MATERNITY EXAM 2 STUDY NOTES
TOPIC TEXTBOOK ATI
Postpartum Adaptations 15 17
Nursing Management During the Postpartum Period 16 18-19
Nursing Management of the Postpartum Woman at Risk 22 20-22
Nursing Management of Pregnancy at Risk: Pregnancy 19 7-8, 10
Related Conditions
Nursing Management of Pregnancy at Risk: Selected Health 20 15,16
Conditions & Vulnerable Populations
Nursing Management of Labor and Birth at Risk 21 9
CHAPTER 15: POSTPARTUM ADAPTATIONS
● Puerperium: period after delivery of placenta, lasting for 6 weeks
, ● Some believe that it lasts well into the first year, making the fourth phase of labor the
longest
● May last between 9 and 12 months as the mother works to lose weight & adjusts
Reproductive System Adaptations
● Uterus Changes
- weighs approx 1,000g (2.2 lb) soon after birth
- 1 week after birth: shrinks in size by 50% & weighs about 500 g (1 lb)
- 6 weeks after birth: weighs approximately 60 g (2 oz) (prepregnancy weight)
- The uterus returns to its normal size via involution, which involves 3 retrogressive
processes:
(1) Contraction of muscle fibers to reduce previously stretched from pregnancy
(2) Catabolism, which shrinks enlarged, individual myometrial cells
(3) Regeneration of uterine epithelium from lower layer of decidua after upper
layers have been sloughed off & shed during lochial d/c
- Uterus descends from level of umbilicus at rate of 1 cm per day.
- By 3 days, the fundus lies 2-3 fingerbreadths below umbilicus (slightly higher in
multiparous women)
- By end of 10 days: fundus cannot be palpated since it descended into true pelvis
- Subinvolution: responsive to early dx & treatment
● Factors that facilitate involution: complete expulsion of amniotic membranes and
placenta; Complication free delivery; breastfeeding mom; early ambulation
● Factors that stop involution: prolonged L&D; incomplete expulsion of amniotic
membranes and placenta; uterine infection; overdistention of uterine muscles (e.g.
multiple gestation, hydramnios, large singleton fetus); full bladder; anesthesia relaxes
uterine muscles; close child birth spacing
● Lochia: vaginal d/c after birth; results from involution. Continues 4-8 wks
- Superficial layer of decidua basalis becomes necrotic and is sloughed off.
- roughly equal to the amount occurring during a heavy menstrual period (8-9 oz)
- Cesarean section: less bleeding because the uterine debris manually removed
- Foul odor = may indicate infection.
● Danger signs: bright red after lochia rubra has stopped & clots
THREE STAGES OF LOCHIA (SHOULD HAPPEN IN ORDER)
Rubra first 3 to 4 days after birth deep-red mixture of mucus, tissue debris, & blood. As uterine bleeding
subsides, it becomes paler & more serous
Serosa 3 to 10 days postpartum pinkish brown in color; leukocytes, decidua tissue, red blood cells, & serous
fluid
Alba 10 to 14 days postpartum but can last creamy white or light brown d/c & consists of leukocytes, decidual tissue, &
3 to 6 weeks postpartum reduced fluid content.
● Afterpains: painful uterine contractions; more acute in multiparous & breastfeeding
women. Breastfeeding and exogenous oxytocin administration cause painful uterine
contractions due to oxytocin released by sucking reflex.
● Cervix: closure by 6 weeks & now appearing as jagged slit-like opening. Will never
, regain pre-pregnancy appearance.
- Postpartum: shapeless and edematous; easily distensible for several days. Internal
cervical os returns to normal in 2 wks meanwhile external cervical os never returns to
normal
● Vagina: gradual thickening & return of rugae (in approx. 3 weeks).
- Postpartum: returns to pre-pregnant size by 6-8 wks. Dyspareunia. Use water soluble
lubricants for comfortable sex
● Ovarian function: returns & estrogen production resume
● Perineum: edematous & bruised. If episiotomy or laceration, complete healing may take
4 to 6 months in the absence of complications.
- Hemorrhoids can happen. Ice packs, pour warm water over area; witch hazel pads;
anesthetic sprays; sitz baths
- Practice pelvic floor muscle training exercises to improve pelvic floor time, strengthen
perineal muscles, and promote healing. If not done, then incontinence!
Cardiovascular System Adaptations
● Blood volume ↓; returns normal within 4 wks postpartum
● Cardiac output ↓ 1-2 days postpartum & falls fast next 2 wks, then returns to
non-pregnant levels within 6-8 wks ↑
● HCT stable; acute decrease indicates hemorrhage
● Pulse rate (40-60 bpm first two weeks)
- Tachycardic: may indicate hypovolemia, dehydration, hemorrhage
● BP ↓ first 2 days, then increase to pre-pregnancy value 3-7 days after childbirth; returns
to normal by 6 wks
- Increased BP & headache -> preeclampsia
● Elevated BP, cardiac output, and tachycardia indicates hemorrhage
● Coagulation factors remain ↑ during early postpartum period 2-3 wks. Risk
for thromboembolism in lower extremities & lungs
● RBC decreases Day 1, then rise slowly in next 2 wks.
● WBC remains elevated for 4-6 days; then falls to 6,000-10,000/ mm3
Urinary System Adaptations
● 6 wks postpartum: GFR & renal plasma flow return to normal
● Voiding sensation may be affected
● Urinary atony: allows excessive bleeding. Often caused by urinary retention.
- Frequent voiding of small amounts (< 150 mL) suggests urinary retention
● Hematomas: bladder tone r/t to regional anesthesia
● Diuresis r/t large amounts of IV fluids; decreasing antidiuretic oxytocin effect; build up &
retention of extra fluids; decreasing production of aldosterone.
- Begins within 12 hrs of birth & continues for 1 wk. Normal function resumes in 1 mo
GI System Adaptations
● The GI system quickly returns to normal: relief of pressure on organs
● Decreased bowel tones for several days & decreased peristalsis r/t analgesic response;
sx; diminished abd pressure; low-fiber diet; insufficient fluid intake; diminished muscle
tone
, ● Women w/ hemorrhoids, perineal laceration, or episiotomy may fear pooping due to pain
- Stool softener helps
Musculoskeletal System Adaptations
● Joints return to prepregnant state except for feet
● 6 wks postpartum: joints completely stabilized & return to normal
● Diastasis recti: loss in muscle tone and separation of rectus abdominis muscle of the
abdomen. If rectus muscle tone is not regained via exercise, inadequate support may
suffice during future pregnancies.
Integumentary System Adaptations
● Hair loss: first 3 mo PP, when estrogen returns to normal. Returns 4-15 mo
● Pigmentation fades. Stretch marks fade to silvery lines
● Diaphoresis is common for about a week postpartum for 1 wk; common during night
Respiratory System Adaptations
● RR rate usually remains within the normal range; 16 to 24 breaths per minute
● Anatomic changes in thoracic cavity resolve quickly
● 1-3 wks postpartum: tidal volume, minute volume, vital capacity, and functional residual
capacity return to prepregnant values
Endocrine System Adaptations
● Placental hormones, estrogen and progesterone levels drop quickly.
- Estrogen at its lowest 1 wk postpartum
● Engorgement: decreased estrogen & diuresis of excess extracellular fluids.
- Prolactin levels remain elevated for breastfeeding mothers and decline within 2 weeks if
not breastfeeding
- Estrogen levels begin to increase by 2 wks postpartum for non breastfed women
- 3 days postpartum: progesterone levels go undetected & production reestablished w/
first menses (anovulatory)
- Lactating mothers resume their cycle 7-9 weeks PP
Lactation
● Secretion of milk by the breasts via interaction of progesterone, estrogen, prolactin, and
oxytocin. Typically appears 4 to 5 days after childbirth
● AAP recommends exclusive breastfeeding for 6 mo, followed by introduction of
appropriate foods & continued breastfeeding to 1 yr.
● Prolactin (released from anterior pituitary gland) stimulate glandular cells to secrete milk
● Oxytocin released from posterior pituitary gland & initiates milk let-down
● “Breast crawl”: initiates breastfeeding ASAP after childbirth. Newborn skin to skin on
mom’s trunk after birth, moves toward breast for self-attaching.
- 2 days postpartum: soft & non tender breasts w/ tingling sensation “let-down reflex”
● If breastfeeding: frequent emptying, warm showers & compresses before feeding, cold
compresses between feedings.
- In order to maintain milk supply, breasts need to be stimulated by a nursing infant, a
breast pump, or manual expression of the milk.
● If not breastfeeding: tight supportive bra; Ice, 15 to 20 minutes every other hour;
Avoidance of breast stimulation
● Ovulation may occur before menstruation, therefore breastfeeding is unreliable method
TOPIC TEXTBOOK ATI
Postpartum Adaptations 15 17
Nursing Management During the Postpartum Period 16 18-19
Nursing Management of the Postpartum Woman at Risk 22 20-22
Nursing Management of Pregnancy at Risk: Pregnancy 19 7-8, 10
Related Conditions
Nursing Management of Pregnancy at Risk: Selected Health 20 15,16
Conditions & Vulnerable Populations
Nursing Management of Labor and Birth at Risk 21 9
CHAPTER 15: POSTPARTUM ADAPTATIONS
● Puerperium: period after delivery of placenta, lasting for 6 weeks
, ● Some believe that it lasts well into the first year, making the fourth phase of labor the
longest
● May last between 9 and 12 months as the mother works to lose weight & adjusts
Reproductive System Adaptations
● Uterus Changes
- weighs approx 1,000g (2.2 lb) soon after birth
- 1 week after birth: shrinks in size by 50% & weighs about 500 g (1 lb)
- 6 weeks after birth: weighs approximately 60 g (2 oz) (prepregnancy weight)
- The uterus returns to its normal size via involution, which involves 3 retrogressive
processes:
(1) Contraction of muscle fibers to reduce previously stretched from pregnancy
(2) Catabolism, which shrinks enlarged, individual myometrial cells
(3) Regeneration of uterine epithelium from lower layer of decidua after upper
layers have been sloughed off & shed during lochial d/c
- Uterus descends from level of umbilicus at rate of 1 cm per day.
- By 3 days, the fundus lies 2-3 fingerbreadths below umbilicus (slightly higher in
multiparous women)
- By end of 10 days: fundus cannot be palpated since it descended into true pelvis
- Subinvolution: responsive to early dx & treatment
● Factors that facilitate involution: complete expulsion of amniotic membranes and
placenta; Complication free delivery; breastfeeding mom; early ambulation
● Factors that stop involution: prolonged L&D; incomplete expulsion of amniotic
membranes and placenta; uterine infection; overdistention of uterine muscles (e.g.
multiple gestation, hydramnios, large singleton fetus); full bladder; anesthesia relaxes
uterine muscles; close child birth spacing
● Lochia: vaginal d/c after birth; results from involution. Continues 4-8 wks
- Superficial layer of decidua basalis becomes necrotic and is sloughed off.
- roughly equal to the amount occurring during a heavy menstrual period (8-9 oz)
- Cesarean section: less bleeding because the uterine debris manually removed
- Foul odor = may indicate infection.
● Danger signs: bright red after lochia rubra has stopped & clots
THREE STAGES OF LOCHIA (SHOULD HAPPEN IN ORDER)
Rubra first 3 to 4 days after birth deep-red mixture of mucus, tissue debris, & blood. As uterine bleeding
subsides, it becomes paler & more serous
Serosa 3 to 10 days postpartum pinkish brown in color; leukocytes, decidua tissue, red blood cells, & serous
fluid
Alba 10 to 14 days postpartum but can last creamy white or light brown d/c & consists of leukocytes, decidual tissue, &
3 to 6 weeks postpartum reduced fluid content.
● Afterpains: painful uterine contractions; more acute in multiparous & breastfeeding
women. Breastfeeding and exogenous oxytocin administration cause painful uterine
contractions due to oxytocin released by sucking reflex.
● Cervix: closure by 6 weeks & now appearing as jagged slit-like opening. Will never
, regain pre-pregnancy appearance.
- Postpartum: shapeless and edematous; easily distensible for several days. Internal
cervical os returns to normal in 2 wks meanwhile external cervical os never returns to
normal
● Vagina: gradual thickening & return of rugae (in approx. 3 weeks).
- Postpartum: returns to pre-pregnant size by 6-8 wks. Dyspareunia. Use water soluble
lubricants for comfortable sex
● Ovarian function: returns & estrogen production resume
● Perineum: edematous & bruised. If episiotomy or laceration, complete healing may take
4 to 6 months in the absence of complications.
- Hemorrhoids can happen. Ice packs, pour warm water over area; witch hazel pads;
anesthetic sprays; sitz baths
- Practice pelvic floor muscle training exercises to improve pelvic floor time, strengthen
perineal muscles, and promote healing. If not done, then incontinence!
Cardiovascular System Adaptations
● Blood volume ↓; returns normal within 4 wks postpartum
● Cardiac output ↓ 1-2 days postpartum & falls fast next 2 wks, then returns to
non-pregnant levels within 6-8 wks ↑
● HCT stable; acute decrease indicates hemorrhage
● Pulse rate (40-60 bpm first two weeks)
- Tachycardic: may indicate hypovolemia, dehydration, hemorrhage
● BP ↓ first 2 days, then increase to pre-pregnancy value 3-7 days after childbirth; returns
to normal by 6 wks
- Increased BP & headache -> preeclampsia
● Elevated BP, cardiac output, and tachycardia indicates hemorrhage
● Coagulation factors remain ↑ during early postpartum period 2-3 wks. Risk
for thromboembolism in lower extremities & lungs
● RBC decreases Day 1, then rise slowly in next 2 wks.
● WBC remains elevated for 4-6 days; then falls to 6,000-10,000/ mm3
Urinary System Adaptations
● 6 wks postpartum: GFR & renal plasma flow return to normal
● Voiding sensation may be affected
● Urinary atony: allows excessive bleeding. Often caused by urinary retention.
- Frequent voiding of small amounts (< 150 mL) suggests urinary retention
● Hematomas: bladder tone r/t to regional anesthesia
● Diuresis r/t large amounts of IV fluids; decreasing antidiuretic oxytocin effect; build up &
retention of extra fluids; decreasing production of aldosterone.
- Begins within 12 hrs of birth & continues for 1 wk. Normal function resumes in 1 mo
GI System Adaptations
● The GI system quickly returns to normal: relief of pressure on organs
● Decreased bowel tones for several days & decreased peristalsis r/t analgesic response;
sx; diminished abd pressure; low-fiber diet; insufficient fluid intake; diminished muscle
tone
, ● Women w/ hemorrhoids, perineal laceration, or episiotomy may fear pooping due to pain
- Stool softener helps
Musculoskeletal System Adaptations
● Joints return to prepregnant state except for feet
● 6 wks postpartum: joints completely stabilized & return to normal
● Diastasis recti: loss in muscle tone and separation of rectus abdominis muscle of the
abdomen. If rectus muscle tone is not regained via exercise, inadequate support may
suffice during future pregnancies.
Integumentary System Adaptations
● Hair loss: first 3 mo PP, when estrogen returns to normal. Returns 4-15 mo
● Pigmentation fades. Stretch marks fade to silvery lines
● Diaphoresis is common for about a week postpartum for 1 wk; common during night
Respiratory System Adaptations
● RR rate usually remains within the normal range; 16 to 24 breaths per minute
● Anatomic changes in thoracic cavity resolve quickly
● 1-3 wks postpartum: tidal volume, minute volume, vital capacity, and functional residual
capacity return to prepregnant values
Endocrine System Adaptations
● Placental hormones, estrogen and progesterone levels drop quickly.
- Estrogen at its lowest 1 wk postpartum
● Engorgement: decreased estrogen & diuresis of excess extracellular fluids.
- Prolactin levels remain elevated for breastfeeding mothers and decline within 2 weeks if
not breastfeeding
- Estrogen levels begin to increase by 2 wks postpartum for non breastfed women
- 3 days postpartum: progesterone levels go undetected & production reestablished w/
first menses (anovulatory)
- Lactating mothers resume their cycle 7-9 weeks PP
Lactation
● Secretion of milk by the breasts via interaction of progesterone, estrogen, prolactin, and
oxytocin. Typically appears 4 to 5 days after childbirth
● AAP recommends exclusive breastfeeding for 6 mo, followed by introduction of
appropriate foods & continued breastfeeding to 1 yr.
● Prolactin (released from anterior pituitary gland) stimulate glandular cells to secrete milk
● Oxytocin released from posterior pituitary gland & initiates milk let-down
● “Breast crawl”: initiates breastfeeding ASAP after childbirth. Newborn skin to skin on
mom’s trunk after birth, moves toward breast for self-attaching.
- 2 days postpartum: soft & non tender breasts w/ tingling sensation “let-down reflex”
● If breastfeeding: frequent emptying, warm showers & compresses before feeding, cold
compresses between feedings.
- In order to maintain milk supply, breasts need to be stimulated by a nursing infant, a
breast pump, or manual expression of the milk.
● If not breastfeeding: tight supportive bra; Ice, 15 to 20 minutes every other hour;
Avoidance of breast stimulation
● Ovulation may occur before menstruation, therefore breastfeeding is unreliable method
