POSTPARTAL NURSING

Developed by D. Ann Currie, R.N. ,M.S.N.

POSTPARTAL PERIOD

PHYSICAL CHANGESPSYCHOSOCIAL CHANGESNURSING CARE OF THE POSTPARTAL CLIENTHIGH-RISK POSTPARTAL CLIENTS

PHYSICAL CHANGES DURING THE POSTPARTAL PERIOD

REPRODUCTIVE SYSTEMINVOLUTION-IS THE PROCESS OF THE REDUCTION IN SIZE OF THE UTERUS AFTER DELIVERY TO PREPREGNANT SIZE CAUSED BY UTERINE CONTRACTIONS THAT CONSTRICT AND OCCLUDE BLOOD VESSELS AT THE PLACENTA SITE

FACTORS THAT ENHANCE INVOLUTION

UNCOMPLICATED LABOR & DELIVERYBREASTFEEDINGEARLY AMBULATIONCOMPLETE EXPLUSION OF PLACENTA AND MEMBRANES

FACTORS THAT IMPEDE INVOLUTION

PROLONGED LABOR & DIFFICULT DELIVERYANESTHESIAGRAND MULTIPARITYRETAINED PLACENTAL FRAGMENTS OR MEMBRANESFULL URINARY BLADDERINFECTION

CONT.

OVERDISTENTION OF THE UTERUSUSE OF OXYTOCIN DURING LABOR

FUNDUS

TOP PORTION OF THE UTERUSA PALPABLE INDICATOR OF INVOLUTIONBOGGY UTERUS-SOFT,RELAXED..CAN CAUSE HEMORRHAGE FUNDUS SHOULD BE FIRM

Assessing Fundus

FUNDUSLOCATIONRIGHT AFTER DELIVERY THE FUNDUS IS MIDWAY BETWEEN SYMPHYSIS PUBIS AND UMBILICUSONE HOUR AFTER DELIVERY THE FUNDUS RAISES TO THE UMBILICUS OR SLIGHTLY ABOVE-1CM AND REMAINS THERE FOR 24 HRS.

FUNDUSLOCATION- FUNDAL HEIGHT DECREASES 1CM A DAY AFTER THE FIRST 24 HR..BY DAY 10 AFTER THE DELIVERY THE FUNDUS CAN NO LONGER BE FELTFUNDUS SHOULD BE MIDABDOMENDEVIATIONS ARE ABNORMAL AND SHOULD BE CHECKED

Deviation of Fundus Location

LOCHIAIS THE DISCHARGE OF BLOOD AND DEBRIS FOLLOWING DELIVERYTYPES-RUBRA, SEROSA, AND ALBASHOULD NOT CONTAIN LARGE CLOTSTOTAL VOLUME-240-270 ML.DAILY VOLUME GRADUALLY DECREASES

LOCHIA

AMOUNT MAY BE INCREASED BY EXCERTION OR BREASTFEEDINGPOOLING WHEN CLIENT IS RECLINING CAN OCCURC/SECTION CLIENT MAY HAVE LESS BUT SHOULD HAVE LOCHIAUNEXPLAINED INCREASE IN AMOUNT IS ABNORMAL

LOCHIA AMOUNTS

LOCHIA RUBRA

1-3 DAYS AFTER DELIVERYDARK RED,BLOODY FLESHY,MUSTY ODORCLOTS SMALLER THAN NICKELBLOOD,MUCUS, SHREDS OF DECIDUA, EPITHELIAL CELLS

LOCHIA SEROSA

4-10 DAYS AFTER DELIVERYPINK OR BROWNISH-WATERY-ODORLESSSERUM,ERYTHROCYTES,SHREDS OF DEGENERATING DECIDUA,LEUKOCYTES, CERVICAL MUCOUS,BACTERIA

LOCHIA ALBA

11-21 DAYS AFTER DELIVERYMAY PERIST TO 6 WEEKSYELLOW TO WHITE- MAY HAVE STALE ODORLEUKOCYTES,DECIDUA CELLS,EPITHELIAL CELLS,FAT, CERVICAL MUCUS, CHOLESTEROL, BACTERIA

LOCHIA

UNEXPLAINED INCREASE IN AMOUNT OR REAPPEARANCE OF LOCHIA RUBRA IS ABNORMAL..

AFTERPAINS

CAUSED BY INERTMITTENT UTERINE CONTRACTIONS FOLLOWING DELIVERYOCCUR IN ALL WOMENMORE PAINFUL IN MULTIPARIOUS AND BREASTFEEDING WOMANALSO IN WOMEN WHOSE UTERUS WAS OVERDISTENDED

CERVIXSOFT,IRREGULAR,AND EDEMATOUS, MAYBE BRUISED AND/OR SMALL LACERATIONSCLOSES TO 2-3 CM AFTER SEVERAL DAYS..FINGERTIP AFTER 1 WEEKMUST BE SLIGHTLY DILATED TO ALLOW LOCHIA TO DRAINAFTER FIRST DELIVERY SHAPE IS CHANGED

VAGINA

SMOOTH WALLS,EDEMATOUS WITH MULTIPLE SMALL LACERATIONSPERINEAL DISCOMFORT/PAIN SHOULD BE GONE BY 2 WEEKS AFTER DELIVERYLOW ESTROGEN LEVELS WILL TO DECREASED LUBRICATION FOR 6-10 WEEKS

ABDOMINAL WALL

SOFT & FLABBY WITH DECREASED MUSCLE TONESTRIAE(STRETCH MARKS) WILL FADE BUT STAYDIASTISIS RECTI-SEPERATION OF THE RECTUS MUSCLES OF THE ABDOMEN-MAY IMPROVE IN THE POSTPARTUM PERIOD

CARDIOVASCULAR SYSTEM

RETURNS TO PREPREGNANT STATE WITHIN 2 WEEKSTHE ELIMINATION OF THE INCREASED BLOOD VOLUME DURING PREGNANCY IS DONE BY DIURESISBLOOD PRESSURE SHOULD REMAIN STABLE

CV SYSTEM -CONT.

BRADYCARDIA BEGINS SECOND DAY-HR OF 50-70-CONT. FOR 6-10 DAYSTACHYCARDIA-BLOOD LOSS, TEMP.,OR OTHER PROBLEMSWBC’S ELEVATED IN POSTPARTUM PERIOD..LOOK FOR INCREASE OF OVER 30% IN 6 HRS.

CV SYSTEM CONT.

DECREASED HGB IS RELATED TO AMOUNT OF BLOOD LOSS1ST 48 HRS POSTPARTUM ARE THE GREATEST RISK OF COMPLICATIONS FOR CLIENTS WITH HEART DISEASE

RENAL SYSTEMINCREASED BLADDER CAPACITY AND DECREASED BLADDER TONE LEAD TO DECREASED SENSATION AND INCREASED RISK OF URINARY RETENTION AND INFECTIONPOSTPATAL DIURESIS-2000-3000 ML.-ACCOUNTS FOR 5 LB WEIGHT LOSSA FULL BLADDER WILL DISPLACE THE UTERUS

RENAL SYSTEM

FULL BLADDER CAN LEAD TO UTERINE ATONY AND PP HEMORRHAGEFLUIDS ARE ALSO LOST THROUGH DIAPHORESIS..COMMONLY SEEN AT NIGHT

GASTROINTESTINAL SYSTEM

HUNGER AND THRIST ARE COMMON FOLLOWING BIRTH OR IN THE 1ST PP DAY.CONSTIPATION-DECREASED PERISTALSIS, USE OF NARCOTIC ANALGESICS,DEHYDRATION, DECREASED MOBILITY DURING LABOR , AND FEAR OF PAIN

GI SYSTEM CONT.

HEMORRHOIDS-BECAUSE OF PRESSURE OF PUSHING DURING 2ND STAGE OF LABOR.

Assessment for Hemorrhoids

ENDOCRINE SYSTEM

ESTROGEN AND PROGESTERONE LEVELS DROP RAPIDLY AFTER DELIVERY OF THE PLACENTAMENSTRUATION USUALLY RESUMES 7-9 WEEKS FOR NONLACTATING WOMEN- 90% BY 12 WEEKS-1ST CYCLE IS USUALLY ANOVULATORY

ENDOCRINE CONT.OVULATION AND MENSTRUATION RETURN TIME IS PROLONGED WITH LACTATING WOMEN-DEPENDS WHETHER SHE IS SUPPLEMENTING WITH FORMULA-VARY 2 TO 18 MONTHSPLACENTAL HORMONES WHICH CAUSES INSULIN RESISTANCE WILL DECREASE BY 3-4 DAYS AFTER DELIVERY

ENDOCRINE CONT.

LACTATIONCOLOSTRUM/MILKPROLACTINOXYTOCIN

PSYCHOLOGICAL CHANGES IN THE POSTPARTAL PERIOD

PHASES OF MATERNAL ADJUSTMENTPHASES OF PATERNAL ADJUSTMENTBONDINGPOSTPARTUM BLUES

PHASES OF MATERNAL ADJUSTMENT

TAKING-IN/DEPENDENT PHASE-TAKING-HOLD/DEPENDENT-INDEPENDENT PHASE-LETTING-GO/INTERDEPENDENT PHASE-DEVELOPMENTAL TASK- MATERNAL ROLE ATTAINMENT1ST DICUSSED BY R.RUBIN

TAKING-INDEPENDENT PHASE

1ST 1-3 DAYS..CAN BE SHORTENPREOCCUPIED WITH OWN NEEDSPASSIVE AND DEPENDENTTOUCHES AND EXPLORES INFANTNEEDS TO DISCUSS LABOR & DELIVERY EXPERIENCETAKING IN FOOD ,H2O,REST, AND CARE

TAKING-HOLDDEPENEDENT-INDEPENDENT PHASE

3-10DAYS POSTPARTUMOBESSED WITH BODY FUNCTIONSRAPID MOOD SWINGSANTICIPATE GUIDANCE MOST EFFECTIVE NOW…GOOD TIME TO TEACHINTERESTED IN LEARNING CARE OF BABY

LETTING-GOINTERDEPENDENT PHASE

10 DAYS TO 6 WEEKS POSTPARTUMMOTHERING FUNCTIONS ESTABLISHEDSEES INFANT AS A UNIQUE PERSONREESTABLISHES RELATIONSHIP WITH HUSBAND

PATERNAL ROLE

EXPECTATIONSREALITYTRANSITION TO MASTERY

EXPECTATIONS

1ST STAGETHE FATHER HAS PRECONCEPTIONS ABOUT WHAT LIFE WILL BE LIKE AFTER THE BABY COMES HOMEMAY NOT BE REALISTIC

REALITY

2ND STAGEFATHER REALIZES THAT EXPECTATIONS ARE NOT ALWAYS BASED ON FACTCOMMON FEELINGS-SADNESS,AMBIVALENCEJEALOUSLYFRUSTATION

REALITY

OVERWHLMING DESIRE TO BE MORE INVOLVEDSOME ARE PLEASANTLY SURPRISED AT EASE AND FUN OF PARENTING

TRANSITION TO MASTERY

3RD STAGEFATHER MAKES CONSCIOUS DECISION TO TAKE CONTROL AND BECOME MORE ACTIVELY INVOLVED WITH INFANT

BONDING

FINGERTIPS,PALMS AND THEN ENFOLING OF INFANTEN FACE POSITIONMOTHER USES A SOFT HIGH-PITCHED TONE OF VOICENURSE SHOULD ASSIST BOTH MOM AND DAD WITH BONDING-TIME/ISSUES

Face to Face with Eye Contact

POSTPARTUM BLUES

A MATERNAL ADJUSTMENT REACTIONTRANSIENT DEPRESSION USUALLY OCCURS BETWEEN 2ND-3RD PP DAY AND/OR WITHIN THE 1ST 2 WEEKS PPRELATED TO HORMONAL CHANGES,FATIGUE, AND STRESSALL WOMEN EXPERIENCE IT

PP BLUES CONT.CHARACTERIZED BY MOOD SWINGS,ANGER, TEARFULNESS, FEELINGS OF LET-DOWN,ANOREXIA, AND SLEEING PROBLEMSUSUALLY RESOLVES SPONTANEOUSLYIF CONT. OR WOMAN HAS DEEPENING DEPRESSION MAY HAVE PP DEPRESSION

POSTPARTAL NURSING

EVALUATE PRENATAL AND INTRANATAL HISTORY FOR RISK FACTORSPOSTPARTUM ASSESSMENT-BUBBLE-HEB-AND PREECLAMPSIA SCREENINGVITAL SIGNS

PP NURSING-CONT.

PREVENTING PP HEMORRHAGEASSESS FOR RISK FACTORSASSESS FUNDUS & LOCHIAMASSAGE FUNDUS AS NEEDEDKEEP BLADDER EMPTYADMINSTER MEDICATIONS IF NEEDED-PITOCIN,METHERGINE ERGOTRATE

CONT.

PUT BABY TO BREAST EARLY AND FREQUENTLY`MONITOR VS

COMFORT

ICE TO PERINEUM 20 MINUTES ON/1O-2O MINUTES OFF-1ST 24 HRSSITZ BATHS-COOL OR WARM TID AFTER 12-24 HRS…MGSO4 CRYSTRALSPERICARE- AFTER USING BATHROOM OR PRNAPPLY TOPICAL ANALGESICS-

COMFORT

TEACH CLIENT TO TIGHTEN BUTTOCKS THE SITTING…LAY ON SIDEADMINSTER ANALGESICSKEGAL’SH2O,FIBER,& STOOL SOFTNERS,AMBULATE

Kegal’s Exercise

ELIMINATION

BOWELURINARY

INFANT CARE

SUCCESSFUL FEEDINGBATHINGSAFETYADL’SPOSITIONSFOLLOW UP VISITS

SELF CARENUTRITIONRESTCOMFORTDISCOMFORTSACTIVITIESF/UWARNING SIGNSCONTRACEPTION

RHOGAM

ASSESS RH NEG WOMANNEG INDIRECT COOMBSRH POS BABY WITH NEG DIRECT COOMBSNO ALLERGIES TO GLOBULIN PREPARATIONSADMINSTER 300UG IM WITHIN 72 HRS

RUBELLA VACCINE

RUBELLA TITER LESS THAN 1:8-NONIMMUNENO ALLERGY TO NEOMYCINADMINISTER O.5 ML SC PRIOR TO DISCHARGECLIENT SHOULD NOT GET PREGNANT FOR 3-4 MONTHSNOT WITH RHOGAM

PP WARNING SGNS

BRIGHT RED BLEEDING MORE THAN 1 PAD/HOUR OR PASSING LARGE CLOTsTEMPERATURE GREATER THAN 100.4 F AFTER 1ST 24 HRS.CHILLSEXCESSIVE PAIN ANYWHEREREDDENED AREAS ON BREAST

PP WARNING SIGNS

REDDENED OR GAPING EPISIOTOMYFOUL SMELLING LOCHIAINABLE TO VOID..BURNING..ETCCALF PAIN, TENDERNESS,REDNESS, SWELLINGFLU-LIKE S/S.

Mastisis

DEEP VEIN THROMBOSIS