Postpartum Care

September 3, 2017 | Author: Christian | Category: Lactation, Breastfeeding, Infants, Menstrual Cycle, Breast
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C. POSTPARTUM CARE Puerperium/Postpartum Period Refers to the six (6) weeks period after delivery of the baby Time of maternal changes that are both o Retrogressive (involution of uterus and vagina) o

Progressive (production of milk for lactation, restoration of normal menstrual cycle, and beginning parenting role)

*Involution- return of the reproductive organs to their pre-pregnant state (6 weeks) Postpartum Care & Assessment (mnemonic: BUBBLE-HE)











Vital signs •

Assess q 15 min x 4; then q 30 min x2; then q 4 hrs for the first 24 hrs (if stable) then q 8 hrs

BP should be WNL for patient

Pulse- 50-90 bpm

Temp- 98-100.4 degree F (36.6-38 degree C): normal for the 1st 24 hrs due to DHN during labor

Resp- 16-24 cpm o

Increase in body temperature during the first 24 hours is not necessarily a sign of postpartum infection. 


Any mother whose temperature reaches 38 degree C in any two consecutive 24 hrs period during the first 10 postpartum days may suggest infection.

Bradycardia (heart rate of 50-7- bpm) is common for (24-48 hrs) and persist 6-8 days postpartum. 

Returns to non-pregnant rate by 3 months postpartum


Breast •

Lacatation- formation of breast milk (BM); begins in a postpartal woman whether or not she plans to breast-feed. o

BM forms in response to decrease in estrogen and progesterone levels that follows delivery of the placenta (which stimulates prolactin production)

Prolactin- hormone for production of breast milk

Oxytocin- hormone for excretion/ejection of milk

Colostrum is present at the time of delivery; BM is produced by the 3rd and 4th postpartum day; yellow sticky fluid; more protein, less sugar, less fat than mature milk.

Engorgement_ the feeling of tension (heat or throbbing pain) in the breast as breast distention becomes marked (fuller, larger, firmer); occurs on the 3rd -4th day


Due to expanding veins and pressure of new breast milk contained with them


There may be a slight elevation of body temperature during this time


Congestion subsides in 1 or 2 days

In breast, prolactin stimulates alveolar cells to produce milk. Sucking of the newborn triggers a release of oxytocin and contractility of the myoepithelial cells, which stimulate milk flow; this is known as the let down reflex. The average amount of milk produced in 24 hours increases with time: o

First week- 6-10 oz


1-4 weeks- 20 oz


After 4 weeks- 30 oz 

Mature milk •

Foremilk-watery milk coming from full breast (low in fat, high in carbohydrates)

Hindmilk- creamy milk coming from a nearly empty breast

Amount of supply depends on how often the mother nurse or pumps ( the more the mother nurses, the more milk is produced)

For those who choose not to breastfeed, lactation can be suppressed through: o

Use a well-fitting bra


Avoid any type of nipple stimulation or heat to the breasts (such as warm/hot showers)


May use ice packs or cold cabbages leaves to east breast discomfort until milk production ceases (it generally takes 5-7 days)



Mild analgesics as prescribed

Uterus •

After delivery of the newborn, involution of the uterus must occur; 2 main processes: o

Area where placenta is implanted is sealed off to prevent bleeding


Uterus reduced to its pregestational size (grapefruit) 

Firm, midline, reduced in its size

Soft & boggy, displaced (hemorrhage risk)

Few minutes after birth, fundus halfway between umbilicus and symphysis pubis

One hour later, rise to the level of umbilicus and it remains for the next 24 hours

First postpartal day (day 1)- one fingerbreadth below umbilicus

Day 2- 2 finngerbreadth below and so forth until day 10, it can no longer be palpated because it is already behind symphysis pubis

At 10-14 postpartum days, the uterus cannot be palpated abdominally


Subinvoluted Uterus 


To encourage return of the uterus to its usual anteflexed position, PRONE and KNEE CHEST positions are advised.

Fundal massage, ice pack over hypogastrium, IV oxytocin, nipple stimulation (breastfeeding)

Afterpains/afterbirth pains 

Uterus larger than normal and vaginal bleeding with clots. Since blood clots are good media for bacteria; it is therefore as sign of puerperal sepsis

Strong uterine contractions felt more particularly by multis, those who delivered larger babies or twins and those who breastfeed. It is normal and rarely last for more than 3 days.

Menstruation o

If not breastfeeding- return in 6-8 weeks after birth


If breastfeeding, in 3-4 months (lactational amenorrhea) or entire lactation period 

Though does not guarantee that woman will not conceive because she may ovulate well before menstruation returns


Bladder Elimination •

Marked dieresis to eliminate excess fluid (as much as 2000-3000ml accumulates in the body during pregnancy)

o •

May complain of frequent urination in small amounts: explain that this is due to urinary retention with overflow

May have difficulty voiding because of abdominal pressure or trauma to the trigone of the bladder

Assess hypogastric area for overdistention of bladder:



Urine output from 1500ml/day to as much as 3000ml/day 2nd-5th after birth


Palpation: hard or firm just above symphysis pubis


Percussion: resonant

Voiding may be initiated by: o

Pouring warm and cool water alternately over the vulva


Encourage the client to go to the comfort room


Let her listen to the sound of running water


If these measures fail, catheterization, done gently and aseptically, is the last resort on doctor’s order. (if there is resistance to the catheter when it reaches the internal sphincter, ask patient to breathe through the mouth while rotating the catheter before moving it inward again.)

Bowel Elimination •

Full diet (unless GA)

Constipation: delayed bowel evacuation postpartally may be due to: o

Decrease muscle tone


Lack of food and enema during labor




Fear of pain from perineal tenderness due to episiotomy, lacerations or hemorrhoids

Lochial discharge ( during the 1st 3 weeks after delivery)- uterine discharge consisting of blood, deciduas, WBC, mucus and some bacteria •

It should approximate menstrual flow. It increases with activity and decreases with breastfeeding.

Types of lochia:





Lochia rubra 

Dark red in color within first 2-3 days

Contains epithelial cells, erythrocytes, leukocytes, and deciduas and has a characteristic human odor.

Lochia alba 

Pinkish to brownish discharge

It is a serosanguineous discharge containing erythrocytes, leukocytes, cervical mucus and microorganism

It has a strong odor

Lochia serosa 

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

It contains leukocytes, deciduas, epithelial cells, fat, cervical mucus, cholesterol crystals and bacteria


Episiotomy/Perineum •

Appears edematous and bruised after delivery caused by episiotomy (if performed) and some degree of laceration

Assess s/s of infection and inflammation: o

REEDA (redness, edema, ecchymosis, discharge, approximation of sutures)

Assess for lacerations:


1st degree- lacerations extend through the skin and superficial layers of the perineum


2nd degree- through perineal muscles


3rd degree- through anal sphincters


4th degree- through the anterior rectal wall and can be damaging to the perineum

Prevention of lacerations: o



Warm compress


Manual support (Ritgen’s maneuver)


Birthing in a lateral position



To relieve pain: o

Sim’s position- minimizes strain on the suture line


Perineal heat lamp or warm sitz baths twice a day- vasodilation increases blood supply and therefore, promotes healing


Apply ice or cold therapy to the episiotomy or laceration immediately after delivery to decrease edema and provide anesthesia; thereafter apply moist or dry heat therapy to promote comfort and healing


Application of topical analgesics or administration of mild oral analgesics as ordered.

Homan’s sign/Legs •

Relative inactivity/prolonged time in stirrups leads to stasis of blood and promotes clotting of blood in the lower extremities

Assess s/s of DVT o

Redness, warmth, tenderness, Homan’s sign (pain upon dorsiflexion of foot)


It is also important to note that a DVT may be present despite a negative Homan’s sign

Early ambulation

Avoid crossing of legs, constrictive clothings/undergarments

Emotions: Psychological Adaptation (Reva Rubin): ESSENTIAL CONCEPTS •

The postpartum period represents a time to emotional stress for the new mother, made even more difficult by the tremendous physiologic changes that occur

Factors influencing successful transition to parenthood during the postpartum period include:


Response and support of family and friends


Relationship of the birthing experience to expectations and aspirations


Previous childbearing and childrearing experiences


Cultural influences

Rubin (1997) describes this period as occurring in three stages: taking-in, taking-hold and letting-go o


Occurring 1-2 days after delivery, the new mother typically is passive and dependent

Energies are focused on bodily concerns



She may review her labor and delivery frequently

Uninterrupted sleep is important if the mother is to avoid the effects of sleep deprivation, which include fatigue, irritability, and interference with normal restorative process

Additional nourishment may be needed because the mother’s appetite unusually increased; poor appetite may be a clue that the restorative process is not progressing normally

Encourage her to talk about the birth will her integrate it into her life experiences


2-4 days after delivery

Mother becomes concerned with her ability to parent successfully and accepts increasing responsibilities for her newborn

Woman begins to initiate action; she prefer to get her own wash cloth and make her own decisions

Mother focuses on regaining control over her bodily functions: bowel and bladder function, strength and endurance

The mother strives to master newborn care skills (holding, breastfeeding, or bottlefeeding, bathing and diapering) •

She may be sensitive to feelings of inadequacy

The nurse should take this into instructions and emotional support,

Provide praises




Redefines her new role

Generally occurs after the new mother returns home. It involves a time of family reorganization

Mother assumes responsibility for newborn care; she must adapt to demands of the newborn’s dependency and to her decreased autonomy, independence and social interaction

She gives up the fantasized image of her child and accepts the real one.



Refers to the emotional connection between a patient and her infant

Behaviors indicating a positive attachment include:





Talking and singing

Choosing the “en face” position

Expressing pride in the infant

Mal-attachment behaviors vary, but can include: •

Refusing to look at the infant

Refusing to touch or hold the infant

Refusing to name the infant

Negative comments about the infant

Refusing to respond or responding negatively to infant cues ( crying, smiling)


“baby blues”; normal part of postpartum experience but only for a few days

Tearfulness, irritability, sometimes insomnia

Causes: hormonal fluctuations, physical exhaustion, maternal role adjustment o

Reassure that this is normal


Anticipatory guidance and individualized support from health care personnel are important to help the parents understand


Keeping lines of communication open


Allow her to make as many decision as possible can help give her sense of control over her life


Allow her to verbalize her feelings and concerns


A serious & debilitating depression, occurring within first 9 months after delivery, often within the initial weeks or months

Sadness, crying, insomnia, decreased appetite, withdrawal and sometimes suicidal ideation or the desire to harm the infant

Somatic symptoms: headaches, diarrhea, constipation, severe anxiety, feeling as though they are jumping out of their skinm and/or just not feeling like themselves

Management: o

Assessment tools:

Edinburg Postnatal Depression Scale (EPDS)

Postpartum Depression Screening Scale (PDSS)


Refer to doctor; counseling and medication


Help patient and family to understand this condition and assist to explore spiritual aspect of care

Additional physiologic adaptations after delivery: 1.

Cardiovascular system •

30-50% increase in total cardiac volume during pregnancy will be reabsorbed into the general circulation within 5-10 minutes after placental delivery

Blood loss: vaginal birth- 300-500 ml; cesarean birth- 500-1000ml

Blood volume decrease to non pregnant levels by fourth week after delivery

Hematocrit rises by the 3rd-7th postpartum day

WBC increases to 20000-30000/mm3


Cannot be used as an indicator or signs of postpartum infection


Part of body’s defense system against infection


Aid to healing

Extensive activation of the clotting factors which encourages thromboembolization: o

Ambulation is done early 4-8hours after normal vaginal delivery 




When ambulating the newly-delivered patient for the first time, the nurse should hold on to the patient’s arm.

Massage is contraindicated.

All blood values are back to prenatal levels by the 3rd-4th week postpartum

Reproductive system (Vagina) •

Smooth and swollen with poor tone after delivery

Rugae reappears by 3-4 postpartum weeks

Diameter is greater than normal. Hymen is permanently torn.

The estrogen index returns in 6-10 weeks.

Vaginal dryness and painful intercourse (dyspareunia) may be noted during the postpartum period due to decreased estrogen levels.

Integumentary system




Mask of pregnancy (chloasma) usually disappears, while stretch marks (striae gravidarum) and linea negra fade but generally do not disappear

Endocrine system •

Estrogen and progesterone level decreases as soon as the placenta is no longer present

HPL and HCG are almost negligible by 24 hours

FSH remains low for about 12 days and begins to rise as new menstrual cycle is initiated. Menstruation return in approximately 6-8 weeks; ovulation cam return within 4 weeks.

Musculoskeletal system •

Relaxin is the hormone responsible for the relaxation of the pelvic ligaments and joints during pregnancy. After delivery, relaxin level subsides and the pelvic ligaments and joints return to their pre pregnant state. However, the joints of the feet remain altered and many patients notice a permanent increase in shoe size.

Abdominal wall is weakened and the muscle tone of the abdomen is diminished after pregnancy. Some patients have a separation between the abdominal wall muscles, called diastasis recti. This separation can ofte be corrected with certain abdominal exercises (sit ups) performed during the postpartum period.

Urinary changes •

Extensive diuresi begins to take place almost immediately after birth to rid the boyd of fluid

Increases the daily output a postpartal woman from a 1500- 3000 ml/day during the 2nd-5th day after birth

Contain more nitrogen than normal (due to breakdown of protein in a portion of uterine muscle)

Urinary retention as a result of decreased bladder tone and emptying can lead to urinary tract infections

PATIENT TEACHING: Self-care guidelines to the mother •

Instruct the client on sitting properly to relieve pain (squeeze the buttocks together and contract pelvic floor muscles before sitting)

Instruct to wear perineal pads loosely and to lie in sim’s position

Demonstrate how to clean the perineum after each voiding and defecation (wiping form front to back), washing the hands and applying a perineal pad from front to back

Teach the importance of adequate fluid intake, exercise, proper diet and a regular defecation time

Instruct to avoid garters or constricting clothing that can impair circulation

Encourage client to shower as soon as she can ambulate and to take tub baths if desired after two weeks. Recommended daily shower to promote comfort and a sense of well-being/

Provide adequate dietary fiber and fluids to promote bowel movements; if necessary administer stool softeners, laxatives, suppositories or enema

Demonstrate newborn care and safery measures

Recommended exercise:


Kegel’s and abdominal breathing on postpartum day one


Chin-to-chest on postpartum day 2 to tighten and firm up abdominal muscles


Knee-to-abdomen when perineum has healed, to strengthen abdominal and gluteal muscles

Sexual activity


Resume by the 3rd-4th week postpartum


Bleeding has stopped


Espisiprrhaphy has healed ( usually 1 week after delivery)


Lochia has turned to alba.


Decreased physiologic reactions to sexual stimulation are expected for the 1st 3 months postpartum because of hormonal changes and emotional factors.


She should be protected against subsequent pregnancy by observing a method of contraception, except the PILLS.

Postpartum check up- 4-6 weeks after birth. Woman should return to her physician for an examination (visit is important to ensure that involution is complete and reproductive planning is desired and may be discussed further.)


Feed newborn per demand (breastfeeding or bottlefeeding) or at least every two hours and intervals should not exceed 5 hours

If breastfeeding o

From birth to at least 2 years and should continue as long as the mother and child wish


Exclusive breastfeeding until 6 months of age (when solid are gradually introduced)


Correct latching on ( to prevent nipple sores and allow baby to get enough milk)


Large part of the breast and areola need to enter the baby’s mouth

Nipple should be at the back of the baby’s throat with the baby’s tongue lying flat in its mouth

10-20 minutes each breast

o •

Cradling position

Storage of expressed breastmilk o

Hard sided containers with airtight seals

Place of storage


Maximum storage time

In a room

25 degree C

6-8 hours

Insulated thermal bag with ice packs

Up to 24 hours

In a refrigerator

4 degree C

Up to 5 days

Freezer compartment inside a refrigerator

-15 degree C

2 weeks

A combined refrigerator and freezer with separate doors

-18 degree C

3-6 months

Chest or upright manual defrost deep freezer

-20 degree C

6-12 months

Oral contraceptives are contraindicated in lactating mothers because they contain estrogen and progesterone derivatives, thereby decreasing milk supply


Wash breast daily at bath or shower time

Soap or alcohol should never be used on the breast as they tend to dry and crack the nipples and cause sore nipples

Wash hands before and after every feeding

Insert clean OS squares or piece of cloth in the brassiere to absorb moisture when there is considerable breast discharges.

Engorgement managemet: o

Nurse often (not going more than 3 hours without nursing and not skipping night feedings)


Well-fitted bra


Warm compress/shower


Chilled cabbage leaves (placed on breast with nipple exposed)


Acetaminophen or ibuprofen for pain


Pumping or manually expressing breast milk

How to Manually Express Breastmilk - The Marmet Technique Draining the Milk Reservoirs

1. Position the thumb (above the nipple) and first two fingers (below the nipple) about 1” to 1–1/2” from the nipple, though not necessarily at the outer edges of the areola. Use this measurement as a guide, since breasts and areolas vary in size from one woman to another. Be sure the hand forms the letter “C” and the finger pads are at 6 and 12 o’clock in line with the nipple. Note the fingers are positioned so that the milk reservoirs lie beneath them. • Avoid cupping the breast 2. Push straight into the chest wall

• Avoid spreading the fingers apart. • For large breasts, first lift and then push into the chest wall 3. Roll thumb and fingers forward at the same time. This rolling motion compresses and empties milk reservoirs without injuring sensitive breast tissue. Note the position of thumb and fingernails during the finish roll as shown in the illustration. 4. Repeat rhythmically to completely drain reservoirs. • Position, push, roll... • Position, push, roll... 5. Rotate the thumb and fingers to milk other reservoirs, using both hands on each breast. Avoid These Motions 1. Do not squeeze the breast, as this can cause bruising. 2. Sliding hands over the breast may cause painful skin burns. 3. Avoid pulling the nipple which may result in tissue damage

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