Chapter 15 Postpartum Adaptations

Uterine Atony

- Difficulty voiding can lead to urinary retention, bladder distention, and urinary tract infection. Urinary retention and bladder distention can cause displacement of the uterus from the midline to the right and can inhibit the uterus from contracting properly, which increases the risk of postpartum hemorrhage. - Urinary retention is a major cause of uterine atony, which allows excessive bleeding. Frequent voiding of small amounts (less than 150 mL) suggests urinary retention with overflow, and catheterization may be necessary to empty the bladder to restore tone.

Subinvolution

- Generally responsive to early diagnosis and treatment. Factors that facilitate uterine involution include complete expulsion of amniotic membranes and placenta at birth, a complication free labor and birth process, breastfeeding, and early ambulation. - Factors that inhibit involution include a prolonged labor and difficult birth, incomplete expulsion of amniotic membranes and placenta, uterine infection, over-distention of uterine muscles (such as by multiple gestation, hy- dramnios, or a large singleton fetus), a full bladder (which displaces the uterus and interferes with contractions), anesthesia (which relaxes uterine muscles), and close childbirth spacing.

Stage 1: Expectations

- New fathers or partners pass through stage 1 (expectations) with preconceptions about what home life will be like with a newborn. Many men may be unaware of the dramatic changes that can occur when this newborn comes home to live with them. For some, it is an eye opening experience.

Vagina

- After birth vaginal mucosa is edematous and thin with few rugae. As ovarian function returns and estrogen production resumes, mucosa thickens and rugae returns in about 3 weeks - Vagina returns to its prepregnant size by 6-8 weeks, but will always remain a little larger - Normal mucus production and thickening of the vaginal mucosa usually return with ovulation. The vagina gradually decreases in size and regains tone over several weeks. By 3 to 4 weeks, the edema and vascularity have decreased.Localized dryness and coital discomfort (dyspareunia) usually plague most women until menstruation returns. Water soluble lubricants can reduce discomfort during intercourse.

Integumentary system adaptations

- As estrogen and progesterone levels decrease, the darkened pigmentation on the abdomen (linea nigra), face (melasma), and nipples gradually fades. Some women experience hair loss during pregnancy and the postpartum periods. - Hairloss: The most common period for hair loss is within 3 months after birth, when estrogen returns to normal levels and more hairs are allowed to fall out. This hair loss is temporary, and regrowth generally returns to normal levels in 4 to 6 months in two thirds of women and by 15 months in the remainder, although hair may be less abundant than before pregnancy - Stretch marks: Striae gravidarum that developed during pregnancy on the breasts, abdomen, and hips gradually fade to silvery lines. These lines do not disappear completely. - Sweating: Many women will wake up drenched with perspiration during the puerperium. This postpartum diaphoresis is a mechanism to reduce the amount of fluids retained during pregnancy and restore prepregnant body fluid levels. It can be profuse at times. Common, especially at night during the first week after birth.

Coagulation

- Clotting factors that increased during pregnancy tend to remain elevated during the early postpartum period. Giving birth stimulates this hypercoagulability state further. As a result, these coagulation factors remain elevated for 2 to 3 weeks postpartum - This hyper-coagulable state, combined with vessel damage during birth and immobility, places the woman at risk for thromboembolism (blood clots) in the lower extremities and the lungs.

Cardiovascular System Adaptations

- During pregnancy heart is displaced slightly upward and to the left. Cardiac output remains high for the first few days postpartum and then gradually declines within 3 months to non pregnant values - Blood volume increases during pregnancy and drops rapidly after birth and returns to normal within 4 weeks pp. Decrease in cardiac output and blood volume reflects the birth-related blood loss (avg 500ml with vag birth and 1000ml with c-section) - Blood plasma volume is further reduced through diuresis. Despite the decrease in blood volume, the hematocrit level remains relatively stable and may even increase. Thus, an acute decrease in hematocrit is not an expected finding and may indicate hemorrhage.

Maternal Physiologic Adaptations

- During pregnancy, the woman's entire body changed to accommodate the needs of the growing fetus. After birth, the woman's body once again undergoes significant changes in all body systems to return her body to its prepregnant state.

Partner psychological adaptations

- During the postpartum period, men frequently find themselves struggling to balance personal and work needs with the new demands of father status and their new self-image. The complexities of the transitional process involved in forging a fatherhood identity can be viewed at three different levels: 1. readjustment to a new self-image 2.formation of a triadic family relationship, and 3. adaptation to redefining himself and his relationship with his partner - Keep fathers informed about birth and postpartum routines, report on their newborn's health status, and reviewing infant development. They can also contribute by creating "participative space" for new fathers during the postpartum period. - Helping fathers take on their new role by supporting and promoting their degree of involvement in the process. Encouraged to actively participate in caring for, and maintaining contact with, their newborns.

Endocrine system adaptations

- Estrogen is at its lowest level a week after birth. For the woman who are not breastfeeding, estrogen levels begin to increase by 2 weeks after birth. For the breastfeeding woman, estrogen levels remain low until breastfeeding frequency decreases. - Other placental hormones hCG and hPL, decline rapidly after birth. hCG levels are nonexistent at the end of the first postpartum week, and hPL is undetectable within 1 day after birth - Progesterone levels are undetectable by 3 days after childbirth, and production is reestablished with the first menses. - Prolactin levels decline within 2 weeks for the woman who is not breastfeeding, but remain elevated for the lactating woman

Stage 3: Transition to mastery

- Father or partner makes a conscious decision to take control and be at the center of his newborn's life regardless of his preparedness. This adjustment period is similar to that of the mother's letting-go phase, when she incorporates the newest member into the family.

Stage 2: Reality

- Fathers or partners realize that their expectations in stage 1 are not realistic. Their feelings change from elation to sadness, ambivalence, jealousy, and frustration. Many wish to be more involved in the newborn's care and yet do not feel prepared to do so. Some find parenting fun but at the same time do not feel fully prepared to take on that role. - Men's stress, irritability and frustration in the days, weeks, and months after the birth of their child can turn into depression, just like new mothers experience. Unfortunately, men rarely discuss their feelings or ask for help - Depression in men can cause marital conflicts, reckless or violent behavior, poor job performance, and substance abuse. In addition, paternal depression following childbirth can have a detrimental effect on a couple's relationship, the parent-child relationship, and on their children's future development

Urinary System Adaptations

- Glomerular filtration rate and renal plasma flow increase significantly during pregnancy and both usually return to normal by 6 weeks after birth. - Women have difficulty feeling the sensation to void after giving birth if they received an anesthetic block during labor (which inhibits neural functioning of the bladder) or if they received oxytocin to induce or augment their labor (antidiuretic effect). These women will be at risk for incomplete emptying, bladder disten- tion, difficulty voiding, and urinary retention. - In addition, urination may be impeded by: - Perineal lacerations - Generalized swelling and bruising of the perineum and tissues surrounding the urinary meatus - Hematomas - Decreased bladder tone as a result of regional anesthesia - Diminished sensation of bladder pressure as a result of swelling, poor bladder tone, and numbing effects of regional anesthesia used during labor

Taking in phase

- Immediately after birth when the client needs sleep, depends on others to meet her needs, and relives the events surrounding the birth process. - This phase is characterized by dependent behavior. During the first 24 to 48 hours after giving birth, meeting their own basic needs for food, fluids, and rest, allowing the nurse to make decisions for them concerning activities and care. - They spend time recounting their labor experience to anyone who will listen. Such actions help the mother integrate the birth experience into reality; the pregnancy is over and the newborn is now separate from herself. - When interacting with the newborn, new mothers spend time claiming the newborn and touching him or her, commonly identifying specific features in the newborn, such as "he has my nose" or "his fingers are long like his father's"

Maternal psychological adaptations

- In the postpartum period, mood disorders can be divided into three distinct entities in ascending order of severity: maternal (baby) blues, postpartum depression, and psychosis - Baby blues: characterized by mild depressive symptoms, anxiety, irritability, mood swings, tearfulness (often for no reason), increased sensitivity, and fatigue. The "blues" typically peak days 4 and 5 but usually resolved in 10 days. Does not affect mothers ability to function and care for child - Depression: signs and symptoms • Restless • Worthless • Guilty • Hopeless • Moody • Sad • Overwhelmed - Behavior patterns of mothers experiencing post- partum depression, such as withdrawal and detachment, are likely to have a negative impact on the infant, which may lead to poor mother-baby bonding - Postpartum depression can lead to alienation from loved ones, daily dysfunction secondary to overwhelming sorrow and disorientation, and, at its most extreme, personal terror resulting in dangerous thoughts and violent actions.

Pulse and Blood Pressure

- Increase in cardiac output and stroke volume during pregnancy begins to diminish after birth once the placenta has been delivered. Decrease in cardiac output is reflected in bradycardia (40 to 60 bpm) for up to the first 2 weeks postpartum. Is related to the increased blood that flows back to the heart and to the central circulation after it is no longer perfusing the placenta - This increase in central circulation brings about an increased stroke volume and allows a slower heart rate to provide maternal circulation. Cardiac output returns to levels by 3 months after childbirth - Tachycardia (heart rate above 100 bpm) in the postpartum woman warrants further investigation. It may indicate hypovolemia, dehydration, or hemorrhage. - In most instances of postpartum hemorrhage, blood pressure and cardiac output remain increased because of the compensatory increase in heart rate. Thus, a decrease in blood pressure and cardiac output are not expected changes during the postpartum period. Early identification is essential to ensure prompt intervention. - BP values should be similar to those during the labor process. There might be a slight increase lasting about a week after childbirth. Increase accompanied by headache might indicate preeclampsia. Decreased blood pressure may suggest an infection or a uterine hemorrhage.

Musculoskeletal System Adaptations

- Increased ligament laxity, weight gain, change in the center of gravity and carpal tunnel syndrome revert back during the pp period. - During pregnancy, the hormones relaxin, estrogen, and progesterone relax the joints. After birth, levels of these hormones decline, resulting in a return of all joints to their pre pregnant state, with the exception of the woman's feet. Parous women will note a permanent increase in their shoe size - Good body mechanics and correct positioning are important during this time to prevent low back pain and injury to the joints. Within 6 to 8 weeks after delivery, joints are completely stabilized and return to normal. - During pregnancy, stretching of the abdominal wall muscles occurs to accommodate the enlarging uterus. This stretching leads to a loss in muscle tone and possibly separation of the longitudinal muscles of the abdomen, common in women who have poor abdominal muscle tone before pregnancy. - After birth, muscle tone is diminished and the abdominal muscles are soft and flabby. Specific exercises are necessary to help the woman regain muscle tone. Fortunately, diastasis responds well to exercise, and abdominal muscle tone can be improved.

Engrossment

- Infants have a powerful effect on their fathers and others, who become intensely involved with them The father's or significant other's developing bond with the newborn, a time of intense absorption, preoccupation, and interest. Characterized by seven behaviors: 1. Visual awareness of the newborn the father or partner perceives the newborn as attractive, pretty, or beautiful. 2. Tactile awareness of the newborn the father or partner has a desire to touch or hold the newborn and considers this activity to be pleasurable. 3. Perception of the newborn as perfect, the father or partner does not "see" any imperfections. 4. Strong attraction to the newborn, the father or partner focuses all attention on the newborn when he is in the room. 5. Awareness of distinct features of the newborn, the father or partner can distinguish his newborn from others in the nursery. 6. Extreme elation, the father or partner feels a "high" after the birth of his child. 7. Increased sense of self-esteem, the father or partner feels proud, "bigger," more mature, and older after the birth of his child - A father or partner's nurturing responses may be less automatic and slower to unfold than a mother's, but they are capable of a strong bonding attachment to their newborns

Perineum

- Often edematous and bruised for the first day or two after birth. If the birth involved an episiotomy or laceration, complete healing may take as long as 4 to 6 months in the absence of complications at the site, such as hematoma or infection - Perineal lacerations may extend into the anus and cause considerable discomfort for the mother when she is attempting to defecate or ambulate. Ice packs, pouring warm water over the area via a peribottle, witch hazel pads, anesthetic sprays and sitz baths can relieve pain - Encourage all women to practice Kegel exercises to improve pelvic floor tone, strengthen the perineal muscles, and promote healing

Psychological adaptations

- Parenting involves caring for infants physically and emotionally to foster the growth and development of responsible, caring adults. During the early months of parenthood, mothers experience more life changes and get more satisfaction from their new roles than fathers. However, fathers interact with their newborns much like mothers

Afterpains

- Part of the involution process involves uterine contractions. Many women are bothered by painful uterine contractions termed afterpains. - All women experience afterpains, but they are more acute in multiparous and breastfeeding women secondary to repeated stretching of the uterine muscles from multiple pregnancies or stimulation during breastfeeding with oxytocin released from the pituitary gland. - Primiparous women typically experience mild afterpains because their uterus is able to maintain a contracted state. - Breastfeeding and administration of exogenous oxytocin both cause powerful and painful uterine contractions. They usually respond to oral analgesics

Breast milk production

- Prolactin levels increase at term with a decrease in estrogen and progesterone levels. - Estrogen and progesterone levels decrease after the placenta is delivered. - Prolactin is released from the anterior pituitary gland and initiates milk production. - Oxytocin is released from the posterior pituitary gland to promote milk let-down. - Infant sucking at each feeding provides continuous stimulus for prolactin and oxytocin release

Gastrointestinal System Adaptations

- Quickly returns to normal after birth because the gravid uterus is no longer filling the abd cavity and producing pressure on the abd organs. Progesterone levels which caused relaxation of smooth muscle during pregnancy and diminished bowel tone (declining) - Most women experience decreased bowel tone and sluggish bowels for several days after birth. Decreased peristalsis occurs in response to analgesics, surgery, diminished intra-abdominal pressure, low-fiber diet, insufficient fluid intake, and diminished muscle tone. - Women with an episiotomy, perineal laceration, or hemorrhoids may fear pain or damage to the perineum with their first bowel movement and may attempt to delay it. Subsequently, constipation is a common problem during the postpartum period. A stool softener can be prescribed for this reason. - Most women are hungry and thirsty after childbirth, commonly related to NPO restrictions and the energy expended during labor. Appetite returns to normal immediately after giving birth

Blood cellular components

- RBC production ceased early causing H&H levels to decrease slightly in the first 24 hours. During the next 2 weeks, both levels rise slowly. - WBC increases in labor and remains elevated 4-6 days after birth and then falls to 6,000-10,000

Reproductive System Adaptations

- Reproductive system goes through a lot of changes to return to the pre pregnancy state. All organs and tissues of the reproductive system are involved. - Shedding of the placenta and subsequent uterine involution, involve substantial tissue destruction and subsequent repair and remodeling. - The uterus, which has undergone tremendous expansion during pregnancy to accommodate progressive fetal growth, will return to its prepregnant size over several weeks. - The mother's breasts have grown to prepare for lactation and do not return to their prepregnant size as the uterus does.

Respiratory system adaptations

- Respirations usually remain within the normal range of 16 to 24 breaths per minute. As the abdominal organs resume their nonpregnant position, the diaphragm returns to its usual position. - Anatomic changes in the thoracic cavity and rib cage caused by increasing uterine growth resolve quickly. As a result, discomforts such as shortness of breath and rib aches are relieved. Functional residual capacity return to prepregnant values, typically within 1 to 3 weeks of birth

Lactation

- Secretion of milk by the breasts. Brought about by the interaction of progesterone, estrogen, prolactin, and oxytocin. Breast milk typically appears within 4 to 5 days after childbirth. -During pregnancy, the breasts increase in size and functional ability in preparation for breastfeeding. - Estrogen stimulates growth of the milk collection (ductal) system, whereas progesterone stimulates growth of the milk production system. Prolactin from the anterior pituitary gland, secreted in increasing levels throughout pregnancy, triggers the synthesis and secretion of milk after the woman gives birth. - Oxytocin acts so that milk can be ejected from the alveoli to the nipple. Therefore, sucking by the newborn will release milk. A decrease in the quality of stimulation causes a decrease in prolactin surges and thus a decrease in milk production. Prolactin levels increase in response to nipple stimulation during feedings.

Three stage role development process

- Similar to mothers, fathers or partners also go through a predictable three stage process during the first 3 weeks as they too "try on" their roles as parents. The three stages are expectations, reality, and transition to mastery

Engorgement

- Swelling of the breast tissue as a result of an increase in blood and lymph supply as a precursor to lactation, usually peaks 3-5 days pp. - Can occur from infrequent feeding or ineffective emptying of the breasts and typically lasts about 24 hours. Breasts increase in vascularity and swell in response to prolactin 2 to 4 days after birth. If engorged, the breasts will be hard and tender to touch. - Frequent emptying of the breasts helps to minimize discomfort and resolve engorgement. Standing in a warm shower or applying warm compresses immediately before feedings will help to soften the breasts and nipples in order to allow the newborn to latch on easier. - Treatments to reduce the pain of breast engorgement include heat or cold applications, cabbage leaf compresses, breast massage and milk expression, breast pumping, and anti-inflammatory agents - If a woman is not breastfeeding, some relief me sures include wearing a tight, supportive bra 24 hours daily, applying ice to her breasts for approximately 15 to 20 minutes every other hour, avoiding sexual stimulation, and not stimulating the breasts by squeezing or manually expressing milk from the nipples. Avoiding exposing the breasts to warmth will help relieve breast engorgement. In women who are not breastfeeding, engorgement typically subsides within 2 to 3 days with application of these measures.

Ovulation and return of menstruation

- The timing of first menses and ovulation after birth differs between women who are breastfeeding and women who are not breastfeeding. For non- lactating women, menstruation may resume as early as 7 to 9 weeks after giving birth, but the majority take up to 3 months, with the first cycle being anovulatory - The return of menses in the lactating woman depends on breast-feeding frequency and duration. It can return anytime from 3 to 18 months after childbirth, depending on whether the woman is exclusively breast-feeding or supplementing with formula.

Involution

- The uterus returns to its normal size through a process call involution which involves retrogressive changes that return it to its non pregnant size and condition. It involves 3 retrogressive processes. 1. Contraction of muscle fibers to reduce those previously stretched during pregnancy 2. Catabolism, which reduces enlarged, individual myometrial cells 3.Regeneration of uterine epithelium from the lower layer of the decidua after the upper layers have been sloughed off and shed during lochial discharge

Puerperium Period

- This period begins after the delivery of the placenta and lasts approximately 6 weeks. - During this period the woman's body begins to return to its prepregnant state, and these changes generally resolve by the sixth week after giving birth.

Parental attachment behaviors

- To enable an attachment to be built, closeness of this family unit is essential. Attachment is the formation of a relationship between a parent and his or her newborn through a process of physical and emotional interactions - Attachment begins before birth, during the prenatal period where acceptance and nurturing of the growing fetus takes place. It continues after giving birth as parents learn to recognize their newborn's cues, adapt to the newborn's behaviors and responses, and meet their newborn's needs. - Nurses can facilitate skin-to-skin contact (kangaroo care) by placing the infant onto the bare chests of mothers and fathers. Enable them to get close to their newborn and experience connectedness and feelings of being nurturing parents. Encouraging breast-feeding is another way to foster attachment between mothers and their newborns. Encourage nurturing activities and contact such as touching, talking, singing, comforting, changing diapers, and participating in routine newborn care.

Taking hold phase

- Typically starts on the 2nd to 3rd day and may last several weeks. Start taking hold and becoming preoccupied with the present. Concerned about her health, the infant's condition, and her ability to care for her or him. - Demonstrates increased autonomy and mastery of her own body's functioning, and a desire to take charge with support and help from others. - She will show independence by caring for herself and learning to care for her newborn, but she still requires assurance that she is doing well as a mother. She expresses a strong interest in caring for the infant by herself.

Cervix

- Usually returns to its pre-pregnant state by week 6. Cervix gradually closes but never regains its pre pregnant appearance. - Right after childbirth, cervix is shapeless and edematous and easily distensible for a few days. - Cervical os gradually closes and returns to normal by 2 weeks, whereas external os widens and never appears the same after childbirth. External os no longer shaped like a circle but looks like a jagged slit like opening "fish mouth"

Lochia

- Vaginal discharge that occurs after birth, results from involution where the superficial layer of the decidua becomes necrotic and is sloughed off. - Bright red after birth and consists of blood, fibrinous products, decidual, red and white cells. - Lochia from the uterus is alkaline but becomes acidic as it passes through the vagina. Average amount of discharge is 240-270 mL. Present for at least 3 weeks after birth but can be as long at 6 weeks. - Women who have C-sections tend to have less of a flow because the uterine debris is removed manually along with the delivery of the placenta.

Uterus

- Weighs approx 2.2 lbs after birth. Approx one week after birth it shrinks in size by 50% and weighs about 1 lb. At the end of 6 weeks it weighs about 2 oz (weight before pregnancy) - During the 1st few days after birth the uterus usually descends from the level of the umbilicus at a rate of 1 cm per day. By the end of 10 days, the funds usually cannot be palpated because it has descended into the "true pelvis" - If these retrogressive changes do not occur as a result of retained placental fragments or infection, subinvolution of the uterus results.

Cultural considerations

- Western practices frequently use cold packs or sitz baths to reduce perineal swelling and discomfort. These practices are not acceptable to women of many cultures and can be viewed as harmful. - Hot-cold beliefs are common among Latin American, African, and Asian people, good health requires the balancing of hot and cold substances. Because 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 food. Foods consumed should be hot in nature, and cold foods, such as fruits and veggies should be avoided. - Postpartum nurses need to understand these diverse cultural beliefs and provide creative strategies for encouraging hygiene (sponge baths, perineal care), exercise, and balanced nutrition, while remaining respectful of the cultural significance of these practices

Letting go phase

- Woman reestablishes relationships with other people. She adapts to parenthood through her new role as a mother. Assumes the responsibility and care of the newborn with a bit more confidence - The focus of this phase is to move forward by assuming the parental role and to separate herself from the symbiotic relationship that she and her newborn had during pregnancy. - She establishes a lifestyle that includes the infant. The mother relinquishes the fantasy infant and accepts the real one.

BAM (becoming a mother)

1. Commitment, attachment to the unborn baby, and preparation for delivery and motherhood during pregnancy 2.Acquaintance/attachment to the infant, learning to care for the infant, and physical restoration during the first 2 to 6 weeks following birth 3. Moving toward a new normal 4. Achievement of a maternal identity through redefining self to incorporate motherhood (around 4 months). The mother feels self-confident and competent in her mothering and expresses love for and pleasure interacting with her infant

Stages of Lochia

Has 3 different stages: 1. Lochia rubra: deep-red mixture of mucus, tissue debris, and blood that occurs for the first 3 to 4 days after birth. As uterine bleeding subsides, it becomes paler and more serous. 2. Lochia serosa: pinkish brown and is expelled 3 to 10 days postpartum. Lochia serosa primarily contains leukocytes, decidual tissue, red blood cells, and serous fluid. 3. Lochia alba: discharge is creamy white or light brown and consists of leukocytes, decidual tissue, and reduced fluid content. It occurs from days 10 to 14 but can last 3 to 6 weeks postpartum in some women and still be considered normal. - Lochia at any stage should have a fleshy smell; an offensive odor usually indicates an infection, such as endometritis.