- Due to the many physiological maternal changes during the postpartum period, various pain and discomforts can occur.
- It is especially important to adequately address these after mom and baby experienced labor and delivery, which is also uncomfortable and painful.
- Afterbirth pains, perineal discomfort, lacerations, breast discomfort, and emotional changes are examples
- Assess, provide comfort measures, educate, follow up, and resources
- Afterbirth pains
- Typically feel like painful menstrual cramping
- Patients more likely to experience increased afterbirth pains:
- Breastfeeding mothers; nursing often triggers these pains
- Those who were given oxytocin
- Those with an overdistended uterus (carrying multiples)
- Large baby
- Perineal area
- Incision (C-section or Episiotomy)
- Breast discomfort
- Nipple damage
- Clogged ducts
- Postpartum blues
- Crying, occasionally unprovoked and randomly
- Increased irritability
- Feelings of sadness and confusion
- Issues with sleeping (in addition to normal postpartum sleep deprivation)
- Labile emotions
- Postpartum depression
- Feelings of guilt
- Low energy levels
- Suicidal thoughts
- Not very responsive to newborn / feeling disconnected
- Problems concentrating
- Loss of enjoyment in normal activities
- Crying, unrelenting sadness
- Extreme irritability
- Postpartum psychosis
- Disconnected from reality
- Heating pad
- Perineal pain/discomfort
- Ice packs during first 24 hours and sitz baths thereafter relieve swelling provide substantial pain relief
- Sitz baths can be done in a small basin over the toilet or at home in a bath
- Lacerations and episiotomies and incisions
- Analgesic sprays may be helpful
- Appropriately clean perineal area after every trip to the bathroom
- Splint incision when coughing
- Ibuprofen/motrin, oxycodone, ketorolac/toradol
- Passing stool may be more difficult after delivery, especially if hemorrhoids resulted
- Provide stool softeners and other pharmacological interventions as ordered
- Promote hydration and ambulation
- Emotional changes/discomforts
- Encourage dialogue between yourself, mom and support system
- Ask open-ended questions
- Validate feelings
- Hot line, support groups
- Patient-centered care
- Educate on use of sitz bath, numbing sprays, ice, stool softeners
- Educate about afterbirth pains before they occur
- Easier to stay on top of the pain instead of trying to fight it off
- Educate patient and support system about signs of PPD
- Mom isn’t going to know she’s having difficulty so signs the family should be aware of like her being anxious or making comments of feeling sad
- Educate about the difference between postpartum blues, PPD, and postpartum psychosis
In this lesson I will explain postpartum discomforts and your role in providing care.
So I just wanted to briefly list some of the postpartum discomforts that can be experiences. After pains, breast discomfort, perineal pain, and postpartum blues, depression, and psychosis. Not every woman will experience discomforts and some women might experience many of them. Alright so let’s dive into our assessment of all these various discomforts.
So let’s talk about what each assessment piece is going to look like. Afterbirth pains are basically the pains after birth. These are felt as the uterus contracts as it is trying to move itself back into the pelvis. So these just really feel like painful menstrual cramps. So who feels after pains? Everyone! Afterpains can be more intense for some. So who is going to feel more after pains? So think of it like this…Anything that makes the uterus bigger means the uterus has to contract more to get back to prepregnancy size. So what would make the uterus bigger? Twins or multiples, a large baby or someone with polyhydramnios, which just means they have extra amniotic fluid are all things that would make the uterus larger. So another cause of afterpains will be things that make the uterus contract more. So this would be breastfeeding because this triggers the release of oxytocin, causing uterine contractions. A patient that has been given oxytocin is going to have more afterpains because the uterus is contracting more. Also a patient that has had multiple pregnancies. The cramps get worse with each pregnancy. So think of the uterus as this tired muscle and it is just worn out from holding babies so it has to contract more to get this tired stretched out uterus back in place. Perineal discomfort occurs from the delivery of the baby. So a laceration or episiotomy can cause this pain. Assessment should be done of the site as well as incision site for a c-section patient. Breast discomfort is another assessment piece as this will be mostly for our breastfeeding moms but engorgement will occur for all because milk is still produced in the beginning even for a bottle feeder. Nipple damage such as cracking, blisters and bleeding can be assessed. Other discomforts comes from clogged ducts and when these clogged milk ducts don’t get drained then mastitis can occur. Postpartum blues assessment will involve crying, occasionally unprovoked and randomly. These patients are crying at every commercial, crying because the cafeteria was out of chocolate ice cream, they are just emotional and its ok. Hormones have crashed after delivery and every patient will have some form of postpartum blues. The patients might be anxious, irritable, have feelings of sadness and confusion and mostly because they don’t know why they feel like this. Postpartum depression is going to be all the blues emotions on overdrive and not going away. So this is when it goes beyond 10 days. The patients need medications to help rebalance their hormone levels. Patients are feeling all these emotions and are sleep deprived, which makes it worse. When it gets worse or postpartum depression goes untreated the patient can enter a state of psychosis. So this is the patient that hears voices telling her to do things and unfortunately sometimes they are bad things like drowning their kids. I always joked with my husband that during the night when I would be up feeding the baby and see him next to me sleeping so soundly and then snoring and I couldn’t fall back asleep I thought “I could just chuck a pillow at him or throw something at him” of course I never did but thought it in my head. So these patients think worse things and carry it out because they are in psychosis. I had a friend in high school that two years ago had a baby and she seemed so happy. She posted pictures of her new sweet baby and was always a very caring sweet person. Not a thing seemed wrong. She moved to california with her husband and made cookies to introduce herself to the new neighbors. The next day she called her husband to come home and get the baby and she went to a field and committed suicide. No one suspected it. And unfortunately this can happen. Sometimes patients show every symptom and other times not one symptom. It is so important to normalize it and give patients resources in case they are in need and hopefully they will reach out for help. Alison couldn’t be helped because no one knew and she hid it so well.
So our management is going to be very different for all of these because the discomforts are so different. Let’s start with afterpains. So remember these are the painful cramps after birth so ibuprofen or motrin, heating pads and even sometimes a narcotic like oxycodone. The perineal pain will also be taken care of with medications but ice is a huge relief. There is swelling and pain so the ice really helps. Sitz baths and a numbing spray and ensuring that the perineum gets clean and stays clean after each bathroom use it important. Incision pain is going to be better treated with a narcotic but ibuprofen can be given too. So when the patient first has her c-section we don’t want to give her these big pills because she had anesthesia and she will probably just throw it up so ketorolac or toradol is good bc it is IV and is typically give for the first 24 hours. The patient should also be told to splint the incision when she coughs to reduce discomfort. Constipation discomfort can be helped with stool softeners, encouraging the patient to get up and walk the halls, drink more water and increase fiber. Breast discomfort will be handled with lanolin or Jack Newman’s ointment in the hospital for nipple damage. There is also hydrogel pads which are a cooling pad to help relieve nipple pain. The patient can use some ice to reduce pain but a breastfeeding mom needs to be careful not to ice too long to affect milk supply. Cabbage leave for our bottle feeding mom can help dry up the milk and reduce engorgement pain. For all our emotional concerns there is counseling and anti-depressants for those that go from blues to depression. Hotline numbers and support groups can be helpful as well.
We need education on many different items to relieve the discomforts. education on use of sitz bath, numbing sprays, ice, and stool softeners to help with perineal pain and constipation. It is also important to educate about afterbirth pains and to stay on top of medications so we can treat it before they occur. It is easier to stay on top of the pain instead of trying to fight it off after it has started. We need to put a big emphasis on postpartum blues, depression and psychosis education. They need to understand that blues are normal and its ok and they will cry but if it goes longer than 10 days they need to call the doctor. I always make sure I educate in the presence of a support person and make a comment that “Mom isn’t going to know she’s having difficulty necessarily” so it is important for everyone to be aware and watch for this. This is a topic that really needs to be normalized so just acting like if it happens it is ok, there is treatment can help.
Comfort, coping, and patient-centered care are our nursing concepts because we are providing comfort for the patient with discomforts. We are helping her cope with the changes and her adjustment as well as involving her in this care.
Let’s wrap all this up. So just remember there are several discomforts and they will vary between the person. Afterpains are best treated with medications, perineal discomforts are best treated with medications, ice, sitz baths, and numbing spray. Constipation is treated with walking, fiber, water, and stool softeners. Breast is treated with ice, cabbage leaves, medications, and nipple ointment. And our big one is emotions so depending on how severe just support, therapy and antidepressant medications.
Make sure you check out the resources attached to this lesson and review the treatment for each discomfort. Now, go out and be your best selves today. And, as always, happy nursing.