Postpartum Care

Definition

Postpartum care encompasses management of the mother, newborn, and infant during the postpartal period. This period usually is considered to be the first few days after delivery, but technically it includes the six-week period after childbirth up to the mother's postpartum checkup with her health care provider.

Purpose

Immediately following childbirth, a new mother experiences profound physical and emotional changes. She may stay in the hospital or birthing center a very short time, even as little as 24–48 hours after delivery. The physical and emotional care a woman receives during the postpartum period can influence her for the remainder of her life.

Precautions

During the postpartum period the mother is at risk for such problems as infection, hemorrhage, pregnancyinduced hypertension, blood clot formation, the opening up of incisions, breast problems, and postpartum depression.

Postpartum care in the hospital

The initial phase of the postpartum period encompasses the first one to two hours after delivery. It takes place most often in the birthing room or in a recovery room. Once this initial phase is over, the woman has passed through the most dangerous part of childbirth. Assessments of pain, the condition of the uterus, vaginal discharge, the condition of the perineum, and the presence/absence of bladder distension (followed by appropriate interventions) are part of the initial postpartum evaluation; and should be done every 15 minutes for the first hour, then generally every 30 minutes for the second hour, and every four to eight hours thereafter depending on facility policy.

PAIN/DISCOMFORT. The degree of pain and discomfort from incisions, lacerations, and uterine cramping (afterbirth pains) is assessed by hospital staff. The woman may also complain of muscle pain after a prolonged labor. If the level of pain warrants it, analgesic medications are given, usually orally. Women who have undergone cesarean births may have more pain than women who have given birth vaginally, and may need injectable analgesics. If a woman complains of pain in her calf, she should be evaluated for thrombophlebitis. Also, if a woman complains of a headache, her blood pressure should be checked to rule out the presence of pregnancy-induced hypertension. A woman who received epidural anesthesia during delivery may develop a "spinal headache." A spinal headache is due to the loss of cerebrospinal fluid from the subarachnoid space that may occur during the administration of the spinal anesthesia. Spinal headaches should be treated by the anesthesiologist or nurse-anesthetist. Treatment for this type of headache typically includes keeping the patient flat in bed, encouraging increased fluid intake, and administering pain medication.

Breast engorgement is characterized by low-grade fever and the absence of systemic symptoms. It is usually bilateral; the breasts feel warm to the touch and appear shiny. Pain from breast engorgement can be minimized for the breastfeeding mother by mild analgesics, the application of warm packs, and frequent nursing. For the mother who is not breastfeeding, this pain can be minimized by mild analgesics and the application of cold packs. A nursing mother may find that the use of a lanolin-based preparation or a nipple shield (although controversial) provides relief for sore or cracked nipples. Changing positions for the nursing baby also can help in reducing irritation and minimizing stress on sore spots.

A plugged duct can also cause breast pain. Breast pain caused by a plugged duct is distinguished from breast engorgement by the fact that it is usually confined to one breast and the breast is not warm to the touch. This pain may be relieved by heat packs, gentle massage of the breast toward the nipple, and changing positions for nursing the baby.

FUNDUS. The condition of the uterus is assessed by evaluating the height and consistency of the fundus (the part of the uterus that can be palpated abdominally). Immediately after delivery, uterine contractions begin triggering involution. Involution is the process whereby the uterus and other reproductive organs return to their state prior to pregnancy. To properly palpate the uterus, the woman is positioned flat on her back (supine). The health care provider places one hand at the base of the uterus above the symphysis pubis (the interpubic joint of the pelvis) in a cupping manner (to support the lower uterine ligaments). Then, she presses in and downward with the other hand at the umbilicus until she makes contact with a hard, globular mass. If the uterus is not firm, light massaging usually results in tightening. Massaging of the uterus should not be so vigorous as to cause the mother pain. A mother who has had a cesarean delivery should be medicated, if possible, prior to assessment of the fundus; and the health care provider should use the minimal amount of pressure necessary to locate her fundus. The height of the fundus after the first hour following delivery is at the umbilicus or above it. Every day the fundal height decreases by approximately the width of one finger (one cm).

The fundal height may be palpated off of midline because of a distended bladder. If possible, the woman should be encouraged to empty her bladder prior to assessment of the fundus. A full bladder can prevent uterine involution.

A woman sometimes receives the medication oxytocin (Pitocin) after the delivery of the placenta. Oxytocin causes the uterus to contract and can decrease the amount of postpartum bleeding. The health care provider should assess the condition of the uterus frequently, and may need to massage the uterus gently to encourage its clamping down on itself, especially when oxytocin has not been given. If the uterus does not firm to gentle massage, then a clot may be present inside. Gentle pressure on the uterus following massage, and while simultaneously supporting the base of the uterus, may expel the clot.

If massaging the uterus does not result in a firming of the fundus, then the physician or nurse-midwife should be contacted immediately. The existence of severe atony or a retained fragment of placenta may result in excessive loss of blood.

VAGINAL DISCHARGE (LOCHIA). The color and amount of vaginal discharge (lochia) is assessed by frequently removing the perineal pad and checking the flow of lochia after delivery. An excessive amount could be a sign of a complication such as clot formation or a retained portion of the placenta. The vaginal discharge is red for one to three days following delivery and is called lochia rubra. Between days two and 10, the discharge changes to a pink or brownish color and is called lochia serosa. The last phase occurs when the vaginal discharge turns white. This vaginal discharge is referred to as lochia alba and may occur from 10–14 days postpartum. The spotting can continue for another six weeks. It is common in mothers who breastfeed their babies. A constant trickling of blood or the soaking through of a perineal pad in an hour or less is not normal and should be further evaluated.

PERINEUM. The condition of the perineal area is assessed for an episiotomy or laceration repair. An episiotomy is the surgical procedure whereby the physician or nurse-midwife extends the vaginal outlet immediately prior to delivery of the baby. The incision is repaired with sutures after delivery.

Generally an episiotomy will be 1–2 inches (2.5–5 cm) in length. By 24 hours postpartum the edges of the episiotomy should be fused together. An episiotomy may be covered over with edematous tissue and not easily visible, so the examination must the done carefully. If the laceration or episiotomy is infected it appears red and swollen, and discharges pus. Treatment depends on the severity of the infection and may include sitz baths; application of an antibiotic cream to the wound; oral antibiotics; or opening the wound, cleansing the site, and resuturing it.

When the perineal area is examined, the patient should also be checked for the presence of a hematoma (a round area filled with blood) that is caused by the rupturing of small blood vessels on the surface of the perineum. After observing the perineum, the rectal area also is evaluated for hemorrhoids, making note of their size, character, and number.

The following measures are effective in providing relief of perineal discomfort:

• Application of cold packs to the perineum for the first 24 hours after delivery.
• Application of warm packs to the perineum after the first 24 hours.
• Rinsing of the perineal area with warm water after every void and/or bowel movement. (This is also helpful in preventing infection and in promoting healing.)
• Use of anesthetic sprays and creams. Cleaning the area with witch hazel pads (Tucks) is also soothing.
• Sitting in a sitz bath—a small basin that fits on top of the toilet through which warm water flows—three or four times a day. After discharge a woman may use her bathtub at home for this purpose.

BLADDER DISTENTION. In the first 48 hours after delivery it is normal to have an increase in the formation and secretion of urine (postpartum diuresis). A full bladder can cause the uterus to shift upwards and not contract effectively. An overdistended bladder can even cause injury to the urinary system. A woman should be encouraged to void within her first hour postpartum; and her bladder should be checked after voiding, since urinary retention can be a problem. If the woman had a cesarean section and has a Foley catheter in place in her bladder, then the output is checked every hour during the initial postpartum period. The Foley catheter is likely to be removed approximately eight hours after surgery. The health care provider needs to assess for voiding after removal of the Foley catheter.

Postpartum care after hospital discharge

Ideal postpartum care would include several home visits by health care providers in the one to two weeks following delivery to assess the status of the mother and her family. This rarely happens in the United States, but follow-up phone calls by health care providers during the first week and a visit by the mother and baby to her physician or nurse-midwife one to two weeks after the birth are desirable.

Several problems that may arise during the postpartum period do not typically develop until after the new mother is discharged from the hospital. These include mastitis, endometritis, and postpartum depression.

MASTITIS. Mastitis is an inflammation of the breast, usually caused by streptococcal or staphylococcal infection. It can develop any time a woman is breastfeeding, but usually does not occur before the tenth postpartum day. Symptoms of mastitis often mimic those of the flu, and include body aches and a fever of 101°F (38.6°C) or more. Mastitis is treated with a course of antibiotics, and women should begin to feel better within 24 hours of beginning the antibiotics. If this does not happen, the woman may need to be hospitalized for intravenous antibiotics.

Other measures that may help the mother feel better include bed rest for at least 24 hours, moist heat on the infected breast every two to three hours (when awake), acetaminophen for pain and fever relief, increased fluid intake, and going without a bra for several days. Mastitis does not contaminate the breast milk and the baby should continue to nurse from both breasts. If nursing from the affected breast is too painful, use of a breast pump or manual expression of milk may be needed to prevent engorgement and facilitate continued milk production.

ENDOMETRITIS. Endometritis is an inflammation of the endometrium, the mucous membrane lining the uterus. It is usually caused by a bacterial infection. Symptoms of this infection include fever, abdominal pain, and foul-smelling vaginal discharge. Physical examination of the patient reveals a tender uterus. Endometritis is treated with a course of antibiotics and other care, including bed rest, acetaminophen for pain and fever relief, and increased fluid intake. Severe cases may require hospitalization.

POSTPARTUM DEPRESSION. Postpartum depression may appear at any time during the first year after a baby's birth. It ranges in severity from mild, postpartum "blues" that last only a few days shortly after birth, to intense, suicidal, depressive psychosis. Not only does postpartum depression cause distress for the new mother and her partner, but it can also interfere with the new mother's ability to bond with her baby and to relate to any other children she may have.

Symptoms of severe postpartum depression or psychosis include insomnia, hallucinations, agitation, and bizarre feelings or behavior. Any new mother exhibiting signs of postpartum depression should be referred to mental health professionals, support groups, and/or new mother groups. Psychotropic medication is often helpful, as is psychotherapy. About 10% of cases of postpartum depression are caused by postpartum thyroiditis, a temporary inflammation of the thyroid gland that usually clears up spontaneously in one to four months. Whenever postpartum depression occurs, thyroid function should be tested to rule out hyperthyroidism or hypothyroidism as the cause of symptoms.

Six-week postpartum check-up

Although this postpartum check-up is traditionally scheduled six weeks after delivery, it may be done any time between four weeks and eight weeks after delivery. It usually includes a breast examination, a pelvic examination, any necessary laboratory tests, and a health education component covering such areas as breastfeeding, birth control, weight reduction, etc. This checkup is also an opportunity to review the pregnancy and birth experience, to discuss problems and assess for depression, to provide emotional support, to answer questions, and to consider if any further referrals are necessary for the new mother.

Health care team roles

The new mother is given instruction in how to hygienically care for her perineal area. She is encouraged to change her perineal pad frequently and to wash her hands afterwards. The presence of a wet pad against sutures is an excellent medium for the development of an infection that could potentially spread to the uterus. The woman is also instructed not to use tampons for six weeks after delivery, since tampon use can cause infection or even toxic shock syndrome.

New mothers may be overwhelmed by the degree of discomfort after giving birth, and may be frustrated by their desire to interact with their new baby while at the same time being limited by pain, discomfort, and exhaustion. The health care team member can help the new mother by providing perineal care for her until she is able to get out of bed, and by administering pain medications as ordered.

Other important things health care providers can do for postpartum women include:

• Evaluate pulse, respiratory rate, and blood pressure every 15 minutes during the first hour postpartum, every 30 minutes for two hours, and then every eight hours. Evaluate the woman's temperature at the end of the first hour postpartum and then every four hours for the first 2–12 hours postpartum.
• Help the woman take a shower as soon as she is allowed to, while monitoring her for lightheadedness.
• Place a warm blanket over the mother after delivery if she experiences shaking and chills.
• Provide emotional support to the mother and family through explanations about childbirth and how it can be a highly emotional and psychologically overwhelming time.
• Promote adequate rest.
• Encourage a generous intake of nutrients and fluids.
• Ask if the woman has had a bowel movement prior to discharge and offer medication to soften stools if desired.
• Monitor the woman's voiding and ensure the woman is not having difficulty. Catheterization is sometimes required.
• Assist with ambulation until the woman is steady on her feet.
• Review laboratory tests for signs of anemia, infection, and electrolyte imbalance.
• Teach the woman muscle-strengthening exercises.
• Prepare the mother and family for discharge through discharge teaching.
• Arrange for a home visit if this is provided for through the facility and/or patient's insurance.

KEY TERMS

Perineum—The area between the rectum and the outlet of the vagina.

Pregnancy-induced hypertension—Vasospasm occurring during pregnancy resulting in such symptoms as hypertension, swelling, and protein in the urine. If not treated, it can sometimes result in a seizure.

Thrombophlebitis—Blood clot formation resulting in inflammation of the lining of a blood vessel.

Umbilicus—Navel; depression in the center of the abdomen where the umbilical cord was attached.

BOOKS

Pillitteri, Adele. Maternal & Child Health Nursing, 3rd ed. Philadelphia: Lippincott, 1999.

Wheeler, Linda. Nurse-Midwifery Handbook: A Practical Guide to Prenatal and Postpartum Care. Philadelphia: Lippincott, 1997.

ORGANIZATIONS

Association of Women's Health, Obstetric, and Neonatal Nurses, 2000 L Street, NW, Suite 740, Washington, D.C. 20036. Phone (U.S.): (800) 673-8499. Phone (Canada):(800) 245-0231. <http://www.awhonn.org/>.

Nadine M. Jacobson