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Nursing Care of the Low-Risk Postpartum Family
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Clinical Assessment Review antepartum and intrapartum histories
Receive report from labor room personnel Client may want to review birth experience Education Consider religious and cultural factors Assess language barriers
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Physical Assessment Vital signs Breasts Uterus, level of fundus
Amount and type of lochia Uterine pain Bladder
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Physical Assessment (continued)
Bowels, hemorrhoids Episiotomy Extremities Emotional status
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Postpartum Assessment
B – Breasts U – Uterus B – Bowel B – Bladder L – Lochia E – Episiotomy/Lacerations
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Postpartum Assessment (continued)
H – Homans’/Hemorrhoids E – Emotions
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Distended Bladder Postpartum
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Uterine Involution
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Figure 34–1 Involution of the uterus
Figure 34–1 Involution of the uterus. (A) Immediately after delivery of the placenta, the top of the fundus is in the midline and approximately two thirds to three-fourths of the way between the symphysis pubis and the umbilicus (B). About 6 to 12 hours after birth, the fundus is at the level of (or one fingerbreadth below) the umbilicus. The height of the fundus then decreases about one fingerbreadth (approximately 1 cm) each day.
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Other Assessments Hemodynamic status Integumentary system
WBC, H&H, coagulation factors Integumentary system Striae, perspiration, acne, hair loss Musculoskeletal system Diastasis Activity, exercise, and weight loss Sexuality and contraception
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Postpartum Changes in Lab Values
Nonpathologic leukocytosis occurs in the early postpartum period Blood loss averages mL (vaginal), mL (cesarean) Plasma levels reach the prepregnant state by 4-6 weeks postpartum Platelet levels will return to normal by the 6th week Diuresis Cardiac output returns to normal by 6-12 weeks
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Immunizations Rubella Rho(D) immune globulin Rubella nonimmune clients
Safe for nursing mothers Transient rash, fever, joint symptoms Rho(D) immune globulin Mother Rh negative, infant Rh positive Negative Coombs’ test 300 mcg IM within 72 hours of delivery Card issued to client Coombs: Direct – demonstrates if pts RBCs have been attacked by antibodies in pts own blood. Indirect – maternal anti- Rh antibiodies.
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Family Considerations
Maternal-infant attachment Maternal adjustment and role attainment Taking-in phase Taking-hold phase Letting-go phase Paternal adjustment Sibling adjustment Grandparent adjustment Taking-in phase: Passive. Accepts help of others. talks about birth experience. Taking-hold phase: becomes more independent & takes interest in and responsibility of own care. welcomes opportunity to learn about behavior of infant & cares for infant. Letting-go phase: gives up carefree lifestule of couple. establishs lifestyle including child.
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Postpartum Uterine Changes
Decrease in weight 100g Spongy layer of the decidua is sloughed off Basal layer differentiates into two layers Outer layer sloughs off Inner layer begins the foundation for the new endometrium Placental site heals by exfoliation
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Postpartum Uterine Changes (continued)
Uterine cells will atrophy Uterine debris in the uterus is discharged through lochia Lochia rubra is red (first 2-3 days) Lochia serosa is pink (day 3 to day 10) Lochia alba is white (continues until the cervix is closed)
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Factors Retarding Involution
Table 34–1 Factors that retard uterine involution.
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Postpartal High-Risk Factors
Table 34–2 Postpartal high-risk factors.
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Postpartal Concerns Table 34–3 Common postpartal concerns.
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Lochia Rubra Scant amount Large amount with clots
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Lochia Changes Table 35–3 Changes in lochia that cause concern.
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Postpartum Cervical and Vaginal Changes
Cervix is spongy, flabby, and may appeared bruised External os may have lacerations and is irregular and closes slowly Shape of the external os changes to a lateral slit Vagina may be edematous, bruised with small superficial lacerations Size decreases and rugae reappear within 3-4 weeks Returns to prepregnant state by 6 weeks
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Perineal Changes and Return of Menstruation
Perineum may be edematous, with bruising Lacerations or an episiotomy may be present Menstruation generally returns between 6 and 10 weeks (nonbreastfeeding)
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Postpartum Abdominal and Breast Changes
Loose and flabby but will respond to exercise Uterine ligaments will gradually return to their prepregnant state Diastasis recti abdominis Striae will take on different colors based on the mother’s skin color Breasts are ready for lactation
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Figure 34–3 Diastasis recti abdominis, a separation of the musculature, commonly occurs after pregnancy.
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Postpartum Bowel Changes
Bowels will be sluggish Episiotomy, lacerations, or hemorrhoids may delay elimination
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Postpartum Bladder Changes
Increased bladder capacity Swelling and bruising of tissues around the urethra Decrease in sensitivity to fluid pressure Decrease in sensation of bladder filling Urinary output is greater due to puerperal diuresis Increased chance of infection due to dilated ureters and renal pelves
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Postpartum Changes in Vital Signs
Temperature may be elevated to 38C for up to 24 hours after birth Temperature may be increased for 24 hours after the milk comes in BP rises early and then returns to normal Bradycardia occurs during first 6-10 days
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Postpartum Weight Changes
Initial weight loss of lbs Postpartum diuresis causes a loss of 5 lbs Return to their prepregnant weight by the 6th to 8th week
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Postpartal Nutrition Table 34–5 Daily eating to encourage healthful nutrition during the postpartal period.
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Maternal Psychological Adjustment
“Taking In” “Taking Hold”
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Figure 34–4 The mother has direct face-to-face and eye-to-eye contact in the en face position. SOURCE: © Stella Johnson (
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Maternal Role Attainment
Anticipatory stage Formal stage Informal stage Personal stage
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Postpartum Blues Transient periods of depression; sometimes occurs during the first few days postpartum Mood swings Anger Weepiness Anorexia Difficulty sleeping Feeling let down
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Causes of Postpartum Blues
Changing hormones Lack of supportive enviornment
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Cultural Influence in the Postpartum Period
Non-Western cultures emphasize postpartum period Food and liquids after birth Hot-cold balance Role of grandmother
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Principles of Conducting a Postpartum Assessment
Selecting the time that will provide the most accurate data Providing an explanation of the purpose of the assessment Ensuring that the woman is relaxed before starting Recording and reporting the results clearly Body fluid precautions
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Breast Assessment Size and shape
Abnormalities, reddened areas, or engorgement Presence of breast fullness due to milk presence Assess nipples for cracks, fissures, soreness, or inversion
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Abdominal Assessment Position of fundus related to umbilicus
Position of fundus to midline Firmness Assess incision for bleeding, approximation, and signs of infection
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Figure 34–6 Measuring the descent of the fundus for the woman having a vaginal birth. The fundus is located two fingerbreadths below the umbilicus. Always support the bottom of uterus during any assessment of fundus.
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Figure 34–2 The uterus becomes displaced and deviated to the right when the bladder is full.
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Assessment of Lochia and Perineum
Assess lochia for amount, color, and odor Presence of any clots Wound is assessed for approximation, redness, edema, ecchymosis, and discharge Presence of hemorrhoids Level of comfort/discomfort Efficacy of any comfort measures
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Figure 34–8 Intact perineum with hemorrhoids.
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Assessment of Extremities, Bowel, and Bladder
Homan’s sign Assess calf for redness and warmth Adequacy of urinary elimination Bladder distention and pain during urination Intestinal elimination Maternal concerns regarding bowel movements
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Assessment of Psychological Adaptation and Nutrition
Adaptation to motherhood Fatigue Nutritional status Cesarean birth Return of bowel function Tolerance of dietary progression
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Physical and Developmental Tasks
Gain competence in caregiving Confidence is role as parent Return of all physical systems to prepregnant state
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Factors that Influence Parent-Infant Attachment
Family of origin Relationships Stability of the home environment Communication patterns The degree of nurturing the parents received as children
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Nursing Responsibilities for Client Teaching
Assess educational needs Develop and implement a teaching plan Evaluate client learning Revise plan as needed
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Postpartal Teaching Table 35–1 Areas to include in postpartal teaching.
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Postpartal Teaching Table 35–1 (continued) Areas to include in postpartal teaching.
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Postpartal Teaching Table 35–1 (continued) Areas to include in postpartal teaching.
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Postpartal Teaching Table 35–1 (continued) Areas to include in postpartal teaching.
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Postpartal Teaching Table 35–1 (continued) Areas to include in postpartal teaching.
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Postpartal Teaching Table 35–1 (continued) Areas to include in postpartal teaching.
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Postpartal Uterine Monitoring
Table 35–2 Key facts to remember about monitoring postpartal uterine status.
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Postpartum Drugs Table 35–4 Essential information for common postpartum drugs.
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Postpartum Drugs Table 35–4 (continued) Essential information for common postpartum drugs.
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Parent Attachment Table 35–5 Parent attachment behaviors.
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Uterine Well-Being and Comfort Measures
Assess uterus Assess lochia Afterpains Positioning Ambulation Analgesics
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Perineal Well-Being and Comfort Measures
Assess perineum Perineal care Ice packs Surgigator® Analgesics
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Comfort Measures Diaphoresis Suppression of lactation Well-fitting bra
Cold compresses or cabbage leaves Anti-inflammatory medication
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Pharmacologic Interventions
Rubella vaccine RhoGAM
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Emotional Stress Interventions
Encourage mothers to tell birth stories Maternal role attainment
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Rest and Activity Provide opportunities for rest
Encourage frequent rest periods Resumption of activity Avoid heavy lifting Avoid frequent stair climbing Avoid strenuous activity
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Postpartal Family Wellness
Family-centered care Information Time for interaction Supportive environment
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Figure 35–3 The nurse provides discharge instructions to the mother and father before discharge.
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Resumption of Sexual Activity
Resume after episiotomy healed and lochia stopped Lubrication may be required Contraception Potential limiting factors Fatigue Demands of the infant
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Parent-Infant Attachment
Incorporate family goals in care plan Postpone eye prophylaxis for 1 hour after delivery Provide private time for the family to become acquainted Encourage skin-to-skin contact Encourage mother to tell her birth story
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Parent-Infant Attachment
Encourage involvement of the sibling Prepare parents for potential problems with adjustment Initiate and support measures to minimize fatigue Help parents identify, understand, and accept feelings
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Care of the Mother after Cesarean Birth
Minimize complications Deep breathing and incentive spirometry Ambulation Pain management Rest Minimize gas pains
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Pharmacologic Management of Pain
Epidural analgesia PCA
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Needs after Discharge Increased need for rest and sleep
Incisional care Assistance with household chores Infant and self-care Relief of pain and discomfort
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Parent-Infant Attachment
Factors that hinder attachment Physical condition of the mother and the newborn Maternal reactions to stress Anesthesia Medications Newborn safety
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Nursing Care of the Adolescent
Postpartum hygiene Contraceptive counseling Newborn care Include family in teaching Positive feedback
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Post-discharge Adolescent Needs
Child care Transportation Financial support Nonjudgmental emotional support Education regarding newborn care and illness Education regarding self-care
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Care of the Mother who Relinquishes her Infant
Active listening Provide nonjudgmental support Show concern and compassion Personalize care for the mother
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Early Discharge Signs of possible complications Rest and activity
Resumption of sexual activity Referral numbers for questions Contact information about local agencies or support groups Bottle or breastfeeding information
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Early Discharge (continued)
A scheduled postpartal and newborn well-baby visit Procedure for obtaining the birth certificate Newborn care Signs and symptoms of infant complications
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Lactation and Newborn Nutrition
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American Academy of Pediatrics Recommendations
Newborns should be nursed when they show signs of hunger No supplements should be given unless there is a medical indication Exclusive breastfeeding is sufficient for approximately six months
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American Academy of Pediatrics Recommendations (continued)
Gradual introduction of iron-rich solids should begin after six months Breastfeeding should continue for at least 12 months
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Nutrients in Breast Milk
Protein Source of amino acids for growth Whey fraction more easily digested and promotes gastric emptying Fat Greatest concentration in hind milk Necessary for brain development Carbohydrates Enhance immunity and brain development
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Nutrients in Breast Milk (continued)
Water and electrolytes Minerals Trace elements Fat-soluble and water-soluble vitamins
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Anatomy of the Breast Clavicle Ribs Pectoralis major muscle Lobes
(glandular tissue) Adipose tissue Cooper’s ligament Areola Areola Nipple Nipple Lactiferous duct Opening of lactiferous duct
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Lactogenesis Estrogen and progesterone levels fall
Prolactin triggers milk production Oxytocin elicits the let-down reflex Milk production depends on supply and demand Feed often (every two to three hours) Avoid supplements Encourage night feedings
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Interferences with Lactation
Poor nutrition, inadequate fluid intake Maternal anxiety Medical conditions Pendulous breasts Flat or inverted nipples Postoperative pain Deficient knowledge
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Promoting Successful Breastfeeding
Maternal comfort and relaxation Positioning of mother and infant Correct latching on of the infant Removal of the infant from the breast Burping
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Promoting Successful Breastfeeding (continued)
Timing Feed immediately after delivery if possible Offer both breasts at each feeding 15 minutes on each breast Offer the breast every two to three hours
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Positioning for Breastfeeding
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Techniques for Successful Breastfeeding
Breaking suction Proper latching-on technique Rooting reflex
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Benefits of Breastfeeding
Maternal benefits Contraception Less anemia Weight loss Involution of the uterus Prevention against breast and ovarian cancer
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Benefits of Breastfeeding (continued)
Infant benefits Bonding between mother/infant Optimal nutrition Prevention against infection Enhanced cognitive development Prevention against disease (diabetes, SIDS, asthma)
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Nursing Implications: Barriers to Successful Breastfeeding
Maternal barriers Diet, medications, smoking, fatigue Prior breast surgery Nipple abnormalities Contraceptives Psychologic issues, modesty Infant barriers Prematurity Illness and disability Hypoglycemia Jaundice Nipple shields Breastfeeding the preterm infant
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Assessment for Insufficient Lactation
Low urination pattern Low stooling frequency Minimal breast changes after delivery Irritable or sleepy infant Nursing less than seven times a day Weight loss of more than 10% of the birth weight Continued weight loss after day 10 of life Need 6 or more wet diapers per day.
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Contraindications to Breastfeeding
Maternal disease Hepatitis B, C HIV Maternal medications Infant Severe illness Inborn errors of metabolism
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Common Breastfeeding Problems
Cracked or sore nipples Change positions Assess for proper latching on Apply breast milk after nursing Cabbage leaves, tea bags Mastitis Antibiotics
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Common Breastfeeding Problems (continued)
Engorgement Feed frequently, avoid supplements Good support bra Apply warmth (towels, shower) before nursing
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Breast Pumps
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Resources for Breastfeeding Mothers
Lactation consultants La Leche League International Lactation Consultant Association
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Formula Feeding Available in powder, concentrate, ready-to-feed forms
Ensure that parents know how to mix formula Ensure cleanliness in preparation Cow- or soy-based preparations Monitor for food allergy symptoms Rash, colic, diarrhea, bloody stool, respiratory symptoms
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Formula Feeding (continued)
Solids usually introduced at about four months One new food at a time Wait at least three days between new foods
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