PATHOPHYSIOLOGICAL AND PSYCHOSOCIAL CHANGES OF POSTPARTUM

POSTPARTUM ASSESSMENT AND CARING INTERVENTIONS

LABORATORY VALUES OF THE POSTPARTUM CLIENTMEDICATIONS USED IN POSTPARTUM

PHYSIOLOGY OF BREASTFEEDING AND THE BREASTFEEDING CLIENT

FORMULA FEEDINGDISCHARGE TEACHING

Postpartum Nursing Care

Pathophysiology of Postpartum

Involution - rapid reduction in size of uterus and return to prepregnant state

Subinvolution = failure to descentUterus is at level of umbilicus within 6 to 12 hours

after childbirth - decreases by one finger breadth per day

Exfoliation - allows for healing of placenta site and is important part of involution – may take up to 6 weeks

Enhanced by uncomplicated labor and birth complete expulsion of placenta or membranes breastfeeding early ambulation

FIGURE 23–1 Involution of the uterus. A, Immediately after expulsion of the placenta, the top of the fundus is in the midline and approximately halfway between the symphysis pubis and the umbilicus. B, About 6 to 12 hours after birth, the fundus is at the level of the umbilicus. The height of the

fundus then decreases about one finger-breadth (approximately 1cm) each day.

Pathophysiology of Postpartum

Uterus rids itself of debris remaining after birth through discharge called lochia

Lochia changes: Bright red at birth Rubra - dark red (2 – 3 days after delivery) Serosa – pink (day 3 to 10 after delivery) Alba – white Clear

If blood collects and forms clots within uterus, fundus rises and becomes boggy (uterine atony)

Ovulation and Menstruation/Lactation

Return of ovulation and menstruation varies for each postpartal woman Menstruation returns between 6 and 10 weeks

after birth in nonlactating mother - Ovulation returns within 6 months

Return of ovulation and menstruation in breastfeeding mother is prolonged related to length of time breastfeeding continues

Breasts begin milk production a result of interplay of maternal hormones

Pathophysiology of Bowel Elimination

Intestines sluggish because of lingering effects of progesterone and decreased muscle tone Spontaneous bowel movement may not occur for 2 to

4 days after childbirth Mother may anticipate discomfort because of perineal

tenderness or fear of episiotomy tearingElimination returns to normal within one weekAfter cesarean section, bowel tone return in

few days and flatulence causes abdominal discomfort

Pathophysiology of Urinary tract

Increased bladder capacity, decreased bladder tone, swelling and bruising of tissue

Puerperal diuresis leads to rapid filling of bladder - urinary stasis increases chance of urinary tract infection

If fundus is higher than expected on palpation and is not in midline, nurse should suspect bladder distension

FIGURE 23–2 The uterus becomes displaced and deviated to the right when the bladder is full.

Laboratory Values

White blood cell count often elevated after delivery Leukocytosis

Elevated WBC to 30,000/mm3

Physiologic Anemia Blood loss – 200 – 500 Vaginal delivery Blood loss 700 – 1000 ml C/S RBC should return to normal w/in 2 - 6 weeks Hgb – 12 – 16, Hct – 37% - 47%

Activation of clotting factors (PT, PTT, INR) predispose to thrombus formation - hemostatic system reaches non-pregnant state in 3 to 4 weeks Risk of thromboembolism lasts 6 weeks

Weight Loss

10 –12 pounds w/ delivery5 pounds with diuresisReturn to normal weight by 6 – 8 weeks if

gained 25 - 30 poundsBreastfeeding will assist with weight loss

even with extra calorie intake

Psychosocial Changes

Taking in - 1 to 2 days after delivery Mother is passive and somewhat dependent as she

sorts reality from fantasy in birth experience Food and sleep are major needs

Taking hold - 2 to 3 days after delivery Mother ready to resume control over her life She is focused on baby and may need reassurance

Psychosocial Changes

Maternal Role Attachment Woman learns mothering behaviors and becomes

comfortable in her new roleFour stages to maternal role attainment

Anticipatory stage - During pregnancy Formal stage - When baby is born Informal stage - 3 to 10 months after delivery Personal stage - 3 to 10 months after delivery

Father-Infant Interaction Engrossment Sense of absorption Preoccupation - Interest in infant

Postpartum Assessment

Vital signs: Temperature elevations should last for only 24 hours – should not be greater than 100.4°F

Bradycardia rates of 50 to 70 beats per minute occur during first 6 to 10 days due to decreased blood volume

Assess for BP within normal limits: Notify MD for tachycardia, hypotension, hypertension

Respirations stableBreath sounds should be clearComplete systems assessmentBUBBLEHE assessmentPostpartum chills or shivers are common

Breasts Assessment

Assess if mother is breast- or bottle-feeding - inspect nipples and palpate for engorgement or tenderness – should not observe redness, blisters, cracking

Breasts Assessment

Breasts should be soft, warm, non-tender upon palpation

Secrete colostrum for 1st 2-3 days –yellowish fluid - protein and antibody enriched to offer passive immunity and nutrition

Milk comes in around 3 – 4 days – feel firm, full, tingly to client

Uterus Assessment

Monitor uterus and vaginal bleeding, every 30 minutes x 2 for first PP hour, then hourly for 2 more hours, every 4 hours x 2, then every 8 hours or more frequently if there is bogginess, position out of midline, heavy lochia flow

Determine firmness of fundus and ascertain positionapproximate descent of 1 cm or 1 fingerbreadth

per dayIf boggy (soft), gently massage top of uterus until

firm – notify health care provider if does not firmDisplaced to the right or left indicates full

bladder – have client void and recheck fundus

Uterus Assessment

FIGURE 23–6 Measurement of descent of fundus for the woman with vaginal birth. The fundus is

located two finger-breadths below the umbilicus. Always support the bottom of the uterus during any

assessment of the fundus.

Anesthesia or edema may interfere with ability to void – palpate for bladder distention - may need to catheterize – measure voided urine

Assess frequency, burning, or urgency Diuresis will occur 12 – 24 hours after

delivery – eliminate 2000 – 3000 ml fluid, may experience night sweats and nocturia

Bowel: Assess bowel sounds, flatus, and distention

Bladder and Bowel Assessment

Lochia – Rubra Assessment

Lochia = blood mucus, tissue vaginal discharge

Assess amount, color, odor, clotsIf soaking 1 or > pads /hour, assess uterus,

notify health care providerTotal volume – 240 – 270 mlResume menstrual cycle within6 – 8 weeks, breast feeding may be 3 months

Episiotomy, Lacerations, C/S Incisions

Inspect the perineum for episiotomy/lacerations with REEDA assessment

Inspect C/S abdominal incisions for REEDA

R = redness (erythema) E = edema E = ecchymosis D = drainage, discharge A = approximation

Episiotomy

Postpartum Nursing Interventions

Relief of Perineal Discomfort Ice packs for 24 hours, then warm sitz bath Topical agents - Epifoam Perineal care – warm water, gently wipe dry front

to back

FIGURE 24–1 A sitz bath promotes healing and provides relief from perineal discomfort during the initial weeks

following birth.

Hemorrhoids, Homan’s Sign

Assess for hemorrhoidsRelief of hemorrhoidal discomfort may

include Sitz baths Topical anesthetic ointments Rectal suppositories Witch hazel pads - Tucks

Extremities Assess for pedal edema, redness, and warmth Check Homan's sign – dorsiflex foot with knee

slightly bent

FIGURE 23–9 Homans’ sign: With the woman’s knee flexed, the nurse dorsiflexes the foot. Pain in the foot or leg is a positive Homans’ sign.

Emotional Status/Bonding Assessment

Describe level of attachment to infant Determine mother's phase of adjustment to

parentingPostpartum Blues

Transient period of depression Occurs first few days after delivery Mother may experience tearfulness, anorexia, difficulty

sleeping, feeling of letdown

Usually resolves in 10 to 14 daysCauses:

Changing hormone levels, fatigue, discomfort, overstimulation Psychologic adjustments Unsupportive environment, insecurity

Postpartum Nursing Interventions

After pains Uterine contractions as uterus involutes

Relief of after pains Positioning (prone position) Analgesia administered an hour before breastfeeding Encourage early ambulation - monitor for dizziness

and weakness

Medications

Bleeding oxytocin (Pitocin) – watch for fluid overload and hypertension methylergonovine (Methergine) – causes hypertension prostaglandin F (Hemabate, carboprost) – n/v, diarrhea

Pain Medications NSAIDS – GI upset Oxycodone/acetaminophen (Percocet) – dizziness, sleepiness PCA – Morphine for C/S – respiratory distress

docusate (Senna) – causes diarrheaRubella Vaccine – titer 1:10, do NOT get pregnant for

3 monthsRh Immune Globulin (RhoGAM) – Rh negative mother

– do not administer rubella vaccine for 3 months

Mother and Family Needs

Nurse can assist in restoration of physical well-being by Assessing elimination patterns Determining mother's need for sleep and rest Encourage regular diet as tolerated and

increasing fluidsIdentify available support persons - involve

support person and siblings in teaching as appropriate

Determine family's knowledge of normal postpartum care and newborn care

Breastfeeding Pathophysiology

Before delivery, increased estrogen stimulates duct formation, progesterone promotes development of lobules and alveoli

After delivery, estrogen and progesterone decrease, prolactin increases to promote milk production by stimulating alveoli

Newborn suck releases oxytocin to stimulate let-down reflex

Composition of Breast Milk

Breast milk is 90% water; 10% solids consisting of carbohydrates, proteins, fats, minerals and vitamins

Composition can vary according to gestational age and stage of lactation

Helps meet changing needs of babyForemilk – high water content, vitamins,

proteinHindmilk - higher fat content

Immunologic and Nutritional Properties

Secretory IgA, immunoglobulin found in colostrum and breast milk, has antiviral, antibacterial, antigenic-inhibiting properties Contains enzymes and leukocytes that protect

against pathogens Composed of lactose, lipids, polyunsaturated fatty

acids, amino acids, especially taurine Cholesterol, long-chain polyunsaturated fatty

acids, and balance of amino acids in breast milk help with myelination and neurologic development

Advantages of Breastfeeding

Provides immunologic protectionInfants digest and absorb component of

breast milk easierProvides more vitamins to infant if mother's

diet is adequateStrengthens mother-infant attachmentNo additional costBreast milk requires no preparationAAP= Only food for 6 months, w/ foods for 12

months

Disadvantages of Breastfeeding

Many medications pass through to breast milk

Father unable to equally participate in actual feeding of infant

Mother may have difficulty being separated from infant

Breastfeeding Mother

Breastfeeding mother needs to know How breast milk is produced How to correctly position infant for feeding Procedures for feeding infant Number of times per day breastfed infant should be

put to the breast How to express and store breast milk How and when to supplement with formula How to care for breasts Medications that pass through breast milk Support groups for breastfeeding

Review signs and symptoms of engorgement, plugged milk ducts, mastitis

Breastfeeding Assessment

Figure 29–2 Four common breastfeeding positions. A, Football hold. B, Lying down. C, Cradling. D, Across the lap.

Formula Preparations

Three categories of formulas based on cow milk proteins, soy protein-based formulas, specialized or therapeutic formulas - all are enriched with vitamins, particularly vitamin D

Most common cow milk protein-based formulas attempt to duplicate same concentration of carbohydrates, proteins, fats as 20kcal/oz same as breast milk

Bottle-Feeding Advantages

Provides good nutrition to infantFather can participate in infant feeding

patterns

Bottle-Feeding Disadvantages

May need to try different formulas before finding one that is well-tolerated by infant

Proper preparation necessary for nutrition adequacy

Bottle-Feeding Mother

Bottle-feeding mother needs to know Types of formula available and how to prepare each

type Procedure for feeding infant How to correctly position infant for bottle-feeding How to safely store formula How to safely care for bottles and nipples Amount of formula to feed infant at each feeding How often to feed infant Expected weight gain

Bottle Feeding Mother

Teach to wear a binder or tight-fitting sports bra day and night for two weeks.

Do not allow hot water from shower to run over breasts

Avoid manual stimulationApply cabbage leaves (dries up breast)Use acetaminophen for discomfort

Cesarean Section Needs

Assess vital signsAssess breastsAssess location and firmness of uterine fundusAssess lochiaAssess incision site – REEDAAssess breath sounds Assess indwelling urinary catheter - color and

amount of urine notedAssess bowel sounds: present, hypoactive or

hyperactive

Cesarean Section Needs

Cesarean birth is major abdominal surgery - if general anesthesia used, abdominal distension may cause discomfort, assess for bowel obstruction Position client on left side, include exercises, early ambulation,

increase po intake, avoid carbonated beverages, avoid straws - may need enemas, stool softeners, antiflatulent meds

Pulmonary infections may occur related to immobility and use of narcotics because of altered immune response TCDB, use incentive spirometer q 2 hours

Pain and Comfort

Administer analgesics within the first 24 to 72 hours - allows woman to become more mobile and active

Comfort is promoted through proper positioning, back rubs, and oral care - reduce noxious stimuli in environment

Encourage visits by family and newborn, which provides distraction from painful stimuli

Encourage non-pharmacologic methods of pain relief (breathing, relaxation, and distraction) - encourage rest

Attachment After a Cesarean Birth

Physical condition of mother and newborn and maternal reactions to stress, anesthesia, and medications may impact mother-infant attachment

By second or third day, cesarean birth mother moves into "taking-hold period" Emphasize home management and encourage

mother to allow others to assume housekeeping responsibilities

Stress how fatigue prolongs recovery and may interfere with attachment process

Discharge Instructions

S/S complicationsPP ExercisesRestAvoid overexertionSexual activityHygieneSitz bathsIncision care

Referral numbersNutritionPP appointmentBirth certificate infoInfant careInfant complicationsInfant follow-upFamily bonding

Discharge Teaching

New mother should gradually increase activities and ambulation after birth

Avoid heavy lifting, excessive stair climbing, strenuous activity, vacuuming

Resume light housekeeping by second week at home

Delay returning to work until after 6-week postpartum examination

Discharge Teaching

Recommend exercise to provide health benefits to new mother

Nurse should encourage client to begin simple exercises while on nursing unit

Inform her that increased lochia and pain may necessitate a change in her activity

Sexual Activity and Contraception

Sleep deprivation, vaginal dryness, and lack of time together may impact resumption of sexual activity

Usually sexual intercourse is resumed once episiotomy has healed and lochia has stopped (about 3 – 6 weeks)

Breastfeeding mother may have leakage of milk from nipples with sexual arousal due to oxytocin release

Contraception

Information on contraception should be part of discharge planning

Nursing staff need to identify advantages, disadvantages, risk factors, any contraindications

Breastfeeding mothers concerned that contraceptive method will interfere with ability to breastfeed - they should be given available options – progesterone only

Parent-Infant Attachment

Tell parents it is normal to have both positive and negative feelings about parenthood

Stress uniqueness of each infantProvide time and privacy for the new familyInclude parents in nursing intervention

Reaction of Siblings

Sibling visits reassure children their mother is well

Father may need to hold new baby, so mother can hug older children

Suggest to parent that bringing doll home allows young child to "care for" and identify with parents

Infant Care

New mother and family should know basic infant care Information about tub baths Cord treatment, When to anticipate cord will fall off Family should be comfortable in feeding and handling

infant, as well as safety concerns Immunizations When to call the doctor

Discharge Teaching

Nurse should review with new mother any information she has received regarding postpartum exercises, prevent of fatigue, sitz bath and perineal care, etc. - nurse should spend time with parent to determine if they have any last-minute questions before discharge

Printed information about local agencies and support groups should be given to new family

Types of Follow-Up Care

Telephone calls - nurses must listen carefully and ask open-ended questions

Return visits - Within one week after first visitTelephone follow-up - Within 3 days of dischargeBaby care/postpartum classesNew mother support groupsNeed to have a caring attitude in these activities

Main Purpose of the Home Visit

Assessment Status of mother and infant Adaptation and adjustment of family to new baby

Determine current informational needsTeaching

Self-care Infant Care

Opportunity to answer additional questions related to infant care and feeding

Counseling Provide emotional support to mother and family Referrals

Maternal Assessments at Home

Vital signs: Should be at prepregnancy levelWeight: Expect weight to be near prepregnancy

level at 6 weeks postpartumCondition of breastsCondition of abdomen, including healing cesarean

incision if applicableElimination pattern: should return to normal by 4

to 6 weeks postpartum

Maternal Assessment

Lochia Should progress from lochia rubra to lochia alba If not breastfeeding, menstrual pattern should

return about 6 weeks postpartumFundus

Uterus should return to normal size by 6 weeks postpartum

Perineum: Episiotomy and lacerations should show signs of healing

Breastfeeding Assessment

Nipple soreness - Peaks on days 3 and 6, then recedes

Cracked nipplesAllow nipples to air dry after breastfeedingNurse frequentlyAlternate breastsChange infant's position regularly Breast engorgement, plugged ductsEffect of alcohol and medicationsReturn to workWeaning

Family Assessment

Bonding: Appropriate demonstration of bonding should be apparent

Level of comfort: parents should display appropriate levels of comfort with the infant

Siblings should be adjusting to new babyParental role adjustment

Parents should be working on division of labor Changes in financial status Communication changes Readjustment of sexual relations Adjustment to new daily tasks

Contraception: Parents understand need to choose and use a method of contraception

Relinquishing a Baby

Many reasons why a woman decides she cannot parent her baby Emotional crisis may arise as woman attempts to

resolve her concerns As she faces these concerns, social pressures

against giving up babyMother may need to complete grieving

process to work through her decision - she may have made considerable adjustments to her lifestyle to give birth

Relinquishing a Baby (cont’d)

Nursing staff need to honor any special requests after birth and encourage mother to express her feelings

Seeing newborn may assist mother in grieving process

Some mothers may request early discharge or transfer to another unit