Postpartum Care and Lactation

Postpartum Care & Lactation

• BUBBLE PLEB is an assessment acronym:
  • Breast & Chest
  • Uterus & Abdomen
  • Bladder
  • Bowels
  • Lochia
  • Episiotomy/Lacerations
  • Pain
  • Lower & Upper Extremities
  • Emotional Status
  • Bonding

Lactation

• Serum prolactin stays elevated, suppressing ovulation
• Prolactin is affected by frequency, length of feedings, and supplement use
• Infant sucking affects prolactin levels
• Exclusive breastfeeding often delays the first postpartum ovulation for about 6 months
• Breastfeeding releases oxytocin

Non-Lactating

• Prolactin decreases
• Ovulation returns 27-75 days after birth
• Menses return around 6 weeks postpartum

Breast Care

• Types of milk:
  • Colostrum: 3-5 days
  • Transitional: 3-5 to 14 days
  • Mature: 14 days and beyond
• Infant positioning is important
• Breast engorgement may occur
• Nipple care is important
• Fungal infection (thrush) is possible
• For non-lactating mothers:
  • Avoid stimulation.
  • Wear a supportive bra.

Breast Changes

• Colostrum transforms into mature milk within 72-96 hours after birth
• Engorgement comes from lymphatic circulation, milk production and temporary vein congestion
  • Occurs on days 2-5
• Increased milk production occurs 48-96 hours postpartum
• Letdown Reflex releases milk when a baby sucks or a breast pump is used

Breastfeeding RN Considerations

• Encourage skin-to-skin contact and cue-based feeding
• Babies may cluster feed
• Look for correct latching
• Ask about redness, tenderness, cracked nipples, blistering, or bruising
• Change positions for latching

Engorgement

• Nurse frequently
• Use cold packs or cabbage leaves
• Can be very painful
• Breastfeed to empty both breasts
• Pump
• Assess sore nipples every shift
• Ineffective feeding is possible

Breastfeeding Positions

• Cradle hold
• Cross-cradle hold
• Football hold
• Lying down
• Phalange lips
• Feed frequency: every 2-3 hours, on demand, or cluster feedings

Complications

• Mastitis
• Cracked nipples
• Redness
• Engorgement

Prevention

• Handwashing

Lochia

• Lanolin use is helpful
• For engorgement use: Frequent breastfeeding and cabbage leaves
• Three stages of Lochia:

Rubra

• Bright red, bloody with a fleshy odor
• May contain small clots, smaller than a chicken egg
• There may be a transient increase in flow with breastfeeding
• Lasts day 1-3

Serosa

• Pinkish-brown, serosanguineous
• Lasts day 4-10

Alba

• Yellowish-white with a fleshy odor
• Lasts from day 11- 4/8 weeks

Amount

• Scant = less than 2.5 cm
• Light = 2.5cm to 10cm
• Moderate = >10cm
• Heavy = one pad per hour
• Excessive = one pad within 15 min or less, or pooling of blood under the buttocks

Nursing Actions

• Notify the provider if:
  • Spurting of bright red blood from vagina
  • Large clots & excessive blood loss
  • Foul odor
  • Rubra beyond day 3
  • Discharge amount increases after 2 weeks

Postpartum Immunity

Rubella

• If titer is less than 1:8, rubella vax or MMR is needed prior to discharge
• Tell patient not to get pregnant for 1 month after vaccination

Varicella

• Give prior to discharge if patient has no immunity
• Tell patient not to get pregnant for 1 month after first dose and second dose due 4-8 weeks

T-DAP

• Give vaccine at 28 weeks gestation
• If not administer before, give before discharge

RhoGAM

• Administer to Rh- mothers within 72 hours of delivery to prevent complications for future pregnancies
• Not for immunocompromised patients

Perineum Care

• Assess with REEDA:
  • Redness
  • Edema
  • Ecchymosis
  • Discharge
  • Approximation
• The Perineum can be bruised and edematous in the postpartum period
• The pelvic floor is overstretched
• Care for lacerations
  • Ice for 24 hours
  • Heat-whirlpool or sitz bath
  • Clean: rinse after toilet
  • Frequent pad changes
  • Pat dry
  • Use topical anesthetics
  • PO analgesia
  • Sit on pillows
• Encourage pelvic floor exercises
• Assessment for Prolapse:
  • Rectocele
  • Cystocele
  • Uterine Prolapse

Postpartum Assessment

Postpartum Danger Signs

• Fever more than 100.4 F
• Foul-smelling lochia or a change in amount or color
• Large blood clots, heavy bleeding saturating a peripad in an hour Severe headache
• Visual changes or blurred vision, or seeing spots
• Calf pain
• 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 lack of interest in self or baby

Fundal Assessment

• Involution of uterus occurs from contractions of uterine smooth muscle
• Encourage breastfeeding
• Administer oxytocin IM or IV after placenta birth
• Encourage patient to empty bladder every 2-3 hours to prevent uterine displacement and atony
• On Day 1 fundus should be at or slightly above the umbilicus
• By Day 10 it is no longer palpable
• Steps for Fundal Check:
  • Support lower segment of uterus with one hand
  • Palpate abdomen to locate fundus with the other hand
  • Document the height, location, and firmness
    • Fundal height measured by fingerbreadths (centimeters) above or below umbilicus
    • Determine if fundus is midline or displaced
    • Determine firmness or boggy
      • If boggy uterine massage

Vital Signs

• Normal: 38 or 100.4 >24hrs of birth = afebrile
• Due to dehydration, metabolism changes and lactation
• If >38 >24 hrs or 2 days = puerperal sepsis
• Pulse: elevated x1 then begin to decrease
• A rapid or increased pulse indicates hypovolemia to hemorrhage
• RR: decreases
• Can be d/t hypoventilation with epidural, narcotics
• BP: no or slight alteration
• A low BP may indicate hypovolemia or hemorrhage
• Pain:
  • Afterpains
  • MSK
  • Perineal
  • Nipple

MSK

• Joints stabilizing
• Separation of abdominal muscle
• Pelvic floor stretch

Postpartum Complications

Postpartum Depression

• Symptoms include:
  • Sadness
  • Flat Affect
  • Anhedonia
  • Low Energy
  • Sleep Problems
  • Somatic Complaints not subsiding
  • Appetite Changes
  • Withdraw from friends and family
  • Concentration problems
  • Guilt, low self worth
  • Thoughts of harm to self or others
• Assessment involves:
  • Interview
  • Talk to partner and family
  • Observe affect and behavior
  • Standardized instruments:
    • Edinburgh postnatal depression scale (EPDS)
    • Center for epidemiologic Studies Depression Scale (CESD)
  • Ruling out physical health problems: thyroid dx
• Prevalence: 15% and 60% teen mothers
• Onset is typically within 6 months postpartum
• Risk factors include:
  • History of depression
  • Perinatal complications
  • Infant illness, temperament
  • Marital discord
  • Social support
  • Low SES
  • Other life stresses
• Chronic depression can affect child development and mother-child relation
• Treatments include
  • Psychotherapy
  • Medication
    • Antidepressants
    • Hormone therapy
  • Hospitalization if there are concerns for safety
  • ECT

Postpartum Infections

• Risk Factors:
• Preconception and antepartal factors
• Intrapartum complications
• C-Section
• PROM
• Hematoma
• Catheterization
• Multiple Vaginal Exams
• Depressed Immune System
• Invasive Procedures
• Lapse in aseptic technique
• DM
• Obesity
• Facts about postpartum infections:
  • Common cause of maternal morbidity and mortality
  • Occur up to 28 days after birth
  • Fever of 38* or higher for 2 consecutive days for the first 10 days PP
  • Early detection and treatment is key

Endometritis

• Infection of the endometrial lining, decidua, and adjacent myometrium
• Common causative agents: E. Coli, Klebsiella pneumonia, G. Vaginalis
• Risk Factors:
• C section
• Retained placental fragments
• Manual extraction of the placenta
• Prolonged ROM
• Internal monitoring
• Frequent vaginal exams
• Long labor
• Postpartum hemorrhage
• Further invasive things done to control bleeding
• Symptoms:
• May start days 2-5 PP
• Pelvic pain
• Uterine tenderness
• Subinvolution
• Scant to profuse lochia: malodorous or purulent
• High Fever
• Treatment:
• Antibiotics
• Analgesics

Wound Infection

• Sites: C-Section, Episiotomy, lacerations, etc
• C-Section infections are usually due to poor hand hygiene
• Healthcare professionals or the patient can introduce infection to incisions via lochia
• Teach proper perineal care and keep pad away from the surgical incision and change pad frequently with good hand hygiene
• Obese patients are more at risk
• Symptoms:
• Warmth
• Swelling
• Tenderness
• Pain
• Edema
• Seropurulent drainage
• Wound dehiscence
• Evisceration
• Fever>
• Treatment:
  • Wound care
  • Antibiotics Analgesics Comfort measures Good hand hygiene Sitz bath

Mastitis

• Infection of the breast-interlobular connective tissue
• Often caused by milk stasis or Staph Aureus
• Usually Unilateral
• Typically one-sided, not usually both breasts
• Esp. when mom prefers to feed on one breast more over the other, both must be drainage
• Etiology: inadequate hand washing between handling perineal pads and breast
• Nipple trauma
• Cracked and bleeding nipples
• Can progress to abscess if untreated and lead to sepsis
• Symptoms:
• fever/chills/fatigue
• pain/tenderness
• Redness/erythema
• Odor
• Malaise
• Inflammation
• Purulent drainage
• Can not just occur at the site
• enlarged/tender lymph nodes

UTI

• Caused by bladder trauma during birthing or poor technique with catheter insertion
• E.coli, klebsiella, proteus, enterobacter are common causative agents
• Risk Factors:
• Hypotonic bladder or urethra
• Epidural anesthesia
• Urinary catheter
• Frequent pelvic exams
• Genital tract injury

UTI Treatment

• Antibiotics: PO or IV
• Pain relievers/analgesia
• Warm compress
• Rest and fluids
• Teach signs of infection before discharge

Postpartum Hemorrhage

• Identify who is at risk
  • Most at risk: Blood loss of >500ml for vaginal birth and 1,000 for C-section Recognition:
  • VS >15% change
  • HR>110
  • BP >85/45
  • 02 <95
  • Increased bleeding

OB Hemorrhage

• Initiates sequential steps to treat bleeding and, if needed, activates massive transfusion protocol
• Etiologies Occur: EARLY, <24 hours PP:
  • Uterine atony
  • Placenta accreta
  • Perineal laceration
  • Hematomas
  • DIC
  • Uterine or inversion
  • LATE, 24hrs-6W PP:
    • Subinvolution
    • Placental fragments
    • Pelvic infection
    • Coagulopathy
• Assessment includes checking for bleeding. Check for:
• Uterine tone, massage uterus, asses the effect
• Administer uterine stimulants as ordered
• Monitor VS, I/O, LOC, fundal tone and placement and bleeding
• Assist to void, place foley if needed
• Replace fluids and administer blood products as ordered
• Prepare for surgery if needed
• Provide information and support to patient and family members
• Medications:
  • Pitocin (IVFs?IM)
  • Methergine (IM)
  • TXA (tranexamic Acid) IVPB
  • Hemabate IM
  • Cytotec SL
• Provider:
• Bimanual exam: a manual exploration of the cavity
• consider Jada System: if uterine atony persists anticipate hysterectomy

Postpartum Blood Clotting

DIC

• Life-threatening: acquired coagulopathy
• Clotting activated: depletion of platelets and coag factors
• Risk of internal and external bleeding and organ damage
• Secondary cause: tx: cause

ITP

• AUTOIMMUNE DISORDER
• Destruction of PLT by antibodies
• low platelet
• Tx: glucocorticoids and immune globulin

VON WILLEBRAND DISEASE

• Congenital bleeding disorder: autosomal DOMINANT TRAIT
• Prolonged bleeding time, deficiency impaired PLT adhesion
• RN CON:
  • Findings: excessive blood loss
  • LABS: clotting factors

THROMBOEMBOLIC DISORDERS

• Management: correct the cause and perform support with more volume
• Etiology:
  • Altered clotting
  • Venous status: d/t changes of pregnancy, decreased mobility PP
• Venous thromboembolic conditions:
  • Superficial venous thrombosis
• DVT
• PE
• High risk during first 3 weeks of PP
• Prevention:
• Early ambulation
• Leg exercise in bed
• Anti Embolism stockings

Newborn Care

Thermoregulation

• "Cold Stressed" : O2 demand increased = acidosis: resp issues = hypoxia
• They are prone to heat loss and limited in their ability to maintain temperature. Newborns can't shiver and are adapting to a new environment, making them more at risk of losing heat.:
• Types of Heat Loss:
  • Conduction: heat loss through contact with cold surfaces
  • Convection: heat loss through air currents Evaporation: heat loss through moisture; baby not dried off right Radiation: by transferring heat to cooler surfaces that they are not in direct contact with. Skin to skin with mom helps with thermoregulation, as does drying baby off with a towel s/sx:
  • Cold extremities
  • Lethargy
  • Apnea
  • Tachypnea
  • Poor feeding
  • Nasal flaring
  • Expiratory grunting
  • Retractions

Management

• Place NB skin-to-skin on mom or apply a hat
• Dry newborn quickly
• Keep environment warm and the baby's head covered
• Assess with NB at Skin to skin contact

Complications

• Increased O2 consumption: O2 is not getting to tissues = acidosis = increased RR, vasoconstriction, and further acidosis
• Shock, DIC, death
• Premature infants are more at risk for cold stress d/t decreased brown fat stores
• Hypoglycemia from increasing glucose consumption and further depletion of brown fat stores
• Jaundice
• Metabolic acidosis
• Hypoxia
• Decreased surfactant production

Brown Fat Stores

• A part of thermogenesis
• Specialized vascular fat on newborns
• Typically not seen in weeks 26-30
• As cold stress occurs, NB burns up reserves
• Between scapula, axilla, nape of neck, and abdomen 2-6% of TBW

Feeding Assessment

• Infant Feedings:
• Provide info on nutritional, and immunological values, and benefits to infant and mother in, a nonjudgmental manner and with respect for their decision Always Discuss the benefits of breastfeeding Possible risks of using formula: intolerance and constipation

Stool

• Meconium = first stool, is black
• Breast Milk is highly digestible so immediate large BM, and more frequent
• Formula BM is not so digestible so it can take longer like in the 1st or 2nd week

Newborn Assessment

• Head-To-Toe

HEENT

• Head: Assessment of anterior and posterior fontanels Futures - palpable; overlapping, separated, un-joined
• Caput succedaneum:
• Generalized area of edema on scalp
• Crosses the suture
• Results of sustained pressure on pelvis during labor
• Resolves in 3-4 days and does not require any treatment
• Cephalohematoma:
• Collection of blood under the periosteum of a skull bone
• Does not cross suture lines
• Feels fluctuant
• Often with caput
• Peaks 2-3 days
• Spontaneous resolution 2-8W
• Forms trauma in birth from head against maternal elvis form, or with a prolonged or difficult potential labor
• esp with forceps or vacuum use
• Babies can have more of a cone-shaped, off-center head

Facial Symmetry

• Assess when infant is crying and suckling if it shows trauma or a nerve injury
• Eyes: Spacing Edematous at birth Eye color & tearless can be seen Subconjunctival hemorrhages •
• if low placement suggests: chromosomal disorders, intellectual disabilities or kidney disorders
• Ears should have Placement & Cartilages. They respond to sound
• Coiling - ballard scale: respond to noise stimuli
• Mouth:
• Check Lips, plate, and scukle tongue

Skin

• LANUGO: downy hair which serve as protection for the fetus in the watery environment & Helps with thermoregulation. Will be lost
• MONGOLIAN SPOTS: bluish, black pigmentation NOT bruising
• MILIA: present at birth, small, white sebaceous cysts adjusting to the new environment with air.
• Peeling skin post mature can occur, and is considered, vernix diminishes
• Erythema toxicum - common Newborn rash, which is caused by adjusting new environment • goes away, so teach parents it's not a skin infection
• Vernix - white substance waxy coating baby at birth: Another protective barrier, thermal Control, provides a protective against watery environment and is thick pasty Rashes / Bruises & their Color CHEST: barrel-shaped which is ABN Abd. breathing, No costal retractions or nasal flaring. Breast buds + are prominent also seen in a bit of estrogen board in female newborns.
• Abdomen - Umbilical cord should have : 2 A, 1 V. Will Protrude
• Anogenital:
• Annus should by considered patent when baby passes meconium 24-48 hrs
• Sterile meconium is sterile - containing RBC, and does not have smell compared to GI bleed, no bacteria present
• Bilirubin is also in the stools.
• In general; Bilirubin will linger more the longer meconium has not passed
• Urine should be passed within 24hrs
• If Uric acid crystals are present, they will have peachy colored stains on diape.r Not all passes this, but its normal; pt teaching
• For Females the Labia majora typically covers clitoris and minora Can see pseudomenses which is Not uncommon to pass a bit of blood related to high estrogen levels from mother Males: .Descent of testis in the scrotum and rugae, urethral opening at end of penis/foreskin should be noted

Extremities/Posture

• should have full range of motion and spontaneous movement; symmetrical, flexed, palm creases
• Ortolani's Maneuver hips should be without click - if dislocated this is more common with the breech presenting babies
• flexed posture, Spine straight/Without sacral opening, deep dimple, gluteal folds symmetrical are normal
• Sole creases should be 2/3 of feet/Nail beds, pink/no extra digitals

Spine

: Straight; No sacral opening/deep dimple/ No meningocele

• Reflexes- Newborns respond to stimuli, cry, muscle tone, and activity Sucking, moro/startle, Rooting/Tonic neck (fencing position) should all be present Babies should have a Babinski reflex (stroke foot and toes spray out). palmar/plantar grasp, Stepping Reflex, and exhibit the Craw reflex
• Ballard Scale can be performed

SGA/AGA/LGA

• SGA/AGA/LGA and the meaning of gestational Terms needs to understood.
• Appropriate for Gestational Age (AGA): 10th to 90th percentiles and have Normal hxLxW plus have a normal head circumference and BMi
• Small for gestational age (SGA): will be <10%
• complications:
• Perinatal asphyxia/Meconium aspiration/Hypoglycemia/Polycythemia/Temperature instability
• Risk factors:
• Congenital or chromosomal abnormalities / Maternal infection, disease or malnutrition / Gestational HTN or DM / Maternal smoking, drugs, ETOH / Placenta previa/ decreased placental perfusion plus small placenta/Fetal congenital infections : rubella, toxoplasmosis
• Assessment for SGA Wt below 10th percentile/Normal head circumference, Hair; little/Dry loose skinLittle subQ fat Decreased muscle mass, esp. Cheeks and buttocks/Respiratory distress and hypoxia/Acrocyanosis Umbilical Cord thin, dry, yellow, dull instead of gray, glistening and moist / The Flat abdomen Should instead of well rounded

LGA

• large for gestational age will be >90% These are macrosomic newborn

• 4000g and will at higher risks for birth injuries: Shoulder dystocia Clavicle fracture and facial palsies are possible. Assessment should include:

• Wt above 4000g and Large head, increase subQ, and chubby cheeks are common
• birth Traumas should be identified; possible Sluggishness; hypotonic/Tremors

Low Birth Weight (LBW) for a newborn is if they below <2,500 Intrauterine Growth Restriction causes growth does not meet expected norms A Term Birth is at : 37-42 Weeks gestation s/sx of a Preterm Baby are; Minimal subcutaneous fat; scrawny appearance/Skin: thin/smooth/shiny and translucent Skull and rib cage feel soft. Extremities would have •Limited tone + paralysis

Wrinkled features with and abundance of lanugo (this may not be seen) A. RN con's should include Daily V/S with the infants weight and I&O. Asses for bleeding and provide skin care.

The Etiology of 40% of preterm births is unknown, but it is generally related with 4 main causes (Infections, maternal issues, stressors, birth issues) Complications could involved the respiratory or neurological system

Goals:

Stabilize infant, offer stabilization of oral feedings. Possible Maternal factor affecting this patient may involved: Gestational hypertension Close, Multipes pregnancy and use of substances

NB Jaundice

Normally, it occurs when the liver conjugates bilirubin (its water soluble) and excretes in feces The issue with newborns specifically, is that unconjugated RBC builds up in their bloodstream = jaundice when their immature Liver get's overwlemend by RBCs

The Liver becomes overwhelmed and the RBCS build up in the blood RF: 6-8mg/kg and can be caused from decreased liver functions and increase in RBC productions

NB's in general produce more RBCS and therefor at more at risk The Liver is also immature and the large amount of RBC can overwhelms it. at 24 hrs it starts to produce the bilirubin •If there is high levels unconjugated bilruben over >24 It can then lead to - KERNICUTERUS from HIGH BILLS over >25

Symptoms included: •Jaundice •Elevated serum bilirubin •Irreversible

If HIGH B/R deposited in the brain it can cause a encephalopathy Symptoms included

Intervention: Phototherapy should occur and cover the patients eyes

• Do NOT let any lotion or ointment and be used
• Observe skin is important and Maintain adequate fluid intake ( frequent feedings, encourage breastfeed, Monitor how much they are eating and make sure they are not gaining too much kernicterus)

POLYCYTHEMIA

• Causes : increased thickness visosity of the blood or affects BF, but its more common wiht 12% of neonates