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Chapter 21: p 446
Reproductive: Involution – rapid ↓ in size of uterus to nonpregnant state. Decidua sheds as lochia; placental site is exfoliated. Cells grow smaller, reversing the uterine hyperplasia. Factors slowing down process: prolonged labor, anesthesia or excessive analgesia, difficult birth, full bladder, multiparity, incomplete expulsion of the placenta or membrane fragments. Factors enhancing involution: breastfeeding, early ambulation, & uncomplicated birth.
Changes in fundal position: /p placental delivery: uterus grapefruit-size. Fundus midline; at level of umbilicus at 6 -12 hrs /p. Boggy uterus:  blood & clots collect, uterus rises, contractions interrupted; moves to  R side: suspect distended bladder. PP day #1: 1 cm ↓ umbilicus; descends 1 fingerbreath/day. Breastfeeding → pitocin → faster; nonpregnant size @ 5-6wks
Lochia: uterine debris /p birth.
rubra – 3-4 days –  dark red, bloody, fleshy, musty, stale non-offensive odor; clots < nickle; composition: blood /c sm amts mucus, shreds of diciua, epithelial cells, leukocytes; may contain fetal meconium, lanugo, or vernix caseosa
serosa – 4 – 10 days – pink,or brownish; watery; odorless. Composition: serum, erythrocytes, shreds of degenerating decidua, leukocytes, cervical mucus, numerours bacteria
alba – 11 – 21 days; u/t 6 wks if lactating – yellow to white, possible stale odor. Composition: leukocytes, decidual cells, epithelial cells, fat, cervical mucus, cholesterol, bacteria
Cervical changes: soft, irregular, edematous; bruised-looking /c multiple small lacerations;  closes to 2 -3 cm /p few days; admits fingertip /p 1 wk; permanent change to os /p 1st delivery to slit-like
Vaginal changes: smooth walls, edematous, multiple small lacerations; perineal pain d/c /p 2 wks; ↓ PP estrogen → ↓ vaginal lubrication & vasoconstricition 6 – 10 wks  → painful intercourse.
Chp 9, Figure 9-9, p 197 : Perineal muscle tightening, also called Kegel exercises  strengthen the pubococcygeus muscle, which improves support to the pelvic organs. p 195: how to teach: compare to elevator, 1-4 floors; properly done, does not contract the buttocks & thighs; done any time
Perineal: bruising; episiotomy edges together; separation
Recurrence of ovulation & menstruation:  nonlactating: 6-8 wks; 1st cycle usually anovulatory;  breastfeeding: delayed, but not reliable form of birth control. Exclusive breastfeeding → wider spacing of pregnancies
Abdominal: soft, flabby; striae or stretch marks; diastisis recti, separation of rectus muscle, may improve PP r/t woman’s physical condition, gravidity, exercise Cardiovascular/blood values: returns to prepreg. Within 2 wks; 40% inc in blood volume eliminated through diuresis; 1st 48 hrs greatest risk for PP hemorrhage; BP -  baseline; Inc in fibrinogen   → ↑ risk of thrombophlebitis;  inc  WBCs  25-30,000/mm3 -  nonpathologic leukocytosis; an ↑ of > 30% in 6 hrs indicate pathology GI: hunger & thirst common; risk for constipation ↑ d/t ↓  peristatlsis, narcotics, dehydration & ↓ mobility; risk for hemorrhoids ↑ d/t pressure of pushing Urinary: inc bladder capacity & ↓ bladder tone → ↓sensation & ↑ risk of urinary retention & UTI; PP diuresis  1st 12-24 hrs  of 2,000 – 3,000 ml urine; 5 lb loss; full bladder displaces uterus, usually R side; fluids lost through diaphoresis, esp at night
Endocirine: estrogen & progesterone drop rapidly;
Lactation: nipple stimulation  → pitocin release → release of prolactin → milk production & let-down reflex & release of milk by contractions of alveoli of breast; colostrum - 1st milk, rich in protein & immunoglobulins; engorgement occurs 2nd/3rd day; usually 2-5 days; mature milk produced after 2 weeks
Afterpains: intermittent uterine contractions; > common in multigrav than primi (“rubber band”), esp when  breastfeeding
Taking-in: 1st  PP day or 2 ; preoccupied /c own needs; tells her story;  passive, independent; touches & explores infant     Taking-hold: 2nd or 3rd day ready to resume control; obsessed with body functions; anticipatory guidance most effective; rapid mood swings    Taking-hold – in other texts: mothering functioning established; sees infant as unique person
Your text: Maternal role attainment: takes abour 3 – 10 months
1.Anticipatory stage during pregnancy; role model
2.Formal stage – birth of child; influenced by others; tries to please everybody
3.Informal – mother begins making own decisions
4.Personal stage – final; comfortable with her concept of maternal role
Challenges: finding time for self; feelings of incompetence; fatigue from sleep deprivation; loss of freedom/added responsibility; challenge caring for active baby. Nurses can give anticipatory guidance
Postpartum blues: transient depression 1st few days &/or within 1st 2 wks, manifested by mood swings, anger, tearfulness, felling let-down, anorexia, & insomnia; usually resolves spontaneously; evaluation necessary if persistent
Bonding: also known as attachment: process by which parents form emotional relationship with infant over time; influenced by many factors: family, stability of home environment, nurturing she received as child. Certain characteristics important: level of trust, level of self esteem, reactions to present pregnancy; interest in child rearing.
Initial attachment behavior: mother explores infant with fingertips, then palms, & then enfolding newborn with whole hands & arms; holds infant in en face position, face-to-face position about 20cm , same plane; mother uses soft, high-pitched voice; engrossment  - father’s absorption, preoccupation, & interest in infant; stimulated by active participation in the birth
Cultural influences: remember that mother’s expectations may be different from what the nurse or physician expect; foods, hygiene practices, support from family members vary
Breasts: breast or bottle? Palpate for engorgement; inspect nipples for redness, cracks, erectility, if nursing Uterus: fundal height, firmness, position r/t abdominal midline; fundal location r/t expected descent’ inspect abdominal incisions, c-sec, or BTL for REEDA: redness, edema, ecchymosis, discharge, & approximation of skin edges Bladder: void within 6 - 8hrs of delivery; assess frequency , burning, urgency (UTI); retention, distension
Bowel: passage of flatus; signs of distension
Lochia: type, quantity, amount, & presence of odor; expected findings? C-sec pts may have < bleeding; refer to Figure 21-6, p 457
Episiotomy: inspect perineum for REEDA; hemorrhoids
Assess for lacerations: 1. 1st degree: ; limited to perineal skin & vaginal mucous membrane2. 2nd degree: involves perineal skin, vaginal mucous membrane, underlying fascia, & muscles; 3. 3rd degree: through perineal skin, vaginal mucous membrane, involves anal sphincter, possibly anterior wall of rectum
4. 4th degree: same as 3rd but extends through rectal mucosa to lumen of rectum
Homan’s sign: pain in calf upon dorsiflexion of foot – possible thrombophlebitis; pedal edema/pedal pulse Emotional Status: appropriate for situation; phase of psychological adjustment; “postpartum blues”
Bonding: interactions with infant