Chapter 15 Caring for the Postpartal Woman and Her Family

1. Chapter 15Caring for the Postpartal Woman and Her Family Gloria Nwagwu MSN, FNP-BC, RN

2. Question? • The most effective and least expensive treatment of puerperal infection is prevention. What is important in this strategy? • a. Large doses of vitamin C during pregnancy • b. Prophylactic antibiotics • c. Strict aseptic technique, including handwashing, by all health care personnel • d. Limited protein

3. Fourth Trimester • Begins immediately after childbirth • Puerperium—first 6 weeks after birth • Close observation—identify hemorrhage and complications during first critical hour • Ongoing education and support

4. Safety for Mother and Infant • Prevent infant abductions • Check ID bands • Educate mother about safety measures

5. Early Maternal Assessment • Vital signs • Temperature—below 100.4oF (38oC) • Pulse—bradycardia • Blood pressure • Respirations

6. Fundus • Immediate postpartum—halfway between the symphysis pubis and the umbilicus • 1 hour postpartum—level of the umbilicus or one fingerbreadth above • Then, descends one fingerbreadth each day • Assess lochia

7. Perineal Assessment • Sim’s position • REEDA • Hemorrhoids • Teach regarding comfort measures • If severe, teach how to manually reposition

8. Postpartum Assessment Guide

9. Bubble-He • Breasts • Uterus • Bladder • Bowel • Lochia • Episiotomy

10. Other Important Components • Maternal pain • Homans’ sign • Mother’s emotional status • Infant bonding

11. Breast Assessment • Firmness, filling • Nodules • Fissures, cracks • Blood • Dried milk • Erect or inverted nipples

12. Assessment of Uterus • Placental expulsion usually occurs within 15 minutes after birth • Uterine contractions control bleeding • Technique for uterine palpation • Involution • Subinvolution

13. Fundal Assessment • Location immediately after birth • Descends 1 cm/day • Consistency • Location • Height • Measured in fingerbreadths

14. Afterpains • Occur during process of involution • More pronounced in multipara • Nursing care • Explain cause • Prone position with abdominal pillow • Sitz baths • Encourage ambulation • Administer mild analgesics

15. Bladder • Spontaneous void within 6 to 8 hours pp • Monitor first voiding • Anticipate maternal diuresis • Urinary output may reach 3000 mL/day • Urine volume, flow returns to pre-pregnant levels within 2 to 3 days pp

16. Assessment Findings: Bladder • Incomplete emptying • Overdistention • Urinary retention • Nursing interventions • Support and enhance attempts to void

17. Bowel • Hunger and thirst after childbirth • Relaxin—depresses bowel motility • Strategies to prevent constipation • Early ambulation • Abundant fluids • High-fiber diet

18. Lochia • Characteristic indicative of status in process of involution • Lochia rubra • Lochia serosa • Lochia alba • Document amount

19. Episiotomy • 1 to 2 inch surgical incision • Assess REEDA • Ice for first 24 hours • Moist heat—Sitz bath • Dry heat—hot packs

20. Pain Assessment • Determine source • Document location, type, and duration • Administer Tylenol or Ibuprofen • Sitz bath • Educate regarding nonpharmacological measures

21. Assess for DVT • Homans’ sign • Dorsiflex foot and ask about pain • Clinical assessment • Erythema, unequal calf circumference, heat • Clinical signs are NOT reliable

22. Emotional Status • Wide range of emotions • May be sad during first 1 to 2 weeks pp • Ongoing assessment and education • Educate regarding “baby blues”

23. Maternal Physiological Adaptations • Continued Assessment of the Patient

24. Hematological System • Decrease in blood volume • Blood loss • Diuresis • White blood count increased x 5 to 6 days • Fibrinogen increased • Returns to normal by third to fourth week

25. Hormonal Levels • Estrogen and progesterone decrease • Anterior pituitary—prolactin • Placental lactogen, cortisol, growth hormone, and insulinase levels decrease • Insulin needs decrease—“Honeymoon phase”

26. Neurological System • Altered sleep patterns—maternal fatigue • Numbness in legs, dizziness • Safety for infant and mother • Headaches • Assess quality and location, and carefully monitor vital signs • Implement environmental interventions

27. Renal System, Fluid and Electrolytes • GFR, Creatinine, and BUN return to pre-pregnant levels within 2 to 3 months • Urinary glucose • Proteinuria • Rapid, sustained natriuresis and diuresis • Output may reach 3000 mL/day

28. Respiratory System • Respiratory alkalosis and compensated metabolic acidosis may persist • Decrease in intra-abdominal pressure • Relief from dyspnea

29. Integumentary System • Hormonal changes cause skin alterations • Most disappear • Striae gravidarum

30. Cardiovascular System • Delivery of the baby, expulsion of the placenta, and loss of amniotic fluid can create cardiovascular instability • Cardiac output remains elevated • Physiological diuresis

31. Immune System • Rho (D) immune globulin (RhoGAM) • Rubella vaccination • Nonimmune status • Signed consent form • Avoid pregnancy for 1 month • Flu-type symptoms may occur

32. Reproductive System • Involution of uterus • Healing of placental site • Vaginal changes • Labia majora and labia minora flaccid

33. Menstruation and Ovulation • Nonlactating women • Menstruation returns in 6 to 8 weeks • First cycle may be anovulatory • Lactating women • Delayed ovulation and menstruation • Educate—ovulation can precede menstruation, need contraception

34. Gastrointestinal System • Decreased gastric motility • Decreased muscle tone in abdominal wall • Constipation • Stool softeners

35. Musculoskeletal System • Laxity of pelvic joints and ligaments • Relaxation of soft tissues • Muscle fatigue • Body aches • Rectus abdominis diastasis • Correct posture • Modified sit-ups

36. Enhancing Cultural Sensitivity • Conduct cultural assessments • Expand knowledge and understanding • Culturally influenced beliefs • Common health care practices • Customs and rituals

37. Question? • To provide optimum care for the postpartum woman, the nurse understands that the most common causes of subinvolution are: • a. Postpartum hemorrhage and infection. • b. Multiple gestation and postpartum hemorrhage. • c. Uterine tetany and overproduction of oxytocin. • d. Retained placental fragments and infection.

38. Promoting Recovery and Self-Care

39. Activity and Rest • Early postpartum ambulation • Mild exercises • Kegel • Increase gradually • Encourage frequent rest periods • Obtain adequate sleep

40. Nourishment • Weight loss • Appetite • Balanced diet • Multivitamin supplement • Iron if hemoglobin low

41. Elimination • Void every 4 to 6 hours • Monitor intake and output x 24 hours • Increased risk of infection • Urinary retention • Constipation

42. Perineal Care • Risk of infection • Teach perineal hygiene • Hand washing • Tampons contraindicated • Cesarean births • Nurse provides perineal care until ambulatory

43. Ice Packs • Reduce edema and pain • Vasoconstriction and numbing • Apply for 20 minutes every 2 to 4 hours • First 24 hours

44. Afterbirth Pain • Intermittent uterine contractions during involution • Breastfeeding (release of oxytocin) • Duration: 2 to 3 days • Mild analgesics

45. Special Considerations • Women with HIV/AIDS • Gloves, safety glasses • Discourage breastfeeding • Patient teaching for infant safety

46. Postpartal Surgical Patient • Tubal ligation • Cesarean birth • Incisional wound • Recovery from anesthesia • Respiratory care

47. Infant Feeding Choices • Breastfeeding • Bottle feeding • Educate • Support

48. Physiology of Lactation • Breast structure • Lactogenesis • Milk ejection reflex—“let down” reflex

49. Assisting the Breastfeeding Mother • Strategies for Success

50. Breastfeeding • Initiating the feeding • Achieving proper latch-on • Assessing for milk let-down • Assuming a position of comfort • Assessing for infant weight gain