POSTPARTUM ASSESSMENT AND NURSING CARE

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					POSTPARTUM ASSESSMENT
AND NURSING CARE
    Maternal Newborn Nursing
POSTPARTUM PERIOD
 Puerperium-6 wks.-from childbirth to return
  of uterus and other organs to pre-pregnant
  state.
 Immediate postpartum- first 24 hours
 Early postpartum-first week
 Late postpartum-after the first week-6th
  week
GOALS OF POSTPARTUM
CARE
 Assist and support recovery -educate mom
  about self-care and infant care
 After the initial dangers of hemorrhage and
  shock are past, the primary danger is
  infection
 REVIEW: Clinical Pathway 13-1—
  Postpartum Care
INVOLUTION OF THE
UTERUS
 Rapid reduction in size and return of the
  uterus to the pre-pregnant state
 Exfoliation is a unique healing process
  enables the placental site to heal without
  scarring. Future ova will implant in an
  unscarred uterus.
 Endometrial regeneration - 3 wks. Placental
  site- 6 wks.
DESCENT OF THE UTERINE
FUNDUS
 Fundal height-measured in fingerbreadths
  or cm in relation to the umbilicus, used to
  assess the rate of uterine involution, figure
  13-1,A &B, and procedure 13-1
 Afterpains-occur first 2-3 days pp and
  uterine cramping occurs when
  breastfeeding. Muscles contract and relax
CHARACTERISTICS OF
LOCHIA—Table 13-1
 LOCHIA RUBRA- days      Fig 13-2 AMOUNT – size
  1-3- RED                 of area stain on peri pad in
                           1 hour:
 LOCHIA SEROSA- days     Scant - 2 inch (10ml)
  4-9 PINKISH BROWN       Small or slight -4 inch
 LOCHIA ALBA- day 10-     (10-25ml)
  3wks.-WHITE             Moderate -6 inch ( 25-
                           50ml)
                          Heavy or large - > 6 inch
                           (50-80ml)
                          Excessive: pad saturated
                           within 15 minutes
Changes in the Reproductive System
 Vagina
 within 6 weeks the vagina almost returns to it’s
  prepregnancy form
 Perineum
 depends on whether there has been an episiotomy
  done. May be very edematous
 if done use the acronym, REEDA for assessment
• R-redness, E-edema, E-ecchymosis or bruising,
  D-discharge, A-approximation of the wound
 skill 13-2 assessing the perineum
Changes in the Musculoskeletal
System
 Lower extremeties
 due to venous stasis the woman is at risk
  for blood clots, do Homan’s sign
CARDIOVASCULAR SYSTEM
CHANGES
 EXCESS BLOOD VOLUME IS
  DISPOSED OF IN TWO WAYS:
 DIURESIS-(POLYURIA) 3000 ML. PER
  DAY POSSIBLE
 DIAPHORESIS-(PROFUSE
  SWEATING)
VITAL SIGNS
 FIRST 24 HOURS-100.4F. NORMAL DUE TO
  EXERTION AND DEHYDRATION. AFTER 24
  HR. SHOULD BE AFEBRILE- IF NOT, MAY
  BE INFECTION REPORT TO M.D.
 PULSE 50-70, IF ELEVATED MAY MEAN
  EXCESSIVE BLOOD LOSS, INFECTION,
  PAIN, ANXIETY, CV DISEASE
BLOOD PRESSURE
 SHOULD REMAIN STABLE
 DECREASE- EXCESSIVE BLOOD LOSS
 INCREASE W/ HEADACHE MAY = PIH,
  A LEADING CAUSE OF MATERNAL
  DEATH- MONITOR AND CALL M.D.
CHANGES IN THE URINARY
SYSTEM
 BLADDER- LOSES MUSCLE TONE &
  HAS INCREASED CAPACITY
 URETHRA, BLADDER, URINARY
  MEATUS BECOME EDEMATOUS &
  TRAMATIZED
 DIMINISHED AWARENESS DUE TO
  ANESTHESIA, BLADDER FILLS &
  DISPLACES THE UTERUS
FAST FOCUS 13-1,SIGNS OF
DISTENDED BLADDER
 FUNDUS ABOVE UMBILICUS
 FUNDUS TO ONE SIDE
 BULGE OF BLADDER ABOVE
  SYMPHYSIS
 EXCESSIVE LOCHIA
 TENDERNESS OVER BLADDER AREA
 FREQUENT VOIDINGS -LESS THAN
  150CC
Changes In the GI system
 CONSTIPATION
 Decreased peristalsis from progesterone
 lack of solid food and limited fluid intake
 fear of pain from hemorrhoids and
  episiotomy
 common problem in PP period
 stool softeners and laxatives prescribed and
  administered
ENDOCRINE CHANGES
 AFTER EXPULSION OF PLACENTA,
  ESTROGEN & PROGESTERONE
  LEVELS DECREASE
 LACTATION BEGINS & IS
  MAINTAINED WITH THE INFANT
  SUCKLING
 MENSTRUAL CYCLE FUNCTION
  RETURNS
SUPPRESSION OF
LACTATION
 IF NOT BREASTFEEDING, AVOID ANY
  BREAST STIMULATION- NO INFANT
  SUCKLING OR PUMPING OF BREASTS
 A SUPPORTIVE BRA MAY HELP WITH
  ENGORGEMENT
 MENSES -NONLACTATING-7-9 WKS.
 LACTATING-APPROX. 3 MO.
WEIGHT LOSS
 Immediate loss- 10-12 lbs from loss of fetus,
  placenta & amniotic fluid
 5 or more lbs from diuresis and diaphoresis
 5 to7 lbs are stored for lactation needs, if not
  lactating, may not lose this extra wt as quickly
 exercises are encouraged to lose the wt gained
  during pregnancy & to increase muscle tone
RUBIN’S TAKING-IN AND
TAKING-HOLD PHASES
 Taking-in birth to as much as 2 days PP,
  Passive, dependent behavior. Focuses on
  her needs and health of infant
 Taking-hold asserts independence,
  participates in infant care, becomes
  exhausted and verbalizes anxiety
 third stage is letting-go maternal role,
  maybe PP BLUES
MATERNAL ROLE-
ACCORDING TO MERCER
 ANTICIPATORY STAGE-during
  pregnancy
 FORMAL STAGE- infant is born
 INFORMAL STAGE-mother makes her
  own choices about mothering
 PERSONAL STAGE-at 3-10 months, does
  what she is comfortable with
POSTPARTUM BLUES
 OCCURS FIRST FEW DAYS
 TEARFULNESS, INSOMNIA, LACK OF
  APPETITE, A FEELING OF ―LET-
  DOWN‖
 SUPPORT, GUIDANCE, AND
  REASSURANCE ARE HELPFUL, IF
  INTENSE MOOD SWINGS, FURTHER
  EVALS ARE NECESSARY
CARE MANAGEMENT
AFTER DELIVERY
 First 1-2 hours recovery period
 every 15 minutes v/s, fundal assessment,
  & amount of bleeding
 Once taken to the PP unit
 baseline assessment
 assessment of client’s level of knowledge
  & continuation of teaching as applicable
Postpartum Check
 Table 13-3
 Ambulation encouraged, but needs
  assistance for the 1st time out of bed
 Postpartum Chill – women often experience
  a shaking, uncontrollable chill immediately
  after birth. Unknown cause. Assure mother
  that this is normal & will pass
PROMOTING COMFORT
   Sit on a pillow
   Use an ice pack
   Moist or dry heat
   Topical applications may be ordered
   Cleanse perineum with a squeeze bottle
   warm showers, sitz baths, skill 13-4
PARENT-INFANT
ATTACHMENT
   FAST FOCUS13-2
   CUDDLES INFANT
   MAKES EYE CONTACT
   SPEAKS & SINGS TO INFANT
   ADMIRES INFANT, CALLS BY NAME
   STROKES AND MASSAGES INFANT
SIBLING PREPARATION FOR
BABY
 Box 13-1:
 ENCOURAGE TO FEEL FETUS MOVE
 TAKE ON PRENATAL VISIT
 INCREASE INVOLVEMENT OF
  FATHER WITH THE CHILD
 GIVE A GIFT TO CHILD WHEN BABY
  COMES HOME
Postpartum Discharge Instructions
Table 13-4
 WASH BREASTS WITH CLEAR WATER
  TO REDUCE DRYING, CRACKING OF
  NIPPLES-AIR DRY FOR 15 MIN.
 WASH PERI AREA FRONT TO BACK
  APPLY PADS FRONT TO BACK
 DO NOT RUB OR MASSAGE LEGS FOR
  RISK OF EMBOLI OR THROMBI
AMBULATION
 REDUCES RISK OF INFECTION OR
  THROMBOSIS
 LESSENS CHANCE OF RESPIRATORY,
  CIRCULATORY, AND URINARY
  PROBLEMS
 LESSENS CONSTIPATION
 PROMOTES RETURN OF STRENGTH
NUTRITIONAL STATUS
 THREE WELL-BALANCED MEALS QD
 HIGH FIBER DIET
 INCREASE CALORIES BY 500 PER
  DAY IF BREASTFEEDING
 INCREASE FLUIDS, MILK SUPPLY
 AVOID GAS-FORMING FOODS
Postpartum Discharge
Instructions
 Start slowly with activities, most will return to
  normal by 4-5 weeks-back to work 6 wk
 Sexual intercourse when lochia has ceased,
  episiotomy is healed, and when woman is
  ready(from 3-6 weeks)
 Contraception – begin prior to 1st intercourse; may
  become pregnant even if haven’t had 1st menses
  yet; breastfeeding NOT an effective form of birth
  control
Postpartum Discharge Instructions
 Follow up care within 2-6 weeks of delivery; see
  fast focus 13-3 PP Danger Signs
 Newborn care:
 prior to dc from hospital ensure these things are
  known: how to take baby’s temp, give bath, feed,
  change & burp the baby, care for the cord, when to
  go for follow up, immunization plan, & have a car
  seat
PP EXERCISES
 TIGHTENING BUTTOCKS-AVOIDS
  DIRECT TRAUMA TO PERINEUM
 KEGEL EXERCISES-PERINEAL
  TIGHTENING, PROMOTES HEALING
 PELVIC TILT-RELIEVES STRAIN ON
  LOWER BACK, STRENGTHENS BACK
  MUSCLES
VACCINES
 RUBELLA VACCINE MAY BE GIVEN
  DURING POSTPARTUM PERIOD TO
  PROTECT NEXT FETUS. MUST NOT
  GET PREGNANT FOR 3 MONTHS!
 RH NEG.WOMAN MAY RECEIVE
  RHOGAM WITHIN 72 HOURS FOR
  HEALTH OF NEXT CHILD IF INFANT
  IS RH POSITIVE