Postpartum Changes and Comprehensive Nursing Care

Learning Outcomes

• Describe the anticipated physiologic and psychosocial changes in the mother in the immediate postpartum period.

• Discuss how sociocultural factors affect the postpartum period.

• Identify pertinent postpartum nursing assessments and care considerations.

• Describe common postpartum psychological adjustments of the patient and family.

• Identify variations in postpartum care required by patients with vaginal births when compared with those with Cesarean births.

• Discuss options for medications in the postpartum phase.

• Discuss the important aspects of discharge instructions.

Stages of Labor and the Fourth Stage

• The focus of these notes is the Fourth Stage of Labor.

• Timeline: The fourth stage starts immediately after planetary delivery.

• Main Focus:

  • Stabilization of the neonate.

  • Promotion of bonding between the parents and the newborn.

Holistic Health History and Assessment of the Postpartum Patient

• Nursing care begins with a comprehensive health history, including a review of the labor and delivery events to understand the patient’s clinical trajectory.

• Identification of risk factors is critical during this period. Key risks include:

  • Hemorrhage.

  • Infection.

  • Postpartum Depression.

  • Thrombophlebitis / Deep Veid Thrombosis ($DVT$).

  • Alterations in sleep patterns.

  • Evaluation of attachment vs. mal-attachment behaviors.

Physiologic Changes: Cardiovascular, Circulatory, and Hematologic Systems

• Cardiovascular and Circulatory System Changes:

  • Blood Volume: There is a significant recovery process as blood volume increases by approximately $50\%$ during pregnancy; return to baseline occurs postpartum.

  • Fluid Volume: The body undergoes diuresis to eliminate excess fluid volume.

  • Pulse: Bradycardia is often observed in the immediate postpartum period.

  • Vital Signs: Monitoring remains a priority for assessing stabilization.

• Hematologic System Changes:

  • Recovery of Red Blood Cells ($RBCs$) and Iron levels.

  • Sharp Leukocytosis: It is common to see an elevated White Blood Cell ($WBC$) count during the early postpartum period.

• Musculoskeletal System Changes:

  • Assessments involve monitoring bone density changes.

• Endocrine and Metabolic Changes:

  • The patient experiences profound hormonal shifts following the delivery of the placenta.

Reproductive System Changes and Uterine Involution

• Involution of the Uterus:

  • Definition: The process by which the uterus returns to its pre-pregnant size and condition.

  • Onset: Begins during the third stage of labor and accelerates significantly after the expulsion of the placenta.

• Fundal Position Guidelines:

  • Immediately after birth: The fundus is located approximately $2\,\text{cm}$ (or $2$ fingerbreadths) below the level of the umbilicus.

  • First several hours: The fundus may rise to $1$ fingerbreadth above the umbilicus.

  • By $24\,\text{hours}$ after birth: The uterus should be at the level of the umbilicus.

  • Subsequent days: The fundal height decreases by approximately $1\,\text{cm/day}$.

• Assessment Frequency:

  • Frequent assessments are required for the first few hours.

  • Frequency decreases to once per shift after the initial $24\,\text{hours}$.

• Patient Inquiries During Assessment: Nurses should ask the patient about their:

  • Last void (urination).

  • Last pad change.

  • Last breastfeed.

  • Presence of any afterpains (uterine contractions post-delivery).

  • Last time the patient ambulated (walked).

The "BUBBLE-HE" Assessment Tool

• B - Breast: Assessment for engorgement, nipple integrity, and lactation status.

• U - Uterus: Assessment of fundal height, position, and firmness (tone).

• B - Bowel: Assessment of bowel sounds and bowel movements.

• B - Bladder: Assessment of voiding patterns and bladder distention.

• L - Lochia: Assessment of vaginal discharge color, amount, and odor.

• E - Episiotomy: Assessment of the perineum, including incisions, lacerations, or swelling.

• H - Homan’s Sign: Assessment for potential Deep Vein Thrombosis (evaluating calf pain).

• E - Emotional Status: Assessment of maternal-infant bonding and psychological well-being.

Lochia Assessment: Color and Quantity

• Definitions of Amount:

  • Scant: Blood only present on tissue when wiped, or a $1$- to $2\text{-inch}$ stain on a peripad.

  • Light: A stain of $4\,\text{inches}$ or less.

  • Moderate: A stain of less than $6\,\text{inches}$.

  • Heavy: A saturated peripad.

• Types and Progression of Lochia:

  • Lochia Rubra: Dark red color. Lasts $3-4\,\text{days}$.

  • Lochia Serosa: Pinkish brown color. Lasts $4-10\,\text{days}$.

  • Lochia Alba: Whitish yellow color. Lasts $10-28\,\text{days}$.

Perineal Care and Wound Assessment

• Assessment: The perineum must be assessed for signs of infection, varicosities, trauma, and healing progress.

• REEDA Score: A standardized tool used to assess wound healing (Redness, Edema, Ecchymosis, Discharge, Approximation).

• Pain Management and Comfort Measures:

  • Pharmacology: Tylenol ($acetaminophen$) and Ibuprofen.

  • Topical treatments: Anesthetics and Witch Hazel compresses.

  • Non-pharmacological: Ice packs (typically for the first $24\,\text{hours}$) and warm water Sitz baths (typically after the first $24\,\text{hours}$).

  • Hygiene: The use of a Peri Bottle for cleansing after every void or stool.

Cesarean Birth: Specialized Considerations

• Hospitalization: Typically lasts $3\,\text{days}$.

• Nursing Care:

  • Foley catheter remains in place until the patient is able to ambulate.

  • Post-surgical assessment must include checking for flatus (gas) to ensure bowel function returns.

  • Surgical dressing is generally removed after $24\,\text{hours}$.

• Common Complications:

  • Ileus (lack of bowel motility).

  • Blood clots.

  • Wound complications (infection or dehiscence).

  • Surgical injury to internal organs.

  • Hemorrhage.

• Post-Discharge Restrictions:

  • Lifting restrictions (nothing heavier than the baby).

  • Driving restrictions until cleared by a provider.

• Psychosocial Support: Patients may need to express feelings of "letdown" if the Cesarean was unplanned or different from their birth plan.

Diagnostic Data and Pharmacotherapeutics

• Laboratory Monitoring: Nurses must compare pre-delivery and post-delivery values for:

  • $H/H$ (Hemoglobin and Hematocrit).

  • $WBC$ (White Blood Cell count).

  • Platelet Count.

  • Group Beta Strep ($GBS$) status.

  • Blood Type and Rh factor.

  • Rubella Titer.

  • HIV Status.

• Key Medications for Maternal Safety:

  • Rho(d) Immune Globulin: Administered if the mother is Rh-negative and the infant is Rh-positive.

  • Rubella Vaccine: Given postpartum if the mother is non-immune.

  • TDaP Booster: Recommended to prevent pertussis transmission to the neonate.

• Symptomatic Treatments:

  • Pain Management.

  • Hemorrhage Prevention.

  • Pruritus (itching) relief.

  • Constipation prevention (stool softeners).

  • Nutritional supplementation.

Gastrointestinal, Nutritional, and Reproductive Health

• GI System Changes:

  • Patients often experience increased hunger and thirst immediately after birth.

  • Constipation is a common concern.

  • First stool typically occurs within $2-3\,\text{days}$ postpartum.

  • Normal bowel patterns usually return $8-14\,\text{days}$ after birth.

• Diet and Nutrition:

  • Continue prenatal vitamins and iron supplements.

  • Maintain a well-balanced diet.

  • Support for both lactating and bottle-feeding mothers.

• Reproductive Additions:

  • Resumption of menses varies based on feeding practices.

  • Education on birth control is necessary, as ovulation can occur before the first period.

• Follow-up: Instructions on making the postpartum visit and when to call the provider after discharge.

Psychological and Spiritual Well-being

• Societal Context: Childbirth is a transitory period and a social celebration across cultures.

• Cultural Variations: Nursing care must respect the variations between traditional and modern care practices in different societies.

• Phases of Maternal Adjustment:

  • Taking-in Phase: Characterized by dependency and focus on self and birth story.

  • Taking-hold Phase: Characterized by increasing autonomy and focus on infant care.

  • Letting-go Phase: The mother re-establishes relationships and her new role.

• Maternal Identity Outcomes: These phases include attaining maternal identity, navigating frustration and fatigue, managing feelings of loss of control, and experiencing emotional changes.

Maternal and Parental Role Adaptation

• Attachment Assessment: All partners should be assessed for an emotional connection to the infant.

• Positive Attachment Behaviors:

  • Touching, holding, kissing, and cuddling.

  • Talking and singing to the baby.

  • Maintaining the "En Face" position (eye-to-eye contact).

  • Expressing pride in the newborn.

• Engrossment: Specific term for the father's absorption, preoccupation, and intense interest in the infant.

• Mal-attachment Behaviors:

  • Refusing to look at, touch, or hold the infant.

  • Responding negatively to infant cues (e.g., crying or smiling).

  • Factors Affecting Attachment: Anesthesia, high pain levels, or a traumatic birth experience. These observations must be reported and monitored.

Postpartum Blues and Nursing Support

• Postpartum Blues:

  • Nature: A normal, mild, and transient condition.

  • Timeline: Begins $3-4\,\text{days}$ after childbirth, peaks on Day $4-5$, and resolves within $2\,\text{weeks}$.

  • Symptoms: Insomnia, fatigue, tearfulness, mood instability, and anxiety.

• Nursing Care for Well-being:

  • Plan care based on individual client needs.

  • Provide choices to empower the patient.

  • Encourage expression of feelings and talking through the experience.

  • Provide recognition and support.

Family Well-being and Discharge Instruction

• Support Units:

  • Provide a supportive environment and encourage "rooming-in" with the neonate.

  • Prepare siblings for the new addition and educate parents about potential sibling regression.

• Activity and Health Management:

  • Urinary and bowel elimination promotion.

  • Advise that sexual activity can resume once the episiotomy/laceration is healed and bleeding has stopped.

  • Counseling on contraception.

Postpartum Warning Signs (When to Call the Provider)

• Bleeding: Color/amount saturating more than (>) $1\,\text{pad/hour}$.

• Clots: Passing large clots.

• Fever: Temperature greater than (>) $101.4\,^{\circ}F$.

• Symptoms of Infection/Illness:

  • Chills.

  • Excessive pain.

  • Foul-smelling lochia.

  • Inability to urinate.

• Breast Issues: Reddened or warm areas of the breast (potential mastitis).

• Wound Issues: Reddened or gaping episiotomy or incision.

• Circulatory/DVT Issues: Calf pain, tenderness, redness, or swelling.

• Emotional Health: Severe depression symptoms.