Postpartum: Adaptation, Assessment, and Home Care

• Postpartum Family Part 1 is about adaptation, assessment, and home care in the postpartum period

Objectives for Today

• Explain the physiologic changes that occur during the postpartum period
• Describe nursing assessments and care for the postpartum physiologic needs of the mother
• Explain nursing teaching that should occur during the postpartum hospital stay
• Apply various comfort measures to ease the discomfort of the postpartum
• Discuss the role of the nurse to promote the psychosocial adaptations of childbearing mother and family
• Explain the factors that will influence maternal role attainment/becoming a mother, as well as the family's adaptation
• Consider cultural influences on family adaptation
• Compare the nursing assessments and cares for women that deliver vaginally versus operatively
• Describe the process of bonding and attachment, including maternal touch and verbal interactions
• Explain criteria indicating readiness for discharge of the postpartum family
• Discuss the cause, manifestations, assessment, and interventions for the postpartum baby blues

Postpartum Period

• Commonly referred to as the 4th trimester
• It is a period for woman, newborn, and family physiologically
• It is a period after delivery of placenta, lasting for 6 weeks
• It involves changes in all aspects of mother's life that occur during the first year
• This is a time of maternal physiologic and psychological changes
• It is a time of mother and family adjustment to new family member

Retrogressive Process

• This refers to the body returning or regressing to the pre-pregnancy state

Involution of Uterus

• This is one part of the retrogressive process
• It involves a return of the uterus to it's pre-pregnancy size
• There are three processes:
  • Contraction of muscle fibers
  • Catabolism
  • Regeneration
• Cramping can be relieved with warm water and analgesics
• After delivery the uterus enlarges immediately
• Day 1 of postpartum the uterus is at the umbilicus
• Two weeks postpartum the uterus is positioned within the pelvis
• Six weeks postpartum the uterus is non pregnant size
• In about 3 weeks the uterus reduces from 1200gm to 100 gm

Assessment of the Uterus

• Assessment of the uterus involves measurement

Placental Site: Exfoliation

• This is a part of the retrogressive process
• Maternal side is called "Dirty Duncan", fetal side is called "Shiny Schult"
• Uterus does not scar; tissue replaced by new growth from the basal endometrium
• Endometrium persists for about six weeks and first menses normally

Cervix

• This is one part of the retrogressive process
• Returns to normal within hours of delivery
• Transverse slit like external os persists due to laceration

Vagina

• This is one part of the retrogressive process
• Vaginal and perineal tears may remain inflamed
• Vagina appears normal by 6 weeks
• Not rapidly so in non lactating women
• Breastfeeding women are hypoestrogenic

Discharge/Lochia

• This is vaginal discharge after birth and part of the retrogressive process
• Quicker when breastfeeding
• Stages of lochia:
  • Rubra for 1-4 days
  • Serosa for 4-7/10 days
  • Alba 7/10-6 weeks
• Estimate amount
• Note any clots

Perineum

• This is one part of the retrogressive process
• Focus on assessment
• Assess for signs of infection
• Assess for REEDA
• Deliveries can cause operative injuries

Assessment (of Perineum)

• Assess intact suture line
• Check for hemorrhoids
• Be aware of 1-4 degree lacerations degree

Treatment (of Perineum)

• Ice X 24
• Topicals
• Positioning
• KEGALS

Degrees of Perineal Lacerations

• 1st Degree Tear involves the vaginal mucosa
• 2nd Degree Tear involves the vaginal mucosa and torn perineal muscles
• 3rd Degree Tear involves the torn anal sphincter
• 4th Degree Tear involves the torn anal sphincter and torn rectum

Abdomen

• This is one part of the retrogressive process
• After delivery diminished muscle tone is common
• Diastasis Recti is common after delivery
• No full sit ups
• Check C/S-incision-REEDA

Menstruation

• This is one part of the retrogressive process
• Returns usually 7-9 weeks postpartum in 50% of women
• For lactating women, menstruation return is dependent on length of feeding
• Exclusively breastfeeding delays menstruation for at least 3 months (2-18)
• Suckling-gonadotropin hormone production
• Breastfeeding reduces risk of pregnancy for 6 months

Postpartum Changes in Lab Values

• Nonpathologic leukocytosis occurs in the early postpartum period
• Blood loss averages 200 to 500 ml (vaginal)
• 700 to 1000 ml (cesarean)
• Platelet levels will return to normal by the sixth week
• Plasma levels reach the prepregnant state by 4 to 6 weeks postpartum

Postpartum Changes in Vital Signs

• Temperature may be elevated to 38 Celsius (100F) for up to 24 hours after birth
• Temperature may be increased for 24 hours after the milk comes in
• BP rises early and then returns to normal
• "Bradycardia” occurs during first 6 to 10 days

Progressive Processes

• Breast changes
• Cardiovascular
• GI
• Renal
• Integumentary
• Respiratory

Breast

• Decline in Estrogen and Progesterone
• Increased prolactin for breastfeeding
• Colostrum produced from 36 weeks gestation
• By day 3, breast engorgement sets in
• Engorgement involves increased blood and lymph -Frequent Empting -Compresses, warm before and cold after feeds
• If not breast feeding, no stimulation

Breast Assessment

• Note the Size and abnormalities
• Check for reddened areas or presence of fullness
• Assess the nipples
• Express milk and look for cracks, fissures, soreness or inverted
• Assess for a Properly fitting bra

Cardiovascular Changes

• Cardiovascular pregnancy changes reverse over 2 to 12 weeks
• Cardiac Output increases during labor and birth
• Cardiac Output stabilizes within 1 hour after birth
• 1000ml blood loss is normal during birth
• Maternal hypervolemia is normal during birth
• It is normal to be Hypercoaguable after birth

Assessment of Lower Extremities

• Assess for signs of thrombophlebitis
• Assess Homan's sign
• Assess legs for edema, redness, tenderness, and warmth
• Assess for return of sensation following anesthesia
• Ambulate to prevent thrombophlebitis; teach signs
• Cesarean delivery receives medication
• Heparin/Lovenox are common

GI

• Relief of pressure on organs after birth
• Assess for Bowel Sounds and Constipation
• Stool is common 2-3 days post delivery
• Can treat with on: laxatives, stool softeners

Assessment of Nutritional Status

• Teach about all needs
• Referrals as needed
• Provide nutrition info:
  • High Fiber
  • High Iron

Top High-Fiber Foods

• Beans/legumes
• Broccoli
• Berries
• Avocados
• Popcorn
• Whole grains
• Applies
• Dried Fruit
• Brown Rice
• Nuts
• Baked Potato with Skin

High iron food and drinks

• Clams
• Cold cereals
• Hot cereals
• Dark chocolate
• White beans
• Oysters
• Organ meats
• Soybeans
• All red meat, fish & poultry
• Prune Juice
• Beetroot juice
• Smoothies: Spinach, Cashew, & Raspberry
• Cocoa & liver
• Pea protein shake
• Pumpkin juice

Renal-DIURESIS

• 5-6 kg weight loss is expected at delivery, with an Additional 3-4 kg over next couple days
• Increased GFR returns to normal within several days
• 6 weeks for ureters and renal pelvis return to pre PG size
• Urination effected by lacerations, hematomas, swelling, regional anesthesia causing dec. bladder tone and sensation
• Assess for UTI if had foley
• Decrease Oxytocin-antidiuretic
• Replenish with food and fluids

Integumentary

• Striae
• Linea of nigra
• Diaphoresis
• Pigmentation fades

Respiratory

• Vital capacity and functional residual capacity return to prepregnant values within 1 to 3 weeks after birth

Endocrine

• Estrogen levels subside quickly
• Progesterone levels subside quickly
• Placental hormones decline rapidly
• Prolactin levels decline within 2 weeks if not breastfeeding

Psychological Changes

• Vulnerability
• Tremendous challenges
• Opportunity to help women learn, gain confidence, and experience growth

Postpartum "Baby" Blues

• Mood swings
• Anger
• Weepiness
• Anorexia
• Difficulty Sleeping
• Lasts a brief period of time
• Feelings of sadness that sometimes occur during the first few days postpartum
• Could be caused by Changing hormones, Psychologic adjustments, Lack of a supportive environment Insecurity, Fatigue, Discomfort/pain, Overstimulation
• May become postpartum depression--or psychosis

Postpartum Psychiatric Disorder Assessment

• Recommended Screening tools -Edinburgh Postnatal Depression Scale (EPDS) -Becks revised Postpartum Depression

Physical Assessment

• Frequent: -First 2 hours: every 15 minutes -Third hour: every 30 minutes -Rest of 1st 24 hours: every 4 hours

PP specific assessment -Vitals, fundus, pain, perineum, bleeding After 24 hours: every shift -PP specific with the Physical

• Vaginal-vs-Cesarean
• VS & Pain
• Breasts (size, contour, engorgement)
• Uterus (height of fundus, firmness)
• Bladder (voiding, bladder emptying)
• Bowels (bowel sounds, distention)
• Lochia (amount, color, odor)

POST-PARTUM ASSESSMENT "BUBBLE HE"

• B-BREAST: breast or bottle, size, sha firmness,
• U-UTERUS: Firm, midline, height
• B-BOWEL: stool softener,
• B-BLADDER: last void, UTI, regular voi
• L-LOCHIA: Color, amount, odor
• E-EPISIOTOMY: REEDA, hematoma, hem pericare
• H-HOMAN'S SIGN: DVT, prevention
• E-EMOTIONAL STATUS: Bonding, PPD

Vital Signs Assessment

• Temperature: slight elevation during first 24 hours; normal afterward
• Pulse: 50 to 80 bpm; puerperal bradycardia
• Respirations: 16 to 20 breaths per minute
• Blood pressure: within usual range
• Pain: goal between 0 and 2 on pain scale

Discomforts

• Episiotomy/Laceration
• Hemorrhoids
• Cramps
• Engorgement

Other hospital considerations for mom

• Rhogam-Rh Immune Globulin -Mom Rh negative -Baby Rh positive
• Vaccines: Rubella (MMR), Pertussis (Tdap)

Lactation Consultant

• Provide support, education, and consultation
• AAP says: 6 months exclusively breastfeeding and continuing breastfeeding for one year of life

Danger Signs #1

• Fever more than 100.4°F (38°C)
• Foul-smelling lochia or an unexpected change in color or amount
• Large blood clots, or bleeding that saturates a peri pad in 1 hour
• Severe headaches or blurred vision
• Visual changes, such as blurred vision or spots, or headaches

Danger Signs #2

• Calf pain with dorsiflexion of the foot
• Swelling, redness, or discharge at the 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

Emotional Status

• Interaction s with family
• Level of independence
• Energy levels
• Eye contact with infant
• Be alert for mood swings, irritability, or crying
• Comfort level with infant
• Sleep and rest patterns

Four Stages in Parenthood

1. Commitment, attachment, preparation for an infant during pregnancy
2. Acquaintance with and attachment to the infant, learning how to care for the infant; physical restoration in first weeks after birth
3. Moving toward a new normal routine in the first 4 months after birth
4. Achievement of a parenthood role around 4 months

Nursing Interventions

• Providing optimal cultural care
• Promoting comfort through Cold and heat applications, Topical preparations, & Analgesics
• Assisting with elimination by promoting or voiding promoting bowel elimination
• Promoting activity, rest, and exercise
  • Early ambulation
  • Rest periods
  • Exercise program -Kegel exercises
• Assisting with self-care measures
• Ensuring safety
• Counseling about sexuality and contraception

Nursing Interventions Cont.

• Promoting nutrition
  • General recommendations -Needs for the breast-feeding woman
• Supporting choice of newborn feeding method -Assistance with breast-feeding -Assistance with bottle-feeding

Preparation for Discharge

• Preparation for discharge should begin when expectant mother enters birthing unit
• The mom needs to be aware of signs of postpartum complications
• The mom should be aware of her self-care

Teaching Topics

• Pain and discomfort
• Nutrition
• Hygiene-peri, incision, handwashing
• Activity and exercise-kegals, modified sit ups, restrictions
• Lactation
• Discharge teaching
• Sexuality and contraception
• Follow-up: telephone, outpatient, home care visits

Postpartum Care Box

• Contains materials the mother will need after birth:
  • Uterus Model
  • Pad
  • PP Mesh Briefs
  • Perineal Irrigation Bottle-Pericare
  • Hemorrhoid towelette
  • Handkerchief-PPD
  • Moon -Pinto Beans -Breast soothing gel pads -Thermometer-physical warnings -Condom -Orange juice-Nutrition -Glob of fat-exercise-start light -Mirror-change of appearance

Maternal Psychological Adaptations

• Attachment: formation of a relationship between a parent and his or her newborn through a process of physical and emotional interactions
• Early and sustained contact between newborns and parents is vital
• Nurses play a crucial role in assisting with this process of attachment
• Factors influencing attachment include environmental circumstances, newborn health, and quality of nursing care

Rubin's Maternal Psychological Adaptation

• "Taking in"
  • Woman tends to be passive, follows suggestions, hesitates to make decisions, preoccupied with her birth experience
• "Taking hold"
  • Ready to resume control of her body, her mothering, and life in general
  • Breastfeeding worries
• "Letting Go"
  • Focus on family as a unit
  • Reassertion of relationship with partner, sexual intimacy
  • Resolution of individual roles

Mother-Infant Attachment

• Acquaintance phase -Phase of mutual regulation -Balance needs of baby and mother -Some maternal negative feelings may be expressed; nurse should be supportive
• Reciprocity -Phase of mutual regulation -Both enjoy each other's company

Factors Affecting Attachment

• Parent's background
• Infant temperament and health at birth
• Care practices: complementary behavior and sensitivity
• Separation immediately after birth
• Policies discouraging exploring infant
• Intensive care environment
• Staff indifference or lack of support for parents

Mother-Infant Attachment

• Relies on senses of sight/touch/hearing -Exploration of the newborn -Fingertips -Palms -Enfold in hand and arm
• En face
• Direct eye contact
• Positive or negative response
• Baby factors that can influence -Preterm, ill, multiples

Father-Infant Attachment

• In Western cultures, many fathers experience similar feelings of attachment as the mother
• Strong attraction to the newborn
• Engrossment
• In some cultures, father's involvement with newborn care is minimal

Sibling attachment

• Depends on age and developmental level
• Toddler is not completely aware of baby before birth
• Older children May be fearful of competition for parents' attention
• Attention seeking behaviors may emerge
• Preschoolers are more looking than touching infant
• Older siblings may talk to mother more than infant
• To reduce conflict take a Relaxed approach

Special Post partum considerations

• Teenage moms-challenge-don't have strong sense of self -May appear more passive/less affectionate -Use role modeling
• Obese moms -Airway obstructions, SCD's, care of incision
• Developmentally disabled -Provide information that can be easily understood -Community and private resources
• History of sexual abuse -Trust issues, being touched, anxiety with procedures
• Mental Health disorders -More at risk, increase screening and referrals
• Cultural -Communication -Verbal, interpreters -Dietary -Hot-cold -Health Beliefs -Bring them sense of security -Vary widely-care of mother and baby by female relative very prevalent

Relinquishing a Baby

• Many reasons why a woman decides she cannot parent her baby
  • Emotional crisis may arise as woman attempts to resolve her concerns
  • As she faces these concerns, there are many social pressures against placing using adoption services (family and friends)
• Proper terminology: Placing baby vs. "put up" for adoption

Infant Care

• New mother and family should know basic infant care
  • When to anticipate cord will fall off
  • Information about tub baths and immunizations
  • Family should be comfortable in feeding and handling infant, as well as safety concerns
• Follow up visits

Main Purposes of the Home Visit

• Assess the status of the mother and infant
• Assess Adaptation and adjustment of the family to the new environment
• Determine current informational needs
• Provide teaching as needed
• Answer additional questions related to infant care and parenting
• Providing emotional support to mother and family

Accommodations at the Workplace

• Pregnancy accommodations
• More frequent food, water and bathroom breaks
• Seating accommodations
• Limits on lifting over 20 pounds
• Any other reasonable accommodation requested, such as transfer to a less strenuous or demanding position

Nursing accommodations

• Enough unpaid break time to nurse or pump
• A private room to nurse or pump
• A room other than a bathroom or toilet stall

MN chapters 17, 18, & 19

• Picmonics X4

1. Postpartum Hemorrhage
2. Breastfeeding
3. Pitocin
4. Postpartum Infection

• ATI Real Life Maternal Newborn 4.0 Postpartum Hemorrhage

ATI Practice Assessment Review/Remediation Help

• Take assessment-rationales off
• Complete Remediation
• If scored less than 75% on assessment, retake the assessment-now the rationales are on for your learning
• Complete all steps, remediate well and improve your score, to earn 10 points