Nursing Care of a Postpartal Family

PSYCHOLOGICAL CHANGES OF THE

POSTPARTAL PERIOD
 The postpartum period is a time of transition, during which a couple gives up
concepts such as “childless” or “parents of one” and moves to the beginning of new
parenthood.
Phases of the Puerperium
Taking-In Phase
 the first phase experienced, is a time of reflection. During this 2- to 3-day period,
a woman is largely passive. She prefers having a nurse minister to her (such as
bringing her a bath towel or a clean nightgown) and make decisions for her, rather
than do these things herself.
 As a part of thinking and pondering about her new role, the woman usually wants
to talk about her pregnancy. During the taking-in phase, she rests to regain her
physical strength and to calm and contain her swirling thoughts.
 Encouraging her to talk about the birth helps her integrate it into her life
experiences.
Taking-Hold Phase
 After a time of passive dependence, a woman begins to initiate
action. She prefers to get her own washcloth and to make her own
decisions. Women who give birth without any anesthesia may reach
this second phase in a matter of hours after birth.
 During the taking-in period, a woman may have expressed little
interest in caring for her child. Now, she begins to take a strong
interest. As a rule, therefore, it is always best to give a woman brief
demonstrations of baby care and then allow her to care for her child
herself—with watchful guidance
Letting-Go Phase
 woman finally redefines her new role. She gives up the fantasized
image of her child and accepts the real one; she gives up her old
role of being childless or the mother of only one or two (or
however many children she had before this birth).
A woman who has reached this phase is well into her new role.
 Development of Parental Love and Positive
Family Relationships
 Many women may not experience maternal feelings for their
infants until days or even weeks after giving birth.
 The ability of both parents to reach out to their child can be
strengthened by allowing them to touch and spend as much
time as possible with the new child during the first few hours of
life
Rooming-In
 Ifher infant stays in the birthing room with her (called
rooming-in) rather than in a central nursery, she can become
better acquainted with her child and begin to feel more
confident in her ability to care for him or her after
discharge.
 There are two types of rooming-in:
 complete, in which the mother and child are together 24 hours a
day,
 and partial, in which the infant remains in the woman’s room for
most of the time, perhaps from 8:00 AM to 9:00 PM, but then the
infant is taken to a small nursery near the woman’s room or
returned to a central nursery for the night.
Sibling Visitation
A Chance to visit the hospital and see the new baby and their
mother reduces feelings that their mother cares more about the
new baby than about them. It can help to relieve some of the
impact of separation. It helps to make the baby a part of the family.
 You may need to caution a woman that the opinions of a new
brother or sister expressed by her older children may not be
complimentary.
Maternal Concerns and Feelings in the
Postpartal Period
 Abandonment
 Disappointment
 Postpartal Blues - They may burst into tears easily or
feel let down or irritable. This temporary feeling after
birth has long been known as the “baby blues.” This
phenomenon may be caused by hormonal changes,
particularly the decrease in estrogen and progesterone
that occurs with delivery of the placenta.
 postpartaldepression- Thirty percent of women
experience a more serious level of sadness after birth.
Serious depression requiring formal counseling or
psychiatric care also can occur in women during this
time.
PHYSIOLOGIC CHANGES OF THE
POSTPARTAL PERIOD

Reproductive System Changes

 Involution is the process whereby the reproductive organs
return to their nonpregnant state. A woman is in danger of
hemorrhage from the denuded surface of the uterus until
involution
is complete
The Uterus

 Involution of the uterus involves two main processes.

 First, the area where the placenta was implanted is sealed
off to prevent bleeding.
 Second, the organ is reduced to its approximate
pregestational size.
Lochia
 Lochia is the vaginal discharge you have after giving
birth. It contains a mix of blood, mucus and uterine
tissue.
o lochia rubra. - It’s mainly red color. For the first 3 days after
birth, a lochia discharge consists almost entirely of blood, with
only small particles of decidua and mucus.
o lochia serosa. – the flow becomes pink or brownish. As the
amount of blood involved in the cast-off tissue decreases
(about the fourth day) and leukocytes begin to invade the area.
o lochia alba. - On about the 10th day, the amount of the flow
decreases and becomes colorless or white.
The Cervix

 Immediately after birth, a uterine cervix is soft and

malleable.
 By the end of 7 days, the external os has narrowed to the
size of a pencil opening; the cervix feels firm and
nongravid again.
The Vagina

 The hymen is permanently torn and heals with small, separate tags of
tissue.
 It takes the entire postpartal period for the vagina to involute (by
contraction, as with the uterus) until it gradually returns to its
approximate prepregnancy state.
The Perineum

 Because of the great amount of pressure experienced during

birth, the perineum feels edematous and tender immediately
after birth. Ecchymosis from ruptured capillaries may show on
the surface.
 Thelabia majora and labia minora typically remain atrophic and
softened after birth, never returning to their prepregnancy
state.
Systemic Changes

 Thesame body systems that were involved in

pregnancy are also involved in postpartal changes as
the body returns to its prepregnancy state.
 The Hormonal System
 Pregnancy hormones begin to decrease as soon as the placenta is no longer
present. Levels of human chorionic gonadotropin (hCG) and human placental
lactogen (hPL) are almost negligible by 24 hours.
 By week 1, progestin, estrone, and estradiol are all at prepregnancy levels.
Estrol may be elevated for an additional week before it reaches prepregnancy
levels. Follicle-stimulating hormone (FSH) remains low for about 12 days and
then begins to rise as a new menstrual cycle is initiated.
The Urinary System

 During the entire postpartal period, urine tends to contain more

nitrogen than normal.
 This is probably due in part to a woman’s increased muscle activity
during labor and in part to the breakdown of protein in a portion of
the uterine muscle that occurs during involution.
 Lactose levels in the urine are slightly elevated the same as during
pregnancy, as the body prepares for breastfeeding. Diaphoresis
(excessive sweating) is another way by which the body rids itself of
excess fluid. This is noticeable in women soon after birth.
 The Circulatory System
 The diuresis that is evident between the second and fifth days after birth, as
well as the blood loss at birth, acts to reduce the added blood volume a
woman accumulated during pregnancy.
 This reduction occurs so rapidly, in fact, that the blood volume returns to its
normal prepregnancy level by the first or second week after birth.
The Gastrointestinal System

 Digestion and absorption begin to be active again soon

after birth unless a woman has had a cesarean birth.
Almost immediately, the woman feels hungry and thirsty
and she can eat without difficulty from nausea or vomiting
during this time.
 The Integumentary System
 After birth, the stretch marks on a woman’s abdomen (striae
gravidarum) still appear reddened and may be even more prominent
than during pregnancy, when they were tightly stretched.
 Excessive pigment on the face and neck (chloasma) and on the
abdomen (linea nigra) will become barely detectable in 6 weeks’
time.
 Effects of Retrogressive Changes
 Exhaustion - As soon as birth is completed, a woman experiences total
exhaustion. For the last several months of pregnancy, she probably has
experienced some difficulty sleeping.
 Weight Loss - The rapid diuresis and diaphoresis during the second to fifth
days after birth usually result in a weight loss of 5 lb (2 to 4 kg), in addition
to the approximately 12 lb (5.8 kg) lost at birth.
 Vital Sign Changes - Vital sign changes in the postpartum period reflect the
internal adjustments that occur as a woman’s body returns to its
prepregnant state.
 Temperature - A woman may show a slight increase in temperature during
the first 24 hours after birth because of dehydration that occurred during
labor. If she receives adequate fluid during the first 24 hours, this
temperature elevation will return to normal
 Pulse - Evaluate pulse rate conscientiously in the postpartal period, because a
rapid and thready pulse during this time could be a sign of hemorrhage.
 Blood Pressure - Blood pressure should also be monitored carefully during the
postpartal period, because a decrease in this can indicate bleeding.
Lactation

 The formation of breast milk (lactation) begins in a postpartal woman

whether or not she plans to breastfeed.
 Breast milk forms in response to the decrease in estrogen and
progesterone levels that follows delivery of the placenta.
 The nipple secretion changes from the clear colostrum to bluish white,
the typical color of breast milk.
Return of Menstrual Flow

 With the delivery of the placenta, the production of

placental estrogen and progesterone ends. The resulting
decrease in hormone concentrations causes a rise in
production of FSH by the pituitary, which leads, with only
a slight delay, to the return of ovulation.
 This initiates the return of normal menstrual cycles.
NURSING CARE OF A WOMAN AND
FAMILY DURING THE FIRST 24 HOURS
AFTER BIRTH
 Assessment
 Health History
 Family Profile
 Pregnancy History
 Labor and Birth History
 Infant Data
 Postpartal Course
 Laboratory Data
 Women routinely have their hemoglobin and hematocrit levels measured 12
to 24 hours after birth, to determine whether blood loss at birth has left
them anemic.
 Physical Assessment
 General Appearance - early ambulation and eating a varied diet are
encouraged.
 Hair - Palpate the woman’s hair to determine its firmness and strength.
 Face - Assess the woman’s face for evidence of edema such as puffy eyelids or
a prominent fold of tissue inferior to the lower eyelid.
 Eyes - Inspect the color and texture of the inner conjunctiva. If a woman is
dehydrated, the area appears dry.
 Breasts - Breast tissue increases in size as breast milk forms, so a bra that was
adequate during pregnancy may no longer be adequate by the second or third
postpartal day.
 Uterus - If the uterus is not firm on palpation, massage it gently with the
examining hand. This usually causes the uterus to contract and become firm
immediately.
 Lochia - A woman can expect to have lochia for 2 to 6 weeks.
 Perineum - While evaluating lochia, also inspect the perineum. Observe for
ecchymosis, hematoma, erythema, edema, intactness, and presence of drainage
or bleeding from any episiotomy stitches.
NURSING CARE OF A WOMAN AND
FAMILY IN PREPARATION FOR
DISCHARGE

 The greatest need of a postpartal woman before discharge from a

health care agency is education to prepare her to care for herself and
her newborn at home
Group Classes

 Providing group classes on bathing infants, breastfeeding

techniques, minimizing jealousy in older children, and
maintaining health in the newborn can be helpful to
mothers and fathers, because in these settings they can
learn not only from the instructor but also from other
parents.
Individual Instruction

 Every family needs some individual instruction in how to

care for their infant and how the woman can care for
herself after discharge.
 How to bathe and feed the baby, how to care for the
infant’s cord and circumcision if the infant has this, a
review of how much infants sleep during 24 hours, and
how to fit a newborn into the family’s pattern of living are
topics parents like to discuss.
Discharge Planning

 Before discharge, make sure a woman is aware that she must

return for an examination 4 to 6 weeks after birth, and that
she should make an appointment to take her baby to a
primary care provider for an examination at 2 to 4 weeks of
age.
 Be certain that discharge instructions for the family are given
both verbally and in writing. Getting ready to go home,
dressing the baby, seeing him or her in new clothes for the
first time, and experiencing the thrill of realizing the baby is
really theirs to take home is so exciting that oral instructions
may go unheard.
NURSING CARE OF A WOMAN AND
FAMILY AFTER DISCHARGE
 Postpartal Home Visits - The purposes of a home visit for
the well postpartum woman and her newborn are to help
integrate the infant into the family and to provide the
family with additional information on newborn care that
they may not have been able to learn during a brief
hospital stay.
A Woman Who Is Discharged but Whose Child
Remains Hospitalized

 Maintaining communication with the nursery is important

so that parents can begin to bond with their child.
 Urge them to call the nursery at least once daily to ask
about their infant. If the infant is hospitalized in the same
hospital, help the mother arrange visiting time with the
infant.