Postpartum Period
critical transition time for woman, newborn, and family physiologically and psychologically
Puerperium Period
begins after the delivery of the placenta and lasts approximately 6 weeks
How does the uterus return to its normal size?
Gradual process of involution which involves retrogressive changes
What are the 3 retrogressive processes of involution?
- Contraction of the muscle fibers to reduce those previously stretched during pregnancy
- Catabolism
- Regeneration of uterine epithelium
What happens during catabolism?
Enlarged , individual myometrial cells shrink
Lochia
vaginal discharge that occurs after birth and continues for approximately 4-8 weeks
What are the 3 stages of Lochia
Lochia rubra
Lochia Serosa
Lochia Alba
Lochia Rubra
Deep-red mixture that occurs the first 3-4 days after birth
-Mucus, tissue debris, and blood
Lochia Serosa
Second stage: pinkish brown and is expelled 3-10 days postpartum
-Leukocytes, decidual tissue red blood cells, and serous fluid
Lochia Alba
Final stage: Creamy white or light brown occurring from days 10-14 but can last 3-6 weeks postpartum
-Leukocytes, decidual tissue, and reduced fluid content
What is given to reduce the effects of afterpains?
oral analgesics
Who typically experiences worse after pains?
Women who are breast feeding or still receiving exogenous oxytocin
When does the cervix typically return to its prepregnant state?
Week 6 of the postpartum period
What will the cervical os now look like after birth?
Jagged slit-like opening–“Fish mouth”
How long does is take for the vaginal mucosa to thicken and rugae to return?
3 weeks
When will the vagina return to its prepregnant size?
6-8 weeks postpartum
When does normal mucus production and thickening of the vaginal mucosa return?
With ovulation
What is a common problem for postpartum women until menstruation returns?
Vaginal dryness and coital discomfort (dyspareunia)
How long can complete healing of the perineum take after an episiotomy or lacerations?
4-6 months
What comfort measures can be implemented for the perineum?
ice packs pouring warm water over area via peribottle witch hazel pads anesthetic sprays sitz baths
Why should nurses encourage women to practice pelvic floor exercises?
Improve pelvic muscle tone
Strengthen perineal muscles
Promote healing
When does cardiac output return to normal after birth?
3 months
How long does it take blood volume to return to normal after pregnancy?
4 weeks
A decrease in hematocrit during the postpartum period may indicate what?
hemorrhage
Is bradycardia or tachycardia normal during postpartum?
bradycardia
What causes bradycardia postpartum?
Increased blood that flows back to the heart and central circulation after it is no longer perfusing the placenta
Why may tachycardia in postpartum women indicate further investigation?
May indicate hypovolemia, dehydration, or hemorrhage
What happens with BP postpartum?
falls first 2 days and then increases 3-7 days after birth and returns to prepregnancy after 6 weeks
What may an increase in BP accompanied by headaches indicate?
preeclampsia
What may decreased BP during postpartum indicate?
infection or uterine hemorrhage
What places women at an increased risk for thromboembolism postpartum?
hypercoagulable state, combined with vessel damage during birth, and immobility
Urination may be affected by?
- Perineal lacerations
- Generalized swelling and bruising of the perineum and tissues surrounding urinary meatus
- Hematomas
- Decreased bladder tone
- Diminished sensation of bladder pressure
Difficulty voiding can lead to what?
urinary retention
bladder distention
UTI’s
Urinary retention and bladder distention can cause what?
Displacement of the uterus from the midline and can inhibit the uterus from contracting properly which increases risk of hemorrhage
Urinary retention is a major cause of what?
Uterine atony
What are some causes of Postpartum Diuresis?
- large amounts of intravenous fluids given during labor
- decreasing antidiuretic effect of oxytocin
- buildup and retention of extra fluids during pregnancy
- decreasing production of aldosterone
Aldosterone
hormone that decreases sodium retention and increases urine production
What causes decreased peristalsis to occur postpartum?
Analgesics Surgery Diminished intra-abdominal pressure -Low-fiber diet -Insufficient fluid intake -Diminished muscle tone
Which moms would be extra fearful of a bowel movement after giving birth?
Women with an episiotomy, lacerations, or hemorrhoids
When does the women’s appetite return?
immediately after birth
What can be done to assist mom’s with their first bowel movement after birth?
Stool softeners
All of moms joints will return to their prepregnant state except for where?
Her feet
What will a decline in relaxin and progesterone levels cause?
Fatigue, activity intolerance, and distorted body image
-hip and joint pain that interferes w/ activity and exercise
What leads to a loss in abdominal muscle tone and possibly separation from abdominal wall during pregnancy?
Stretching of the abdominal wall and muscles to accommodate the growing uterus
What happens to the integumentary system postpartum?
- pigmentation fades
- stretch marks fade to silvery lines
- Diaphoresis is common for about a week
- hair loss is common first 3 months
When will tidal volume, minute volume, vital capacity, and functional residual capacity return to prepregnant values?
within 1-3 weeks of birth
What happens to the endocrine system postpartum?
Estrogen and progesterone levels drop quickly
Placental hormones decline rapidly
Prolactin levels decline w/in 2 weeks if NOT breastfeeding
Lactation
secretion of milk by the breasts
What is thought to bring on the process of lactation?
Interaction of progesterone, estrogen, prolactin, and oxytocin
When does breast milk typically appear?
4-5 days after childbirth
How long is exclusive breast feeding recommended?
6 months
What is the gold-standard to initiate breast feeding?
Skin to skin contact during the first hour following birth
Breast Crawl
baby moves on their mother’s abdomen up to her breast instinctively
Engorgement
postnatal physiologic painful condition in which distention and swelling of the breast tissue occurs as a result of an increase in blood and lymph supply as a precursor to lactation
When does breast engorgement peak
3-5 days postpartum
What treatments can be used to reduce pain of engorgement?
heat or cold applications cabbage leaf compress breast massage and milk expression ultrasound breast pumping anti-inflammatory agents tight-supportive bra avoid stimulation when not feeding
What are the four main influential hormones during the postpartum period?
estrogen
progesterone
prolactin
oxytocin
Estrogen
levels drop profoundly after birth and reach lowest level a week into postpartum period
Progesterone
Quiets the uterus to prevent preterm birth during pregnancy and its increasing levels prevent lactation from starting before birth
-decrease dramatically after birth
When are progesterone levels reestablished?
The first menstrual cycle
Oxytocin
- stimulates the uterus to contract during breastfeeding and for as long as 20 minutes after
- elicits the milk let-down reflex during feeding
Prolactin
stimulates milk production
How long does prolactin remain elevated in women who breastfeed?
6 weeks after birth
How long does prolactin take to reach prepregnant levels in women who do not breastfeed?
Third week postpartum
How can prolactin delay ovulation during postpartum period?
By inhibiting ovarian response to FSH
When may menstruation return for NON-lactating women?
7-9 weeks or up to 3 months after birth
When may menstruation return for lactating women?
Depends on breast feeding frequency and duration; anywhere from 2-18 months
When are afterpains usually stronger?
During breast feeding
Why are afterpains typically stronger during breastfeeding?
Because oxytocin is released by the sucking reflex which strengthens the contractions
What can be given to the mom to reduce discomfort of afterpains?
Mild analgesics
What can lead to urinary incontinence later in life for many women?
Failure to maintain and restore perineal muscular tone
If rectal tone is not regained through exercise it can be a problem for what?
Support may not be adequate during future pregnancies
For Multicultural families nurses must be?
Open, respectful, and nonjudgmental
How do Vietnamese women view the postpartum period?
A cold state and must protect themselves through warmth
What would cultural practices include for Vietnamese women?
- Warm water for hygiene and stimulation of lactation
- Consuming warm foods
- Stay indoors
How is postpartum and childbirth viewed in China?
States which disturb the normal health balance between yin and yang
How is balance reestablished between yin and yang for these women?
They engage in practices for a month related to the maternal role, physical activity, maintenance of body warmth, and certain food consumption
Balance of Hot and Cold
Childbirth involves the loss of blood, which is considered hot, the postpartum period is considered cold, so the mother must balance that with the intake of hot foods
Who is typically involved with hot-cold beliefs?
Latin American, African, and Asian people
What may some women try to reduce infant/mom vulnerability and potential illness?
A month long confinement period after birth
Confinement Period
- Rest and recuperate
- Avoid cold
- Kept warm
- Stay inside
- Bathe infrequently
- Avoid exercise
What hormone plays an essential role in the chemistry aspect of bonding?
Oxytocin
How can oxytocin be enhanced?
Skin to skin breastfeeding eye contact social vocalizations maternal and milk odors newborn massage
Attachment
formation of a relationship between a parent and his or her newborn through a process of physical and emotional interactions
What factors will influence attachment?
Environmental circumstances
Newborn health
Quality of nursing care
What are the 3 phases of postpartum mood disorders?
Baby Blues
Postpartum Depression
Psychosis
Baby Blues Characteristics
Mild depressive symptoms Anxiety Irritability Mood swings Tearfulness Increased sensitivity Fatigue
When will the Baby Blues peak and then typically resolve?
Peak at days 4 and 5
Resolve by day 10
Postpartum depression and Psychosis
- symptoms last longer, more severe, and will require treatment
- lead to poor bonding, alienation, daily dysfunction, and violent thoughts/actions
What are the 3 Stages for Partner Adaptation to Newborn?
Expectations
Reality
Transition to mastery
Expectation Stage
Preconceptions about what home life will be like with newborn
Reality Stage
- Partners realize their expectations in stage 1 are not realistic
- Feelings of being unprepared, stressed, irritable, frustrated, and possibly turned into depression
Risk Factors for Postpartum Partner Depression
- history of depression
- financial problems
- poor relationship w/ partner
- unplanned pregnancy
Transition to Mastery Stage
Partner makes conscious decision to take control and be at the center of newborns life regardless of preparedness
Seven Behaviors of Engrossment
- visual awareness of newborn
- tactile awareness of newborn
- perception of newborn as perfect
- strong attraction to newborn
- awareness of distinct features
- extreme elation by father
- increased sense of self-esteem
Reva Rubin’s 3 Phases of Maternal Adjustment to Newborn
Taking-in Phase
Taking-hold Phase
Letting-go Phase
Taking-In Phase
time immediately after birth when the client needs others to meet her needs and relives the birth process
Taking-Hold Phase
Second Phase
- dependent and independent maternal behavior
- typically starts on day 2 or 3 postpartum
Letting-Go Phase
Third Phase
- women reestablish relationship with others
- adapts to parenthood through her new role as a mother
Maternal Variables affecting Maternal Role
Confidence, age, relationship w/ father, socioeconomic status, birth experience, stress, support system, personality, self-concept, health status, preparation, depression, anxiety, relationship w/ own mom
Infant Variables affecting Maternal Role
Appearance, responsiveness, temperament, health status
What are the 4 stages of becoming a mother?
- Commitment, attachment to unborn baby, preparation for delivery
- Acquaintance/attachment to infant, learning to care for baby
- Moving toward new normal
- Achievement of maternal identity
