High Risk Post Partum Continuing Education

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Definition

The postpartum period begins at the time of delivery of the infant and ends approximately 6 to 8 weeks after that time, once most of the woman's body systems have returned to their pre-pregnancy state.

Physiologic Changes

The first change that occurs after delivery is uterine involution. After the placenta is delivered, the uterus returns to a non-pregnant shape and condition. The uterus contracts, and the vessels at the placental site thrombose. These steps help prevent postpartum hemorrhage (UpToDate, 2019). Breastfeeding can help to cause the uterus to contract. This process may cause pain for the new mom. Bleeding will occur after delivery. This blood is called lochia. Lochia rubra is bright red to red-brown and can occur up to a few days after delivery, when it then turns to lochia serosa (pinkish brown and thinner), then turns white or yellow, which can last up to 6 weeks. Reproductive hormones will gradually return to normal. Return of menstruation typically ranges from 45 to 64 days postpartum, and the mean time to ovulation ranges from 45 to 94 days but can occur as early as 25 days postpartum, meaning that the woman can get pregnant at this time. Approximately 40 percent of exclusively breastfeeding women will remain amenorrhoeic at six months postpartum (UpToDate, 2019).

Breast changes occur in the postpartum period. Lactation will begin. Women who are not breastfeeding should be taught to wear a tight bra and avoid breast stimulation. There are changes to the woman's heart. Cardiac output and stroke volume increase after delivery but will gradually decrease in cardiac output from 7.42 L/min at 38 weeks of gestation to 4.96 L/min at 24 weeks postpartum. As early as two weeks postpartum, there are reductions in left ventricular size and contractibility compared to term pregnancies.

The woman's hematologic state returns to baseline 6 to 12 weeks after delivery, but she remains at risk for thromboembolic events for a few weeks after delivery (UpToDate, 2019). Weight loss is normal and may increase with breastfeeding. Hair loss and changes in the skin may result as hormones change.

Postpartum Assessments

Once a woman delivers, she should have her blood pressure (BP) and pulse monitored every 15 minutes for 2 hours, and her temperature monitored every 4 hours for the first 8 hours. All vital signs should then be monitored at least every 8 hours while the woman is in the hospital (AAP, 2017). The woman should also assess her fundus to check for uterine tone and monitor her lochia. Uterine atony is the leading cause of postpartum hemorrhage. Women will likely have hemoglobin and hematocrit levels checked the day after delivery. The woman should always be assessed for signs of anemia, such as dizziness, pale color, lightheadedness, low blood pressure, and elevated heart rate. The woman will need to have her perineum inspected to look for signs of infection or a hematoma. A hematoma is a blood collection under the skin that can be painful. A large amount of blood can be collected in a hematoma, so a provider must be notified immediately.

Venous thromboembolism (VTE) is more common in postpartum women, so these women should be assessed for VTE. Any signs or symptoms such as calf redness or tenderness should be reported to the provider. Women with any cardiac or hypertensive disorders will also need specialized monitoring, which could include cardiac monitoring if necessary. These women may need an increased frequency of vital signs as ordered by the provider. They may also need continuous pulse oximetry monitoring as ordered. Women should also be assessed for any signs of infection in the perineum, episiotomy or laceration site, or abdominal incision site. Signs could include pain, redness, swelling, tenderness, discharge, or fever. Women in the postpartum period also need their bladder assessed to ensure they are frequently voiding and without difficulty.

All women in the postpartum period should undergo depression screening while still in the hospital. The Edinburgh scale is the most commonly used tool, but any validated tool is acceptable. It is important to teach women about postpartum mood disorders and that this is not something they should be embarrassed about and must speak up about (ACOG, 2018).

Needs of the Postpartum Woman

The most important need for a healthy postpartum woman is education. Women and their partners have expressed their desire to learn competence in caring for their babies (Gaboury et al., 2017). Newborn care is the major education point, especially for first-time mothers. These new moms need reassurance that they can care for their babies. This education must include basic newborn care such as bathing and circumcision care to more complex education such as when to call the doctor. Education should also include safe sleep practices and shaken baby syndrome. There is much information, and it can be overwhelming. Giving resources for the woman to refer to at home may be useful.

It is also important to teach the mom about self-care. The woman should be taught to rest because sleep is difficult with a new baby. It is also important to teach the woman to walk to prevent VTE. The nurse must teach the patient about the signs and symptoms of complications that can occur in the postpartum period. Maternal morbidity and mortality rates are too high in the United States. Over half of maternal deaths occur within the first year after childbirth, and the most common causes of maternal mortality include:

• cardiovascular and coronary conditions
• cardiomyopathy
• venous thromboembolism
• hemorrhage
• infection
• mental health conditions
• preeclampsia and eclampsia

The Association for Women's Health, Obstetric, and Neonatal Nursing (AWHONN) have a program that provides hand-outs that can be used to teach women about signs and symptoms. Nurses must educate these women about making a postpartum follow-up appointment with their obstetric provider because follow-up care is important (POST-BIRTH, 2020). New research looks at the "4th Trimester," which is the 12 weeks following delivery. During this time, a woman must recover, adapt to changing hormones, and learn to feed and care for her newborn. During this "4th Trimester," many women experience challenges, including fatigue, pain, breastfeeding difficulties, depression, lack of sexual desire and incontinence, and may consider this normal and not seek care (Tully et al., 2017). Women should not suffer during this time and should receive appropriate care.

Pain is another problem that postpartum women may experience and can interfere with the woman's ability to care for herself and the baby. Women who have had a vaginal birth may experience uterine cramping, which can increase with each delivery and perineal pain, which can be severe with a laceration or episiotomy. These women may also have hemorrhoids. Nonsteroidal anti-inflammatory drugs (NSAIDs) are usually effective at treating cramp pain. Ice packs, topical sprays, and creams can help with perineal and hemorrhoidal pain. Women who have had a c-section will have abdominal pain. Multimodal pain management, including nonpharmacologic and pharmacologic therapies, is important. There is a variation in the types and intensity of pain women experience during the early postpartum period. There is also a concern that 1 in 300 opioid-naive patients exposed to opioids after cesarean birth will become persistent users of opioids. For postoperative cesarean pain, standard oral and parenteral analgesic adjuvants, including acetaminophen, NSAIDs, and mild opioids, should be used first (ACOG, 2018). Stronger opioids should be reserved for use when the other medications do not relieve pain. It is also important to educate the woman that opioids can pass through breastmilk and sedate the baby.

Complications

The most common causes of maternal morbidity and mortality are cardiovascular and coronary conditions, cardiomyopathy, venous thromboembolism, hemorrhage, infection, mental health conditions, and preeclampsia and eclampsia. These are important conditions to teach the woman about. A woman with known cardiac conditions should follow up with her cardiologist immediately. The woman with preeclampsia and other hypertensive disorders needs to know the signs of any problems, such as elevated blood pressure, headache, blurred vision, or epigastric pain. Bleeding, which soaks more than 1 pad an hour, is too much, and the woman should call her provider. A woman also needs to know about the risk of VTE and the signs and symptoms to look for, such as swelling, redness, or pain in their calf. Infection is also a possibility that should be discussed. Possible sources of infection are the bladder (urinary tract infection), especially if the woman had a foley catheter, the perineum, especially if the woman has an episiotomy or laceration, the breasts (mastitis), especially if breastfeeding), and the abdominal incision if the woman had a c-section. Women should be taught to report any redness, swelling, pain, or discharge at these sites, as well as difficulty or pain with urination (Postpartum care, 2020).

Nursing Considerations

Childbirth is a natural process. However, women having babies are getting older and have more co-morbidities than in the past. Nurses must know how to care for these women and teach them to care for themselves and report any problems.

Case Study

A.L. is a 38-year-old woman who just had her first baby at 35 weeks gestation. After 14 hours of labor, AL had a c-section to deliver her twin sons. She is exhausted and tearful because 1 of her babies is in the Neonatal Intensive Care Unit (NICU) for difficulty breathing. AL tells you that she has not had much experience with babies and is worried about how she will care for these babies. Her medical history is negative, except for some mild anxiety that she says comes and goes throughout time. When you first speak to her about postpartum depression, she expresses that she could not possibly get postpartum depression because she has wanted and tried for a baby for many years and could not be happier.

Is she at risk for postpartum depression? How can you educate her about postpartum depression?

• AL is at risk for postpartum depression. Any woman is, but her age, twins, first babies, NICU stay, and history of anxiety increase her risk of developing it. It is important to teach AL that postpartum depression does not mean she is unhappy with having her babies. It is a postpartum condition caused by changing hormones and sleep deprivation and can happen to any woman. It does not signify that she is not a good mom. The nurse must give her resources for when she goes home if she develops postpartum depression. It may also be helpful to educate them when their partner is present to hear the information.

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References

• ACOG Committee Opinion No. 757: Screening for Perinatal Depression. Obstet Gynecol 2018; 132:e208.
• ACOG Committee Opinion No. 757: Screening for Perinatal Depression. Obstet Gynecol 2018; 132:e208.
• ACOG Committee Opinion No. 742: Postpartum Pain Management. Obstet Gynecol 2018; 132:e35.
• American Academy of Pediatrics, American College of Obstetricians and Gynecologists. Postpartum Care of the Mother. In: Guidelines for Perinatal Care, 8th edition, Sarah Kilpatrick, Lu-Ann Papile (Eds), 2017. p.284-285.
• Gaboury J, Capaday S, Somera J, Purden M. Effect of the Postpartum Hospital Environment on the Attainment of Mothers and Fathers Goals. Journal of Obstetric, Gynecologic & Neonatal Nursing. 2017;46(1):40-50. doi:10.1016/j.jogn.2016.08.008.
• POST-BIRTH Warning Signs Education Program. POST-BIRTH Warning Signs Education - Association of Women's Health, Obstetric and Neonatal Nurses. Accessed January 7, 2020. Visit Source.
• Postpartum care: After a vaginal delivery. Mayo Clinic. Published May 11, 2018. Accessed January 8, 2020. Visit Source.
• Tully KP, Stuebe AM, Verbiest SB. The fourth trimester: a critical transition period with unmet maternal health needs. Am J Obstet Gynecol 2017; 217:37.
• UpToDate. Updated August 29, 2019. Accessed January 7, 2020. Visit Source.

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