The postpartum recovery period covers the time period from birth until approximately six to eight weeks after delivery. This is a time of healing and rejuvenation as the mother’s body returns to prepregnancy states. Nurses and other healthcare professionals need to be aware of the normal physiologic and psychological changes that take place in women’s bodies and minds after
delivery in order to provide comprehensive care during this period. In addition to patient and family teaching, one of the most significant responsibilities of the postpartum nurse is to recognize potential medical complications after delivery. Show
Postpartum Physiologic ChangesImmediately after delivering, women experience massive shifting as the body returns to its pre-pregnant state. Some of the physiologic adaptations to the reproductive system are described below: Exfoliation also occurs at this time. Exfoliation is the sloughing off of dead tissue at the site where the placenta is attached to the uterine wall. Afterpains, or intermittent uterine contractions, are a normal occurrence during the postpartum period. As with all other reproductive organs and structures, the cervix also changes as the body returns to a prepregnancy state. The internal os closes almost completely within three to four months of delivery. After delivery there is a significant decrease in estrogen and progesterone levels. Prolactin initiates milk production, and the breasts become engorged, as well as warm and tender, between postpartum days 3 and 4. Mothers often refer to this as having their milk “come
in.” The postpartum body removes excess fluid accumulated during pregnancy by diuresis. In addition, women frequently experience excessive perspiration (diaphoresis), which also releases accumulated fluid during the postpartum period. After delivery, the diaphragm descends and postpartum women’s respirations normally return to the prepregnant state. After delivery, relaxin levels subside and the pelvic ligaments and joints return to their prepregnant state. However, the joints of the feet remain altered, and many women notice a permanent increase in shoe size. The abdominal wall is weakened and the muscle tone of the abdomen is diminished after pregnancy. Patients should be instructed to begin abdominal exercises anytime following a vaginal delivery and after abdominal tenderness resolves following a cesarean section, generally in four weeks. Postpartum Psychological ChangesBonding, sometimes referred to as attachment, between mothers and infants is affected by a multitude of factors, including socioeconomic status, family history, role models, support systems, disturbed sleep, cultural factors, and birth experiences.
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 who do not form attachments appropriately. Malattachment behaviors vary and can include:
If malattachment is noted, providers should immediately report the observation and continue to monitor both the mother and infant. Postpartum depression is a serious and debilitating depression that affects many women throughout the world. Postpartum depression occurs in 8% to 15% of women after delivery. Various screening tools are available. Routine Postpartum Assessment and Patient EducationPrimary responsibilities of nurses in postpartum settings are to assess postpartum patients, provide care and teaching, and if necessary, report any significant findings. It is imperative for nurses to distinguish between normal and abnormal findings and to have a clear understanding of the nursing care necessary to promote patients’ health and well-being. BUBBLE-LE
BREASTSThe breasts are assessed for:
UTERUSThe fundus is assessed for:
In addition, patients are assessed for uterine cramping and treated for pain as needed. BOWELAssessment of the bowel is important in all postpartum patients. It is especially vital for patients following C-sections. The bowel is assessed for:
Prescribed stool softeners or laxatives are administered as needed to treat constipation and ease perineal discomfort during defecation. BLADDERAssessment of urination and bladder function includes:
The bladder should be nonpalpable above the symphysis pubis. LOCHIALochia is assessed during the postpartum period:
It is important to note that patients who had a C-section will typically have less lochia than patients who delivered vaginally; however, some lochia should be present. EPISIOTOMY/PERINEUMThe acronym REEDA is often used to assess an episiotomy or laceration of the perineum. REEDA stands for: REEDA
Redness is considered normal with episiotomies and lacerations; however, if there is significant pain present, further assessment is necessary. The use of ice packs during the immediate postpartum period is generally indicated. There should be an absence of discharge from the episiotomy or laceration, and the wound edges should be well approximated. Perineal pain must be assessed and treated. LOWER EXTREMITIESTo assess for deep vein thrombosis (DVT), the lower extremities are examined for the presence of hot, red, painful, and/or edematous areas. An elevated temperature may also be present. The legs for assessed for adequate circulation by checking the pedal pulses and noting temperature and color. In addition, the lower extremities are assessed for edema. EMOTIONSEmotions are an essential element of the postpartum assessment. Postpartum women typically exhibit symptoms of the “baby blues” or “postpartum 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. If symptoms last longer than a few weeks or if the postpartum patient becomes nonfunctional or expresses a desire to harm herself or her infant, she should be instructed to report this to her certified nurse-midwife or physician immediately.
Postpartum ComplicationsCESAREAN SECTION ISSUESMother care after a C-section has some additional assessment needs during the postpartum period, including incision status, pain, respirations, and lung and bowel sounds. POSTPARTUM HEMORRHAGE (PPH)Postpartum hemorrhage is one of the leading causes of death among postpartum women. PPH refers to a blood loss of at least 500 mL after a vaginal birth and at least 1000 mL after a C-section. Postpartum hemorrhage is categorized as early or late. Early refers to a hemorrhage occurring within the first 24 hours after birth, while late refers to a hemorrhage occurring 24 hours to 12 weeks after delivery. Early postpartum hemorrhage is often caused by uterine atony, or 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. 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. HYPOVOLEMIC SHOCKA sequelae of PPH is hypovolemic shock. In the presence of a PPH, hypovolemic shock can occur and cause severe organ damage and even death if untreated. These patients will also require oxygen (usually 8–10 L 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. THROMBOPHLEBITISWomen 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 of the lower extremities or pelvis. All postpartum women are at risk. However, certain risk factors predispose some women to developing thrombophlebitis. These risk factors include:
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. POSTPARTUM INFECTIONSPostpartum infections are infections accompanied by a temperature of 38 °C or higher on two separate occasions during the first 10 days postpartum, exclusive of the first 24 hours. Postpartum patients are carefully monitored for signs and symptoms of infection during this period. Common infections that may occur during the postpartum period include:
HEMORRHOIDS AND INCONTINENCE AFTER CHILDBIRTHHemorrhoids are common in late pregnancy (7.8%). Symptomatic hemorrhoids may be treated with
local anesthetics, topical astringents/protectants, bulk-forming laxatives, stool softeners, topical corticosteroids, or topical vasoactive agents. About Wild Iris Medical Education:Wild Iris Medical Education, Inc., is a privately held, woman-owned company providing online healthcare continuing education. In 1998, we began offering online ANCC-accredited nursing continuing education courses and since then have expanded to provide CEUs for occupational therapists, physical therapists, paramedics, EMTs, and other healthcare professionals. Accredited and Approved Nationwide. Join Our More Than 750,000 Satisfied Customers Now!High-quality, accredited, evidenced-based continuing education courses in an easy-to-use format designed for learning, from Wild Iris Medical Education. We’ve been providing online CE since 1998. VIEW COURSES NOW Why would a fundus be deviated?Bladder distention results in an elevation of the fundus above the umbilicus and deviation to the right or left of midline.
What does the position of the fundus tell the nurse?Fundal height tells your healthcare provider important things about your baby's size, growth and position in your uterus. It helps confirm that your baby is growing as they should. It can also tell them how much amniotic fluid is in your uterus.
Why is the fundus check each shift?Palpation of the uterine fundus postpartum helps to determine uterine size, degree of firmness, and rate of descent, which is measured in fingerbreadths above or below the umbilicus.
Where is the fundus right after delivery?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 one hour post delivery, the fundus is firm and at the level of the umbilicus.
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