WEEK 10: POSTPARTUM (6 weeks), it weighs approximately 50 g, similar to Module its prepregnancy weight. • Because uterine contraction begins immediately after placental delivery, the fundus of the uterus WHAT IS UTILITARIANISM? may be palpated through the abdominal wall, halfway between the umbilicus and the UTILITARIANISM 🦖 symphysis pubis, within a few minutes after birth. • The postpartal period, or puerperium (from the One hour later, it will have risen to the level of the Latin puer, for “child,” and parere, for “to bring umbilicus, where it remains for approximately the forth”), refers to the 6-week period after childbirth. next 24 hours. From then on, it decreases one • It is a time of maternal changes that are both fingerbreadth per day—on the first postpartal retrogressive (involution of the uterus and vagina) day, and so forth. By the ninth or tenth day, the and progressive (production of milk for lactation, uterus will no longer be detected by abdominal restoration of the normal menstrual cycle, and palpation beginning of a parenting role). • Uterine involution may be delayed by a condition • Assessment during the puerperium, assessment of such as the birth of multiple fetuses, hydramnios, a woman is accomplished by health interview, exhaustion from prolonged labor or a difficult physical examination, and analysis of laboratory birth, grand multiparity, or physiologic effects of data. It is important to ensure that physical changes, excessive analgesia. Contraction may be difficult such as uterine involution, are occurring by if there is retained placenta or membranes. evaluating uterine size and consistency and lochia Involution will occur most dependably in a flow amount. woman who is well nourished and who ambulates PHYSIOLOGICAL CHANGES OF THE POSTPARTAL early after birth (gravity may play a role). PERIOD • An estimation of the consistency of the postpartal uterus is as important as measurement of its REPRODUCTIVE SYSTEM CHANGES height. A well-contracted fundus feels firm. It can Involution be compared with a grapefruit in both size and tenseness. Whenever the fundus feels boggy (soft • is the process whereby the reproductive organs or flabby), it is not as contracted as it should be, return to their nonpregnant state. By the time despite its position in the abdomen. involution is complete (6 weeks), the uterus is • The first hour after birth is potentially the most completely return to its prepregnancy state dangerous time for a woman. If her uterus should The Uterus become relaxed during this time (uterine atony), she will lose blood very rapidly, because no • The sealing of the placenta site is accomplished by permanent thrombi have yet formed at the rapid contraction of the uterus immediately after placental site. delivery of the placenta. This contraction pinches the blood vessels entering the 7-cm-wide area left Lochia denuded by the placenta and stops bleeding. With • Uterine flow, consisting of blood, fragments of time, thrombi form within the uterine sinuses and decidua, white blood cells, mucus, and some permanently seal the area. bacteria, is known as lochia. • Although the uterus will never completely return • The portion of the uterus where the placenta was to its prepregnancy state, its reduction in size is not attached is so fully cleansed by this sloughing dramatic. Immediately after birth, the uterus process that it will be in a reproductive state in weighs about 1000 g. At the end of the first week, about 3 weeks’ time. It takes approximately 6 Page 1 of 10 NCMA 217 (Midterms) Annotated by: C. Danting weeks (the entire postpartal period) for the • By the end of 7 days, the external os has placental implantation site to be healed. narrowed to the size of a pencil opening; the • For the first 3 days after birth, a lochia discharge cervix feels firm and nongravid again. consists almost entirely of blood, with only small • Like the fundus, the cervix does not return exactly particles of decidua and mucus. Because of its to its prepregnancy state. The internal os closes mainly red color, it is termed lochia rubra. As the as before, but after a amount of blood involved in the cast-off tissue vaginal birth the decreases (about the fourth day) and leukocytes external os usually begin to invade the area, as they do with any remains slightly open healing surface, the flow becomes pink or and appears slitlike or brownish (lochia serosa). On about the 10th day, stellate (star shaped), the amount of the flow decreases and becomes whereas previously it colorless or white (lochia alba). Lochia alba is was round. present in most women until the third week after birth, although it is not unusual for a lochia flow The Vagina to last the entire 6 weeks of the puerperium. • After a vaginal birth, the vagina is soft, with few rugae, and its diameter is considerably greater than normal. The hymen is permanently torn and heals with small, separate tags of tissue. It takes the entire postpartal period for the vagina to involute (by contraction, as with the uterus) until it gradually returns to its approximate prepregnancy state. • Because a woman who is breastfeeding may have delayed ovulation, she may continue to have thin- walled or fragile vaginal cells that cause slight vaginal bleeding during sexual intercourse until about 6 weeks’ time. • Like the cervix, the vaginal outlet remains slightly • Saturating a perineal pad in less than 1 hour is more distended than before. If a woman practices considered an abnormally heavy flow and should Kegel exercises, the strength and tone of the be reported. Lochia should contain no large clots. vagina will increase more rapidly Clots may indicate that a portion of the placenta has been retained and is preventing closure of the The Perineum maternal uterine blood sinuses. Lochia should not • Because of the great amount of pressure have an offensive odor. Lochia has the same odor experienced during birth, the perineum feels as menstrual blood. An offensive odor usually edematous and tender immediately after birth. . indicates that the uterus has become infected The labia majora and labia minora typically remain atrophic and softened after birth, never The Cervix returning to their prepregnancy state. • Immediately after birth, a uterine cervix is soft and malleable. Both the internal and external os Breast are open. Like contraction of the uterus, • In many women, breast distention becomes contraction of the cervix toward its prepregnant marked, and this often is accompanied by a state begins at once. feeling of heat or pain. The distention is not limited to the milk ducts but occurs in the Page 2 of 10 NCMA 217 (Midterms) Annotated by: C. Danting surrounding tissue as well, because blood and it with the middle finger of the other hand), a full lymph enter the area to contribute fluid to the bladder sounds resonant, in contrast to the dull, formation of milk. This feeling of tension in the thudding sound of non–fluid-filled tissue. breasts on the third or fourth day after birth is termed primary engorgement. It fades as the THE CIRCULATORY SYSTEM infant begins effective sucking and empties the • The diuresis that is evident between the second breasts of milk. and fifth days after birth, as well as the blood loss SYSTEMIC CHANGES at birth, acts to reduce the added blood volume a • Pregnancy hormones begin to decrease as soon woman accumulated during pregnancy. This as the placenta is no longer present. Levels of reduction occurs so rapidly, in fact, that the blood human chorionic gonadotropin (hCG) and human volume returns to its normal prepregnancy level placental lactogen (hPL) are almost negligible by by the first or second week after birth. 24 hours. • The usual blood loss with a vaginal birth is 300 to • By week 1, progestin, estrone, and estradiol are 500 mL. With a cesarean birth, it is 500 to 1000 all at prepregnancy levels. Estrol may be elevated mL. A 4-point decrease in hematocrit (proportion for an additional week before it reaches of red blood cells to circulating plasma) and a 1-g prepregnancy levels. Folliclestimulating hormone decrease in hemoglobin value occur with each (FSH) remains low for about 12 days and then 250 mL of blood lost. begins to rise as a new menstrual cycle is • Women usually continue to have the same high initiated. level of plasma fibrinogen during the first postpartal weeks as they did during pregnancy. THE URINARY SYSTEM This is a protective measure against hemorrhage. However, this high level also increases the risk of • During pregnancy, as much as 2000 to 3000 mL thrombus formation. excess fluid accumulates in the body. An extensive diuresis begins to take place almost THE GASTRO INTESTINAL SYSTEM immediately after birth to rid the body of this fluid. This easily increases the daily output of a • Digestion and absorption begin to be active again postpartal woman from a normal level of 1500 mL soon after birth unless a woman has had a to as much as 3000 mL/day during the second to cesarean birth. Almost immediately, the woman fifth day after birth. This marked increase in urine feels hungry and thirsty and she can eat without production causes the bladder to fill rapidly. difficulty from nausea or vomiting during this • During a vaginal birth, the fetal head exerts a time. great deal of pressure on the bladder and urethra • Hemorrhoids (distended rectal veins) that have as it passes on the bladder’s underside. This been pushed out of the rectum because of the pressure may leave the bladder with a transient effort of pelvic-stage pushing often are present. loss of tone that, together with the edema • Bowel sounds are active, but passage of stool surrounding the urethra, decreases a woman’s through the bowel may be slow because of the ability to sense when she has to void. still-present effect of relaxin on the bowel. Bowel • To prevent permanent damage to the bladder evacuation may be difficult because of the pain of from overdistention, assess a woman’s abdomen episiotomy sutures or hemorrhoids. frequently in the immediate postpartal period. On palpation, a full bladder is felt as a hard or firm THE INTEGUMENTARY SYSTEM area just above the symphysis pubis. On • After birth, the stretch marks on a woman’s percussion (placing one finger flat on the abdomen (striae gravidarum) still appear woman’s abdomen over the bladder and tapping Page 3 of 10 NCMA 217 (Midterms) Annotated by: C. Danting reddened and may be even more prominent than BLOOD PRESSURE during pregnancy, when they were tightly • Blood pressure should also be monitored stretched. carefully during the postpartal period, because a • Excessive pigment on the face and neck decrease in this can indicate bleeding. In contrast, (chloasma) and on the abdomen (linea nigra) will an elevation above 140 mm Hg systolic or 90 mm become barely detectable in 6 weeks’ time. Hg diastolic may indicate the development of • If diastasis recti (overstretching and separation of postpartal pregnancy-induced hypertension, an the abdominal musculature) is present, the area unusual but serious complication of the will appear slightly indented. If the separation is puerperium. large, it will appear as a bluish area in the • To evaluate blood pressure, compare a woman’s abdominal midline. Modified sit-ups help to pressure with her prepregnancy level if possible, strengthen abdominal muscles and return rather than with standard blood pressure ranges. abdominal support to its prepregnant level • Oxytocics, drugs frequently administered during the postpartal period to achieve uterine VITAL SIGN CHANGES contraction, cause contraction of all smooth muscle, including blood vessels that can increase TEMPERATURE blood pressure. • A woman may show a slight increase in temperature during the first 24 hours after birth PROGRESSIVE CHANGES because of dehydration that occurred during labor. If she receives adequate fluid during the • Two physiologic changes that occur during the first 24 hours, this temperature elevation will puerperium involve progressive changes, or the return to normal. building of new tissue. Because building new • Any woman whose oral temperature rises above tissue requires good nutrition, caution women 100.4° F (38° C), excluding the first 24-hour against strict dieting that would limit cell-building period, is considered by criteria of the Joint ability during the first 6 weeks after childbirth. Commission on Maternal Welfare to be febrile. In such women, a postpartal infection may be LACTATION present. • The formation of breast milk (lactation) begins in • Occasionally, when a woman’s breasts fill with a postpartal woman whether or not she plans to milk on the third or fourth postpartum day, her breastfeed. For the first 2 days after birth, an temperature rises for a period of hours because average woman notices little change in her of the increased vascular activity involved. If the breasts from the way they were during elevation in temperature lasts longer than a few pregnancy. hours, however, infection is a more likely reason. • Since midway through pregnancy, she has been secreting colostrum, a thin, watery, prelactation PULSE secretion. She continues to excrete this fluid the • A woman’s pulse rate during the postpartal first 2 postpartum days. On the third day, her period is usually slightly slower than normal. breasts become full and feel tense or tender as During pregnancy, the distended uterus milk forms within breast ducts. obstructed the amount of venous blood returning • Breast milk forms in response to the decrease in to the heart; after birth, to accommodate the estrogen and progesterone levels that follows increased blood volume returning to the heart, delivery of the placenta (which stimulates stroke volume increases. This increased stroke prolactin production and, consequently, milk volume reduces the pulse rate to between 60 and production). When breast milk first begins to 70 beats per minute. form, the milk ducts become distended.
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• The distention of the breast is not limited to the hours healing increases best if circulation to the area milk ducts but occurs in the surrounding tissue as by the use of heat. Dry heat in the form of a perineal well, because blood and lymph enter the area to hot pack or moist heat with a sitz bath. contribute fluid to the formation of milk. This e. Episiotomy Care - the perineal area heals rapidly, you feeling of tension in the breasts on the third or can assure a woman that this discomfort is normal fourth day after birth is termed primary and does not usually last longer than 5 or 6 days. engorgement. It fades as the infant begins Many physicians and nurse-midwives order a effective sucking and empties the breasts of milk soothing cream or anesthetic spray to be applied to the suture line to reduce discomfort. f. Inspect Lochia - Check the Consistency: Lochia should RETURN OF MENSTRUAL FLOW contain no large clots. Clots may indicate that a • With the delivery of the placenta, the production portion of the placenta has been retained and is of placental estrogen and progesterone ends. The preventing closure of the maternal uterine blood resulting decrease in hormone concentrations sinuses. In any event, large clots denote poor uterine causes a rise in production of FSH by the pituitary, contraction, which needs to be corrected. which leads, with only a slight delay, to the return Observe the Pattern: Lochia is red for the first 1 to 3 of ovulation. This initiates the return of normal days (lochia rubra), pinkishbrown from days 4 to 10 menstrual cycles. (lochia serosa), and then white (lochia alba) for as • A woman who is not breastfeeding can expect her long as 6 weeks after birth. The pattern of lochia menstrual flow to return in 6 to 10 weeks after (rubra to serosa to alba) should not reverse. birth. If she is breastfeeding, a menstrual flow PSYCHOLOGICAL CHANGES may not return for 3 or 4 months (lactational amenorrhea) or, in some women, for the entire • Postpartal Blues During the postpartal period, as lactation period. However, the absence of a many as 50% of women experience some feelings menstrual flow does not guarantee that a woman of overwhelming sadness (Buultjens & will not conceive during this time, because she Liamputtong, 2007). They may burst into tears may ovulate well before menstruation returns easily or feel let down or irritable. This temporary feeling after birth has long been known as the NURSING RESPONSIBILITIES “baby blues.” • This phenomenon may be caused by hormonal a. Perineal Care - inspect the perineum. Observe for changes, particularly the decrease in estrogen ecchymosis, hematoma, erythema, edema, and progesterone that occurs with delivery of the intactness, and presence of drainage or bleeding from any episiotomy stitches. placenta. For some women, it may be a response b. Provide Pain Relief for After pains - Pain from to dependence and low self-esteem caused by uterine contractions can be intense, but you can exhaustion, being away from home, physical assure a woman that this type of discomfort is discomfort, and the tension engendered by normal and rarely lasts longer than 3 days. assuming a new role, especially if a woman is not c. Relieve Muscular Aches - Many women feel sore receiving support from her partner. and aching after labor and birth because of the • The syndrome is evidenced by tearfulness, excessive energy they used for pushing during the feelings of inadequacy, mood lability, anorexia, pelvic division of labor. A backrub is effective for and sleep disturbance. relieving an aching back or shoulders. • Anticipatory guidance and individualized support d. Administer Cold and Hot Therapy - Applying an ice or from health care personnel are important to help cold pack to the perineum during the first 24 hours the parents understand that this response is reduces perineal edema and the possibility of normal. You can assure a woman that sudden hematoma formation, thereby reducing pain and crying episodes may occur; otherwise, she may promoting healing and comfort. After the first 24
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have difficulty understanding what is happening NURSING CARE OF A WOMAN AND FAMILY DURING to her. THE FIRST 24 HOURS AFTER BIRTH • Her support person also needs assurance, or he 1. Provide pain relief after pains can think the woman is unhappy with him or their new baby or is keeping some terrible secret about • Pain from uterine contractions can be intense, the baby from him. but you can assure a woman that this type of discomfort is normal and rarely lasts longer than 3 days. If necessary, either ibuprofen (such as Motrin), which has anti-inflammatory properties, or a common analgesic such as acetaminophen (such as Tylenol) is effective for pain relief. As with any abdominal pain, heat to the abdomen should be avoided, because it could cause relaxation of the uterus and subsequent uterine bleeding. 2. Relieve muscular aches PHASES OF THE PUERPERIUM • Many women feel sore and aching after labor and • Reva Rubin, a nurse, divided the puerperium into birth because of the excessive energy they used three separate phases (Rubin, 1977). for pushing during the pelvic division of labor. They describe feeling as if they have “run for Taking-In Phase miles.” A woman may need a mild analgesic such • A time when the new parents review their as acetaminophen for the pain. A backrub is pregnancy and the labor and birth, a time of effective for relieving an aching back or reflection. During this 2- to 3-day period, a shoulders. Carefully assess a woman who states woman is largely passive. This dependence that she has pain on standing. Pain in the calf of results partly from her physical discomfort the leg on standing (a position that dorsiflexes the because of after pains; partly from her foot) is a sign similar to Homans’ sign suggesting uncertainty in caring for her newborn; and partly thrombophlebitis may be present. from the extreme exhaustion that follows 3. Administer cold and hot therapy childbirth. • Applying an ice or cold pack to the perineum Taking-Hold Phase during the first 24 hours reduces perineal edema • After a time of passive dependence, a woman and the possibility of hematoma formation, begins to initiate action. Now, she begins to take thereby reducing pain and promoting healing and a strong interest. , it is always best to give a comfort. Be certain not to place ice or plastic woman brief demonstrations of baby care and directly on the woman’s perineum. Wrap an ice then allow her to care for her child herself—with bag first in a towel or disposable pad, to decrease watchful guidance. the chance of a thermal burn (risk of injury increases because the perineum has decreased Letting-Go Phase sensation from edema after birth). Commercial • In the third phase, called letting-go, a woman cold packs combined with perineal pads also are finally redefines her new role. She gives up the available. For a low-cost alternative, a rubber fantasized image of her child and accepts the real glove may be partially filled with ice chips, one; she gives up her old role of being childless or provided latex allergy is not a concern. the mother of only one or two (or however many • Ice to the perineum after the first 24 hours is no children she had before this birth). longer therapeutic. After this time, healing
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increases best if circulation to the area is a sitz bath is not too hot before you help a woman encouraged by the use of heat. Dry heat in the to use it; it should feel pleasantly warm, not hot. form of a perineal hot pack or moist heat with a 7. Provide Perineal Care sitz bath is an effective way to increase circulation • Postpartal women are particularly prone to to the perineum, provide comfort, reduce edema, perineal infection because lochia, if allowed to and promote healing. dry and harden on the vulva and perineum, 4. Promote Perineal Exercises furnishes a rich bed for bacterial growth, which • Some women find that carrying out perineal then can spread to the uterus. Because the vagina exercises three or four times a day can greatly lies inclose proximity to the rectum, there is also relieve perineal edema. The exercise consists of always the danger that bacteria will spread from contracting and relaxing the muscles of the the rectum to the vagina. Interruption in skin perineum 5 to 10 times in succession, as if trying integrity from an episiotomy also increases the to stop voiding (Kegel exercises). This aids client’s risk for infection. Teach a woman to comfort by improving circulation to the area and include perineal care as part of her daily bath or decreasing edema. When repeated frequently, shower and after every voiding or bowel Kegel exercises also help a woman regain her movement. If the woman is on bed rest during the prepregnant muscle tone and help prevent first hour after birth, you will need to provide urinary incontinence (Hay-Smith & Dumoulin, perineal care for her. 2009). 8. Promote Rest in the early postpartal period 5. Give Episiotomy care • Few women are prepared for the degree of • Although relatively small in size, episiotomy fatigue they experience after childbirth. Try to do sutures can cause considerable discomfort, all procedures swiftly yet gently, to allow as much because the perineum is an extremely tender time for sleep as possible. If a woman has area and the muscles of the perineum are discomfort from hemorrhoids, perineal stitches, involved in so many activities such as sitting, or afterpains, be sure she has pain relief so that walking, stooping, squatting, bending, urinating, she can rest comfortably or sleep. Urge her not to and defecating. Most women expect labor to be fall asleep in a narrow hospital bed with her new painful. They usually do not anticipate the pulling infant. Sharing bed space is controversial even in pain from perineal stitches in the postpartal a large bed (Horsley et al., 2007). period, discomfort that interferes with their rest and sleep, with eating, and with being able to sit 9. Assess Peripheral Circulation and hold their baby comfortably. Because the • To determine whether peripheral circulation is perineal area heals rapidly, you can assure a adequate, assess a woman’s thigh for skin turgor. woman that this discomfort is normal and does Assess for edema at the ankle and over the tibia not usually last longer than 5 or 6 days. on the lower leg. Although this technique is not 6. Administer Sitz Baths totally reliable, assess for thrombophlebitis by • A sitz bath is a portable basin that fits on a dorsiflexing a woman’s ankle and asking her if she toilet seat. A reservoir filled with water provides notices pain in her calf on that motion (Homans’ a constant supply of swirling water to the basin. sign). Assess also for redness in the calf area, The movement of water soothes healing tissue, because thrombophlebitis can be present even decreases inflammation by causing vasodilation with a negative Homans’ sign. Continue to assess in the area, and thereby effectively reduces for adequate peripheral circulation once every 8 discomfort and promotes healing. Sitz baths hours during the woman’s stay in a health care usually use water that is maintained at 100° to facility. If you suspect thrombophlebitis, do not 105° F (38° to 41° C). Be certain that the water in Page 7 of 10 NCMA 217 (Midterms) Annotated by: C. Danting massage the area—doing so could cause an abscess. It is not necessary for women to wash embolus. their breasts more often than daily, because • Be certain to allow a woman to dangle her legs on excessive washing means unnecessary the edge of the bed for a few minutes to prevent. manipulation. Dizziness before she gets up for the first time. 12. Teach Methods to promote uterine Involution Then, assist her as needed to take the few steps • All during the postpartal period, lying on the to a nearby bathroom. Remain with her to be abdomen gives support to abdominal muscles certain that dizziness does not occur. After this, and may aid involution, because it tips the uterus she may be up on her own as she wishes. As a into its natural forward position. If this puts too rule, women who ambulate quickly feel stronger much pressure on sore breasts, placement of a and healthier by the end of their first week and small pillow under the abdomen usually solves have fewer bowel, bladder, and circulatory the problem. It may be dangerous for a woman to complications than those who do not assume a knee–chest position until at least the 10. Prevent/ Alleviate Breast Engorgement third week after birth. In a knee–chest position, • If a woman is breastfeeding, encouraging her the vagina tends to open. Because the cervical os newborn to suck at the breast is the main remains open to some extent until the third treatment for relief of the tenderness and week, there is a danger that air will enter the soreness of primary breast engorgement. Many vagina and the open cervix, penetrate the open women find the application of warm compresses blood sinuses inside the uterus, enter the or standing under a warm shower beneficial to circulatory system, and cause an air embolism. relieve engorgement discomfort. Good support from a bra also offers relief because it prevents BUBBLE-HE unnecessary strain on the supporting muscles of BUBBLE-HE is an acronym used to denote the the breasts, positions the breasts in good components of the postpartum maternal nursing alignment, and diminishes the amount of assessment. This method enhances the standard physical engorgement caused by blocked milk ducts. If the assessment process typically performed on hospitalized woman has not packed a bra in her suitcase, ask patients by the RN, such as those on a Medical-Surgical her to arrange to have one brought from home. floor. For stable patients, vital signs are taken every 15 • Cold compresses, applied to the breasts three or minutes during the first hour following delivery and then four times a day during the period of gradually less frequently. While performing the BUBBLE- engorgement, or an oral analgesic, or both, HE, the RN often uses the assessment time to provide for provide relief. Wearing a snug-fitting bra and patient education. avoiding nipple stimulation may help. Restricting 8-POINT POSTPARTUM ASSESSMENT INSTRUCTIONS fluid and pumping milk from the breasts are not effective measures and are to some degree 1. Breast harmful, so these actions should be avoided. a. Gently palpate each breast 11. Promote Breast hygiene b. If you feel nodules in the breast, the ducts may not have been emptied at last. • Breast care during the postpartal period includes c. Stroke downward towards the nipple, then cleanliness and support. These issues are the gently release the milk by manual. same whether or not a woman is breastfeeding. d. If nodules remain, notify the doctor. Teach a woman to wash her breasts daily with e. Take this opportunity to explain the process of clear water at the time of her bath or shower and milk production, what to do about engorgement, then dry them with a soft towel. She should avoid how to perform self breast examinations, and using soap, because it tends to dry and crack the answer any questions she may have about nipples, possibly leading to fissures and breast breastfeeding.
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▪ What is the contour? 5. Lochia ▪ Are the breast full, firm, tender, shiny? a. Assess the amount and type of lochia on pad in ▪ Are the veins distended? relations to the number of postpartum days. ▪ Is the skin warm? First 3 days of postpartum, you should find a very ▪ Does the patient complain of sore nipples? red lochia similar to the menstrual flow (lochia ▪ Are breasts so engorged that she requires ruba). pain medication? b. During the next few days, it should become 2. Uterus wateryserous (lochia serosa). Onthe tenth day, a. Palpate the uterus it b. Have the patient feel her uterus as you explain c. should become thin and colorless (lochia alba). the process of involution d. .Inform the mother about what changes she c. If uterus is not involution properly, check for should expect in the lochia and when it should infection, fibroids and lack of tone. cease. d. Uterus should the firm decrease approximately e. Tell the mother when her next menstrual period one finger breadth below will probably begin and when she can resume e. Unsatisfactory involution may result if there are sexual relations. retained secundines or the bladder not f. Discuss family planning at this time. f. completely empty g. Notify the doctor if the lochia looks abnormal in 3. Bladder to color or contains clogs other than small ones. a. Inspect and palpate the bladder simultaneously 6. Episiotomy while checking the height of the fundus. a. Inspect episiotomy thoroughly using flashlight if b. An order from the physician is necessary necessary, for better visibility. cauterization may be done. An order for culture b. Check rectal area. If hemorrhoids are present, and sensitivity test since definitive treatment the doctor may want to start on sitz bath and may be required. local analgesic medication. Reassure patient and c. Talk to mother about proper perineal care. answer questions she may have regarding pain, Explain that she should wipe from front to back cleanliness, and coitus. after voiding and defecating. c. Check episiotomy for proper wound healing, d. Bladder distention should not be present after infection, inflammation and suture sloughing. recent emptying. d. Is the surrounding skin warm to touch? e. When bladder distention does occur, a pouch e. Does the patient complain of discomfort? Notify over the bladder area is observed, felt upon the doctor if any occurs palpation; mother usually feels need to urinate. 7. Homan’s Sign f. It is imperative that the first three post-partum a. Press down gently on the patient’s knee (legs voiding be measured and should be at least extended flat on bed) ask her to flex her foot 150cc. Frequent small voiding with or without b. Pain or tenderness in the calf is a positive pain and burning may indicate infection or Homan’s sign and indication of retention. thrombophlebitis. Physician should be notified 4. Bowel Function immediately. a. Question patient daily about bowel movements. 8. Emotional Status She must not become constipated. If her bowels a. Throughout the physical assessment, notice and have not functioned by the second postpartum evaluate the mother’s emotional day, the doctor may start her on a mild laxative b. status. b. Encourage patient to drink extra fluids. c. Explain to the mother and to her family that she c. Have patient select fruits and vegetables from may cry easily for a while and that her emotions her menu may shift from high to low. The changes are normal and are probably caused by the tremendous hormonal changes occurring in her
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body and by her realization of new responsibilities that accompany each child’s birth. d. Does the patient appear dependent or independent? Is she elated or despondent? What does she say about family? Are there other nonverbal responses?
TERMINOLOGIES
• PUERPERIUM/Postpartum – 6 weeks period after
giving birth • Engorgement - swell with blood, water, or another fluid • Involution - return of the reproductive organs to their non-pregnant state. • Lochia - Uterine flow, consisting of blood, fragments of decidua, white blood cells, mucus • Sitz bath - type of therapy done by sitting in warm, shallow water.
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How To Have an Easy and Safe Pregnancy and Bring Forth a Healthy Baby: A Pregnancy Book for First Time Moms for a Successful and Healthy Journey through Pregnancy, Childbirth and Newborn