Nursing Care Postpartum Assessment

Chapter 9: Nursing Care and Assessment After Birth

• Class Objectives:
  • Individualize postpartum and newborn nursing care for diverse patients.
  • Understand cultural beliefs impacting postpartum and newborn care.
  • Describe postpartum maternal system changes and associated nursing care.
  • Modify assessments and interventions for cesarean births.
  • Address emotional needs of postpartum individuals and families.

Puerperium (p. 216)

• Postpartum period, lasting 6 weeks after childbirth.
• Sometimes referred to as the fourth trimester of pregnancy.

Nursing Considerations for Specific Groups of Patients

• Adolescents: Require help with parenting skills, support from peers, and connection with social workers. Often lack financial support and family support in some cases.
• Lone Parents: Require access to support systems, social workers, and potentially more time off from work due to financial limitations.
• Families with Poverty: Require social services referrals.
• Homelessness: Need connection to social workers and support systems, including housing and outreach programs.
• LGBTQ2+ Families: Require support and resources available in their community.
• Families with Twins (Multiples): May experience challenges with multiple medical needs and different hospital stays, impacting bonding with the baby and support systems.
• Important Considerations for specific groups, including cultural factors.

Cultural Influences on Postpartum Care

• Communication: Use interpreters when necessary to avoid cultural or religious conflicts between the patient's family or religious background and the interpreter.
• Written Material: Ensure written materials are available in the correct language.
• Dietary Practices: Be mindful of cultural dietary practices (some cultures have specific dietary restrictions after childbirth).

Postpartum Changes

• Physiological and psychological changes occur immediately after birth.
• Nurses must assess all body systems, not just the reproductive system.
• BUBBLLEE is a specific postpartum assessment:
  • Breasts
  • Uterus
  • Bladder
  • Bowel
  • Lochia
  • Episiotomy/Laceration/Incison (evaluation and assessment)
  • Legs
  • Emotions/bonding

BUBBLLEE- Table 9.1

• Breasts: observe for redness, tenderness, sore nipples, fullness
• Uterus: assess for the bladder distention if the fundus is located off midline
• Bladder: assess for burning or pain on urination.
• Bowel: assess for bowel sounds, hemorrhoids, constipation.
• Lochia: note clots, and heavy blood loss.
• Legs: note swelling, assess for pain, which may indicate venous thromboembolism (VTE).
• Episiotomy/Laceration/Incison: assess with REEDA (Redness, Edema, Ecchymosis, Drainage, Approximation)
• Emotions: assess for signs of the "blues" or bonding.

Clinical Assessment

• Vital Signs: Blood pressure, pulse, respiratory rate, temperature. Any observed abnormalities need to be noted and assessed to evaluate for a possible co-morbidity, pain, pre-eclampsia, shock, or infection.

Reproductive System

• Uterus:

  • Involution (returns to pre-pregnancy size and condition within 6 weeks).
  • Uterine lining changes (from "endometrium" to "decidua," healing within 6-7 weeks).
  • Afterpains (intermittent contractions similar to menstrual cramps).

• Cervix: Regains muscle tone but does not fully close.

• Vagina: Stretches; rugae (vaginal folds) disappear and walls become smooth; rugae reappear within 3 weeks post-delivery. Returns to pre-pregnancy size within 6 weeks but may not return to the exact size before pregnancy.

• Breasts: Engorgement (increased blood and lymph supply leading to fullness) occur 2-3 days postpartum; breastfeeding is recommended to subside this. Assessment for pain relief should be implemented.

• Lochia:

  • Vaginal discharge post-birth, composed of endometrial tissue, blood.
  • Stages:
    • Rubra (red, first 3–4 days)
    • Serosa (pinkish-brown, days 3–10; may last up to 25 days)
    • Alba (white/yellowish, typically begins around the 10th day, lasting 4–6 weeks)

• Abnormal Lochia: Foul odor, unusually heavy flow, return to bright red after other stages.

• Cervix: Regains muscle tone but never fully closes as it did prior to pregnancy.

• Vagina: Rugae (folds) diminish but the walls become smooth and more spacious. Returns to pre-pregnancy form in 6 weeks and resumes normal size gradually.

• Breasts: Engorgement occurs due to increased blood and lymph supply, leading to milk production. Nursing or expressing milk helps relieve engorgement.

• Reproductive System: Perineum, episiotomy, care, and pain management, as well as postpartum return to ovulation and menstruation (typically 6-8 weeks if not breastfeeding).

Adaptation of Care Following Cesarean Birth

• Similar to vaginal deliveries, except including abdominal dressing monitoring.
• Lochia generally is observed to be less profuse.
• Urinary catheter may be used.
• Respiratory care.
• Prevention of thrombophlebitis (swollen or inflamed veins due to blood clots).
• Pain management is frequently required.

Emotional Care

• Rubin's Stages of Postpartum Adjustment

  • Taking-in: 24-48 hours- passively receiving care and support.
  • Taking-hold: 2-10 days or weeks- increasing assertiveness and control.
  • Letting-go: ongoing- adjusting to life with a new baby and a changing lifestyle.

• Postpartum Blues/Depression

• Perinatal Mood and Anxiety Disorders (PMADs):

• Fatigue (needs for sleep when baby sleeps).

Parenthood

• Communication Issues between partners, division of responsibility, and fatigue or stress levels often lead to conflict.
• Loss of freedom and decreased socialization may cause feelings of loneliness.

Other Family Members

• Siblings: Reactions vary based on the child's age; parents need to be prepared for possible behavioral changes in older children.
• Grandparents: Interactions and support can vary; open communication is beneficial in preparing grandparents for caring for the baby.

Family Care Plan

• Studying the family and the patient together provides insight into community-care needs.

Discharge Planning

• Begins on admission.
• Often begins before mothers are psychologically ready.
• Clinical pathways can and should be used to guide the process.
• 'Teachable moments' and written materials/online resources need to be provided as a reference and support in postpartum care.

Postpartum Self-Care

• Hygiene: Showering, care of self, and perineal care until bleeding stops.
• Diet and Exercise: Healthy diet, high fiber, and moderate exercise.
• Follow-up Appointments: Typically 6 weeks post-birth.
• PMAD Screening: Essential for early identification and intervention.
• Danger Signs: High fever, foul lochia odor, bright red bleeding after lochia change, pain, large clots, VTE, breast tenderness and pain, SOB, headache, and other acute signs and symptoms need to be reported immediately to a healthcare professional.

Nutrition for 3rd or 4th Degree Laceration

• High-fiber diets and adequate fluids prevent constipation-related perineal issues.

Breasts

• First 2-3 days postpartum, breasts are full but soft.
• Day 3, breasts become firm and lumpy due to increased blood flow and milk production.
• Engorgement occurs in both nursing and non-nursing mothers.
• Nipples should be assessed for redness and cracking and appropriate measures recommended.
• Support bra should be used.

Pain

• Potential sources of pain: Perineum, uterus, breasts, and hemorrhoids.
• Pain management strategies: Ice, heat, and medication.

Cardiovascular System

• Cardiac output and blood volume: Increase of approximately 50% during pregnancy.
• Normal blood loss: 300-500 mL in vaginal deliveries, 500-1000 mL in cesarean sections.
• Increased elimination: Diaphoresis and diuresis can occur due to elevated blood and fluid levels.
• Other changes: Orthostatic hypotension, elevated coagulation factors, and return to normal blood values within 8 weeks.
• Chills: Result from a sudden release of pressure on the pelvic nerves and vasomotor response from epinephrine in the delivery process.

Urinary System

• Full bladder can displace the uterus, leading to postpartum hemorrhage.
• Kidney function returns to normal within one month.
• Strategies for voiding: privacy, avoidance of rushing, warm water to perineal area.

Gastrointestinal System

• Constipation: Increased fluid and fiber intake, along with increased activity like walking can improve constipation issues.

Integumentary System

• Hyperpigmentation: Skin changes due to hormonal fluctuations.
• Linea Gravidarum: (pregnancy line) fades.
• Striae: Stretch marks fade to silver in color.

Musculoskeletal System

• Diastasis recti: Separation of abdominal muscles is normal after pregnancy, but exercises and physical therapy can help address this.
• Hypermobility of the joints: Joints may be more lax postpartum, but strengthening exercise can ease this.
• Specific post-partum exercises: Abdominal muscle tightening, head lift, pelvic tilts, and Kegel exercises.

Immune System

• Blood Incompatibilities and Infection Prevention: Rho(D) immune globulin should be administered to Rh-negative pregnant people and the baby is Rh-positive.
• Immunizations: Immunizations for rubella should be given or verified from the previous.