Postpartum Changes Student Copy PDF

Maternal and Child Health Nursing Postpartum Changes Juvy G. Reyes MAN, RN Wk. 10 CU Postpartum Changes Learning Objectives: 1. Describe the psychological and physiological changes that occur in a postpartum woman and her family. 2. Assess a woman and her family for physiologic...

Maternal and Child Health Nursing Postpartum Changes Juvy G. Reyes MAN, RN Wk. 10 CU Postpartum Changes Learning Objectives: 1. Describe the psychological and physiological changes that occur in a postpartum woman and her family. 2. Assess a woman and her family for physiologic and psychological changes after childbirth. 3. Integrate knowledge of the physiologic and psychological changes of the postpartum period with the nursing process to achieve quality maternal and child health nursing care Postpartal period (Puerperium) – refers to the 6 weeks period after childbirth Latin word “puer” - means “child” parere – “to bring forth” Fourth trimester of pregnancy Physiological and Psychological Changes of Postpartum Period Physiological Changes of the Postpartal Period 2 Changes: 1. Involution (Retrogressive) – return of the uterus and vagina to their non-pregnant state 2. Progressive – production of milk for lactation, restoration of normal menstrual cycle and beginning of parenting role. Physiological Changes of the Postpartal Period Involution (Retrogressive) – is the process whereby the reproductive organs return to their nonpregnant state. Involution is complete (6 weeks), the uterus is completely return to its prepregnancy state. Involution (Retrogressive) – reproductive system changes and other systemic changes Reproductive System Systemic Changes 1. Cervix 1. Hormonal System 2. Perineum 2. Urinary System 3. Vagina 3. Circulatory System 4. Uterus 4. Gastrointestinal System 5. Integumentary System Physiological Changes of the Postpartum Period A. Reproductive System Changes Involution (Retrogressive) 1. Cervix a. Soft and malleable to palpation b. Both Internal os external os are open c. Contraction of the cervix towards prepregnant state begins d. End of 7 days external os narrowed to size of a pencil opening. A. Reproductive System Changes Involution (Retrogressive) 1. Cervix involves formation of new muscle cells and because of this cervix does not return to its prepregnancy state Internal os closes as before, after vaginal birth external os remain slightly open and appears slit - like or stellate (star shaped) A. Reproductive System Changes Involution (Retrogressive) 2. Perineum – great amount of pressure experienced during birth a. Edematous and tender b. Ecchymosis patches from ruptured capillaries c. Labia majora and minora remain atrophic and soften A. Reproductive System Changes Involution (Retrogressive) 2. Perineum Nursing Responsibilities: 1. Perineal Care - inspect the perineum. 2. Observe for ecchymosis, hematoma, erythema, edema, intactness, and presence of drainage or bleeding from any episiotomy stitches. 3. Assess rectal area for the presence of hemorrhoids  A. Reproductive System Changes Involution (Retrogressive) Nursing Responsibilities: 4. Nonpharmacologic comfort measures applying an ice or cold pack to the perineum during the first 24 hours reduces perineal edema and the possibility of hematoma formation, A. Reproductive System Changes Involution (Retrogressive) 2. Perineum Nursing Responsibilities: After the first 24 hours healing increases best if circulation to the area by the use of heat. 5. Dry heat in the form of a perineal hot pack or moist heat with a sitz bath to increase circulation to the perineum  A. Reproductive System Changes Involution (Retrogressive) 2. Perineum Nursing Responsibilities: 6. Episiotomy Care - the perineal area heals rapidly, discomfort is normal and does not usually last longer than 5 or 6 days. Soothing cream or anesthetic spray to be applied to the suture line to reduce discomfort. Acetaminophen or ibuprofen administer according to prescription order A. Reproductive System Changes Involution (Retrogressive) 2. Perineum Nursing Responsibilities: 7. Promote Perineal exercises (Kegel exercises) a. 3-4 x /day can improve circulation and decrease perineal edema b. Regain prepregnant muscle tone and help prevent urinary incontinence A. Reproductive System Changes Involution (Retrogressive) 8. Relieve Muscular Aches Nursing Responsibilities: a. Sore and aching after labor and birth due to excessive energy used for pushing during the pelvic division of labor. b. Backrub is effective for relieving an aching back or shoulders.  A. Reproductive System Changes Involution (Retrogressive) 3. Vagina a. Vagina is soft with few rugae and its diameter is greater than normal b. Hymen is permanently torn and heals with small, separate tags of tissue c. Thickening of the vaginal walls appears (It takes the entire postpartal period for the vagina to involute)  A. Reproductive System Changes Involution (Retrogressive) 4. Uterus Involution of the uterus involves two process: a. The area where the placenta was implanted is sealed off by rapid contraction to prevent bleeding b. The organ is reduced to its approximate pregestational size A. Reproductive System Changes Involution (Retrogressive) d. Uterus The sealing of the placenta site is accomplished by rapid contraction of the uterus immediately after delivery of the placenta. This contraction pinches the blood vessels and left denuded by the placenta and stops bleeding. With time, thrombi form within the uterine sinuses and permanently seal the area. d. Uterus - fundus is palpable, halfway between umbilicus and symphysis pubis few mins. after birth ▪ One hr. later – at the level of umbilicus and remains for 24 hrs. ▪ First day postpartum – decreases by one fingerbreadth per day (1 cm.) a day in size ▪ Day 9-10 no longer palpable A. Reproductive System Changes Involution (Retrogressive) d. Uterus Immediately after birth uterus weighs about 1,000 grams End of the first week, it weighs 500 grams Involution is complete (6 weeks) - it weighs approximately 50 grams (prepregnancy weight) d. Uterus the uterus of a breastfeeding mother may contract more quickly because of the released of oxytocin which stimulates uterine contraction d. Uterus Delayed Involution Causes: 1. Multiple fetuses 2. Hydramnios 3. Exhaustion from prolonged labor 4. Grand multiparity 5. Physiologic effect of analgesia 6. Retained placenta or membrane Uterine atony - is failure of the uterus to contract adequately following delivery The first hour after birth is potentially the most dangerous time for a woman. If the uterus is relaxed during this time patient will lose blood very rapidly, because no permanent thrombi have yet formed at the placental site.  Uterine atony Assessment: 1. Assess vital signs every 15 mins for the first hour 2. Palpate the fundus (size, consistency, and position (Fundal height) 3. Observe the amount and characteristics of lochia d. Uterus Involution will occur most dependably: 1. Well-nourished 2. Ambulates early after delivery Advantages: a. Decreased incidence of thrombophlebitis b. Better uterine drainage and enhanced uterine involution  d. Uterus Involution will occur most dependably: 2. Ambulates early after delivery Advantages: c. Preventing urinary retention and constipation d. Less respiratory complications (Pneumonia and Pulmonary embolism) Pulmonary embolism - is a blockage in one of the pulmonary arteries in the lungs d. Uterus Involution will occur most dependably: 2. Ambulates early after delivery Advantages: e. Early regain of maternal strength f. Improved well-being and self-esteem g. Greater confidence in providing baby care h. Shorter hospitalization days (If hospitalized) d. Uterus Nursing Responsibilities: 1. Provide pain relief for uterine cramping (After pains) Pain from uterine contractions can be intense, this type of discomfort is normal and rarely lasts longer than 3 days. a. Ibuprofen - an anti-inflammatory and anti prostaglandin properties b. Analgesic (Acetaminophen) effective for pain relief Avoid: Heat to abdomen A. Reproductive System Changes Involution (Retrogressive) e. Lochia – is the vaginal discharge of a postpartum mother, consists of shreds of decidua, erythrocytes (RBC) leucocytes, epithelial cells, and bacteria Reasons for Lochial evaluation: 1. To detect the normality of vaginal discharge and rule out postpartum hemorrhage 2. To evaluate the state of uterine involution 3. To detect the presence of puerperal sepsis A. Reproductive System Changes Involution (Retrogressive) e. Lochia Characteristics of Lochia: 1. Lochia Rubra – red color, 1 - 3 days (Blood, small particles of decidua and mucus) 2. Lochia Serosa – pink or brownish, 3 - 10 days (Blood, mucus, and invading leukocytes) 3. Lochia Alba – white with streaks of brownish mucus , 10 - 14 days until 3 – 6 wks. (Largely mucus, leukocytes count high) Physiological Changes of the Postpartum Period A. Reproductive System Changes 1. Involution (Retrogressive) e. Lochia Evaluate the Lochia: 1. Color: red, pinkish brown, whitish with or without clots Reddish color – more than two wks. Indications: a. Retention of small portions of the placenta b. Imperfect involution of the uterus 2. Odor Normal: fleshy, musky, non-offensive, non-foul odor Abnormal: malodorous or foul odor Evaluate the Lochia: 3. Amount – depending on how much the perineal pad is stained within one hour period a. Heavy/large: one perineal pad saturated in 15-30 mins. b. Moderate: Perineal pad blood stain less than 15 cm (6 inch) c. Light/small: Perineal pad blood stain less than 10 cm. (4 inch) d. Scant: Perineal pad blood stain less than 2.5 cm. (1 inch) e. Lochia Nursing Responsibilities: 1. Inspect Lochia – color, odor, amount a. Check the consistency - lochia should contain no large clots b. Clots - may indicate that a portion of the placenta has been retained and is preventing closure of the maternal uterine blood sinuses. Large clots denote poor uterine contraction, which needs to be corrected Progressive Changes of the Puerperium A. Reproductive System Changes 2. Progressive Changes of the Puerperium Progressive Changes or the building of new tissue requires good nutrition caution women against strict dieting that would limit cell- building ability during the first 6 weeks after childbirth  A. Reproductive System Changes 2. Progressive Changes of the Puerperium First 2 days after birth, an average woman notices little changes in her breasts from the way they were during pregnancy a. Lactation – the formation of breast milk begins in a postpartal woman whether or not she plans to breastfeed A. Reproductive System Changes 2. Progressive Changes of the Puerperium a. Lactation Since midway through pregnancy, she has been secreting colostrum Colostrum – is a thin, watery, yellow fluid composed of protein, sugar, fat, mineral, water, vitamins, and antibodies A. Reproductive System Changes 2. Progressive Changes of the Puerperium a. Lactation Breast milk forms in response to the decrease in Estrogen and Progesterone levels that follows delivery of the placenta , which stimulates Prolactin production and, consequently, milk production When breast milk first begins to form, the milk ducts become distended  A. Reproductive System Changes 2. Progressive Changes of the Puerperium a. Lactation Primary engorgement - feeling of tension in the breasts and fades on the 3rd or 4th day after birth as the infant begins effective sucking and empties the breasts of milk 2. Progressive Changes of the Puerperium a. Lactation Engorgement – feeling of tension in the breast 3rd or 4th day after birth. Signs: a. Breast distention b. Feeling of heat or throbbing pain c. Breast tissue appear reddened Prevent / Relieve Breast Engorgement 1. Empty the breasts of milk by having the infant suck more often or at least continue to suck as much as before 2. Mild analgesic for pain relief 3. Good breast support from a Firm-fitting bra 4. Warm packs applied to both breasts or standing under a warm shower for a few minutes before feeding Prevent or Relieve of Engorgement 5. Massage to begin milk flow 6. Use of breast pump to completely empty the breast after the baby has nursed  Promote Breast Hygiene Breast care during the postpartum period includes cleanliness and support. 1. Teach a woman to wash her breasts daily with clear water at the time of her bath or shower and then dry them with a soft towel. 2. She should avoid using soap - tends to dry and crack the nipples, possibly leading to fissures and breast abscess. 3. It is not necessary for women to wash their breasts more often than daily, because excessive washing means unnecessary manipulation. Progressive Changes of the Puerperium b. Return of Menstrual flow Delivery of the placenta, ends the production of estrogen and progesterone Decrease in hormone causes delayed rise in production of FSH which leads to a slight delay the return of ovulation that initiates the return of normal menstrual cycles 2. Progressive Changes of the Puerperium b. Return of Menstrual flow – increase production of FSH, leads to return of ovulation a. Breastfeeding mothers – menstrual flow may not return for 3-4 months or for the entire lactation period (Lactational Amenorrhea) Absence of a menstrual flow does not guarantee that a woman will not conceive during this time, because she may ovulate well before menstruation returns b. Not breastfeeding – flow return in 6-10 weeks after birth Systemic Changes B. Systemic Changes 1. Hormonal System – hormones begins to decrease as the placenta no longer present a. HCG and HPL decreased are negligible by 24 hrs. b. FSH remains low for 12 days then begins to rise to initiate new menstrual cycle c. Wk.1 – Progestin, estrone and estradiol are all at prepregnancy level 2. The Urinary System During pregnancy, as much as 2000 to 3000 mL excess fluid accumulates in the body. An extensive diuresis begins to take place almost immediately after birth to rid the body of this fluid. Increases the daily output of a postpartal woman 2. Urinary System a. Diuresis - from a normal level of 1500 mL to as much as 3000 mL/day during the 2nd to 5th day afterbirth, increase in urine production causes the bladder to fill rapidly b. Hydronephrosis – increase in size of ureters present for about 4 wks. Postpartum Side effects: Urinary stasis and UTI 2. Urinary System a. Diuresis b. Hydronephrosis Causes: a. Pressure on the bladder and urethra due to fetal head exertion. b. Transient loss of bladder tone c. Edema surrounding the urethra decreases the ability to sense when to void d. Epidural anesthesia – can feel no sensation in the bladder area until anesthetic has worn off Management of Full bladder: To prevent permanent damage to the bladder from overdistention: 1. Assess the client abdomen frequently a. Palpation – hard or firm area just above the symphysis pubis b. Percussion – full bladder sounds resonant 3. Circulatory System – blood volume return to its normal level 1-2 wks. after birth Blood loss after delivery: a. Vaginal birth – 300-500 ml b. Caesarean birth – 500 – 1000 ml. A 4-point decrease in hematocrit (proportion of red blood cells to circulating plasma) 1-g decrease in hemoglobin value occur with each 250 mL of blood loss. 4. Gastrointestinal System a. Digestion and absorption begins to be active after birth b. Bowel sounds are active, but passage of stool may be slow because of the still-present effect of relaxin on the bowel. c. Bowel evacuation may be difficult because of the pain of episiotomy sutures or hemorrhoids.  5. Integumentary System a. Striae gravidarum - after birth stretch marks still appear reddened will fade to a pale white over the next 3-6 mons. b. Melasma (Chloasma) – excessive pigmentation from the face and neck is barely detectable by 6 wks. time c. Linea nigra – barely detectable by 6 wks. 5. Integumentary System Diastasis recti is - the partial or complete separation of the rectus abdominis, which meet at the midline of your stomach overstretching and separation of the abdominal musculature - the area will appear slightly indented. If the separation is large, it will appear as a bluish area in the abdominal midline. 5. Integumentary System Diastasis recti Management; 1. Modified sit-ups help to strengthen abdominal muscles and return abdominal support to its prepregnant level 2. May require surgery to correct 6. Vital Signs 1. Temperature ▪ first 24 hrs. – slightly increase due to dehydration ▪ 3 - 4th day after birth – slightly increase due to breast fill with milk Any woman whose oral temperature rises above 100.4° F (38° C), excluding the first 24-hour period, is considered to be febrile. In such women, a postpartal infection may be present. 2. Pulse - slightly slower than normal ▪ End of first week – pulse return to normal ▪ Rapid, thready pulse – sign of hemorrhage 6. Vital Signs c. Blood pressure – should be monitored 1. Decrease BP – indicates bleeding Complications: a. Acute blood loss b. Orthostatic hypotension c. Dizziness 2. Increase BP – (140/90 mmhg) Indication: a. Pregnancy induced hypertension b. Oxytocin drugs Psychological Changes of Postpartum Period Psychological Changes of Postpartal Period Behavioral Adjustment Phases of Puerperium 1. Taking-in- Phase 2. Taking - hold phase 3. Letting- go phase Psychological Changes of Postpartal Period Behavioral Adjustment Three Phases of Puerperium (Reva Rubin, 1977) 1. Taking – in Phase – 1-3 days period, time of dependence a. The woman is passive b. Time of reflection c. Sense of wonder d. Wants to talk about her pregnancy (Labor and birth) Psychological Changes of Postpartal Period Behavioral Adjustment Three Phases of Puerperium (Reva Rubin, 1977) 1. Taking – in Phase – 1-3 days period, time of dependence Cause: a. Physical discomfort (afterpains, hemorrhoids) b. Uncertainty in caring for her newborn c. Exhaustion that follows childbirth Psychological Changes of Postpartal Period Three Phases of Puerperium (Reva Rubin, 1977) 1. Taking – in Phase Nursing Responsibilities: a. Encourage her to talk about the birth. b. Ensure bonding but there must be enough rest period. Psychological Changes of Postpartum Period Three Phases of Puerperium (Reva Rubin, 1977) 2. Taking- Hold Phase – begins to initiate action and make her own decisions. a. Begins to take a stronger interest for her infant and begins maternal role behaviors b. Often feels insecure about the ability to care for her new child 2. Taking- Hold Phase Nursing Responsibilities: a. Give a brief demonstration of baby care. b. Allow her to care for her child with watchful guidance c. Praise for the things she does well to give her confidence. Psychological Changes of Postpartum Period Three Phases of Puerperium (Reva Rubin, 1977) 3. Letting- Go Phase – redefines her new role a. Gives up fantasized image of her child and accept the real one b. Gives up her old role of being childless or the mother of only one or two c. Readjustment of relationships, extended and continues during the child’s growing years. Maternal concerns and feelings in the Postpartal Period 1. Abandonment – it is a feeling of abandonment and less important after giving birth. 2. Disappointment – common feelings parents may experience disappointment in the baby 3. Postpartal Blues – feelings of overwhelming sadness Ma ternal concerns and feelings in the Postpartal Period 3. Postpartal Blues During the postpartal period, 50% of women experience feelings of overwhelming sadness burst into tears easily or feel let down or irritable temporary feeling after birth has long been known as the “baby blues.” Maternal concerns and feelings in the Postpartal Period Postpartal Blues – feeling of sadness 1-10 days after childbirth Causes: 1. Hormonal changes (decrease estrogen and progesterone) 2. Physical discomfort 3. Disappointment in some aspect of her newborn 4. Not receiving support from her parents 5. Response to dependence and low self-esteem Maternal concerns and feelings in the Postpartal Period 3. Postpartal Blues Symptoms: 1. Tearfulness 2. Feelings of inadequacy 3. Mood lability 4. Anorexia, and sleep disturbance. Maternal concerns and feelings in the Postpartal Period 3. Postpartal Blues 1. Anticipatory guidance and individualized support from health care personnel 2. Give a chance to verbalize her feelings and make as many decisions as she wants to help gain a sense of control and move past postpartal emotion BUBBLE-HE BUBBLE-HE - is a acronym used to denote the components of the postpartum maternal nursing assessment method enhances the standard physical assessment performed on hospitalized patients by the RN For stable patients, a. Vital signs are taken every 15 minutes during the first hour following delivery and then gradually less frequently. b. While performing the BUBBLE-HE, the RN often uses the assessment time to provide for patient education. 8 - POINT POSTPARTUM ASSESSMENT INSTRUCTIONS 1. Assessment of the Breast a. Gently palpate each breast b. If you feel nodules in the breast, the ducts may not have been emptied at last. c. Stroke downward towards the nipple, then gently release the milk by manual. d. If nodules remain, notify the doctor. 8-POINT POSTPARTUM ASSESSMENT INSTRUCTIONS 1. Breast e. Explain the process of milk production, (engorgement, how to perform self breast examinations, and answer any questions she may have about breastfeeding. 1. What is the contour? 2. Are the breast full, firm, tender, shiny? 3. Are the veins distended? Is the skin warm? 4. Does the patient complain of sore nipples? 5. Are breasts so engorged that she requires pain medication? 8- POINT POSTPARTUM ASSESSMENT INSTRUCTIONS 2. Uterus a. Palpate the uterus b. Have the patient feel her uterus as you explain the process of involution c. If uterus is not involution properly, check for infection, fibroids and lack of tone. 8- POINT POSTPARTUM ASSESSMENT INSTRUCTIONS 2. Uterus d. Uterus should be firm and decrease approximately one finger breadth below e. Unsatisfactory involution may result if there are retained secundines or the bladder not completely empty 8-POINT POSTPARTUM ASSESSMENT INSTRUCTIONS 3. Bladder a. Inspect and palpate the bladder simultaneously while checking the height of the fundus. b. An order of catheterization may be done for culture and sensitivity test c. Proper perineal care. Explain that she should wipe from front to back after voiding and defecating 8-POINT POSTPARTUM ASSESSMENT INSTRUCTIONS 3. Bladder d. Bladder distention should not be present after recent emptying. e. Bladder distention occur - a pouch over the bladder area is observed, felt upon palpation and mother usually feels need to urinate f. First 3-post-partum voiding be measured and should be at least 150cc. g. Frequent small voiding with or without pain and burning may indicate infection or retention. 8-POINT POSTPARTUM ASSESSMENT INSTRUCTIONS 4. Bowel Function a. Daily about bowel movements. If her bowels have not functioned by the second postpartum day, the doctor may start her on a mild laxative b. Encourage patient to drink extra fluids. c. Have patient select fruits and vegetables from her menu 8- POINT POSTPARTUM ASSESSMENT INSTRUCTIONS 5. Lochia a. Assess amount, type of lochia on pad in relations to the number of postpartum days. First 3 days of postpartum - red lochia similar to the menstrual flow (lochia rubra). During the next few days - watery serous (lochia serosa). 10th day - thin and colorless (lochia alba). 8- POINT POSTPARTUM ASSESSMENT INSTRUCTIONS 5. Lochia b. Inform the mother about what changes she should expect in the lochia and when it should cease. c. Tell the mother when her next menstrual period will probably begin and when she can resume sexual relations. d. Discuss family planning at this time. e. Notify the doctor if the lochia looks abnormal in to color or contains clogs other than small ones. 8-POINT POSTPARTUM ASSESSMENT INSTRUCTIONS 6. Episiotomy (REEDA) Assessment: a. Inspect episiotomy for REEDA b. Check rectal area If hemorrhoids are present (sitz bath and local analgesic medication). Reassure patient and answer questions she may have regarding pain, cleanliness, and coitus. 8-POINT POSTPARTUM ASSESSMENT INSTRUCTIONS 6. Episiotomy (REEDA) c. Check episiotomy for proper wound healing, infection, inflammation and suture sloughing, warm to touch? e. Does the patient complain of discomfort? Notify the doctor if any occurs 8-POINT POSTPARTUM ASSESSMENT INSTRUCTIONS 7. Homan’s Sign Assessment: a. Press down gently on the patient’s knee (legs extended flat on bed) ask her to flex her foot b. Pain or tenderness in the calf is a positive Homan’s sign and indication of thrombophlebitis. Physician should be notified immediately. 8-POINT POSTPARTUM ASSESSMENT INSTRUCTIONS 8. Emotional Status Assessment: a. Throughout the physical assessment, notice and evaluate the mother’s emotional status. b. Explain to the mother and to her family that she may cry easily for a while and that her emotions may shift from high to low. 8-POINT POSTPARTUM ASSESSMENT INSTRUCTIONS 8. Emotional Status The changes are caused by the hormonal changes occurring in her body and by her realization of new responsibilities that accompany each child’s birth c. Does the patient appear dependent or independent? Midterm