NCM 107 – Mother and Child Nursing Disappointment
Nursing Care of Post-Partal Family › It can be difficult for the mother to feel positive
Psychological Changes of the Post-Partal Period
Post-Partum Period
- Also called puerperium
- Refers to the period beginning immediately after the
birth of a child and extending for about 6 to 8
weeks period after delivery during which of the
mother's body returns to its pre pregnant state.
- Many psychological changes occur in the mother
during this time. Nursing care should focus on helping
the mother and her family adjust to these changes
and on easing the transition to the parenting role.
Phases of Puerperium
1. Taking In
2. Taking Hold
3. Letting Go
Taking In Phase (Dependent Phase)
› First 3 days of post-partum
› The mother is focused on self, not infant
› Focused on her own needs for sleep and rest
› The mother is passive, dependent and cannot make
decisions
› There is a sense of wonderment when looking at the
neonate
› Nurses need to discuss with the mother her labor
experience
Taking Hold Phase (Independent Phase)
› Last from the 3rd to 10th day of post-partum
› The mother is now focused on the infant
› The mother initiates self-care activities
› Focuses on bowels, bladder and breastfeeding
› Active, independent and can make decisions
› Mother responds to instructions about infant care and
self-care
› May express lack of confidence in caring for the
neonate
Letting Go Phase (Independent Phase)
› Last from 10 days to 6 weeks post-partum
› The mother may feel deep loss over separation of
the baby from her body
› May feel caught in dependent/independent role,
wanting to feel safe and secure yet wanting to make
decisions
› The woman finally redefines her new role
› See self as separate from infant
› Gives up fantasized image of her child and accepts
the real one
› Readjustment
Maternal Concerns and Feelings
during Postpartum Period
Abandonment
› Only hours before she was the center of attention,
with everyone asking about her health and well-
being. Now suddenly, the baby is the chief interest.
› The woman may feel confused by a sensation very
close to jealousy. Shared responsibility for infant
care can help alleviate these feelings.
immediately about a child who does not meet their
expectations.
Post-Partal blues
› The baby blues generally show up 3 to 4 days after
birth and may last for the few weeks after delivery.
› Signs: 50% of women experience some feelings of
overwhelming sadness
› Mood swings, sudden crying episodes, irritability,
anxiety, loneliness
› Feeling of happiness and love for the new-born may
be accompanied by feelings of helplessness, sadness
and anxiety
› Causes:
 Sudden and quick change in the hormones
 The emotional and physical stress of giving birth
 It may be a response to dependence and low
self-esteem caused by exhaustion
 Many new mothers tend to have an increased
sense of anxiety and tension assuming by a new
role
 The fatigue and lack of sleep that affects all new
mothers only serves to compound the problem
Here are some helpful tips:
 Advice woman to exercise regularly
 Advice woman to eat a healthy, well-balanced
diet
 A woman needs assurance that sudden crying
episodes are normal
 Allow time to verbalize feelings
 Make time each day for herself to enjoy
 Join a support group for new mothers
 Talk with her partner about dividing up the
parenting responsibilities so she doesn’t feel like
she is doing everything by herself
Postpartum Depression
› It is a moderate to severe depression in a woman
after she has given birth. It may occur soon after
delivery or up to a year later.
› Causes:
 Women commonly have mood changes during
pregnancy, especially after delivery
 These mood changes may be caused by changes
in hormone levels.
› Symptoms:
 Irritability changes in appetite
 Feeling depressed majority of the day, almost
every day of the week
 Feeling of worthlessness or guilty
 Feeling withdrawn or unconnected
 Lack of pleasure or interest in most or all
activities
Here are some helpful tips:
 Ask partner, family and friends of the woman for
help with her baby
 Advice the woman doesn’t hide her feelings. Talk
about her feeling with her partner, family and
friends
 Don’t make any major life changes during or
right after giving birth
Postpartum psychosis
› In comparison to the incidence of depression and
anxiety that the experienced by new mothers in the
postpartum period, postpartum psychosis is rare.
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 Nevertheless, when it is experienced by a new
mother, she might be scared or confused, once out of
the psychotic state.
› A woman experiencing postpartum psychosis requires
immediate attention, especially if her symptoms
include thoughts of suicide or other harm to herself or
baby.

› Symptoms:
 Hallucinations (hearing, sight, touch, etc)
 Delusion (false, bizarre beliefs, which are not
reality-based)
 Drastic mood swings
 Disorganization of speech incoherence)
 Disorganization of behavior (extremely
inappropriate dress)
 Extreme restlessness
 Anger and agitation

Cervix
› Complete cervical involution may take 3 – 4months
› After 1 week the muscle begins to regenerate but is
still about 1 cm dilated
› Permanent change cause by childbirth – the cervical
os becomes slit-like or elongated

Physiologic Changes of the Post-Partal Period

Uterine Involution
› The rapid decrease in the size of the uterus as it
returns to the non-pregnant state
› Weight decreases from 2 lbs. to 2 oz.
› Endometrium regenerates
› Fundus steadily descends into the pelvis Vagina
› Fundal height decreases about 1 fingerbreadth (1 › Vaginal distention decreases
cm) per day › Smooth and swollen
› By 10 days postpartum, the uterus cannot be › Rugae reappear by 3 – 4 weeks
palpated abdominally › Muscle tone is never restored to the pregravid state
› A flaccid fundus indicates uterine atony and should
be massaged until firm
› A tender fundus indicates infection

Lochia / Normal Vaginal Bleeding Postpartum

› Discharge from the uterus that consists of blood from
the vessels of the placental site and debris from the
decidua Perineum
› Fleshy in odor, smells like normal menstruation › Appears edematous and bruised
› Discharge decreases daily in amount but may › Episiotomy or lacerations may be present
increase with ambulation
 RUBRA
Bright red discharge from day 1 to day 3
 SEROSA
Brownish pink discharge from day 4 to 12
 ALBA White discharge from day 12 to 3 weeks

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Breast
› Rapid decrease in Estrogen and Progesterone and
increase in prolactin
› Colostrum is present at the time of delivery
› Breast milk is produced by the 3rd or 4th day
› Sucking of the newborn triggers the release of
OXYTOCIN – milk letdown and contraction of the
uterus
› Average amount of milk produce in 24 hours
increases with time
Ovarian Function and Menstruation
› Depends on the rapidity with which the pituitary
function is restored
› Menses resume:
 Within 8 weeks in non-breastfeeding mothers
 Within 3 – 4 months in breastfeeding mothers
 Women may ovulate without menstruating, so
breastfeeding is not a reliable method of birth
control
Integumentary System
› Chloasma, palmar erythema, linea nigra and other
skin changes during pregnancy gradually disappear
during the postpartum period.
› Striae gravidarum do not disappear and assumes a
silvery white appearance.
› Hyperpigmentation of the areola may not disappear
completely. Some women are left with a wider and
darker areola after pregnancy.
› Linea nigra will be barely detectable in 6 weeks’
time
Gastrointestinal System
› Women are usually very hungry after delivery due
to lack of food during labor and dehydration
› Constipation occurs due to decreased intestinal
muscle tone, perineal discomfort and pain from
episiotomy, hemorrhage and laceration
› Bowel sounds are active, but passage of stool
through the bowel may be slow
› Hemorrhoids are common
Urinary System
› May have urinary retention as a result of loss of
elasticity and tone, loss of sensation in the bladder
from trauma, medications, anesthesia and lack of
privacy
› Diuresis begins within the first 12 hours of delivery
› Ambulation may be encouraged 4 – 8 hours after
delivery
› Done to avoid complications, promote involution and
improve emotional outlook
Musculoskeletal System
› Ambulation may be encouraged 4 – 8 hours after
delivery
› Done to avoid complications, promote involution and
improve emotional outlook
› Advantages of early ambulation
 Prevent constipation
 Prevent thrombophlebitis
 Prevent urinary problems
 Promote rapid recovery and return of
 woman’s strength
 Hastens drainage of lochia
 Improves GIT & GUT function
 Provides a sense of well-being
Rest and Sleep
› The woman should rest & sleep as much as needed
during the early postpartum period to overcome
fatigue, excitement, anxiety & discomfort associated
with long & exhausting labor & delivery. Sleep and
rest promote healing by reducing BMR and allowing
O2 & nutrients to be utilized for tissue growth,
healing & regeneration.
› Instruct the mother to avoid heavy lifting and
strenuous activity after discharge
› The woman may resume light housekeeping on the
second week and can go back to normal activities by
4 to 6 weeks.
Resumption of Sexual Activity
› Sexual intercourse can be resumed 3 to 4 weeks
after vaginal delivery if :
 Bleeding has stopped
 Perineum is healed
 It does not cause pain to the woman
Nursing Responsibility
› Assessment
› Monitor VS
› Assess height, consistency and location of fundus
› Monitor color, odor, & amount of lochia
› Assess for breast engorgement
› Monitor perineum for swelling or discoloration
› Monitor episiotomy for healing
› Assess incisions or dressings of CS birth client
› Monitor bowel status and I&O
› Encourage ambulation and frequent voiding
› Assess bonding with newborn infant
› Assess emotional status
Postpartum implementation
› Client teaching
› Demonstrate newborn skills as necessary
› Provide the opportunity for mothers to bathe the
infant
› Instruct in feeding technique
› Instruct mother to avoid heavy lifting for at least 3
weeks
› Instruct the mother to plan at least 1 rest period per
day
› Contraception should start after delivery or with the
initiation of coitus (postponed at least until after the
lochia ceases)
› Instruct the mother in the importance of follow up,
which should be scheduled in 4-6 weeks
Client teaching
› Instruct to come back immediately if with:
 Heavy vaginal bleeding or bright red vaginal
discharge
 Fever
 Foul smelling lochia
 Swollen, tender, hot area on her leg
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 Burning sensation on urination Postpartum Complications
 Persistent pelvic or perineal pain › MASTITIS
› URI
Postpartum Discomforts › UTI
› THROMBOPHLEBITIS
Afterbirth Pains › HEMATOMA ABSCESS FORMATION
› Occurs as a result of contraction of the uterus › ENDOMETRITIS
› Are more common in multiparas, those with over › PERINEAL CELLULITIS
distended uterus, breastfeeding mothers & clients
treated with oxytocin Hemorrhage
› Bleeding of 500 ml or more following delivery
Perineal Discomfort Causes: uterine atony, lacerations, retained placental
› Apply ICE PACKS to the perineum during the first 24 fragments
hours to reduce swelling EARLY LATE
› Sitz bath after the first 24 hours › During the 1st 24 › After the 1st 24 hours
hours after delivery after delivery
Episiotomy › Caused by uterine › Caused by retained
› Administer perineal care after each voiding atony, lacerations or placental fragments
› Analgesics as prescribed inversion of the uterus

Perineal Laceration Uterine atony

› First Degree - The inability of the myometrium to contract and
- Skin and superficial to muscle constrict the blood vessels, resulting in open sinuses at
› Second Degree the site of placental separation
- Muscles of the perineum › Cause of 80 – 90% of early hemorrhage
› Third Degree › May be slow and steady or sudden and massive
- Continues to anal sphincter › Bleeding may be or may not be visible
› Fourth Degree › BP and PR may not change until it’s too
- Involves the anterior anal wall › Causes:
 Multiple pregnancy
 Hydramnios
 Large babies (macrosomia)
 Placental accidents
 Prolonged and difficult labor
 Previous uterine surgeries
 Deep anesthesia
 Endometritis
 Anemia
 History of postpartum hemorrhage
 Maternal age>30yrs.

Breast discomfort from engorgement Nursing Management

› Breastfeed frequently
› Apply warm packs before feeding
› Apply ice packs between feedings
› Wearing of support bra
› Ice or ice packs if not breastfeeding
› Use of warm soaks before feeding for breastfeeding
mothers
› Analgesics as prescribed
Breast discomfort from cracked nipples
› Expose to nipples to air 10 – 20 minutes after
feeding
› Rotate the position of the baby for each feeding
› Be sure that the baby is latched on to the areola and
not just the nipple
Nutritional counselling
› Discuss caloric intake for breastfeeding and non-
breastfeeding mothers
› Nutritional needs depend on the pre-pregnancy
weight, ideal weight for height, and whether mother
is breastfeeding
› If breastfeeding, needs increase by approximately
500 calories per day, increased fluids, continuance
of prenatal vitamins and minerals
› Medications to stimulate uterine contractions – IM
Methergine and IV Oxytocin
› Manual massage of the uterus to stimulate
contractions
› Administer ice pack on the abdomen
› Bimanual massage.
› Blood transfusion.
› Hysterectomy - surgical removal of the uterus.
› If with respiratory distress from decreasing blood
volume, give O2 and place in supine to allow
adequate blood flow to brain and kidneys
Subinvolution
› Uterus remains large, and soft at 4 to 6 weeks
postpartum.
› Incomplete return of the uterus to its pre-pregnant
size and shape.
› Lochia is still present
› Causes of Subinvolution:
 Endometritis or postpartal infection
 Retained placental fragments
 Accompanying problem like myoma
 Any factor that interferes with complete
contraction
› Symptoms of Subinvolution:

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 Lochia fails to progress and remains red
 Leukorrhea with backache and infection
Cystitis
› Infection of the urinary bladder
› Lower abdominal pain, burning and pain on
urination, increased frequency of urination, fever,
costovertebral angle tenderness
› Forced fluids up to 3L/day, institute measures to
assist to void, encourage frequent and complete
emptying of the bladder
› Urinalysis, antibiotics as prescribed
Pulmonary embolism
› The passage of thrombus, often originating in one of
the uterine or pelvic veins, into the lungs, where it
disrupts the circulation of blood
› Dyspnea, tachypnea, tachycardia, cough, rales,
hemoptysis, pleuritic chest pain, feeling of impending
doom
› Give O2, head of the bed elevated, monitor VS,
streptokinase and anticoagulants as prescribed
Thrombophlebitis
› Formation of a clot in the vessel wall due to
inflammation of the vessel wall
› Partial obstruction of the vessel can occur
› Increased blood-clotting factors
› Superficial, femoral, pelvic
› Elevate legs, never massage, monitor for signs of
pulmonary embolism
› Warm packs, analgesics and heparin as prescribed

Vulvar Hematoma
› Localized collection of blood into the tissues of the
reproductive sac after delivery
› Abnormal, severe pain, pressure in the perineal area
with discolored skin, signs of shock (pallor,
tachycardia, hypotension)
› Monitor VS, place ice at hematoma site, prepare for
incision and evacuation of hematoma, ligation of
bleeders
› Administer analgesics, antibiotics or blood products
as required

Infection
› Any infection of the reproductive organs that occurs
within 28 days of delivery or abortion
› Fever, chills, pelvic discomfort or pain, vaginal
discharge, elevated WBC count
› Monitor VS, antibiotics as prescribed

Mastitis
› Inflammation of the breast as a result of infection
› Seen in breastfeeding mothers 2-3 weeks after
delivery but may occur anytime during lactation
› Localized heat and swelling, pain, elevated
temperature, flu-like symptoms
› Advise good hand washing and breast hygiene
techniques, warm or cold packs, encourage
breastfeeding, use of support bra, analgesic and
antibiotics as prescribed

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