Care of the Postpartum ClientCare of the Postpartum Client

Postpartum Physical Adaptations Postpartum Physical Adaptations (pg. 906-929)(pg. 906-929)

Uterine InvolutionUterine Involution Fundal position Fundal position

changes: “Boggy” changes: “Boggy” Lochia: Rubra, Lochia: Rubra,

Serosa, AlbaSerosa, Alba Cervical changesCervical changes Vaginal changesVaginal changes Perineal changesPerineal changes Recurrence of Recurrence of

ovulation and ovulation and menustrationmenustration

LactationLactation Gastrointestinal Gastrointestinal

SystemSystem Urinary tractUrinary tract Vital signsVital signs Weight lossWeight loss Postpartum chillPostpartum chill Postpartal Postpartal

diaphoresisdiaphoresis Afterpains or Afterpains or

Afterbirth painsAfterbirth pains

Uterine InvolutionUterine Involution

The rapid reduction in size of the The rapid reduction in size of the uterus and it’s return to a condition uterus and it’s return to a condition similar to its pre-pregnancy state.similar to its pre-pregnancy state.

The uterus remains slightly larger The uterus remains slightly larger than it was before the first pregnancy.than it was before the first pregnancy.

Process is complete at 3 weeks Process is complete at 3 weeks except at the placental site (6 to 7 except at the placental site (6 to 7 weeks)weeks)

SubinvolutionSubinvolution may be caused by an may be caused by an infection or retained placenta infection or retained placenta fragments.fragments.

WEIGHT OF THE WEIGHT OF THE UTERUSUTERUS

Right after delivery: 1000 gramsRight after delivery: 1000 grams 1 week after 1 week after :500 grams:500 grams 2 weeks after2 weeks after : 300 grams: 300 grams 6 weeks after6 weeks after : 50 – 60 grams: 50 – 60 grams

Fundal Position ChangesFundal Position Changes

After birth :After birth : 1st day: one fingerbreadth below 1st day: one fingerbreadth below

umbilicusumbilicus 2nd day: two fingerbreadths 2nd day: two fingerbreadths

below umbilicusbelow umbilicus 9th to 10th day: cannot be 9th to 10th day: cannot be

palpated abdominallyThe first palpated abdominallyThe first postpartum day it is located 1 cm or postpartum day it is located 1 cm or fingerbreadth below the umbilicus.fingerbreadth below the umbilicus.

Fundal Position ChangesFundal Position Changes

May be displaced to the left or May be displaced to the left or right by a distended bladder.right by a distended bladder.

Becomes “boggy” with uterine Becomes “boggy” with uterine atonyatony

“ “ Boggy Uterus ”Boggy Uterus ”

Massage the uterusMassage the uterus Place infant on mother’s breastPlace infant on mother’s breast Administer oxytocin Administer oxytocin

Check BPCheck BP Do not give if BP > 140/90Do not give if BP > 140/90

UTERINE CONTRACTIONSUTERINE CONTRACTIONS

Prevent bleedingPrevent bleeding Afterpains – uncomfortable Afterpains – uncomfortable

crampscramps Common in multipara Common in multipara Oxytocin treatedOxytocin treated Breastfeeding mothersBreastfeeding mothers

2 – 3 days2 – 3 days

NURSING MEASURESNURSING MEASURES

Explain the cause and purpose Explain the cause and purpose of afterpainsof afterpains

Keep bladder emptyKeep bladder empty Prone position to lessen Prone position to lessen

discomfortdiscomfort Gentle massageGentle massage Administer analgesicsAdminister analgesics

VAGINAL DISCHARGEVAGINAL DISCHARGE

LOCHIALOCHIA Uterine discharge after delivery Uterine discharge after delivery Blood, mucus, epithelial cells, Blood, mucus, epithelial cells,

leukocytes and bacterialeukocytes and bacteria

COLOR AND PATTERNCOLOR AND PATTERN Rubra: Rubra:

dark red in colordark red in color present the first 2-3 days postpartumpresent the first 2-3 days postpartum few small clotsfew small clots

Serosa: Serosa: pinkish to brownishpinkish to brownish 44thth to the 10th day to the 10th day

Alba: Alba: creamy or yellowishcreamy or yellowish persists for a week or two after serosa, persists for a week or two after serosa,

may be later inmay be later in breastfeeding clients. breastfeeding clients.

SIGNS OF ABNORMAL SIGNS OF ABNORMAL LOCHIALOCHIASIGNSSIGNS POSSIBLE CAUSEPOSSIBLE CAUSE

FOUL SMELLFOUL SMELL INFECTIONINFECTION

LARGE CLOTSLARGE CLOTS RETAINED RETAINED FRAGMENTSFRAGMENTS

EXCESSIVE EXCESSIVE AMOUNTAMOUNT

LACERATION OF BIRTH LACERATION OF BIRTH CANALCANAL

RETURN TO RETURN TO RUBRIA AFTER RUBRIA AFTER SEROSA OR SEROSA OR ALBAALBA

RETAINED RETAINED FRAGMENTSFRAGMENTS

INFECTIONINFECTION

BLEEDING BLEEDING AFTER 6 WEEKSAFTER 6 WEEKS

SUBINVOLUTION OF SUBINVOLUTION OF THE UTERUSTHE UTERUS

CERVICAL CHANGESCERVICAL CHANGES

Spongy, flabby, formless and Spongy, flabby, formless and bruised.bruised.

Original form is regained in a few Original form is regained in a few hourshours

The shape is permanently The shape is permanently changed by the first childbearing.changed by the first childbearing.

Goes from dimple like to a lateral Goes from dimple like to a lateral slit (fish mouth)slit (fish mouth)

VAGINAL CHANGESVAGINAL CHANGES

Edematous and bruisedEdematous and bruised Small superficial lacerations Small superficial lacerations

may be presentmay be present Laceration and episiotomy heals Laceration and episiotomy heals

after 2 weeksafter 2 weeks Size and rugae return to pre Size and rugae return to pre

pregnancy in 3 weekspregnancy in 3 weeks By 6 weeks appears normalBy 6 weeks appears normal

PERINEAL CHANGESPERINEAL CHANGES

edematous with some bruisingedematous with some bruising Episiotomy edges should be Episiotomy edges should be

approximatedapproximated Ecchymosis may occur and Ecchymosis may occur and

delay healingdelay healing Suture: 7 to 10 daysSuture: 7 to 10 days Perineal muscle tone regained : Perineal muscle tone regained :

66thth weeks weeks

PERINEAL CAREPERINEAL CARE

Flush with warm water Flush with warm water Pat dry from front to backPat dry from front to back Change pead frequentlyChange pead frequently Observe signs of infectionObserve signs of infection Reduce hemorrhoidsReduce hemorrhoids

PERINEAL CAREPERINEAL CARE

ICE PACKSICE PACKS SITZ BATHSITZ BATH

PROMOTE CIRCULATIONPROMOTE CIRCULATION 20 MINUTES20 MINUTES

PERINEAL LAMPPERINEAL LAMP Promote vasodilationPromote vasodilation 25 to 40 watts light25 to 40 watts light 12 -18 inches away12 -18 inches away 20 minutes 3x a day20 minutes 3x a day

Recurrence of Ovulation and Recurrence of Ovulation and MenustrationMenustration

VariableVariable Generally returns to non-nursing Generally returns to non-nursing

mothers between 7 and 9 weeks mothers between 7 and 9 weeks after birthafter birth

The first cycle is non-ovulatoryThe first cycle is non-ovulatory Breastfeeding clients may Breastfeeding clients may

experience menstruation and experience menstruation and ovulation based on the amount of ovulation based on the amount of time nursing…may occur from 2nd to time nursing…may occur from 2nd to 18th month18th month

LACTATIONLACTATION

During pregnancy, the breasts During pregnancy, the breasts develop in preparation for develop in preparation for lactation as a result of both lactation as a result of both estrogen and progesterone. estrogen and progesterone. After birth, the interplay of After birth, the interplay of maternal hormones leads to the maternal hormones leads to the establishment of milk establishment of milk production.production.

GASTROINTESTINAL GASTROINTESTINAL

May have a regular dietMay have a regular diet High in protein, iron and vitaminsHigh in protein, iron and vitamins

Bowels tend to be sluggishBowels tend to be sluggish Episiotomy clients may delay Episiotomy clients may delay

bowel movement for fear of painbowel movement for fear of pain Cesarean birth clients may Cesarean birth clients may

receive clear liquids and receive clear liquids and progress to a regular dietprogress to a regular diet

Stool softeners may be usedStool softeners may be used

URINARY TRACTURINARY TRACT

increased bladder capacity, swelling and increased bladder capacity, swelling and bruising of tissue, decreased sensitivity to bruising of tissue, decreased sensitivity to fluid pressure, and decreased sensation of fluid pressure, and decreased sensation of bladder filling.bladder filling.

At risk for over-distention, incomplete At risk for over-distention, incomplete emptying, and buildup of residual urine.emptying, and buildup of residual urine.

Urinary output increases 1rst 24 hours post Urinary output increases 1rst 24 hours post delivery (delivery (puerperal diuresispuerperal diuresis))

Urine specimens should be obtained as a Urine specimens should be obtained as a catheterized specimen. catheterized specimen.

CARDIOVACULARCARDIOVACULAR Blood loss: NSD: 300 to 500 ml CS: 500 to Blood loss: NSD: 300 to 500 ml CS: 500 to

1000 ml1000 ml reduction in blood volume reduction in blood volume 40% increase of maternal blood volume after 40% increase of maternal blood volume after

delivery of the placentadelivery of the placenta Return of cardiac output to pregnant state takes Return of cardiac output to pregnant state takes

about 2- 3 weeks from deliveryabout 2- 3 weeks from delivery Hemoconcentration in the first 3 to 7 daysHemoconcentration in the first 3 to 7 days Leukocytosis in the first 12 daysLeukocytosis in the first 12 days Elevated fibrinogen levels up to the third weeksElevated fibrinogen levels up to the third weeks Physiologic bradycardia during the first 24 Physiologic bradycardia during the first 24

hourshours Orthostatic hypotension in the first 24 hoursOrthostatic hypotension in the first 24 hours

INTEGUMENTARYINTEGUMENTARY Disappearance of skin changes Disappearance of skin changes

(6 weeks) except for striae and (6 weeks) except for striae and diastisis rectidiastisis recti

Areolar hyperpigmentation may Areolar hyperpigmentation may not disappear completelynot disappear completely

Vital SignsVital Signs

afebrile after the first 24 hours. afebrile after the first 24 hours. BP WNL, BP WNL, a decrease may a decrease may

occuroccur. An . An ↑BP may indicate ↑BP may indicate toxemia, PIH.toxemia, PIH.

Pulse rate may decrease to 50-Pulse rate may decrease to 50-70. 70. Tachycardia should alert the Tachycardia should alert the nurse to blood loss/difficult birthnurse to blood loss/difficult birth..

Blood ValuesBlood Values

Blood values should return to the Blood values should return to the prepregnant state by the end of the prepregnant state by the end of the postpartum period.postpartum period.

Leukocytosis with white blood cell Leukocytosis with white blood cell (WBC) counts up to 30,000 per mL (WBC) counts up to 30,000 per mL may occur early postpartum. may occur early postpartum.

Convenient rule of thumb is a 2 point Convenient rule of thumb is a 2 point drop in hematocrit equals a blood drop in hematocrit equals a blood loss of 500 mL.loss of 500 mL.

Weight LossWeight Loss

An initial weight loss of 10 to 12 An initial weight loss of 10 to 12 lbs occurs as a result of the birth lbs occurs as a result of the birth of the infant, placenta and of the infant, placenta and amniotic fluid.amniotic fluid.

Puerperal diuresis accounts for Puerperal diuresis accounts for loss of an additional 5 lbs during loss of an additional 5 lbs during the early postpartum period.the early postpartum period.

Normally return to pre-pregnant Normally return to pre-pregnant weight by 6 weeks postpartum.weight by 6 weeks postpartum.

Postpartum Chill andPostpartum Chill andPostpartal DiaphoresisPostpartal Diaphoresis

Most clients experience a shaking Most clients experience a shaking chill or tremor after delivery. chill or tremor after delivery. Warm blankets usually relieve this Warm blankets usually relieve this

tremor or chill.tremor or chill. Chills and fever late in the Chills and fever late in the

postpartum period may indicate postpartum period may indicate sepsis.sepsis.

Diaphoretic episodes may occur at Diaphoretic episodes may occur at night, a normal occurrence as the night, a normal occurrence as the body rids itself of waste products.body rids itself of waste products.

AMBULATIONAMBULATION

NSD : 4 – 8 hoursNSD : 4 – 8 hours ANESTHESIA : 8 hoursANESTHESIA : 8 hours ADVANTAGES:ADVANTAGES:

Prevent constipationPrevent constipation Prevent circulatory problems, Prevent circulatory problems,

urinary problemsurinary problems Promote recovery Promote recovery Hasten drainage of lochiaHasten drainage of lochia

EXERCISEEXERCISE

PurposePurpose Prevent complicationsPrevent complications Psychological well beingPsychological well being Strengthen muscles of back, Strengthen muscles of back,

pelvic floor and abdomenpelvic floor and abdomen

EXERCISEEXERCISE

POSTPARTUM EXERCISEPOSTPARTUM EXERCISE Abdominal breathingAbdominal breathing Kegel exercise: tighten perineal Kegel exercise: tighten perineal

musclemuscle Arm RaisingArm Raising Leg RaisingLeg Raising Sit-upsSit-ups

REST AND SLEEPREST AND SLEEP

At least 8 hoursAt least 8 hours Avoid heavy liftingAvoid heavy lifting Light housekeeping: 2 weeksLight housekeeping: 2 weeks Normal activities: 4 – 6 weeksNormal activities: 4 – 6 weeks

RESUMPTION OF SEXRESUMPTION OF SEX

VAGINAL DELIVERY: 3 – 4 VAGINAL DELIVERY: 3 – 4 WEEKS WEEKS

CS: 2 WEEKSCS: 2 WEEKS

DischargeDischarge Primiparas : 2 to 3 daysPrimiparas : 2 to 3 days

Multipara: 1 to 2 daysMultipara: 1 to 2 days CS: 3 to 4 CS: 3 to 4 daysdays

Discharge IE is done before Discharge IE is done before leavingleaving

Follow up: 4 to 6 weeks after Follow up: 4 to 6 weeks after deliverydelivery

Postpartum Psychological Postpartum Psychological AdaptationsAdaptations

Postpartum Psychological Postpartum Psychological AdaptationsAdaptations

Postpartum bluesPostpartum blues Development of Parent-Infant Development of Parent-Infant

attachmentattachment Initial attachment BehaviorInitial attachment Behavior Father-Infant InteractionsFather-Infant Interactions Cultural InfluencesCultural Influences

RUBIN’S POSTPARTUM RUBIN’S POSTPARTUM PHASEPHASE

TAKING-IN PHASETAKING-IN PHASE 11stst 2- 3 days postpartum 2- 3 days postpartum Need for sleep and restNeed for sleep and rest Dependence on otherDependence on other

TAKING-HOLD PHASETAKING-HOLD PHASE Transition phaseTransition phase 33rdrd day to 2 weeks postpartu,m day to 2 weeks postpartu,m Control body functionControl body function

TAKING-HOLD PHASETAKING-HOLD PHASE Ability to assume the mother roleAbility to assume the mother role

LETTING-GO PHASELETTING-GO PHASE Realize that the infant is a Realize that the infant is a

separate individual and not a part separate individual and not a part of herselfof herself

Feeling of lossFeeling of loss Adjustment phaseAdjustment phase

Postpartum bluesPostpartum blues

Transient period of depression : Transient period of depression : 1 - 2 weeks after birth.1 - 2 weeks after birth.

Manifested by mood swings, Manifested by mood swings, anger, weepiness, anorexia, anger, weepiness, anorexia, difficulty sleeping, and a feeling difficulty sleeping, and a feeling of letdown.of letdown.

CAUSE: Hormonal changes and CAUSE: Hormonal changes and psychological adjustments psychological adjustments

Postpartum bluesPostpartum blues

Resolve naturally in 2 to 3 Resolve naturally in 2 to 3 weeks with support and weeks with support and reassurance. reassurance.

If symptoms persist, the If symptoms persist, the client should be evaluated client should be evaluated for postpartum for postpartum depression.depression.

Development of Parent-Infant Development of Parent-Infant attachmentattachment

Level of trustLevel of trust Level of self-esteemLevel of self-esteem Capacity for enjoying herselfCapacity for enjoying herself Interest in and adequacy of Interest in and adequacy of

knowledge about childbearing and knowledge about childbearing and childrearingchildrearing

Client’s prevailing mood or usual Client’s prevailing mood or usual feeling tonefeeling tone

Reactions to the present pregnancyReactions to the present pregnancy

Initial attachment BehaviorInitial attachment Behavior Progression of touching activitiesProgression of touching activities En face position dominatesEn face position dominates Relies heavily on senses of sight, Relies heavily on senses of sight,

touch, hearing in getting to know the touch, hearing in getting to know the babybaby

Some negative feelings may occur; Some negative feelings may occur; be understanding not condescendingbe understanding not condescending

Reciprocity is an interactional cycle Reciprocity is an interactional cycle that occurs simultaneously between that occurs simultaneously between mother and infant. (mutual cueing mother and infant. (mutual cueing behaviors, expectancy, delight in behaviors, expectancy, delight in each others company when each others company when synchronous)synchronous)

Father-Infant InteractionsFather-Infant Interactions

Primary role has been Primary role has been supporting rolesupporting role

Engrossment (the characteristic Engrossment (the characteristic sense of absorption, sense of absorption, preoccupation, and interest in preoccupation, and interest in the infant demonstrated by the infant demonstrated by fathers during early contact with fathers during early contact with the newborn.the newborn.

Cultural InfluencesCultural Influences

Postpartum care my be affected Postpartum care my be affected by cultural beliefs: No shower, by cultural beliefs: No shower, no breastfeeding for the first no breastfeeding for the first three days, “hot” and “cold” three days, “hot” and “cold” foodsfoods

Do not make generalizationsDo not make generalizations Extended family may play an Extended family may play an

important role in careimportant role in care

Postpartum AssessmentPostpartum Assessment

Vital signs: BP should remain Vital signs: BP should remain consistent with baseline BP during consistent with baseline BP during pregnancy. Pulse 50 -90, pregnancy. Pulse 50 -90, respirations 16-24, temp 98-100.4respirations 16-24, temp 98-100.4

Breasts: Smooth, even Breasts: Smooth, even pigmentation, soft, filling, full, pigmentation, soft, filling, full, engorgedengorged

Abdomen: soft, fundus firm, midline Abdomen: soft, fundus firm, midline and at/or below umbilicus, may be and at/or below umbilicus, may be tender on palpationtender on palpation

Lochia: rubra, scant to moderate, no Lochia: rubra, scant to moderate, no clots, rubra to serosa to albaclots, rubra to serosa to alba

Postpartum AssessmentPostpartum Assessment

Perineum: Slight edema, no bruising, Perineum: Slight edema, no bruising, episiotomy without redness, swelling episiotomy without redness, swelling or drainage, hemorrhoids (none or or drainage, hemorrhoids (none or small)small)

Lower extremities: No pain with Lower extremities: No pain with palpation, negative Homan’s signpalpation, negative Homan’s sign

Elimination: voiding 4-6 hrs, no Elimination: voiding 4-6 hrs, no bladder distention noted, normal bladder distention noted, normal bowel movement by the 2bowel movement by the 2ndnd to 3 to 3rdrd day day post deliverypost delivery

Psychological adaptation: cultural Psychological adaptation: cultural assessment, bonding, holding en assessment, bonding, holding en face, attachment behaviorsface, attachment behaviors

Postpartum AssessmentPostpartum Assessment

Dysfunctions of the Postpartum Dysfunctions of the Postpartum Period Period

Postpartal Uterine Infection: Endometritis, Postpartal Uterine Infection: Endometritis, Pelvic CellulitisPelvic Cellulitis

Perineal Wound InfectionPerineal Wound Infection Cesarean Wound InfectionCesarean Wound Infection Urinary Tract Infection (UTI)Urinary Tract Infection (UTI) MastitisMastitis Thromboembolitic Disease: Superficial Leg Thromboembolitic Disease: Superficial Leg

Vein Disease, Deep Vein Thrombosis, Vein Disease, Deep Vein Thrombosis, Septic Pelvic ThrombophlebitisSeptic Pelvic Thrombophlebitis

Postpartum Psychiatric Disorder: “baby Postpartum Psychiatric Disorder: “baby blues”, Postpartum Psychosis, Postpartum blues”, Postpartum Psychosis, Postpartum Major Mood DisorderMajor Mood Disorder

Two methods of milk Two methods of milk suppressionsuppression

a. mechanical (tight bras, a. mechanical (tight bras, avoiding nipple stimulation, ice avoiding nipple stimulation, ice packs)packs)

b. pharmacologic b. pharmacologic (bromocriptine)(bromocriptine)