CHAPTER 13
Physical and Psychologic Changes
1 Identify normal physiologic changes in the reproductive system after childbirth.
2 Describe systemic physiologic changes after childbirth.
3 Evaluate common emotional changes in the family in response to childbirth.
4 Recognize normal attachment behaviors in parents and infants.
5 Differentiate between “baby blues” and postpartum depression.
6 Analyze postpartum complications using assessment data.
7 Design individualized patient education based on assessed needs.
8 Develop a discharge teaching plan designed to facilitate competent self-care and assumption of the parenting role.
INTRODUCTION
(1) Involution is the retrogressive return to normal condition after pregnancy (Simpson & James, 2005).
(a) Immediately after delivery
[i] Weight is approximately 1000 g (2 pounds, 4 ounces).
[ii] Fundal height is midway between symphysis and umbilicus in midline.
[iii] Afterpains (uterine contractions) are common, especially for multiparas and breastfeeding mothers.
(c) Within 12 hours: uterine muscles relax slightly and uterus returns at the level or 1 cm above the umbilicus.
• Scant: less than 2.5 cm (1 inch) on menstrual pad in 1 hour
• Light: less than 10 cm (4 inches) on menstrual pad in 1 hour
• Moderate: less than 15 cm (6 inches) on menstrual pad in 1 hour
• Heavy: saturated menstrual pad in 1 hour
[ii] Serosa (pink, brown-tinged): 3 to 10 days
[iii] Alba (yellowish-white): 10 to 14 days but can last 3 to 6 weeks and remain normal
(c) A danger sign is the reappearance of bright red blood after lochia rubra has stopped.
(d) Odor is normally that of menstrual flow; foul-smelling lochia might indicate infection.
(e) Amount might increase temporarily on standing because of pooling in uterus and vagina.
(f) Amount of lochia might be less after cesarean section, but stages remain unchanged.
(g) Average amount of lochial discharge varies from 150 to 400 mL (Simpson & James, 2005).
(3) Return of the menstrual cycle
(b) Lactating women: Some resume menstruation as early as 12 weeks, but some might not resume menstruation for as long as 18 months.
(4) Ovulation: depends on prolactin levels
b. Cervical changes (Simpson & Creehan, 2008)
(1) Cervix is edematous immediately postdelivery.
(2) Cervix is dilated 2 to 3 cm at 2 to 3 days postdelivery.
(3) Cervix narrows to 1 cm in diameter by the end of the first week.
(1) Rugae reappear in 3 weeks.
(2) Vagina returns to near prepregnant size at 6 to 8 weeks postdelivery, but will always remain slightly larger.
a. Changes of pregnancy regress in 1 to 2 weeks’ postpartum if mother is not breastfeeding.
b. Nipples become erect when stimulated.
c. Breasts increase in vascularity and swell in response to presence of prolactin at the second or third postpartum day (engorgement).
d. Nonbreastfeeding engorgement subsides in 2 to 3 days (see Chapter 14 for a complete discussion of lactation).
(1) Human chorionic gonadotropin (hCG) levels are nonexistent at the end of the first postpartum week.
(2) Human chorionic somatomammotropin (hCS) (human placental lactogen [hPL]) is undetectable by 24 hours postdelivery.
(3) Plasma progesterone levels are undetectable by 72 hours postdelivery; production is reestablished with the first menstrual cycle.
(4) Plasma estrogen levels decrease to 10% of the prenatal value within 3 hours after delivery and reach the lowest levels by day 7.
(1) Returns to normal position because of shift in diaphragm and abdominal contents
(2) Cardiac output increases during first and second stages of labor, reaches prelabor values at approximately 1 hour postpartum, and gradually returns to normal within 2 weeks to 3 months (Simpson & James, 2005).
(3) Cardiac load is increased by 60% to 80% within the first 15 to 20 minutes after birth due to the “autotransfusion” effect, in which 500 mL of blood is redirected to the maternal circulation (Fujitani & Baldisseri, 2005).
(1) There is an immediate decrease at delivery related to blood loss (normal blood loss at delivery is 200 to 500 mL for a vaginal delivery and 600 to 800 mL for a cesarean delivery).
(2) Return to normal prepregnant volume takes 1 to 2 weeks (Simpson & Creehan, 2008)
(1) Hematocrit and hemoglobin (Simpson & Creehan, 2008)
(a) Increase in hematocrit is seen between day 3 and day 7 due to the plasma volume decrease being greater than the loss of red blood cells after birth.
(b) Returns to prepregnant value in 4 to 8 weeks
(c) Difficult to determine blood loss during the first 48 hours due to hemodilution. Degree of blood loss is reflected in postpartum hemoglobin levels (500-mL blood loss equals 1- to 1.5-g decrease in hemoglobin levels or 4- to 3-point decrease in hematocrit levels).
(d) Stabilizes in 2 to 3 days and returns to prepregnant values 4 to 6 weeks postpartum
(a) Might increase to 20,000 to 25,000/mm3 and returns to normal by the end of the first postpartum week (Blackburn, 2007)
(b) Increase is primarily in granulocytes (Simpson & Creehan, 2008).
(c) Might increase without the presence of infection; however, an increase of more than 30% over a 6-hour period is suggestive of infection (see Chapter 28 for further discussion)
(1) Blood pressure readings immediately postdelivery should be the same as those taken during labor.
(a) Increased blood pressure might suggest pregnancy-induced hypertension.
(b) Decreased blood pressure might suggest orthostatic hypotension or uterine hemorrhage.
(2) Temperature might be slightly elevated in the first 24 hours because of dehydration: 36.2° to 38° C (98° to 100.4° F).
(3) Pulse rate: Normal range is 40 to 80 beats per minute (bpm).
a. Pulmonary function: returns to prepregnant state after the birth of the baby (Simpson & Creehan, 2008)
(1) Is affected primarily by change in thoracic cage
(2) Returns to prepregnant levels by 6 to 8 weeks’ postpartum
b. Acid-base balance returns to prepregnant levels by 3 weeks’ postdelivery.
c. Basal metabolic rate remains elevated for as long as 14 days’ postpartum.
a. Gastrointestinal motility might remain decreased, leading to constipation and possibly postpartum ileus (Simpson & James, 2005).
b. Normal bowel elimination resumes at 2 to 3 days postdelivery.
c. Average weight loss is 5.5 kg (12 pounds) at time of delivery; another 2.3 kg (5 pounds) is lost during the first postpartal week because of diuresis.
a. Postdelivery edema of bladder, urethra, and urinary meatus is common because of delivery trauma.
(1) Urinary retention might occur.
(2) An elevated or laterally displaced uterus (to the right) is a common sign of urinary retention after delivery.
(1) Muscles relaxed because of stretching during pregnancy
(2) Separation of the rectus muscle (diastasis recti), usually 2 to 4 cm (1 to 2.5 inches), can resolve by 6 weeks with gentle exercise.
a. Hyperpigmentation gradually disappears after delivery.
b. Diaphoresis is common, especially at night, for the first week.
a. For women with Rh incompatibility, anti-RhD immunoglobulin is administered within 72 hours after delivery to prevent antibody formation if the mother is nonsensitized.
b. Blood group incompatibility: ABO incompatibility should be detected early to prevent neonatal complications.
c. If the rubella titer is 1:18 or less or “equivocal”
(1) The woman should receive a rubella virus vaccine and instructions to avoid pregnancy for the next 28 days (Centers for Disease Control and Prevention [CDC], 2008a).
(2) If anti-RhD immunoglobulin and a live virus vacccine, such as measles or rubella, is administered during postpartum, instruct the patient to obtain a postvaccination serology test in 3 months to check immunity (CDC, 2008b).
1. Role change is an important psychologic change for the mother.
a. The mother must relinquish other roles and take on the role of mother.
b. New mothers typically progress through a series of developmental stages: the rate of progression through these stages is unique to each mother.
(1) Dependent and taking-in phase of mother (Rubin, 1975)
(a) Increase in dependent behavior of mother; wants care for herself
(b) Mother asks many questions and talks a great deal about delivery experience.
(c) Phase typically lasts 1 to 2 days.
(d) Might be the only phase observed by nurse during hospitalization because of a trend toward a shortened inpatient stay for obstetric patients without complications
(2) Dependent-independent or “taking-hold” phase of mother (Rubin, 1975)
(a) Begins to focus on needs of infant
(b) Relinquishes pregnant role
(d) Is interested in learning to care for infant
(e) Experiences a period of high fatigue and increased demands by infant
(f) Might experience baby blues at 3 to 4 days postpartum during this phase
(3) Interdependent, or letting-go, phase of mother (Rubin, 1975)
a. Attachment is the enduring emotional bond between a parent (or parent figure) and an infant (Klaus & Kennell, 1982).
b. Attachment is essential to the infant’s growth and survival.
c. The mother-infant bond is the basis on which all subsequent attachments are formed and plays a major role in the infant’s developing sense of self (Bowlby, 1969).
d. Besides the mother, infants also attach to the father, siblings, and other significant caregivers.
a. Baby blues or postpartum blues are described as a mild, transient mood disturbance that frequently begins on the third postpartum day and lasts 2 or 3 days.
b. Approximately 60% to 80% of women experience baby blues during the postpartum period.
c. The onset of postpartum blues coincides with the normal physiologic drop in estrogen and progesterone, and this, along with fatigue, may be a possible cause of this emotional change.
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