The Postpartal Family: Adaptation and Nursing Assessment Needs and Care

Postpartum Uterine Changes Uterine cells will atrophy Uterine debris in the uterus is discharged through lochia Lochia rubra is red (first 2-3 days) Lochia serosa is pink (day 3 to day 10) Lochia alba is white (continues until the cervix is closed)

Involution of the uterus Involution of the uterus. Immediately after delivery of the placenta, the top of the fundus is in the midline and approximately two thirds to three-fourths of the way between the symphysis pubis and the umbilicus

Postpartum Cervical and Vaginal Changes Cervix is spongy, flabby, and may appeared bruised External os may have lacerations and is irregular and closes slowly Shape of the external os changes to a lateral slit Vagina may be edematous, bruised with small superficial lacerations Size decreases and rugae reappear within 3-4 weeks Returns to prepregnant state by 6 weeks

Perineal Changes and Return of Menstruation Perineum may be edematous, with bruising Lacerations or an episiotomy may be present Menstruation generally returns between 6 and 10 weeks (nonbreastfeeding

Postpartum Abdominal and Breast Changes Loose and flabby but will respond to exercise Uterine ligaments will gradually return to their prepregnant state Diastasis recti abdominis Striae will take on different colors based on the mother’s skin color Breasts are ready for lactation

Postpartum Bowel Changes Bowels will be sluggish Episiotomy, lacerations, or hemorrhoids may delay elimination

Postpartum Bladder Changes Increased bladder capacity Swelling and bruising of tissues around the urethra Decrease in sensitivity to fluid pressure Decrease in sensation of bladder filling Urinary output is greater due to puerperal diuresis Increased chance of infection due to dilated ureters and renal pelves

Postpartum Changes in Vital Signs Temperature may be elevated to 38C for up to 24 hours after birth Temperature may be increased for 24 hours after the milk comes in BP rises early and then returns to normal Bradycardia occurs during first 6-10 days

Postpartum Changes in Lab Values Nonpathologic leukocytosis occurs in the early postpartum period Blood loss averages 200-500 mL (vaginal), 700-1000 mL (cesarean) Plasma levels reach the prepregnant state by 4-6 weeks postpartum Platelet levels will return to normal by the 6th week Diuresis Cardiac output returns to normal by 6-12 weeks

Postpartum Weight Changes Initial weight loss of 10-12 lbs Postpartum diuresis causes a loss of 5 lbs Return to their prepregnant weight by the 6th to 8th week

Maternal Psychological Adjustment “Taking In” “Taking Hold”

The mother has direct face-to-face and eye-to-eye contact in the en face position.

Postpartum Blues Transient periods of depression; sometimes occurs during the first few days postpartum Mood swings Anger Weepiness Anorexia Difficulty sleeping Feeling let down

Causes of Postpartum Blues Changing hormones Lack of supportive enviornment

Cultural Influence in the Postpartum Period Non-Western cultures emphasize postpartum period Food and liquids after birth Hot-cold balance Role of grandmother

Principles of Conducting a Postpartum Assessment Selecting the time that will provide the most accurate data Providing an explanation of the purpose of the assessment Ensuring that the woman is relaxed before starting Recording and reporting the results clearly Body fluid precautions

Postpartum Assessment B – Breasts U – Uterus B – Bowel B – Bladder L – Lochia E – Episiotomy/Lacerations

Postpartum Assessment (continued) H – Homans’/Hemorrhoids E – Emotions

Breast Assessment Size and shape Abnormalities, reddened areas, or engorgement Presence of breast fullness due to milk presence Assess nipples for cracks, fissures, soreness, or inversion

Abdominal Assessment Position of fundus related to umbilicus Position of fundus to midline Firmness Assess incision for bleeding, approximation, and signs of infection

Measuring the descent of the fundus for the woman having a vaginal birth. The fundus is located two fingerbreadths below the umbilicus. Always support the bottom of uterus during any assessment of fundus

The uterus becomes displaced and deviated to the right when the bladder is full.

Assessment of Lochia and Perineum Assess lochia for amount, color, and odor Presence of any clots Wound is assessed for approximation, redness, edema, ecchymosis, and discharge Presence of hemorrhoids Level of comfort/discomfort Efficacy of any comfort measures

Assessment of Extremities, Bowel, and Bladder Homan’s sign Assess calf for redness and warmth Adequacy of urinary elimination Bladder distention and pain during urination Intestinal elimination Maternal concerns regarding bowel movements

Assessment of Psychological Adaptation and Nutrition Adaptation to motherhood Fatigue Nutritional status Cesarean birth Return of bowel function Tolerance of dietary progression

Physical and Developmental Tasks Gain competence in caregiving Confidence is role as parent Return of all physical systems to prepregnant state

The father experiences strong feelings of attraction during engrossment.

Factors that Influence Parent-Infant Attachment Family of origin Relationships Stability of the home environment Communication patterns The degree of nurturing the parents received as children

The Postpartal Family: Needs and Care

Nursing Responsibilities for Client Teaching Assess educational needs Develop and implement a teaching plan Evaluate client learning Revise plan as needed

Postpartal Teaching Mom topics Baby topics

Uterine Well-Being and Comfort Measures Assess uterus Assess lochia Afterpains Positioning Ambulation Analgesics

Perineal Well-Being and Comfort Measures Assess perineum Perineal care Ice packs Surgigator® Analgesics

Comfort Measures Diaphoresis Suppression of lactation Well-fitting bra Cold compresses or cabbage leaves Anti-inflammatory medication

Pharmacologic Interventions Rubella vaccine RhoGAM

Emotional Stress Interventions Encourage mothers to tell birth stories Maternal role attainment

Rest and Activity Provide opportunities for rest Encourage frequent rest periods Resumption of activity Avoid heavy lifting Avoid frequent stair climbing Avoid strenuous activity

Postpartal Family Wellness Family-centered care Information Time for interaction Supportive environment

Resumption of Sexual Activity Resume after episiotomy healed and lochia stopped Lubrication may be required Contraception Potential limiting factors Fatigue Demands of the infant

Parent-Infant Attachment Incorporate family goals in care plan Postpone eye prophylaxis for 1 hour after delivery Provide private time for the family to become acquainted Encourage skin-to-skin contact Encourage mother to tell her birth story

Parent-Infant Attachment Encourage involvement of the sibling Prepare parents for potential problems with adjustment Initiate and support measures to minimize fatigue Help parents identify, understand, and accept feelings

Care of the Mother after Cesarean Birth Minimize complications Deep breathing and incentive spirometry Ambulation Pain management Rest Minimize gas pains

Pharmacologic Management of Pain Epidural analgesia PCA

Needs after Discharge Increased need for rest and sleep Incisional care Assistance with household chores Infant and self-care Relief of pain and discomfort

Parent-Infant Attachment Factors that hinder attachment Physical condition of the mother and the newborn Maternal reactions to stress Anesthesia Medications Newborn safety

Nursing Care of the Adolescent Postpartum hygiene Contraceptive counseling Newborn care Include family in teaching Positive feedback

Post-discharge Adolescent Needs Child care Transportation Financial support Nonjudgmental emotional support Education regarding newborn care and illness Education regarding self-care

Care of the Mother who Relinquishes her Infant Active listening Provide nonjudgmental support Show concern and compassion Personalize care for the mother

Early Discharge Signs of possible complications Rest and activity Resumption of sexual activity Referral numbers for questions Contact information about local agencies or support groups Bottle or breastfeeding information

Early Discharge (continued) A scheduled postpartal and newborn well-baby visit Procedure for obtaining the birth certificate Newborn care Signs and symptoms of infant complications