Postpartum Adaptations Flashcards by Kaylie Krauzyk

Postpartum Period - the first 6 weeks after birth

Retrogressive changes (back to normal) & progressive changes (e.g. initiation of lactation)

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___ refers to the changes the reproductive organs undergo after childbirth to return to their nonpregnant size & condition

This begins immediately following the delivery of the placenta

Involution

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Uterine involution entails 3 processes:

Contraction of the ___
Catabolism
Regeneration of the ___

muscle fibers

uterine epithelium

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Contraction of the muscle fibers

Immediate contraction

Uterus contracts down & returns to normal shape & size

Can take up to 6 weeks to heal

Catabolism

Breakdown of cells into similar compounds

Products absorbed by bloodstream that get excreted by urine as nitrogenous waste

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Regeneration of the uterine epithelium

Outer portion of epithelial lining gets expelled w/placenta
In about 2-3 days the remaining decidua (the endometrial present during pregnancy) separates into 2 layers

> ___ layer that gets expelled into lochia (vaginal discharge)

> second layer as source for new endometrium

2-3 weeks after birth except for area of placenta (can take up to 6 weeks to heal)

superficial

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How big is the placenta-sized wound in your uterus after giving birth?

About the diameter of an average-sized dinner plate; 8.5 inches

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Descent of the Uterine Fundus

Measured in relation to the umbilicus
Descends by 1 centimeter, or 1 “fingerbreadth” per day
Is documented in relation to the umbilicus (e.g. U-1, at U, U+2)
If the process of involution does not occur properly, ___ occurs & can cause postpartum hemorrhage

> The uterus goes higher; a major cause is a full bladder

> Important to monitor location & contractility of the uterine fundus

subinvolution

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“Afterpains”

Multiparous women

Multifetal/gestational pregancies

Polyhydramnios

Larger children

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Lochia (vaginal discharge)

___ - red/reddish brown; mostly blood w/small particles of decidua & mucous; 3 days

___ - white/cream/light yellow; leukocytes, decidual cells, epithelial cells, fat, cervical mucous, & bacteria; 11th day to 3rd week, could last to 6th week

___ - pink/brown tinged; serous exudate, erythrocytes, leukocytes, & cervical mucous; days 4-11

Rubra

Alba

Serosa

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Amount

Scant: less than a 2.5cm (1 inch) stain on a perineal pad

Light: 2.5-10cm (1-4 inch) stain

Moderate: 10-15cm (4-6 inch) stain

Heavy: saturated perineal pad

Excessive: saturated perineal pad in 15 minutes

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Cervical Changes

Heals rapidly (by end of 1st week)

Internal OS closes, external OS (seen on speculum exam) remains permanently changed

Oval = nulliparous; Slit-like = multiparous

Cervix will have some slight dilation to it afterwards

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Vagina

* Edematous

* Multiple small lacerations may be present

* Rugae are initially absent, return by 3-4 weeks postpartum

* Complete involution takes 6-10 weeks

* Vaginal mucosa is ___

* Lactation suppresses ovarian function & that will affect estrogen production

> Breastfeeders = dyspareunia

atrophic

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Perineum

* Edematous

* May be ___

* Episiotomy/laceration

* Hemorrhoids

* Nursing care is focused on relief of discomforts

> ___ for healing; ___ for pain

> Topical anesthetics & prescribed analgesics

ecchymotic (bruising)

warmth; ice

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Episiotomies

Midline episiotomy
Medio-lateral episiotomy

Right or left more common

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Perineal Lacerations

1st / 2nd / 3rd / 4th º

> 2nd º most common w/perineal muscles torn

Perineal lacerations & vaginal/cervical lacerations

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Cardiovascular System - Cardiac Output

* Transient increase immediately following childbirth

* Returns to pre-labor values within 1 hour after delivery

* Returns to pre-pregnancy levels by 6-12 weeks after birth

Plasma Volume

* Body rids itself of the excess plasma volume via diuresis & diaphoresis; decline in aldosterone

Blood Values

* Marked leukocytosis as high as 30,000 during labor & immediate postpartum period; >6 days - normal

* Hgb & hct are difficult to interpret due to remobilization of excess body fluid

Coagulation

* 4-6 weeks for hemostasis

* Elevations in clotting factors continue for several days or longer following delivery, increasing risk for thromboembolism formation

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Gastrointestinal System

* Anticipate client needs: fluids & foods soon after childbirth

___ is common in the postpartum period

* Bowel tone & intestinal motility remain sluggish for several days

* Abdominal musculature is relaxed

* Decreased food & fluid during labor may lead to small, hard stools

* Perineal lacerations, episiotomies, & rectal hemorrhoids can add discomfort

Constipation

* Often prescribed stool softeners & laxatives postpartum to prevent and/or treat constipation

* First stool occurs within 2-3 days postpartum, w/normal bowel patterns resuming 8-14 days postpartum

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Urinary System

* Edema can be present from birth trauma

* Women are still @ risk of urinary retention & bladder distension, increasing the risk of UTI & inc postpartum bleeding

* Stress incontinence may begin during pregnancy or during the postpartum period

> Encourage Kegel exercises

* Ureters & kidneys complete involution 2-8 weeks after delivery

Musculoskeletal System: Muscles and Joints

* Muscle fatigue (in neck, shoulders, arms)

* Headaches

* Pelvis begins to return to pre-pregnancy position

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Musculoskeletal System: Abdominal Wall

* Muscle tone is diminished during pregnancy

* Diastasis recti may occur

> Minimal to severe

Integumentary System

* Receding pigmentation

* Resolution of melasma & linea nigra

* Striae gravidarum fade to silver

* Postpartum hair loss (due to hormone changes; 4-20 weeks > delivery)

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Neurological System

* Temporary changes from anesthesia (lack of feeling in legs or dizziness)

* Bilateral & frontal headaches (due to fluid & electrolyte imbalances)

> Be wary for a spinal headache or signs of preeclampsia

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Endocrine System

Rapid decline in estrogen, progesterone, & human placental lactogen
___ is able to fully activate w/the decrease of estrogen & progesterone, stimulating milk production

> 2-3 days > childbirth

In non-breastfeeding mothers, ___ returns to nonpregnant levels
___ is secreted & stimulates “letdown”

Prolactin

prolactin

oxytocin

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Ovulation & Menstruation

* Ovulation may occur before the 1st postpartum menses

* Education regarding contraception is important

* Return of menses

> Non-nursing mothers: 6-9 weeks after childbirth

> Nursing mothers: as early as 2 months or as late as 18 months

Postpartum Weight Loss

Approximately 5.5kg is lost during childbirth

An additional 4kg is lost over the following 2 weeks, & another 2.5kg is lost by 6 months

Many women do not lose all of their pre-pregnancy weight, and retain 1kg w/each pregnancy

Diets are not recommended for lactating mothers as they need an additional ___ calories per day for infant nutrition

500

Postpartum Vaccination

* Rh_O(D) Immune Globulin

> Give within 72 hours > childbirth

> RhoGAM

> Given to prevent the development of maternal antibodies that will affect subsequent pregnancies

> Scenario where mother is Rh (-) & baby is Rh (+)

* Rubella vaccine (MMR)

> Live vaccine; wait 28 days to get pregnant

* Pertussis vaccine (Tdap)

* Flu vaccine

> Thimerosol-free

> NOT nasal route (is live); 9/30-5/1 flu season range

* COVID vaccine (in postpartum)

Focused Assessments - During the Recovery Period \* 1st 2 hours after delivery of the placenta Initial assessment of the woman following childbirth includes: - Vital signs / skin color / location & firmness of fundus - Amount & color of lochia / perineum / presence, degree, location of pain - IV infusions / urinary output / status of abdominal incision (if present d/t cesarean delivery) - Level of feeling & ability to move s/p anesthesia (e.g. moving legs; strength level)

Focused Assessments - Following a Vaginal Birth Vital signs / fundus / lochia / perineum / bladder elimination / breasts / lower extremities

Lochia - Lessened but shouldn't be absent (could be a clot that is masking a postpartum hemorrhage) Perineum - "REEDA" Redness / Edema / Ecchymosis / Discharge / Approximation (i.e. laceration, healing or suture for episiotomy)

Bladder elimination - S/S of urinary retention Breasts - Engorgement regardless of breastfeeding status - Nipple characteristics

Vital signs - Obtain weight for quantitative blood loss - Hypovolemia - dehydration - Orthostatic hypotension - 140/90 BP: preeclampsia; can happen up to 2 weeks later - Lower pulse after placenta delivery - Tachycardia to rule out hemorrhage & infection - Temperature up to 100.4° common post delivery (\>100.4° or persists more than 24 hours = seek out provider)

Lower extremities - Look for S/S of thrombophlebitis - Weakened or absent peripheral pulses - Signs of thromboembolism development - Check DTR's (hyperactive can indicate preeclampsia)

Focused Assessments - Following a Cesarean Birth - In addition to the usual postpartum assessment, also must assess as postoperative patient! Pain Relief - Patient may be on PCA or receive opioid rx into the epidural space, providing 18-24 hours of comfort [at risk up to 24 hours] - Assess respiratory status frequently, including respiratory rate & oxygen saturation

Gastrointestinal - Assess for S/S of a paralytic ileus (abdomen distension, absent bowel sounds, inability to pass gas or stool) - Assess dressing/incision

Assessing the Uterine Fundus - Feel firm, soft? - Support the lower uterine segment so we prevent inversion of the uterus \> Inversion - uterus kind of prolapses through into vagina but is inverted

? Rx's that serve as uterine relaxants ? Given for management of preeclampsia; is a uterine relaxant

Tocolytics magnesium sulfate

? Term that describes when the placenta detaches before it should; prior to delivery

abruptio placentae

? Term that describes when the placenta might have started to invade the uterine wall

placenta accreta

? Term that describes a placenta set low in the uterus

placenta previa

Assessment of the Perineum - Turn patient on to the side & lift the buttocks; able to visualize the anus in this way too (i.e. check for hemorrhoids)

Risk Factors for Postpartum Infection \* Operative procedures (cesarean birth, vacuum extraction, forceps) \* Multiple cervical exams \* Prolonged labor; prolonged rupture of membranes \* Manual extraction of placenta or retained fragments \> Provider manually puts whole hand into vagina into uterus to pull out placenta

\* Diabetes \* Catheterization \* Bacterial colonization of the lower genital tract

Nursing Care During the **Immediate** Postpartum Period *First 24 hours after delivery of placenta* \* Providing comfort measures - Ice packs (create vasoconstriction; prevent edema of perineum & numb associated pain) - Sitz Baths (cool H₂O in 1st 24 hours) - Perineal care - Topical medications - Sitting measures (squeeze buttocks as you sit) - Analgesics (NSAIDs, ibuprofen, acetaminophen)

\* Promoting bladder elimination \* Providing fluids & food \> Encourage 2,500mL of fluids per day \* Preventing thrombophlebitis

Maternal Role Adaptation ? Begins in pregnancy & lasts for many months after birth Reciprocal

Attachment

? Unilateral Promoted during first 30-60 minutes after birth

Bonding

Reciprocal Attachment Behaviors \* Make eye contact & engage in prolonged, intense mutual gazing \* Move their eyes in an attempt to "track" the parent's face \* Grasps & holds the parent's finger \* Moves synchronously in response to rhythms & patterns of the parent's voice ( ? ) \* Root, latch onto the breast, & suckle \* Be comforted by the parent's voice or touch

entrainment

Becoming Acquainted Maternal Touch \* En face (eye contact made) \* Fingertipping \* Enfold (bringing in very close) \* Claiming/binding

Verbal Behaviors \* High-pitched voice \* Begins to identify baby by name

Puerperal Phases 1. Taking-In Phase 2. Taking-Hold Phase 3. Letting-Go Phase

\_\_\_ Phase Time of relinquishment

Letting-Go

\_\_\_ Phase Mother is focused on her own needs of fluid, food, & sleep She details her labor to others as a way of realizing the pregnancy is over Typically lasts for a day or less; may be prolonged in mothers who had cesarean deliveries

Taking-In

\_\_\_ Phase Mother assumes responsibility for her own care May have anxiety about caretaking abilities Lasts several days

Taking-Hold

Maternal Role Attainment Anticipatory Stage Formal Stage Informal Stage Personal Stage

*"**A**ll **F**amilies **I**nherit **P**roblems"*

? Stage Mother accepts & feels comfortable w/the role of a parent

Personal

? Stage Begins at birth & lasts 4-6 weeks Behavior is mainly guided by others (healthcare professionals, family, friends)

Formal

? Stage Begins during pregnancy Seeks out role models to learn the role of a mother

Anticipatory

? Stage May overlap the formal stage - begins once mother identifies appropriate responses to infant cues She is now following unique needs of the infant versus generalized directives

Informal

Postpartum Blues \* Normal, is NOT depression Mild, transient conditions (not lasting more than 2 weeks) Affects 70-80% of new mothers

Characterized by: Insomnia / irritability / fatigue / tearfulness / mood instability / anxiety **Contact healthcare provider if signs of depression become severe or last longer than two weeks**

? Is a term used to describe displaying interest in the infant

engrossment

Family Role Adaptations Affects: Fathers/partners Siblings Grandparents

Factors that affect: Discomfort & fatigue Knowledge of infant needs Previous experience Expectations about the newborn Maternal age Maternal temperament Temperament of the infant Availability of strong support systems

Cultural Influences on Adaptation Communication \* Numerous dialects & languages spoken Dietary Practices \* Understanding the hot-cold theory of health & diet (cold being the postpartum period) \* Some cultures may not like hospital food - encourage them to bring meals from home

Health Benefits \* Another female member of the family is often involved in the care of the infant & the mother \* Variations in hygiene practices