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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

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postpartum nursing care

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
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 23–1Involution of the uterus. A, Immediately after expulsion of the placenta, the top of thefundus is in the midline and approximately halfway between the symphysis pubis and theumbilicus. 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 postpartum1
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
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
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
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
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
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
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
psychosocial changes1
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
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
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 assessment1
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
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 assessment1
Uterus Assessment

FIGURE 23–6 Measurement of descent of fundus for the woman with vaginal birth. The fundus is locatedtwo finger-breadths below the umbilicus. Always support the bottom of the uterus during anyassessment of the fundus.

bladder and bowel assessment
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 – 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
Episiotomy, Lacerations, C/S Incisions
  • Inspect the perineum for episiotomy/lacerations with REEDA assessment
  • Inspect C/S abdominal incisions for REEDA
    • R = redness (erythema)
    • E = edema
    • E = ecchymosis
    • D = drainage, discharge
    • A = approximation
postpartum nursing interventions
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
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 thefoot or leg is a positive Homans’ sign.

emotional status bonding assessment
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 interventions1
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
  • 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
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
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
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
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
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
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
  • 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

Figure 29–2 Four common breastfeeding positions. A, Football hold. B, Lying down. C, Cradling. D, Across the lap.

formula preparations
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
Bottle-Feeding Advantages
  • Provides good nutrition to infant
  • Father can participate in infant feeding patterns
bottle feeding disadvantages
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
  • 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 mother1
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
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 needs1
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
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
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
Discharge Instructions
  • S/S complications
  • PP Exercises
  • Rest
  • Avoid overexertion
  • Sexual activity
  • Hygiene
  • Sitz baths
  • Incision care
  • Referral numbers
  • Nutrition
  • PP appointment
  • Birth certificate info
  • Infant care
  • Infant complications
  • Infant follow-up
  • Family bonding
discharge teaching
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 teaching1
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
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
  • 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
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
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
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 teaching2
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
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
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
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
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 assessment1
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
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
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
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