POSTPARTUM PERIOD Irene L.

Gardiner, MD Maternal and Child Health Nursing FEU Institute of Nursing Postpartum Period Puerperium Puer (latin) child Parere to bring forth The 6 week period after childbirth The fourth trimester of pregnancy The period when the reproductive tract returns to the normal, nonpregnant state Goals of Postpartum Care Promote normal uterine involution and return to the nonpregnant state Prevent or minimize postpartum complications Promote comfort and healing of pelvic, perianal and perineal tissues Assist in restoration of normal body functions Increase understanding of physiologic and psychological changes Facilitate newborn care and self-care by the new mother Promote the newborns successful integration into the family unit Support parenting skills and parent newborn attachment Provide effective discharge planning, including appropriate referral for home care follow-up

Factors Affecting the Postpartum Experience The nature of labor and delivery and the birth outcome Preparation of labor, delivery and parenting Abruptness of the transition to parenthood The familys individual and collective experiences with childbearing rearing Family members role expectations Sensitivity and effectiveness of medical and nursing care Rubins Phases of Postpartum Regenaration TAKING IN PHASE First 3 days : DEPENDENT Phase Mother focuses on her own primary needs, such as sleep and food She may review her labor and delivery experience frequently Help the mother interpret the events of delivery to make them more meaningful Not a good time to teach baby care Provide rest periods and additional nutrition TAKING HOLD PHASE Days 3 10 : Dependent to INDEPENDENT PHASE More in control of independence Begins to assume the tasks of mothering Optimum time to teach about baby care

May be sensitive to feelings of inadequacy and tends to perceive suggestions as criticism

down or be irritable. Maybe due to hormonal changes (decrease estrogen & progesterone). Physiological Maternal Changes UTERINE INVOLUTION The rapid decrease in the size of the uterus as it returns to the nonpregnant state Weight decreases from 2 lbs. to 2 oz. Endometrium regenerates Fundus steadily descends into the pelvis

LETTING GO PHASE 7 days and more : INTERDEPENDENT Phase Mother may feel deep loss over separation of baby from her body May feel caught in dependent / independent role, wanting to feel safe and secure yet wanting to make decisions The woman finally redefines her new role Gives up fantasized image of her child and accepts the real one Gives up her old role of being childless or the mother of only one or two Extended and continues during the childs growing years Maternal Concerns & Feelings during Postpartum ABANDONMENT - Only hours before, they were the center of attention, with everyone asking about their health and well-being. Now suddenly, the baby is the chief interest. The woman may feel confused by a sensation very close to jealousy. DISAPPOINTMENT - It can be difficult for parents to feel positive immediately about a child who does not meet their expectations. Handle the child warmly. Comment on the child good points. POSTPARTUM BLUES (Baby blues)- 50% of women experience some feelings of overwhelming sadness. The mother burst into tears easily or may feel let

Fundal height decreases about 1 fingerbreadth (1 cm) per day By 10 days postpartum, the uterus cannot be palpated abdomionally A flaccid fundus indicates uterine atony and should be massaged until firm A tender fundus indicates infection LOCHIA Discharge from the uterus that consists of blood from the vessels of the placental site and debris from the decidua Fleshy in odor, smells like normal menstruation Discharge decreases daily in amount but may increase with ambulation RUBRA Bright red discharge from day 1 to day 3 SEROSA Brownish pink discharge from day 4 to 10 2

ALBA White discharge from day 10

to 14 CERVIX Complete cervical involution may take 3 4months After 1 week the muscle begins to regenerate but is still about 1 cm dilated Permanent change cause by childbirth the cervical os becomes slit-like or elongated VAGINA Vaginal distention decreases Smooth and swollen Rugae reappear by 3 4 weeks Muscle tone is never restored to the pregravid state PERINEUM Appears edematous and bruised Episiotomy or lacerations may be present Physiological Maternal Changes BREAST Rapid in E and P and in prolactin Colostrum is present at the time of delivery Breast milk is produced by the 3rd or 4th day Sucking of the newborn triggers the release of OXYTOCIN milk letdown and contraciton of the uterus Average amount of milk produce in 24 hrs increases with time OVARIAN FUNCTION AND MENSTRUATION

Depends on the rapidity with which the pituitary function is restored Menses resume: Within 8 weeks in nonbreastfeeding mothers Within 3 4 mos in breastfeeding mothers Women may ovulate without menstruating, so breastfeeding is not a reliable method of birth control
INTEGUMENTARY SYSTEM Chloasma, palmar erythema, linea nigra and other skin changes during pregnancy gradually disappear during the postpartum period. Striae gravidarum do not disappear and assumes a silvery white appearance. Hyperpigmentation of the areola may not disappear completely. Some women are left with a wider and darker areola after pregnancy. Linea nigra will be barely detectable in 6 weeks time GASTROINTESTINAL SYSTEM Women are usually very hungry after delivery due lo lack of food during labor and dehydration Constipation occurs due to decreased intestinal muscle tone, perineal discomfort and pain from episiotomy, hemorrhage and laceration Bowel sounds are active, but passage of stool through the bowel may be slow Hemorrhoids are common URINARY SYSTEM

May have urinary retention as a result of loss of elasticity and tone, loss of sensation in the bladder from trauma, medications, anesthesia and lack of privacy Diuresis begins within the first 12 hours of delivery MUSCULOSKELETAL SYSTEM Ambulation may be encouraged 4 8 hours after delivery Done to avoid complications, promote involution and improve emotional outlook VITAL SIGNS Temperature may be elevated within the first 24 hours because of dehydration Bradycardia is common during the first week at around 50 70 bpm Blood pressure remains stable AMBULATION Advantages of early ambulation Prevent constipation Prevent thrombophlebitis Prevent urinary problems Promote rapid recovery and return of womans strength Hastens drainage of lochia Improves GIT & GUT function Provides a sense of wellbeing REST & SLEEP The woman should rest & sleep as much as needed during the early postpartum period to overcome fatigue, excitement, anxiety & discomfort associated with long & exhausting labor & delivery. Sleep

and rest promote healing by reducing BMR and allowing O2 & nutrients to be utilized for tissue growth, healing & regeneration. Instruct the mother to avoid heavy lifting and strenous activity after discharge The woman may resume light housekeeping on the second week and can go back to normal activities by 4 to 6 weeks. RESUMPTION OF SEX Sexual intercourse can be resumed 3 to 4 weeks after vaginal delivery if : Bleeding has stopped Perineum is healed It does not cause pain to the woman NURSING RESPONSIBILITIES ASSESSMENT Monitor VS Assess height, consistency and location of fundus Monitor color, odor, & amount of lochia Assess for breast engorgement Monitor perineum for swelling or discoloration Monitor episiotomy for healing Assess incisions or dressings of CS birth client Monitor bowel status and I&O Encourage ambulation and frequent voiding Assess bonding with newborn infant Assess emotional status Postpartum Implementation 4

CLIENT TEACHING Demonstrate newborn skills as necessary Provide the oppurtunity for mothers to bathe the infant Instruct in feeding technique Instruct mother to avoid heavy lifting for at least 3 weeks Instruct the mother to plan atleast 1 rest period per day Contraception should start after delivery or with the initiation of coitus (postponed atleast until after the lochia ceases) Instruct the mother in the importance of follow up, which should be scheduled in 4-6 weeks Postpartum Implementation CLIENT TEACHING Instruct to come back immediately if with: Heavy vaginal bleeding or bright red vaginal discharge Fever Foul smelling lochia Swollen, tender, hot area on her leg Burning sensation on urination Persistent pelvic or perineal pain Postpartum Discomforts AFTERBIRTH PAINS Occurs as a result of contraction of the uterus Are more common in multiparas, those with overdistended uterus breastfeeding mothers & clients treated with oxytocin PERINEAL DISCOMFORT

Apply ICE PACKS to the perineum during the first 24 hours to reduce swelling Sitz bath after the first 24 hours EPISIOTOMY Administer perineal care after each voiding Analgesics as prescribed PERINEAL LACERATION First Degree Skin and superficial to muscle Second Degree Muscles of the perineum Third Degree Continues to anal sphincter Fourth Degree Involves the anterior anal wall BREAST DISCOMFORT FROM ENGORGEMENT Breasfeed frequently Apply warm packs before feeding Apply ice packs between feedings Wearing of support bra Ice or ice packs if not breastfeeding Use of warm soaks before feeding for breastfeeding mothers Analgesics as prescribed BREAST DISCOMFORT FROM CRACKED NIPPLES Expose to nipples to air 10 20 minutes after feeding Rotate the position of the baby for each feeding

Be sure that the baby is lached on to the areola and not just the nipple Nutritional Counselling Discuss caloric intake for breastfeeding and nonbreastfeeding mothers Nutritional needs depend on the prepregnancy weight, ideal weight for height, and whether mother is breastfeeding If breastfeeding, needs increase by approximately 500 calories per day, increased fluids, continuance of prenatal vitamins and minerals Postpartum Complications HEMORRHAGE Bleeding of 500 ml or more following delivery Causes : uterine atony, lacerations, retained placental fragments EARLY During the 1st 24 hours after delivery Caused by uterine atony, lacerations or inversion of the uterus LATE After the 1st 24 hours after delivery Caused by retained placental fragments UTERINE ATONY The inability of the myometrium to contract and constrict the blood vessels, resulting in open sinuses at the site of placental separation Cause of 80 90% of early hemorrhage

May be slow and steady or sudden and massive Bleeding may be or may not be visible BP and PR may not chenge until its too late Causes: Multiple pregnancy Hydramnios Large babies (macrosomia) Placental accidents Prolonged and difficult labor Previous uterine surgeries Deep anesthesia Endometritis Anemia History of postpartum hemorrhage Maternal age>30yrs.

NURSING MANAGEMENT Medications to stimulate uterine contractions - IM Methergine and IV Oxytocin Manual massage of the uterus to stimulate contractions Administer ice pack on the abdomen Bimanual massage. Blood transfusion. Hysterectomy - surgical removal of the uterus. If with respiratory distress from decreasing blood volume, give O2 and place in supine to allow adequate blood flow to brain and kidneys SUBINVOLUTION Uterus remains large, and soft at 4 to 6 weeks postpartum. Incomplete return of the uterus to its prepregnant size and shape. Lochia is still present.

CAUSES OF SUBINVOLUTION Endometritis or postpartal infection Retained placental fragments Accompanying problem like myoma Any factor that interferes with complete contraction SYMPTOMS OF SUBINVOLUTION Lochia fails to progress and remains red Leukorrhea with backache and infection CYSTITIS Infection of the urinary bladder Lower abdominal pain, burning and pain on urination, increased frequency of urination, fever, costovertebral angle tenderness Forced fluids up to 3L/day, institute measures to assist to void, encourage fequent and complete emptying of the bladder Urinalysis, antibiotics as prescribed VULVAR HEMATOMA Localized collection of blood into the tissues of the reproductive sac after delivery Abnormal, severe pain, pressure in the perineal area with discolored skin, signs of shock (pallor, tachycardia, hypotension) Monitor VS, place ice at hematoma site, prepare for incision and evacuation of hematoma, ligation of bleeders Administer analgesics, antibiotics or blood products as required INFECTION

Any infection of the reproductive organs that occurs within 28 days of delivery or abortion Fever, chills, pelvic discomfort or pain, vaginal discharge, elevated WBC count Monitor VS, antibiotics as prescribed MASTITIS Inflammation of the breast as a result of infection Seen in breastfeeding mothers 2-3 weeks after delivery but may occur anytime during lactation Localized heat and swelling, pain, elevated temperature, flu-like symptoms Advise good handwashing and breast hygiene techniques, warm or cold packs, encourage breastfeeding, use of support bra, analgesisc and antibiotics as prescribed PULMONARY EMBOLISM The passage of thrombus, often originating in one of the uterine or pelvic veins, into the lungs, where it disrupts the circulation of blood Dyspnea, tachypnea, tachycardia, cough, rales, hemoptysis, pleuritic chest pain, feeling of impending doom Give O2, head of the bed elevated, monitor VS, streptokinase and anticoagulants as prescribed

THROMBOPHLEBITIS

 Formation of a clot in the vessel wall due to inflammation of the vessel wall Partial obstruction of the vessel can occur Increased blood-clotting factors Superficial, femoral, pelvic Elevate legs, never massage, monitor for signs of pulmonary embolism Warm packs, analgesics and heparin as prescribed
POSTPARTUM BLUES Condition is caused by physiological and emotional stress The mother may feel upset and depressed at times Verbalization should be encouraged May progress to postpartum depression if unresolved PP Blues ONSET 1 12 days after birth PP Depression 1-12 months after birth PP Psychosis Within 1st mo after birth Delusions of hallucinations 1-2%of all births

SYMPTOMS Sadness, tears Anxiety, feeling of loss, sadness INCIDENCE 70% of all births 10% of all births

POSSIBLE Probable Hx of previous activation of previous ETIOLOGY hormonal depression,hormonal mental illness family hx changes,stress response, lack of of bipolar d/o of life changes social support THERAPY Support and Counselling; drug Psychotherapy; drug empathy therapy therapy NURSING ROLE Offering Referring to compassion & counseling understanding Referring to counseling,safeguarding mother from injury to self or to newborn 8