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Chapter 15

Chapter 15. Caring for the Postpartal Woman and Her Family. Fourth Trimester. Begins immediately after childbirth Puerperium — first 6 weeks after birth Close observation — identify hemorrhage and complications during first critical hour Ongoing education and support.

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Chapter 15

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  1. Chapter 15 Caring for the Postpartal Woman and Her Family

  2. Fourth Trimester • Begins immediately after childbirth • Puerperium—first 6 weeks after birth • Close observation—identify hemorrhage and complications during first critical hour • Ongoing education and support

  3. Safety for Mother and Infant • Prevent infant abductions • Check ID bands • Educate mother about safety measures

  4. Early Maternal Assessment • Vital signs • Temperature—below 100.4oF (38oC) • Pulse—bradycardia • Blood pressure • Respirations

  5. Fundus • Immediate postpartum—halfway between the symphysis pubis and the umbilicus • 1 hour postpartum—level of the umbilicus or one fingerbreadth above • Then, descends one fingerbreadth each day • Assess lochia

  6. Perineal Assessment • Sim’s position • REEDA • Hemorrhoids • Teach regarding comfort measures • If severe, teach how to manually reposition

  7. Postpartum Assessment Guide

  8. Bubble-He • Breasts • Uterus • Bladder • Bowel • Lochia • Episiotomy

  9. Other Important Components • Maternal pain • Homans’ sign • Mother’s emotional status • Infant bonding

  10. Breast Assessment • Firmness, filling • Nodules • Fissures, cracks • Blood • Dried milk • Erect or inverted nipples

  11. Assessment of Uterus • Placental expulsion usually occurs within 15 minutes after birth • Uterine contractions control bleeding • Technique for uterine palpation • Involution • Subinvolution

  12. Fundal Assessment • Location immediately after birth • Descends 1 cm/day • Consistency • Location • Height • Measured in fingerbreadths

  13. Afterpains • Occur during process of involution • More pronounced in multipara • Nursing care • Explain cause • Prone position with abdominal pillow • Sitz baths • Encourage ambulation • Administer mild analgesics

  14. Bladder • Spontaneous void within 6 to 8 hours pp • Monitor first voiding • Anticipate maternal diuresis • Urinary output may reach 3000 mL/day • Urine volume, flow returns to pre-pregnant levels within 2 to 3 days pp

  15. Assessment Findings: Bladder • Incomplete emptying • Overdistention • Urinary retention • Nursing interventions • Support and enhance attempts to void

  16. Bowel • Hunger and thirst after childbirth • Relaxin—depresses bowel motility • Strategies to prevent constipation • Early ambulation • Abundant fluids • High-fiber diet

  17. Lochia • Characteristic indicative of status in process of involution • Lochia rubra • Lochia serosa • Lochia alba • Document amount

  18. Episiotomy • 1 to 2 inch surgical incision • Assess REEDA • Ice for first 24 hours • Moist heat—Sitz bath • Dry heat—hot packs

  19. Pain Assessment • Determine source • Document location, type, and duration • Administer Tylenol or Ibuprofen • Sitz bath • Educate regarding nonpharmacological measures

  20. Assess for DVT • Homans’ sign • Dorsiflex foot and ask about pain • Clinical assessment • Erythema, unequal calf circumference, heat • Clinical signs are NOT reliable

  21. Emotional Status • Wide range of emotions • May be sad during first 1 to 2 weeks pp • Ongoing assessment and education • Educate regarding “baby blues”

  22. Maternal Physiological Adaptations • Continued Assessment of the Patient

  23. Hematological System • Decrease in blood volume • Blood loss • Diuresis • White blood count increased x 5 to 6 days • Fibrinogen increased • Returns to normal by third to fourth week

  24. Hormonal Levels • Estrogen and progesterone decrease • Anterior pituitary—prolactin • Placental lactogen, cortisol, growth hormone, and insulinase levels decrease • Insulin needs decrease—“Honeymoon phase”

  25. Neurological System • Altered sleep patterns—maternal fatigue • Numbness in legs, dizziness • Safety for infant and mother • Headaches • Assess quality and location, and carefully monitor vital signs • Implement environmental interventions

  26. Renal System, Fluid and Electrolytes • GFR, Creatinine, and BUN return to pre-pregnant levels within 2 to 3 months • Urinary glucose • Proteinuria • Rapid, sustained natriuresis and diuresis • Output may reach 3000 mL/day

  27. Respiratory System • Respiratory alkalosis and compensated metabolic acidosis may persist • Decrease in intra-abdominal pressure • Relief from dyspnea

  28. Integumentary System • Hormonal changes cause skin alterations • Most disappear • Striae gravidarum

  29. Cardiovascular System • Delivery of the baby, expulsion of the placenta, and loss of amniotic fluid can create cardiovascular instability • Cardiac output remains elevated • Physiological diuresis

  30. Immune System • Rho (D) immune globulin (RhoGAM) • Rubella vaccination • Nonimmune status • Signed consent form • Avoid pregnancy for 1 month • Flu-type symptoms may occur

  31. Reproductive System • Involution of uterus • Healing of placental site • Vaginal changes • Labia majora and labia minora flaccid

  32. Menstruation and Ovulation • Nonlactating women • Menstruation returns in 6 to 8 weeks • First cycle may be anovulatory • Lactating women • Delayed ovulation and menstruation • Educate—ovulation can precede menstruation, need contraception

  33. Gastrointestinal System • Decreased gastric motility • Decreased muscle tone in abdominal wall • Constipation • Stool softeners

  34. Musculoskeletal System • Laxity of pelvic joints and ligaments • Relaxation of soft tissues • Muscle fatigue • Body aches • Rectus abdominis diastasis • Correct posture • Modified sit-ups

  35. Enhancing Cultural Sensitivity • Conduct cultural assessments • Expand knowledge and understanding • Culturally influenced beliefs • Common health care practices • Customs and rituals

  36. Promoting Recovery and Self-Care

  37. Activity and Rest • Early postpartum ambulation • Mild exercises • Kegel • Increase gradually • Encourage frequent rest periods • Obtain adequate sleep

  38. Nourishment • Weight loss • Appetite • Balanced diet • Multivitamin supplement • Iron if hemoglobin low

  39. Elimination • Void every 4 to 6 hours • Monitor intake and output x 24 hours • Increased risk of infection • Urinary retention • Constipation

  40. Perineal Care • Risk of infection • Teach perineal hygiene • Hand washing • Tampons contraindicated • Cesarean births • Nurse provides perineal care until ambulatory

  41. Ice Packs • Reduce edema and pain • Vasoconstriction and numbing • Apply for 20 minutes every 2 to 4 hours • First 24 hours

  42. Afterbirth Pain • Intermittent uterine contractions during involution • Breastfeeding (release of oxytocin) • Duration: 2 to 3 days • Mild analgesics

  43. Special Considerations • Women with HIV/AIDS • Gloves, safety glasses • Discourage breastfeeding • Patient teaching for infant safety

  44. Postpartal Surgical Patient • Tubal ligation • Cesarean birth • Incisional wound • Recovery from anesthesia • Respiratory care

  45. Infant Feeding Choices • Breastfeeding • Bottle feeding • Educate • Support

  46. Physiology of Lactation • Breast structure • Lactogenesis • Milk ejection reflex—“let down” reflex

  47. Assisting the Breastfeeding Mother • Strategies for Success

  48. Breastfeeding • Initiating the feeding • Achieving proper latch-on • Assessing for milk let-down • Assuming a position of comfort • Assessing for infant weight gain

  49. Ineffective Breastfeeding • Incorrect latch-on (nipple trauma) • Breast engorgement • Complementary care • Ethnocultural considerations • Collecting and storing breast milk

  50. Expressing Breast Milk • Manual—hand • Electric pump • Types of breast pumps • Storage of breast milk • Weaning

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