Care of the Mother During the Postpartum Period

Nursing Care of the Mother

• Mother means; - Postpartum women - Puerperial women - After childbirth women

• The puerperium is the period beginning af-ter delivery and ending when the woman’s body has returned as closely as possible to its prepregnant state.

• The period lasts approximately 6 weeks.

Physiologic Changes of the puerperium

1. Uterine changes a. The fundus is usually midline and about at

the level of the woman’s umbilicus after de-livery.

Within 12 hours of delivery, the fundus may be 1cm above the umbilicus.

After this, the level of the fundus descends about 1 finger breadth (or 1 cm) each day, until by the 10th day, it has descended into the pelvic cavity and can no longer be pal-pated.

Level of fundus height

Lochia

b. After delivery, lochia, a vaginal discharge consisting of fatty epithelial cells, shreds of membrane, decidua, and blood, is red color (lochia rubra) for about 2 or 3 days.

It then progresses to a paler or more brown-ish color (lochia serosa), followed by a whitish or yellowish color (lochia alba) in the 7th to 10th day.

Lochia usually ceases by 3 weeks, and the placental site is completely healed by the 6th week

Vagina

2. The vaginal walls, uterine ligaments, and muscles of the pelvic floor and abdominal wall regain most of their tone during the puerperium.

Urination

3. Postpartum diuresis occurs between the 2nd and 5th postpartum days, as extracellular water accumulated dur-ing pregnancy begins to be excreted. Diuresis may also occur shortly after delivery

if urinary output was obstructed be-cause of the pressure of the present-ing part(less sensitive of bladder)

4. Breasts

a. With loss of the placenta, circulating levels of estrogen and progesterone decrease while levels of prolactin increase, thus initiating lactation in the postpartum woman.

b. Colostrum, a yellowish fluid containing more minerals and protein and immunologic component(IgA) but less sugar and fat than mature breast milk and having a laxative effect on the infant, is secreted for the first 2 days postpartum.

c. Mature milk secretion is usually present by the third postpar-tum day but may be present earlier if a woman breast-feeds immediately after delivery.

d. Breast engorgement with milk, venous and lymphatic sta-sis, and swollen, tense, and tender breast tissue may occur between days 3 and 5 postpartum.

 

Breast milk production

Breast engorgement

Emotional and Behavioral Status

1. After delivery the woman may progress through Rubin’s stages of “taking in” and “taking hold.”

a. Taking in phase (1) May Begin with a refreshing sleep after delivery. (2) Woman exhibits passive, dependent behavior. b. Taking hold phase (1) Woman begins to initiate action and to function more in-

dependently. (2) Woman may require more explanation and reassurance

that she is functioning well, especially in caring for her infant. (3) As the woman meets success in caring for the newborn,

her concern extends to other family members and their activ-ities.

Postpartum blue/depression

2. Many women may experience temporary mood swings during this period because of the discomfort, fatigue, and exhaustion after labor and delivery and because of hormonal changes after delivery(decrease of Estrogen).

3. Some mothers may experience “postpartum blues” at about the third postpartum day and exhibit irritability, poor appetite, insomnia, tearfulness, or crying. This is a temporary sit-uation. Severe or prolonged depression is usually a sign of a more serious condition

Contributing factors of postpartum blue/depression

Difficult of Coping with:a. The physical changes and discomforts of the

puerperum, including a need to regain their prepregnancy figure.

b. Changing family relationships and meeting the needs of family members, including the infant.

c. Fatigue emotional stress, feelings of isolation, and being “tied down.”

d. A lack of time for personal needs and inter-ests.

 

NURSING ASSESSMENT

Immediate Postpartum Assess-ment

• The first 1 hour after delivery of the placenta (fourth stage of labor) is a critical period; post partum hemor-rhage is most likely to occur at this time.

Subsequent Postpartum Assessment

1. Check firmness of the fundus at regular in-tervals.

2. Inspect the perineum regularly for frank bleeding.

a. Note color, amount, and odor of the lochia.

b. Count the number of perineal pads that are saturated in each 8 hour period.

3. Assess vital signs at least twice daily and more frequently if indicated.

• Palpating the uterine fundus• Firm or “ *Boggy”

– not palpable by 10 days PP

• “afterpains”• Multiparas, multiple births, breastfeeding

=>

Amount of bleeding

Subsequent Postpartum Assessment

4. Assess for bowel and bladder elimination.5. Assess for breast engorgement and con-

dition of nipples if breast-feeding. 6. Assess perineal incisions(episiotomy

wound) for signs of infection and healing.7. Inspect legs for signs of thromboem-

bolism, and assess Homan’s sign.8. Evaluate interaction and care skills of

mother and family with infant.

Common site of thrombophlebitis

Homan’s sign

NURSING MANAGEMENT

• Nursing Diagnoses

A. Risk for Fluid Volume Deficit related to blood loss and effects from anes-thesia

B. Altered Urinary Elimination related to birth traumaC. Colonic Constipation related to physiologic changes from birthD. Risk for Infection related to birth processE. Fatigue related to laborF. Pain related to perineal discomfort from birth trauma, hemorrhoids, and

physiologic changes from birthG. Altered Health Maintenance related to lack of knowledge of postpartum

careH. Altered Health Maintenance related to lack of knowledge of newborn careI. Ineffective Breastfeeding related to lack of knowledge and inexperience

 

Nursing Interventions

A. Monitoring for Hypotension and Bleeding

1. Monitor vital signs every 4 hours during the first 24 hours, then every 8 to 12 hours. Observe for the following:

a. Decreased respiratory rate below 14 to 16 breaths per minute may occur.normal

b. Increased respiratory rate greater than 24 breaths per minute may be due to increased blood loss, pulmonary edema, or a pulmonary embolus.

c. Increased pulse rate greater than 100 beats per minute may be present with increased blood loss, fever, or pain.

d. Decrease in blood pressure 15 to 20 mm Hg below baseline pressures may indicate decreased fluid volume or increased blood loss.

A. Monitoring for Hypotension and Bleeding

2. Assess the woman for light-headedness and dizzi-ness when sitting upright or before ambulating.

3. Assess vaginal discharge for amount and pres-ence of clots.

4. Evaluate lower extremity sensory and motor func-tion before ambulation if the woman had regional anesthesia.

5. Encourage food and drink as tolerated.6. Maintain intravenous line as indicated.7. Monitor postpartum hemoglobin and hematocrit. 

B. Encouraging Bladder Emptying

1. Observe for the woman’s first void within 6 to 8 hours after delivery.

2. Palpate the abdomen for bladder distention if the woman is unable to void or complains of fullness after voiding.

a. Uterine displacement from the midline sug-gests bladder distention

3. Instruct the woman to void every several hours and after meals to keep her bladder empty.

C. Promoting Proper Bowel Function

1. Teach the woman that bowel activity is sluggish be-cause of decreased abdominal muscle tone, anes-thetic effects, effects of progesterone, decreased solid food intake during labor, and prelabor enema.

2. Inform the woman that pain from hemorrhoids, lac-erations, and episiotomies may cause her to delay her first bowel movement.

3. Review the woman’s dietary intake with her.4. Encourage daily adequate amounts of fresh fruit,

vegetable, fiber, and at least eight glasses of water.5. Encourage frequent ambulation.6. Administer stool softener as indicated.

D. Preventing Infection

1. Observe for elevated temperature above 38℃.

2. Evaluate episiotomy/perineum for red-ness, ecchymosis, edema, discharge (color, amount, odor) and approximation of the skin.

3. Assess for pain, burning, and frequency on urination.

4. Administer antibiotics as ordered. 

Inspection of perineum

E. Reducing Fatigue

1. Provide a quiet and minimally dis-turbed environment.

2. Organize nursing care to keep inter-ruptions to a minimum.

3. Encourage the woman to minimize visitors and phone calls.

4. Encourage the woman sleep while the baby is sleeping.

F. Minimizing Pain

1. Instruct the woman to apply ice packs to the perineal area for the first 24 hours for perineal trauma or edema.

2. Initiate the use of sitz baths for perineal dis-comfort after the first 24 hours

a. Use three times a day for 15 to 20 minutes3. Instruct the woman to contract her buttocks be-

fore sitting to reduce perineal discomfort.4. Assist the woman in the use of positioning cush-

ions and pillows while sitting or lying. 5. Administer pain medication as indicated.

F. Minimizing Pain8. Check the breasts for signs of engorgement (swollen, tender, tense,

shiny breast tissue).a. If breasts are engorged and the woman is breast-feeding: (1) Allow warm-to-hot wet towel to over the breasts and massage to

improve comfort. (2) Express some milk manually or by breast pump to improve com-

port and make nipple more available for infant feeding. (3) Feeding the infant. (4) A mild analgesic may be used to enhance comfort.b. If breasts are engorged and the mother is bottle-feeding: (1) Teach the woman to wear a supportive bra night and day. (2) Teach the woman to avoid handling her breasts, because this

stimulates more milk production. (3) Suggest ice bags to the breasts to provide comport. (4) Moderately strong analgesics maybe needed to provide comfort.

G. Promoting Postpartum Health Maintenance

1. Teach the woman to perform perineal care-warm water over the perineum after each voiding and bowel move-ment routinely several times a day to promote comfort, cleanliness, and healing.

2. Promote sitz baths for the same purpose.3. Teach the woman to apply perineal pads by touching the

outside only, thus keeping clean the portion that will touch her perineum.

4. Assess the condition of the woman’s breasts and nip-ples. Inspect nipples for reddening, erosions, or fissures.

Reddened areas may be improved with A & D ointment, a lanolin cream, and air drying for 15 minutes several times a day.

G. Promoting Postpartum Health Maintenance

5. Teach the woman to wash her breasts with warm water and No soap, which prevents the removal of the protective skin oils(lanolin).

6. Teach the woman to wear a bra that provides good support night and day.

7. Instruct the breast-feeding woman to add between 500 and 750 additional calories daily for milk production.

G. Promoting Postpartum Health Maintenance

8. Instruct the woman in postpartum exercises for the immedi-ate and later postpartum period.

a. Immediate postpartum exercises can be performed in bed. (1) Toe Stretch (tightens calf muscles)- While lying on your

back, keep your legs straight and point your toes away from you, then pull your legs toward you and point your toes to-ward your chest. Repeat 10 times.

(2) Pelvic floor exercise (tightens perineal muscles)-Contract your buttocks for a count of 5 and relax. Contract your but-tocks and press thighs together for a count of 7 and relax. Contract buttocks, press thighs together, and draw in anus for a count of 10 and relax.

b. Exercises for the later postpartum period can be done after the first postpartum visit.

postpartum exercises(1) Bicycle (tightens thighs, stomach, waist)-Lie on your back on the

floor, arms at sides, palms down. Begin rotating legs as if you were riding a bicycle, bringing the knees all the way in toward the chest and stretching the legs out as long and straight as possible. Breathe deeply and evenly. Do the exercises at a moderate speed and do not tire yourself.

(2) (2) Buttocks exercise (tightens buttocks)-Lie on your stomach and keep your legs straight. Raise your left leg in the air, then repeat with your right legs (feel the contraction in your buttocks). Keep your hips on the floor. Repeat 10 times.

(3) Twist (tightens waist)-Stand with legs wide apart. Hold your arms at your sides, shoulder level, palms down. Twist your body from side to front and back again. Feel the twist in your waist.

 

Postpartum exercise

H. Promoting Health Maintenance of the Newborn

1. Encourage the parents to participate in daily care of the infant.

2. Advise the parents to attend parenting and baby care classes offered during their stay at the birth facility mother’s class

3. Teach the parents to bathe and diaper the infant, per-form circumcision care, and initiate either breast feed-ing.

4. Foster bonding by encouraging skin-to-skin contact with the infant, eye contact, and talking to and touch-ing the infant.

 

I. Promoting Breast-Feeding

1. Assist the woman and infant in the breast-feeding process. a. Have the mother wash her hands before feeding to help prevent

infection. b. Encourage the mother to assume a comfortable position, such

as sitting upright, tailor sitting, lying on her side. c. Have the woman hold the baby so that he or she is facing the

mother. Common positions for holding the baby are - the “cradle hold,” with the baby’s head and body supported

against the mother’s arm with buttocks resting in her hand; - the “football hold,” in which the baby’s legs are supported un-

der the mother’s arm while the head is at the breast resting in the mother’s hand;

-lying on the side with the baby lying on his/her side facing the mother.

cradle hold

“football hold

facing the mother.

I. Promoting Breast-Feedingd. Teach the woman to bring the baby close to her, to prevent back,

shoulder, and arm strain.e. Have the woman cup the breast in her hand in a “C” position with bot-

tom of the breast in the palm of her hand the thumb on top.f. Have the woman place her nipple against the baby’s mouth, and when

the mouth opens, guide the nipple and the areola into the mouth.g. Encourage the woman to alternate the breast she begins feeding with

at each feeding to ensure emptying of both breasts and stimulation for maintaining milk supply.

h. Have the mother breast-feed frequently and on demand (every 2 to 4 hours) to help maintain the milk supply.

i. Have the mother air dry her nipples for about 15 to 20 minutes after feeding to help prevent nipple trauma.

j. Have the mother burp the infant at the end or midway through the feeding to help release the air in the stomach and make the infant less fretful.

I. Promoting Breast-Feeding

2. Alert the mother that uterine cramping may oc-cur, especially in multiparous women, due to the release of oxytocin, which can be worse in women with lessened uterine tone.

3. Teach the mother to provide for adequate rest and to avoid tension, fatigue, and a stressful envi-ronment, which can inhibit the letdown reflex and make breast milk less available at feeding.

4. Advise the woman to avoid taking medications and drugs, because many substances pass into the breast milk and may affect milk production or the infant.

Evaluation

A. Vital signs within normal limits; decreasing color and amount of lochia

B. Voids freely and without discomfortC. Lack of constipation; eats high-fiber foods and uses

stool softenersD. Afebrile, no abnormal redness of perineum, no purulent

discharge or foul odor of lochiaE. Verbalizes feeling restedF. Verbalizes decreased painH. Demonstrates confidence in performing infant care;

shows signs of maternal-child bondingI. Demonstrates successful breast-feeding; breasts and

nipples infant and without redness or cracks