I got this from a website when I was doing my OB rotation, but I don’t remember where.  If anyone sees their work here, let me know and I’ll give you credit.  I found it very useful.

Chapter 34 – Postpartal Adaptation and Nursing Assessment

 

􀂄 Postpartum or puerperium – period woman adjust physically and psychologically to birth

􀂄 Begins immed after birth , lasts about 6 wks or until body has returned to near pre-preg state

􀂄 This section will describe changes that occur PP and aspects of assessment of the PP woman

 

Post Partum tasks

􀂄 In first few wks must mother must accomplish certain physical and developmental tasks:

􀂅 Restore physical condition of herself

􀂅 Establish relationship with infant

􀂅 Develop competence in caring for and meeting needs of infant

􀂅 Adapt to altered lifestyles and family structures

􀂅 Adapt to and alter their unrealistic expectancies about PP period

􀂅 Deal with fatigue – greatest but most underestimated problem, esp if no support

 

Postpartum physical adaptations

􀂄 Uterus

􀂅 Process called involution describes rapid reduction in size of uterus and return to pre-preg condition

􀂄 Results from hypoplasia of uterine cells

􀂄 Breastfeeding, uncomplicated L&D, complete expulsion of placenta and membranes and early ambulation enhances involution

􀂄 Anesthesia, prolonged labor, difficult birth, grand multiparity, retained placenta, infection and over distention of the uterus delays involution

􀂅 Spongy layer of decidua cast off as lochia, new endometrium formed

􀂄 Process complete in 3 wks except at site of placenta, it takes 6-7 wk to completely heal

􀂅 Heals by process called exfoliation without forming a scar

 

Postpartum physical adaptations

􀂄 Uterus continued

􀂅 Changes in Fundal Position

􀂄 Immed after placenta expelled:

􀂅 Uterus contracts to compress blood vessels

􀂃 Size of large grapefruit

 

􀂅 Fundus in midline, about half way to 2/3 way between umbilicus and symphysis pubis

􀂃 Rises to level of navel about 6-12 hours after delivery changes in ligaments

􀂄 Fundus above umbilicus and soft and spongy (boggy) associated with excess bleeding

􀂄 If high and displaced to side (usually right), prob secondary to full bladder

􀂅 Empty bladder and reassess

 

Postpartum physical adaptations

􀂄 Uterus continued

􀂅 Uterus remains at level of umbilicus about ½ day after birth

􀂅 On first day following birth – top of fundus about 1cm below umbilicus

􀂄 Fundus descends about 1 fingerbreadth or 1 cm daily

􀂅 Descends into pelvis on 10^th day, can no longer be palpated

􀂅 Returns to pre-preg size and location by 5-6 wks

􀂄 If descends slower, called subinvolution

Postpartum physical adaptations

􀂄 Lochia

􀂅 Debris eliminated in discharge called lochia, is classified according to appearance

􀂄 Lochia rubra:

􀂅 Dark red, first 2-3 days after delivery

􀂅 Clotting result of pooling in vagina, nickel size clots otherwise ok

􀂄 Lochia serosa:

􀂅 Pinkish to brownish

􀂅 3-10 days pp

􀂄 Lochia alba:

􀂅 Yellowish-whitish

􀂅 Duration varies

 

Postpartum physical adaptations

􀂄 Lochia

􀂅 When lochia stops, cervix is closed, less chance of uterine infection

􀂅 Total lochia blood loss volume is 225 mL

􀂄 Volume decreases gradually, may increase with nursing, exertion

􀂅 Normal odor slightly musty, non-offensive

􀂄 Foul odor to lochia suggests infection

􀂅 Assessment of lochia necessary

􀂄 Type, amt of lochia corresponds to involution & healing of placental site

􀂄 Failure of lochia to progress and decrease in amount = subinvolution or PP hemorrhage

􀂄 If continuous bright red seep with firm uterus right after birth, must consider possibility of laceration

Postpartum physical adaptations

􀂄 Cervical Changes

􀂅 Spongy and flabby, formless after birth

􀂅 Reforms with in few hours & closes slowly, by end of first week will only admit fingertip

􀂅 Shape permanently changed

􀂄 Vaginal Changes

􀂅 May be edematous and bruised, no rugae

􀂅 Size decreases and rugae returns in 3-4 wks, normal by 6 wks

􀂅 Can improve tone with Kegel’s exercises

􀂅 If nursing may be dry, pale

 

Postpartum physical adaptations

􀂄 Perineal Changes

􀂅 Appears swollen and bruised

􀂅 If episiotomy or laceration, should be well approx

􀂅 Should be healed by 2-3 weeks after delivery with complete healing by 4-6 months

􀂄 May have some discomfort during this time

􀂄 Recurrence of Ovulation and Menstruation

􀂅 Generally 6-10 wks after birth if not nursing

􀂅 If nursing, return is prolonged

􀂄 Depends on length of breastfeeding and supplements

􀂄 Not reliable form of contraception

 

Postpartum physical adaptations

􀂄 Abdomen

􀂅 Appears loose and flabby

􀂄 Responds to exercise with in 2-3 months

􀂄 If abdomen over distended or poor muscle tone pre-preg, may not regain tone, remains flabby

􀂅 Diastasis recti abdominis

􀂄 Is separation of abdominis muscles

􀂄 Often occurs with preg, especially if poor abd tone

􀂄 Abdominal wall has no muscle support

􀂄 Improvement depends on cond of mom, type and amt of exercise, number of pregnancies and spacing

􀂄 May result in pendulous abd

􀂅 Striae

􀂄 Results from rupture of elastic fibers of skin

􀂄 Fade to silvery white if Caucasian

􀂄 If dark skin, they stay darker than surrounding skin

 

Postpartum physical adaptations

􀂄 Gastrointestinal system

􀂅 Hunger, thirst immediately after birth common

􀂅 Bowels tend to be sluggish

􀂄 d/t progesterone, decreased abdominal tone

􀂄 If episiotomy – scared will hurt or tear sutures with BM

􀂄 Nursing interventions may help prevent, relieve

􀂅 If C/S, clear liq till bowel sounds, then solid food

 

Postpartum physical adaptations

􀂄 Urinary system

􀂅 At risk for over distention, incomplete emptying with residual urine d/t

􀂄 Increased bladder capacity

􀂄 Swelling and bruising of tissues around urethra

􀂄 Decreased sensation of full bladder (anesthetic block)

􀂄 Output first 12-24 hrs pp (PP diuresis)

􀂅 Eliminate 2000-3000 mL preg fluid, more if PIH

􀂅 Fills bladder quickly, watch closely for distention

􀂅 Risk of UTI high

􀂅 Full bladder will also uterine relaxation, bleeding

 

Postpartum physical adaptations

􀂄 Vital signs

􀂅 Should be afebrile after 24 hrs

􀂄 May have temp up to 100.4 F (38 C) for 24 hrs d/t dehydration

􀂄 May also have elevation of 100 to 102 F (37.8-39 C) when milk comes in

􀂅 BP may spike immediately after delivery

􀂄 Should have normal BP within few days

􀂄 Orthostatic hypotension common first couple days

􀂄 Decrease = hemorrhage versus normal?

􀂄 Increase = preeclampsia, excess oxytocin use?

􀂅 Decreased pulse common for first 6-10 days PP

􀂄 Pulse > 100 related to hemorrhage, fear, pain, infection

 

Postpartum physical adaptations

􀂄 Blood values

􀂅 Values return to normal by 6-8 wk after delivery

􀂅 Increased coagulation factors continue for variable time, increases risk for blood clot

􀂅 Blood loss averages

􀂄 H & H difficult to determine in first 2 days pp d/t changing blood volume (diuresis)

􀂄 200-500 cc with vag del

􀂄 700-1000cc with C/S

􀂄 Rule of thumb – 2 point drop in Hct = 500 mL blood lost

􀂅 WBC increases in labor & early pp to 25,000-30,000

􀂅 Platelets return to normal by 6 weeks

 

Postpartum physical adaptations

􀂄 Cardiovascular changes

􀂅 Blood volume increases because no longer has blood circulating to placenta

􀂄 Works to protect mother against excess blood loss

􀂅 Diuresis decreases extracellular fluid

􀂄 If fails to happen, can lead to pulmonary edema esp in mother with preeclampsia or existing cardiac problems

􀂄 Weight loss

􀂅 10-12 # immediately after birth (infant, placenta, amniotic fluid)

􀂅 Diuresis additional 5# first wk

􀂅 By 6-7 wks return to pre-preg wt if gained normal amt

 

Postpartum physical adaptations

􀂄 Afterpains

􀂅 Are intermittent contrx of uterus

􀂅 More common in multips, retained placenta or with overdistention of uterus

􀂅 Oxytocin & breastfeeding increases afterpains

􀂄 Can use mild analgesic 1 hour before nursing

􀂅 May be very uncomfortable for 2-3 days

􀂄 Usually gone in 5 minutes

 

Postpartal Nursing Physical Assessment

􀂄 Physical Assessment – see guide pg 1001-1004

􀂅 Explain to pt purposes

􀂅 Record and report results

􀂅 Avoid exposure to body fluids

􀂅 Teach pt as assess – use q opportunity since limited time

 

Post Partum Nursing Assessment

􀂄 Assessment necessary to identify individual needs or potential problems

􀂅 See page 1053-1055 for complete assessment guide

􀂅 Also see table on page 1052 about postpartal high risk factors and their implications

􀂅 Term BUBBLEHE can help remember components

􀂄 breast, uterus, bladder, bowel, lochia, episiotomy, Homan’s/hemorrhoids, emotional

􀂅 Principles in assessment of pp woman

􀂄 Provide explanation of assessment to client

􀂄 Perform procedures gently to avoid unnecessary discomfort

􀂄 Record and report results

􀂄 Take appropriate precautions to prevent exposure to body fluids

􀂅 Provides excellent opportunity for client teaching about physical changes of pp and common concerns

 

Post Partum Nursing Assessment

􀂄 Vital signs

􀂅 Alterations in VS can indicate complications already discussed

􀂄 Lung auscultation

􀂅 Lungs should be clear

􀂅 Women treated for PTL, PIH @ risk for pulmonary edema

 

Post Partum Nursing Assessment

􀂄 Breasts

􀂅 Assess fit and support of bra

􀂄 Helps maintain shape by limiting stretching of ligaments and connective tissue

􀂄 Bra for nursing mother

􀂅 Non-elastic straps

􀂅 Be one size larger than normal

􀂅 Have cups that fold down for nursing

􀂅 Breast assessment

􀂄 Inspect for redness, engorgement

􀂄 Palpate for warmth, firmness of filling or engorgement, tenderness

􀂄 In nursing women:

􀂅 Assess nipples for cracks, bleeding, soreness, fissures, inversion

 

Post Partum Nursing Assessment

􀂄 Abdomen and Fundus – pg 1057 -1058

􀂅 Pt should void prior to checking fundus

􀂄 Uterus positioned better

􀂄 More comfortable to client

􀂅 Position pt on back with legs flexed

􀂅 Assess relationship of fundus to umbilicus, midline

􀂅 Assess firmness of uterus

􀂄 Massage prn if not firm

􀂄 Assess any blood discharged during massage

􀂅 Assess gently, uterus slightly tender

􀂄 Excessive pain with palpation clue to infection

􀂅 If cesarean

􀂄 Palpate fundus gently

􀂄 Assess incision (REEDA, patency of staples)

 

Post Partum Nursing Assessment

􀂅 If uterine atony (boggy):

􀂄 Question patient about her bleeding, passage of clots

􀂄 Re-eval bladder

􀂄 Babe to breast if nursing

􀂄 Assess maternal BP, pulse

􀂄 Notify MD since may need oxytocic med

 

Post Partum Nursing Assessment

􀂄 Lochia – pg 1059

􀂅 Assess for character, amt, odor, clots

􀂅 Should never be more than moderate amt with non-offensive odor:

􀂄 Partially saturate 4-8 pads, 6 average/day

􀂅 Women with C/S bleed less first day than vag del

􀂄 Also assess woman’s pad changing practices, her type of pad

􀂄 Assess chux pad

􀂅 If pt reports heavy bleeding, change pad, reassess in 1 hr

􀂄 If need accurate assessment, can weigh pad; 1g = 1cc

􀂅 Teach proper wiping, progression of lochia

 

Post Partum Nursing Assessment

􀂄 Perineum – pg 1061-1062

􀂅 Inspect with pt in Sims position

􀂅 Lift buttock to expose perineum, anus

􀂅 If present, assess episiotomy or laceration for REEDA

􀂄 Should have minimal tenderness with gentle palpation

􀂄 No hardened areas or hematomas

􀂅 Also assess hemorrhoids: size, pain

􀂅 Evaluate effectiveness of any comfort measures performed

􀂅 Educate about suture absorption

 

Post Partum Nursing Assessment

􀂄 Lower Extremities

􀂅 PP woman at increased risk of thrombophlebitis, thrombus formation; most likely site is legs

􀂅 To screen, use Homan’s sign (not diagnostic)

􀂄 Nurse grasps foot and dorsiflexes sharply

􀂄 Should have no calf pain

􀂄 If positive for pain notify MD

􀂅 Check for edema, redness, tenderness, warmth of leg

􀂅 Prevention best

􀂄 Early ambulation

􀂄 Passive ROM for cesarean client till sensation returns

􀂅 Teach

􀂄 Signs and symptoms to watch after discharge

􀂄 Self care for prevention – ambulate, leg exercises in bed, avoid crossing legs and pressure behind knees

 

Post Partum Nursing Assessment

􀂄 Elimination

􀂅 Urinary

􀂄 Should void within 4 hours, then q 4-6 hours

􀂄 Monitor bladder carefully first few hrs (diuresis)

􀂅 Watch for distention

􀂃 Misplaced or boggy uterus, palpable bladder signs

􀂅 Check to see if empty first few times

􀂄 Use techniques to encourage void

􀂅 If can’t void after 8 hours or voiding small (<100 mL) amounts frequently, then cath

􀂄 Evaluate for fluid intake, ask if bladder feels empty, UTI symptoms

 

Post Partum Nursing Assessment

􀂄 Elimination

􀂅 Bowels

􀂄 Ask about concerns

􀂄 Evaluate whether having stools since delivery

􀂄 Constipation causes pressure on sutures, increases discomfort

􀂅 To avoid constipation:

􀂃 Stool softeners

􀂃 Encourage ambulation

􀂃 Force fluids (>2000mL/day)

􀂃 Fresh fruits and veggies

 

Post Partum Nursing Assessment

􀂄 Rest status

􀂅 Requires energy to make adjustments to motherhood and infant

􀂅 Fatigue often significant problem

􀂅 Evaluate amount of rest mother is getting

􀂄 Determine cause of not sleeping, use appropriate interventions

􀂅 Encourage daily rest period

􀂄 Arrange activities in hospital

 

Post Partum Nursing Assessment

􀂄 Nutritional status

􀂅 Non-nursing

􀂄 Decrease calories by 300/day

􀂄 Return to pre-preg nutritional requirements

􀂅 If nursing

􀂄 Increases calories by 200 over preg level or 500 over pre-preg level

􀂅 Refer to dietician if vegetarian, food allergies, lactose intolerance or have specific food needs related to culture/religion

􀂅 Advise iron supplements, prenatal vitamins for 3 months esp if nursing

 

Postpartal Psychologic Adaptations

􀂄 PP time of adjustment and adaptation to new baby, pp discomfort, change in body, loss of pregnancy

􀂄 2 periods of adjustment:

􀂅 Taking in period

􀂄 First couple days, tends to be passive, dependent

􀂄 Hesitates to make decisions, follows suggestions

􀂄 Preoccupied with her needs

􀂅 Must assimilate experience

􀂃 Talks about labor, sorts out reality

􀂅 Sleep, eat is major focus

 

Postpartal Psychologic Adaptations

􀂄 Periods of adjustment

􀂅 Taking hold period

􀂄 By 2^nd – 3^rd day ready to resume control of body, mothering and her life

􀂄 Needs reassurance needed she’s doing well as mother

􀂅 This theory 40 years old, slightly outdated as women more independent today

􀂄 Adjust more rapidly in shorter time periods than these

 

Postpartal Psychologic Adaptations

􀂄 Maternal role attainment

􀂅 Another psychologic adaptation

􀂅 Process by which woman learns mothering behaviors, becomes comfortable with her identity as mom

􀂅 Formation of maternal identity means woman has attained maternal role (role of mom)

􀂄 Process reoccurs with each child as she gets to know him/her and “binds in” to infant

􀂅 Attainment occurs in stages, but usually complete within 3-10 months after birth of infant

􀂅 Many factors influence success in attaining role: social support, woman’s age, her personality, marital relationship, presence of anxiety or depression, previous childcare skills, infant’s temperament, economic status

 

Postpartal Psychologic Adaptations

􀂄 Many challenges while adjusting to new role

􀂅 Finding time for self

􀂅 Feeling incompetent

􀂅 Fatigue

􀂅 Increased responsibility, loss of freedom

􀂅 Finding time for older children, sibling rivalry

􀂄 Nurse can provide anticipatory guidance about realities of parenting

 

Postpartal Psychologic Adaptations

􀂄 Postpartum Blues

􀂄 Transient period of depression first few days after delivery

􀂄 Manifested by

􀂅 Mood swing, weeping, anorexia, difficulty sleeping, feelings of letdown

􀂄 Contributing factors:

􀂅 Hormones shifts

􀂅 Fatigue

􀂅 Discomfort

􀂅 Over-stimulation

􀂅 Psychologic adjustments

􀂄 Usually resolve naturally in 10-14 days

􀂅 If Sx persist or intensify, seek care

Postpartal Psychologic Adaptations

 

􀂄 Importance of Social Support

􀂅 Psychologic outcome in pp period more positive if parents have access to support network

􀂄 May find family relationships become more important, but can be source of stress too

􀂄 Concern if no family, friends to form social network

􀂅 Contributing factor to pp depression, child neglect or abuse

 

Development of Attachments

􀂄 Initial Attachment Behavior

􀂅 Consistent pattern of maternal behaviors seen at first contact with newborn

􀂄 Fingertip exploration of newborns extremities

􀂄 Palmar contact with larger areas

􀂄 Enfold infant with whole hand and arms

􀂄 Time to accomplish from minutes to days

􀂅 Arranges infant so has direct face to face and eye to eye contact

􀂅 Intense interest in having baby’s eyes open

􀂅 Talks in high pitched tones

􀂅 Responds verbally to noises baby makes

􀂅 Finds similarities of baby and other family members

 

Development of Attachments

􀂄 Father–infant interaction

􀂅 Father’s strong attraction and feelings about newborn similar to mother’s

􀂅 Sense of absorption, preoccupation and interest in infant termed engrossment

􀂄 Siblings and grandparents

􀂅 Infants can maintain number of strong, high quality attachments

􀂄 Open visitation, rooming in permits these attachments

 

Psychologic Assessment of Post Partum Woman

􀂄 Assessment should focus on:

􀂅 Moms general attitude

􀂅 Feelings of competence

􀂅 Support system available

􀂅 Fatigue level

􀂅 Level of overall satisfaction with experience

 

Psychologic Assessment of Post Partum Woman

􀂄 Mom may feel overwhelmed, if becomes passive, quiet instead of asking questions, nurse may mistake for disinterest, depression

􀂄 Signs of problems that may indicate actual problem:

􀂅 Excessive, continued fatigue

􀂅 Marked depression

􀂅 Excessive preoccupation with physical discomforts

􀂅 Low self-esteem

􀂅 Lack of support systems

􀂅 Marital problems

􀂅 Current family crisis

􀂄 Have potential to lead to child abuse or neglect

 

Psychologic Assessment of Post Partum Woman

􀂄 Assessment of Early Attachment

􀂅 Observe and note mom’s attachment progress

􀂄 Is mother attracted to infant?

􀂄 Is she exhibiting progression from fingertip to embracing infant

􀂄 Does she seek info?

􀂄 Mother sensitive to baby’s needs consistently?

􀂄 Pleased with baby’s response to efforts?

􀂄 Pleased with baby’s appearance and sex?

􀂄 Talk with baby, call him/her by name?

􀂄 Point out characteristics she sees in baby?

􀂄 Any cultural factors that modify response?