.

POSTPARTUM CARE
Puerperium/Postpartum Period
Refers to the six (6) weeks period after delivery of the baby
Time of maternal changes that are both
o
Retrogressive (involution of uterus and vagina)
o
Progressive (production of milk for lactation, restoration of normal menstrual
cycle, and
beginning parenting role)
*Involution- return of the reproductive organs to their pre-pregnant state (6
weeks)
Postpartum Care & Assessment (mnemonic: BUBBLE-HE)

BREASTS

UTERUS

BLADDER

BOWELS

LOCHIA

EPISIOTOMY

HOMANS SIGN

EMOTIONAL STATUS
A.IMMEDIATE NURSING CARE
1.Vital signs

Assess q 15 min x 4; then q 30 min x2; then q 4 hrs for the first 24 hrs (if
stable) then q 8
hrs

BP should be WNL for patient

Pulse- 50-90 bpm

Temp- 98-100.4 degree F (36.6-38 degree C): normal for the 1

st
24 hrs due to DHN during
labor

Resp- 16-24 cpm

o
Increase in body temperature during the first 24 hours is not necessarily a
sign of
postpartum infection.

Any mother whose temperature reaches 38 degree C in any two

consecutive 24 hrs period during the first 10 postpartum days may
suggest infection.
o
Bradycardia (heart rate of 50-7- bpm) is common for (24-48 hrs) and persist
6-8
days postpartum.

Returns to non-pregnant rate by 3 months postpartum

2.Breast

Lacatation- formation of breast milk (BM); begins in a postpartal woman

whether or not she
plans to breast-feed.
o
BM forms in response to decrease in estrogen and progesterone levels that
follows
delivery of the placenta (which stimulates prolactin production)

Prolactin- hormone for production of breast milk

Oxytocin- hormone for excretion/ejection of milk

Colostrum is present at the time of delivery; BM is produced by the 3

rd
and 4
th
postpartum
day; yellow sticky fluid; more protein, less sugar, less fat than mature milk.

Engorgement_ the feeling of tension (heat or throbbing pain) in the breast as

breast
distention becomes marked (fuller, larger, firmer); occurs on the 3
rd
-4
th
day
2

o
Due to expanding veins and pressure of new breast milk contained with them
o
There may be a slight elevation of body temperature during this time
o
Congestion subsides in 1 or 2 days

In breast, prolactin stimulates alveolar cells to produce milk. Sucking of the

newborn triggers
a release of oxytocin and contractility of the myoepithelial cells, which
stimulate milk flow;
this is known as the let down reflex. The average amount of milk produced in
24 hours
increases with time:
o
First week- 6-10 oz
o
1-4 weeks- 20 oz
o
After 4 weeks- 30 oz

Mature milk

Foremilk-watery milk coming from full breast (low in fat, high in

carbohydrates)

Hindmilk- creamy milk coming from a nearly empty breast

Amount of supply depends on how often the mother nurse or pumps ( the
more the mother
nurses, the more milk is produced)

For those who choose not to breastfeed, lactation can be suppressed

through:
o
Use a well-fitting bra
o
Avoid any type of nipple stimulation or heat to the breasts (such as warm/hot
showers)
o
May use ice packs or cold cabbages leaves to east breast discomfort until
milk
production ceases (it generally takes 5-7 days)

o
Mild analgesics as prescribed
3.Uterus

After delivery of the newborn, involution of the uterus must occur; 2 main
processes:
o
Area where placenta is implanted is sealed off to prevent bleeding
o
Uterus reduced to its pregestational size (grapefruit)

Firm, midline, reduced in its size

Soft & boggy, displaced (hemorrhage risk)

Few minutes after birth, fundus halfway between umbilicus and symphysis
pubis

One hour later, rise to the level of umbilicus and it remains for the next 24
hours

First postpartal day (day 1)- one fingerbreadth below umbilicus

Day 2- 2 finngerbreadth below and so forth until day 10, it can no longer be
palpated
because it is already behind symphysis pubis

At 10-14 postpartum days, the uterus cannot be palpated abdominally

o
Subinvoluted Uterus

Uterus larger than normal and vaginal bleeding with clots. Since blood clots
are good media for bacteria; it is therefore as sign of puerperal sepsis

To encourage return of the uterus to its usual anteflexed position,

PRONE and KNEE CHEST positions are advised.

Fundal massage, ice pack over hypogastrium, IV oxytocin, nipple

stimulation (breastfeeding)
o
Afterpains/afterbirth pains

Strong uterine contractions felt more particularly by multis, those who

delivered larger babies or twins and those who breastfeed. It is normal and
rarely last for more than 3 days.
4


Menstruation
o
If not breastfeeding- return in 6-8 weeks after birth
o
If breastfeeding, in 3-4 months (lactational amenorrhea) or entire lactation
period

Though does not guarantee that woman will not conceive because she may
ovulate well before menstruation returns
Mask of pregnancy (chloasma) usually disappears, while stretch marks (striae
gravidarum) and
linea negra fade but generally do not disappear
4.Endocrine system

Estrogen and progesterone level decreases as soon as the placenta is no longer

present

HPL and HCG are almost negligible by 24 hours

FSH remains low for about 12 days and begins to rise as new menstrual cycle is
initiated.
Menstruation return in approximately 6-8 weeks; ovulation cam return within 4 weeks.
5.Musculoskeletal system

Relaxin is the hormone responsible for the relaxation of the pelvic ligaments and joints
during
pregnancy. After delivery, relaxin level subsides and the pelvic ligaments and joints
return to their
pre pregnant state. However, the joints of the feet remain altered and many patients
notice a
permanent increase in shoe size.

Abdominal wall is weakened and the muscle tone of the abdomen is diminished after
pregnancy.
Some patients have a separation between the abdominal wall muscles, called diastasis
recti. This
separation can ofte be corrected with certain abdominal exercises (sit ups) performed
during the
postpartum period.
6.Urinary changes

Extensive diuresi begins to take place almost immediately after birth to rid the boyd of
fluid


Increases the daily output a postpartal woman from a 1500- 3000 ml/day during the
2Nd -5THh day after birth

Contain more nitrogen than normal (due to breakdown of protein in a portion of uterine
muscle)

Urinary retention as a result of decreased bladder tone and emptying can lead to urinary
tract infections
PATIENT TEACHING: Self-care guidelines to the mother

Instruct the client on sitting properly to relieve pain (squeeze the buttocks together and
contract
pelvic floor muscles before sitting)

Instruct to wear perineal pads loosely and to lie in sims position

Demonstrate how to clean the perineum after each voiding and defecation (wiping form
front to
back), washing the hands and applying a perineal pad from front to back

Teach the importance of adequate fluid intake, exercise, proper diet and a regular
defecation time

Instruct to avoid garters or constricting clothing that can impair circulation

Encourage client to shower as soon as she can ambulate and to take tub baths if
desired after
two weeks. Recommended daily shower to promote comfort and a sense of well-being/

Provide adequate dietary fiber and fluids to promote bowel movements; if necessary
administer
stool softeners, laxatives, suppositories or enema

Demonstrate newborn care and safery measures

Recommended exercise:
o
Kegels and abdominal breathing on postpartum day one
o
Chin-to-chest on postpartum day 2 to tighten and firm up abdominal muscles
o
Knee-to-abdomen when perineum has healed, to strengthen abdominal and gluteal

muscles

Sexual activity
o
Resume by the 3
rd
-4
th
week postpartum
o
Bleeding has stopped
o
Espisiprrhaphy has healed ( usually 1 week after delivery)
o
Lochia has turned to alba.
o
Decreased physiologic reactions to sexual stimulation are expected for the 1
st
3 months
postpartum because of hormonal changes and emotional factors.
o
She should be protected against subsequent pregnancy by observing a method of
contraception, except the PILLS.

Postpartum check up- 4-6 weeks after birth. Woman should return to her physician for
an
examination (visit is important to ensure that involution is complete and reproductive
planning is
desired and may be discussed further.)
BREASTFEEDING

Feed newborn per demand (breastfeeding or bottlefeeding) or at least every two hours
and
intervals should not exceed 5 hours

If breastfeeding
o
From birth to at least 2 years and should continue as long as the mother and child wish
o
Exclusive breastfeeding until 6 months of age (when solid are gradually introduced)
o
Correct latching on ( to prevent nipple sores and allow baby to get enough milk)

Large part of the breast and areola need to enter the babys mouth

Nipple should be at the back of the babys throat with the babys tongue lying
flat in its mouth
7

o
10-20 minutes each breast
o
Cradling position

Storage of expressed breastmilk

o
Hard sided containers with airtight seals
Place of storageTemperature Maximum storage time
In a room25 degree C6-8 hours
Insulated thermal bag with ice packsUp to 24 hours
In a refrigerator4 degree CUp to 5 days
Freezer compartment inside a refrigerator-15 degree C2 weeks
A combined refrigerator and freezer with separate
doors
-18 degree C3-6 months
Chest or upright manual defrost deep freezer-20 degree C6-12 months

Oral contraceptives are contraindicated in lactating mothers because they contain

estrogen and
progesterone derivatives, thereby decreasing milk supply
BREAST CARE:

Wash breast daily at bath or shower time

Soap or alcohol should never be used on the breast as they tend to dry and crack the
nipples and
cause sore nipples

Wash hands before and after every feeding

Insert clean OS squares or piece of cloth in the brassiere to absorb moisture when there
is
considerable breast discharges.

Engorgement managemet:
o
Nurse often (not going more than 3 hours without nursing and not skipping night
feedings)
o
Well-fitted bra
o
Warm compress/shower
o

Chilled cabbage leaves (placed on breast with nipple exposed)

o
Acetaminophen or ibuprofen for pain
o
Pumping or manually expressing breast milk
How to Manually Express Breastmilk - The Marmet Technique
Draining the Milk Reservoirs
.
Position the thumb (above the nipple) and first two fingers (below the nipple) about 1 to
11/2 from the
nipple, though not necessarily at the outer edges of the areola. Use this measurement
as a guide,
since breasts and areolas vary in size from one woman to another. Be sure the hand
forms the letter
C and the finger pads are at 6 and 12 oclock in line with the nipple. Note the fingers
are positioned
so that the milk reservoirs lie beneath them.
Avoid cupping the breast
2.
Push straight into the chest wall
Avoid spreading the fingers apart.
For large breasts, first lift and then push into the chest wall
3.
Roll thumb and fingers forward at the same time. This rolling motion compresses and
empties milk reservoirs
without injuring sensitive breast tissue.
Note the position of thumb and fingernails during the finish roll as shown in the
illustration.
4.
Repeat rhythmically to completely drain reservoirs.
Position, push, roll...
Position, push, roll...
5.
Rotate the thumb and fingers to milk other reservoirs, using both hands on each breast.
Avoid These Motions
1. Do not squeeze the breast, as this can cause bruising.
2. Sliding hands over the breast may cause painful skin burns.
3. Avoid pulling the nipple which may result in tissue damage