I. Postpartum
A. Description: Period when the reproductive tract returns to the normal, non-pregnant state
B. The postpartum period starts immediately after birth and is usually completed by week 6 following birth.
II. Physiological Maternal Changes
A. Involution
1. Description
a. Involution is the rapid decrease in the size of the uterus as it returns to the non-pregnant state.
b. Clients who breast-feed may experience a more rapid involution because of the release of oxytocin during breast-feeding.
2. Assessment
a. The weight of the uterus decreases from approximately 2 lb (900 g) to 2 oz (57 g) in 6 weeks.
b. The endometrium regenerates.
c. The fundus steadily descends into the pelvis.
d. Fundal height decreases about 1 cm/day.
e. By 10 days postpartum, the uterus cannot be palpated abdominally.
f. A flaccid fundus indicates uterine atony, and it should be massaged until firm; a tender fundus indicates an infection.
g. After pains decrease in frequency after the first few days.
B. Lochia
1. Description: Discharge from the uterus that consists of blood from the vessels of the placental site and debris from the decidua
2. Assessment
a. Rubra is bright red discharge that occurs from day of birth to day 3.
b. Serosa is brownish pink discharge that occurs from days 4 to 10.
c. Alba is white discharge that occurs from days 11 to 14.
d. The discharge should smell like normal menstrual flow.
e. Discharge decreases daily in amount.
f. Discharge may increase with ambulation.
To determine most accurately the amount of lochial flow, weigh the perineal pad before and after use and identify the amount of time between pad changes.
C. Cervix: Cervical involution occurs, and the muscle begins to regenerate after 1 week.
D. Vagina: Vaginal distention decreases, although muscle tone is never restored completely to the pregravid state.
E. Ovarian function and menstruation
1. Ovarian function depends on the rapidity with which pituitary function is restored.
2. Menstrual flow resumes within 1 to 2 months in non–breast-feeding mothers.
3. Menstrual flow usually resumes within 3 to 6 months in breast-feeding mothers.
4. Breast-feeding mothers may experience amenorrhea during the entire period of lactation.
Women may ovulate without menstruating, so breastfeeding should not be considered a form of birth control.
F. Breasts
1. Breasts continue to secrete colostrum for the first 48 to 72 hours after birth.
2. A decrease in estrogen and progesterone levels after birth stimulates increased prolactin levels, which promote breast 356 milk production.
3. Breasts become distended with milk on the third day.
4. Engorgement occurs on approximately day 4 in both breast-feeding and non–breast-feeding mothers. Box 29-2 summarizes care of breasts for non–breast-feeding mothers.
5. Breast-feeding relieves engorgement.
G. Urinary tract
1. The client may have urinary retention as a result of loss of elasticity and tone and loss of sensation in the bladder from trauma, medications, anesthesia, and lack of privacy.
2. Diuresis usually begins within the first 12 hours after birth.
H. Gastrointestinal tract
1. Clients are usually hungry after birth.
2. Constipation can occur, with bowel movement (soft, formed stool) by the second or third postpartum day.
3. Hemorrhoids are common.
I. Vital signs
III. Postpartum Interventions
A. Assessment
1. Monitor vital signs.
2. Assess pain level.
3. Assess height, consistency, and location of the fundus (have client empty the bladder before fundal assessment)
4. Monitor color, amount, and odor of lochia.
5. Assess breasts for engorgement.
6. Monitor perineum for swelling or discoloration.
7. Monitor for perineal lacerations or episiotomy for healing.
8. Assess incisions or dressings of client who had a cesarean birth.
9. Monitor bowel status.
10. Monitor intake and output.
11. Encourage frequent voiding.
12. Encourage ambulation.
13. Assess extremities for thrombophlebitis (redness, tenderness, or warmth of the leg).
14. Administer Rho(D) immune globulin if prescribed within 72 hours postpartum to Rh-negative client who has given birth to Rh-positive newborn.
15. Evaluate rubella immunity. If not immune, administer rubella immunization.
16. Assess bonding with the newborn.
17. Assess emotional status.
B. Client teaching
1. Demonstrate newborn care skills as necessary.
2. Provide the opportunity for the client to bathe the newborn.
3. Instruct in feeding technique.
4. Instruct the client to avoid heavy lifting for at least 3 weeks.
5. Instruct the client to plan at least 1 rest period per day.
6. Instruct the client that contraception should begin after birth or with the initiation of intercourse (intercourse should be postponed at least until lochia ceases). With rubella immunization, avoid conception for 1 to 3 months based on health care provider (HCP) recommendation.
7. Instruct the client in the importance of followup, which should be scheduled at 4 to 6 weeks.
8. Instruct the client to report any signs of chills, fever, increased lochia, or depressed feelings to the HCP immediately.
IV. Postpartum Discomforts
A. Afterbirth pains
1. Occur as a result of contractions of the uterus
2. Are more common in multiparas, breast-feeding mothers, clients treated with oxytocin, and clients who had an over-distended uterus during pregnancy, such as with carrying twins
B. Perineal discomfort
1. Apply ice packs to the perineum during the first 24 hours to reduce swelling.
2. After the first 24 hours, apply warmth by sitz baths.
C. Episiotomy
1. If done, instruct the client to administer perineal care after each voiding.
2. Encourage the use of an analgesic spray as prescribed.
3. Administer analgesics as prescribed if comfort measures are unsuccessful.
D. Perineal lacerations
1. Care as for an episiotomy; administer perineal care and use analgesic spray and analgesics for comfort.
2. Rectal suppositories and enemas may be contraindicated (to avoid injury to sutures).
E. Breast discomfort from engorgement
1. Encourage the client to wear a support bra at all times, even while she is sleeping.
2. Encourage the use of ice packs between feedings if the client is breast-feeding.
3. Encourage the use of warm soaks or a warm shower before feeding for the breast-feeding mother.
4. Administer analgesics as prescribed if comfort measures are unsuccessful.
F. Constipation
1. Encourage adequate intake of fluids (2000 mL/day).
2. Encourage diet high in fiber.
3. Encourage ambulation.
4. Administer stool softener, laxative, enema, or suppository if needed and prescribed.
G. Postpartum emotional changes
1. Acknowledge the client’s feelings and demonstrate a caring attitude.
2. Determine availability of family support and other support systems and resources as needed.
3. Encourage and assist the client to verbalize her feelings.
4. Monitor the newborn for appropriate growth and development expectations.
5. Assist the significant other and other appropriate family members to discuss feelings and identify ways to assist the client.
All clients should be assessed for depression during pregnancy and in the postpartum period.
V. Nutritional Counseling
A. Discuss caloric intake with breast-feeding and non– breast-feeding mothers.
B. Nutritional needs depend on pre-pregnancy weight, ideal weight for height, and whether the client is breast-feeding.
C. If the client is breast-feeding, calorie needs increase by 200 to 500 calories/day, and the client may require increased fluids and the continuance of prenatal vitamins and minerals.
VI. Breast-Feeding
A. Interventions
1. Put the newborn to the mother’s breast as soon as the mother’s and newborn’s conditions are stable (on delivery table, if possible).
2. Stay with the client each time she nurses until she feels secure and confident with the newborn and her feelings.
3. Assess LATCH (latch achieved by newborn; audible swallowing; type of nipple; comfort of mother; hold or position of baby).
4. Uterine cramping may occur the first day after birth while the client is nursing, when oxytocin stimulation causes the uterus to contract.
5. Instruct the client to use general hygiene and wash the breasts once daily.
6. If engorgement occurs, breast-feed frequently, apply warm packs before feeding, apply ice packs between feedings, and massage the breasts.
7. The client should not use soap on the breasts because it tends to remove natural oils, which increases the chance of cracked nipples.
8. If cracked nipples develop, the client should expose the nipples to air for 10 to 20 minutes after feeding, rotate the position of the baby for each feeding, and ensure that the baby is latched on to the areola, not just the nipple.
9. The bra should be well fitted and supporting; avoid an underwire bra.
10. Breasts may leak between feedings or during coitus; place breast pad in bra.
11. Calories should be increased by 200 to 500 calories/day, and the diet should include additional fluids; prenatal vitamins should be taken as prescribed.
12. Newborn’s stools are usually light yellow, seedy, watery, and frequent.
13. Medications, including over-the-counter medications, need to be avoided unless prescribed because they may be unsafe when breast-feeding.
14. Gas-producing foods and caffeine should be avoided.
15. Oral contraceptives containing estrogen are not recommended for breast-feeding mothers; progestin-only birth control pills are less likely to interfere with the milk supply.
16. The infant will develop his or her own feeding schedule.
