Chapter 11 Nursing Care of the Client During the Postpartum Period – Flashcards
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The postpartum period, or puerperium
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includes physiological and psychosocial adjustments. This period begins at the start of the fourth stage of labor (1 to 4 hr after the delivery of the placenta) and ends when the body returns to the prepregnant state. This process takes approximately 6 weeks.
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The greatest risks during the postpartum period are
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hemorrhage, shock, and infection
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Postpartum data collection
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Nurses should perform postpartum data collection per facility protocols. Clients with stable vital signs are usually monitored every 15 min x 4 for the first hour, every 30 min x 2 for the second hr, hourly x 2 for at least 2 hr, then every 4 to 8 hr
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Additional data is collected using the acronym BUBBLE:
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1. B - Breasts 2. U - Uterus (fundal height, uterine placement, and consistency) 3. B - Bowel and GI function 4. B - Bladder function 5. L - Lochia (color, odor, consistency, and amount [COCA]) 6. E - Episiotomy (edema, ecchymosis, approximation)
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Thermoregulation - Data collection
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Postpartum chill, which occurs in the first 2 hr puerperium, is an uncontrollable shaking chill experienced by clients immediately following birth. Postpartum chill is possibly related to a nervous system response, vasomotor changes, a shift in fluids, and/or the work of labor. This is a normal occurrence unless accompanied by an elevated temperature
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Thermoregulation - Nursing Actions
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Provide clients with warm blankets and fluids.
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Thermoregulation - Client education
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Assure clients that these chills are a self-limiting common occurrence that will only last a short while.
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Fundus - Data collection
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1. Physical changes of the uterus include involution of the uterus. Involution occurs with contractions of the uterine smooth muscle, whereby the uterus returns to its prepregnant state. The uterus also rapidly decreases in size from approximately 1,000 g (2.2 lb) to 50 to 60 g (< 2 oz) over a period of 6 weeks with the fundal height steadily descending into the pelvis approximately one fingerbreadth (1 cm) per day. 2. Immediately after delivery, the fundus should be firm, midline with the umbilicus, and approximately at the level of the umbilicus. At 12 hr postpartum, the fundus may be palpated at 1 cm above the umbilicus. 3. Every 24 hr the fundus should descend approximately 1 to 2 cm. It should be halfway between the symphysis pubis and the umbilicus by the sixth postpartum day. 4. By day 10, the uterus should lie within the true pelvis and should not be palpable.
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Fundus - Nursing Actions - A
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1. Explain the procedure to the client. 2. Apply clean gloves and place a lower perineal pad under the client's buttocks. 3. Cup one hand just above the symphysis pubis to support the lower segment of the uterus, and with the other hand, palpate the client's abdomen to locate the fundus. A. Determine the fundal height by placing fingers on the abdomen and measuring how many fingerbreadths (centimeters) fit between the fundus and the umbilicus above, below, or at the umbilical level. B. Determine if the fundus is midline in the pelvis or displaced laterally (caused by a full bladder). C. Determine if the fundus is firm or boggy. If the fundus is boggy (not firm), lightly massage the fundus in a circular motion. D. Observe lochia flow as the fundus is palpated.
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Fundus - Nursing Actions - B
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4. Document the fundal height, location, and uterine consistency. 5. Monitor clients receiving oxytocics [oxytocin (Pitocin), methylergonovine maleate (Methergine), and carboprost tromethamine (Hemabate)] to promote uterine contractions and to prevent hemorrhage. 6. Monitor for hypotension with oxytocin administration. 7. Monitor for hypertension with administration of methylergonovine maleate, ergonovine maleate, and carboprost tromethamine.
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Fundus - Client Education
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1. Encourage early breastfeeding for clients who are lactating. This will stimulate the production of natural oxytocin and will help prevent hemorrhage. 2. Encourage frequent emptying of the bladder every 2 to 3 hr to prevent possible uterine displacement and atony.
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Lochia - Data collection - Three stages of lochia (vaginal discharge)
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1. Lochia rubra - Bright red color, bloody consistency, fleshy odor, may contain small clots, transient flow increases during breastfeeding and upon rising. Lasts 1 to 3 days after delivery. 2. Lochia serosa - Pinkish brown color and serosanguineous consistency. Lasts from approximately day 4 to day 10 after delivery. 3. Lochia alba - Yellowish, white creamy color, fleshy odor. Lasts from approximately day 11 up to and beyond 6 weeks postpartum.
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Lochia - Data collection - Lochia amount
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Lochia amount is determined by the quantity of saturation on the perineal pad as being either: 1. Scant (< 2.5 cm) 2. Light ( 10 cm) 4. Heavy (one pad saturated within 2 hr) 5. Excessive blood loss (one pad saturated in 15 min or less or pooling of blood under buttocks)
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Lochia - Data collection - Monitoring lochia flow - Expected findings
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Monitor the lochia flow for normal color, amount, and consistency. 1. Lochia typically trickles from the vaginal opening, but flows more steadily during uterine contractions. 2. A gush of lochia with the expression of clots and dark blood that has pooled in the vagina may occur with ambulation or massage of the uterus.
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Lochia - Data collection - Monitoring lochia flow - Abnormal findings
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1. Excessive spurting of bright red blood from the vagina, possibly indicating a cervical or vaginal tear. 2. Numerous large clots and excessive blood loss (saturation of one pad in 15 min or less), which may be indicative of a hemorrhage. 3. Foul odor, which is suggestive of an infection. 4. Persistent lochia rubra in the early postpartum period beyond day three, which may indicate retained placental fragments. 5. Continued flow of lochia serosa or alba beyond the normal length of time may indicate endometritis, especially if it is accompanied by a fever, pain, or abdominal tenderness.
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Lochia - Nursing actions
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1. Notify the provider. 2. Administer antibiotics if indicated. 3. Assist with emergency care of clients.
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Lochia - Client education
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Instruct clients to notify the provider of abnormal findings of lochia.
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Cervix, Vagina, and Perineum - Data collection
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1. The cervix is soft directly after birth and may be edematous, bruised, and have some small lacerations. Within 2 to 3 days postpartum, it shortens and regains its form becoming firm with the os gradually closing. 2. The vagina, which has distended, gradually returns to its prepregnancy size with the reappearance of rugae and a thickening of the vaginal mucosa. However, muscle tone is never restored completely. 3. The soft tissues of the perineum may be erythematous and edematous, especially in areas of an episiotomy or lacerations. Hematomas or hemorrhoids may be present. The pelvic floor muscles may be overstretched and weak. 4. Monitor for cervical, vaginal, and perineal healing. 5. Observe for perineal erythema, edema, and hematoma. 6. Check episiotomy and lacerations for approximation, drainage, quantity, and quality. A. A bright red trickle of blood from the episiotomy site in the early postpartum period is a normal finding.
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Cervix, Vagina, and Perineum - Nursing actions - A
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1. Encourage clients to eat a well-balanced diet, with adequate fruits, vegetables, fiber, and fluids. 2. Educate clients about proper cleansing to prevent infection. Tell clients to: A. Wash hands thoroughly before and after voiding. B. Use a squeeze bottle filled with warm water or antiseptic solution after each voiding to cleanse the perineal area. C. Clean the perineal area from front to back (urethra to anus). D. Blot dry, do not wipe. E. Use a topical application of antiseptic cream or spray. F. Change the perineal pad from front to back after voiding or defecating.
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Cervix, Vagina, and Perineum - Nursing actions - B
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3. Promote comfort measures. A. Apply ice packs to the client's perineum for the first 24 to 48 hr to reduce edema and provide anesthetic effect. B. Encourage sitz baths at a temperature of 38° to 40° C (100° to 104° F) or cooler at least twice a day. C. Administer analgesia such as nonopioids (acetaminophen [Tylenol]), nonsteroidal anti-inflammatories (ibuprofen [Advil]), and opioids (codeine, hydrocodone) as prescribed for pain and discomfort. D. Apply topical anesthetics (Americaine spray or Dermoplast) to the client's perineal area as needed or witch hazel compresses (Tuck's) to the rectal area for hemorrhoids.
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Cervix, Vagina, and Perineum - Client education
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1. Recommend clients avoid sexual intercourse until the episiotomy/laceration is healed, vaginal discharge has turned white (lochia alba), and a provider has verbalized that sexual intercourse can resume. This usually takes 2 to 4 weeks or longer, depending on the patient. Over-the-counter lubricants may be needed during the first 6 weeks due to a decrease in estrogen that reduces vaginal lubrication. 2. Inform clients that physiological reactions to sexual activity may be slower and less intense for the first 3 months following birth. 3. Advise clients to begin using contraception upon resumption of sexual activity and that pregnancy can occur while breastfeeding even though menses has not returned. 4. Inform clients who are breastfeeding that menses may not resume for 3 months or until cessation of breastfeeding. 5. Inform clients who are not breastfeeding that menses may not resume until around 4 to 10 weeks.
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Breasts - Data collection
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1. Secretion of colostrum occurs during pregnancy and 2 to 3 days immediately after birth. Milk is produced 2 to 3 days after the delivery of the newborn. 2. Monitor clients for: A. Redness and tenderness of the breast B. Cracked nipples and indications of mastitis (infection in a milk duct of the breast with concurrent flu-like symptoms)
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Breasts - Nursing actions
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1. Encourage early-demand breastfeeding, which will also stimulate the production of natural oxytocin and help prevent uterine hemorrhage. 2. Assist clients into a comfortable position and have her try various positions during breastfeeding (cradle hold, side-lying, and football hold) and explaining how varying positions can prevent nipple soreness. 3. Reinforce to clients the importance of proper latch techniques (the newborn takes in part of the areola and nipple, not just the tip of the nipple) to prevent nipple soreness.
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Breasts - Client education
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Instruct clients to wear a well-fitting bra continuously for the first 72 hr after birth.
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Breasts - Client education - For clients who are lactating - A
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1. Emphasize the importance of hand hygiene prior to breastfeeding to prevent infection. 2. Instruct clients to: A. Completely empty the breasts at each feeding. Massaging the breasts during feeding can help with emptying. B. Allow newborns to nurse on demand. Allow newborns to feed 15 to 20 min per breast or until the breast softens. Begin the next breastfeeding session on the breast that was not completely emptied. 3. Instruct clients to manage breast engorgement. 4. Apply cool compresses between feedings.
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Breasts - Client education - For clients who are lactating - B
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5. Apply warm compresses or take a warm shower prior to breastfeeding. 6. Apply cold cabbage to the breasts to decrease swelling and relieve discomfort. 7. Instruct clients with flat nipples to roll the nipples between her fingers just before breastfeeding to help them become more erect and make it easier for newborns to latch on. 8. Instruct clients with sore nipples to apply a small amount of breast milk to the nipples and allow it to air-dry after breastfeeding. 9. Instruct clients to apply breast creams as prescribed and wear breast shields in their bra to soften the nipples if they are irritated and cracked. 10. Encourage clients to consume 2 to 3 L of fluid/day from food and beverage sources to replace fluid lost from breastfeeding, as well as produce an adequate amount of milk for the newborn.
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Breasts - Client education - For nonlactating women
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1. Instruct clients to avoid breast stimulation and running warm water over the breasts for prolonged periods until no longer lactating. 2. Instruct clients to manage breast engorgement (may occur on the third or fifth postpartum day). 3. Apply cold compresses 15 min on and 45 min off. 4. Place fresh cabbage leaves inside the bra. 5. Take a mild analgesic for pain and discomfort.
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Cardiovascular System and Fluid and Hematologic Status - Data collection - A
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1. The cardiovascular system undergoes a decrease in blood volume during the postpartum period related to: A. Blood loss during childbirth (average blood loss is 500 mL in an uncomplicated vaginal delivery and 1,000 mL for a cesarean birth). B. Diaphoresis and diuresis of the excess fluid accumulated during the last part of the pregnancy. Loss occurs within the first 2 to 3 days postdelivery. 2. Increased Hct and Hgb values are present immediately after delivery for up to 72 hr. Leukocytosis (white blood cell count elevation) of up to 20,000 to 25,000/mm3 occurs for the first 10 to 14 days without the presence of infection and then returns to normal. 3. Coagulation factors and fibrinogen levels increase during pregnancy and remain elevated for 2 to 3 weeks postpartum. Hypercoagulability predisposes the postpartum woman to thrombus formation and thromboembolism.
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Cardiovascular System and Fluid and Hematologic Status - Data collection - B
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4. Blood pressure is usually unchanged with an uncomplicated pregnancy, but may have an insignificant slight transient increase. 5. Possible orthostatic hypotension within the first 48 hr postpartum may occur immediately after standing up with feelings of faintness or dizziness resulting from splanchnic (viscera/internal organs) engorgement that can occur after birth. 6. Elevation of pulse, stroke volume, and cardiac output for the first hour postpartum occurs and then gradually decreases to a prepregnant state baseline by 8 to 10 weeks. 7. Elevation of temperature to 38° C (100° F) resulting from dehydration after labor during the first 24 hr may occur, but should return to normal after 24 hr postpartum.
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Cardiovascular System and Fluid and Hematologic Status - Nursing actions
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1. Monitor vital signs per facility protocol. 2. Inspect the client's legs for redness, swelling, and warmth, which are additional signs of venous thrombosis. 3. Encourage early ambulation to prevent venous stasis and thrombosis. 4. Apply antiembolism hose to the lower extremities of clients who are at high-risk for developing venous stasis and thrombosis. The hose should be removed as soon as clients are ambulating. 5. Administer medications as prescribed.
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Gastrointestinal System and Bowel Function - Data collection
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1. An increased appetite following delivery 2. Constipation with bowel evacuation delayed until 2 to 3 days after birth 3. Hemorrhoids
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Gastrointestinal System and Bowel Function - Nursing actions
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1. Monitor clients for reports of hunger. 2. Check for bowel sounds and the return of normal bowel function. A. Spontaneous bowel movement may not occur for 2 to 3 days after delivery secondary to decreased intestinal muscle tone during labor and puerperium and prelabor diarrhea and dehydration. Clients may also anticipate discomfort with defecation because of perineal tenderness, episiotomy, lacerations, or hemorrhoids. 3. Observe the client's rectal area for varicosities (hemorrhoids). 4. Administer stool softeners (docusate sodium) as prescribed to prevent constipation.
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Gastrointestinal System and Bowel Function - Client education
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1. Encourage clients to eat a well-balanced diet, with adequate fruits, vegetables, fiber, and fluids. 2. Encourage clients to ambulate. 3. Reinforce the importance of eating a nutritious diet including all food groups. 4. Encourage a diet high in protein, which will aid in tissue repair. Clients should also consume 2 to 3 L of fluid each day from food and beverage sources. A. Encourage women who are lactating to add an additional daily intake of 330 calories during the first 6 months, and an additional daily intake of 400 calories during the second 6 months.
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Urinary System and Bladder Function - Data collection
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1. Urinary retention secondary to loss of bladder elasticity and tone and/or loss of bladder sensation resulting from trauma, medications, or anesthesia. 2. A distended bladder as a result of urinary retention can cause uterine atony and displacement to one side, usually to the right. The ability of the uterus to contract is also lessened. 3. Postpartal diuresis with increased urinary output begins within 12 hr of delivery. 1,500 to 3,000 mL/day is expected within the first 2 to 3 days after delivery.
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Urinary System and Bladder Function - Nursing actions
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1. Determine the client's ability to void every 2 to 3 hr (perineal/urethral edema may cause pain and difficulty in voiding during the first 24 to 48 hr). 2. Observe the client's bladder elimination pattern (client should be voiding every 2 to 3 hr). 3. Monitor clients for signs of a distended bladder A. Fundal height above the umbilicus or baseline level B. Fundus displaced from the midline over to the side C. Bladder bulges above the symphysis pubis D. Excessive lochia E. Tenderness over the bladder area F. Frequent voiding of less than 150 mL of urine is indicative of urinary retention with overflow 4. Insert a straight or indwelling urinary catheter, if necessary, for bladder distention if clients are unable to void to ensure complete emptying of the bladder and allow uterine involution.
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Urinary System and Bladder Function - Client education
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Encourage clients to empty their bladder frequently (every 2 to 3 hr) to prevent possible displacement of the uterus and atony.
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Musculoskeletal System - Data collection
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1. By 6 to 8 weeks after birth: A. The joints return to their pregnant state and are completely restabilized. The feet however, may remain permanently increased in size. B. Muscle tone begins to be restored throughout the body with the removal of progesterone's effect following delivery of the placenta. 2. The rectus abdominis muscles of the abdomen and the pubococcygeal muscle tone are restored following placental expulsion.
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Musculoskeletal System - Nursing actions
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Monitor the client's abdominal wall for diastasis recti (a separation of the rectus muscle) anywhere from 2 to 4 cm. It usually resolves within 6 weeks.
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Musculoskeletal System - Client education - A
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1. Reinforce the important of postpartum strengthening exercises, advising them to start with simple exercises, and then gradually progressing to more strenuous ones. 2. Kegel exercises use the same muscles that are used when starting and stopping the flow of urine. Have clients relax and contract the pelvic floor muscles 10 times, eight times a day. 3. Pelvic tilt exercises strengthen back muscles and relieve strain on the lower back. Instruct clients to alternately arch and straighten the back. 4. Advise clients to use good body mechanics and proper posture.
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Musculoskeletal System - Client education - B
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5. Recommend that clients: A. Not perform housework requiring heavy lifting for at least 3 weeks. B. Not lift anything heavier than the newborn. C. Avoid sitting for prolonged periods of time with legs crossed (to prevent thrombophlebitis). D. Limit stair-climbing for the first few weeks postpartum. E. Not to drive for the first 2 weeks postpartum, or while taking opioids for pain control. 6. Advise clients who have had a cesarean birth to: A. Postpone abdominal exercises until about 4 weeks after delivery, or as directed by the provider. B. Wait until the 6-week follow-up visit before performing strenuous exercise, heavy lifting, or excessive stair-climbing.
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Immune System - Nursing actions
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1. Review rubella status - a client who has a titer of less than 1:8 is administered a subcutaneous injection of rubella vaccine or an measles, mumps and rubella vaccine during the postpartum period to protect a subsequent fetus from malformations. Clients should not get pregnant for 4 weeks following the vaccination. 2. Review hepatitis B status - Newborns born to infected mothers should receive the hepatitis B vaccine and the hepatitis B immune globulin within 12 hr of birth. 3. Review the Rh status - All Rh-negative mothers who have newborns, and are Rh-positive, must be given RHo(D) immune globulin (RhoGAM) administered IM within 72 hr of the newborn being born to suppress antibody formation in the mother.
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Immune System - Client education
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Remind clients who receive both the rubella vaccine and RhoGAM to return to provider after 3 months to determine if immunity to rubella has been developed.
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Comfort and Rest - Nursing actions
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1. Monitor the client's pain level related to episiotomy, lacerations, incisions, afterpains, and sore nipples. 2. Administer pain medications as prescribed.
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Comfort and Rest - Client education
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Recommend for clients to plan at least one daily rest period and to rest when the newborn sleeps.
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Maternal Adaptation - Data collection
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1. Psychosocial adaptation and maternal adjustment begin during pregnancy as clients go through commitment, attachment, and preparation for the birth of the newborn. During the first 2 to 6 weeks after birth, clients go through a period of acquaintance with her newborn, as well as physical restoration. During this time she also focuses on competently caring for her newborn. Finally, the act of achieving maternal identity is accomplished around 4 months following birth. It is important to note that these stages may overlap, and are variable based on maternal, newborn, and environmental factors.
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Maternal Adaptation - Data collection - Facilitate bonding
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Monitor clients for behaviors that facilitate and indicate mother-infant bonding. 1. Considers the newborn a family member 2. Holds the newborn face to face (en face) maintaining eye contact 3. Assigns meaning to the newborn's behavior and views positively 4. Identifies the newborn's unique characteristics and relates them to those of other family members 5. Touches the newborn and maintains close physical proximity and contact 6. Provides physical care for the newborn such as feeding and diapering 7. Responds to the newborn's cries 8. Smiles at, talks to, and sings to the newborn
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Maternal Adaptation - Data collection - Impaired bonding
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Monitor clients for behaviors that impair and indicate a lack of mother-infant bonding. 1. Apathy when the newborn cries 2. Disgust when the newborn voids, stools, or spits up 3. Expresses disappointment in the newborn 4. Turns away from the newborn 5. Does not seek close physical proximity to the newborn 6. Does not talk about the newborn's unique features 7. Handles the newborn roughly 8. Ignores the newborn entirely
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Maternal Adaptation - Data collection - Conflicts
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Monitor clients for signs of mood swings, conflict about maternal role, and/or personal insecurity. 1. Feelings of being "down" 2. Feelings of inadequacy 3. Feelings of anxiety related to ineffective breastfeeding 4. Emotional labiality with frequent crying 5. Flat affect and being withdrawn 6. Feeling unable to care for the newborn
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Maternal Adaptation - Nursing actions
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1. Provide a quiet and private environment that enhances the family bonding process. 2. Facilitate the bonding process by placing the newborn skin-to-skin with the mother soon after birth in an en face position. 3. Encourage the parents to bond with their newborn through cuddling, feeding, diapering, and inspection.
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Maternal Adaptation - Client education
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1. Provide frequent praise, support, and reassurance to the mother as she moves toward independence in caring for her newborn and adjusting to her maternal role. 2. Encourage the mother/parents to express their feelings, fears, and anxieties about caring for their newborn.
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Paternal Adaptation - Data collection - Fatherhood stages
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Paternal transition to fatherhood consists of a predictable three-stage process during the first few weeks of transition. 1. Expectations - The father has preconceived ideas about what it will be like to be a father. 2. Reality - The father discovers that his expectations may not be met. Commonly expressed emotions include feeling sad, frustrated, and jealous. He embraces the need to be actively involved in parenting. 3. Transition to mastery - The father decides to become actively involved in the care of the newborn.
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Paternal Adaptation - Data collection - Father-infant bond
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The development of the father-infant bond consists of three stages. 1. Making a commitment - The father takes the responsibility of parenting. 2. Becoming connected - Experiences feelings of attachment to the newborn. 3. Making room for the newborn - The father modifies his life to include the care of the newborn.
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Paternal Adaptation - Nursing actions
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1. Monitor fathers for behaviors that facilitate and indicate father-infant bonding. A. Fathers touch, hold, and maintain eye-to-eye contact with their newborn. B. Fathers observe newborns for features similar to their own to validate claim of the infant. C. Fathers talk and sing to the infant. 2. Provide education about newborn care when fathers are present.
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Paternal Adaptation - Client education
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1. Assist fathers in their transition to fatherhood by providing guidance and involving him as a full partner rather than just a helper. 2. Encourage couples to verbalize their concerns and expectations related to newborn care.
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Sibling Adaptation - Data collection
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1. Monitor for positive responses from the sibling. A. Interest and concern for the newborn B. Increased independence 2. Monitor for adverse responses from the sibling. A. Signs of sibling rivalry and jealousy B. Regression in toileting and sleep habits C. Aggression toward the newborn D. Increased attention-seeking behaviors and whining
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Sibling Adaptation - Nursing actions
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1. Take siblings on a tour of the obstetric unit. 2. Encourage the parents to: A. Let siblings be one of the first to see the newborn. B. Provide a gift from the newborn to give the sibling. C. Arrange for one parent to spend time with siblings while the other parent is caring for the newborn. D. Allow older siblings to help in providing care for the newborn. E. Provide toddlers and preschoolers with a doll to care for.
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Family Adaptation - Nursing actions
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1. Emphasize verbal and nonverbal communication skills between the mother, caregivers, and the infant. 2. Encourage the continued support of grandparents and other family members. 3. Provide information regarding community resources for families with young children. 4. Encourage attendance at parenting classes or support group for new parents. Give the mother/caregivers information about social networks that provide a support system where the mother and caregivers can seek assistance.
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Postpartum Discharge - Nursing actions
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1. Schedule a postpartum follow-up visit. Following a vaginal delivery, the follow-up visit should take place in 6 weeks, and following a cesarean birth, the visit should take place in 2 weeks. 2. Provide postpartum and newborn instructions in written form.
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Postpartum Discharge - Nursing actions - Danger signs
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Instruct clients to report danger signs to the provider. 1. Chills or fever greater than 38° C (100.4° F) for 2 or more days 2. Change in vaginal discharge with increased amount, large clots, and change to a previous lochia color, such as bright red bleeding and a foul odor 3. Episiotomy, laceration, or incision pain that does not resolve with analgesics, foul-smelling drainage, redness, and/or edema 4. Pain or tenderness in the abdominal or pelvic areas that does not resolve with analgesics 5. Breast(s) with localized areas of pain and tenderness with redness and swelling and/or nipples with cracks or fissures 6. Calves with localized pain and tenderness, redness, and swelling; a lower extremity with either areas of redness and warmth or coolness and paleness 7. Urination with burning, pain, frequency, urgency; urine that is cloudy or has blood 8. Feelings of apathy toward the newborn, inability to provide self- or newborn-care, or feelings that may result in self- or newborn injury
