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.
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.
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.
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
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
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:
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.