Unit 2- Normal Postpartum

Normal Postpartum Module Overview

1. In this module, we will examine normal adaptation and nursing care in the postpartum period.

Chapter 20 – pp. 399-429
Chapter 23 – pp. 487-506

Objectives

1. Describe the normal changes that occur during the postpartum period for each body system to return to the non-pregnant state.

Cardio Vascular System

• Cardiac output:

  • There is a transient increase in cardiac output after childbirth.

  • Excess plasma volume is eliminated by diuresis (increased urination) and diaphoresis (increased sweating).

  • Gradually, cardiac output decreases and returns to normal within 6–12 weeks.

  • Postpartum, women experience more urine output and sweat production.

  • There is a decreased cardiac output in the 6–12-week timeframe, leading to increased risk for clotting due to elevated coagulation factors.

Coagulation

• Coagulation factors are increased which predisposes postpartum women to clot formation.

Gastrointestinal System

• An increase in hunger after birth can be attributed to energy expenditure during labor.

• Constipation may occur due to several factors:

  • Decreased food and fluid intake during labor.

  • Reduced muscle and bowel tone post-delivery.

  • Fear of pain during defecation.

  • Increased risk of constipation because peristalsis slows down during labor.

  • Stitches in the patient may cause hesitancy in having a bowel movement.

First stool tends to occur 2–3 days post-birth.

Urinary System

• Diuresis occurs after childbirth which may cause urinary retention due to:

  • Increased bladder capacity as the bladder was compressed during pregnancy.

  • Emptying the bladder is essential for better fundus palpation.

  • Decreased awareness of fluid pressure can lead to stasis of urine, raising the risk for bacterial growth and urinary tract infections.

• Distended bladder can displace the uterus leading to excessive bleeding.

• Signs of a distended bladder include:

  • Fundus location above baseline level.

  • Fundus displaced from midline, often to the right side.

  • Excessive lochia (vaginal bleeding).

  • Bladder discomfort.

  • Bulge of bladder above symphysis.

  • Frequent voiding resulting in less than 150 ml of urine, potentially indicating urinary retention with overflow or urge incontinence.

Musculoskeletal System

• During the first 1–2 days after childbirth, new mothers may experience muscle fatigue and aches.

• Abdominal wall:

  • Possible diagnosis of diastasis recti (separation of the abdominal wall).

  • Doctor clearance is required before undertaking strenuous exercises.

  • Exercises to strengthen abdominal muscles are encouraged.

• Musculoskeletal discomfort can be alleviated through good posture and proper body mechanics, such as lifting with legs rather than back.

Integumentary System

• Skin gradually returns to its non-pregnant state.

• Diaphoresis helps rid the body of excess fluids after delivery.

• Stretch marks (striae gravidarum) may fade but do not disappear completely.

• Loss of hair post-delivery is a normal response to hormone changes, beginning 4–20 weeks after delivery, and can regrow in 6–15 months.

  • It is important to reassure patients that hair shedding is a common phenomenon.

Neurological System

• Complaints of headache require careful assessment as:

  • Bilateral and frontal headaches are common; they can be attributed to changes in fluid and electrolyte balance or spinal headaches due to anesthesia.

  • Blurred vision, photophobia, and abdominal pain can indicate preeclampsia.

Endocrine System

• Hormonal changes post-delivery include:

  • Decrease in human chorionic gonadotropin (hCG), produced by the ovum.

  • Fall in estrogen and progesterone levels.

  • Increased levels of prolactin (which initiates milk production) and oxytocin (the love hormone aiding in bonding and milk ejection reflex).

• The resumption of ovulation and menstruation may be delayed by breastfeeding; ovulation may occur before the first menstrual cycle.

Postpartum Assessment and Nursing Care

2. Identify the critical elements of a systematic postpartum assessment and nursing care during the postpartum period:

   • Postpartum assessments begin during the fourth stage of labor, within the first 1-2 hours after childbirth.

   • Assess the physical stability of the mother, including vital signs:

     • Blood pressure: An increase may be due to pain or anxiety; a reading of 140/90 mmHg or greater may indicate pre-eclampsia.

     • A decrease may signal dehydration or hypovolemia due to excessive bleeding.

     • Assess for orthostatic hypotension where blood vessel engorgement contributes to a rapid decrease in BP by 15-20 mm Hg.

     • An intervention is to dangle the patient, stand slowly, and return to bed.

     • Monitor pulse:

     • bradycardia is normal for some women in the first 6-10 days postpartum,

     • while tachycardia can indicate various conditions such as pain or infection.

     • Assess respirations: especially in mothers with a history of respiratory issues or C-sections.

     • Temperature elevation might occur due to epidural use or elevated WBC counts.

     • Be alert for signs of afterpains, perineal discomfort, and breast tenderness.

Breasts Assessment

• Palpate breasts for abnormalities: Dark nipples should show no cracks or bleeding. Breasts will appear firmer after the first 3 days and are nontender.

Uterus Assessment

• The uterus should be firm at the level of the umbilicus.

Bladder Assessment

• Palpation may reveal a bulge indicating a distended bladder.

Bowels Assessment

• Assess for signs of constipation from medications.

Lochia Assessment

• A constant trickle, dribble, or oozing of lochia indicates excessive bleeding necessitating immediate attention.

• Excessive lochia alongside a contracted uterus suggests lacerations within the birth canal that require notification to the healthcare provider (HCP).

• The normal odor of lochia is characterized as “fleshy”, “earthy”, or “musty”; any foul odor suggests endometrial infection.

Episiotomy Assessment

• Examine the laceration site for signs of infection or bleeding.

Emotional Status Assessment

• Assess for sensitivity and potential postpartum depression (PPD).

Interventions

• Provide comfort measures, which may include:

  • Ice packs, Sitz baths, perineal care, topical medications, and sitting measures such as Kegel exercises.

  • Analgesics should include NSAIDs for pain management.

Comparison of Nursing Assessment, Care, and Expected Outcomes for Cesarean and Vaginal Birth

3. Compare nursing assessment, care and expected outcomes for women who have undergone cesarean birth and vaginal birth:

Nursing Assessment Cesarean Birth

• Evaluate the effectiveness of pain medication.

• Frequent respiratory assessments due to narcotics depressing respiratory function.

• Auscultate the abdomen for bowel sounds until normal peristalsis resumes in all quadrants.

• Monitor incision site for infection, bleeding, or dehiscence.

• Monitor vital signs, urine output, and pain, particularly related to the surgical site.

• Assess uterine involution, lochia, and abdominal tenderness.

• Evaluate the emotional state, support system, and readiness for infant care, as cesarean birth may be emotionally taxing.

Nursing Care Cesarean Birth

• Manage pain using prescribed medications and non-pharmacological methods.

• Ensure continued evaluation of respiratory status, especially if elevated respiratory rate is noted.

• Encourage early ambulation to prevent thromboembolism and strengthen recovery.

• Support breastfeeding while ensuring comfort regarding incision pain.

• Educate on wound care and signs of infection at home.

• Promote rest, nutrition, hydration, and infant care support.

• Prevent abdominal distention through early ambulation, tightening and relaxing abdominal muscles, Kegel exercises, and avoiding carbonated drinks.

Expected Outcomes Cesarean Birth

• Incision heals correctly without infections or dehiscence.

• Uterus contracts well with normal bleeding levels.

• Pain is managed; mother can perform self-care and infant care by discharge within 24 hours.

• No major complications like thromboembolism, severe infection, or wound separation.

• The mother verbalizes understanding of home care and signs to watch for.

Nursing Assessment Vaginal Birth

• Assess vital signs.

• Evaluate fundus consistency and location (should be firm and near umbilical level).

• Assess lochia quantity, color, and odor, observing peri pads while checking the perineum.

• Assess perineum for lacerations, episiotomy, swelling, or hematoma using REEDA:

• Redness,

• Edema,

• Ecchymosis,

• Discharge,

• Approximation

• Monitor uterine involution, lochia, and bladder function; signs of bladder distention include:

  • Fundus above baseline, .

  • midline displacement,

  • excessive lochia,

  • bladder discomfort,

  • bulge above symphysis,

  • frequent voiding of < 150 mL of urine.

• Evaluate for discomfort, pain, energy levels, emotional state, and readiness for infant care.

• Check for signs of postpartum hemorrhage and infections.

Nursing Care Vaginal Birth

• Provide perineal care using ice packs and sitz baths, particularly if lacerations or episiotomies are present.

• Educate on proper hygiene to avoid infections.

• Support early and frequent breastfeeding.

• Encourage early ambulation and healthy nutrition.

• Address bladder elimination issues due to labor trauma or anesthesia.

• Promote bladder elimination through early mobilization after childbirth.

Expected Outcomes Vaginal Birth

• Perineal area heals well without excessive pain or infection.

• Uterus involutes effectively, lochia decreases, and vital signs stabilize.

• Early bonding through breastfeeding is established.

• Mother is able to ambulate and care for herself and her infant soon after delivery.

• The patient is educated about postpartum warning signs and can demonstrate understanding of self-care instructions by the time of discharge.

Common Postpartum Laboratory Tests and Expected Findings

4. Describe common postpartum laboratory tests and expected findings:

• Hemoglobin and Hematocrit:

  • Post-birth, hemoglobin and hematocrit levels may drop initially due to blood loss but typically stabilize within a few days.

  • Values should not fall below normal thresholds to avoid indicating excessive blood loss or postpartum hemorrhage.

• White Blood Cell Count (WBC):

  • Can elevate postpartum, sometimes reaching 20,000-25,000/mm³ due to physiological stress from childbirth.

  • Elevated levels without clinical symptoms do not indicate infection immediately postpartum.

• Platelets and Coagulation:

  • Platelet counts may slightly decrease post-birth but should remain at or just below the normal range.

  • Coagulation factors remain elevated postpartum, contributing to an increased risk for thromboembolic events in the early days post-delivery.

• Urinalysis:

  • Assesses for protein, glucose, and possible urinary tract infection.

  • Trace proteinuria or glucosuria can be normal immediately postpartum; persistent abnormalities require evaluation.

• Additional Labs Depending on Clinical Indication:

  • Blood type and antibody screening, especially if not previously documented.

  • Serum glucose in women with diabetes or those at risk for hypoglycemia.

Expected Lab Value Trends (Reference: Maternal-Child Nursing 6th ed.)

Maternal Psychosocial Adaptation and Parent-Infant Attachment

5. Explore characteristics and factors that influence maternal psychosocial adaptation and the development of parent-infant attachment:

• Taking-in Phase:

  • Mother focuses on personal needs for food and sleep, typically showing passive dependent behavior lasting 1-2 days.

• Taking-hold Phase:

  • The mother becomes more independent and focused on self-care, often expressing anxiety about her competence as a mother.

  • Nurses should avoid taking over infant care and instead encourage the mother’s involvement with caretaking tasks.

• Letting-go Phase:

  • The mother relinquishes previous roles and adjusts to any disappointments.

Nursing Care Related to Lactation

6. Examine nursing care related to lactation including teaching, assessment, and nursing interventions:

• Lactation Assessment:

  • Initial assessments focus on breast anatomy, maternal and infant readiness to breastfeed, and any physical barriers to effective feeding.

  • Observations should include proper latch, infant positioning, audible swallowing, and mother’s comfort during breastfeeding.

  • Utilizing tools like the LATCH assessment tool can aid in evaluating breastfeeding effectiveness by evaluating:

  • latch,

  • audible swallowing,

  • nipple type,

  • comfort, and

  • hold.

  • Assess for maternal pain, cracked nipples, engorgement, and signs of mastitis or infection.

  • Evaluate infant output (voids and stools) and satiety cues as well as monitor weight changes indicating adequate milk intake.

• Teaching for Successful Lactation:

  • Educate mothers about breastfeeding benefits while using evidence-based and family-centered approaches.

  • Instruct on hand hygiene, breast care, and signs indicating correct latching and effective feeding.

  • Demonstrate different holds (cradle, cross-cradle, football, side-lying) and correct latch techniques that ensure comfort for the mother.

  • Teach the signs of adequate feeding such as swallowing sounds, the presence of milk in the infant's mouth, and signs of satiety.

  • Encourage feeding on demand, recommending frequency at around 8–12 times daily and explaining normal feeding patterns for newborns.

  • Explain expressing and storing breast milk for instances when the infant is unable to nurse directly.

• Nursing Interventions:

  • Aid in initiating breastfeeding within the first hour post-birth for healthy newborns, promoting skin-to-skin contact.

  • Provide hands-on support for achieving a deep latch and comfortable positioning.

  • Address common breastfeeding challenges such as engorgement, sore nipples, low milk supply, or infant latching difficulties.

  • Encourage frequent feeding to support milk production and relieve engorgement.

  • Advocate for rooming-in and minimizing separation of mother and infant to facilitate demand feeding.

  • Track daily infant weights and elimination patterns and alert providers to signs of insufficient milk intake.

  • Refer to lactation consultants for persistent challenges or specialized needs.

• Key Considerations:

  • Respect maternal choices regarding feeding methods and provide nonjudgmental support.

  • Incorporate education for partners and family members to support a nurturing home environment.

  • Consider cultural preferences and barriers when providing lactation education and support.

Hospital Discharge Criteria

7. Examine the criteria for discharge from the hospital after delivery including patient teaching, follow-up care, and community resources:

• The patient should have no active complications.

• Labs must be reviewed including hemoglobin or hematocrit levels, ensuring Rh (D) immune globulin has been administered if applicable.

• Teaching:

  • Provide education on postpartum activity, exercise, and relief of postpartum discomfort.

  • Teach warning signs to monitor post-discharge.

  • Discuss postpartum follow-up plans and available support at home.

Learning Guide

• Begin this module by reviewing the learning objectives and reading the assigned textbook chapters:

  • Chapter 20 – pp. 399-429

  • Chapter 23 – pp. 487-506

• Attend the in-person lesson and review associated lecture slides.

• Supplemental learning activities are available at the bottom of the module.

• Post any questions to the Q & A section of the Discussion Board.

• Watch the video: Postpartum Assessment and Interventions.