Postpartum Care
Postpartum refers to the first 6 weeks following delivery, the time during which the woman’s reproductive organs return to their normal, nonpregnant state. The general care of the postpartum client is similar to that of other clients. Observe the woman’s overall state, appetite, activity, patterns of sleep and rest, and interactions with her newborn. Note the client’s vital signs. Postpartum women are usually discharged from the hospital within a day or two. Client teaching on all aspects of postpartum care and documentation of this teaching are vital. The new mother must know what to expect as her body undergoes the rapid changes of the postpartum period and when to call her practitioner for assistance.
Important Changes in Maternal Anatomy and Physiology
The process by which the reproductive organs return to their nonpregnant state is called involution. To provide competent and safe nursing care to the postpartum client, you must understand the physiologic changes that occur following childbirth.
Uterus. Immediately after delivery, the uterus weighs approximately 2 pounds (900 g) and is about the size of a grapefruit. It can be felt at the level of, or slightly below, the umbilicus. After delivery, it begins to return to its normal position and smaller size. When this process is complete, the uterus will weigh about 2 ounces (50 g) and will be low, at or near the center of the pelvic cavity.
During the postpartum period, the uterus should be positioned midline and feel firm to the touch. The height of the fundus indicates the progress of involution. By palpating the abdomen, the fundus can be located; measure its height in finger widths above or below the umbilicus. Normal involution is occurring when the fundus descends one finger width each day. Record the fundal height as indicated in Box 66-4.
Abnormal findings include the following:
• If the uterus is deviated to the side, suspect a distended bladder. Increased bladder size will prevent the uterus from contracting, and will contribute to excessive bleeding. The uterus should contract after the client voids.
• A soft or boggy uterus indicates relaxation of the uterine muscles and is also a danger sign.
Lochia. Normally the flow of lochia continues for 3 to 4 weeks, with the following gradual changes:
Lochia rubra is seen for the first 2 days. It is mostly red and bloody. It should smell like blood (slightly metallic); a foul odor indicates infection.
Lochia serosa starts after the bleeding diminishes. The color of the lochia changes to pink or brown-tinged for approximately the next 7 days. Lochia serosa has a slightly earthy odor.
Lochia alba, which is yellow or white, starts on about day 10. At this point, the lochia has decreased greatly in amount. Lochia alba also has an earthy smell.
The amount of lochia after delivery should be about the same as the blood flow during normal menstruation. Abnormal findings include:
• Large clots
• Foul odor
• Lochia that does not change color and characteristics as described
Record the amount, color, and any other characteristics that may be significant. Teach the client to report abnormal lochia.
Cervix and Vagina. The cervix is soft and edematous following delivery. It constricts and firms during the postpartum period. The vagina, too, regains muscle tone, and lacerations and episiotomies heal. The vagina and vulva lose their congested, purplish color and return to their prepregnant pinkish hue.
You will not be able to assess cervical and vaginal changes; doing so requires a sterile pelvic examination.
Episiotomy and Perineum. The client should turn on her side to facilitate a better view of the perineal area. If the client has had an episiotomy or lacerations, examine the area carefully to determine the healing process.
Make certain the perineum is intact. You may need a flashlight; the mother will need a mirror. The episiotomy and any lacerations should appear clean, with very slight edema. The sutures should not be pulling against the tissue. Note any hemorrhoids to initiate measures to alleviate them. Abnormal findings include:
• Inflammation, redness, and discharge from the episiotomy or lacerations
• Hematomas, ecchymosis, and edema
If the client is unable to ambulate, administer perineal care. Apply a fresh perineal pad, usually to the panties, and pull the panties straight up. If using tabbed pads, attach the front first.
Abdominal Wall and Weight Loss. The woman’s abdominal wall often remains soft and flabby for several weeks following childbirth, because of the extensive stretching of the tissue and loss of muscle tone. By approximately 6 weeks after delivery, the woman should regain muscle tone. The new mother can begin an exercise program gradually as the birth attendant recommends. The length of time it takes for a client to regain her figure depends on the amount of weight she gained during the pregnancy, the amount of weight she lost during the delivery, the amount of exercise she has after delivery, her diet and eating patterns, and whether or not she is breastfeeding. Body weight decreases by approximately 12 to 15 pounds (5,440 to 6,800 g) at delivery and by about 5 pounds (2,270 g) during the next few days due to loss of excess body fluid.
Breasts. Changes in the breasts following childbirth prepare for the newborn’s nourishment. During the last half of pregnancy and the first few days postpartum, the breasts produce colostrum, a thin yellowish secretion that provides vitamins and immune substances that protect the newborn against infection. On about the second or third day postpartum, the breasts begin to secrete milk.
Each time a newborn is put to a breast, milk is secreted. Lactation, the production of milk, occurs because of the release of two hormones: prolactin and oxytocin. As the newborn sucks the nipple, a reflex reaction occurs whereby the posterior pituitary gland releases oxytocin, which stimulates cells to produce milk and to move it to the milk ducts. The oxytocic hormone also results in uterine contractions, and mothers often experience abdominal cramping while breastfeeding. This entire process is commonly known as the “letdown reflex”; the milk is said to “let down” or “come in.” Because the risks outweigh the benefits, medications to suppress lactation are rarely given to nonbreastfeeding mothers.
For the first few days, the breasts should be soft. The nipples should be intact, without drying, cracking, or fissures. When the milk comes in, the breasts will feel full and firm to touch. Abnormal breast findings are listed below:
• Engorgement is the response of the breasts to the presence of an increased volume of milk and a sudden change in hormones. It usually occurs on the third to fifth postpartum day. The breasts become tender, swollen, hot, and hard. The swelling may extend into the axilla. The breasts may look shiny and red. The woman may experience a headache, breast discomfort, and a slight temperature elevation at this time (see In Practice: Educating the Client 66-2).
IN PRACTICE :EDUCATING THE CLIENT 66-2
ENGORGEMENT
The following measures help to relieve the nursing mother’s engorgement:
♦ Wearing a supportive bra
♦ Frequent breastfeeding
♦ Applying warm packs to the breast for 15 minutes before nursing or standing in the shower with warm water spraying on the breast for 15 minutes before nursing.
The following measures can help to relieve the nonnursing mother’s engorgement:
♦ Wearing a supportive bra
♦ Avoiding excessive fluid intake
♦ Placing cold packs on her breasts three to four times per day
♦ Avoiding stimulation (e.g., hot shower spray)
♦ Avoiding manual expression or pumping her breasts
♦ Using medications (usually acetaminophen) as prescribed for discomfort
Bladder. Pregnancy and labor place added strains on a woman’s urinary system. The abdominal muscles may be weakened. In addition, bruising and swelling of the urethra and general loss of muscle tone are common. The involution process places an increased demand on the kidneys and bladder, as the mother’s fluid balance is restored. Because of these factors, new mothers may have stress incontinence or difficulty voiding.
Palpate the bladder for a rounded bulge in the suprapubic region, which indicates distention. By questioning the client regarding voiding, you can gain information related to urinary symptoms.
Abnormal urinary system findings include:
• Voiding in small amounts
• Residual urine
• Dysuria
• Bladder infection
• Urinary retention
Gastrointestinal System. The mother may be constipated for 1 to 2 weeks following delivery because the abdominal muscles have been stretched, and the intestines have been inactive.
Whether or not the mother had hemorrhoids during pregnancy, she may have problems with them after the birth.
Extremities. To check for thrombophlebitis, the client’s legs should be exposed. Ask the client to straighten her legs on the surface of the bed and to flex her feet toward her face. Abnormal findings in the legs include:
• Redness, pain, and swelling along the path of a vein may indicate a superficial thrombophlebitis.
• Pain behind the knee on flexion of the feet indicates a positive Homans’ sign and suggests thrombophlebitis.
Observation and Data Gathering
To prepare the client for the postpartum assessment, ask her to empty her bladder and then lie flat in bed. Always follow Standard Precautions when contact with body secretions is possible. Teach the woman to check herself frequently.
Measure and record the client’s vital signs (see In Practice: Nursing Care Guidelines 66-1). Ask her about any problems she may be having with her breasts, bleeding (lochia), sutures, cramping, constipation, or hemorrhoids.
Begin the postpartum observation with the fundus. Palpate the fundus. If it is boggy, perform fundal massage to encourage muscle contraction of the uterus and reduce blood loss (see In Practice: Nursing Procedure 66-2). If the boggy uterus does not become firm with massage or if large clots are expressed with fundal massage, notify the team leader.
Nursing Alert Never massage a contracted fundus. Rationale: Massage of an already contracted uterus may cause it to invert, which can present an emergency situation. Observe the amount, color and odor of the lochia.
For the first few days after delivery, the mother may have painful cramps as the uterine muscles contract. These cramps are called after-pains and are more likely to occur in multigravidas. Breastfeeding stimulates uterine contractions and therefore often brings on the cramping. An analgesic may be ordered as needed for these pains. Heat application is sometimes helpful.
IN PRACTICE :NURSING CARE GUIDELINES 66-1
POSTPARTUM PERIOD
Immediate Postpartum Care
• Check blood pressure (BP) and pulse every 15 minutes X 1-2 hours or until stable; then every 30 minutes X 1 hour; then every 4 hours X 12 hours or as ordered.
• Check uterine fundus, lochia, and episiotomy at the same time as BP and pulse.
• Check for any signs of hemorrhage (check the perineal pad, and be alert to the possible pooling of blood under the client).
• Monitor for urinary distention and document first voiding for quantity of urine. Ask the mother if she had any difficulty voiding because urinary retention is not uncommon. Swelling of the urethra and around the perineal area can inhibit the patency of the urinary meatus. If voiding has not occurred in 6-8 hours, or if she voids in small, frequent amounts (< 100 mL), notify the healthcare provider
• Monitor interactions with infant. If signs of bonding are not present, determine cause (e.g., pain, complications, exhaustion) and address these issues. Psychological and emotional issues that interfere with normal bonding need to be addressed as soon as possible.
General Postpartum Care
• After the first 12 hours, check vital signs every 4 hours X 12 hours and then every 8 hours.
• Check breasts, fundus, lochia, stitches (if present), and legs (for signs of thrombosis) at least once every shift. (Memory aid: BUB-BLLEEE—breast, uterus, bladder, bowels, legs, lochia, episiotomy emotions, education.)
In the Breastfeeding Mother
• Observe that the breasts begin to produce milk by the third or fourth day
• Monitor that the breasts are not engorged
In the Nonnursing Mother
• Observe that breast engorgement does not last more than 2 or 3 days.
• Check that the fundus remains firm and contracted and moves downward. If the fundus is soft and spongy cup a hand around the fundus, and massage it gently until it becomes firm and contracted.
• Monitor elimination patterns (urinary and bowel) until they return to the normal, prepregnant state. Check that mother demonstrates correct perineal care.
• Evaluate for thrombophlebitis in the legs. Check for presence of a positive Homans’ sign.
• Observe that lochia progresses on schedule from lochia rubra to lochia alba.
• Monitor incision (episiotomy or cesarean incision, if present) for healing.
• Evaluate quality of maternal/newborn bonding and family dynamics.
• Educate mother, family and significant others so they know what to expect after discharge.
Observe the episiotomy or lacerations for healing. Provide perineal care; change the sanitary pad. While tucking it in at the back, ask the woman to roll onto her left side. Lift the right buttock and examine the anus for hemorrhoids. Ice packs, witch-hazel pads (Tucks), suppositories, creams, ointments, or sitz baths may be necessary for hemorrhoids.
Wash your hands, and then examine the breasts. Observe the breasts for tightness and redness, and palpate for fullness and temperature. Observe the nipples for drying, cracking, or fissures. Teach the mother to examine the nipples to determine that they are in good condition and to observe them for cracking, caking, dryness, or bleeding. If the mother is breastfeeding, observe whether her nipples protrude sufficiently for adequate nursing. She can palpate the breasts gently to determine if they are soft, firm, or engorged.
Engorgement in the nursing mother generally subsides within 48 hours if the mother feeds her infant from both breasts every 2 to 3 hours, alternating the breast that she uses first on each feeding. Engorgement in the nonnursing mother is treated with breast binders and ice packs.
Constipation is a common problem for new mothers. Diet, adequate fluids, and activity help to regulate this condition. Many birth attendants routinely order stool softeners, such as docusate sodium (Colace) (In Practice: Important Medications 66-3), or mild laxatives until good bowel function is re-established. The woman may need a suppository or small enema if a laxative is ineffective.
Nursing Alert The new mother should never take an enema without a specific physician’s order An enema could cause the rupture of episiotomy sutures and could be the source of incisional infection.
Client Teaching
Client teaching begins early (at the time of admission) because mothers are often discharged a short time after delivering. The mother receives instruction in these aspects of self-care:
• Breast care and nursing
• Perineal care and care of the stitches
• Fundus observation
• Fluid intake
• Voiding
• Ambulation
• Engorgement
• Involution
IN PRACTICE: IMPORTANT MEDICATIONS 66-3
DOCUSATE SODIUM (COLACE)
Dose: 100 mg oral (PO) three times daily (t.i.d.) as needed (PRN)
Expected effect: Stool softener Adverse side effects: None
Nursing Considerations
♦ Colace is not a laxative but simply makes the stool softer to pass.
Teach the client how to massage her uterine fundus and document this teaching. The client should use a mirror to check her stitches. Teaching the client the normal sequence of lochia changes is important, as she will probably go home the first or second postpartum day. She must know danger signs so she can spot a problem early and report it to her birth attendant. See In Practice: Educating the Client 66-3 for client information on changing the perineal pad.
Breastfeeding. Reinforce the benefits of breastfeeding for the client and newborn. Nursing the newborn is beneficial for many reasons:
• Breast milk is readily available and convenient.
• Breast milk is always the correct temperature.
• Breast milk contains antibodies.
• Nursing helps in the bonding process.
• Nursing speeds involution.
• Breast milk is less likely to cause allergic reactions and other difficulties.
• Breast milk is cheaper than formula.
Most mothers can nurse their babies unless complications, such as severely retracted nipples, infections, or breast malformations, arise. The first requirement for breastfeeding is a good supply of milk; the woman’s emotional status, diet, fluid intake, and amount of rest all influence milk production. Generally, the mother who is happy, wants to nurse her newborn, and is not worried or overly tired has an excellent chance to have a good milk supply. An adequate diet based on the MyPlate Framework and ample fluids are essential. Intake of dairy products and fluids may be increased. Supplemental vitamins are often prescribed for breastfeeding women.
IN PRACTICE :EDUCATING THE CLIENT 66-3
CHANGING THE PERINEAL PAD
When removing a soiled pad, the client should pull her panties straight down. If using a sanitary belt, she should unhook the pad from the front first. Advise the client always to start removal of the perineal pad by first removing the pad from “clean" areas in the front and then removing the pad from the 1 ‘dirty’ ‘ area near the rectum. When applying a clean pad, she should hook it onto the front first, which helps prevent infection.
“Expression of milk” means artificial emptying of the breasts. It may be used when a preterm newborn must be fed in the newborn intensive care unit or for the convenience of a working mother. An electric breast pump offers the best method for expressing milk because the suction is steady and controlled. Milk also can be expressed by hand. Milk that is to be used later should be collected in a sterile bottle and refrigerated. Refrigerated milk should be used within 48 hours. Breast milk can be kept in a home freezer for 1 month or in a frozen food locker for 6 months.
Bottle Feeding. Although breast milk is the preferred milk for most infants, there are times when it is not the best milk for a particular baby. For instance, some blood-borne infections, such as HIV, may be transmitted through breast milk. The client who has chosen to bottle-feed should receive equal support from nursing staff.
The mother who does not choose to nurse her newborn should wear a bra that gives firm support. She may have fluids as desired for the first 24 hours after delivery, but after this time, fluids are often restricted. Ice packs and a breast binder can be applied to reduce discomfort.
Perineal Care. Perineal care provides comfort and cleanliness and prevents odor and infection. Encourage the client to use a peri-bottle (a flexible plastic bottle containing clear, warm water), a sitz bath, or surgigator (a hand-held sprayer device) after toileting, whether or not she has an episiotomy. In addition to promoting healing, these methods help keep the perineum clean and decrease the risk of infection. You may give initial perineal care with the client in bed on a bedpan. When the client is ambulatory, she may attend to it herself. Methods vary, but the purpose is the same: to avoid contamination from fecal material.
Perineal care is necessary after the client voids or has a bowel movement. Teach the client to wash her hands and to change the perineal pad every 2 to 3 hours during the day. Help remove the pad she is wearing carefully, moving from front to back, and place it in a paper bag for later disposal.
After voiding or a bowel movement, teach the woman to spray tepid water onto the perineum from the peri-bottle, sitz bath, or surgigator. Use fresh toilet tissues to pat dry from front to back, on each side, and then in the middle. Discard the tissues in the toilet. Do not use undue pressure, which can cause discomfort. Without touching the inner surface of the perineal pad, the woman should fasten the tab of the sanitary belt, or attach the adhesive side of the pad to her panties, from front to back so that it will not slip forward.
A soothing analgesic ointment or spray may be applied as ordered. Witch hazel (Tucks) pads may be used. Frequent sitz baths (four times a day) will increase the mother’s comfort and promote healing of the episiotomy. Oral analgesics and warm or cold compresses may be ordered to relieve discomfort. Squeezing the buttocks together before sitting down helps provide a cushion.
Bathing. When the mother is ambulating and stable, she is permitted to take a shower. You will need to assist her the first time, assembling supplies and instructing her on the procedure. Instruct the nursing mother to avoid using soap on the nipples (soap will cause the nipples to dry and crack). The client usually receives a bed bath on the first day after a cesarean delivery.
Activity, Rest, and Diet. The new mother needs a combination of rest and activity. In most cases, she is up within 4 hours after a normal delivery, which helps to prevent respiratory and circulatory complications. Encourage the client to nap during the day. In some cases, visitors may need to be restricted. Analgesics may facilitate her ability to rest.
Assist the new mother in her initial ambulation. Encourage her first to sit on the edge of the bed and to take deep breaths. If she feels dizzy, she should not get up further until that sensation passes. When she gets up, she should move slowly. Remain with her the first few times until she feels totally stable.
Sometimes the client experiences an increase in lochia while ambulating, which may cause her alarm. Monitor the flow, and assure the client that the increase is likely due to gravity when arising. Explain that the increased lochia helps the uterus to drain and to return to its normal position and size.
The new mother should have a nutritious, balanced diet. If she is nursing, extra quantities of milk and other liquids may be added.
Discharge
Examination by the Birth Attendant. The birth attendant checks the client before discharging her from the healthcare facility. She is told to return for a follow-up examination at the end of 6 weeks, and she is usually advised not to have sexual intercourse or use vaginal douches until then.
Discharge Procedures and Teaching. Routine discharge procedures are followed when the mother and her newborn leave the facility, and specific obstetric procedures also are performed. The mother should be informed that menstruation will resume in 6 to 8 weeks if she does not nurse her newborn. If she does nurse, menstruation is usually delayed for 4 to 5 months or until she stops nursing.
Although ovulation does not usually occur during the nursing period, prolonging nursing is no guarantee that pregnancy will not occur. To a great extent, the degree of protection from pregnancy depends on whether the infant has all its sucking needs met at the breast. A baby who uses a pacifier or sucks on its fists will not provide as much stimulation to the nipple, and therefore provides less contraceptive benefit. Many nursing mothers do become pregnant. The new mother should be made aware that pregnancy is a possibility before the first normal menstrual period because as a rule, ovulation occurs before menstruation.
Discharge teaching should also include normal maternal responses to sex and sexuality, contraception, and when to resume intercourse.
At the time of discharge, rubella vaccine and Rho(D) immune globulin (RHOGAM, Gamulin Rh) may be administered to the Rh-negative mother as indicated. The newborn may be given the first hepatitis vaccine. All these medications require informed consent. If the mother receives rubella vaccine, she must be cautioned to avoid pregnancy for 3 months to avoid harm to the next fetus.
The practitioner examines the mother and newborn approximately 6 weeks after delivery. The purpose of this examination includes making sure the mother’s uterus has returned to normal size, her episiotomy has healed, and no infection is present. The examiner will advise the mother at that time regarding resumption of regular activities.
KEY POINTS
• The role of the labor and delivery nurse is to ensure maternal and fetal well-being.
• The onset of true labor may be difficult to recognize, even for the multigravida.
• Rhythmic uterine contractions causing cervical dilation and effacement, and the descent of the fetal presenting part characterize true labor.
• Normal labor has four distinct stages. In Stage I, cervical dilation and effacement occur, along with fetal descent; in Stage II, the neonate is born; in Stage III, the placenta is delivered. Family bonding, maternal recovery, and infant stabilization occur in Stage IV.
• An important nursing responsibility during labor is performing frequent assessments of the woman’s progress and any deviations from normal for the woman or fetus.
• FHR can be heard and assessed using a fetoscope, Doppler ultrasound device, or electronic fetal monitor.
• Various patterns of fetal response to uterine activity can be identified with electronic fetal monitors, and appropriate interventions can be started early.
• Stage IV is a critical time for the mother and her newborn. The major concerns during this time are preventing maternal hemorrhage, maintaining the newborn’s respiratory and cardiac function, and initiating family bonding.
• In the postpartum woman, major changes (involution) occur in most body systems, restoring them to their normal prepregnant state.
• The uterus decreases in size, the placental site and epi-siotomy heal, and lochia progresses from rubra to serosa, then to alba, during the 6 weeks following delivery.
• Breasts will begin producing milk within 2 to 4 days after delivery.
• Lactation may be suppressed by mechanical means, such as ice packs and compression binders, and by avoiding breast stimulation. Medications usually are not used because the risks outweigh the benefits.
• Client teaching regarding fundal height and consistency, lochia, perineal care, nursing and breast changes, uterine cramping, backache, and fatigue ensures that these important self-care concepts are learned by the new mother.
