Post Partum PeriodChapters 15 & 16

High Risk Chapter 22

Mary L. Dunlap MSNFall 2015

Post Partum

• Begins immediately after child birth through the 6th post partum week

• Reproductive track returns to nonpregnant state

• Adaptation to the maternal role and modification to the family system

Safety for Mother and Infant

• Prevent infant abductions

• Check ID bands

• Educate mother about safety measures

Infant ID Bands

Security Band

Clinical Assessment

• Receive report

• Review Antepartum and Intrapartum history

• Determine educational needs

• Consider religious and cultural factors

• Assess for language barriers

Post Partum AssessmentBUBBLE-EE

• Breast

• Uterus

• Bladder

• Bowel

• Lochia

• Episiotomy

• Extremities

• Emotion

Vital signs

• Temperature

• Pulse

• Blood pressure

• Respirations

Pain Assessment

• Determine source/location and pain level

• Interventions- based on pain

• Document location, type, pain level and intervention

• Reassess in 30 min and document pain level

Breast

Initial assessment

•Inspect for size, contour, and asymmetry

•Note if nipples are flat, inverted or erect

Ongoing assessments

•Check for cracks, redness, or fissures

•Engorgement

•Mastitis

Breast Care Lactating Mother

• Supportive bra

• Clean areola & nipples with water

• Air dry

• Express colostrum apply to areola & nipple

• Change breast pads frequently

Breast CareNon-Lactating Mother

• Avoid stimulation

• Wear support bra 24hrs

• Ice packs or cabbage leaves

• Mild analgesic for discomfort

Assessment of Uterus

• After birth midline between umbilicus and the symphysis pubis

• Within 1h returns to the umbilicus• Descends 1 cm/day• Consistency- firm/boggy• Height- measured in fingerbreadths• Fundal massage procedure 22.1 p 753

Nursing care

• Boggy fundus- massage until firm

• Medications- Pitocin, Methergine, Hemabate

• Teach new mom to massage her fundus

Afterpains

• Intermittent uterine contractions due to involution

• Primiparous-mild

• Multipara- more pronounced

• Breastfeeding causes an increase in contractions due to release of oxytocin

Nursing Interventions

• Patient in a prone position and place a small pillow to support her abdomen

• Ambulation

• Medicate with a mild analgesic

Bladder

• Monitor for bladder distention and displacement of uterus

• Assess for voiding difficulty

• Monitor output

• Postpartum Diuresis

Nursing care

• Encourage frequent voiding every 4-6 hours

• Monitor intake and output for 24 hrs

• Early ambulation

• Void within 4-6 hrs after birth

• Catheterize if unable to void

Preventing Stress Incontinence

• Vaginal delivery causes direct pelvic muscle trauma and disruption of fascial support contributing to the development of urinary stress incontinence.

• Prevention strategies: Loss weight, avoid bladder irritates, decrease fluid intake

• Kegal exercises

Teaching Guidelines 16.3. 502 pg

Bowel

• Relaxin depresses bowel motility• Progesterone ↓ muscle tone• Diminished intra-abdominal pressure• Incontinence if sphincter lacerated (4th

degree)• Spontaneous BM 2nd to 3rd post partum

day• Normal bowel pattern 8-14 days

Nursing Care

• Increase fiber in diet

• 6-8 glasses of water or juice

• Stool softener- especially 4th degree

• Laxative

• Sitz bath for discomfort

• Medications for hemorrhoids

Lochia

• Rubra

• Serosa

• Alba

• Documentation

Lochia Assessment

Scant

• 1-2 in

• About 10 ml

Small

• 2-4 in

• About 10-25 ml

Moderate

• 4-6in

• About 25-50 mL

Heavy

• Saturated pad greater than 6 in

• About 50-80 mL within 1 hr.

Nursing Care

• Educate on the stages of lochia

• Increase in lochia, foul odor or return to Rubra lochia is not normal

• Change Peri pad frequently

• Peri care after each voids to decrease risk of infections

Episiotomy

• 1-2 inch incision in the muscular area between the vagina and the anus

• Assess REEDA

• Lacerations

• Episiotomy care

Nursing Care

• Peri care

• Ice packs

• Dry heat

• Topical medications

• Sitz bath

Teaching guidelines 16.1 p. 499

Extremities

• Increases the risk of thromboembolic disorders

• Risk factors venous stasis, altered coagulation and vascular damage due to birth process increase risk of clot formation

Assess for Thrombosis

• Homan’s sign

• Assess extremities

• Monitor for signs of PE

Post Partum Assessment

•Post Partum Assessment Video

Emotional Status

• Bonding is a vital component of the attachment process. It helps establish parent infant attachment and a healthy loving relationship.

• Bonding takes during the first 30 to 60 min. after birth

Emotional Status

Bonding process helps to lay the foundation for nurturing care

•Touch- skin to skin

•Eye contact

•Breastfeeding

•Engrossment

•Factors that interrupt bonding

Engrossment

Seven Behaviors

•Visual awareness

•Tactile awareness

•Perception NB is perfect

•Focus is on NB

•Aware of NB’s distinct features

•Extreme Elation

•Increase sense of self esteem- proud

Tactile Awareness

Bonding

Factors that may interfere with bonding process

•Stress over finances

•Lack of support

•Cultural beliefs

•Interruption of process-sick child NICU

Transitioning to parenthood

• Difficult and challenging

• Provide emotional support

• Accurate information

• Nursing goal create a supportive teaching environment

Assuming the mothering role

Rubin’s three phases

• Taking –in

• Taking –hold

• Letting-go

Taking in Phase

Fathers Development Process

Three stages

•Expectations

•Reality

•Transition to Mastery

Maternal Physiological Adaptations

Hematological System

• Decrease in blood volume

• Elevated WBC

• Increased Fibrinogen

Hormonal Levels

• Estrogen and Progesterone decrease

• Anterior pituitary → prolactin for lactation

• Expulsion of the placenta- placental lactogen, cortisol, growth hormone, and insulinase levels decrease

• “Honeymoon phase”- insulin needs decrease

Neurological System

• Maternal fatigue

• Transient neurological changes

• Headaches

• Carpel tunnel improvement

Integumentary System

• Darken pigmentation gradually fades

• Hair regrowth returns to normal in 6-12 months

• Striae( stretch marks) fade to silvery lines

Immune System

Rubella

• Administer to nonimmune mothers

• Safe for nursing mothers

• Avoid pregnancy for 1 month

• Flu-type symptoms may occur

Immune System

• Rho (D) immune globulin

• Mother Rh negative, infant Rh positive

• Negative coombs’ test

• 300 mcg of RhoGam within 72 hrs after delivery

• Card issued to mother

Reproductive System

• Involution of uterus

• Healing of placental site

• Vaginal changes

Menstruation and Ovulation

Nonlactatating mother

• Menstruation returns in 7-9 wks, can take up to 3mo.

• First cycle may be anovulatory

Lactating mother

• Delayed ovulation and menstruation

Musculoskeletal System

• Relaxation of pelvic joints, ligaments, and soft tissue

• Muscle fatigue and general body aches from labor and delivery of newborn

• Rectus abdominis diastasis

Postpartal Surgical Patient

• Tubal ligation

• Cesarean birth

Breast Feeding

• American Academy of Pediatrics (AAP) recommends infants be breastfed exclusively for first 6 months of life

• Breastfeeding should continue for at least 12 months

• If infants are weaned before 12 months, they should receive iron-fortified infant formula

Breast Feeding

• Optimal method of feeding infant

• Breast milk- Bacteriologically safe, fresh, readily available

• Milk transition: Colostrum, Transitional milk & mature milk

• Breastfeeding benefits 18.2 p 583

• Nursing Care Plan 18.1 pg 587

Contraindications to Breastfeeding

• Maternal cancer therapy/ radioactive isotopes

• Active tuberculosis

• HIV

• Maternal herpes simplex lesion

• Galactosemia in infant

• Cytomegalovirus (CMV)

• Maternal substance abuse

Breast Feeding

Keys to successful breast-feeding

•Initiate first feeding within first hr.

•No supplements

•Feed on demand, unrestricted at least 8-12 feeds in 24hrs

•Avoid artificial nipples

•Mother and newborn to stay together

Breastfeeding

• Cue signs

• Latch-on

• Assess for milk let down

• Scoring tool table 18.6 p 509

Cue Signs

• Rooting

Latch on

•Open mouth gape

•Infant tip of nose,

cheeks and chin

touching breast

THE LATCH SCORING TOOL

Parameters 0 Point 1 Point 2 Point

L LATCH

Sleepy infantNo latch achieved

Hold nipple in infants mouth to

latch & suckStimulate to suck

Latches on rhythmic sucking

A:Audible swallow

none Few with stimulation

Spontaneous and Intermittent

TType of nipple

Inverted Flat Protruding

C Comfort of nipple

Engorged cracked bleeding sever discomfort

Filling, reddened, small blistersMild to mod. discomfort

Soft nontender

HPositioning

Nurse must hold infant to breast

Minimal assistance then

mother takes over

No help needed

Breastfeeding

Positions

• Cradle hold

• Foot ball

• Side lying

Cradle Hold

Foot Ball Hold

Foot Ball Hold

Side Lying

Breastfeeding

• A newborns stomach is the size of a small marble and can hold 5-7 cc’s. This is matches the amount of colostrum produced

• From 7-10 days it increases to the size of a golf ball and can hold 1.5 to 2 oz

Breastfeeding

• Newborns nurse on average 8-12 times/24hrs

• Feed by cue signs about every 1-3 hours

• Should have no more than one 4 hr period

• Teaching Guidelines 18.4 pg.588

Milk Expression

• Manually

• Manual or handheld breast pump

• Electric breast pump

• Hand Express

Manual Pump

Electric Hand Held

• Electric Pump

Electric Pump

Breast Milk Storage

• Room temperature- 4 hrs

• Refrigerator- 5-7 days

• Deep freezer- 6-7 months

Ineffective Breastfeeding

• Incorrect latch-on

• Inverted nipples

• Breast engorgement

Special Considerations

• Sleepy baby- use gentle stimulate to

bring to alert state

• Fussy baby- use calming techniques

• Slow weight gain- evaluate breastfeeding

Formula Feeding

• Formula preparation

• Periodically check nipple integrity

• Bottle preparation

Teaching Guidelines 18.5 p. 591

Discharge Teaching

• Fundus and Lochia

• Episiotomy care

• Incision care

• Signs of PP infection- table 22.3 p 761

• Elimination

• Nutrition Box 16.4 p 504

Discharge Teaching

• Exercise- 16.2 p 501

• Activity

• Pain management

• Sexual activity

• Contraception

• Blues

• Community resources

Postpartum Women at RiskChapter 22

Postpartum Hemorrhage

• Blood loss >500 ml of blood after a vaginal birth

• 1000 ml of blood after cesarean section

• Major hemorrhage >2,500 mL

• Transfusion of >5 units

• Any amount of bleeding that places mother in hemodynamic jeopardy

• Table 22.1 pg 748

Postpartum Hemorrhage

• 5 T’s- factors associated with PPH

• Tone

• Tissue

• Trauma

• Thrombin

• Traction

• Table 22.2 pg. 751

Tone / Atony

• Altered muscle tone due to overdistention

• Prolonged or rapid labor• Infection• Anesthesia

Tissue

• Retained placental fragments

• Uterine inversion

• Clots

• Subinvolution

Trauma

• Cervical lacerations

• Vaginal lacerations

• Hematomas of vulva, vagina or peritoneal areas

Trauma

Hematoma

•Localized collection of blood in connective or soft tissue under the skin( caused by laceration to blood vessel)

•Risk factors

•Signs and symptoms

•Management

Thrombin

• Disorders of the clotting mechanism

• This should be suspected when bleeding persists without an identifiable cause

Management of PPH

• Frequent VS q 15 min times 1 hr.

• Fundal massage

• Administer medications

• Monitor blood loss for amount

• Maintain IV

• Type & cross match

• Empty bladder

Fundal Massaging

• Procedure 22.1

pg. 753

Uterotonic Drugs

• Oxytocin (Pitocin)

• Misoprostol (Cytotec)

• Dinoprostone (Prostin E2)

• Methylergonovine maleate (Methergine)

• Prostaglandin (Hemabate)

Drug Guide 22.1 pg.754

Management of PPH

• Balloon Tamponade Catheter

Post Partum Hemorrhage

• PPH Simulation

• PPH Noell

Thromboembolic Conditions

• Thrombosis (blood Clot) can cause inflammation of the blood vessel (Thrombophlebitis) which can cause Thromboembolism (obstruction of blood vessel)

Assessment Superficial

• Tenderness and pain in extremity

• Warm and pinkish red color over thrombus area

• Palpable- feels bumpy and hard

• Increased pain when ambulating

Nursing Care

• NSAIDs for pain

• Bed rest elevate affected leg

• Warm compresses

• Elastic stockings

• No anticoagulants required

Assessment For Deep Vein Thrombosis

• Calf swelling

• Warmth

• Tenderness

• Pedal edema

• Diminished peripheral pulses

• Color blue

• Homan’s sign

Nursing Care

• Bed rest

• Elevate effected leg

• Continuous moist heat

• TED hose both legs

• Analgesics PRN

• Anticoagulation therapy

Thrombosis

Patient Education

•Anticoagulation Teaching Guidelines 22.1 pg. 758

•Eliminate risk factors

•Continue using Compression stockings

•Avoid constrictive clothing & prolonged standing

•Danger signs

Pulmonary Embolism

• Abrupt onset: chest pain, dyspnea, diaphoresis, syncope, anxiety

• ABC response

Postpartum Infections

• Temp of 100.4 or higher after the first 24 hrs. for 2 successive days of the first 10 PP days

• Temp of 102.2 or greater within first 24 hrs.- sever pelvic sepsis Group A or B streptococcus

Postpartum Infections

• Endometritis

• Wound infection

• UTI

• Mastitis

• Septic Pelvic Thrombophlebitis

• Box 22.1 Risk Factors

• Table 22.3 pg. 761 signs & symptoms

Metritis

• Involves the endometrium, decidua and adjacent myometrium of the uterus

• Lower abdominal tenderness or pain

• Temperature

• Foul-smelling lochia

Nursing Care

• Administer broad spectrum antibiotic

• Provide analgesia

• Provide emotional support

Wound Infection

• Sites- Cesarean incision, episiotomy and genital tract laceration

• Drainage

• Edema

• Tenderness

• Separation of wound edges

Nursing Care

• Aseptic wound management

• Frequent perineal pad changes

• Good hand washing

• Administer antibiotics

• Analgesics

Urinary Tract Infection

• Burning and pain on urination

• Lower abdominal pain

• Low grade fever

• Flank pain

• Proteinuria, hematuria, bacteriuria, nitrates and WBC

Nursing Care

• Frequent emptying of bladder

• Increase fluid intake

• Antibiotics

• Analgesics

• Peri care

Mastitis

• Infection of the breast (one sided)

• Seen first 2 weeks after delivery

• Most common organism staphylococcus aureus

• Infected nipple fissure - to ductal system involvement- edema obstructs milk flow in a lobe- mastitis

Mastitis Symptoms

• Flu like symptoms

• Tender, hot, red area on one breast

• Breast distention with milk

Nursing Management

• Empty the breast by increasing the frequency of nursing or pumping

• Control infection- Antibiotics

• Analgesics

• Warm/ice compresses

• Assess infants mouth for thrush

Postpartum Infection Education

• Continue antibiotics

• Monitor temperature and notify provider if temp greater then 100.4

• Watch for signs and symptoms of a recurrence

• Practice good hand washing

• Teaching Guidelines 22.2 pg. 765

Postpartum Affective Disorders

• Plummeting levels of estrogen and progesterone after delivery contribute to the mood disorders

• Disorders based on their severity:

Postpartum blues

Postpartum depression

Postpartum psychosis

Postpartum Blues

Transient periods of depression during the first 1 to 2 weeks postpartum

•Tearfulness

•Sad feeling

•Confusion

•Insomnia

•Feel overwhelmed

Nursing Care

• Remind mom that the “Blues” are normal

• Encourage rest

• Utilize relaxation techniques

• Share her feelings with her partner

• If symptoms do not resolve and progress to depression medical treatment needs to be sought

Postpartum Depression

• Gradual onset and is evident within first 6 wks.

• Cause combination of body, mind, and lifestyle

• Symptoms- sleep disturbances, guilt, fatigue, feelings of hopelessness Box 22.2 pg. 771

• Screening tools

Postpartum Depression

Management same as that for major depression

•Antidepressants

•Antianxiety

•Psychotherapy

•Marriage counseling if that is part of the causes

Postpartum Psychosis

• Emergency psychiatric condition which could put the women at risk for suicide & infanticide

• Detect within 3 wks. of giving birth

• Symptoms: delusions, hallucinations, agitation, inability to sleep, bizarre irrational behavior

Postpartum Psychosis

Management

•Usually hospitalized for several months

•Psychotropic drugs

•Individual psychotherapy

•Support group therapy