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									Postpartum Nursing Care

            Pathophysiology of Postpartum

 Involution - rapid reduction in size of uterus and return to
  prepregnant state
 Subinvolution = failure to descent
 Uterus is at level of umbilicus within 6 to 12 hours after
  childbirth - decreases by one finger breadth per day

 Exfoliation - allows for healing of placenta site and is
  important part of involution – may take up to 6 weeks
 Enhanced by
     uncomplicated labor and birth
     complete expulsion of placenta or membranes
      breastfeeding
     early ambulation
   FIGURE 23–1 Involution of the uterus. A, Immediately after
 expulsion of the placenta, the top of the fundus is in the midline and
approximately halfway between the symphysis pubis and the umbilicus.
   B, About 6 to 12 hours after birth, the fundus is at the level of the
 umbilicus. The height of the fundus then decreases about one finger-

                breadth (approximately 1cm) each day.
        Pathophysiology of Postpartum

 Uterus rids itself of debris remaining after birth
  through discharge called lochia
 Lochia changes:
  Bright red at birth
  Rubra - dark red (2 – 3 days after delivery)
  Serosa – pink (day 3 to 10 after delivery)
  Alba – white
  Clear

 If blood collects and forms clots within uterus,
 fundus rises and becomes boggy (uterine atony)
      Ovulation and Menstruation/Lactation

 Return of ovulation and menstruation varies for
  each postpartal woman
   Menstruation returns between 6 and 10 weeks after birth
    in nonlactating mother - Ovulation returns within 6
   Return of ovulation and menstruation in breastfeeding
    mother is prolonged related to length of time
    breastfeeding continues
 Breasts begin milk production
   a result of interplay of maternal hormones
     Pathophysiology of Bowel Elimination

 Intestines sluggish because of lingering effects of
 progesterone and decreased muscle tone
  Spontaneous bowel movement may not occur for 2 to 4
   days after childbirth
  Mother may anticipate discomfort because of perineal
   tenderness or fear of episiotomy tearing
 Elimination returns to normal within one week
 After cesarean section, bowel tone return in few
 days and flatulence causes abdominal discomfort
       Pathophysiology of Urinary tract

 Increased bladder capacity, decreased bladder tone,
  swelling and bruising of tissue
 Puerperal diuresis leads to rapid filling of bladder -
  urinary stasis increases chance of urinary tract
 If fundus is higher than expected on palpation and is
  not in midline, nurse should suspect bladder
FIGURE 23–2   The uterus becomes displaced and deviated to the right when

                         the bladder is full.
                      Laboratory Values

 White blood cell count often elevated after delivery
   Leukocytosis
         Elevated WBC to 30,000/mm3
 Physiologic Anemia
   Blood loss – 200 – 500 Vaginal delivery

   Blood loss 700 – 1000 ml C/S

   RBC should return to normal w/in 2 - 6 weeks

   Hgb – 12 – 16, Hct – 37% - 47%

 Activation of clotting factors (PT, PTT, INR)
  predispose to thrombus formation - hemostatic
  system reaches non-pregnant state in 3 to 4 weeks
     Risk of thromboembolism lasts 6 weeks
                    Weight Loss

 10 –12 pounds w/ delivery
 5 pounds with diuresis
 Return to normal weight by 6 – 8 weeks if gained 25
  - 30 pounds
 Breastfeeding will assist with weight loss even with
  extra calorie intake
                 Psychosocial Changes

 Taking in - 1 to 2 days after delivery
   Mother is passive and somewhat dependent as she sorts reality
    from fantasy in birth experience
   Food and sleep are major needs

 Taking hold - 2 to 3 days after delivery
   Mother ready to resume control over her life

   She is focused on baby and may need reassurance
                   Psychosocial Changes

 Maternal Role Attachment
    Woman learns mothering behaviors and becomes comfortable in her
     new role
 Four stages to maternal role attainment
    Anticipatory stage - During pregnancy
    Formal stage - When baby is born
    Informal stage - 3 to 10 months after delivery
    Personal stage - 3 to 10 months after delivery
 Father-Infant Interaction
    Engrossment
    Sense of absorption
    Preoccupation - Interest in infant
                Postpartum Assessment

 Vital signs: Temperature elevations should last for only 24
    hours – should not be greater than 100.4°F
   Bradycardia rates of 50 to 70 beats per minute occur during
    first 6 to 10 days due to decreased blood volume
   Assess for BP within normal limits: Notify MD for
    tachycardia, hypotension, hypertension
   Respirations stable
   Breath sounds should be clear
   Complete systems assessment
   BUBBLEHE assessment
   Postpartum chills or shivers are common
               Breasts Assessment

 Assess if mother is breast- or bottle-feeding - inspect
 nipples and palpate for engorgement or tenderness –
 should not observe redness, blisters, cracking
                Breasts Assessment

 Breasts should be soft, warm, non-tender upon
 Secrete colostrum for 1st 2-3 days –yellowish fluid -
  protein and antibody enriched to offer passive
  immunity and nutrition
 Milk comes in around 3 – 4 days – feel firm, full,
  tingly to client
                Uterus Assessment

 Monitor uterus and vaginal bleeding, every 30
  minutes x 2 for first PP hour, then hourly for 2 more
  hours, every 4 hours x 2, then every 8 hours or more
  frequently if there is bogginess, position out of
  midline, heavy lochia flow
 Determine firmness of fundus and ascertain position
   approximate descent of 1 cm or 1 fingerbreadth per
 If boggy (soft), gently massage top of uterus until
  firm – notify health care provider if does not firm
 Displaced to the right or left indicates full bladder –
  have client void and recheck fundus
                      Uterus Assessment

  FIGURE 23–6 Measurement of
 descent of fundus for the woman with
vaginal birth. The fundus is located two
 finger-breadths below the umbilicus.
Always support the bottom of the uterus

 during any assessment of the fundus.
        Bladder and Bowel Assessment

 Anesthesia or edema may interfere with ability to
  void – palpate for bladder distention - may need to
  catheterize – measure voided urine
 Assess frequency, burning, or urgency
 Diuresis will occur 12 – 24 hours after delivery –
  eliminate 2000 – 3000 ml fluid, may experience
  night sweats and nocturia

 Bowel: Assess bowel sounds, flatus, and distention
           Lochia – Rubra Assessment

 Lochia = blood mucus, tissue vaginal discharge
 Assess amount, color, odor, clots
 If soaking 1 or > pads /hour, assess uterus, notify
  health care provider
 Total volume – 240 – 270 ml
 Resume menstrual cycle within
6 – 8 weeks, breast feeding may
be 3 months
     Episiotomy, Lacerations, C/S Incisions

 Inspect the perineum for episiotomy/lacerations
  with REEDA assessment
 Inspect C/S abdominal incisions for REEDA

    R = redness (erythema)
    E = edema
    E = ecchymosis
    D = drainage, discharge
    A = approximation
       Postpartum Nursing Interventions

 Relief of Perineal Discomfort
   Ice packs for 24 hours, then warm sitz bath

   Topical agents - Epifoam

   Perineal care – warm water, gently wipe dry front to back
FIGURE 24–1       A sitz bath promotes healing and provides relief

from perineal discomfort during the initial weeks following birth.
           Hemorrhoids, Homan’s Sign

 Assess for hemorrhoids
 Relief of hemorrhoidal discomfort may include
   Sitz baths
   Topical anesthetic ointments
   Rectal suppositories
   Witch hazel pads - Tucks

 Extremities
   Assess for pedal edema, redness, and warmth
   Check Homan's sign – dorsiflex foot with knee slightly
FIGURE 23–9 Homans’ sign: With the woman’s knee flexed,
the nurse dorsiflexes the foot. Pain in the foot or leg is a positive
Homans’ sign.
      Emotional Status/Bonding Assessment

 Describe level of attachment to infant
 Determine mother's phase of adjustment to parenting
 Postpartum Blues
     Transient period of depression
     Occurs first few days after delivery
     Mother may experience tearfulness, anorexia, difficulty sleeping,
      feeling of letdown
 Usually resolves in 10 to 14 days
 Causes:
     Changing hormone levels, fatigue, discomfort, overstimulation
     Psychologic adjustments
     Unsupportive environment, insecurity
       Postpartum Nursing Interventions

 After pains
   Uterine contractions as uterus involutes

 Relief of after pains
   Positioning (prone position)

   Analgesia administered an hour before breastfeeding

   Encourage early ambulation - monitor for dizziness and

 Bleeding
   oxytocin (Pitocin) – watch for fluid overload and hypertension
   methylergonovine (Methergine) – causes hypertension
   prostaglandin F (Hemabate, carboprost) – n/v, diarrhea
 Pain Medications
   NSAIDS – GI upset
   Oxycodone/acetaminophen (Percocet) – dizziness, sleepiness
   PCA – Morphine for C/S – respiratory distress
 docusate (Senna) – causes diarrhea
 Rubella Vaccine – titer 1:10, do NOT get pregnant for 3
 Rh Immune Globulin (RhoGAM) – Rh negative mother –
  do not administer rubella vaccine for 3 months
            Mother and Family Needs

 Nurse can assist in restoration of physical well-
 being by
  Assessing elimination patterns
  Determining mother's need for sleep and rest
  Encourage regular diet as tolerated and increasing fluids

 Identify available support persons - involve
  support person and siblings in teaching as
 Determine family's knowledge of normal
  postpartum care and newborn care
        Breastfeeding Pathophysiology

 Before delivery, increased estrogen stimulates duct
  formation, progesterone promotes development of
  lobules and alveoli
 After delivery, estrogen and progesterone decrease,
  prolactin increases to promote milk production by
  stimulating alveoli
 Newborn suck releases oxytocin to stimulate let-
  down reflex
             Composition of Breast Milk

 Breast milk is 90% water; 10% solids consisting of
    carbohydrates, proteins, fats, minerals and vitamins
   Composition can vary according to gestational age
    and stage of lactation
   Helps meet changing needs of baby
   Foremilk – high water content, vitamins, protein
   Hindmilk - higher fat content
  Immunologic and Nutritional Properties

 Secretory IgA, immunoglobulin found in colostrum
 and breast milk, has antiviral, antibacterial,
 antigenic-inhibiting properties
  Contains enzymes and leukocytes that protect against
  Composed of lactose, lipids, polyunsaturated fatty acids,
   amino acids, especially taurine
  Cholesterol, long-chain polyunsaturated fatty acids, and
   balance of amino acids in breast milk help with
   myelination and neurologic development
            Advantages of Breastfeeding

 Provides immunologic protection
 Infants digest and absorb component of breast milk
   Provides more vitamins to infant if mother's diet is
   Strengthens mother-infant attachment
   No additional cost
   Breast milk requires no preparation
   AAP= Only food for 6 months, w/ foods for 12
        Disadvantages of Breastfeeding

 Many medications pass through to breast milk
 Father unable to equally participate in actual feeding
  of infant
 Mother may have difficulty being separated from
                 Breastfeeding Mother

 Breastfeeding mother needs to know
   How breast milk is produced
   How to correctly position infant for feeding
   Procedures for feeding infant
   Number of times per day breastfed infant should be put to the
   How to express and store breast milk
   How and when to supplement with formula
   How to care for breasts
   Medications that pass through breast milk
   Support groups for breastfeeding

 Review signs and symptoms of engorgement, plugged milk
  ducts, mastitis
Breastfeeding Assessment
Figure 29–2      Four common breastfeeding positions. A, Football hold. B,
Lying down. C, Cradling. D, Across the lap.
              Formula Preparations

 Three categories of formulas based on cow milk
  proteins, soy protein-based formulas, specialized or
  therapeutic formulas - all are enriched with vitamins,
  particularly vitamin D
 Most common cow milk protein-based formulas
  attempt to duplicate same concentration of
  carbohydrates, proteins, fats as 20kcal/oz same as
  breast milk
           Bottle-Feeding Advantages

 Provides good nutrition to infant
 Father can participate in infant feeding patterns
         Bottle-Feeding Disadvantages

 May need to try different formulas before finding one
  that is well-tolerated by infant
 Proper preparation necessary for nutrition adequacy
                Bottle-Feeding Mother

 Bottle-feeding mother needs to know
   Types of formula available and how to prepare each type

   Procedure for feeding infant

   How to correctly position infant for bottle-feeding

   How to safely store formula

   How to safely care for bottles and nipples

   Amount of formula to feed infant at each feeding

   How often to feed infant

   Expected weight gain
               Bottle Feeding Mother

 Teach to wear a binder or tight-fitting sports bra day
    and night for two weeks.
   Do not allow hot water from shower to run over
   Avoid manual stimulation
   Apply cabbage leaves (dries up breast)
   Use acetaminophen for discomfort
             Cesarean Section Needs

 Assess vital signs
 Assess breasts
 Assess location and firmness of uterine fundus
 Assess lochia
 Assess incision site – REEDA
 Assess breath sounds
 Assess indwelling urinary catheter - color and
  amount of urine noted
 Assess bowel sounds: present, hypoactive or
                   Cesarean Section Needs

 Cesarean birth is major abdominal surgery - if general
  anesthesia used, abdominal distension may cause
  discomfort, assess for bowel obstruction
     Position client on left side, include exercises, early ambulation, increase
      po intake, avoid carbonated beverages, avoid straws - may need enemas,
      stool softeners, antiflatulent meds

 Pulmonary infections may occur related to immobility and
  use of narcotics because of altered immune response
     TCDB, use incentive spirometer q 2 hours
                   Pain and Comfort

 Administer analgesics within the first 24 to 72 hours -
  allows woman to become more mobile and active
 Comfort is promoted through proper positioning, back
  rubs, and oral care - reduce noxious stimuli in environment
 Encourage visits by family and newborn, which provides
  distraction from painful stimuli
 Encourage non-pharmacologic methods of pain relief
  (breathing, relaxation, and distraction) - encourage rest
      Attachment After a Cesarean Birth

 Physical condition of mother and newborn and
  maternal reactions to stress, anesthesia, and
  medications may impact mother-infant attachment
 By second or third day, cesarean birth mother
  moves into "taking-hold period"
  Emphasize home management and encourage mother to
   allow others to assume housekeeping responsibilities
  Stress how fatigue prolongs recovery and may interfere
   with attachment process
                 Discharge Instructions

 S/S complications           Referral numbers
 PP Exercises                Nutrition
 Rest                        PP appointment
 Avoid overexertion          Birth certificate info
 Sexual activity             Infant care
 Hygiene                     Infant complications
 Sitz baths                  Infant follow-up
 Incision care               Family bonding
               Discharge Teaching

 New mother should gradually increase activities and
  ambulation after birth
 Avoid heavy lifting, excessive stair climbing,
  strenuous activity, vacuuming
 Resume light housekeeping by second week at home
 Delay returning to work until after 6-week
  postpartum examination
               Discharge Teaching

 Recommend exercise to provide health benefits to
  new mother
 Nurse should encourage client to begin simple
  exercises while on nursing unit
 Inform her that increased lochia and pain may
  necessitate a change in her activity
      Sexual Activity and Contraception

 Sleep deprivation, vaginal dryness, and lack of time
  together may impact resumption of sexual activity
 Usually sexual intercourse is resumed once
  episiotomy has healed and lochia has stopped (about
  3 – 6 weeks)
 Breastfeeding mother may have leakage of milk from
  nipples with sexual arousal due to oxytocin release

 Information on contraception should be part of
  discharge planning
 Nursing staff need to identify advantages,
  disadvantages, risk factors, any contraindications
 Breastfeeding mothers concerned that contraceptive
  method will interfere with ability to breastfeed - they
  should be given available options – progesterone
            Parent-Infant Attachment

 Tell parents it is normal to have both positive and
  negative feelings about parenthood
 Stress uniqueness of each infant
 Provide time and privacy for the new family
 Include parents in nursing intervention
                Reaction of Siblings

 Sibling visits reassure children their mother is well
 Father may need to hold new baby, so mother can
  hug older children
 Suggest to parent that bringing doll home allows
  young child to "care for" and identify with parents
                         Infant Care

 New mother and family should know basic infant
    Information about tub baths
    Cord treatment, When to anticipate cord will fall off
    Family should be comfortable in feeding and handling infant,
     as well as safety concerns
    Immunizations
    When to call the doctor
                 Discharge Teaching

 Nurse should review with new mother any information she
  has received regarding postpartum exercises, prevent of
  fatigue, sitz bath and perineal care, etc. - nurse should
  spend time with parent to determine if they have any last-
  minute questions before discharge
 Printed information about local agencies and support
  groups should be given to new family
                Types of Follow-Up Care

 Telephone calls - nurses must listen carefully and ask open-
    ended questions
   Return visits - Within one week after first visit
   Telephone follow-up - Within 3 days of discharge
   Baby care/postpartum classes
   New mother support groups
   Need to have a caring attitude in these activities
          Main Purpose of the Home Visit

 Assessment
    Status of mother and infant
    Adaptation and adjustment of family to new baby
 Determine current informational needs
 Teaching
    Self-care
    Infant Care
 Opportunity to answer additional questions related to
  infant care and feeding
 Counseling
    Provide emotional support to mother and family
    Referrals
         Maternal Assessments at Home

 Vital signs: Should be at prepregnancy level
 Weight: Expect weight to be near prepregnancy level at 6
  weeks postpartum
 Condition of breasts
 Condition of abdomen, including healing cesarean incision
  if applicable
 Elimination pattern: should return to normal by 4 to 6
  weeks postpartum
                Maternal Assessment

 Lochia
   Should progress from lochia rubra to lochia alba
   If not breastfeeding, menstrual pattern should return
    about 6 weeks postpartum
 Fundus
   Uterus should return to normal size by 6 weeks
 Perineum: Episiotomy and lacerations should
  show signs of healing
              Breastfeeding Assessment

 Nipple soreness - Peaks on days 3 and 6, then
   Cracked nipples
   Allow nipples to air dry after breastfeeding
   Nurse frequently
   Alternate breasts
   Change infant's position regularly
   Breast engorgement, plugged ducts
   Effect of alcohol and medications
   Return to work
   Weaning
                     Family Assessment

 Bonding: Appropriate demonstration of bonding should
  be apparent
 Level of comfort: parents should display appropriate
  levels of comfort with the infant
 Siblings should be adjusting to new baby
 Parental role adjustment
    Parents should be working on division of labor
    Changes in financial status
    Communication changes
    Readjustment of sexual relations
    Adjustment to new daily tasks
 Contraception: Parents understand need to choose and
 use a method of contraception
              Relinquishing a Baby

 Many reasons why a woman decides she cannot
 parent her baby
  Emotional crisis may arise as woman attempts to resolve
   her concerns
  As she faces these concerns, social pressures against
   giving up baby
 Mother may need to complete grieving process to
 work through her decision - she may have made
 considerable adjustments to her lifestyle to give
         Relinquishing a Baby (cont’d)

 Nursing staff need to honor any special requests
  after birth and encourage mother to express her
 Seeing newborn may assist mother in grieving
 Some mothers may request early discharge or
  transfer to another unit

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