Postpartum Adaptation and Discharge Education

Postpartum Adaptation

• Postpartum adaptation includes a variety of topics to assist in care for the mother and newborn after delivery.

Discharge Education

• Early discharge after birth is within 48 hours.
• Discharge teaching includes infant feeding, bathing, breastfeeding, perineal hygiene, physical activity/rest, and emotional changes.
• Sponge baths are recommended until the umbilical cord falls off, avoiding soaking.
• Bathing every day is not required.
• Physical activity should include lifting the baby and car seat at most and limiting stair climbing to once a day to prevent tearing.

Care for the Breastfeeding Client

• Education is key when caring for the breastfeeding client.
• Colostrum, a yellowish/gold fluid from nipples before lactation, is full of antibodies that build the GI flora and is high in beta keratin and immunoglobulins.
• Breast stimulation increases prolactin (milk) and oxytocin, which leads to contraction and no hemorrhage with afterpains.
• Tenderness of the breasts is expected.
• Lanolin cream or breast milk can be used for dry/cracked nipples.
• Use minimal soap/water on nipples or avoid it altogether if nipples are dry/cracked.
• Air drying after feedings is recommended.
• The lowest breastfeeding rates are among women under 29 years old, non-Hispanic Black women, or those participating in WIC.
• Breastfeeding should NOT be painful.
• Optimal feeding occurs within the first hour after birth.
• Pumping should be held off for 2-3 weeks to regulate the milk supply to the baby's needs.
• Feed the baby every 2-3 hours or on demand.
• Engorgement typically occurs bilaterally within 48-72 hours (3 days).
• Breastfeeding frequently helps to remove milk from the breasts.
• Massage the breasts before and during feeds.
• Cold compresses can be used for swelling because of the lymphatic and hormonal response.
• Engorgement will resolve around days 4-5.

Care for the Postpartum Client Who is Not Breastfeeding

• Education is important for postpartum clients who are not breastfeeding.
• Wearing a supportive bra, such as a sports bra, is helpful.
• Ice packs to the axillary area can help stop or lessen milk production.
• Ibuprofen or acetaminophen can be taken for discomfort.
• Education about safe water sources for formula and how to mix it according to directions is important.
• Engorgement resolves spontaneously, with discomfort decreasing within 24-36 hours.
• A breast binder or tight bra (sports bra works well) can be used.
• Ice packs and mild analgesics can provide pain relief.
• Avoid stimulation, such as turning your back to the shower.
• Cool washcloths or cabbage leaves can provide relief.

Mastitis

• Mastitis is caused by a blocked milk duct or bacteria.
• It typically involves unilateral breast involvement.
• A break in the nipple increases the risk, so watch the latch.
• Fever usually occurs.
• It can occur around 2 weeks postpartum.
• Treatment includes antibiotics (ABX), moist heat, increased fluid intake, and Tylenol/Motrin.
• Continue to breastfeed during treatment.

Stages of Psychological Recovery, Assessing Emotional Well-Being

• The phases associated with the mothering role are:
• Phase 1: Taking In (Day 1-2). The mother is recovering from immediate exhaustion of labor and is relatively dependent on others to meet physical needs.
• Phase 2: Taking Hold (Day 2-3). The mother starts to initiate action and begin some tasks of motherhood.
• Phase 3: Letting Go (Weeks 2-6). The mother redefines her new role and is able to focus on her partner, other children, and family issues.

Fundal Assessment and Interventions

• One week after birth, the uterus is thickened and the vagina is stretched.
• Six weeks after birth, the uterus and vagina return to their normal, contracted state.
• To assess the uterus, measure the fundal height (hand on symphysis pubis + fundus).
• Involution is the return to a non-pregnant state following birth.
• This is normal and starts immediately after the placenta comes out.
• It can take longer in multiparas women.
• At the umbilicus after delivery, it decreases by one finger breadth a day for 10 days until it is normal.
• Subinvolution is when the uterus is not decreasing in size, which is ABNORMAL and indicates a possible hemorrhage.
• Retained placental fragments can produce progesterone which can affect returning the uterus to it's typical size.
• Pelvic infection requires antibiotics (ABX).
• Symptoms include prolonged lochial discharge, which is discharge from the placenta detaching from the uterus (open wound).
• Lochia Rubera is red and lasts for 3-4 days.
• Lochia Serosa is pink/brown and lasts for 4-10 days.
• Lochia Alba which is white/yellow and lasts for 10-14 days.
• Irregular or excessive bleeding (sometimes hemorrhage) requires Methergine PO , which contracts to push fragments.
• Always make sure to cup the uterus so that it doesn't fall out.
• Afterpains are most severe 2-3 days after delivery and are similar to menstrual cramps.
• Multiparas and patients with larger uterine distention (large baby) experience more vigorous contractions that may cause pain.
• Ibuprofen or naproxen can be taken for pain.

Postpartum Blues vs. Postpartum Depression

• Postpartum blues are normal due to hormones.
• They affect 50-85% of mothers in the first 2 weeks after birth.
• Symptoms include irritability, anxiety, and fluctuating mood and are mild and occasional.
• It is not considered a psychiatric disorder.
• Postpartum depression is abnormal affecting 10-20% of mothers in the first year after birth and lasts for more than 2 weeks, affecting the ability to care for self and baby.
• Symptoms include excessive guilt, anxiety, depressed mood, insomnia/hypersomnia, suicidal thoughts, and fatigue.
• Symptoms are moderate to severe and prolonged.
• Risk factors include chronic/prenatal depression, low self-esteem, stress of childcare, prenatal anxiety, life stress, lack of social support, history of depression, and multiple births/fatigue.
• Postpartum psychosis involves abnormal depression, delusions, and thoughts of harming the infant or self.
• It is usually evident in the first 8 weeks and may present with symptoms of PPD.
• Signs include hallucinations, delusions, agitation, confusion, disorientation, sleep disturbances, and loss of touch with reality.
• Interventions include possible suicide and/or infanticide and are a psychiatric emergency requiring hospitalization and medical management.
• Most improve with treatment including antidepressants, antipsychotics, and anti-anxiety medications.

Postpartum Hemorrhage Assessment, Nursing Care, Interventions, Complications

• Postpartum hemorrhage is the leading cause of maternal morbidity and mortality in the U.S. and around the world.
• Early postpartum hemorrhage occurs in the first 24 hours after delivery, with a higher risk in the first 4 hours.
• Frequent checks are necessary every 15 minutes.
• The highest risk time is 2 hours postpartum, with tachycardia being the first sign and hypotension being a late sign.
• Late postpartum hemorrhage occurs from 24 hours to 12 weeks after delivery.
• Diagnosis includes vaginal bleeding >500 mL EBL, cesarean bleeding >1000 mL EBL, HCT levels dropping more than 10%, and the need for RBC transfusion due to anemia or hemodynamic instability.
• Tone is one of the 4 T's of postpartum hemorrhage.
• Uterine atony is the most common cause, with risk factors including:
• Pitocin use during induction or augmentation of labor.
• Over distended uterus (macrosomia, multiple gestation).
• Obesity.
• Prolonged labor.
• Previous history.
• Trauma during birth.
• Manual placental removal.
• Use of anesthesia.
• Intermittent/continuous dark red blood with clots and a soft, boggy uterus indicate a potential concern.
• Trauma is one of the 4 T's.
• Causes include rapid labor, C/S, episiotomy (perinatal care, warm water, big baby), and perineum, vagina, and cervix trauma from poor fit through birth canal or instrumental delivery.
• Steady, bright red blood with no clots and uterus contracted is a sign of trauma.
• Tissue is one of the 4 T's.
• Retained placental fragments should be carefully examined, and manual removal might be needed.
• Placenta previa (grows on cervix) and placenta accreta (endometrium) have higher risk.
• Hematomas may fill with 250-500 mL of blood rapidly.
• Ice packs, analgesia, or surgical management may be needed.
• Thrombin is one of the 4 T's.
• Thrombocytopenia can cause delayed blood clotting.
• Normal platelet count is 150,000-400,000.
• HELLP, DIC, and sepsis are potential concerns.
• Management and care includes palpating the fundus for location, tone, and lochia, and massaging it if boggy.
• Express clots (inhibits contraction of uterus) and note the length of time to saturate a pad.
• Assess the perineum for hematoma and unrepaired lacerations.
• Perform QBL with weight (1 g = 1 mL).
• Empty the bladder with a bedpan, straight cath, or foley.
• Start IV with large bore 18G for rapid infusion of 1L fluids, preferably NS or LR with oxytocin.
• Administer oxygen at 10-12 L/min for compromised perfusion.
• Medications include:
• Oxytocin (Pitocin): stimulates contractions (uterine smooth muscle) and can be given via IV or IM if no IV access.
• Contraindications= hypersensitivity.
• Nursing considerations= is the first line for PPH or uterine atony, but a bolus can lead to hypotension and cardiac arrhythmias.
• Methylergonovine maleate (Methergine): stimulates contractions (uterine and vascular smooth muscles) and can be given IM followed by PO.
• Contraindications= hypersensitivity, or history of HTN or current high BP.
• Nursing considerations= do not mix with other meds.
• Carboprost tromethamine (Hemabate): stimulates contractions (myometrium) and can be given via IM or directly into the uterus.
• Contraindications=ASTHMA, or hepatic/renal/cardiac disease.
• Nursing considerations=very expensive and do not administer if patient demonstrates signs or symptoms of shock.
• Misoprostol (Cytotec): stimulates powerful contractions (myometrium) and can be given rectally, PO, or sublingually.
• Contraindications= hypersensitivity to prostaglandins.
• Nursing considerations= when given rectally are much slower than IV.
• Dinoprostone (Prostin E2/ cervadil): stimulates powerful contractions (myometrium) and can be given vaginally or rectally.
• Contraindications= hypersensitivity to prostaglandins or severe HTN.
• Nursing considerations=if vaginal bleeding, vaginal suppository likely ineffective, and fever is common.
• Hypovolemic shock requires rapid intervention to prevent shock by restoring blood volume and treating the cause of hemorrhage.
• Classic signs = Maternal dyspnea, tachycardia, thready pulse, dropping BP, increasing HR.
• Nursing Interventions=summom help especially anesthesia, #1= massage fundus (atony), assessment; must know clients risk factors, rapid infusion of crystalloids: NS/RBCs, Airway - 02, Monitor status.

Complications During Pregnancy, Labor, & Birth

• Ectopic Pregnancy: fertilized egg implants outside of the uterine cavity.
• Incompatible with life and 99% implant in the fallopian tube.
• Diagnosed via evaluation of S/S (low sharp, stabbing unilateral pain), and transvaginal U/S. HCG quant is low because it will be poorly implanted.
• Treatment is to GET IT OUT.
• Non-ruptured ectopic pregnancy can be treated w/ Methotrexate IM (abortion pill) – non-surgical option.
• Laparoscopy / Salpingostomy (open fallopian tube and remove cells).
• Ruptured ectopic pregnancy is treated with Laparostomy / Salpingectomy (tube removal).
• Hyperemesis Gravidarum is nausea accompanied by severe vomiting during pregnancy.
• Nausea does NOT subside, and vomiting can cause severe dehydration and electrolyte disturbance.
• Weight loss of 5% or more of pre-pregnancy weight is seen.
• More severe cases require a hospital stay, often getting other forms of nutrition like g tube.
• Normal morning sickness can progress to hyperemesis if vomiting occurs w/ subsiding @ 12 weeks or sooner, does not cause severe dehydration.
• Placental Abruption is separation of the placenta from the wall of the uterus before delivery of the baby.
• Hemorrhage is a potential complication, and causes include smoking + cocaine (due to vasoconstriction), trauma, polyhydramnios, age, domestic violence.
• Assessment findings include: dark red vaginal bleeding, rigid abdomen (painful, and increasing ABD size.
• Placenta Previa is when the implantation is over or near the cervix.
• Dilation exposes villi with risk of bleeding.
• Risk factors include prior C/S or uterine surgery, grand multiparity (> or = 5 births > 20 weeks), and age.
• Assessment findings: bright red vaginal bleeding, and painless or w/ uterine activity, with also normal FHR pattern.
• Stable previa:
  • Nothing in the vagina (sex or exam), and schedule C/S @ 39 weeks.
  • Shoulder NOT be induced.
• Unstable previa: Emergency C/S.
  • Prep for C/S (two 18 gauge IVs, continual FHR monitoring, setup OR, etc.)
• Mnemonic: Painless, bright red bleeding (vaginal), Relaxed, soft, non-tender uterus, Episodes of bleeding, Visible bleeding (not concealed) Inspect FHR Aveoid vaginal exams.
• Cervical Insufficiency: inability of the cervix to remain closed & support the growing pregnancy.

• It can be congenital or acquired (hx of cervical trauma, previous spontaneous delivery in 2nd trimester).

• Associated w/ recurrent abortions and/or preterm birth.
• Signs & Symptoms: increased pelvic pressure, pink-stained vaginal discharge or bleeding, uterine contractions.
• Treated w/ cerclage (sewn closed).
• Magnesium Sulfate is used in PreE as an anticonvulsant.
• Administered IV and reduces seizure threshold (by depressing CNS).
• Secondary effect = decreased BP as it relaxes smooth muscle (monitor BP).
• NI: Use infusion control to maintain regular flow rate, Pt may feel flushed, hot, sedated w/ initial bolus, Monitor VS, CNS, LOC HA or visual disturbances reflexes, renal perfusion, output (indwelling cath), epigastric pain, FHR. Place pt on fluid restriction of 100-125 mL/hr and maintain UO of 30 mL/hr or greater, Monitor for mag toxicity.
• Magnesium Sulfate Toxicity:
• Respiratory distress should be noted (particularly respiratory depression).
• Decreased LOC.
• Absence of patellar deep tendon reflexes (hyporeflexia).
• UO <30 mL/hr.
• Cardiac Dysrhythmias.
• NI= Discontinue immediately, Antidote Calcium Glucontate, Notify provider , Take actions to prevent respiratory or cardiac arrest
• Preeclampsia is a dangerous disorder involving high BP during pregnancy. Preeclampsia in previous pregnancy is a huge risk factor.
• Signs & Symptoms: Onset > 20 weeks (+ up to 6 weeks postpartum), Greater than 140/90 on 2 occasions 4 hours apart or BP > 160/110, >1+ Proteinuria, Thrombocytopenia (platelets <100,000), Renal insufficiency, Impaired liver function, Pulmonary edema, New-onset HA unresponsive to medication.
• Interventions: Only treatment is delivery of baby/placenta, Monitor BP, Administer meds (Antihypertensives – hydralazine/labetalo IV, Anticonvulsant – magnesium sulfate ), Discuss nutrition , Maternal assessment (daily weights I&Os, reflexes CNS), Obtain fetal assessments (serial ultrasound doppler NST, BPP, contraction stress test fetal kick count), Encourage bedrest, Initiate seizure precautions, Can have strike keep watch (due to high BP) ,Provide quiet environment ,Monitor for HELLP & DIC (w/ severe preE/E), Immediately after a sz patient may be confused or combative DO NOT LEAVE ALONE.
• Preeclampsia w/ Severe Features:
• BP > 160/110 on >2 occasions 4 hours apart, Thrombocytopenia ,Impaired liver function (elevated liver function or SEVERE PERSISTANT RIGHT UPPER QUADRANT PAIN unresponsive to medications , Renal insufficiency (increased creatinine > 1.1), Oliguria Pulmonary edema, Protein/creatinine ration >0.3g, New onset HA unresponsive to medications, Visual disturbances.
• HELLP Syndrome: severe form of PreE
• Hemolysis of RBC's resulting in anemia and jaundice (destruction of RBCs).
• Elevated Liver enzymes (elevated ALT & AST, epigastric pain, N/V).
• Low Platelets (<100,000=thrombocytopenia abnormal bleeding & clotting time, bleeding gums, petechiae ,possible DIC).

Risk Factors for DIC:

• Disseminated Intravascular Coagulation is a hematological disorder that is characterized by a pathological form of clotting that consummates large amounts of clotting factors (clothing & bleeding at the same time).
• Causes/Risk Factors : Postpartum hemorrhage (vaginal <500mL C/S >1000 mL), Placental abruption, Amniotic fluid embolism, Severe preeclampsia/HELLP syndrome, Fetal demise.
• Gestational Diabetes Mellitus (GDM): impaired tolerance to glucose during the first onset or recognition of DM during pregnancy.
• Ideal BG = 70-110, Usually developed in 2nd or 3rd trimester.
• Contributing factors: obesity, maternal age >25, family hx of DM, previous delivery of infant who was large or stillborn
• Symptoms: Hypoglycemia (nervousness HA weakness irritability hunger blurred vision), Hyperglycemia (thirst nausea ABD pain frequent urination, flushed dry skin fruity breath)
• Labs/Diagnostics: Routine UA w/ glycosuria, GTT - done @ 24-28 weeks, Monitor HbA1C & ketones BPP/NST for fetal well-being Amniocentesis
• At risk to develop: Macrosomia Birth trauma Shoulder dystocia PreE/E, PTL , Polyhydramnios ,Congenital abnormalities, Fetal distress, Stillbirth & neonatal death, Decreased surfactant in the lungs, Low blood sugars at birth
• Management during pregnancy: Diet w/ reduced carbs frequent small meals, Daily fingerstick checks, Possible need for Glyburide PO, Possible need for Insulin SQ.
• Postpartum management- Decreased insulin requirements = IMMEDIATE (progesterone & estrogen decrease after birth ,what caused the issues in the first place), Type 1 = recalculate caloric & insulin needs, Type 2 = may not need insulin (can use oral meds) Most pts with GDM revert back to normal
• Cephalopelvic Disproportion (CPD): the head just won't fit through pelvis (big baby).
• Can lead to dystocia (long, difficult or abnormal labor) due to passenger (1 of the 5 P's).

Contraction Frequency

• Interventions: C/S, Maybe vacuum or forceps to help guide baby through pelvis.
• Abnormal = more often than 1 every 2 minutes or 5 in 10 minutes (tachsystole), Contraction duration longer than 90 seconds ,contraction intensity greater than 90 w/ IUPC ,no relaxation of uterus between contractions.
• Prolapsed umbilcal cord: occurs when the cord lies below the presenting part of the uterus (cord falls out).
• Contributing factors: long umbilical cord (approx=>1oo cm), Malpresentation (breech ,transverse lie), Unengaged presenting part ( negative station).
• Risks: Fetal hypoxia resulting from cord compression = variable decels.
• Interventions : insert hand into vagina & hold presenting part off the cord- do not take hand out until baby is dilvered C/S ,Placing the woman in the knee chest or Trendelenburg/ left lateral position , Covering the cord in sterile gauze in aline if it we're to protrude outside of the vagina.
• Tolac/Vbac:tolac / trial of labor after cesrean Vbac/ vagail birth afte cesrean.
• Requirements: Previous low transverse uretine incision-cannont have classical vertical incision, <2 previous C/S adequate pelvis, No other uterine scars. No hx of uterine rupture , Baby must be in vertex (cephalic) position Ctrol - cleared for trial of labor, Risk of uterine rupture = <1%. Doing to much Pitocin, previous C/S followed by spontaneous vaginal delivery Needs continuous fetal monitoring during labor
• Forceps and vacuum assisted deliveries. Indications: Maternal exhaustion or epidural anesthesia, Suspected fetal distress, Need to rotate fetal head (e.g sunny side up).
• Forceps: Indications : Poor progress during second stage, Fetal distess, Persistent occiput posterior position , Abonormal Persecution , Ni: access neonale for intracranial hemorrhage ,fecal bruising and facial palsy and check FHR before forceps are applied immediately after application .
• Vacuum : Indications: maternal exhaustion, and ineffective pushing. Fetal distess during 2nd stage of labor.Ni; place patient in lithotomy position and support width position, access and record FHR before during vacuum application, document number of pools pressure 8, pop offs and observe neonatal for bruising and cabut succeedanenm.
• Types of cesarean births. Classical- vertical incision (cannon have Tola), Low- transverse : Horizontal uterine incision- Indications- CPT,
• Placenta previa , Previous Classical incision , breech presentation

Post- Term Pregnancy Complications:

• Maternal risks ; dysfunctional labor, Interventions more lily necessary ( c/s , forceps,Vacuum ),Birth canal trauma (d/m/ macrosonia) Macrosonia *616oz,4000 grams), pph, infection, psychological ryn & Fatigue, Fetal risks ; shoulder dystopia macrosonia, Asphyxia, aging placenta -= co2 oxidation ( happens offer co weeks (wterteroplocetral msi/fecency - date deel,

Post -Term Pragnaney Complications

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Premature Labor Complications

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