6. Nursing Care During the Postpartum Period

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Questions and Answers

What should the nurse do if the mother's uterus is found to be poorly contracted?

Encourage the mother to ambulate immediately.

Massage the uterus until it becomes firm. (correct)

Push down on the uterus to contract it.

Apply a warm pack to the uterus.

What does a constant trickle of brighter red lochia indicate?

Excessive fluid retention.

Normal recovery process.

Possible bleeding from lacerations. (correct)

Infection in the vaginal area.

Which characteristic of lochia is considered abnormal?

Lochia rubra persisting beyond the third day. (correct)

Brief increase in lochia flow while breastfeeding.

Small clots present in lochia.

Change of lochia from serosa to alba.

What is the purpose of applying an ice pack to the perineum after childbirth?

To numb the area and reduce edema and bruising. Signup and view all the answers

When is it considered safe to resume sexual intercourse after childbirth?

When bleeding has stopped and the perineum has healed. Signup and view all the answers

Which statement regarding the postpartum period is accurate?

The postpartum period is commonly referred to as the fourth trimester. Signup and view all the answers

What specific support do adolescent mothers often require during the postpartum period?

Skills to effectively integrate with their peer group. Signup and view all the answers

What challenges do poor families face after the arrival of a newborn?

A newborn adds financial strain to already existing difficulties. Signup and view all the answers

How should nursing care be adapted for families who have multiple births?

By addressing the unique bonding and care challenges for each newborn. Signup and view all the answers

What cultural considerations are critical for postpartum care in the United States?

Acknowledgement of diverse cultural practices at significant life events. Signup and view all the answers

What is the purpose of using a sitz bath with cool water for postpartum care?

To cleanse the area and provide immediate pain relief Signup and view all the answers

What is recommended for mothers to reduce discomfort when sitting post-delivery?

Squeezing and relaxing the buttocks Signup and view all the answers

When can combined oral or transdermal estrogen-progesterone contraceptives be initiated for non-breastfeeding mothers?

About 2 to 3 weeks after delivery Signup and view all the answers

What should non-nursing mothers do to suppress lactation effectively?

Wear an elastic binder and a supportive bra Signup and view all the answers

What physiological change occurs in a woman's cardiovascular system after delivery?

Blood volume and cardiac output temporarily increase Signup and view all the answers

What does involution refer to in the context of postpartum recovery?

The return of the reproductive organs to their prepregnancy size Signup and view all the answers

Which dietary practice is associated with the 'hot' and 'cold' theory found in certain cultures after childbirth?

Classifying foods based on their believed intrinsic properties Signup and view all the answers

What is the routine frequency for postpartum assessment unless risk factors suggest otherwise?

Every 4-6 hours Signup and view all the answers

Which of the following correctly describes lochia in the postpartum period?

It changes in color and consistency from bright red to clear over time Signup and view all the answers

What is the recommended practice for employing interpreters during sensitive discussions in a healthcare setting?

Choosing interpreters who are not in social or religious conflict with the patient Signup and view all the answers

What is the primary intervention for a postpartum patient experiencing bladder distention and uterine atony?

Catheterize to empty the patient's bladder Signup and view all the answers

Which of the following assessment findings 24 hours after birth indicates a complication?

Bradycardia Signup and view all the answers

What should a nurse emphasize in discharge teaching for a patient who had a cesarean delivery compared to a vaginal delivery?

Risk of urinary tract infection due to catheter use Signup and view all the answers

Which statement regarding lochia after a cesarean delivery is accurate?

Lochia is typically less in quantity immediately after cesarean birth Signup and view all the answers

Which aspect of postpartum care is most crucial for a woman with a vertical skin incision?

Gently palpating towards the midline when checking the fundus Signup and view all the answers

What physiological changes increase the risk of blood clot formation in women postpartum?

Increased blood volume and stasis in the venous system Signup and view all the answers

What is a common cause of postpartum chills experienced by many mothers?

A release of pressure on pelvic nerves Signup and view all the answers

When postpartum vital signs are taken, which temperature reading may be normal in the first 24 hours after delivery?

38° C (100.4° F) Signup and view all the answers

What may indicate the presence of a urinary tract infection during the postpartum period?

Full bladder displacing the uterus Signup and view all the answers

What nursing intervention is recommended to assist women with urination postpartum?

Providing complete privacy and minimal interruption Signup and view all the answers

Which sign may suggest a more serious condition rather than normal postpartum recovery?

Chills accompanied by fever beyond the first 24 hours Signup and view all the answers

Which of the following factors could lead to orthostatic hypotension shortly after childbirth?

Decreased resistance to blood flow in pelvic vessels Signup and view all the answers

What common issues may arise due to postpartum constipation?

Abdominal muscle weakness Signup and view all the answers

Which exercise may a woman perform to strengthen her abdominal muscles after giving birth?

Head lifts Signup and view all the answers

What is the purpose of administering Rho(D) immune globulin (RhoGAM) to Rh-negative mothers?

To prevent sensitization to Rh-positive blood Signup and view all the answers

Why should women who receive the rubella vaccine in the postpartum period avoid pregnancy for one month?

The vaccine is teratogenic Signup and view all the answers

What is indicated by a rubella titer of 1:8 or greater during pregnancy?

Immunity to rubella virus Signup and view all the answers

What is a potential complication of Kegel exercises if performed incorrectly?

Urinary stasis Signup and view all the answers

How can a new mother best manage postpartum constipation?

Increase fiber intake Signup and view all the answers

What effect does pregnancy have on the joints of a woman postpartum?

Joint hypermobility may remain for several weeks Signup and view all the answers

What is a standard recommendation for managing abdominal wall weakness after childbirth?

Regular light abdominal exercises Signup and view all the answers

What is likely to change in a woman's body after childbirth concerning abdominal appearance?

It may initially appear doughy Signup and view all the answers

Study Notes

Postpartum Period

Postpartum period, also known as puerperium, is the 6 weeks following childbirth.
Considered the fourth trimester of pregnancy.
Focuses on the physiological and psychological changes in the mother and her family along with initial newborn care.
Postpartum care may extend beyond 6 weeks for women planning future pregnancies.

Adapting Nursing Care

Nurses must adapt care to individual circumstances, such as:
- Single or adolescent parents
- Families experiencing poverty
- Multiple births
- Families from diverse cultural backgrounds

Adolescent Mothers

Adolescents, especially younger ones, require assistance with parenting skills.
Peer group is crucial for adolescents, nurses should assist them in maintaining social connections during pregnancy and postpartum.
They often exhibit passivity in self-care and newborn care.
May face single parenthood and poverty.
Young adolescent mothers in poverty often have multiple children within a short period, exacerbating social challenges.

Single Mothers

Single women lacking a strong support system may face difficulties with postpartum adjustments.
Often required to return to work early due to being the sole provider.

Poor Families

Poor families may struggle to meet basic needs before a newborn arrives, adding strain to the family.
Women may lack adequate or consistent prenatal care, increasing the risk of complications extending into the postpartum period and impacting the child.
Families may require social service referrals to connect them with public assistance programs or other resources.

Multiple Births

Families with twins or more face unique challenges.
Newborns are more likely to require intensive care due to preterm birth, delaying parent-infant bonding and routine newborn care.
Difficulty conceptualizing the individuality of each newborn, potentially leading to viewing them as a unit.
Newborns may need care at distant hospitals for severe health issues.
Financial strain increases with each additional complication.

Cultural Influences on Postpartum Care

The United States has a diverse population with unique cultural practices, especially during significant life events like birth and death.
Nurses should tailor care to align with the health beliefs, values, and practices of the specific culture to ensure a meaningful and safe birth experience.

Using Translators

Interpreters may be necessary to facilitate understanding and provide optimal care for the woman and her family.
Utilize interpreters who are not family members to ensure accurate information and avoid selective interpretation.
Choose interpreters who are not in social or religious conflict with the patient and family.
Be cautious, a woman's affirmative nod might be a gesture of courtesy rather than understanding or agreement.

Dietary Practices

Some cultures follow the "hot" and "cold" theory of diet after childbirth.
Temperature is not a factor in classifying foods as hot or cold; it relates to the perceived intrinsic property of the food.
For example, eggs, chicken, and rice are "hot" foods.
Women may prefer hot water versus cool or cold water.
Balancing yin (e.g., bean sprouts, broccoli, carrots) and yang (e.g., broiled meat, chicken, soup, eggs) foods is a common practice.

Postpartum Changes in the Mother

Nursing Assessment
- Routinely performed every 4-6 hours unless the patient has risk factors warranting more frequent assessment.
- Assess all body systems, not just reproductive changes.
- Use the BUBBLE-HE acronym for postpartum assessment.

Reproductive System

After birth, the levels of placental hormones (human placental lactogen, human chorionic gonadotropin, estrogen, progesterone) decrease, returning the body to its pre-pregnant state.
The most significant postpartum changes occur within the reproductive system.

Uterus

Involution refers to the process of reproductive organs, especially the uterus returning to their pre-pregnancy size and condition.
The uterus undergoes rapid size and weight reduction after birth.
It should reach its pre-pregnant size within 5-6 weeks.
Subinvolution occurs if the uterus doesn't return to its pre-pregnancy state after 6 weeks.
Uterine lining (endometrium) sheds after placental detachment.
A basal layer remains to generate new endometrium for future pregnancies.
The placental site heals completely within 6-7 weeks.

Descent of the Uterine Fundus

The uterine fundus descends predictably as muscle cells contract to control bleeding and reduce cell size.
Immediately after placenta delivery, the fundus is felt midline, at or below the umbilicus, as a firm mass.
It descends about 1 cm daily after 24 hours.
Should no longer be palpable by day 10 post-partum.
A full bladder can interfere with uterine contraction, pushing the fundus upward and deviating it to the right.

Afterpains

Intermittent uterine contractions may cause afterpains similar to menstrual cramps.
Discomfort is self-limiting and diminishes rapidly within 48 hours postpartum.
More frequent in multiparas and women with overly distended uteruses.
Breastfeeding can increase afterpains due to oxytocin release.
Mild analgesics may be prescribed, but aspirin is not used as it interferes with blood clotting.

Lochia

Vaginal discharge after delivery, called lochia, consists of endometrial tissue, blood, and lymph.
Its characteristics change throughout the early postpartum period.
- Lochia rubra: Red, mostly blood, lasting 3 days.
- Lochia serosa: Pinkish, blood and mucus, lasting from day 3 - 10.
- Lochia alba: Mostly mucus, clear/colorless/white, lasting from day 10 - 21.
Lochia has a normal fleshy or menstrual odor; any foul odor should be reported.
Pads should be checked frequently to estimate the amount of vaginal discharge.
Discharge increases briefly when ambulating or breastfeeding due to uterine contraction.
Women with cesarean births have less lochia in the first 24 hours because of uterine cavity sponging.
Absence of lochia is abnormal and may indicate retained blood clots or infection.

Nursing Care (Uterus and Lochia)

Assess fundus for firmness, location, and position routinely.
Increased frequency for women with higher postpartum hemorrhage risks.
Teach women fundal assessment and report any deviations in uterine descent.
Massage a soft or boggy uterus to prevent hemorrhage.
Assist women in voiding due to full bladder contributing to poor uterine contraction.
Catheterization may be necessary if the woman cannot void.
Teach women about expected lochia changes and volume.
Report any abnormal lochia characteristics:
- Foul smell with or without fever
- Lochia rubra beyond day 3
- Unusually heavy flow
- Lochia returning to a bright red color after transitioning to serosa or alba.
Medications to promote uterine contraction:
- Oxytocin (Pitocin)
- Methylergonovine (Methergine)
Newborn suckling triggers oxytocin release and uterine contractions.
Mild analgesics provide relief for afterpains.
Report afterpains lasting beyond 48 hours.

Cervix and Vagina

Cervix
- Regains muscle tone but never fully closes to prepregnancy size.
- Some edema persists for a few weeks after delivery.
- Constant trickle of brighter red lochia indicates cervical or vaginal laceration bleeding, especially if the fundus remains firm.
Vagina
- Undergoes significant stretching during childbirth.
- Rugae (vaginal folds) disappear, and the walls become smooth and spacious.
- Rugae reappear within 3 weeks postpartum, and the vagina regains most of its pre-pregnancy form within 6 weeks but never fully returns to its pre-pregnancy size.
Nursing Care
- Discuss resumption of sexual activity after childbirth.
- Recommend waiting until bleeding stops and the perineum heals.
- Educate women about vaginal lubrication limitations in the initial weeks after childbirth.
- Instruct on Kegel exercises to strengthen pelvic floor muscles.

Perineum

Often edematous, tender, and bruised following childbirth.
An episiotomy or perineal laceration may have occurred.
Hemorrhoids commonly worsen due to birth process pressure.

Nursing Care (Perineum)

Assess for normal healing and complications using the REEDA acronym.
REEDA acronym:
- Redness
- Edema
- Ecchymosis (bruising)
- Discharge
- Approximation (of wound edges)
Focus on comfort and hygiene.
Apply ice packs for the first 24 hours to reduce edema and bruising.
Use a disposable rubber glove filled with ice chips for alternate ice pack application.
After 24 hours, apply heat via warm packs, bidets, or sitz baths to promote healing.
Teach perineal care techniques (warm water bottle, front-to-back cleansing, blotting dry).
Use peripads in a front-to-back direction to avoid fecal contamination.

Perineal Pain Treatment

Topical and systemic medications:
- Hydrocortisone and pramoxine (Epifoam)
- Benzocaine (Americaine or Dermoplast)
Witch hazel pads (Tucks) and sitz baths reduce hemorrhoid discomfort.
Teach women to squeeze their buttocks together when sitting to reduce pain.
Use an air ring (donut) or egg crate pad to relieve perineal pressure.

Interconceptual Care: Return of Menstruation and Contraception

Menstruation
- Placental estrogen and progesterone production stops at delivery, increasing follicle-stimulating hormone production.
- Menstrual cycles resume around 5 weeks post-delivery for non-breastfeeding women and 8 weeks for exclusively breastfeeding women.
Contraception
- Discuss contraception options before discharge.
- Combined oral or transdermal estrogen-progesterone contraceptives can be started 2-3 weeks postpartum in non-breastfeeding women.
- Low-dose, progestin-only contraceptives can be initiated 4 weeks postpartum for breastfeeding women.
- Avoid progestin-only contraception for breastfeeding Hispanic women with gestational diabetes due to the high type 2 diabetes risk.
- Other contraception methods can be started once lactation is well-established.
Interconceptual care refers to the 1 year period following postpartum, promoting the mother's health between pregnancies.
Ideal pregnancy spacing is approximately 2 years apart.

Breasts

Nursing and non-nursing mothers experience breast changes after birth.
Assessments are similar; nursing care differs.

Breast Changes

For the first 2-3 days, breasts are full but soft.
By day 3, they become firm and lumpy as blood flow increases, and milk production begins.
Breast engorgement may occur in both types of mothers, characterized by hard, erect, and uncomfortable breasts.
Non-nursing mothers return to normal breast size in 1-2 weeks.

Breastfeeding Care

Assess breast consistency, size, shape, and symmetry at each assessment.
Inspect nipples for redness and cracking, which can cause discomfort and pose an infection risk.
Flat or inverted nipples make breastfeeding more difficult.
Breastfeeding mothers should wear a supportive but not too tight bra.
Avoid nipple stimulation for non-nursing mothers.
Non-nursing mothers should wear bras at all times and avoid nipple stimulation.
Avoid soap on nipples, as it can cause dryness and cracking.

Cardiovascular system

The woman's cardiovascular system adapts to blood loss at delivery:
- 500 mL in vaginal birth
- 1000 mL in cesarean birth
Despite blood loss, there is a temporary increase in blood volume and cardiac output due to the return of blood from the uterus and placenta to main circulation.

Postpartum Changes

Blood volume increases due to added fluid from tissues.
Increased stroke volume leads to bradycardia.
Pulse rate can be as low as 50 to 60 beats/min for 48 hours after birth.
Excess fluid is eliminated through diuresis (up to 3000 mL/day) and diaphoresis.
Blood clotting factors are elevated during pregnancy and for 4 to 6 weeks postpartum, increasing risk of blood clots, especially with venous stasis.
Pulmonary embolus is a potential complication; dyspnea and tachypnea require immediate medical attention.
Cesarean births may include prophylactic anticoagulant therapy (heparin) and pneumatic compression devices.
Hemoglobin and hematocrit values may be difficult to interpret in early postpartum due to fluid shifts.
White blood cell count may rise to 12,000 to 20,000/mm3, a normal response to inflammation, pain, and stress.
Postpartum chills (tremors) are common, related to pressure release on pelvic nerves and epinephrine release.
Postpartum orthostatic hypotension can cause dizziness or fainting.
Vital signs should be monitored every 4 hours for the first 24 hours.
Temperature may rise to 38°C (100.4°F) during the first 24 hours.
Pulse rate is a good indicator of infection or hypovolemia.
Diaphoresis is a temporary physiological response.
Assess extremities for edema, a common occurrence after delivery.
Edema above the waist may indicate pregnancy-induced hypertension.
Assess for signs of thrombosis.
Early and regular ambulation helps prevent venous stasis and clots.

Postpartum Urinary System

Kidney function returns to normal within a month.
Decreased bladder tone and increased fluid intake can cause bladder distention.
Bladder distention can lead to postpartum hemorrhage or urinary tract infection (UTI).
Measure urine output for the first two or three voidings.
Encourage privacy and offer strategies to aid in voiding (running water, warm water, peribottle).
Burning or urgency of urination suggests UTI.

Postpartum Gastrointestinal System

Gastrointestinal function returns to normal as progesterone levels decrease.
Constipation is common due to medication, stretched abdominal muscles, pain, and dehydration.
Encourage fluids, fiber, and ambulation.
Stool softeners (docusate calcium, docusate sodium) may be prescribed.

Postpartum Integumentary & Musculoskeletal System

Skin hyperpigmentation (chloasma, linea nigra) fades with hormonal changes.
Striae fade from reddish purple to silver.
Abdominal wall muscles may appear lax; exercise can help restore tone.
Diastasis recti (separation of abdominal muscles) may persist for 6 to 8 weeks.
Joint hypermobility stabilizes within 6 weeks, but feet may remain separated.
Light exercise can begin on the first day after vaginal birth (later after cesarean).

Postpartum Immune System

Rh-negative mothers receive Rho(D) immune globulin (RhoGAM) within 72 hours of delivering an Rh-positive newborn to prevent sensitization.
Rubella vaccination is given postpartum to women who are not immune.
Rubella vaccine should not be administered if the woman is sensitive to neomycin.

Postpartum Care After Cesarean Birth

Assess descent and firmness of the fundus.
Lochia quantity is generally less after cesarean birth.
Monitor the dressing for drainage and the incision for infection.
Check the incision for REEDA (redness, edema, ecchymosis, drainage, and approximation).
Incision staples may be removed on the third day or in the healthcare provider’s office.
The woman can shower as soon as she can ambulate reliably.
A urinary catheter is usually removed within 24 hours.
Monitor urine output and observe for signs of UTI.
Auscultate lung sounds for clarity.
Encourage deep breathing, coughing to move secretions, and early ambulation.
Higher risk for thrombophlebitis, may receive prophylactic heparin and pneumatic compression devices.
Encourage leg exercises.
Pain management is critical to reduce discomfort and facilitate movement.
Assess pain severity, frequency, character, and location.
Epidural narcotics may cause respiratory depression, requiring close monitoring.

Postpartum Emotional Care

Motherhood changes: hormonal, body image, psychological acceptance of self as a mother
Postpartum blues: common, self-limiting feelings of joy and emotional letdown, lasting a few weeks
Postpartum depression: persistent unhappiness, should be reported to a health care provider
Fatigue is common: modern lifestyle requires postpartum mothers to work, care for newborns, and manage household duties
Parenthood: learning new roles and making adjustments, particularly for first-time parents who may experience changes in their relationship and communication
Fathers: often display intense interest in their newborns (engrossment), and adjust to fatherhood in four phases: having expectations, confronting reality, creating a personal father role, and reaping rewards
Siblings: adjustments vary depending on their age and developmental level, toddlers may regress or be angry, preschoolers may hesitate to touch the newborn, older children may enjoy involvement
Grandparents: involvement is often dictated by proximity to the family and their own expectations and cultural influences
Grieving parents: postpartum period is typically joyous, but nurses may care for grieving parents, therapeutic communication is important to support them
Postpartum Grief: can manifest in different ways, parents may experience regret, remorse, or guilt, anniversaries can be painful, birth of a new child can awaken grief, baptism can be performed if the newborn dies, or has a birth defect
Family Care Plan: considers the family as the patient, uses information about family structure, culture composition in providing care

Postpartum Care

Cesarean section: requires increased nursing care due to surgical procedure
Cesarean section nursing assessments: assess incision, fundal height, lochia, surgical dressings (REEDA method), urine output (indwelling catheter), fluid intake and output, pulmonary assessment (lung sounds, respiratory secretions), pain levels, leg exercises to prevent thrombophlebitis

Rubin's Theory of Psychological Changes During the Puerperium

Taking-in phase: passive, focus on personal needs and birth experience
Taking-hold phase: interest in infant care, awareness of abilities, desire to assume responsibility for self and infant care
Letting-go phase: mother integrates her new roles and identity as a mother

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Test your knowledge on essential nursing care practices during the postpartum period. This quiz covers topics such as lochia characteristics, uterine contraction, cultural considerations, and parental support. Perfect for nursing students and healthcare professionals.