Care of the Postpartum Client

Lecture Nine: Care of the Postpartum Client

NURS 2208

T. Dennis RNC, MSN, Instructor

Postpartum Physical Adaptations
(pg. 906-929)

• Uterine Involution
• Fundal position changes: “Boggy”
• Lochia: Rubra, Serosa, Alba
• Cervical changes
• Vaginal changes
• Perineal changes
• Recurrence of ovulation and menustration
• Lactation
• Gastrointestinal System
• Urinary tract
• Vital signs
• Weight loss
• Postpartum chill
• Postpartal diaphoresis
• Afterpains or Afterbirth pains

Uterine Involution (pg 906-908)

• The rapid reduction in size of the uterus and it’s return to a condition similar to its pre-pregnancy state.
• The uterus remains slightly larger than it was before the first pregnancy.
• Process is complete at 3 weeks except at the placental site (6 to 7 weeks)
• Subinvolution may be caused by an infection or retained placenta fragments.

Fundal position changes (pg 907-908)

• After birth the top of the fundus remains at the level of the umbilicus for 12 to 24 hours.
• The first postpartum day it is located 1 cm or fingerbreadth below the umbilicus.
• May be displaced to the left or right by a distended bladder.
• Becomes “boggy” with uterine atony

Lochia: Rubra, Serosa, Alba (pg 908-909)

• Rubra: dark red in color, present the first 2-3 days postpartum, should not contain clots, a few small clots are considered normal.
• Serosa: pinkish to brownish in color, from the 3rd to the 10th day post delivery.
• Alba: creamy or yellowish in color, persists for a week or two after serosa, may be later in breastfeeding clients.
• Following birth it is spongy and flabby and formless and may appear bruised.
• Original form is regained in a few hours
• The shape is permanently changed by the first childbearing.
• Goes from dimple like to a lateral slit (fish mouth)

Vaginal Changes

• Following birth appears edematous
• May be bruised
• Small superficial lacerations may be present
• Size and rugae return to pre pregnancy in 3 weeks
• By 6 weeks appears normal

Perineal Changes

• May appear edematous with some bruising
• Episiotomy edges should be approximated
• Ecchymosis may occur and delay healing

Recurrence of Ovulation and Menustration

• Varies for each postpartum client
• Generally returns to non-nursing mothers between 7 and 9 weeks after birth
• The first cycle is non-ovulatory
• Breastfeeding clients may experience menustration and ovulation based on the amount of time nursing…may occur from 2nd to 18th month

Lactation

• During pregnancy, the breasts develop in preparation for lactation as a result of both estrogen and progesterone. After birth, the interplay of maternal hormones leads to the establishment of milk production.

Gastrointestinal System

• May have a regular diet
• Bowels tend to be sluggish
• Episiotomy clients may delay bowel movement for fear of pain
• Cesarean birth clients may receive clear liquids and progress to a regular diet
• Stool softeners may be used

Urinary Tract

• The postpartum client has an increased bladder capacity, swelling and bruising of tissue, decreased sensitivity to fluid pressure, and decreased sensation of bladder filling.
• At risk for over-distention, incomplete emptying, and buildup of residual urine.
• Urinary output increases 1rst 24 hours post delivery (puerperal diuresis)
• Urine specimens should be obtained as a catheterized specimen.

Vital Signs

• Client should be afebrile after the first 24 hours. A temperature up to 100.4 may be due to dehydration and/or exertion in the first 24 hours.
• BP WNL, a decrease may occur. An ↑BP may indicate toxemia, PIH.
• Pulse rate may decrease to 50-70. Tachycardia should alert the nurse to blood loss/difficult birth.

Blood Values

• Blood values should return to the prepregnant state by the end of the postpartum period.
• Predisposed to the development of thromboembolism
• Leukocytosis with white blood cell (WBC) counts up to 30,000 per mL may occur early postpartum. Treat the symptoms, not the lab work.
• Convenient rule of thumb is a 2 point drop in hematocrit equals a blood loss of 500 mL.

Weight Loss

• An initial weight loss of 10 to 12 lbs occurs as a result of the birth of the infant, placenta and amniotic fluid.
• Puerperal diuresis accounts for loss of an additional 5 lbs during the early postpartum period.
• Normally return to pre-pregnant weight by 6 weeks postpartum.

Postpartum Chill and
Postpartal Diaphoresis

• Most clients experience a shaking chill or tremor after delivery. Warm blankets usually relieve this tremor or chill.
• Chills and fever late in the postpartum period may indicate sepsis.
• Diaphoretic episodes may occur at night, a normal occurrence as the body rids itself of waste products.

Afterpains or Afterbirth pains

• Occur more commonly in multiparas than the primiparas.
• Caused by intermittent contractions.
• May cause severe discomfort for the first 2-3 days.
• Breastfeeding may increase the severity.
• Oxytocins may increase severity. (Pitocin, Methergine, Ergotrate)
• Mild analgesic may be indicated for pain relief. Tylenol #3, Davocet N-100, Percocet, Motrin)

Postpartum Psychological Adaptations (pg 911-916)

• Maternal Role
• Postpartum blues
• Development of Parent-Infant attachment
• Initial attachment Behavior
• Father-Infant Interactions
• Cultural Influences

Maternal Role

• Time of readjustment and adaptation
• During the first day or two, the client tends to be passive and somewhat dependent
• Hesitant about making decisions
• Food or sleep are of major importance, May feel a great need to talk
• “Taking In” phase according to Rubin
• By second or third day, client is ready to resume control. “Taking Hold” phase occurs during this time.
• Today’s client adjust more rapidly as LOS has shortened.
• Maternal role attainment: process by which a woman learns mothering behaviors. (anticipatory, formal, informal, and personal)

Postpartum blues

• Describes a transient period of depression that occurs in most women during the first week or two after birth.
• May be manifested by mood swings, anger, weepiness, anorexia, difficulty sleeping, and a feeling of letdown.
• Hormonal changes and psychological adjustments are thought to be main causes.
• Usually resolve naturally in 2 to 3 weeks with support and reassurance. If symptoms persist, the client should be evaluated for postpartum depression.

Development of Parent-Infant attachment

• Level of trust
• Level of self-esteem
• Capacity for enjoying herself
• Interest in and adequacy of knowledge about childbearing and childrearing
• Client’s prevailing mood or usual feeling tone
• Reactions to the present pregnancy

Initial attachment Behavior

• Progression of touching activities
• En face position dominates
• Relies heavily on senses of sight, touch, hearing in getting to know the baby
• Emotional distance may be occur.
• The acquaintance phase, the phase of mutual regulation
• Some negative feelings may occur; be understanding not condescending
• Reciprocity is an interactional cycle that occurs simultaneously between mother and infant. (mutual cueing behaviors, expectancy, delight in each others company when synchronous)

Father-Infant Interactions

• Primary role has been supporting role
• Engrossment (the characteristic sense of absorption, preoccupation, and interest in the infant demonstrated by fathers during early contact with the newborn.

Cultural Influences

• Postpartum care my be affected by cultural beliefs: No shower, no breastfeeding for the first three days, “hot” and “cold” foods
• Do not make generalizations
• Extended family may play an important role in care

Postpartum Assessment (pg. 916-929)

• Vital signs: BP should remain consistent with baseline BP during pregnancy. Pulse 50 -90, respirations 16-24, temp 98-100.4
• Breasts: Smooth, even pigmentation, soft, filling, full, engorged
• Abdomen: soft, fundus firm, midline and at/or below umbilicus, may be tender on palpation
• Lochia: rubra, scant to moderate, no clots, rubra to serosa to alba

Postpartum Assessment (pg. 916-929)

• Perineum: Slight edema, no bruising, episiotomy without redness, swelling or drainage, hemorrhoids (none or small)
• Lower extremities: No pain with palpation, negative Homan’s sign
• Elimination: voiding 4-6 hrs, no bladder distention noted, normal bowel movement by the 2 nd to 3 rd day post delivery
• Psychological adaptation: cultural assessment, bonding, holding en face, attachment behaviors

Postpartum Assessment (pg. 916-929)

Dysfunctions of the Postpartum Period (pg. 989-1008)

• Postpartal Uterine Infection: Endometritis, Pelvic Cellulitis
• Perineal Wound Infection
• Cesarean Wound Infection
• Urinary Tract Infection (UTI)
• Mastitis
• Thromboembolitic Disease: Superficial Leg Vein Disease, Deep Vein Thrombosis, Septic Pelvic Thrombophlebitis
• Postpartum Psychiatric Disorder: “baby blues”, Postpartum Psychosis, Postpartum Major Mood Disorder

Contraception: Fertility Awareness Methods

• Basal Body Temperature (BBT)
• Calendar or Rhythm Method
• The Cervical Mucous Method
• Symptothermal Method

Advantages and Disadvantages

• Free
• Safe
• Acceptable to many whose religious beliefs prohibit other methods
• Provide an increased awareness of the body
• Involve no artificial substances or devices
• Encourage communication
• Useful in planning a pregnancy
• Require extensive initial counseling to be effective
• May interfere with sexual spontaneity
• Require a couple to keep records for several cycles before beginning to use them
• May be difficult or impossible for women with irregular cycles
• May not be reliable in preventing pregnancy

Contraception: Situational Contraceptives

• Abstinence
• Coitius Interruptus
• Douching after intercourse

Contraception: Spermicides

• Creams, jellies, foams, vaginal film, and suppositories
• Minimally effective when used alone
• Major advantage is wide availability and low toxicity

Contraception: Mechanical Contraceptives

• Condoms (male and female)
• Diaphragm
• The cervical Cap
• The Intrauterine Device (IUD)

Contraception: Oral Contraceptives

• The use of hormones, specifically the combination of estrogen and progesterone, is a very successful birth control method.
• Work by inhibiting the release of an ovum, by creating an atrophic endometrium, and by maintaining cervical mucus that is hostile to sperm.

Contraception: Long-Acting Progestin Contraceptives

• Norplant
• Depo-Provera

 

Emergency Postcoital Contraception

• Actually takes two pills as soon after intercourse as possible and two more 12 hours later. Must be initiated within 72 hours after unprotected intercourse.

Operative Sterilization

• Vasectomy: 1) Involves surgical severing of the vans deferens in both sides of the scrotum, 2) It takes 4-6 weeks or 6-36 ejaculations to clear remaining sperm, 3) Must be rechecked at 6 to 12 months to insure fertility has not been restored.
• Tubal Ligation: The fallopian tubes are ligated, clipped, electrocoagulated, banded or plugged. This interrupts the patency of the fallopian tune, thus preventing the ovum and sperm from meeting.
• Reversal may be accomplished surgically with both procedures. Reversal may also occur naturally.

Surgical and Medical Interruption of Pregnancy

• Methotrexate can be used alone or in conjunction with misoprostil to terminate pregnancy up to approximately 50 days from the last menstrual period.
• Mifepristone (RU 486) blocks progesterone, altering the endometrium and making it unsuitable for implantation (currently not made in the US).
• Surgical intervention D&C, D&S

Questions?

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