Postpartum Care: Body Changes, Nursing, and Daily Assessments

1. By the time a man realizes that maybe his father was right, he usually has a son who thinks he’s wrong. Charles Wadsworth

2. Maternal & Newborn Nursing Postpartum Care Unit 4

3. Body Changes: Breasts Colostrum Secreted by breasts 1st 2–3 days after childbirth Watery, yellowish fluid, ↑ in protein & ↓ in CHO & fats Acts as a laxative = aids expelling meconium

4. Body Changes: Breasts (cont.) Engorgement Breasts swollen, hard & painful Around 3rd day after childbirth; last 24-36 hrs. Breast milk comes in after engorgement Lactation process Prolactin hormone → secretion of milk Oxytocin → expulsion of milk or let down Incomplete emptying = ↓ production

6. Breastfeeding 500 extra calories/day with 8-10 glasses water /day Nurse 10-15 minutes on each breast Nurse every 2-3 hrs & switch breast starting with at each feeding If not breastfeeding – wear well fitting bra 24/7 until discomfort subsides Wash with plain water; no soap

7. Body Changes: Uterus Involution – gradual return of uterus to its normal size; approx. 6 wks Measured in finger breadths in relation to the umbilicus Immediately after delivery – just below umbilicus By 10th postpartum day, descended into pelvic cavity; not palpable above symphysis pubis Cramping pains while breastfeeding; lessen after a few days

9. Body Changes: Lochia Lochia rubra 1st 2-3 days; red & bloody Lochia serosa By 3rd-4th day ↓ & more serous, pink or brown Lochia alba 9th-10th day scant & yellowish-white Amount more profuse in multigravida, ambulating 1st time after delivery, after breast feeding

10. Body Changes: Lochia (cont.) Menstrual period returns Non-nursing = 8 wks after delivery Nursing = 2 months after lactation ceases Is possible for both non & nursing moms to become pregnant before menstruation returns Lochia remaining reddish brown after 4th day = involution may not have taken place

11. Body Changes: Cervix Soft, flabby, & partly open Small lacerations may heal spontaneously or require cauterization External os remains somewhat wider

12. Body Changes: Perineal Area Vagina recovers slowly, muscle tone never returns to predelivery state Labia loses cushion of fat & may become flabby Perineal tone slowly returns over 6-8 wk. period but not to predelivery state

13. Body Changes: Abdomen Good nutrition, adequate rest & proper exercise help muscle regain tone Striae gradually fade to silvery white but not disappear Separation of abd. muscles may occur d/t loss of tone

14. Body Changes: Vital Signs Temperature Slight rise above normal may occur after del. After 1st 24 hrs., 2 consecutive temp of 100.4⁰F or higher may indicate sign of infection Pulse Rapid may indicate hemorrhage, shock or infection BP ↓ BP with rapid, thready P = hemorrhage

15. Body Change: Urinary Tract Urge to urinate may be ↓ d/t anesthesia, analgesia, or over distension Tone usually restored within 24-48 hrs. Failure to empty = ↑ bladder infections Urine output greatly ↑ 1st 24-48 hrs. as body excretes flds retained during preg.

16. Body Changes: Circulatory System Moderate anemia d/t blood loss WBC ↑ during labor & early postpartum Fibrinogen level ↑ Diaphoresis may occur several wks d/t metabolic changes

17. Body Changes: GI System Appetite usually good Bowel function may be delayed ↓ intake during labor, flaccid abd. muscles, ↓ pressure from uterus, &/or fear of pain Good nutrition, flds., exercise, & return of bowel tone usually corrects problem

18. Body Changes: Emotions Need for rest & sleep in the immediate postpartum period Following del., common for mood change frequently from irritable or tearful May feel inadequate & unsure of ability to cope with new role

19. Body Changes: Emotions (cont.) Postpartum blues – about 3 days after birth, temporary depression believed to be d/t hormonal changes, & emotional stress If symptoms persist or become severe, refer to MD

20. Daily Assessments VS Report temp. > 100.4⁰F, abnormal HR or resp. rate Fundus Firmness, ht. & location Massage C/section: massage from side of uterus to midline

21. Daily Assessments • Perineum • Observe for hematoma, edema • Assess episiotomy, hemorrhoids & discomfort • Cleanse front to back with warm water • Bladder • Observe for fullness, output, dysuria

22. Daily Assessments • Bowel • Flatus, bowel sounds & BM • Pain • Location, character, severity, use of relief measures & need for analgesics

23. Daily Assessments • Extremities • Observe for signs of thrombophlebitis, ability to ambulate & Homan’s sign • Emotional state • Evaluate family interaction, support, & signs of depression • Attachment/Bonding • Observe interest in newborn, eye & touch contact, ability to respond to infant cries

24. Daily Assessments • Cultural variations • Observe for cultural practices to be incorporated into plan of care • Breast • Lochia • Immunization • MMR given before discharge if not immune; no chance of being pregnant at this time

25. Uterine Hemorrhage • Causes • Uterine atony: failure of uterine muscles to contract & control bleeding from placental site • Retention of placental fragments • Multiple births • Multiparity • Hematologic disorders

26. Uterine Hemorrhage • Assessment data • Rapid bleeding or bleeding over a period of 2 or more hrs. in excess of 500 mL (normal loss during & after delivery → 50 – 300 mL • Rapid &/or thready pulse (usually seen first) • ↓ BP • Pallor, chills, dyspnea, air hunger • Restlessness, disorientation, disturbed vision

27. Uterine Hemorrhage • Treatment • Determine cause • Massage fundus until firm • Stay with pt. & send someone else for help • Oxytocin (Pitocin) &/or Vit. K given • Repair laceration, D & C or other surgery • Fld. & blood replacement • Prophylactic antibiotic

28. Laceration of Birth Canal • Cervical tear: suspect if uterus is firm • 3 types of lacerations • Labial • Vaginal • Perineal – classified in 4 degrees

29. Laceration of Birth Canal • Perineal laceration degrees • 1st - involves mucosa & skin with some superficial musculature • 2nd – deeper structures of perineum • 3rd – all structures of vaginal wall; the anal sphincter & muscles are severed • 4th – all of the above & anal wall open

30. Laceration of Birth Canal • Causes • Forceps delivery • Unattended spontaneous delivery • Contracted pelvis • Size, presentation & position of fetus • Prior scarring from infection • Injury or surgery

31. Laceration of Birth Canal • Assessment • Blood loss, pain, inability to void • Treatment • Blood replacement, ↑ flds. • Vaginal packs • Analgesics, stool softeners • Heat or cold applications • NO enemas or suppositories with 4th degree

32. Vaginal Hematomas • Causes • Forcep delivery • Prolonged or rapid delivery • Symptoms • c/o persistent perineal pain or feeling of fullness in vagina • Observe a large purplish mass

33. Vaginal Hematomas • Treatment • Small will resolve without tx. • Larger ones → I & D to remove clots • Nursing interventions • Adm. analgesics & ice packs for sm. ones • Report c/o severe pain, perineal or vaginal pressure or inability to void = may be concealed blood loss • Keep NPO until MD examines her & prescribes tx.

34. Pulmonary Embolism • Pulmonary artery obstructed by blood clot that breaks off & lodges in lungs • Causes • Often originates in uterine or pelvic vein • May occur following infection, thrombosis or severe hemorrhage or shock

35. Pulmonary Embolism • Assessment • Sudden, severe pain over heart • Severe dyspnea • Irregular, feeble, or imperceptible pulse • Extreme apprehension • Syncope, pallor or cyanosis • Coma & death if completely occluded

36. Pulmonary Embolism • Treatment & nursing interventions • O₂, analgesic, sedation, anticoagulants • Quiet environment, bedrest • Frequent VS

37. Thrombophlebitis • Causes • Venous stasis • Clotting defects • Excess fibrinogen • Prevention • Early ambulation

38. Thrombophlebitis • Assessment • Chills & fever, pain in leg • Leg feels hot to touch • Red streaks or local inflammation in leg • Edema • + Homan’s

39. Thrombophlebitis • Treatment • Anticoagulants for 6 wks. • Daily PT & clotting time • Heat or cold application • Bedrest • TEDS

40. Thrombophlebitis • Nursing interventions • ↑ leg 30-40⁰ • DO NOT massage leg • Maintain bedrest • Provide emotional support • Observe for hemorrhage from anticoagulants

41. Plans are only good intentions unless they immediately degenerate into hard work. Peter F. Drucker

42. Puerperal Infection • Septicemia after childbirth • Risk factors • Tissue trauma during labor • Open wound of placental site • Surgical incision • Cracks in nipples • ↑ vaginal pH after delivery

43. Puerperal Infection • Assessment • Foul smelling lochia • 2 days or more of 100.4⁰F temp excluding the first 24 hrs., chills • Rapid pulse & resp. • Large & tender uterus • Headache, insomnia, anorexia

44. Puerperal Infection • Treatment & nursing care • Use & teach hygienic measures • Promote adequate rest • Observe signs of infection & teach signs to report • Teach to take all antibiotics as prescribed

45. Mastitis • Infection of breast usually 2-3 wks after giving birth after milk flow is established • Assessment • Chills, fever, malaise • Breast tenderness, redness & heat in breast • Edema & heaviness to breast • Not tx’d→ breast abscess at which time breast milk is then affected = no breastfeeding with an abscess

46. Mastitis • Treatment • Antibiotics • Continued removal of milk from breast • Breast support • Warm or cold packs with mild analgesics • Abscess = I & D, no breastfeeding but pump & discard milk because build up milk worsens the condition

47. Mastitis • Nursing interventions • Administer analgesics • Apply warm or cold packs • Encourage @ least 3L / day of fld. intake • Wear good support bra • Emotional support especially if had to abruptly stop nursing • Encourage warm shower before nursing

48. Postpartum Psychosis • Postpartum depression – occurs 2 wks or longer after delivery • Psychosis occurring 4-6 wks. after delivery • Causes – unknown although 1/3 who experience psychosis probably had some mental illness prior to preg. • Stresses of preg., delivery, & new responsibilities

49. Postpartum Psychosis • Assessment • Clouding of consciousness • Depression, withdrawal • Hostility • Fear & suspicion • Inadequacy feelings • Hallucination / delusions

50. Postpartum Psychosis • Treatment & nursing care • Consult with psychiatrist or psychologist • Adm. psychotropic meds • Reduce anxiety & hostility • Close observation • Teach woman & family parenting skills