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Chapter 20 Postpartum Adaptations
Terms in this set (63)
postpartum period, or puerperium
The first 6 weeks after the birth of an infant
- refers to the changes the reproductive organs, particularly the uterus, undergo after childbirth to return to their nonpregnant size and condition.
-begins immediately after delivery of the placenta, when uterine muscle fibers contract firmly around maternal blood vessels at the area where the placenta was attached.
Uterine involution entails three processes:
(1) contraction of muscle fibers
(2) catabolism (the process of converting cells into simpler compounds)
(3) regeneration of uterine epithelium.
The placental site
which is about 8 to 10 cm (3 to 4 inches) in diameter, heals by a process of exfoliation (scaling off of dead tissue)
The location of the uterine fundus
(top of the uterus above the openings of the fallopian tubes) helps determine whether involution is progressing normally.
The size of the uterus immediately after delivery
size of a large grapefruit and weighs approximately 1000 g (2.2 lb).
right after birth in the 1st hour
The fundus can be palpated midway between the symphysis pubis and umbilicus and in the midline (middle) of the abdomen.
Within 12 hours
the fundus rises to about the level of the umbilicus
The fundus descends by approximately
🌟1 cm, or one fingerbreadth, per day, so that by the 14th day it is in the pelvic cavity and cannot be palpated abdominally
Normal with cramps
For the 2nd time mother to have worse cramps than the 1st time mother.
-Cramps of the uterus
-Medicate 1 hour before breast feeding
-1st Bleeding or shedding of the lining of the uterus
-May take 6 to 7 weeks
-Heavier with activity, full bladder
Less for women who had C Section because some of the endometrial lining is removed during surgery
Decent of the fundus documenting
U − 1 or ↓ 1 indicates the fundus is palpable 1 cm or fingerbreadth below the umbilicus.
Within a week, the weight of the uterus decreases
to about 500 g (1 lb); at 4 weeks, the uterus weighs about 100 g (3.5 oz) or less
Days 1-3: lochia rubra
Bloody; small clots; fleshy, earthy odor, red or red/brown
Large clots; saturated perineal pads; foul odor
Days 4-10: lochia serosa
Decreased amount; serosanguineous; pink or brown-tinged
Excessive amount; foul smell; continued or recurrent reddish color
Days 11-21: lochia alba (may last until 6th week postpartum)
Further decreased amounts; white, cream, or light yellow
Persistent lochia serosa; return to lochia rubra, foul odor; discharge continuing
One method for estimating the amount of lochia in 1 hour uses the following labels
Scant: Less than a 2.5-cm (1-inch) stain on the perineal pad
Light: 2.5- to 10-cm (1- to 4-inch) stain
Moderate: 10- to 15-cm (4- to 6-inch) stain
🌟🌟Heavy: Saturated perineal pad, changing pad more than 1 time an hour
Excessive: Saturated peripad in 15 minutes
Assess your self in the 1st hour
Placenta still in the uterus
Bright red bleeding
-Although the rugae are regained by 3 to 4 weeks, it takes 6 to 10 weeks for the vagina to complete involution and to gain approximately the same size and contour it had before pregnancy. The vagina does not entirely regain the nulliparous size
-Immediately after childbirth the is formless, flabby, and open wide
-by the end of the 1st week the cervix feels firm, and the external os is dilated 1 cm
- The internal os closes as before pregnancy, but the shape of the external os is permanently changed.
- It remains slightly open and appears slit-like rather than round
-(discomfort during intercourse).
-breastfeeding mothers are likely to experience vaginal dryness
LACERATIONS and episiotomies OF THE BIRTH CANAL
•First-degree: Involves the superficial vaginal mucosa or perineal skin.
•Second-degree: Involves the vaginal mucosa, perineal skin, and deeper tissues, which may include fascia and muscles of the perineum.
•Third-degree: Same as second-degree lacerations but involves the anal sphincter.
•Fourth-degree: Extends through the anal sphincter into the rectal mucosa.
Initial healing of the episiotomy site occurs in 2 to 3 weeks, but complete healing may take 4 to 6 months
Relief of perineal discomfort
is a nursing priority and includes teaching self-care measures, such as applying ice, performing perineal care, using topical anesthetics, and taking ordered analgesics.
Lose of blood during birth
up to 500 mL of blood is lost in vaginal deliveries, and 1000 mL is lost in cesarean births
-a transient increase in maternal cardiac output occurs after childbirth.
- This increase is caused by (1) an increased flow of blood back to the heart when blood from the uteroplacental unit returns to the central circulation, (2) decreased pressure from the pregnant uterus on the vessels, and (3) the mobilization of excess extracellular fluid into the vascular compartment.
-The cardiac output returns to prelabor values within an hour after delivery.
- Gradually, cardiac output decreases and returns to prepregnancy levels by 6 to 12 weeks after childbirth
•Diuresis (increased excretion of urine)
-is facilitated by a decline in the adrenal hormone aldosterone, which increases during pregnancy to counteract the salt-wasting effect of progesterone. As aldosterone production decreases, sodium retention declines and fluid excretion accelerates. A decrease in oxytocin, which promotes reabsorption of fluid, also contributes to diuresis. A urinary output of up to 3000 mL/day is common, especially on days 2 through 5 of the postpartum period
•Diaphoresis (profuse perspiration)
-also rids the body of excess fluid. It can be uncomfortable and unsettling for the mother who is not prepared for it. Explanations of the cause and provision of comfort measures, such as showers and dry clothing, are generally sufficient.
-Complains of being hot an hour after delivery
Coagulation problems after birth
POST PARTUM HEMORRHAGE
Perineal trauma, episiotomy, and hemorrhoids
cause discomfort and interfere with effective bowel elimination. In addition, many women anticipate pain when they attempt to defecate and are unwilling to exert pressure on the perineum.
Stool softeners and laxatives
-are frequently prescribed to prevent or treat constipation. The first stool usually occurs within 2 to 3 days postpartum.
-Normal patterns of bowel elimination usually resume by 8 to 14 days after birth
During childbirth, the urethra, bladder, and tissue around the urinary meatus may become edematous and traumatized as the fetal head passes beneath the bladder.
This condition often results in diminished sensitivity to fluid pressure, and many new mothers have no sensation of needing to void even when the bladder is distended.
because of the diuresis that follows childbirth
the mother is at risk for overdistention of the bladder, incomplete emptying of the bladder, and retention of residual urine.
In the first 1 to 2 days after childbirth
many women experience muscle fatigue and aches, particularly of the shoulders, neck, and arms, because of the effort of labor. Warmth and gentle massage increase circulation to the area and provide comfort and relaxation.
-The longitudinal muscles of the abdomen may separate during pregnancy
-The separation may be minimal or severe.
-The mother may benefit from gentle exercises to strengthen the abdominal wall.
-The diastasis usually resolves within 6 weeks
Striae gravidarum (stretch marks)
gradually fade to silvery lines but do not disappear.
Resumption of Ovulation and Menstruation
-anovulatory, ovulation may occur before the first menses. For some women, ovulation resumes as early as 3 weeks postpartum.
- Approximately 40% to 45% of non-nursing mothers resume menstruation at 6 to 8 weeks after childbirth, 75% by 12 weeks, and all within 6 months.
-Menses while lactating may resume as early as 8 weeks or as late as 18 months. Frequent breastfeeding with no supplements is more likely to delay menses, but menses and ovulation are increasingly likely after the infant is 6 months old.
While breast feeding- may take as long as 56 days
is necessary for milk ejection, or "letdown." Oxytocin causes milk to be expressed from the alveoli into the lactiferous ducts during suckling
Postpartum Risk Factors Hemorrhage
• Grand multiparity (five or more)
• Overdistention of the uterus (large baby, twins, hydramnios)
• Rapid or prolonged labor
• Retained placenta
• Placenta previa or previous placenta accreta or abruptio placentae
• Drugs (tocolytics, magnesium sulfate, general anesthesia, prolonged use of oxytocin)
• Operative procedures (cesarean birth, vacuum extraction, forceps)
• Uterine fibroids
• History of postpartum hemorrhage
• Coagulation defects
Postpartum Risk Factors Infection
• Operative procedures (cesarean birth, vacuum extraction, forceps)
• Multiple cervical examinations
• Prolonged labor
• Prolonged rupture of membranes
• Manual extraction of placenta or retained fragments
• Bacterial colonization of lower genital tract
The acronym REEDA is used as a reminder that the site of an episiotomy or a perineal laceration should be assessed for five signs:
redness (R), edema (E), ecchymosis (bruising) (E), discharge (D), and approximation (the edges of the wound should be closed, as though stuck or glued together) (A)
Signs of a Distended Bladder
• Location of fundus above baseline level
• Fundus displaced from midline
• Excessive lochia
• Bladder discomfort
• Bulge of bladder above symphysis
• Frequent voidings of less than 150 mL of urine, which may indicate urinary retention with overflow
-Discomfort in the calf with passive dorsiflexion of the foot is a positive Homans sign and may indicate deep vein thrombosis.
-A negative Homans sign is indicated by absence of discomfort.
-A positive Homans sign should be reported to the health care provider, along with redness, tenderness, or warmth of the leg.
-causes vasoconstriction and is most effective if applied soon after the birth to prevent edema and numb the perineum.
-Chemical ice packs and plastic bags or nonlatex gloves filled with ice may be used during the first 12 to 24 hours after a vaginal birth.
- It should be left in place until the ice melts. It is then removed for 10 minutes before a fresh pack is applied.
-used in some agencies to cleanse and comfort the traumatized perineum.
-Cool water may be used during the first 24 hours to reduce pain from edema.
-Warm water increases circulation and promotes healing and may be most effective after 24 hours.
-consists of squirting warm water over the perineum after each voiding or bowel movement.
- The bottle should not touch the perineum.
- The perineum is gently patted rather than wiped dry.
The Kegel exercise
involves contracting muscles around the vagina (as though stopping the flow of urine), holding tightly for 10 seconds, and then relaxing for 10 seconds. The woman should work up to 30 contraction-relaxation cycles or more each day.
describes the initial attraction felt by parents for their infants. It is unidirectional, from parent to child, and is enhanced when parent and infant are permitted to touch and interact during the first 30 to 60 minutes after birth. Infants may be placed skin-to-skin on the mother's chest after delivery.
is the process by which an enduring bond between a parent and child is developed through pleasurable, satisfying interaction. The process begins in pregnancy and extends for many months after childbirth.
reciprocal attachment behaviors
-Repertoire of infant behaviors that promotes attachment between parent and newborn.
Reciprocal Attachment Behaviors
Newborn infants have the ability to:
•Make eye contact and engage in prolonged, intense, mutual gazing
•Move their eyes and attempt to "track" the parent's face
•Grasp and hold the parent's finger
•Move synchronously in response to rhythms and patterns of the parent's voice (called entrainment)
•Root, latch on to the breast, and suckle
•Be comforted by the parent's voice or touch
common during the early minutes as the mother gets acquainted with the tiny stranger. It describes the mother's first exploration of the infant's body. She may gently explore the infant's face, fingers, and toes with her fingertips only
-First phase of maternal adaptation, during which the mother passively accepts care and comfort and details about the newborn.
-the mother is focused primarily on her own need for fluid, food, and sleep. Inexperienced nurses may be puzzled by the mother's passive, dependent behavior as she takes in or receives attention and physical care.
- it probably lasts a day or less today.
-Second phase of maternal adaptation, during which the mother assumes control of her own care and initiates care of the infant.
-When she feels more comfortable and in control of her body, she shifts her attention to the behaviors of the infant.
-has been called the "teachable, reachable, referable moment."
🌟🌟Best time for teaching
The letting-go phase
-is a time of relinquishment for the mother and often for the father.
-If this is a first child, the couple must give up their previous role as a childless couple and acknowledge the loss of their more carefree lifestyle.
The transition to the maternal or paternal role follows four stages
-2.The formal stage
-3.The informal stage
-4.The personal stage
begins during the pregnancy when the pregnant woman chooses a physician or nurse-midwife. She may attend childbirth classes to prepare for the birth experience. She seeks out role models to learn the role of mother.
2.The formal stage
begins with the birth of the infant and continues for approximately 4 to 6 weeks (Mercer, 1995a). During this stage, behaviors are mainly guided by others such as health professionals, close friends, or parents. A major task during this stage is for parents to become acquainted with their infants so that they can mesh their caregiving with infant cues.
3.The informal stage
may overlap the formal stage. It begins once the mother has learned appropriate responses to her infant's cues or signals. She begins to respond according to the unique needs of the infant rather than following textbook or health professionals' directives.
4.The personal stage
is attained when the mother feels a sense of harmony in her role, sees the infant as a central person in her life, and has internalized the parental role. The mother accepts and feels comfortable with the role of parent.
Mild depression, also known as postpartum blues, baby blues, or maternity blues
-The condition begins in the 1st week and usually lasts 2 to 10 days
-It should last no longer than 2 weeks
-It is characterized by insomnia, irritability, fatigue, tearfulness, mood instability, and anxiety. The symptoms are usually unrelated to events, and the condition does not seriously affect the mother's ability to care for the infant.
-may be caused by the mother's emotional letdown after birth, postpartum discomforts, fatigue, anxiety about her ability to care for the infant, and body image concerns
🌟🌟🌟May need an injection of Progesterone
Postpartum blues must be distinguished from postpartum depression and postpartum psychosis, which are disabling conditions and require therapeutic management for full recovery. Screening for risk factors or early signs are important during the birth facility stay.
Nurses should teach the woman and her family to call the health care provider if the depression becomes severe, lasts longer than 2 weeks, or if the woman is unable to cope with daily life.
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