1. POSTPARTUM MANAGEMENT

2. Out Line: • Introduction of post partum care • Physical and psychosocial post partum care • Examples of physical &psychosocial midwifery diagnosis in the post partum care • Expected out comes for post partum care • Physiological needs during post partum • Cultural aspects and beliefs about post partum

3. Out -line • Post partum care • Discharge teaching • Follow up after discharge

4. Introduction • The goal of midwifery care in the immediate post partum period is to assist women and their partners during their initial transition to parenting

5. Cont--- • The midwives provided care that focuses on: • The woman physiologic recovery • Psychological well being • Her ability to care for her self and her newborn

6. Post partum physicalassessment • Physical assessment - Vital signs - Evaluation of breast -Uterine fundus -Lochia (amount ,color, odor) -perineum area

7. Cont—physical assessment -Bladder and bowel function -Energy level -Appetite

8. Cont- • Check laboratory test immediate for -Hb, hematocrite ,urine analysis • Check signs of potential complication

9. Signs of potential complications • Temperature --- more than 38 c after the first 24hrs • Pulse--- tachycardia ,marked Brady cardia • Blood pressure---hypotension or hyper

10. Cont-signs • Energy level ---lethargy ,extreme fatigue • Uterus---deviated from the mid line ,boggy consistency, remains above the umbilicus after 24 hrs • Lochia---heavy, foul odor ,bright red bleeding that is not lochia

11. Cont- • Perineum---pronounced edema, not intact, signs of infection, marked discomfort • Breasts ---redness, heat, cracked and fissured nipples, inverted nipples, palpable mass

12. Cont-- • Elimination -urine: inability to void, urgency, frequency, dysuria -bowel: constipation, diarrhea

13. Midwife DX • Acute pain RT • Risk for constipation RT • Disturbed sleep pattern RT • Ineffective breast feeding RT • Risk for infection RT

14. Expected out come of care • Remain free from infection • Demonstrate normal involution and lochial characteristic

15. Cont—Expected • Demonstrate normal bladder and bowel elimination patterns • Protect the health of future pregnancies and children

16. Physical care during post partum period

17. Physical care • Prevention of infection by: -apply hand washing techniques to prevent cross- infection - maintenance of clean environment -bed linens should be changed as needed

18. Cont-- -disposable pads should be changed frequently -Supervision of use equipment to prevent contamination as common sitz bath

19. Episiotomy ,laceration care: • Wash hand before and after cleaning perineum and changing pads • Wash perineum with mild soap and warm water at least once daily • Cleanse from urethra to anal area • Apply peripad from front to back • Change pad with each void or defecation (more than 4 times /day)

20. Cont--episiotomy • Assess amount and character of lochia with each pad change • Apply covered ice pack to perineum from front to back • Timing---------? 1- during first 2 hrs to decreased edema formation and increased comfort 2- after the 2 hrs to provide anesthetic effect

21. Prevention of excessive bleeding : • Most frequent cause of excessive bleeding after child birth is uterine atony • Uterine atony means the failure of uterine muscle to contract firmly • Accurate visual estimation of blood loss is an important nursing responsibility

22. Cont--- • Loss of blood is usually described subjectively as : • scant----less than 2.5cm • Light----less than or equal 10 cm • Moderate—more than 10 cm • Heavy (profuse)—one pad saturated within 2 hrs

24. Cont-- • Most objective estimate of blood loss include weighting blood clots and items saturated with blood • Using devices that catch and measure blood flowing from the vagina • Establishing the milliliters of blood it takes to saturate perineal pads being used

25. Evidence • RCT Found that drape estimation of blood loss is more accurate than visual estimation in detection of post partum hemorrhage • (patella ,drape estimation vs visual assessment for estimating post partum hemorrhage ,International J of Gyaecology,2006)

26. Cont- • midwife must alert if: • A perineal pad saturated in 15 minute or less or pooling of blood under the buttocks are in indications of excessive blood loss

27. Cont— • The most important intervention to prevent excessive bleeding is to: 1-maintenance good uterine tone 2-preventing bladder distention

28. Maintenance uterine atony • Gently massaging of the uterine fundus until it’s firm to restore good tone • Under standing the causes and dangers of uterine atony and the purpose of fundal massage can help the women to be more cooperative

29. Evidence • CRT found that intermittent uterine massage after delivery is effective in reducing post partum hemorrhage and stimulate uterine contraction • (Abdel-A Leem, uterine massage and post partum blood loss, J of Obstetrics' and Gynecology,2006)

30. Cont–maintenance • Teaching the woman to do fundal self massage enables her to maintain some control and decreased her anxiety

31. Cont-- • midwife should be alert if : • The uterus remains boggy even after massage and expulsion of clots which indicated the major warning sign of uterine atony

32. Prevention of bladder distention: • Full bladder causes the uterus to be displaced above the umbilicus and well to one side of the mid line in the abdomen • Also prevents the uterus from contracting normally

33. Cont- • midwife intervention focus on : • -helping the woman to empty her bladder as soon as possible by assist to bathroom or onto bed pan if she unable to ambulate • The mother should void spontaneously within 6-8 hrs after giving birth

34. Cont- • Having the woman listen to running water, placing her hands in warm water or pouring water from a squeeze bottle over her perineum can stimulate voiding if the woman isn’t able to void spontaneously

35. physiological needs during post partum period

36. Physiological needs 1-Comfort -causes of discomfort: -after birth pains -episiotomy -perineal lacerations -hemorrhoids -breast engorgement

37. Cont-physiological needs • Management: • First, the mide assess the type and severity of pain to choose an appropriate intervention • Inspect and palpate areas of pain for redness, swelling ,discharge and observe body and facial tension

38. Non pharmacologic interventions include: • Warmth, distraction, deep breathing ,therapeutic touch, relaxation and inter action with the infant may deceased the after pains discomfort

39. Cont- • for episiotomy, perineal laceration discomfort: • Encouraging the woman to lie on her side • Use pillow when sitting • Use ice pack

40. Cont- • For breast engorgement discomfort -heat- ice compresses according to breast or bottle feeding -cold cabbage leaves to breasts -wearing of well fitted support bra

41. Cont--management • Pharmacologic management include: -narcotic or non narcotic medication -topical application of antiseptic or anesthetic ointment or sprays

42. CONT 2-Rest & sleep • Causes of fatigue: -excitement and exhilaration after birth -long labor -infant behavior and demands -Breast feeding

43. Cont-rest& sleep • Management • Establish woman's routine sleep patterns and compare with current sleep pattern ,exploring things that interfere with sleep to determine scope of problem and direct intervention • Provide asleep -promoting environment to mother as quiet environment • The nurse can help the family limit visitors and provide comfortable bed for partner

44. Cont-sleep& rest • Administer sedation or pain med to enhance quality of sleep • Teach woman's to use infant nap time as time for her to nap and decreased fatigue

45. Ambulation: • Early ambulation is successful in reducing the incidence of thrombo embolism and promote the woman's more rapid recovery of strength • Nurse should be consider the base line of BP, amount of bld loss, type ,timing of analgesic when assisting woman to ambulate

46. Exercise: • Begin soon after birth • Woman should be encouraged to start with simple exercise and gradually progress to more strenuous ones

48. Evidence • Exercise in the post partum period is shown to produce a more relax mother-child relation ship ,combat depression and improve perception of the new relation ship • Exercise help new mother sleep better and have less anxiety • ( Shelby, exercise in the post partum period ,J of health,2006)

49. cont • Kegel pelvic exercise are extremely important to strengthen muscle tone and maintaining urinary Continence • Woman must learn to perform the kegel exercises correctly ……..??

50. Cont—exercise • The health care provider can teach and assess the woman's techniques during the pelvic examination at the 6 weeks check up by – inserting tow fingers intra vaginally and checking whether the pelvic floor muscle correctly contract or relax