hey i'm back again and we are going to be talking about chapter 15 postpartum adaptations postpartum period the fourth trimester is the time from birth of the baby till six weeks postpartum it is considered the fourth trimester even though the baby is here it is the birth of the baby till six weeks postpartum it's a critical transition period for the woman the baby everyone involved including the uh the mom the dad the siblings um it's a period of adjustment for all family members reproductive system adaptations involution is the gradual change that the uterus undergoes in the postpartum period it begins immediately after the delivery of the placenta when the uterine muscles contract around the placental separation site they start contracting the minute the uterus you uh the minute the placenta starts separating sub sublution is the term used when the uterus does not go through the the process lokia lokia is the mount color and odor that you see after a vaginal birth sometimes if there is odor it can a strong odor it can suggest infection you do see less with the c-section and sometimes you see hardly none with the c-section you do count how many pads per hour to see if a possibility of the mom hemorrhaging lochia vaginal bleeding or drainage provides information about how involution is progressing there's different stages rubra is the first three to four days and it consists mostly of blood uh decidua and mucus red or dark brown in color serosa is day three through ten the flow becomes lighter and pink or brown tinged it's composed of exudate leukocytes and mucus next is the abba day 10 to 21 becomes lighter still and is white cream or light yellow contains leukocytes epithelial cells fat mucus and bacteria may last up to six weeks but normally loki is gone after the third week um you do have less local with c-section deliveries and you usually don't go through all three phases excuse me um it's heavier just after delivery and when mom gets up for the first time especially in a gravida it will um it's like it'll gush but then that does slow down because there was some pooling um should have a fleshy odor any foul odor is not normal should never get darker heavier once it's slowed and lightened an amount is estimated by observing the parry pad and um it's termed scant excuse me scant less than one inch light one to four inches moderate four to six inches heavy pad saturated in one hour excessive pad saturated in 15 minutes you also want to make sure that you look at the perineum especially if there was um an episiotomy um the cervix is going to be closed and it's going to have like a little jagged slit like opening um next this is um a picture of the actual uh length of funda when the uterus starts to move from the umbilicus moving down or the fundus uh the fundus should be firm and near the umbilicus if boggy you'll need to massage it until firm with support um and the first time the first day of delivery it will be at the umbilicus assessing the fundal height is a great indicator of how evolution is progressing the fundus is palpated midway between the symphysis pubis and the umbilicus by about 12 hours post delivery the fundus is found at the umbilicus or um at or just below the fundus descends about 1cm for or or one finger width per day and is usually in the pelvic cavity by about day 14. when documented the fundus assessment you document relation to the umbilicus like u1 and firm is one finger with one finger with below the uh umbilicus um or u2 and displaced to the right means the fundus is two fingers with above the umbilicus and shifted to the right so mom probably has a full bladder and you need to take her to void and then recheck and see where it is at that point but this gives you some idea postpartum day one and then it goes down a finger width every day this shows the cervix uh from a woman that has never been pregnant versus one from a moment that has been pregnant uh it the cervix never regains its pre-pregnant look but returns to its um its new normal by about six weeks it never has that little round hole anymore it's now slit where the baby has come through and that's the way it grew back and it takes about six weeks for it to return to that cardiovascular adaptations remember mom has increased volume during pregnancy so she can normally tolerate the blood loss associated with delivery without problem 500 milliliters with vaginal and a thousand with c-section i believe we've i said that earlier in a chapter this is a normal estimated blood loss just after delivery cardiac output increases when there is increased blood flow in mom's circulation once the placenta blood flow is no longer needed decreased pressure from an over oversized uterus um in excess extracellular fluid moving into the vascular system this lasts for about 24 to 72 hours then it returns to normal um slowly over several weeks as the body adjusts so it does take several weeks to get back to a pre-pregnant what pre-pregnancy state wbcs are slightly elevated postpartum then return to normal in a week or so pulse should say stable or uh even a little slower um tachycardia is not normal and can indicate hypovolemia dehydration or bleeding hyper coagulation remains for two to three weeks postpartum putting mom at increased risk for thrombose thrombolytic events wbc increases in labor and may stay elevated for four to six weeks are four to six days i'm sorry may stay elevated for four to six days and this are all normal reactions to giving birth urinary system bladder illumination palpate or bladder scan may be required output you want to record output amount color and character right after delivery should void in six to eight hours after delivery if you have to things like turning on the faucet uh rinsing putting like warm water over their perineum a sitz bath anything that helps them may be drinking if they're allowed something po anything that helps them go to the bathroom making sure mom empties her bladder running water over the perrier area area blow bubbles through straw are always to encourage voiding uh should void four to six hours after delivery may need to straight cath if mom can't void a bladder scan may be needed and is usually available on the unit epidural anesthesia and trauma may affect ability to void it may increase the time because they can't feel the fullness urinary retention is a big factor with poor uterine tone and postpartum hemorrhage poor fat a big factor with poor uterine tone and postpartum hemorrhage so remember it's important that they go to the bathroom but they may have had some type of anesthesia and they may have diminished sensation of the bladder due to swelling so it's important to try whatever works for them to dry it and see if you can get them to go causes of postpartum diuresis mom rinse herself of extra pla extra plasma volume by diuresis with uh and diaphoresis after delivery urinary output is often up to three thousand milliliters per day on postpartum days two to five so mom is dumping a lot of extra fluid volume hematocrit however should remain stable plasma loss only nothing else no blood decrease in hematocrit is abnormal heart rate may slow somewhat post delivery tachycardia is not normal after delivery and could mean possibly hemorrhage urinary kidney function doesn't return to normal until four to six weeks post delivery protein and acetone in human urine normally is normal immediately postpartum if bladder is descended the fundus will be palpated abnormally high and displaced to one side or the other and mom is more prone to increase bleeding if she has a full bladder so it's important to for her to go to the bathroom gi system adaptation the gi system quickly returns to normal and because you don't have all of the pressure and you don't have a baby laying on the organs they do have decreased bowel tones for several days and decreased peristalsis does occur mom is usually ravenous after delivery often excessively thirst thirsty as well constipation is common bowel tone and gastric um motility are sluggish for several days constipation is compounded if mom has perineal trauma and ends up within a pc episiotomy or has hemorrhoids because they're afraid to have a bowel movement um because it's going to hurt still softeners and laxatives are routinely used should have a bm in the first two to three days post delivery really encourage lots of po fluids and mom to take those stool softeners sometimes they don't want to but encourage them to do so and tell them constipation is common because they're afraid to strain so make sure that and really encourage those stool softeners musculoskeletal system um joints return to pre-pregnant state except for feet usually they experience fatigue and activity intolerance for several weeks after giving birth abdominal muscle tone is diminished special exercise exercises are needed to return it to normal if there is such a thing as returning it to normal musculoskeletal aches joint pain common post delivery from stretching muscle fatigue and exertion feet get bigger and stay bigger but i'll honestly say that's one of the things about me that did not get bigger they stayed the same uh integumentary system adaptations integumentary changes caused by hormonal hormonal changes you get the linea [ __ ] the melisma and other things which gradually fades as the hormone levels drop the striat gravidarum the stretch marks fade but they do not disappear um diaphoresis is common for about a week postpartum so you get red you have a lot of sweating issues respiratory and endocrine system adaptations endocrine ovulation and administration for non-breastfeeding mom returns in seven to nine weeks breastfeeding delays ovulation but don't count on it for birth control method a lot of women i have seen women do this but it is not a surefire thing they need to start taking some type of contraceptive if they are not going to have btl um estrogen and progesterone levels do drop quickly placental hormones decline rapidly prolactin levels will decline within two weeks if they're not breastfeeding otherwise they'll stay high lactation lactation occurs once estrogen and progesterone levels drop after delivery prolactin levels stimulate milk production within four to five days post delivery supply and demand system the more the baby nurses excuse me the more mom produces so try to get them nursing right away so that mom will keep on producing milk newborn breast crawl process please read about that in your book um be aware um that there is lactation consultants almost in every facility um and moms that have breastfeeded successfully are great resources for the new mother because they know what's going on and some of the tricks of the trade that work so but there is lactation consultants in almost every facility across the country excuse me engorgement engorgement happens two to four days after delivery when there is an increase in blood and lymph supply to the breast this can be quite painful it's in a painful experience tips for relief for breastfeeding moms um frequent emptying helps relieve it warm showers and compresses before feeding compress it cold compresses between feeding and if you're not going to breastfeed a tight supportive bra ice and avoidance of any breast stimulation okay and that will help decrease the pain ovulation and return administration menstrual periods return in six to eight weeks breastfeeding delays ovulation but don't count on that for birth control like i said earlier it's very important that you educate your women your postpartum moms maternal adaptation um you have the pupil phase which changes in maternal behaviors um the taking in phase where mom is focused on her own needs initially exhibits dependent behavior and lets others take care of her she relates her delivery story over and over to others to realize that the pregnancy has ended and the baby's now here and a separate individual claims the baby by identifying familiar familial features uh taking hold phase mom becomes more independent and active in her own care interested in the performance and health of her infant also in her own health she assumes role of the caring for herself and her infant very teachable time this is the time that you can do a lot of education with your moms provide lots of resources letting go phase this gives that previous role as a couple an idealized birth plan and gerber baby they put away their fantasy and accept the reality of what they have at this time they assume the parental role with mom with more confidence and becoming a mother bonding and attachment bonding usually starts when pregnancy is confirmed and continues after birth we need to back off and allow this process to unfold if at all possible by itself um and it will attachment tied between parents and infant the parents provides food warm security for the infant and the mother accepts responsibility for the infant putting the baby's needs before her own touch is another process touch is another process at first you see mothers gazing at their infant once she gets to hold the infant she holds it in her face in her in the position of her face so that she can look at it and they can look at each other next she begins to touch but only with her fingertips and gentle exploration eventually she uses more of her hand or palm than her entire hand and arms to unfold the baby close to her finally she starts to identify familiar features that the baby has as she claims this child as her own this attachment that starts at birth is the basis on erickson's theory first step was trust first versus mistrust and if this attachment is not formulated it leaves a lifelong consequences on the child and a lot of mistrust life in a lifetime stages of becoming a mother bam make sure that you read these commitment attachment to unborn baby preparation for delivery and motherhood during pregnancy where you have your nesting acquaintance and attachment to infant learning to care for infant and physical restoration two to six weeks post birth moving toward a new normal and achievement of a maternal identity through redefining self to incorporate motherhood around the fourth month postpartum engrossment um visual awareness of the newborn baby is beautiful handsome tactical awareness of the newborn baby desire to touch the baby perception of the newborn um as perfect their baby's perfect even though it's um even though it may not be um and usually newborn babies are with with the cone head and different things and it takes a little while um strong attraction to the newborn focused all their attention on the baby awareness of distinct features of the newborn can distinguish their baby from others extreme elation by the father daddy high increased sense of self-esteem proud all grown up now those are some of the the psychological steps that you go through three stages of role development process expectations reality transition to mastery expectations gerber baby sleeps well breastfeeds like a champ uh reality stressful frustrated sleep deprived transition to mastery you realize you're not an authority but take on the role of parent anyway you're going to survive this adventure cultural considerations please read on page 512 and 513 about cultural considerations in each culture pregnancy antipartum intrapartum and postpartum is different with different beliefs practices and customs and it's important that you know these different beliefs practices and customs when you're working with varying cultures so please read this section