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