20.4: Nursing Care During the Postpartum Period
By the end of this section, you will be able to:
- Explain nursing care responsibilities and education of the postpartum couplet during the early postpartum period
- Determine appropriate nursing interventions to promote maternal comfort and well-being
- Discuss holistic nursing care for surgical and vulnerable postpartum patients
- Identify the goals and discharge planning for the patient and newborn, and the nursing care and education that must be completed
Nursing care during the postpartum period includes physical and psychologic assessment and recognition of normal and abnormal findings. Nursing interventions will differ for persons having a vaginal or cesarean birth, choosing to breast-feed or not to breast-feed, and having a single birth or multiple births. Nurses provide support to all postpartum persons with individualized interventions based on the patient’s educational level and social factors. Education on parenting, self-care, newborn care, and warning signs will be presented and reinforced at the time of discharge.
Postpartum recovery begins after birth. The nurse assesses vital signs every 15 minutes during the first hour of postpartum recovery , every 30 minutes to 1 hour during the second hour, then every 4 hours (Milton, 2024). Once the postpartum person is stable, recording vital signs might be changed to every 8 hours or once per shift according to the health-care provider’s orders or facility policy. Pain will be assessed, and different options for pain management will be offered.
Postpartum Education
Postpartum education is provided by the nurse throughout the postpartum stay by demonstration and verbal education. During the first 8 hours, the nurse will demonstrate how to perform a fundal massage and will assist with breast-feeding techniques. The nurse explains the assessment of vaginal bleeding, use of pads and peri-care, and pain expectations. The nurse also demonstrates immediate newborn care.
After the first 8 hours, the nurse will demonstrate newborn cord care, feeding techniques, use of the bulb syringe , bathing, and newborn warning signs (see Chapter 25 Care of the Newborn at Risk). The nurse discusses the importance of rest for the postpartum person and encourages them to rest when the newborn is resting, to increase fluid intake, and to eat a well-balanced diet. Cultural traditions are considered during education.
At approximately 24 hours postpartum, the nurse teaches about caring for the newborn at home, lochia and its changing characteristics, rest, constipation, hemorrhoids, and perineal healing. The nurse assesses the person’s support system, signs of attachment, ability to care for the self and newborn, emotional status, and pain control. Most persons will be discharged between 24 and 36 hours after a vaginal birth and between 48 and 72 hours after a cesarean birth. This provides limited time for education and nursing interventions. Early discharge can lead to complications and possible readmission to the hospital. In addition to education on normal physiologic and emotional expectations, postpartum persons and their support persons should be provided education on the signs and symptoms of complications and information on how to contact health-care providers to answer questions and concerns.
Education for Pharmacologic Interventions
During the postpartum period, the nurse will educate the postpartum patient on prescribed pharmacologic medications including immunizations (flu, rubella , hepatitis B), pain medications, and Rh immune globulin (RhoGAM).
Pharmacologic Pain Management
Pain medication is used for postpartum cramping, perineal pain, surgical incision pain, and general pain from childbirth. Analgesics are the most common pain medications administered. The nurse will offer acetaminophen (Tylenol) and nonsteroidal anti-inflammatory drugs (ibuprofen; Motrin) for mild to moderate pain. For moderate to severe pain, the nurse will offer the narcotic ordered for the postpartum pain. Many times, the narcotic is paired with acetaminophen. The nurse must be aware of how much total acetaminophen the postpartum person receives daily and ensure that the person does not take more than 4g per 24 hours. The nurse assesses pain before and 30 minutes to 1 hour after administering pain medication.
Immunizations
The nurse educates the postpartum person that the influenza vaccine is safe during pregnancy and the postpartum period and is recommended during influenza season (ACOG, 2018). If the patient has not received it during pregnancy, they will be offered the vaccine prior to discharge. The tetanus, diphtheria, and pertussis (TDP) vaccine is usually administered during pregnancy. The nurse can offer this vaccine if the person has not received it during pregnancy to protect the newborn against pertussis. If the person is not immune to rubella, the nurse will explain that the vaccine is not safe during pregnancy and should be given postpartum to protect the person and any subsequent pregnancy. The rubella vaccine is manufactured in a combination of measles, mumps, and rubella (MMR). The nurse can administer the vaccine prior to discharge and teaches the person to avoid pregnancy for 3 months after the administration of the live vaccine.
The Measles, Mumps, and Rubella Vaccine
The measles, mumps, and rubella (MMR) vaccine is given to postpartum persons to provide immunity against the rubella virus and to gain immunity prior to the next pregnancy. Rubella is a contagious virus that, when contracted during pregnancy, can cause miscarriage, stillbirth, and severe birth defects. A pregnant person is tested for immunity to rubella at the first visit. If the person is not immune, they are instructed that they cannot receive the vaccine until after pregnancy because it is a live vaccine. Signs of rubella are provided to the pregnant person (low-grade fever, headache, swollen lymph nodes, cough, sore throat, and rash that starts on the face and spreads to the rest of the body) with instructions to call their health-care provider if they experience any of those symptoms.
- Generic Name: measles, mumps, and rubella virus vaccine
- Trade Name: M-M-R II
- Class/Action: vaccine, live (viral)
- Route/Dosage: sub-Q 0.5 mL
- High Alert/ Black Box Warning: anaphylactoid/hypersensitivity reaction; use with caution in persons with thrombocytopenia, active untreated tuberculosis, immunocompromised status, allergy to eggs, sensitivity to neomycin
- Indications: active immunization against measles, mumps, and rubella
- Mechanism of Action: A live, attenuated vaccine, MMR vaccine offers active immunity to disease.
- Contraindications: pregnancy; hypersensitivity to measles, mumps, and/or rubella vaccine or any component of the formulation (neomycin, eggs); current febrile respiratory illness; those receiving immunosuppressive therapy; primary and acquired immunodeficiency states; blood dyscrasias
- Adverse Reactions/Side Effects: syncope, vasculitis, acute disseminated encephalomyelitis, ataxia, dizziness, Guillain-Barré syndrome, headache, seizure, erythema multiforme, IgA vasculitis, Stevens-Johnson syndrome, urticaria, thrombocytopenia, anaphylactoid reaction, angioedema, local injection site reaction, bronchospasm, fever
- Nursing Implications: The nurse ensures the consent is signed. The nurse educates the person that this is a live vaccine and that it is recommended not to get pregnant for 12 weeks.
- Parent/Family Education: Call health-care provider for severe abdominal pain, severe back pain, severe nausea/vomiting, high blood sugar, confusion, severe dizziness, seizures, swollen glands, change in hearing/vision, wheezing, chest tightness, fever, itching, bad cough, blue skin, swelling of face/lips/tongue/throat
(Vallerand & Sansoski, 2023; CDC, 2020)
Rh Immune Globulin
If the postpartum person is Rh negative and the newborn is Rh positive, the person should be offered Rh immune globulin ( RhoGAM ) to protect against isoimmunization in future pregnancies. If the Rh-positive fetal blood mixes with the Rh-negative maternal blood, maternal antibodies are created to attack Rh-positive antigens. If the maternal antibodies cross the placenta to a future fetus, fetal red blood cells will be destroyed and can lead to extreme fetal anemia (Neamţu et al., 2022). Rh immune globulin prevents maternal blood from creating antibodies against the Rh antigen. Rh-negative pregnant persons receive Rh immune globulin at 28 weeks due to the unknown fetal blood type. Some providers will test the blood type of the baby’s father. If Rh negative, the pregnant person does not need the immune globulin because the fetus can have only Rh-negative blood. Some providers, however, give the immune globulin to all Rh-negative persons regardless of the partner’s Rh status. After birth, the newborn’s blood is typed; if it is Rh positive, the postpartum person receives Rh immune globulin. If the baby is Rh negative, another dose is not warranted.
Rh Immune Globulin
Rh immune globulin is given to Rh-negative pregnant persons to prevent isoimmunization caused by the fetus being Rh positive.
- Generic Name: Rh immune globulin
- Trade Name: HyperRHO S/D, MICRhoGAM Ultra-Filtered Plus, Rho GAM Ultra-Filtered Plus, Rhophylac, WinRho SDF
- Class/Action: immune globulin
- Route/Dosage: 300 mcg intramuscularly (IM) at 28 weeks and within 72 hours after birth; if less than 13 week’s gestation and given within 72 hours of termination, spontaneous abortion, or threatened abortion, 50 mcg (microdose) IM can be given.
- High Alert/Black Box Warning: none
- Indications: Rh-negative person who is not sensitized to the Rh factor who is pregnant or recently birthed an Rh-positive newborn
- Mechanism of Action: prevents isoimmunization by suppressing the immune response and antibody formation by Rh-negative individuals to Rh-positive red blood cells
- Contraindications: anaphylactic or severe systemic reaction to a previous dose of human immune globulin; Rh-positive individuals
- Adverse Reactions/Side Effects: chills, headache, increased bilirubin, fever, dizziness, infection
- Nursing Implications: Rh immune globulin must be refrigerated. The nurse should confirm the pregnant or postpartum person’s blood type and confirm Rh-negative status. The nurse also confirms the newborn’s blood type to confirm Rh-positive status. The nurse gives the immune globulin IM within the first 72 hours of birth. If the newborn’s blood type is unknown, the immune globulin is administered.
- Parent/Family Education: The pregnant person is educated on the prevention of isoimmunization due to their blood type being Rh negative and the fetus’ blood type being unknown or identified as positive after birth.
(Brunton et al., 2018; Haider et al., 2020)
Nursing Interventions for Common Postpartum Discomforts
Postpartum persons will experience some discomfort after birth. Discomforts depend on mode of birth, breast-feeding, and any birth complications. The nurse will determine if the discomforts are normal or warning signs requiring further evaluation.
Breast Discomfort
Postpartum persons who do not breast-feed will have discomfort when their milk comes in. They are likely to experience engorgement pain. The nurse educates them on how to relieve this discomfort by wearing a sports bra or support bra to compress the breasts. The nurse instructs the patient to apply cool packs or cabbage leaves to the breasts to relieve feelings of engorgement (Safitri et al., 2022). The nurse recommends avoiding any breast stimulation, including running hot water over the breasts in the shower, as this can increase milk production. Medications such as acetaminophen (Tylenol) and ibuprofen (Motrin) can be taken to decrease pain and inflammation.
Cabbage Leaves and Breast Pain
Cabbage leaves have been used to reduce pain from breast engorgement for many years. Some people use cold cabbage leaves from the refrigerator. The cold temperature helps numb the pain and reduce swelling. Cabbage leaves contain enzymes called flavonoids that are anti-inflammatories and help reduce the swelling associated with engorgement. Safitri et al. (2022) created a gel using cabbage leaves and found that the gel resulted in better relief from breast swelling than standard breast care of warm compresses and massage. Aprilina et al. (2021) created a cabbage leaf compress and placed it in the postpartum patients’ bras for 30 minutes or until it wilted two times per day for 3 days. Their study found a significant reduction in pain and swelling for those postpartum persons. Neither study found negative side effects with the cabbage leaves. The nurse can safely suggest the use of cabbage leaves for treating engorgement pain to their postpartum patients.
Persons choosing to breast-feed can experience engorgement pain as well. Unlike the non–breast-feeding person, the breast-feeding patient should be encouraged to lightly hand express milk and nurse the baby or to use warm compresses to promote comfort. The nurse explains that acetaminophen and ibuprofen are safe during breast-feeding and can be utilized for breast discomfort. When breast-feeding persons experience nipple pain, it is most often due to latching problems. The nurse assists the person with latching. If unsuccessful, they can contact the lactation consultant or counselor, if available, to help the person improve the latch and decrease nipple trauma. Nipple creams can help relieve pain, and applying breast milk to the nipple and allowing it to air dry can aid in nipple healing. Lanolin, a thick, waxy substance found in sheep’s wool, is nourishing and protects the nipple; it is commonly used as a nipple ointment. Other natural options, such as coconut oil or cocoa butter, may also appeal to breast-feeding persons (Şahin et al., 2023). Other nipple creams use olive oil or beeswax as a base. All nipple creams will be ingested by the newborn and should be researched for safety; some creams must be wiped off prior to breast-feeding.
The nurse also educates the postpartum person about the importance of regular, frequent feedings (every 2 to 3 hours) and checking their breasts for clogged ducts. This information is important to prevent a breast infection or mastitis . (Mastitis and clogged ducts are discussed in more detail in Chapter 21 Postpartum Complications.)
Uterine Discomforts
Uterine cramping after birth can be painful. Multiparous persons experience more uterine discomfort than primiparous persons. The nurse educates the person that breast-feeding releases oxytocin , causing uterine contractions and the letdown of breast milk. The breast-feeding person may take a mild pain medication prior to nursing. The nurse encourages the postpartum person to empty their bladder often. A full bladder displaces the uterus, causing the uterus to contract more to stay firm and thereby increasing pain.
Perineal Discomfort
Perineal discomfort is common in persons after a vaginal birth. The nurse assesses the perineum, looking for any warning signs of infection, hematoma, or breakdown of laceration repair. The nurse educates the person on multiple techniques to decrease perineal pain. These are summarized in Table 20.6. Ice/cold packs can be applied to the perineum for the first 24 hours. Topical anesthetic sprays or foams and witch hazel pads can be applied to the peripad or directly to the perineum after voiding. The nurse can prepare a sitz bath , a warm bath for soaking the perineum, which can be used for 15 to 20 minutes multiple times during the facility stay and after returning home. The nurse instructs the person to avoid sitting on hard chairs or sitting for long periods. The patient should use a pillow or cushion under the buttocks when sitting on a hard surface. A peri-bottle can be used after voiding to keep the perineum clean and for relief of discomfort. The nurse can offer oral pain medications as needed.
| Comfort Measure | Action | Instructions |
|---|---|---|
| Ice pack | Reduces swelling and numbs painful area | Apply an ice pack or cold pack to perineum or hemorrhoids for 10–20 minutes at a time for first 24–72 hours after birth. |
| Witch hazel | Reduces swelling, helps repair broken skin, fights bacteria | Apply witch-hazel pads to perineum and hemorrhoids; can place witch-hazel pads in refrigerator/freezer for further comfort. |
| Sitz bath | Speeds healing by increasing blood flow to the injured area, soothes pain, reduces inflammation, cleans perineum |
Prepare warm shallow bath; sit in water without soap and soak up to three times per day for 10–15 minutes. Gently pat the perineum or hemorrhoids when drying.
Some health-care providers will instruct to add iodine, Epsom salt, or baking soda to the water. Do not add unless instructed by provider. |
| Peri-bottle | Cleans perineum and hemorrhoids, soothes pain | Fill peri-bottle with warm water and clean perineum and rectal area after each void and bowel movement. Pat dry after use. |
| Lidocaine gel/foam/spray | Numbs the injured area; antimicrobial added to some sprays to fight infection | Spray perineum and rectal area after cleaning with peri-bottle or apply foam/gel to peripad after cleaning perineum and rectal area. Use after voiding or bowel movement. |
| Stool softener | Brings water into the intestines to soften stool, which reduces pain with defecation and lessens the need to strain with bowel movement | Take stool softener per order by the health-care provider. |
| Hemorrhoid cream/suppository with hydrocortisone | Relieves pain and itching, promotes healing | Apply to hemorrhoids or insert in rectum after bowel movements or with pain |
Hemorrhoid Discomfort
Many pregnant persons experience hemorrhoid discomfort prior to and after birth (see Table 20.6). Postpartum persons with hemorrhoids will have pain upon defecation or throbbing pain at rest. The nurse evaluates the anus for hemorrhoids and offers pain relief techniques, including sitz baths, topical anesthetics, oral analgesics, and cool packs. Witch hazel pads have been shown to be soothing and to promote healing. A hemorrhoid cream or suppository with hydrocortisone can be helpful. Some persons become constipated due to the fear of pain with defecation. The nurse educates the person that stool softener s help prevent hard, painful stools. The nurse can encourage the person to avoid sitting on hard chairs and to lie on their side to relieve pressure.
Voiding Discomfort
Some postpartum persons experience lacerations near the urethra. This causes pain with urination. Other persons will have discomfort voiding after having had a urinary catheter. Urinary retention can occur and cause pain. The nurse assesses for signs of infection, then educates the person on comfort measures. The nurse recommends that the postpartum person with urinary retention stand in the shower and attempt to urinate. The warm water aids in releasing tightened bladder muscles. The nurse also educates the person to increase water intake to dilute urine to decrease discomfort while urinating. If pain continues, the nurse can contact the health-care provider to discuss ordering a urine culture.
Bowel Discomfort
Bowel discomfort during the postpartum period can be caused by decreased peristalsis during labor. If the person had anesthesia, this causes the bowels to become sluggish, leading to the risk of bloating and constipation. Being NPO during labor or consuming only small amounts of water and food can lead to dehydration, which contributes to constipation. The nurse assesses the bowels for return of peristalsis. Some postpartum persons are anxious about having their first bowel movement due to anxiety about “ripping” any sutures open and increasing their pain. This leads to delay of defecation, increasing the risk for constipation. The nurse educates the person on not delaying defecation and encourages them to increase water intake and ambulation, as both will aid in natural bowel movements that are less uncomfortable to pass. Stool softeners and simethicone (Gas-X) can be offered by the nurse to aid in relieving bowel discomfort (Vallerand & Sanoski, 2023).
Yoga is an excellent exercise that can be used throughout pregnancy and postpartum. (Patients should consult with their health-care provider prior to starting an exercise routine.) Yoga is beneficial for reducing stress, increasing circulation, and helping with constipation. Twisting poses are very helpful for the postpartum person experiencing constipation.
Nursing Care of Surgical and Postpartum Populations at Higher Risk for Complications
Postpartum persons undergoing a cesarean birth will have different needs than those having a vaginal birth. Their recovery will take longer, and they will have more pain during recovery. The nurse will educate those persons on pain relief and care of the incision. Populations at higher risk for complications will also have different needs. The nurse can assist these patients in obtaining resources necessary to help in their recovery.
Nursing Care of the Patient Following a Cesarean Birth
Nursing care after a cesarean birth is more intensive due to the postsurgical care. Compared to someone with a vaginal birth, the person with a cesarean has more pain, increased risk for DVT, increased risk for incisional infection, and difficulty in ambulating. The nurse uses a different care plan for the patient who had a cesarean birth.
The patient’s pain level is assessed often. Pain medication can be administered during the insertion of spinal anesthesia, through a patient-controlled pump, or orally. The nurse monitors the incision using the REEDA scale . The extremities are monitored for signs of DVT. The nurse encourages the person to turn and cough while splinting the incision and use an incentive spirometer to avoid pneumonia. The nurse assesses for bowel sounds and passing of flatus. Early ambulation is very important for bowel peristalsis, prevention of DVT, and prevention of pneumonia. The nurse removes the indwelling catheter when the person feels steady enough to ambulate to the restroom.
Teamwork and Collaboration
Following a cesarean birth, teamwork is important to keep the patient safe and comfortable. The team includes:
- obstetrician: responsible for performing the C-section and monitoring postoperative recovery
- nurse-midwife: oversees postpartum care, including pain management, breast-feeding support, and emotional well-being
- neonatal nurse: assesses the newborn’s health and provides care, especially if there are any complications
- lactation consultant: offers expertise in breast-feeding support and education
- social worker: addresses any psychosocial concerns or challenges
- anesthesiologist: monitors pain management and provides interventions as needed
Step 1. The nurse communicates with the obstetrician to determine any special needs for the patient.
Step 2. The nurse assesses the patient’s pain and communicates the need for pain management with the anesthesiologist or certified nurse-anesthetist.
Step 3. When pain control is adequate, the nurse discusses the patient’s desire for newborn skin-to-skin and breast-feeding with the neonatal nurse.
Step 4. The nurse communicates with the lactation consultant and nurse-midwife to discuss breast-feeding needs and cultural or religious traditions, and explore any special needs for the patient.
Step 5. The nurse evaluates the patient’s psychosocial needs and communicates with the social worker if needed.
Teamwork and collaboration ensure optimum care for the newborn and patient.
Holistic Nursing Care for Populations at Higher Risk for Complications
The nurse provides support to all postpartum persons, with the awareness that some postpartum persons have specific needs or unique circumstances that require a different approach to care. The nurse adapts their care to include special equipment, education, and resources.
Nursing Care of the Adolescent Patient
Adolescent pregnant persons are population at higher risk for abuse and poor health outcomes due to their social situations and are at risk for sex trafficking and coerced sex (Powers & Takagishi, 2021). The nurse should assess for signs of abuse, especially in the very young adolescent.
Adolescent persons may not be developmentally prepared for parenting. These persons have higher rates of parenting stress and depression, leading to less effective parenting practices. Ineffective parenting practices place the newborn at risk for failure to thrive, abuse, neglect, and impaired cognitive functioning (Wu et al., 2023). Involvement of the significant other during the prenatal period and a supportive relationship with their partner have been shown to increase the significant other’s involvement after the birth (Wu et al., 2023). The nurse spends time educating the parents on newborn care. The nurse provides community resources for adolescent parents. Research has shown that home visits, postpartum education , and cognitive behavior therapy can reduce rates of postpartum depression in adolescent parents (Sangsawang et al., 2019). The nurse can collaborate with the social worker to ensure the parents have the resources needed to allow them to transition into the parenting role.
Adolescent persons are at increased risk for repeat pregnancies (Powers & Takagishi, 2021). Postpartum education on contraception techniques is essential, and the nurse encourages the person to discuss their options with their health-care provider. Long-acting, reversible contraceptives (IUDs, implants) are very good options for adolescent persons. Some facilities offer this service prior to discharge.
Nursing Care of Postpartum Couplets at Higher Risk for Complications
The newborn and postpartum person are considered as one unit or patient, called a couplet . Persons who were not aware that they were pregnant until the very end of their pregnancy, migrant workers, those of lower socioeconomic status, and those with mental or physical disabilities are at higher risk for complications. The nurse will order a referral to social services or social workers as indicated. Pregnant persons who are either in denial of their pregnancy status or unaware of their pregnancy until late into the pregnancy can suffer from attachment disorders. They can also feel ill prepared for their unexpected role as a new parent. The nurse can assist with support for bonding with their newborn by encouraging skin-to-skin time, demonstrating newborn care, and encouraging the person to talk about their feelings regarding the newborn. They can also assist the person to reach out to support systems or ask for a social worker consult to help this new couplet in challenges they might face.
Postpartum Support International is a nonprofit organization that provides information and support to postpartum persons who are unprepared for their newborn or who have experienced a pregnancy loss. This site is helpful for supporting perinatal patients.
Migrant workers may move several times during their pregnancy. This can interrupt their prenatal care or prevent them from having any prenatal care at all. At their birth, they may not know their health-care provider. A language barrier may exist. These patients can be distrustful due to their unfamiliarity with the health-care system. The nurse can help the migrant worker by assessing the need for a translator and using a medical translator instead of a family member (Heath et al., 2023). The nurse can explain the postpartum routine care and inquire about any special needs.
Postpartum couplets in the lower socioeconomic demographic can suffer from limited access to health care because of lack of transportation, inability to take time off work, and lack of health insurance. The nurse can consult with the social worker to provide resources that could benefit the couplet. During discharge teaching, the nurse asks the patient about their ability to get to their follow-up appointments, if they have a car seat, and if they have a safe place to live. The nurse is supportive and caring about the struggles of these couplets.
Postpartum persons with disabilities are at higher risk for depression, social isolation, and smoking than those without disabilities (Becker et al., 2021). Those with physical disabilities may have challenges such as difficulty in bathing the newborn, lifting the newborn in and out of the crib, and limited reliable options for transporting their newborns (Becker et al., 2021). The nurse will assess the person’s abilities and difficulties and discuss with the health-care provider to ensure the person has what is needed to care for themselves and their newborn at home. For the postpartum person with mental disabilities, the nurse assesses the level of disability and alters the education provided to a level the person can understand. The nurse can ask for a social worker consult to assess the person’s support system.
The postpartum person with a spinal cord injury can have physical challenges after taking their newborn home. This video tells the story of how one person made alterations to help her accommodate this disability while caring for her newborn.
Nursing Care of LBGTQIA+ Parents
The health-care system may be unfamiliar with the needs of some LBGTQIA+ families. The nurse should ask the postpartum person how they wish to be addressed and what practices the health-care team can adopt to make them feel included and involved in their care. The nurse includes the partner in education and decision making.
Same-sex partners can experience social stigma over becoming parents. This stigma can negatively affect their mental health and make them question their competence in parenting (Farr & Vázquez, 2020). Confidentiality is very important, as some couples have not shared their relationship with others in their family, or they fear they will be treated poorly if their sexuality is made known to other health-care providers (Pachankis et al., 2020). The postpartum nurse can create a safe space for these couples to discuss their fears, concerns, and wishes during their stay in the facility. Research has shown that the non-birthing person can feel role resentment, exclusion from health-care services, and feelings of neglect (Howat et al., 2023). The nurse includes the non-birthing person in all education and decision making.
A transgender man may experience challenges during the postpartum period. For transgender men who have had surgery to remove their breast tissue (top surgery), lactation can be challenging. Without adequate breast tissue or nipple size, milk may not be produced, and latching can be difficult (Gedzyk-Nieman & McMillian-Bohler, 2022). Most transgender men use the term chest-feeding rather than breast-feeding. Postpartum depression should be monitored closely, as it is reported more often in trans men. Nurses should also encourage postpartum persons to discuss contraception during their follow-up visit with their health-care provider.
Another challenge is the lack of education of nurses and health-care providers on the special needs of the pregnant transgender male. A study showed that health-care providers felt they needed more education regarding childbearing as a trans person, including how to use inclusive language effectively and policies and processes to support childbearing trans people (Pezaro et al., 2023).
Nursing Care of Patients Who Are Incarcerated
People who are incarcerated often come from poverty, have had poor educational opportunities, and have only limited access to health care (ACOG, 2021b). The person who is incarcerated is at higher risk of having acute and chronic illnesses, substance use disorder, mental illness, and reproductive health needs (ACOG, 2021b). Therefore, the nurse is aware that these persons can have multiple health-care needs beyond pregnancy and birth. These persons are also at higher risk for sexually transmitted infections. The nurse will look at the prenatal history to determine testing and treatment for these infections.
The nurse ensures that the postpartum person has time to bond with their newborn. Separation from the newborn upon return to the facility causes higher rates of postpartum depression among this population (ACOG, 2021b). The American College of Obstetricians and Gynecologists (ACOG) (2021b) recommends breast-feeding and milk expression for incarcerated birthing patients and suggests that correctional facilities have private places for persons to pump. ACOG (2021b) also strongly opposes the use of any type of restraint for these patients during labor, birth, or the postpartum period. The nurse’s role is to support the person and newborn and facilitate bonding.
Nursing Care of Persons Who Are Relinquishing Newborns
Many emotions surround the person who is relinquishing their newborn. Birth parents can feel attached to the newborn and feel regret about their decision for adoption. They can feel judged by friends and family. They can also feel relieved and happy about their decision. The nurse provides care that is sensitive to the person’s emotions. The nurse is careful to avoid phrases like “giving away your child” or “giving up for adoption.” Instead, the nurse can use the phrase “making an adoption plan” or “entrusting the baby to another parent” (Rousseau & Friedrichs, 2021). The nurse should ask about expectations for the newborn, such as how much time the birth parent wants to spend with the newborn, their desire for photos or video, and when the adoptive parents will take the newborn home. The nurse’s responsibility is to provide support and offer resources for support groups or online groups that can help the birth parent cope with their emotions.
Surrogates can also struggle with relinquishing the newborn. They can become attached to the newborn after carrying the fetus for 9 months. The nurse is sensitive to these feelings and supports the surrogate in their need to talk about and process their feelings. The nurse validates these feelings and offers resources to help the person go through this process.
Nursing Care of Postpartum Patients Who Have Experienced Abuse
For people who have experienced abuse, especially childhood sexual abuse, birth can be a traumatic experience. This is thought to be caused by the focus of care on the areas of the body most likely to have been violated (Brunton & Dryer, 2021). Risk factors associated with abuse include substance use during pregnancy and eating disorders affecting weight gain during pregnancy (Brunton & Dryer, 2021). These persons have higher rates of postpartum depression and anxiety. The nurse will assess for a history of abuse and tailor the postpartum care to decrease the person’s anxiety. The nurse asks permission to touch the postpartum person prior to exams and includes the person in the assessment. For example, the nurse can ask the person to massage her fundus while the nurse observes for bleeding. This allows the person to have control over their body and reassures them they are safe. The nurse is supportive of the person’s boundaries.
Postpartum Discharge
Prior to postpartum discharge education, the nurse assesses if the postpartum person is ambulating, is voiding, has sufficient pain control, demonstrates self-care, and demonstrates newborn nursing or bottle-feeding and routine newborn care. The nurse includes the significant other in discharge instructions as well. Time is provided for questions. The nurse has demonstrated patient care and newborn care throughout the person’s stay; however, formal verbal and written instructions will be provided at discharge. Contraception information is also provided at this time (see Chapter 5 Family Planning). The healthy postpartum person is discharged between 24 and 48 hours after birth.
The nurse assesses the person’s support system, signs of attachment, ability to care for the self and newborn, emotional status, pain control, and any other support services the postpartum person and support persons may need or request. The final physical assessment is completed, and warning signs are reviewed. Instructions are given to call the health-care provider for:
- fever above 100.4° F (38º C) or chills
- pain upon urination
- shortness of breath
- unilateral extremity edema
- unusual facial edema
- headache not resolved with pain medication
- blurred vision
- heavy, bright red blood or clots saturating more than one pad in an hour
- foul-smelling lochia
- uterine tenderness or pain
- postpartum depression (crying, feelings of hopelessness, anger, disengaging with newborn, withdrawal lasting longer than 2 weeks)
- severe lower abdominal or uterine pain
- redness or pain in the breasts
- pain, redness, or swelling of the legs or calves
The nurse reinforces the importance of perineal care . They encourage use of the peri-bottle with warm water. Sitz baths are recommended for those with sutures. The nurse reviews the use of spray or foam local anesthetic, changing the pad with each void, and cleansing from front to back.
Medication use is reviewed, and prescriptions are provided. The nurse encourages the person to continue the prenatal vitamins and take prescribed iron. Stool softeners may be needed, and the nurse encourages increased water intake to help with elimination and breast-feeding. NSAID s are typically recommended for pain, and the patient should be taught to take them with food. If the person is given a prescription for a narcotic , the nurse instructs the person not to drive a car or consume alcohol. They also explain that constipation can be a side effect of narcotic pain medications.
Signs of postpartum depression are outlined. Some facilities perform a formal postpartum depression scale prior to discharge. Some also send a depression scale home with the new parents. Differences between postpartum blues and depression are reviewed. The nurse stresses the importance of calling the health-care provider with extreme changes in sleep, appetite, feelings of sadness, hopelessness, isolation, and anxiety.
Activity Limitations
The postpartum person should avoid lifting any object heavier than their newborn for the first few weeks after birth. Normal activity is encouraged. It is recommended to wait until the postpartum person is seen by the health-care provider to initiate exercise and sexual activity. The person should not be on bed rest, however, due to the risk of DVT.
Promotion of Rest
Rest is important for healing and for bonding with the newborn. The nurse encourages the patient to take frequent naps. It is recommended that the patient have certain times set aside for family and friends to visit and certain times for rest. The new parents should not feel they need to entertain others.
Sexual Health
The nurse explains that the body is not ready to resume intercourse at this time. The nurse stresses the importance of letting the body heal. It is recommended that nothing be placed in the vagina until that patient is cleared by the health-care provider. This pelvic rest allows the vagina and placenta site to heal and decreases the risk for endometritis. The person with a cesarean birth should postpone intercourse until 6 weeks after birth or until cleared by their health-care provider to resume normal physical activities. The nurse recommends the couple discuss ways to stay intimate without sexual intercourse.
Breast Care
Discharge teaching for the breast-feeding person includes (Elsevier, 2024) the following:
- Wear a supportive bra.
- Expose the nipples to air.
- Feed the newborn on demand with both breasts.
- If engorged, take a warm shower and hand express a small amount of milk prior to feeding.
- Ensure a good latch.
- Break the suction with your finger.
- Do not use soap on the nipples.
- Use breast milk or lanolin cream to promote nipple healing if necessary.
The nurse reminds the person to call their provider or clinic if they notice areas of redness or heat in the breasts. The non–breast-feeding person should wear a supportive bra and avoid breast stimulation. The nurse encourages application of cold packs to the breasts if engorged.
Contraception
During prenatal care, the health-care provider and the pregnant person should discuss postpartum contraception . The nurse inquires what contraception the person has chosen and reinforces use of that contraception. If the person has not chosen a contraceptive method, the nurse encourages the person to discuss this with the health-care provider prior to discharge. The nurse explains that the person can become pregnant even while breast-feeding during the postpartum period. For more information on contraception, see Chapter 5 Family Planning.