Postpartum Nursing Care

PATHOPHYSIOLOGICAL AND PSYCHOSOCIAL

CHANGES OF POSTPARTUM
POSTPARTUM ASSESSMENT AND CARING
INTERVENTIONS
LABORATORY VALUES OF THE POSTPARTUM
CLIENT
MEDICATIONS USED IN POSTPARTUM
PHYSIOLOGY OF BREASTFEEDING AND THE
BREASTFEEDING CLIENT
FORMULA FEEDING
DISCHARGE TEACHING
 Pathophysiology of Postpartum

 Involution - rapid reduction in size of uterus and return to

prepregnant state
 Subinvolution = failure to descent
 Uterus is at level of umbilicus within 6 to 12 hours after
childbirth - decreases by one finger breadth per day

 Exfoliation - allows for healing of placenta site and is

important part of involution – may take up to 6 weeks
 Enhanced by
 uncomplicated labor and birth
 complete expulsion of placenta or membranes
 breastfeeding
 early ambulation
 FIGURE 23–1 Involution of the uterus. A, Immediately after
expulsion of the placenta, the top of the fundus is in the midline and
approximately halfway between the symphysis pubis and the umbilicus.
B, About 6 to 12 hours after birth, the fundus is at the level of the
umbilicus. The height of the fundus then decreases about one finger-

breadth (approximately 1cm) each day.

 Pathophysiology of Postpartum

 Uterus rids itself of debris remaining after birth

through discharge called lochia
 Lochia changes:
 Bright red at birth
 Rubra - dark red (2 – 3 days after delivery)
 Serosa – pink (day 3 to 10 after delivery)
 Alba – white
 Clear

 If blood collects and forms clots within uterus,

fundus rises and becomes boggy (uterine atony)
 Ovulation and Menstruation/Lactation

 Return of ovulation and menstruation varies for

each postpartal woman
 Menstruation returns between 6 and 10 weeks after birth
in nonlactating mother - Ovulation returns within 6
months
 Return of ovulation and menstruation in breastfeeding
mother is prolonged related to length of time
breastfeeding continues
 Breasts begin milk production
 a result of interplay of maternal hormones
 Pathophysiology of Bowel Elimination

 Intestines sluggish because of lingering effects of

progesterone and decreased muscle tone
 Spontaneous bowel movement may not occur for 2 to 4
days after childbirth
 Mother may anticipate discomfort because of perineal
tenderness or fear of episiotomy tearing
 Elimination returns to normal within one week
 After cesarean section, bowel tone return in few
days and flatulence causes abdominal discomfort
 Pathophysiology of Urinary tract

 Increased bladder capacity, decreased bladder tone,

swelling and bruising of tissue
 Puerperal diuresis leads to rapid filling of bladder -
urinary stasis increases chance of urinary tract
infection
 If fundus is higher than expected on palpation and is
not in midline, nurse should suspect bladder
distension
FIGURE 23–2 The uterus becomes displaced and deviated to the right when

the bladder is full.

 Laboratory Values

 White blood cell count often elevated after delivery

 Leukocytosis
 Elevated WBC to 30,000/mm3
 Physiologic Anemia
 Blood loss – 200 – 500 Vaginal delivery

 Blood loss 700 – 1000 ml C/S

 RBC should return to normal w/in 2 - 6 weeks

 Hgb – 12 – 16, Hct – 37% - 47%

 Activation of clotting factors (PT, PTT, INR)

predispose to thrombus formation - hemostatic
system reaches non-pregnant state in 3 to 4 weeks
 Risk of thromboembolism lasts 6 weeks
 Weight Loss

 10 –12 pounds w/ delivery

 5 pounds with diuresis
 Return to normal weight by 6 – 8 weeks if gained 25
- 30 pounds
 Breastfeeding will assist with weight loss even with
extra calorie intake
 Psychosocial Changes

 Taking in - 1 to 2 days after delivery

 Mother is passive and somewhat dependent as she sorts reality
from fantasy in birth experience
 Food and sleep are major needs

 Taking hold - 2 to 3 days after delivery

 Mother ready to resume control over her life

 She is focused on baby and may need reassurance

 Letting Go – 5-6 weeks after delivery

 Psychosocial Changes

 Maternal Role Attachment

 Woman learns mothering behaviors and becomes comfortable in her
new role
 Four stages to maternal role attainment
 Anticipatory stage - During pregnancy
 Formal stage - When baby is born
 Informal stage - 3 to 10 months after delivery
 Personal stage - 3 to 10 months after delivery
 Father-Infant Interaction
 Engrossment
 Sense of absorption
 Preoccupation - Interest in infant
 Postpartum Assessment

 Vital signs: Temperature elevations should last for only 24

hours – should not be greater than 100.4°F
 Bradycardia rates of 50 to 70 beats per minute occur during
first 6 to 10 days due to decreased blood volume
 Assess for BP within normal limits: Notify MD for
tachycardia, hypotension, hypertension
 Respirations stable
 Breath sounds should be clear
 Complete systems assessment
 BUBBLEHE assessment
 Postpartum chills or shivers are common
 Breasts Assessment

 Assess if mother is breast- or bottle-feeding - inspect

nipples and palpate for engorgement or tenderness –
should not observe redness, blisters, cracking
 Breasts Assessment

 Breasts should be soft, warm, non-tender upon

palpation
 Secrete colostrum for 1st 2-3 days –yellowish fluid -
protein and antibody enriched to offer passive
immunity and nutrition
 Milk comes in around 3 – 4 days – feel firm, full,
tingly to client
 Uterus Assessment

 Monitor uterus and vaginal bleeding, every 30

minutes x 2 for first PP hour, then hourly for 2 more
hours, every 4 hours x 2, then every 8 hours or more
frequently if there is bogginess, position out of
midline, heavy lochia flow
 Determine firmness of fundus and ascertain position
 approximate descent of 1 cm or 1 fingerbreadth per
day
 If boggy (soft), gently massage top of uterus until
firm – notify health care provider if does not firm
 Displaced to the right or left indicates full bladder –
have client void and recheck fundus
 Uterus Assessment

FIGURE 23–6 Measurement of

descent of fundus for the woman with
vaginal birth. The fundus is located two
finger-breadths below the umbilicus.
Always support the bottom of the uterus

during any assessment of the fundus.

 Bladder and Bowel Assessment

 Anesthesia or edema may interfere with ability to

void – palpate for bladder distention - may need to
catheterize – measure voided urine
 Assess frequency, burning, or urgency
 Diuresis will occur 12 – 24 hours after delivery –
eliminate 2000 – 3000 ml fluid, may experience
night sweats and nocturia

 Bowel: Assess bowel sounds, flatus, and distention

 Lochia – Rubra Assessment

 Lochia = blood mucus, tissue vaginal discharge

 Assess amount, color, odor, clots
 If soaking 1 or > pads /hour, assess uterus, notify
health care provider
 Total volume – 240 – 270 ml
 Resume menstrual cycle within
6 – 8 weeks, breast feeding may
be 3 months
 Episiotomy, Lacerations, C/S Incisions

 Inspect the perineum for episiotomy/lacerations

with REEDA assessment
 Inspect C/S abdominal incisions for REEDA

 R = redness (erythema), kemerahan

 E = edema , bengkak
 E = ecchymosis , perdarahan bawah kulit
 D = drainage/discharge, perubahan lochea
 A = approximation, pertautan jaringan
Episiotomy
 Postpartum Nursing Interventions

 Relief of Perineal Discomfort

 Ice packs for 24 hours, then warm sitz bath

 Topical agents - Epifoam

 Perineal care – warm water, gently wipe dry front to back

FIGURE 24–1 A sitz bath promotes healing and provides relief

from perineal discomfort during the initial weeks following birth.

 Hemorrhoids, Homan’s Sign

 Assess for hemorrhoids

 Relief of hemorrhoidal discomfort may include
 Sitz baths
 Topical anesthetic ointments
 Rectal suppositories
 Witch hazel pads - Tucks

 Extremities
 Assess for pedal edema, redness, and warmth
 Check Homan's sign – dorsiflex foot with knee slightly
bent
FIGURE 23–9 Homans’ sign: With the woman’s knee flexed,
the nurse dorsiflexes the foot. Pain in the foot or leg is a positive
Homans’ sign.
 Emotional Status/Bonding Assessment

 Describe level of attachment to infant

 Determine mother's phase of adjustment to parenting
 Postpartum Blues
 Transient period of depression
 Occurs first few days after delivery
 Mother may experience tearfulness, anorexia, difficulty sleeping,
feeling of letdown
 Usually resolves in 10 to 14 days
 Causes:
 Changing hormone levels, fatigue, discomfort, overstimulation
 Psychologic adjustments
 Unsupportive environment, insecurity
 Postpartum Nursing Interventions

 After pains
 Uterine contractions as uterus involutes

 Relief of after pains

 Positioning (prone position)

 Analgesia administered an hour before breastfeeding

 Encourage early ambulation - monitor for dizziness and

weakness
 Medications

 Bleeding
 oxytocin (Pitocin) – watch for fluid overload and hypertension
 methylergonovine (Methergine) – causes hypertension
 prostaglandin F (Hemabate, carboprost) – n/v, diarrhea
 Pain Medications
 NSAIDS – GI upset
 Oxycodone/acetaminophen (Percocet) – dizziness, sleepiness
 PCA – Morphine for C/S – respiratory distress
 docusate (Senna) – causes diarrhea
 Rubella Vaccine – titer 1:10, do NOT get pregnant for 3
months
 Rh Immune Globulin (RhoGAM) – Rh negative mother –
do not administer rubella vaccine for 3 months
 Mother and Family Needs

 Nurse can assist in restoration of physical well-

being by
 Assessing elimination patterns
 Determining mother's need for sleep and rest
 Encourage regular diet as tolerated and increasing fluids

 Identify available support persons - involve

support person and siblings in teaching as
appropriate
 Determine family's knowledge of normal
postpartum care and newborn care
 Breastfeeding Pathophysiology

 Before delivery, increased estrogen stimulates duct

formation, progesterone promotes development of
lobules and alveoli
 After delivery, estrogen and progesterone decrease,
prolactin increases to promote milk production by
stimulating alveoli
 Newborn suck releases oxytocin to stimulate let-
down reflex
 Composition of Breast Milk

 Breast milk is 90% water; 10% solids consisting of

carbohydrates, proteins, fats, minerals and vitamins
 Composition can vary according to gestational age
and stage of lactation
 Helps meet changing needs of baby
 Foremilk – high water content, vitamins, protein
 Hindmilk - higher fat content
 Immunologic and Nutritional Properties

 Secretory IgA, immunoglobulin found in colostrum

and breast milk, has antiviral, antibacterial,
antigenic-inhibiting properties
 Contains enzymes and leukocytes that protect against
pathogens
 Composed of lactose, lipids, polyunsaturated fatty acids,
amino acids, especially taurine
 Cholesterol, long-chain polyunsaturated fatty acids, and
balance of amino acids in breast milk help with
myelination and neurologic development
 Advantages of Breastfeeding

 Provides immunologic protection

 Infants digest and absorb component of breast milk
easier
 Provides more vitamins to infant if mother's diet is
adequate
 Strengthens mother-infant attachment
 No additional cost
 Breast milk requires no preparation
 AAP= Only food for 6 months, w/ foods for 12
months
 Disadvantages of Breastfeeding

 Many medications pass through to breast milk

 Father unable to equally participate in actual feeding
of infant
 Mother may have difficulty being separated from
infant
 Breastfeeding Mother

 Breastfeeding mother needs to know

 How breast milk is produced
 How to correctly position infant for feeding
 Procedures for feeding infant
 Number of times per day breastfed infant should be put to the
breast
 How to express and store breast milk
 How and when to supplement with formula
 How to care for breasts
 Medications that pass through breast milk
 Support groups for breastfeeding

 Review signs and symptoms of engorgement, plugged milk

ducts, mastitis
Breastfeeding Assessment
Figure 29–2 Four common breastfeeding positions. A, Football hold. B,
Lying down. C, Cradling. D, Across the lap.
 Formula Preparations

 Three categories of formulas based on cow milk

proteins, soy protein-based formulas, specialized or
therapeutic formulas - all are enriched with vitamins,
particularly vitamin D
 Most common cow milk protein-based formulas
attempt to duplicate same concentration of
carbohydrates, proteins, fats as 20kcal/oz same as
breast milk
 Bottle-Feeding Advantages

 Provides good nutrition to infant

 Father can participate in infant feeding patterns
 Bottle-Feeding Disadvantages

 May need to try different formulas before finding one

that is well-tolerated by infant
 Proper preparation necessary for nutrition adequacy
 Bottle-Feeding Mother

 Bottle-feeding mother needs to know

 Types of formula available and how to prepare each type

 Procedure for feeding infant

 How to correctly position infant for bottle-feeding

 How to safely store formula

 How to safely care for bottles and nipples

 Amount of formula to feed infant at each feeding

 How often to feed infant

 Expected weight gain

 Bottle Feeding Mother

 Teach to wear a binder or tight-fitting sports bra day

and night for two weeks.
 Do not allow hot water from shower to run over
breasts
 Avoid manual stimulation
 Apply cabbage leaves (dries up breast)
 Use acetaminophen for discomfort
 Cesarean Section Needs

 Assess vital signs

 Assess breasts
 Assess location and firmness of uterine fundus
 Assess lochia
 Assess incision site – REEDA
 Assess breath sounds
 Assess indwelling urinary catheter - color and
amount of urine noted
 Assess bowel sounds: present, hypoactive or
hyperactive
 Cesarean Section Needs

 Cesarean birth is major abdominal surgery - if general

anesthesia used, abdominal distension may cause
discomfort, assess for bowel obstruction
 Position client on left side, include exercises, early ambulation, increase
po intake, avoid carbonated beverages, avoid straws - may need enemas,
stool softeners, antiflatulent meds

 Pulmonary infections may occur related to immobility and

use of narcotics because of altered immune response
 TCDB, use incentive spirometer q 2 hours
 Pain and Comfort

 Administer analgesics within the first 24 to 72 hours -

allows woman to become more mobile and active
 Comfort is promoted through proper positioning, back
rubs, and oral care - reduce noxious stimuli in environment
 Encourage visits by family and newborn, which provides
distraction from painful stimuli
 Encourage non-pharmacologic methods of pain relief
(breathing, relaxation, and distraction) - encourage rest
 Attachment After a Cesarean Birth

 Physical condition of mother and newborn and

maternal reactions to stress, anesthesia, and
medications may impact mother-infant attachment
 By second or third day, cesarean birth mother
moves into "taking-hold period"
 Emphasize home management and encourage mother to
allow others to assume housekeeping responsibilities
 Stress how fatigue prolongs recovery and may interfere
with attachment process
 Discharge Instructions

 S/S complications  Referral numbers

 PP Exercises  Nutrition
 Rest  PP appointment
 Avoid overexertion  Birth certificate info
 Sexual activity  Infant care
 Hygiene  Infant complications
 Sitz baths  Infant follow-up
 Incision care  Family bonding
 Discharge Teaching

 New mother should gradually increase activities and

ambulation after birth
 Avoid heavy lifting, excessive stair climbing,
strenuous activity, vacuuming
 Resume light housekeeping by second week at home
 Delay returning to work until after 6-week
postpartum examination
 Discharge Teaching

 Recommend exercise to provide health benefits to

new mother
 Nurse should encourage client to begin simple
exercises while on nursing unit
 Inform her that increased lochia and pain may
necessitate a change in her activity
 Sexual Activity and Contraception

 Sleep deprivation, vaginal dryness, and lack of time

together may impact resumption of sexual activity
 Usually sexual intercourse is resumed once
episiotomy has healed and lochia has stopped (about
3 – 6 weeks)
 Breastfeeding mother may have leakage of milk from
nipples with sexual arousal due to oxytocin release
 Contraception

 Information on contraception should be part of

discharge planning
 Nursing staff need to identify advantages,
disadvantages, risk factors, any contraindications
 Breastfeeding mothers concerned that contraceptive
method will interfere with ability to breastfeed - they
should be given available options – progesterone
only
 Parent-Infant Attachment

 Tell parents it is normal to have both positive and

negative feelings about parenthood
 Stress uniqueness of each infant
 Provide time and privacy for the new family
 Include parents in nursing intervention
 Reaction of Siblings

 Sibling visits reassure children their mother is well

 Father may need to hold new baby, so mother can
hug older children
 Suggest to parent that bringing doll home allows
young child to "care for" and identify with parents
 Infant Care

 New mother and family should know basic infant

care
 Information about tub baths
 Cord treatment, When to anticipate cord will fall off
 Family should be comfortable in feeding and handling infant,
as well as safety concerns
 Immunizations
 When to call the doctor
 Discharge Teaching

 Nurse should review with new mother any information she

has received regarding postpartum exercises, prevent of
fatigue, sitz bath and perineal care, etc. - nurse should
spend time with parent to determine if they have any last-
minute questions before discharge
 Printed information about local agencies and support
groups should be given to new family
 Types of Follow-Up Care

 Telephone calls - nurses must listen carefully and ask open-

ended questions
 Return visits - Within one week after first visit
 Telephone follow-up - Within 3 days of discharge
 Baby care/postpartum classes
 New mother support groups
 Need to have a caring attitude in these activities
 Main Purpose of the Home Visit

 Assessment
 Status of mother and infant
 Adaptation and adjustment of family to new baby
 Determine current informational needs
 Teaching
 Self-care
 Infant Care
 Opportunity to answer additional questions related to
infant care and feeding
 Counseling
 Provide emotional support to mother and family
 Referrals
 Maternal Assessments at Home

 Vital signs: Should be at prepregnancy level

 Weight: Expect weight to be near prepregnancy level at 6
weeks postpartum
 Condition of breasts
 Condition of abdomen, including healing cesarean incision
if applicable
 Elimination pattern: should return to normal by 4 to 6
weeks postpartum
 Maternal Assessment

 Lochia
 Should progress from lochia rubra to lochia alba
 If not breastfeeding, menstrual pattern should return
about 6 weeks postpartum
 Fundus
 Uterus should return to normal size by 6 weeks
postpartum
 Perineum: Episiotomy and lacerations should
show signs of healing
 Breastfeeding Assessment

 Nipple soreness - Peaks on days 3 and 6, then

recedes
 Cracked nipples
 Allow nipples to air dry after breastfeeding
 Nurse frequently
 Alternate breasts
 Change infant's position regularly
 Breast engorgement, plugged ducts
 Effect of alcohol and medications
 Return to work
 Weaning
 Family Assessment

 Bonding: Appropriate demonstration of bonding should

be apparent
 Level of comfort: parents should display appropriate
levels of comfort with the infant
 Siblings should be adjusting to new baby
 Parental role adjustment
 Parents should be working on division of labor
 Changes in financial status
 Communication changes
 Readjustment of sexual relations
 Adjustment to new daily tasks
 Contraception: Parents understand need to choose and
use a method of contraception
 Relinquishing a Baby

 Many reasons why a woman decides she cannot

parent her baby
 Emotional crisis may arise as woman attempts to resolve
her concerns
 As she faces these concerns, social pressures against
giving up baby
 Mother may need to complete grieving process to
work through her decision - she may have made
considerable adjustments to her lifestyle to give
birth
 Relinquishing a Baby (cont’d)

 Nursing staff need to honor any special requests

after birth and encourage mother to express her
feelings
 Seeing newborn may assist mother in grieving
process
 Some mothers may request early discharge or
transfer to another unit