Nursing Care During the Postpartum Period

Nursing Care During the Postpartum Period

Postpartum Period • Time placenta delivered (4th stage of labor) until reproductive organs return to non-pregnant size and position. Usual time is 42 days. • The new mother needs to know how to care for herself and how to care for the newborn. • Teaching must be done throughout the postpartum stay of the mom and baby.

Overview of Anatomic and Physiological Changes • Reproductive Organs • Uterus • Involution • Autolysis • Self-dissolution or self-digestion that occurs in tissues or cells by enzymes in the cells themselves • Occurs as a result of withdrawal of estrogen and progesterone

Overview of Anatomic and Physiological Changes • Reproductive Organs • Uterus • After the delivery of the placenta, oxytocin causes the uterus to contract and compress blood vessels at the site where the placenta separated from the wall; this site is 3 to 4 inches in diameter. • If the uterus does not contract adequately, blood loss can be excessive. • Placental site will heal with sloughing of the uterine lining; this is necessary if more pregnancies are to occur. Need new endometrial layer.

Overview of Anatomic and Physiological Changes • Reproductive Organs (continued) • Uterus • Immediately after delivery, the fundus is about midway between the umbilicus and symphysis pubis or slightly higher. Should be firm and midline. • Within 12 hours, it rises to the umbilicus; after 24 to 48 hours, it begins a gradual descent; within 1 week, the level is at the symphysis pubis and barely palpable; within 6 weeks, the uterus is at the prepregnant state.

Figure 27-1, A & B (From Lowdermilk, D.L., Perry, S., Bobak, I.M. [1999]. Maternity nursing. [5th ed.]. St. Louis: Mosby.) A, Normal progress of uterus, days 1 through 9. B, Size and position of uterus 2 hours after delivery.

Figure 27-1, C & D (From Lowdermilk, D.L., Perry, S., Bobak, I.M. [1999]. Maternity nursing. [5th ed.]. St. Louis: Mosby.) C, Involution of uterus two days after delivery. D, Four days after delivery.

Overview of Anatomic and Physiological Changes • Reproductive Organs (continued) • Uterus • Lochia: fluid waste discharges after delivery • Lochia rubra • Bright-red drainage;sticky and thick; first day or two after delivery • Lochia serosa • Pink to brown drainage; until day 7 • Lochia alba • Yellow to white drainage; continues for an additional 10 days to 4 weeks

Figure 27-6 (From Lowdermilk, D.L., Perry, S., Bobak, I.M. [1997]. Maternity & women’s health care. [6th ed.]. St. Louis: Mosby.) Suggested guidelines for assessing lochia volume.

Overview of Anatomic and Physiological Changes • Cervix/Vagina/Perineum • The cervix will appear edematous, with bruising present. • The external cervical os will have ragged, slit-like appearance instead of being round as seen in the nulliparous woman. • The vagina will be thin, with an absence of rugae and with dryness present. • The perineum may have some edema and bruising. • The episiotomy or lacerations (if present) should be free of erythema, with the edges well approximated. • Assess for Hematoma

Overview of Anatomic and Physiological Changes • Cervix/Vagina/Perineum (continued) • Cervical Injuries • Injury occurs when the cervix retracts over the advancing fetal head. • It occurs at the lateral angles of the external os. • Most are shallow and bleeding may be minimal, but will not stop until repaired • Extensive lacerations may be a consequence of a hasty attempt to enlarge the cervical opening artificially or to deliver the fetus before the cervix is fully dilated

Overview of Anatomic and Physiological Changes Cardiovascular • Blood volume is reduced to nonpregnant levels by 2 to 4 weeks. • Diuresis • Diaphoresis • Blood loss in delivery • Cardiac output declines rapidly; patient is at risk for thrombus due to high level of platelets in the early postpartum period.

Overview of Anatomic and Physiological Changes Urinary • Possible trauma in delivery and regional anesthesia; there may be edema of the bladder, urethra, and meatus, as well as a decreased urge to void. • Much of the excess blood volume is eliminated through diuresis. • A full bladder can displace uterus to right or left side, cause a boggy/atonic uterus, and lead to extra postpartum bleeding.

Overview of Anatomic and Physiological Changes Gastrointestinal • Appetite returns to normal. • Gastric motility may continue to decrease, leading to constipation. • Normal bowel elimination should return in 2 to 3 days. • Decreased abdominal tone and tenderness resulting from episiotomy or hemorrhoids may make the patient reluctant to strain for a bowel movement.

Overview of Anatomic and Physiological Changes Endocrine • Placental hormone levels rapidly reduce after delivery. • Estrogen and progesterone levels drop markedly following expulsion of the placenta. • Decreased estrogen levels are associated with breast engorgement and diuresis of excess extracellular fluid that has accumulated during pregnancy. • Prolactin is secreted only with nipple stimulation.

Overview of Anatomic and Physiological Changes • Endocrine ( continued) °Return of the Menstrual Cycle • When estrogen levels return to normal • 1st cycles may be anovulatory • Occurs between 6 weeks and 6 months post delivery • Nonlactating mothers have an earlier return

Overview of Anatomic and Physiological Changes Musculoskeletal • Abdominal muscle tone and joint stabilization occur during the 6- to 8-week period after delivery. • Some pelvic joints may never return to their prepregnant position. • Discomfort may be felt in the joints immediately after delivery because of the hormone relaxin. • There may be a permanent increase in shoe size.

Overview of Anatomic and Physiological Changes Integument • Changes seen in pregnancy recede, with hyperpigmentation gradually disappearing after delivery. • Hair and nail growth returns to normal and skin elasticity returns. • Striae may not fade completely but turns silver-gray. • Diaphoresis is common, especially at night during the first week postpartum.

Postpartum Assessment: BUBBLE-HE • Breasts • Uterus • Bladder • Bowel • Lochia • Episiotomy • Homan’s sign • Emotional status • Taking in • Taking hold • Letting go

Postpartum Assessment • Vital signs: q 15 minutes X 4 if stable, then q 4 hrs or q shift • Temp: may increase 1st 24 hrs, then afebrile • Pulse: Bradycardic 6-8 days, slowly return to normal within 3 months • Respirations: wnl, no alterations • BP: wnl, no alterations

Postpartum Assessment • Pain: control of discomforts is important in postpartum period • After birth pains: Similar to menstrual cramps Are self limiting Worse with each pregnancy Cause=intermittent uterine contractions Decrease within 48 hours postpartum Breastfeeding increases Pain meds ordered

Postpartum Assessment • Pain: Perineal Discomfort Ice to perineum x 24 hrs, then sitz baths May offer air ring for perineal discomfort

Transfer from the Recovery Area • After the initial recovery period of 1 or 2 hours, the woman may be transferred to a postpartum room. • Women who have had general or regional anesthesia must be cleared from the recovery room by a member of the health care team. • In some hospitals, the baby stays with the mother wherever she goes; in others, the baby is taken to the nursery for several hours for observation.

Transfer report: to postpartum nurse • Healthcare provider- mom and baby • G&P, Age • Anesthetic/analgesics used; any other meds • Duration of labor • Time of ROM • Augmentation/Inductions • Type and time of birth • Blood type & Rh factor • Rubella immunity; other lab results (GBS) • BUBBLE-HE info • Sex of baby

Transfer report – to Nursery staff • Sex & weight of infant • Time of birth • Health Care Provider- mom and baby • Feeding method & if feeding started • Apgar scores • Voiding & stool passage • Interventions completed (vitamin K, etc.) • Lab reports on mom (GBS, Blood type, culture results) • Newborn assessment • OB history of mom

Postpartum Nutrition: • OK to eat after delivery if no nausea • Offer variety of fluids • Verify bowel sounds – general anesthesia • Nonlactating: • Continue eating well-balanced diet, PNV • Calories same as pre-pregnancy • Lactating • Continue eating well-balanced diet, PNV • Increase calorie intake (500 above pre-pregnancy) • Fluids 2-3 liters daily

Postpartum Weight loss: • Important that dieting not deprive of necessary nutrients • If did not gain excess weight, should be able to lose in 6-8 wks without dieting • Most Dr’s do not recommend until after 6-8 wks • No dieting while breastfeeding.

Postpartum hygiene: • Showers • Tub baths • Pericare • Analpram • Sitz Baths

Postpartum safety measures: • Instruct to use call light • 1st Shower – remain outside door • Ammonia ampules ready • Encourage to rest after activity • Assess color, pulse, LOC after ambulation • Epidural – keep in bed until full movement & sensation returned & BP & pulse WNL

Exercise • Start with Dr. OK • Begin gradually • Isotonic exercises may improve tone • Avoid vigorous exercise until after 6 wk exam • If too active too soon, may see lochia change from serosa or alba back to rubra. Need to take it more slowly. • If bleeding does not subside after rest, call Dr.

Maintenance of Safety • Rest and Sleep • Rest and sleep are important throughout the postpartum period. • After the discomforts at the end of pregnancy, many women enjoy being able to sleep in any position desired. • Sleep should not be disturbed unless it is necessary to protect the patient's well-being. • If she is breastfeeding, instruct the patient on the importance of naps and rest periods during the day to compensate for lost sleep.

Nursing Assessment of and Intervention for the Mother • Health Perception/Health Management • Parent-Newborn Relationships • The mother’s reaction to the sight of her newborn may range from excited outbursts of laughing, talking, and even crying, to apparent apathy. • Whatever the reaction and cause, the mother needs continuing acceptance and support from all of the staff. • Nurses should become knowledgeable about the child-bearing beliefs and practices of diverse cultural and ethnic groups.

Nursing Assessment of and Intervention for the Mother • Health Perception/Health Management (continued) • Promoting Parenting Skills • Stress that parenthood is a learned role; it takes time to master, improves with experience, and evolves gradually and continually as the needs of the parent and child change. • Through the loving and attentive manner nurses exhibit while providing physical care, they act as role models.

Nursing Assessment of and Intervention for the Mother • Health Perception/Health Management • Women with uncomplicated deliveries remain in the hospital a short time after giving birth. • It may be only hours, or it may be 1 to 2 days after delivery; cesarean rarely requires more than 4 days. • Because early discharge is increasingly common, it is important to assess the woman’s ability to meet her own needs and those of her infant. • Postpartum teaching • Maternal needs • Infant needs

Postpartum Teaching: Maternal • Assess Fundus • Assess Lochia • Perineum • Nutrition • Sexual Activity • Breast Care: lactating vs. nonlactating • Pain • Voiding • Bowel elimination • Psychological reactions • Physical activity and exercise • Cesarean Section Care- incision

Postpartum Teaching: Infant • Diaper changing • Baths - hygiene • Cord care • Car seat • Immunizations • Reflexes • Safety • Feeding: bottle vs. breast • Circ care • Temperature

Psychosocial Assessment • Coping and Stress Tolerance • Many new mothers feel overwhelmed by the responsibility of motherhood. • They feel intimidated by the nurse’s capability and skill in taking care of the newborn. • They often feel inept and may not wish to ask questions that might be viewed as unintelligent. • Establishing a rapport is essential; listen for fears and anxieties. • Often women experience a period of depression after delivery, triggered by a rapid hormonal shiftpostpartum depression, or “blues.”

Danger signs for parent-newborn relationship: • Passive reaction • Hostile reaction • Disappointment over baby’s sex • Lack of eye contact • Non-supportive interaction between parents

Infant Feeding: Breastfeeding • Lactation: function of secreting milk from breasts for nourishment of infant • Estrogen stimulates the growth of milk ducts to prepare for lactation • The first secretion produced by the breast is colostrum- thin, watery, and slightly yellow; rich in protein, calories, antibodies, and lymphocytes • Prolactin(from the anterior pituitary) is responsible for stimulating milk production in the mammary alveolar cells • Stimulation of nipples, particularly by the infant’s sucking, causes the release of oxytocin(from posterior pituitary) to maintain milk supply; it also stimulates contraction of the mammary ducts and causes milk to be ejected from the breasts

Breastfeeding ( continued) • Let down reflex: tingling sensation in breasts may cause abdominal cramping from uterine contractions - oxytocin released by posterior pituitary causes milk to be delivered from alveoli thru duct system to nipple. - infant suckling at breast stimulates release of oxytocin - may use warm cabbage leaves or warm shower to assist with let down.

Figure 27-3 (From Lowdermilk, D.L., Perry, S., Bobak, I.M. [1999]. Maternity nursing. [5th ed.]. St. Louis: Mosby.) Maternal breastfeeding reflexes. A, Milk production reflex. B, Let-down reflex.

Figure 27-2 (From Lowdermilk, D.L., Perry, S., Bobak, I.M. [1999]. Maternity nursing. [5th ed.]. St. Louis: Mosby.) Detailed structural features of the human mammary gland.

Breastfeeding (cont) Breast Care: • If the patient is breastfeeding, nipples should be kept soft and supple. • Nipples should be inspected for inflammation, fissures, or tenderness • Avoid the use of soap or other chemicals; plain water and air drying may prevent problems. • Modifications in positioning of the baby may needed if tender or cracked nipples are a problem. • Assist the breastfeeding mother to be successful in establishing lactation. • May use Lanolin cream to tender nipples

Breastfeeding (cont) • Engorgement • This uncomfortable fullness of the breasts occurs when the milk supply initially comes in. • It is a result of venous and lymphatic stasis that occurs during lactation. • Filling of the breast with milk usually occurs in the axillary regions. • It is usually seen on the third day postpartum and resolves in about 48 hours. • May use ice packs, cold cabbage leaves, Tylenol

Figure 27-7, A & B (B, Courtesy of Marjorie Pyle, RNC, Lifecircle, Costa Mesa, California.) A, Football hold. B, Cradling.

Figure 27-7, C & D (C, D, Courtesy of Marjorie Pyle, RNC, Lifecircle, Costa Mesa, California.) C, Lying down. D, Across the lap.

Figure 27-8 (From Lowdermilk, D.L., Perry, S., Bobak, I.M. [1999]. Maternity nursing. [5th ed.]. St. Louis: Mosby.) Engrossement

Breastfeeding (cont) • Manual pumping of the breasts may be necessary in some cases, such as an infant who is unable to suckle at the breast or a mother who must spend an extended period of time away from her infant. • May also pump if engorged and infant unable to latch on

Breastfeeding (cont) • Benefits of breastfeeding • There is more rapid involution of the uterus. • Mother enjoys social closeness with their infant. • Human milk has antibacterial and antiviral properties, immunoglobins, and antiallergy factors to protect the infant. • The milk contains growth factors, digestive enzymes, and proteins. • Need to feed on Demand

Bottlefeeding • Bottle-feeding is another choice of the newly delivered woman. • Lactation must be suppressed: can do so by wearing tight fitting bra 24/7 until milk comes in, dries up, and goes away; use ice packs for discomfort and analgesics • Limit fluid intake • Do not release milk from breasts, will make more

Nursing Care During the Postpartum Period