20.3 Nursing Care During the Postpartum Period

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.

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.

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.

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.

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.