CH_12

Safe Maternity and Pediatric Nursing Care

Chapter 12 Postpartum Nursing Care

• Authors: Linnard-Palmer | Haile Coats

• Publisher: F.A. Davis

• Copyright ©2021 F.A. Davis Company

Introduction

• Family dynamics become more complicated with the birth of each child.

• Importance of support for family dynamics:

  • Include family members in teaching and care for better understanding.

  • Provide information on sibling rivalry to ease transitions.

  • Observe interactions to identify any problems and make recommendations or referrals as necessary.

Puerperium

• Defined as the period following the delivery of the placenta until the reproductive organs return to a nonpregnant state.

• Generally lasts about 6 weeks.

Postpartum Physical Adaptations

Immediate Changes Post-Delivery

• The body changes immediately after delivery:

  • Postpartum Shivering:

    • Exact cause unknown.

    • Provide a warm blanket and reassurance that shivering will pass.

Reproductive System Changes

• Uterus Involution:

  • Process: Oxytocin continues after placenta delivery, causing contractions that shrink the uterus.

  • Size and weight of the uterus decreases.

  • Fundus: Top portion of the uterus descends.

  • Afterpains: Intermittent uterine contractions often more noticeable in multiparous women.

  • Exfoliation: Sloughing off dead tissue at the placental site.

• Lochia:

  • Vaginal discharge consisting of blood, mucus, and tissue.

  • Can last up to 6 weeks; lighter in color and amount over time.

• Cervix: Closes slowly, with os barely dilated by day 14.

• Vagina:

  • Loses tone after delivery; over 4 weeks, edema decreases and rugae (folds) reappear, but the vagina does not return to pre-pregnancy size.

• Perineum:

  • Bruised and edematous following delivery; muscle tone restored in 4-6 weeks with Kegel exercises promoting recovery.

• Ovaries and Ovulation:

  • Normal function after delivery is variable and influenced by breastfeeding.

  • Menstruation can be delayed for weeks or months if breastfeeding; for non-breastfeeding women, ovulation may occur as early as 27 days post-delivery.

  • Menstruation typically begins 6-12 weeks postpartum for those bottle-feeding.

• Breasts:

  • Secrete colostrum before milk production begins.

  • Nipple stimulation releases prolactin, initiating lactation.

  • Breasts may feel engorged, warm, and tender between the second and fourth days.

  • Non-breastfeeding mothers require interventions to suppress milk production.

Integumentary System

• Abdominal skin usually resumes a pre-pregnancy state except for stretch marks.

• Linea Nigra: May fade but not completely disappear.

• Melasma: Typically fades over weeks.

• Hair thinning resolves gradually.

Gastrointestinal System

• Women commonly feel hungry and thirsty post-delivery; may experience sluggish intestinal peristalsis and constipation.

• Hemorrhoids may cause pain during defecation, and stool softeners may be prescribed.

Cardiovascular System

• Cardiac output increases by 60-80% immediately post-delivery, nearing normal levels within one hour.

• Loss of plasma volume results in a temporary rise in hemoglobin and hematocrit.

• Fibrinogen Levels: Increase post-delivery and remain elevated for several days, raising the risk for blood clot formation.

• Removal of excess fluid leads to diuresis (large urine output) and diaphoresis (excess sweating).

Respiratory System

• Diaphragm returns to normal position, and respiratory rate returns to pre-pregnancy levels; pregnancy-related nasal congestion benefits quickly.

Urinary System

• Decreased bladder tone can lead to distention, pushing the uterus up and to the side, which may interfere with involution and potentially lead to hemorrhage.

Musculoskeletal System

• Levels of relaxin decrease post-delivery.

• Women may experience hip pain for a few days.

• Diastasis recti may occur—a separation of abdominal muscles that may require exercises or surgery for correction.

Nursing Care During the Early Postpartum Period

Immediate Postpartum Care

• Often occurs in a hospital setting.

• Most women remain 1-2 days after vaginal delivery and 3-4 days after cesarean delivery.

• Nurses provide physical care, monitor for complications, and teach self-care.

Uterine Assessment

• Palpate fundus to assess position, location, and consistency; support lower uterine segment during palpation.

• If boggy, massage in a circular pattern to firm it up.

• If ineffective, large blood clots or uterine atony must be considered to prevent hemorrhaging.

• Check for bladder fullness which can lead to uterine atony.

Lochia Assessment

• Inspect the amount and character of lochia during uterine massage.

• Lochia lasts 3-6 weeks and occurs in three stages:

  • Lochia Rubra: First discharge, dark red blood.

  • Lochia Serosa: Day 3-4, brownish-red, lighter in color.

  • Lochia Alba: Over 1-2 weeks, lighter and yellowish.

• Lochia Amount Descriptors:

  • Scant: Less than 1 inch on pad.

  • Light: Less than 4 inches on pad.

  • Moderate: Less than 6 inches on pad.

  • Heavy: Saturated pad within an hour.

Nursing Care During First Hour

• First hour after delivery is critical due to risk of hemorrhage:

  • Check vital signs every 15 minutes.

  • Palpate fundus.

  • Assess uterine tone and vaginal bleeding amount.

  • Once stable, transfer to postpartum or mother-baby unit.

Postpartum Assessment and Nursing Interventions

• Use the BUBBLE LE acronym:

  • Breasts, Uterus, Bladder, Bowels, Lochia, Episiotomy/Laceration, Legs, Emotions

Breast Assessment

• Check for breast and nipple pain and manage accordingly.

Nursing Care for Other Systems

• Uterus:

  • Ensure firmness and proper location; document fundus relative to the umbilicus.

• Bladder:

  • Assess for distention.

• Bowels:

  • Auscultate bowel sounds.

• Lochia:

  • Document amount and type.

• Episiotomy/Laceration:

  • Inspect perineum for issues such as bruising, erythema, or hematoma.

• Legs:

  • Assess for leg pain, circulation, and temperature.

• Emotions:

  • Monitor for “postpartum blues” after hormonal changes with placenta expulsion.

Nursing Care Following Cesarean Birth

• Monitor uterine involution and lochia postoperatively to prevent complications.

• Assess pain levels and the surgical incision.

Nursing Care for Adolescents

• Provide structured teaching about newborn care and self-care.

• Treat adolescents as adults and direct teaching towards them, including the father in discussions.

• Encourage bonding during the taking-in phase and be aware of higher risk for postpartum depression.

Nursing Care for Mothers Who Relinquish Infants for Adoption

• Understand and respect the mother's birth plan.

• Provide compassionate care and physical support just like other postpartum patients, keeping in mind their heightened risk for postpartum depression.

Postpartum Psychological Adaptations

Three Phases of Postpartum Adjustment

• Taking-In Phase:

  • Centered on her own needs; dependent and may not initiate contact with the newborn.

  • Begins bonding process; may last 1-2 days.

• Taking-Hold Phase:

  • Initiates baby care and seeks independence.

  • Concerns about health care and breastfeeding prevail; needs reinforcement.

  • May last up to 10 days and experience postpartum blues.

• Letting-Go Phase:

  • Accepts her new identity as a mother.

  • Develops a positive relationship with the newborn and learns to interpret their needs.

Nurse Observations During Phases

• Observing a mother who asks questions about baby care indicates she is in the taking-hold phase.

Development of Family Attachment

Importance of Partner Bonding

• The partner can bond through prenatal appointments.

• Encourage presence in hospital for rooming-in to promote bonding.

• Engrossment:: Staring at the newborn for extended periods signifies bonding.

Sibling Bonding

• Include siblings in hospital visits; monitor for jealousy or regression in behavior.

Preparation for Discharge

Prenatal Care and Vaccinations

• Administer MMR to susceptible women during pregnancy, and ensure those around the newborn receive updated Tdap vaccinations.

Self-Care Instructions

• Provide written and verbal instructions:

  • Care for sutures and episiotomy, perineal care, pain management, breast care, and activity guidelines.

  • Address when to contact the healthcare provider and discuss sexual activity and contraception.

Follow-Up

• Ensure follow-up appointments are scheduled and maintain communication about overall health.

Clicker Check Questions

• Case Scenario Responses:

  • Patients experiencing postpartum symptoms should be educated about normal timelines for ovulation, contraception, and monitoring health issues, such as fever indicative of infection.