Postpartum Nursing Care
PATHOPHYSIOLOGICAL AND PSYCHOSOCIAL
CHANGES OF POSTPARTUM
POSTPARTUM ASSESSMENT AND CARING
INTERVENTIONS
LABORATORY VALUES OF THE POSTPARTUM
CLIENT
MEDICATIONS USED IN POSTPARTUM
PHYSIOLOGY OF BREASTFEEDING AND THE
BREASTFEEDING CLIENT
FORMULA FEEDING
DISCHARGE TEACHING
Pathophysiology of Postpartum
 Involution - rapid reduction in size of uterus and return to
prepregnant state
 Subinvolution = failure to descent
 Uterus is at level of umbilicus within 6 to 12 hours after
childbirth - decreases by one finger breadth per day
 Exfoliation - allows for healing of placenta site and is
important part of involution – may take up to 6 weeks
 Enhanced by
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uncomplicated labor and birth
complete expulsion of placenta or membranes
breastfeeding
early ambulation
FIGURE 23–1 Involution of the uterus. A, Immediately after
expulsion of the placenta, the top of the fundus is in the midline and
approximately halfway between the symphysis pubis and the umbilicus.
B, About 6 to 12 hours after birth, the fundus is at the level of the
umbilicus. The height of the fundus then decreases about one fingerbreadth (approximately 1cm) each day.
Pathophysiology of Postpartum
 Uterus rids itself of debris remaining after birth
through discharge called lochia
 Lochia changes:
Bright red at birth
 Rubra - dark red (2 – 3 days after delivery)
 Serosa – pink (day 3 to 10 after delivery)
 Alba – white
 Clear
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 If blood collects and forms clots within uterus,
fundus rises and becomes boggy (uterine atony)
Ovulation and Menstruation/Lactation
 Return of ovulation and menstruation varies for
each postpartal woman
Menstruation returns between 6 and 10 weeks after birth
in nonlactating mother - Ovulation returns within 6
months
 Return of ovulation and menstruation in breastfeeding
mother is prolonged related to length of time
breastfeeding continues
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 Breasts begin milk production
 a result of interplay of maternal hormones
Pathophysiology of Bowel Elimination
 Intestines sluggish because of lingering effects of
progesterone and decreased muscle tone
Spontaneous bowel movement may not occur for 2 to 4
days after childbirth
 Mother may anticipate discomfort because of perineal
tenderness or fear of episiotomy tearing
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 Elimination returns to normal within one week
 After cesarean section, bowel tone return in few
days and flatulence causes abdominal discomfort
Pathophysiology of Urinary tract
 Increased bladder capacity, decreased bladder tone,
swelling and bruising of tissue
 Puerperal diuresis leads to rapid filling of bladder urinary stasis increases chance of urinary tract
infection
 If fundus is higher than expected on palpation and is
not in midline, nurse should suspect bladder
distension
FIGURE 23–2
The uterus becomes displaced and deviated to the right when
the bladder is full.
Laboratory Values
 White blood cell count often elevated after delivery
 Leukocytosis
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Elevated WBC to 30,000/mm3
 Physiologic Anemia
 Blood loss – 200 – 500 Vaginal delivery
 Blood loss 700 – 1000 ml C/S
 RBC should return to normal w/in 2 - 6 weeks
 Hgb – 12 – 16, Hct – 37% - 47%
 Activation of clotting factors (PT, PTT, INR)
predispose to thrombus formation - hemostatic
system reaches non-pregnant state in 3 to 4 weeks
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Risk of thromboembolism lasts 6 weeks
Weight Loss
 10 –12 pounds w/ delivery
 5 pounds with diuresis
 Return to normal weight by 6 – 8 weeks if gained 25
- 30 pounds
 Breastfeeding will assist with weight loss even with
extra calorie intake
Psychosocial Changes
 Taking in - 1 to 2 days after delivery
 Mother is passive and somewhat dependent as she sorts reality
from fantasy in birth experience
 Food and sleep are major needs
 Taking hold - 2 to 3 days after delivery
 Mother ready to resume control over her life
 She is focused on baby and may need reassurance
Psychosocial Changes
 Maternal Role Attachment
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Woman learns mothering behaviors and becomes comfortable in her
new role
 Four stages to maternal role attainment
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Anticipatory stage - During pregnancy
Formal stage - When baby is born
Informal stage - 3 to 10 months after delivery
Personal stage - 3 to 10 months after delivery
 Father-Infant Interaction
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Engrossment
Sense of absorption
Preoccupation - Interest in infant
Postpartum Assessment
 Vital signs: Temperature elevations should last for only 24
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hours – should not be greater than 100.4°F
Bradycardia rates of 50 to 70 beats per minute occur during
first 6 to 10 days due to decreased blood volume
Assess for BP within normal limits: Notify MD for
tachycardia, hypotension, hypertension
Respirations stable
Breath sounds should be clear
Complete systems assessment
BUBBLEHE assessment
Postpartum chills or shivers are common
Breasts Assessment
 Assess if mother is breast- or bottle-feeding - inspect
nipples and palpate for engorgement or tenderness –
should not observe redness, blisters, cracking
Breasts Assessment
 Breasts should be soft, warm, non-tender upon
palpation
 Secrete colostrum for 1st 2-3 days –yellowish fluid protein and antibody enriched to offer passive
immunity and nutrition
 Milk comes in around 3 – 4 days – feel firm, full,
tingly to client
Uterus Assessment
 Monitor uterus and vaginal bleeding, every 30
minutes x 2 for first PP hour, then hourly for 2 more
hours, every 4 hours x 2, then every 8 hours or more
frequently if there is bogginess, position out of
midline, heavy lochia flow
 Determine firmness of fundus and ascertain position
 approximate descent of 1 cm or 1 fingerbreadth per
day
 If boggy (soft), gently massage top of uterus until
firm – notify health care provider if does not firm
 Displaced to the right or left indicates full bladder –
have client void and recheck fundus
Uterus Assessment
FIGURE 23–6 Measurement of
descent of fundus for the woman with
vaginal birth. The fundus is located two
finger-breadths below the umbilicus.
Always support the bottom of the uterus
during any assessment of the fundus.
Bladder and Bowel Assessment
 Anesthesia or edema may interfere with ability to
void – palpate for bladder distention - may need to
catheterize – measure voided urine
 Assess frequency, burning, or urgency
 Diuresis will occur 12 – 24 hours after delivery –
eliminate 2000 – 3000 ml fluid, may experience
night sweats and nocturia
 Bowel: Assess bowel sounds, flatus, and distention
Lochia – Rubra Assessment
 Lochia = blood mucus, tissue vaginal discharge
 Assess amount, color, odor, clots
 If soaking 1 or > pads /hour, assess uterus, notify
health care provider
 Total volume – 240 – 270 ml
 Resume menstrual cycle within
6 – 8 weeks, breast feeding may
be 3 months
Episiotomy, Lacerations, C/S Incisions
 Inspect the perineum for episiotomy/lacerations
with REEDA assessment
 Inspect C/S abdominal incisions for REEDA
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R = redness (erythema)
E = edema
E = ecchymosis
D = drainage, discharge
A = approximation
Episiotomy
Postpartum Nursing Interventions
 Relief of Perineal Discomfort
 Ice packs for 24 hours, then warm sitz bath
 Topical agents - Epifoam
 Perineal care – warm water, gently wipe dry front to back
FIGURE 24–1
A sitz bath promotes healing and provides relief
from perineal discomfort during the initial weeks following birth.
Hemorrhoids, Homan’s Sign
 Assess for hemorrhoids
 Relief of hemorrhoidal discomfort may include
 Sitz baths
 Topical anesthetic ointments
 Rectal suppositories
 Witch hazel pads - Tucks
 Extremities
 Assess for pedal edema, redness, and warmth
 Check Homan's sign – dorsiflex foot with knee slightly
bent
FIGURE 23–9 Homans’ sign: With the woman’s knee flexed,
the nurse dorsiflexes the foot. Pain in the foot or leg is a positive
Homans’ sign.
Emotional Status/Bonding Assessment
 Describe level of attachment to infant
 Determine mother's phase of adjustment to parenting
 Postpartum Blues
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Transient period of depression
Occurs first few days after delivery
Mother may experience tearfulness, anorexia, difficulty sleeping,
feeling of letdown
 Usually resolves in 10 to 14 days
 Causes:
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Changing hormone levels, fatigue, discomfort, overstimulation
Psychologic adjustments
Unsupportive environment, insecurity
Postpartum Nursing Interventions
 After pains
 Uterine contractions as uterus involutes
 Relief of after pains
 Positioning (prone position)
 Analgesia administered an hour before breastfeeding
 Encourage early ambulation - monitor for dizziness and
weakness
Medications
 Bleeding
 oxytocin (Pitocin) – watch for fluid overload and hypertension
 methylergonovine (Methergine) – causes hypertension
 prostaglandin F (Hemabate, carboprost) – n/v, diarrhea
 Pain Medications
 NSAIDS – GI upset
 Oxycodone/acetaminophen (Percocet) – dizziness, sleepiness
 PCA – Morphine for C/S – respiratory distress
 docusate (Senna) – causes diarrhea
 Rubella Vaccine – titer 1:10, do NOT get pregnant for 3
months
 Rh Immune Globulin (RhoGAM) – Rh negative mother –
do not administer rubella vaccine for 3 months
Mother and Family Needs
 Nurse can assist in restoration of physical well-
being by
Assessing elimination patterns
 Determining mother's need for sleep and rest
 Encourage regular diet as tolerated and increasing fluids
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 Identify available support persons - involve
support person and siblings in teaching as
appropriate
 Determine family's knowledge of normal
postpartum care and newborn care
Breastfeeding Pathophysiology
 Before delivery, increased estrogen stimulates duct
formation, progesterone promotes development of
lobules and alveoli
 After delivery, estrogen and progesterone decrease,
prolactin increases to promote milk production by
stimulating alveoli
 Newborn suck releases oxytocin to stimulate letdown reflex
Composition of Breast Milk
 Breast milk is 90% water; 10% solids consisting of
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carbohydrates, proteins, fats, minerals and vitamins
Composition can vary according to gestational age
and stage of lactation
Helps meet changing needs of baby
Foremilk – high water content, vitamins, protein
Hindmilk - higher fat content
Immunologic and Nutritional Properties
 Secretory IgA, immunoglobulin found in colostrum
and breast milk, has antiviral, antibacterial,
antigenic-inhibiting properties
Contains enzymes and leukocytes that protect against
pathogens
 Composed of lactose, lipids, polyunsaturated fatty acids,
amino acids, especially taurine
 Cholesterol, long-chain polyunsaturated fatty acids, and
balance of amino acids in breast milk help with
myelination and neurologic development
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Advantages of Breastfeeding
 Provides immunologic protection
 Infants digest and absorb component of breast milk
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easier
Provides more vitamins to infant if mother's diet is
adequate
Strengthens mother-infant attachment
No additional cost
Breast milk requires no preparation
AAP= Only food for 6 months, w/ foods for 12
months
Disadvantages of Breastfeeding
 Many medications pass through to breast milk
 Father unable to equally participate in actual feeding
of infant
 Mother may have difficulty being separated from
infant
Breastfeeding Mother
 Breastfeeding mother needs to know
 How breast milk is produced
 How to correctly position infant for feeding
 Procedures for feeding infant
 Number of times per day breastfed infant should be put to the
breast
 How to express and store breast milk
 How and when to supplement with formula
 How to care for breasts
 Medications that pass through breast milk
 Support groups for breastfeeding
 Review signs and symptoms of engorgement, plugged milk
ducts, mastitis
Breastfeeding Assessment
Figure 29–2
Four common breastfeeding positions. A, Football hold. B,
Lying down. C, Cradling. D, Across the lap.
Formula Preparations
 Three categories of formulas based on cow milk
proteins, soy protein-based formulas, specialized or
therapeutic formulas - all are enriched with vitamins,
particularly vitamin D
 Most common cow milk protein-based formulas
attempt to duplicate same concentration of
carbohydrates, proteins, fats as 20kcal/oz same as
breast milk
Bottle-Feeding Advantages
 Provides good nutrition to infant
 Father can participate in infant feeding patterns
Bottle-Feeding Disadvantages
 May need to try different formulas before finding one
that is well-tolerated by infant
 Proper preparation necessary for nutrition adequacy
Bottle-Feeding Mother
 Bottle-feeding mother needs to know
 Types of formula available and how to prepare each type
 Procedure for feeding infant
 How to correctly position infant for bottle-feeding
 How to safely store formula
 How to safely care for bottles and nipples
 Amount of formula to feed infant at each feeding
 How often to feed infant
 Expected weight gain
Bottle Feeding Mother
 Teach to wear a binder or tight-fitting sports bra day
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and night for two weeks.
Do not allow hot water from shower to run over
breasts
Avoid manual stimulation
Apply cabbage leaves (dries up breast)
Use acetaminophen for discomfort
Cesarean Section Needs
 Assess vital signs
 Assess breasts
 Assess location and firmness of uterine fundus
 Assess lochia
 Assess incision site – REEDA
 Assess breath sounds
 Assess indwelling urinary catheter - color and
amount of urine noted
 Assess bowel sounds: present, hypoactive or
hyperactive
Cesarean Section Needs
 Cesarean birth is major abdominal surgery - if general
anesthesia used, abdominal distension may cause
discomfort, assess for bowel obstruction
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Position client on left side, include exercises, early ambulation, increase
po intake, avoid carbonated beverages, avoid straws - may need enemas,
stool softeners, antiflatulent meds
 Pulmonary infections may occur related to immobility and
use of narcotics because of altered immune response
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TCDB, use incentive spirometer q 2 hours
Pain and Comfort
 Administer analgesics within the first 24 to 72 hours -
allows woman to become more mobile and active
 Comfort is promoted through proper positioning, back
rubs, and oral care - reduce noxious stimuli in environment
 Encourage visits by family and newborn, which provides
distraction from painful stimuli
 Encourage non-pharmacologic methods of pain relief
(breathing, relaxation, and distraction) - encourage rest
Attachment After a Cesarean Birth
 Physical condition of mother and newborn and
maternal reactions to stress, anesthesia, and
medications may impact mother-infant attachment
 By second or third day, cesarean birth mother
moves into "taking-hold period"
Emphasize home management and encourage mother to
allow others to assume housekeeping responsibilities
 Stress how fatigue prolongs recovery and may interfere
with attachment process
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Discharge Instructions
 S/S complications
 Referral numbers
 PP Exercises
 Nutrition
 Rest
 PP appointment
 Avoid overexertion
 Birth certificate info
 Sexual activity
 Infant care
 Hygiene
 Infant complications
 Sitz baths
 Infant follow-up
 Incision care
 Family bonding
Discharge Teaching
 New mother should gradually increase activities and
ambulation after birth
 Avoid heavy lifting, excessive stair climbing,
strenuous activity, vacuuming
 Resume light housekeeping by second week at home
 Delay returning to work until after 6-week
postpartum examination
Discharge Teaching
 Recommend exercise to provide health benefits to
new mother
 Nurse should encourage client to begin simple
exercises while on nursing unit
 Inform her that increased lochia and pain may
necessitate a change in her activity
Sexual Activity and Contraception
 Sleep deprivation, vaginal dryness, and lack of time
together may impact resumption of sexual activity
 Usually sexual intercourse is resumed once
episiotomy has healed and lochia has stopped (about
3 – 6 weeks)
 Breastfeeding mother may have leakage of milk from
nipples with sexual arousal due to oxytocin release
Contraception
 Information on contraception should be part of
discharge planning
 Nursing staff need to identify advantages,
disadvantages, risk factors, any contraindications
 Breastfeeding mothers concerned that contraceptive
method will interfere with ability to breastfeed - they
should be given available options – progesterone
only
Parent-Infant Attachment
 Tell parents it is normal to have both positive and
negative feelings about parenthood
 Stress uniqueness of each infant
 Provide time and privacy for the new family
 Include parents in nursing intervention
Reaction of Siblings
 Sibling visits reassure children their mother is well
 Father may need to hold new baby, so mother can
hug older children
 Suggest to parent that bringing doll home allows
young child to "care for" and identify with parents
Infant Care
 New mother and family should know basic infant
care
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Information about tub baths
Cord treatment, When to anticipate cord will fall off
Family should be comfortable in feeding and handling infant,
as well as safety concerns
Immunizations
When to call the doctor
Discharge Teaching
 Nurse should review with new mother any information she
has received regarding postpartum exercises, prevent of
fatigue, sitz bath and perineal care, etc. - nurse should
spend time with parent to determine if they have any lastminute questions before discharge
 Printed information about local agencies and support
groups should be given to new family
Types of Follow-Up Care
 Telephone calls - nurses must listen carefully and ask open
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ended questions
Return visits - Within one week after first visit
Telephone follow-up - Within 3 days of discharge
Baby care/postpartum classes
New mother support groups
Need to have a caring attitude in these activities
Main Purpose of the Home Visit
 Assessment
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Status of mother and infant
Adaptation and adjustment of family to new baby
 Determine current informational needs
 Teaching
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Self-care
Infant Care
 Opportunity to answer additional questions related to
infant care and feeding
 Counseling
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Provide emotional support to mother and family
Referrals
Maternal Assessments at Home
 Vital signs: Should be at prepregnancy level
 Weight: Expect weight to be near prepregnancy level at 6
weeks postpartum
 Condition of breasts
 Condition of abdomen, including healing cesarean incision
if applicable
 Elimination pattern: should return to normal by 4 to 6
weeks postpartum
Maternal Assessment
 Lochia
 Should progress from lochia rubra to lochia alba
 If not breastfeeding, menstrual pattern should return
about 6 weeks postpartum
 Fundus
 Uterus should return to normal size by 6 weeks
postpartum
 Perineum: Episiotomy and lacerations should
show signs of healing
Breastfeeding Assessment
 Nipple soreness - Peaks on days 3 and 6, then
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recedes
Cracked nipples
Allow nipples to air dry after breastfeeding
Nurse frequently
Alternate breasts
Change infant's position regularly
Breast engorgement, plugged ducts
Effect of alcohol and medications
Return to work
Weaning
Family Assessment
 Bonding: Appropriate demonstration of bonding should
be apparent
 Level of comfort: parents should display appropriate
levels of comfort with the infant
 Siblings should be adjusting to new baby
 Parental role adjustment
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Parents should be working on division of labor
Changes in financial status
Communication changes
Readjustment of sexual relations
Adjustment to new daily tasks
 Contraception: Parents understand need to choose and
use a method of contraception
Relinquishing a Baby
 Many reasons why a woman decides she cannot
parent her baby
Emotional crisis may arise as woman attempts to resolve
her concerns
 As she faces these concerns, social pressures against
giving up baby
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 Mother may need to complete grieving process to
work through her decision - she may have made
considerable adjustments to her lifestyle to give
birth
Relinquishing a Baby (cont’d)
 Nursing staff need to honor any special requests
after birth and encourage mother to express her
feelings
 Seeing newborn may assist mother in grieving
process
 Some mothers may request early discharge or
transfer to another unit