Module 8 Postpartum Period 2024.pdf

NCM 107 – Care of the Mother, Child and Adolescent S.Y. 2024-2025 | 1st Semester | Mid Term Module 8: Care of the Mother during Postpartum Period Description This module presents the physiological and psychological c...

NCM 107 – Care of the Mother, Child and Adolescent S.Y. 2024-2025 | 1st Semester | Mid Term Module 8: Care of the Mother during Postpartum Period Description This module presents the physiological and psychological changes that occur in a postpartum woman and her family. The postpartal period refers to the 6-week period after childbirth and sometimes referred to as the stage four of labor and delivery. It is a time of physical and psychological adjustment for the mother and her family. The nurse’s knowledge and care provided during this stage can have a life-long impact in shaping the new family. Learning Outcomes LO1 Integrate knowledge of physiological and psychological changes during postpartum stage and application of appropriate nursing care to the mother and the newborn. LO3 Assess the physiologic and psychological changes of the postpartum woman and her family. LO4 Formulate nursing diagnosis/es related to physiologic and psychological transition of the postpartal period. LO5 Implement safe and quality nursing interventions to aid the progression of physiologic and psychological transitions occurring in a postpartal woman and family LO7 Evaluate with the mother and family the health outcomes of nurse-client relationship. Module Outline I. Physiological and Psychological changes during postpartal period II. Physiology of Lactation III. Nursing Diagnoses related to postpartal period IV. Outcome Identification and Planning V. Evaluating nursing care Module 8: Care of the Mother during Postpartum Period 1  Module I. Physiological and Psychological changes during postpartal period Involution is the process whereby the reproductive organs return to their nonpregnant state. Physiological and psychological changes happen in the body of the woman. Vital signs changes in the prostpartum period reflect the internal adjustments that occur as a woman’s body returns to its prepregnant state (Table 1). 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 woman may show a slight increase in temperature during the first 24 hours after birth because of dehydration that occurred during labor. If she receives adequate fluid during the first 24 hours, this temperature elevation will return to normal. Most women are thirsty immediately after birth and are eager to take in fluid. This makes drinking a large quantity of fluid not a problem unless the woman is nauseated from a birth anesthetic. Any woman whose oral temperature rises above 100.4° F (38° C), excluding the first 24-hour period, is considered to be febrile. In such women, a postpartal infection may be present. Occasionally, when a woman’s breasts fill with milk on the third or fourth postpartum day, her temperature rises for a period of hours because of the increased vascular activity involved. If the elevation in temperature lasts longer than a few hours, however, infection is a more likely reason. An infection during lactation is known as mastitis. Infection is a major cause of postpartal mortality and morbidity. Because nurses play a major role in assessing postpartum temperature, they have the important role of being the health care providers who may first detect the problem. Pulse A woman’s pulse rate during the postpartal period is usually slightly slower than normal. 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 Module 8: Care of the Mother during Postpartum Period 2 rate conscientiously in the postpartal period, because a rapid and thready pulse during this time could be a sign of hemorrhage. Be certain to compare a woman’s pulse rate with the slower range expected in the postpartal period, not with the normal pulse rate in the general population. Otherwise, this important finding of hemorrhage may be missed. Blood Pressure Blood pressure should also be monitored carefully during the postpartal period, because a decrease in this can indicate bleeding. In contrast, an elevation above 140 mm Hg systolic or 90 mm Hg diastolic may indicate the development of postpartal pregnancy-induced hypertension, an unusual but serious complication of the puerperium. To evaluate blood pressure, compare a woman’s pressure with her prepregnancy level, if possible, rather than with standard blood pressure ranges; otherwise, if her blood pressure rose during pregnancy, a significant postpartal decrease in pressure could be missed. Oxytocics, drugs frequently administered during the postpartal period to achieve uterine contraction, cause contraction of all smooth muscle, including blood vessels. Consequently, these drugs can increase blood pressure. To prevent blood pressure from rising too high, always measure it before administering one of these agents. If the blood pressure is greater than 140/90 mm Hg, withhold the agent and notify the woman’s physician or nurse-midwife to prevent hypertension and, possibly, a cerebrovascular accident. A major complication in women 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 woman will be susceptible to orthostatic hypotension, assess her blood pressure and pulse while she is 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 woman might be susceptible to dizziness and fainting when she ambulates. Advise her to always sit up slowly and “dangle” on the side of her bed before attempting to walk. If she notices obvious dizziness on sitting upright, support her during ambulation to avoid the possibility of a fall. Caution her not to attempt to walk carrying her newborn until her cardiovascular status adjusts better to her blood loss. Inform the woman’s physician or nurse-midwife of these findings. Module 8: Care of the Mother during Postpartum Period 3 Table 1. Normal postpartum vital signs. Vital signs Normal Findings Abnormal Findings Temperature Slight increase during the first 24 Above 38° C is postpartal infection: hours due to dehydration mastitis Pulse Slight slower due to dieresis; Rapid, thready pulse could be a increased stroke volume sign of hemorrhage Blood pressure Normal A Decrease is due to bleeding An increase is due to postpartal hypertension or oxytocic drugs Respirations Normal A significant increase suspect pulmonary embolism or bleeding To further assist with the postpartum assessment and to understand physiological and psychological changes, the mnemonic BUBBLE-HE is commonly used to guide nursing practice. BUBBLE-HE reminds the nurse to assess breasts, uterus, bladder, bowel, lochia and episiotomy, Homan’s sign, and emotional status and initiation of infant bonding. A. Breasts Breast milk forms in response to the decrease in estrogen and progesterone levels that follows delivery of the placenta which stimulates prolactin (milk producing hormone) and oxytocin (milk ejection hormone). A woman’s breasts become fuller, larger, and firmer as blood and lymph enter the area to contribute fluid to the formation of milk. In many women, breast distention is accompanied by a feeling of heat and tenderness. During engorgement, the breast tissue may appear reddened as if an acute inflammatory or infectious process were present and some mothers experience increased tenderness and throbbing. The feeling of tension in the breasts on the third or fourth day after birth is termed as primary engorgement. Interventions: 1. Encourage the mother to wear support bra at all times, even while she is sleeping. 2. Empty the breasts regularly 3. Encourage the use of warm soaks or a warm shower before feeding for the breastfeeding mother. Module 8: Care of the Mother during Postpartum Period 4  4. Encourage the use of ice packs between feedings if the client is not breast-feeding. Use of ice packs diminishes milk supply for breastfeeding mother. 5. Administer analgesics as prescribed if comfort measures are unsuccessful. 6. Engorgement usually resolves within 24-36 hours after it begins B. Uterus and cervix Involution of the uterus involves two processes. First, the area where the placenta is sealed off to prevent bleeding and second, the organ is reduced to its approximate pregestational size. The sealing of the placenta is accomplished by rapid contraction of the uterus after the delivery of the placenta. This contraction pinches the blood vessels entering the 7-cm wide area left denuded by the placenta and seals the area. The same contraction process reduces the bulk of the uterus. The weight of the uterus decreases from approximately 900 g to 57 grams in 6 weeks. The fundus steadily descends into the pelvis by about 1cm/day so that by 10th postpartum day, the uterus cannot be palpated abdominally (Fig. 1). The fundus is normally located at the midline of the abdomen. Assess the fundal height shortly after a woman has emptied her 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. Figure 1. Uterine involution. The uterus decreases in size at a predictable rate during the postpartal period. After 10 days, it recedes under the pubic bone and is no longer palpable. The first hour after birth is potentially the most dangerous time for a woman. If her uterus should become relaxed during this time (uterine atony), she will lose blood rapidly because no permanent thrombi have yet formed at the placental site. The uterus must be maintained well contracted by: Module 8: Care of the Mother during Postpartum Period 5  1. Massage uterus until well contracted. 2. Breastfeed the baby to allow the release of oxytocin. 3. Empty the bladder. 4. Apply ice pack to the fundus 5. Administer oxytocin as prescribed if interventions are unsuccessful Immediately after birth, a uterine cervix is soft and malleable. Both the internal and external os are open. Like 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. Unlike the uterus, the cervix does not return exactly to its prepregnant state. The external os usually remains slightly open appears slit-like, whereas previously, it was round. In some women, contraction of the uterus after birth causes intermittent cramping termed after pains. After pains tend to be noticed most by multipara, who gave birth to large babies and multiple births, since the uterus must contract more forcefully to regain its prepregnancy size. This sensation is also common among breastfeeding, when oxytocin is released increasing the strength of the contractions. C. Bladder During pregnancy, as much as 2,000 to 3,000 ml of excess fluid accumulated in the body to extensive diaphoresis (excessive sweating) and dieresis (excessive urine production) begin almost immediately after birth to rid the body of this fluid. This easily increase the daily urine output of a postpartal woman form a normal level of 1,500 ml to as much as 3,000 ml/day during the second to fifth day after birth. The mother may have urinary retention as a result of loss of elasticity and tone and loss of sensation in the bladder from trauma, medications, anesthesia or lack of privacy. D. Bowel 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 softens and lengthens the cervix and pubic symphysis for preparation of infant’s birth during pregnancy) on the bowel. Bowel evacuation may be Module 8: Care of the Mother during Postpartum Period 6  difficult because of pain if a woman has episiotomy sutures or from hemorrhoids (distended rectal veins that have been pushed out of rectum because of the effort of pelvic stage pushing often are present). Interventions: 1. Encourage adequate intake of fluids (2,000 ml/day) 2. Encourage diet high in fiber since digestion and absorption begin to be active again as soon after delivery. The woman usually feels hungry and thirsty, and she can eat without difficulty. 3. Encourage ambulation 4. Administer stool softener, laxative, enema, or suppository if needed and prescribed. E. 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 uterine discharge similar to a menstrual flow. This uterine flow, consisting of blood, fragments of decidua, white blood cells, mucus, and some bacteria, is known as 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’ time. It takes approximately 6 weeks (the entire postpartal period) for the placental implantation site to be healed. The type of lochia is summarized below: Type of Lochia Color Postpartal Day Composition 1. Lochia rubra Red 1-3 Blood, fragments of decidua, and mucus 2. Lochia serosa Pink 3-10 Blood, mucus, and invading leukocytes 3. Lochia alba White 10-14 Largely mucus; leukocyte (may last 6 weeks) high Module 8: Care of the Mother during Postpartum Period 7  The following are the characteristics of a normal lochia: 1. Always present whichever the manner of delivery. 2. Discharge should smell like a normal menstrual flow. A foul-smelling discharge indicates infection. 3. Discharge decreases daily in amount. Saturating a menstrual pad is heavy bleeding which requires referral to the doctor. 4. Discharge may increase with ambulation The amount of lochia can be described as follows: 1. Scant: less than 2.5 cm (