Postpartum Nursing Care PDF

Chapter 12: Postpartum Nursing Care Introduction: - Family dynamics become more complicated with each child born - Support family dynamics - Include family in teaching and care - Provide info about sibling rivalry - Observe interactions: identify problems, ma...

Chapter 12: Postpartum Nursing Care Introduction: - Family dynamics become more complicated with each child born - Support family dynamics - Include family in teaching and care - Provide info about sibling rivalry - Observe interactions: identify problems, make recommendations, and referrals Puerperium - Period following delivery of placenta until reproductive organs return to a nonpregnant state - Usually about 6 weeks - Might take longer with multiple pregnancies Postpartum Physical Adaptations - Body begins to change immediately after delivery: - Postpartum shivering: - Exact cause unknown - Could be due to fetal/maternal blood mixing after delivery of placenta or amniotic fluid in bloodstream - Provide with warm blankets - Reassure patient that shivering will pass - Reproductive system: Experiences most changes immediately after delivery - Uterus involution: Process where oxytocin continues to be released after placental delivery, causing uterus to contract and shrink - Size and weight decreases - Fundus: firm, even with umbilicus 1 hour later - Uterus descends 1 cm per day, by 10 days it is not palpable. - Give patients extra oxytocin to help with involution - Afterpains: Intermittent uterine contractions can occur; more noticeable for multiparous women - Can be intensified by breastfeeding - Exfoliation: Sloughing of dead tissue at the placental site - Lochia: Caginal discharge made up of blood, mucus, and tissue (Inner layer of uterus sloughing off) - May last up to 6 weeks - Lighter in color and amount over time - Cervix: Os closes slowly and by day 14 is barely dilated - Vagina: - Lacks tone after delivery - Over 4 weeks, edema decreases. Rugae (vaginal folds) appear: may not lubricate easily until hormonal balance is restored - Will never return to pre-pregnancy size. - Perineum: - Bruised and edematous after delivery - Muscle tone restored over 4 to 6 weeks  - Kegel exercises promote return of tone - Ovaries and Ovulation: - Normal function after delivery variable and influenced by breastfeeding - Menstruation delayed and may not resume for weeks/months if breastfeeding - Not breastfeeding: May ovulate as soon as 27 days after delivery - Menstruation beings 6-12 weeks for bottle feeding women - Teach patients about birth control - Breasts: - Breasts secrete colostrum before milk is produced - Thick, can be hand expressed but not pumped through a pump - Babies only need a fistful and get tired out from sucking - Nipple stimulation causes prolactin to be released, initiating milk production - Between the second and fourth day breasts are engorged with milk. - Doesn’t always happen with premature babies - Breasts may feel warm and tender - Pain and redness are not okay - If not breastfeeding, needs interventions to suppress milk production - Integumentary System: - Abdominal skin resumes pre-pregnancy state except for stretch marks - Teach woman to embrace stretchmarks - Linea nigra fades but may never go away - Melasma fades over days or weeks - Hair loss resolves - Gastrointestinal System: - Hungry and thirsty after delivery due to the exerted energy - Don’t allow mothers to eat or drink beforehand to prevent aspiration - May have sluggish intestinal peristalsis and constipation - Due to restricted intake, increased progesterone, and anesthesia - Hemorrhoids cause pain with defecation - Stool softener may be prescribed - Docusate: onset 12-72 hours - Cardiovascular System: - Blood loss is 250-500mL for vaginal birth and 800-1000mL for c-section - 60-80% increase in cardiac output after delivery (normally 1 hr post delivery) - 500-700mL enters after delivery of placenta - Uterus is smaller, more blood is in circulation - Improved blood flow to vena cava due to size and weight loss in uterus - Rapid mobilization of extracellular fluid by body - Loss of plasma volume causes temporary decrease in hemoglobin & hematocrit - Fibrinogen levels increase and remain increased for several days after delivery - Increases risk for blood blot development - Ambulation maintains venous stasis  - Removal of excess fluid stored during pregnancy. - Diuresis: Secretion of passage of large amounts of urine - Up to 3000mL for a few days - Make sure women can pee, feel the urge; help them pee - Sitz bath can help urge to pee - It is important to urinate to prevent distention of the bladder and infection - Diuresis is an expected loss of fluid - Diaphoresis: Excessive perspiration - Sweat to get rid of excess fluid - Respiratory System: - Diaphragm returns to normal position - Respiratory rate returns to prepregnancy level - Pregnancy nasal congestion disappears quickly - Urinary System: - Bladder tone decreases - Bladder distended and pushes uterus up and to the side - Displaced uterus can interfere with involution and can lead to hemorrhage - Musculoskeletal System: - Hormone relaxin begins to subside - Hip pain may continue for a few days - Diastasis Recti of abdominal muscles may occur - Separation of abdominal wall muscles - Corrected with exercises or surgery - 4 weeks postpartum after vaginal birth - 6 weeks for C-Section Nursing Care During Early Postpartum Period: - Immediate postpartum care often occurs in a hospital - Most women stay 1-2 days after vaginal birth and 3-4 days after c-section - Nurses provide physical care, monitor for complications, and teach self care. - Uterine Assessment: - Palpate fundus - Note position and location - Never palpate without supporting lower segment - One hand at base of symphysis pubis and the other at umbilicus - Assess consistency - Boggy (Soft): Support lower uterine segment and massage in circular pattern with other hand flattened until uterus becomes firm - If massage is not effective, a large blood clot of extreme uterine atony may occur, which can lead to postpartum hemorrhage - If oxytocin and massage are ineffective, notify HCP - Full bladder can lead to uterine atony  - Urinate and reassess - Never palpate without supporting lower segment: uterus can invert - Lochia Assessment: - Inspect amount and character during uterine massage - Lochia lasts 3-6 weeks and occurs in 3 stages: - Lochia rubia: First discharge, dark red blood - Lochia serosa: 3-4th day, brownish red, lighter color, yellowish - Lochia alba: Over 1-2 weeks, light and white color - Amount of lochia while palpating fundus: - Scant: Less than 1 inch of lochia on pad - Light: Less than 4 inches of lochia on pad - Moderate: Less than 6 in of lochia on pad - Heavy: Pad is saturated within one hour - Common for two pads to be saturated in first hour; Beyond that more than 1 pad per hour is excessive. - Nursing Care During First Hour After Delivery - Most dangerous hour due to risk of hemorrhage - Check vital signs every 15 minutes - Palpate fundus Q15 minutes - Assess uterine tone and amount of vaginal bleeding - Assess lochia, color, odor, and presence of clots - When stable, transfer to postpartum or mother baby unit - Postpartum Assessment and Nursing Interventions - BUBBLE LE: Breasts, uterus, bladder, bowels, lochia, episiotomy/laceration, legs, and emotion. - Breasts: - Assess for breast and nipple pain - Patient teaching for engorgement: Not breast feeding - Supportive bra - Ice packs to breasts for 20 minutes several times a day - Cold cabbage leaves relieve engorgement - Avoid nipple stimulation - Do not pump/hand express milk - Take analgesics for pain (tylenol or norco) - Engorgement subsides in 48 hours - Nursing Interventions: - Supportive bra for comfort - Soreness: observe breastfeed/latch-on problems - Acetaminophen for nipple pain - Assess knowledge of breastfeeding and provide teaching - Arrange for lactation specialist if problems arise - Breastfeeding every 2-2.5 hours will prevent engorgement - Uterus: Palpate for location and consistency  - Should be firm and in the midline - Document location of fundus in relation to umbilicus - Inquire about abdominal pain: some is expected - Nursing Interventions: - If uterus is not involuting as expected, not lack of tone or signs of infection and report findings - Show patient how to feel fundus - Bladder: Palpate when assessing the fundus - Distention should not be present - Nursing Interventions: - Urination: Do not get patient up if fundus is not firm. - Straight cath order if patient cannot urinate - Question about frequency and amount of urination - Drink 8 glasses of water a day to prevent UTI - Teach patient about normal diuresis after birth - Proper perineal care: peri-bottle for cleansing - Change peripad after urination/defecation - Bowels: - Auscultate bowel sounds - May not hear after c-section for several hours - Nursing Interventions: - Inquire about last BM - Drink extra fluids and eat fruits and vegetables - Administer stool softener - Encourage ambulation - Lochia: - Assess and document amount and type - Nursing Interventions: - Discover when pad was changed last - Report abnormalities - Teach patient about progression of lochia - Episiotomy/Laceration: - Inspect perineum for bruising, erythema, edema, hematoma, intactness of repair - Turn patient to side, bring upper knee forward, gently lift upper buttocks - Note hemorrhoids and notify HCP if large and painful - Nursing Interventions: - Level of rectal or perineum pain and medicate - Report abnormal findings - Offer ice pack in first 24 hours - Teach how to use episiotomy spray - After 24 hours, sitz bath may relieve pain and aid healing. - Legs:  - Assess for leg pain, adequate circulation, edema, temp - Pedal pulses - Pedal edema may last a few days - Nursing Interventions: - Report abnormal findings - Encourage frequent ambulation - Don’t cross legs - Elevate legs when sitting - Ted hose/SCDs for patients who are high risk - Emotions: - When placenta is expelled, sudden drop in progesterone - Notice emotions and “postpartum blues” - Nursing Interventions: - Explain postpartum blues are normal - Reassure they pass in a few days - Contact HCP if they don’t resolve or if they worsen - Encourage patient to verbalize needs, rest, and allow family to assist during recovery Nursing Care following C-Section - Monitor uterine involution and lochia - Post-op care to prevent complications - Atelectasis, thrombosis, infection - Assess pain and incision - Abdomen incision, not perineal - Nursing Considerations: - Assess and medicate for pain - Monitor incision for infection - REEDA: Redness, edema, ecchymosis, drainage, approximation - Encourage ambulating when stable and catheter removed - Discontinue catheter and monitor output - Teach abdominal splinting with pillow; decrease pain while coughing/moving - Turn, cough, deep breathe Q2hrs and use of incentive spirometer Nursing Care of the Adolescent - Same assessment and physical care - More structured teaching: care of self and newborn - Treat as an adult - Encourage questions - Direct teaching to teenage, not parents. Include father in teaching. - Teach in small segments: use videos, demos, and written materials - Periods of rest between teaching to prevent overwhelming patient - Role model infant care - Encourage bonding during taking-in phase - At higher risk for postpartum depression - Teach signs and symptoms and refer to support groups Nursing Care for Woman who Relinquishes Infant for Adoption - Find out patient’s birth plan - May want adoptive parents there - May or may not want to hold infant after birth - Provide empathetic care - Requires same physical care and teaching - High risk for postpartum depression - Teach signs and symptoms and refer to suppler groups/counseling Postpartum Psychological Adaptations - New role of motherhood may be overwhelming - Three phases of postpartum adjustments: - Taking-in, taking-hold, letting-go Taking-In Phase: - Mother centered on own needs - Feels dependent and needs mothering - May not initiate interaction with newborn - Use en face position and fingertip touching - Position baby facing her to explore baby’s face - Identify the infant - Begin the bonding process - Start of a lifelong relationship - May be slow or instantaneous - Skin to skin contact - Breast feeding - Encourage eye contact - Keep baby with parent as much as possible - May last a few days Taking-Hold Phase: - Mother initiates care of baby - Wants to be more independent - Concerned/anxious about own physical care, breastfeeding, and baby care. - Requires praise and positive reinforcement - Open to learning: best time for teaching - May last up to 10+ days - May experience postpartum blues - Can elevate to postpartum depression (PPD) Letting-Go Phase - Letting go of being childless and more independent - Adjustment to baby’s dependence and lifestyle changes - Attachment with the newborn occurs - Establishment of emotionally positive, rewarding relationship between infant and parent - Learns to understand infant’s cries and body language - Receives positive feedback from infant when needs are met  - Learns to trust self and instincts Development of Family Attachment: - Family attachment may take more time - Mother’s partner begins bonding by attending appointments, ultrasounds, and childbirth classes. - Partner should be encouraged to room-in and stay as much as possible with mother and newborn at hospital. - Engrossment: Stare at newborn for extended periods of time - Partner should be included in newborn teaching - Sibling bonding and attachment: - Visit in hospital - Older child may exhibit jealousy and may regress - Vacillates between protective, loving feelings and dislike for new family member Preparation for Discharge: - Administer MMR to woman susceptible to Rubella - Those in contact with newborn should have up-to-date Tdap vaccine - Self care instructions: Should be written and verbal - Sutures for lacerations will dissolve - Perineal care: analgesics/sitz bath - Menstrual pad changes: No tampons/douche - Breast care: supportive bra - Hand hygiene - Follow up appointments - Prenatal vitamins and iron - Exercise and sex limitations - Symptoms to follow up about.