Postpartum Care: Understanding Psychosocial Changes and Nursing Strategies for New Mothers

1. Maternal/Child Health Nursing Module 7

2. objectives • Discuss postpartum psychosocial changes, discharge, education, postpartum complications and infections

3. Weight loss after childbirth • Mostly water loss • Diaphoresis, diuresis • Role of breastfeeding in weight loss • Teach importance of extra calorie intake in breastfeeding • Teach importance of nutrient-rich foods in postpartum period

4. Mother/baby nursing care • Maternal discharge from hospital • 12 hours-2 days postpartum: uncomplicated vaginal deliveries • Length of stay may be increased by psychosocial adaptation difficulties , very young mothers or mothers considered at-risk for developing postpartum issues • 3-7 days for Cesarean section deliveries or complex vaginal deliveries

5. Mother/baby nursing care • May add inpatient time for: instrumentation, surgery, interventions, infection, interruption of physiologic/psychosocial systems, complications • Mother/baby dyad care vs separate nursery • Bonding, breastfeeding, care roles, perceptions /expectations of families and staff members

6. Mother/baby nursing care • Nursing plan of care: • Recovery stage • Readiness for home/return to responsibilities • Adult assistance available • Mother or family’s ability to care for mother/infant • Teaching: care tasks, self-care, recognition of danger signs, safety and security • Discussion of social services, follow-up appointments

7. Maternal psychosocial changes • Expected changes • Rubin’s Restorative/Adaptive Phases • 1st: Taking in: Mom focuses on: • Maternal recovery: food, fluids, restorative sleep • Birth experience: discussion, “re-living” • Infant, but willing to let others do things for her and may not yet perform infant care tasks

8. Maternal psychosocial changes • Rubin’s restorative/adaptive Phases: • 2nd: Taking hold: Mom focuses on: • Infant care, shows initiative • Self-care responsibilities • May be self-critical of “performance”

9. Maternal psychosocial changes Rubins’ restorative/adaptive phases: • 3rd: Letting go: Mom focuses on: • Letting go of expectations or idealized experience to incorporate real child into real family situation • Often done by both parents or mother and other caregiver

10. Maternal psychosocial changes • Postpartum blues • “baby blues”: common, onset days 2-7, lasting about a week, mood swings, fades quickly • Rapid hormonal shifts • Needs reassurance: may feel required to be happy • s/s: anxiety, mood swings, sadness, irritability, crying, decreased concentration, trouble sleeping

11. Maternal psychosocial changes • Cesarean birth (and other interventions) • Response may vary if unplanned • Anxiety, guilt/blame, need for education, requires adjustment to recovery, scar, self-image, post-operative as well as postpartum adjustment required

12. Maternal psychosocial changes • If family had ideal birth planned which didn’t include interventions, assess for unresolved feelings toward birth experience

13. Maternal psychosocial changes • Monitor pain and coping • Affects recovery, baby care, breastfeeding, rest, mood, anxiety, adaptation, care of other children, partner interaction, self-care

14. Maternal psychosocial changes • Evaluate learning • Is Mom getting the education she needs for her situation? • Does she seem unwilling or afraid to ask questions? • Are pain medications or untreated pain affecting her discharge goals?

16. Maternal psychosocial changes • Monitor moods and expectations • Report issues, changes to provider • Home care: • Doula care, home visits by lactation consultant, midwife • Health problems likely to be admitted to hospital

17. Maternal psychosocial changes • Unexpected changes: • Postpartum depression • Generally lasting more than a week, more severe and persistent S/S: • Appetite loss, insomnia, intense irritability/anger, overwhelming fatigue, loss if interest in sex, lack of joy in life, feelings of shame, inadequacy, guilt; more severe mood swings, difficult bonding, withdrawal, thoughts of self-harm or harming baby

18. Maternal psychosocial changes • Postpartum depression: • Should be seen by healthcare provider if increasing in severity, continuing past two weeks, interrupt ADLs and/or baby care, include thoughts of harm

19. Maternal psychosocial changes • Treatments • Counseling, antidepressants, hormone therapy • May need evaluation for postpartum hypothyroidism • Appropriate depression treatment usually helps within a few months • Severe S/S may benefit from electroconvulsive therapy • Healthy lifestyle support and expectations

20. Maternal psychosocial changes • Postpartum psychosis (severe depression) • Attempts to harm to self/baby • hallucinations • confusion/disorientation • paranoia • Requires EMERGENCY treatment

21. Maternal psychosocial changes • Infant with a problem • Requires additional stabilization away from mother • NICU • Feeding problems • “Rule out” tests (even if normal result) • Family may need help accepting real baby

22. Signs of potential psychosocial problems • No discussion of labor/birth • No interaction with baby • Refusal to discuss contraception or learn care • Negative self-references (“ugly”)

23. Signs: potential psych problems • Excessive self-preoccupation • Marked depression • Lack of support • Negative partner/family reaction to baby

24. Signs of potential psychosocial problems • Expresses disappointment over baby’s sex • Sees baby negatively: “messy,” “unattractive” • Baby reminds mother of someone she doesn’t like

25. Discharge • Newborns’ and Mothers’ Protection Act of 1996 • Insurance must cover minimum in-hospital stay after delivery • 48 hours after vaginal • 96 hours after C-section • Providers may consult with mothers for earlier discharge

26. Postpartum nursing management • Assessment: • Subjective/objective data: pain, status, appetite, breastfeeding, etc. • Breasts: size, color; cracked or bleeding nipples? Does breastfeeding hurt? Proper support? • Uterus: cramping? Prolapse? • Bladder: palpate position, signs retaining urine if output decreased

27. Postpartum nursing management • Bowels: last BM? Constipation? abdominal discomfort/gas? diarrhea? Response to pain meds and foods • Lochia: quantity, color • Fundus: position? Firmness? • Episiotomy: s/s infection, healing, tenderness • Vital signs: changes in baseline, changes expected with medications

28. Postpartum nursing management • Assessment (cont’d) • Lower extremities • Homan’s sign • Bonding/attachment • Parenting and family education • Activity • Comfort • Self-care

29. Postpartum teaching • Fundus • Teach how to massage, how “firm” feels, about involution • Lochia: • red, pink/brown, white • Increase or change should be reported to provider • Perineum • Cleansing • Report pain, swelling, bleeding

30. Postpartum teaching • Breasts • Breastfeeding/bottle-feeding • Support, nipple care • Nutrition • Fresh fruits, vegetables, enough iron and protein rich foods • Calorie increases needed • Sexuality • Avoid sex, tampons, douching for at least six weeks

31. Postpartum teaching • exercise • Avoid moderate/heavy lifting unless cleared by provider • Daily, moderate exercise as tolerated • Thromboses • Healing • Mood

32. Postpartum teaching • Emotions • The difference between “baby blues”, postpartum depression, postpartum psychosis • Support services available • Discuss Mom’s expectations • Cesarean birth • Incision care, lifting restrictions, prescriptions and safety, breastfeeding adaptations

33. Postpartum teaching • Report to healthcare provider: s/s infection, medication questions, baby care issues, anything of concern • Reassure parents, answer questions, anticipate baby care questions and concerns • Teach baby care safety, reinforce feeding information, ensure written reinforcement of follow-up appointments and contact numbers

34. Postpartum teaching • Safety: infant must ride in rear-facing car seat until both 1 year old and 20 pounds • Make sure parents have car seat installation instructions

35. Health promotion • Rh and gamma globulin • Rhogam IM for Rh-negative mom within 72 hours of birth of Rh-positive baby • Prevents Rh-negative mom from forming antibodies to Rh-positive babies in future • Rubella immunization (mom) • Should be given if not already immune

36. Infections • Wound infection • Abdominal incision, perineal lacerations, tears or incisions • Edema, erythema, exudate • Condition of site (sutures? Tape? Dressing?)

37. infections • Metritis • Also called “endometritis” • Tender, enlarged uterus • Prolonged, severe cramping

38. Infections • Metritis (cont’d) • Foul lochia • Fever, systemic signs infection • Failure of uterus to involute properly • Uterine cavity swab may be cultured • Antibiotics (IV, then PO) • Assess for signs of spread: abnormal lochia progression, N/V, absent bowel sounds

39. Infections • Mastitis • Infection of breast: skin break maybe not apparent • Ineffective latch • Often seen in 2nd, 3rd weeks postpartum • Usually unilateral (one-sided) • Staphylococcus aureus often causative organism

40. mastitis

41. infections: • mastitis • Often triggered by engorgement, milk stasis • Skipped feeding, infant sleeps through night, breastfeeding stopped suddenly • May prevent emptying of breastmilk -> further stasis and infection, swelling, feeding problems

42. Infections • Mastitis (cont’d) • Flulike symptoms • Temp 101.1F or higher • Fatigue, achiness, chills, malaise, headache, localized area redness/inflammation • Antibiotics, antifungals

43. infections • Mastitis: • Emptying of breasts: feeds or pumping or both • Feeds no less frequent than every 2-3 hours, avoid supplement feedings, keep area clean, dry • Supportive bra • 5% may develop abscess: surgical drainage, antibiotics

44. Infections • Urinary tract: • May be related to impaired bladder emptying • Encourage PO fluids, correct antibiotic use, regular emptying of bladder

45. Thromboembolytic conditions • Disseminated intravascular coagulation (DIC) • Disruption in clotting cascade • May be seen with abruptio placentae, incomplete abortion, hypertensive disease, infections, prolonged retained dead fetus

46. Thromboembolytic conditions • DIC • Rare in first-trimester abortion • The body’s attempts to correct excessive blood loss may lead to too much thrombin production • This triggers fibrinogen to convert to fibrin, leading to many small clots in small blood vessels

47. Thromboembolytic conditions

48. Thromboembolytic conditions • DIC • Small vessels may become obstructed -> ischemia, damage to vital organs • Small clots trap platelets -> generalized hemorrhage • Since DIC is a secondary diagnosis, cure depends upon fixing the underlying problem

49. Thromboembolytic conditions • DIC • S/S: sudden onset of chest pain, dyspnea, restlessness, cyanosis, coughing up bloody, frothy mucus -> profound circulatory shock s/s, maternal/fetal death

50. Thromboembolytic conditions • Assessment: • Nosebleeds, petechiae from B/P cuff, bleeding gums, excessive bleeding from sites of slight trauma (IV sites, IM/SQ injection sites, shaving nicks, urinary catheter insertion) • Report to provider immediately!