Postpartum Care (University of Bisha) PDF

18/04/1446 Changes and care ‫الرئيسي‬ during ‫العنوان‬ postpartum Dr. Murtada Tia, RN, PhD ‫العنوان الفرعي‬ I. Physiological changes  1. REPRODUCTIVE SYSTEM a. Involution: refers to return of the reproductive organs to their non- pregnant state. It begins i...

18/04/1446 Changes and care ‫الرئيسي‬ during ‫العنوان‬ postpartum Dr. Murtada Tia, RN, PhD ‫العنوان الفرعي‬ I. Physiological changes  1. REPRODUCTIVE SYSTEM a. Involution: refers to return of the reproductive organs to their non- pregnant state. It begins immediately after delivery of the placenta ▪ Descent is documented in relation to the umbilicus. For example, U-1 or ↓1 indicates that the fundus is palpable about 1 cm (a fingerbreadth) below the umbilicus. ▪ Sub involution causes postpartum hemorrhage. b. Descent of the Uterine Fundus Immediately after delivery, the uterus is about the size of a large grapefruit and weighs approximately 1000 g. The fundus descends by approximately 1 cm, or one fingerbreadth, per day. By the 14th day, it has descended into the pelvic cavity and cannot be palpated abdominally. c. After pains Intermittent uterine contractions causes maternal discomfort. Afterpains are particularly severe during breastfeeding. Oxytocin, released from the posterior pituitary to stimulate the milk-ejection reflex causes strong contractions of uterine muscles. Nursing Considerations 1.The nurse can reassure the mother that afterpains are self- limiting and decrease in frequency and intensity by the third day. 2. Lying in a prone position with a small pillow under the abdomen helps keep the uterus contracted and provides relief. 3. Analgesics are frequently used to lessen the discomfort of afterpains. d. Lochia: uterine discharge through the vagina; it provides information about whether involution is progressing normally. Lochia rubra: dark red or red-brown from the 1st day to the 3rd day postpartum. Lochia serosa: pink or brown-tinged; it startsfrom the 4th to the 10th day postpartum. Lochia Alba: white, cream, or light yellow color; decreasing amounts; it starts from the 11th day to the 21st day postpartum.  2. CARDIOVASCULAR SYSTEM 1. Up to 500 mL of blood is lost in vaginal deliveries and up to 1000 mL is lost in cesarean births; despite that, a transient increase in maternal cardiac output occurs after childbirth. 2. Marked leukocytosis may occur, with the white blood cell (WBC) count increasing to 30,000/mm3 during labor and the immediate postpartum period. 3. Although fibrinolysis increases shortly after delivery, elevations in clotting factors continue for several days or longer, causing a continued risk of thrombus formation.  3. GASTROINTESTINAL SYSTEM 1.The new mother is usually hungry because of the energy expended in labor. She is thirsty because of decreased oral intake during labor and fluid loss from exertion, mouth breathing, and early diaphoresis. 2.Constipation is a common problem during the postpartum period due to diminished bowel tone and motility.  4. URINARY SYSTEM 1.Protein and acetone may be present in the urine for the first few postpartum days. Acetone suggests dehydration that often occurs during the exertion of labor. Mild proteinuria due to the catabolic processes involved in uterine involution. 2.The woman is at risk for bladder over distention, incomplete emptying of the bladder, and retention of residual urine. Urinary retention is more common after the first vaginal delivery, regional anesthesia, and catheterization before delivery. 3. Stress incontinence may occur during pregnancy or after giving birth.  5. MUSCULOSKELETAL SYSTEM In the first 1 to 2 days after childbirth, many women experience muscle fatigue and aches in the shoulders, neck, and arms, because of exertion during labor. Warmth and gentle massage increase circulation to the area and provide comfort and relaxation  6. INTEGUMENTARY SYSTEM 1. Striae gravidarum gradually fades to silvery lines, do not disappear. 2.Loss of hair may especially concern the woman. After childbirth, hair loss occurs 2 to 4 months following childbirth. Hair growth returns to normal within 6 to 12 months after childbirth.  7. NEUROLOGIC SYSTEM Lack of feeling in the legs and dizziness is temporary neurologic changes in case of using analgesia or anesthesia. Frontal and bilateral headaches are common in the first week postpartum as a result of changes in fluid and electrolyte balance. Pain feeling that interferes with ability to care for herself or infant.  8. ENDOCRINE SYSTEM 1. Resumption of ovulation and menstruation Although the first few menstrual cycles for lactating and non lactating women are often an ovulatory, ovulation may occur before the first menses. For some women, ovulation resumes as early as 3 weeks postpartum. Therefore, contraceptive measures are important considerations when sexual relations are resumed for lactating and non lactating women. 2. Lactation After expulsion of the placenta, estrogen and progesterone levels decline rapidly and prolactin initiates milk production within 2 to 3 days after childbirth. WEIGHT LOSS Approximately 4.5 to 5.8 kg are lost during childbirth. This includes the weight of the fetus, placenta, and amniotic fluid and blood lost during the birth. An additional 2.3 to 3.6 kg are lost as a result of diuresis and 0.9 kg to 1.4 kg from involution and lochia by the end of the first week. II. Psychological changes  Taking-In Phase ▪ During the taking-in phase, the mother is focused primarily on her own need for fluid, food, and sleep. ▪ She takes in every detail of the neonate but allow others to make decisions. ▪ Although Rubin believed that the taking-in phase lasted for approximately 2 days, it probably lasts a day or less today. ▪ The phase may be prolonged when a cesarean birth, especially in an emergency, has been necessary.  Taking-Hold Phase ▪ The mother becomes more independent during the taking-hold phase. She exhibits concern about managing her own body functions and assumes responsibility for her own care.  Letting-Go Phase The letting-go phase is a time of waiver for the mother and often for the father. If this is their first child, the couple must give up their previous role as a childless couple and acknowledge the loss of their more carefree lifestyle.  POSTPARTUM BLUES ▪ Mild depression, also known as postpartum blues, baby blues, or maternity blues, is a frequent concern for new mothers. ▪ This mild transient condition affects 60% to 80% of women who have given birth. ▪ The condition begins in the first week, peaks around day 5, and ends within 2 weeks. ▪ If it lasts beyond 2 weeks, it may be a more serious condition.  Care of a postpartum mother Postpartum assessment: It begins during the 4th stage of labor and include: Vital signs Skin color Location and firmness of the fundus, amount and color of lochia Perineum (edema, episiotomy, lacerations, hematoma) Intravenous (IV) infusions: type, rate of administration, type and amount of added medications, patency of the IV line, redness, pain, etc. III. Care of a postpartum mother  Postpartum assessment It begins during the 4th stage of labor and include: ▪ Vital signs ▪ Skin color ▪ Location and firmness of the fundus, amount and color of lochia ▪ Perineum (edema, episiotomy, lacerations, hematoma) ▪ Intravenous (IV) infusions: type, rate of administration, type and amount of added medications, patency of the IV line, redness, pain, etc. ▪ Presence, degree, and location of pain ▪ Urinary output: time and amount of last void or catheterization, presence of a catheter, color and character of urine ▪ Status of abdominal incision and dressing, if present ▪ Level of feeling and ability to move if regional anesthesia was administered Focused assessments after Vaginal Birth Nurses perform postpartum assessments according to facility protocol. For example, a protocol might require assessment as follows: ▪ Every 15 minutes for the first hour ▪ Every 30 minutes for the second hour ▪ Every 4 hours for the first 24 hours ▪ Every 8 to 12 hours thereafter Fundus ▪ The fundus should be assessed for consistency and location. It should be firmly contracted and at or near the level of the umbilicus. ▪ The location of the fundus should be rechecked after the woman has emptied her bladder. ▪ If the fundus is difficult to locate or is soft or “boggy,” the nurse stimulates the uterine muscle to contract by gently massaging the uterus. Lochia ▪ Important assessments include the amount, color, and odor of lochia. ▪ Nurses observe the lochia on peripad while checking the perineum. 1.A constant trickle, dribble, or oozing of lochia indicates excessive bleeding and requires immediate attention. 2.Excessive lochia in the presence of a contracted uterus suggests lacerations of the birth canal. 3.An absence or foul odor lochia suggests endometrial infection, and assessments should be made for additional signs of infection. These signs include maternal fever, tachycardia, uterine tenderness, and pain. Perineum The acronym REEDA is used as a reminder that the site of an episiotomy or a perineal laceration should be assessed for five signs: 1. Redness (R), 2. Edema (E), 3. Ecchymosis (bruising) (E), 4. Discharge (D), 5. Approximation (the edges of the wound should be close, as though stuck or glued together) (A). Bladder Elimination 1. Frequent voiding of less than 150 ml suggests urinary retention with overflow. Signs of an empty bladder include a firm fundus in the midline and a non- palpable bladder. 2. Two to three voiding should be measured after birth or the removal of a catheter to determine if normal bladder function has returned. Lower Extremities The legs are examined for varicosities and signs or symptoms of thrombophlebitis. Homans’ Sign. Discomfort in the calf with passive dorsiflexion of the foot is a positive Homans’ sign that may indicate deep vein thrombosis. Edema and Deep Tendon Reflexes. ▪ Pedal or pretibial edema may be present for the first few days, until excess interstitial fluid is excreted. ▪ Deep tendon reflexes should be 1+ to 2+. ▪ Report brisker-than average and hyperactive reflexes (3+ to 4+), which suggest preeclampsia.  Reference Pilliteria A., (2017): Maternal and child health nursing, care of the childbearing and childbearing family, 8th ed, page 883 - 943 ‫شكرا‬