MAIN LESSON (45 minutes)

Please refer to Chapter 17: Nursing Care of a Postpartal Family p. 396

POSTPARTAL PERIOD/ PUERPERIUM
POSTPARTAL PERIOD/ PUERPERIUM B. TAKING-HOLD PHASE
 Lat. Puer, “child,” and parere “to bring forth”  3rd to the 10th day
 6-week period after childbirth  less dependent, take a strong interest in
 retrogressive (involution of the uterus & the care of her child and make her own
vagina) and progressive (production of milk decisions but still feels insecure about her
for lactation) mothering skills
 FOURTH TRIMESTER OF PREGNANCY  give guidance and demonstrations on how
to care for her child
I. PSYCHOLOGICAL CHANGES OF THE C. LETTING-GO PHASE
POSTPARTAL PERIOD  10 days to 6 weeks
A. TAKING-IN PHASE  woman redefines her new role &
 1st 2 to 3 days postpartum motherhood functions are established
 passive and dependent  gives up her fantasized image of her
 preoccupied with her own needs child and accepts her child as a unique
 wants to talk about her pregnancy, labor and person
birth
 Touches & explores her baby
 Encourage her to talk about the birth to
help her integrate it into her life
experience
DEVELOPMENT OF PARENTAL LOVE & POSTPARTUM BLUES/BABY BLUES
POSITIVE FAMILY RELATIONSHIPS  2nd, 3rd postpartal day or within the 1st 2
 En face position- looking directly at weeks
her newborn’s face with direct eye  mood swings, anger, tearfulness, feeling
contact let-down, anorexia, insomnia,
 Engrossment- fathers staring at the NB for overwhelming sadness, feeling of
long periods of time inadequacy, mood lability
 related to hormonal changes (sudden
decrease in
  Complete rooming-in- mother and child E/P), fatigue & psychological stress
are together 24h a day related to infant dependency
 Partial rooming-in- infant remains in  Anticipatory guidance, individualized
the woman’s room most of the time support, chance to verbalize are
 Sibling preparation necessary

 resolves spontaneously
II. REPRODUCTIVE SYSTEM CHANGES
A. The UTERUS  1st postpartal day,1 fingerbreadth below
 2 processes: the umbilicus; on 2nd day, 2 fingerbreadths
 area where the placenta was implanted is below the umbilicus, and so on.
sealed off to prevent bleeding and the  By the 9th or 10th day, it can no longer be
 uterus is reduced to its approximate palpated
pregestational size  A well-contracted uterus feels firm, like a
grapefruit in size & tenseness; if it is boggy
INVOLUTION- reduction in size of the uterus after (soft & flabby), it is not contracted
delivery to prepregnant size caused by uterine
contractions that constrict or occlude underlying AFTERPAINS- uterine cramps similar to menstrual
blood vessels cramps caused by intermittent uterine
contractions after delivery; more painful in
 Immediately after birth, the uterus breastfeeding & multiparous women
weighs about 1,000g; after a week, 50g;
after involution is complete(6 weeks), Factors that enhance involution
50g  Uncomplicated labor & delivery
 Breastfeeding
FUNDUS- the top portion of the uterus; an  Early ambulation
indicator of involution  Complete expulsion of placenta &
membranes
 after delivery, fundus is palpated halfway
 Factors that slow involution
between the umbilicus & symphysis pubis,
 Prolonged labor & difficult delivery
at midline or slightly to the right.
 Anesthesia
 1 hour after, fundus will rise to the level of
 Grand multiparity
the umbilicus & remain there for 24 hours.
 Retained placental fragments
From then on, it decreases 1 fingerbreadth
 Full urinary bladder
per day (1 cm).
 Infection
 Overdistention of the uterus
LOCHIA
 should not contain large clots
 Total volume is 240 to 270 ml, gradually decreasing daily; increased by exertion or breast-feeding
 Unexplained increase in amount or reappearance of lochia rubra is abnormal

Type of Lochia Appearance Occurrence Composition Type

Lochia Rubra Dark red, bloody; 1 to 3 days Blood, mucus,
fleshy, musty, stale fragments of decidua,
odor that is non- epithelial cells, WBC’s,
offensive; may have fetal meconium,
tiny clots lanugo, vernix caseosa
Lochia Serosa Pink or brownish; 4 to 10 days Serum, RBC’s shreds of
watery; odorless decidua, WBC’s,
cervical mucus,
bacteria
Lochia Alba Yellow to white; may 11 to 21 days, my persist WBC’s. decidual cells,
have for 6 weeks in epithelial cells, fat
slightly stale odor lactating women cervical
mucus,
cholesterol,
bacteria
B. The CERVIX C. The VAGINA
 Soft, irregular & edematous; may appear  The vagina is soft, edematous, with
bruised with multiple small lacerations greater diameter & multiple small
 Both internal & external os are open lacerations
 By the end of 1 week, the external os  Low E levels postpartum lead to
has narrowed to the size of a pencil decreased vaginal lubrication &
opening (may admit 1 fingertip) and it vasocongestion for 6 to 10 weeks, which
will be firm once again can result in painful intercourse
 The internal os closes as before but the  KEGEL’s exercises will improve the
external os remains slightly open and slit- strength & tone of the vagina
like or stellate (star shaped)
D. The PERINEUM
III. SYSTEMIC CHANGES
A. The ABDOMINAL WALL D. The CIRCULATORY SYSTEM
 Soft & flabby with decreased muscle tone  Blood Volume returns to normal levels by
 DIASTASIS RECTI- may improve depending within 2
on the physical condition, number of weeks, eliminated by diuresis
pregnancies, type & amount of exercise  1st 48 hours are the time of greatest
risk for complications for clients with
B. The HORMONAL SYSTEM heart disease
 hCG & HPL are almost negligible by 24  Bradycardia of 50 to 70 bpm is common in
hours by week 1, progestin, estrone & the 1st 6 to 10 days; tachycardia is related
estradiol are at pre- pregnancy levels to blood loss, temperature elevation or
 FSH is low for about 12 days & will begin difficult, prolonged birth
to rise and initiate a new menstrual cycle  Fibrinogen remains increased for 1
 Menstruation usually resumes in 7 to 9 week increasing the risk for
weeks in thrombophlebitis
non-lactating women (90% in 12 weeks); 1 st  WBC count is up to 30,000/mm3 especially if
cycle is usually anovulatory the
 Return of ovulation varies from 2 to 18 labor is prolonged or difficult; aids
months healing & prevents infection
 Varicosities will recede but won’t disappear
C. The URINARY SYSTEM  Hemoglobin returns to normal in 2 to 6 weeks
 On palpation, a full bladder is felt as a firm
or hard area just above the symphysis E. The GASTROINTESTINAL SYSTEM
pubis  Hunger and thirst are common following
 Postpartal diuresis/Diaphoresis of 2 to 3 L birth
increases the output in the 1st 12 to 24  Risk for constipation increases due to
hours & accounts for a 5-pound weight decreased peristalsis, use of analgesics,
loss dehydration, decreased mobility during
labor, & fear of pain from having a bowel
movement
  Risk for hemorrhoids increases
because of pushing during the 2nd
stage of labor

F. The INTEGUMENTARY SYSTEM

 Stretch marks will fade over the next 6
months
 Chloasma & linea nigra will become
barely detectable in 6 weeks
III. EFFECTS OF RETROGRESSIVE CHANGES
 Exhaustion due to pregnancy, labor & delivery
 Weight loss (19 lbs from delivery to the 5th day postpartum/ initially due to diuresis, influenced by
breastfeeding,
 exercise, nutrition
IV. VITAL SIGN CHANGES
Temperature Blood Pressure

 Slight increase during 1st 24 hours due  Assess for orthostatic hypotension
to dehydration; relieved by adequate  Monitor if woman has history of
fluid intake preeclampsia
 Any woman whose oral temperature rises
above
100.4°F (38°C) excluding the 1st 24 Respirations
hours is considered febrile  Normal range is 16 to 24 breaths per minute

Pulse

 Normal postpartal range is 50 to 80 bpm

 PR is usually slightly lower than normal
& will return to normal levels at the end
of the week
 A rapid & thready pulse indicates
hemorrhage
 Pulse > 100 bpm should be reported
to the healthcare provider
V. PROGRESSIVE CHANGES
LACTATION  Advise to drink adequate fluids daily, eat
a nutritious diet and consult the doctor
 Lactation or formation of breastmilk
before ingesting alternative therapies
begins in a postpartal woman whether or
and supplements as they may be found
not she plans to breastfeed
in breast milk
 Breast milk forms in response to decrease
in E/P levels following delivery of the
placenta (which stimulates Prolactin RETURN OF MENSTRUAL FLOW
release)  With delivery of the placenta, E/P levels
decrease leading to ovulation
 Nipple stimulation leads to release of
OXYTOCIN from the pituitary gland; this  Not breastfeeding- menstrual flow returns in
stimulates the release of PROLACTIN from 6 to 8 weeks
the pituitary gland which causes production
of milk & the let-down reflex, release of  Breastfeeding- menstrual flow returns in 3
milk by the contractions of the alveoli of the to 4 mos (lactational amenorrhea) or in
breasts some, during the entire lactation period

 Primary engorgement- 3rd or 4th day as the  She may ovulate before menstruation occurs
supply of blood & lymph in the breast is
increased & transitional milk is produced;
fades as effective sucking and emptying
begins
NURSING CARE OF A WOMAN & FAMILY DURING THE 1ST 24 HOURS AFTER BIRTH
POSTPARTUM ASSESSMENT
General Considerations
1. Evaluate prenatal & intrapartal history for complications
2. Provide privacy & encourage client to void prior to assessment
3. Position client in bed with head flat for accurate findings
4. Proceed in a head-to-toe direction
5. Vital Signs
6. Monitor breath sounds & practice deep breathing & coughing exercises
Assessment 5. EPISIOTOMY OR PERINEAL LACERATIONS
1. BREASTS  Inspect the perineum for REEDA
 Determine if bottle feeding or breast feeding  Episiotomy is usually 1 to 2 in long
 Palpate for engorgement or tenderness  Inspect for hemorrhoids
 Inspect the nipples for redness, cracks &
erectility if nursing
2. UTERUS 5. LOCHIA
  Gently place the non-dominant hand on  Inspect type, quantity, odor & color
the lower uterine segment just above the
symphysis pubis; the dominant hand  Correlate findings with expected
palpates the fundus characteristics of bleeding

 Palpation should not cause pain  CS- delivered women may have less lochia

 Determine uterine firmness, height of the 6. HOMAN’S SIGN

fundus, & ascertain the position of the  Pain in the calf upon dorsiflexion of the
fundus in relation to the midline of the foot is a positive sign & may indicate
abdomen thrombophlebitis

 If the uterus is boggy, massage gently  Inspect for pedal edema, redness, or
using a gently, rotating motion to warmth; if abnormal changes are
induce contraction; administer oxytocin present, assess pedal pulse
as ordered
7. EMOTIONAL STATUS
 The fundal location must descend 1 cm  Assess if the client’s emotions are
each postpartal day appropriate for the situation

 Inspect any abdominal incisions, CS  Determine the client’s phase of

delivery, or tubal ligation, for REEDA: postpartal psychological adjustment
redness, edema, ecchymosis, discharge,
and approximation of the skin edges  Assess for postpartum blues

3. BLADDER 8. BONDING
 The client should void within 6 to 8
hours after delivery; catheterization  Describe how the parents interact with the
may be necessary if delayed & bladder infant
is distended

 Assess frequency, burning or urgency,

which could indicate UTI

 Evaluate the ability to completely

empty the bladder

 Palpate for bladder distention, if unable to

vid or complete emptying is in question

4. BOWEL
 Assess for passage of flatus

 Inspect for signs of distention

 Auscultate for bowel sounds in all 4

quadrants for postoperative patients
IMPLEMENTATION
1. PREVENT HEMORRHAGE 6. PROMOTE REST & GRADUAL RETURN
 Assess for risk factors TO ACTIVITY
 Organize nursing care to avoid
 Keep bladder empty frequent interruptions

 Gently massage fundus, if boggy;  Plan maternal rest periods when baby is
teach self- massage of uterus expected to sleep

 Administer OXYTOCIC medications if  Teach woman to resume activity gradually

ordered; oxytocin (Pitocin), over 4 to 5 weeks; avoid lifting, stair-
methylergonovine maleate climbing & strenuous activity
(Methergine), ergonovine maleate
(Ergotrate)  Simple postpartal exercises may be

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 started: Kegel’s exercises, raising the
 Monitor for side effects of oxytocics; chin to the chest,
hypotension with rapid IV bolus of
Pitocin,
hypertension with Methergine & Ergotrate
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 knee rolls, buttocks lifts
2. PROVIDE COMFORT
 Apply ice to perineum for 20 mins on/10  Increases lochia indicates overexertion;
mins off for 1st 24 hours modify exercise plan

 Encourage Sitz bath, warm or cool, TID & 7. PROMOTE ADEQUATE NUTRITIONAL INTAKE
PRN after the 1st 12 to 24 hours Add 500 kcal/day to pre-pregnancy diet; bottle-
feeding mothers should return to pre-
 Teach client perineal care after every pregnancy diet
elimination
Fluid intake of 2 liters/day
 Teach client to tighten buttocks, then sit
and relax muscles Continue prenatal vitamins & iron; iron is best
absorbed in the presence of Vitamin C & may
 Apply topical anesthetics or witch increase constipation
hazel compresses
8. PROMOTE PSYCHOLOGICAL WELL-BEING
 Monitor for side effects of morphine
epidural: late- onset respiratory depression  Encourage & support expression of
( 8 to 12 hours), N/V, itching, urinary feelings, positive & negative, without
retention, and somnolence guilt

 Encourage client to recount birth

3. PROMOTE BOWEL ELIMINATION experience to be able to integrate
 Encourage early & frequent ambulation expectations & fantasies with reality
 Encourage increased fluids & fiber  Provide recognition & praise for self- &
infant-care activities
 Administer stool softeners; suppositories
are contraindicated is client has a 3rd- or 9. PROMOTE FAMILY WELL-BEING
4th-degree perineal laceration involving  Encourage rooming-in, presence of
the rectum family members & their
participation
 Teach client to avoid straining; normal
bowel patterns return in 2 to 3 weeks  Advise resumption of sexual activities
after episiotomy has healed & lochia
4. URINARY ELIMINATION has stopped, about 3 weeks after
 Encourage voiding every 2 to 3 hrs even delivery
if no urge is felt
 Counsel the couple regarding
 Catheterize, as ordered, for urinary contraception before discharge
retention; Foley catheter for 12 to 24
hours after CS 10. PROMOTE MATERNAL SAFETY
Give RhoGAM or RhIg to Rh (-) mom not
5. PROMOTE SUCCESSFUL INFANT FEEDING sensitized (- indirect Coomb’s test)
PATTERN
Give rubella vaccine if titer is < 1:8 (0.5 ml SC)
Suppression of lactation & bottle feeding and advise to avoid pregnancy for at least 3
months
-utilize snug bra or breast binder continuously
for 5 to 7 days preventing engorgement Teach postpartum warning signs to be reported:

-avoid heat & stimulation of breasts -bright red bleeding saturating > 1 pad/hr or
passing of large clots
-apply ice packs for 20 min qid, if engorgement
occurs -temp > 100.4°F, chills, excessive pain, reddened
or warm areas of the breast, reddened or gaping
-encourage demand feedings q 3 to 4 hours, episiotomy, foul- smelling lochia
awakening during the day & allowing to sleep at
night Establishment of lactation & successful -inability to urinate; burning, frequency, or urgency
breast- feeding
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-utilize well-fitting bra for support -calf pain, tenderness, redness or swelling

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 -teach breast care including no use of soap &
air-drying nipples after feedings

-encourage nursing on demand q 2 to 3 hours,

awakening during the day 7 allowing to sleep at
night

-advise mother to nurse 10 to 15 min on 1 st breast

until the baby lets go of the 2nd; alternate the
breast used first & rotate positions

-suggest football hold or side-lying position for

moms with CS or tubal ligation to avoid discomfort

-provide help with positioning, latching-on, &

breaking suction when done nursing

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