Course Price  $18.00 Contact Hours  2 Instructions  Study the course, then take the test. You can also print the course and test questions and return later to take the test.

Quicklinks Print this course Take the test How to take a course

Postpartum Care

Bethany Derricott, RN, BSN, MSN (candidate)

Wild Iris Medical Education is an approved provider (#PA-54) of continuing nursing education by the Washington State Nurses Association, an accredited approver by the American Nurses Credentialing Center's Commission on Accreditation. Our courses fulfill continuing nursing education requirements in all 50 states.
Wild Iris Medical Education (CBRN Provider #12300) is approved as a provider of continuing education for RNs, LVNs, and respiratory therapists by the California Board of Registered Nursing.

The postpartum period comprises the time from giving birth until approximately 6 weeks after delivery. This is a time of healing and rejuvenation as the mother's body returns to its pre-pregnant state. Nurses need to be aware of the normal physiologic and psychological changes that take place in the woman's body and mind in order to provide comprehensive care during this period. One of the most significant responsibilities of the postpartum nurse is to recognize potential medical complications after delivery.

NORMAL POSTPARTUM ADAPTATIONS: PHYSIOLOGIC

Reproductive System

UTERUS

Immediately after delivering her baby, the mother experiences massive shifting as her body returns to its pre-pregnant state. This process, known as involution, begins immediately after the delivery of the placenta. The uterus, with the assistance of the uterine muscles, contract the blood vessels at the site of placental attachment to control bleeding. A process known as exfoliation also occurs at this time. Exfoliation is the sloughing off of dead tissue at the site where the placenta attached to the uterine wall. Exfoliation leaves the site smooth and without scar tissue to allow for the implantation of fertilized ova in subsequent pregnancies.

The uterus continues to contract after delivery, and its size decreases rapidly as estrogen and progesterone levels diminish. Immediately after delivery, the upper portion of the uterus, known as the fundus, is midline and palpable halfway between the symphysis pubis and the umbilicus. By approximately 1 hour post delivery, the fundus is firm and at the level of the umbilicus. The fundus continues to descend into the pelvis at the rate of approximately 1 cm (finger breadth) per day and should be nonpalpable by 10 days postpartum. Uterine involution can be impeded by anything that would cause distention of the uterus, including an unusually large (macrosomic) infant, multiple pregnancies, multiple births, or excessive amniotic fluid.

Afterpains, intermittent uterine contractions, are a normal occurrence during the postpartum period. Afterpains are caused by the release of the hormone oxytocin and the subsequent relaxation and contraction of the uterine muscles. Afterpains can be quite intense for postpartum patients, particularly for multiparas, due to the loss of uterine muscle tone following numerous pregnancies. Women may also experience severe afterpains during breastfeeding due to nipple stimulation and the resulting release of oxytocin. Afterpains generally last for 2 days and can be alleviated by relaxation techniques and, if necessary, analgesics.

Lochia

After delivery, the endometrial surface of the uterus is shed via the vagina. The shedding endometrium is known as lochia. Lochia occurs in three successive stages that include lochia rubra, lochia serosa, and lochia alba. Lochia rubra is bright red and is noted on postpartum days 1 to 3, while lochia serosa is pink to brown in color and occurs after day 3. By 10 days postpartum, lochia is yellow to white in color and is referred to as lochia alba.

Cervix

As with all other reproductive organs and structures, the cervix also changes as the body returns to a pre-pregnancy state. After delivery, the cervix is edematous and may appear bruised. The external os resembles a slit as compared to the circular, dimpled opening prior to the first pregnancy. The internal os closes almost completely within 2 weeks of delivery.

VAGINA

The vaginal walls are smooth after delivery and the vaginal folds, known as rugae, do not return until approximately 4 weeks postpartum. The vagina itself will never return to the pre-pregnant size, but will become smaller and return to a near pre-pregnancy state as the postpartum period progresses. The vagina usually appears edematous and may have small lacerations incurred during the delivery. Vaginal dryness and painful intercourse, known as dyspareunia, may be noted during the postpartum period due to decreased estrogen levels. Mucous production should return with ovulation and patients are encouraged to use water-based lubricants (eg, K-Y Jelly) with intercourse to ease discomfort.

PERINEUM

The perineum is the area between the posterior portion of the labia majora and the anus. This area stretches and thins during birth to accommodate the delivering infant. Lacerations of the perineum may occur during delivery, or an episiotomy (surgical incision) may be performed in this area to accommodate the delivery of the infant.

Lacerations of the perineum are identified as first-, second-, third-, or fourth-degree. First-degree lacerations extend through the skin and superficial layers of the perineum. Second-degree lacerations extend through the perineal muscles, while third-degree lacerations extend through the anal sphincter muscles. Fourth-degree lacerations extend through the anterior rectal wall and can be damaging to the perineum. In 2004, 42% of patients who delivered vaginally had lacerations (DeFrances & Podgornik, 2004). This rate showed an increase over the laceration rate of 40% reported in 1998 (Popovic & Kozak, 1998). Hastings-Tolsma and colleagues (2007) indicated that factors "…protective against perineal trauma (ie, lacerations) included massage, warm compress use, manual support, and birthing in the lateral position" (p. 158).

An episiotomy to aid in the delivery of the infant should be performed only when necessary. There is much debate regarding the maternal benefits of episiotomies and researchers continue to denounce its usage, except under extenuating circumstances. In 2004 episiotomies occurred in approximately 23% of vaginal births (DeFrances & Podgornik, 2004); this rate decreased dramatically, as the episiotomy rate in 1998 was 45% (Popovic & Kozak, 2000).

Regardless of the presence of lacerations or an episiotomy, the perineum is generally edematous and often bruised immediately following delivery. The muscle tone of this area is weakened as a result of delivery and never completely returns to the state it was prior to the first pregnancy.

BREASTS

After delivery there is a significant decrease in estrogen and progesterone levels. Before milk production begins, the breasts secrete colostrum, a thin, yellowish fluid that helps maintain the blood glucose level in the breastfeeding infant. Nipple stimulation by the infant causes the release of the hormone oxytocin from the posterior pituitary gland, which triggers the release of the hormone prolactin from the anterior pituitary. Prolactin initiates milk production and the breasts become full (engorged), as well as warm and tender, between postpartum days 3 and 4. Mothers often refer to this as having their milk "come in." There may be a slight elevation in body temperature during this time.

Patients who choose not to breastfeed will also experience their milk "coming in"; however, lactation can be suppressed through the use of a well-fitting bra. Non-breastfeeding patients should also avoid any type of nipple stimulation or heat to the breasts, such as warm or hot showers in which the water is allowed to run continuously over the breasts. Patients may use ice packs or cool cabbage leaves to ease breast discomfort until milk production ceases. It generally takes 5 to 7 days for the breasts to stop producing milk. Healthcare providers may consider prescribing mild analgesics if the patient has significant discomfort.

Endocrine System

With the sharp decrease of estrogen and progesterone levels following delivery of the placenta, lactation begins and menstruation returns. Estrogen is a prolactin-inhibiting hormone. When a woman chooses to bottlefeed her infant, prolactin levels diminish and estrogen levels begin to rise. Menstruation returns in approximately 6 to 8 weeks for these women. However, ovulation can return within 4 weeks.

When a patient is breastfeeding, prolactin levels increase as breastfeeding continues, so menstruation does not return until 12 weeks or later. Because ovulation can return prior to menses, it is important for healthcare providers to discuss family planning with patients during the early postpartum period in order to prevent undesired pregnancies.

Cardiovascular System

As the body prepares the pregnant woman for blood loss at birth, there is an increase in circulating blood volume during pregnancy. Patients may lose up to 500 mL of blood during a vaginal delivery and between 800 and 1000 mL of blood during a cesarean delivery. However, due to the increase in circulating blood volume that occurs during pregnancy, blood loss at delivery can easily be managed by the postpartum patient who does not have cardiovascular problems.

At delivery, there are fluid changes within the body to accommodate postpartum blood loss and to prevent hypovolemia. "These changes include (1) elimination of the placenta, which diverts 500 to 750 mL of blood flow into the maternal systemic circulation; (2) rapid reduction of the size of the uterus, which puts more blood in the systemic circulation; (3) increase of blood flow to the vena cava from elimination of compression by the gravid uterus; and (4) mobilization of body fluids accumulated during pregnancy" (Leifer, 2005).

The postpartum patient's body removes excess fluid accumulated during pregnancy by diuresis. Patients may excrete up to 3000 mL of fluid per day during the postpartum period. In addition, patients experience excessive perspiration (diaphoresis), which also releases accumulated fluid during the postpartum period. Women should be educated about increased urination and perspiration during this period.

During the early postpartum period there is a loss of plasma blood volume greater than that of red blood cells. Thus, there is a temporary rise in hemoglobin and hematocrit levels by the seventh postpartum day (Crum, cited in Lowdermilk & Perry, 2006). It is difficult to measure hemoglobin and hematocrit levels accurately at this time. However, these levels do eventually return to normal.

Due to the inflammation, pain, and stress of birth, neutrophils, a type of white blood cell, are increased and are responsible for a marked increase in the white blood cell count (McKinney et al., 2005). As a result of this normal increase in the white blood cell count, it is important for healthcare providers to monitor patients closely for indications of infection during the postpartum period.

Fibrinogen is a protein that, along with other clotting factors, is responsible for the clotting of blood. In addition to the increase in circulating blood volume during pregnancy, plasma fibrinogen levels increase and remain increased for several days after delivery. Postpartum patients have an increased risk of developing blood clots and emboli, so early ambulation is imperative.

Respiratory System

During pregnancy, the diaphragm is slightly elevated as the fetus nears term. This, along with other respiratory changes, causes thoracic versus abdominal breathing in the third trimester (McKinney et al., 2005). After delivery, the diaphragm descends and patients' respirations normally return to the pre-pregnant state.

Gastrointestinal System

Women are generally hungry and thirsty after delivery due to the amount of energy expended during labor. Food and fluid intake is usually restricted during labor and many patients may not have eaten or had fluids for a number of hours prior to delivery. The diaphoresis that occurs during the postpartum period may also lead to increased thirst. It is important for nurses to provide nourishment and hydration upon delivery.

Many patients experience constipation from the lack of fluid and food intake during labor. Furthermore, bowel tone is sluggish as a result of elevated progesterone levels. Often patients are hesitant to have a bowel movement due to pain in the perineal area resulting from an episiotomy, lacerations, or hemorrhoids. Some patients are also fearful that they will rip their stitches should they have a bowel movement. Healthcare providers may prescribe stool softeners and/or laxatives to treat constipation and provide perineal comfort during defecation.

Urinary System

The bladder, urethra, and urinary meatus are edematous after delivery as a result of the fetal head passing through the birth canal. Bladder tone is diminished, and many patients are unable to feel the need to void, despite the rapid diuresis that occurs following delivery. In this situation the bladder can become distended and displace the uterus upward and to the side, which prevents the uterine muscles from contracting properly and can lead to a postpartum hemorrhage. Nurses should carefully monitor bladder distention, the firmness of the fundus, and bleeding during the postpartum period.

Urinary retention as a result of decreased bladder tone and emptying can lead to urinary tract infections (UTIs). It is imperative that nurses monitor patients for signs of urinary tract infection, including tenderness over the costovertebral angle, fever, urinary frequency and/or urgency, and difficult or painful urination.

According to Varney and colleagues (2004), 40% of postpartum patients have protein in their urine that can be noted up to the second postpartum day. Proteinuria during this time is considered benign unless there are signs of a UTI or preeclampsia.

Musculoskeletal System

As with all other body systems, the musculoskeletal system undergoes changes during the postpartum period. Relaxin is the hormone responsible for the relaxation of the pelvic ligaments and joints during pregnancy. After delivery, relaxin levels subside and the pelvic ligaments and joints return to their pre-pregnant state. However, the joints of the feet remain altered and many patients notice a permanent increase in shoe size (Crum, cited in Lowdermilk & Perry, 2006).

Additionally, the abdominal wall is weakened and the muscle tone of the abdomen is diminished after pregnancy. Some patients have a separation between the abdominal wall muscles, called diastasis recti. This separation can often be corrected with certain abdominal exercises performed during the postpartum period. Patients should be instructed to begin abdominal exercises anytime following a vaginal delivery and after abdominal tenderness resolves following a cesarean section (Cunningham et al., 2005). Patients should also be instructed to avoid over-exertion during the first few weeks after delivery.

Integumentary System

Melanocyte-stimulating hormone (MSH) is responsible for the hyperpigmentation that occurs during pregnancy. MSH levels rapidly decrease after delivery and the skin changes that occurred as a result of pregnancy revert back to the pre-pregnant state or are permanently altered. More specifically, the mask of pregnancy (chloasma) usually disappears, while stretch marks (striae gravidarum) and linea nigra fade, but generally do not disappear. Additionally, hair loss may occur during the postpartum period, but it usually resolves without the need for intervention. Finally, diaphoresis is common during the postpartum period, and patients should be informed that they may need to change clothes and bed linens more frequently than usual.

Immune System

There are few changes in the immune system during the postpartum period. However, it is important for Rh-negative patients to receive Rh immune globulin within 72 hours of delivery to prevent maternal antibody production in response to the Rh-positive antigen received from infants during pregnancy or birth.

The rubella vaccine should also be administered to postpartum patients who tested non-immune or had a rubella titer less than 1:10 prior to delivery. Patients should be informed that the vaccination is given to prevent fetal anomalies in subsequent pregnancies. Additionally, the rubella vaccine is a live virus and is contraindicated during pregnancy. Therefore, patients should be instructed to avoid becoming pregnant for the 4 weeks following the administration of the vaccine (CDC, 2008).

NORMAL POSTPARTUM ADAPTATION: PSYCHOLOGICAL

The postpartum period is a time of immense change for the new mother and her family. Roles and expectations often shift as families adjust to their newest addition and patients learn to "become mothers" (Mercer, 2004). Bonding, sometimes referred to as attachment, between the patient and her infant is affected by a multitude of factors, including the patient's socioeconomic status, family history, role models, support systems, cultural factors, and birth experiences. Nurses need to consider these variables when assessing the attachment process between a mother and her infant. It is also important to note that women begin to show attachment behaviors not only in the postpartum period but also during pregnancy. Healthcare providers have multiple opportunities to assess how pregnant women will likely bond with their infants.

Attachment

In maternal-newborn healthcare, attachment refers to the emotional connection between a patient and her infant. This attachment is reciprocal; both the mother and the infant exhibit attachment behaviors. The infant responds to the patient by cooing, grasping, smiling, and crying. However, these behaviors are nondiscriminatory before approximately 8 weeks. Nurses can assess for attachment behaviors by observing the interaction between the mother and her infant. Behaviors indicating a positive attachment include:

• Touching
• Holding
• Kissing
• Cuddling
• Talking and singing
• Choosing the "en face" position
• Expressing pride in the infant

Postpartum assessment of attachment should begin immediately after delivery and continue throughout the infant's first year of life. Most women positively attach to their newborn infants. However, there are some patients who do not form attachments appropriately with their infants. Mal-attachment behaviors vary, but can include:

• Refusing to look at the infant
• Refusing to touch or hold the infant
• Refusing to name the infant
• Negative comments about the infant
• Refusing to respond or responding negatively to infant cues (eg, crying, smiling)

It is important to note that during the early postpartum period many factors can affect attachment, including anesthesia after a cesarean section (C-section), pain, or a traumatic birthing experience. Nurses need to consider these factors when assessing attachment. If mal-attachment is noted, nurses should immediately report the observation and continue to monitor both mother and infant.

Paternal/Domestic Partner Adjustment

As previously mentioned, the postpartum period is a time of great change within the family unit. Just as postpartum women are required to adjust to new role of mother, fathers and domestic partners also face a period of adjustment upon the arrival of the newborn. All partners, if possible, should be assessed for attachment behaviors when interacting with infants.

PATIENT CARE AND TEACHING

Primary responsibilities of the nurse in a postpartum setting are to assess the postpartum patient, provide care and teaching, and, if necessary, report any significant findings. Postpartum nurses are essentially detectives searching for findings that might lead to a negative outcome for the patient if left unattended. Thus it is imperative for nurses to distinguish normal and abnormal findings and to have a clear understanding of the nursing care necessary to promote the mother's health and well-being.

Many nurses find it useful to use the acronym BUBBLE-HE to remember the necessary components of the postpartum assessment and teaching topics. The following is organized according to this acronym.

Breasts

Assess the breasts for signs of engorgement, including fullness around postpartum days 3 and 4; assess for hot, red, painful, and edematous areas, which could indicate mastitis; assess nipple condition for patients who are breastfeeding.

PATIENT TEACHING

Breastfeeding patients should wear a comfortable support bra. Instruct mothers to gently rub colostrum or breast milk into their nipples and allow them to air dry after each feeding to "condition" the nipples. Patients should avoid washing the nipples with soap. It is also extremely important to teach patients proper breastfeeding techniques to ensure a positive experience for both the patient and infant.

Teaching proper latch-on techniques and how to break the infant's suction after feeding can have a positive and lasting effect upon women's breastfeeding experiences. Otherwise, patients may have sore, cracked, and sometimes bleeding nipples, which can discourage the continuation of breastfeeding. Instruct bottlefeeding patients to wear a tight-fitting bra and to avoid any type of nipple stimulation until lactation ends.

Uterus

Assess the fundus for firmness; by approximately one hour post delivery the fundus is firm and at the level of the umbilicus. The fundus continues to descend into the pelvis at the rate of approximately 1 cm or finger breadth per day and should be nonpalpable by 10 days postpartum. Encourage patients to void before palpation of the uterine fundus because a full bladder displaces the uterus and can lead to excessive bleeding. In addition, assess the patient for uterine cramping and treat for pain as needed.

PATIENT TEACHING

Patients or a family member can be taught to assess the firmness of the fundus and to provide massage in the event of a boggy uterus or excessive bleeding.

Bowel Function

Assessment of the bowel is important for all postpartum patients, however, it is vital for patients following a C-section. Assess the patient's bowel sounds, return of bowel function, and flatus, as well as color and consistency of stool. Administer prescribed stool softeners or laxatives as needed to treat constipation and ease perineal comfort during defecation.

PATIENT TEACHING

Encourage patients to ambulate soon after delivery. Teach that they need to eat fruits, vegetables, and other high-fiber foods daily. Postpartum patients should consume at least 2000 mL/day of fluid. Many patients consider 2000 mL a lot to drink in one day. Teach these patients to drink throughout the day rather than drinking 2000 mL at one time.

Bladder

Assess for the return of urination, which should occur within 6 to 8 hours of delivery. The amount of urine at each void should be assessed for approximately 8 hours after delivery; patients should void a minimum of 150cc per void. Less than 150cc per void could indicate urine retention due to decreased bladder tone post delivery, in the absence of preeclampsia or other significant health problems. It is important to assess for signs and symptoms of a urinary tract infection (UTI). The bladder should be nonpalpable above the symphysis pubis.

PATIENT TEACHING

Encourage patients to drink adequate fluid each day and to report signs and symptoms of a UTI, including frequency, urgency, painful urination, and hematuria.

Lochia

Assess lochia during the postpartum period, noting any excessive amount, any large blood clots, or any foul odors emitted from the lochia. Saturating 1 pad in less than an hour, a constant trickle of lochia, or the presence of large blood clots is indicative of more serious complications (eg, retained placenta fragments, hemorrhage) and should be investigated immediately.

If a patient has a significant amount of lochia despite a firm fundus, there may be a laceration in the birth canal, which would need to be addressed immediately. Furthermore, foul-smelling lochia typically indicates an infection and needs to be addressed immediately.

Lochia should progress from rubra to serosa to alba. Any changes in this progression could be considered abnormal and should be reported. It is important to note that C-section patients will typically have less lochia than a patient who delivered vaginally; however, some lochia should be present.

PATIENT TEACHING

Instruct discharged patients to report any abnormal progressions of lochia, excessive bleeding, foul-smelling lochia, or large blood clots to their physician immediately. Instruct patients to avoid sexual activity until lochial flow has ceased.

Episiotomy/Perineum

The acronym REEDA is often used to assess an episiotomy or laceration of the perineum. REEDA stands for redness, edema, ecchymosis, discharge, and approximation. Redness is considered normal with episiotomies and lacerations—however, if there is significant pain present, further assessment is necessary. Excessive edema can delay wound healing and the use of ice packs during the immediate postpartum period is generally indicated.

There should be no discharge from the episiotomy or laceration and the wound edges should be well approximated. Perineal pain must be assessed and treated. Nurses should assess the rectal area for hemorrhoids and, if present, instruct the patient in hemorrhoidal treatments (eg, witch hazel pads, Tucks).

PATIENT TEACHING

Patients can use a sitz bath to aid in perineal healing. To avoid infection, teach them to pat from front to back and to use a peri-bottle for gentle cleansing of the perineum after a bowel movement or urination. Many healthcare providers prescribe topical ointments and sprays to ease the discomfort of a sore perineum. Instruct patients to use the sitz bath and then apply the suggested topical agent for best results.

Analgesics are often prescribed for pain. Patients are generally instructed to apply ice packs to the perineum immediately after delivery. Inform patients with lacerations and episiotomies that, as sutures dissolve and heal, the perineum may itch and that this is normal. Instruct patients to avoid tampons and sexual activity until the perineum has healed.

Completing Kegel exercises are an important component of strengthening the perineal muscles, therefore teach patients to perform Kegel exercises as soon as is they can comfortably do so.

Homan's Sign

Homan's sign can be obtained by dorsiflexion of the foot. The presence of pain when eliciting the Homan's sign, is indicative of a deep vein thrombosis (DVT). is important to note that that a DVT may be present despite a negative Homan's sign so nurses must monitor patients for other signs of a DVT. Specifically, the lower extremities should be assessed for the presence of hot, red, painful, and edematous areas, all indicative of a DVT. Assess the legs for adequate circulation by checking the pedal pulses and noting temperature and color. In addition, the lower extremities should be assessed for edema. Pedal edema is normally present for several days after delivery as fluids in the body shift. However, lasting edema should be reported for further assessment.

PATIENT TEACHING

Get patients to ambulate as soon as possible after delivery to improve circulation and prevent the development of thrombi. Teach them not to cross their legs for long periods of time and to keep the legs elevated while sitting.

Emotions

Emotions are an essential element of the postpartum assessment. Patients typically exhibit symptoms of the "baby blues," demonstrated by tearfulness, irritability, and sometimes insomnia. The postpartum blues are caused by a multitude of factors, including hormonal fluctuations, physical exhaustion, and maternal role adjustment. This is a normal part of the postpartum experience. However, if these symptoms last longer than a few weeks, if the patient becomes nonfunctional, or if the she expresses a desire to harm herself or her infant, you should report it immediately and implement appropriate interventions to protect the patient and infant; this behavior falls under the category of postpartum depression (discussed under Postpartum Complications here).

PATIENT TEACHING

New mothers and their families need to understand that baby blues are a normal part of the postpartum experience. Encourage patients to rest regularly and to allow family members to care for them during the postpartum period. Instruct patients to get plenty of fresh air and gentle exercise. Acquaint patients with groups for new mothers that provide the support of other women experiencing postpartum blues. Finally, teach patients and their families the signs and symptoms of postpartum depression.

OTHER ASSESSMENTS

Vital Signs

During the postpartum period, patients may exhibit a slight temperature elevation due to dehydration following delivery or as a result of breast milk coming in around day 3 or 4. Immediately after delivery, the blood pressure should remain the same as it was during delivery. An increase in blood pressure could indicate pregnancy-induced hypertension, while a decrease could indicate shock or orthostatic hypotension. Bradycardia is normal immediately after delivery; however, tachycardia could indicate hemorrhage or infection and should be monitored carefully. Respirations are usually within the normal range for an adult.

Pain

During the postpartum period, it is very important that nurses continually assess patient's for pain, taking into account the patient's acceptable pain levels. The nurse should look for pain in all areas of the body, including the head, chest, breast, back, limbs, abdomen, uterus, perineum, and extremities. just as important, patients should also be assessed for emotional pain and treated accordingly.

PATIENT TEACHING

Mild analgesics or narcotics may be prescribed. Nurses can also teach nonpharmacologic methods of pain relief to the patient and her family. Some of these methods include the application of hot or cold packs, massage, progressive relaxation, and meditation.

Cesarean Section

Patients who deliver via C-section have some addition assessment needs during the postpartum period, including incision status, pain, respirations, and lung and bowel sounds. Patients may have vertical or horizontal incisions that will need to be assessed throughout the postpartum period. Nurses can use the REEDA method (redness, edema, ecchymosis, discharge and approximation) to assess C-section incisions. The incision should be well approximated and without signs and symptoms of infection, including significant redness, edema, and drainage. There should be minimal to no drainage from the incision. If drainage is present, it should not have a foul odor.

PATIENT TEACHING

It is important to teach patients to examine their incision each day with a mirror or have a family member monitor the incision for them. Instruct patients to report any abnormal findings to their healthcare provider.

Nurses need to monitor pain especially carefully in postoperative C-section patients. To manage pain, these patients generally have either an epidural or a continuous intravenous infusion of pain medication via a patient-controlled anesthesia (PCA) pump. According to Karlstrom and colleagues (2007), patients experience their worst pain level during the first 24 hours postoperatively and during the second day after surgery. Nurses should implement appropriate interventions if patients experience levels of pain they find unacceptable.

When patients receive narcotics for pain relief, there is a possibility of respiratory depression so the monitoring of respirations is imperative. If a patient exhibits respirations below 12 breaths per minute, instantaneous intervention is necessary. The anesthesiologist should be notified immediately, oxygen should be administered, pulse oximetry levels must be monitored, and the head of the bed should be elevated. Naloxone hydrochloride (Narcan), a narcotic antagonist, should be readied for administration per hospital policy or as ordered.

Assessment of patients delivering via C-section should also include the auscultation of lung sounds because respiratory depression and prolonged periods of immobility may cause secretions to accumulate in the lungs, leading to further complications. Patients can be taught to turn, cough, and deep-breathe to aid in clearing the lungs. Bowel sounds and the presence of flatus are assessed regularly to ensure proper GI functioning prior to discharge.

Intimate Partner Violence

In addition to the typical assessments deemed necessary during the postpartum period, it is vital that nurses assess for signs and symptoms of domestic violence, often referred to as intimate partner violence (IPV). IPV touches the lives of countless women and children around the world.

According to the Centers for Disease Control and Prevention (CDC, 2006), "each year, women experience about 4.8 million intimate partner–related physical assaults and rapes." The American Nurses Association (ANA) Position Statement on Violence Against Women (2000) indicates that the ANA supports the "…assessment of women in healthcare institutions and community settings [for IPV]…." Abusive behaviors are often exacerbated during pregnancy and after delivery, therefore the maternal-child nurse has a special opportunity to assess and assist patients suffering from IPV. It is essential that nurses have a clear understanding of the tools and techniques necessary to assess this population during the postpartum period.

Intimate partner violence is abuse that occurs between two people who are in a close or intimate relationship. It can manifest as physical, verbal/emotional, or sexual abuse, or as threatened abuse. Symptoms of IPV include chronic pain, migraine, depression, anxiety, bruises at various stages of healing, bruises resembling cords or belts, pelvic inflammatory disease (PID), and UTIs. An abusive partner may exhibit hostile or demanding behavior, or may refuse to leave the patient's side. Abusers may also answer for the patient and find ways to alienate the patient from her family and friends. In assessing patients for IPV, nurses should provide a private space for the assessment and assure patients of confidentiality.

Since IPV occurs between husband and wife, boyfriend and girlfriend, and domestic partners, nurses should avoid questions such as "Do you feel safe at home?" or "Is anyone abusive to you?" in the presence of others, including family members and friends. Furthermore, it is essential that nurses ask questions in a nonjudgmental manner because many patients are both afraid and ashamed. Judgmental questions like "Why don't you just leave?" or "Why do you continue to go back?" are not likely to be helpful. Furthermore, Hathaway and colleagues (as cited in Watts, 2004) indicate that if a patient felt the questioner was rushed when completing the IPV assessment she was less likely to disclose her abuse. It is essential for nurses to assess patients in an unhurried and supportive manner.

Various tools are available to screen and assess patients for IPV and many healthcare organizations have agreed to follow the ANA recommendation of screening all women who enter healthcare facilities for IPV. The CDC has published Measuring Intimate Partner Violence—Victimization and Perpetration: A Compendium of Assessment Tools (see References) which lists and evaluates IPV screening tools that can be used by healthcare providers to assess patients for IPV. With the assistance of such tools, nurses are able to refer patients to the appropriate resources within the hospital and community.

POSTPARTUM COMPLICATIONS

The postpartum period is a time filled with joy and excitement. However, despite the normalcy of childbirth, sometimes complications arise that can have detrimental effects on the patient. Several complications have the potential of occurring during the postpartum period, including postpartum hemorrhage, thrombophlebitis, postpartum infections including mastitis, endometritis, and UTIs, as well as postpartum depression. Nurses working with postpartum patients must have a clear understanding of these complications, including the symptoms, nursing interventions, and treatment.

Hemorrhage

Postpartum hemorrhage (PPH) is one of the leading causes of death among postpartum women. Postpartum hemorrhage refers to a blood loss of more than 500 mL after a vaginal birth and more than 1000 mL after a C-section. Every patient has the potential to hemorrhage after delivery, however, some patients have attributes that place them at higher risk for postpartum hemorrhage. These risk factors include:

• Multiple parity
• Multi-fetal pregnancy
• Macrosomia
• Prolonged or precipitous labor
• Labor induction
• Vacuum or forceps delivery
• Lacerations
• Stillbirth
• Placenta previa
• Use of certain medications (eg, magnesium sulfate)
• Mechanical factors, such as a full bladder

Postpartum hemorrhage is categorized as late or early. Early refers to a hemorrhage occurring within the first 24 hours after birth, while late refers to a hemorrhage occurring after 24 hours.

Early postpartum hemorrhage is often caused by uterine atony. With uterine atony, there is a failure of the uterine muscles to contract properly, thereby inhibiting the healing of blood vessels at the site of placental attachment. The blood vessels continue to bleed until the uterine muscles contract. Signs of uterine atony include a boggy uterus, a fundus that is higher than expected upon palpation, and excessive lochia.

If the fundus is not firm (boggy), there are several nursing interventions that can alleviate the problem: (1) massage the fundus; (2) express blood clots only if the uterus is firmly contracted, otherwise, uterine inversion and severe hemorrhage can occur; (3) encourage the patient to void, or catheterize as needed; and (4) administer prescribed medications, such as Pitocin, Ergonovine, Methergine, or Hemabate. It is important to note that Methergine can cause an elevation in blood pressure and therefore, should not be used with hypertensive patients.

The nurse must report a PPH immediately and prepare for the insertion of a large-bore intravenous catheter, if one is not already present, and the administration of intravenous fluids and oxygen. A large-bore intravenous catheter is inserted to allow possible administration of blood products. Assess continually for bleeding, vital signs, and oxygen saturation. The patient's legs may also be elevated "…to a 20- to 30-degree angle to increase venous return" (Leifer, 2005). Patients and their families will need support during this time.

Early postpartum hemorrhage can also be caused by damage to the birth canal during labor and birth, however the most common cause is uterine atony. If a PPH is due to trauma to the birth canal, such as a hematoma, an extension of a perineal incision or an improperly sutured laceration, patients may exhibit one or more of the following symptoms: a contracted uterus with excessive lochia, bright red lochia, a constant trickle of blood from the vagina, severe pain (possibly from a hematoma), or shock.

In the case of an early PPH caused by damage to the birth canal, surgical repair is usually necessary. In the case of hematoma formation, surgical incision, evacuation of blood clots, and ligation of the bleeding blood vessel may be necessary. However, in the case of a small hematoma, observation and application of ice or alternate hot and cold applications may be all that is required (Leifer, 2005).

Late postpartum hemorrhage is often caused by subinvolution of the uterus or by retained placental fragments that prevent the uterus from contracting. In the case of retained placental fragments, clots develop around the retained fragments and hemorrhaging can occur days later when the clots are shed. The certified nurse-midwife or physician is responsible for examining the placenta after delivery and ensuring that it is intact; therefore, a late PPH is usually preventable. Patients with placenta accreta or with providers who attempt to extract the placenta prior to uterine wall separation are at higher risk for a late PPH.

Assessment and manual expression of placental fragments by the physician or nurse-midwife can often alleviate the problem, however, surgical intervention, such as a dilation and evacuation (D&E) may be necessary. With subinvolution and a late PPH, fundal massage in addition to medications (Pitocin, Ergonovine) and the previously mentioned interventions for early PPH may be used to minimize bleeding.

Important note: A sequela of PPH is hypovolemic shock. Under normal circumstances, patients are able to withstand blood loss during the postpartum period as a result of increased blood volume during pregnancy. However, in the presence of a PPH, hypovolemic shock can occur and cause severe organ damage and even death if untreated.

Often tachycardia is the first sign of hypovolemic shock. The blood pressure usually decreases and the respiratory rate increases. The skin becomes cool and pale initially and then cold and clammy. Patients also become anxious, agitated, and restless as blood loss starts to affect the brain. Hypovolemic shock can be stopped by stopping blood loss. Patients will also require oxygen (usually 8–10 mL via face mask), IV fluids, and possibly blood products. This is a very serious situation and nurses must be prepared to assist in this life-threatening emergency.

Thrombophlebitis

Patients can suffer from thrombophlebitis as a result of venous stasis and the normal hypercoagulability state of the postpartum period. Thrombophlebitis is an inflammation of the blood vessel wall in which a blood clot forms and causes problems in the superficial or deep veins (DVT) of the lower extremities or pelvis. All patients are at risk, however certain risk factors predispose patients to developing thrombophlebitis. These risk factors include varicose veins, clotting disorders, delivering via C-section, diabetes mellitus, smoking, obesity, prolonged sitting or standing, and advanced maternal age.

The blood clot that develops in thrombophlebitis can lead to a life-threatening pulmonary embolism as a result of the clot detaching from the vein wall and blocking the pulmonary artery. The major signs of pulmonary embolism include dyspnea and chest pain.

In monitoring patients for the development or presence of thrombophlebitis, nurses should assess for the presence of pain when eliciting the Homan's sign and for the presence of hot, red, painful, or edematous areas on the lower extremities or groin area. An elevated temperature may also be present. Again, it is important to remember that a negative Homan's sign does not always indicate the absence of a DVT. Therefore, it is important to assess for the other signs and symptoms of thrombophlebitis.

Interventions to treat thrombophlebitis depend on the severity of the thrombosis. Usually, for superficial thrombosis, analgesics, bed rest, and elevation of the affected limb is enough to alleviate the problem. However, in the presence of a DVT, anticoagulants may be necessary. In addition to use of compression stockings and warm, moist heat applications, patients should be instructed to keep their legs elevated and uncrossed. Patients are typically allowed to ambulate only after symptoms subside.

Infections

Postpartum infections are infections accompanied by a temperature of 38°C or higher on two separate occasions where no other explanation is responsible for the elevation in temperature. Patients should be carefully monitored for signs and symptoms of infection during this period. Common infections that patients may exhibit include mastitis, endometritis, wound infections, and UTIs.

MASTITIS

Mastitis is a breast infection caused by Staphylococcus aureus. S. aureus is found on the hands and can also be in the mouth of the infant. Bacteria can enter through cracked nipples caused by improper latch-on during breastfeeding. Mastitis can develop due to blocked milk ducts and milk stasis in the breastfeeding patient. Blocked milk ducts and milk stasis occurs as a result of improper latching and inadequate breast emptying. It is crucial that postpartum nurses teach patients proper latch technique. Additionally, nurses must stress that patients feed infants and allow the breast to empty completely. Patients should also be encouraged to avoid missing feedings and allowing the breast to become engorged.

The classic symptom of mastitis is a unilateral mass in the breast accompanied by pain and redness. Often patients experience a low-grade fever, chills, and general malaise. If untreated, a breast abscess may develop. Treatment for mastitis typically involves antibiotic therapy and regular breastfeeding or pumping the breast. Nurses can encourage the patient to apply cold or warm compresses to ease discomfort and to take analgesics as needed. Mastitis usually resolves quickly, as long as patients continue to breastfeed or pump regularly.

ENDOMETRITIS

Endometritis is an infection of the uterus characterized by uterine subinvolution, abdominal cramps, and purulent, foul-smelling lochia. It is caused by the bacteria normally present in the uterus and cervix, such as E. coli and group B streptococcus. Manual removal of the placenta, multiple vaginal examinations during labor, C-sections, premature rupture of members, and internal fetal and/or uterine monitoring predispose patients to developing endometritis.

In addition to cramping and foul-smelling lochia, patients with endometritis usually have a fever, chills, general malaise, and may exhibit tachycardia. Blood cultures to identify the causative organism are typically done and white blood cell (WBC) counts monitored. However, it is important to remember that the white blood cell count is normally elevated after delivery for a short period; continued monitoring of the WBC count is required in identifying endometritis. Endometritis is usually treated with intravenous antibiotics and rest.

WOUNDS

Wound infections are infections that occur at wound sites. Commonly affected wound sites include the perineum, where lacerations and episiotomies occur, and the C-section incision. As with all infections, every patient is at risk. However, patients with diabetes are at a higher risk for developing an infection.

Patients with wound infections typically have wounds that exhibit redness, warmth, poor wound approximation, tenderness, and pain. If untreated, the patient may develop a fever and other symptoms of an infection, such as malaise. As with endometritis, blood cultures may be obtained to isolate the causative organism. Antibiotics will typically be administered and drainage of the wound may be necessary.

Dressing changes using normal saline will aid in the healing process. Patients should be taught about proper handwashing, encouraged to maintain adequate fluid intake, and to increase protein intake to assist in wound healing. Wound infections can be intensely painful, especially in the perineum. Therefore, the nurse should assist the patient in managing her pain through the use of analgesics and positioning.

URINARY TRACT (UTIS)

Urinary tract infections are common during the postpartum period. Patients' urethra and bladder are often traumatized during labor and birth due to intermittent catheterizations and the pressure of the infant as it passes through the birth canal. Additionally, the bladder and urethra loose tone after delivery, making the retention of urine and urinary stasis common. The risk of developing a UTI is high. Patients that deliver via C-section may also develop a UTI due to the placement of a Foley catheter, which remains in place for several hours or days after delivery.

Patients with urinary tract infections often complain of frequent and/or painful urination as well as flank pain. A low-grade fever and hematuria may also be present. Urinary tract infections are treated with antibiotics, but it is important that patients drink adequate fluids to flush bacteria out of the system. Encourage patients to drink plenty of water. Additionally, it has been suggested that cranberry juice is useful in preventing urinary tract infections due to acidifying the urine and preventing bacteria from attaching to the bladder walls. However, there is great debate over this issue.

Postpartum Depression

Postpartum depression is a serious and debilitating depression that affects many women throughout the world. According to Blum (2007) "There are no specific, generally accepted criteria for time after delivery for a depression to be considered a postpartum depression, but typically these depressions occur within the first nine months after the baby's birth, often within the initial weeks or months" (p. 46). Symptoms typically include sadness, crying, insomnia, decreased appetite, withdrawal, and sometimes suicidal ideation or the desire to harm the infant. Additionally, women may present with somatic symptoms, such as "…headaches, diarrhea, constipation, severe anxiety, feeling as though they are jumping out of their skin, and/or just not feeling like themselves" (Driscoll, 2006, p. 401).

It is the responsibility of nurses to assess patients for signs and symptoms of postpartum depression. Various assessment tools are available, including the Edinburgh Postnatal Depression Scale (EPDS) and the Postpartum Depression Screening Scale (PDSS). These tools are quick and provide a simple way to assess patients while at the hospital, at home during postpartum home visits, and during postpartum checkup visits.

These tools can also be used to assess mothers at pediatric follow-up visits. After the screening and assessment, patients who are at risk for developing (or who are suffering from) postpartum depression can be referred to the appropriate healthcare provider for follow-up and treatment. According to Lowdermilk and Perry (2006), symptoms of postpartum depression "…rarely disappear without outside help"; therefore, it is imperative that nurses appropriately assess and refer patients suffering from this type of depression (p. 837).

Postpartum depression is usually treated with counseling and medication. Nurses can support patients in the healing process at follow-up appointments and during home visits. Driscoll (2006) recommends that nurses help patients and their families understand postpartum depression and assist patients in exploring the spiritual aspects of their suffering as an aid in the healing process. Additionally, nurses should encourage patients who are suffering from postpartum depression to get adequate nutrition, rest, relaxation, and exercise (Driscoll, 2006).

DISCHARGE INSTRUCTIONS

Patients and their families should be instructed to call the healthcare provider if the patient has any of the following:

• Fever
• Foul-smelling lochia
• Large blood clots, or bleeding that saturates a pad in 1 hour
• Discharge or severe pain from incisions
• Hot, red, painful areas on the breasts or legs
• Bleeding and severe pain in the nipples
• Severe headaches or blurred vision
• Chest pain or dyspnea without exertion
• Frequent, painful urination
• Signs of depression

CONCLUSION

The postpartum period is a time of joy and satisfaction for patients and their families. In order to ensure that patients are off to a healthy and happy start with their newborns, nurses must be prepared to assess, intervene, and teach patients during this time. Most hospitals and birthing centers provide guidelines for nurses providing postpartum care and you should always follow the recommendations of your facility.

Posted March 31, 2008

Expires April 1, 2010

Copyright © 2008 Wild Iris Medical Education. All rights reserved.

Accreditation   Home
Site Map   Contact   Privacy   Disclaimer

NursingCEU.com is a division of Wild Iris Medical Education
© 2008 Wild Iris Medical Education, Inc.