The Post Partum Period by MikeJenny

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									POST PARTUM

  Lecture 8
Puerperium: “to bring forth” 6 wk > childbirth.
  “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.
Fundus: assess for firmness. Palpate > delivery.
   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.
   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
   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
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.
 Placenta separates from spongy layer of uterus -
  decidua BASALIS.

   Inner layer of decidua remains & forms new layer of
    endometrium . Outer becomes necrotic & sheds.
   Consists of blood, fragments of decidua, mucus,
   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.
 Neck; remains slightly opened & contracts > delivery.
 In 7 days, opening narrow as pencil. Os remains slit-like .

 Slightly distended after birth. Kegel exercises ^muscle
   tone and strength. Important for lacerations.

 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.
 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
 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:
    Pregnancy hormones decrease w. delivery of
    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.
The Urinary System:
  Loss of bladder tone d/t swelling & anesthesia ;
   urinating difficult. May not feel urge to void.
  Hydronephrosis [enlargement of ureters] occurs after
   delivery & to 4 wks. PP. DIURESIS!
  ↓ bladder sensitivity - ↑ risk for bladder infection -
   urinary stasis.
  Avoid bladder damage - assess bladder q 1-2 hrs.til
   voids qs. Teach voiding q 2 – 3 hours.
  Palpate abdomen gently, note location of fundus.
When do you suspect full bladder?
   During preg., 2000-3000 ml. of fluid accumulates in
    body - Client loses 5- 10 lbs. of water weight in 1st
      Circulatory System: Blood volume ^ 30 – 50% in
      With diuresis & blood loss @ delivery, blood volume
      returns to normal in 1-2 wks.
         Blood loss for NSVD = 300 cc. & C/S = 500 cc.

   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.
Gastrointestinal System:

   NSVD: bowels sounds. Eat right away.
   C/S: bowel sounds hypoactive 1st 8 hrs.
   Epidural/spinal: po clears after delivery, advance diet if
   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.
   Modified sit-ups strengthen abdomen
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
   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
 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)

   Taking-In Phase:
       time of reflection for client regarding new role
       may be passive or excited
       talks at length about birth experience
       on phone with family/friends recounting birth
       Usually lasts 1-2 days.
       Delayed d/t pain r/t vaginal or C/S.

   Taking-Hold Phase:
       woman makes own decisions regarding self & infant
       Usually day 2 - 3. Occur on day 1 esp. if woman is
       Can occur later, depends on recovery process or
        cultural beliefs.
Letting Go Phase:
      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.

 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.

   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.
        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

   Always refer to social worker to assess for degree of
   Ask: is mother able to take infant home without danger
    to self or baby?
   Studies show breast feeding helps reduce symptoms d/t
    oxytocin “feel good” effect
    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

The Post Partum Resource Center of New York, Inc.

 s/s depression
 s/s manic
 auditory hallucinations
 delusions
 guilt
 worthlessness
Development of Parental Love & Positive
 Family Relationships:

   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 starts regardless if pt. is
    breastfeeding or not.
   Entirely up to mother
   Must feel comfortable doing so.

Advantages to Breast Feeding:
   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:
   hands on demo
   lactation specialist [in clinical settings]
   Offer support

Contraindications to Breast Feeding:
 Mom receiving meds not appropriate for Br. fdg.
 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.

      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
    ^ production of prolactin by anterior pituitary
    Milk ducts become distended & fluid turns bluish-white
               Physiology cont.

   Infant suckling on breast produces more
    prolactin, which in turn stimulates more milk
   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:

   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
 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
   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
   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
   firm nodule under arm; temporarily blocked
    duct; relieved by infant sucking. Evaluate
    carefully since may be malignant growth. Warm
    compresses prn.
Mastitis –
   “inflammation”; milk duct/gland becomes
    infected. Poss. antibiotic therapy. Manual
    expression, continue to breast feed, frequent
    warm compresses.
Nursing Care : Promote successful breast feeding:

•    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
   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

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]

Assessment – minimum of twice daily
  Vital signs
  Emotional Status
  Breasts
  Fundus, lochia, & perineum
  Voiding & bowel function - flatus, BM
  Legs [+ Homan’s sign, ankle edema ]
  S/S complications [PP hemorrhage, infection, ↑ BP ]

Nursing Care
 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).
       Stool softeners, as ordered [Colace]
       Encourage ambulation
       Increase dietary fiber
       Provide adequate fluid intake
Health teaching & discharge planning
      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]
Keep 6 week PP appt.

Maternal Warning Signs to Report
        a) Heavy Vaginal Discharge [poss. hemorrhage]
        b) Pelvic or perineal pain [traveling clot]
        c) Fever [temp 100.4 or greater = infection]
        d) Burning sensation during urination [UTI]
        e) Swollen area on leg ; painful, red, or hot
        f) Breast: painful, red, hot area [mastitis]
Infant care

 a]   Bathing, cord care, circumcision care, diapering
 b]   Feeding, burping, scheduling feedings [mom can keep chart]
 c]   Temperature, skin color [dusky], newborn rash, jaundice
 d]   Stool & voiding [BM’s ; 6 or more voids/day]
e]    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]

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