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Care of the PostpartumCare of the PostpartumClientClient

Romamea MagdayaoRomamea Magdayao

Ana Marie LopezAna Marie Lopez

Rowena Jenniesa LabordoRowena Jenniesa Labordo

Hanna Mae MagtolesHanna Mae Magtoles

BSN2BSN2--CC

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Postpartum Physical AdaptationsPostpartum Physical Adaptations(pg. 906(pg. 906--929)929)

Uterine InvolutionUterine Involution Fundal positionFundal position

changes: Boggychanges: Boggy Lochia: Rubra, Serosa,Lochia: Rubra, Serosa,

AlbaAlba Cervical changesCervical changes Vaginal changesVaginal changes Perineal changesPerineal changes Recurrence ofRecurrence of

ovulation andovulation andmenustrationmenustration

LactationLactation

GastrointestinalGastrointestinalSystemSystem

Urinary tractUrinary tract

Vital signsVital signs

Weight lossWeight loss

Postpartum chillPostpartum chill

Postpartal diaphoresisPostpartal diaphoresis

Afterpains or AfterbirthAfterpains or Afterbirthpainspains

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Uterine InvolutionUterine Involution

The rapid reduction in size ofThe rapid reduction in size ofthe uterus and its return to athe uterus and its return to acondition similar to its precondition similar to its pre--pregnancy state.pregnancy state.

The uterus remains slightlyThe uterus remains slightlylarger than it was before thelarger than it was before thefirst pregnancy.first pregnancy.

Process is complete at 3 weeksProcess is complete at 3 weeks

except at the placental site (6except at the placental site (6to 7 weeks)to 7 weeks)

SubinvolutionSubinvolution may be causedmay be causedby an infection or retainedby an infection or retained

placenta fragments.placenta fragments.

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WEIGHT OF THE UTERUSWEIGHT OF THE UTERUS

Right after delivery: 1000Right after delivery: 1000gramsgrams

1 week after1 week after :500:500gramsgrams

2 weeks after2 weeks after : 300 grams: 300 grams

6 weeks after6 weeks after : 50: 50 6060

gramsgrams

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Fundal Position ChangesFundal Position Changes

After birth :After birth :

1st day: one fingerbreadth below1st day: one fingerbreadth below

umbilicusumbilicus 2nd day: two fingerbreadths below2nd day: two fingerbreadths below

umbilicusumbilicus

9th to 10th day: cannot be palpated9th to 10th day: cannot be palpated

abdominallyThe first postpartum day it isabdominallyThe first postpartum day it islocated 1 cm or fingerbreadth below thelocated 1 cm or fingerbreadth below theumbilicus.umbilicus.

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Fundal Position ChangesFundal Position Changes

May be displaced to the left or rightMay be displaced to the left or rightby a distended bladder.by a distended bladder.

Becomes boggy with uterine atonyBecomes boggy with uterine atony

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Boggy Uterus Boggy Uterus

Massage the uterusMassage the uterus

Place infant on mothers breastPlace infant on mothers breast

Administer oxytocinAdminister oxytocin Check BPCheck BP

Do not give if BP > 140/90Do not give if BP > 140/90

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UTERINE CONTRACTIONSUTERINE CONTRACTIONS

Prevent bleedingPrevent bleeding

AfterpainsAfterpains uncomfortable crampsuncomfortable cramps

Common in multiparaCommon in multipara Oxytocin treatedOxytocin treated

Breastfeeding mothersBreastfeeding mothers

22 3 days3 days

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NURSING MEASURESNURSING MEASURES

Explain the cause and purpose ofExplain the cause and purpose ofafterpainsafterpains

Keep bladder emptyKeep bladder empty Prone position to lessen discomfortProne position to lessen discomfort

Gentle massageGentle massage

Administer analgesicsAdminister analgesics

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VAGINAL DISCHARGEVAGINAL DISCHARGE

LOCHIALOCHIA

Uterine discharge after deliveryUterine discharge after delivery

Blood, mucus, epithelial cells, leukocytesBlood, mucus, epithelial cells, leukocytesand bacteriaand bacteria

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COLOR AND PATTERNCOLOR AND PATTERN

Rubra:Rubra: dark red in colordark red in color

present the first 2present the first 2--3 days3 dayspostpartumpostpartum

few small clotsfew small clots Serosa:Serosa:

pinkish to brownishpinkish to brownish

44thth to the 10th dayto the 10th day

Alba:Alba: creamy or yellowishcreamy or yellowish

persists for a week or two afterpersists for a week or two after

serosa, may be later inserosa, may be later in

breastfeeding clients.breastfeeding clients.

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SIGNS OF ABNORMAL LOCHIASIGNS OF ABNORMAL LOCHIA

SIGNSSIGNS POSSIBLE CAUSEPOSSIBLE CAUSE

FOUL SMELLFOUL SMELL INFECTIONINFECTION

LARGE CLOTSLARGE CLOTS RETAINED FRAGMENTSRETAINED FRAGMENTS

EXCESSIVEEXCESSIVEAMOUNTAMOUNT

LACERATION OF BIRTHLACERATION OF BIRTHCANALCANAL

RETURN TORETURN TO

RUBRIA AFTERRUBRIA AFTERSEROSA OR ALBASEROSA OR ALBA

RETAINED FRAGMENTSRETAINED FRAGMENTS

INFECTIONINFECTION

BLEEDING AFTERBLEEDING AFTER

6 WEEKS6 WEEKS

SUBINVOLUTION OFSUBINVOLUTION OF

THE UTERUSTHE UTERUS

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CERVICAL CHANGESCERVICAL CHANGES

Spongy, flabby, formless andSpongy, flabby, formless andbruised.bruised.

Original form is regained in a fewOriginal form is regained in a fewhourshours

The shape is permanently changed byThe shape is permanently changed bythe first childbearing.the first childbearing.

Goes from dimple like to a lateral slitGoes from dimple like to a lateral slit(fish mouth)(fish mouth)

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VAGINAL CHANGESVAGINAL CHANGES

Edematous and bruisedEdematous and bruised

Small superficial lacerations may beSmall superficial lacerations may be

presentpresent Laceration and episiotomy heals afterLaceration and episiotomy heals after

2 weeks2 weeks

Size and rugae return to preSize and rugae return to prepregnancy in 3 weekspregnancy in 3 weeks

By 6 weeks appears normalBy 6 weeks appears normal

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PERINEAL CHANGESPERINEAL CHANGES

edematous with some bruisingedematous with some bruising

Episiotomy edges should beEpisiotomy edges should be

approximatedapproximated Ecchymosis may occur and delayEcchymosis may occur and delay

healinghealing

Suture: 7 to 10 daysSuture: 7 to 10 days Perineal muscle tone regained : 6Perineal muscle tone regained : 6thth

weeksweeks

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PERINEAL CAREPERINEAL CARE

Flush with warm waterFlush with warm water

Pat dry from front to backPat dry from front to back

Change pad frequentlyChange pad frequently

Observe signs of infectionObserve signs of infection

Reduce hemorrhoidsReduce hemorrhoids

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PERINEAL CAREPERINEAL CARE

ICE PACKSICE PACKS

SITZ BATHSITZ BATH

PROMOTE CIRCULATIONPROMOTE CIRCULATION 20 MINUTES20 MINUTES

PERINEAL LAMPPERINEAL LAMP Promote vasodilationPromote vasodilation

25 to 40 watts light25 to 40 watts light 1212 --18 inches away18 inches away

20 minutes 3x a day20 minutes 3x a day

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Recurrence of Ovulation andRecurrence of Ovulation andMenustrationMenustration

VariableVariable

Generally returns to nonGenerally returns to non--nursing mothersnursing mothersbetween 7 and 9 weeks after birthbetween 7 and 9 weeks after birth

The first cycle is nonThe first cycle is non--ovulatoryovulatory

Breastfeeding clients may experienceBreastfeeding clients may experiencemenstruation and ovulation based on themenstruation and ovulation based on the

amount of time nursingmay occur fromamount of time nursingmay occur from2nd to 18th month2nd to 18th month

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LACTATIONLACTATION

During pregnancy, the breastsDuring pregnancy, the breastsdevelop in preparation for lactation asdevelop in preparation for lactation as

a result of both estrogen anda result of both estrogen andprogesterone. After birth, theprogesterone. After birth, theinterplay of maternal hormones leadsinterplay of maternal hormones leadsto the establishment of milkto the establishment of milk

production.production.

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GASTROINTESTINALGASTROINTESTINAL

May have a regular dietMay have a regular diet High in protein, iron and vitaminsHigh in protein, iron and vitamins

Bowels tend to be sluggishBowels tend to be sluggish Episiotomy clients may delay bowelEpisiotomy clients may delay bowel

movement for fear of painmovement for fear of pain

Cesarean birth clients may receiveCesarean birth clients may receive

clear liquids and progress to a regularclear liquids and progress to a regulardietdiet

Stool softeners may be usedStool softeners may be used

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URINARY TRACTURINARY TRACT

increased bladder capacity, swelling and bruising ofincreased bladder capacity, swelling and bruising oftissue, decreased sensitivity to fluid pressure, andtissue, decreased sensitivity to fluid pressure, anddecreased sensation of bladder filling.decreased sensation of bladder filling.

At risk for overAt risk for over--distention, incomplete emptying, anddistention, incomplete emptying, and

buildup of residual urine.buildup of residual urine. Urinary output increases 1rst 24 hours post deliveryUrinary output increases 1rst 24 hours post delivery

((puerperal diuresispuerperal diuresis))

Urine specimens should be obtained as a catheterizedUrine specimens should be obtained as a catheterizedspecimen.specimen.

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CARDIOVACULARCARDIOVACULAR

Blood loss: NSD: 300 to 500 ml CS: 500 to 1000Blood loss: NSD: 300 to 500 ml CS: 500 to 1000mlml reduction in blood volumereduction in blood volume

40% increase of maternal blood volume after40% increase of maternal blood volume after

delivery of the placentadelivery of the placenta Return of cardiac output to pregnant state takesReturn of cardiac output to pregnant state takes

about 2about 2-- 3 weeks from delivery3 weeks from delivery

Hemoconcentration in the first 3 to 7 daysHemoconcentration in the first 3 to 7 days

Leukocytosis in the first 12 daysLeukocytosis in the first 12 days

Elevated fibrinogen levels up to the third weeksElevated fibrinogen levels up to the third weeks Physiologic bradycardia during the first 24 hoursPhysiologic bradycardia during the first 24 hours

Orthostatic hypotension in the first 24 hoursOrthostatic hypotension in the first 24 hours

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INTEGUMENTARYINTEGUMENTARY

Disappearance of skin changes (6Disappearance of skin changes (6weeks) except for striae and diastisisweeks) except for striae and diastisisrectirecti

Areolar hyperpigmentation may notAreolar hyperpigmentation may notdisappear completelydisappear completely

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Vital SignsVital Signs

afebrile after the first 24 hours.afebrile after the first 24 hours.

BP WNL,BP WNL, a decrease may occura decrease may occur. An. An

BP may indicate toxemia, PIH.BP may indicate toxemia, PIH. Pulse rate may decrease to 50Pulse rate may decrease to 50--70.70.

Tachycardia should alert the nurse toTachycardia should alert the nurse toblood loss/difficult birthblood loss/difficult birth..

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Blood ValuesBlood Values

Blood values should return to theBlood values should return to theprepregnant state by the end of theprepregnant state by the end of thepostpartum period.postpartum period.

Leukocytosis with white blood cell (WBC)Leukocytosis with white blood cell (WBC)counts up to 30,000 per mL may occurcounts up to 30,000 per mL may occurearly postpartum.early postpartum.

Convenient rule of thumb is a 2 point dropConvenient rule of thumb is a 2 point drop

in hematocrit equals a blood loss of 500in hematocrit equals a blood loss of 500mL.mL.

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Weight LossWeight Loss

An initial weight loss of 10 to 12 lbsAn initial weight loss of 10 to 12 lbsoccurs as a result of the birth of theoccurs as a result of the birth of the

infant, placenta and amniotic fluid.infant, placenta and amniotic fluid. Puerperal diuresis accounts for loss ofPuerperal diuresis accounts for loss of

an additional 5 lbs during the earlyan additional 5 lbs during the earlypostpartum period.postpartum period.

Normally return to preNormally return to pre--pregnantpregnantweight by 6 weeks postpartum.weight by 6 weeks postpartum.

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Postpartum Chill andPostpartum Chill andPostpartal DiaphoresisPostpartal Diaphoresis

Most clients experience a shaking chill orMost clients experience a shaking chill ortremor after delivery.tremor after delivery.

Warm blankets usually relieve this tremor orWarm blankets usually relieve this tremor or

chill.chill.

Chills and fever late in the postpartumChills and fever late in the postpartumperiod may indicate sepsis.period may indicate sepsis.

Diaphoretic episodes may occur at night, aDiaphoretic episodes may occur at night, a

normal occurrence as the body rids itself ofnormal occurrence as the body rids itself ofwaste products.waste products.

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AMBULATIONAMBULATION

NSD : 4NSD : 4 8 hours8 hours

ANESTHESIA : 8 hoursANESTHESIA : 8 hours

ADVANTAGES:ADVANTAGES: Prevent constipationPrevent constipation

Prevent circulatory problems, urinaryPrevent circulatory problems, urinaryproblemsproblems

Promote recoveryPromote recovery

Hasten drainage of lochiaHasten drainage of lochia

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EXERCISEEXERCISE

PurposePurpose

Prevent complicationsPrevent complications

Psychological well beingPsychological well being

Strengthen muscles of back, pelvic floorStrengthen muscles of back, pelvic floorand abdomenand abdomen

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EXERCISEEXERCISE

POSTPARTUM EXERCISEPOSTPARTUM EXERCISE

Abdominal breathingAbdominal breathing

Kegel exercise: tighten perineal muscleKegel exercise: tighten perineal muscle

Arm RaisingArm Raising

Leg RaisingLeg Raising

SitSit--upsups

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REST AND SLEEPREST AND SLEEP

At least 8 hoursAt least 8 hours

Avoid heavy liftingAvoid heavy lifting

Light housekeeping: 2 weeksLight housekeeping: 2 weeks Normal activities: 4Normal activities: 4 6 weeks6 weeks

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RESUMPTION OF SEXRESUMPTION OF SEX

VAGINAL DELIVERY: 3VAGINAL DELIVERY: 3 4 WEEKS4 WEEKS

CS: 2 WEEKSCS: 2 WEEKS

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DischargeDischarge

Primiparas : 2 to 3 daysPrimiparas : 2 to 3 days Multipara: 1Multipara: 1to 2 daysto 2 days CS: 3 to 4 daysCS: 3 to 4 days

Discharge IE is done before leavingDischarge IE is done before leaving

Follow up: 4 to 6 weeks after deliveryFollow up: 4 to 6 weeks after delivery

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PostpartumPostpartumPsychologicalPsychological

AdaptationsAdaptations

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Postpartum PsychologicalPostpartum PsychologicalAdaptationsAdaptations

Postpartum bluesPostpartum blues

Development of ParentDevelopment of Parent--InfantInfant

attachmentattachment Initial attachment BehaviorInitial attachment Behavior

FatherFather--Infant InteractionsInfant Interactions

Cultural InfluencesCultural Influences

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RUBINS POSTPARTUM PHASERUBINS POSTPARTUM PHASE

TAKINGTAKING--IN PHASEIN PHASE

11stst 22-- 3 days postpartum3 days postpartum

Need for sleep and restNeed for sleep and rest

Dependence on otherDependence on other

TAKINGTAKING--HOLD PHASEHOLD PHASE

Transition phaseTransition phase

33rdrd day to 2 weeks postpartumday to 2 weeks postpartum

Control body functionControl body function

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TAKINGTAKING--HOLD PHASEHOLD PHASE

Ability to assume the mother roleAbility to assume the mother role

LETTINGLETTING--GO PHASEGO PHASE Realize that the infant is a separateRealize that the infant is a separate

individual and not a part of herselfindividual and not a part of herself

Feeling of lossFeeling of loss

Adjustment phaseAdjustment phase

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Transient period of depression : 1Transient period of depression : 1 -- 22weeks after birth.weeks after birth.

Manifested by mood swings, anger,Manifested by mood swings, anger,weepiness, anorexia, difficultyweepiness, anorexia, difficultysleeping, and a feeling of letdown.sleeping, and a feeling of letdown.

CAUSE: Hormonal changes andCAUSE: Hormonal changes and

psychological adjustmentspsychological adjustments

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Resolve naturally in 2 to 3Resolve naturally in 2 to 3weeks with support andweeks with support and

reassurance.reassurance.

If symptoms persist, theIf symptoms persist, the

client should be evaluatedclient should be evaluatedfor postpartum depression.for postpartum depression.

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Development of ParentDevelopment of Parent--InfantInfantattachmentattachment

Level of trustLevel of trust

Level of selfLevel of self--esteemesteem

Capacity for enjoying herselfCapacity for enjoying herself

Interest in and adequacy of knowledgeInterest in and adequacy of knowledgeabout childbearing and childrearingabout childbearing and childrearing

Clients prevailing mood or usual feelingClients prevailing mood or usual feeling

tonetone Reactions to the present pregnancyReactions to the present pregnancy

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Initial attachment BehaviorInitial attachment Behavior Progression of touching activitiesProgression of touching activities

En face position dominatesEn face position dominates

Relies heavily on senses of sight,Relies heavily on senses of sight,touch, hearing in getting to knowtouch, hearing in getting to knowthe babythe baby

Some negative feelings maySome negative feelings mayoccur; be understanding notoccur; be understanding notcondescendingcondescending

Reciprocity is an interactionalReciprocity is an interactional

cycle that occurs simultaneouslycycle that occurs simultaneouslybetween mother and infant.between mother and infant.(mutual cueing behaviors,(mutual cueing behaviors,expectancy, delight in each othersexpectancy, delight in each otherscompany when synchronous)company when synchronous)

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FatherFather--Infant InteractionsInfant Interactions

Primary role has been supportingPrimary role has been supportingrolerole

Engrossment (the characteristicEngrossment (the characteristicsense of absorption,sense of absorption,preoccupation, and interest inpreoccupation, and interest in

the infant demonstrated bythe infant demonstrated byfathers during early contact withfathers during early contact withthe newborn.the newborn.

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Cultural InfluencesCultural Influences

Postpartum care my be affected byPostpartum care my be affected bycultural beliefs: No shower, nocultural beliefs: No shower, nobreastfeeding for the first three days,breastfeeding for the first three days,

hot and cold foodshot and cold foods

Do not make generalizationsDo not make generalizations

Extended family may play anExtended family may play an

important role in careimportant role in care

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Postpartum AssessmentPostpartum Assessment

Vital signs: BP should remainVital signs: BP should remainconsistent with baseline BPconsistent with baseline BPduring pregnancy. Pulse 50during pregnancy. Pulse 50 --90,90,respirations 16respirations 16--24, temp 9824, temp 98--100.4100.4

Breasts: Smooth, evenBreasts: Smooth, evenpigmentation, soft, filling, full,pigmentation, soft, filling, full,engorgedengorged

Abdomen: soft, fundus firm,Abdomen: soft, fundus firm,

midline and at/or belowmidline and at/or belowumbilicus, may be tender onumbilicus, may be tender onpalpationpalpation

Lochia: rubra, scant toLochia: rubra, scant to

moderate, no clots, rubra tomoderate, no clots, rubra to

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Postpartum AssessmentPostpartum Assessment Perineum: Slight edema, noPerineum: Slight edema, no

bruising, episiotomy withoutbruising, episiotomy withoutredness, swelling or drainage,redness, swelling or drainage,hemorrhoids (none or small)hemorrhoids (none or small)

Lower extremities: No pain withLower extremities: No pain with

palpation, negative Homans signpalpation, negative Homans sign Elimination: voiding 4Elimination: voiding 4--6 hrs, no6 hrs, no

bladder distention noted, normalbladder distention noted, normalbowel movement by the 2bowel movement by the 2ndnd to 3to 3rdrd

day post deliveryday post delivery

Psychological adaptation: culturalPsychological adaptation: culturalassessment, bonding, holding enassessment, bonding, holding enface, attachment behaviorsface, attachment behaviors

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Postpartum AssessmentPostpartum Assessment

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Dysfunctions of the PostpartumDysfunctions of the PostpartumPeriodPeriod

Postpartal Uterine Infection: Endometritis, PelvicPostpartal Uterine Infection: Endometritis, PelvicCellulitisCellulitis

Perineal Wound InfectionPerineal Wound Infection

Cesarean Wound InfectionCesarean Wound Infection

Urinary Tract Infection (UTI)Urinary Tract Infection (UTI)

MastitisMastitis

Thromboembolitic Disease: Superficial Leg VeinThromboembolitic Disease: Superficial Leg VeinDisease, Deep Vein Thrombosis, Septic PelvicDisease, Deep Vein Thrombosis, Septic PelvicThrombophlebitisThrombophlebitis

Postpartum Psychiatric Disorder: baby blues,Postpartum Psychiatric Disorder: baby blues,Postpartum Psychosis, Postpartum Major MoodPostpartum Psychosis, Postpartum Major MoodDisorderDisorder

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Two methods of milk suppressionTwo methods of milk suppression

a. mechanical (tight bras, avoidinga. mechanical (tight bras, avoiding

nipple stimulation, ice packs)nipple stimulation, ice packs)b. pharmacologic (bromocriptine)b. pharmacologic (bromocriptine)

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44429761 Postpartum