Care of the Postpartum Patient

CARE OF THE POSTPARTUM PATIENT

Objectives

• Describe normal physiologic changes occurring in the postpartum period.
• Differentiate normal from abnormal postpartum emotional changes.
• Differentiate normal and abnormal physiologic changes in the postpartum period.
• Describe principles related to discharge/discharge teaching.
• Identify causes, signs/symptoms (s/s), and possible complications in the postpartum period.

Your Role

• Promote maternal physical well-being and facilitate the transition to motherhood.
• Focus should be family-centered, assessing the needs of the woman within the context of her family support network, however family may be defined.

Key Terminology

• G/P = Gravida/Para (term, preterm, abortion, living)
  • Example: G2 P2-0-0-2
• EDC: Estimated date of confinement (due date)
• Primigravida: Pregnant for the first time.
• Multigravida: Two or more pregnancies.
• Precipitous: Quick birth.
• SVD: Spontaneous vaginal delivery.
• LDRP: Labor, delivery, recovery, postpartum room.
• PP: Postpartum.
• C/S: Cesarean section.

Nursing Care of the Postpartum Woman

• Care focuses on assessment and support of the woman’s physiological and emotional adaptations after birth.
• Care is wellness-oriented and involves the interprofessional team.
• Typical hospital stay is 1-2 days for vaginal birth; cared for in LDRP or PP room.
• If C/S performed, initially cared for in PACU (Post-Anesthesia Care Unit).

Postpartum Physiology

• Postpartum period: From delivery of placenta to the return of the reproductive system to the non-pregnant state, usually lasting 6-8 weeks. This period is also called the puerperium, or the 4th trimester of pregnancy.

Involution

• Involution refers to the process where the uterus returns to its non-pregnant size and condition.
  • Within 12 hours of birth, the fundus may be palpated at 1 cm above the umbilicus.
  • Fundus height descends 1-2 cm per day.
  • By 2 weeks postpartum, the fundus should not be palpable.
  • Subinvolution: Usually caused by retained placental fragments and infection.

Uterine Contractions

• Uterine contractions are necessary to achieve hemostasis at the placental site.
• Stimulated by:
  • Release of oxytocin from the posterior pituitary.
  • Administration of exogenous oxytocin.
  • Breastfeeding.

Afterpains/Postpartum Contractions

• Afterpains are painful intermittent uterine contractions, usually stronger and more frequent in multiparous women due to loss of uterine tone.
• Common in conditions involving an over-distended uterine muscle, such as multifetal gestations, polyhydramnios, and macrosomia.
• Postpartum contractions may persist through the early postpartum period and can be intensified by breastfeeding and administration of oxytocin.

Typical Situations for Afterpains

1. When ambulating.
2. While taking a sitz bath.
3. During breastfeeding.
4. Once the client arrives home and activities are increased.

Placental Site

• The placenta usually separates from the uterus within 15-30 minutes.
• Endometrial regeneration at the placental site is usually completed within 6 weeks postpartum.
• If the placenta does not separate within 30 minutes, perform a bimanual exam and provide emotional support and pain management.

Lochia

• Lochia is a combination of blood, mucus, and tissue discharged from the uterine lining.
• Types of lochia:
  • Lochia rubra: Bright red, first 1-3 days post-delivery, may contain small clots (grape size).
  • Lochia serosa: Pink/brown tinged, seen 3-10 days after delivery.
  • Lochia alba: Yellowish-white, persists beyond 10 days, can last up to 6 weeks.

Types of Lochia Details

Volume of Lochial Flow

• Saturation of perineal pad in 15 minutes or less is considered excessive and may indicate a Postpartum Hemorrhage (PPH).
• Patients who had a C/S typically have less lochia.
• Normal blood loss:
  • Vaginal:
  • C/S:
• If excessive blood loss is observed, weigh linen; 1 ml of blood = 1 g in weight.

Postpartum Cervix and Vagina

• By approximately 18 hours, the cervix should be firm and shortened and have regained form.
• Presence of free-flowing bright red blood may indicate a cervical laceration.
• The vagina should return to normal size within 6-8 weeks after delivery.
• Possible hematoma: accumulation of blood in the pelvic tissue; characterized by unrelenting pain and sensation of pressure in the rectum or vagina. Late signs include tachycardia, elevated respiratory rate, and low blood pressure.

Episiotomy

• An episiotomy is an incision made into the body of the perineum during the second stage of labor.
• Healing episiotomies may only be visible when the patient is lying on her side; usually heals within 2-3 weeks after delivery.
• Infection Check: Assess for redness, warmth, swelling, discharge, or separation of edges.
• Check for hemorrhoids, which are common and will generally decrease in size within 6 weeks.

Lacerations

• Types of lacerations:
  • 1st degree: through skin superficial to muscles.
  • 2nd degree: extends through muscles of perineal body.
  • 3rd degree: through the anal sphincter.
  • 4th degree: involves the anterior rectal wall.
  • Urethral: tear upward from the vagina towards the urethra.

Urinary System

• Reduced renal function due to diminishing steroid levels after birth.
• Diuresis occurs as a response to decreased aldosterone production, leading to decreased sodium and water retention.
• It is not uncommon to void in excess of 3,000 ml per day during the first few days postpartum.
• Perineal pain and swelling may make it difficult to void. UTIs may develop.

GI System

• Abdominal distention and delayed bowel movements may occur due to several factors:
  • Decreased muscle tone and motility.
  • Lack of food intake during labor.
  • Dehydration.
  • Pain from perineal trauma or hemorrhoids.
  • Effects of anesthesia/analgesia.

Breasts

• Colostrum can be expressed shortly after birth to meet the nutritional needs of the infant.
• Milk production begins within 72-96 hours after birth; breasts may feel firm and warm.
• Breast milk has a consistency similar to skim milk.
• Tenderness may be present for 48 hours following the start of lactation. Engorgement is temporary and resolves in 24-48 hours.

Cardiovascular System

• Heart rate, stroke volume, and cardiac output increase immediately after birth and peak in the first 30-60 minutes.
• Blood from fetal circulation shifts back into maternal circulation; cardiac output remains elevated for 48 hours, returning to normal in about 2-3 weeks.
• Mothers may experience orthostatic hypotension when sitting up from a reclined position; advise sitting up slowly and dangling before standing.

Changes in Blood Volume

• Changes depend on the amount of blood loss at delivery and the amount of extravascular water excreted; normally blood volume increases are eliminated within the first 2 weeks after delivery.
• Postpartum anemia may arise from iron deficiency or hemorrhage post-delivery.
• Pregnancy induces a hypercoagulable state due to elevated fibrinogen and clotting factors; WBC count, typically about 12,000 in the non-pregnant state, may rise to 20,000 to 25,000 days after delivery.

Neuro System

• Headaches are common due to hormonal shifts and physiological changes; can also have pathological etiology such as spinal headaches or postpartum onset of preeclampsia.
• Teach mothers to alert the ED healthcare providers about being in the postpartum period if experiencing headache.

Musculoskeletal System

• Relaxation and hypermobility of joints and changes in mother’s center of gravity should stabilize within 6-8 weeks postpartum.
• Joints in a parous woman’s feet may not return to normal, potentially resulting in an increased shoe size.

Physical & Psychosocial Assessment

Care Management: Physical Needs

• Ongoing physical assessment and routine labs.
• Individualized care plans should be developed.
• Focus on:
  • Preventing excessive bleeding.
  • Maintaining uterine tone.
  • Preventing bladder distention and infection.
  • Health promotion for future pregnancies, such as vaccinations (Rubella, Varicella, Tdap) and Rh isoimmunization.
• Promoting comfort (both pharmacological and non-pharmacological), rest, ambulation, exercise, nutrition, and normal bladder/bowel function. Emphasize breastfeeding or lactation suppression.

Care Management: Psychosocial Needs

• Ongoing assessment of psychological adaptation.
• Evaluate the effect of birth experience on maternal mental health and family function.
• Understand the cultural beliefs and practices that may affect postpartum adaptation.
• Be knowledgeable about Perinatal Mood Disorders (PPD) using tools like the Edinburgh Postnatal Depression Scale.

Physical Assessment: Postpartum Recovery

• Key parameters to assess:
  • Vital signs (VS).
  • Fundal height, tone, and location.
  • Perineum condition.
  • Amount, character, and color (e.g., red) of lochia.
  • Pain levels.
• Possible physical reactions include chills and tremors secondary to stress or anesthesia effects.

Special Attention After C-Section

• The postpartum woman is also a new mother and not just a post-surgical patient. Evaluation should include:
  • Abdominal dressing assessment.
  • Monitoring level of consciousness (LOC) and return of sensation if an epidural or spinal was used.
  • Monitoring cardiac status and oxygen saturation.
  • Checking IV rates and sites, intake/output (I&O), bowel sounds in all quadrants, and urine output.
  • Auscultating lungs and teaching/deep breathing exercises and use of the incentive spirometer.
  • Monitoring for anesthesia side effects, assessing pain levels, and need for additional pain medication.

Potential Postoperative Complications

• Cardiovascular: hemorrhage, hypovolemic shock, DVT (Deep Venous Thrombosis).
• Pulmonary: PE (Pulmonary Embolism), pneumonia.
• GI: paralytic ileus.
• GU: renal failure, hematuria, UTI (Urinary Tract Infection), oliguria.
• Reproductive: endometritis, septic pelvic emboli.
• Integumentary: wound dehiscence, infection.

BUBBLEHE Assessment Framework

• Breasts: Condition and symptoms, latch-on during breastfeeding.
• Uterus: Fundal height and tone assessment, ensuring firmness.
• Bladder: Voiding pattern and assessing for bladder distention.
• Bowel: Bowel sounds and abdominal tenderness, presence of hemorrhoids.
• Lochia: Type, amount, and presence of clots and odor.
• Episiotomy: Assessment for healing, signs of infection, and support strategies.
• Homans Sign: Checking for signs of thrombophlebitis.
• Emotional Response: Assessing emotional well-being and attachment to the infant.

Assessing Breasts

• Inspect color, noting any discoloration or redness.
• Evaluate pain/discomfort levels and nipple condition (intact, bruised, cracked).
• Observe breast consistency (soft, firm, engorged) and check latch on if breastfeeding.

Assessing Uterus/Bladder

• Palpate the uterus/fundus using a two-hand technique to note height, location, and tone.
• Firmness should be expected (like grapefruit); discomfort may be reported by C/S patients. Check the bladder for voiding patterns, amount, distention, dysuria, frequency, and burning.

Assessing Bowel

• Monitor for bowel sounds, abdominal distension, and tenderness.
• Note the last bowel movement (BM) and check for hemorrhoids by visualizing the perineum.

Assessing Lochia/Episiotomies/Lacerations

• Position the woman on her side for recovery assessment.
• Assess the amount and type of bleeding, color, character, and odor.
• Stress infection prevention measures such as handwashing and perineal hygiene.
• Visualize episiotomy, encouraging the use of a mirror for personal inspection.

Assessing Lower Extremities/Homans Sign

• Identify signs of thrombophlebitis by checking for pain with dorsiflexion of the foot, typically unilateral.
• Assess for redness/warm areas on legs and check pedal pulses.
• Teach strategies to minimize the risk for thrombophlebitis, such as ambulation and avoiding restrictive clothing.

Assessing Emotional Response

• Observe emotions, mood, bonding, and attachment during each interaction.
• Pay attention to interactions between family members as well.

REEDA Assessment Tool

• Evaluates Cesarean incisions, episiotomies, and lacerations based on:
  • Redness
  • Edema
  • Ecchymosis
  • Discharge
  • Approximation

Perineal Care

• The perineum experiences significant pressure during birth. Use ice packs or frozen peri-pads 12-24 hours after delivery.
• Administer analgesics and topical agents as warranted.
• Encourage regular perineal cleansing.
• Advise tightening glute muscles before sitting to alleviate pressure on the perineum.

Pain Management

• Address pain from:
  • Episiotomy or laceration repairs.
  • C/S incision site pain.
  • Hemorrhoids.
  • Postpartum uterine contractions (afterpains).
  • Nipple trauma.
  • Breast engorgement.
  • Gas pain.
• Consider both non-pharmacologic and pharmacologic interventions.

Transition to Parenthood

• The transition period is characterized by both disorder/disequilibrium and satisfaction.
• Factors affecting adaptation include:
  • Personal feelings about self.
  • Relationships with family of origin.
  • Existence of social support networks.
  • Relationship dynamics with partner and infant.
  • Overall attachment and bonding.

Factors Affecting Parent-Infant Bonding

• Challenges include discomfort, fatigue, lack of knowledge regarding infant needs, previous parenting experiences, unrealistic newborn expectations, cultural practices, adolescent parent status, and unexpected events.

Maternal Adaptation Phases (Reva Rubin)

1. Taking In or Dependent Phase:
   • Occurs in the first 24 hours after birth; may last hours.
   • Focus on meeting her basic needs (food, sleep).
2. Taking Hold Phase:
   • Occurs Day 2-3 up to several weeks.
   • Focus shifts to care of the newborn and competent mothering.
3. Letting Go or Interdependent Phase:
   • Involves forward movement of the family as a unit.

Paternal Adaptation Phases

1. Entering parenthood with the intention of being an emotionally involved father.
2. Confronting reality and reconciling expectations with the realities of life with a newborn in the first few weeks.
3. Working to establish the role of an involved father.
4. Reaping rewards and experiencing reciprocity from the infant (e.g., smiles).

Influences on Transition to Parenthood

• Considerations include age (adolescent or advanced maternal age over 35), same-sex couples, social support, cultural background, socioeconomic conditions, and personal aspirations.

Sibling Adaptation

• Needs time and energy for family reorganization to occur.
• Siblings must adjust to their new standing in the family structure; the goal is to maintain their lead position.
• Responses can be positive or negative; parents should facilitate bonding.

Nursing Care Management: Facilitating Parental Adaptation

• Prioritize care for both mother and newborn.
• Suggest that the mother sleeps when the newborn sleeps.
• Encourage communication and open expression of feelings.
• Emphasize the need for proper nutrition and recreation.
• Recommend relaxation and breathing exercises.
• Enlist support from relatives for practical assistance (meals, shopping).
• Encourage parental involvement in newborn care.

Discharge Planning

• Nurses prepare mothers for their return home.
• Length of stay (LOS) is influenced by factors such as maternal and infant condition, mental and emotional status, social support at home, education needs, and financial constraints.

Discharge Teaching for Postpartum Women

• Topics include self-care, signs of complications, sexual activity and contraception, medications, and understanding cultural beliefs impacting maternal response.
• Follow-up after discharge should include routine care schedules, potential home visits, support groups, and community resources.

Discharge Criteria for Mother

• Requirements for discharge:
  • Stable vital signs.
  • Appropriate amount and color of lochia.
  • Ability to ambulate.
  • Adequate pain control.
  • Demonstration of readiness to care for herself and infant.
  • Availability of family support persons.
  • Knowledge about what to do in case of an emergency.
  • Blood type and Rh status determined and treated if indicated.

Maternal Self-Care Focus Areas

• Handwashing and perineal self-care.
• Monitoring uterine involution and lochial flow.
• Noticing breast changes, maintaining diet, and resuming regular elimination and exercise practices.
• Managing pain effectively, including medications.
• Planning for follow-up care and addressing stress management and coping mechanisms.

Maternal Warning Signs

• Fever over 100.4°F.
• Breast issues: redness, pain, cracked nipples.
• Changes in lochia: foul smell, regressing back to bright red bleeding, excessive amounts, large clots.
• Uterine tenderness.
• Signs of wound infection.
• Leg pain or red, warm areas on the legs.
• Burning or painful urination.
• Swelling in legs or around the face and eyes.
• Inability to care for self or the baby.
• Severe headache or blurred vision.
• Persistent or severe mood swings or thoughts of self-harm or harm to the baby.

Post-Birth Warning Signs

• Pain in Chest: can indicate cardiac event or pulmonary embolism.
• Obstructed Breathing: or shortness of breath signifies potential complications.
• Seizures: may indicate conditions like eclampsia.
• Thoughts of Harming Self or Baby: require immediate attention.
• Bleeding: soaking through 1 pad/hour or blood clots the size of an egg or bigger (indicating hemorrhage).
• Incision Issues: not healing, increased redness, or pus from episiotomy or C-section site.
• Redness or Swelling in Calf Area: painful and warm indicates potential blood clots.
• Temperature Extremes: over 100.4°F or under 96.8°F can signal infection or other issues.
• Headache Changes: that do not improve with medication or accompanied by vision changes or upper right quadrant pain potentially signals preeclampsia.

SAVE YOUR LIFE: Get Care for Post-Birth Warning Signs

• Understanding postpartum warning signs can be life-saving. Trust instincts and seek medical care for concerns.
• Call 911 for severe symptoms (pain in chest, obstructed breathing, seizures, and harmful thoughts).
• Call healthcare provider for concerning symptoms needing attention.

References

• Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN): Perinatal orientation and education program (4th ed.). AWHONN.
• Lowdermilk, D. L., Perry, S. E., Cashion, K., Aldean, K. R., Olshansky, E. F. (2024). Maternity and women’s health care (13th Ed.). Elsevier.