Chapter 15

1. Chapter 15 Caring for the Postpartum 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 Key Patient Safety Concerns: • Prevent infant abductions • Check ID bands • Educate mother about safety measures • #1 risk on postpartum is Falls

5. Postpartum Psychological AdaptationReva Rubin • Taking in: Mom wants to talk about her experience of labor & birth, preoccupied with her own needs • Taking hold: More ready to resume control of her body, baby & taking on mothering role. Needs reassurance if inexperienced. • Letting-go: by 5th week, total abandon to NB • Bonding: en face position, engrossement. Encourage through early interaction & breast-feeding (within 1/2 hr of birth is best).

6. Reva Rubin Maternal Responses to Newborn • Touch- progresses from fingertips → palming →cuddling → • Voice- high-pitched & babies respond • Odor- mom’s respond to baby’s unique smell • Eye contact-en face position delay eye ointment & bright lights • Nurse role-be able to answer ? About baby

7. Blues vs Depression Postpartum/baby blues: transient depression in first few days: weepiness mood swings anorexia difficulty sleeping feeling of letdown  Postpartum Depression *If persists past 2 weeks, or worsens Symptoms:very sad feelings hopeless worthless anxiety trouble caring for and bonding with your baby Have trouble sleeping. Not be able to concentrate. Not feel hungry and may lose weight. (But some women feel more hungry and gain weight)

8. Postpartum Psychosis • Onset within first 8 weeks after childbirth • Distinguishing signs: hallucinations, agitation, confusion, suicidal/homicidal thoughts, delusions, sleep disturbances, loss of touch with reality • Requires hospitalization & treatment

9. Postpartum Nursing forVulnerable Populations • Victims of abuse • History of depression/ mental illness • Special needs population- support • Adolescents- Teen support groups • Undocumented immigrants • Limited Access to care/homelessness

10. Endocrine Adaptations Hormones: -drop after delivery of placenta. • hCG & hPL gone by 24 hours • Estrogen & progesterone drop within 1 wk • FSH remains low for 12 days, then rises to begin new cycle • Sex is ok once lochia is alba. Menstrual period in 6-10 wks. • Contraception necessary.

11. Early Maternal Assessment • Vital signs • 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 • Lochia • Rubra, serosa, alba

12. Postpartum Assessment Guide Bubble-He • Breasts Homan’s sign • Uterus Emotions & bonding • Bladder • Bowel • Lochia • Episiotomy

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

16. 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

17. 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

18. Deep Vein Thrombosis • Homans’ sign • Clinical assessment • Erythema, unequal calf circumference, heat • Clinical signs are NOT reliable

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

20. 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

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

22. Menstruation & 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

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

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

25. Postpartum Complications • Postpartum Hemorrhage • CAUSES: Uterine atony, lacerations, retained placental fragments • Risk factors: • ↑ uterine distension: multiples, polyhydramnios, macrosomia, fibroids • Trauma: rapid or operative birth • Placental problems: previa, accreta, abruptio, retained placental fragments • Atonic uterus: prolonged pitocin, magnesium sulfate or labor; ↑ maternal age or parity; uterine scar; chorioamnionitis; anemia; prior history • Inadequate blood coagulation: fetal death or DIC

26. Interventions: Fundal massage, ensure bladder emptying. If uterus is firm but bleeding persists, suspect laceration. Administer oxtocics (pitocin, methergine, hemabate, prostaglandins), blood replacement. Frequent assessment of bleeding, vital signs. Hemorrhage MD: Bimanual massage, manual exploration of uterus, uterine packing, D & C, hysterectomy.

27. Postpartum Hemorrhage • Definition • Accurately estimating blood loss • Hypovolemic shock DIC • Early vs. late • LARRY • 4 “T’s”

28. Postpartum Hemorrhage • Uterine atony • Hallmark—soft uterus filled with clots and blood • Genital tract trauma- lacerations • Uterus firm • Tissue trauma- hematoma • Thrombin

29. Postpartum Hemorrhage • Late postpartum hemorrhage • Retained placental fragments • Ergonovine medication- Methergine • antibiotics • possible D&C

30. Collaborative Management • Frequent vital signs and fundal massage • Note patient’s behavior- PTSD noted • Medical management depends on cause • Administer oxygen • Obtain laboratory tests • Accurate I/O

31. Hematomas Cause: Trauma • Puerperal hematomas occur in 1:300 to 1:1500 deliveries • Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams, preeclampsia, prolonged second stage of labor, multifetal pregnancy, vulvar varicosities, or clotting disorders • Assessment: location, size, vital signs, pain, H&H • Treatment: evacuation and repair of bleeding source by MD

32. Puerperal Infections • Definition • Types of puerperal infections • Endometritis • Mastitis • Operative wound • Urinary tract • Careful and thorough assessment

33. Postpartum Infection • Puerperal Infection: Endometritis • infection of reproductive tract within 6 wks of childbirth • Increased risk with: • C-section • Prolonged ROM, chorioamnionitis • Retained placental fragments • Preexisting anemia • Prolonged/difficult birth, instrumental birth • Internal fetal monitoring or IUPC • Uterus explored after birth/manual removal of placenta • Preexisting vaginal infection (BV or chlamydia)

34. Postpartum Infection • Endometritis: infection of endometrium • Associated with chorioamnionitis & C-section • Signs & Symptoms • Can progress to pelvic cellulitis or peritonitis.

35. Endometritis • Ttreatments: • antibiotics • oxytocics such as methergine, • ↑ fluid intake • pain relief • diet • Nursing considerations: Fowler’s position or walking encourages drainage by gravity, gloves, strict handwashing • Usual course is 7-10 days • May result in tubal scarring & interfere with future fertility

36. Post op C/Section Complications • Paralytic Ileus • Wound Dehiscence • Wound infection

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

38. Discharge Planning and Teaching • Fundus and lochia • Hygiene • Abdominal incision • Body temperature • Elimination • Nutrition

39. Discharge Planning and Teaching • Fatigue • Weight loss • Exercise • Pain management • Mood • Sexual activity and contraception

40. Community Resources • Support groups • Home visits • Telephone follow-up • Outpatient clinics

41. Critical Thinking • A mother is experiencing shaking chills during the hour following birth. What is the nurse’s initial action? • A. Take a rectal temperature • B. Notify the physician or nurse-midwife • C. Cover the woman with warmed blankets • D. Review the order sheet for antibiotic orders

42. Critical Thinking \ The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right. What is the appropriate nursing action? A. Encourage the client to breastfeed B. Assist the client to empty her bladder C. Massage the fundus D.Assist the client to a prone position and place a small pillow under her abdomen

43. A nurse is caring for a client who is 2 hours postpartum who complains of severe, unremitting vaginal pain and inability to void. The fundus is firm at the umbilicus with moderate lochia rubra, and the perineum appears edematous with significant bruising. The nurse suspects the client may have: A. A fourth-degree episiotomy. B. Distended bladder. C. Hematoma. D. Endometritis.

44. A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage. What should be the nurse’s correct initial response? • A. Instruct the client to take her pain medication as prescribed • B. Notify the physician or nurse-midwife • C. Instruct the client to increase rest and seek assistance with household tasks • D. Instruct the client to call the physician or nurse-midwife if her temperature reaches 100.8.

45. A 6-day postpartum client complains of fatigue and episodes of crying during the past two days. Which of the following statements is a correct response by the nurse? A. “This must be very difficult for you.” B. “This sounds like postpartum blues. It is a normal response to birth.” C. “You sound exhausted. Try and sleep when the baby sleeps.” D. “This sounds like postpartum depression; you should contact your health care provider for referral to a counselor.”

46. 6. A nurse is caring for a client with a superficial thrombophlebitis. Which of the following is the most appropriate nursing action? A. Administer anticoagulants per order B. Elevate the affected limb C. Apply ice packs to the affected limb D. Administer antibiotics per order

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

48. Breastfeeding Promotion • WHO promotes Breastfeeding around the world • Healthy People 2020 • APA advocates breastfeeding for 12 months • Baby Friendly initiatives in hospitals ↑breastfeeding rates and duration

49. Breastfeeding Initiation • Prolactin produced (stimulates milk production) when progesterone levels fall after placenta is delivered • Colostrum- First milk produced: thick, creamy, yellow fluid composed of protein, sugar, fat, water, minerals, vitamins and maternal antibodies--digestible. Has laxative effect to aid baby to excrete meconium.

50. Milk flows from lactiferous sinuses • Fore milk- constantly formed milk. Low in fat. • As infant sucks, oxytocin is released from the posterior pituitary. Produces let-down reflex • Let-down reflex- stimulation of baby at breast, sound of baby. Hind milk ejected. • Hind milk is formed after the let-down reflex. Higher in fat and calories.