Post Labor Nursing Care PDF

Nursing Care of a Postpartal Family NCM 107 CHAPTER 17 Psychological Changes of the Postpartal Period The postpartal period represents an important psychological transition for most. An individual who has just given birth must now assume a new role, either as a first-time parent or as a paren...

Nursing Care of a Postpartal Family NCM 107 CHAPTER 17 Psychological Changes of the Postpartal Period The postpartal period represents an important psychological transition for most. An individual who has just given birth must now assume a new role, either as a first-time parent or as a parent incorporating a new person into their family. Without proper support, postpartum depression (PPD) is more likely. Even without the added stressors of postpartum depression, there are psychological transitions that occur as a person assumes the role of caregiver to a wholly dependent newborn. Psychological Changes of the Postpartal Period In addition to discovering or redefining their own role as a caregiver to a newborn, they may also be navigating changes within a romantic relationship—both as a romantic partner and as a co-parent to this newborn if their partner will be participating in childcare. These relationship adjustments can be challenging as families figure out parenting styles, work on communication skills, and bond with their newborn, all while sleep-deprived. In total, a new parent could be struggling with ideas of their own autonomy and independence, competence as a caregiver, and relationships with other family members DEVELOPMENT OF PARENTAL ATTACHMENT, BONDING, AND POSITIVE FAMILY RELATIONSHIPS When a parent has successfully linked with their newborn, it is termed attachment bonding. Although a person carried the child inside for 9 months, they often approach the newborn not as someone they love but more as they would approach a stranger. The first time holding the infant, they may touch only the blanket. If they unfold the blanket to examine the baby or count the fingers or toes, they may use only fingertips for touch. Skin-to-skin contact soon after birth facilitates the early attachment and bonding phase. This should ideally occur within the first hour of any birth, even cesarean deliveries, as soon as the birthing parent and baby are stable and, last, at least until completion of the first breastfeeding DEVELOPMENT OF PARENTAL ATTACHMENT, BONDING, AND POSITIVE FAMILY RELATIONSHIPS Gradually, after holding the child more, they begin to express more warmth, touching the child with the palm of their hand rather than with their fingertips. They may smooth the baby’s hair, brush a cheek, play with toes, and let the baby’s fingers clasp theirs. Soon, they feel comfortable enough to press their cheek against the baby’s or kiss the infant’s nose; they have successfully bonded or become a parent tending to their child. Looking directly at the newborn’s face, with direct eye contact (termed an en face position), is a sign a parent is beginning effective attachment. Often termed engrossment, this action alerts caregivers to how actively the parents are beginning bonding DEVELOPMENT OF PARENTAL ATTACHMENT, BONDING, AND POSITIVE FAMILY RELATIONSHIPS The length of time parents take to bond with a child depends on the circumstances of the pregnancy and birth, the wellness and ability of the child to meet the parents’ expectations, reciprocal actions by the newborn, and the opportunities the parents have to interact with the child. When pregnancy or newborn complications lead to separation of the parents from their newborn, it places the birthing parent at greater risk for developing posttraumatic stress disorder and interferes with the usual process of bonding ROOMING-IN The more time a parent has to spend with their baby, the sooner they can become better acquainted with the child, feel more confident in their ability to care for their baby, and more likely form a sound parent–child relationship Rooming-in occurs when the infant remains in the birthing parent’s room and the birthing parent and child are together 23 out of 24 hours a day, for newborns born vaginally or by cesarean. ROOMING-IN With both complete and partial rooming-in, other family members can hold the infant when they visit. In many settings, a partner or support person can stay overnight in the birthing parent’s room Rooming-in and increased skin-to-skin contact have a positive impact on promoting healthy newborn bonding opportunities and breastfeeding initiation. INFANT SAFETY To improve safety immediately after birth, recent reports have highlighted the need also for continuous monitoring and observation of both the birthing parent and the newborn to reduce the risk of sudden unexpected postnatal collapse (SUPC). SUPC can occur if a newborn’s airway becomes compromised or obstructed, which can cause respiratory distress and neurologic damage and may lead to death. Nurses must take an active role to improve newborn safety with continuous monitoring and observation and thorough instruction on safe infant positioning to all family members so that the newborn is always well supported, airway is clear, and the newborn is well oxygenated  Sibling Visitation A chance to visit the hospital and see the new baby and their parent reduces feelings that their parent cares more about the new baby than about them. During the COVID-19 pandemic, sibling visitations were highly restricted, although there is hope that these visits can become a “norm” once again. The visit can help to relieve some of the impact of separation and also help to make the baby a part of the family Assess to be certain that siblings are free of contagious diseases such as upper respiratory tract illnesses and fever or other signs of contagious diseases before they visit. Then, have them wash their hands, wear a mask as a preventative measure, and, if they choose, hold or touch the newborn with parental assistance. Sibling Visitation Encourage the success of a family visit by evaluating if the parent would like to take pain medication before the visit. If they have had a cesarean delivery, protecting their abdomen with padding can decrease anxiety of the siblings about the condition of their parent. You may need to caution a patient that the opinions of a new sibling expressed by their older children may not be complimentary; for example, this baby with little hair may not be their idea of a “pretty baby.” MATERNAL CONCERNS AND FEELINGS IN THE POSTPARTAL PERIOD Typical issues that patients would like to hear discussed are breast soreness; achieving prepregnancy levels of physical fitness; regulating the demands of a job, housework, their partner, and their children; coping with emotional tension and sibling jealousy; and how to combat fatigue. Feeling Overlooked or Forgotten Many birthing parents, if given the opportunity, admit to feeling abandoned and less important after giving birth than they did during pregnancy or labor. Only hours before, after all, they were the center of attention, with everyone asking about their health and well-being. Now, suddenly, the baby is everyone’s chief interest. Relatives ask about the baby’s health; the gifts are all for the baby. Feeling Overlooked or Forgotten You can help a person move past these feelings by verbalizing the problem: “How things have changed! Everyone’s asking about the baby today and not about you, aren’t they?” These are reassuring words and help them realize that, although uncomfortable, this feeling is normal. Feeling Overlooked or Forgotten When a newborn comes home, a partner may express similar feelings as they feel resentful of the time the other parent spends with the infant. Examination of these competitive feelings can help a couple realize that parenthood involves some compromise in favor of the baby’s interests. Making infant care a shared responsibility can help alleviate these feelings and make both partners feel equally involved in the baby’s care. You can help parents or partners move past this competitive stage by pointing out positive parenting behaviors, positive self-care behaviors, and the warm infant response to their behaviors. Disillusionment All during pregnancy, they may have pictured a chubby-cheeked, curly-haired, smiling baby. They may have instead, for example, a thinner baby, without any hair, who seems to cry constantly, or may have a congenital condition. This can make it difficult to feel positive immediately toward a child who does not meet their expectations. With time, most parents come to embrace and bond with their newborn and soon cannot imagine their baby appearing other way. Nurses can help reassure parents that this can be part of a normal parent–child bonding process. Postpartal Blues During the postpartal period, as many as 50% of patients experience some feelings of overwhelming sadness or “baby blues” They may burst into tears easily or feel let down and irritable. This phenomenon may be caused by hormonal changes, particularly the decrease in estrogen and progesterone that occurred with delivery of the placenta. Postpartal Blues Breastfeeding has been shown to help elevate baby blues and counteract the effects of the hormonal drop that occurs after childbirth. For some, it may be a response to dependence and low self-esteem caused by exhaustion, being away from home, physical discomfort, and the tension engendered by assuming a new role, especially if they are not receiving support from their partner. In addition to crying, the syndrome is evidenced by feelings of inadequacy, mood lability, anorexia, and sleep disturbance. Postpartal Blues Anticipatory guidance and individualized support from healthcare personnel are important to help the parents understand that this response is normal. Give the parents a chance to verbalize their feelings. Empower the birthing parent in particular to make as many decisions as they want to help gain a sense of control and move through these emotions. Postpartal Blues Birthing parents are at greater risk (19% to 48%) for moderate to severe postpartal depression (PPD) after childbirth and require formal counseling, especially if they are economically stressed or have a comorbid condition such as diabetes. Severe psychosis also can occur in individuals during this time. PPD is one of the most underdiagnosed pregnancy-related conditions, and untreated postpartum depression has implications not only for patients but for their newborns and families. If a person appears to have a level of depression that is beyond baby blues and/or has a history of previous PPD, closer observation and referral is indicated immediately. POSTPARTUM COMPLICATION SIGNS AND SYMPTOMS Respiratory—Pain in chest, difficulty breathing Neurologic—Seizures, persistent headache, visual changes Mental health—Thoughts of hurting self or others Infection—Temperature of 100.4°F or higher, edema/redness of lower extremities, incision not healing Hemorrhage—Excessive bleeding, soaking through one pad/hour or larger than quarter size clots Call 911 Call Healthcare Provider Physiologic Changes of the Postpartal Period Retrogressive physiologic changes that occur during the postpartal period include those related specifically to the reproductive system as well as other systemic changes.  ASSESSING THE POSTPARTAL PATIENT REPRODUCTIVE SYSTEM CHANGES Involution is the process whereby the reproductive organs return to their nonpregnant state. A birthing parent is in danger of hemorrhage from the denuded surface of the uterus until involution is complete  The Uterus Involution of the uterus involves two processes. First, the area where the placenta was implanted is sealed off to prevent bleeding. Second, the organ is reduced to its approximate pregestational size. The sealing of the placenta site is accomplished by rapid contraction of the uterus immediately after delivery of the placenta. This contraction pinches the blood vessels entering the 7-cm-wide area left denuded by the placenta and halts bleeding. With time, thrombi form within the uterine sinuses and permanently seal the area. Eventually, endometrial tissue undermines the site and obliterates the organized thrombi, covering and healing the area so completely that the process leaves no scar tissue within the uterus and therefore does not compromise future implantation sites. The Uterus The same contraction process reduces the bulk of the uterus. Devoid of the placenta and the membranes, the walls of the uterus thicken and contract, gradually reducing the uterus from a container large enough to hold a full-term fetus to one the size of a grapefruit, a phenomenon that can be compared with a rubber band that has been stretched for many months and now is regaining its normal contour. The Uterus Immediately after birth, the uterus weighs about 1,000 g. At the end of the first week, it weighs 500 g. By the time involution is complete (6 weeks), it weighs approximately 50 g,similar to its prepregnancy weight. Because uterine contraction begins immediately after placental delivery, the fundus of the uterus is palpable through the abdominal wall, halfway between the umbilicus and the symphysis pubis, within a few minutes of birth. One hour later, it will rise to the level of the umbilicus, where it remains for approximately the next 24 hours.  The Uterus From then on, it decreases by one fingerbreadth, or 1 cm, per day; for example, on the first postpartal day, it will be palpable 1 cm below the umbilicus. In the average person, by the 9th or 10th day, the uterus will have contracted so much that it is withdrawn into the pelvis and can no longer be detected by abdominal palpation The Uterus The uterus of a breastfeeding parent may contract even more quickly because oxytocin, which is released with breastfeeding, stimulates uterine contractions. Breastfeeding alone, however, is not sufficient to protect against postpartum hemorrhage. The fundus is normally located in the midline of the abdomen. Assess fundal height shortly after a patient has emptied their bladder for most accurate results because a full bladder can keep the uterus from contracting, pushing it upward and increasing the risk of excess bleeding and blood clot formation in the uterus. The Uterus Involution will occur most dependably in a person who is well nourished and who ambulates early after birth as gravity may play a role. Involution may be delayed by a condition such as the birth of multiple fetuses, hydramnios, exhaustion from prolonged labor, grand multiparity, or physiologic effects of excessive analgesia. Contraction may be ineffective if there is retained placenta or membranes The Uterus An estimation of the consistency of the postpartal uterus is as important as measurement of its height. A well-contracted fundus feels so firm that it can be compared with a grapefruit in both size and tenseness. Whenever the fundus feels boggy (soft or flabby), it is not as contracted as it should be, despite its position in the abdomen. The first hour after birth is potentially the most dangerous time for a birthing parent. If the uterus should become relaxed during this time (uterine atony), they will lose blood very rapidly because no permanent thrombi have yet formed at the placental site. The Uterus In some patients, contraction of the uterus after birth causes intermittent cramping termed afterpains, similar to that accompanying a menstrual period. Afterpains tend to be noticed most by multiparas than by primiparas and by those who have given birth to large babies or have had multiple births. In these situations, the uterus must contract more forcefully to regain its prepregnancy size. These sensations are noticed most intensely with breastfeeding, when the infant’s sucking causes a release of oxytocin from the posterior pituitary, increasing the strength of the contractions. Lochia The separation of the placenta and membranes occurs in the spongy layer or outer portion of the decidua basalis of the uterus. By the second day after birth, the layer of decidua remaining under the placental site (an area 7 cm wide) and throughout the uterus differentiates into two distinct layers. The inner layer attached to the muscular wall of the uterus remains, serving as the foundation from which a new layer of endometrium will be formed. The layer adjacent to the uterine cavity becomes necrotic and is cast off as a vaginal discharge similar to a menstrual flow. This flow, consisting of blood, fragments of decidua, white blood cells, mucus, and some bacteria, is termed lochia Lochia The portion of the uterus where the placenta was not attached is so fully cleansed by this sloughing process that it will be in a reproductive state in about 3 weeks; it takes approximately 6 weeks (the entire postpartal period) for the placental implantation site to be healed. Lochia For the first 3 days after birth, a lochia discharge consists almost entirely of blood, with only small particles of decidua and mucus. Because of its mainly red color, it is termed lochia rubra. As the amount of blood involved in the cast-off tissue decreases (about the fourth day) and leukocytes begin to invade the area, as they do with any healing surface, the flow becomes pink or brownish (lochia serosa). On about the 10th day, the flow decreases and becomes colorless or white, with streaks of brownish mucus (lochia alba). Lochia alba is present in most patients until the third week after birth, although it is not unusual for a lochia flow to last the entire 6 weeks of the puerperium. Characteristics of lochia Amount: Lochia amount varies greatly among patients. Those who breastfeed tend to have less lochial discharge than those who do not because the natural release of the hormone oxytocin during breastfeeding strengthens uterine contractions. Lochial flow increases on exertion, especially the first few times a person is out of bed but decreases again with rest. Saturating a perineal pad in less than 1 hour is considered an abnormally heavy flow and should be reported. Don’t use tampons to halt the flow as this could lead to infection. Characteristics of lochia Consistency: Lochia should contain no exceedingly large clots as these may indicate that a portion of the placenta has been retained and is preventing closure of the uterine blood sinuses. In any event, large clots denote poor uterine contraction, which needs to be corrected. Pattern: Lochia is red for the first 1 to 3 days (lochia rubra), pinkish-brown from days 4 to 10 (lochia serosa), and then white (lochia alba) for as long as 6 weeks after birth. The pattern of lochia (rubra to serosa to alba) should not reverse as this suggests that a placental fragment has been retained or uterine contraction is decreasing and new bleeding is beginning. Characteristics of lochia Odor: Lochia should not have an offensive odor as this suggests that the uterus has become infected. Immediate intervention is needed to halt postpartal infection. Absence: Lochia should never be absent during the first 1 to 3 weeks as absence of lochia, like presence of an offensive odor, may indicate postpartal infection. Lochia may be scant in amount after cesarean delivery, but it is never altogether absent. The Cervix Immediately after birth, a uterine cervix feels soft and malleable to palpation. Both the internal and external os are open. Like the contraction of the uterus, contraction of the cervix toward its prepregnant state begins at once. By the end of 7 days, the external os has narrowed to the size of a pencil opening; the cervix feels firm and nongravid again. The Cervix In contrast to the process of uterine involution, in which the changes consist primarily of old cells being returned to their former position by contraction, the process in the cervix does involve the formation of new muscle cells. Because of this, the cervix does not return exactly to its prepregnancy state. The internal os closes as before, but after a vaginal birth, the external os usually remains slightly open and appears slitlike or stellate (star shaped), whereas previously, it was round. Finding this pattern on pelvic examination suggests that childbearing has taken place. The Vagina After a vaginal birth, the vagina feels soft, with few rugae, and its diameter is considerably greater than normal. It takes the entire postpartal period for the vagina to involute (by contraction, as with the uterus) until it gradually returns to its approximate prepregnancy state. Thickening of the walls appears to depend on renewed estrogen stimulation from the ovaries. Because a person who is breastfeeding may have delayed ovulation, they may continue to have thin-walled or fragile vaginal cells that cause slight vaginal bleeding during sexual intercourse for up to about 6 weeks. The Perineum Because of the great amount of pressure experienced during birth, the perineum is edematous and tender immediately after birth. Ecchymosis patches from ruptured capillaries may show on the surface. The labia majora and labia minora typically remain atrophic and softened after birth never returning to their prepregnancy state. Suggesting nonpharmacologic comfort measures such as ice or warm packs or a gentle pillow or doughnut pad to sit on are helpful interventions. Nurses should discuss with the provider about available pharmacologic pain relievers, such as acetaminophen or ibuprofen, and administer according to the prescription orders when deemed necessary or by patient request. SYSTEMIC CHANGES The same body systems that were involved in pregnancy are also involved in postpartal changes as the body returns to its prepregnancy state. The Hormonal System Pregnancy hormones begin to decrease as soon as the placenta is no longer present. Levels of human chorionic gonadotropin (hCG) and human placental lactogen (hPL) are almost negligible by 24 hours. By week 1, progestin, estrogen, and estradiol are all at prepregnancy levels (estriol may take an additional week before it reaches prepregnancy levels). Follicle-stimulating hormone (FSH) remains low for about 12 days and then begins to rise as a new menstrual cycleis initiated. The Urinary System During pregnancy, as much as 2,000 to 3,000 mL of excess fluid accumulates in the body so that extensive diaphoresis (excessive sweating) and diuresis (excess urine production) begin almost immediately after birth to rid the body of this fluid. This easily increases the daily urine output of a postpartal patient from a normal level of 1,500 mL to as much as 3,000 mL per day during the second to the fifth day after birth. This marked increase in urine production causes the bladder to fill rapidly. Reassure the patient that this is normal and they still need to continue drinking a healthy amount of fluids daily, especially if breastfeeding The Urinary System Because during a vaginal birth, the fetal head exerts a great deal of pressure on the bladder and urethra as it passes on the bladder’s underside, this may leave the bladder with a transient loss of tone that, together with the edema surrounding the urethra, decreases a patient’s ability to sense when they have to void. A patient who has had epidural anesthesia can feel no sensation in the bladder area until the anesthetic has worn off. The Urinary System To prevent permanent damage to the bladder from overdistention, assess the abdomen frequently in the immediate postpartal period. On palpation, a full bladder is felt as a hard or firm area just above the symphysis pubis. On percussion (placing one finger flat on the abdomen over the bladder and tapping it with the middle finger of the other hand), a full bladder sounds resonant, in contrast to the dull, thudding sound of non–fluid-filled tissue. Pressure on this area may make a patient feel as if they have to void, but are then unable to do so. As the bladder fills, it displaces the uterus; uterine position and lack of contraction are therefore a second good gauge of whether a bladder is full or empty. The Urinary System The hydronephrosis or increased size of ureters that occurred during pregnancy remains present for about 4 weeks after birth. The increased size of these structures, in conjunction with reduced bladder sensitivity, increases the possibility of urinary stasis and urinary tract infection in the postpartal period. The Circulatory System The diuresis that is evident between the second and fifth days after birth, as well as the blood loss at birth, acts to reduce the added blood volume that accumulates during pregnancy. This reduction occurs so rapidly, in fact, that the blood volume returns to its normal prepregnancy level by the first or second week after birth. The Circulatory System The usual blood loss with a vaginal birth is 300 to 500 mL. With a cesarean delivery, it is 500 to 1,000 mL. A 4-point decrease in hematocrit (proportion of red blood cells to circulating plasma) and a 1-g decrease in hemoglobin value occur with each 250 mL of blood lost. For example, if an average patient enters labor with a hematocrit of 37%, it will be about 33% on the first postpartal day, and hemoglobin will fall from 11 to 10 g per dL. If the patient was anemic during pregnancy, they can expect to continue to be anemic afterward. As excess fluid is excreted, the hematocrit gradually rises (because of hemoconcentration), reaching prepregnancy levels by 6 weeks after birth. The Circulatory System Patients usually continue to have the same high level of plasma fibrinogen during the first postpartal weeks as they did during pregnancy. This is a protective measure against hemorrhage. However, this high level also increases the risk of thrombus formation. There is also an increase in the number of leukocytes in the blood. The white blood cell count may be as high as 30,000 cells per mm3 (mainly granulocytes) compared to a normal level of 5,000 to 10,000 cells per mm3, particularly if labor was long or difficult. This, too, is part of the body’s defense system, a defense against infection and an aid to healing. The Circulatory System Any varicosities that are present from pregnancy will recede, but they rarely return to a completely prepregnant appearance. Although vascular blemishes, such as spider angiomas, fade slightly, they may not disappear completely. Bilateral ankle edema is not uncommon but should not progress above the knees. This decreases over time as fluid shifts and returns to the circulatory system. The Gastrointestinal System Digestion and absorption begin to be active again soon after birth unless a patient has had a cesarean delivery. Almost immediately, the patient feels hungry and thirsty and can eat without difficulty from nausea or vomiting during this time. Hemorrhoids (distended rectal veins) that have been pushed out of the rectum because of the effort of pelvic-stage pushing often are present. The Gastrointestinal System Bowel sounds are active, but passage of stool through the bowel may be slow because of the still-present effect of relaxin (a hormone which, during pregnancy, softens and lengthens the cervix and pubic symphysis for preparation of the infant’s birth) on the bowel. Bowel evacuation may be difficult because of pain if a patient has episiotomy sutures or from hemorrhoids. Encouraging the patient to eat produce and soluble fiber foods, especially fruits, will help keep the stools naturally soft and ease bowel movements The Integumentary System After birth, the stretch marks on a birthing parent’s abdomen (striae gravidarum) still appear reddened and may be even more prominent than during pregnancy, when they were tightly stretched. Typically, in people with lighter skin tones, these will fade to a pale white over the next 3 to 6 months; in people with darker skin tones, they may remain as areas of slightly darker pigment. Excessive pigment on the face and neck (chloasma) and on the abdomen (linea nigra) will become barely detectable within 6 weeks. If diastasis recti (overstretching and separation of the abdominal musculature) occurred, the space between the rectus muscles can be palpated as the patient lifts their head and shoulders while contracting their abdominal muscles. Modified sit- ups help to strengthen abdominal muscles and return abdominal support to its prepregnant level. MONITORING AND CARE FOR POSTPARTAL PHYSIOLOGIC CHANGES The overall effects of postpartal retrogressive changes are exhaustion and weight loss. Exhaustion As soon as birth is completed, a birthing parent experiences total exhaustion. For the last several months of pregnancy, they probably experienced some difficulty sleeping. All during labor, they worked hard with little or no sleep. Now, they have “sleep hunger,” which may make it difficult to cope with new experiences and stressful situations until they have enjoyed a sustained period of sleep. Weight Loss The rapid diuresis and diaphoresis during the second to fifth days after birth usually result in a weight loss of 5 lb (2 to 4 kg), in addition to the approximately 12 lb (5.8 kg) lost at birth. Lochia flow causes an additional 2- to 3-lb (1-kg) loss, for a total weight loss of about 19 lb. Additional weight loss is dependent on the amount of pregnancy weight gain and on whether a patient continues active measures to lose weight. It is also influenced by nutrition, exercise, and breastfeeding. The weight a patient reaches at 6 weeks after birth becomes their baseline postpartal weight unless they continue active measures to lose weight. Vital Sign Changes Vital sign changes in the postpartum period reflect the internal adjustments that occur as the body returns to its prepregnant state. Temperature Temperature is always taken orally or tympanically (never rectally) during the puerperium because of the danger of vaginal contamination and the discomfort involved in rectal intrusion. A patient may show a slight increase in temperature during the first 24 hours after birth because of dehydration that occurred during labor. Taking in adequate fluid during the first 24 hours allows this temperature elevation to return to normal. Most people are thirsty immediately after birth and are eager to take in fluid, so drinking a large quantity of fluid is not a problem unless they are nauseated. Temperature Any patient whose oral temperature rises above 100.4°F (38°C), excluding the first 24-hour period, is considered to be febrile, and such a high temperature may indicate that a postpartal infection is. Occasionally, when the breasts fill with milk on the third or fourth postpartum day during lactogenesis II, body temperature will rise for a few hours because of the increased vascular activity involved; this process is termed engorgement. If the elevation in temperature lasts longer than a few hours, however, infection may be the reason. Temperature An infection of the breast during lactation is termed mastitis. Those experiencing mastitis often feel breast pain or experience redness of the breast, and they will almost always have a high temperature and feel flulike symptoms such as malaise and fatigue. Mastitis can interfere with lactation, and, sometimes, an infant will refuse to nurse on the affected side. Temperature The medical provider must be notified to initiate antibiotic treatment (congruent with breastfeeding). Even with mastitis, a patient should be instructed to continue breastfeeding if the infant will breastfeed from the affected side. If the infant refuses, instruct the patient to pump to maintain flow (and to avoid clogged ducts) and then offer the affected breast after 12 to 24 hours. Once the mastitis is treated, infants often will resume breastfeeding. Unless specifically directed otherwise, infants are safe to continue to breastfeed while a patient is being treated for mastitis; there is no reason to provide alternative feeding methods or to wean because of mastitis. Pulse A patient’s pulse rate during the postpartal period is usually slightly slower than usual. During pregnancy, the distended uterus obstructed the amount of venous blood returning to the heart; after birth, to accommodate the increased blood volume returning to the heart, stroke volume increases. This increased stroke volume reduces the pulse rate to between 60 and 70 beats per minute. As diuresis diminishes the blood volume and causes blood pressure to fall, the pulse rate increases accordingly. By the end of the first week, the pulse rate will have returned to normal. Evaluate pulse rate conscientiously in the postpartal period because a rapid and thready pulse during this time could be a sign of hemorrhage. Blood Pressure Blood pressure should also be monitored carefully during the postpartal period because a decrease can also indicate bleeding. In contrast, an elevation above 140 mm Hg systolic or 90 mm Hg diastolic may indicate the development of postpartal hypertension of pregnancy, an unusual but serious complication of the puerperium To evaluate blood pressure, compare a patient’s pressure with their prepregnancy level if possible rather than with standard blood pressure ranges; otherwise, if their blood pressure rose during pregnancy, a significant postpartal decrease in pressure could be missed. Blood Pressure Uterotonics, drugs frequently administered during the postpartal period to achieve uterine contraction, cause contraction of all smooth muscle, including blood vessels Consequently, some of these drugs, particularly methergine, can increase blood pressure. Always measure blood pressure before administering one of these agents; if blood pressure is greater than 140/90 mm Hg, withhold the agent and notify the primary care provider to prevent hypertension and, possibly, a cerebrovascular accident. Blood Pressure A major complication in patients who have lost an appreciable amount of blood with birth is orthostatic hypotension, or dizziness that occurs on standing because of the lack of adequate blood volume to maintain nourishment of brain cells. To test whether a patient will be susceptible to this, assess blood pressure and pulse while they are lying supine. Next, raise the head of the bed fully upright, wait 2 or 3 minutes, and reassess these values. If the pulse rate is increased by more than 20 beats per minute and blood pressure is 15 to 20 mm Hg lower than formerly, the patient might be susceptible to dizziness and fainting when they ambulate. Blood Pressure Inform the primary care provider of these findings. Advise the patient to always sit up slowly and “dangle” on the side of their bed before attempting to walk. If they notice obvious dizziness on sitting upright, support them during ambulation to avoid the possibility of a fall. Caution them not to attempt to walk carrying the newborn until the patient’s cardiovascular status adjusts to the blood loss. PROGRESSIVE CHANGES OF THE PUERPERIUM Two physiologic changes that occur during the puerperium involve progressive changes, or the building of new tissue. Because this requires good nutrition, caution patients against strict dieting that would limit cell-building ability during the first 6 weeks after childbirth Lactation The early lactation process, which is driven by hormones from the hypothalamus to the pituitary gland in order to secrete the lactation hormones, is identified by four phases of lactogenesis (human milk production). Prolactin hormone is responsible for milk production, and oxytocin is responsible for the let-down reflex arch. A retained placenta can inhibit this process by causing continual circulation of progesterone, which inhibits prolactin and thus milk production. Lactation The lactogenesis I (milk synthesis) process begins around 16 weeks gestation as the glandular luminal cells in the breast begin secreting colostrum, a thin, watery prelactation secretion. Lactogenesis II is triggered at birth by the delivery of the placenta, when the progesterone hormone and other circulating pregnancy hormones suddenly decrease. Prolactin is no longer inhibited, and oxytocin sharply increases as a result of the infant suckling. Oxytocin helps the uterus to shrink to its prepregnancy size; some will feel uterine cramps initially when breastfeeding until the uterus fully involutes. Lactation Lactogenesis II is often when the “milk has come in” (engorgement) and occurs from birth to 5 to 10 days postpartum; this is often termed “transitional milk.” Lactogenesis III can occur from day 10 until weaning postpartum, when the “mature milk” supply is now driven by the circulating lactation hormones oxytocin and progesterone. Lactogenesis IV occurs after complete weaning and the breasts involute to their prelactation state. Other hormones are associated with breastfeeding, such as endorphins and oxytocin, and may help to mitigate and reduce the risk of developing postpartum depression Lactation The formation of breast milk (lactation) begins in a postpartal birthing parent whether or not they plan to breastfeed. Early in pregnancy, the increased estrogen level produced by the placenta stimulated the growth of milk glands; breasts increased in size because of these larger glands, accumulated fluid, and some extra adipose tissue. For the first 2 days after birth, an average birthing parent notices little change from the way that the breasts were during pregnancy because, since midway through pregnancy, colostrum secretion may have begun. On the third day after birth, the breasts become full and feel tense or tender as milk forms within breast ducts and replaces colostrum. Generally, breastfeeding complications are rare and typically stem initially from a painful latch, a problem that can be addressed quickly. Most female Americans are able to successfully breastfeed their newborn and even twins or triplets. Lactation Breast milk forms in response to the decrease in estrogen and progesterone levels that follows delivery of the placenta (which stimulates prolactin production and, consequently, milk production) and an increase in prolactin and oxytocin. The breasts become fuller, larger, and firmer as blood and lymph enter the area to contribute fluid to the formation of milk. In many,breast distention/engorgement is accompanied by a feeling of heat or tenderness Lactation During the engorgement phase, the breast tissue may appear reddened as if an acute inflammatory or infectious process were present, and some experience increased tenderness or throbbing. This feeling of tension in the breasts on the third or fourth day after birth is termed primary engorgement. It fades as the infant begins effective latching and begins transferring colostrum initially followed by milk from the breasts. Whether milk production (lactogenesis) continues will depend on an infant’s successful latch and ability to suck and transfer milk effectively, as this releases oxytocin and prolactin which promote the lactogenesis process. Lactation Primigravidas tend to have a longer initial lactogenesis phase and may not have an abundance of milk until the fourth to sixth day postpartum. This is normal and does not indicate that a person cannot breastfeed. Multigravidas’ breast milk often “arrives” quickly within the first few days, and their milk volume tends to be fuller earlier. First-time parents may need additional breastfeeding support and lots of encouragement and assurance to continue efforts to breastfeed.  Lactation Whether they continue to breastfeed after hospital discharge is influenced by such factors as lactation support, latch, milk supply, employment, personal habits, and how important they view breastfeeding to be for themselves and their newborn The tri-core lactation model is an evidence-based practice (EBP) model that can help guide nurses in providing early postpartum lactation promotion, incorporating breastfeeding support, education, and parental self-efficacy (confidence) strategies to improve the chances of a successful breastfeeding relationship with the infant Lactation A person who is breastfeeding must be certain to drink adequate fluid daily, eat a varied nutritious diet, and check with their healthcare provider before ingesting medicine or alternative therapies such as herbs because most of these can be found in breast milk and their use may not be evidence-based It is best to refer patients who are having difficulty maintaining their milk supply and wish to use herbal support (galactagogues) to an International Board Certified Lactation Constant (IBCLC).  RETURN OF MENSTRUAL FLOW With the delivery of the placenta, the production of placental estrogen and progesterone ends. The resulting decrease in hormone concentrations causes a rise in production of FSH by the pituitary, which leads, with only a slight delay, to the return of ovulation. This initiates the return of normal menstrual cycles. A person who is not breastfeeding can expect their menstrual flow to return in 6 to 10 weeks after birth. If they are breastfeeding, a menstrual flow may not return for 3 or 4 months or more (lactational amenorrhea) or, in some, for the entire lactation period. However, the absence of a menstrual flow does not guarantee that a person will not conceive during this time because ovulation may occur well before menstruation returns. Nursing Care During the First 24 Hours After Birth A birthing parent remains in a birthing room for at least the first hour after birth to become acquainted with the newborn and to allow for careful healthcare team observation. Skin-to-skin cuddling with the newborn should be encouraged as well as offering the newborn the breast to try to suckle. The birthing parent then remains in the room as a postpartal patient or is transferred to a separate postpartal room. With this, the most dangerous hour in childbearing—the first hour after birth—has passed. Nursing Care During the First 24 Hours After Birth Hemorrhage is still a possibility for the first 2 or 3 days after birth, until the myometrial vessels have sclerosed. One of the worries with home births or early release from the hospital or birthing center is that the patient and family may not appreciate how dangerous a time this is. With attention focused more on the newborn than on the birthing parent, postpartal hemorrhage could occur. In the hospital, various healthcare personnel may be involved in caring for the birthing parent: Be certain all members of your healthcare team are knowledgeable about this danger. Nursing Care During the First 24 Hours After Birth Patients may have cultural preferences such as the temperature of the room and the fluids they drink. A warm room and drink may be preferred over a cooler room and ice water. Some may choose not to shower or bathe their newborn immediately for fear that the cool water will cause illness or to reap benefits of the vernix coating. POSTPARTAL NURSING ASSESSMENT Postpartal assessment includes history, physical examination, and analysis of laboratory findings. Health History The technical aspects of pregnancy, labor, and birth can be learned from the patient’s electronic record. Most of this information is best obtained from the patient, however, because this supplies not only information on the events of the pregnancy and labor but also the patient’s emotions and impressions about them. Family Profile Information for a family profile includes age, partner and/or newborn’s nonbirthing parent, support persons, other children, type of housing and community setting, occupation, education and socioeconomic level, and other information necessary to evaluate the impact a new child will have on the patient and their family. This information also lays the foundation for teaching self- care and childcare specific to the patient’s knowledge level and needs. Pregnancy History Information for a pregnancy history includes para and gravida status (and the reason for any discrepancy), expected date of birth, whether the pregnancy was intended, and any problems or complications such as spotting or gestational hypertension that occurred during pregnancy. This information helps you gauge a patient’s potential for bonding because an unplanned pregnancy or complications arising during pregnancy can interfere greatly with bonding. Labor and Birth History It’s important to gather information on the length of labor, position of the fetus, type of birth, any analgesia or anesthesia used, problems during labor such as fetal distress, supine hypotension syndrome, and the presence of perineal sutures because this information helps in planning necessary procedures. In addition, explore the patient’s thoughts and feelings about labor and birth and whether this was a positive experience. Infant Data The sex and weight of the infant, Apgar scores, any difficulties at birth such as the need for resuscitation, plans to breastfeed or formula feed, and any congenital anomalies present are the major facts to obtain because, again, this information helps in planning care for the infant and promoting bonding with the parents. Prior to discharge, the nurse should review infant screening tests performed such as the hearing screening, the critical congenital heart defect (CCHD) test, the newborn metabolic test, and the car-seat safety test. Postpartal Course To assess a patient’s postpartal course and plan anticipatory guidance needed, ask about general health; activity level since the birth; a description of lochia; the presence of perineal, abdominal, or breast pain; difficulty with elimination; success with infant feeding; and response of a support person, partner, and/or newborn’s nonbirthing parent to parenting. Laboratory Data Patients who had a cesarean delivery, prenatal anemia, or excessive blood loss will routinely have their hemoglobin and hematocrit levels measured 12 to 24 hours after birth to determine whether blood loss at birth has left them anemic. If the hemoglobin finding is lower than 10.5 g per 100 mL, supplemental iron is usually prescribed. It’s important that postpartal anemia be detected because the responsibilities of being a new parent, coupled with the additional burden of an undetected low hemoglobin level, can severely tax a person’s energy levels and increase the risk of postpartum depression Physical Assessment During early labor, a patient is given a fairly complete physical examination. During the immediate postpartal period, therefore, repetition of a complete examination is not usually necessary. However, crucial assessments examining particular aspects of health, such as an estimation of nutrition and fluid state, energy level, presence or absence of pain, breast health, fundal height and consistency, lochia amount and character, perineal integrity, and circulatory adequacy, are required. General Appearance A patient’s general appearance in the postpartal period reveals a great deal about energy level, self-esteem, and whether they are progressing through normal adjustment to their role as a parent. Observe how much energy they use when reaching for a robe or walking to the bathroom—do they struggle or move listlessly, or do they accomplish this task quickly? Observe whether their hair is combed and they have put on their own clothing. They may be chatty and enjoy talking with the nurse and inquire about the baby’s disposition. In contrast, a birthing parent who is extremely exhausted or depressed probably will not bother with their appearance this way. An overspent patient will often not have the energy to chat and may want to avoid extra conversations Hair Many begin to lose a quantity of hair in the postpartal period because, during pregnancy, their increased metabolism caused hair to grow rapidly and many hairs to reach maturity at the same time. As their body returns to a normal metabolism level following birth, this rapid-growth hair will be lost, especially around 6 to 12 weeks postpartum. You may need to reassure a patient that hair loss is not a sign of illness but just another aspect of return to the prepregnant state. Face Assess the patient’s face for evidence of edema such as puffy eyelids or a prominent fold of tissue inferior to the lower eyelid. Normally, this should be negligible. However, in a patient who had gestational hypertension and thus accumulated excessive fluid, it will be evident. It also will become evident in a person who is developing postpartal hypertension (although this condition is rare). Facial edema is most apparent early in the morning because the patient has been lying flat with their head level during the night. Eyes Inspect the color and texture of the inner conjunctiva. If a patient is dehydrated, the area appears dry. The conjunctiva of a patient who is anemic from poor pregnancy nutrition or excessive blood loss is pale. Be alert to possible variations because of skin color, however, as dark-skinned patients may have a ruddy conjunctiva appearance even with anemia. Check the electronic record of any patient with paler than usual conjunctivae to determine whether anemia (revealed by a low hemoglobin level) is present. Breasts Breast tissue increases in size as breast milk forms. To assess breasts, ask a patient to remove their bra and cover their breasts with a towel or folded sheet to protect modesty. Ask them to raise their hands and tuck them under their head because this stretches and thins breast tissue. Inspect and then palpate for breast size, shape, and color. Breasts Breast tissue should feel soft on palpation on the first and second postpartal day. On the third day, it should begin to feel firm and warm (described as filling). On the third or fourth day, breasts appear large and reddened, with taut, shiny skin (engorgement) and, on palpation, feel hard and tense and painful. Because, normally, engorgement causes the entire breast to feel warm or appear reddened, if only one portion of a breast appears this way, inflammation or, possibly, infection of glands or milk ducts (mastitis) is suggested. It is also normal for the breast to swell into the axillary area due to lymph node swelling and/or breast tissue engorgement. This is called the tail of Spence area; reassure the patient that this finding is normal Breasts Occasionally, a firm nodule is detected on palpation. Usually, this is only a temporarily blocked milk duct preventing milk from flowing forward to the nipple. Often, hand massages and warm compresses will help to soften the nodule area. One of the best interventions for engorgement is an effective latch and to have the newborn breastfeed often from both sides initially while the milk is coming in (lactogenesis I and II). If the nodule remains troublesome, note the location of the nodule and report its presence to the primary care provider so that it can be thoroughly assessed to ascertain whether a fibrocystic or malignant growth unrelated to the pregnancy is present. Uterus For uterine assessment, position the patient supine so that the height of the uterus is not influenced by an elevated position. Observe the abdomen for contour, to detect distention, and for the appearance of striae or a diastasis. If a diastasis is present (a slightly indented groove in the midline of the abdomen), then measure the width and length by fingerbreadths. Uterus Palpate the fundus of the uterus by placing one hand on the base of the uterus, just above the symphysis pubis, and the other at the umbilicus. Press in and downward with the hand at the umbilicus until you “bump” against a firm globular mass in the abdomen: the uterine fundus Assess consistency (firm, soft, or boggy), location (midline), and height. For the first hour after birth, the height of the fundus is at the umbilicus or even slightly above it; it then decreases one fingerbreadth in size daily. Measure the distance under the umbilicus in fingerbreadths, such as “2 F↓” or 2 cm beneath the umbilicus. Uterus Never palpate a uterus without supporting the lower segment because the uterus potentially could invert (turn inside out) if not stabilized, resulting in a massive hemorrhage. If the uterus is not firm on palpation, massage it gently with the examining hand; this usually causes the fundus to contract and immediately become firm. If the uterine fundus does not grow firm with massage, extreme atony, possibly retained placenta fragments, or an excess amount of blood loss may be occurring. Notify the primary care provider. Administer oxytocin as prescribed. In addition, placing the infant at the patient’s breast will cause endogenous release of oxytocin and achieve an effect similar to that of oxytocin administration. Uterus If massage appears ineffective, the cause may be a clot present in the cavity of the uterus. This may be expressed from the uterus by gentle pressure on the fundus but only after the uterus has been massaged and is fairly firm. As mentioned earlier, if fundal pressure is applied with the uterus totally relaxed, it could cause inversion of the uterus, an extremely serious complication that leads to rapid hemorrhage. Another reason the uterus may not be well contracted is that a rapidly filling bladder is preventing contraction. If contraction remains inadequate, a lower abdominal ultrasound may be prescribed to help detect an abnormality. Uterus A patient who received no oxytocin after birth to help the uterus contract is at greater risk for poor uterine contraction than one who did receive oxytocin and thus needs frequent uterine assessment (about every 10 to 15 minutes for the first hour). Once this first hour has passed, height and consistency can be assessed less frequently, depending on institutional policy. By the 9th or 10th day after delivery, the uterus will usually have become so small that it is no longer palpable above the symphysis pubis. Lochia A patient can expect to have lochia for 2 to 6 weeks. During the first hour after birth, when the fundus is checked every 15 minutes, also remove the patient’s perineal pad and evaluate lochia character, amount, color (rubra, serosa, or alba), odor, and the presence of any clots. If the patient has perineal stitches, be certain the pad is not adhering to those before removing it. Lochia Ask the patient to turn, so you can inspect under the buttocks to be certain blood is not pooling beneath them. If you observe a constant trickle of vaginal flow or a patient is soaking through a pad every 60 minutes, they are losing more than the average amount of blood. It is concerning if the patient appears disoriented and/or vital signs are abnormal. They need to be examined by the primary care provider to be certain there is no cervical or vaginal tear or that poor uterine contraction is not causing excessive bleeding. Lochia While a patient is at the healthcare facility, inspect their lochia discharge once every 15 minutes for the first hour and then according to the institution’s policy (usually hourly for the next 4 hours and then every 8 hours after that). Make certain a patient understands that they should wash their hands after handling pads and must use only their own personal care equipment to avoid contracting or spreading infection. Lochia Encourage a patient to change perineal pads frequently as they begin self-care because lochia is an excellent medium for bacterial growth thatcould spread through the vagina to the uterus. The presence of constantly wet pads against an episiotomy suture line also slows healing. Be certain the patient knows not to use tampons until after returning for the postpartal checkup to diminish the risk of infection and possibly toxic shock syndrome and to contact the provider if they develop a fever upon returning home. Perineum While asking a patient to turn on their side to evaluate whether lochia is pooling, also inspect the perineum. If a patient has no episiotomy or a midline one, which side they turn to does not matter. With a mediolateral incision, ask the patient to turn so that the incision is on the bottom buttock because this tends to cause less pain and offers better visibility. Gently lift the upper buttock and inspect for ecchymosis, a hematoma, erythema, edema, intactness, and presence of drainage or bleeding from any episiotomy stitches Perineum Episiotomies are rarely done today because they may increase the risk of extended perineal lacerations. If stitches are present, the suture line is 1 or 2 in. long. If a laceration extends beyond the episiotomy incision, stitches may extend from the vagina back to the rectum or go into the muscle and tissues surrounding the perineal area. Before discharge, teach a patient who has stitches how to lie on their back and view their perineum with a handheld mirror, so that, once a day while at home, they can inspect their perineum for redness, sloughing of sutures, pus formation, drainage at the suture line, or development of a hematoma. Perineum Following perineal assessment, assess the rectal area for the presence of hemorrhoids. If any are present, document their number, appearance, and size in centimeters. Because postpartum patients are not on bed rest unless they have a serious complication, assess risk of skin breakdown as per facility protocol using an assessment scale such as the Braden Assessment Scale  Make certain that a patient is aware that they must return to the primary care provider for an examination 4 to 6 weeks after birth for their postpartum exam and that they should make an appointment to take the baby to a primary care provider for an examination within the first 3 to 5 days postpartum. A follow-up consultation with a community lactation consultant and lactation support group is highly recommended, especially with birthing parents who experience initial difficulties or who are breastfeeding for the first time MATERNAL IMMUNIZATIONS Recent maternal natal immunization guidelines, supported by the CDC and the American College of Obstetricians and Gynecologists, recommend that each pregnant person receive a Tdap vaccine as early as possible within the 27 to 36 weeks of gestation window with each pregnancy and seasonal influenza vaccine with each pregnancy. Determine if this was provided prenatally and, if not, inform the primary provider of the need to administer the Tdap and seasonal influenza (if applicable) vaccines prior to discharge. Other close caregivers of the newborn are also recommended to be up to date on their Tdap and influenza vaccines If a patient does not have an adequate rubella antibody titer and anticipates further pregnancies, they should also be asked if they want a rubella immunization before discharge and the provider made aware of this need. MATERNAL IMMUNIZATIONS Patients who are Rh negative and who have had an Rh-positive infant will receive Rho(D) immunoglobulin (RhIG) or Rh antibodies to prevent isoimmunization concerns in a future pregnancy. At the time of printing of this text, ACOG (2020) and the CDC (2021b) recommend that COVID-19 vaccines should not be withheld from pregnant individuals who meet criteria for vaccination based on Advisory Committee on Immunization Practices (ACIP)-recommended priority groups. POSTPARTAL EXAMINATION Every birthing parent should have a checkup by their primary care provider at 4 to 6 weeks after birth (the end of the postpartal period) to confirm they are in good health and have no residual problems from the pregnancy or signs of postpartum depression POSTPARTAL EXAMINATION During this examination, the patient’s abdominal wall is inspected for tone and to determine that uterus involution is complete and the uterus is no longer palpable abdominally. Breasts are inspected to see whether they have returned to their nonpregnant state if the patient is not breastfeeding. If they are breastfeeding, assess that they are free of nipple pain or damage and have an established milk supply; discuss any concerns regarding returning to work or school to ensure their goals of breastfeeding are successful. Most important, a thorough internal examination is performed to be certain involution is complete, the ligaments and the pelvic muscle supports have returned to functional alignment, and any lacerations sustained during birth have healed POSTPARTAL EXAMINATION Always ask about the possibility of intimate partner violence because this can increase during the postpartal period due to the added stress of adding a new family member Review the necessity of having a breast examination, Papanicolaou (Pap) smear, and pelvic examination every year as a means of screening for breast, cervical, and uterine cancer. If a patient is older than 40 years, include a discussion about the need for mammogram examinations. Encourage patients who have stopped smoking during pregnancy to continue to be smoke free as yet another good health measure for both themselves and their new child, especially if breastfeeding. POSTPARTAL EXAMINATION If reproductive life planning was not discussed immediately after birth, this visit is the opportune time for such a discussion. If a patient desires to use a diaphragm or a cervical cap, these can be fitted during this examination. Injectable progesterone (depot medroxyprogesterone acetate) also can be begun at this time or an intrauterine device (IUD) can be placed. Patients who are breastfeeding can begin on progesterone-only birth control pills, an implant, or an IUD BUBBLEHE ACRONYM B – BREAST U –UTERUS B – BLADDER B – BOWELS L – LOCHIA H – HOMAN SIGN E – EPISIOTOMY AND PERINEUM