POSTPARTUM

puer parere
Puerperium = Puer - child, parere - to bring forth

Woman goes through 2 phases:

1. Retrogressive - uterus and vagina retrogressive

2. Progressive - breasts, menstruation, new parenting role progressive

NURSING INDEPENDENT RESPONSIBILITIES:

BUBBLESHE

fever colostrum
B - BREASTS - engorgement/mastitis will lead to fever. First milk (Colostrum)
Encourage breastfeeding - enhances release of oxytocin - initiates uterine contraction
oxytocin
for successful involution of the uterus.

uterine atony
U - UTERUS - massage gently. To prevent "uterine atony" failure of the uterus to
contract - lossing blood- hemorrhage - mortality death of the mother.

B - BOWELS - within 24 hours - activity peristaltic movement - flatus several times.

B - BLADDER - within 24 hours. Empty her bladder- a full bladder prevents the uterus
to contract. Boggy

L - LOCHIAL MONITORING

E - EPISIOTOMY/LACERATION/INCISION CS - monitor signs of Infection

REEDA:
redness, ecchymosis, edema, discharges, assessment of skin
REDNESS,
ECCHYMOSIS
EDEMA
DISCHARGES - foul smelly, pus and greenish in color,
ASSESSMENT OF THE SKIN WARM TO THE TOUCH

dehydration
S - SKIN - evaluate for the skin turgor of the mother if indicates dehydration.

thrombophlebitis
H - HOMAN'S SIGN - POSITIVE RESULT WOULD INDICATE thrombophlebitis
or blood clots at the lower extremities.

E - EMOTION

reva rubin
REVA RUBIN TASKS: PSYCHOLOGICAL TASKS
taking in

I. TAKING IN - 2-3 days postpartum. Passive. Talks about her labor and delivery.
Talks about self. About her journey during pregnancy. Labor and delivery.

taking hold
II. TAKING HOLD - 3-7 days. Seeks independence/autonomy/ seeks participation
on her new role as a mother.

letting go
III. LETTING GO - defines her new role as mother... To take care of herself/other
children/husband/ go back to work. Incorporates new changes in her life.

CONFLICTS:
I. POSTPARTUM BLUES - transient feeling. 1-2 weeks. Depressed - but not clinically
depressed. postpartum blues
II. POSTPARTUM DEPRESSION - medications needed/seek professional help. Sense
of loss of self worth. postpartum depression

postpartum psychosis
III. POSTPARTUM PSYCHOSIS - losses her sense of worth and sense of reality.
Thinking suicide and even hurting or killing her children and herself.

ROOMING IN:
● Parent - infant bonding
● Claiming
● Identify
● Attachment
● Develops confidence in maternal role/ support system

latching on
LATCH ON - the first skin to skin contact between the mother and her newborn done
right after delivery.

PHYSIOLOGICAL CHANGES POSTPARTUM:

involution
INVOLUTION: is the process whereby the reproductive organs return to their
nonpregnant state. A mother is in danger of hemorrhage from the denuded surface of
the uterus until involution is complete.

Involution of the uterus - uterus involution refers to the process where your pregnant
uterus (womb) returns to the way it was before pregnancy.

Reproductive changes
I. UTERUS: involution of the uterus. Uterine contraction is important to prevent
uterine atony. uterine atony
normal
● Afterpains - normal - due to uterine contractions.
● Lochial - decidua means falling off.
● Boggy uterus - indicates a full bladder. Uterus that does not contract

hegar's sign - softening of uterus

II. CERVIX - nonpregnant state
godell's sign - softening of cervix
III. VAGINA – edematous/chadwick’s sign
chadwick's sign - discoloration
IV. PERINEUM - episiotomy must heal

VITAL CHANGES:
● TEMPERATURE
dehydration
❖ Temp rises slightly within 24 hours-sign of dehydration
❖ Temp continous after 24 hours -- indicates infection... Episiotomy/incision site
infection
cs - signs of reeda.
R - REDNESS ON THE SITE
E - EDEMA
E - ECCHYMOSIS
D - DISCHARGES FROM EPISIOTOMY AND CS SITE... FOUL ORDER AND
GREENISH
A - ASSESSMENT OF SKIN TURGOR FOR SKINS OF DEHYRATION.
● PULSE RATE
● BLOOD PRESSURE

LOCHIAL DISCHARGES

lochia rubra
I. LOCHIA RUBRA - present on 1-3 days postpartum
Blood is dark red or red in color
 lochia serosa
II. LOCHIA SEROSA - present on 3 to 10 days postpartum
Blood is pinkish in color

lochia alba
III. LOCHIA ALBA - present at 10 to 14 days onward postpartum
Blood is whitish in color

NOTE: The nurse must monitor lochial discharges daily. If discharges does not manifest
any of these, it indicates failure of uterus to contract that will lead to blood loss and
even death.

Neonate/ newborn - a newborn in a neonate period

Neonatal period: from birth through 28 days of life

INTRODUCTION

● At birth, the newborn adapts life outside the uterus. (extrauterine). Physiologic
changes occur in the major organ systems within 24 hours after birth.
● How the newborn adapts to these new physical conditions depends on several
factors:

1. MATERNAL AND NEWBORN ANTEPARTAL STATUS:

Conditions and experiences (exposure, illness during pregnancy, maternal and partner
attitudes towards the pregnancy.
2. INTRAPARTUM MATERNAL AND FETAL CONDITIONS. Events (progression
of labor - length, complications.)

Transition Period: crucial for the NB. Within 48 - 72 hours, the NB adapts to
extrauterine life.

3. PHYSIOLOGICAL CAPACITY OF THE NEWBORN TO ADAPT TO LIFE

OUTSIDE THE UTERUS.

4. IMMEDIATE APPROPRIATE AND ADEQUATE RESPONSES OF

PHYSICIANS, NURSES, MIDWIVES TO EMERGING PROBLEMS DURING
PREGNANCY, LABOR AND DELIVERY. AFTER BIRTH AND THE NEONATAL
PERIOD.

PHYSIOLOGIC ADJUSTMENT TO EXTRAUTERINE LIFE:

● During the first 48 to 72 hours of extrauterine life, the newborn is in a period of
transition characterized by instability as the newborn adjusts. The first 6 hours
of life is the periods of irregular adjustment.

PHASES:
1. FIRST PERIOD OF REACTIVITY:
Immediately after birth, the newborn breathes rapidly (up to 80 breaths per minúte)
exhibiting brief periods of grunting, sternal retractions and nasal flaring. (nose
obligates) a heart rate of up to 180 beats per minute may be seen during the first few
minutes after birth
Following this time, the newborn becomes quieter and is able to sleep. This "sleep
phase" occurs at approximately 2 hours after birth and has duration of several minutes
to hours.

2. SECOND PERIOD OF REACTIVITY:

Begins when the newborn awakes and at this time it exhibits increased responsiveness
to external stimuli, an increased heart rate and changes in its skin color varying from
pink to becoming slightly cyanotic. At this time, coughing, choking or gagging reflex
may be present.

3. STABILITY: 6 hours to 24 hours. Adjusted to extrauterine life.

ADAPTATION OF THE NEWBORN'S.

I.CARDIOVASCULAR SYSTEM:
Changes in the fetal circulatory system occur immediately after birth and during the
neonatal period.
● ductus venosus: becomes obliterated and becomes the ligamentum venosum.
● Ductus arteriosus: is obliterated and becomes the ligamentum arteriosum.
● Foramen ovale: usually becomes obliterated
● Changes in the cardiovascular system are necessary after birth. The lungs now
must oxygenate the blood that was formerly oxygentaed by the placenta.
● When the cord is clamped, the newborn is forced to take in oxygen through the
lungs. As the lungs inflate for the first time, it decreases pressure in the chest
most specially in the pulmonary artery that is responsible in the closure of ductus
arteriosus. As pressure increases in the left side of the heart, the foramen ovale
closes.
 ● Acrocyanosis or cyanosis of hands and feet and perioral area result from the slow
peripheral circulation after birth. An average blood pressure level of 80/46mmhg
can be observed and this depends of the newborn size as well as its level of
activity.

● The pulse rate varies from 120 to 160 beats per minute during waking periods
and 100 beats per minute while sleeping. Crying or after crying 180 beats/min.

II. RESPIRATORY SYSTEM: 30 TO 60 BREATHS PER MINUTE. NEWBORNS

ARE OBLIGATORY NOSE BREATHERS.

● A first breath is a major undertaking because it requires a tremendous amount of

pressure in the lungs. Fluid in the lungs that was accumulated intrauterine life
allows the lungs to inflate more.
Signs of RDS : (respiratory distress syndrome)
1. Apnea - breathing that eases for 10 to 15 seconds
2. Grunting
3. Sternal retraction
4. Nasal flaring - frequent/fast
5. Generalized cyanosis - the entire body is blue
6. Weak muscle coordination
7. Poor suck

III. GASTROINTESTINAL SYSTEM: STOMACH HOLDS 60 TO 90ML.

● Meconium - after birth. Soft and yellowish in color.
● Transition stool - 2nd to 3rd day of life. Greenish in color.
● Formula milk: bright yellow in color
 ● Breastfeed: light yellow in color
● Jaundice: bright green stool
● Bile problem: clay-colored stool
● Anal fissure: blood tinged stool

IV. URINARY SYSTEM:

Pass out urine within 24 hours after birth. 15ml single voiding.

V. IMMUNE SYSTEM:
Immature, permitting the entry of numerous invading organisms and responding poorly
to infection.

VI. THERMOREGULATION AND METABOLIC ADAPTATION:

There is a significant decrease in body temperature as the newborn adapts to cooler
extrauterine life.

What is a newborn reflex?

 Newborn reflexes are reflex actions originating in the central nervous system
(brain) that are exhibited by normal infants, in response to particular stimuli
 These reflexes disappear or are inhibited by the frontal lobes as the child moves
through normal child development
 Because reflexes originate in the central nervous system, doctors are able to track
the progression of a newborn’s nervous system by watching the progression of
their reflexes
 Most reflexes generally disappear before the 3rd and 4th months, but can last as
long as a year
Also called primitive, infantile or infant reflexes
Reflex description appears disappears CNS origin

Moro Extend head > birth 4-6 mos Brain stem

extension, vestibular
flexion of muclei
arms, legs
Grasp Finger in palm birth 4-6 mos Brain stem
> hand, elbow, vestibular
shoulder muclei
flexion
Rooting Cheek birth 4-6 mos Brain stem
stimulus > trigeminal
turns mouth to system
that side
Trunk Withdrawal birth 6-9 mos Spinal cord
incurvation from stroking
along ventral
surface
placing Steps up when birth 4-6 mos Cerebral
dorsum of foot cortex
stimulated
Tonic neck Fencing birth 4-6 mos Brain stem
posture when vestibular
supine muclei
parachute Stimulate fall > 6-8 mos never Brain stem
extends arms vestibular
muclei
BALLARD SCORING:
● The Ballard score is commonly used to determine gestational age. Here's how it
works: Scores are given for 6 physical and 6 nerve and muscle development
(neuromuscular) signs of maturity. The scores for each may range from -1 to 5.
The scores are added together to determine the baby's gestational age.

NEWBORN SENSORY PARAMETERS

● HEARING: detection of sounds is possible once eustachian tubes are clear.
● VISION: objects 6 to 8 inches away are visible to the infant. preference for black
and white patterns. Sensitivity to light. Ability to track patterns using the eyes.
Extraocular muscle coordination is immature at this time.
● TOUCH: ability to sense pressure, pain and touch. Sensitivity to cuddling.
● TASTE: taste buds develop after birth. Preference to sweet taste.
● SMELL: ability to differentiate pleasant from unpleasant odors.

THE IMMEDIATE NEWBORN CARE:

I. ESTABLISH AIRWAY : TOP PRIORITY
● Newborn are nose breathers
● Position newborn in slight tredelenburg - to allow secretions to drain
● ABC: (airway, breathing, circulation. Suction the mouth and nose
● Suction secretions shallowly and riefly. Preterm - less than 10 seconds. Full term
- 5 to 10 seconds
 ● Administration of oxygen: not a routine newborn care but to ensure patient
airway ad good supply of atmospheric air
● Retrolental fibroplasia - injudicious use of oxygen can damgae the retina causing
permanent blindness

II. KEEP THE NEWBORN WARM. AT BIRTH 37.3, DROPS 35.5 DUE TO
MECHANISM OF HEAT LOSS.
● Evaporation - allowing the newborn to dry without covering a towel.
● Conduction = direct contact with cold equipment
● Convection = loss of heat to surroundings - such aircon.
● radiation = not in direct contact. Walls, floor and ceiling.
Note: initial temperature taking is done per rectum to detect imperforate anus.

IV. CREDE'S PROPHYLAXIS:

Terramycin eye ointment. To prevent ophthalmia neonatorum.

V. PERFORM CORD DRESSING TO PREVENT TETANUS NEONATORUM.

● Omphalitis: infection/swelling of the umbilical cord
● Omphalanghia: bleeding of the umbilical cord

VI. VIT. K - VASTUS LATERALIS. BLEEDING AND CLOTTING ISSUES.

VII. IDENTIFICATION BAND.

To identify the newborn properly
Wrist band: name, gender, time of delivery, name of doctor
VIII. PROVIDE SKIN CARE.

VII. ANTHROPOMETRIC MEASUREMENTS:

● Weight: weight loss of 5 to 10% of birth weight during the first week of life is
considered normal. "physiologic weight loss".
1. Urine and meconium passage
2. Drop of water retaining maternal hormones from the nb body.
3. Inadequate intake. NB is adjusting to feeding. Breastfed or bottlefed
- height: 19 to 21 inches or 50 cm (crown to heal)
-head circumference : 33 to 35 cm (eyebrow)
-abdominal girth : 31 to 33 cm (umbilicus)
-chest circumference : 31 – 32 cm (2 cm less than head) (nipple line)

COMPREHENSIVE PHYSICAL EXAMINATION – ALERT, ACTIVE AND

WITH GOOD CRY
1. HEAD AND FACE:
- head size in relation to the body
-look for molding
-presence of cephalohematoma – collection of blood in the skull. Does not cross
suture
-caput succedaneum – edema of the scalp. Crosses sutures
-feel for fontanels (if bulging indication increase intraocular pressure)

2. EYES:
-color. Check for any discharge from the eyes conjunctivits
-presence of symmetrical and clear pupils which are equal, round and reactive to
light
-presence of intact blink reflex
-strabismus – absent
-presence of red reflex – reddish orange reflection of light from the back of the
eye
-absence of doll’s eye reflex

3. NOSE AND MOUTH:

-patency of nares
-presence secretions
-presence of sucking and crying movements
-tongue tie (frenulum)
-epstein pearls – whitish secretions on the tongue
-oral thrush – candida albicans
-cleft lip/palate
-uncoordinated sucking and swallowing – abnormal
Rooting/suck/extrusion/swallowing/gag – survival of the newborn

4. EARS AND NECK

-presence of normal soft, symmetrical firm ears with good recoil
-position of ears – low set below the level of the canthi og eyes – points to genetic
abnormality
-presence of neck webbing – indicates possible chromosal abnormality
May kulang ja!!!

6. CHEST
-presence of normal round and symmetrical chest
-breasts swelling with occasional milky secretions “witch milk” – after birth due
to maternal hormones
-presence of symmetrical shallow breathing coinciding with movements of the
abdomen
-presence of crackels or rhonchi – abnormla findings
-heart sounds and presence of murmurs – heart problems

7. ABDOMEN:
-bowel sounds – present within about 2 hours of life
-kidneys palpable
-umbilical cord
-check for any masses

8. ANUS:
-patency
-first stool within 24 hours of life

Genitalie: female
-presence of edematous labia, enlarged clitoris – normal
-preence of smegma (thick, white mucus vaginal discharge)
-pseudomenstruation or vaginal discharge due to the release maternal hormone
-first voiding should occur with 24 hours after birth

Male:
-presence of prepuce or foreskin – circumcision
-assess for hernia/hydrocele
-first voiding should occur within 24 hours of life
-cryptorchidism: absences of testes/ undescended testes
-epispadias: opening of urinary meatus is on the dorsal surface – upper
-hypospadias: opening of urinary meatus is on the ventral surface – down
Micropenis –

10. BACK AND SPINE:

Flexed posture, flexed arms and legs with chin flexed on upper chest.
Skin: assess for intact skin and absence of lesions – spina bifida

11. upper and lower extremities:

-presence of palmar. Plantar grasp reflexes
-assess for symmetry of movement
-check presence, strength and symmetry of pulses

12. SKIN:
-hemagiomas: vascular tumors, flat or elevated
- harlequin ; lying on his side – upper body turns red. Common in preterm
- nevus flammeus: purple, dark red lesion “portwine” found on face and thighs
-storkbeak marks: patches on napes of neck
-strawberry hemagiomas: elevated – red in color. Flat bigger patches. Disappears
at 4 months
-caverrneous hemagiomass: raised patches but does not disappear
-mongolian spots: collection of pigments (melanocytes)
-desquamation – dryness of the skin (post term)
-erythema toxicum – rashes
-flea bite rash – petechiae
-milia – white small spots on the nose
-lanugo
-vernix caseosa
NEWBORN NURSING CARE: PLANNING AND OUTCOME
DETERMINATION
During the transition period, goal should set and achieved:
 Maintenance of a patent airway
 Provision of a conducive thermal environment for the newborn
 Protection of the newborn against infection and injury
 Identification and management of existing and potential complications

THE GOALS FOR CONTINUING CARE INCLUDE:

 Adequate newborn nourishment
 Urine voiding and bowel movement within 24 hours
 Strong parent-infant bonding
 Family education regarding newborn care

SUMMARY PROFILE OF THE NEWBORN:

 Length: 46 to 54 cm (measurement from crown to heel)
 Head circumference: 34 to 35 cm
 Chest circumference : 31 to 32 cm
 Heart rate: 120 to 160 beats/min
 Respiration: 30 to 60 breaths/min
 Periodic respiration: common and normal during this time after birth
 Coughing and sneezing: reflexes are present at birth to clear airway
 Newborns are obligate nose breathers. They breathe through their nose
 Weight: 2.5 to 3.4 kg
 During the first few days of life, the newborn loses 5 to 10 percent of birth
weight. This is called PHYSIOLOGIC WEIGHT LOSS
  Newborn is no longer under the influence of salt and fluid retaining
maternal hormones
 Passing of feces and urine
 Limited intake of milk

GROWTH AND DEVELOPMENT THROUGHOUT THE LIFE SPAN

Growth – height and weight

Development – cognitive, moral, maturity
Note: except for issues of health which may be affecting each of these

Issues:
1. stress management
2. Safety
3. Physical activity
4. Interpersonal relationships
5. Nutrition
6. Environmental safety

THEORIES OF GROWTH AND DEVELOPMENT

 Growth and development are continuous process from conception to death
 Growth and development proceed in an orderly sequence (head to toe)
 Children pass through the predictable stages at different rates
 All body systems do not develop at the same time
 Development is cephalocaudal
 Development proceeds from proximal to distal body parts
  Development proceeds from gross to refined skills
 There is an optimum tine for initiation of experiences of learning
 Neonatal reflexes must be lost before development
 A great deal of skill and behavior is learned by practice

BASIC DIVISION OF CHILDHOOD

stage Age period
Neonate First 28 days of life
Infant 1 month to 1 year
Toddler 1 to 3 y
preschooler 3 to 5 years
School age 6 to 12 years
Adolescent 13 to 21 years
Young age 21 to 30 years
Middle age 30 to 50 years
Late adolescent 60 onward

INFANCY:

Freud: trust vs. mistrust

Erikson: oral stage – explores the world by using mouth
Piaget: sensorimotor. Related to the world using their senses
0-3 months: recliner sleeps 20 hours a day
3-6 months: sitter. Starts roll over. Birth weight may double at 6 months
6-9 months: bouncer or crawler. Can pull self to a sitting position. Everything goes in
the mouth. Safety precautions
9-12 months: cruiser or walker. Walks with help. Loves to cruise around furniture. Birth
weight triples and length doubled
Solitary play and entertain self for short period of time
First social smile: 6 months

TODDLER (1-3 YEARS)

Freud: autonomy vs. shame and doubt

Erikson: anal stage – letting go
Piaget: preoperative stage
Into everything
Temper tantrums
Negativistic
Favorite word : no
Push and pull toys
Parallel play – two toddlers are seated together they don’t share their toys, just play on
their own
Rituals and routines
Separation anxiety
Major milestone: elimination and explorative (toilet training)

PRESCHOOLER (3 TO 6 YEARS)

Fears mutilation of genitalia – male: masturbate

Associative play
Fears abandonment – hate to be admitted in the hospital
Freud: initiative vs. guilt
Erikson: phallic stage – genitalia stage
Piaget: intuitive thinking. Egocentrism
Imaginary friends are common- talking to themselves
Curious
Pandora box
Favorite word: why

SCHOOL AGE (6 TO 12 YEARS OLD)

Fear death of your parents

Freud: industry vs. inferiority
Erikson: latent stage (no sexual progress)
Piaget: concrete operational
Modesty/polite particular
Favor peers – girls with girls, boys with boys. Crushes starts
Loss of control
Explanation of procedure
Competitive play with the opposite sex

ADOLESCENT (12 TO 18 YEARS) PUBERTY STAGE

Peer group is very important

Parents are their enemies
Altered body image
Freud: identity vs. role confusion
Erikson: genital stage
Piaget: formal operational thought
Suicide and depression – find yourself
Young adult: intimacy vs. isolation
Middle aged: generativity vs. stagnation
Older adult: integrity vs. despair

Moralist

KOHLBERG’S THEORY OF MORAL DEVELOPMENT

Preconventional level
Stage 1 – avoiding punishment
Stage 2 – aiming at a reward

Conventional level
Stage 3 – good boy and good girl attitude
Stage 4 – loyalty to law and order

Postconventional level
Stage 5 – justice and the spirit of the law
Stage 6 – universal principles of ethics

PIAGET: COGNITIVE DEVELOPMENT STAGES

Sensorimotor (birth – 2 years old)

Preoperational (2-7 years old)
Concrete operational (7-11 years old)
Formal operational (adolescence – adulthood)
FREUD: PSYCHOSEXUAL

Oral – the mouth – sucking, swallong, etc (ego develops)

Anal – the anus – withholding or expelling feces
Phallic – the penis or clitoris – masturbation (superego develops)
Latent – little or no sexual motivation present
Genital – the penis or vagina – sexual intercourse

ERIKSON: PSYCHOSOCIAL DEVELOPMENT

Infant – trust vs. mistrust trust vs. mistrust

Toddler – autonomy vs. shame & doubt autonomy vs. shame & doubt

Pre-schooler – initiative vs. guilt initiative vs. guilt

Grade-schooler – industry vs. inferiority industry vs. inferiority

Teenager – identity vs. role confusion identity vs. role confusion

Young adult – intimacy vs. isolation intimacy vs. isolation

Middle-age adult – generativity vs. stagnation
generativity vs. stagnation
Older adult – integrity vs. despair integrity vs. despair