Postpartum
Postpartum
Postpartum
POSTPARTUM
The postpartum period, or puerperium, refers to the 6-to-8-week period after delivery during which the
mother’s body returns to its prepregnant state. Some people refer to this period as the fourth trimester of
pregnancy. Many physiologic and psychological changes occur in the mother during this time. Nursing care
should focus on helping the mother and her family adjust to these changes and on easing the transition to the
parenting role.
Known as the 5th stages labor.
Physiologic changes: Two types of physiologic changes occur during the postpartum period: retrogressive and
progressive changes.
Getting back to normal: Retrogressive changes involve returning the body to its prepregnant state. Retrogressive
changes include:
• Shrinkage and descent of the uterus into its prepregnancy position in the pelvis
• Sloughing of the uterine lining and development of lochia
• Contraction of the cervix & vagina
• Recovery of vaginal and pelvic floor muscle tone.
Postpartum care should respond to the special needs of the mother and baby and should include
• Prevention and early detection and treatment of complications and disease.
• Provision of advice and services on breastfeeding, birth spacing, immunization and maternal
nutrition.
a. Taking in phase – dependent phase (1st three days) mom – passive, cant make decisions, activity is to
tell child birth experiences. During this time, the woman’s attention is focused on her own needs for
sleep, rest and she is dependent on others.
Nursing Care: - proper hygiene
b. Taking hold phase – dependent to independent phase (4 to 7 days). Mom is active, can make decisions,
The concern of the mother at this time is focused on her ability to control body function and her ability
to assume the mothering role. She prefers to do things by herself. As she is not yet completely
recovered, she feels impatient that she’s not strong enough to do everything she wishes to accomplish.
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Because of the tendency of the woman to overwork herself, fatigue and exhaustion is common at this
stage.
HT:
- Allow her to care for the child herself with watchful guidance
common post partum blues/ baby blues present 4 – 5 days 50-80% moms – overwhelming feeling of
depression characterized by crying, despondence- inability to sleep & lack of appetite. – let mom cry –
therapeutic.
c. Letting go – interdependent phase – 7 days & above. Mom - redefines new roles may extend until child
grows. Letting-Go – the act of ending old ways of thinking or believing
- The woman finally redefines her new role
- Gives up fantasized image of her child and accepts the real one
- Gives up her old role of being childless or the mother of only one or two
CARDIOVASCULAR SYSTEM – 1st or 2nd week postpartum, the blood volume has returned to its
normal pre-pregnancy level.
Blood Volume
Hemorrhage – bleeding of > 500cc
CS – 600 – 800 cc normal NSD 500 cc
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Early postpartum hemorrhage– bleeding within 1st 24 hrs. Baggy or relaxed uterus & profuse bleeding –
uterine atony. Complications: hypovolemic shock.
Mgt:
Blood Components
Hct rises in the first 3 to 7 days due to hemoconcentration caused by excretion of large amounts of fluids
in the urine (diuresis during the first few days after delivery). Hct level returns to normal on the fourth to
fifth postpartum week.
Leukocytosis of 20,000 to 30,000 (normal is 5000 to 10000) during the first 12 days characterized by
increased neutrophils and easinophils and decreased lymphocytes.
Fibrinogen and thromboplastin remains elevated until the 3rd postpartum week.
Increased leukocyte sedimentation rate.
INTEGUMENTARY SYSTEM
-Chloasma, palmar erythema, linea nigra and other skin changes during pregnancy gradually disappear
during the postpartum period.
-Striae gravidarum do not disappear and assumes a silvery white appearance.
-Hyperpigmentation of the areola may not disappear completely. Some women are left with a wider and
darker areola after pregnancy.
Linea nigra will be barely detectable in 6 weeks time
GASTROINTESTINAL SYSTEM
Many women are hungry after delivery because of foods and fluids restriction during labor, diaphoresis
and the strenuous labor they just went through.
Bowel movement maybe delayed for days after delivery resulting in constipation. This is caused by:
Decreased muscle tone during labor and puerperium
Lack of food during labor
Dehydration
Perineal pain caused by episiotomy, hemorrhage,laceration
Bowel sounds are active, but passage of stool through the bowel may be slow
URINARY SYSTEM
o VOIDING is difficult because of the pressure on the bladder and urethra making it edematous
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o To prevent permanent damage to the bladder from over distention, assess the woman’s abdomen
frequently in the immediate postpartum period
o Increase daily output
o From 1500ml/day to 3000ml/day during the second to fifth day after birth
oDiuresis begins 12 hour after delivery and extends up to the 5th day as the body gets rid of extracellular
fluid accumulated during pregnancy. The woman loses up to 9 lbs. weight from the excretion of these
fluids and electrolytes.
o Acetone in the urine right after labor and lactosuria during the first week is normal.
o The bladder and urethra are traumatized by the pressure exerted by the fetal head as it passes through
the birth canal. Trauma to bladder results in loss of bladder tone, edema and hyperemia. As a result,
the woman experiences ↓ bladder tone that results in ↑ bladder capacity. Decreased bladder tone
causes decreased sensation to the filling and distention of the bladder, the woman may not experience
the urge to void even if her bladder is already distended with urine w/c predisposes to infection.
When catheterization of postpartum patient with urinary retention:
Use straight catheter if one hour catheterization is ordered; use foley for 24 hours catheterization
Maitain aseptic technique.
Provide gentle touch as the area is sore.
When amount of urine reaches 900-1000 cc, clamp catheter to prevent rapid decompression in
the abdomen w/c can cause hypotension
Check vital signs after catheterization.
Unclamp after 1 hour to drain urine.
HORMONAL SYSTEM
HCG & HPL almost negligible by 24 hours
Progestin, Estrone & Estradiol are at pre-pregnant level by 7th day
FSH remains low for about 12 days, then begins to rise to initiate a new menstrual cycle
Pregnancy hormones begin to decrease as soon as the placenta is no longer present.
REPRODUCTIVE SYSTEM
Uterus
INVOLUTION – a process whereby the reproductive organs return to their non-pregnant state.
2 main processes of involution of the uterus:
The area where the placenta was implanted is sealed off, preventing bleeding
Organ is reduced to its approximate pregestational size
Promotion of Uterine Involution : (well-nourished, ambulates early after birth,breastfeeding)
24 hours after birth the uterus is at the level of umbilicus.
CERVIX
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BENEFITS OF BREASTFEEDING
POSTPARTAL HEMORRHAGE
Assess Any blood loss from the uterus greater than 500 ml within 24 hour period.
EARLY POSTPARTUM HEMORRHAGE
>500mL in first 24 hrs (blood loss often underestimated)
• LATE POSTPARTUM HEMORRHAGE
>500mL after first 24 hrs
Acreta – attached placenta to myometrium.
Increta – deeper attachment of placenta to myometrium hysterectomy
Percreta – invasion of placenta to perimetrium
SYMPTOMS OF POSTPARTUM HEMORRHAGE
uncontrolled bleeding (>2pads/30min)
decreased blood pressure
increased heart rate
decrease in the red blood cell count (hematocrit)
swelling and pain in tissues in the vaginal and perineal area
Light headedness, nausea and visual disturbances
Anxiety, pale and clammy skin
Increase in pulse rate and respiratory rate
Decrease in blood pressure because of the blood loss
VAGINAL LACERATION
Easier to assess but harder to repair
Vaginal tissue is friable so lacerations are harder to repair.
PERINEAL LACERATION
Occurs when woman is placed on lithotomy position during delivery (increase tension on the perineum).
CLASSIFICATIONS OF PERINEAL LACERATIONS
Classification Description of Involvement
First Degree Vaginal mucus membrane & skin of the perineum to the fourchette
Second Degree Vagina,perineal skin,fascia,levator ani muscles,& perineal body
Third Degree Entire perineum,& reaches the external sphincter of the rectum
Fourth Degree Entire perineum, rectal sphincter,and some of the mucus membrane of the rectum
NURSING MANAGEMENT
Repair as episiorrhapy.
document degree of laceration.
Provide increase fluid and stool softener for 1 week.
For 3rd and 4th degree: no enema, suppository or rectal temperature.
DISSEMINATED INTRAVASCULAR COAGULATION
A deficiency in clotting ability caused by vascular injury an emergency.
Hypofibrinogenemia
May occur in any postpartal woman
CAUSES: Premature separation of the placenta (abruptio placenta); Missed abortion ; Fetal death in
utero.
NURSING MANAGEMENT
Start IV Heparin as ordered.
Prepare blood replacement blood typing.
SUBINVOLUTION
Uterus remains large, and soft at 4 to 6 weeks postpartum.
Incomplete return of the uterus to its prepregnant size and shape.
Lochia is still present.
CAUSES OF SUBINVOLUTION
Endometritis or postpartal infection
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NURSING MANAGEMENT
Administer topical or systemic antibiotic as ordered.
Perineal packing to allow drainage
Analgesic as ordered for pain relief
Sitz baths or warm compress to hasten drainage
Encourage good handwashing
Encourage the woman to ambulate.
MASTITIS
Infection of the breast may occur as early as 7th postpartal day or may not occur until the baby is weeks
or months old.
It is cause by the nasal-oral cavity of the infant
It is caused by the agent: Staph. aureus and Candidiasis
NURSING MANAGEMENT
The mother will placed on a broad spectrum antibiotic, such as cephalosporin
Ice compress
Good, supportive bra give a great deal of pain relief until the process improves
Warm, wet compress
PERITONITIS
Life-threatening infection of the peritoneum
Abcesses on the uterine ligaments, in the cul de sac, and/or in the subdiaphragmatic space.
May result from pelvic thromboplebitis
Infection of the peritoneal cavity which usually an extension of endometritis
One of the gravest complications of childbearing
A major cause of death from puerperal infection
Infection spreads through lymphatic system or directly through fallopian tubes or uterine wall
Interferes with future fertility ( LEAVING SCARRING)
SYMPTOMS OF PERITONITIS
High temperature
Chills
Malaise
Lethargy
Pain
Subinvolution
Abdominal Rigidity (Uterus may be well-contracted but remainder of abdomen is soft guarding )
Tachycardia
Local or referred pain
Rebound tenderness
Thirst
Distension
Nausea and vomiting
NURSING MANAGEMENT
Insertion of NGT (Nasogastric tube) -to prevent vomiting & rest bowel
IVF or Total Parenteral Nutrition
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Anti biotic
Prevention
Keeping the genital area clean and remembering to wipe from front to back may reduce the chance of
introducing bacteria from the rectal area to the urethra.
Increase fluid intake.
SALPHINGITIS
In contrast, salpingitis only refers to infection and inflammation in the fallopian tubes.
Causes and pathophysiology
The infection usually has its origin in the vagina, and ascends to the fallopian tube from there.
Because the infection can spread via the lymph vessels, infection in one fallopian tube usually leads to
infection of the other.
Treatment
Salpingitis is most commonly treated with antibiotics
Diagnosis
By Pelvic examination, blood tests and mucus swab a doctor can diagnose salpingitis.
Oophoritis is an inflammation of the ovaries.
It is often seen in combination with salpingitis (inflammation of the fallopian tubes).
PYELONEPHRITIS
Kidney infection, usually of the R. kidney
Ascends from bladder
SYMPTOMS: elevated temperature, chills, flank pain, CVA pain, Nausea and vomiting, history of asymptomatic bacteruria
or pyelonephritis
Urgency, frequency, dysuria
Back pain
PREVENTION AND TREATMENT
Increased Fluid Intake
Ensure complete emptying of the bladder
Sterile technique for catheterization
Good perineal care
PP Blues PP Depression PP Psychosis
onset 1-10 days after birth 1-12 months after birth Within first month after birth