Postpartum Care

C. POSTPARTUM CARE Puerperium/Postpartum Period Refers to the six (6) weeks period after delivery of the baby Time of maternal changes that are both o Retrogressive (involution of uterus and vagina) o

Progressive (production of milk for lactation, restoration of normal menstrual cycle, and beginning parenting role)

*Involution- return of the reproductive organs to their pre-pregnant state (6 weeks) Postpartum Care & Assessment (mnemonic: BUBBLE-HE)

A.



BREASTS



UTERUS



BLADDER



BOWELS



LOCHIA



EPISIOTOMY



HOMAN’S SIGN



EMOTIONAL STATUS

IMMEDIATE NURSING CARE 1.

Vital signs •

Assess q 15 min x 4; then q 30 min x2; then q 4 hrs for the first 24 hrs (if stable) then q 8 hrs

•

BP should be WNL for patient

•

Pulse- 50-90 bpm

•

Temp- 98-100.4 degree F (36.6-38 degree C): normal for the 1st 24 hrs due to DHN during labor

•

Resp- 16-24 cpm o

Increase in body temperature during the first 24 hours is not necessarily a sign of postpartum infection. 

o

Any mother whose temperature reaches 38 degree C in any two consecutive 24 hrs period during the first 10 postpartum days may suggest infection.

Bradycardia (heart rate of 50-7- bpm) is common for (24-48 hrs) and persist 6-8 days postpartum. 

Returns to non-pregnant rate by 3 months postpartum

2.

Breast •

Lacatation- formation of breast milk (BM); begins in a postpartal woman whether or not she plans to breast-feed. o

BM forms in response to decrease in estrogen and progesterone levels that follows delivery of the placenta (which stimulates prolactin production)

•

Prolactin- hormone for production of breast milk

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Oxytocin- hormone for excretion/ejection of milk

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Colostrum is present at the time of delivery; BM is produced by the 3rd and 4th postpartum day; yellow sticky fluid; more protein, less sugar, less fat than mature milk.

•

Engorgement_ the feeling of tension (heat or throbbing pain) in the breast as breast distention becomes marked (fuller, larger, firmer); occurs on the 3rd -4th day

•

o

Due to expanding veins and pressure of new breast milk contained with them

o

There may be a slight elevation of body temperature during this time

o

Congestion subsides in 1 or 2 days

In breast, prolactin stimulates alveolar cells to produce milk. Sucking of the newborn triggers a release of oxytocin and contractility of the myoepithelial cells, which stimulate milk flow; this is known as the let down reflex. The average amount of milk produced in 24 hours increases with time: o

First week- 6-10 oz

o

1-4 weeks- 20 oz

o

After 4 weeks- 30 oz 

•

Mature milk •

Foremilk-watery milk coming from full breast (low in fat, high in carbohydrates)

•

Hindmilk- creamy milk coming from a nearly empty breast

Amount of supply depends on how often the mother nurse or pumps ( the more the mother nurses, the more milk is produced)

•

For those who choose not to breastfeed, lactation can be suppressed through: o

Use a well-fitting bra

o

Avoid any type of nipple stimulation or heat to the breasts (such as warm/hot showers)

o

May use ice packs or cold cabbages leaves to east breast discomfort until milk production ceases (it generally takes 5-7 days)

o

3.

Mild analgesics as prescribed

Uterus •

After delivery of the newborn, involution of the uterus must occur; 2 main processes: o

Area where placenta is implanted is sealed off to prevent bleeding

o

Uterus reduced to its pregestational size (grapefruit) 

Firm, midline, reduced in its size



Soft & boggy, displaced (hemorrhage risk)

•

Few minutes after birth, fundus halfway between umbilicus and symphysis pubis

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One hour later, rise to the level of umbilicus and it remains for the next 24 hours

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First postpartal day (day 1)- one fingerbreadth below umbilicus

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Day 2- 2 finngerbreadth below and so forth until day 10, it can no longer be palpated because it is already behind symphysis pubis

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At 10-14 postpartum days, the uterus cannot be palpated abdominally

o

Subinvoluted Uterus 

o

•

To encourage return of the uterus to its usual anteflexed position, PRONE and KNEE CHEST positions are advised.

•

Fundal massage, ice pack over hypogastrium, IV oxytocin, nipple stimulation (breastfeeding)

Afterpains/afterbirth pains 

•

Uterus larger than normal and vaginal bleeding with clots. Since blood clots are good media for bacteria; it is therefore as sign of puerperal sepsis

Strong uterine contractions felt more particularly by multis, those who delivered larger babies or twins and those who breastfeed. It is normal and rarely last for more than 3 days.

Menstruation o

If not breastfeeding- return in 6-8 weeks after birth

o

If breastfeeding, in 3-4 months (lactational amenorrhea) or entire lactation period 

Though does not guarantee that woman will not conceive because she may ovulate well before menstruation returns

4.

Bladder Elimination •

Marked dieresis to eliminate excess fluid (as much as 2000-3000ml accumulates in the body during pregnancy)

o •

May complain of frequent urination in small amounts: explain that this is due to urinary retention with overflow

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May have difficulty voiding because of abdominal pressure or trauma to the trigone of the bladder

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Assess hypogastric area for overdistention of bladder:

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5.

6.

Urine output from 1500ml/day to as much as 3000ml/day 2nd-5th after birth

o

Palpation: hard or firm just above symphysis pubis

o

Percussion: resonant

Voiding may be initiated by: o

Pouring warm and cool water alternately over the vulva

o

Encourage the client to go to the comfort room

o

Let her listen to the sound of running water

o

If these measures fail, catheterization, done gently and aseptically, is the last resort on doctor’s order. (if there is resistance to the catheter when it reaches the internal sphincter, ask patient to breathe through the mouth while rotating the catheter before moving it inward again.)

Bowel Elimination •

Full diet (unless GA)

•

Constipation: delayed bowel evacuation postpartally may be due to: o

Decrease muscle tone

o

Lack of food and enema during labor

o

Dehydration

o

Fear of pain from perineal tenderness due to episiotomy, lacerations or hemorrhoids

Lochial discharge ( during the 1st 3 weeks after delivery)- uterine discharge consisting of blood, deciduas, WBC, mucus and some bacteria •

It should approximate menstrual flow. It increases with activity and decreases with breastfeeding.

•

Types of lochia:

o

o

o

7.

Lochia rubra 

Dark red in color within first 2-3 days



Contains epithelial cells, erythrocytes, leukocytes, and deciduas and has a characteristic human odor.

Lochia alba 

Pinkish to brownish discharge



It is a serosanguineous discharge containing erythrocytes, leukocytes, cervical mucus and microorganism



It has a strong odor

Lochia serosa 

Almost colorless to creamy yellowish discharge occurring from 10 days to 3 weeks after delivery.



It contains leukocytes, deciduas, epithelial cells, fat, cervical mucus, cholesterol crystals and bacteria



Odorless

Episiotomy/Perineum •

Appears edematous and bruised after delivery caused by episiotomy (if performed) and some degree of laceration

•

Assess s/s of infection and inflammation: o

•

REEDA (redness, edema, ecchymosis, discharge, approximation of sutures)

Assess for lacerations:

o

1st degree- lacerations extend through the skin and superficial layers of the perineum

•

o

2nd degree- through perineal muscles

o

3rd degree- through anal sphincters

o

4th degree- through the anterior rectal wall and can be damaging to the perineum

Prevention of lacerations: o

Massage

o

Warm compress

o

Manual support (Ritgen’s maneuver)

o

Birthing in a lateral position

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8.

9.

To relieve pain: o

Sim’s position- minimizes strain on the suture line

o

Perineal heat lamp or warm sitz baths twice a day- vasodilation increases blood supply and therefore, promotes healing

o

Apply ice or cold therapy to the episiotomy or laceration immediately after delivery to decrease edema and provide anesthesia; thereafter apply moist or dry heat therapy to promote comfort and healing

o

Application of topical analgesics or administration of mild oral analgesics as ordered.

Homan’s sign/Legs •

Relative inactivity/prolonged time in stirrups leads to stasis of blood and promotes clotting of blood in the lower extremities

•

Assess s/s of DVT o

Redness, warmth, tenderness, Homan’s sign (pain upon dorsiflexion of foot)

o

It is also important to note that a DVT may be present despite a negative Homan’s sign

•

Early ambulation

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Avoid crossing of legs, constrictive clothings/undergarments

Emotions: Psychological Adaptation (Reva Rubin): ESSENTIAL CONCEPTS •

The postpartum period represents a time to emotional stress for the new mother, made even more difficult by the tremendous physiologic changes that occur

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Factors influencing successful transition to parenthood during the postpartum period include:

•

o

Response and support of family and friends

o

Relationship of the birthing experience to expectations and aspirations

o

Previous childbearing and childrearing experiences

o

Cultural influences

Rubin (1997) describes this period as occurring in three stages: taking-in, taking-hold and letting-go o

TAKING-IN PERIOD 

Occurring 1-2 days after delivery, the new mother typically is passive and dependent



Energies are focused on bodily concerns

o

o



She may review her labor and delivery frequently

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Uninterrupted sleep is important if the mother is to avoid the effects of sleep deprivation, which include fatigue, irritability, and interference with normal restorative process

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Additional nourishment may be needed because the mother’s appetite unusually increased; poor appetite may be a clue that the restorative process is not progressing normally

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Encourage her to talk about the birth will her integrate it into her life experiences

TAKING-HOLD PERIOD 

2-4 days after delivery



Mother becomes concerned with her ability to parent successfully and accepts increasing responsibilities for her newborn

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Woman begins to initiate action; she prefer to get her own wash cloth and make her own decisions

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Mother focuses on regaining control over her bodily functions: bowel and bladder function, strength and endurance

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The mother strives to master newborn care skills (holding, breastfeeding, or bottlefeeding, bathing and diapering) •

She may be sensitive to feelings of inadequacy

•

The nurse should take this into instructions and emotional support,

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Provide praises

when

providing

LETTING-GO PERIOD 

Redefines her new role



Generally occurs after the new mother returns home. It involves a time of family reorganization



Mother assumes responsibility for newborn care; she must adapt to demands of the newborn’s dependency and to her decreased autonomy, independence and social interaction

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She gives up the fantasized image of her child and accepts the real one.

ATTACHMENT o

account

Refers to the emotional connection between a patient and her infant

Behaviors indicating a positive attachment include:

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Touching

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Holding

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Kissing

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Cuddling

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Talking and singing

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Choosing the “en face” position

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Expressing pride in the infant

Mal-attachment behaviors vary, but can include: •

Refusing to look at the infant

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Refusing to touch or hold the infant

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Refusing to name the infant

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Negative comments about the infant

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Refusing to respond or responding negatively to infant cues ( crying, smiling)

POSTPARTUM BLUES •

“baby blues”; normal part of postpartum experience but only for a few days

•

Tearfulness, irritability, sometimes insomnia

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Causes: hormonal fluctuations, physical exhaustion, maternal role adjustment o

Reassure that this is normal

o

Anticipatory guidance and individualized support from health care personnel are important to help the parents understand

o

Keeping lines of communication open

o

Allow her to make as many decision as possible can help give her sense of control over her life

o

Allow her to verbalize her feelings and concerns

POSTPARTUM DEPRESSION •

A serious & debilitating depression, occurring within first 9 months after delivery, often within the initial weeks or months

•

Sadness, crying, insomnia, decreased appetite, withdrawal and sometimes suicidal ideation or the desire to harm the infant

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Somatic symptoms: headaches, diarrhea, constipation, severe anxiety, feeling as though they are jumping out of their skinm and/or just not feeling like themselves

•

Management: o

Assessment tools:



Edinburg Postnatal Depression Scale (EPDS)



Postpartum Depression Screening Scale (PDSS)

o

Refer to doctor; counseling and medication

o

Help patient and family to understand this condition and assist to explore spiritual aspect of care

Additional physiologic adaptations after delivery: 1.

Cardiovascular system •

30-50% increase in total cardiac volume during pregnancy will be reabsorbed into the general circulation within 5-10 minutes after placental delivery

•

Blood loss: vaginal birth- 300-500 ml; cesarean birth- 500-1000ml

•

Blood volume decrease to non pregnant levels by fourth week after delivery

•

Hematocrit rises by the 3rd-7th postpartum day

•

WBC increases to 20000-30000/mm3

•

o

Cannot be used as an indicator or signs of postpartum infection

o

Part of body’s defense system against infection

o

Aid to healing

Extensive activation of the clotting factors which encourages thromboembolization: o

Ambulation is done early 4-8hours after normal vaginal delivery 

o

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2.

3.

When ambulating the newly-delivered patient for the first time, the nurse should hold on to the patient’s arm.

Massage is contraindicated.

All blood values are back to prenatal levels by the 3rd-4th week postpartum

Reproductive system (Vagina) •

Smooth and swollen with poor tone after delivery

•

Rugae reappears by 3-4 postpartum weeks

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Diameter is greater than normal. Hymen is permanently torn.

•

The estrogen index returns in 6-10 weeks.

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Vaginal dryness and painful intercourse (dyspareunia) may be noted during the postpartum period due to decreased estrogen levels.

Integumentary system

•

4.

5.

6.

Mask of pregnancy (chloasma) usually disappears, while stretch marks (striae gravidarum) and linea negra fade but generally do not disappear

Endocrine system •

Estrogen and progesterone level decreases as soon as the placenta is no longer present

•

HPL and HCG are almost negligible by 24 hours

•

FSH remains low for about 12 days and begins to rise as new menstrual cycle is initiated. Menstruation return in approximately 6-8 weeks; ovulation cam return within 4 weeks.

Musculoskeletal system •

Relaxin is the hormone responsible for the relaxation of the pelvic ligaments and joints during pregnancy. After delivery, relaxin level subsides and the pelvic ligaments and joints return to their pre pregnant state. However, the joints of the feet remain altered and many patients notice a permanent increase in shoe size.

•

Abdominal wall is weakened and the muscle tone of the abdomen is diminished after pregnancy. Some patients have a separation between the abdominal wall muscles, called diastasis recti. This separation can ofte be corrected with certain abdominal exercises (sit ups) performed during the postpartum period.

Urinary changes •

Extensive diuresi begins to take place almost immediately after birth to rid the boyd of fluid

•

Increases the daily output a postpartal woman from a 1500- 3000 ml/day during the 2nd-5th day after birth

•

Contain more nitrogen than normal (due to breakdown of protein in a portion of uterine muscle)

•

Urinary retention as a result of decreased bladder tone and emptying can lead to urinary tract infections

PATIENT TEACHING: Self-care guidelines to the mother •

Instruct the client on sitting properly to relieve pain (squeeze the buttocks together and contract pelvic floor muscles before sitting)

•

Instruct to wear perineal pads loosely and to lie in sim’s position

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Demonstrate how to clean the perineum after each voiding and defecation (wiping form front to back), washing the hands and applying a perineal pad from front to back

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Teach the importance of adequate fluid intake, exercise, proper diet and a regular defecation time

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Instruct to avoid garters or constricting clothing that can impair circulation

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Encourage client to shower as soon as she can ambulate and to take tub baths if desired after two weeks. Recommended daily shower to promote comfort and a sense of well-being/

•

Provide adequate dietary fiber and fluids to promote bowel movements; if necessary administer stool softeners, laxatives, suppositories or enema

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Demonstrate newborn care and safery measures

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Recommended exercise:

•

o

Kegel’s and abdominal breathing on postpartum day one

o

Chin-to-chest on postpartum day 2 to tighten and firm up abdominal muscles

o

Knee-to-abdomen when perineum has healed, to strengthen abdominal and gluteal muscles

Sexual activity

o

Resume by the 3rd-4th week postpartum

o

Bleeding has stopped

o

Espisiprrhaphy has healed ( usually 1 week after delivery)

o

Lochia has turned to alba.

o

Decreased physiologic reactions to sexual stimulation are expected for the 1st 3 months postpartum because of hormonal changes and emotional factors.

o

•

She should be protected against subsequent pregnancy by observing a method of contraception, except the PILLS.

Postpartum check up- 4-6 weeks after birth. Woman should return to her physician for an examination (visit is important to ensure that involution is complete and reproductive planning is desired and may be discussed further.)

BREASTFEEDING •

Feed newborn per demand (breastfeeding or bottlefeeding) or at least every two hours and intervals should not exceed 5 hours

•

If breastfeeding o

From birth to at least 2 years and should continue as long as the mother and child wish

o

Exclusive breastfeeding until 6 months of age (when solid are gradually introduced)

o

Correct latching on ( to prevent nipple sores and allow baby to get enough milk)

o



Large part of the breast and areola need to enter the baby’s mouth



Nipple should be at the back of the baby’s throat with the baby’s tongue lying flat in its mouth

10-20 minutes each breast

o •

Cradling position

Storage of expressed breastmilk o

Hard sided containers with airtight seals

Place of storage

Temperature

Maximum storage time

In a room

25 degree C

6-8 hours

Insulated thermal bag with ice packs

Up to 24 hours

In a refrigerator

4 degree C

Up to 5 days

Freezer compartment inside a refrigerator

-15 degree C

2 weeks

A combined refrigerator and freezer with separate doors

-18 degree C

3-6 months

Chest or upright manual defrost deep freezer

-20 degree C

6-12 months

•

Oral contraceptives are contraindicated in lactating mothers because they contain estrogen and progesterone derivatives, thereby decreasing milk supply

BREAST CARE: •

Wash breast daily at bath or shower time

•

Soap or alcohol should never be used on the breast as they tend to dry and crack the nipples and cause sore nipples

•

Wash hands before and after every feeding

•

Insert clean OS squares or piece of cloth in the brassiere to absorb moisture when there is considerable breast discharges.

•

Engorgement managemet: o

Nurse often (not going more than 3 hours without nursing and not skipping night feedings)

o

Well-fitted bra

o

Warm compress/shower

o

Chilled cabbage leaves (placed on breast with nipple exposed)

o

Acetaminophen or ibuprofen for pain

o

Pumping or manually expressing breast milk

How to Manually Express Breastmilk - The Marmet Technique Draining the Milk Reservoirs

1. Position the thumb (above the nipple) and first two fingers (below the nipple) about 1” to 1–1/2” from the nipple, though not necessarily at the outer edges of the areola. Use this measurement as a guide, since breasts and areolas vary in size from one woman to another. Be sure the hand forms the letter “C” and the finger pads are at 6 and 12 o’clock in line with the nipple. Note the fingers are positioned so that the milk reservoirs lie beneath them. • Avoid cupping the breast 2. Push straight into the chest wall

• Avoid spreading the fingers apart. • For large breasts, first lift and then push into the chest wall 3. Roll thumb and fingers forward at the same time. This rolling motion compresses and empties milk reservoirs without injuring sensitive breast tissue. Note the position of thumb and fingernails during the finish roll as shown in the illustration. 4. Repeat rhythmically to completely drain reservoirs. • Position, push, roll... • Position, push, roll... 5. Rotate the thumb and fingers to milk other reservoirs, using both hands on each breast. Avoid These Motions 1. Do not squeeze the breast, as this can cause bruising. 2. Sliding hands over the breast may cause painful skin burns. 3. Avoid pulling the nipple which may result in tissue damage