1. By Khadeejeh Al dasoqi 2015\2016
Postpartum care
By Khadeejeh Al dasoqi
2015\2016

2. Definition
Postpartum refers to the first 6 weeks following delivery, the time during which the woman’s reproductive organs return to their normal, non-pregnant state.
The general care of the postpartum client is similar to that of other clients.
Observe the woman’s overall state, appetite, activity, patterns of sleep and rest, and interactions with her newborn.
Assess the client’s vital signs.
Postpartum women are usually discharged from the hospital within a day or two.

3. Precautions Postpartum infection Postpartum hemorrhage
Pregnancy induced hypertension
Blood clot formation
Opening up of incisions
Breast problems
Postpartum depression.

4. Postpartum care in the hospital
The initial phase: the first one to two hours after delivery in the birthing room or in a recovery room.
Initial postpartum assessment:
Pain
The condition of the uterus
Vaginal discharge (lochia)
The condition of the perineum
The presence/absence of bladder distension *should be done every 15 minutes for the first hour, then generally every 30 minutes for the second hour, and every four to eight hours thereafter depending on facility policy.

5. Sources of pain
Incisions, lacerations, and uterine cramping (afterbirth pains)
Muscle pain after a prolonged labor.
Calf pain: thrombophlebitis.
Headache: pregnancy induced hypertension
Epidural anesthesia: spinal headache: due to the loss of CSF from the subarachnoid space.
Breast engorgement
A plugged duct

6. Involution
The process by which the reproductive organs return to their nonpregnant state is called involution.
Immediately after delivery, the uterus weighs approximately 2 pounds (900 g) and is about the size of a grapefruit. It can be felt at the level of, or slightly below, the umbilicus. After delivery, it begins to return to its normal position and smaller size. When this process is complete, the uterus will weigh about 2 ounces (50 g) and will be low, at or near the center of the pelvic cavity.

7. Involution
During the postpartum period, the uterus should be positioned midline and feel firm to the touch. The height of the fundus indicates the progress of involution. By palpating the abdomen, the fundus can be located; measure its height in finger widths above or below the umbilicus. Normal involution is occurring when the fundus descends one finger width each day.

8. Abnormal findings of involution
• If the uterus is deviated to the side, suspect a distended bladder. Increased bladder size will prevent the uterus from contracting, and will contribute to excessive bleeding. The uterus should contract after the client voids.
• A soft or boggy uterus indicates relaxation of the uterine muscles and is also a danger sign.

9. Lochia
Normally the flow of lochia continues for 3 to 4 weeks, with the following gradual changes:
Lochia rubra is seen for the first 2 days. It is mostly red and bloody. It should smell like blood (slightly metallic); a foul odor indicates infection.
Lochia serosa starts after the bleeding diminishes. The color of the lochia changes to pink or brown-tinged for approximately the next 7 days. Lochia serosa has a slightly earthy odor.
Lochia alba, which is yellow or white, starts on about day 10. At this point, the lochia has decreased greatly in amount. Lochia alba also has an earthy smell.

10. Lochia
The amount of lochia after delivery should be about the same as the blood flow during normal menstruation.
Abnormal findings include:
Large clots
Foul odor
Lochia that does not change color and characteristics as described
Record the amount, color, and any other characteristics that may be significant. Teach the client to report abnormal lochia.

11. Cervix and Vagina. The cervix is soft and edematous following delivery
Cervix and Vagina. The cervix is soft and edematous following delivery. It constricts and firms during the postpartum period. The vagina, too, regains muscle tone, and lacerations and episiotomies heal. The vagina and vulva lose their congested, purplish color and return to their pre-pregnant pinkish hue.
Relief of perineal discomfort:
Application of cold packs
Application of warm packs to the
Rinsing of the perineal area with warm water after every void and/or bowel movement.
Use of anesthetic sprays and creams..
Sitting in a sitz bath

12. Episiotomy and Perineum
The client should turn on her side to facilitate a better view of the perineal area. If the client has had an episiotomy or lacerations, examine the area carefully to determine the healing process.
Make certain the perineum is intact. You may need a flashlight; the mother will need a mirror. The episiotomy and any lacerations should appear clean, with very slight edema. The sutures should not be pulling against the tissue. Note any hemorrhoids to initiate measures to alleviate them.

13. Episiotomy and Perineum
Abnormal findings include:
Inflammation
Redness
Discharge from the episiotomy or lacerations
Hematomas
Ecchymosis
Edema

14. Bladder
Pregnancy and labor place added strains on a woman’s urinary system. The abdominal muscles may be weakened. In addition, bruising and swelling of the urethra and general loss of muscle tone are common. The involution process places an increased demand on the kidneys and bladder, as the mother’s fluid balance is restored. Because of these factors, new mothers may have stress incontinence or difficulty voiding.
Palpate the bladder for a rounded bulge in the suprapubic region, which indicates distention. By questioning the client regarding voiding, you can gain information related to urinary symptoms.

15. Abnormal urinary system findings include
Voiding in small amounts
Residual urine
Dysuria
Bladder infection
Urinary retention

16. Gastrointestinal System
 The mother may be constipated for 1 to 2 weeks following delivery because the abdominal muscles have been stretched, and the intestines have been inactive.
Whether or not the mother had hemorrhoids during pregnancy, she may have problems with them after the birth.

17. Extremities
To check for thrombophlebitis, the client’s legs should be exposed. Ask the client to straighten her legs on the surface of the bed and to flex her feet toward her face. Abnormal findings in the legs include:
•  Redness, pain, and swelling along the path of a vein may indicate a superficial thrombophlebitis.
•    Pain behind the knee on flexion of the feet indicates a positive Homans’ sign and suggests thrombophlebitis.

18. Breasts
Changes in the breasts following childbirth prepare for the newborn’s nourishment. During the last half of pregnancy and the first few days postpartum, the breasts produce colostrum, a thin yellowish secretion that provides vitamins and immune substances that protect the newborn against infection. On about the second or third day postpartum, the breasts begin to secrete milk.

19. Breasts
Each time a newborn is put to a breast, milk is secreted. Lactation, the production of milk, occurs because of the release of two hormones: prolactin and oxytocin. As the newborn sucks the nipple, a reflex reaction occurs whereby the posterior pituitary gland releases oxytocin, which stimulates cells to produce milk and to move it to the milk ducts. The oxytocic hormone also results in uterine contractions, and mothers often experience abdominal cramping while breastfeeding. This entire process is commonly known as the “letdown reflex”; the milk is said to “let down” or “come in.” Because the risks outweigh the benefits, medications to suppress lactation are rarely given to nonbreastfeeding mothers.

20. Breasts
For the first few days, the breasts should be soft. The nipples should be intact, without drying, cracking, or fissures. When the milk comes in, the breasts will feel full and firm to touch. Abnormal breast findings are listed below:
• Engorgement is the response of the breasts to the presence of an increased volume of milk and a sudden change in hormones. It usually occurs on the third to fifth postpartum day. The breasts become tender, swollen, hot, and hard. The swelling may extend into the axilla. The breasts may look shiny and red. The woman may experience a headache, breast discomfort, and a slight temperature elevation at this time

21. ENGORGEMENT
The following measures help to relieve the nursing mother’s engorgement:
♦    Wearing a supportive bra
♦    Frequent breastfeeding
♦    Applying warm packs to the breast for 15 minutes before nursing or standing in the shower with warm water spraying on the breast for 15 minutes before nursing.

22. ENGORGEMENT
The following measures can help to relieve the nonnursing mother’s engorgement:
♦    Wearing a supportive bra
♦    Avoiding excessive fluid intake
♦    Placing cold packs on her breasts three to four times per day
♦    Avoiding stimulation (e.g., hot shower spray)
♦    Avoiding manual expression or pumping her breasts
♦    Using medications (usually acetaminophen) as prescribed for discomfort

23. Client Teaching
Client teaching begins early (at the time of admission) because mothers are often discharged a short time after delivering. The mother receives instruction in these aspects of self-care: • Breast care and nursing • Perineal care and care of the stitches • Fundus observation • Fluid intake • Voiding • Ambulation • Engorgement • Involution