buttocks together when sitting or rising
from a chair to help keep repair intact
wear good supportive bra
use lanolin crm to prevent cracking of nipples
warm packs before breast feeding, cool packs
post
walk as soon as possible-helps with gas pains
take pain meds prn
encourage rubella vaccine if non-immune
pt should prevent getting pregnant for at least
4 weeks post vaccination
Tdap-Pertussisrhogam given to Rh – moms who had Rh+ babies
Early Discharge
A.
Candidates and criteria
1.
Newborns’ and Mothers’ Health Protection Act of 1996
a.
48 hours minimum post vaginal delivery
b.
96 hours minimum post C/S
c.
pt and doctor may agree on earlier D/C
2.
Maternal criteria for early D/C
a.
VSS
b.
voiding
c.
Hgb >10
d.
no bleeding
e.
instructions on self-care
3.
Infant criteria for early D/C
a.
term infant
b.
VSS
c.
normal physical assessment
d.
at least 2 successful feedings
e.
at least 1 void and 1 defecation
f.
no jaundice
g.
circ site ok
h.
newborn blood/hearing screenings done
i.
follow-up in 1 week
j.
maternal/infant teaching cklist completed
Care of the Cesarean Birth Patient
A.
Assessment/Interventions
1.
VS every 15 min X 1hour, 30 min X 1 hour, then per
hospital protocol
2.
monitor I & O’s-need UO at least 30 ml/hr
6
3.
4.
5.
6.
7.
8.
V.
assess abdominal dressing for drainage
assess need for pain medication
assess fundal location, tone, and lochia
(still have 3 distinct lochia stages)
ambulate asap
assess for passage of gas-advance diet as tolerated
C & DB-may use inspirometer
B.
Nursing diagnoses
1.
Fluid volume deficit
2.
Pain
3.
Risk for infection
4.
Risk for injury
5.
Anxiety R/T surgery, fetal well-being
6.
Situational low self-esteem
C.
Possible post-op complications
1.
CV-hemorrhage, shock, dvt
2.
Pulm-embolus, pnemothorax
3.
GI-paralytic ileus
4.
GU-renal failure, hematuria, UTI, oliguria
5.
Reprod-endometritis, emboli
6.
Skin-wound infection, dehiscence
Care of the Lactating Woman
A.
Physiology of Lactation
1.
Female breast has 15-20 lobes containing alveoli
(the milk producing cells)
2.
alveoli→ductules→lactiferous ducts→nipple
3.
↓ estrogen & progesterone post delivery=↑ prolactin
levels which remain above baseline thru duration of
lactation (highest level is at day 10)
4.
Prolactin:
-highest level at day 10
-is produced in response to infant’s sucking
-promotes milk production by stimulating alveolar cells
B.
Other hormone changes/reflexes
1.
Oxytocin responsible for let-down reflex
nipple stimulation→pituitary produces oxytocin→
makes cells around the alveoli contract→sends milk to
nipple
2.
Nipple erection reflex
infant cries or rubs against the breast→nipple becomes
erect→propulsion of milk
7
VI.
C.
Supply/demand
1.
First milk called colostrum
a.
rich in immunoglobins
b.
higher concentration of protein and minerals to
mature milk but less fat
c.
promotes growth of Lactobacillus bifides in GI
2.
If infant is well nourished, will see 6-8 wet diapers and
3 stools in 24 hours at day 5 of breastfeeding
3.
Incomplete emptying can lead to ↓ milk supply
4.
watch for infant growth spurts
-10 days
-3 weeks
-6 weeks
-3 months
-4.5-6 months
D.
Maternal nutrition/considerations
1.
add addition 200-500 calories/dy while breastfeeding
2.
drink 2-3 liters of fluid daily
3.
continue on PN Vitamins and iron as directed
4.
watch for engorgement/plugged milk ducts/
sore nipple/monilial (yeast) infections/mastitis
Care of the Woman/Neonate Formula-fed
A.
Formula types
1.
commercial formulas primarily cow-milk based but
soy and other specialty formulas available
2.
may be in powdered, concentrated, or ready to eat
B.
Common problems
1.
positioning-need to make sure milk covers nipple area
2.
warming-never microwave bottle
3.
propping-don’t leave infant unattended while feeding
C.
Nutritional requirements
1.
first day-only give 7.5-15 ml formula at one time
-their eyes are bigger than their stomachs
2.
usually feed every 2-4 hours
3.
some infants swallow air as they feed-burp them!
4.
by 1 week of age, babies will be drinking 700-900 ml
in 24 hours
*bottle fed because-returning to work, +HIV, mastectomies,
adopted infant, maternal medications
8
VII.
Contraception Education
A.
Considerations for Choosing a Method
1.
resumption of sexual activities should wait 2-3 weeks
to decrease risk from infection
2.
best to use condoms/foam at this time
3.
when discussing contraception with your doctor,
-action
-safety
-effectiveness
-convenience
-availability
-expense
-personal preference
B.
Methods (failure rates listed within 1st year of use)
1.
Coitus interruptus (withdrawal)
-action-prevents fertilization
-safety-no protection from STI’s
-convenience/availability-good
-expense-N/A
2.
Fertility awareness methods
-periodic abstinence-no sex 4 days before and 4 days
after ovulation
-rhythm-based on 3-4 cycles-use shortest and longest
-BBT-sl. ↓ temp before ovulation (0.050C) then ↑
0.3-0.60C
-cervical mucus-ck for changes-amt. and consistency
-symptothermal-combo of BBT and cervical mucus
-ovulation kits-detect surge in LH that occurs approx.
12-24 hours before ovulation
3.
Barrier methods
a.
spermicides
-action-physical/chemical barrier to sperm
-safety-may provide some protection from STI’s
-convenience-needs to placed before act
-availability-good if thought of in advance
-expense-cheap
b.
condoms
-action-physical barrier to sperm
-safety-protect against STI’s/HIV if used properly
-effectiveness-can ↓ failure rate with use
of spermicides
-vaginal sheath/condom
c.
diaphragm
-action-mechanical barrier to sperm
-safety-see condoms, small amt of cases with
9
TSS-toxic shock syndrome
-effectiveness-needs to be fitted to woman’s
anatomy, needs to be used with
spermicide
-convenience-may be placed 6 hours before
intercourse but must be left in for 6 hours
post act, additional spermicide each time
-availability-MD appt
-expense-affordable
d.
4.
cervical cap/sponges
-cervical cap needs fitting
-must ck position of cap before intercourse
-failure rate in parous women-40%
-sponge-moisten with water before insertion
-have spermicide
-risk of TSS if not removed after 24 hours
Hormones
a.
over 30 different formulations
b.
may have estrogen/progestin or only prog.
c.
may be oral, subdermal implantation, IM,
vaginal
d.
prevent pregnancy by stopping ovulation or
prevention of implantation
e.
do not protect against STI’s
f.
not recommended for some women
-h/o thromboembolic
-smoker
-h/o estrogen dependent tumors
-h/o CAD
-h/o impaired liver
-over the age of 35
-HTN
g.
mini pill (progestin-only)
-problems with irregular menses
h.
injectable progestin-Depo Provera
-injected q 11-13 weeks-may need appt.
-↑ risk of venous thrombosis
i.
implanted progestin-Nexplanon
-good for 3 years
-implanted in arm
-no STI protection
j.
Emergency contraception
Plan B One Step-OTC any age -levonorgestrel
-needs to used within 72 hours
-prevents ovulation/implantation
-90% effective
10
-(Plan B-two pills-being D/C’d)
Ella-non-hormonal
-needs to used within 120 hours
-needs Rx
-90% effective
IUD insertion
-98% effective if inserted within 5 days
5.
Intrauterine Devices
a.
usually T-shaped
b.
loaded with either copper or levonorgestrel
c.
may be used for 5 yr (hormone)-10 yrs (copper)
d.
prevents fertilization
e.
Mirena (hormone IUD)-helps to diminish menses
f.
Copper “T”-good choice for women over 35, smokers,
h/o CAD, HTN
g.
not recommended for women with:
-h/o PID
-suspected pregnancy
-h/o distorted uterine cavity
-h/o multiple partners
6.
Sterilization
a.
females
- bilateral tubal ligation
-surgical procedure
-expense usually higher than vasectomy
-electrocoagulation, ligation, banded,
crushed, or plugged
-no protection against STI’s
-should be considered permanent
-informed consent needed at least 72 hours
before procedure
-eSSURE
-done in clinic or OR
-uses water to visualize fallopian tube
meatus
-coil placed and tissue collects on coil
creating a blockage
-HSG performed at 3 months to establish
closure
-back-up BC method used during this
period
b.
males-vasectomies
-done in clinics under local anesthetic
-vas deferens are ligated/cauterized
-takes multiple ejaculations to clear
remaining sperm from vas deferens
11
BIRTH CONTROL COMPARISONS
FAILURE
RATES
MECHANISM OF ACTION
STD
USER
method of
birth control
perfect actual prevents prevents
postpone protection continuation
use fertilization implantation sex
use
rates
No Method
85
85
Spermicides
18
29
++++
+
42
Male Condoms
2
15
++++
++
53
Female Condoms
5
21
++++
++
49
Diaphragm
6
16
++++
+
57
Cervical FemCap 4
w/o prior pregnancy
14
++++
+
57
Sponge
9
w/o prior pregnancy
16
++++
+
57
Sponge
20
w/ prior pregnancy
32
++++
+
46
Ovulation Method
3
22
+++
+
51
Sympto-Thermal
2.5
16
+++
+
51
Standard Days
Method
5
12
+++
+
Calendar Method
5
13-20 +++
+
Lactation (LAM)
0.5
6
++++
Withdrawal
4
27
++++
Oral Contraceptives 0.3
8
+++
+
68
Ortho Evra Patch
0.3
8
+++
+
68
Nuva Ring
0.3
8
+++
+
68
Shot (DepoProvera)
0.3
3
+++
+
56
Shot (Lunelle)
0.05
3
+++
+
59
IUD (ParaGard
Copper)
0.8
0.6
++
++
80
IUD (Mirena)
0.1
0.1
++
++
80
Abstinence
0
0
++++
51
+
++++
43
++++
For added protection against pregnancy, you can use more than one method of contraception at a time.
For example, many clinicians recommend that when using condoms, spermicides be used as well. If a
woman is allergic to spermicides she can use a natural method and a condom and for extra protection.
Any of these combinations will reduce the predicted failure rate
01/16