Postpartum Assessment and Care

Postpartum Period

• Begins immediately after delivery and lasts approximately 6 weeks.
• Characterized by significant physiological and psychological changes for the new mother.

Postpartum Focused Assessment: BUBBLEEE

• Comprehensive assessment tool utilized to evaluate the postpartum woman's overall well-being.

Breasts

• Assess for:
  • Fullness or engorgement
  • Nipple irritation, cracks, or bleeding
  • Discomfort
  • Mastitis (inflammation of the breast tissue)

Uterus

• Assess for:
  • Tone (firm or boggy)
  • Position (midline or deviated to the side)
  • Location (above, at, or below the umbilicus)
  • Discomfort

Bladder

• Assess for:
  • Ability to void
  • Urine retention
  • Signs of urinary tract infection (dysuria, frequency)
  • Hydration

Bowels

• Assess for:
  • Bowel sounds
  • Abdominal palpation
  • Constipation
  • Hemorrhoids

Lochia

• Assess for:
  • Amount, color, and odor of vaginal discharge
  • Presence of clots

Episiotomy/Perineum/Epidural Site

• Assess for:
  • Redness, edema, ecchymosis, discharge, and approximation (REEDA)
  • Discomfort
  • Peri-care (hygiene)

Postpartum Maternal Adaptations

• Major physiological changes occur in multiple systems to restore the body to its pre-pregnancy state.

Uterine Involution

• Process of the uterus returning to its normal size and shape following childbirth.
• Involves three key mechanisms: contraction of muscle fibers, catabolism of myometrial cells, and regeneration of uterine epithelium.
• Typically complete within 6 weeks postpartum.

Cardiovascular

• Changes in cardiovascular system stabilize after childbirth.
• Pulse rate gradually decreases to pre-pregnancy levels.
• Blood pressure returns to pre-pregnancy levels within 2 weeks.
• Blood coagulation factors remain elevated postpartum, increasing the risk of blood clots (thromboembolism).
• Observe for signs of bleeding, deep vein thrombosis (DVT), and pulmonary embolism (PE).

Musculoskeletal

• Musculoskeletal system gradually returns to pre-pregnancy state.
• Muscle aches and pains are common.
• Encourage ambulation and exercise to enhance recovery.

Integumentary

• Skin elasticity returns to pre-pregnancy state, although stretch marks may remain.
• Assess for any skin changes, including wound healing progression.

Respiratory

• Respiratory system typically returns to its normal state within days of delivery.
• Observe for respiratory rate and signs of complications (pneumonia, pulmonary embolism).

Endocrine

• Hormone levels rapidly fluctuate postpartum.
• These fluctuations can contribute to mood changes and emotional instability.
• Monitor for postpartum mood disorders.

Gastrointestinal

• Normal bowel function may be delayed due to hormonal changes and pain medication.
• Encourage dietary changes to promote regular bowel movements.
• Observe for signs of constipation and hemorrhoids.

Uterus Assessment and Interventions

• Assess uterine tone (firm or boggy)
• Assess uterine position (midline or deviated)
• Assess uterine location (above, at, or below umbilicus)
• Assess uterine pain
• Interventions:
  • Massage fundus to firm it
  • Empty bladder
  • Administer uterotonic medications
  • Provide pain management

Lochia

• Vaginal discharge composed of blood, mucus, and uterine tissue.
• Three stages:
  • Lochia Rubra (Red): First 3 to 4 days, bright red color, contains mucus, tissue debris, blood, and red blood cells.
  • Lochia Serosa (Pinkish Brown): Days 3 to 10, pinkish-brown color, contains leukocytes, decidual tissue, and serous fluid.
  • Lochia Alba (Creamy White): Days 10 to 14, up to 3-6 weeks, creamy white or light brown color, contains leukocytes, decidual tissue, and fluid content.

Lochia Assessment and Interventions

• Assess lochia each time the uterus is assessed for amount, color, odor and presence of clots.
• Interventions:
  • Massage fundus if excessive bleeding or clots are present
  • Empty bladder if necessary
  • Administer uterotonic medications to control bleeding
  • Notify provider if foul odor, heavy bleeding, and prolonged lochia rubra.

5 Causes of Postpartum Hemorrhage

• Postpartum hemorrhage is defined as blood loss exceeding 500ml for vaginal delivery and 1000ml for cesarean delivery.
• The risk of postpartum hemorrhage can be increased by:
  • Uterine atony: Relaxation of the uterine muscle
  • Retained placental fragments: Pieces of the placenta are left in the uterus after delivery
  • Lacerations of the cervix, vagina, or perineum: Tears in these tissues.
  • Uterine inversion: The uterus turns inside out
  • Disseminated intravascular coagulation (DIC): A rare but serious bleeding disorder

Cardiac

• Changes in the cardiovascular system associated with postpartum return to a pre-pregnancy state.
• Pulse rate gradually returns to pre-pregnancy levels, but can increase in cases like hypovolemia, dehydration, and hemorrhage.
• Blood pressure may decrease during the first day or two postpartum, followed by a gradual increase.
• Assess vital signs frequently for changes that may signal complications like hypotension (low blood pressure) which can be a sign of infection or hemorrhage.
• Hematocrit values (measure of red blood cells) may be affected by hemorrhage.

Coagulation

• Changes in the coagulation system, which increases the risk of blood clots.
• Pregnancy naturally promotes a hypercoagulable state to reduce blood loss during delivery, but this poses a higher risk for postpartum thrombosis.
• Blood clotting factors return to pre-pregnancy levels after approximately 3 weeks.
• Educate on prevention and treatment of DVT and PE

Blood Cellular Components

• Red Blood Cells: RBC production decreases postpartum leading to a slight decrease in hematocrit levels in the first 24 hours but returns to normal after 2 weeks.
• White Blood Cells: WBC levels increase during labor and remain elevated for 4 to 6 days, returning to baseline afterward.

Extremities Assessment and Interventions

• Assess for signs of superficial venous thrombosis and deep vein thrombosis (DVT).
• Interventions:
  • Prevent with:
    • Anti embolism stockings
    • Ambulation
    • Compression devices
    • Anticoagulation therapy.
  • Notify provider of possible thromboembolism.
• Assess for progression to pulmonary embolism.
  • Assess for signs like dyspnea (shortness of breath), chest pain, hypotension, syncope (fainting), and SOB (shortness of breath).
  • Educate on prevention and treatment long-term.
• Assess for risk factors for blood clots.
• Assess for generalized edema.
• Assess for return of sensation following epidural/spinal anesthesia.

Lactation

• Process of milk production and secretion from the breasts.
• Progesterone stimulates ductal system growth and vessels during pregnancy.
• Breastfeeding is influenced by various factors including maternal health, infant factors, and environmental factors.

Physiology of Lactation

• Hormonal changes initiate lactation.
• Prolactin, a hormone released from the pituitary gland, stimulates milk production.
• Oxytocin, another hormone released from the pituitary gland, stimulates milk ejection.
• The first milk produced, known as colostrum, is rich in antibodies and nutrients.
• Milk production and ejection are controlled by the infant's sucking and the mother's hormonal response.

Lactation Suppression

• Approximately 30% of US women do not breastfeed, many of them stop within the first two weeks.
• There is no universal guideline for lactation suppression, so women who are not breastfeeding can experience engorgement, leaking, and discomfort.
• Current recommendations include:
  • Tight, supportive bra at all times
  • Ice applications intermittently
  • Avoiding sexual stimulation
  • Avoiding nipple stimulation
  • Avoiding milk expression

Breast Assessment and Interventions

• Assess for size, contour, and symmetry.
• Interventions:
  • Provide lactation suppression education and support if the mother chooses not to breastfeed.
  • Administer medications as needed to manage engorgement and discomfort.

Maternal Adaptations to Parenthood

• Women adapt to their new maternal role through a series of phases:
  • Taking-In Phase (first 1 to 2 days): Focus on physical recovery, reliving birth experience, and bonding with the newborn.
  • Taking-Hold Phase (starts 2 to 3 days, lasts for several weeks): Increases interest in taking care of herself and the infant, but can be anxious about her ability to do so.
  • Letting-Go Phase (more established): Reestablishes relationships with others and adapts to the new role of mother, with more confidence in caring for the infant.

Attachment and Perinatal Mood Disorders

• Bonding: A unidirectional relationship from parent to newborn, begins within the first 30–60 days postpartum.

• Attachment: A bidirectional relationship between parent and newborn involving shared behaviors and interactions, like skin-to-skin contact, breastfeeding, vocalizations, and eye contact.

• Perinatal mood disorders are common in the postpartum period.

Baby Blues vs Postpartum Depression vs Postpartum Psychosis

• Baby Blues: Mild depressive symptoms that usually occur during the first 10-14 days postpartum, typically resolve independently without intervention.
• Postpartum Depression: More serious condition that typically begins within the first 6 weeks and worsens over time. Symptoms require therapeutic intervention. The condition can continue for 6 months or more.
• Postpartum Psychosis: A severe mental illness that can occur any time in the first year, but most often in the first 3 months. Symptoms include delusions, hallucinations, and thoughts of harming the baby. Hospitalization is often required.

Assessment and Interventions for Mood Disorders

• Screen for postpartum mood disorders using validated tools, such as the Edinburgh Postnatal Depression Scale (EPDS).
• Interventions:
  • Active listening to concerns regarding birth, parenting, and other stressors.
  • Referrals to mental health professionals.
  • Support groups.
  • Medications (if necessary and appropriate).

Explore key concepts of the postpartum period, focusing on the BUBBLEEE assessment tool. This quiz will cover the physiological and psychological changes new mothers experience after delivery, as well as specific assessments for breasts, uterus, bladder, bowels, and lochia.