Post Partum Care & Teaching

1. Post Partum Care & Teaching Presented by: Anna Mackey, RN BSN Authors: Tina Schmidt, RN & Evelyn Hom, RN, MSN, CNS

2. Objectives 1. Discuss psychological changes during the puerperium. • Discuss the role of the postpartum nurse in providing care and instruction to women during the puerperium. • Describe the emotional/ psychological needs of postpartum women.

3. Postpartum Period • Puerperium – Latin “puer” means child and “parere” means to bring forth • Immediate PP – “Fourth Stage Labor” birth to two hours • Long term PP – “Fourth Trimester” period of time from the delivery of the placenta to return of woman’s reproductive system to its non-pregnant state (typically 6 weeks)

4. Uterus after delivery=weighs about 1,000 gms (2lb 4oz) Fundal height Immediately PP = Midway between umbilicus and symphysis pubis One hour PP= At the umbilicus or slightly below umbilicus 12 hours PP= 1 cm above umbilicus 24 hours PP = 1 cm below umbilicus Day 2 to day 7= Decreases about 1 cm/day Day 7= Just palpable at the symphysis Day 10-14= Non palpable Week 6= Returns to non-pregnant size Uterus and Involution

5. Reasons for Delayed Involution • Multiple gestation • Polyhydramnios (AFI > 25) • Prolonged labor • Grand multiparity (> 5) • Prolonged or excessive analgesia • Extended period of use of prostaglandins or Oxytocin for labor induction and augmentation • Retained placenta • Uterine fibroids • Cesarean birth

6. Uterine “After-pains” • Painful uterine contractions that occur after delivery of the baby • Intensity associated with: • Uterine tonics – Oxytocin administered post partum • Breastfeeding • Conditions producing over distension of the uterus • Multiple fetuses • Polyhydramnios • LGA and macrosomic fetus • Intensity greatest immediate PP and diminishes 1st wk

7. Uterine“After-pains” • Nursing Care: • Pain medication • Educate patient that: • Normal for involution process • During breast feeding that it is a positive sign baby is properly latched and getting colostrum

8. Lochia • Composed of endometrial tissue, blood and mucous. • Clots: • Can be normal part of lochia if small and patient has had some pooling • Should be decreasing in size and amount as patient moves through postpartum period

9. Stages of Lochia Rubra • Dark red or brownish with clots • Contains blood and tissue fragments • Fleshy smell • Duration: 1-3 days Abnormal Findings: Foul smell, numerous or large clots, quickly saturates pad.

10. Stages of Lochia Serosa • Pink, brown tinged, serosanguineous consistency • Contains blood, ertyhrocytes, leukocytes, mucous and decidua • Fleshy odor • Duration: 3-10 days Abnormal Findings: Foul smell; quickly saturates pad; serosa

11. Stages of Lochia Alba • Yellowish-white • Contains mostly leuckocytes, as well as decidua, mucous, bacteria and epithelial cells. • No strong odor • Duration: 10-14 days Abnormal Findings: Foul smell, saturated pad, pink or red lochia, discharge beyond 6 weeks

12. Lochia • Average amount 240-270 mL (8-9 oz) • Scant = one inch • Light = 4 inches • Moderate = 6 inches • Heavy = Saturate one pad in one hour • Hemorrhage = Saturate one pad in 15 minutes

13. Cardiovascular • Heart position returns to normal from being shifted by diaphragm and uterus within about 2 weeks • Cardiac output decreases rapidly following delivery returning to normal by 2-3 weeks PP • Varicosities improve with the decrease in cardiac output

14. Vaginal Delivery: normal blood loss = 500mL C/S: normal blood loss = 1000mL Normal blood loss during first week PP is another 800 mL Return to non-pregnant circulating volume in 3-4 weeks post delivery Blood Volume Changes

15. Lab Values: Hct, Hgb • For every 500 ml of blood loss, the hemoglobin will drop 1-1.5 gram/dl and the hematocrit will drop 3 - 4% • Hct rises immediately after delivery due to blood volume loss & dehydration(28 - 35 %) • Returns to normal 4-5 wks (37 - 47%) • PP anemia is common. Anemia usually considered when Hgb less than 10 and Hct is less than 30% • Clotting Factors remain elevated in early PP period, return to normal in 4-5 wks post delivery

16. Lab Values: WBC • WBC’s- may increase to 20,000/mm3 or more during 1st 10 days PP • Average PP WBC is 14,000 - 16,000/mm3 • Slightly higher with cesarean delivery and traumatic deliveries due to body’s inflammatory response • An increase of more than 30% over a 6-hour period is indicative of infection • CBC with differential is indicated if the WBC count has significantly increased or the patient has a risk factor or is symptomatic for infection

17. Vital Signs • BP- should be similar to intrapartum values • High BP may suggest PIH • Low BP may suggest orthostatic hypotension or a late sign of hypovolemia and/or hemorrhage • Pulse - bradycardia normal immediate PP(40-80 bpm) • Tachycardia – abnormal and suggests hemorrhage or infection • Respiratory Rate- usually normal 16-24/min • Temperature– Normal slight elevation 1st 24 hrs PP > 100.4 degrees F indicates infection

18. Teaching Activity/Exercise • Do not overdo…Only care for self and baby • Lochia guides activity level • Limit stairs/lifting • Gradual resumption of activity • Start kegels and walking right away • PP exercises for abdomen— Seek advice from provider. Usually after 6 weeks pp.

19. Edematous immediately PP 1 week PP- about 1cm Easily distensible several days PP Internal OS closes by 2 weeks PP Abnormal Finding: Presence of free flowing bright red blood Cervix

20. Rugae reappears 3 weeks postpartum Return to near pre-pregnant state 6-8 weeks post partum Normal mucus production returns with ovulation Need to educate patient - nothing in the vagina for 6 weeks post partum Vagina

21. Menstrual Cycle • Non-lactating: • 40-45% will resume at 6-8 wks • 75% will resume at 12 weeks • 100% will resume within 6 months • Lactating: • As early as 12 wks or as late as 18 months

22. Ovulation • Non-lactating: 50% will be anovulatory first few cycles of menses • Lactating: 80% will be anovulatory first few cycles of menses

23. Teaching Sexuality • Nothing in the vagina for first 4-6 weeks: “No intercourse. No tampons. No douching” • Increased risk for acquiring STD’s • Women can still ovulate without menses! • Lowered interest due to hormones/fatigue • Dry vaginal mucosal lining…Use lubrication • Let-down reflex may occur during intercourse

24. Perineum • Episiotomy is normally without redness, discharge, or edema • Intact perineum may still have edema and/or ecchymosis secondary to pressure at delivery • May experience burning with urination • Healing takes place in 1-2 weeks

25. Lacerations • 1st degree: through the skin and structures superficial to the muscles • 2nd degree: above plus through the muscles of the perineum • 3rd degree: above plus through the anal sphincter muscle • 4th degree: above plus through the anterior rectal wall

26. Teaching Perineal Care • Good hygiene – hand washing, peri-bottle and frequent pad changes • Comfort measures • Ice first 24 hours • Sitz baths after 24 hours • Witchhazel • Stitches dissolve in 1-2 weeks, • Itching normal as skin heals • Infection uncommon, watch for symptoms: fever, abnormal discharge, foul smelling discharge • Monitor for dehiscence of repair

27. Hemorrhoids • Grape-like clusters at the anus • May not be visible or palpable until straining for BM • Should shrink in in about three weeks • Teach: • Avoid constipation and straining • Soft diet with foods or drink that normally help the patient have bowel movements • Sitz baths and witchhazel • See provider if still a problem after 3 weeks

28. Pulmonary function returns to normal in 6-8 weeks as diaphragm descends Acid/base balance returns to pre-pregnant levels by 3 weeks PP Oxygen Saturations should be above 95% Patients at risk for pulmonary compromise: Fluid overloaded Preeclamptic patients, particularly those on Magnesium Sulfate Cardiac Patients Asthmatics Smokers Patients with preexisting pneumonia or URI Respiratory System

29. Appetite is strong immediately PP period Decreased GI motility can lead to constipation BM should resume 2-3 days PP Average weight loss of 12 lbs at delivery plus 5 lbs in first week due to diuresis Cesarean birth: Greater incidence of distension, discomfort, constipation and illeus R/T trauma and manipulation of bowel GI System

30. Eat well balanced diet of all foods in moderation. Increase intake by 500 calories/day for breastfeeding (approx ½ sandwich) Consult provider if plan to diet prior to 6 wks PP or while breastfeeding Interventions to prevent constipation: ambulation, increase fluids and high fiber, stool softeners, laxatives, foods and fluids that usually make patient have BM Having BM will not cause them to tear repairs Call provider if no BM by 4th day PP GI System Teaching

31. Fluid shifts common- edema and swelling (patient may weigh more!) Uterus that is elevated and laterally displaced may indicate filling bladder or urinary retention. Full bladder will cause increased lochia. Diuresis begins at 12 hours-48 hours PP and continues for about one week. Kidney function normal by 4 wks PP (GFR returns to pre-pregnant rate, ) Increased risk for UTI first 6 wks PP Urinary System

32. Common to feel numb first few days PP, so empty bladder frequently Tricks to assist voiding: Ice to perineum to prevent swelling (first 24 hrs to reduce edema and for analgesic affect) Administer analgesic prior to void if have sutures Lean forward on toilet – puts pressure on bladder Sound of running/trickling water Peppermint oil Blowing bubbles in cup of warm water Shower, sitz bath (warm water increases urge to void) Urinary System Teaching

33. Teach patient symptoms of UTI Urgency Frequency Dysuria Fever, chills Back or lower abdominal pain Decrease in Level of Consciousness – confusion Increase in fatigue / lethargy Urinary System Teaching

34. Diastasisrecti (rectus muscle) may separate 2-4 cm. Will resolve by 6 wks. Most common in black patients Joint stabilization returns in 6-8 wks post partum Teach caution when starting a vigorous exercise program or stomach exercises prior to 6 wk PP follow-up visit. Need to consult with care provider Musculoskeletal System

35. Hyperpigmentation of face (chloasma), abdomen (lineanegra) and areaolas gradually lighten and may or may not disappear Stretch marks will gradually fade Hair loss will occur within 6 weeks Diaphoresis for first several weeks, especially at night (night sweats) Integumentary System

36. Rh Sensitivity / Isoimmunization: Administer anti (D) Immune Globulin within 72 hours PP to prevent formation of maternal antibodies against Rh positive fetal blood cells and destroy Rh positive cells. Rubella titer less than 1:8 ratio: Administer Rubella Virus Vaccine prior to discharge. Instruct patient to avoid pregnancy next 3 months. Immune System

37. Breasts • Prolactin – Initiates milk production • Oxytocin – Milk “let-down reflex” • Milk removal from breast (by breast feeding or pumping)– facilitates continued milk production • Lactating: • Colostrum: 1st week PP • Transitional milk: between 7-14 days • Mature milk comes in after 2 weeks

38. Breasts • Non-lactating: breast changes of pregnancy regress in 1-2 weeks postpartum • Teach: • Well fitting support bra 24 hours a day for 2 weeks • No heat or warm water/shower on breasts • No stimulation of breasts • Ice packs to breast maximum 20 minutes at a time • No longer use lactation suppressive medications due to rebound engorgement

39. Engorgement • Symptoms • Engorgement begins at 2nd - 3rd day and subsides in 24 - 36 hours • Tender, swollen, and firm breasts (including the areola) making it difficult for infant to latch – like trying to latch on to a basketball • Slight fever (<100.4 F)

40. Engorgement • Interventions to prevent engorgement: • Encourage early feedings • Encourage frequent feedings • Minimum 8 feedings/ 24 hours • Minimum 10 - 15 minutes per breast • Avoid supplement for infant unless medically indicated • Assess and ensure correct positioning and latch

41. Engorgement • Nursing Care: • Wear a well fitting support bra • Warm compresses or shower prior to feeding • Gentle massage of breasts from axilla towards nipple to stimulate letdown • Express milk by hand or pump to soften areola tissue to assist infant in latch • Ice packs to axilla for a maximum 20 minutes at a time after feeding

42. Psychological System • Role Changes: Grieve the loss of old role and acquire new role and expectations • Acquiring the Role of Mother (Rubin, 1975) • Taking in phase: days 1-2; passive, dependent, wants care for self; asks many questions • Taking hold phase: 4 -5 wks; begins to focus on needs of infant, receptive to teaching, high fatigue • Letting go phase: 5+ wks; sees infant as separate individual, refocuses on relationship with partner, may return to work/uses babysitter

43. Attachment • Definition: The enduring emotional bond between parent and infant (Klaus & Kennell, 1976) • Essential to infant’s growth and survival • The mother-infant bond is the basis on which all subsequent attachments are formed and plays major role in infant developing a sense of self (Bowlby, 1969) • Patterns of attachment vary with culture

44. Attachment Behaviors • Observable maternal attachment behaviors: • Touching • Holding • Gazing • Cuddling • Kissing • En face position • Observable Paternal attachment behaviors: • “Engrossment”: to stare for long periods of time

45. Attachment Behaviors • Observable infant attachment behaviors (before 8 weeks): • Cuddling into mother • Following with eyes and gazing • Providing clear feeding cues and needs cues • Crying • Grasping • Smiling • Babbling

46. Assessing Attachment • Maternal factors to consider that might impede attachment: Length of labor, analgesia used, type of delivery, high risk pregnancy, physical health, age extremes, intelligence, wanted or unwanted pregnancy, past experience with own mother, gravida/para, socioeconomic status, degree of maternal support available, relationship with FOB, prolonged separation from infant, how well infant matches maternal/parental expectations

47. Assessing Attachment • Paternal Factors to Consider • How involved with the pregnancy/baby, maturity level, age, past experience with infants, own expectations for infant, relationship with infant’s mother, relationship with own father

48. Assessing Attachment • Infant factors to consider • Gestational age, multiple birth, admission to SCN/NICU, transferred to tertiary setting, physical anomalies, gender, temperament, degree of alertness

49. Prenatal Mal-Attachment Behaviors • Excessive moodiness • Emotional withdrawal • Excessive preoccupation with own personal appearance – ignoring infant • Numerous physical complaints • Failure to prepare for infants arrival during last trimester (although had opportunity and resources)

50. Postnatal Mal-Attachment Behaviors • Negative comments about baby’s appearance • Disappointment about baby’s gender • Failure to look at, touch, or handle infant • Failure to respond to signaling behaviors • Failure to name infant • Failure to meet infant’s physical needs