POSTPARTUM CAREPhysiological and Psychological Adaptation after ChildbirthLEARNING OUTCOMES:

• Describe the basic physiological changes that occur in a woman’s body during the postpartal period, the related nursing assessment and care with patient education.

• Formulate nursing diagnosis and nursing care based on “normal” findings of the postpartum assessment.• Compare abnormal findings in the nursing assessment with possible causes and appropriate nursing care.• Examine the nurse’s impact in assessing predisposing factors of postpartum complications, implementing

preventive care, and teaching for self help.• Describe the psychological adjustments that normally occur during the postpartal period, the related nursing

assessment and care including education to promote patient and family wellness.• Identify the impact of cultural influences on providing holistic nursing care for the postpartal family.• Examine the individualized postpartal nursing needs of the woman, including the childbearing adolescent, who

delivered vaginally or by cesarean section.• Evaluate identified teaching topics and outcomes related to postpartum discharge.

Postpartal (Puerperium) Period • 4TH Stage of Labor: 1-4 hrs. after delivery • Begins immediately after delivery of placenta• Continues for 6 weeks, or until body returns to near pre-pregnant statePhysical Adaptations Reproductive

Involution of uterus • Rapid reduction in size of uterus to nonpregnant state (5-6 wks).• Contractions constrict and occlude underlying blood vessels at placental site.

Placental site• Heals by exfoliation (6wks)• No scar formation occurs

Subinvolution • Any slowing of decent

Involution/Fundal Position (do not need to know)Stages of Involution

• Post-delivery: midway between umbilicus and symphysis pubis• 6-12 hrs: rises to level of umbilicus then at 1-2 cm below first PP day• 24 hrs – 10 days: descends 1cm/day until reaches pelvic cavity• Universal measurement

Fundal position • May be displaced to the left or right by a distended bladder (massage)• Becomes “boggy” with uterine atony increased risk for hemorrhage

Lochia • Debris from delivery and uterine lining

Rubra—dark red 1-3 days Serosa—pink 4-10 daysAlba—white 11-24 days

• Increased with exertion and breastfeeding (due to the release of oxytocin)

Vaginal changes Following birth edematous and bruised Small superficial lacerations may be present Decreases in size for 3 weeks in nonlactating woman Decreases in size slower in lactating woman due to hypoestrogenic state Low estrogen leads to painful intercourse due to decreased vaginal lubrication (6-10 wks) Cervical Changes (never goes back to the way it was) Following birth - spongy and flabby and formless and may appear bruised. Permanently changed by the first childbearing. Dimple-like to a lateral slit (fish mouth)

Unexplained increase or return to Rubra is abnormal (teach pt to monitor)

Perineal changes (normal changes)• May appear edematous with some bruising• Episiotomy edges should be approximated

Ovulation and menstruation• Estrogen/Progesterone drop rapidly after delivery of placenta

In nonlactating woman, returns within 6 weeksIn lactating woman, return varies due to increased levels of prolactin (supports milk production)

• May precede menstruation, making breastfeeding not reliable means of contraception

Additional Physiological Adaptations

Lactation Preparation for lactation - estrogen and progesterone After birth, the interplay of maternal hormones leads

the establishment of milk productionInfant sucking: stimulates prolactin / milk production; stimulates release of oxytocin milk “let down” uterine contractions/cramping (normal response)

Abdominal / GI • Risk for constipation; Sluggish due to progesterone• Decreased abdominal musculature/peristalsis• Narcotic usage; Dehydration• Fear of pain and tearing episiotomy delays elimination• Flatulence causes abdominal discomfort

Urinary• Puerperal diuresis – 2000-3000cc/24hrs.(due to excess blood volume during pregnancy • Overdistention of bladder due to rapid filling of bladder• Increased distension / retention leads to UTI• Uterine relaxation (atony)• Increased risk of hemorrhage• Uterus deviates to side and becomes boggy

Cardiovascular • Pre-pregnancy state by 12 weeks• Natural diuresis of increased blood volume (especially night sweats)

• Increased cardiac output• First 48hrs – Increased risks CHF and pulmonary edema especially with history of PIH or heart

disease(shortness of breath, wt gain, etc)• CBC decrease normal due to blood loss - pre-labor values in 2-6 weeks• Risk of thromboembolism for 6 weeks • Increased fibrinogen for 1 wk – increased risk of DVT (up to 6wks)• Headaches due to fluid shift - HTN, Epidural/Spinal

Vital signs • A temperature up to 100.4 or less may be due to dehydration and/or exertion in the first 24 hours -

Afebrile after 24 hr BP WNL, may decrease initially - ↑BP may indicate PIH• Pulse rate may decrease to 50-70. Tachycardia - hemorrhage

Lab Values• Prepregnant state by the end of the postpartum period• Increased risk of thromboembolism • White blood cell (WBC) counts up to 30,000 may occur early postpartum. Treat the symptoms, not the

lab values• Convenient rule of thumb is a 2 point drop in hematocrit equals a blood loss of 500 mL

Postpartal chill • First 2 hours after delivery• Nervous response or vasomotor change• Due to shift in fluids and work of labor• Treat with warm blanket or warm beverage• Assure pt. that it is common occurrence • Chills / fever late in the postpartum period may indicate sepsis

Postpartal diaphoresis• Fluid shift• Increased perspiration• Common at night

Afterpains • Common in multiparas • Increased with uterine distention • Caused by intermittent contractions• May cause severe discomfort for the first 2-3 days• Breastfeeding, Oxytocins may increase the severity

(Pitocin, Methergine, Ergotrate)• Mild analgesic may be indicated for pain relief.

(Toradol, Norco, Davocet N-100, Percocet, Motrin)

Psychological AdaptationsMaternal Role adjustment

• 1st - 2nd PP days - passive and somewhat dependent• Hesitant about making decisions• Food or sleep are of major importance• “Taking In” phase according to Rubin• 3rd day, mother is ready to resume control. “Taking Hold” phase occurs during this time• Today’s mother’s adjust more rapidly as LOS has shortened

Maternal role attainment • Process by which a woman learns mothering behaviors• Initial attachment Behavior

• En face• Fingertip exploration• Reciprocity

• Father-Infant Interactions• Engrossment (the characteristic sense of absorption, preoccupation, and interest in the infant

demonstrated by fathers during early contact with the newborn)• Cultural Influences

• Postpartum care may be affected by cultural beliefs: • Do not make generalizations• Extended family may play an important role in care

Baby blues• Transient period of depression during first 2 weeks • Mood swings, anger, weepiness, anorexia, insomnia, and a feeling of letdown• Cause? Hormonal changes and psychological adjustments • Usually resolve naturally in 2 to 3 weeks with support and reassurance. If symptoms persist, the client

should be evaluated for postpartum depression• Postpartum depression• Postpartum psychosis

Postpartum Assessment and Nursing Care Current OB Status

• Admit assessment (prenatal hx)• Delivery information• Blood type – mom/baby• Rubella status • L/D complications• Medications/Narcotics – last 24 hrs

Prenatal History• Previous pregnancies – complications• Abnormal lab results• Antepartal testing and procedures

Medical History• Allergies• Chronic illness – HTN, DM, HIV• STD

Psychosocial history• Depression prior to pregnancy• Support system

Culture• Ethnicity• Demographics• Personal Beliefs/Preferences• Socioeconomic• Diet• Religious beliefs (Jehovah’s witness…no blood)

Vital Signs – q 4 hours • BP should remain at baseline during pregnancy

• High BP – preeclampsia, essential HTN• Low BP - hemorrhage or may be WNL for pt

• HR 50 – 90 bpm – tachycardia – hemorrhage• Respirations – 16-24 – tachypnea – respiratory dx

• CDB and IS post-op• Unless pt has had a spinal and respiration are decreasing due to reaction…mostly seen in

Csection pts• Temperature – 98 – 100.4 – first 24 hours only due to dehydration• After 24 hours 100.4 or above suggests infection- due PROM, prolonged labor

• May have low grade temp when lactating• Teach pt. how to take temperature

Pain Assessment

• Orient patient to pain scale • Assess origin of pain – uterine, abdominal, perineal, rectal, headache, breasts • Evaluate for hematomas: vulvar, vaginal, pelvic – severe pain with firm uterus. (apply ice!!!)• Pain Mngmnt: Epidural, PCA, Analgesics, Nonpharmacologic measures. Note patients response to pain meds.• Monitor for side effects of medications • Incisions

• Tubal Ligation:• Small umbilicus incision

• Post-op Cesarean Section:• Low transverse abdominal• Midline abdominal• Heals in 6-8 weeks

• Perineal:• Episiotomy or laceration• Heals in 4 to 6 weeks• No intercourse for 6 wks to facilitate healing • REEDA: redness, edema, ecchymosis, discharge, approximation***• BUBBLEHEB*****

• B = Breast• U = Uterus• B = Bladder• B = Bowel• L = Lochia • E = Episiotomy/Laceration• H = Hemorrhoids/Homans • E = Emotional• B = Bonding

Breasts• Determine breast or bottle-feeding• General appearance – reddened area- Mastitis. Size (may affect breastfeeding)• Encourage supportive bra

• Sports bra for 2 weeks if bottle-feeding • Palpation – soft, filling, full, engorged• Mastitis – mass, tender, red, heat • Engorgement – tenderness, heat, edema, express milk, warm packs, pump• Nipples – supple, intact, erect with stimulation• Cracked, sore, red, bleeding, flat inverted• May need shields or shells with breastfeeding• Assess technique, Lactation specialist referral

Uterus and Fundus• Have pt. void before assessment. Full bladder will displace uterus above umbilicus and cause uterine atony with

increased bleeding • Assess risk factors Gently massage fundus

If soft and boggy – Teach self-massage• Assess every 15 minutes for first hour after delivery, 30 minutes for second hour, hourly for 2 more hours, then

every 4 hours - monitor for complications Oxytocics to promote contractions, decrease bleeding, side effects: Pitocin: Hypotension Methergine: (given IM to relax uterine muscles) can cause HTN

With cesarean section, abdomen very tender, use care and inspect incisional area for signs of infection, healing.

Bladder • Increased risk for distension, retention due to postpartal diuresis (2000-3000cc)• Must void q 4-6 hours post vaginal delivery, or within 4 hours of removal of foley catheter. Use alternatives

(warm water, running water in sink, peppermint oil, increased fluids) to assist voiding before straight cath or reinserting foley

• Full bladder leads to uterine atony and increase bleeding • Assess for UTI

Bowel • Increased risk of constipation due to fear of pain from episiotomy, hemorrhoids, perineal trauma• Normal BM by 2nd or 3rd day.• Encourage fluids, ambulation, stool softeners, roughage in diet • Post-op cesarean section / BTL need to pass flatus before eating to avoid abdominal distension and discomfort.

No straws, carbonated drinks, or heavy sweets Lochia

• Amount, color, odor, presence of clots

• Scant to moderate amount, no clots. Large amount with clots must be evaluated for hemorrhage due to uterine atony, retained placenta, unknown cervical laceration (heavy bleeding with firm uterus). Pools in vaginal vault after lying down, may ‘gush’ when pt. stands up. Always reassess with clean pad

• Usually with cesarean section lochia is scant due to uterine evacuation.• Odor is nonoffensive, earthy. If foul, suspect infection• Last 3-4 weeks until placental site is healed • Return to rubra - subinvolution

Episiotomy and Perineum • Inspected perineum and anus with woman lying in Sims’ position • With episiotomy or laceration with repair, assess wound (REEDA). Edema, bruising, tenderness, normal.

Hardened areas with increased pain – hematoma, infection. Apply ice pack, teach to pat dry after voiding, use Dermoplast spray, sitz bath, pain meds (Norco, Toradol, Darvocet, Tylenol).

NOTHINGRECTALLY with 3rd or 4th degree episiotomy or tear • Hemorrhoids may be present. Assess size, pain or tenderness. Tucks, sitz bath, stool softeners • Provide teaching concerning episiotomy, hygiene, comfort measures, hand washing

Homan’s/Lower Extremities • Increased risk for thrombophlebitis, thrombus formation due to hypercoagulability, anemia, obesity, traumatic

childbirth, surgery • Homan’s not diagnostic, only evaluation tool. Only true diagnostic is LEVD • Heparin therapy with DVT• Early ambulation, SCD’s, ROM while bedridden • Teach signs and symptoms of DVT, especially for discharge

Emotional Status • First 24 hrs – passive ‘taking in’ – passive, talks about labor and birth experience. Sleeps frequently (fatigue

from labor)• 12 -36 hrs – ‘taking hold’ – begins to assume responsibility. May have mood swings, crying, irritability (baby

blues)• Assess mother’s attitude, support systems, caregiving skills, feelings of competence in comparison to disinterest,

withdrawn behavior, depression • Educate patient and family concerning postpartal depression, sign, symptoms, support groups, referrals

Bonding

• Observe interaction with newborn; en face, cuddles, soothes, identifies family characteristics • Disappointment over sex usually transient, yet continued expressions, refusal to care for infant, lack of

bonding behaviors must be evaluated further • Cultural practices may modify mother’s response to infant• Provide supportive, nonjudgemental teaching and evaluate mother’s knowledge level

• Family centered care and rooming in facilitates bonding with father and siblings

• Promote successful infant feeding • Bottlefeeding: supportive bra, ice packs 4 times a day if engorgement develops, avoid heat and stimulation of

breasts. Feed every 3-4 hours • Breastfeeding: supportive bra, nursing on demand, assist with positioning (football, cradle, side lying hold).

Teach breast care: no soap, air dry after breastfeeding, use lanolin. Lactation specialist referral • After cesarean birth, assess for grief due to loss of fantasized birth. Support effective coping

Assess adolescent mother’s needs and maternal-infant interaction based on level of maturity. Include self-care, infant care, contraception, goal setting, peer relationships, resources.For the woman giving up her newborn, nonjudgemental support is essential. Respect special requests regarding her care and infant: See and hold infant, early discharge, admit to med/surg unit.Many factors for putting infant up for adoption: single, adolescent, economic status, result of incest or rape, partner disapproval of pregnancy.

Discharge criteria and teaching*****• VS, assessment stable• RhoGAM received if mom Rh-negative and infant Rh-positive. RhoGAM is blood product; consent with

verification by 2 nurses required. 300 mu given IM within 72 hours of delivery. (Also received at 28 weeks)• Rubella received if titer 1:10 or less, 0.5 cc sq – AVOID PREGNANCY FOR 3 MONTHS• Instruct in proper administration of medications

• Antibiotics, analgesics, prenatal vitamins, Iron• Resuming home medications

• Get Pediatrician approval if breastfeeding• Teaching content: Maternal/Infant care, home safety, special needs (C/S, multiple births, infant with anomaly).Signs/symptoms of postpartum complications: Hemorrhage, infection, DVT, depression and when to report complications to physician• Newborn care: feeding, bathing, cord and circumcision care, safety – MUST have car seat• Resume sexual activity when episiotomy is healed and lochia flow has stopped. Use water soluble lubricant.

Plan for contraceptive by 6 wk PP visit. • Resumption of activity, especially post-op

Postpartal Complications Complications:• Postpartum Hemorrhage

• Early• Late

• DVT/PE Infections UTI Mastitis PP Blues PP Depression PP Psychosis

• PP Hemorrhage • Early

• >500 cc in first 24 hrs after vaginal birth• >750-1000 cc after cesarean section• decrease in HCT of 10 points

• Blood loss often underestimated• May occur intra-abdominally• Late or Delayed

• 24 hrs – 6 wks after delivery• Predisposing Factors

• Uterine over distention – large infant• Grand multiparity • Anesthesia or MgSO4(muscle relaxant)• Trauma• Abnormal labor pattern• Oxytocin Induction• Prolonged labor• Hx anemia, hemorrhage• Red headed

Impending signs• Excessive bleeding

• >2 pads/30min-1hr• Light headedness - Nausea• Visual disturbances• Anxiety• Pale/ashen color, clammy skin• Increasing P/R and lower BP

Action to take• Check uterine tone, massage, effect• Elevate legs, lower head• Oxygen - IV Fluids• Pitocin, Methergine, Prostin • Call for help

Early PP Hemorrhage • Within first 24 hrs.

• Causes• Uterine atony (uterus not clamping down like it should)• Lacerations – vaginal/cervical• Retained placental fragments• Hematomas – vulvar, vaginal, pelvic• Subinvolution of uterus (uterus not clamping down, even with medication)• Prolonged labor• Multipara

• Uterine Atony • Failure of the uterus to stay firmly contracted

• Slow, steady or massive hemorrhage• Underestimated blood loss• May be hidden behind blood clot

• Treatment• Uterine massage• IVF, Oxytocin • Surgery – curettage, ligation, hysterectomy• Retained Placental Fragments

• Partial separation caused by:• Pulling on cord• Uterine massage prior to separation• Placenta accreta

• Treatment:• Uterine massage• Manual removal• Oxytocin, Methergine • D & E• Most common cause of Late PP Hemorrhage• Late PP Hemorrhage

• Occurs 24 hrs. – 6 wks after delivery• Causes:

• Irritation at placental healing site due to retained placental fragments or fibrin deposits• Subinvolution of placental site

• Symptoms:• Excessive, bright red bleeding (return)• Boggy fundus with large clots• Backache• Increase T,P,R – decreased B/P

• Treatment:• Massage, IV Oxytocin, D&E• Hematomas

• Results from injury to blood vessel• Usually in vagina or vulva• May extend to other pelvic structures

• Develop rapidly• May contain 300 – 500cc blood• Commonly caused by vac or foreceps

• Symptoms:• Severe pain • Difficulty voiding• Mass felt on vaginal exam• Flank pain• Abdominal distention• Shock

• Treatment: Ice to area, I&D, Incisional packing• Subinvolution of Uterus

• Uterus remains large, does not involute • Causes:

• Retained placental fragments• Infection

• Symptoms:• Lochia fails to progress – returns to Rubra • Leukorrhea – backache and infection

• Treatment:• Methergine • Curettage • Antibiotics - IVF

• Postpartum Infections• Temp of 101 or higher in first 24hrs following delivery• Temp of 100.4 or higher for 2 days during the next 10 days postpartum• Types: Endometritis

Parametritis, Peritonitis Pyelonephritis / Cystitis Thrombophlebitis Mastitis

• Predisposing factors (not on test) Antepartal/Intrapartal Hx of infections Prolonged labor / PROMAnemia Vacuum/Forceps deliveryImmunodeficiency Diabetes / HTNPoor nutrition Multiple Vag ExamsPostpartalInternal MonitoringManual removal of Episiotomyplacenta Cesarean sectionHemorrhage Poor aseptic techniqe Retained placenta Localized IV site phlebitis EpisiotomyDiabetes LacerationsC/S incision

• Endometritis • Infection of the uterine lining-placental site • Most common pp infection. • Sometimes secondary to chorioamnionitis

• Reason why we normally administer antibiotic• prophylaxis on C/S patients after the cord is• clamped • Pyelonephritis/UTI

• Kidney infection – usually R kidney• UTI – Common after delivery

• Spiking temps - Chills• Flank pain• Nausea and vomiting• Urgency, frequency, dysuria

Prevention/Treatment: Antibiotics• Force fluids• Insure complete emptying of bladder

• It can be very difficult and uncomfortable to cath a pt after a vaginal delivery. • Sterile technique for cath

• Educate patients to change pads frequently, proper wiping and perineal care• Thrombophlebitis • Blood clot associated with bacterial infection.

• Superficial• Deep Vein Thrombosis• PE

Symptoms TreatmentBedrest? Elevate extremity Tenderness Heattachycardia TED’s / SCD’sHot to touch AnalgesicsLow grade fever Bedrest? +/- Homan’s Hot to touchRedness

• DVT• Symptoms

• Low grade fever• Edema• Chills• Extremity pain below clot• Decreased peripheral pulse

• Dx: LEVD• Treatment

• Heparin (DOC if breastfeeding) /Coumadin (cannot breastfeed)• TED’s• Bedrest • Elevate extremity• Analgesics

• Pulmonary Embolism - EmergencySudden onset TreatmentChest Pain Call MDDyspnea, SOB OxygenSweating Morphine SulfatePallor – Cyanosis Aminophylline Confusion HeparinHypertension StreptokinaseCough/hemoptysis TachycardiaSense of “impending death”.

• DIC - Disseminated Intravascular Coagulation (clotting anticoagulant dysfunction) • Increased prothrombin / platelets• Widespread formation of clots with • Severe generalized hemorrhaging• Life threatening!• Predisposing factors:

• PIH• Septic shock• Placental/Uterine hemorrhage• IUFD• Amniotic fluid embolism• Thrombi secondary to preeclampsia• Thrombi secondary to Thrombophlebitis

• Early s/s• Increased PT• Thrombocytopenia• Bleeding – gums, puncture sites• Ecchymosis • Treatment• Very complex• Transfusions – PRBC, Plasma, Whole blood, Fibrinogen• Mastitis

• Infection of breast connective tissue, occurs mainly in lactating women• Infectious mastitis, more serious, fever, flu like symptoms, reddened area of breast• Symptoms seldom occur prior to 2 weeks post delivery• Infection usually due to breast trauma, cracks in nipples• Treatment

• Do not stop breastfeeding• Heat• Pump breast to avoid engorgement• Analgesics• Antibiotics

• Postpartum Depression/Psychosis • Postpartum psychosis

• most serious disorder• psychiatric emergency

• Postpartum anxiety disorders• occurs in patients with past history of panic disorder or obsessive compulsive disorder

• Observe for signs of depression• Overwhelmed feeling, unable to cope, fatigued, anxious, tearful

• Observe for signs of psychosis• Mood lability, agitation, insomnia, irrational, poor judgment• Administer a depression scale or inventory