Nursing Management During Postpartum Period - Chapter 16 PDF

NURSING MANAGEMENT DURING POSTPARTUM PERIOD : CHAPTER 16 SOCIAL SUPPORT AND CULTURAL CONSIDERATIONS · Strong social support needed · Understand woman in her social and cultural context so humility and sensitivity are applied- be aware of wishes and beliefs · Teach self-care and baby...

NURSING MANAGEMENT DURING POSTPARTUM PERIOD : CHAPTER 16 SOCIAL SUPPORT AND CULTURAL CONSIDERATIONS · Strong social support needed · Understand woman in her social and cultural context so humility and sensitivity are applied- be aware of wishes and beliefs · Teach self-care and baby care basics · Provide emotional support · "mother" the new mother with physical care, emotional support, information, and practical help · Help them gain confidence · Promote breastfeeding ASSESSMENT · During the first hour: every 15 minutes · During the second hour: every 30 minutes · During the first 24 hours: every 4 hours · After 24 hours: every 8 hours VITAL SIGNS · Temperature normal range or low-grade elevation for first 24 hours postpartum- due to dehydration from fluid loss during labor Should be normal after 24 hours with replacement of fluid Temp of 100.4 or higher at any time or abnormal temp within first 24 hours may indicate infection- report this Temperature can indicate maternal sepsis- be vigilant VITAL SIGNS · Pulse- 60-80 bpm first week after birth Called puerperal bradycardia Increase in intravascular volume postpartum Elevated stroke volume decreases heart rate Tachycardia suggests anxiety, excitement, fatigue, pain, excess blood loss or delayed hemorrhage, infection, underlying cardiac problems If higher than 100, warrents investigation into cause VITAL SIGNS · Respirations 12-20 breaths per minute at rest Pulmonary function returns to prepregnant state after childbirth when diaphragm descents and organs revert to normal positions Any changes indicate pulmonary edema, atelectasis (side effect of epidural), or pulmonary embolism Lungs should be clear VITAL SIGNS · Blood pressure Compare to usual range- report any deviation- should remain same as during labor Increase in bp- gestational hypertension Decrease- shock or orthostatic hypotension, dehydration (side effect of epidural) Should not be higher than 140-90 or lower than 85/60 VITAL SIGNS · Pain Type of pain, severity, and location 0-10 pain scale Provide comfort measures – perineal care, clean gown, mouth care, warm blankets, fluid intake, reposition frequently, and encourage rest Premedicate for afterbirth pain if possible Try to keep pain between 0-2 at all times, especially after breastfeeding Assess frequently, especially for hematoma by inspecting and palpating area- report if you find PHYSICAL ASSESSMENT · Breasts ▪ Inspect size, contour, asymmetry, engorgement or erythema ▪ Check nipples for cracks, redness, fissures, bleeding, ▪ Check nipples to determine if flat, inverted, or erect ▪ Lactogenesis-onset of milk secretion- triggered by delivery of placenta- decreased levels of estrogen and progesterone with presence of prolactin ▪ "filling" breasts fill with milk as milk comes in ▪ Engorged breasts are hard, tender, and taut ▪ Any discharge that is not creamy yellow or bluish white should be reported ▪ Breast milk matures within first week and changes throughout breastfeeding to meet infant's demands PHYSICAL ASSESSMENT · Uterus Assess fundus to determine uterine involution Empty bladder before palpating, auscultate bowel sounds prior Premedicate before massaging fundus if necessary Two handed approach in supine position PHYSICAL ASSESSMENT · Uterus Should be firm and midline Boggy or relaxed uterus is sign of uterine atony (loss of muscle tone in uterus)- can be caused by bladder distension or retained placental fragments- increases risk for hemorrhage Once located, count fingerbreadths from fundus to umbilicus 1-2 hours after birth- between umbilicus and symphysis pubis 6-12 hours after birth- fundus at level of umbilicus 1 cm per day after childbirth until nonpalpable at 10-14 days postpartum If not firm, gently massage using circular motion until firm PHYSICAL ASSESSMENT · Bladder Diuresis up to 3,000 mL/day begins within 12 hours after birth and continues for several days Single void may be 500mL or more By 21 days, diuresis is complete Due to lack of sensation to void, bladder may feel causing distension and displacement of uterus upward and to the side- can lead to hemorrhage Postpartum urinary retention- inability to empty bladder within 6 hours after vaginal birth Assess for distension and signs of infection PHYSICAL ASSESSMENT · Bowels ▪ Constipation is common due to low pelvic floor trauma, pain medications, lack of fiber, fluids, and infant care ▪ Normal bowel elimination usually resumes in one week ▪ Fear due to pain, the unknown, hemorrhoids, or fear to rip stitches ▪ Stool softeners and laxatives to treat ▪ Abdomen should be soft, nontender, and nondistended PHYSICAL ASSESSMENT · Lochia assess amount, odor, color, and change with activity and time Ask how many pads she has used in past 1-2 hours and how much drainage Lochia has definite musky scent with odor similar to menstrual flow without large clots (fist sized) Foul smelling lochia suggests infection; large clots suggest poor uterine involution and needs further intervention Observe lochia on pad and relate to other pads PHYSICAL ASSESSMENT · Lochia flow increase when woman gets out of bed and when breastfeeding (oxytocin release causes uterine contraction) · Length of time determines flow of lochia- if a woman saturates a pad in one hour they are bleeding more than someone who saturates in two hours · Scant: a 1- to 2-in lochia stain on the perineal pad or approximately a 10-mL loss · Light or small: an approximately 4-in stain or a 10- to 25-mL loss · Moderate: a 4- to 6-in stain with an estimated loss of 25 to 50 mL · Large or heavy: a pad is saturated within 1 hour after changing it PHYSICAL ASSESSMENT · Lochia- C-section will have less lochia than vaginal births Notify physician if lochia rubra returns after serosa and alba have taken place- may indicate subinvolution or that woman is too active and needs rest EPISIOTOMY/PERINEUM AND EPIDURAL SITE Assess in position of photo-----> Majority of healing takes place in first 2 weeks but may take 4-6 months to health completely First-degree laceration: involves only skin and superficial structures above muscle Second-degree laceration: extends through perineal muscles Third-degree laceration: extends through the anal sphincter muscle Fourth-degree laceration: continues through anterior rectal wall EPISIOTOMY AND EPIDURAL SITE · Assess every 8 hours to detect hematoma and sign of infection · Large areas of swollen, bluish skin with complaints of severe pain in perineal area indicate pelvic or vulvar hematomas · Redness, swelling, increased discomfort, or purulent drainage indicate infection · White line running down length of episiotomy or swelling and discharge are sign of infection · Ice relieves discomfort and reduces edema; sitz baths promote comfort and healing · Assess epidural site and for side effects of medication such as itching, n/v, or urinary retention PHYSICAL ASSESSMENT · Extremities Increased risk for venous thromboembolism- PE and DVT Hypercoagulable pregnant state increases risk of thromboembolic disorders during pregnancy and postpartum stasis (compression of the large veins because of the gravid uterus) altered coagulation (state of pregnancy) localized vascular damage (may occur during the birthing process) Observe for signs/symptoms of DVT or PE Antiembolism or graduated compression stockings and early ambulation PSYCHOSOCIAL ASSESSMENT · Emotional status- observe interaction with family, level of independence, energy levels, eye contact with infant, posture and comfort levels when holding the newborn and sleep and rest patterns- watch for mood swings, irritability or crying · Bonding and attachment Bonding is close emotional attraction to newborn by parents that develops in first 30-60 minutes after birth- unidirectional from parent to infant Close contact within first few minutes to hours after birth Attachment- development of strong affection between infant and significant other- reciprocal- progressive and developmental that changes over time ▪ Individualized and multifactoral process PSYCHOSOCIAL ASSESSMENT · Attachment is facilitated through en face position with newborn or face-to-face · Attachment can be delayed with pain, exhaustion, NICU stay, traumatic birth experience, substance abuse, anesthesia, or unwanted outcome · Infant task- trust vs. mistrust PSYCHOSOCIAL ASSESSMENT · Attachment stages Proximity is physical and psychological experience of parents being close to infant. Three dimensions: ▪ Contact: sensory experiences of touching, holding, and gazing at infant are part of proximity-seeking behavior. ▪ Emotional state: emotional state emerges from affective experience of new parents toward infant and parental role. ▪ Individualization: Parents are aware of the need to differentiate infant’s needs from themselves and to recognize and respond appropriately, making attachment process also, in a way, one of detachment.  PSYCHOSOCIAL ASSESSMENT · Reciprocity is process of infant’s abilities and behaviors elicit parental response. Two dimensions: complementary behavior and sensitivity. · Complementary behavior involves taking turns and stopping when the other is not interested or becomes tired.- for a positive relationship, an infant's coo should be responded to with similar response such as smiling, vocalizing, touching, and kissing · Commitment is enduring nature of the relationship. Two parts: centrality and parent role exploration. · In centrality, parents place the infant at center of lives- acknowledge and accept responsibility to promote safety, growth, and development. · Parent role exploration is parents’ ability to find their own way and integrate the parental identity into themselves POSITIVE AND NEGATIVE ATTACHMENT BEHAVIORS NURSING INTERVENTIONS · Less is more · Discharge vaginal deliver- 24-48 hours or sooner · C-section- up to 72 hours · Focus on pain and discomfort, immunizations , nutrition, activity and exercise, infant care, lactation instructions, discharge teaching, sexuality, contraception, and follow-up teaching PROVIDING OPTIMAL CULTURAL CARE · Cultural humility- explore cultural competency as process rather than outcome- understand traditional folk beliefs, involvement and support by family members, respect, presence of significant other, breastfeeding, healthy eating, observing principles of hot and cold, avoidance of postnatal sexual intercourse, encouragement, empowerment, importance of spiritual dimension, avoidance of evils spirits, and hope that nurse will anticipate the needs of mother and infant · Determine cultural beliefs before intervening PROMOTING COMFORT · Pain sources- episiotomy, perineal lacerations, backache due to epidural, pain from full bladder, edematous perineum, inflamed hemorrhoids, engorged breasts, afterbirth pains, and sore nipples · Relieve underlying problem · Use cold- ice pack to relieve perineal discomfort from edema, episiotomy or laceration- minimize edema, reduce inflammation, decrease capillary permeability, and reduce nerve conduction to site- wrap in a covering and use intermittently for 20 minutes at a time PROMOTING COMFORT · Heat- peri bottle- plastic squeeze bottle filled with warm tap water sprayed over perineal area after each void before applying a new peripad · Should use immediately on first void and take home to use for the first few weeks- provide education · After 24 hours, sitz bath with room temp water can be prescribed for swelling and discomfort · Hydrotherapy is external use of any form of water for health promotion or treatment with varying temperatures, duration, and application sites · Plastic sitz bath that sits on commode with a bag of warm water that is hung from a hook and connects to a tube that goes to the front of the basin TOPICAL PREPARATIONS · Local anesthetic spray such as benzocaine topical to numb area and used after cleaning with water via peribottle or sitz bath · Hemorrhoid relief- ice packs, ice sitz bath, and cool, witch hazel pads placed on rectal area to cool area, relieve swelling, and minimize itching- can also use local anesthetics or steroids (hydrocortisone acetate) · Side-lying position, proper toileting habits, assuming positions that minimize pressure on hemorrhoids and not straining · Nipple pain- lanolin and hydrogel- avoid Beeswax, glycerin-based products, and petrolatum due to need to remove before breastfeeding- apply breastmilk and allow to dry ANALGESICS · Acetaminophen and oral NSAIDs like ibuprofen or naproxen · For moderate or severe pain, narcotics such as codeine or oxycodone are used with aspirin or acetaminophen · Instruct about adverse effects including dizziness, lightheadedness, n/v, constipation and sedation · Inform that drugs are secreted in breastmilk but acetaminophen and ibuprofen are considered safe ASSISTING WITH ELIMINATION · Bladder distension, incomplete emptying and inability to void are common · Full bladder interferes with uterine contraction and can lead to hemorrhage · Encourage voiding and assist in assuming normal voiding position on toilet · Run warm water over perineal area, hear sound of running tap water, blow bubbles through a straw, take a warm shower, drink fluids, provide with privacy, or place hands in warm water · If voiding does not occur within 4-6 hours catheterization may be needed- use sterile technique ASSISTING WITH ELIMINATION · Constipation is common- could be physical or psychological due to fear · Stool softener, docusate with or without laxative · Ambulation, increase fluid and fiber intake, prune juice, hot liquids PROMOTING ACTIVITY, REST, AND EXERCISE · Early ambulation reduces risk for embolism and improves strength · Postpartum fatigue – shorter sleep time, lots of sleep disturbances, and greater fatigue increases depression symptoms · Nap when baby naps, reduce participation in outside activities and limit visitors, determine sleep-wake cycles, eat balanced diet, share household tasks, ask for help with nighttime care, and review routine to cluster activities · Obstacles to exercise-physical changes, competing demands, lack of information, and stress incontinence PROMOTING EXERCISE · Vaginal delivery can resume light exercise immediate postpartum period- start slow and increase level of period of several weeks · Jogging strollers used for 6-12 months- infant strollers and carriers for newborns · Exercise videos and home exercise can help · Gradual and begin with pelvic floor exercises on first day postpartum or by second week · Exercising too soon can cause lochia to return to bright red and bleed more- if this occurs, slow down routine PREVENTING STRESS INCONTINENCE · Pelvic floor exercise (Kegel exercises) improves urethral sphincter function- 10 5 seconds contractions when changing diaper, talk on phone, or watch tv · The more vaginal deliveries, the more likely stress incontinence is · Can occur with activity that causes increase in intra-abdominal pressure · Low-impact exercises like walking, biking, swimming, or low-impact aerobics is best · Lose weight if necessary · Avoid smoking and decrease alcohol and caffeine intake · Avoid word incontinence and use leakage, loss of urine, and bladder control issues  ASSISTING WITH SELF-CARE MEASURES · Frequently change perineal pads, applying and removing them from front to back to prevent spreading contamination from the rectal area to the genital area. · Avoid using tampons after giving birth to decrease the risk of infection. · Shower once or twice daily using a mild soap. Avoid using soap on nipples. · Use a sitz bath after every bowel movement to cleanse the rectal area and relieve enlarged hemorrhoids. · Use the peribottle filled with warm water after urinating and before applying a new perineal pad. · Avoid tub baths for 4 to 6 weeks until joints and balance are restored to prevent falls. · Wash your hands before changing perineal pads, after disposing of soiled pads, and after voiding ENSURING SAFETY · Check blood pressure first before ambulating the client. · Check for low hemoglobin and hematocrit on lab work before ambulating client. · Elevate the head of the bed for a few minutes before ambulating the client. · Have the client sit on the side of the bed for a few moments before getting up. · Help the client to stand up, and stay with her. · Ambulate alongside the client and provide support if needed. · Frequently ask the client how her head feels. · Stay close by to assist if she feels light-headed. COUNSELING ABOUT SEXUALITY AND CONTRACEPTION · Delay sexual activity until 6 week postpartum check-up · Vaginal lubrication may be impaired postpartum so water-based gel lubricant can be used · Discuss contraceptive options · Progestin-only contraceptive used in breastfeeding woman · Open and effective communication  PROMOTING MATERNAL NUTRITION · Eat a wide variety of foods with high nutrient density. · Eat meals that require little or no preparation. · Make sure all foods are well-cooked to prevent bacteria ingestion. · Avoid high-fat fast foods. · Drink plenty of fluids daily—at least 2,500 mL (approximately 84 oz). · Avoid fad weight-reduction diets and harmful substances such as alcohol, tobacco, and drugs. · Avoid excessive intake of fat, salt, sugar, and caffeine. · Eat the recommended daily servings from each food group NUTRITION FOR MOTHER · Calories: +500 cal/day for the first and second 6 months of lactation · Protein: +20 g/day, adding an extra 2 c of skim milk · Calcium: +400 mg daily—consumption of four or more servings of milk · Iodine: 290 μg daily—dairy products, seafood and iodized salt · Fluid: +2 to 3 qt of fluids daily (milk, juice, or water); no sodas · Some foods affect flavor of breastmilk and can cause gas in infants SUPPORTING WOMAN'S CHOICE FOR FEEDING · Offer sound, evidence-based information to help mother choose how to feed infant and support her decision · Breastfeeding should be encouraged but respect choices · Women who should not breastfeed- antithyroid drugs, antineoplastic drugs, alcohol, active herpes infection on the breasts, HIV or street drugs enter breastmilk and galactosemia or PKU · Answer all questions and provide instructions if needed · Kangaroo care regardless of feeding technique  SUPPORTING WOMAN'S CHOICE · Have a written breastfeeding policy that is communicated to all staff. · Ensure that staff have sufficient knowledge, competence, and skills to support breastfeeding. · Discuss the importance and management of breastfeeding with pregnant women and their families. · Facilitate immediate and uninterrupted skin-to-skin contact, and support mothers in initiating breastfeeding as soon as possible after birth. · Support mothers in initiating and maintaining breastfeeding, and manage common difficulties. · Demonstrate to all mothers how to initiate and maintain breastfeeding. · Encourage breastfeeding on demand. · Counsel mothers on the use and risks of feeding bottles, teats, and pacifiers. · Establish breastfeeding support groups and refer mothers to them. · Enable mothers and their infants to remain together and to practice rooming-in 24 hours a day PROVIDE ASSISTANCE WITH BREASTFEEDING · Quiet environment with rocking chair · Relax and drink water, listen to soothing music · Cuddle and caress infant while feeding · Set out extra cloth diapers to use as burping cloths · Allow sufficient time · Involve family members in all other care · Contact La Leche League for support and guidance ASSISTANCE WITH BREASTFEEDING · Skin to skin contact to encourage · Suggest sandwich technique to insert breast into newborn's mouth to elicit sucking- grasp breast while making a "C" with thumb and index finger · Massage or pump breast to soften and extend nipple for easier latch · Assess infant hydration and satisfaction · Reassure mother about breastfeeding capacity PROVIDING ASSISTANCE WITH BOTTLE-FEEDING · Discuss type of formula- cow's milk based, soy protein based, or specialized or therapeutic formulas for infants with protein allergies · Can be powdered, condensed liquid, ready to use, or prepackaged · Newborns-100-110cal/kg or 650 calories per day- 2-4 ounces to feel satisfied with each feeding · Until 4 month- 6 feedings per day, once food is added, this number declines PROVIDING ASSISTANCE WITH BOTTLE-FEEDING · Wash hands, bottles, nipples, and other utensils · Promote bonding with eye contact, smiling, singing, and talking · Use room temperature to dissolve powder faster and more easily · Do not microwave formula- causes hot spots · Use comfortable position, never prop bottle · Tilt bottle so nipple and neck is filled with formula to prevent air intake · Refrigerate powdered formula that has been combined with water · Do not force feed, add cereal, or overdilute powder to save money · Discard formula 1 hour after feeding TEACHING ABOUT BREAST CARE · Supportive, snug bra 24 hours a day · Use plain water to cleanse breast · Examine daily and assess milk supply, condition of nipples, and success of breastfeeding · Breast engorgement is common problem- usually resolves within 72 hours · Encourage frequent feeding every 2-3 hours, using manual expression before feeding to soften breast so newborn can latch easier · Feed on breast until it softs and then switch to other side ALLEVIATING BREAST ENGORGEMENT AND SUPPRESSING LACTATION IN BOTTLE-FEEDING WOMAN · Encourage ice packs, wear snug, supportive bra 24 hours a day, take mild analgesic like acetaminophen · Avoid stimulation to breasts that fosters milk production- warm showers, pumping, massaging breasts · Medication is not used anymore to suppress lactation due to limited effectiveness and adverse side effects PROMOTING FAMILY ADJUSTMENT AND WELL-BEING · Postpartum period allows "getting-to-know-you" time when parents involve newborn in life and reconcile fantasy child with real one · Provide anticipatory guidance about sibling' potential responses to new baby, increased emotional tension, child development, and meeting the multiple needs of expanding family · Do not assume knowledge is current and accurate if there are other children · Reinforce information PROMOTING PARENTAL ROLES · Provide as many opportunities as possible to interact with newborn- praise their efforts · Model behavior by holding newborn close, calling newborn's name and speaking positively · Assess risk factors · Observe culture · Monitor attachment and bonding- positive include en face position- negative behaviors avoid contact, call them names, or show lack of interest  PROMOTING PARENTAL ROLES Provide anticipatory guidance to reduce the new parents’ frustration: · Newborn sleep–wake cycles (they may be reversed) · Variations in newborn appearance and developmental milestones (growth spurts) · How to interpret crying cues (hunger, wet, discomfort) and what to do about them · Sensory enrichment and stimulation (colorful mobile) · Signs and symptoms of illness and how to assess for fever · Important phone numbers, follow-up care, and needed immunizations · Physical and emotional changes associated with the postpartum period · Need to integrate siblings into care of the newborn; stress that sibling rivalry is normal and offer ways to reduce it · Ways to make time together for the couple EXPLAINING SIBLING ROLES · Other siblings may require extra attention or reassurance that they are loved and important , may view as competition, or experience stress · Expect and tolerate some regression · Explain childbirth appropriately · Encourage discussion about new addition and for siblings to participate in decisions · Spend special time with child- read with child or role play safe handling of newborn with a doll · Arrange for child to come to hospital to see newborn DISCUSSING GRANDPARENT'S ROLE · Depend on how close they live to family, willingness to be involved, cultural expectations of their role · Practices have changed since grandparents have had their own children · A grandparents "take charge approach" may not be welcome for parents testing their roles · Encourage grandparents to learn new practices and attend grandparenting classes TEACH ABOUT POSTPARTUM BLUES · Postpartum blues- phase of emotional lability characterized by crying episodes, irritability, anxiety, confusion, and sleep disorders · Symptoms arise within first few days after childbirth and peak at 3-5 days- disappears spontaneously within 10 days · Benign and self-limiting- but can be frightening to the woman · Explain that these are common and revolve spontaneously, offer reassurance · If mood does not improve within 2 weeks, postpartum depression may be developing · No formal treatment needed PREPARING FOR DISCHARGE · Shortened hospital stay if: · Mother is afebrile and vitals are WNL · Lochia is appropriate amount and color, hgb and hct are normal · Fundus is firm, urinary output is adequate · Rhogam administered if needed · Surgical wounds are healing, no infection present · Mother is able to ambulate, eat, give infant and self care, and is aware of possible complications PROVIDING IMMUNIZATIONS · Rubella- Sign consent form, should not be given if immunocompromised · CDC recommends TDAP during postpartum stay · Flu vaccine is administered if flu season · Educate about adverse reactions and to avoid pregnancy for at least 28 days after due to risk of teratogenic effects RH STATUS · Blood types are determined by antigens on red blood cells (proteins on surface of RBC that cause immune response) · If Rh negative, check Rh status of newborn · If Rh negative and not sensitized, check if indirect Coombs test (antibody screen) is negative and that newborn is Rh positive. · If Rh negative and give birth to Rh positive, should receive Rhogam within 72 hours to prevent sensitization reaction of Rh positive cells during birthing process · Prevents initial isoimmunization in Rh negative mothers by preventing maternal memory cells from being sensitized- passive immunization · Signed consent – blood product- Jehovah's witnesses and others who forbid use of blood products should be educated about Rhogam and decide accordingly ENSURING FOLLOW-UP CARE · If discharged too soon, risk of uterine subinvolution, discomfort at episiotomy or c-section site, infection, fatigue, and maladjustment to new role · Telephone follow up should occur during first week of discharge to check on how things are going at home- can be made by perinatal nurses or by local health department- nurse cannot see client so must rely on mother or family observations · Office visit scheduled for 4-6 weeks after childbirth · If c-section- 2 weeks after discharge · Newborn exams and lab studies should be scheduled within first week · Postpartum home visits can be made within first week after discharge and do maternal and infant assessments HOME CARE VISIT · Breastfeeding or bottle-feeding technique and procedures · Appropriate parenting behavior and problem solving · Maternal/newborn physical, psychosocial, and cultural–environmental needs · Emotional needs of the new family Warning signs of problems and how to prevent or eliminate them · Sexuality issues, including contraceptive use · Immunization needs for both mother and infant · Family dynamics for smooth transition · Links to health care providers and community resources