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Course: Maternity Nursing

Topic: Postnatal Care - Normal Vaginal Delivery

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Module Goals

The learner will be able to:

Define postnatal care
List the physical changes which occur during the postnatal period
Describe the recognition and management of postnatal danger signs
Recognise the puerperal psychiatric disorders
Identify client teaching regarding postnatal care

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What is Postnatal Care?

‘Postnatal care is the individualized care provided to meet the needs of a mother and her baby following childbirth. Although the postnatal period is uncomplicated for most women and babies, care during this period needs to address any variation from expected recovery after birth.’ (National Institute for Health and Care Excellence)

Interchangeably called the postpartum period/puerperium, the most common time frame described as the postnatal period is six weeks after childbirth. However, depending on the needs of the mother and the baby, postnatal care can extend beyond six weeks

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Why Is Postnatal Care Important?

To support mother and baby in transition to post-childbirth physical, psychological and emotional adjustment and adaptation

For prevention and early diagnosis and treatment of complications related to pregnancy and childbirth

Prevent or reduce pregnancy and childbirth-related maternal mortality and morbidities

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Physical Changes During Postnatal Period

General condition soon after delivery:

May experience shivering without change in body temperature
Pulse rate may be slow, normal, or fast, but should not exceed 100 bpm
Blood pressure may vary, but should not exceed 140/90 mmHg
There is an immediate drop in weight of 8 kg

Further weight loss follows involution of uterus and normal diuresis (through perspiration and increased urination)

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Physical Changes During Postnatal Period

Skin:

Increased pigmentation of the face
The abdominal wall and vulva lightens, but the areola may remain darker than pre-pregnancy
With onset of diuresis reduces puffiness and oedema within a few days

Abdominal wall:

Becomes flaccid (loose and wrinkled)
Some separation of the abdominal muscle occurs called diastasis recti
Pregnancy marks (striae gravidarum) eventually fade to a whitish silver color

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Physical Changes During Postnatal Period

Gastrointestinal tract:

Thirst is common, appetite varies, and flatulence may be present
May be constipated,especially in the presence of episiotomy or painful hemorrhoids

Urinary tract:

Retention of urine caused by decreased bladder tone in pregnancy and oedema of the urethra during delivery
Diuresis usually occurs on the second or third day postpartum
Stress incontinence (leaking of urine) common when laughing or coughing improves with time and kegel exercises

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Physical Changes During Postnatal Period

Blood:

Hemoglobin concentration becomes stable around the 4^th day
Platelet count rises, and become stickier between the 4^th and 10^th day
Changes in clotting (coagulation) factors may cause thromboembolism

Breasts: Marked changes with the production of milk
Genital Tract:

Vulva and vagina: swelling and congestion post-delivery rapidly disappear, small tears/episiotomy usually heal without treatment

some degree of vaginal prolapse (cystocele/rectocele) may occur

Cervix: circular external os of nullipara becomes slit-like; os closes by 7th day

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Physical Changes During Postnatal Period

Uterus:

Involution occurs (return of uterus to its pre pregnant state)
Decreases in height by about a centimeter a day below umbilicus
At two weeks, the fundus of the uterus should no longer be palpable above symphysis pubis. After 6 weeks it has decreased to the size slightly larger than the nulliparous uterus
Vaginal bleeding decreases with time and ceases by 6 weeks postpartum
Lochia changes from red to straw colored, is present for 24 days, and has a characteristic, earthy,non-offensive odor

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Glossary:
Lochia: The decidua of uterus necrosis (dies) due to ischemia and is shed per vagina called lochia.
Glossary:
Lochia: The decidua of uterus necrosis (dies) due to ischemia and is shed per vagina called lochia. ".

These are the normal stages of lochia.

1. Lochia rubra — first 2 to 4 days after delivery

• the lochia is mostly blood

• the blood looks bright red

• the blood flow can be heavy to moderate

• there may be small blood clots

2. Lochia serosa — starts about day 4 and lasts until day 10

• the color changes to pink or pinkish-brown

• the flow is much less

• blood clots or bright red blood during this time may be signs of a problem.

3. Lochia alba — from about day 10 until day 21

• the color is light yellow to a cream color

• the flow has almost stopped and does not smell

• the presence of clots, a bad smell, or bright red blood may be signs of a problem.

The progression from lochia rubra to lochia serosa to lochia alba should not reverse. The color should always turn from red to pink to white as the amount of discharge gets less and less. If you see a red flow after the flow has turned pink or white, call your doctor right away.

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Routine Postnatal Care at Healthcare Facilities before Discharge

Mother and baby must have a companion all the times

Monitor vital signs
Monitor Bleeding
Assist the mother to urinate within 6 hrs
Provide nutrition and promote rest
Promote Maternal attachment
Provide postnatal patient education

Mother and her companion should be counseled about warning signs and what to do in the event of an emergency

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Vital Signs

Assess and record blood pressure (BP), pulse rate, respiratory rate, temperature

WHO (2015) recommends monitoring in first 2, 3 and 4 hours, then every other 4 hours until discharged. Document all assessments

Monitor for signs of shock: systolic pressure < 90 mmHg, weak, rapid thready pulse rate, high respiratory rate
Immediately summon help if signs of shock are present
Monitor for fever ( > 38^oC)

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Monitor Bleeding

Estimate and record blood loss by checking the mother’s vaginal pad
Assess fundus for firmness
Assess perineum for healing
Inform mother about normal/abnormal bleeding and perineal care
Monitor voiding

Postpartum hemorrhage (PPH) is life threatening. Frequent assessment in the initial 24 hours is essential.

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Close monitoring of postpartum uterine tone, vaginal bleeding, pulse, and blood pressure is recommended for prompt identification of and rapid response to uterine atony, excessive bleeding, and haemodynamic changes

According to WHO (2017) - Managing Complications in Pregnancy and Childbirth’:
PPH is commonly defined as blood loss over 500 ml within 24 hours after birth
Severe PPH is defined as blood loss of 1000 mL or more in 24 hours
Signs of shock is present

o Fast, weak pulse (110 beats per minute or more)

o low blood pressure ( systolic less than 90 mmHg)

o Other symptoms/signs:

pallor (especially of the inner eyelid, palms, or around the mouth)
sweating or cold, clammy skin
rapid breathing (rate of 30 breaths/minutes or more)
anxiousness, confusion, or unconsciousness
Scanty urine output (less than 30 mL per hour)

According to WHO (2017) Managing Complications in Pregnancy and Childbirth’ and WHO (2015) Integrated management of pregnancy and childbirth:

Abnormal postpartum bleeding are:

Increased vaginal bleeding within the first 24 hours after childbirth (primary PPH)
Increased vaginal bleeding following the first 24 hours after childbirth (secondary PPH)
Continuous slow bleeding or sudden bleeding is an emergency, needs early and aggressive intervention
More than 1 pad soaked in 5 minutes
Uterus is not hard and not round

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What Would the Nurse Do?

Gita delivered her baby vaginally at 1200 hrs. An hour later, she was moved from the delivery ward to the postnatal care unit.

how can the nurse help Gita play a role in preventing postpartum hemorrhage?

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Voiding after Delivery

For RH Negative Mothers

Encourage the mother to urinate soon after delivery
A full bladder prevents the uterus from contracting effectively and causes increased bleeding
If the mother cannot urinate within 4 -6 hours, catheterization of the bladder is indicated

Rh negative mothers will receive one dose of Rh immune-globulin given IM within 72 hours after childbirth to prevent RH used to prevent RH immunization, a condition in which an individual with RH-negative blood develops antibodies after exposure to RH-positive blood

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Patient Education/Counselling

Postpartum care and hygiene
Nutrition and breastfeeding
Substance abuse
Physical exercise and activities
Birth spacing and family planning
Immunizations
HIV protection
Infant care

Where appropriate, it is important to involve family members in the counseling session, so they are informed and accountable for assisting in mother and baby care.

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Postpartum Hygiene

Pelvic rest-avoid sexual intercourse until the perineal wound heals

do not to insert anything into the vagina (tampons, douche etc.)

Prevention of infection- (for mother and baby)

Wash hands before handling baby
Wash perineum daily and after fecal excretion
Clean perineum from front to back (wiping back and away from the vagina)
Change perineal pads every 4 to 6 hours, or more frequently if needed
Wash used reusable pads or dispose of them safely
Bathe the body daily

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Postnatal Nutrition

No special diet is necessary as long as the mother eats a healthy diet
A healthy diet includes balanced combinations of a variety of fruits and vegetables, starchy foods (whole grain bread, pasta, rice, potato), plenty of fibre, and proteins
Two portions of fish a week is recommended, including some oily fish
Non-dairy sources of calcium suitable for vegans include tofu, brown bread pulses, and dried fruit
Drinking plenty of fluids, mineral water and 100% fruit juice
Restrict caffeine intake to less than 200 mg a day
If anemia present, iron supplementation alone or in combination with folic acid is recommended during the 6-12 weeks postnatal period

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Refer to slide deck ‘Nutrition during pregnancy and lactation’ of this course for further information.

Refer to slide deck ‘Breastfeeding’ for information on breastfeeding postpartum.

WHO recommendations for Iron with or without folic acid supplementation in women (https://www.who.int/elena/titles/full_recommendations/ifa_supplementation/en/):

Where gestational anemia is a public health concern, daily oral elemental iron 30 mg - 60 mg, with or without folic acid 0.4 mg (400 µg) may be provided to postpartum mothers 6-12 weeks following delivery for reducing the risk of anemia

Determine if there birth rituals about foods {hot or cold foods are restricted in some cultures during pregnancy and postpartum.
According to the NHS UK website on ‘Breastfeeding and nutrition’ :

Caffeine inhibits the absorption of iron ad may cause sleeplessness in the mother and infant

Caffeine amount

· 1 mug of filter coffee: 140mg

· 1 mug of instant coffee: 100mg

· 1 250ml can of energy drink: 80mg (larger cans may contain up to 160mg caffeine)

· 1 mug of tea: 75mg

· 1 50g plain chocolate bar: up to 50mg

· 1 cola drink (354mls): 40mg

Try decaffeinated tea and coffee, herbal teas. Avoid energy drinks, which can be very high in caffeine.

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Substance Abuse

Advise the woman to continue abstinence from tobacco

She should not take any medications for tobacco cessation

Talk to family members about second-hand smoke exposure

The woman should consult the healthcare provider before taking any medications if she are breastfeeding

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Safe Physical Activities and Teaching Points

Early ambulation as convenient for mother, is good for blood circulation, wound healing, sleep, and rest
Perform Kegel exercises regularly to strengthen pelvic floor muscles. May start soon after childbirth
Start light walking for exercise when feeling comfortable

Swimming is recommended only after the approval of the physician at six weeks postnatal checkup

Do not engage in heavy lifting activities until the physician’s approval
Use their leg muscles, instead of abdomen or back muscles while lifting
Maintain proper posture while sitting or standing as muscles are vulnerable post-childbirth

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Where possible, counsel family members along with the mother.
According to NHS UK website on ‘Your post-pregnancy body’(https://www.nhs.uk/conditions/pregnancy-and-baby/your-body-after-childbirth/):· Regular pelvic floor exercises and deep stomach muscle exercises can help to reduce the size of the separation between stomach muscles.

· Pelvic floor muscle exercises:

o Strengthen muscles around the bladder, vagina, and bottom

o Can help stop incontinence, improve prolapse, and make sex better too

o Can be done lying down, sitting, or standing, anywhere and anytime

o Squeeze and draw in the bottom as if holding in wind.

o Squeeze around the vagina and bladder (urethra) as if stopping the flow of urine

o Long squeezes- hold for as long as you can, but no longer than 10 seconds, then relax

o short squeezes- quickly squeeze the muscles and then let them go immediately. Do this until muscles get tired

· Aim to build up to 10 repeats of each exercise, at least 3 times a day

· Important to keep breathing normally while doing these exercises

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Birth Spacing And Family Planning

If appropriate, ask the woman if she would like her partner or another family member to be included in the counseling session
Explain that if she has sex and is not exclusively breastfeeding, she can become pregnant as soon as three weeks after delivery. Therefore it is important to start thinking early about the family planning method they will use
Make arrangements for the woman to see a family planning counselor, or counsel her directly if you are trained and competent to do so
Her partner can decide to have a vasectomy (male sterilization) at any time

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Counsel on Birth Spacing and Family Planning

WHO (2015). Pg- D27

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Counsel on Birth Spacing and Family Planning

For HIV infected women:

Inform her that future pregnancies can have significant health risks for her and her baby; That includes transmission of HIV to the baby (during pregnancy, delivery, or breastfeeding), miscarriage, preterm labour, stillbirth, low birth weight, ectopic pregnancy, and other complications.
Advise waiting at least two years before trying to become pregnant again for the women’s and the baby’s health.
Discuss her options for preventing both pregnancy and infection with other sexually transmitted infections or HIV reinfection.
Condoms may be the best option for the woman with HIV, counsel the woman on safer sex, including the use of condoms.

WHO (2015). Pg- G4

Contact info: info@nursesinternational.org

Counsel on safer sex including the use of condoms for dual protection from sexually transmitted infection (STI) or HIV and pregnancy. Promote their use, especially if at risk for STI or HIV.

According to WHO(2015)Pregnancy, childbirth, postpartum, and newborn care: A guide for essential practice (3^rd ed.), pg-G4:
If the woman thinks that her partner will not use condoms, she may wish to use an additional method for pregnancy protection. However, not all methods are appropriate for the HIV infected woman:

Given the woman’s HIV status, she may not choose to breastfeed and the lactational amenorrhoea method (LAM) may not be suitable.
Spermicides are not recommended for HIV-infected women.
Intrauterine device (IUD) use is not recommended for women with AIDS who are not on antiretroviral (ART).
Due to changes in the menstrual cycle and elevated temperatures fertility awareness methods may be difficult if the woman is infected or is on treatment for HIV infections.
If the woman is taking pills for tuberculosis (rifampin) she usually cannot use contraceptive pills, monthly injectable, or implants.

The family planning counselor will provide more information.

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Case study:

After normal delivery, Alita was moved to the postnatal care unit. Alita was hungry and wanted to eat a whole meal. The nurse informed her family that it was completely fine for the mother to eat whatever she wanted.

Following the meal, Alita got up to walk around the unit, but her mother-in-law told her that she needed to remain in bed for several days after having a baby.

Did the nurse give the right advice regarding eating a whole meal soon after childbirth?

How should the nurse counsel mother and family regarding diet and nutrition?

How should the nurse counsel mother and family regarding physical activities after childbirth?

Contact info: info@nursesinternational.org

Did the nurse give the right advice regarding eating the whole meal soon after childbirth?

Yes. It is completely fine for mothers to eat the whole meal if she desires, soon after childbirth.

What should the nurse counsel mother and family regarding diet and nutrition?

The nurse counsel mother/family members to eat a healthy diet during the postnatal period.

A healthy diet contains balance in the mix of starchy foods, fruits/vegetables, proteins, and fibers.
Drink plenty of water, 100% fruit juice is fine but not more than 150 ml per day.
Avoid energy drinks like soda that do not have any nutrition.
Limit caffeine to 200 mg per day.

What should the nurse counsel mother and family regarding physical activities after childbirth?

The nurse should inform mother/family members that early ambulation is good for the overall health of the mother.

The nurse should provide patient education on:

How to do kegel exercises, and that it can be done soon after the childbirth if the mother feels comfortable
walking is a good start, and gradually increasing physical activities that the mother is comfortable doing.
Avoid heaving lifting activities
Use leg muscles instead of wait or back while lifting.
Maintaining proper posture to prevent back injuries.
Get a physician's advice first before starting any exercises

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HIV Protection Education

Correct and consistent use of condoms during every sexual act.
How to use condoms and where to get them.
Choose sexual activities that do not allow semen, fluid from the vagina, or blood to enter the mouth, anus, or vagina of the partner.
Reduce the number of sexual partners:

If HIV negative, explain the importance of remaining negative during pregnancy and breastfeeding. The risk of infecting the baby is higher when a woman is newly infected.
If HIV infected, explain to her that condom use during every sexual act will protect her and her baby from other sexually transmitted infections, or re-infection with another HIV strain, condoms will prevent the transmission of HIV infection to her partner.

WHO (2015). Pg- G2

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Immunizations

For the baby, provide BCG, OPV-O, Hepatitis B vaccine birth dose, within 24 hours after birth, preferably before discharge
For an un-immunized newborn first seen 1-4 weeks of age, give BCG only
Document immunizations administration in child record
Advise the mother to carry the immunization card when she takes her baby to health care centers for other immunizations
Advise when to return for the next immunization
Know the national/local regulations/policies/guidelines regarding immunizations for the babies and counsel mother/family accordingly

Partial source: WHO (2015) - Pg. K13

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Maternal Attachment

If the mother and baby both are healthy, then the baby should be given to the mother soon after birth
Inform mothers about the condition of the baby and answer her queries about the baby’s health
Privacy to talk, laugh, cry, or celebrate in some way promotes bonding between mother and baby
Assist the mother in self and baby care, so she is not overwhelmed with the task
Praise mother for giving care to her baby
If the mother is not interested in her baby, talking to her about her feelings might help

Contact info: info@nursesinternational.org

According to Hesperian Health Guides ‘A Book for Midwives’, Chapter 14:

· Some mothers do not feel good about their new babies. Help her explore her feelings.

o mother may be very tired

o she may be ill or bleeding

o She may not have wanted the baby, or

o She might be worried that she cannot take care of the baby

o She may be very depressed

What to do

· Check mother for signs of blood loss or infection

· you might talk to the mother about her feelings, or you may feel it is better to leave her alone and to watch and wait

· if the mother was depressed after a past birth, talk to the family about giving her extra attention and support in the next weeks. Advise them on he symptoms of the baby blues, depression and signs of serious depression.

· The ‘baby blues’ pass in time, but feelings of sadness, but persistent feelings should be reported to the health care provider.

· Recommend that someone in the family helps the mother with baby care and household responsibilities.

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Psychological and Emotional Support

At each postnatal contact, women should be asked about:

Emotional well-being and family and social support
Coping strategies in dealing with day-to-day matters
Both mother and their families should be encouraged to report changes in mood, emotional state, or behaviour that are outside the woman’s normal pattern

Provide patient and family education regarding:

Identifying signs of postnatal depression/psychosis
Immediately seek medical care for symptoms of depression/psychosis
Never leave mother and baby alone if she suffers severe depression or psychosis; someone must take care of the baby
Mother’s can recover with early identification and treatment

Contact info: info@nursesinternational.org

According to the WHO(2017)Managing complications in pregnancy and childbirth:

· Postpartum emotional distress is fairly common after pregnancy

· Mild postpartum blues develop between two days and resolve within two weeks

· Postpartum depression occurs in early postpartum weeks or months and persists for a year

· Postpartum psychosis pose a threat to the life of mother and baby

Mild postpartum blues symptoms:

· sadness

· tearfulness

· irritability

· anxiety

· insomnia

· decreased concentration

At increased risk of developing postpartum minor or major depression

Postpartum Depression symptoms:

· low energy and motivational levels

· feelings of helplessness and hopelessness,

· loss of libido, and appetite

· sleep disturbances

· obsessional thinking

· fear of harming baby or self

· suicidal thoughts

· depersonalization

· Headache, asthma, backache, vaginal discharge, and abdominal pain may be reported.

Prognosis is good with early diagnosis and treatment.

More than two thirds of women recover within a year.

Postpartum Psychosis symptoms:

· Delusions

· Hallucinations

· Sleep disturbances

· Obsessive thoughts about the baby

· Severe depression

· Anxiety

· Despair

· Suicidal or infanticidal impulses

Women who have bipolar disorders or schizoaffective disorder have a higher risk of developing postpartum psychosis.

About half of women experiencing postpartum psychosis has a history of mental illness.

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Psychological and Emotional Support

Treatment of depression or psychosis may need antidepressants/ antipsychotic medications along with family/social support
These medications must carefully take into consideration the breastfeeding status of the mother
Counsel family to provide ongoing practical support:

Listen to the woman and provide encouragement
Structured physical activity, relaxation, and problem-solving, can be integrated into the daily routine
Create an environment such that the mother exercises regularly, gets rest, sleep and eats a healthy diet
Allow her time to do things she enjoys

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Patient Education Regarding Danger Symptoms/Signs

Patient/family education on danger symptoms/signs must be provided before discharge

Fever
Increasing pain or swelling of episiotomy or sutured laceration
Breastfeeding concerns, engorgement and fever
Excessive or offensive lochia
Recurrence /increase of vaginal bleeding
Depressed mood or other symptoms of postnatal depression

Patient/family must be advised to seek medical care as soon as possible if danger symptoms/signs present.

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Patient Education Regarding Danger Symptoms/Signs

WHO (2015)- Pg. D28

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Before Discharge

Ensure mother and baby are in sound health
Ensure all the necessary patient teaching/counseling has been done
Discuss and decide together with mother/family:

How to prepare for an emergency in postpartum
Routine Postnatal Contacts
Arrangements for follow-up postpartum visits

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Routine Postnatal Check-up

WHO (2015 Pregnancy, childbirth, postpartum and newborn care: A guide for essential practice (3^rd ed.), recommends following routine postnatal visits:

First contact: within 24 hours after childbirth

Second contact: on day 3 (48-72 hrs)

Third contact: between day 7 and 14 after birth

Final contact: at six weeks after birth

A postnatal check-up can continue the past six weeks depending on needs of the mother and baby

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Routine Postnatal Check-up Activities

Inquire about general well-being
Inquire and assess:

Bowel and urinary function, urinary incontinence
Healing of perineal wound
Breast pain, uterine tenderness, perineal pain

Assess breastfeeding progress
Ask about emotional well-being (as mentioned in previous slides)
Allow the mother to share her concerns and questions and address them
If any warning signs/danger symptoms/signs observed, immediately seek medical care

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Case study:

Rita had normal uncomplicated vaginal delivery at the birthing center. After 24 hours postpartum she was getting ready to get discharged.

What should the nurse do?

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Cultural Considerations

Cultural practices that do not harm the mother and the baby should not be discouraged

Healthy foods that are deemed culturally harmful to the mother in the postpartum should be discussed to determine how to make them acceptable (adding hot spice to ‘cold” foods etc.)

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Reference:

Bettercare (n.d.). Maternal Care/12. The puerperium. Retrieved from: https://bettercare.co.za/learn/maternal-care/text/12.html#hiv-positive-mothers

KidsHealth.org (October 2018). Rh Incompatibility During Pregnancy.Retrieved from: https://kidshealth.org/en/parents/rh.html?ref=search

National Institute for Health and Care Excellence (July 2013). Postnatal Care. Retrieved from: https://www.nice.org.uk/guidance/qs37/chapter/Introduction

NHS UK (December 2018). Breastfeeding and diet. Retrieved from: https://www.nhs.uk/conditions/pregnancy-and-baby/breastfeeding-diet/

NHS UK (December 2018). Overview- Postnatal depression. Retrieved from: https://www.nhs.uk/conditions/post-natal-depression /

Contact info: info@nursesinternational.org

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Reference:

NHS UK (October 2019). Your post-pregnancy body. Retrieved from: https://www.nhs.uk/conditions/pregnancy-and-baby/your-body-after-childbirth/

WHO (2013). WHO recommendations on Postnatal care of the mother and newborn. Retrieved from: https://apps.who.int/iris/handle/10665/97603

WHO (2015). Pregnancy, childbirth, postpartum and newborn care: A guide for essential practice (3^rd ed.) Switzerland, Geneva: WHO Press. https://apps.who.int/iris/handle/10665/249580

WHO (2017).Managing complications in pregnancy and childbirth: a guide for midwives and doctors (2nd ed). Licence: CC BY-NC-SA 3.0 IGO. Retrieved from: https://apps.who.int/iris/handle/10665/255760

Contact info: info@nursesinternational.org

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