Postpartum Assessment and Nursing Care

Dramatic changes to the maternal cardiovascular system occur in the postpartum period. During pregnancy, an approximately 50% increase in circulating blood volume occurs (hypervolemia), which allows the woman to tolerate considerable blood loss at birth without adverse effects. Many women lose at least 200 to 500 mL of blood during vaginal births and approximately twice as much during cesarean births. Readjustments in the maternal vasculature after childbirth are rapid. During postpartum adaptation, dramatic and immediate changes take place in the circulating blood volume that prevent hypovolemia from normal blood loss during delivery. 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. Cardiac output may remain increased for 1 year or more (Gabbe, Niebyl, & Simpson, 2007). A healthy woman’s body can make these changes, but a woman with a heart disorder can encounter problems.

Excess blood volume, which is necessary during pregnancy, is removed to help the woman’s body return to the pre-pregnant state. This excess is disposed of in two ways: (1) diuresis (increased excretion of urine), in which a daily urinary output can be as much as 3000 mL; and (2) diaphoresis (profuse perspiration).

Mild proteinuria may occur as a result of the breakdown of uterine cells. The urine may also test positive for acetone or ketones from dehydration during a prolonged labor. Lactosuria may occur in breastfeeding women as a result of the lactation process. Normal status returns by 4 weeks’ postpartum. The following measures may help a woman urinate:

Lactation (the secretion of milk) is the end result of many interacting factors (see Chapter 11). After delivery, estrogen, progesterone, and human placental lactogen (hPL) (all prolactin-inhibiting agents) decrease rapidly, causing a brisk increase in prolactin secretion. Once lactation has been established, suckling is the most important stimulus for the maintenance of milk production and ejection. Prolactin, secreted by the anterior pituitary gland, promotes milk production by stimulating the alveolar cells of the breast, and oxytocin, secreted by the posterior pituitary, triggers the ejection of milk as the newborn sucks. Oxytocin also stimulates uterine contractions (afterpains) felt by the mother.

By the third day after delivery, the prolactin effect on the breast tissue is evident, and the hormone is present in sufficient quantity to cause breast engorgement. The breasts become distended, firm, tender, and warm. At this time, milk, which is thin and bluish, begins to replace the colostrum (premilk).

If the woman does not wish to breastfeed her newborn, she should avoid any breast stimulation, including newborn suckling, pumping the breasts, or allowing warm water to flow on the breasts during showers. Prolactin levels drop rapidly. Palpation of the breast on the second or third day will likely reveal engorgement. The breasts become distended (swollen), firm, tender, and warm to touch (due to vasocongestion). Breast engorgement is primarily caused by the temporary congestion of veins and lymphatics rather than by an accumulation of milk. Engorgement spontaneously resolves, and discomfort usually decreases within 24 to 36 hours. A snug, supportive bra worn for 72 hours, ice packs, and mild analgesics may be used to relieve breast discomfort. If suckling has never begun and nipple stimulation is avoided, lactation ceases within a few days to a week. Breastfeeding is discussed in detail in Chapter 11.

Immediately after delivery, the woman’s weight decreases by approximately 4.5 to 5.8 kg (10 to 13 lbs). This weight loss is accounted for by the removal of the fetus, placenta, and amniotic fluid. An additional 2.3 to 3.6 kg (5 to 8 lbs) are lost during the early postpartum period as a result of diuresis and diaphoresis. An additional 0.9 to 1.4 kg (2 to 3 lbs) is lost via lochia and involution in the first week postpartum (Blackburn, 2007).

During pregnancy, the woman’s body stores 2.3 to 3.2 kg (5 to 7 lbs) of fat for lactation needs. The breastfeeding mother gradually uses this fat store over the first 6 months, and she often returns to her approximate pre-pregnancy weight. Some women tend to retain some of the excess weight gained during pregnancy. Therefore, women are encouraged to perform postpartum exercises to lose the excess weight gained during pregnancy and to increase the strength and tone of various muscles in their bodies. Aerobic exercise has no adverse effects on breastfeeding (Gabbe, Niebyl, & Simpson, 2007).

Maternal adaptation has been described by Rubin (1984) as a series of three phases (Box 12-1). The taking-in phase begins immediately after birth and lasts for a few hours to approximately 2 days’ postpartum. This phase is characterized by passive, dependent behavior. The woman focuses on her own needs and is concerned about the overall health of her newborn. The mother often repeatedly reviews her labor and birth experience.

The taking-hold phase is the second maternal phase, when the woman is ready to assert her independence. She becomes the initiator and is ready to participate independently in newborn care. She often becomes exhausted in her new role and verbalizes anxiety about it.

The third stage is the letting-go phase. In this stage, the woman assumes her position in the home and her new maternal role. Sometimes, demands placed on her may lead to feelings of mild depression ).

Maternal role attainment occurs in four stages. These four stages correspond to those identified by Rubin (1984). In the anticipatory stage, which occurs during pregnancy, the woman looks to role models of how to be a mother. In the formal stage, which begins when the newborn is born, the mother is still influenced by the guidance of others. The informal stage begins when the mother starts to make her own choices about mothering, and she begins to find her own style. In the personal stage, the mother does what she is comfortable with in the role of mother. This stage occurs from 3 to 10 months after delivery. Social support, the mother’s age, her personality traits, and her socioeconomic status all influence her success in assuming the mothering role.

The transition to motherhood is a complex behavioral process. Today’s new mothers tend to be less dependent and are better able to assume the self-care responsibilities because of factors such as the reduced amount of medications received during labor, early ambulation, rooming-in, and increased support from the father, significant other, or family.

Parents who are ill-prepared for the changes in relationships, lifestyle, and roles associated with the integration of the newborn in the family have more difficulty making the necessary transition. The woman’s immaturity, minimum exposure of the mother to the baby in the days after birth, lack of a support system, or ill health also can interfere with maternal role attainment.

Postpartum blues occur in approximately 70% of women during the first few days after birth and generally last up to 10 days. This state is characterized by tearfulness, insomnia, lack of appetite, and a feeling of being disappointed. Psychological adjustments and hormonal factors are thought to contribute, and discomfort, anxiety, anger, and fatigue seem to play a part. There is no obstetric, social, personality, or economic factor that predisposes a woman to developing postpartum blues. It is possible that altered function of central neurotransmitters and hypothalamic-pituitary-thyroid interaction may be involved. However, rapid role changes and new responsibilities play a major role (Gabbe, Niebyl, & Simpson, 2007). Rest, empathy, and supportive care are the primary management strategies (Table 12-2). Teaching relaxation techniques, increasing confidence in self-care and newborn care, and promoting communication between the woman and her partner are essential nursing responsibilities. Postpartum support groups may be available in the community. Postpartum depression is discussed in Chapter 17.

Birth control practices vary among cultures and must be considered when discussing family planning. The nurse must be sensitive to the various practices and recognize that some women may feel distressed when they are told to ambulate early and participate in newborn and self-care activities. The nurse should incorporate cultural practices of the patient in the care plan (Nursing Care Plan 12-1).

The postpartum check, which can be remembered by the mnemonic BUBBLE-HE, includes assessment of the Breasts, Uterus, Bladder, Bowel, Lochia, Episiotomy (perineum), Homans’ sign, and Emotions (psyche) (Table 12-3). The Homans’ sign checks for the development of blood clots in the lower extremities. The emotional status includes bonding between parents and infant.

In addition to these specific assessments, observation and recording of vital signs, pain, hydration status, the woman’s ability to ambulate, and the ability to care for her newborn should also be included. When performing the postpartum check, the nurse explains that the reason for the assessment is to rule out any deviation from normal. In addition, the nurse teaches the woman how to assess the height and firmness of the uterus (Table 12-4). Because of early discharge, the woman is encouraged to continue this assessment when at home. If the uterus appears relaxed or boggy during the assessment, the uterus should be massaged until it is firm and remains firm. When the uterus is massaged, it is important not to be too vigorous because this may cause overstimulation, which can result in uterine atony (loss of muscular tone of the uterus) and hemorrhage.

On completion of the postpartum check, the nurse documents the findings and promptly reports any abnormal findings. In addition to the usual postpartum assessments, the post-cesarean mother must also be assessed as a postoperative patient. Care of the woman after a cesarean birth is discussed in Chapter 14. Breast care and breastfeeding are discussed in Chapter 11.

Engrossment is the keen awareness and interest in the newborn, characterized by holding the newborn en face; studying and touching features; accepting and expressing unique resemblances of the newborn to family or themselves; and feeling pride, elation, and increased self-esteem (Figure 12-4). The reality is established when the partner participates in newborn care. A stage of conflict may follow when the partner may resent the time the mother spends focused on the newborn; the partner may seek recognition or feel excluded. Adjustment and transition occur when the partner is able to increase interaction with the newborn and understand that there will be time set aside for partner interaction as well. Family crises can be prevented by helping the parents incorporate the newborn into their modified lifestyle and helping them communicate personal and family issues and needs. The role of siblings and grandparents may need to be reestablished. The availability of social support and community resources should be explored and telephone numbers for support and advice given to parents.

Sibling response to the birth of a new sister or brother depends on their age and development. Younger siblings may consider the newborn to be competition and may fear that they will be replaced in the parents’ affections. Experts believe that children benefit from seeing the mother and newborn in the hospital setting (Figure 12-5). Early involvement can help reduce the older child’s anxiety, jealousy, and rivalry toward the newborn (Box 12-2). Behaviors that may surface include regression to more infantile behaviors such as thumb sucking. Some may show jealousy and frustration when they see the mother holding or feeding the newborn and miss how it feels to be the baby. Special time must be taken by both parents and grandparents to give attention to older siblings.

The involvement of grandparents with grandchildren depends on many factors. One of the most significant factors is proximity. Grandparents who live nearby often develop a strong attachment that involves sharing love, which adds security for the grandchildren (Figure 12-6). However, parenting practices change from one generation to the next, and this may bring conflict in child rearing. Attending classes, especially for grandparents, should be encouraged. In some cultures, the grandparents are expected to be with the new mother for the first 1 to 3 months to both help with the household duties and care for the new baby.

Bonding and attachment are processes that produce an affectionate and emotional commitment between two individuals. This process is intense during the early post-birth period. The newborn, when alert, is able to elicit a strong positive response from the mother by making eye contact with her. Touch is important and elicits a positive response from the mother and stimulates the newborn. Mothers are observed using a high-pitched voice as they comfort the newborn, which causes newborns to become more alert and turn toward the mother. The attachment process is usually progressive over time. It is made easier with positive newborn behaviors, such as sucking, smiling, clinging by the grasp reflex, and eye-to-eye contact. During the postpartum stay, the nurse is responsible for monitoring that attachment is developing between family members and the newborn. Promoting and facilitating parental attachment are important. The nurse must recognize that the attachment process is strengthened through the use of sensual responses between the parents and newborn. Every positive interaction between parent and newborn intensifies the attachment (Box 12-3).