Lesson 6: Maternity Client: Postpartum Care Lochia

 The vaginal discharge that occurs after childbirth.

Postpartum Period
 Reproductive tract returns to normal, nonpregnant state Assessment
 Starts immediately after delivery and is usually complete by week 6  Rubra is a bright-red discharge that appears from delivery day to day
after delivery 3.
 Serosa is a brownish-pink discharge that appears on days 4 to 10
 Maternal Physiological Changes after delivery.
 Alba is a white discharge that appears on days 10 to 14 after
Involution delivery.
 This term is used to describe changes in the uterus as it returns to its  Normally the discharge has a fleshy odor.
nonpregnant size and condition.  Discharge diminishes daily but may increase with ambulation.
 Clients who breastfeed may experience more rapid involution.  Weigh perineal pad before and after use and identify the amount of
time between pad changes to most accurately determine the
amount of lochial flow.

Cervix
 Cervical involution occurs.
 After 1 week, the muscle begins to regenerate.

Vagina
 Distention decreases, although muscle tone never recovers
completely to the pregravid state.
Assessment
 The weight of the uterus decreases from 2 lb to 2 oz (0.9kg to 57 gm) Ovarian Function and Menstruation
in 6 weeks.
 Ovarian function depends on the rapidity with which pituitary
 Immediately after delivery, the fundus can be palpated midway function is restored.
between the symphysis pubis and umbilicus, after which it rises to a
 Menstrual flow resumes within 8 weeks in nonbreastfeeding
level just above the umbilicus; next it sinks to the level of the
mothers.
umbilicus and remains at this level for about 24 hours.
 Menstrual flow usually resumes within 3 to 4 months in
 After 24 hours, the fundus begins to descend by approximately 1 cm,
breastfeeding mothers.
or one fingerbreadth, each day.
 Breastfeeding mothers may experience amenorrhea during the
 By the 10th to 14th day after delivery, the fundus is in the pelvic
entire period of lactation.
cavity and cannot be palpated abdominally.
 Women may ovulate without menstruating, so breastfeeding should
 Note that a flaccid fundus indicates uterine atony and should be
not be considered a form of birth control.
massaged until firm; a tender fundus indicates infection.
Breasts
 Breasts continue to secrete colostrum.
 A decrease in estrogen and progesterone levels after delivery
stimulates the secretion of prolactin, which promotes production of
breast milk.
 Breasts become distended with milk on the third day after delivery.
 Engorgement occurs in 48 to 72 hours in nonbreastfeeding mothers.
 Breastfeeding relieves engorgement.
 Urinary Tract
 Urine retention may result from loss of elasticity and tone; loss of
sensation in the bladder caused by trauma, medications, anesthesia;
or lack of privacy.
 Diuresis usually begins within 12 hours of delivery.

Gastrointestinal Tract
 Women are usually very hungry after delivery.
 Constipation may occur.
 Hemorrhoids are common.

Vital Signs
 Temperature may be increased up to 100.4° F (38°C) during the 24
hours after delivery because of dehydration, and fluids should be
encouraged; if the temperature rises higher than 100.4° F (38°C),
notify the health care provider, because this could indicate infection.
 Bradycardia is common during the first week, with a range of 50 to
70 beats/min; a pulse rate greater than 100 beats/min could indicate
blood loss or infection.
 Blood pressure usually remains unchanged; if the blood pressure
drops, bleeding or hypovolemia should be suspected.
 Respirations rarely change; if they increase significantly, suspect
pulmonary embolism, uterine atony, or bleeding.

Nursing Care
 Monitor vital signs.
 Assess height, consistency, and location of fundus.
 Monitor color, amount, and odor of lochia.
 Assess breasts for engorgement.
 Monitor perineum for swelling or discoloration.
 Monitor episiotomy site for healing.
 Assess incisions or dressings of client who has given birth by
cesarean.
 Monitor bowel status.
 Monitor intake and output.
 Encourage frequent voiding.
 Encourage ambulation.
 Administer Rho(D) immune globulin (RhoGAM) as prescribed within
72 hours of delivery to the Rh factor–negative client who has given
birth to an Rh-positive newborn.
 Assess mother's bonding with the newborn.
 Assess emotional status of the new mother.
Postpartum Interventions
Client Teaching
 Demonstrate newborn-care skills as necessary.
 Provide the opportunity for the mother to bathe the newborn.
 Instruct mother in feeding technique.
 Instruct the mother to avoid heavy lifting for at least 3 weeks.
 Instruct the mother to plan at least one rest period per day.
 Instruct the mother in postpartum exercises.
 Instruct the mother that contraception should begin after delivery or
with the initiation of sexual intercourse. (Intercourse should be
postponed at least until lochia ceases and the episiotomy has
healed.)
 Instruct the mother to report any chills, fever, increased lochia, or
feelings of depression to the health care provider immediately.
 Instruct the mother in the importance of follow-up.
Postpartum Discomforts
Afterbirth Pains
 These pains, which result from contraction of the uterus, are more
common in multiparas, breastfeeding mothers, clients treated with
oxytocin, and clients who had an overdistended uterus during
pregnancy, such as those who carried twins.
Perineal Discomfort
 Apply ice packs to the perineum during the 24 hours after delivery to
reduce swelling.
 After the first 24 hours, apply warmth through the use of sitz baths.
Episiotomy
 Administer perineal care after each voiding.
 Encourage the use of an analgesic spray as prescribed.
 Administer analgesics as prescribed if nonpharmacological comfort
measures are unsuccessful.
Breast Discomfort from Engorgement
 Encourage client to wear a supportive bra at all times, even while
sleeping.
 Encourage the use of ice packs if the client is not breastfeeding.
 Encourage the use of warm soaks before feeding for the
breastfeeding mother.
 Administer analgesics as prescribed if nonpharmacological comfort
measures are unsuccessful.
 Psychological Concerns
 Rubin’s postpartum phases of regeneration is a good guide to what
the new mother may be feeling.
Taking-In Phase: First 3 Days
 Mother focuses on her own primary needs, such as sleep
and food.
 It is important for the nurse to listen and to help the
mother interpret the events of delivery to make them
more meaningful.
 It is not the optimal time to teach the mother about baby
care.
Taking-Hold Phase: Days 3 Through 10
 Mother is more in control of independence.
 Client begins to assume the tasks of mothering.
 Optimal time to teach the mother about baby care.
Letting-Go Phase
 Mother may feel deep loss over separation of the baby
from her body and may grieve the loss.
 Mother may be caught in a dependent/independent role,
wanting to feel safe and secure yet wanting to make
decisions.
 Teenage mothers need special consideration because of
the conflict taking place within them as part of
adolescence.
Postpartum Blues
 Caused by physiological and emotional stress, may also be due to
hormonal changes in the mother.
 The mother may feel upset and depressed at times.
 Verbalization of concerns and fears should be encouraged
Nutritional Counseling
 Nutritional needs depend on the mother's prepregnancy weight, the
ideal weight for her height, and whether she is breastfeeding.
 If the mother is breastfeeding, calorie needs are increased by
approximately 200 to 500 calories per day as prescribed by the
health care provider, and the mother may require increased fluids
and the continuation of prenatal vitamins and minerals.
Breastfeeding
 Instruct mother in breastfeeding procedure.
 Wash hands and assume a comfortable position.
 Start with the breast that the last feeding ended with.
 Brush infant's lower lip with nipple.
 Tickle lips to have the infant open mouth wide.
 Guide nipple and areola into infant's mouth.
 After baby has nursed, release suction by depressing the
infant's chin or inserting a clean finger into the infant's
mouth.
 Burp infant after first breast.
 Repeat procedure on the second breast until infant stops
nursing.
 Burp infant again.
 Listen for audible sucking and swallowing during feeding.
 Put the baby to breast as soon as the mother and baby's conditions
are stable (on delivery table, if possible).
 Stay with the mother each time she nurses until she feels secure or
confident with the baby and her feelings.
 Uterine cramping may occur the first day after delivery while the
mother is nursing, when oxytocin stimulation causes the uterus to
contract.
 Use general hygiene and wash the breasts once daily.
 If engorgement occurs, the mother should breastfeed frequently,
apply warm packs before feeding, apply ice packs after feedings, and
massage the breasts.
 The mother should not use soap on the breasts, because it tends to
remove natural oils, increasing the likelihood of cracked nipples.
 If cracked nipples develop, they should be exposed to air for 10 to 20
minutes after feeding, the baby's position should be rotated for each
feeding, and the mother should ensure that the baby is latched onto
the areola, not just the nipple.
 The client’s bra should be well fitted and supportive.
 The breasts may leak between feedings or during coitus; place a
breast pad in bra.
 Medications should be avoided unless prescribed.
 Gas-producing foods and caffeine should be avoided.
 Hormonal contraceptives may cause a decrease in the milk supply
and are best avoided during the 6 weeks after birth.
 Oral contraceptives containing estrogen are not recommended for
breastfeeding mothers; progestin-only birth control pills are less
likely to interfere with the milk supply.
 The baby will develop his or her own feeding schedule.
Priority Points to Remember!
 The priority nursing care of the mother after birth is to promote firm
uterine contraction, promote comfort, and promote parent-infant
attachment.
 To most accurately determine the amount of lochial flow, weigh the
perineal pad before and after use and keep track of the time
between pad changes.
 Encourage fluids in the postpartum period because of the
dehydrating effects of the labor and delivery process.
 If the client’s temperature rises higher than 100.4° F (38°C), health
care provider is notified, because this could indicate infection.
 In the postpartum period, a pulse rate greater than 100 beats/min
could indicate blood loss or infection.
 If the blood pressure drops, bleeding or hypovolemia should be
suspected.
 Women may ovulate without menstruating, so breastfeeding should
not be considered a form of birth control.
 All women should be assessed for depression during pregnancy and
in the postpartum period.