POSTPARTUM CARE

1. POSTPARTUM CARE

3. Postpartum Psychological AdaptationsReva Rubin • Taking in: Mom wants to talk about her experience of labor & birth, preoccupied with her own needs • Taking hold: More ready to resume control of her body, baby & taking on mothering role. Needs reassurance if inexperienced. • Letting-go: by 5th week, total abandon to NB • Bonding: en face position, engrossement. Encourage through early interaction & breast-feeding (within 1/2 hr of birth is best).

4. Maternal Responses to NewbornReva Rubin • Touch- progresses from fingertips → palming →cuddling → • Voice- high-pitched & babies respond • Odor- mom’s respond to baby’s unique smell • Eye contact- en face position delay eye ointment & bright lights • Nurse role- be able to answer ? About baby

5. Blues vs Dpression Postpartum/baby blues: transient depression in first few days: weepiness mood swings anorexia difficulty sleeping feeling of letdown  Postpartum Depression *If persists past 2 weeks, or worsens Symptoms:very sad feelings hopeless worthless anxiety trouble caring for and bonding with your baby Have trouble sleeping. Not be able to concentrate. Not feel hungry and may lose weight. (But some women feel more hungry and gain weight)  Postpartum Psychosis A woman who has postpartum psychosis may feel cut off from her baby. She may see and hear things that aren't there. Any woman who has postpartum depression can have fleeting thoughts of suicide or of harming her baby. But a woman with postpartum psychosis may feel like she has to act on these thoughts.

6. Endocrine Adaptations • Hormones: drop after delivery of placenta. • hCG & hPL gone by 24 hours • Estrogen & progesterone drop within 1 wk • FSH remains low for 12 days, then rises to begin new cycle • Sex is ok once lochia is alba. Menstrual period in 6-10 wks. • Contraception necessary.

7. Physiological Adaptations • Uterine involution • @ umbilicus first 24 hours--should feel firm • Decreases 1 finger’s breadth per day • By 10th day, no longer palpable • If high (3 or 4 fingers above U) and/or deviated to right, have pt. void • Risk for delayed involution: • Multiples, hydramnios, exhaustion, grand multiparity, excessive analgesia • Afterpains • www.youtube.com/watch?v=EbItF_7KYCc&feature=related

9. Fundal Assessment • Every 10-15 mins in first hour. Supine position • Palpate: one hand at base of uterus & other at umbilicus. Press inward and downward and feel for firm globular mass. • Assess: • Height (fingers above/below umbilicus) • Position (midline, deviated to right or left) • Consistency: firm, soft, boggy • If not firm, massage & should become firm. If still boggy, notify MD/assess for clots, hemorrhage. Administer oxytocin or other oxytocic (methergine, hemabate).

11. Lochia • Rubra • Serosa • Alba • If flow increases, woman should rest more • Warning sign: if lochia returns to previous type (alba to serosa, or serosa to rubra)

12. Lochia Assessment • Check q 15 mins in 1st hour. • Assessment: • Color (rubra, serosa, alba), amount, odor, presence of clots. • Constant trickle of vaginal flow, or soaking pad every 60 minutes is more than average. Can weigh pads--1 gm = 1 ml of blood. • Lochia should not exceed a moderate amount: 4 to 8 partially saturated pads/day

13. Lochia Assessment • Assessing Amounts: • Scant: peripad has stain less than 1 inch in length after 1 hour • Small: stain less than 4 inches after 1 hour--10-25 mL • Moderate: stain less than 6 inches after 1 hour--25-50 mL. • Instruct in perineal care: ∆ pad frequently, hand washing, s/s of infection & hemorrhage, no tampons

14. Cervix & Vagina • Cervix returns to firm, nongravid consistency by about 7 days, but external os remains slit-like or stellate • Vagina involutes in 6 wk period, with return of rugae. • Kegel exercises for pelvic floor muscles.

15. Perineum • Assessment: turn pt to side in Sim’s position. Lift upper buttock and assess for: • Ecchymosis, hematoma, erythema, edema, intactness, approximation, drainage or bleeding from stitches • Assess for hemorrhoids & document number, appearance & size

16. Episiotomy • Midline or mediolateral • Nursing care: • Assess for approximation, swelling, oozing, infection • Relief for pain: ice pack in first 24 hours, then heat, local analgesic spray, witch hazel pads (Tucks), sitz bath, peri-bottle for voiding, pain medications

17. Other Assessments • Constipation: Give stool softeners as ordered, prune juice, encourage ambulation, adequate fluid intake, fiber in diet. • Homan’s sign: assess calves for redness, warmth, pain, swelling. -↑risk of DVT, thrombophlebitis. -Occur in postpartum because: • Fibrinogin level is elevated • Dilatation of lower extremity veins • Relative inactivity during labor or prolonged time in delivery room stirrups leads to pooling, stasis & clotting of blood in lower extremities.

18. Thrombophlebitis • Superficial leg vein disease: • S/s: tenderness in portion of vein, local heat & redness, normal temperature or low-grade fever • Tx: local heat, elevate limb, bed rest, analgesia, elastic support hose • Deep Vein Thrombosis (DVT): • S/s: edema of ankle, leg, initial low-grade fever, then high temperature & chills, tenderness & pain, changes in limb color & difference in circumference • Tx: IV heparin, bed rest, elevation of leg, analgesics, warm moist heat, antibiotics

19. Urinary Retention • Diuresis begins after birth to rid extra fluid (2000-3000 mL) • Trauma to bladder & urethra during birth or anesthesia may cause loss of tone, difficulty sensing need to void • Must assess abdomen frequently to prevent permanent damage to bladder from over distention. Check fundus to see if bladder is full. • Nursing interventions??

20. Vital Signs • May have slight elevation of temp in 1st 24 hours--dehydration. If 100.4 or above, suspect infection. • Rapid or thready pulse--sign of hemorrhage. • BP: monitor--still at risk of PIH. Methergine (oxytocic) can ↑BP. ↓BP could be sign of hemorrhage. • Can have orthostatic hypotension due to blood loss. Assist pt. with first trip to BR. Instruct pt to dangle legs and sit first, before rising. If dizzy, do not ambulate.

21. Breast Assessment • Breasts • Soft: Soft on palpation, day 1 & 2 • Filling: firmer & warmth, day 3 • Engorged: appear large, reddened, taut, shiny skin, warm, hard, tense & tender/painful on palpation • Mastitis (infection): only one part of breast is warm/reddened—UNILATERAL • Nipples: look for cracking, fissures, blisters, pain

22. Lactation • Engorgement: day 3 or 4. • If breastfeeding: • Encourage frequent breastfeeding. • Warm compresses or warm shower. • If not breastfeeding: • Cold compresses/ice, snug bra or breast binder, oral analgesics. • Breast care: • Wash daily with water and air dry –NO SOAP • Advise pt to wear nursing bra--1-2 sizes larger than bra during pregnancy. Avoid underwires. Use cotton nursing pads for leaking--keep nipples dry.

23. Discharge Instructions • Avoid/limit heavy lifting, stairs. • Good diet, increase fluids if breastfeeding. • Adequate rest, exercise/activity as tolerated. • Report fever, foul smelling discharge, increased pain or bleeding to MD. • Sex/contraception. • Follow up in 6 weeks with MD.

24. Postpartum Complications • Postpartum Hemorrhage • CAUSES: Uterine atony, lacerations, retained placental fragments • Risk factors: • ↑ uterine distension: multiples, polyhydramnios, macrosomia, fibroids • Trauma: rapid or operative birth • Placental problems: previa, accreta, abruptio, retained placental fragments • Atonic uterus: prolonged pitocin, magnesium sulfate or labor; ↑ maternal age or parity; uterine scar; chorioamnionitis; anemia; prior history • Inadequate blood coagulation: fetal death or DIC

25. Interventions: Fundal massage, ensure bladder emptying. If uterus is firm but bleeding persists, suspect laceration. Administer oxtocics (pitocin, methergine, hemabate, prostaglandins), blood replacement. Frequent assessment of bleeding, vital signs. Hemorrhage • MD: Bimanual massage, manual exploration of uterus, uterine packing, • D & C, hysterectomy.

26. Hemorrhage (cont.) • Lacerations: cervical, vaginal, perineal • Retained placental fragments: • can occur well after delivery. Maternal serum test for hCG or US. Possible D&C. • May see symptoms even after 1 week • Subinvolution: retained placenta, infection, fibroids • PO methergine, antibiotic.

27. Hematomas Cause: Trauma during the birth process Puerperal hematomas occur in 1:300 to 1:1500 deliveries Most common locations for puerperal hematomas are the vulva, vaginal/paravaginal area, and retroperitoneum Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams, preeclampsia, prolonged second stage of labor, multifetal pregnancy, vulvar varicosities, or clotting disorders Assessment: location, size, vital signs, pain, H&H Treatment: evacuation and repair of bleeding source by MD

28. Postpartum Infection • Puerperal Infection: Endometritis • infection of reproductive tract within 6 wks of childbirth • Increased risk with: • C-section • Prolonged ROM, chorioamnionitis • Retained placental fragments • Preexisting anemia • Prolonged/difficult birth, instrumental birth • Internal fetal monitoring or IUPC • Uterus explored after birth/manual removal of placenta • Preexisting vaginal infection (BV or chlamydia)

29. Postpartum Infection • Endometritis: infection of endometrium • Associated with chorioamnionitis & C-section • Signs & Symptoms • Can progress to pelvic cellulitis or peritonitis.

30. Endometritis • Ttreatments: • antibiotics • oxytocics such as methergine, • ↑ fluid intake • pain relief • diet • Nursing considerations: Fowler’s position or walking encourages drainage by gravity, gloves, strict handwashing • Usual course is 7-10 days • May result in tubal scarring & interfere with future fertility

31. Post op C/Section Complications • Paralytic Ileus • Wound Dehiscence • Wound infection

32. A mother is experiencing shaking chills during the hour following birth. What is the nurse’s initial action? • A. Take a rectal temperature • B. Notify the physician or nurse-midwife • C. Cover the woman with warmed blankets • D. Review the order sheet for antibiotic orders

33. \ • The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right. What is the appropriate nursing action? A. Encourage the client to breastfeed B. Assist the client to empty her bladder C.Assist the client to a prone position and place a small pillow under her abdomen D. Massage the fundus

34. A nurse is caring for a client who is 2 hours postpartum who complains of severe, unremitting vaginal pain and inability to void. The fundus is firm at the umbilicus with moderate lochia rubra, and the perineum appears edematous with significant bruising. The nurse suspects the client may have A. A fourth-degree episiotomy. B. Distended bladder. C. Hematoma. D. Endometritis.

35. A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage. What should be the nurse’s correct initial response? • A. Instruct the client to take her pain medication as prescribed • B. Notify the physician or nurse-midwife • C. Instruct the client to increase rest and seek assistance with household tasks • D. Instruct the client to call the physician or nurse-midwife if her temperature reaches 100.8.

36. 5. A 6-day postpartum client complains of fatigue and episodes of crying during the past two days. Which of the following statements is a correct response by the nurse? A. “This must be very difficult for you.” B. “This sounds like postpartum blues. It is a normal response to birth.” C. “You sound exhausted. Try and sleep when the baby sleeps.” D. “This sounds like postpartum depression; you should contact your physician or nurse-midwife for a referral to a counselor.”

37. 6. A nurse is caring for a client with a superficial thrombophlebitis. Which of the following is the most appropriate nursing action? A. Administer anticoagulants per order B. Elevate the affected limb C. Apply ice packs to the affected limb D. Administer antibiotics per order

38. Breastfeeding • www.youtube.com/watch?v=CIZ6rVzs4CE&feature=PlayList&p=BD065FA5F03CD81A&index=38 (Breastfeeding Basics) • www.youtube.com/watch?v=RuvJZGFOHU&feature=PlayList&p=1330DE183266B0BC&playnext=1&playnext_from=PL&index=3 (What’s the Big Deal?) • www.youtube.com/watch?v=Ox8ht-EVnQA&feature=PlayList&p=1330DE183266B0BC&index=8 (latch-on 1) • www.youtube.com/watch?v=WOQzEN_dcPc&feature=PlayList&p=1330DE183266B0BC&index=9 (latch-on 2)

39. The Amazing Newborn

40. Profile of a Newborn • Vital statistics • Weight:2.5 to 3.4 kg.Immediately after birth. Establishes baseline. Baby may lose up to 5-10%. • Length:18 - 21 inches • Head Circumference:32 - 35 cm • Chest Circumference:32 - 35 cm • Vital Signs: Heart Rate 120-160 bpm; Respirations 30-60 breaths/minute; • Temperature 97.6- 98.6 axillary

41. Profile of a Newborn • Temperature: Can be unstable. Guard against loss due to: • Convection • Conduction • Radiation • Evaporation • Dry immediately with warm blankets

43. Cardiovascular Changes after Birth • Closure of the ductus arteriosus/fetal shunts occurs when a neonate takes in oxygen through the lungs for the first time and when the lungs inflate, pressurein chest decreases (pulmonary artery) • Common to have acrocyanosis, investigate central cyanosis (look at mucous membranes) • Transition from fetal to postnatal circulation: “transitioning”

44. Critical Thinking During a prenatal examination, an adolescent client asks, "How does my baby get air?" The nurse would give correct information by saying: A) "The fetus is able to obtain sufficient oxygen due to the fact that your hemoglobin concentration is 50% greater during pregnancy." B) "The lungs of the fetus carry out respiratory gas exchange in utero similar to what an adult experiences." C) "The placenta assumes the function of the fetal lungs by supplying oxygen and allowing the excretion of carbon dioxide into your bloodstream."

45. Acrocynanosis Cyanosis

46. Respiratory • Breathing is a result of replacement of air for fluid • Big Squeeze with vaginal birth

47. Maternal history of diabetes Premature rupture of membranes Maternal use of barbiturates or narcotics close to birth Non-reassuring fetal monitoring strip C-section birth Cord prolapse Low APGAR Meconium staining Prematurity Postmaturity Small for gestational age Breech birth Chest, heart or respiratory tract anomalies Factors predisposing respiration problems

48. Newborn Assessment: Respiratory Distress • 5 symptoms of respiratory distress • Tachypnea • Cyanosis • Nasal flaring • Expiratory grunting • Retractions • Transition period (1-2 hrs post birth) vs signs of respiratory distress that persist

49. Sleep Wake Cycle • Supine position decreases risk for SIDS • Sleep 16 out of 24 hours, avg. of 3-4 hours at a time (wake q 2-3 for feeding) • Don’t add cereal to diet till 4-6 months of age • Infants should never sleep in parents’ bed

50. Gastrointestinal • Accumulation of bacteria in GI tract necessary for digestion and synthesis of vitamin K • Uncoordinated peristalsis • Limited ability to digest fats & starch (deficient enzymes) • Immature cardiac sphincter-regurgitates easily • Stools- • 1st meconium, sticky tarlike • 2nd-3rd day- transitional (diarrhea like) • BF: 3-4 light yellow/day. Formula: 2-3 bright yellow/day • Infants receiving phototherapy have bright green stools as a result of increased bilirubin excretion