postpartum

Maternal and Child Health Nursing

Postpartum

MCHN Abejo

MATERNAL and CHILD HEALTH NURSING

POSTPARTUM

Lecturer: Mark Fredderick R. Abejo RN, MAN

_____________________________________________________________________________

. I. PHYSIOLOGICAL MATERNAL CHANGES

A. LOCHIA – discharge from the uterus during the first 3 weeks after delivery.

Increasing Lochia as the day passes by may indicate Heparin Intoxication.

LOCHIAL CHANGES

LOCHIA RUBRA

• Dark red discharge occurring in the first 2-3 days.

• Contains epithelial cells, erythrocytes and decidua.

• Characteristic human odor.

LOCHIA SEROSA

• Pinkish to brownish discharge occurring 3-10 days after delivery.

• Serosanguineous discharge containing decidua, erythrocytes, leukocytes, cervical mucus and

microorganisms.

• Has a strong odor.

LOCHIA ALBA • Almost colorless to creamy yellowish discharge occurring from 10 days to 3 weeks after delivery.

• Contains leukocytes, decidua,epithelial cells, fat, cervical mucus, cholesterol crystals, and bacteria.

• Has no odor.

B. UTERUS

• Process of involution takes 4-6 weeks to complete.

• Weight decreases from 2 lbs to 2 oz.

• Fundus steadily descends into true pelvis; Fundal height decreases about 1 fingerbreadth (1 cm)/day; by

10-14 days postpartum, cannot be palpated abdominally.


Postpartum

MCHN Abejo

C. Uterine Involution

1. Description

a. The rapid decrease in the size of the uterus as it returns to the nonpregnant state

b. Clients who breastfeed may experience a more rapid involution

2. Assessment

a. Weight of the uterus decreases from 2 pounds

to 2 ounces in 6 week

b. Endometrium regenerates

c. Fundus steadily descends into the pelvis

d. Fundal height decreases about 1 fingerbreadth (1 cm) per day

E. By 10 days postpartum, uterus cannot be palpated abdominally

NOTE: Deviation of the fundus to the right or left and location of the fundus above the umbilical are signs that the

bladder is distended

NOTE: Height of the Umbilicus on the First Postpartum Day

The height is usually SLIGHTLY below the umbilicus about 24 hours after delivery. The top of the umbilicus is

normally MIDWAY between the umbilicus and the symphysis pubis.

D. Breasts

1. Breasts continue to secrete colostrum

2. A decrease in estrogen and progesterone levels after delivery stimulates increased prolactin levels, which

promote breast milk production.

3. Breasts become distended with milk on the third day

4. Engorgement occurs in 48 to 72 hours in non breast feeding mothers.

NOTE:

Bradycardia is a normal physiologic change for 6-10 days postpartum

E. Gastrointestinal tract

1. Women are usually very hungry after delivery

2. Constipation can occur

3. Hemorrhoids are common

II. POSTPARTUM NURSING INTERVENTIONS

Monitor Vital Signs

NOTE: Maternal temperature during the first 24 hours following delivery may rise to 100. 4` F (38`C) as a

result of dehydration. The nurse can reassure the new mother that these symptoms are normal.

Postpartum Exercise

Supine Position with the knee’s flexed, and then inhale deeply while allowing the abdomen to expand and

exhale while contracting the abdominal muscles. The purpose of this exercise is to strengthen the

abdominal muscles. Examples are reaching for the knees; push ups and sits ups on the first postpartum

day.

Assess height, consistency, and location of the fundus

Monitor color, amount, and odor of lochia

Assess lochia and color volume

Give RhoGAM to mother if ordered. RhoGAM promotes lysis of fetal Rh (+) RBCs.

Administer RhoGam as prescribed within 72 hours postpartum to the Rh-negative client who has given

birth to an Rh-positive neonate.

Rhogam (D) immune globulin is given by intramuscular injection

Check episiotomy and perineum for signs of infection.

Promote successful feeding.

Non-nursing woman- tight bra for 72 hours, ice packs, minimizes breast stimulation.

Nursing woman- success depends on infant sucking and maternal production of milk.

“Postpartum Blues” (3-7 days) – Normal occurrence of “roller coaster” emotions


Postpartum

MCHN Abejo

Sexual activities- abstain from intercourse until episiotomy is healed and lochia ceased

around 3-4 weeks. Remind that Assess height, consistency, and location of the fundus breastfeeding

does not give adequate protection.

Assess breasts for engorgement

Monitor episiotomy for healing ( assess dehiscence & evisceration)

Assess incisions or dressings of cesarean birth client ( prone to infection)

Monitor bowel status ( prone to constipation)

Monitor I &0

Encourage frequent voiding (prevent urinary retention which will predispose the mother to uterus

displacement & infection)

Encourage ambulation ( to prevent thromboplebitis & paralytic ileus

Assess bonding with the newborn infant ( to prevent failure to thrive)

NOTE:

A positive bonding experience is indicated when the mother turns her face toward the baby to initiate eye-to-eye

contact. Observation of new mothers has shown that a fairly regular pattern of maternal behaviors is exhibited at

first contact with the newborn. The mother follows a progression of touching activities from fingertip exploration

toward palmar contact to enfolding the infant with the whole hand and arm. The mother also increase the time

spent in the en face position. The mother arranges herself or the newborn so that her face and eyes are in the same

plane as in her infant.

III. POSTPARTUM DISCOMFORTS

A. Perineal discomfort

Apply ice packs to the perineum during the first 24 hours to reduce swelling after the first 24 hours, apply

warmth by sitz baths

B. Episiotomy

1. Instruct the client to administer perineal care after each voiding

2. Encourage the use of an analgesic spray as prescribed

3. Administer analgesics as prescribed if comfort measures are unsuccessful

C. Breast discomfort

PREVENTION:

The BEST PREVENTION TECHNIQUE IS TO EMPTY THE BREST REGULARLY AND FREQUENTLY

WITH FEEDINGS. The 2nd

is EXPRESSING A LITTLE MILK BEFORE NURSING, MASSAGING THE BREASTS

GENTLY OR TAKING A WARM SHOWER BEFORE FEEDING MAY HELP TO IMPROVE MILK FLOW. Placing

as much of the areola as possible into the neonate’s mouth is one method. Other methods include changing position

with each nursing so that different areas of the nipples receive the greatest stress from nursing and avoiding breast

engorgement, which make I difficult for the neonate to grasp. In addition, nursing more frequently, so that a

ravenous neonate is not sucking vigorously at the beginning of the feedings, AND FEEDING ON DEMAND to

prevent over hunger is helpful. AIRDRYING THE NIPPLES AND EXPOSING THEM TO THE LIGHT HAVE ALSO

BEEN RECOMMENDED. Warm Tea bags, which contain tannic acid also, will sooth soreness. WEARING A

SUPPORTIVE BRASSIERE DOES NOT PREVENT BREAST ENGORGEMENT. APPLYING ICE and LANOLIN

DOES NOT RELIEVE BREAST ENGORGEMENT.


Postpartum

MCHN Abejo

INTERVENTION:

Measures that help relieve nipple soreness in a breast-feeding client include lubricating the nipples with a

few drops of expressed milk before feedings, applying ice compresses just before feedings, letting the nipples air dry

after feedings, and avoiding the use of soap on the nipples.

NOTE: Specific nursing care for breast Engorgement

1. Breastfeed frequently

2. Apply warm packs before feeding

3. Apply ice packs between feedings

NOTE: Specific Nursing Care for Cracked nipples

1. Expose nipples to air for 10 to 20 minutes after feeding

2. Rotate the position of the baby for each feeding

3. Be sure that the baby is latched on to the areola, not just the nipple

NOTE: Do not use soap on the breasts, as it tends to remove natural oils, which increases the chance of cracked

nipples

IV. POST PARTUM COMPLICATIONS

A. HEMORRHAGE

CAUSES SIGNS OF HEMORRHAGE MANAGEMENT

The #1 cause of POSTPARTUM

HEMORRHAGE IS RETAINED

PLACENTAL FRAGMENTS.

Uterine atony and vaginal &

cervical tears are associated with

early postpartum hemorrhage

The #2 cause is OVER-

DISTENTION OF THE UTERUS

from more than (10) pounds,

OTHERS ARE: 4000 gms,

neonate, excessive oxytocin use,

Polyhydramnios and Placental

Disorders.

You should assess for uterine

atony after a c-section delivery.

This is more common after a c-

section than after a vaginal

delivery.

Boggy uterus (does not

respond to massage)

A boggy uterus would be

palpable above the umbilicus and

would be soft and poorly

contracted.

Abnormal clots unusual

pelvic discomfort or headache

Excessive or bright-red

bleeding

Signs of shock

Early Hemorrhage starts on the

first 24 hours, or more than 500

ml of blood on the first 24 hrs in

a Normal spontaneous delivery..

Fluid replacement

Emergency lay

Oxygen

Vital signs

Perineal pad count

Psychological support

Massaging the lower abdomen

after delivery is done to maintain

a firm uterus, which will aid in

the clumping down of blood

vessels in the uterus, thereby

preventing any further bleeding.

“BOGGY UTERUS

Uterine atony means that the

uterus is not firm or it is not

contracting. The nurse should

gently massage the uterus which

will contract the uterus and make

it firm. Clients who are

predisposed are usually

MULTIPLE GESTATION,

POLYHYDRAMNIOS,

PROLONGED LABOR and LGA

(LARGE GESTATIONAL AGE

fetus.

B. THROMBOPLEBITIS

Inflammation of the vein caused by a clot

The positive Homan’s sign indicate is possibility of thrombophlebitis or a deep venous thrombosis that is

present in the lower extremities.

When assessing for Homan’s sign ask the patient to stretch her kegs out with the knee slightly flexed while

dorsiflex the foot. A positive sign is present when pain is felt at the back of the knee or calf. It is normal for a

patient on magnesium sulfate to feel tired because it acts as a central nervous depressant and often makes the

patient drowsy.


Postpartum

MCHN Abejo

MANIFESTATION MANAGEMENT CURATIVE

Edematous extremities

Fever with chills

Pain and redness in affected

area

Positive Homan’s sign

Preventive Immobilize extremity

Analgesics

Anticoagulant

Thrombolytics

C. INFECTION

PREDISPOSING FACTORS MANIFESTATION MANAGEMENT

Rupture of membranes over

24 hours before delivery

Retained placental

fragments

Internal fetal monitoring

Vaginal infection

Fever

Chills

Poor appetite

General body malaise

Abdominal pain

Foul-smelling lochia

Puerperial infection is an

infection of the genital tract.

Early signs and symptoms of

puerperial infection include

chills, fever, and flu-like

symptoms. It can occur up to one

month after delivery.

Antibiotics

Oxytocin

Analgesics

Maintain hygiene

Semi-fowlers positions

Vital signs

Early ambulations

Assess lochia

Bright red blood is a normal

lochial finding in the first 24

hours after delivery. Lochia

should never contain large clots,

tissue fragments, or membranes.

A foul odor may signal infection,

as may absence of lochia.

D. MASTITIS


Postpartum

MCHN Abejo

ASSESSMENT MANAGEMENT

Elevated temperature, chills,

general aching, malaise and

localized pain

Engorgement, hardness and

reddening of the breasts

Nipple soreness and fissures

Inflammation of the breast as a

result of infection

Primarily seen in breastfeeding

mothers 2 to 3 weeks after

delivery but may occur at any

time during lactation

Instruct the mother in good hand washing and breast

hygiene techniques

Apply heat or cold to site as prescribed

Maintain lactation in breastfeeding mothers

Encourage manual expression of breast milk or use

of breast pump every 4 hours

Encourage mother to support, breasts by wearing a

supportive bra

Administer analgesics & antibiotics as prescribed

E. Postpartum Mood Disorders

MOOD DISORDERS ASSESSMENT

Postpartum Blues Onset: 1-10 days postpartum lasting 2 weeks or less

Fatigue

Weeping anxiety

Mood instability

Postpartum Depression

Normal processes during

postpartum include the withdrawal

of progesterone and estrogen and

lead to the psychological response

known as "the blues."

Postpartum depression is a

psychiatric problem that occurs

later in postpartum and is

characterized by more severe

symptoms of inadequacy.

Because the client's behavior is

normal, notifying her physician and

conducting a home assessment

aren't necessary.

Onset: 3-5 days lasting more than 2 weeks

Confusion

Fatigue

Agitation

Feeling of hopelessness and shame “let down feeling”

Alterations in mood “roller coaster emotions”

Appetite and sleep disturbance

According to Rubin, dependence and passivity are typical during the taking-

in period, which may last up to 3 days after delivery. A client experiencing

postpartum depression demonstrates anxiety, confusion, or other signs and

symptoms consistently. Maternal role attainment occurs over 3 to 10 months.

Attachment also is an ongoing process that occurs gradually.

Postpartum Psychosis

Onset: 3-5 days postpartum

Symptoms of depression plus delusions

Auditory hallucinations

Hyperactivity

POSTPARTUM WARNING S/S TO REPORT TO THE PHYSICIAN Increased bleeding, clots or passage of tissue.

Bright red vaginal bleeding anytime after birth.

Pain greater than expected.

Temperature elevation to 100.4º F.

Feeling of full bladder accompanied by inability to void.

Enlarging hematoma.

Feeling restless accompanied by pallor; cool, clammy skin; rapid HR; dizziness; and visual disturbance.

Pain, redness, and warmth accompanied by a firm area in the calf.

Difficulty breathing, rapid heart rate, chest pain, cough, feeling of apprehension, pale, cold, or blue skin

color


Postpartum

MCHN Abejo

V. Psychological Adaptation

Psychological Adaptation

Taking-in Phase Postpartum blues: overwhelming sadness

Taking-hold Phase Postpartum depression

Letting-Go Postpartum Psychoses

Rubin's Postpartum Phases of Regeneration (POSTPARTUM PSYCHOSOCIAL ADAPTATION)

“TAKING IN” PHASE (DEPENDENT) First 3 Days

During this time, food and sleep are a major focus for the client. In addition, she works through the birth

experience to sort out reality from fantasy and to clarify any misunderstandings. This phase lasts 1 to 3 days after

birth. The primary concern is to meet her own needs.

• Takes place 1-2 days postpartum

• Mother is passive and dependent; concerned with own needs.

• Verbalizes about the delivery experience.

• Sleep/food important.

• Mother focuses on her own primary needs, such as sleep and food

Important for the nurse to listen and to help the mother interpret the events of delivery to make them more

meaningful

Not an optimum time to teach the mother about baby care

“TAKING HOLD” PHASE (DEPENDENT/INDEPENDENT)

The client is concerned regarding her need to resume control of all facets of her life in a competent manner. At this

time, she is ready to learn self-care and infant care skills.

• 3-10 days postpartum

• Mother strives for independence and begins to reassert herself.

• Mood swings occur. May cry for no reason.

• Maximal stage of learning readiness.

• Mother requires reassurance that she can perform tasks of motherhood. • Begins to assume the tasks of mothering

• An optimum time to teach the mother about baby care.

“LETTING GO” PHASE (INTERDEPENCE)

• 10 to 6 weeks postpartum

• Realistic regarding role transition.

• Shows pattern of life-style that includes the new baby but still focuses on entire family as a unit.

• Accepts baby as separate person.

Mother may feel deep loss over separation of the baby from part of the body and may grieve over the loss

Mother may be caught in a dependent/independent role, wanting to feel safe and secure yet wanting to

make decisions

Teenage mothers need special consideration because of the conflict taking place within them as part of

adolescence

postpartum

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