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Questions and Answers
What is the duration of the postpartum period following childbirth?
Why is peer group support considered crucial for adolescent mothers during the postpartum period?
What challenge is commonly faced by single mothers during the postpartum period?
How might poverty affect a family's experience during the postpartum period?
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What unique challenge do families dealing with multiple births face?
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What should nurses consider when providing postpartum care to families from diverse cultural backgrounds?
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When might interpreters be necessary in postpartum care?
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What is a common misconception about adolescent mothers in the context of self-care?
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What does the REEDA assessment for the incision monitor for?
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Which of the following is NOT a common emotional change experienced in the postpartum period?
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During which phase does a mother focus on her personal needs and the birth experience according to Rubin's Theory?
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What is a critical aspect of pain management postpartum?
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Which of the following factors is likely to influence a grandparent's involvement in the family unit?
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What is the process called when the uterus returns to its pre-pregnancy size and condition?
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Which of the following dietary practices is commonly followed after childbirth in some cultures?
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What should be done if lochia has a foul odor after delivery?
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What nursing assessment acronym can be used to guide postpartum assessments?
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What could a constant trickle of brighter red lochia indicate?
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What is a common cause of afterpains that may be experienced postpartum?
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What is the normal duration of lochia rubra after delivery?
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Which medication is commonly used to promote uterine contractions postpartum?
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What does REEDA stand for in assessing perineal healing?
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What effect can a full bladder have on the uterine fundus postpartum?
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What is the recommended method for performing perineal cleansing to avoid contamination?
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When can combined oral or transdermal contraceptives be safely initiated for non-breastfeeding women postpartum?
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What physiological change occurs in the cardiovascular system postpartum following delivery?
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Which of the following is true regarding menstrual cycles after childbirth?
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What symptom suggests a potential urinary tract infection (UTI) postpartum?
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What skin change may occur postpartum due to hormonal changes?
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What type of breast changes can occur in non-nursing mothers after delivery?
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Study Notes
Postpartum Period Overview
- The postpartum period, also known as the puerperium, is the 6 weeks following childbirth.
- This period is considered the fourth trimester of pregnancy.
- During this time, focus is on the physiological and psychological changes in the mother and her family, as well as initial newborn care.
- Postpartum care may extend beyond 6 weeks for women planning future pregnancies.
Adapting Nursing Care
- Nurses must adapt care to each woman's circumstances, including:
- Single or adolescent parents
- Families experiencing poverty
- Multiple births
- Families from diverse cultural backgrounds
Adolescent Mothers
- Adolescents, particularly younger ones, may require assistance with parenting skills.
- Peer group is crucial for adolescents. Nurses should help them maintain social connections throughout pregnancy and postpartum.
- Adolescent mothers often exhibit passivity in self-care and newborn care.
- These mothers may face single parenthood and poverty.
- Younger adolescent mothers in poverty often have multiple children within a short period, which can exacerbate social challenges.
Single Mothers
- Single women without a strong support system may experience difficulties with postpartum adjustments.
- They often have to return to work early due to being the sole provider.
Poor Families
- Poor families may struggle to meet essential needs even before a newborn arrives, adding strain on the family.
- These women may lack adequate or consistent prenatal care, increasing the risk of complications extending into the postpartum period and impacting the child.
- Families may need social service referrals to connect them with public assistance programs or other resources.
Multiple Births
- Families with twins or more face unique challenges.
- Newborns are more likely to require intensive care due to preterm birth, which delays parent-infant bonding and routine newborn care.
- It can be difficult to conceptualize the individuality of each newborn, potentially leading to viewing them as a unit.
- Newborns may need care at distant hospitals for severe health issues.
- Financial strain increases with each additional complication.
Cultural Influences
- The United States has a diverse population with unique cultural practices, especially during significant life events like birth and death.
- Nurses should tailor care to align with the health beliefs, values, and practices of the specific culture to ensure a meaningful and safe birth experience.
Using Translators
- Interpreters may be necessary to facilitate understanding and provide optimal care for the woman and her family.
- It is crucial to utilize interpreters who are not family members to ensure accurate information and avoid selective interpretation.
- Choose interpreters who are not in social or religious conflict with the patient and family.
- Be cautious, as a woman's affirmative nod might be a gesture of courtesy rather than understanding or agreement.
Dietary Practices
- Some cultures follow the "hot" and "cold" theory of diet after childbirth.
- Temperature is not a factor in classifying foods as hot or cold; it relates to the perceived intrinsic property of the food.
- For example, eggs, chicken, and rice are considered "hot" foods.
- Women may prefer hot water over cool or cold water.
- Balancing yin (e.g., bean sprouts, broccoli, carrots) and yang (e.g., broiled meat, chicken, soup, eggs) foods is a common practice.
Postpartum Changes in the Mother: Nursing Assessment
- Nursing assessments are routinely performed every 4-6 hours unless the patient has risk factors warranting more frequent assessment.
- Assess all body systems, not just reproductive changes.
- Use the BUBBLE-HE acronym for postpartum assessment (Breasts, Uterus, Bladder, Bowels, Lochia, Episiotomy/perineum, Homan's, Emotional).
Reproductive System
- After birth, the levels of placental hormones (human placental lactogen, human chorionic gonadotropin, estrogen, progesterone) decrease, returning the body to its pre-pregnant state.
- The most significant postpartum changes occur within the reproductive system.
Uterus
- Involution refers to the process of reproductive organs, particularly the uterus, returning to their pre-pregnancy size and condition.
- The uterus undergoes rapid size and weight reduction after birth.
- It should reach its pre-pregnant size within 5-6 weeks.
- Subinvolution occurs if the uterus doesn't return to its pre-pregnancy state after 6 weeks.
- The uterine lining (endometrium) sheds after placental detachment.
- A basal layer remains to generate new endometrium for future pregnancies.
- The placental site heals completely within 6-7 weeks.
Descent of the Uterine Fundus
- The uterine fundus descends predictably as muscle cells contract to control bleeding and reduce cell size.
- Immediately after placenta delivery, the fundus is felt midline, at or below the umbilicus, as a firm mass.
- It descends about 1 cm daily after 24 hours.
- It should no longer be palpable by day 10 post-partum.
- A full bladder can interfere with uterine contraction, pushing the fundus upward and deviating it to the right.
Afterpains
- Intermittent uterine contractions may cause afterpains similar to menstrual cramps.
- Discomfort is self-limiting and diminishes rapidly within 48 hours postpartum.
- They are more frequent in multiparas and women with overly distended uteruses.
- Breastfeeding can increase afterpains due to oxytocin release.
- Mild analgesics may be prescribed, but aspirin is not recommended as it interferes with blood clotting.
Lochia
- Vaginal discharge after delivery, called lochia, consists of endometrial tissue, blood, and lymph.
- Its characteristics change throughout the early postpartum period:
- Lochia rubra: Red, mostly blood, lasting 3 days.
- Lochia serosa: Pinkish, blood and mucus, lasting from day 3 - 10.
- Lochia alba: Mostly mucus, clear/colorless/white, lasting from day 10 - 21.
- Lochia has a normal fleshy or menstrual odor; any foul odor should be reported.
- Pads should be checked frequently to estimate the amount of vaginal discharge.
- Discharge increases briefly when ambulating or breastfeeding due to uterine contraction.
- Women with cesarean births have less lochia in the first 24 hours because of uterine cavity sponging.
- Absence of lochia is abnormal and may indicate retained blood clots or infection.
Nursing Care (Uterus and Lochia)
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Assess fundus for firmness, location, and position routinely.
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Increased frequency for women with higher postpartum hemorrhage risks.
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Teach women fundal assessment and report any deviations in uterine descent.
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Massage a soft or boggy uterus to prevent hemorrhage.
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Assist women in voiding due to a full bladder contributing to poor uterine contraction.
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Catheterization may be necessary if the woman cannot void.
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Teach women about expected lochia changes and volume.
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Report any abnormal lochia characteristics:
- Foul smell with or without fever
- Lochia rubra beyond day 3
- Unusually heavy flow
- Lochia returning to a bright red color after transitioning to serosa or alba.
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Medications to promote uterine contraction:
- Oxytocin (Pitocin)
- Methylergonovine (Methergine)
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Newborn suckling triggers oxytocin release and uterine contractions.
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Mild analgesics provide relief for afterpains.
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Report afterpains lasting beyond 48 hours.
Cervix and Vagina
Cervix
- Regains muscle tone but never fully closes to prepregnancy size.
- Some edema persists for a few weeks after delivery.
- Constant trickle of brighter red lochia indicates cervical or vaginal laceration bleeding, especially if the fundus remains firm.
Vagina
- Undergoes significant stretching during childbirth.
- Rugae (vaginal folds) disappear, and the walls become smooth and spacious.
- Rugae reappear within 3 weeks postpartum, and the vagina regains most of its pre-pregnancy form within 6 weeks but never fully returns to its pre-pregnancy size.
Nursing Care
- Discuss resumption of sexual activity after childbirth.
- Recommend waiting until bleeding stops and the perineum heals.
- Educate women about vaginal lubrication limitations in the initial weeks after childbirth.
- Instruct on Kegel exercises to strengthen pelvic floor muscles.
Perineum
- Often edematous, tender, and bruised following childbirth.
- An episiotomy or perineal laceration may have occurred.
- Hemorrhoids commonly worsen due to birth process pressure.
Nursing Care (Perineum)
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Assess for normal healing and complications using the REEDA acronym.
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REEDA acronym:
- Redness
- Edema
- Ecchymosis (bruising)
- Discharge
- Approximation (of wound edges)
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REEDA acronym:
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Focus on comfort and hygiene.
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Apply ice packs for the first 24 hours to reduce edema and bruising.
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Use a disposable rubber glove filled with ice chips for alternate ice pack application.
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After 24 hours, apply heat via warm packs, bidets, or sitz baths to promote healing.
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Teach perineal care techniques (warm water bottle, front-to-back cleansing, blotting dry).
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Use peripads in a front-to-back direction to avoid fecal contamination.
Perineal Pain Treatment
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Topical and systemic medications:
- Hydrocortisone and pramoxine (Epifoam)
- Benzocaine (Americaine or Dermoplast)
- Witch hazel pads (Tucks) and sitz baths reduce hemorrhoid discomfort.
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Teach women to squeeze their buttocks together when sitting to reduce pain.
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Use an air ring (donut) or egg crate pad to relieve perineal pressure.
Interconceptual Care: Return of Menstruation and Contraception
Menstruation
- Placental estrogen and progesterone production stops at delivery, increasing follicle-stimulating hormone production.
- Menstrual cycles resume around 5 weeks post-delivery for non-breastfeeding women and 8 weeks for exclusively breastfeeding women.
Contraception
- Discuss contraception options before discharge.
- Combined oral or transdermal estrogen-progesterone contraceptives can be started 2-3 weeks postpartum in non-breastfeeding women.
- Low-dose, progestin-only contraceptives can be initiated 4 weeks postpartum for breastfeeding women.
- Avoid progestin-only contraception for breastfeeding Hispanic women with gestational diabetes due to the high type 2 diabetes risk.
- Other contraception methods can be started once lactation is well-established.
- Interconceptual care refers to the 1 year period following postpartum, promoting the mother's health between pregnancies.
- Ideal pregnancy spacing is approximately 2 years apart.
Breasts
- Nursing and non-nursing mothers experience breast changes after birth.
- Assessments are similar; nursing care differs.
Breast Changes
- For the first 2-3 days, breasts are full but soft.
- By day 3, they become firm and lumpy as blood flow increases, and milk production begins.
- Breast engorgement may occur in both types of mothers, characterized by hard, erect, and uncomfortable breasts.
- Non-nursing mothers return to normal breast size in 1-2 weeks.
Breastfeeding Care
- Assess breast consistency, size, shape, and symmetry at each assessment.
- Inspect nipples for redness and cracking, which can cause discomfort and pose an infection risk.
- Flat or inverted nipples make breastfeeding more difficult.
- Breastfeeding mothers should wear a supportive but not too tight bra.
- Avoid nipple stimulation for non-nursing mothers.
- Non-nursing mothers should wear bras at all times and avoid nipple stimulation.
- Avoid soap on nipples, as it can cause dryness and cracking.
Cardiovascular System
- The woman's cardiovascular system adapts to blood loss at delivery:
- 500 mL in vaginal birth
- 1000 mL in cesarean birth
- Despite blood loss, there is a temporary increase in blood volume and cardiac output due to the return of blood from the uterus and placenta to main circulation.
Postpartum Changes
- Blood volume increases due to added fluid from tissues.
- Increased stroke volume leads to bradycardia.
- Pulse rate can be as low as 50 to 60 beats/min for 48 hours after birth.
- Excess fluid is eliminated through diuresis (up to 3000 mL/day) and diaphoresis.
- Blood clotting factors are elevated during pregnancy and for 4 to 6 weeks postpartum, increasing the risk of blood clots, especially with venous stasis.
- Pulmonary embolus is a potential complication; dyspnea and tachypnea require immediate medical attention.
- Cesarean births may include prophylactic anticoagulant therapy (heparin) and pneumatic compression devices.
- Hemoglobin and hematocrit values may be difficult to interpret in early postpartum due to fluid shifts.
- White blood cell count may rise to 12,000 to 20,000/mm3, a normal response to inflammation, pain, and stress.
- Postpartum chills (tremors) are common, related to pressure release on pelvic nerves and epinephrine release.
- Postpartum orthostatic hypotension can cause dizziness or fainting.
Vital Sign Monitoring
- Vital signs should be monitored every 4 hours for the first 24 hours.
- Temperature may rise to 38°C (100.4°F) during the first 24 hours
- Pulse rate is a good indicator of infection or hypovolemia.
- Diaphoresis is a temporary physiological response.
- Assess extremities for edema, a common occurrence after delivery.
- Edema above the waist may indicate pregnancy-induced hypertension.
- Assess for signs of thrombosis.
- Early and regular ambulation helps prevent venous stasis and clots.
Postpartum Urinary System
- Kidney function returns to normal within a month.
- Decreased bladder tone and increased fluid intake can cause bladder distention.
- Bladder distention can lead to postpartum hemorrhage or urinary tract infection (UTI).
- Measure urine output for the first two or three voidings.
- Encourage privacy and offer strategies to aid in voiding (running water, warm water, peribottle).
- Burning or urgency of urination suggests UTI.
Postpartum Gastrointestinal System
- Gastrointestinal function returns to normal as progesterone levels decrease.
- Constipation is common due to medication, stretched abdominal muscles, pain, and dehydration.
- Encourage fluids, fiber, and ambulation.
- Stool softeners (docusate calcium, docusate sodium) may be prescribed.
Postpartum Integumentary & Musculoskeletal System
- Skin hyperpigmentation (chloasma, linea nigra) fades with hormonal changes.
- Striae fade from reddish purple to silver.
- Abdominal wall muscles may appear lax; exercise can help restore tone.
- Diastasis recti (separation of abdominal muscles) may persist for 6 to 8 weeks.
- Joint hypermobility stabilizes within 6 weeks, but feet may remain separated.
- Light exercise can begin on the first day after vaginal birth (later after cesarean).
Postpartum Immune System
- Rh-negative mothers receive Rho(D) immune globulin (RhoGAM) within 72 hours of delivering an Rh-positive newborn to prevent sensitization.
- Rubella vaccination is given postpartum to women who are not immune.
- Rubella vaccine should not be administered if the woman is sensitive to neomycin.
Postpartum Care After Cesarean Birth
- Assess descent and firmness of the fundus.
- Lochia quantity is generally less after cesarean birth.
- Monitor the dressing for drainage and the incision for infection.
- Check the incision for REEDA (redness, edema, ecchymosis, drainage, and approximation).
- Incision staples may be removed on the third day or in the healthcare provider’s office.
- The woman can shower as soon as she can ambulate reliably.
- A urinary catheter is usually removed within 24 hours.
- Monitor urine output and observe for signs of UTI.
- Auscultate lung sounds for clarity.
- Encourage deep breathing, coughing to move secretions, and early ambulation.
- Higher risk for thrombophlebitis, may receive prophylactic heparin and pneumatic compression devices.
- Encourage leg exercises.
- Pain management is critical to reduce discomfort and facilitate movement.
- Assess pain severity, frequency, character, and location.
- Epidural narcotics may cause respiratory depression, requiring close monitoring.
Postpartum Emotional Care
- Motherhood changes include hormonal, body image, and psychological acceptance of self as a mother.
- Postpartum blues: Common, self-limiting feelings of joy and emotional letdown, lasting a few weeks.
- Postpartum depression: Persistent unhappiness, should be reported to a health care provider.
- Fatigue is common due to modern lifestyle demands on postpartum mothers.
- Parenthood: Learning new roles and making adjustments, particularly for first-time parents who may experience changes in their relationship and communication.
- Fathers: Often display intense interest in their newborns (engrossment), and adjust to fatherhood in four phases: having expectations, confronting reality, creating a personal father role, and reaping rewards.
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Siblings: Adjustments vary depending on their age and developmental level.
- Toddlers may regress or be angry.
- Preschoolers may hesitate to touch the newborn.
- Older children may enjoy involvement.
- Grandparents: Involvement is often dictated by proximity to the family and their own expectations and cultural influences.
- Grieving parents: The postpartum period is typically joyous, but nurses may care for grieving parents. Therapeutic communication is important to support them.
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Postpartum Grief: Can manifest in different ways.
- Parents may experience regret, remorse, or guilt.
- Anniversaries can be painful.
- Birth of a new child can awaken grief.
- Baptism can be performed if the newborn dies or has a birth defect.
- Family Care Plan: Considers the family as the patient. Uses information about family structure and cultural composition in providing care.
Postpartum Care: Cesarean Section
- Requires increased nursing care due to the surgical procedure.
- Nursing assessments:
- Assess incision, fundal height, lochia, surgical dressings (REEDA method), urine output (indwelling catheter), fluid intake and output, pulmonary assessment (lung sounds, respiratory secretions), pain levels, leg exercises to prevent thrombophlebitis
Rubin's Theory of Psychological Changes During the Puerperium
- Taking-in phase: Passive, focus on personal needs and birth experience
- Taking-hold phase: Interest in infant care, awareness of abilities, desire to assume responsibility for self and infant care
- Letting-go phase: Mother integrates her new roles and identity as a mother
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Description
This quiz explores the postpartum period, also known as the puerperium, focusing on the physiological and psychological changes that mothers experience. It delves into how nursing care should be adapted to meet the diverse circumstances of mothers, including those who are adolescents or from different cultural backgrounds. Understand the importance of support during this critical time for both mothers and their newborns.
