Attachment and Postpartum Care Quiz

Nursing Management During Postpartum Period

• This chapter focuses on nursing management during the postpartum period.
• Strong social support is essential for the mother. Nurses must understand the mother's social and cultural context to provide appropriate care. Understanding her wishes and beliefs is crucial.
• Teaching self-care and baby care basics is important.
• Providing emotional support, physical care, information, and practical help is critical.
• Helping mothers gain confidence is important.
• Promoting breastfeeding is also key.

Assessment

• First hour: Assessment every 15 minutes.
• Second hour: Assessment every 30 minutes.
• First 24 hours: Assessment every 4 hours.
• After 24 hours: Assessment every 8 hours.

Risk Factors for Postpartum Complications

• Infection: Operative procedures (forceps, c-section, vacuum extraction), history of diabetes (including gestational-onset), prolonged labor (>24 hours), use of indwelling urinary catheter, anemia (Hb < 10.5 mg/dL), multiple vaginal exams during labor, prolonged rupture of membranes (>24 hours), manual extraction of placenta, compromised immune system (HIV positive)
• Hemorrhage: Precipitous labor (<3 hours), uterine atony, placenta previa or abruption, labor induction or augmentation, operative procedures (vacuum extraction, forceps, c-section), retained placental fragments, prolonged third stage of labor (>30 minutes), multiparity (more than three births closely spaced), uterine overdistention (large infant, twins, hydramnios).

Postpartum Danger Signs

• Fever > 100.4°F (38°C)
• Foul-smelling lochia or unexpected change in color or amount
• Large blood clots or bleeding saturating a pad in an hour
• Severe headaches or blurred vision
• Visual changes (blurred vision, spots, headaches)
• Calf pain with dorsiflexion of the foot
• Swelling, redness, or discharge at episiotomy, epidural, or abdominal sites
• Dysuria, burning, or incomplete emptying of the bladder
• Shortness of breath or difficulty breathing without exertion
• Depression or extreme mood swings

Vital Signs

• Temperature: Normal range or low-grade elevation for first 24 hours (due to dehydration from fluid loss during labor). Normal after 24 hours with fluid replacement. Temperature of 100.4°F or higher may indicate infection—report this.
• Pulse: 60-80 bpm first week after birth. Increase in intravascular volume postpartum can cause decreased pulse. High pulse (>100 bpm) warrants investigation into cause.
• Respirations: 12-20 breaths per minute at rest. Pulmonary function returns to pre-pregnant state after childbirth. Any changes indicate possible issues (e.g., pulmonary edema, atelectasis, pulmonary embolism)—report changes.
• Blood pressure: Compare to usual range; report deviations. Increase in blood pressure may indicate gestational hypertension. Decrease indicates shock or orthostatic hypotension—dehydration (side effect of epidural). Should not be higher than 140/90 or lower than 85/60.

Pain

• Assess type, severity, and location using a 0-10 pain scale.
• Provide comfort measures (perineal care, clean gown, mouth care, warm blankets).
• Fluid intake, repositioning frequently, and encouraging rest.
• Premedicate for afterbirth pain if possible.
• Aim to keep pain between 0-2, especially after breastfeeding.
• Frequently assess for hematoma and report findings.

Physical Assessment

• Breasts: Inspect size, contour, asymmetry, engorgement, or erythema. Check nipples for cracks, redness, fissures, bleeding, flat, inverted, or erect nipples.
• Uterus: Assess fundus to determine uterine involution by measuring distance from umbilicus to fundus . Should be firm and midline. Boggy or relaxed uterus could indicate uterine atony. Location and firmness indicate the progress of involution.
• Bowels: Constipation is common due to low pelvic floor trauma, pain medications, lack of fluids, and infant care. Normal bowel elimination resumes in a week. Use stool softeners and laxatives if needed. Abdomen should be soft, nontender, and nondistended.
• Lochia: Assess amount, odor, color, and change with activity and time. Compare to previous lochia output and to menstrual flow. Foul smelling lochia suggests infection. Observe on pads.
• Extremities: Assess for increased risk of venous thromboembolism (VTE). Observe for signs/symptoms of DVT or PE. Consider use of antiembolism or graduated compression stockings and early ambulation. Evaluate for swelling or redness.

Psychosocial Assessment

• Emotional Status: Observe interactions with family, independence levels, energy levels, eye contact with infant, posture and comfort, and sleeping and rest patterns; watch for mood swings, irritability, or crying.
• Bonding and Attachment: Bonding is a close emotional attraction to the newborn by parents. It develops within the first 30-60 minutes after birth. Attachment is the development of strong reciprocal affection between the infant and significant others. Evaluate for closeness, interaction, and appropriate behavior. Assess for any potential issues.
• Attachment stages: Physical and psychological experience of closeness to infant includes contact, emotional state, and individualization.

Nursing Interventions

• Discharge timing differs based on delivery method; vaginal delivery- 24-48 hours or sooner. C-section- up to 72 hours.
• Focus on pain and discomfort management, immunizations, nutrition, activity and exercise, infant care, lactation instructions, and follow-up teaching.

Providing Optimal Cultural Care

• Approach with cultural humility to explore cultural competency.
• Understand traditional beliefs, involvement of family members, respect, presence of significant others, breastfeeding practices, and eating habits in the cultural context.
• Be aware of the cultural norms regarding hot and cold in relation to foods, and avoid any postnatal sexual intercourse.

Promoting Comfort

• Relieve pain sources (episiotomy, perineal lacerations, backache from epidural).
• Use cold compresses, ice packs, or warm sitz baths for pain management.
• Use ice packs for relieving perineal discomfort; minimize edema, reduce inflammation, decrease capillary permeability, and reduce nerve conduction (use intermittently 20 minutes at a time).

Promoting Maternal Nutrition

• Eat a wide variety of foods with high nutrient density.
• Choose meals that require little or no preparation.
• Ensure all foods are well-cooked.
• Avoid high-fat fast foods.
• Drink plenty of fluids (at least 2,500 mL or 84 ounces daily).
• Avoid fad diets, harmful substances, and excessive amounts of fat, salt, sugar, and caffeine.
• Follow recommended daily servings from each food group.

Positive and Negative Attachment Behaviors

• Include in the assessment for the mother and baby. Table for assessment.

Teaching About Breast Care

• Use supportive and snug bras 24/7.
• Cleanse the breasts with plain water daily.
• Assess breast milk supply, condition of nipples, and success of breastfeeding.
• Encourage frequent feeding every 2-3 hours; promote manual expression before feeding.

Alleviating Breast Engorgement and Suppressing Lactation in Bottle-Feeding Women

• Encourage ice packs and supportive bras 24/7.
• Avoid stimulation of breasts that fosters milk production.
• Medications are not recommended for suppressing lactation due to limited effectiveness and adverse effects.

Promoting Family Adjustment and Well-being

• The postpartum period allows for the process of getting to know the newborn and adjusting to the new family dynamics.
• Provide anticipatory guidance about siblings, potential responses to the new baby, their emotional tension, and the needs of the growing family.

Promoting Parental Roles

• Provide opportunities for parents to interact with newborns, model positive interaction behavior, and assess risk factors.
• Observe culture; monitor attachment and bonding.
• Provide anticipatory guidance to reduce the new parents' frustration (newborn sleep-wake cycles, variations in new born appearance, how to interpret crying cues, sensory enrichment.)
• Evaluate situations with potential for stress.

Explaining Sibling Roles

• Address concerns about siblings' feelings of being loved and important during the transition period.
• Expect and tolerate some regression.
• Explain childbirth appropriately.
• Encourage participation of siblings in decisions. Spend special time with each child.
• Allow siblings to have face-to-face interaction.

Discussing Grandparent's Role

• Understand that the role of the grandparents depends on the closeness of the family, willingness to be involved, and cultural expectations.
• Encourage grandparents to learn new practices and attend grandparenting classes.

Teach About Postpartum Blues

• Postpartum blues is a phase of emotional lability, characterized by crying episodes, irritability, anxiety, confusion, and sleep disorders.
• Symptoms typically arise within a few days of childbirth, peak between 3-5 days, and spontaneously disappear within 10 days.
• Explain to mothers that these symptoms are common and resolve spontaneously. Reassure the mother about the normal nature of the experience.
• Refer for help if the mood does not improve within two weeks. Formal treatment may be needed.

Preparing for Discharge

• Discharge criteria include: afebrile mother, stable vital signs, appropriate lochia, firm fundus, adequate urinary output and healing surgical wounds.
• Ensure the mother is able to ambulate safely, eat, manage infant care, give self-care, and is aware of potential complications.

Providing Immunizations

• CDC recommends TDAP during postpartum stay; rubella given only if not immunocompromised.
• Educate about adverse reactions to avoid pregnancy for at least 28 days due to teratogenic risk.

Rh Status

• Blood types are determined by antigens on red blood cells.
• Negative Rh mothers with Rh positive newborns need Rhogam within 72 hours.
• Rhogam protects against Rh sensitization.
• Obtain signed consent for blood products from mothers with different views.

Ensuring Follow-Up Care

• Arrange telephone follow up to check on how things are going at home in the first week and 4-6 weeks after childbirth, following c-section- 2 weeks after.
• If needed, schedule newborn exams, lab studies, and postpartum home visits within the first week after discharge.

Home Care Visit

• Addressing breastfeeding or bottle-feeding techniques
• Parenting behavior and problem solving
• Psychosocial and environmental needs
• Important emotional needs of the new family
• Addressing sexuality issues, immunizations, family dynamics, and transition needs.

Challenges Facing Families After Discharge

• Lack of role models, support from the mother, mobility of family, nonsupportive partner, feelings of isolation, shortened hospital stays, limited access to education and support are major challenges.

Assisting with Self-Care Measures

• Frequently change perineal pads, applying and removing them from front to back to prevent spreading contamination. Avoid using tampons after childbirth, use mild soap when showering. Use sitz bath after bowel movement.

Assisting with Elimination

• Assess for bladder and bowel function, Encourage voiding and assist in assuming proper voiding positions on the toilet
• Consider bladder or bowel issues if mother not urinating or passing stool.

Promoting Activity, Rest, and Exercise

• Emphasize early ambulation to reduce risk for embolism.
• Encourage rest and naps to address the fatigue and stress of the postpartum period.
• Include support for the mother and encourage participation in household tasks.

Promoting Exercise

• Vaginal deliveries can resume light exercise immediately, and increase the level gradually over several weeks.
• Offer exercise choices (brisk walking, biking, water aerobics).
• Include exercise videos to support the mother. Pelvic floor exercises are recommended for postpartum.
• Remind mothers that any exercise routine should be started slowly and increased over time.

Preventing Stress Incontinence

• Pelvic floor exercises (Kegel exercises) improve urethral sphincter function. Stress incontinence is more likely with multiple vaginal deliveries. Low-impact exercises like biking, swimming, and walking are often best.
• Lose weight if necessary. Avoid smoking, limit alcohol and caffeine.

Teaching Guidelines for Performing Pelvic Floor Muscle Training Exercises

• Identify the correct pelvic floor muscles to become familiar with them and tighten those muscles
• Relax the muscles for 10 seconds.
• Perform those exercises daily in various positions (Standing, sitting, laying down).
• Avoid contractions in other parts of the body (Abdomen, thighs, etc.)

Providing Assistance With Bottle-Feeding

• Discuss types of formula.
• Recommend using room temperature, not microwaving, formula. Use comfortable feeding position.
• Maintain Proper Hygiene
• Formula expiration dates.

Counseling About Sexuality and Contraception

• Delay sexual activity until 6 weeks post-partum
• Water-based lubricants are useful (vaginal lubrication may be impaired during postpartum)
• Discuss contraceptive options. Progestin-only oral contraceptives are often a good choice for women who are breastfeeding.