The Healthy Postpartum Period

Introduction to the Healthy Postpartum Period

  • Speaker: Melissa Dyer, PhD, RN, MSN, MBA

Physical and Psychological Adaptations

Physical Adaptations

Reproductive System

  • Uterine Involution:
      - Complete process typically takes 6 weeks.

  • Placental Site Recovery:
      - Healing time for the placental site is also approximately 6 weeks.

  • Return of Menstruation:
      - Variable, generally begins 6-10 weeks if not breastfeeding.
      - Important consideration: A patient can still become pregnant before menstruation resumes.

Breasts

  • Lactation:
      - Initial milk is called colostrum.
      - Full milk production typically begins 3-5 days postpartum.

Abdomen/Gastrointestinal (GI) System

  • Bowel Sounds: May show decreased activity.

  • Monitoring Recommendations:
      - Assess for abdominal distention.
      - Decreased peristalsis attributed to progesterone levels.
      - Patients often experience anxiety regarding bowel movements (BMs).

Urinary Tract

  • Urinary Output: Generally increases significantly due to Puerperal Diuresis, often ranging between 2000-3000 ml.

  • Increased urination could be caused by:
      - IV fluid administration during labor.
      - Use of Pitocin which may lead to edema affecting voiding ability.

  • Monitor for complications:
      - Signs and symptoms (s/sx) of urinary tract infections (UTIs).

Cardiovascular Changes

  • Cardiac Output Stabilization:
      - Typically stabilizes within 1 hour postpartum.

  • Hypervolemia:
      - Initial states of high blood volume occur as blood flow no longer needs to supply the placenta.
      - Postpartum diuresis corrects this hypervolemia.

Laboratory Values

  • Hemoglobin and Hematocrit (H&H):
      - Interpretation can be challenging initially during the postpartum period.
      - Estimated Blood Loss (EBL) during childbirth is significant to monitor for complications.

  • White Blood Cells (WBCs): May show initial elevation.

  • Platelets: Typically show a reduction shortly postpartum.

Vital Signs

  • Temperature:
      - May rise to up to 38°C during the first 24 hours, usually due to exertion and dehydration.
      - Should stabilize to afebrile status after 24 hours.

  • Blood Pressure (BP):
      - Slightly elevated BP can be expected; low BP may suggest potential complications.

  • Pulse:
      - Slightly decreased pulse rate; tachycardia may indicate underlying issues.

Neurological Changes

  • Common indicators:
      - Headaches (HA) caused by:
        - Fluid shifts.
        - Hypertension (HTN).
        - Potential spinal headaches.

Weight Loss

  • Initial Weight Loss:
      - New mothers can expect a weight drop of 10-12 lbs (infant, placenta, fluid).

  • Postpartum Diuresis:
      - Contributes to an additional 5 lbs lost.

  • Weight Loss Timetable:
      - Complete weight loss often occurs by 6-8 weeks postpartum unless diet or exercise is modified.

After Pains

  • Uterine Contractions/Cramping:
      - Common after delivery, particularly in multiparous women.
      - Cramping may be exacerbated by the use of Pitocin and can occur during breastfeeding sessions.

Psychological Adjustments to Parenthood

  • Conceptual Framework by Rubin (1984):
      - Taking In: Passive phase where mothers allow others to make decisions.
      - Taking Hold: More active role in parenting is assumed, often requires reassurance from caregivers.

Nursing Assessment and Interventions

Postpartum Nursing Assessment

  • A systematic approach summarized as BUBBLEHE:
      - Breasts
      - Uterus
      - Bowel
      - Bladder
      - Lochia
      - Episiotomy/Laceration/C-Section Incision
      - Homan’s (DVT) assessment
      - Emotional status

Breast Assessment

  • Breast Consistency Assessment:
      - Soft, filling, firm, or engorged status.

  • Nipple Examination:
      - Examine for intactness: Reports of cracked, blistered, bruised—important for breastfeeding status.

Breast Care

  • Recommendations for care include:
      - Wearing a supportive bra, nursing on demand, use lanolin or hydrogel dressings if needed.
      - If not breastfeeding, avoid stimulation; ice packs can help alleviate discomfort.

Assessing the Uterus

  • Pre-Assessment Requirement: Client should void before the examination.

  • Positioning: Place head of the bed (HOB) flat for assessment.

  • Location Assessment: Determine the fundus' relation to the umbilicus.

  • Consistency Check: Determine if the fundus is firm or boggy.
      - Interventions for a boggy uterus include:
        - Uterine massage, monitoring bleeding, assessing vital signs (VS), level of consciousness, and calling for help if necessary.

Uterine Assessment and Involution

  • Assessing the fundus is essential to understand the pace of involution back to a prepregnancy state.

Assessing Bowel and Bladder

  • Bowel Assessment:
      - Determine the last bowel movement, assess for gas passage, bowel sounds (BS), and distention.
      - Fear of BM due to pain can lead to complications.

  • Bladder Assessment:
      - Postpartum diuresis may lead to frequent urination, making it difficult to void due to perineal edema.
      - Assess for symptoms of frequency, urgency, or burning upon urination.
      - Important to consider the UTI risk factors.

Assessing Lochia

  • Source of Lochia: Originates from the placental site and uterine debris, not just from vaginal trauma.

  • Composition of Lochia: Understanding the nature of lochia is essential.

  • Color Staging:
      - Rubra (red): 2-3 days post-delivery.
      - Serosa (pink): 3-10 days.
      - Alba (clear/white): 1-2 weeks.

Lochia Amount Assessment

  • Definitions of Different Amounts:
      - Scant: Blood only on tissue or less than 1-inch stain within 1 hour.
      - Light: Less than 4-inch stain within 1 hour.
      - Moderate: Less than 6-inch stain within 1 hour.
      - Heavy: Saturated peri-pad within 1 hour.

Assessing the Perineum

  • Methodology: Have the client turn to their side. Assess for intactness with the following criteria:
      - Redness, Edema, Ecchymosis, Drainage, Approximation.
      - Look for additional complications such as edema, ecchymosis, hemorrhoids, purulent drainage, or hematoma.

Perineal Care

  • Care Recommendations:
      - Change pads after every void and as needed.
      - Utilize a peri bottle while bleeding continues.
      - Avoid tampons and recommend ice packs for comfort and swelling reduction.
      - Sitz baths can be beneficial for promoting circulation and healing.

Assessing the Cesarean Section Incision

  • Assessment components mirror those used for perineal assessment:
      - Redness, Edema, Ecchymosis, Drainage, Approximation.
      - Clarity on whether C/S clients experience lochia or vaginal bleeding is necessary.

Assessing Emotional Status

  • Importance of Education:
      - Discussing postpartum blues, a transient depression period characterized by mood swings, weepiness, and anger, typically linked to hormonal fluctuations.
      - Reinforcement of the necessity for support systems is critical for maternal health.

Psychological Adaptation: Family Attachment

  • Bonding Indicators:
      - Parents display care for the baby, console, talk, and maintain affectionate contact (i.e., en face position).
      - Active parental engagement and asking questions about the baby's needs signify attachment.

Development of Family Attachment through Evidence-Based Practice

  • Recommended: Skin-to-skin contact fosters bonding and supports physiological stability for infants.

Common Medication Orders

  • Common medications include:
      - Pitocin for uterine contractions and control of postpartum hemorrhage.
      - Stool softeners to prevent constipation.
      - Pain Medications:
        - Ibuprofen (IBU) and Tylenol (considerations for organ predispositions).
        - Percocet and Vicodin (noting organ toxicity).
      - Rubella Vaccine: Convey that pregnancy should be avoided for at least 1 month post-vaccination.
      - Rhogam: Administered if the mother is Rh negative.

Home Care of the Postpartum Family

Teaching Self-Care

  • Essential guidelines include:
      - Hygiene practices to prevent infection.
      - Use of ice packs to axilla if not breastfeeding.
      - Sitz baths can support circulation and healing.
      - Advise against anything per vagina during initial recovery.
      - Discuss rationale for abstaining from sexual intercourse, including future birth control options.

Teaching: Indicator for Further Care

  • When to Contact the Provider:
      - Sore, red breasts, indicating possible infections.
      - Saturating more than 1 pad/hour suggesting excessive bleeding.
      - Signs of infection with purulent vaginal drainage.
      - Symptoms of urgency, dysuria, hematuria, or difficulty voiding.
      - Severe headaches (HA), chest pain (CP), shortness of breath (SOB), or visual changes indicative of complications.
      - Incision issues: redness, edema, drainage, or separation.
      - Occurrence of fever indicating potential infection.
      - Depression indicators needing mental health support.

Conclusion

  • Emphasizing the importance of recognizing and managing various aspects of the postpartum period helps ensure both physical and emotional well-being for the mother, ultimately contributing to a healthy family environment.