POST PARTUM Lecture 8

1. POST PARTUM Lecture 8

2. Puerperium: “to bring forth” 6 wk > childbirth. • “4th trimester” - transition for woman/family (pregnancy ends/parenting role begins) • I. Physiological Changes of Post Partum Period A. Reproductive System Changes: UTERUS: contx’s begin > birth & delivery of placenta 1. placental site seals 2. Entire uterus contracts & reduces gradually for 8-10 days. “INVOLUTION”. Pt. in danger of hemorrhage uterus until involution is complete. Oxytocin released > uterine contx’s.

3. Fundus: assess for firmness. Palpate > delivery. • Remains @ umbilicus X 24 hrs. Soft aka “boggy” - danger of hemorrhage. Massage uterus! Uterus descends one finger breadth every day. • Delivery day, uterus @ umbilicus • 1st day PP uterus 1 FB ↓ Umbilicus • 2nd day PP uterus 2 FB ″ and so forth. • Support lower segment of uterus when palpating to prevent uterine eversion.

4. By day 10, uterus almost back to pre-pregnant size & position in pelvic cavity. [1000 grams→ 50 grams] No longer palpated in abdomen. • Full bladder raises fundal height, gives false reading. • Natural oxytocin released with breast feeding. ^ contractions . 2FB ↓ umb. on 1st day PP. • Breast fdg.offers little protection against hemorr.

5. Delay in uterine involution: retained placenta/clots - effective contraction of uterus not possible. Risk of PP Hemorr. Delay also with: • multiparous pt. [grand multip ] • exhaustion • multi-fetuses. • C/S involutes slower; d/t surgery & less initiation of breast feeding > delivery. After-birth pains = cramping caused by contractions • more in multi-parous women than in primips . • With Br. Fdg. because of release of oxytocin.

6. 2. LOCHIA • Placenta separates from spongy layer of uterus - decidua BASALIS. • Inner layer of decidua remains & forms new layer of endometrium . Outer becomes necrotic & sheds. • Consists of blood, fragments of decidua, mucus, bacteria. • 1st 3 days = rubra =”red” [blood] • >3 days = serosa = “pink” • 10th day – alba - “white” [up to 3 wks] • Total flow lasts about 4-5 wks • Should not be bright red; could be PP hemorrhage.

7. 3. CERVIX • Neck; remains slightly opened & contracts > delivery. • In 7 days, opening narrow as pencil. Os remains slit-like . 4. VAGINA • Slightly distended after birth. Kegel exercises ^muscle tone and strength. Important for lacerations. 5. PERINEUM • Can be edematous/ecchymotic • Ice x 24 hrs. then heat [Sitz] • Topical anesthetics creams/sprays apply for comfort. • Perineal massage relaxes perineum before delivery. May prevent episiotomy/laceration. Teach Kegels - tightening & releasing of perineal muscles. Improves circulation & healing of epis/lac.

8. Complications of Perineum: • Hematomas [blood from bleeding vessel] • Area of swelling on one side of perineum. • If small, absorbs in few days; apply ice & give analgesics. • If large bleed, to OR for evacuation & vaginal packing. • Common - forceps deliveries • Perineal Care - use warm water; wipe from front to back.

9. Laceration • size of baby, timing of delivery, tension on perineum. • Sutured & treated as episiotomies. • Analgesics, ice, topical creams, Sitz bath. • 1st degree = from base of vagina to base of labia minora. • 2nd “ = from base of vagina to mid perineum • 3rd = entire perineum to anal sphincter • 4th = entire perineum through anal sphincter & some rectal tissue. • Nothing into rectum - no rectal temps., suppositories, or enemas with 4th degree to avoid further damage. • Colace TID, ^ po fluids to promote BM. Ice X 24 hrs., Sitz baths TID; topicals. KEGELS!

10. SYSTEMIC CHANGES - Body returns to pre-pregnant state by 6 wks. Hormonal System: • Pregnancy hormones decrease w. delivery of placenta. • HCG & HPL disappear by 24 hrs. FSH rises 12 days - to begin new menstrual cycle. Menses resumes by 4-5 wks. if not Br. Fdg.

11. The Urinary System: • Loss of bladder tone d/t swelling & anesthesia ; urinating difficult. May not feel urge to void. • Hydronephrosis [enlargement of ureters] occurs after delivery & to 4 wks. PP. DIURESIS! • ↓ bladder sensitivity - ↑ risk for bladder infection - urinary stasis. • Avoid bladder damage - assess bladder q 1-2 hrs.til voids qs. Teach voiding q 2 – 3 hours. • Palpate abdomen gently, note location of fundus. When do you suspect full bladder? • During preg., 2000-3000 ml. of fluid accumulates in body - Client loses 5- 10 lbs. of water weight in 1st wk. How?

12. Circulatory System: Blood volume ^ 30 – 50% in pregnancy. With diuresis & blood loss @ delivery, blood volume returns to normal in 1-2 wks. • Blood loss for NSVD = 300 cc. & C/S = 500 cc. • Non pregnant: HCT=37 - 47% & HGB=12 - 16g/dL • Pregnant: HCT=32 -42 % & HGB = 11.5 – 14g/dL • HCT drops by 4 pts. & HGB drops by 1 g. for every 250cc. of blood client loses. • Patient should not be anemic entering delivery • Possible blood transfusion with large blood loss. • Average blood volume: pre-pregnant = 4000cc; pregnant state = 5250cc.

13. ^ Blood volume: provides adequate exchange of nutrients in placenta & compensates for blood loss during delivery. • HR remains ^ x 24-48 hrs. PP • With diuresis, HCT levels rise [^ hemoconcentration] reach pre-preg level by 6 wks. Plasma fibrinogen ^^ 50% during pregnancy & remains elevated 6 wks. PP. [^ estrogen levels] WHY? Can cause ^ thrombus formation. • Assess pts. legs/calves for s/s thrombus. • Rise in leukocytes; WBC ^ protective measure to prepare for stress of delivery. As high as 20-25,000.

14. Gastrointestinal System: • NSVD: bowels sounds. Eat right away. • C/S: bowel sounds hypoactive 1st 8 hrs. • Epidural/spinal: po clears after delivery, advance diet if +BS. • General anesthesia: usually NPO for ~ 6-8 hrs. • Duramorph/astromorph can cause N/V up to 12 hrs. • antiemetic meds. [Reglan/Zofran] . • BM - difficult/painful d/t lacerations/hemmorhoids. • C/S - BM 3rd - 4th day. GI activity slowed d/t surgery. • Can go home without BM if + flatus.

15. Integumentary System: Stretch marks [striae gravidarum] appear reddened on abdomen. Fade by 3-6 months; Pearly white marks may remain in lighter skinned pts. & darker marks in darker skinned pts. • Modified sit-ups strengthen abdomen

16. VITAL SIGNS PP Temperature: slightly ^ - dehydration during labor 1st 24 hrs. Returns to normal within 24 hrs. • T = 100.4 or > PP infection suspected. • Temp. also rises 3rd - 4th day with filling of breast milk • Observe for s/s infection - nurse usually 1st to detect ↑ temp. [universal sign of infection 100.4 x 2 readings, on days 2-10 PP] Pulse: HR ^ slightly x 1st hr. • Stroke volume & cardiac output also ^ x 1st hr. then decreases • 8-10 wks.,returns to pre-pregnant state. • Rapid, thready pulse- sign of PP hemorrhage, infection

17. Blood Pressure - Monitor carefully. 1st trimester Heart works faster to handle ^ volume. BP remains same. 2nd trimester BP drops slightly d/t lowered peripheral resistance in blood vessels as placenta expands rapidly. Heart beats faster, more efficiently d/t ^ blood volume. Pre-pregnant BP 120/80. Pregnant BP 114/65. 3rd trimester BP back to pre-pregnant value.

18. BP Complications ↓ BP [90/60 or less] with dizziness is “Orthostatic hypotension”; could signify hemorrhage. • Take BP/pulse lying/sitting/standing. Compare values. • Orthostatic: If BP drops 15-20 mmHg and pulse increases 20 bpm or more. Caution for falls. • Needs IV fluids. Take VS. Report to MD > order for CBC. ↑ BP [140/90 or >] could signify PP pre-eclampsia. • Notify MD. Could develop into serious complication. • Oxytocic meds [Pitocin] > delivery could ^ BP

19. Other Changes Exhaustion: • Common • Frequent rest periods • RN coordinates nursing care & infant feeding times • provide maximum rest time. Weight Loss: • Average wt. loss 12 lb. [infant & placenta] • 5 lbs. - diuresis & diaphoresis in wk. that follows. • Lochial flow - 2-3 lbs. • Total = approx. 19-20 lbs. {depends on total wt. gain} • At 6 wks. wt. may still be above pre-preg. weight. Return of Menses: > delivery FSH levels rise causing ovulation • No Br. Fdg.- menses resumes ~ 6 wks. • Lactation delays menses for several months (6 mos)

20. PSYCHOLOGICAL CHANGES OF POST PARTUM PERIOD: ADJUSTMENTS Taking-In Phase: • time of reflection for client regarding new role • may be passive or excited • talks at length about birth experience • on phone with family/friends recounting birth experience. • Usually lasts 1-2 days. • Delayed d/t pain r/t vaginal or C/S. Taking-Hold Phase: • woman makes own decisions regarding self & infant care. • Usually day 2 - 3. Occur on day 1 esp. if woman is multip. • Can occur later, depends on recovery process or cultural beliefs.

21. Letting Go Phase: • Woman gives up fantasy image of baby and accepts real child. • Occurs within few weeks of getting home • Needs time to adjust to new experience. Bonding: • Expressing maternal love & attachment toward new baby. Develops gradually. • Enface position: close eye contact with infant. • Healthy bonding - kissing, touching, counting fingers & toes, cooing, etc. • Factors Interfering with Bonding: difficult labor, separation @ birth (NICU)

22. Other Maternal Feelings of Post Partum Period • Abandonment: feelings that occur > birth of child; woman no longer center of attention. • Disappointment: infant does not meet expectations of mother/father. Eg. eye color; sex . • Post Partum Blues: d/t normal hormonal changes; Drop in estrogen/progesterone; lasts 1st few days of PP period. Occurs in 50% of women.

23. PP Depression: 30% of women exp. this. • Therapy & medication may be necessary. • Hx of depression & anxiety prior to pregnancy puts mother @ higher risk for developing this. • Can manifest itself up to 1 year > birth. • Screening tool: Edinburgh PP depression tool • Always refer to social worker to assess for degree of depression. • Ask: is mother able to take infant home without danger to self or baby? • Studies show breast feeding helps reduce symptoms d/t oxytocin “feel good” effect

24. MANIFESTATIONS OF POSTPARTUM DEPRESSION •  interest in surroundings •  interest in food • unable to feel pleasure • fatigue • health c/o • sleep disturbance • panic attacks • obsessive thinking •  hygiene •  ability to concentrate • odd food cravings • irritability • rejection of infant

25. PPD: Teaching • relaxation therapy • rest & nutrition • frequent contact with other adults Resource: The Post Partum Resource Center of New York, Inc. 631-422-2255 www.postpartumNY.org MANIFESTATIONS OF POSTPARTUM PSYCHOSIS • s/s depression • s/s manic • auditory hallucinations • delusions • guilt • worthlessness

26. Development of Parental Love & Positive Family Relationships: • Rooming In: most hospitals offer this; infant stays in room with mom 24hrs. (partial or complete) • Sibling Visitation: encourage siblings to visit to promote family togetherness.

27. LACTATION & BREAST FEEDING • Lactation starts regardless if pt. is breastfeeding or not. • Entirely up to mother • Must feel comfortable doing so. Advantages to Breast Feeding: • Promotes bonding between mother & baby. • High nutritional value for infant. • Promotes uterine involution thru release of oxytocin from posterior pituitary. • Reduces cost of feeding & preparation time.

28. Nurse has major role as educator of benefits & methods of breast feeding. Ways to teach new moms about lactation: videos handouts hands on demo lactation specialist [in clinical settings] Offer support Contraindications to Breast Feeding: • Mom receiving meds not appropriate for Br. fdg. [Lithium] • Exposure to radioactive compounds [thyroid testing]; pump & dump breast milk x 48 hrs. Flush in toilet. • Breast Cancer; HIV

29. Physiology of Lactation Body prepares for lactation during pregnancy; stores fat & nutrients; provide energy, vitamins, minerals in breast milk. • Early pregnancy, ↑ estrogen (placenta) stimulates growth of milk glands & size of breasts. • Colostrum: middle of pregnancy & day 1-3 PP, • Thin, watery pre-lactation secretion. Rich in antibodies; passes to baby in 1-3 days. • Breasts begin to get tender; fill up w. milk. Breast milk by 3rd to 4th day in response to: • falling levels of estrogen & progesterone > delivery of placenta. • ^ production of prolactin by anterior pituitary • Milk ducts become distended & fluid turns bluish-white

30. Physiology cont. • Infant suckling on breast produces more prolactin, which in turn stimulates more milk production. • Finally, oxytocin released > delivery of placenta causing mammary glands to send milk to nipples [let down reflex]. • Progesterone levels drop after delivery which leads to ↑ milk production.

31. Anatomy of Lactation Colostrum: protein, sugar, fat, water, minerals, vitamins, maternal antibodies. • Provides total nutrition for infant • Transitional breast milk by 3 – 4th day. • Mature breast milk by 10th day. • Each breast - 15-20 lobes of glandular tissue -alveoli. • Acinar or alveolar cells of glands form milk. • Each alveolus ends in a ductule. • Each alveoli produces milk, ejects it into ductules aka let down reflex; milk transported to lactiferous sinus and ejected into infant’s mouth.

32. Pathway of Droplet of Milk: • Milk → mammary ducts → reservoirs behind nipples [lactiferous sinuses] → infant’s mouth Foremilk: constantly accumulating. “Let-down reflex” –lets foremilk be available right away. • Triggered by sound of baby crying Hind milk: forms after let-down reflex. Has most calories; Feed until breast empty. Breast Milk: Provides complete nutrition for 1st 6 mos of life. • > 6 months, iron-fortified cereal. • Breast milk easier to digest than formula. • Iron in breast milk absorbed better than iron in formula.

33. Supply & Demand Response - Every time woman breast feeds, more prolactin produced which then produces ^milk. • Time Interval to ↑ milk volume. It takes approx. 30-60 min. to fill up breast after nursing. Assessment: Antepartum Changes • Breasts enlarge [each breast gains ~ 0.5 - 0.9 lb. or more] • Glands enlarge • Increased blood flow to breasts, causing blood vessels to enlarge & become more visible. • Areola [dark circle around nipple] enlarges and darkens • Small bumps on areola [Montgomery’s tubercles] enlarge and produce oils to soften nipples and keep them clean. • Teach moms no soap on nipples;may ^ irritation. • Lanolin; tea bags [wet] [tanic acid] on sore nipples.

34. Common Problems: Engorgement : milk enters on 3rd - 4th day; C/S - prior to D/C • breasts hard, painful to touch. • Warm soaks, hot showers, express milk manually, breast feed q 2-3 • Pumping produces more milk. Cabbage leaves; diuretic property. • nursing bra. • tight bra and ice packs x 24-36 hrs– why? • Analgesics [Tylenol 650 mg. q 4 - 6 hrs.prn] Sore/Cracked/Bleeding Nipples • Common - from improper positioning or not enough areola in infant’s mouth; may continue to feed; up to mom. Reposition infant. Reattempt nursing. • Rest the nipple; apply lanolin ointment prn. • Apply tea bag [tanic acid] natural healing property.

35. Plugged Duct • firm nodule under arm; temporarily blocked duct; relieved by infant sucking. Evaluate carefully since may be malignant growth. Warm compresses prn. Mastitis – • “inflammation”; milk duct/gland becomes infected. Poss. antibiotic therapy. Manual expression, continue to breast feed, frequent warm compresses.

36. Nursing Care : Promote successful breast feeding: • Encourage first feeding [L&D, PP; establish pt’s. desire to breast feed] • Emptying of breasts ~ 20 minutes • Teach: start on breast where she left off - maintains good supply. • Rest, relaxation, ↑ fluids by four 8 oz glasses/day. • Not enough fluids, ^ anxiety may lower milk production. • Nutritional Counseling: ^ 500 calories/day.

37. Health Teaching • Rooting – sign of hunger • Breast feed q 2-3 hrs. for 20-30 minutes • Teach “latching”: nipple and part of areola to prevent nipple irritation. Listen for swallowing. • Nursing Bra • Feeding & Burping [bottle fed infants] upright position • Nipple care: no soap; nipple creams -Lansinoh • Avoid drugs, alcohol, smoking

38. FORMULA FEEDING Feeding Skills • Position upright position- support head and shoulders] • Formula [Similac, Enfamil, Isomil; all have iron] • milk or soy based • Burp Safety Tips • never prop bottle; choking or ear infection. • ^ amt. ½-3/4 oz./day; feed q 3 – 4 hrs. x 24 hrs. Discharge Follow up: • Telephone calls & home visits [if needed] • Help line; Support groups [La Leche]

39. NURSING MANAGEMENT OF POST PARTUM CLIENT Assessment – minimum of twice daily • Vital signs • Emotional Status • Breasts • Fundus, lochia, & perineum • Voiding & bowel function - flatus, BM • Legs [+ Homan’s sign, ankle edema ] • S/S complications [PP hemorrhage, infection, ↑ BP ] Nursing Care Safety • Prevent hemorrhage- massage uterus on admission and q 4 for first 8 hrs. • Prevent falls – assess when getting out of bed for 1st 8 hrs. Assist when necessary. Check labs for low H&H.

40. Bowel function (1-3 days to resume). • Stool softeners, as ordered [Colace] • Encourage ambulation • Increase dietary fiber • Provide adequate fluid intake Health teaching & discharge planning • Reinforce self care -hand washing, peri care, Self-breast exam q month; S/S PPD Comfort Measures Ice , Sitz Baths, Topical Anesthetics Analgesia, Kegels for NSVD; modified sit-ups for NSVD & C/S, Breast Care

41. Birth Control Plans Family Planning options [condoms, depo, OC’s, IUD] Exercises Keep 6 week PP appt. Maternal Warning Signs to Report • a) Heavy Vaginal Discharge [poss. hemorrhage] • b) Pelvic or perineal pain [traveling clot] • c) Fever [temp 100.4 or greater = infection] • d) Burning sensation during urination [UTI] • e) Swollen area on leg ; painful, red, or hot • f) Breast: painful, red, hot area [mastitis]

42. Infant care a] Bathing, cord care, circumcision care, diapering b] Feeding, burping, scheduling feedings [mom can keep chart] c] Temperature, skin color [dusky], newborn rash, jaundice d] Stool & voiding [BM’s ; 6 or more voids/day] e] Back to Sleep [SIDS] Newborn warning signs: 1. Diarrhea, constipation 2. Colic, repeated vomiting esp. projectile vomiting 3. Fever [temp. 100.0 Rectal or greater] 4. S/S inflammation/ infection @ cord stump [yellow drng.] 5. Bleeding @ circumcision site 6. Rash, jaundice 7. Deviation from normal patterns [long period of sleep >5 hrs.; projectile vomiting, etc. R/O sepsis; intestinal obstruction]