5/4/2010

By
Ida Maryati, S.Kp., M.Kep., Sp.Mat

Peurperium
◦ Postpartal period
◦ Immediately after birth through
6 wks
◦ Body returning to near-
prepregnant state

Uterus
◦ Involution

Reduction in size of uterus and
return to a condition similar to
prepregnant state

Process of uterine changes takes
about 3 - 4 wks except at site of
placenta

Placental site heals in about 6 wks

Heals by “exfoliation”

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Uterus
◦ Involution

Uterus palpable until about day 9

On PPD 1, usually at Umb or 1FB↓

↓1FB/day

to prepregnant size in about 4-6
wks
◦ Subinvolution

Slowing of descent of uterus

Uterus
◦ Subinvolution

Slowing of descent of uterus
◦ Factors that retard involution

Retained placenta or membranes

Full bladder

Infection

Overdistension of uterus

Prolonged labor

Grandmultipara

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Fundal position
◦ Immediately after delivery

Midline of abd

Approx ½ between symph and
umbilicus

Firm
◦ If uterus deviated from above, can
cause excessive bleeding

Uterine deviations
◦ If higher than normal and/or soft
(boggy)

Very large baby

Grandmultip

Multiple gestation

Full bladder

Usually deviates to right side

Lochia
◦ Discharge after birth
◦ Foul smell indicates need for further
testing
◦ Total volume is about 240 -270 mL
◦ Should get lighter in color and lighter
in amount
◦ Can have slight increase after
exercise, breastfeeding

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Lochia Rubra
◦ 3-4 days
◦ Epithelial cells, erythrocytes, leukocytes, decidua,
bacteria, may have some meconium, vernix

Lochia Serosa
◦ About 10 days
◦ Serous exudate, decidua, erythrocytes,
leukocytes, cervical mucus, microorganisms

Lochia Alba
◦ About 3 wks
◦ Leukocytes, decidual cells, epithelial cells, fat,
cervical mucus, cholesterol crystals, bacteria

Cervical Changes
◦ Returns to original form in
about a week
◦ Os changes to lateral slit

Vaginal changes
◦ Immediately after delivery, is
edematous and bruised
◦ Size and rugae return by 3-4 wks

Perineal Changes
◦ May appear edematous with some
bruising
◦ May have episiotomy or laceration

Recurrence of Ovulation and
Menstruation
◦ Non-breastfeeding: menstruation
returns about 6-8 wks
◦ Breastfeeding: if < 1 month, similar to
above; if exclusive breastfeeding, may
be 3 months or longer

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Abdomen
◦ Abd wall loose and flabby
◦ Striae change colors

GI System
◦ Hunger and thirst common
◦ May have sluggish bowels
◦ If C/S, may have flatus

Striae gravidarum
Linea nigra

Diastasis rectus abdominis

Urinary System
◦ Output increases: ~ 2000 to
3000mL in very short time
◦ Risk for overdistension, incomplete
emptying, urinary stasis, infection

Swelling, bruising of tissue around
urethra

Decreased sensation of bladder
filling

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Vital Signs
◦ Temp

1st 24 hrs, may have temp up to 38C

After 24 hrs, must evaluate >38C
◦ Blood Pressure

Stable
◦ Pulse

May be slightly bradycardic (50-70)
◦ Respiratory

Stable

Blood values
◦ Leukocytosis (up 30,000) normal in
early PP period
◦ Hemoglobin and RBC dependent
upon pre-delivery values and blood
loss; should equal pre-delivery
values w/i 6 weeks
◦ Hematocrit elevated early in PP due
to hemoconcentration (excretion of
extracellular fluid); returns to normal

Wt loss
◦ Initial wt loss cause of: baby,
placenta, amnion, diuresis
◦ By 6-8 wks may be pre-pregnant wt

PP Chill
◦ Severe shaking due to neurologic
response or vasomotor changes
◦ Not r/t being cold

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Afterpains
◦ Uterine contractions
◦ More in multiparitas,
overdistended uterus,
breastfeeding, clots, retained
placenta, receiving oxytocin

Rubin’s Taking-In Phase

◦ First day or two
◦ Passive and dependent on others
◦ Hesitant about making decisions
◦ Preoccupied with her needs
◦ Talks a lot about her labor and birth
◦ Food and Sleep very important

Rubin’s Taking-hold
phase
◦About 2nd or 3rd day
◦Ready to assume control
◦Needs frequent
assurances that she is a
good mother

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Maternal Role Attainment

◦ Anticipatory stage

Occurs during pregnancy

Looks for role models on how to be a mother
◦ Formal stage

Tries to act as she believes others expect her to
act
◦ Informal stage

Makes her own choices about mothering
◦ Personal stage

Becomes comfortable with the idea of herself as
“mother”

Maternal Role Attainment

◦ Usually occurs w/i 3 – 10 months
◦ Social support, age and personality,
temperament of infant,
socioeconomic status, culture affects
ability to attain

Postpartum Blues
◦ Transient depression occurring
during 1st week or two after birth
◦ Resolves naturally

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Initial Attachment Behaviors

◦ Fingertip exploration of extremities

palmer exploration of larger body areas

enfolding infant with whole hand and
arms
◦ Increases en face time
◦ Interest in having baby open his eyes
◦ Talks in high-pitched tones to baby
◦ Phase of mutual regulation

reciprocity

Father-Infant Interactions
◦ Studies show fathers have some
of the same feelings of attachment
◦ Engrossment

Sense of absorption, preoccupation and
interest in the infant

Mother’s culture and

personal values influence her
beliefs about her postpartal care

Don’t generalize—ask

In many cultures, extended
family (esp mother’s mother)
plays important role

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Must be aware of risk

factors

Assessment and teaching go
hand-in-hand

Vital signs
◦ Should be stable
◦ May have slight temp
elevation w/i 1st 24 hrs;
Should not be > 38C

Physical Assessment
◦ BUBBLEHE

Breasts
◦ Should be soft first 48 hrs; starts to
“fill” about 48-72 hrs
◦ Inspect nipples
◦ Bras encouraged but not necessary
◦ If bottle-feeding, compression
important, ice
◦ May have slight temp elevation when
milk “comes in” ( usually 60-72 hrs)

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Uterus
◦ Assess fundal characteristic, size,
position q 15 min x 1 hr; then
usually q 30 min x 2, then q4 hrs or
q shift
◦ Recorded as Firm, 1FB↓ U or Firm
@U,
sl boggy 1 FB ↑U, massaged, midline
◦ Deviations from norm need to be
further assessed

☺Full bladder common cause

Overdistended uterus

Uterus
◦ If boggy

Must massage!

Teach mom to massage

Non-dominant hand above
symphysis

Watch closely

May need medication to assist
w/ contracting

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Bowels
◦ May be sluggish
◦ Encourage fluids, fiber, activity
◦ Fear
◦ If C/S

Auscultasi for listen

Anti-gas interventions

Diet controversy

Bladder
◦ High risk for bladder
infection
◦ Assess for distended bladder
◦ Encourage to void ~ q 2 – 4
hours while awake
◦ May need to be cathether

Varises

Odem

Lochia

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Lochia
◦ Previous discussion are: color,
amount, odor
◦ Assessed q 15min during 1st hr; then
usually q 30 min x 2 then q4 hrs or q
shift
◦ Teach to change pad with each void
◦ Usually described as scant, light,
moderate, heavy
◦ If need to ID more exact amount, weight
pads

SCANT LIGHT

MODERATE HEAVY

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Episiotomy
◦ Inspect perineum for approximation,
state of healing, hemorrhoids
◦ May have ice pack for several hours
◦ Pain relief measures
◦ If C/s

Examine incision

Also evaluate for hemorrhoids

Pain relief measures

hemorrhoids

Odem

Varises

Homan sign

Refleks patella

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Homan’s sign
◦ Assessed q shift
◦ Especially important if
prolonged bedrest

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Emotions
◦Observe affect, interaction
w/ baby, others
◦Provide adequate rest
◦PP Blues vs serious
problems

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Newborns’ and Mothers’

Health Protection Action

Home Visits

Methods

Timing

Content

Evaluation

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Uterine Discomfort
◦ Causes
◦ Relief measures

Perineal Discomfort
◦ Causes
◦ Relief measures

Muscle Strain Discomfort

◦ Causes
◦ Relief measures

Postpartal Diaphoresis
◦ Causes
◦ Relief measures

Suppression of Lactation
◦ No medication
◦ Snug compression
◦ No nipple stimulation
◦ Ice
◦ No warm shower water on
breasts

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Rubella vaccine
◦ Given after delivery
◦ Teach woman about avoiding
pregnancy for at least 3 months

RhoGam
◦ Rh negative mom with Rh
positive baby

Storytelling

Recognition and praise

Instruct on S&S of normal vs
abnormal adjustment

“Listento your body”

Important to balance both

When to start work?

Exercise program
◦ Start w/ kegal exercises
◦ Short walks, abd exercises
◦ Build up to regular program after 6
wks

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Usually when epis heals and

lochia flow stops (~3rd – 6th wk)

May have to use different
positions at first

May use other forms of sexual
pleasure until mom is ready

Recognize factors that may delay
mom being “ready”

Hasboth “normal” PP needs

as well as post surgical needs
◦ Resp risk
◦ immobility
◦ Surgical Pain
◦ Bowels
◦ Handling baby
◦ Activity/Rest

Psychological issues

Painrelief
◦ NSAIDs
◦ Narcotics
◦ Antiflatulents, suppositories,
enemas
◦ Other pain relief measures

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Offer choices
◦Infant involvement
◦PP floor or other

Psychological issues

Legal issues

Long Of Stay ~ 2 days NSVD

3 days C/S

Teaching
◦ Self care
◦ Infant care
◦ Support

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Hospital/Health Dept may

provide follow-up phone
calls and/or home visits

Does early d/c compromise
mom and newborn health?

Suddent Infant Death

Syndrome (SIDS) prevention
◦ “Back to Sleep”
◦ Highest risk factors

Prone sleeping

Sleeping on soft materials

Maternal smoking

Overheating baby

Crib Safety
◦ No pillows, stuffed animals,
loose blankets
◦ Slats no more than 2-3/8” apart
◦ Make sure latch works
◦ Mattress fits snuggly

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Co-sleeping
◦ Place infant on firm mattress
◦ Never sleep with baby if you are
intoxicated for heavily medicated
◦ Ensure infant can’t fall off bed
◦ Same rules as crib
◦ Ensure plenty of ventilation
◦ Avoid overdressing (parent’s body heat)
◦ Never smoke in bed with baby
◦ Don’t allow other children to sleep directly
next to baby

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