Chapter 16: Nursing Management During the Postpartum Period

Bonding versus Attachment

 Bonding
o Close emotional attraction to a newborn by the parents that develops the first 30 to 60 minutes after birth
o Unidirectional, from parent to infant
 Attachment
o Development of a strong affection between an infant and a significant other (mother, father, sibling, caregiver)
Typical Assessments in Postpartum Period
 During the first hour: every 15 minutes
 During the second hour: every 30 minutes
 During the first 24 hours: every 4 hours
 After 24 hours: every hour
Factors Increasing a Woman’s Risk for Postpartum Complications
 Risk Factors for Postpartum Infection
o Operative procedure (forceps, cesarean birth, vacuum extraction)
o History of diabetes, including gestational-onset diabetes
o Prolonged labor (more than 24 hours)
o Use of indwelling urinary catheter
o Anemia (hemoglobin <10.5 mg/dL)
o Multiple vaginal examinations during labor
o Prolonged rupture of membranes (>24 hours)
o Manual extraction of placenta
o Compromised immune system (HIV-positive)
 Risk Factors for Postpartum Hemorrhage
o Precipitous labor (less than 3 hours)
o Uterine atony
o Placenta previa or abruptio placenta
o Labor induction or augmentation
o Operative procedures (vacuum extraction, forceps, cesarean birth)
o Retained placental fragments
o Prolonged third stage of labor (more than 30 minutes)
o Multiparity, more than three births closely spaced
o Uterine overdistention (large infant, twins, hydramnios)
o Postpartum Danger Signs
 Postpartum Danger Signs
o Fever >100.4°F (38°C)
o Foul-smelling lochia or an unexpected change in color or amount
o Large blood clots or bleeding that saturates a peripad in an hour
o Severe headaches or blurred vision
o Visual changes, such as blurred vision or spots, or headaches
o Calf pain with dorsiflexion of the foot
o Swelling, redness, or discharge at the episiotomy, epidural, or abdominal sites
o Dysuria, burning, or incomplete emptying of the bladder
o Shortness of breath or difficulty breathing without exertion
o Depression or extreme mood swings
Vital Signs Assessment
 Temperature: slight elevation during first 24 hours; normal afterward
 Pulse: 40 to 80 bpm; puerperal bradycardia
 Respirations: 16 to 20 breaths per minute
 Blood pressure: within usual range
 Pain: goal between 0 and 2 on pain scale
Some women experience a slight elevation in temperature during the first 24 hours postpartum; this may be the result of
dehydration secondary to fluid loss during labor.
Physical Assessment: Postpartum Period
 Breasts (size, contour, engorgement)
 Uterus (height of fundus, firmness)
 Bladder (voiding, bladder emptying)
 Bowels (bowel sounds, distention)
 Lochia (amount, color, odor)
  Episiotomy and perineum (lacerations, hematoma)
o First-degree laceration: involves only skin and superficial structures above muscle
o Second-degree laceration: extends through perineal muscles
o Third-degree laceration: extends through the anal sphincter muscle
o Fourth-degree laceration: continues through anterior rectal wall
 Extremities (swelling, or signs of DVTs)
 Emotional status
Emotional Status Assessment: Postpartum Period
 Interactions with family
 Level of independence
 Energy levels
 Eye contact with infant
 Posture and comfort level with infant
 Sleep and rest patterns
 Be alert for mood swings, irritability, or crying episodes
Nursing Management: Bonding and Attachment
 Transition to parenthood
o Stages
o Factors affecting attachment: parent’s background, infant, care practices
 Critical attributes of attachment: proximity, reciprocity, commitment
 Positive and negative attachment behaviors (see Table 16.1)
Stages in the Transition to Parenthood (Mercer, 2006)
 Commitment, attachment, preparation for an infant during pregnancy
 Acquaintance with and attachment to the infant, learning how to care for the infant; physical restoration in first weeks after
birth
 Moving toward a new normal routine in the first 4 months after birth
 Achievement of a parenthood role around 4 months
Factors Affecting Attachment
 Parent’s background
 Infant temperament and health at birth
 Care practices
 Separation immediately after birth
 Policies discouraging exploring infant
 Intensive care environment
 Staff indifference or lack of support for parents
Teaching Topics for Postpartum Period
 Pain and discomfort
 Immunizations
 Nutrition
 Activity and exercise
 Lactation
 Discharge teaching
 Sexuality and contraception
 Follow-up
Nursing Management in Postpartum Period: Nursing Interventions #1
 Providing optimal cultural care (see Box 16.3)
 Promoting comfort
o Cold and heat applications
o Topical preparations
o Analgesics
 Assisting with elimination
o Promoting voiding
o Promoting bowel elimination
Nursing Management in Postpartum Period: Nursing Interventions #2
 Promoting activity, rest, and exercise
o Early ambulation
o Rest periods
o Exercise program; recommended exercises; Kegel exercises
 Assisting with self-care measures
 Ensuring safety
 Counseling about sexuality and contraception
Nursing Management in Postpartum Period: Nursing Interventions #3
 Promoting nutrition
o General recommendations (see Box 16.4)
o Needs for the breast-feeding woman
  Supporting choice of newborn feeding method
o Assistance with breast-feeding
o Assistance with bottle feeding
Ensuring Safety During Ambulation
 Check blood pressure first
 Elevate head of bed for a few minutes before ambulating
 Have client sit on side of bed for a few moments first
 Help client stand up and stay with her
 Ambulate alongside client and provide support if needed
 Frequently ask client how her head feels
 Stay close by to assist if she feels lightheaded
Teaching about Breast Care
 Breast assessment: measures to alleviate breast engorgement
o Breast-feeding woman
o Bottle feeding woman (lactation suppression)
Promoting Family Adjustment and Well-Being
 Parental roles
 Sibling roles
 Grandparent roles
Promoting Parental Roles
Teaching about Postpartum Blues
 Transient emotional disturbances
 Characterized by anxiety, irritability, insomnia, crying, loss of appetite, and sadness (King et al., 2015)
 Symptoms usually begin 2 to 4 days after childbirth and resolve by day 8
 Blues typically resolve with restorative sleep
 Postpartum depression and psychosis are more serious and require professional referral
Preparing for Discharge
 Preparing for discharge (criteria)
 Providing immunizations
 Ensuring follow-up care
o Telephone follow-up
o Outpatient follow-up
o Home visit follow-up
 Challenges Facing Families after Discharge
o Lack of role models for breast-feeding and infant care.
o Lack of support from the new mother’s own mother if she did not breast-feed.
o Increased mobility of society, which means that extended family may live far away and cannot help care for the
newborn and support the new family.
o Nonsupportive, overwhelmed, and fatigued partner.
o Feelings of isolation and limited community ties for women who work full-time.
o Shortened hospital stays; parents may be overwhelmed by all the information they are given in the brief hospital
stay.
o Prenatal classes usually focus on the birth itself rather than on skills needed to care for themselves and the
newborn during the postpartum period.
o Limited access to education and support systems for families from diverse cultures.