ch 16 Postpartum Nursing Management

Bonding

• Close emotional attraction to a newborn by the parents that develops the first 30 to 60 minutes after birth

• Unidirectional, from parent to infant

• the infant is in a quiet, alert state, looking directly at the person holding them

• completely normal to take a few days, a few weeks, or several months to feel that special _______

Attachment

• Strong affection develops between an infant and a significant other (parent, sibling, caregiver)

  • psychological, not biologic

• reciprocal; both the newborn and significant other exhibit these behaviors

• Progressive process, evolving over time, not immediate

• A unique, multifactorial process influenced by infant health, birthing parent, environment, and quality of care

  • complicating factors: stress, no support system, separation, substance use, a traumatic birth experience, unwanted outcome

• newborn responds with cooing, grasping, smiling, and crying

• Maternal _______ begins during pregnancy

postpartum assessment - during the first hour

assess every 15 mins

postpartum assessment - during the second hour

assess every 30 mins

postpartum assessment - during the first 24 hours

assess every 4 hours

postpartum assessment - after the first 24 hours

follow the institutions protocol

Risk Factors for Postpartum Infection

• Operative procedure (forceps, cesarean birth, vacuum extraction)

• History of diabetes, including gestational-onset diabetes

• Prolonged labor or ROM (more than 24 hours)

• Use of indwelling urinary catheter

• Anemia (hemoglobin <10.5 mg/dL)

• Multiple vaginal examinations during labor

• Manual extraction of placenta

• Compromised immune system (HIV-positive)

Risk Factors for Postpartum Hemorrhage

• Operative procedures (vacuum extraction, forceps, cesarean birth)

• Precipitous labor (less than 3 hours)

• Uterine atony

• Placenta previa or abruptio placenta

• Labor induction or augmentation

• Retained placental fragments

• Prolonged third stage of labor (more than 30 minutes)

  • delivery of placenta

• Multiparity, more than three births closely spaced

• Uterine overdistention (large infant, twins, hydramnios)

• Obesity

Precipitous labor

a rapid and unexpected delivery that occurs within three hours of the onset of regular contractions

Postpartum Danger Signs

• Fever > 100.4°F (38°C)

• Foul-smelling lochia or an unexpected change in color or amount

• Large blood clots or bleeding that saturates a peripad in an hour

• Swelling, redness, or discharge at the episiotomy, epidural, or abdominal sites

• Severe headaches or visual changes that do not go away

• Calf pain with dorsiflexion of the foot (foot towards head)

• Sudden weight gain

• Feeling faint, dizzy, or weak

• Rapid HR

• Dysuria, burning, or incomplete emptying of the bladder

• SOB or difficulty breathing without exertion

• Depression or extreme mood swings

Vital Signs Assessment - temperature

• slight elevation during first 24 hours; normal afterward (possibly with the help of replacement fluids)

  • may be due to dehydration secondary to fluid loss, sweating, diaphoresis, or the systemic absorption of metabolites accumulated due to muscle contractions

Vital Signs Assessment - Pulse

• 60-80bpm = normal during the first week after birth

  • 40-60bpm possible in the first few days

    • puerperal bradycardia = a temporary decrease in HR in postpartum individuals, usually within the first 7–10 days after birth

• >100 bpm warrants further investigation

• may be elevated if temp is elevated

Vital Signs Assessment - Respirations

• should be within normal range of 12-20 bpm at rest

• Pulmonary function returns to prepregnant state after childbirth when the diaphragm descends and the organs revert to their normal positions

• Lungs should be clear on auscultation

Vital Signs Assessment - BP

• should be within usual range, report any deviations from baseline

• assess in the same position every time

• should remain the same immediately after childbirth as it did during labor

• an increase = possible gestational HTN

• a decrease = dehydration, shock, orthostatic hypotension, or a side effect of epidural anesthesia

• preeclampsia = ___ gradually returns to normal levels following childbirth

  • Postpartum onset may occur from 2 days to 6 weeks following birth

  • higher than 140/90 mmHg = further investigation

Vital Signs Assessment - Pain

• use numeric scale (0-10), goal is between 0-2

• assess type, location, and severity

• focus on providing comfort measures

  • perineal care, a clean gown, mouth care, providing warm blankets, ensuring adequate fluid intake to facilitate healing, repositioning frequently, and encouraging rest between assessments

physical assessment - breasts

• Inspect for size, contour, asymmetry, engorgement, or erythema

• Check the nipples for cracks, redness, fissures, or bleeding; note whether they are erect, flat, or inverted

  • Flat or inverted nipples can make breastfeeding challenging for both parent and infant

  • Cracked, blistered, fissured, bruised, or bleeding nipples usually indicate poor latching due to improper positioning

Lactogenesis

the onset of milk secretion

physical assessment - Uterus

• assess height and firmness of fundus which should be midline

• boggy or relaxed fundus = uterine atony (loss of muscle tone in the uterus)

  • possible result of bladder distention (displaces the uterus upward and to the right) or retained placental fragments

• fundus 1-2 hours after birth = between umbilicus and symphysis pubis

• fundus ~6-12 hours after birth = at the level of the umbilicus

• fundus above umbilicus = unexpected finding and warrants further investigation immediately to prevent excessive bleeding

  • patients bladder may be full

the fundus progresses downward at a rate of ___ per day after childbirth and should be nonpalpable by ________ postpartum

1cm; 10 to 14 days

where is the fundus 1-2 hours after birth?

between umbilicus and symphysis pubis

where is the fundus ~6-12 hours after birth?

• at the level of the umbilicus

  • blood, clots, and tissue in the uterus cause it to temporarily rise to the umbilicus

the uterus has descended below the rim of the symphysis pubis by day ___ postpartum

14

what if the fundus is above the umbilicus?

• it’s an unexpected finding and warrants further investigation immediately to prevent excessive bleeding

• patients bladder may be full

physical assessment - bladder

• Diuresis (up to 3,000 mL/day) starts within 12 hours postpartum and lasts several days to 2 weeks

• Voiding should be encouraged, even if they dont have to go

  • pt doesn’t feel the urge → bladder distension → uterus displacement (upward and to the side) → prevents uterine contraction → risk of excessive bleeding

• Postpartum urinary retention: the inability to empty the bladder within 6 hours after a vaginal birth

Postpartum urinary retention

the inability to empty the bladder within 6 hours after a vaginal birth

physical assessment - Bowels

• Spontaneous bowel movements may not occur for 1-3 days after giving birth

  • elevated progesterone levels decrease intestinal muscle tone

• Constipation = most common GI symptom in postpartum people

  • caused by local pelvic floor trauma, pain medications, and lack of dietary fiber and fluids

physical assessment - Lochia

• assess amount, color, odor, and change with activity and time

  • weigh the peri pads, ask how many they used in the past 1-2 hours, and how much drainage was on each pad

  • normal = musky scent without any large clots (fist size); smells like a normal menstrual period

    • Foul-smelling = infection

    • large clots = poor uterine involution

• flow will increase when pt gets out of bed and during breastfeeding (oxytocin release causes uterine contractions)

physical assessment - Episiotomy and perineum

• assess q8h for irritation, ecchymosis, tenderness, lacerations, or hematomas

  • Assess for hemorrhoids and their condition if applicable

  • assess laceration degree (separate flashcards)

• redness, swelling, a white line, and drainage at the incision site may mean infection

• peri area is typically swollen and slightly bruised during early postpartum period

• position the patient on their side with their top leg flexed upward at the knee and drawn up toward their waist

First-degree laceration

involves only skin and superficial structures above muscle

Second-degree laceration

extends through perineal muscles

Third-degree laceration

extends through the anal sphincter muscle

Fourth-degree laceration

continues through anterior rectal wall

physical assessment - Extremities

• Pregnancy = increased risk of venous thromboembolism (VTE), which includes PE and DVT, due to hypercoagulability which protected mom against excessive blood loss during childbirth and placental separation

  • comorbidities, lifestyle factors, and pregnancy complications, and other factors can further increase the risk of VTE

• during inspection, also determine the degree of sensory and motor function return (recovery from anesthesia)

  • a spinal block makes them less likely to feel anything or be moving around

physical assessment - Emotional status

• Be alert for mood swings, irritability, or crying episodes

• Assess by observing their:

  • interaction with family

  • level of independence

  • energy levels

  • eye contact with their infant (within a cultural context)

  • posture and comfort level while holding the newborn

  • sleep and rest patterns

stages of attachment

proximity, reciprocity, and commitment

stages of attachment - proximity

• the physical and psychological experience of the parents being close to their infant

• this attribute has 3 dimensions:

  • Contact: touching, holding, and gazing at the infant

  • Emotional state: emerges from the affective experience of the new parents toward their infant and the parental role.

  • Individualization: Parents learn to differentiate the infant’s needs from their own, recognizing and responding appropriately, making attachment also a process of detachment.

stages of attachment - reciprocity

• the process by which the infant’s abilities and behaviors elicit parental response

• 2 dimensions:

  • complementary behavior: involves taking turns and stopping when the other is not interested or becomes tired

  • sensitivity: parents who are sensitive and responsive to their infant’s cues will promote their development and growth

stages of attachment - commitment

• the enduring nature of the relationship

• 2 dimensions:

  • centrality: parents place the infant at the center of their lives

  • parent role exploration: the parents’ ability to find their own way and integrate the parental identity into themselves

cold application

• commonly the first measure used after a vaginal birth to relieve perineal discomfort from edema, an episiotomy, or a laceration

  • also helps reduce discomfort from hemorrhoids

• can be used for the first 24 hours intermittently, 20 minutes on then 10 minutes off

Hydrotherapy

the external use of any form of water for health promotion or treatment with varying temperatures, duration, and application sites

Suri-Gators

• hygienic sitz baths that spray an antiseptic, water, or both onto the perineum

• patient sits on the toilet with their legs apart so that the nozzle spray reaches their perineal area

Topical Preparations

• these agents numb the perineal area and are used after cleansing the area with water via the peribottle and/or a sitz bath

• applied for temporary relief of perineal pain and discomfort

• ex: local anesthetic spray such as benzocaine topical

Pharmacologic methods used to reduce hemorrhoid pain

• local anesthetics (dibucaine)

• steroids (hydrocortisone acetate)

• stool softeners help to prevent constipation

Nonpharmacologic methods used to reduce hemorrhoid pain

• cold application (ice packs, ice sitz baths, cool witch hazel pads)

• consume large amounts of water and eat high-fiber foods and fruits

• perform frequent ambulation

• utilize proper toileting habits and avoid straining during defecation

postpartum, avoid jarring and bouncing movements because joints do not stabilize until _______ postpartum

6 to 8 weeks

Exercising too much too soon postpartum can cause the person to bleed more, and their lochia may return to _______

bright red

postpartum analgesics

• mild discomfort → acetaminophen or oral NSAIDs (ibuprofen, naproxen)

• moderate to severe pain → codeine or oxycodone with aspirin or acetaminophen

Administering a mild analgesic approximately ______ before breastfeeding will usually relieve afterpains and/or perineal discomfort

an hour

Ways to support parental rest and sleep

• sleep when the infant does

• Reduce participation in outside activities

• limit the number of visitors

• Encourage infant daytime wakefulness to improve nighttime sleep.

• balanced diet = promotes healing and increases energy levels

• Share household tasks to conserve energy

• Have family members assist with nighttime infant care so parents can rest uninterrupted, if not breastfeeding.

• “cluster” daily activities to conserve energy and promote rest

benefits of a regular exercise program

• Helps the person lose pregnancy weight

• Increases overall postpartum well-being

• Reduces the risk of postpartum depression

• Maintains cardiovascular fitness

• Reduces mental fatigue

postpartum obstacles to exercising

• physical changes (ligament laxity: looseness or increased flexibility of the ligaments)

• competing demands (newborn care)

• lack of information about weight retention (inactivity equates to weight gain)

• stress incontinence (leaking of urine during activity)

Routine exercise should be resumed gradually, beginning with pelvic floor muscle exercises on the _____ day postpartum and by the ______ week , progressing to abdominal, buttock, and thigh-toning exercises.

first ; second

excessive exercise

• avoids jarring and bouncing movements because joints do not stabilize until 6 to 8 weeks postpartum

• can increase bleeding and cause lochia to turn bright red

  • pt should stop exercising and rest lying down until the bleeding slows

Recommended exercises for the first few weeks postpartum

• abdominal breathing

• head lifts, modified sit-ups, double knee roll, and pelvic tilt

vaginal delivery can cause ___________

stress incontinence

Lifestyle changes to help prevent stress incontinence

• begin regular pelvic floor muscle training exercises after childbirth.

• Increase physical activity daily.

• bladder retraining = lengthens amount of time between voidings (scheduled voiding).

• Lose weight if necessary; obesity is associated with stress incontinence.

• Limit bladder irritants (alcohol, caffeine)

• Maintain fluid intake of 64oz per day.

• Avoid constipation

kegel exercises → strengthen muscles of pelvic floor → improves ___________

urethral sphincter function

Avoid using _______ after giving birth to decrease the risk of infection.

tampons

Avoid tub baths for _______ until joints and balance are restored to prevent falls

4 to 6 weeks

orthostatic hypotension safety before ambulation

• instruct pt to place baby back in the crib on their back if the pt is feeling sleepy to prevent a fall.

• Check BP first

• Check for low h&h

• Elevate HOB for a few minutes

• Have the patient sit on the side of the bed

• Help the patient to stand up, and stay with them.

• Ambulate alongside the patient and provide support if needed.

• Frequently ask the patient how their head feels.

sexual intercourse can be resumed when?

• once bright red bleeding has stopped and the perineum is healed from an episiotomy or lacerations

  • usually 3-6 weeks postpartum

• there is no set time to resume

hormonal contraceptives in breastfeeding people

• Progestin-only _______ appear to have no effect on the quality or quantity of milk

• Estrogen–progestin _________ are not ideal during lactation

  • reduces the quantity and quality of milk

  • may increase the risk of DVT

  • If used, start after 6 weeks postpartum once lactation is established

The breastfeeding person’s nutritional needs are ______ than they were during pregnancy

higher

breastfeeding - calories requirements

+400 _____ daily for the first 6 months, then +380 _____ daily thereafter

breastfeeding - calcium requirements

• 1,000mg daily

• 1,300mg daily for adolescent females

• ~4+ servings of milk

breastfeeding - iodine requirements

• 290 mcg daily

• kale and cruciferous veggies, iodized table salt

breastfeeding - omega-3 fatty acids requirements

• 200-300mg daily

• 2 servings of low-mercury fish weekly

People Who Should Not Breastfeed

• illicit drugs (opioids, cocaine, or phencyclidine (PCP))

  • ppl who are stable on methadone treatment may breastfeed

• HIV infection without antiretroviral therapy

• active herpes infections on their breast

  • dont breastfeed from the affected breast

• Whose newborn has galactosemia

• mpox or brucellosis infection

• active TB or varicella infection

kangaroo care

skin-to-skin contact

breastfeeding suggestions

• Choose a quiet, undisturbed space.

• Use a rocking chair to soothe both you and your infant.

• Take long, slow deep breaths to relax before nursing.

• Drink water while breastfeeding to replenish body fluids.

• Listen to soothing music while breastfeeding.

• Cuddle and caress the infant while feeding.

• Keep extra cloth diapers nearby for burping.

  • Ensure mom has everything she needs within reach

• Allow sufficient time to enjoy each other in an unhurried atmosphere.

• Involve family in the baby's care

  • only mom can breastfeed so make sure family is helping with other things

• Reach out to local support groups like La Leche League for advice, guidance, and support

overweight/obese women have lowered ____ responses to an infant sucking, thus milk production may be inhibited.

prolactin

commercial formula classifications

• cow’s milk-based

• soy protein-based

• specialized or therapeutic formulas for infants with protein allergies

commercial formula

• comes in various forms:

  • powdered (must be mixed with water)

  • condensed liquid (must be diluted with equal amounts of water)

  • ready to use (poured directly into bottles)

  • prepackaged (ready to use in disposable bottles)

• supply about 20 kcal/oz, so a newborn will need 2-4 oz to feel satisfied at each feeding

• Meets infants' nutritional needs from birth to 12 months

• ingredients are carbs, oils/fats, protein, minerals, and vitamins

infant formula’s supply about ____ kcal/oz, so a newborn will need ____ oz to feel satisfied at each feeding

20 ; 2-4

Newborns need how many calories/kg daily?

about 110-135

Until ~4 months of age, most bottle-fed infants need ___ feedings a day, which decreases thereafter

6

bottle feeding guidelines

• Wash hands thoroughly and use clean bottles and utensils.

• Make feeding a relaxing, bonding time

• refrigerate and mix powdered formula with room-temperature water for better dissolving

• never microwave formula (causes uneven hot spots)

• Always hold the baby while feeding; never prop the bottle

• Use a comfortable, safe position to prevent choking and ear infections

  • Never put baby with a bottle to bed (causes prevent tooth decay)

• Keep the bottle tilted to avoid excess air intake

• Avoid placing any food in the bottle

• Discard any leftover formula 1 hour after feeding; do not reuse

• Burp frequently and place the baby on their back for sleep

• dont force feed

• Never dilute formula (causes water intoxication)

breast care - breastfeeding mom

• warm shower and message

• should wear a supportive bra throughout the lactation period

• Use plain water to clean breasts; avoid soap as it dries the skin

breast care - non-breastfeeding mom

• ice and analgesics

• wear a supportive bra until engorgement subsides, then switch to a less restrictive one

• Use plain water to clean breasts; avoid soap as it dries the skin

• Reduce salt intake to decrease fluid retention

breast engorgement decreases as increasing _______ levels suppress milk formation

estrogen

Postpartum blues

• a phase of emotional lability characterized by crying episodes, irritability, anxiety, confusion, and sleep disorders

• typically mild and transient with a short duration

• Symptoms usually arise within 7 to 10 days after childbirth

  • counseling may be needed if not resolved after 2 weeks

Discharge criteria

• afebrile, vital signs within normal range

• Lochia = appropriate amount and color for stage of recovery

• voiding adequately and without difficulty

• h&h are normal

• fundus is firm

• Surgical wounds are healing, and no signs of infection are present.

• ambulation without difficulty.

• Food and fluids are taken without difficulty

• pt has been made aware of possible complications

• infant is feeding well.

• Self-care and infant care are understood and demonstrated.

• ABO blood groups and RhD status are identified, and if needed, anti-D immunoglobulin is given within 72 hours post-childbirth

  • signed consent required (it is a blood product)

• Family or other support system is available to care for both.

• check pts immunity status for rubella, give a subq injection of rubella vaccine if they are not serologically immune (titer less than 1:8)

  • unless pt or close contacts are immunocompromised

  • tdap and flu are also recommended

  • for breastfeeding and non-breastfeeding pts

Telephone follow-up typically occurs during _______ after discharge to check on how things are going at home.

the first week

An office visit for a pt with an uncomplicated vaginal birth is usually scheduled for _____ after childbirth

4-6 weeks

An office visit for a pt with an uncomplicated cesarean birth is usually scheduled for _____ after childbirth

2 weeks

Newborn examinations and further diagnostic laboratory studies are scheduled within the ____ week

first

Home visits are usually made within ___ week after discharge to assess the parent and newborn.

1

Postpartum home visits - Maternal assessment

• vital signs, voiding status, abdominal and musculoskeletal status

• breast health and care, fundus and lochia status

• general well-being, psychological and coping status, family relationships

• proper feeding technique, environmental safety check, newborn care knowledge

• health teaching needed

Postpartum home visits - Infant assessment

• physical examination, general appearance, vital signs

• home safety check

• child development status

• education needed to improve parental skills

BUBBLE-EE

• used for postpartum head-to-toe

• breasts

• uterus

• bladder

• bowels

• lochia

• episiotomy/perineum/epidural site

• extremities

• emotional status

Postpartum assessment of the birthing parent typically includes:

• vital signs, pain level

• epidural site inspection for infection

• systematic head-to-toe review of body systems