OB Ch.

12
Postpartum Nursing Care
Postpartum Physical Adaptions
 Postpartum period is also known as puerperium
 Period following delivery of placenta & lasting until reproductive organs return to nonpregnant state,
usually about 6 wks.
 Postpartum shivers
o Cause unknown; several mechanisms have been proposed, such as the ones below
 Reaction to a fetal-maternal transfusion that occurred when the placenta was delivered &
maternal/fetal blood mixed
 Small amts of amniotic fluid that enters the bloodstream
 Mother experiences a thermal imbalance caused by delivery of the placenta or drop in body temp.
after birth
o Shivering is noticeable and may frighten mother and may occur anytime from 1-30 min after
delivery & last 2-6o min.
o Nurse intervention: provide a warm blanket and reassurance that shivering will pass to comfort
patient

Reproduction System & Associated Structures: Most changes immediately

after delivery
 UTERUS INVOLUTION
o Immediately after birth of placenta : Process called involution takes place ↓
 Estrogen & progesterone levels drop quickly
 Oxytocin Continues to release = uterus contracts & begin shrinking down to nonpregnant size
o Uterus weighs 1,000 to 1,200 g immediately after birth: then gradually decreases d/t decrease in
size of myometrial cells
 After 7 days, weight decreases to 500 g
 By wk. 6 wt.. Decreases to 50g
o Top portion of uterus after delivery is the size of a grapefruit, this is called the FUNDUS
 Fundus located midline & halfway between the umbilicus & symphysis pubis.
 Approx.. 1 hr. after birth the fundus is firm and even with umbilicus
 Uterus continues to descend approx.. 1 cm/day
 By day 10, uterus is not palpable above the symphysis pubis
o Afterpains = intermittent ctx that women describe as “cramping”
 Caused by: release of oxytocin
 Multiparous pt = afterpain more noticeable
 d/t uterus has been stretched before & has to work harder to regain tone & return to
nonpregnant size
 Also can be noticed while breastfeeding as result of nipple stimulation = release of oxytocin
 Usually last for few days and can be alleviated w/ ibuprofen (Motrin)
 Inhibits (prevents) prostaglandin/ in which are produced as part of the inflammatory
process & Motrin can promote pain relief as well as anti-inflammatory
 Side effects: GI discomfort; so take w/ food
o After delivery of placenta the body does things to prevent hemorrhage
 Uterine muscles contract to the blood vessels that were attached to placenta
 Lg. blood vessels @ site of where placenta was attached thrombose = blood clots close the
vessels
 o Exfoliation is the sloughing of dead tissue @ placental site & leaves the site smooth & w/o scar
tissue
 Allows the successful implantation of fertilized ovum in subsequent pregnancies
 Lochia
o Inner lining of uterus begins to slough off= vag. Discharge made of blood, mucus, & tissues
o Total volume of lochia = 200-500 Ml & may last up to 6 wks. & gradually gets lighter in
color/amt
 Cervix
o Post-delivery cervix = open & lacks tone
o Cervical opening slowly closes & by day 14 = barley dilated
 A parous cervix will have a slitlike opening instead of small round opening of a nonporous cervix
 Vagina
o Post-delivery vagina lacks tone.
o Over the next 4 wks. = Edema decreases & vaginal folds (known as rugae) appear.
o Vag tissue may not lubricate easily until hormone balance restored
o It will never appear to pre-pregnant size but does decrease in size as recovery continues
 Perineum
o Area btw vagina & anus stretches & thins to allow the birth.
o Perineal lacerations may occur during delivery or episiotomy may have been preformed
o After delivery its usually bruised & edematous, & muscle tone is weak
 Tone will restore over 4-6 wks.
 Kegel exercises = promote return of tone
 Ovaries & Ovulation
o Normal function of ovaries is variable & influenced by breastfeeding
o Menstruation usually delayed & may not resume for wks. Or months for breastfeeding women
 Depending on how much & how often infant is breastfed
 Delay caused by = suppression of ovulation by hormone prolactin
o Mother who does not breastfeed may ovulate as early as 27 days post delivery
 Menstruation/beginning of ovulation begins in 6-12 wks for bottle feeding women
 Breast
o Before milk, breast secretes colostrum (thin, yellowish fluid that provides nutrition & antibodies
to breastfeeding infant)
o Nipple stimulation provided by infant causes release of prolactin (via anterior pituitary)
 Prolactin: initiates milk production between 2nd & 4th day breast become engorged w/ milk
 Breast may feel warm & tender

INTEGUMENTARY SYSTEM CHANGES

 Abdominal skin will resume pre-pregnancy state
o W/ exception of abdominal striae (stretch marks)
 May take wks to fade to a silver color
 Linea nigra
o Down middle of abdomen will fade but never go away completely
 Effects of melanocyte-stimulating hormones
o Causes hyperpigmentation called Melasma on face
 Fades away over period of days and weeks
 Hair loss over postpartum period is common but resolves w/o medical intervention

GI SYTEM CHANGES
  Combined effects of restricted (food/fluid) intake, elevated progesterone levels during pregnancy, &
anesthesia can lead to sluggish intestinal peristalsis & constipation
o Stool softener prescribed after birth (Ex. Docusate)
 Prescribed to prevent straining
 Onset of oral stool softener = 12-72 hrs
 Safe to use for breastfeeding
 Common effects: diarrhea & abdominal cramping
 Internal & external hemorrhoids caused by weight of the uterus & pushing during birth can cause pain w
defecation
o Most women are hungry & thirsty after delivery d/t amt of energy exerted into birthing process

CARDIOVASCULAR SYSTEM CHANGES

 Expected blood loss from vaginal delivery
o 250-500 ML
 Expected C-section blood loss
o 800-1,000 ML
 Immediately after birth, fluid changes occur that allow body to adjust to postpartum blood loss to
prevent hypovolemia
o 60-80% increase in cardiac output occurs immediately after delivery & decreases to normal by 1 hr.
o High output state is caused by:
 500-700 ML of blood enters circulation after delivery of placenta
 Uterus becomes smaller = more blood to enter circulation
 Reduction in size & weight on uterus = improved blood flow to vena cava
 Rapid mobilization of extracellular fluid by the body
 After delivery there is loss of plasma volume that is greater than the loss of RBC’s
o Causes rise in Hgb & Hct
 Accurate determination of 2 levels may be difficult to obtain
o Increase of circulating blood volume, fibrinogen levels increase and remain increased for several of days
 Pt at risk for blood clots
 Ambulation is important to prevent venous stasis in legs
 Increase in neutrophils (WBC that fight infection) is normal in postpartum period
o d/t inflammation, pain, & stress of birth
o WBC count may increase up to 30,000
 Postpartum pt begins to remove excess fluid stored during pregnancy by diuresis
o Secretion & passage of lg. amts of urine
 May excrete up to 3,000 ML fluid/day for 1st few days
o Fluid also lost through diaphoresis

RESPIRATORY SYSTEM CHANGES

 Elevated diaphragm in late pregnancy will return to normal position
o Reducing SOB & making breathing easier
o RR will return to normal
 Pregnancy nasal congestion also disappears quickly

URINARY SYSTEM CHANGES

 Bladder & urethra are edematous after delivery d/t fetus passing through birth canal
 Bladder tone decreases & pt may not feel urge to urinate
o Bladder can become distended & push upward and to the side
 Displaced uterus = hemorrhage
 o Poor bladder tone & emptying can lead to UTI
 Monitor pt for dysuria (painful urination), urinary urgency/frequency, fever, & tenderness over
costovertebral angle

MUSCULOSKELETAL SYSTEM CHANGES

 Relaxin begins to subside
o Hormone responsible for relaxing pelvic ligaments and joints for delivery
 Pt may feel hip pain for few days as hips recover from over-flexion during pushing
o Tightening of her pelvis to pre-pregnant state
 Abd muscles lack tone after delivery
o Some patients experience diastasis recti: separation of abdominal wall muscles
 Abdominal exercises can regain muscle tone; started at 4 wks postpartum for vag delivery & 6
wks for c-section
 Surgical correction done is exercises are not effective

NURSING CARE DURING THE EARLY POSTPARTUM PERIOD

 Most women remain in hospital 1-2 days after vaginal delivery & 3-4 days after C-section
UTERINE ASSESSMENT
 Palpate fundus
o Position one hand at base of uterus above symphysis pubis & other at umbilicus
 Press downward w/ hand at umbilicus until fundus is palpated as firm, hard, globular mass in abd.
 Note position / Location
 NEVER palpate uterus w/o supporting lower segment d/t uterus could invert if not
stabilized
o Assess consistency of the mass
 If soft or “boggy”
 Support lower uterine & massage in circular pattern with the other hand until uterus
becomes firm
 If massage not effective = may be a large clot in uterus or extreme uterine atony
 Atony: lack of muscle tone; can lead to postpartum hemorrhage
o Oxytocin after delivery to promote uterine ctx is common
 If uterus does not stay firm w/ oxytocin & massage; Notify HCP
 Another problem that can lead to uterine atony (lack of muscle tone; that can lead to hemorrhage) is a
full bladder; which can displace uterus & make involution difficult
o If bladder distention noted: assist pt to urinate
 Reassess uterus = firm & has returned to midline of abd.

LOCHIA ASSESSEMNT
 after delivery of placenta = lg. amts of dark red blood flow from uterus
o as uterus contracts to control bleeding, lochia slows
 Lochia goes through 3 stages
o 1st: lochia rubra = discharge of dark red blood
o 2nd lochia serosa = progressively changes to brownish red then a lighter color around 3 rd or 4th day
o 3rd lochia alba = lighter and yellowish color that last 3-6 wks
 Assess peripad for amt & character or lochia while massaging uterine fundus
o Allows visualization of any sudden expulsions of clots or blood d/t “boggy uterus”
 Nurse document amt of lochia on peripad after 1 hr. by ↓
o Scant: less than 1 in. of lochia
o Light: less than 4 in. of lochia
o Moderate: less than 6 in. lochia
 o Heavy: pad saturated within 1 hr.
 Document character (rubra, serosa, alba) & presence of clots
 Common for smaller clots to be present d/t blood pooling in lower uterine segment
 Turn pt on side to ensure blood is not pooling under thighs instead of being absorbed into pad
 LG. clots report to HCP!!! Indication of hemorrhage
 1st hour common for 2 pads to be saturated; after that bleeding considered excessive saturates more than
1 pad in an hour

NURSING CARE DURING 1ST HOUR AFTER DELIVERY

 New delivered pt remain in labor & delivery area for min. 1 hr. after delivery
 1st hour most dangerous b/c risk of hemorrhage
 Nursing interventions:
o Vitals (pulse & BP) every 15 min
o Palpate fundus for firmness & location every 15 min
o While assessing uterine tone, note amt of vaginal bleeding.
 Peripads = amt lochia, color, odor, & clots
 No signs of hemorrhage after 1 hr. = pt transfer to mother-baby unit

POSTPARTUM ASSESSMENT & NURSING INTERVENTIONS

 Focus on reproductive system
 Mnemonic: BUBBLE LE: Breast; Uterus, Bladder, Bowels, Lochia,
Episiotomy/laceration, Legs, & Emotions
 Breast
o Slightly palpate for engorgement
o Inspect nipples for redness, irritation, blisters, or bleeding
o Nursing interventions:
 Bra w/ good support for comfort as milk comes in
 Nipple soreness present; observe for correct latch-on problems
 Pain relief: acetaminophen
 Assess knowledge & provide teaching If needed
 Arrange for lactation specialist
 Breastfeeding 2- 21/2 hrs. will help prevent engorgement when milk comes in
o Managing engorgement for nonbreastfeeding pt
 Supporting bra 24hr/day
 Ice pack to breast for 20 min. several times a day
 Cold inner cabbage leaves on breast
 Avoid stimulation of nipple
 No standing in warm shower & letting water over breast
 No pumping or hand express milk (breast will replace milk making engorgement worse)
 Take Tylenol of norco for pain
 Subsides within 48 hrs.
 Uterus
o Palpate fundus
 Should be firm & midline
 Document location of fundus to relationship of umbilicus
o Interventions
 Some abd. Cramping norm but abd. Pain/tenderness report
 Uterus not involuting = note lack of tone or s/s of infection
 Show pt how to feel fundus
 Bladder
 o Bladder distention should be not present when assessing fundus
 If distention present: note raised area over bladder
o Interventions
 Assist pt to bathroom to urinate prior to assessment if distention noticed; ask abt frequency & amt
urination
 If fundus not firm, do not allow pt to get out of bed
 Cannot urinate; obtain order for catheter
 Fluid intake of 8 glasses of water to decrease risk of UTI
 Teach pt abt normal diuresis after birth
 Proper perineal care
 Patting dry from front to back after peeing or pooping
 Many HCP order peri-bottle for cleaning perineum: filled w warm water & squirt after
poo/pee
 Change peri-pad after each urination/poop
 Bowels
o Auscultation of bowel sounds
o C-section birth may not have audible B.S for several days b/t of anesthesia on peristalsis
o Interventions:
 Ask abt. Last B.M: sluggish bc of side effects of prenatal iron & decrease in peristalsis from
labor?
 Increase fluids & select fruits/veggies
 Adm. Stool softener
 Increase walking to increase peristalsis
 Lochia
o Document amt & type
o Interventions:
 Ask when pad was last changed
 Report abnormal amt, color, or odor
 Episiotomy/Laceration
o Have pt turn to side & bring upper knee forward. Lift the upper buttocks and inspect perineum
for: bruising, erythema, edema, hematoma, & intactness of episiotomy or repaired laceration
 Note if any hemorrhoids present & notify HCP if large/painful
o Interventions:
 Pain level & medicate if ordered
 Offer ice pack for 1st 24 hours to reduce pain/swelling
 Teach pt how to use anesthetic spray if ordered
 After 24 hrs. warm water soaking (sitz bath) can relieve pain & aid in healing
 No soup, shower gels, or bubble bath added allowed
 Can sit on soft wet towel in warm water for 10-15 min TID
 Legs
o Asses leg pain & for adequate circulation by checking pedal pulses & temp of legs
o Pedal edema may be present for few days as body fluids shift
o Interventions:
 Inspect legs for red, warm, or tender areas & report abnormal findings ASAP
 Ambulate often
 Avoid crossing legs
 Keep legs elevated when sitting
 High risk pts: compression hose or SCD’s to the legs
 Emotions
o Placenta expelled = drop in progesterone which can contribute to “postpartum blues”
o Interventions
 Explain it is normal part of recovery
  Reassure pt/family it usually passes within few days. If it does not contact HCP
 Encourage rest, verbalize needs, allow family/friends assist in recovery

NURSING CARE AFTER A C-SECTION

 Uterine involution & lochia same as vag. Birth w/ addition of post-op care
o Preventing bedrest, atelectasis, thrombosis, & infection
 Typically no pain in perineal area but in abdominal incision
 Nursing care
o Assess & medicating for pain
o S/S of infection: redness, edema, ecchymosis, drainage, & approximation of wound edges (REEDA)
o Encourage ambulation to prevent venous thrombosis when pt stable & urinary cath. Is discontinued
o Discontinue cath. & monitor for normal voiding pattern
o Apply TED hose or SCD’s to prevent sluggish blood flow
o Abdominal splinting w pillow to decrease pain when coughing/moving in bed
o Turn, cough, deep breathe Q2H & use incentive spirometer to prevent atelectasis

NURSING CARE OF THE ADOLESCENT

 Requires more structured teaching abt. The care of newborn and self
 Treat as an adult & do not talk down while being careful w/ tone of interactions
o Teenager can be sensitive to nurse tone/attitude when receiving teaching abt newborn
 Direct teaching to teenager, NOT parents or support person
o Encourage questions and avoid making her feel embarrassed abt. lack of knowledge
o Positive reinforcement on newborn care will increase confidence and self-esteem
o Include father if present
o Teach in small segments, using videos & written material
 Provide rest periods between teaching sessions to prevent overwhelming her
 Encourage role- model infant care & bonding
o May be very centered on own needs
 Require more mothering from nurse & fam. Than older pts.
 Little/none exposure to newborns & have unrealistic expectations
o May not be prepared for amt of time that breastfeeding and infant care required
o Encourage to verbalize fears & needs during recovery
 Provide education, emotional support, & appropriate referrals
 Medical team for postpartum care of adolescent
 Physician/midwife: physical care before & after birth
 Nurse: assessment, physical care, teaching abt self & newborn care
 Social worker: evaluates family support & provides community referrals (support groups)
 Lactation specialist: assist in initial breastfeeding if pt chooses
 Dietician: information abt her own nutritional needs
 Teen mothers have higher risk of postpartum depression
o Teach pt & family s/s & instruct to report to HCP
 Refer to support groups for teeth parents (father as well if involved)

NURSING CARE FOR WOMAN WHO RELINQUISHES HER INFANT

FOR ADOPTION
 Women who “gives up” baby for adoption comes in with birth plan
o If birth plan not in place consult the hospital policy manual for correct procedure for assisting women w/
decision
 May want adoptive parents present at birth or want them called afterwards
  Mother may request to hold baby at delivery then ask infant be kept in nursery
o Pt may not want to see or hold baby at all
o Pt may choose to keep infant in rm until turned over to new parents or to social worker at discharge
 Avoid phrases “giving up the baby” & instead use phrase “plan for adoption”
o Encourage pt to talk by using following prompts
 “What can I do to help you?”
 “Share with me your plan for the baby?”
 “Tell me how you’re feeling today?”
 Women may have open adoption in which adoptive parents stay in contact w/ mother
o Sending pics & updates as child grows up
 Close adoption: no identifying information is shared between mother and adoptive parents
o After closes adoption is finalized & records are sealed & may not be available until child is 18 yrs of age
 Women may experience grief & loss: higher risk for postpartum depression

POSTPARTUM PSYCHOLOGICAL ADAPTIATIONS

 Divided into 3 phases:
o 1st the taking-in phase
o 2nd taking-hold phase
o 3rd the letting-go phase
 Taking-In phase
o Phase last a day or 2
o Mother centered on her own needs such as: rest, pain relief, sleeping, & eating
o Feels dependent at this time, & she herself needs mothering
o Wants to review L&D experience
 Helps her to integrate it w/ reality of baby being born & motherhood
o En face position & Fingertip touching are positive signs of bonding behaviors
 when mother handed newborn & stokes baby with her fingertips & may position baby facing her
to explore baby’s face (En face position)
 This taking-in of information allows her to identify infant and begin bonding process
 Mother may not initiate interaction w/ newborn & may have to be handed baby to start
the bonding process
o Bonding may occur instantly for some but may take few days or wks. For others
o Nursing interventions to promote bonding after childbirth
 Skin-to-skin contact
 Encourage breastfeeding
 Encourage eye contact
 Allow baby to stay w/ parents as much as possible; avoid unnecessary trips to nursery
 Taking-hold Phase
o Phase may last up to 10 days
o Mother initiates care of the baby
 Wants to be more independent & make own decisions
 But is concerned & anxious abt own physical care, breastfeeding, & baby care
 Open to learning about self/newborn care, & bonding
o Therefore, this is the right time to begin teaching
o New mother needs praise & positive reinforcement for things done well
 Ex: supporting baby’s head or correctly positioning baby for breastfeeding
 Phrases that may be helpful in in positive reinforcement
 “You are holding him perfectly”
 “Look! She’s looking right into your eyes”
 “Yes, that’s the right position for breastfeeding”
 o Many women experience “postpartum blues” in this phase
 Caused by decrease in estrogen & progesterone that occur w/ delivery of placenta
 Exhaustion from lack of sleep & demands of breastfeeding every 2 – 21/2 hrs.
 May feel sad, irritable, randomly burst into tears for unexplainable reasons)
 Sadness usually passes in day or 2
o Occasionally depression does not pass & is a serious disorder that needs medical treatment
 Letting-go phase
o Mother is adjusting or “letting go” of previous childless = more independent role
o Adjust to responsibility of having her baby dependent on her & lifestyle changes that go along
with parenthood
 Women who already have kids go through this stage more quickly than 1 st time mothers
o During this phase, attachment w/ newborn occurs
 The establishment of an emotionally positive & rewarding relationship between infant & parents
 Mother understands infants cries & body language & receives positive feedback from infant when
needs are met.
o Mother learns to trust herself & instincts when caring for baby and feels confident in her ability
to mother infant

DEVELOPMENT OF FAMILY ATTACHMENT

 Postpartum = time of change for family unit
o Family attachment & integration of newborn into family takes place
 Mother partner typically begins bonding w fetus before birth
o Attending appointments, childbirth classes, preparing baby’s room, & planning for trip to hospital
 After birth partner encourage to room-in and stay much as possible w/ mother and newborn
 Partner encouraged to hold infant and assist w/ newborn care
 Include in teaching
 Engrossment: new parents stare at newborn for extended period of time
o Comparable to en face bonding btw mother and infant
 Sibling bonding & attachment can be promoted by allowing the sibling to visit in hospital
o Phone video tech. allow chlild to have easy contact w/ mother
 Visit in hospital may reduce separation anxiety and feelings that new baby is more important
o Older child may exhibit jealously & may regress his/her behavior
 Ex: 3 yr old who was potty-trained may begin wetting pants
 Behavior may be unpredictable: may be protective, loving feelings, & dislike

PREPARTATION FOR DISCHARGE

 Nurse adm. Single dose of MMR vaccine to any women who tested susceptible to rubella during
pregnancy
 All household members, close relatives, & friends who are in contact w/ baby need up to date flu,
tetanus, diphtheria, & pertussis (Tdap) vaccines
 During discharge mother is too excited to focus on teaching
o Should have been done in small segments throughout hospital stay
 Written discharge instructions include:
o Sutures for lacerations or episiotomy will dissolve over time
o For sore perineum take ibuprofen (Advil)/ acetaminophen (Tylenol) or use warm sitz baths
o Purchase menstrual pads & change pad after pee/poop
o Cleanse perineum w/ warm water in peri-bottle
o No tampons/douche until follow-up with HCP
o Wear supportive bra as breast adjust to milk production
o Wash hands after every diaper change
 o Cont. prenatal vitamins & iron
o Exercise can be started per HCP instruction s
 Walking & stretching are safe 2 wks postpartum
 Exercise after pregnancy has benefits such as:
 Restoring muscle tone (abdominal muscles)
 Aiding in weight loss if combined w/ reduced calorie intake
 Improving mood/relieving stress
 Improving cardiovascular fitness
 Allowing new mother to take time for self
o Call HCP is any of the following:
 Fever > 38 degrees C. (100.4)
 Increasing pain, redness, swelling, or discharge from a c-section incision/episiotomy
 Increase vag. Bleeding & passing clots larger than a quarter
 Foul lochia odor
 Increasing abdominal or tenderness
 Sexual activity may be hard topic to bring up for mother; as nurse introduce topic in open, matter of fact
manner that makes pt comfortable
o Intercourse can resume when bright-red bleeding has ceased, vagina & vulva are healed, & women
physically/emotionally comfortable
 Women needs to be cautious d/t ovulation may resume at any time & suggest to wear condoms
 Pregnancy within 6 mths. Of a prior pregnancy is associated with:
o Premature birth, placenta abruption,
 Pregnancy within 2 yrs. Of previous birth is associated w/ increase risk of autistm