Postpartum Assessments and Care (Part 1) PDF

Bachelor of Science (Honours) in Nursing (53455-3) SN3180 – Childbearing Family Nursing Postpartum Assessments and Care (Part 1) Maternal Physiological & Psychological Changes in the Puerperium Dr. Lo, Shirley Ph.D., LL.B, RM, RN 2024 ...

Bachelor of Science (Honours) in Nursing (53455-3) SN3180 – Childbearing Family Nursing Postpartum Assessments and Care (Part 1) Maternal Physiological & Psychological Changes in the Puerperium Dr. Lo, Shirley Ph.D., LL.B, RM, RN 2024 Learning outcomes: Toward the end of the lectures, students will be able to: - ▪ Describe the essential changes in puerperium ▪ Physiological changes and adaptations ▪ Psychological changes and adaptations ▪ Understand the relevant nursing assessments and interventions to support postpartum families ▪ Understand and support breastfeeding of the infant ▪ Identify and promote appropriate approaches in family planning Outline of the upcoming 3 lectures: I. Maternal physiological and psychological changes in the puerperium II. Nursing assessments and care in the puerperium III. Breastfeeding and family planning  The puerperium: Fourth Trimester 6 weeks post-childbirth 1-12 weeks 13-27 weeks 28-40 weeks What is puerperium & why it is so important? ▪ Puerperium is defined as Starts immediately after delivery of the placenta and membranes, and continues for 6 weeks (42 days), also known as postpartum period or the fourth trimester of pregnancy ▪ Considerable adaptations, both physiological and psychological, occur towards returning to the pre- or non-pregnant state - 1. The woman recovers from her labour, which often leaves her exhausted, but it is also a period of relief and joyfulness 2. The woman undergoes important psycho-physiological experience in her lifetime – becoming a mother and needing to take care of another human being (the newborn) 3. Breastfeeding (if preferred) should be established 4. The woman should decide, with healthcare professionals’ guidance, on an appropriate contraceptive method The baby is the candy, the mom is the wrapper. Once the candy is out of the wrapper, the wrapper is cast aside … Alison Steube, MD Postpartum physiological changes: 1. Reproductive System 2. Endocrine system 3. Cardiovascular System 4. Respiratory System 5. Digestive System 6. Excretory System 7. Musculoskeletal System 8. Integumentary System 9. Immune System  Postpartum physiological changes: 1. Retrogressive changes (return to pre-pregnancy state), and 2. Progressive changes (initiation of lactation) Uterus: Involution – the process whereby the reproductive organs return to their non-pregnant state. The woman is in danger of hemorrhage from the uterus until involution is complete. Uterine involution ▪ Immediately after delivery of placenta, the uterine fundus should be firm and contracted under the influence of hormonal changes: ▪ Withdrawal of placental hormonals ▪ Decreased level of oestrogen and progesterone ▪ Increased level of Oxytocin ▪ The fundal height is palpated in midline, at or near to the maternal umbilicus, 1-2 hrs after delivery ▪ Uterus is larger following C-section and in multiparous women  Descent of the uterine fundus: ▪ Then the fundal height will decrease by ~1cm (1 finger- breath) per day ▪ D3: about 3cm below the umbilicus ▪ D6: halfway between the umbilicus and the symphysis pubis ▪ By D10, it descends into the pelvis and can no longer be palpated abdominally ▪ Note that a flaccid fundus indicates uterine atony and should be massaged until it firms up ▪ A tender fundus may indicate an infection Whitmer (2016) Murray & McKinney (2019, p.459) Uterine involution involves 3 processes: 1. Contraction of uterine muscle ▪ Postpartum hemostasis is achieved primarily by compression of intra-myometrial blood vessels as the uterine myometrial spiral muscle contracts – stops bleeding especially at the placental site ▪ Exogenous oxytocin is usually administered IV or IM immediately after expulsion of the placenta ▪ Breastfeeding increases the release of oxytocin thereby decreases blood loss and reduces the risk for postpartum hemorrhage (Lawrence & Lawrence, 2011) ▪ Decreases uterine size Uterine blood vessels and muscle fibres: Blood vessels open when A mussels relax Blood vessels shut when B mussels contract Copyright @ Murray & McKinney (2019) Afterpains (afterbirth pain) ▪ Intermittent uterine muscle contractions (under the effects of oxytocin) and cause uncomfortable cramps, and usually last for 2-3 days after delivery ▪ More noticeable or acute after births of macrosomic infant, multifetal gestation, polyhydramnios (over distended uterus) because the uterus has been over distended ▪ More intense in a multipara than a primipara ▪ Mothers who are breastfeeding and/or having received oxytocin can intensify afterpains (strong contractions of the uterine muscles) ▪ Typically resolve in 3 to 7 days The process of uterine involution (2) 2. Autolysis ▪ With the release of proteolytic enzyme after expulsion of placenta, process of autolysis (self-digestion of excess hypertrophied tissue) begins: muscle cells diminish in size, but not in number ▪ Excess protein produced from autolysis is absorbed into the bloodstream and excreted in the urine The process of uterine involution (3) 3. Regeneration of uterine epithelium – ▪ Outer portion: expelled together with placenta ▪ Inner portion: separate into 2 layers within 2-3 days postpartum: ▪ Superficial layer – slough off into lochia ▪ Basal layer – contains ‘residual endometrial glands’ – remain intact as endometrium  Healing at the placental site The placental site during separation. (A) Uterus and placenta before separation. (B) Separation begins. (C) Separation is almost complete. Regeneration at the placental site usually takes 6 weeks to complete after birth (Blackburn, 2013)  Cervical changes ▪ Immediately after childbirth, the cervix is dilated, oedematous and bruised. ▪ Internal os: by the end of 2nd week, it should be closed as before ▪ External os: ▪ In the first 2-3 days the cervix can admit 2 fingers ▪ By the end of the 1st week, the external cervical os is 1 cm in diameter (Whitmer, 2016) ▪ However, the external os can remain open permanently (never returns back to the nulliparous state) - a characteristic funnel / star shaped (Source from Coad & Dunstall, 2019) (Source from Ward & Hisley, 2015) A. Nulliparous cervix B. Multiparous cervix Vaginal changes: ▪ initially the vaginal wall is swollen, rugae (folds) appearance disappear, but rapidly regains tone, remains fragile for 1-2 weeks. ▪ by week 3-4, rugae reappear, but less prominent than in nullipara ▪ Hymen: torn and then healed irregularly in the form of fibrosed nodules of mucosa (called carunculae myrtiformes) ▪ with decreased oestrogen, the amount of vaginal lubrication decreases, vaginal dryness and coital discomfort can persist until ovarian function returns -> normal mucus production returns with ovulation ▪ By 6-8 week, vaginal returns to near pre-pregnant size and appearance ▪ The introits remains permanently larger than the virginal state Lochia ▪ the blood-stained uterine discharge comprising blood and necrotic decidua ▪ only the superficial layer of the decidua becomes necrotic and is sloughed off ▪ the basal layer adjacent to the myometrium is involved in the regeneration of new endometrium and this regeneration is complete by the 3rd week  Lochia changes in the colour and amount: Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 ---->wk 4 - 8 (DD – D3): lochia rubra (D4 – D9): lochia serosa (D10 – D15, may last for 6 weeks): lochia alba Pink Yellow Red White ▪ Moderate amount ▪ Smaller amount ▪ Scant amount ▪ Consists of: RBC, decidua ▪ Consists of: less blood, serous ▪ Consists of: serous fluid & leukocytes, cells, debris from chorion, exudate, shreds of decidua, cervical mucus & micro-organisms meconium & vernix leukocytes & cervical mucus (Katz, 2012) (Coad & Dunstall, 2019) Perineal changes: ▪ about 80% complain of perineal pain in the first 3 days after vaginal delivery, ¼ continues to suffer discomfort at D10 ▪ perineal oedema and bruises persist for some days ▪ lax after delivery, but regains most of its muscle tone by D5 ▪ if there was a prolonged second stage, especially with a long period of pushing, it may take longer for the oedema to subside ▪ laceration may occur during vaginal delivery (read on from uploaded articles) ▪ haemorrhoids (anal varicosities) are commonly seen – due to pelvic pressure, constipation during pregnancy and pushing during labour, usually decrease in size within 6 weeks after birth. Changes in breasts and lactation ▪ The breasts are largely made up of glandular, adipose and connective tissue ▪ Each breast is comprised of 15-20 lobes arranged radially from the nipple and each unit is made up of a lactiferous duct, mammary gland lobule and alveoli. ▪ Milk is made by the alveolar secretory epithelium ▪ During pregnancy: ▪ increased oestrogen stimulate breast duct proliferation & development; ▪ elevated progesterone promote the development of lobules and alveoli and suppressed lactation Copyright @ Pearson 2017 ▪ With expulsion of placenta: progesterone level drops, thus triggering milk production ▪ Smooth (in the D 1-2 postpartum), larger and pigmentation lightens ▪ If the mother is not breastfeeding, by 3rd or 4th day, breast stimulation is not occurring, prolactin levels begin to drop. ▪ Breast fullness: ▪ all lactating mothers experience transitional fullness, caused initially by venous congestion and later, by milk accumulation (D 3-5) ▪ usually lasts only 24 hrs if feeding well (breasts remain soft for newborn to suckle) ▪ Breast engorgement: ▪ hard and painful, and warm to touch ▪ usually occurs in 48-72 hours after childbirth, if feeds are delayed ▪ reduced when new-born begins to suck breast milk ▪ returns to pre-pregnant state by 2 weeks in non-lactating women Postpartum physiological changes: 1. Reproductive System 2. Endocrine system 3. Cardiovascular System 4. Respiratory System 5. Digestive System 6. Excretory System 7. Musculoskeletal System 8. Integumentary System 9. Immune System Placental hormones ▪ with the expulsion of the placenta, both oestrogen and progesterone decrease markedly. Non-pregnancy levels are achieved by Day 7 postpartum ▪ human chorionic gonadotropin (hCG) falls rapidly, and by 10 days neither (hCG & BhCG) should be detectable ▪ placental hormone which causes insulin resistance will decrease by 3-4 days postpartum Hormonal changes during Postpartum breastfeeding and after delivery: Maguire, Jamie. Postpartum Hormones Graph. ScienceDirect Chapter 12 – Hormonal and immunological factors in postpartum psychosis, Editor(s): Jennifer L. Payne, Lauren M. Osborne, Biomarkers of Postpartum Psychiatric Disorders, Academic Press, 2020, Pages 159-179, https://doi.org/10.1016/B978-0-12-815508-0.00012-6. Postpartum physiological changes: 1. Reproductive System 2. Endocrine system 3. Cardiovascular System 4. Respiratory System 5. Digestive System 6. Excretory System 7. Musculoskeletal System 8. Integumentary System 9. Immune System Cardiovascular changes The heart apex position returns to its normal level of 5th rib (from 4th) Pulse: ~ 50-70 bpm in the first 6 – 10 days postpartum Blood volume may expand by 40% during pregnancy, this (hypervolemia) allows (protect) most women to tolerate considerable blood loss during childbirth: blood loss: vaginal birth (single fetus) ~ 300-500 ml blood loss (10% of blood volume); C-section ~ 500-1000 ml blood loss (15% - 30% of blood volume) during first few days after delivery, the blood volume decreases further due to diuresis i) drops in oestrogen allows diuresis in the first 2-5 days, weight loss ~3kg (James, 2014); ii) decreases in progesterone helps to reduce fluid retention (extravascular) during pregnancy excretion of extracellular fluid, by diuresis and diaphoresis; profuse perspiration Blackburn (2013) Blood cells and platelets: ▪ Increased RBC & haemoglobin level after birth and return to normal pre-pregnant level in 4-6 weeks ▪ Hypercoagulable status remains in the early puerperium ▪ Increased platelet and clotting factors and fibrinolytic activity in the first few days & return to pre-pregnancy over a few weeks Hemostatic system reaches its normal pre-pregnant status by 6-12 weeks Postpartum physiological changes: 1. Reproductive System 2. Endocrine system 3. Cardiovascular System 4. Respiratory System 5. Digestive System 6. Excretory System 7. Musculoskeletal System 8. Integumentary System 9. Immune System Respiratory System changes ▪ After childbirth, there is a rapid decreases in intra-abdominal pressure, causing greater excursion of the diaphragm & reduced pulmonary blood flow, hence the chest wall compliance increases ▪ Pulmonary functions return to non-pregnancy state within 1-3 weeks ▪ Rib cage elasticity takes up to 6 weeks to even months to return to non-pregnant state ▪ Respiratory rate: 12-20bpm at rest Postpartum physiological changes: 1. Reproductive System 2. Endocrine system 3. Cardiovascular System 4. Respiratory System 5. Gastrointestinal System 6. Excretory System 7. Musculoskeletal System 8. Integumentary System 9. Immune System Gastrointestinal system Mostly feel hungry and exhausted after a childbirth Full GI mobility and tone return to pre-pregnancy state within 2 weeks Constipation can be common; a spontaneous bowel opening may not occur for 2-3 days after birth due to: Slowing of digestive system during labour (intestinal atony, anorexia, laxity of abdominal muscle after delivery) Dehydration during labor period Temporary decrease in abdominal muscle tone Opiate use Fear of push due to presence of hemorrhoids, stitches, tenderness Normal pattern regains by 8-14 days Avoidance of constipation and straining is important especially in women who have sustained a 3rd or 4th degree tear (see online guided study materials) that involve the anal sphincter. Lactulose may be used for a period of 2 weeks to prevent large and hard stool Body weight changes: ▪ Initial weight loss ~ 10-12 lb (birth of baby, placenta, amniotic fluid, blood, involution of uterus) ▪ ______ ~ 5 lb during the early puerperium (water loss in the 1st week postpartum represents a loss of extracellular fluid) ▪ Many return to pre-pregnant weight by 6-8 weeks after delivery (if they gained the average 25-30 lbs), and if she follows a well-balanced diet ▪ Usually retain average of 1kg with each pregnancy ▪ Weight retention is affected by lifestyle, eating habits and lactation Postpartum physiological changes: 1. Reproductive System 2. Endocrine system 3. Cardiovascular System 4. Respiratory System 5. Digestive System 6. Excretory System 7. Musculoskeletal System 8. Integumentary System 9. Immune System Urinary system ▪ Common feature in postpartum woman: puerperal diuresis (D2-3 postpartum) ▪ increased bladder capacity, ▪ swelling and bruising of the urethra, At risk for over distention, incomplete bladder ▪ decreased sensitivity to fluid pressure, emptying, and build-up of residual urine ▪ decreased sensation of bladder filling ▪ Woman have had anesthetic block (spinal / epidural ) inhibited neural function of the bladder, more susceptible to bladder distension, difficulty voiding & bladder infection (stasis of urine) ▪ Urinary output increases during the early postpartum period (first 12-24 hrs.) because of puerperal diuresis, eliminating 2000 to 3000ml of extracellular fluid with normal pregnancy (Blackburn, 2013)  Bladder function ▪ First voiding is usually difficulty – lingering effect of progesterone, +/- bruising of urethra during labour ▪ The bladder may take up to ____ hs to regain normal sensation: prone to urinary retention on Day 1 after vaginal delivery due to oedema to bladder neck, urethra and urinary bladder ▪ returns to normal function by 4-6 weeks, though dilation of renal pelvis, calyces and ureters may last for 3 months ▪ Overstretching of the detrusor muscle can reduce bladder sensation and make it hypocontractile causing overflow incontinence of small amounts of urine may mistakenly be assumed as normal voiding ▪ Impaired sensation of bladder filling may lead to urinary retention and urinary tract infection Postpartum physiological changes: 1. Reproductive System 2. Endocrine system 3. Cardiovascular System 4. Respiratory System 5. Digestive System 6. Excretory System 7. Musculoskeletal System 8. Integumentary System 9. Immune System  Musculoskeletal System diastasis recti abdominis The return of muscle tone depends on previous tone, proper exercise and amount of adipose tissue Takes about 6-8 weeks for the stretched muscles & softened ligaments return to pre-pregnancy state The abdominal wall muscles stretch and ultimately lose some tone. During the 3rd trimester, the rectus abdominis muscles can separate, termed diastasis recti abdominis, can persist and remains separated after birth If abdominal muscle tone fails to regain → pendulous/hanging abdomen & backache Murray & McKinney (2019) p.463 Muscle and Joints: over exertion during labour → muscles are fatigue and ache pelvic joints may separate slightly during labour → pain and discomfort drop in relaxin → joints become stabilized by 6-8 weeks Integumentary System ▪ Hyperpigmentation: ▪ Melasma usually disappear after birth but ~30% may persist Melasma (‘mask of pregnancy’) ▪ Darken areolae and linea nigra – may not regress completely ▪ Striae gravidarum (stretch marks) – may fade but usually do not vanish completely ▪ Hair: ▪ May have hair loss for the first 3-4 months after birth (abundant of hair growth during pregnancy). Regrowth occurs by 9 months after birth ▪ Any coarse or bristly hair that appears during pregnancy usually remains ▪ Diaphoresis: ▪ Common, especially at nights in the first 2 weeks after birth ▪ Postpartum chill: ▪ Common, but usually self-limiting ▪ Potential causes: ▪ Sudden release of pressure on the pelvic nerves ▪ A response to a fetus-to-mother transfusion during placental separation ▪ Maternal epinephrine during labour and birth ▪ Reaction to epidural anesthesia Immune System ▪ mildly impaired during pregnancy, gradually returns its pre-pregnant state, but the timeline is unclear (Blackburn, 2013) ▪ rebound of immune conditions in postpartum period can trigger ‘flare-ups’ of autoimmune disease (e.g. systemic lupus erythematosus, multiple sclerosis)  Maternal psychological changes: (Transition parenthood) A woman in the postpartum period experiences a variety of responses as she adjusts to a new role, a new family member, discomforts results from delivery, changes in body image and the reality that she is no longer pregnant. Normal emotional and psychologic adaptations The ‘pinks’: for the first 24-48 hrs following delivery, common for women to experience an elevation of mood, a feeling of excitement, some over activity and difficulty sleeping The ‘blues’: as many as 80% of women may experience the ‘postnatal blues’ within 3-5 days and up to the first 2 weeks after delivery. Fatigue, short temper, difficulty sleeping, depressed mood and tearfulness are common but usually mild “Maternal Role Attainment” (MRA) (Rubin, 1977) 1. Taking-in: dependent phase (somewhat passive) 2. Taking-hold: dependent-independent phase 3. Letting-go: interdependent phase 1. Taking-in: dependent phase ▪ First 1-2 days after delivery, a period of dependent behaviour – mainly due to her physical discomfort (haemorrhoids, after pains) ▪ Focus on self and meeting of basic needs: Taking in food, water, rest and care ▪ Passive - follows instructions, hesitates to make decisions ▪ Excited and asks a lot of questions and needs to discuss labour and delivery experience, has great needs to talk about her own experience… on the phone all the times … ▪ This phase provides time for the woman to regain her physical strength and organize her confused thoughts about her new role 2. Taking-hold: dependent-independent phase ▪ 2-10 days postpartum, can last for about 4-5 weeks; women who underwent anesthesia reach this phase only hours after her delivery ▪ Mood swings; obsessed with body functions ▪ Begin to focus on the needs of the newborn and begins to actively participate in newborn care ▪ Take on maternal role & desire to take charge: learn to take care the newborn, still needs positive reinforcements despite the independence about the care of her child ▪ Anticipate advices, interested in learning care of baby, a good time to educate … ▪ If BF, may worry about her technique, Requires assurance that she is doing well as a mother… ▪ Experience fatigue +/- baby blues “Becoming a Mother” (BAM) (Mercer, 2004) Mercer proposed replacing the term maternal role attainment with ‘becoming a mother’… BAM more accurately reflects the transition process of becoming a mother that changes throughout the maternal-child relationship. I. Anticipatory stage - Starts from pregnancy, the woman begins to imagine how to become a mother … by usually copying own mother’s behaviours in preparing for delivery and motherhood II. Formal stage - Immediately after birth, woman tries to copy other’s caring approaches in order to meet the social norm / expectations, demonstrating acquaintance/attachment to the infant during first 2-6 weeks following delivery III. Informal stage - After some period of learning, begin to form her own approaching in parenting – moving toward a new normal IV. Personal stage - After getting use to the new parenting role, becoming handier in taking up the role of a mother, in her own way, redefining self to incorporate motherhood (around 4 months) Process of acquaintance: A. Bonding: ❖ A rapid initial attraction felt by the parents ❖ unidirectional (from parent to the newborn) ❖ this sensitive period is usually for the first 30-60 minutes after birth B. Attachment ❖ a relatively long-lasting bond between parents and infant ❖ mutual: interactive between parents and newborn ❖ parents accept responsibilities for the care of the newborn While the baby receives warmth, food and security, (s)he will show reciprocal attachment behaviours (e.g. eye contact, ‘looking’ for parents’ face, grasp and hold parent’s finger, rooting, latch onto the breast & starts suckling) C. Maternal touch: ▪ ‘finger-tipping’: hold the newborn closer, try to explore newborn’s face, fingers, toes … ▪ ‘binding-in’: identify specific features of newborn to related family members D. Verbal behaviours: ▪ prenatal visit: “it” ▪ postpartum: “she / he” ▪ eventually: name of the baby Maternal touch: holding the baby in an en face position with the infant’s face in the same vertical plane as her own… eye contact During the binding-in process, the mother identifies her baby’s specific features … Source: Murray, McKinney, Holub & Jones (2019)  Direct face-to-face and eye-to-eye in the en face position Source: Murray, McKinney, Holub & Jones (2019)  Psychological Changes ▪ Normal psychological changes due to: ▪ Decrease in oestrogen & progesterone levels ▪ Aggravated by fatigue and decreased social support, high expectation of a mother’s role (high pressure) ▪ Postpartum mood change ranges: ▪ baby blues / postpartum blues ▪ postpartum depression Perinatal ▪ postpartum psychosis mental illness Major mood disorder within the first year after the childbirth (ACOG, 2023) Postpartum blues (transient depression) ▪ A maternal adjustment reaction ▪ Mild & transient mood disturbance ▪ Usually begins at Day 2-3 after birth, may last from a few hours to 1-2 weeks postpartum ▪ May affect 40% to 80% of postpartum women ▪ Characterized by: altered mood, difficult to sleep, anxiety irritability and tearfulness for no clear reason, and a feeling of being letdown; usually unrelated to actual situations ▪ Treatment: support from the partner, family, relatives, friends and health professionals ▪ Usually spontaneous resolve within 10 to 14 days, but if persists, the woman may need assessment to rule out postpartum depression ACOG (2018) Epidemiology (in HK) Baby blues ▪ 40% - 80% of women day 2-3 post delivery, lasting 1-2 days PND ▪ 13% - 19% postpartum women ▪ within 6 months post delivery, peaking 3-4 weeks post childbirth ▪ 90% last less than a month ▪ 4% last more than a year Puerperal psychosis ▪ 0.1% - 0.5% postpartum women ▪ peaks 2-3 weeks postpartum ▪ suicide rate 20.3% of all maternal death (statistic from 2000-2019) References: Bergman, N.J., Linley, L.L., and Fawcus, S.R. (2007). Randomized controlled trial of skin-to-skin contact from birth versus conventional incubator for physiological stabilization in 1200-to 2199-gram newborns. Acta Paediatrica, 93, 6. Blackburn, S. (2013). Maternal, fetal, & neonatal physiology. A clinical perspective (3rd ed.). ST. Louise, MO: Saunders. Chou, D., Abalos, E., Gyte, G.M.L. (2010). Paracetamol/acetaminophen (single administration) for perineal pain in the early postpaertum period. Conchrane Database of Systematic Reviews, 3, Art No. CD008407. Cunningham, F.G. Leveno, K.L., Bloom, S.L., Spong, C.Y., Dashe, J.S., Hoffman, B.L., Sheffield, J.S. (2014). Williamns Obstetrics (24th ed.). New York, NY: McGaw-Hill. Dalton, E. and Castillo, E. (2014). Postpartum infections: a review for the non OBGYN. Obstetric Medicine, 7(3), 98-102. Davidson, M., London, M. & Ladewig, P. (2020). OLDS’ Maternal-Newborn Nursing Women’s Health Across the Lifespan. (11th ed.). Hoboken, NJ: Pearson Family Health Service, HK (2006; 2019). Maternal Health. Available at: https://www.fhs.gov.hk/english/main_ser/process.html References: James, D.C. (2014). Postpartum care. In K.R. Simpson & P.A. Creehan (Eds.), Perinatal nursing (4th ed. P.530). Philadelphia, PA: Lippincott Williams & Wilkins. Leung, S.S.L., Leung, C, Lam, T.H., Hung, S.F., Chan, R., Yeung, T., Miao, M., Cheng, S., Leung, S.H., Lau, S., and Lee, D.T.S. (2010). Outcome of a postnatal depression screening programme using the Edinburgh Postnatal Depression Scale: a randomized controlled trial. Journal of Public Health, 33(2), pp. 292-301. Londdon, M.L., Wieland Ladewig, P.A., Davidson, M.R., Ball, J.W., McGillis Bindler, R.C., & Cowen, K.J. (2017). Maternal & Child Nursing Care (5th ed.). Hoboken, NJ: Pearson Education, Inc. Lowdermilk, D. L., Perry, S.E., & Cashion, K. (2024). Maternity & Women’s Health Care (13th ed.). St. Louis: Mosby. Murray, S., McKinney, E., Holub, K., & Jones, R. (2019). Foundations of Maternal-Newborn and Women’s Health Nursing (7th ed.). St.Louis, Missouri: Elsevier Rubin, R. (1977). Binding-in in the postpartum period. Maternal-Child Nursing Journal, 6, pp.67-76. Whitmer, T. (2016). Physical and psychological changes after childbirth. In S. Mattson & J.E. Smith (Eds). Core curriculum for maternal-newborn nursing (6th ed., pp.297-313). Philadelphia, PA: Association of Women’s Health, Obstetric and Neonatal Nurses / Elsevier. World Health Organization (2019). WHO recommendations on Postnatal Care of the mother and newborn. Available at: https://www.who.int/publications/i/item/9789241506649