Postpartum assessment 

✨The fourth stage of labor - This recovery period starts with delivery of the placenta and includes at least the first 2 hr after birth. It is also at  during this stage, parent-newborn bonding should begins to occur.

🕹️ The main goal during the immediate postpartum period is to prevent postpartum hemorrhage. Other goals include:

• Assisting in client recovery with identification of the deviations from the expected recovery process.
• Provision of comfort measures and pharmacological pain relief
• Client education about newborn and self-care

• Provision of baby-friendly activities to promote infant/ family bonding.

  🔷Postpartum assessment immediately following delivery includes:

  Monitoring of vital signs.

  Assessment of uterine firmness & its location in relation to umbilicus.

  Assessment of uterine position in relation to the midline of the abdomen.

  Amount of vaginal bleeding.

  ✨Thus, immediately after delivery the assessment of the uterus, the fundus should be firm and midline.

• 

• Fundus not midline & boggy=PPH

  ✍️A boggy uterus- start fundal massage.

  ✍️If the fundus is off to one side or above the umbilicus ; assess for bladder distention and empty the bladder.

  Note:  The  American Academy of Pediatrics and American Congress of Obstetricians and Gynecologists recommends that blood pressure and pulse be assessed at least every 15 minutes  for the first 2 hours after birth. Temperature should be assessed every 4 hourly for the first 8 hours after birth and then at least every 8 hourly.

   

  Focused Postpartum Physical Assessment

  This  is  essential in identification of early complications and ensuring the well-being of both mother and newborn. The “BUBBLE-E” approach provides a systemic framework for evaluating key physiological changes after delivery, enabling timely interventions and promoting optimal recovery.

  🔷B- Breats 

• Assess for soft vs. firm/engorged, symmetry, and warmth/redness (infection). Check nipples for cracks or bleeding and ensure colostrum/milk flow is present. Ask about pain or tenderness.

  🔷U-Uterus

• -Assess for fundal height, uterine placement and consistency.

  🔷B- Bowel and GI function.

  🔷B- Bladder function

   🔷L-Lochia

• Assess for color, odor, consistency and amount. Educate the mother that they should not be saturating a perineal pad on less than one hour, and if that happenes, an intervention is necessary. The first intervention is fundal massage. 

• Then assess for bladder distention with emptying the bladder if needed. 📍If the patient is able to urinate independently, they should do so, if not they should be put on straight catheter.

  Note: Unsuccessful in  the first two interventions( Fundal massage & Emptying of the bladder)- move to pharmacological treatment.

  🔷E-Episiotomy

• The key parameters to assess after episiotomy include; edema, ecchymosis and approximation.

🔖Uterus

✨The main physical change of the uterus include- involution.  Involutions occurs with contractions of the uterine smooth muscle, whereby the uterus returns to its pre-pregnant state.

✨The uterus also rapidly decreases in size from approximately 1,000g at the end of the third stage of labor to 60-80g at 6 weeks postpartum with fundal height steadily descending into the pelvis approximately one finger-breadth(1cm) per day.

✨End of the third stage of labor, the uterus should be palpable at the midline and 2cm below the umbilicus.

✨1 hour after delivery, the fundus should rise to the level of the umbilicus. Every 24 hours, the fundus should descend approximately 1 to 2 cm. Thus, it should be halfway between the symphysis pubis and the umbilicus by the sixth day postpartum.

✨After approximately 2 weeks , the uterus should lie within the true pelvis and should not be palpable.

♦️Lochia

✍️Lochia is post-birth uterine discharge that contains blood, mucus and uterine tissue. 

✍️The amount of lochia is similar to a heavy menstrual period for about 2 hour after delivery, then decreases gradually at consistent rate. Small clots are common during this period.

✨Three stages of lochia:

• Lochia rubra- dark red color, bloody consistency, fleshy odor, can contain small clots, transient flow that increases during breastfeeding and upon rising. Lasts 1 to 3 days after delivery.
• Lochia serosa- it is pinkish brown in color with serosanguineous consistency. Contains small clots and leukocytes. It lasts from approximately day 4 to day 10 after delivery.

• Lochia alba- is  yellowish-white creamy color, fleshy odor,containing mucus and leukocytes. Lasts from approximately day 10 upto 8 weeks postpartum.

  Immunizations

  ✔️Rubella-a client who is nonimmune to rubella or has a negative or low titer is administered a subcutaneous injection of rubella vaccine or measles, mumps and rubella(MMR) vaccine during the postpartum period to protect as a subsequent fetus from malformations. 

  N/B: The client should not get pregnant for 1 month following the immunization.

  ✔️Rh- All Rh-negative clients who have newborns who are Rh-positive must be given Rho(D) immune globulin administered IM within 72 hours of the newborn being born to suppress Rh antibody formation in the mother for 1 month following immunization.

  ✔️ Varicella- if the client has no immunity, varicella vaccine is administered before  discharge. 

  N/B: The client should not get pregnant for 1 month following the immunization.

  ✔️Tetanus-diphtheria-acellular pertussis vaccine-recommended for clients who have not previously received it. It is recommended for people who are going to be around the baby frequently  if they have not received the vaccine previously. Administered prior to discharge or soon as possible in the postpartum period.

  Psychosocial Assessment.

  ✨During the postpartum period, a client can experience many different emotions due to hormonal changes. Monitor for conditions such as postpartum blues and depression during the postpartum period.

  ✔️Allow verbalization of the feelings

  ✔️Assess emotional status

  ✔️Observe for bonding with infant-assess for inhibition of parental attachment.

  ✔️Monitor for manifestations of postpartum blue or depression:

🎯Decreased appetite

🎯Difficulty sleeping

🎯Decreased interactions with others

🎯Lack of communication

Baby-Friendly Care

💎Psychosocial & Maternal Adaptation

✨Psychosocial adaptation and maternal adjustment begin during pregnancy as the mother goes through commitment, attachment, and preparation for the birth of the newborn.

✨During the first 2 to 6 weeks after birth, the client goes through a period of acquaintance with the newborn, as well as physical restoration. During this time the client also focuses on competently caring for the newborn.

✨Finally, the act of achieving maternal identity is accomplished around 4 months following birth. Note that, these stages can overlap, and are variable based on maternal, infant, and the environmental factors.

💎Phases of maternal Role Attainment.

✨Dependent: taking-in phase

-This is the first that lasts between 24 to 48 hr.

-Focus on meeting personal needs.

-The mother rely on others for assistance.

-Mother is excited, talkative.

-Need to review birth experience with others.

✨Dependent-independent: taking-hold phase

• Begins on day 2 or 3.
• Lasts 10 days to several weeks.
• Focus on baby care and improving caregiving competenc.
• Want to take charge but need acceptance from others.
• Want to learn and practice.
• Dealing with physical and emotional discomforts, can experience “baby blues”

✨Interdependent: letting-go phase

-Focus on family as a unit.

-Resumption of role (intimate partner, individual).

📍Behaviors that impair & indicate lack of parent-infant bonding/inhibition of parental attachment.

✔️Apathy when the infant cries.

✔️Disgust when the infant voids, stools, or spits up.

✔️Expresses disappointment in the infant.

✔️Turns away from the infant.

✔️Does not seek close physical proximity to the infant.

✔️Does not talk about the infant’s unique features.

✔️Handles the infant roughly.

✔️Ignores the infant entirely.

✔️Does not include the infant in the family context.

✔️Perceives infant behavior as uncooperative or spoiled.

Client Education & Discharge Teaching

             💎Discharge Teaching

✨Discharge teaching is an important aspect of postpartum care. Thus,discharge planning should be initiated at admission with time spent during the hospitalization on providing client education regarding postpartum self-care.

✨It is important for a client to be able to perform self-care and recognize effects that suggest possible complications prior to discharge.

✨Teach the client to monitor for potential signs of complications including infection (fever, redness, swelling, discharge or unrelievable pain at the incision, dysuria or cloudy urine, and vaginal discharge with a foul odor).

✨Encourage the client to continue to take prenatal vitamins.

✨A nurse should use a variety of teaching strategies to promote learning. Return demonstrations are important to ensure that adequate learning has taken place.

              💎Postpartum Perineal Care Teaching

-Perform hand hygiene before and after voiding.

-Cleanse the perineal area from front to back with warm water after each voiding and bowel movement.

-Blot perineal area from front to back

-Remove and apply perineal pads from front to back.

-During the first 24 hr, ice packs and cool water sitz baths are used to promote comfort.

-After 24 hr, the use of heat, such as a warm sitz bath, can be used to promote comfort.

-Wash the perineal area using a squeeze bottle of warm water after each voiding.

         💎Postpartum Breast Care

✍️Clients who plan to breastfeed, the teaching should:

💖Emphasize the importance of hand hygiene prior to breastfeeding to prevent infection.

💖Wear a well‑fitting, nonbinding bra if breast support is needed.

💖Allow the infant to nurse on demand, which would be about 8 to 12 times in 24-hr period. Allow the infant to feed until the breast softens. Offer the second breast to the infant before completing the feeding, and start each feeding with a different breast.

💖To relieve breast engorgement, take a warm shower or apply warm compresses before breastfeeding to promote letdown and milk flow. Encourage frequent breastfeeding, around every 2 hours. Empty each breast completely at feedings, using a pump if needed after the infant has finished feeding. Apply cool compresses after feedings.

💖Apply breast creams as prescribed and wear breast shells in the bra to soften the nipples if they are irritated and cracked.

💖Sore nipples, apply a small amount of breast milk to the nipple and allow it to air dry after breastfeeding. Start breastfeeding with the nipple that is less sore. Change the infant’s position on the nipples.

💖Drink adequate fluids to satisfy the thirst.

💖Time opioid pain medications around breast feedings so they have minimal effect on newborn.

🕹️Check with doctor before taking over the counter medications or herbal remedies.

✍️Clients who do not plan to breastfeed

Suppression of lactation is necessary for clients who are not breastfeeding, thus these clients should:

✔️Wear a well‑fitting, supportive bra continuously for the first 72 hr.

✔️Avoid breast stimulation and running warm water over the breasts for prolonged periods until no longer lactating.

🎯 Breast engorgement, which can occur on the third or fifth postpartum day, apply cold compresses 15 min on and 45 min off. Fresh, cold cabbage leaves can be placed inside the bra. Mild analgesics or anti‑inflammatory medication can be taken for pain and discomfort of breast engorgement.

           💎Sexual Activity

✍️Clients can safely resume sexual intercourse by the fourth week after birth, when bleeding has stopped and perineum has healed, after their first postpartum visit with their OBGYN.

✍️Over-the-counter lubricants might be needed during the first 6 weeks to 6 months.

✍️Physiological reactions to sexual activity can be slower and less intense for the first 3 months following birth.