postpartum nursing diagnosis

The postpartum period, also known as the puerperium and the fourth trimester, refers to the time after birth when the physiologic changes related to pregnancy return to the nonpregnant state (Berens, 2022).

Definition

The postpartum period starts following the expulsion of the placenta until the complete physiological recovery of various organ systems. The postpartum period divides into three arbitrary phases: acute phase (the first 24 hours after delivery of the placenta), early phase (up to seven days), and late phase (up to six weeks to six months.

Postpartum Period Changes

Vital signs

There is generalized physical fatigue immediately after delivery. The pulse rate may be elevated a few hours after childbirth due to excitement or pain. The blood pressure may be elevated due to pain but is generally in the normal range. The temperature is slightly elevated up to 37.2℃ (99℉) along with increased shivering, sweating, or diaphoresis in the first 24 hours and normalizes within 12 hours. The temperature rise may have been caused by the systemic absorption of metabolites accumulated due to muscle contractions. The respiratory rate also begins to fall back to the pre-pregnancy level within two to three days. There is a weight loss of five to six kg due to the expulsion of products of gestation and accompanying blood loss (Chauhan & Tadi, 2021).

Reproductive

Involution is the term given to the process of reproductive organs returning to their prepregnant state. Immediately postpartum, the uterine fundus is palpable at or near the level of the maternal umbilicus. The endometrial lining rapidly regenerates, so that by the seventh day endometrial glands are already evident. Immediately after delivery, a large amount of red blood flows from the uterus until the contraction phase occurs. Therefore, the volume of vaginal discharge rapidly decreases. The cervix also begins to rapidly revert to a nonpregnant state, but it never returns to the nulliparous state. The vagina also regresses but it does not completely return to its prepregnant size. The swollen and engorged vulva rapidly resolves within one to two weeks (Kansky & Isaacs, 2021).

Breasts

The changes to the breasts that prepare the body for breastfeeding occur throughout pregnancy. After delivery of the placenta, there is a rapid decline in progesterone and subsequent swelling, or engorgement, of the breasts in the postpartum period. The colostrum is the liquid that is initially released by the breast during the first two to four days after delivery. Over the first seven days, the milk matures and contains all the necessary nutrients in the neonatal period (Kansky & Isaacs, 2021).

Endocrine

If the client is not breastfeeding, then the menstrual function returns by the sixth to eighth week postpartum in most cases. Elevated serum prolactin levels inhibit the ovarian response to the follicular stimulating hormone, suppress the release of luteinizing hormone, and suppress the secretion of gonadotropins. This approach offers a natural method of contraception to the lactating female. In lactating females, menstruation usually reappears in four to five months and can be as late as 24 months.

Renal

The bladder wall may become edematous, and hyperemic, and the bladder might be overdistended without the urge to pass urine. The retention of urine in the first few days after labor may be due to the laxity of the abdominal musculature, tone of pelvic floor muscles, atony of the bladder, compression of urethra by edema or hematoma, reflex inhibition of micturition due to genitourinary trauma. The dilated ureters and renal pelvis usually return to the pre-pregnant state within four to eight weeks.

Hematologic

The hematocrit may initially drop due to blood loss associated with delivery but starts to rise again as plasma volume decreases due to diuresis and hemoconcentration. The hematocrit values return to normal in three to five days postpartum as plasma volume starts to increase. The discrepancy in hemoglobin values in the postpartum phase indicates that it takes at least four to six months to restore the pregnancy-induced dip in hemoglobin to non-pregnant states The white blood cell count returns to pre-pregnant values within four weeks. The gestational thrombocytopenia resolves in four to ten days after delivery as platelet count increases in response to platelet consumption during delivery.

Cardiovascular

In the immediate postpartum period, following delivery, there is an increase in preload from the relief of the inferior vena cava obstruction, leading to an increase in stroke volume and heart rate leading to a 60 to 80% rise in cardiac output, which rapidly declines to pre-labor values in one to two hours following delivery and to pre-pregnancy values in two weeks postpartum. Systemic vascular resistance decreases by 35 to 40% during pregnancy and increases to pre-pregnant levels two weeks postpartum. There is also a decrease in systemic blood pressure by five to ten mm Hg during pregnancy. Diastolic blood pressure decreases more than systolic blood pressure. The systemic blood pressures start to rise during the third trimester and return to prepregnant values at 16 weeks postpartum.

Gastrointestinal

The client may develop flatulence or constipation due to intestinal ileus (induced by pain or the presence of placental hormone relaxin in the circulation), loss of body fluids, laxity of the abdominal wall, and hemorrhoids. Postpartum constipation is due to the progesterone-induced decrease in gastrointestinal transit time. After delivery, the levels of progesterone and gastrin drop within 24 hours, and the acid reflux and associated symptoms resolve in the next three to four days.

Nursing Diagnosis for Postpartum

Nursing Diagnosis

Risk for Impaired Parent/Infant Attachment


 

Assessment

Lack of support from significant others / ineffective or no role model / anxiety associated with the parental role / unrealistic expectations / presence of stressors, such as financial or employment

Problem

Unmet family needs

Decreased sense of trust

Family role disruption

Depression

Inability to provide a protective environment

 

Nursing Diagnosis

Risk for Deficient Fluid Volume


 

Assessment

Vaginal hemorrhage / dry skin or mucous membranes / decreased skin turgor / tachycardia / fever / hypotension / increased urine output / weakness / changes in mental state / hemoconcentration / altered electrolyte balance 

Problem

Dehydration

Hypovolemic or hemorrhagic shock

Electrolyte imbalances

Cardiac dysrhythmias

 

Nursing Diagnosis

Acute Pain


 

Assessment

Reports of pain / self-focusing / grimacing / distraction / guarding behaviors / increased blood pressure / tachycardia / tachypnea / altered muscle tone

Problem

Fear or anxiety

Decreased tolerance of activities

Isolation or depression

Impaired role performance

Impaired attachment to the infant

 

Nursing Diagnosis

Impaired Urinary Elimination


 

Assessment

Urinary frequency, urgency, or hesitancy / dysuria / incontinence / urinary retention / bladder fullness / suprapubic discomfort

Problem

Decreased self-esteem

Irritation of the urinary tract and urethra

Loss of bladder tone 

Fluid shifts

 

Nursing Diagnosis

Constipation


 

Assessment

Bowel urgency / inappropriate toileting behaviors / incontinence / hard, impacted stools

Problem

Inability to locate the bathroom or recognize need

Lost of neurological functioning and muscle tone

Nutritional imbalance

Trauma to the rectal tissue

 

Nursing Diagnosis

Disturbed Sleep Pattern


 

Assessment

Verbal reports of difficulty in falling asleep / not feeling well-rested / interrupted sleep / frequent yawning / irritability / dark circles under the eyes 

Problem

Discomfort

Weakness

Decreased ability to function

Impaired parental role

Decreased sense of well-being

 

Nursing Diagnosis

Health-seeking behaviors


 

Assessment

Expressed desire to participate in newborn care / expressed concern over the newborn / stated unfamiliarity with resources / observed desired to seek a higher level of wellness

Problem

Situational or maturational occurrence precipitating concern about the newborn

Limited mobility

Physical exertion

Pain of lacerations or episiotomy

 

Nursing Diagnosis

Fear/Anxiety


 

Assessment

Identification of stimulus believed to be a threat / fatigue / anorexia / dry mouth  palpitations / apprehension / increased tension / excitement / jitteriness

Problem

Unfamiliarity with newborn care

Impaired parenting role

Impaired attachment to infant

Chronic/acute disease process

Language barriers

References

  1. Berens, P. (2022). Overview of the postpartum period: Normal physiology and routine maternal care. UpToDate. https://www.uptodate.com/contents/overview-of-the-postpartum-period-normal-physiology-and-routine-maternal-care#:~:text=The%20postpartum%20period%2C%20also%20known,return%20to%20the%20nonpregnant%20state.
  2. Chauhan, G., & Tadi, P. (2021, November 21). Physiology, Postpartum Changes – StatPearls. NCBI. Retrieved November 26, 2022, from https://www.ncbi.nlm.nih.gov/books/NBK555904/
  3. Kansky, C., & Isaacs, C. (2021, December 22). Normal and Abnormal Puerperium: Overview, Routine Postpartum Care, Hemorrhage. Medscape Reference. Retrieved November 26, 2022, from https://emedicine.medscape.com/article/260187-overview
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