post partum period
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Post Partum Period
Mary L. Dunlap MSN, APRNFall 10
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
Clinical Assessment
• Review Antepartum and Intrapartum history
• Receive report
• Determine educational needs
• Consider religious and cultural factors
• Assess for language barriers
Post Partum AssessmentBUBBLE-HE
• Breast
• Uterus
• Bladder
• Bowel
• Lochia
• Episiotomy
• Legs
• Emotion
Early Assessment
Vital signs
• Temperature
• Pulse
• Blood pressure
• Respirations
Breast Assessment
• Inspect for size, contour, asymmetry and engorgement
• Nipples check for cracks, redness, fissures
• Note if nipples are flat, inverted or erect
• Evaluate for mastitis
Nursing Care Lactating Mother
• Supportive bra
• Correct position
• Correct latch-on technique
• Warm showers
• Expose to air
Nursing CareNon-Lactating Mother
• Avoid stimulation
• Wear support bra 24hrs
• Ice packs or cabbage leaves
• Mild analgesic for discomfort
Assessment of Uterus
• Location immediately after birth
• Descends 1 cm/day
• Consistency- firm/boggy
• Location Height- measured in fingerbreadths
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
Nursing Interventions
• Patient in a prone position and place a small pillow under her abdomen
• Ambulation
• Medicate with a mild analgesic
Bladder
• Spontaneous void 6-8 hrs
• 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 hrs after birth
• Catheterize if unable to void
Bowel
• Anatomy returns to normal location
• Relaxin depresses bowel motility
• Diminished intraabdominal pressure
• Incontinence if sphincter lacerated
• Spontaneous BM 2nd – 3rd post partum day
Nursing Care
• Increase fiber in diet
• 6-8 glasses of water or juice
• Stool softener
• Laxative
• Sitz bath for discomfort
• Medications for hemorrhoids
Lochia• Mixture of erythrocytes, epithelial
cells, blood, fragments of decidua, mucus and bacteria
• As involution proceeds it is the necrotic sloughed off decidua
• 240-270 ml• Cesarean less• Present for 3-6 weeks
Lochia
• Rubra
• Serosa
• Alba
• Documentation
Nursing Care
• Educate mother on the stages of lochia
• Caution mother that an increase, foul odor or return to rubra lochia is not normal
• Instruct patient to change peri pad frequently
• Peri care after each void
Episiotomy
• 1-2 inch incision in the muscular area between the vagina and the anus
• Assess REEDA
• Episiotomy care
Nursing Care
• Peri care
• Ice packs
• Sitz baths
• Dry heat
• Topical medications
Pain Assessment
• Determine source
• Document location, type and duration
• Interventions
Assess for DVT
• Homans’ sign
• Clinical assessment
Postpartum Blues
• Transient periods of depression during the first 1 to 2 weeks postpartum
• Tearfulness
• Sad feeling
• Confusion
• Insomnia
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
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
Renal
• GFR, Creatinine, and BUN return to prepregnant levels within 2-3 months
• Urinary glucose levels return to nonpregnant levels by 2nd PP wk
• Protienuria resolves by the 6th PP wk
• Natriuresis / Diuresis
Integumentary System
• Darken pigmentation gradually fades
• Hair regrowth returns to normal in 6-12 months
• Striae( stretch marks) fade to silvery lines
Cardiovascular System
• Heart returns to normal position
• Cardiac output elevated above prelabor levels up to 48 hrs. PP
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
Nonlactactating mother
• Menstruation returns in 6-8 wks
• 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
Multicultural Nursing Care
• Enhance Cultural Sensitivity
• Understand cultural influences on the post partum period
• Provide culturally appropriate care
HIV/AIDS
• Gloves safety glasses
• Discourage breast feeding
• Avoid contact personal body fluid with infants mucous membranes
Postpartal Surgical Patient
• Tubal ligation
• Cesarean birth
Breast Feeding
• Optimal method of feeding infant
• Breast milk- Bacteriologically safe, fresh, readily available
• Box 15-3 pg.489 Breastfeeding benefits
Breastfeeding
• Lactogenesis- secretion of milk
• Milk ejection reflex- “let down” reflex
Breastfeeding
• Cue signs- Box 15-4 pg. 492
• Latch-on- Fig 15-8 pg 492
• Assess for milk let down
Breastfeeding
Positions
• Cradle hold
• Foot ball
• Side lying
• Fig 15-10 pg 494
Ineffective Breastfeeding
• Incorrect latch-on
• Inverted nipples
• Breast engorgement
Collection and Storage Breast Milk
• Room temperature- 4 hrs
• Refrigerator- 5-7 days
• Deep freezer- 6-7 months
Formula Feeding
• Formula preparation
• Periodically check nipple integrity
• Bottle preparation
Family and Infant Bonding
• Transitioning to parenthood
• Assuming the mothering role
• Parental bonding
• Factors that interrupt bonding
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
• Table 15-6 pg. 499
Bonding
• Bonding process helps to lay the foundation for nurturing care
• Touch- skin to skin
• Eye contact
• Breastfeeding
Discharge Planning and Teaching
Self Care
Discharge Teaching
• Fundus and Lochia
• Episiotomy care
• Incision care
• Signs of infection- box 15-5 pg 505
• Elimination
Discharge Teaching
• Nutrition
• Exercise
• Pain management
• Sexual activity
• Contraception
Community Resources
• Support groups
• Home visits
• Telephone follow-up
• Outpatient Clinics
Postpartum Complications
Postpartum Hemorrhage
• Blood loss of more than 500 ml of blood after a vaginal birth
• 1000 ml of blood after cesarean section
• Any amount of bleeding that places mother in hemodynamic jeopardy
Postpartum Hemorrhage
LARRY- common causes of early PPH
• Laceration
• Atony
• Retained placental tissue
• Ruptured uterus
• You pulled to hard on the cord
Postpartum Hemorrhage
• 4 Ts- factors associated with PPH
• Tone
• Trauma
• Tissue
• Thrombin
Postpartum HemorrhageTone/Atony
• Altered muscle tone due to overdistention
• Prolonged or rapid labor• Infection• Anesthesia• Box 16-1 pg 513
Postpartum HemorrhageTrauma
• Cervical lacerations
• Vaginal lacerations
• Hematomas of vulva, vagina or peritoneal areas
• Box 16-2 pg 514
Postpartum HemorrhageTissue
• Retained placental fragments
• Uterine inversion
• Subinvolution
Postpartum HemorrhageThrombin
• Disorders of the clotting mechanism
• This should be suspected when bleeding persists without an identifiable cause
Management of PPH• Frequent VS
• Fundal massage
• Administer medications- Box 16-1
• Monitor blood loss for amount
• Maintain IV
• Type & cross match
• Empty bladder
Hematoma
• Localized collection of blood in connective or soft tissue under the skin
• Risk factors
• Signs and symptoms
• Management
Postpartum Infections
• A fever of 100.4 or higher after the first 24 hrs for 2 successive days of the first 10 PP days
• Fever of 102.2 or greater within first 24 hrs- sever pelvic sepsis Group A or B streptococcus
Postpartum Infections
• Endometritis- Table 16-2 pg 521
• Wound infection- Table 16-3 pg. 523
• UTI- Table 16-4 pg. 524
• Mastitis- Table 16-5 pg 525
• Septic Pelvic Thrombophlebitis-Table 16-6 pg 526
Endometritis
• 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
• Protienuria, hematuria, bacteriuria, nitrates and WBC
Nursing Care
• Frequent emptying of bladder
• Increase fluid intake
• Antibiotics
• Analgesics
Mastitis
• Infection of the breast (one sided)
• Seen 2-3 weeks after delivery
• Caused by 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
• Antibiodics
• Analgesics
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
Thrombophlebitis and Thrombosis
• Thrombosis (blood Clot) can cause inflammation of the blood vessel (thrombophlebitis) which can cause thromboembolism (obstruction of blood vessel)
Assessment Superfical
• 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
Assessment Deep Vein
• Located from foot to pelvis- can dislodge and cause PE
• Calf swelling
• Warmth
• Tenderness
• Pedal edema
• Diminished peripheral pulses
Nursing Care
• Bed rest
• Elevate effected leg
• Continuous moist heat
• TED hose both legs
• Analgesics PRN
• Anticoagulation therapy
Pulmonary Embolism
• Abrupt onset: chest pain, dyspnea, diaphoresis, syncope, anxiety
• ABC response
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