Care of the Mother and Fetus during the Perinatal

Period (The Post-Partum Care)

Lesson 12
LESSON: 12
DURATION: 4 hours

Care of the Mother and Fetus during the Perinatal Period

(The Post-Partum Care)

SPECIFIC OBJECTIVES:

At the end of the lesson, the students should be able to:

1. Describe the systemic physiologic changes occurring in the woman after childbirth.
2. Identify the phases of maternal role adjustment as described by Reva Rubin.
3. Discuss the psychological adaptations occurring in the father after delivery.
4. Describe the parameters requiring assessment during the postpartum period.
5. Discuss the bonding and attachment process.
6. Identify behaviors that enhance or inhibit the attachment process.
7. Outline nursing management for the woman and her family during the postpartum
period.
8. Discuss the role of the nurse in promoting successful breastfeeding.
9. Identify areas of health education needed for discharge planning, home care, and follow-
up.

LESSON PROPER:

 PSYCHOLOGICAL CHANGES OF THE POSTPARTAL PERIOD

Phases of the Puerperium

A. TAKING-IN PHASE: (2-3 days)

• Passive, relies on the nurse, family members to do things for her (dependence results
from her physical discomfort due to perineal stitches, after pains and hemorrhoids),
• Decision making- focuses on her own needs rather than the baby’s needs, verbalization
center on her reactions to recent delivery

B. TAKING-HOLD PHASE:
• Initiates action (beginning to do things for herself and make decision on her own),
• Develops strong interest in taking care of her baby, concerned with their bodily
functions such as bladder and bowel control, often feels insecure about her ability to
care for her new child

Nursing Management:
a. Health teachings on self-care, newborn care and family planning
b. Give brief demonstration of baby’s care and allow her to take care of her child herself-
with watchful guidance
 c. Praise for the things she does well to give her confidence
d. Provide positive reinforcement begins with health care facility, discharge, at home,
postpartum and well-baby visits

 Postpartum blues – experience overwhelming feeling of sadness that cannot be accounted

for, believed to be caused by hormonal changes, or a response to dependency or exhaustive,
being away from home or sheer anxiety over newly acquired role.

NOTE: Provide privacy and reassure this is quite normal and should not be alarmed.
 Postpartum psychosis – emotionally unstable neurotic personality

C. LETTING-GO PHASE:
• Woman redefines her new role
• she gives up fantasized image of her child and accepts the real one
• she gives up old role of being childless

 Physical tolerance – needs abundant rest and encouraged to relax and sleep whenever
possible

 PHYSIOLOGICAL CHANGES OF THE POST PARTAL PERIOD

 Postpartal period (peurperium) – from the latin word puer “child” and parere “to bring
forth”

 Involution – is the process whereby reproductive organs return to their non-pregnant state.

Physical postpartum care guidelines:

1. Promotion of healing and return to normal of the perineum and pelvic structures
2. Prevention of infection of the bladder, the breasts, the uterus, and other body parts
3. Establishment of successful lactation if mother so desires
4. Provision of emotional support
5. Changes during involution may relate to the circulatory and renal systems, GI adaptation,
nutritional demands, genital and breast modification, emotional concerns and physical
tolerance.

A. Reproductive System Changes

UTERUS:

Uterine involution – refers to the return of the uterus to its pre-pregnant size, shape and function.
• Most of the reduction in size and weight occurs in the first 2 weeks.
• It is measured by finger-breaths.

2 PROCESSES:
1. Area where placenta is implanted = SEALED OFF
2. Organ is reduced to its approximately pregestational size
Weight of the uterus:
 Right after delivery: 1000 gms
 One week after delivery: 500 gms
 Two weeks after delivery: 300 gms
 Six weeks after delivery: 50-60 gms

Puerperal sepsis – a sign due to sub-involuted uterus implied the presence of blood clots, which
is a good media for bacteria.

• After Pains- a cramplike pain felt by the mother (Uterine Contractions).

- felt frequently in multiparas, with large babies, twins.
- Also with breast feeding mothers
- Uncommon primipara because they have good uterine tone.
- Normal effect last for 3 days.

Remaining decidua:
 The outer superficial layer – undergoes necrosis and eventually sloughed off (lochia)
 The basal layer, regenerates and gives rise to a new endometrium. On the 16th day the
endometrium is restored throughout the uterus, except on the placental site.
 On the third week the endometrium heals.

*The uterus does not return to its original pre-pregnant condition, uterine size is slightly increased
after each pregnancy.

Nursing Interventions:
• Explain the cause and purpose of afterpains
• Keep bladder empty to decrease afterpains
• Instruct to assume prone position to lessen discomfort
• Massage uterus gently, forceful massage causes too much pain by stimulating very strong uterine
contraction
• Never apply heat on the abdomen, heat causes uterine relaxation –hemorrhage
• Administer analgesics as ordered
• Breastfeeding promotes involution because stimulation of the nipple when the infant suckles
results in the release
of oxytocin.
• If the mother is not breastfeeding- menstrual, flow may return within 8 weeks.
• If breastfeeding, it may return 3-4 months’ time.

LOCHIA
- is a uterine discharge after delivery consisting of blood, mucus, epithelial cells, leukocytes
and bacteria.

TYPES OF LOCHIA, DURATION AND COMPOSITION

1. Lochia RUBRA- Red, 1-3days,- blood, fragments of decidua &mucus ( small clots).
2. Lochia SEROSA- Pink or Brown, 4-9 days- blood mucus& invading leukocytes.
 3. Lochia ALBA – white, 10 days, largely mucus, high in leukocytes (amount may decrease
and last for 6 weeks.)

CHARACTERISTICS OF LOCHIA
Type of Lochia Color Postpartal Day(s) Composition

Lochia rubra Red 1-3 Blood fragments

of decidua, and
mucus
Lochia serosa Pink 4-9
Blood, mucus, and
invading
Lochia alba White 10-21 (may last 6 leukocytes
weeks)
Largely mucus;
leukocyte count
high

Estimation of blood loss:

• 1 inch stain after one hour: scant amount
• 2-4 inch stain after one hour: light amount
• 4-6 inch stain after one hour: moderate amount
• Fully saturated after one hour: heavy amount

Smell:
• Like menstrual discharges
SIGNS POSSIBLE CAUSE
Foul smell Infection
Large clots Retained placenta
Excessive amount with contracted Lacerations of birth canal
uterus
Return of rubra after serosa and Retained placental fragments
alba Infection
Bleeding after 6 weeks Sub-involution of the uterus
Infection

Fundus:

 Assess frequently for firmness, position and height. It should be checked after the bladder
is emptied
 Palpate the fundus: Place the woman in supine position with small pillow under her head
and knees flexed to relaxed abdominal muscles. Palpate by placing a hand at the umbilicus
and pressing it downward while the other hand is placed just above the symphysis to
support the lower uterine segment.
 If boggy:

1. Massage gently in circular motion, first action

2. Place infant on the mother’s breast to stimulate uterine contraction (released of
oxytocin)
3. Administer oxytocin or increase infusion if BP is not above 140/90 mmHg

 Height of the fundus: Measure the position or height by using umbilicus as landmark.
Place fingers on the abdomen of the woman just below the umbilicus and count the number
of fingerbreadths that fit between the top of the fundus and umbilicus. It descends one
fingerbreadth per day.

NURSING MANAGEMENT:
a. Assess fundic height every 15 minutes for the first hour postpartum
b. Assess fundus for consistency (firm, soft, boggy). Massage gently with examining
and rotating motion
c. Palpate fundus gently so not to cause pain
d. Evaluate the uterus height and consistency less frequently ff the first hour after
delivery, every hour next 8 hours then once every shift
e. Assess lochia every 15 minutes for the first hour, once every hour for the first 8 hours,
then every 8 hours. Observe for the character
f. Instruct mother how to perform uterine assessment upon discharge

Vagina:
 After childbirth, smooth and swollen passage
 Lacerations and episiotomy healed after 2 weeks
 Returns to its pre-pregnant condition after 6-8 weeks but does not regain original virginal
state. Kegel’s helps
Increases the strength and tone of the vagina
 If woman is breastfeeding may have delayed ovulation, she may have continued thin walled
or fragile vaginal cells that causes slight vaginal bleeding during sexual intercourse until
about 6 weeks

Perineum:
 Swollen, discolored, painful after delivery, often with lacerations and episiotomy
 Observe for signs of infection and trauma
 Ecchymosis may appear due to rupture of surface of capillaries
 Perineal muscle tone regained by 6 weeks
 Perineal care, Ice packs,
 Labia minora/majora typically remained atrophic and softened after birth never returning
to pre-pregnant state.

5 signs to Assess Perineum (REEDA)

 Redness – excessive tenderness is probably normal inflammation associated with healing,
but pain with the redness is more likely to be infection.
  Edema – mild is common, but severe interferes healing
 Ecchymosis (bruising)- a few small superficial are common, larger interferes healing
 Discharge – no discharges
 Approximation (intact of the suture line) – should not be separated, intact
*This is also helpful in assessing cesarean incision for healing

NURSING MANAGEMENT

A. Perineal care:
a.1. Lochia
a.2. Perineum great deal of pressure
a.3. Perineal stitches at the episiotomy site

B. Care of episiorrhapy

b.1. Application of ice bag for the first 12-24 hours to reduce edema, bruising and numb
the perineal area.

b.2. Exposing perineum to a heat lamp (gooseneck lamp) 25-40-watt bulb after the first
postpartum day. Woman in supine (dorsal recumbent) with knees flexed, properly draped,
heat lamp is placed between her legs about12-16 inches away from the perineum, and left
in place for 20 mins. Done 3-4 x a day.

b.3. Sitz bath: after 24 hours promotes circulation by vasodilation thereby promoting
wound healing. The perineal area is immersed in 4-6 inches of water temperature of 102
to 105°F. For 3-4x a day for no more than 20 minutes

b.4. Placed patient in sim’s position

b.5. Instruct to contract perineal floor muscles

b.6. Instruct to use foam rubber rings

C. Sexual activity – resumed when lochia stops and healing of the perinuem, episiotomy has
occurred usually 3rd – 6 weeks

D. Post natal follow-up

E. NSD mothers are allowed to ambulate 4-8 hrs after chidlbirth reasons for early
ambulation:
 Prevents constipation
 Prevents circulatory problems thrombophlebitis
  Prevents urinary problems
 Promotes rapid recovery
 Hastens drainage of lochia
 Improves GI and urinary function
 Provides sense of well being

F. Exercise:

Purposes:
 Promotes pscychological well being
 Rapid return of woman’s figure
 Strengthens muscle of the back, pelvic floor, abdomen

G. Nutrition:
 High CHON, iron and vitamins to promote wound healing
 Calorie intake 2,200-2,300 (non-lactating) daily. For lactating additional 500 calories
 Daily intake of vitamins and iron supplements for 4-6 weeks postpartum is
recommended for breastfeeding mothers to ensure nutritious milk supply to the infant

SYSTEMIC CHANGES

A. HORMONAL CHANGES:
a. Pregnancy hormones begin to decrease as soon as the placenta is no longer present
b. Hcg, hpl are negligible by 24 hours
c. Progestin, estrone, estradiol are at pre-pregnancy level by one week

B. URINARY SYSTEM:
a. Transient loss of bladder tone such as edema on the surrounding urethra that results to
difficult voiding
b. Full bladder puts pressure on the uterus causing ineffective uterine contractions
c. Epidural, spinal or general anesthesia for delivery can feel no sensation in the bladder area
until anesthesia worn off
d. In poor bladder tone, retains large amount of residual urine which may result to bladder
infection
e. Urinary volume rises from normal level of 1,500cc to about 3,000cc during 2 nd to 5th day
after delivery
f. Diaphoresis to get rid of fluid
g. Generally, bladder tone is regained after one week and normal kidney function after one
month

Assess distended abdomen:

 Palpating hard or firm area above the symphysis pubis
 Uterine position is good gauge to determine if bladder is full or empty
 On percussion, a full bladder sounds resonant; non-filled dull thudding
sound
 Effects of distended abdomen:
 Hemorrhage
 Infection
 Increased discomfort
 Atony of bladder wall
 Overflow incontinence

Signs of full bladder

 Suprapubic swelling
 High fundus
 Increased lochia

NURSING MANAGEMENT: Measures to Induce Voiding (expected to void within 6 – 8 hours

after delivery.

After initial encourage to void every 3-4 hours

 Provide privacy
 Open faucet let the woman listen to running water
 Pour warm water in the perineum
 Offer bedpan
 Place woman’s hand on warm water
 Practice kegel’s exercises
 Liberal fluid intake
 Catheterization

Measures to Prevent Infection:

 Flush perineum with warm water after each voiding
 Apply perineal pad from front to back
 Liberal fluid intake
 Decoction of guava leaves for perineal flushing promotes wound healing
 Instruct signs and symptoms of UTI

Other management:
 Assess women’s abdomen frequently
 Measure the amount of urine for each voiding
 Provide measures of encouraging voiding
 Measure first voiding to detect urinary retention

CIRCULATORY SYSTEM

A. 30-50% increase cardiac volume during pregnancy will be reabsorbed into general
circulation within 5-10 minutes
B. High level of circulating fibrinogen during the week of pregnancy continues during the
first postpartum week
C. All blood volumes are back to their pre-pregnant levels by 3rd or 4th week postpartum
D. Increased in WBC count up to 30,000/mm
 E. Increase plasma fibrinogen during the 1st postpartal weeks
F. Varicosities will recede but rarely return to complete pre-pregnant appearance
G. Vascular blemishes (spider angioma) may fade slightly

Nursing Management:

a. Monitor VS every hour during the first 4 hours then every 4 hours when stable
b. Assess peripheral circulation:
- assess the thigh for skin turgor
- assess presence of ankle edema and over the tibia of the lower leg and observe pitting
edema
- assess homan’s sign
c. Encourage early ambulation (4-6 hours) to prevent bladder and bowel complication
d. Encourage postpartum exercises

GASTROINTESTINAL SYSTEM
A. Digestion and absorption begin to be active as soon after delivery
B. Feels hungry and thirsty from glucose used during labor
C. Delayed bowel elimination because:
- Decreased abdominal and intestinal muscle tone
- Lack of food during labor and delivery
- Dehydrating effects of labor and delivery
- Fear of pain on the episiotomy/presence of hemorroids
- Enema during the first stage of labor

Nursing Management:

a. Provide meal if she is not nauseated. 2,500-2,600 cal/day, high protein, vitamins and
minerals
b. Encourage fluid intake and roughage in her diet
c. Administer mild laxatives or cathartic if no bowel on the 3 rd postpartum
d. Provide relief from hemorrhoid discomfort:
d.1. Hot sitz bath/anesthetic sprays with hazel
d.2. Gentle manual replacing of hemorroidal tissue
d.3. Assume sim’s position to provide good venous return on the rectal area and to
reduce discomfort

INTEGUMENTARY SYSTEM
A. Stretch marks still appears reddened
B. Striae gravidarum may fade and becomes striae albicans over 3-6 month
C. Chloasma and linea nigra will be barely undetectable in 6 weeks
D. Abdominal wall and uterine ligaments are stretched and pouches forward.

Nursing management:
a. Provide abdominal binder or girdle on the first few weeks for comfort
 b. Encourage exercises such as sit-ups, abdominal breathing, chin to chest or head
raising, kegels, legs and arms raising to give support to the abdominal muscles and
aids in involution, return of abdominal tone, and strengthen abdominal and pelvis
muscle.
c. Encourage good posture, body mechanics and rest
BREAST MODIFICATION
A. 3rd day postpartum becomes full, tension (engorgement) and hot with a throbbing pain
B. Breast tissue appears reddened, simulating acute or inflammatory or infectious process
C. Milk fever

Nursing Management:
a. Advise to use firm-fitting brassiere to reduce discomfort and prevent contamination
of the of the nipples and areola
b. Cold compression application on the breast desires not to breastfed and ward who
desires.
c. Breast massage or the use of breast pump if the women will have breastfed.

REFERENCES/ADDITIONAL RESOURCES/READINGS:

Pillitteri, Adele (2018). Maternal and Child Health Nursing, Care of the Childbearing and
Childrearing Family, 8th edition.

Ricci, Susan (2007). Essentials of Maternity, Newborn and Women’s Health Nursing, Lippincott
Williams & Wilkins

Seeley, Rod R. (2005). Essentials of Anatomy and Physiology, 5th Edition

Wong, Donna, et.al.(2009). Maternal Child Nursing Care, 3rd edition, Elsevier (Singapore) Pte Ltd.