Nursing care for the mother following birth

1. Post partum changes in the mother

Reproductive system
Uterus- rapid reduction in size and weight, returns to normal in 5-6 weeks. Failure to do so in
subinvolution
Fundus- found umbilical after birth, descend 1 cm per day, shouldnt palpate after day 10, full bladder
prevents descent, massage soft uterus until firm. Nursing Implication: identify need, supine position,
non-dominant hand at symphysis pubis and press downwards, massage with other, once firm, push
towards vagina to expel fluids and keep other hand planted to avoid invertion, document consistency
and location before and after massage, give meds, report if fundus doesnt remain firm.
Afterpains- similar to menstrual cramps, more often with multiparas or overly distended uterus,
breastfeeding due to release of oxytocin which contracts uterus
Lochia- discharge containing tiddue, blood, and lymph, should not have foul odor, check firmness, weigh
pads, 1g=1mL in blood, when mother ambulates, more discharge, should not have large clots, possible
discharge during breastfeeding due to uterus contracting, absence of lochia is abnormal, possible
retained clots or infection. Nursing Implication: assess lochia quantity, type, and characteristics, scant-
excessive, rubra, serosa, alba.
-lochia rubra, red and 3 days afterbirth
-lochia serosa, pink and days 3-10
-lochia alba, clear/white and days 10-21
Cervix- regains muscle tone but never original state
Vagina- stretched greatly during birth, rugae (vaginal folds) disappear, return after 3 weeks, after 6
weeks regains most form, but never original, REEDA (redness, edema, ecchymosis, drainage,
approximation)
Perineum- often edematous, tender and bruised, possible episiotomy, hemorrhoids may worsen during
birth. Nursing Implication: observe edema, bruising, hematoma, REEDA of episiotomy or laceration,
observe hemorrhoids, document.
Breasts- full but soft during first 2-3 days, afterwards becomes firm and lumpy as blood flow increases
and begins milk production, breast engorgement, hard erect and uncomfortable Nursing Implication:
consistency, size, shape and symmetry, red or cracked nipples, do not use soap for washing.
Cardiovascular system
Cardiac output and blood volume- 50% blood increase during pregnancy, tolerates 500mL for vaginal
and 1000mL for caesarean of blood loss, heart pumps more after each contraction, leads to bradycardia,
50-60 bpm for 48 hours after birth, uses diuresis and diaphoresis to rid excess fluid
Coagulation- blood clots higher during pregnancy, higher chance due to varicose veins, caesarean birth,
or delayed ambulation, causes dyspnea and tachycardia
Blood valves- massive fluid change affects amount of hemoglobin and hematocrit, thus making
interpretation difficult, balances within 8 weeks, hematocrit levels lower, while WBC count rise,
balances by day 12
Chills- tremors/shivering thought to be caused by sudden release of pressure on pelvic nerves and
vasomotor response of epinephrine, stops spontaneously within 20 minutes, chills with fever indicate
infection
Orthostatic hypertension- resistance to blood flow in pelvic vessels drop after birth, blood pressure falls
after sitting or standing, dizziness or lightheaded Nursing Implication: vitals q4h for 24 hours,
temperature may rise to 38 degrees C, normal bradycardia, high pulse indicates infection or
hypovolemia, edema of extremities and face, thrombosis of legs.
Urinary system
Kidney returns to normal within a month, decrease of bladder tone during pregnancy causes quick filling
but incomplete emptying, can cause hemorrhaging when full bladder displaces the uterus or UTI Nursing
Implication: bladder distention, first couple voids are measured, minor discomfort expected.
Gastrointestinal system
Increased hunger and thirst, possible constipation due to medications slowing peristalsis, abdominal
muscles stretching, sore and swollen perineum or hemorrhoids Nursing Implication: extra fluids and
fiber, stool softeners or laxatives
Integumentary system
Chloasma (hyperpigmentation, linea nigra) disappears after hormone levels decrease, striae (stretch
marks) dont disappear but fade
Muskuloskeletal system
Abdomen- stretched during pregnancy may appear doughy
Diastasis recti- longitudinal muscles from chest to pubis are separated, returns after 6-8 weeks
Joints- hypermobility remains for 6 weeks, except joints in feet
Exercise- may begin day 1
-abdominal tightening, inhale and exhale while tightening abdomen, hold for 10 seconds
-head lift, while lying on back lift chin to chest and hold for 3 seconds
-pelvic tilt, while lying on back, tilt hips to contract abdomen, hold for 3 seconds
-Kegel exercise, mother tightens perineal muscles, as if to stop flow of urine, then relax, do not
perform these while urinating
Immune system
Rh (D) immune globin- Rh negative mother should receive dose of RhoGAM within 72 hours of birthing a
Rh positive baby by deltoid IM
Rubella immunization- titer performed to determine immunity, titer of 1:8 or greater is immunity,
vaccine given to mother via SC in upper arm after birth, should not get pregnant for 1 month, dont
administer if sensitive to neomycin
2. Emotional changes of the family
A) Mother- hormonal changes, body image and psychological mother figure, taking in, taking hold,
letting go
Post partum blues-confliction of joy and letdown, self limiting
Post partum depression- persistent mood of unhappiness, to be taught as unexpected
Fatigue- women often working through pregnancy, childs care, and return home with 48 hours
to assume household responsibility, lack of rest and time to adapt
B) Father- engrossement (intense interest), parallel behaviour to mother, altered by relationship
with own parents, previous child experiences, and relationship to mother
Adjustment to fatherhood is facilliated by being involved in childs care
4 phases i- expectations and personal intentions
ii- confronting reality and overcoming frustrations
iii- creating his own father role
iv- reaping rewards of fatherhood
C) Siblings- depends on age and developmental level
Toddlers- regression and anger towards mother for new attention on newborn
Preschoolers- look and discuss but hesitant to touch and hold
Older- enjoy helping with care and curious
3. Breast feeding
Main source of nutrition if not using formula. Especially important due to high energy use caused by
brain and body growth of newborn.

Advantages Disadvantages
Improves mother-child relationship Maternal medication can enter breast milk:
antimetabolites, antineoplastics, and
chloramphenicol are unviable
Decrease chance of childhood respiratory
disorders
True galatosemia is contraindicated
Breast milk contains all nutrients TB, HIV, herpes, and certain cancers should not
breastfeed
Easily digested Alcohol and drug users cannot breastfeed
Cannot cause allergies
Natural immunity
Promotes elimination of myconium, rarely
constipated

Mouth development
Convenient and economical
No risk of contamination
Promotes uterus regulation
Improves brain development
Facilitates maternal weight loss

Physiology of lactation
Infectious diseases- only absolute contraindications for breastfeeding are HIV and T-cell lymphotrophic
viruses (1 and 2). Herpes only contraindicated if lesions are on breasts. TB mothers must pump their
milk and not directly feed.
Hormonal stimulation- two major hormones.
-Prolactin, from anterior pituitary gland causes the production of breast milk
-Oxytocin, from posterior pituitary gland causes milk to be delivered from alveoli through the
duct system to the nipple
Feedings that are infrequent or too short reduce the amount of milk produced, but the opposite is also
true. Very little milk is stored between feedings, most produced during feeding, composition changes
slightly from beginning to end
Fore milk- first milk, more watery to quench thirst
Hind milk- later milk, higher fat content, satisfies hunger
Phases of milk production- three phases;
Colostrum- produced at end of pregnancy and first few days after birth, yellowish and filled with
antibiotics, protein, vitamins A and E, and minerals, but less calories, has laxative effect
Transitional milk- around day 7-10, milk matures with less immunoglobins and proteins, but
more lactose, fat, and calories
Mature milk- 2 weeks after birth, bluish color
Assisting mother- ideally infant is nursed soon after birth, focus is not on obtaining nutrients but
promoting bonding, maintaining temperature, and the suckling stimulates oxytocin release to contract
uterus and control bleeding, shouldnt be delayed more than a few hours, Ideally within 2 hours Nursing
Implication: wash hands and nipples, position self, turn infant to mothers breast, stroke cheek with
nipple, mouth should cover entire areola, avoid time restricting, use pin on bra as a reminder, break
suction with finger, feed every 2-3 hours, burp halfway.
Positions- any position should result in chest-chest contact with head and neck in alignment, stomach
preferred up over down, should be held on nipple level
Feeding techniques- breasts should be alternated each feeding
Position of mothers hands- C position, thumb above nipples, fingers below
Latch-on- allow nipple to brush lower lip, make sure areola is well into the mouth, lips should flare
outwards, tongue under nipple
Evaluating intake- successful breast feeding includes
-breast firm before, softer after
-Let-down reflex, tingling sensation with milk dripping from breast when feeding done
-10-15 minutes per breast, 8-10 times daily
-audible swallowing
-infant demands feeding, appears relaxed after
-6-8 wet diapers daily
-several stools daily
Frequency and duration- usually ever 2-3 hours during first week
Weaning- gradual over abrupt, easier with introduction of solid food, eliminate one feeding at a time,
omit daytime first
4. Formula Feeding
Reasons include embarrassment, medications, or illness
Types of formulas- common policy that first drink is water to test GI tract, most formulas are modified
cows milk, alternatives are soy or protein hydrolysate, 3 forms; ready-to-feed, concentrate liquid,
powdered
Preperation- wash hands, one at a time or 24 hours supple
RTF- no dilution, bottles and cans
Concentrate liquid- can, overdilution and underdilution can cause serious illness, usually one
part formula and one art water
Powder- less expensive, # of scoops per serving
Feeding- Formula digested slower than breast milk, use hot water, not microwave to warm milk, but not
required Nursing Implication: wash hands, verify formula, select appropriate nipple, ensure room
temperature, hold infant in cradle position, feed slowly, document
5. Discharge Planning
There are a lot of teachings that need to be explained during the mothers quick stay, she is often
psychologically unprepared
Hygiene- shower daily to account for increased perspiration, continue perineal care until lochia stops, do
not use douches or tampons until the 6-week check up
Sexual intercourse- avoid until episiotomy healed, and lochia flow stops, can lead to infection and
trauma
Diet- high fiber due to constipation risk, do not try to lose weight, continue prenatal vitamins until 6-
week check up
Complications- framework to realize abnormal progress, most common are hemorrhage, infection, and
thrombosis
-fever above 38 C (100.4 F)
-persistent lochia rubra or has foul odor
-bright red bleeding
-prolonged afterpains, pelvic or abdominal pain, or constant backache
-UTI signs
-pain, redness or tender calves
-breast redness or tenderness
-suture line abnormalities
-depression
7. Cesarean Section
Surgical delivery through incisions of abdomen and uterus, roughly 27% of births
Changes in management of second stage labor
-position variation (upright or horizontal)
-epidural and sub arachnoid analgesia to allow ambulation and delivery in squatting position
-oxytocin (Pitocin) augmentation
-spontaneous open glottis pushing when fetus is at +1 station
-use of vacuum-assisted delivery over forceps
-trial of labor before repeat caesarean
-electronic fetal and uterine monitoring
Indications
-abnormal labor
-inability of fetus passing through pelvis (cephalopelvic disproportion)
-maternal gestational hypertension or diabetes mellitus
-active herpes virus
-previous uterine surgery
-prolapsed umbilical cord
-placenta previa or abruption placentae
Contraindications- avoided if fetus is dead, too premature to survive, or maternal abnormal blood
clotting
Risks- anesthesia, respiratory complications, hemorrhage, blood clots, urinary tract injury, delayed
persistalsis, inadvertent preterm birth
Technique- preparation includes lab testing for anemia, blood clotting, CBC, coagulation, and blood
typing, receives IV drug to reduce gastric acid, indwelling Foley catheter to keep bladder empty
Skin incisions are vertical (for large fetus or obese woman) or transverse (heals better)
Uterine incisions include
Low transverse- less likely to rupture, less blood loss, easier to reair
Low vertical- minimal blood loss, larger fetus delivery, more likely to rupture
Classic- rarely used due to more blood loss, and most like to rupture, only option if fetus is in a
transverse lie
Newborn Care
1. Adjustment to extra uterine life
Three phases: 1. Immediate postbirth care
2. Admission to nursery
3. Physical characteristics and nursing assessments of body systems
Thermoregulation- unstable at first, lack of brown fat, sweat glands not fully functional, unable to
shiver, high metabolism can lead to hypoglycemia, use of incubator
Bowel and urinary function- bladder empties itself automatically, excretes myconium
Weighing and measuring- 46-56 cm (19-21 inches) 2.7-4 kg (6-9 lbs.) weight loss of 5% in first days
2. Physical Charactersistics
Nervous system- reflexes
Head lag- head falls back due to inability to maintain it neutrally
Moro- legs draw up and arms spread out, than come in to embrace
Rooting- head turns to whatever touches cheek
Babinski- toes will fan out when bottom of foot stimulated
Tonic neck- head turned to one side with same extremities stretched, while other side is bent
Dancing- prancing of legs when held upright
Head- Molding, conforming of fetal head to size and shape of birth canal. Caput, swelling of scalp tissue.
Cehalohematoma (head blood tumor), collection of blood protrudes from beneath scalp. Fontanelles,
unossified spaces, or soft spots, of the cranium.
Visual stimuli and sensory overload- eyes fixated on points of contrast, map appear cross eyed, too
much stimulation can be caused by the lights and voices of a hospital environment
Hearing- low set ears may indicate congenital abnormalities, check for fetal alcohol syndrome, presence
of amniotic fluid can diminish hearing, but naturally drains, reacts to sudden sounds with rising pulse
and respirations, early discrimination of mothers voice, important for speech development
Respiratory system- first breath expands the collapsed lungs, assisted by removal of mucus in airway,
infants cry should be strong
APGAR- heart rate, respirations, muscle tone, reflexes, color, scores 1-5 at 1 and 5 minutes after birth
Circulatory system- has 300mL of blood volume. First time its blood is not bypassing lungs. Murmurs can
be functional (innocent) or organic (caused by improper heart formation).
Providing warmth- temp falls to 35.5 C, then climbs to 36.6-37.2, strongly influenced by room temp. and
number of blankets, do not use extremities to determine temp. Nursing Implication: place blanket flat
like a diamond with top corner folded down, place newborn with shoulders at top edge, wrap with arms
in, pull right side over and under left, pull bottom up and around body snugly. Acrocyanosis, sluggish
peripheral circulation (blue extremities).
Obtaining TPR- initial temp. taken via rectal, then axilla, taken after pulse and resps, pulse irregular and
raid, 110-160. Blood pressure is low and roughly 80/46. Resps 30-60. Report and abnormal results, noisy
resps, nasal flaring, or chest retraction.
Muskuloskeletal system- soft bones composed mostly of cartilage with minimal calcium. Skeleton is
flexible with elastic joints since the bones are easily molded by pressure, position must be changed
frequently, otherwise head can flatten. Movements are random and uncoordinated, muscle control
develops from head to feet, thus cannot sit up before being able to support head. Check gestational
maturity by the scarf sign (arm across chest, elbow only reaches as far as chin)
Genitourinary system-kidneys function but not fully developed, renal blood flow is 1/3 of an adults.
Decreased ability to concentrate urine and cope with fluid imbalance, important to note first void.
Make genitalia- testes do not descend is call cryptorchidism
Circumcision- surgical removal of foreskin, can cause infection and hemorrhage. Can lead to
possible cancer prevention, fewer UTIs, lower risk of STIs.
Hypospadias- opening of urethra on underside of penis
Female genitalia- may be slightly swollen, pseumentruation may be discharged, cleaned from
urethra to anus
Integumentary system- tissue turgor, hydration of the skin. Tests elasticity, should spring back to place
after pinch. Lanugo, fine hair that disappears after a week. Vernix caseosa, cheese-like substance that
covers skin, made of cells and gland secretions, protects from irritation. Milia, white pin point pimples
around nose and chin, caused by obstructed sebaceous gland, disappears in a few weeks. Epsteins
pearls, lesion on midline hard palate, collection of epithelial cells. Mongolian spots, bluish skin
discoloration, common for African American, aboriginal people, or Mediterranean descent. Usually
around sacral or gluteal areas.
Desquamation, skin peeling, nose , knees, albows and toes, caused by friction of sheets, keep area dry.
Icterus neonatorum- physiological jaundice, yellow skin tinge caused by rapid destruction of excess
RBCs. Plasma levels of bilirubin increase from 1mg/dL to 5-6mg/dL. Use of Ictometer and
Transcutaneous bilirubin measurement (TcB) to assess.
Gastrointestinal system- stools, intestines are an outlet for amniotic fluid during fetal life. Constipation,
hard dry stool passage, should be 6 stools daily, a few days without is not abnormal. Hiccoughs, normal
and spontaneous, burping and warm water may help. Digestion, an immature cardiac sphincter of the
stomach can cause infants to be prone to regurgitation, avoid overfeeding, position on right side after
feeding. Deficient pancreatic enzymes limit fat absorption. Salivary glands does not secrete saliva until
month 2 or 3, drooling before then is a pathological disturbance and should be reported.
Myconium, first stool, mixture amniotic fluid and secretions of intestinal glands, dark
green/black, thick with tarry texture, gradually changes over first week.
Transitional, loose green/yellow with mucus, follows meconium
Vitamins- need extra C and D, breast milks contains enough C if mothers diet is rich with it. D can be
added to the mothers own milk.
3. Preventing Infection
Immunoglobin G (IgG)- crosses placenta to provide passive immunity to infections which the mother
is immune to, rarely lasts longer than 3 months
Immunoglobin M (IgM)- produced by newborn, elevated level indicates serious infection
Immunoglobin A (IgA)- produced after neonatal stage (1month) which is in breastmilk, provides
resistance against respiratory and GI infections
Handwashing- most reliable precaution for anyone. Always wash between different babies, often
wear clean scrub gowns in nursery.
4. Discharge Planning
Teaching
-basic care (bathing, cord care, circumcision care, feeding, elimination)
-safety measures during sleep
-immunizations
-support groups
-return appointments
-telephone number of nursery
-proper car safety
-signs and symptoms of problems
Car seats- seat should be rear facing and tightly secured by the seat belt. Semi reclined in back seat,
emphasize dangers of no or improper use of a car seat.