Physiological and Psychological Adaptations after Childbirth

1. Postpartum Care Physiological and Psychological Adaptations after Childbirth Debbie Golson MSN, RN

3. Learning Outcomes • Describe the basic physiological changes that occur in a woman’s body during the postpartal period, the related nursing assessment and care with patient education. • Formulate nursing diagnosis and nursing care based on “normal” findings of the postpartum assessment. • Compare abnormal findings in the nursing assessment with possible causes and appropriate nursing care. • Examine the nurse’s impact in assessing predisposing factors of postpartum complications, implementing preventive care, and teaching for self help.

4. Learning Outcomes • Describe the psychological adjustments that normally occur during the postpartal period, the related nursing assessment and care including education to promote patient and family wellness. • Identify the impact of cultural influences on providing holistic nursing care for the postpartal family. • Examine the individualized postpartal nursing needs of the woman, including the childbearing adolescent, who delivered vaginally or by cesarean section. • Evaluate identified teaching topics and outcomes related to postpartum discharge.

5. Postpartal (Puerperium) Period • 4TH Stage of Labor: 1-4 hrs. after delivery • Begins immediately after delivery of placenta • Continues for 6 weeks, or until body returns to near pre-pregnant state

6. Physical Adaptations Reproductive • Involution of uterus- “uterus going back to pre-preg state” • Rapid reduction in size of uterus to nonpregnant state (5-6 wks). • Contractions constrict and occlude underlying blood vessels at placental site. • Placental site • Heals by exfoliation (6wks) • No scar formation occurs, if it does scarring could prevent egg attatchment • Subinvolution • Any slowing of decent

7. Involution/Fundal Position • Stages of Involution • Post-delivery: midway between • umbilicus and symphysis pubis • 6-12 hrs: rises to • level of umbilicus • then at 1-2 cm below first PP day • 24 hrs – 10 days: • descends 1cm/day until reaches • pelvic cavity • Universal measurement

8. Fundal position“usually mid-line” • May be displaced to the left or right by a distended bladder • Becomes “boggy/mushy” with uterine atony • increased risk for hemorrhage“bladder is full and is pushing uterus up” • Lochia • Debris from delivery and uterine lining • Rubra—dark red 1-3 days • Serosa—pink 4-10 days • Alba—white 11-24 days • Increased with exertion and breastfeeding • Unexplained increase or return to Rubra is abnormal

9. Vaginal changes • Following birth edematous and bruised • Small superficial lacerations may be present • Decreases in size for 3 weeks in nonlactating woman • Decreases in size slower in lactating woman due to hypoestrogenic state. B/c you don’t ovulate during breastfeeding. • Low estrogen leads to painful intercourse due to decreased vaginal lubrication (6-10 wks) • Cervical Changes • Following birth - spongy and flabby and formless and may appear bruised. • Permanently changed by the first childbearing. • Dimple-like to a lateral slit (fish mouth)

10. Perineal changes • May appear edematous with some bruising • Episiotomy edges should be approximated • Ovulation and menstruation • Estrogen/Progesterone drop rapidly after delivery of placenta • In nonlactating woman, returns within 6 weeks • In lactating woman, return varies due to increased levels of prolactin (supports milk production) • May precede menstruation, making breastfeeding not reliable means of contraception

11. Additional PhysiologicalAdaptations • Lactation • Preparation for lactation - estrogen and progesterone • After birth, the interplay of maternal hormones leads to the establishment of milk production • Infant sucking: stimulates prolactin / milk production; stimulates release of oxytocin milk “let down” uterine contractions/cramping. Breastfeeding helps lose buldge. • Abdominal / GI • Risk for constipation; Sluggish due to progesterone • Decreased abdominal musculature/peristalsis • Narcotic usage; Dehydration • Fear of pain and tearing episiotomy delays elimination • Flatulence causes abdominal discomfort • Stool softeners approved

12. Urinary • Puerperal diuresis PP Diuresis– 2000-3000cc/24hrs. • Overdistention of bladder due to rapid filling of bladder • Increased distension/ retention leads to UTI • Uterine relaxation (atony) • Increased risk of hemorrhage • Uterus deviates to side and becomes boggy

13. Cardiovascular • Returns to Pre-pregnancy state by 12 weeks • Natural diuresis of increased blood volume • Increased cardiac output • First 48hrs – Increased risks CHF and pulmonary edemaespecially with history of PIH “HTN” or heart disease • CBC decrease normal due to blood loss - pre-labor values in 2-6 weeks • Risk of thromboembolism for 6 weeks • Increased fibrinogen for 1 wk – which will increase risk of DVT • Headaches due to fluid shift - HTN, Epidural/Spinal

14. Vital signs • A temperature up to 100.4 may be due to dehydration and/or exertion in the first 24 hours - Afebrile after 24 hr BP WNL “BP w/in normal limits”, may decrease initially - ↑BP may indicate PIH “preg induced HTN”. If Temp stays high after 24hrs = infection. • Pulse rate may decrease to 50-70 (normal). BUT, Tachycardia  hemorrhage • Lab Values • Prepregnant state by the end of the postpartum period • Increased risk of thromboembolism • White blood cell (WBC) counts up to 30,000 may occur early postpartum. Treat the symptoms, not the lab values • Convenient rule of thumb is a 2 point drop in hematocrit “amount of RBCs in the blood”equals a blood loss of 500 mL

15. Postpartal chill • Normal First 2 hours after delivery • Nervous response or vasomotor change • Due to shift in fluids and work of labor • Treat with warm blanket or warm beverage • Assure pt that it is common occurrence (gone w/in the hr) • Chills / fever late in the postpartum period may indicate sepsis • Postpartal diaphoresis • Fluid shift • Increased perspiration • Common at night

16. Afterpains • Common in multiparas • Increased with uterine distention • Caused by intermittent contractions • May cause severe discomfort for the first 2-3 days • Breastfeeding, Oxytocins may increase the severity • (Pitocin, Methergine “is used if pitocin isn’t working”, Ergotrate) “to stop the bleeding” • Mild analgesic may be indicated for pain relief. (Toradol “caution: can cause urinary distension”, Norco, Davocet N-100, Percocet, Motrin)

17. Psychological Adaptations • Maternal Role adjustment (see Book) • 1st - 2nd PP days - passive and somewhat dependent • Hesitant about making decisions • Food or sleep are of major importance • “Taking In” phase according to Rubin • 3rd day, mother is ready to resume control. “Taking Hold” phase occurs during this time • Today’s mother’s adjust more rapidly as LOS “length of stay” has shortened • Education is more important. • Maternal role attainment • Process by which a woman learns mothering behaviors

19. Psychological Adaptations • Initial attachment Behavior • En face “when the father is looking in the face of the child, bonding) • Fingertip exploration • Reciprocity “mutual dependence or action or influence” • Father-Infant Interactions • Engrossment (the characteristic sense of absorption, preoccupation, and interest in the infant demonstrated by fathers during early contact with the newborn • Cultural Influences • Postpartum care my be affected by cultural beliefs: • Do not make generalizations • Extended family may play an important role in care

20. Psychological Adaptations

21. Psychological Adaptations • Baby blues- anormal emotion • Transient period of depression during first 2 weeks • Mood swings, anger, weepiness, anorexia, insomnia, and a feeling of letdown • Cause? Hormonal changes and psychological adjustments • Usually resolve naturally in 2 to 3 weeks with support and reassurance. If symptoms persist, the client should be evaluated for postpartum depression • Postpartum depression- >3wks, ineffective ADLs, State law that PPD gets educated. • Postpartum psychosis- Extreme PPD, murder/suicide 9:29

22. Postpartum Assessment and Nursing Care

23. 13:48 Current OB Status • Admit assessment • Delivery information • Blood type – mom/baby (very Important Baby/mom match, rh factor) Else mother’s antibodies/RBC could attack the baby. • Rubella status- NEED to know, common cause of most congenital anomalies (mother & baby don’t have antibodies to protect) • L/D complications • Medications/Narcotics – last 24 hrs Prenatal History • Previous pregnancies – complications (Prenatal will affect later) • Abnormal lab results • Antepartal testing and procedures

24. Medical History • Allergies • Chronic illness – HTN, DM, HIV • STD Psychosocial history • Depression prior to pregnancy • Support system Culture- Jehovah’s W.- Will not accept blood transxn • Ethnicity • Demographics • Personal Beliefs/Preferences • Socioeconomic • Diet

25. Vital Signs – q 4 hours • BP- should remain at baseline during pregnancy • High BP – preeclampsia, essential HTN • Low BP - hemorrhage or may be WNL for pt • HR- 50 – 90 bpm – tachycardia – hemorrhage • Respirations- 16-24 – tachypnea – respiratory dx • TCDB and IS post-op • Spinal Duramorph may cause decr resp. • Temperature- 98 – 100.4 – first 24 hours only due to dehydration • After 24 hours 100.4 or above suggests infection- due PROM “Pre-Mature Rupture of membranes” pass, prolonged labor • May have low grade temp when lactating • Teach pt. how to take temperature

26. Pain Assessment • Orient patient to pain scale • Assess origin of pain – uterine, abdominal, perineal, rectal, headache, breasts • Evaluate for hematomas: vulvar, vaginal, pelvic – severe pain with firm uterus. • Pain Management: Epidural, PCA, Analgesics (Tylenol, Norco), Nonpharmacologic measures. (heatpads, ice) Note patients response to pain medications. PostPar med, Toradol- nonsteroidal anti-inflammatory drug” • Monitor for side effects of medications

27. Incisions • Tubal Ligation: “tubes tied” • Small umbilicus incision • Post-op Cesarean Section: “Bikini cut” • Low transverse abdominal • Midline abdominal, risk abd hernia • Heals in 6-8 weeks • Perineal: • Episiotomy or laceration • Heals in 4-6 weeks • No intercourse for 6 wks to facilitate healing • REEDA assessment: redness, edema, ecchymosis, discharge, approximation (great for any type of incision)

28. BUBBLEHEB- Everything you need to check B = Breast U = Uterus B = Bladder B = Bowel L = Lochia “vag discharge after delivery” E = Episiotomy/Laceration H = Hemorrhoids/Homans E = Emotional B = Bonding

29. Breasts • Determine breast or bottle-feeding • General appearance – reddened area- Mastitis. Size (may affect breastfeeding) • Encourage supportive bra • Sports bra for 2 weeks if bottle-feeding, to try and compress to prevent pain • Palpation – soft, filling, full, engorged • Mastitis – (an infection) mass, tender, red, heat • Engorgement – tenderness, heat, edema express milk, warm packs, pump • Nipples – supple, intact, erect with stimulation • Cracked, sore, red, bleeding, flat inverted (can use lanolin cream to treat, or their own breast milk) • May need shields or shells with breastfeeding • Shields to prevent bra irritation • Shells- to make nipple “stand-up” making it easier for infant • Assess technique, Lactation specialist referral

30. 31:00 Uterus and Fundus (Nextslide) • Have pt. voidbeforeassessment. • Full bladderwilldisplaceuterusaboveumbilicus and cause uterineatonywithincreasedbleeding • Assess risk factors Gently massage fundus • If soft and boggy/ mushy– Teach self-massage • Assess every 15 minutes for first hour after delivery, 30min for second hour, hourly for 2 more hours, then every 4 hours - monitor for complications Oxytocics to promote contractions, decrease bleeding, side effects: • Pitocin: Hypotension • Methergine: Hypertension, given IM w/ SE of HTN • Remember, Methergine is alternative to Pitocin. • Withcesarean section, abdomen very tender, use care and inspectincisional area for signs of infection, healing.

31. 34:55

32. One hand to assess the top. Other hand steady.

33. 38:00 Bladder • Increased risk for distension, retention due to postpartal diuresis (2000-3000cc) • Must void q 4-6 hours post vaginal delivery, or within 4 hours of removal of foley catheter. Use alternatives (warm water, running water in sink, peppermint oil, increased fluids) to assist voiding before straight cath or reinserting foley • Full bladder leads to uterine atony and increase bleeding • Assess for UTI

35. Bowel • Increased risk of constipation due to fear of pain from episiotomy, hemorrhoids, perineal trauma • Normal BM by 2nd or 3rd day. • Encourage fluids, ambulation, stool softeners, roughage in diet • Post-op cesarean section / BTL« bilateral tubal ligation » need to pass flatus before eating to avoid abdominal distension and discomfort. No straws, carbonated drinks, or heavy sweets

36. Lochia • Amount, color, odor, presence of clots • Scant to moderate amount, no clots. Large amount with clots must be evaluated for hemorrhage due to uterine atony, retained placenta, unknown cervical laceration (heavy bleeding with firm uterus). Pools in vaginal vault after lying down, may ‘gush’ when pt. stands up. Always reassess with clean pad • Usually with cesarean section lochia is scant due to uterine evacuation. • Odor is nonoffensive, earthy. If foul, suspect infection • Last 3-4 weeks until placental site is healed • Return to rubra – subinvolution “a medical condition in which after childbirth, the uterus does not return to its normal size”

37. Episiotomy and Perineum • Inspected perineum and anus with woman lying in Sims’ position (sideways w/ knees bent and pillow between legs) • With episiotomy or laceration with repair, assess wound (REEDA). Edema, bruising, tenderness, normal. Hardened areas with increased pain – hematoma, infection. Apply ice pack, teach to pat dry after voiding, use Dermoplast spray, sitz bath, pain meds (Norco, Toradol, Darvocet, Tylenol). NOTHING RECTALLY with 3rd or 4th degree episiotomy or tear. • Hemorrhoids may be present. Assess size, pain or tenderness. Tucks ‘hemorrhoid pads’ , sitz bath, stool softeners • Provide teaching concerning episiotomy, hygiene, comfort measures, hand washing

40. Homan’s/LowerExtremities(Homan’s to check for DVTs) • Increasedrisk for thrombophlebitis, thrombus formation due to hypercoagulability, anemia, obesity, traumaticchildbirth, surgery • Homan’s not diagnostic, onlyevaluationtool. Onlytrue diagnostic is LEVD • Homan’sSign- Pain in the calf w/ dorsiflexion of the foot • Heparintherapywith DVT • Early ambulation, SCD’s, ROM whilebedridden • Teachsigns and symptoms of DVT, especially for discharge. • Symptoms: tenderness, pain, swelling, warmth, and discoloration of the skin. Homan’s Sign

41. Emotional Status • First 24 hrs – passive ‘taking in’ – passive, talks about labor and birth experience. Sleeps frequently (fatigue from labor) • 12 -36 hrs – ‘taking hold’ – begins to assume responsibility. May have mood swings, crying, irritability (baby blues) • Assess mother’s attitude, support systems, caregiving skills, feelings of competence in comparison to disinterest, withdrawn behavior, depression • Educate patient and family concerning postpartal depression, sign, symptoms, support groups, referrals

42. Bonding • Observe interaction withnewborn; en face, cuddles, soothes, identifies familycharacteristics • Disappointment over sexusuallytransient"temporary", yetcontinued expressions, refusal to care for infant, lack of bondingbehaviors must beevaluatedfurther • Cultural practices maymodifymother’sresponse to infant • Providesupportive, nonjudgementalteaching and evaluatemother’sknowledgelevel • Familycentered care and rooming in facilitatesbondingwithfather and siblings

43. Promote successful infant feeding • Bottlefeeding: supportive bra, ice packs 4 times a day if engorgement develops, avoid heat and stimulation of breasts. Feed every 3-4 hours • Breastfeeding: supportive bra, nursing on demand, assist with positioning (football, cradle, side lying hold). Teach breast care: no soap, air dry after breastfeeding, use lanolin. Lactation specialist referral • After cesarean birth, assess for grief due to loss of fantasized birth. Support effective coping

44. Assess adolescent mother’s needs and maternal-infant interaction based on level of maturity. Include self-care, infant care, contraception, goal setting, peer relationships, resources. For the woman giving up her newborn, nonjudgemental support is essential. Respect special requests regarding her care and infant: See and hold infant, early discharge, admit to med/surg unit. Many factors for putting infant up for adoption: single, adolescent, economic status, result of incest or rape, partner disapproval of pregnancy.

45. 52:40 • Dischargecriteria and teaching • VS, assessment stable • RhoGAMreceived if momis Rh-negative and infant Rh-positive (meansmother has not been sensitized to 1st baby’sblood). RhoGAMisbloodproduct; consent withverification by 2 nurses required. 300 mu given IM within 72 hours of delivery. (Alsoreceivedat 28 weeks) ( w/ 2nd baby shewillrecRhoGAMat 28wks. Then have dose again post-delivery to protectnextchild.) • Rubellareceived if titer 1:10 or less, 0.5 cc sq – AVOID PREGNANCY FOR 3 MONTHS (RubellaTiter- a serologic test to determine a patient's state of immunity against rubella) • If lessthan 1:10, thenshe’lneed a Rubella dose b/c RubellaMeasleswill cause defects. Live vacinestays in system for 3months sopregpreventionmethodsneed to be in place.

46. Instruct in proper administration of medications • Antibiotics, analgesics, prenatal vitamins, Iron • Resuming home medications • Get Pediatrician approval if breastfeeding • Teaching content: Maternal/Infant care, home safety, special needs (Car seat, multiple births, infant with anomaly). Signs/symptoms of postpartum complications: Hemorrhage, infection, DVT, depression and when to report complications to physician • Newborn care: feeding, bathing, cord and circumcision care, safety – MUST have car seat

47. Resume sexual activity when episiotomy is healed and lochia flow has stopped. Use water soluble lubricant. Plan for contraceptive by 6 wk PP visit. • Resumption of activity, especially post-op

50. Postpartal Complications