Chapter 8 : Postpartum Care and Newborn Nutrition

• Postpartum period


  The interval between the birth of the newborn and the return of the reproductive organs to their normal nonpregnant state
• Puerperium


  The fourth trimester of pregnancy
• Postpartum period duration


  Lasts 6-12 weeks
• Postpartum Changes and Ongoing Physical Assessment

  • Breasts (firmness) and nipples
  • Uterine fundus (location; consistency)
  • Bladder function (amount; frequency)
  • Bowel function (passing gas or bowel movements)
  • Lochia (amount; colour)
  • Legs (peripheral edema)
  • Episiotomy/Laceration or Caesarean birth incision (perineum: discomfort; condition of repair; if done)
  • Emotional status (mood, fatigue)
• Involution


  The term used to describe the return of the uterus to a nonpregnant state following birth
• Involution process


  1. Shrinking of the uterus

  2. Begins immediately after expulsion of the placenta

  3. Progresses during the next few days
• Uterus during involution


  • During the first 12 hours postpartum, the fundus is located at the level of the umbilicus
  • By 24 hours, the uterus is about the same size it was at 20 weeks of gestation
  • Descends 1-2 cm every 24 hours
  • By day 6 of postpartum, located halfway between the umbilicus and the symphysis pubis
  • By 6 weeks, the uterus has basically returned to its nonpregnant state
• Expected uterus findings


  • Loose, floppy abdominal skin
  • Uterus firm and contracting; not boggy (feels spongy), midline of abdomen
  • Boggy uterus may be due to retained placental fragments
  • Massage if the uterus is boggy and empty the bladder
  • Feels large and soft, lacking the expected resistance
  • Very tender, patients may experience pain, mostly in the lower abdomen and back
  • Uterus displaced to the right may indicate full bladder
  • Uterus cannot contract well if bladder full
  • Uterus descending 1 fingerbreadth/day
• Afterpains


  Uterine contractions after birth that cause pain
• Afterpains


  • First-time mothers don't really experience this problem, and if they do it's mild
  • For someone who's had subsequent pregnancies (multiparas), the periodic relaxation and vigorous contractions causes discomfort
  • More noticeable in mothers who had an overdistended belly (multifetal gestation, polyhydramnios, etc)
  • IM,IV oxytocin, and breastfeeding can exacerbate the pain because it causes more contractions
  • Can happen during breastfeeding because oxytocin is released
• Placental site


  Vascular construction and thromboses reduce the placental site to an irregular nodular and elevated area
• Placental site healing


  1. Upward growth of the endometrium happens, which causes sloughing of necrotic tissue and prevents the scar formation characteristic to wound healing

  2. This process allows the endometrium to allow for implantation and placentation in future pregnancies

  3. Endometrium regeneration is completed by postpartum day 16, except at the placental site

  4. Regeneration at the placental site is healed by approximately 6 weeks
• Types of Lochia


  • Lochia rubra (bright red or rust coloured flow, first 3-4 days)
  • Lochia serosa (pale flow, becoming pink or brown, 3-4 days to 2-4 weeks)
  • Lochia alba (whitish-yellow, may last 4-6 weeks postpartum)
• Lochia


  • Initially bright red (lochia rubra) and contains small clots
  • The first 2 hours after birth should be the amount of discharge as a heavy menstrual period. After this, it should gradually decrease
  • Assess amount, colour, odour (should not be foul smelling)
  • If lochia rubra is consistent/too long, it could suggest there's retained fragments of placenta or membranes in the uterus still
• Factors affecting lochia flow/amount/type

  • Oxytocin medication causes the lochia flow to be scant until the medication effects wear off
  • C-section causes less lochia because the surgeon suctions the blood and fluids from the uterus or wipes the uterine lining before closing the incision
  • Flow of lochia increases with ambulation
  • Lochia pools in the vagina when patient is lying in bed, so they'll feel a gush of blood when they stand
• Cervix after birth


  • Soft immediately after birth
  • The ectocervix (portion of the cervix that protrudes into the vagina) appears bruised and has small lacerations
  • The cervical os (which dilated to 10 cm during labour) gradually closes
  • 2nd-3rd post partum day: cervix is shortened, 2-3 cm dilated and firm
  • 1 week after birth: 1 cm dilated
  • Fully closed by about 4 weeks, no longer round in shape but appears as a "fish mouth"
• Vagina and perineum after birth

  • Vagina is thin and rugae is absent due to sudden drop in estrogen levels
  • Remains suppressed until ovulation occurs again, in a couple of weeks to months later
  • The distended vagina gradually decreases in size and regains tone, but will never be the same as its prepregnant state
  • Vaginal mucosa is thin (atrophic), dry and inflamed, becomes thicker when menstruation resumes
  • Episiotomies & lacerations are erythematous and edematous, heal in 2-3 weeks but can take up to 4-6 months to heal completely
  • Hemorrhoids are common, decrease in size within 6 weeks after birth
• Diastasis recti abdominis


  Separation of the abdomen, requires surgery if it happens due to overdistension of abdomen (from multifetal gestation)
• Abdominal assessment post-birth


  • Inspect: distension; incision line post C-section for infection, dehiscing
  • Auscultate: all 4 quadrants for bowel sounds
  • Palpate: uterine descent in relation to umbilicus; firmness and position-abdominal midline
  • Percuss: drum like sound suggests abdominal gas
• Expected abdominal findings


  • Edema, clean incision or tear
• Abnormal abdominal findings


  • Redness, ecchymosis, drainage, skin not approximated, hematoma, tenderness
• Placental hormones


  Estrogen and progesterone level DROP after expulsion of placenta, causes diuresis of extracullar fluid from pregnancy
• Breastfeeding vs non-breastfeeding


  • Women who do not breastfeed will have higher amounts of estrogen than those who do breast feed
  • In patients who breastfeed, prolactin levels are highest during the first month after birth and remain elevated above nonpregnant levels as long as the patient is breastfeeding
• Timing of ovulation


  • Ovulation occurs earlier in non lactating patients, can occur as early as 27 days (mean time of 7-9 weeks)
  • Ovulation for patients who breastfeed has a mean time of about 6 months, persistent breastfeeding suppresses ovulation
• Urine components changes

  • Renal glycosuria disappears by 1 week
  • Lactosuria may occur in lactating patients
  • Plasma creatine returns to normal by 6 weeks postpartum
  • Pregnancy related proteinuria resolves by 6 weeks after birth
  • Ketonuria may occur in patients with an uncomplicated birth or after a prolonged labour with dehydration
• Fluid loss after birth

  • Within 12 hours of birth, patient's lose excess fluid from pregnancy
  • Postpartal diuresis due to decreased estrogen levels, removal of increased venous pressure in the lower extremities and loss of the remaining pregnancy-induced increase in blood volume
  • Urine output of 3 000 mL or more each day during the first 2-3 days is common
  • Profuse diaphoresis can occur at night for the first 2-3 days
  • Fluid loss and perspiration accounts for 2-3 kg (approximately 2.25 kg) of weight loss during early puerperium
• Stress incontinence


  Can occur during the postpartum period, occurs more in vaginal than C-section births, related to tissue trauma to the pelvic floor when pushing and increased size of newborn
• Coached pushing vs uncoached (non-Valsalva) pushing

  Can increase the risk for damage to the pelvic floor and subsequent stress incontinence
• Gastrointestinal changes

  • Most new mothers become more HUNGRY, requests of larger portions is normal
  • A spontaneous BM may take another 2-3 days to occur due to decreased muscle tone during labour, prelabour diarrhea and lack of food + dehydration
  • Patients who had forceps or vacuum assistance to take out the fetus may have postpartum anal incontinence, more incontinent of flatus than stool
• Bladder & bowel considerations after vaginal delivery

  • Voiding usually occurs within first 6 hrs
  • Usually attempt to empty bladder after 2hrs
  • Potential for bladder distention due to normal postpartum diuresis
  • Epidural - potential for urinary retention
  • Should have good bowel sounds; be passing gas
• Nursing considerations for bladder & bowels

  • Encourage voiding - assess ability to void
  • Should be voiding regularly - minimum 360 cc/12 hrs as full bladder may compromise ability of uterus to contract post delivery
  • Remind to pat dry front to back to avoid infection
  • Educate Kegel/pelvic muscles exercises to improve tone
  • Encourage ambulation
  • Encourage adequate fluid and food intake
  • Stool softener
• Postpartum period


  The interval between the birth of the newborn and the return of the reproductive organs to their normal nonpregnant state
• Puerperium


  The fourth trimester of pregnancy
• Postpartum period duration


  Lasts 6-12 weeks
• Breast changes in breastfeeding mothers

  • Little change in the breast tissue in the first 24 hours
  • Colostrum (early milk) that is clear & yellowy develops from breasts
  • The breasts feel soft at first and then start to become fuller and heavier as the colostrum becomes true milk within 72-96 hours after birth
  • Breasts may feel warm, firm, and somewhat tender
  • As milk fills in breasts they begin to feel nodular or lumpy
• Postpartum Changes and Ongoing Physical Assessment

  • Breasts (firmness) and nipples
  • Uterine fundus (location; consistency)
  • Bladder function (amount; frequency)
  • Bowel function (passing gas or bowel movements)
  • Lochia (amount; colour)
  • Legs (peripheral edema)
  • Episiotomy/Laceration or Caesarean birth incision (perineum: discomfort; condition of repair; if done)
  • Emotional status (mood, fatigue)
• Involution


  The term used to describe the return of the uterus to a nonpregnant state following birth
• Breast changes in non-breastfeeding mothers

  • Feel more nodular and it's bilateral
  • Prolactin levels drop quickly
  • Colostrum is present for the first few days after birth
  • Breast tenderness is common upon palpation on the second-third day due to milk production
  • Engorgement may occur on the third-fourth day, but resolves within 24-36 hours
• Involution process


  1. Shrinking of the uterus

  2. Begins immediately after expulsion of the placenta

  3. Progresses during the next few days
• Lactogenesis II


  The "milk coming in" or increase in milk production within 72-96 hours after birth