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Physiologic Adaptations to

Postpartum

Making the decision to have a child its


momentous. It is to decide forever to have
your heart go walking around outside your
body.
Elizabeth Stone

Postpartum or Puerperium

First six weeks after delivery during which


the reproductive system and the body
returns to normal.

Although changes are normal, in no other


period of life is there such marked and rapid
physiological catabolism.

Changes in the following:


Uterus
Breasts
Perineum
Vagina
Bowel
Bladder
Endocrine

Cardiovascular
Blood
Vital Signs
Abdominal
musculature
Sleeping
Psychological

Postpartum Assessment
BUBBLE-HE

Breasts
Uterus
Bladder
Bowel
Lochia
Episiotomy
Homan Sign
Emotion

Breast Changes
Colostrum secreted from third tri. until
lactation begins
Milk--lactation 3rd pp day
Engorgement from increased vascular and
lymphatic circulation
Decreased/absent placental hormones cause
prolactin to be secreted=lactation

Assessment- Engorgement, nipple cracks,


soreness, or discomfort while breastfeeding

Uterine Changes
Blood vessels contract, uterus shrinks
Involutes at 1cm/day 1cm=1fingerbreadth
Below the symphysis by 10-12 days
Process for involution=autolysis of protein

1000gm at delivery, 60gm at 6 wks pp

Assessment- palpate fundus at frequent


intervals for position and firmness (ALWAYS
support with two hands).

Bladder Changes

Bladder Changes
edema and hyperemia,extravasation
increased capacity, decreased sensitivity
overdistension with incomplete emptying
urethral trauma may cause dysuria
transient glycosuria, proteinuria, and keytonuria
are normal in immediate postpartum

Assessment- Dysuria, fullness, tone (ability to


empty), placement, amount, frequency

Bowel Changes
decreased peristalisis
decreased intra abdominal pressure
hemorrhoidal discomfort
perineal discomfort

Increase roughage and fluids, laxatives and


suppositories--bowels normal by 1wk pp

Lochia
Vaginal

discharge after
delivery, composed of
leukocytes, epithelial cells,
decidua, autolysed protein and
bacteria.
Rubra - delivery to 3rd day
Serosa - days 4-10
Alba -10--several weeks post
delivery

Assessmentcolor,amount,odor,&clots

Episiotomy
Episiotomy--subcuticular sutures
Pain for 24-48 hrs

ice for 24 hrs then heat (sitz baths)


Analgesics, systemic and topical
Sit properly
Keep clean--perineal care
AssessmentRedness, Edema, Ecchymosis, Drainage, Approximation

Episiotomy

First Degree

Vaginal membranes

Second Degree

above include fascia

Third Degree

above, include anal


sphincter

above, include anal


canal

Fourth Degree

Homans Sign

Pregnancy and immediate pp is a


hypercoagulable period placing a woman at
risk for DVT.
Elevated clotting factors and fibrinogen

Assessment- Dorsiflexing the foot to assess


calf for pain. Observe for redness, swelling,
pain, or heat at site.

Emotion

Taking In

Taking Hold

Focused on self (not infant)


dependent on others for help in care
decision making difficult
comfort-rest-food needs paramount
relives delivery experience
may last for several hours or days

Letting Go

Moving from dependence to independence


energy level
focus on infant
self care, focus on bowels, bladder, brfeed
responds to instruction, praise
Lasts from 2days to 1wk

Giving up previous role


See self as separate from infant
Give up fantasy delivery and baby
Readjustment
Depression and grief work
from 1wk

Can you tell the difference?


Maternity Blues

50% to 80% of new mothers


first few days- 2 weeks after
delivery
mood swings
feeling sad, anxious, or
overwhelmed
crying spells
loss of appetite
trouble sleeping

Postpartum Depression

13-20% of new mothers

little interest or pleasure in


doing things

feeling down, depressed, or


hopeless

disturbed sleep patterns

not wanting to socialize or join


in

The nurse becomes very frustrated


with Maggie on day one, when she
refuses to participate in the care of
her baby.
All the patient wants to do
is talk about how out of
shape she is.

Endocrine Changes
Placental estrogen and progesterone
removed
Prolactin increases, esp in breastfeeding
women
Estrogen begins to increase to follicular
levels at 3-4 wks after delivery
Menstruation returns--6 wks not
breastfeeding, 2-18 mos breastfeeding

Vital Signs Change

BP first then
increases during uterine massage/pain
if PIH may stay elevated
orthostatic hypotension common

Temp first then


P--
R--

Cardiovascular Changes

Blood volume goes rapidly from


hypervolemia to hypovolemia
blood loss 400-500cc vaginal delivery
700-1000 cc C-section

Blood Changes

HCT (down 16% in transient anemia)

Leukocytes (20,000 to 25,000 mm3 for 10-12


days
)
Lymphocytes
Fibrinogen--risk of thrombophlebitis
Erythrocyte Sedimentation Rate (ESR)

Other Changes

Postpartum Chill
Shaking chill due to vasomotor instability

Postpartum diaphoresis
night sweats and increased odor

Maggie, 32 y/o G4 T2 P1A0 L3,


delivered her infant son one hour ago
Normal Vaginal
Delivery
3rd degree episiotomy
Catheterized just prior
to delivery (200cc)
Epidural anesthesia

Fundus @ the
umbilicus

Lochia, moderate,
Rubra with tissue
debris

VSS

Bonding with newborn

Question
A nurse is assessing the vital signs on a postpartum client who delivered
vaginally 10 hours earlier. Findings indicate a temperature of 100, pulse 76
beats/minute, respirations 18/min, and blood pressure 124/70 mmHg. The client
reports feeling sweaty and having to urinate frequently but is otherwise
comfortable. How should the nurse interpret these findings?
a. The client is demonstrating signs and symptoms of hypovolemic
shock indicated by her slow pulse and diaphoresis.
b. The client's elevated temperature and diaphoresis are an indication of
puerperal infection and need to be addressed.
c. The client is bradycardic and the primary care provider should be
notified for further assessment.
d. The client's vital signs and reports of feeling sweaty are normal and
there is no need for intervention at this time.

Question
The nurse knows that subinvolution is most often the
result of:
a. premature separation of the placenta
b. retained placental fragments and infection
c. self-destruction of excess hypertrophied tissue
d. velamentous insertion of the umbilical cord.

Essential Data

Blood Type

Rh Status

Rubella Status

Infant Feeding

Support System

Additional Assessment Data


Blood

type= O
Rh= Negative
Rubella titer= 1:4
Indirect Coombs= negative
Direct Coombs= negative
Infant Blood Type=O
Breastfeeding
Spouse and extended family in room

Rh Disease
Affects

mothers with negative Rh factor


Fetal blood crosses placental barrier
Sensitization occurs
Administer Rhogam
28 weeks
within 72 hours after delivery

Rh

48 hours post delivery

Uterus @ 2cm below


the umbilicus

Lochia, rubra, large


amount

Diaphoretic

Breasts- filling

Last BM prior to
delivery

Voiding frequent small


amounts

Vital signs stable

Maggie calls the nurse to the room


and she is crying. She tells the
nurse.
I cant breastfeedmy stomach is
hurting all of the time.

Lillian, a 22 y/o multipara,


admitted from the L&D, 2 hours
following vaginal birth of an 8
lb. 10 oz. girl
Fundus

is displaced to the right

Perineal

pads saturated

Four hours after delivery, a


primipara c/o severe perineal pain.
i

Second stage of labor lasted 2 1/2 hours

Third

degree extension of midline


episiotomy

Marked

edema and bruising of


perineum

A patients spouse rushes to the


nurse for HELPstates my
wife just passed out while
walking to the bathroom.

Nursing Considerations

A patient asks the following


questions during discharge
teaching:
When can I...
Take

a bath?
Return to work?
Resume sexual intercourse?
Stop talking my vitamins and iron?
Resume exercise?

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