Postpartum Care
Just the factsIn this chapter, you’ll learn:
physiologic and psychological changes that occur during the postpartum period
key components of a postpartum assessment
nursing care measures required during the postpartum period
physiologic events that occur during lactation
two feeding methods, including their advantages and disadvantages.
A look at postpartum care
The postpartum period, or puerperium, refers to the 6- to 8-week period after delivery during which the mother’s body returns to its nonpregnant state. Some people refer to this period as the fourth trimester of pregnancy. Many physiologic and 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.
Physiologic changes
Two types of physiologic changes occur during the postpartum period: retrogressive changes and progressive changes.
Getting back to normal
Retrogressive changes involve returning the body to its prepregnancy state. Retrogressive reproductive system changes include:
Theory of involution
After delivery, the uterus gradually decreases in size and descends into its prepregnancy position in the pelvis—a process known as involution. Involution normally begins immediately after delivery, when the firmly contracted uterus lies midway between the umbilicus and symphysis pubis. Soon after, the uterus rises to the umbilicus or slightly above it. After the first postpartum day, the uterus begins its descent into the pelvis at the rate of 1 cm/day (or 1 fingerbreadth/day) or slightly less for the patient who has had a cesarean delivery. By the 10th postpartum day, the uterus lies deep in the pelvis—either at or below the symphysis pubis—and it can’t be palpated.
Contraction is key
If the uterus fails to contract or remain firm during involution, uterine bleeding or hemorrhage can result. At delivery, placental separation exposes large uterine blood vessels. Uterine contraction acts as a tourniquet to close these blood vessels at the placental site. Fundal massage, the administration of synthetic oxytocics, and the release of natural oxytocics during breast-feeding help to maintain or stimulate contraction.
All systems undergo
Other body systems undergo retrogressive changes as well. These alterations include:
reduction in pregnancy hormones, such as human chorionic gonadotropin, human placental lactogen, progestin, estrone, and estradiol
extensive diuresis, which rids the body of excess fluid and reduces the added blood volume of pregnancy
gradual rise in hematocrit, which occurs as excess fluid is excreted
reactivation of digestion and absorption
eventual fading of striae gravidarum (stretch marks), chloasma (pigmentation on face and neck), and linea nigra (pigmentation on abdomen)
gradual return of tone to the abdominal muscles, wall, and ligaments
return of vital signs to normal parameters
weight loss due to rapid diuresis and lochial flow
recession of varicosities (although they may never return completely to prepregnancy appearance).
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In addition, estrogen and progesterone production drops abruptly after delivery and follicle-stimulating hormone (FSH) production rises, resulting in the gradual return of ovulation and the menstrual cycle.
Making progress
Progressive changes involve the building of new tissues, primarily those that occur with lactation and the return of menstrual flow. In the postpartum period, fluid accumulates in the breast tissue in preparation for breast-feeding and breast tissue increases in size as breast milk forms. The changes associated with lactation are discussed in more detail later in this chapter.
Psychological changes
The postpartum period is a time of transition for the new mother and her family. Even if the family has other children, each family member must adjust to the neonate’s arrival. The mother, in particular, undergoes many psychological changes during this time in addition to the changes that are occurring in her body.
Don’t let the phases faze you
The mother goes through three distinct phases of adjustment in the postpartum period:
taking in
taking hold
letting go.In the past, each phase of the postpartum period encompassed a specific time span, with women progressing through the phases sequentially. However, with today’s shorter hospitalizations for childbirth, women move through the phases more quickly and sometimes even experience more than one phase at a time. (See Phases of the postpartum period, page 426.)
Building relationships
The mother and her family undergo other changes as well. Ideally, these changes lead to the development of parental love for the neonate and positive relationships among all family members.
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Not all change is good
In some cases, negative psychological reactions may also occur. For example, a mother may feel let down because the neonate is now the center of attention or she may feel disappointed because the neonate doesn’t meet her preconceived expectations.
A mother may also feel overwhelming sadness for no discernible reason; these feelings are commonly termed postpartum blues or baby blues. A mother with postpartum blues may experience emotional lability, a let-down feeling, crying for no apparent reason, headache, insomnia, fatigue, restlessness, depression, and anger. These feelings most commonly peak around postpartum day 5 and subside by postpartum day 10. (See Battling the baby blues.)
First contact
Early contact and interaction between the parents, the neonate, and other siblings—including rooming in and sibling visitation— encourages bonding and helps integrate the neonate into the family.
Education edgeBattling the baby blues
For most women, having a baby is a joyous experience. However, childbirth leaves some women feeling sad, depressed, angry, anxious, and afraid. Commonly called postpartum blues or baby blues, these feelings affect about 70% to 80% of women after childbirth. In most cases, they occur within the first few days postpartum and then disappear on their own within several days.
Help is on the way
To help your patient with postpartum blues, tell her to:
get plenty of rest
ask for help from her family and friends
take special care of herself
spend time with her partner
call her practitioner if her mood doesn’t improve after a few weeks and she has trouble coping (this may be a sign of a more severe depression).
Be sure to explain to the patient that many new mothers feel sadness, fear, anger, and anxiety after having a baby. These feelings don’t mean that she’s a failure as a woman or as a mother. They indicate that she’s adjusting to the changes that follow birth.
Blues versus depression
Unfortunately, about 10% of women experience a more profound problem called postpartum depression. In these cases, maternal feelings of depression and despair last longer than a few weeks and are so intense that they interfere with the woman’s daily activities. Postpartum depression can occur after any pregnancy; it isn’t specifically associated with first pregnancies. It commonly requires counseling or medication to resolve.
Possible causes of postpartum depression include:
doubt about the pregnancy
recent stress, such as loss of a loved one, a family illness, or a recent move
lack of a support system
unplanned cesarean birth (may leave the woman feeling like a failure)
breast-feeding problems, especially if a new mother can’t breast-feed or decides to stop
sharp drop in estrogen and progesterone levels after childbirth, possibly triggering depression in the same way that much smaller changes in hormone levels can trigger mood swings and tension before menstrual periods
early birth of neonate (may cause woman to feel unprepared)
unresolved issues of not being able to be the “perfect” mother
feeling of failure if the mother believes that she should instinctively know how to care for her neonate
disappointment over sex of neonate or other characteristics (neonate isn’t as mother imagined). Signs and symptoms that may indicate that postpartum blues are actually postpartum depression include:
worsening insomnia
changes in appetite; poor intake
poor interaction with the neonate; views the neonate as a burden or problem
suicidal thoughts or thoughts of harming the neonate
feelings of isolation from social contacts and support systems
inability to care for self or neonate due to lack of energy or desire.
Women experiencing signs of postpartum depression should seek medical help as soon as possible. (See chapter 10 for more information on postpartum depression.)
Postpartum assessment
As with any assessment, a postpartum assessment consists of a patient history and a physical examination.
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Patient history
Your postpartum patient history should focus on the patient’s pregnancy, labor, and birth events. You should be able to find much of this information on the medical record. For example, the medical record should contain information about:
problems experienced, such as gestational hypertension or gestational diabetes
time of labor onset and admission to the birthing area
types of analgesia and anesthesia used
length of labor
time of delivery
time of placenta expulsion and appearance of the placenta
sex, weight, and status of the neonate.
You’ll need this information to plan the mother’s care and promote maternal-neonate bonding.
Another reliable source
Don’t rely on the medical record as your sole source of information. Always ask the mother to describe the events and fill in the details in her own words. This is also a good way to find out her emotions and feelings about pregnancy and childbirth.
Also ask the mother about her family and lifestyle, including support systems, other children, other people living in the home, her occupation, her community environment, and her socioeconomic level. This information can help you determine whether additional support, follow-up, or education about self-care and neonatal care are needed.
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Physical examination
In many cases, you won’t need to do a complete physical examination in the postpartum period because the mother already had a complete assessment early in the labor process. However, you should complete a review of systems, covering the following areas:
general appearance
skin
energy level, including level of activity and fatigue
pain, including location, severity, and aggravating factors, such as sitting and walking
gastrointestinal (GI) elimination, including bowel sounds, passage of flatus, and hemorrhoids
fluid intake
urinary elimination, including the time and amount of first voiding
peripheral circulation.
In addition, you’ll need to assess these four critical areas:
breasts
uterus
lochia
perineum
Memory joggerTo help you remember what to evaluate during a postpartum assessment think of the words BUBBLE HE: Breasts Uterus Bowel Bladder Lochia Episiotomy Homans sign Emotions
Breasts
Inspect and then palpate the breasts, noting size, shape, and color. At first, the breasts should feel soft and secrete a thin, yellow fluid called colostrum. However, as they fill with milk—usually around the third post-partum day—they should begin to feel firm and warm. Between feedings, the entire breast may be tender, hard, and tense on palpation. A low-grade temperature (under 101° F [38.3° C]) isn’t uncommon between days 2 and 5, but it shouldn’t last for more than 24 hours. (See Engorgement or something else? page 430.)
Land of nodule
A small, firm nodule in the breast may be caused by a temporarily blocked milk duct or milk that hasn’t flowed forward into the nipple. This problem generally corrects itself when the neonate breast-feeds. Be sure to reassess the breast after the neonate feeds to determine if the problem has resolved, and report your findings—including the location of the nodule—to the practitioner.
Inspect the nipples for cracks, fissures, or configuration. Cracks or breaks in the skin can provide an entry for organisms and lead to infection. Also look for other problems. Successful breast-feeding can be more challenging if the nipples are flat or inverted. A lactation consultant or a breast-feeding counselor may be helpful.
Uterus
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During your examination, palpate the uterine fundus to determine uterine size, degree of firmness, and rate of descent, which is measured in fingerbreadths
above or below the umbilicus. Unless the practitioner orders otherwise, perform fundal assessments every 15 minutes for the first hour after delivery, every 30 minutes for the next hour or two, every 4 hours for the rest of the first postpartum day, and then every shift until the patient is discharged. Fundal assessment will need to occur more frequently if complications are noted.
above or below the umbilicus. Unless the practitioner orders otherwise, perform fundal assessments every 15 minutes for the first hour after delivery, every 30 minutes for the next hour or two, every 4 hours for the rest of the first postpartum day, and then every shift until the patient is discharged. Fundal assessment will need to occur more frequently if complications are noted.
Education edgeEngorgement or something else?
Engorgement, which may result from venous and lymphatic stasis and alveolar milk accumulation, causes the entire breast to appear reddened and to feel warm, firm, and tender. The neonate will experience difficulty latching onto a severely engorged breast, which further complicates the situation. Encourage the woman to perform frequent and regular breast-feedings to help prevent this problem.
Something else
If the warmth, tenderness, and redness are localized to only one portion of the breast and the patient has a fever or flulike symptoms, suspect mastitis—inflammation of the glands or milk ducts.
Mastitis occurs postpartum in about 1% of mothers. It usually results from a pathogen that passes from the infant’s nose or pharynx into breast tissue through a cracked nipple. Teach the mother about mastitis, and warn her to call the practitioner immediately if she has any signs or symptoms.
Pain at the incision site makes fundal assessment especially uncomfortable for the patient who has had a cesarean birth. In such cases, provide pain medication beforehand as ordered.
Ready, set, palpate!
Before palpating the uterus, explain the procedure to the patient and provide privacy. Wash your hands and then put on gloves. Also, ask the patient to void. A full bladder makes the uterus boggier and deviates the fundus to the right of the umbilicus or + 1 or + 2 above the umbilicus. When the bladder is empty, the uterus should be at or close to the level of the umbilicus.
Next, lower the head of the bed until the patient is lying supine or with her head slightly elevated. Expose the abdomen for palpation and the perineum for inspection. Watch for bleeding, clots, and tissue expulsion while massaging the uterus.
Performing palpation
To palpate the uterine fundus, follow these steps:
While supporting the lower segment of the uterus with a hand placed just above the symphysis, gently palpate the fundus with your other hand to evaluate its firmness. (See Feeling the fundus.)
Note the level of the fundus above or below the umbilicus in centimeters or fingerbreadths.
If the uterus seems soft and boggy, gently massage the fundus with a circular motion until it becomes firm. Without digging into the abdomen, gently compress and release your fingers, always supporting the lower uterine segment with your other hand. Observe the vaginal drainage during massage.
Massage long enough to produce firmness but not discomfort. You may also encourage the patient to massage her fundus for 10 to 15 seconds every 15 minutes. This is usually necessary only for a few hours.
Notify the practitioner immediately if the uterus fails to contract and heavy bleeding occurs. If the fundus becomes firm after massage, keep one hand on the lower uterus and press gently toward the pubis to expel clots. (See Complications of fundal palpation.)
Advice from the expertsFeeling the fundus
A full-term pregnancy stretches the ligaments supporting the uterus, placing it at risk for inversion during palpation and massage. To guard against this, place one hand against the patient’s abdomen at the symphysis pubis level, as shown. This steadies the fundus and prevents downward displacement. Then place the other hand at the top of the fundus, cupping it, as shown.
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Education edgeComplications of fundal palpation
Because the uterus and its supporting ligaments are tender after birth, pain is the most common complication of fundal palpation and massage. Excessive massage can stimulate uterine contractions, causing undue muscle fatigue and leading to uterine atony or inversion. Lack of lochia may signal a clot blocking the cervical os. Heavy bleeding may result if a position change dislodges the clot. Take the patient’s vital signs frequently to assess for hypovolemic shock.
Remember the bladder
When assessing the uterine fundus, also assess for bladder distention. A distended bladder can impede the downward descent of the uterus by pushing it upward and, possibly, to the right side. If the bladder is distended and the patient is unable to urinate, you may need to catheterize her.
Lochia
After birth, the outermost layer of the uterus becomes necrotic and is expelled. This vaginal discharge—called
lochia—is similar to menstrual flow and consists of blood, fragments of the decidua, white blood cells (WBCs), mucus, and some bacteria.
lochia—is similar to menstrual flow and consists of blood, fragments of the decidua, white blood cells (WBCs), mucus, and some bacteria.
Three types of lochia
Lochia color, which typically changes throughout the postpartum period, may be categorized as:
lochia rubra—red vaginal discharge that occurs from approximately day 1 to day 3 postpartum
lochia serosa— pinkish or brownish discharge that occurs from approximately day 4 to day 10 postpartum
lochia alba—creamy white or colorless vaginal discharge that occurs from approximately day 10 to day 14 postpartum (although it may continue for up to 6 weeks).
Assessing lochia flow
Lochia is commonly assessed in conjunction with fundal assessment. (See Three types of lochia.)
Help the patient into the lateral Sims position. Be sure to check under the patient’s buttocks to make sure that blood isn’t pooling there. Then, remove the patient’s perineal pad and evaluate the character, amount, color, odor, and consistency (presence of clots) of the discharge. Before removing the perineal pad, make sure that it isn’t sticking to any perineal stitches. Otherwise, tearing may occur, possibly increasing the risk of bleeding.
On the lookout
Here’s what to look for when assessing lochia:
Amount— Although it varies, the amount of lochia is typically comparable to the amount during menstrual flow. A woman who’s breast-feeding may have less lochia. Also, a woman who has had a cesarean birth may have a scant amount of lochia; however, lochia shouldn’t be absent. Lochia should be present for at least 3 weeks postpartum. Lochia flow increases with activity; for example, when the patient gets out of bed the first several times (due to pooled lochia being released) or when she lifts a heavy object or walks up stairs (due to an actual increase in the amount of lochia). If your patient saturates a perineal pad in less than an hour, this is considered excessive flow, and you should notify the practitioner.
Color— Lochia typically is described as lochia rubra, serosa, or alba, depending on the color of the discharge. Lochia color depends on the postpartum day. A sudden change in color— for example, from pink back to red—suggests new bleeding or retained placental fragments.
Odor— Lochia should smell similar to menstrual flow. A foul or offensive odor suggests infection.
Consistency— Lochia should have minimal or small clots, if any. Evidence of large or numerous clots indicates poor uterine contraction and requires further assessment.
Perineum and rectum
The pressure exerted on the perineum and rectum during birth results in edema and generalized tenderness. Some areas of the
perineum may be ecchymotic, caused by the rupture of surface capillaries. Sutures from an episiotomy or laceration may also be present. Hemorrhoids are also commonly seen.
perineum may be ecchymotic, caused by the rupture of surface capillaries. Sutures from an episiotomy or laceration may also be present. Hemorrhoids are also commonly seen.
What’s your position?
Assessment of the perineum and rectum mainly involves inspection and is performed at the same time that you assess the lochia. Help the patient into the lateral Sims position. This position provides better visibility and causes less discomfort for the patient with a mediolateral episiotomy. A back-lying position can also be used for patients with midline episiotomies. Make sure you have adequate light for inspection.
Checking down under
Memory joggerTo help you remember what to look for when assessing an episiotomy site or a laceration, think REEDA:
Redness
Erythema and Ecchymosis
Edema
Drainage or Discharge
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