Course Unit 9 Week 10 PDF

BACHELOR OF SCIENCE IN NURSING: CARE OF MOTHER, CHILD AND ADOLESCENT (Well Clients) COURSE MODULE COURSE UNIT WEEK 3 9 10 POSTPARTUM...

BACHELOR OF SCIENCE IN NURSING: CARE OF MOTHER, CHILD AND ADOLESCENT (Well Clients) COURSE MODULE COURSE UNIT WEEK 3 9 10 POSTPARTUM  Discuss the course and unit objectives  Comprehend study guide prior to class attendance  Read required learning resources; refer to unit terminologies for jargons  Actively participate in classroom discussions  Accomplish and submit assigned course unit tasks on time  Participate in weekly discussion board (Canvas) Answer and submit course unit tasks At the end of this unit, the students are expected to: Cognitive 1. Describe the psychological and physiologic changes that occur in a postpartal woman. 2. Assess a woman and her family for physiologic and psychological changes after childbirth. 3. Integrate knowledge of the physiologic and psychological changes of the postpartal period with the nursing process to achieve quality maternal and child health nursing care. Affective 1. Listen attentively during class discussions 2. Demonstrate tact and respect of other students opinions and ideas 3. Accept comments and reactions of classmates openly. Psychomotor 1. Participate actively during class discussions 2. Follow Class rule and Apply Netiquettes 3. Implement nursing care to aid the progression of physiologic and psychological transitions occurring in a postpartal woman and family such as teaching about breastfeeding. Adele Pillitteri, Maternal & Child Health Nursing:Care of the Childbearing & Childrearing Family, 6th Edition Lipscomb, K., & Novy, M. J. (2007). The normal puerperium. In A. H. DeCherney & L. Nathan (Eds.). Current diagnosis and treatment in obstetrics and gynecology (10th ed.). Columbus, OH: McGraw-Hill. The postpartal period, or puerperium (from the Latin puer, for “child,” and parere, for “to bring forth”), refers to the 6-week period after childbirth. It is a time of maternal changes that are both retrogressive (involution of the uterus and vagina) and progressive (production of milk for lactation, restoration of the normal menstrual cycle, and beginning of a parenting role). Assessment during the puerperium, assessment of a woman is accomplished by health interview, physical examination, and analysis of laboratory data. It is important to ensure that physical changes, such as uterine involution, are occurring by evaluating uterine size and consistency and lochia flow amount. PHYSIOLOGICAL CHANGES OF THE POSPARTAL PERIOD Reproductive System Changes Involution is the process whereby the reproductive organs return to their nonpregnant state. By the time involution is complete (6 weeks), the uterus is completely return to its prepregnancy state. The Uterus The sealing of the placenta site is accomplished by rapid contraction of the uterus immediately after delivery of the placenta. This contraction pinches the blood vessels entering the 7-cm-wide area left denuded by the placenta and stops bleeding. With time, thrombi form within the uterine sinuses and permanently seal the area. Although the uterus will never completely return to its prepregnancy state, its reduction in size is dramatic. Immediately after birth, the uterus weighs about 1000 g. At the end of the first week, it weighs 500 g. By the time involution is complete (6 weeks), it weighs approximately 50 g, similar to its prepregnancy weight. Because uterine contraction begins immediately after placental delivery, the fundus of the uterus may be palpated through the abdominal wall, halfway between the umbilicus and the symphysis pubis, within a few minutes after birth. One hour later, it will have risen to the level of the umbilicus, where it remains for approximately the next 24 hours. From then on, it decreases one fingerbreadth per day—on the first postpartal day, and so forth. By the ninth or tenth day, the uterus will no longer be detected by abdominal palpation. Uterine involution may be delayed by a condition such as the birth of multiple fetuses, hydramnios, exhaustion from prolonged labor or a difficult birth, grand multiparity, or physiologic effects of excessive analgesia. Contraction may be difficult if there is retained placenta or membranes. Involution will occur most dependably in a woman who is well nourished and who ambulates early after birth (gravity may play a role). An estimation of the consistency of the postpartal uterus is as important as measurement of its height. A well-contracted fundus feels firm. It can be compared with a grapefruit in both size and tenseness. Whenever the fundus feels boggy (soft or flabby), it is not as contracted as it should be, despite its position in the abdomen. The first hour after birth is potentially the most dangerous time for a woman. If her uterus should become relaxed during this time (uterine atony), she will lose blood very rapidly, because no permanent thrombi have yet formed at the placental site. Lochia Uterine flow, consisting of blood, fragments of decidua, white blood cells, mucus, and some bacteria, is known as lochia. The portion of the uterus where the placenta was not attached is so fully cleansed by this sloughing process that it will be in a reproductive state in about 3 weeks’ time. It takes approximately 6 weeks (the entire postpartal period) for the placental implantation site to be healed. For the first 3 days after birth, a lochia discharge consists almost entirely of blood, with only small particles of decidua and mucus. Because of its mainly red color, it is termed lochia rubra. As the amount of blood involved in the cast-off tissue decreases (about the fourth day) and leukocytes begin to invade the area, as they do with any healing surface, the flow becomes pink or brownish (lochia serosa). On about the 10th day, the amount of the flow decreases and becomes colorless or white (lochia alba). Lochia alba is present in most women until the third week after birth, although it is not unusual for a lochia flow to last the entire 6 weeks of the puerperium. Saturating a perineal pad in less than 1 hour is considered an abnormally heavy flow and should be reported. Lochia should contain no large clots. Clots may indicate that a portion of the placenta has been retained and is preventing closure of the maternal uterine blood sinuses. Lochia should not have an offensive odor. Lochia has the same odor as menstrual blood. An offensive odor usually indicates that the uterus has become infected. The Cervix Immediately after birth, a uterine cervix is soft and malleable. Both the internal and external os are open. Like contraction of the uterus, contraction of the cervix toward its prepregnant state begins at once. By the end of 7 days, the external os has narrowed to the size of a pencil opening; the cervix feels firm and nongravid again. Like the fundus, the cervix does not return exactly to its prepregnancy state. The internal os closes as before, but after a vaginal birth the external os usually remains slightly open and appears slitlike or stellate (star shaped), whereas previously it was round The Vagina After a vaginal birth, the vagina is soft, with few rugae, and its diameter is considerably greater than normal. The hymen is permanently torn and heals with small, separate tags of tissue. It takes the entire postpartal period for the vagina to involute (by contraction, as with the uterus) until it gradually returns to its approximate prepregnancy state. Because a woman who is breastfeeding may have delayed ovulation, she may continue to have thin-walled or fragile vaginal cells that cause slight vaginal bleeding during sexual intercourse until about 6 weeks’ time. Like the cervix, the vaginal outlet remains slightly more distended than before. If a woman practices Kegel exercises, the strength and tone of the vagina will increase more rapidly The Perineum Because of the great amount of pressure experienced during birth, the perineum feels edematous and tender immediately after birth.. The labia majora and labia minora typically remain atrophic and softened after birth, never returning to their prepregnancy state. BREAST In many women, breast distention becomes marked, and this often is accompanied by a feeling of heat or pain. The distention is not limited to the milk ducts but occurs in the surrounding tissue as well, because blood and lymph enter the area to contribute fluid to the formation of milk. This feeling of tension in the breasts on the third or fourth day after birth is termed primary engorgement. It fades as the infant begins effective sucking and empties the breasts of milk. Systemic Changes Pregnancy hormones begin to decrease as soon as the placenta is no longer present. Levels of human chorionic gonadotropin (hCG) and human placental lactogen (hPL) are almost negligible by 24 hours.  By week 1, progestin, estrone, and estradiol are all at prepregnancy levels. Estrol may be elevated for an additional week before it reaches prepregnancy levels. Folliclestimulating hormone (FSH) remains low for about 12 days and then begins to rise as a new menstrual cycle is initiated. The Urinary System During pregnancy, as much as 2000 to 3000 mL excess fluid accumulates in the body. An extensive diuresis begins to take place almost immediately after birth to rid the body of this fluid. This easily increases the daily output of a postpartal woman from a normal level of 1500 mL to as much as 3000 mL/day during the second to fifth day after birth. This marked increase in urine production causes the bladder to fill rapidly. During a vaginal birth, the fetal head exerts a great deal of pressure on the bladder and urethra as it passes on the bladder’s underside. This pressure may leave the bladder with a transient loss of tone that, together with the edema surrounding the urethra, decreases a woman’s ability to sense when she has to void. To prevent permanent damage to the bladder from overdistention, assess a woman’s abdomen frequently in the immediate postpartal period. On palpation, a full bladder is felt as a hard or firm area just above the symphysis pubis. On percussion (placing one finger flat on the woman’s abdomen over the bladder and tapping it with the middle finger of the other hand), a full bladder sounds resonant, in contrast to the dull, thudding sound of non–fluid-filled tissue. The Circulatory System The diuresis that is evident between the second and fifth days after birth, as well as the blood loss at birth, acts to reduce the added blood volume a woman accumulated during pregnancy. This reduction occurs so rapidly, in fact, that the blood volume returns to its normal prepregnancy level by the first or second week after birth. The usual blood loss with a vaginal birth is 300 to 500 mL. With a cesarean birth, it is 500 to 1000 mL. A 4-point decrease in hematocrit (proportion of red blood cells to circulating plasma) and a 1-g decrease in hemoglobin value occur with each 250 mL of blood lost. Women usually continue to have the same high level of plasma fibrinogen during the first postpartal weeks as they did during pregnancy. This is a protective measure against hemorrhage. However, this high level also increases the risk of thrombus formation. The Gastrointestinal System Digestion and absorption begin to be active again soon after birth unless a woman has had a cesarean birth. Almost immediately, the woman feels hungry and thirsty and she can eat without difficulty from nausea or vomiting during this time. Hemorrhoids (distended rectal veins) that have been pushed out of the rectum because of the effort of pelvic-stage pushing often are present.  Bowel sounds are active, but passage of stool through the bowel may be slow because of the still-present effect of relaxin on the bowel. Bowel evacuation may be difficult because of the pain of episiotomy sutures or hemorrhoids. The Integumentary System After birth, the stretch marks on a woman’s abdomen (striae gravidarum) still appear reddened and may be even more prominent than during pregnancy, when they were tightly stretched. Excessive pigment on the face and neck (chloasma) and on the abdomen (linea nigra) will become barely detectable in 6 weeks’ time. If diastasis recti (overstretching and separation of the abdominal musculature) is present, the area will appear slightly indented. If the separation is large, it will appear as a bluish area in the abdominal midline. Modified sit-ups help to strengthen abdominal muscles and return abdominal support to its prepregnant level Vital Sign Changes Temperature A woman may show a slight increase in temperature during the first 24 hours after birth because of dehydration that occurred during labor. If she receives adequate fluid during the first 24 hours, this temperature elevation will return to normal. Any woman whose oral temperature rises above 100.4° F (38° C), excluding the first 24-hour period, is considered by criteria of the Joint Commission on Maternal Welfare to be febrile. In such women, a postpartal infection may be present. Occasionally, when a woman’s breasts fill with milk on the third or fourth postpartum day, her temperature rises for a period of hours because of the increased vascular activity involved. If the elevation in temperature lasts longer than a few hours, however, infection is a more likely reason. Pulse A woman’s pulse rate during the postpartal period is usually slightly slower than normal. During pregnancy, the distended uterus obstructed the amount of venous blood returning to the heart; after birth, to accommodate the increased blood volume returning to the heart, stroke volume increases. This increased stroke volume reduces the pulse rate to between 60 and 70 beats per minute. Blood Pressure Blood pressure should also be monitored carefully during the postpartal period, because a decrease in this can indicate bleeding. In contrast, an elevation above 140 mm Hg systolic or 90 mm Hg diastolic may indicate the development of postpartal pregnancy-induced hypertension, an unusual but serious complication of the puerperium. To evaluate blood pressure, compare a woman’s pressure with her prepregnancy level if possible, rather than with standard blood pressure ranges.  Oxytocics, drugs frequently administered during the postpartal period to achieve uterine contraction, cause contraction of all smooth muscle, including blood vessels that can increase blood pressure. Progressive Changes Two physiologic changes that occur during the puerperium involve progressive changes, or the building of new tissue. Because building new tissue requires good nutrition, caution women against strict dieting that would limit cell-building ability during the first 6 weeks after childbirth. Lactation The formation of breast milk (lactation) begins in a postpartal woman whether or not she plans to breastfeed. For the first 2 days after birth, an average woman notices little change in her breasts from the way they were during pregnancy. Since midway through pregnancy, she has been secreting colostrum, a thin, watery, prelactation secretion. She continues to excrete this fluid the first 2 postpartum days. On the third day, her breasts become full and feel tense or tender as milk forms within breast ducts. Breast milk forms in response to the decrease in estrogen and progesterone levels that follows delivery of the placenta (which stimulates prolactin production and, consequently, milk production). When breast milk first begins to form, the milk ducts become distended. The distention of the breast is not limited to the milk ducts but occurs in the surrounding tissue as well, because blood and lymph enter the area to contribute fluid to the formation of milk. This feeling of tension in the breasts on the third or fourth day after birth is termed primary engorgement. It fades as the infant begins effective sucking and empties the breasts of milk. Return of Menstrual Flow With the delivery of the placenta, the production of placental estrogen and progesterone ends. The resulting decrease in hormone concentrations causes a rise in production of FSH by the pituitary, which leads, with only a slight delay, to the return of ovulation. This initiates the return of normal menstrual cycles. A woman who is not breastfeeding can expect her menstrual flow to return in 6 to 10 weeks after birth. If she is breastfeeding, a menstrual flow may not return for 3 or 4 months (lactational amenorrhea) or, in some women, for the entire lactation period. However, the absence of a menstrual flow does not guarantee that a woman will not conceive during this time, because she may ovulate well before menstruation returns NURSING RESPONSIBILITIES a. Perineal Care - inspect the perineum. Observe for ecchymosis, hematoma, erythema, edema, intactness, and presence of drainage or bleeding from any episiotomy stitches. b. Provide Pain Relief for After pains - Pain from uterine contractions can be intense, but you can assure a woman that this type of discomfort is normal and rarely lasts longer than 3 days. c. Relieve Muscular Aches - Many women feel sore and aching after labor and birth because of the excessive energy they used for pushing during the pelvic division of labor. A backrub is effective for relieving an aching back or shoulders. d. Administer Cold and Hot Therapy - Applying an ice or cold pack to the perineum during the first 24 hours reduces perineal edema and the possibility of hematoma formation, thereby reducing pain and promoting healing and comfort. After the first 24 hours healing increases best if circulation to the area by the use of heat. Dry heat in the form of a perineal hot pack or moist heat with a sitz bath. e. Episiotomy Care - the perineal area heals rapidly, you can assure a woman that this discomfort is normal and does not usually last longer than 5 or 6 days. Many physicians and nurse-midwives order a soothing cream or anesthetic spray to be applied to the suture line to reduce discomfort. f. Inspect Lochia - Check the Consistency: Lochia should contain no large clots. Clots may indicate that a portion of the placenta has been retained and is preventing closure of the maternal uterine blood sinuses. In any event, large clots denote poor uterine contraction, which needs to be corrected. Observe the Pattern: Lochia is red for the first 1 to 3 days (lochia rubra), pinkishbrown from days 4 to 10 (lochia serosa), and then white (lochia alba) for as long as 6 weeks after birth. The pattern of lochia (rubra to serosa to alba) should not reverse. PSYCHOLOGICAL CHNGES Postpartal Blues During the postpartal period, as many as 50% of women experience some feelings of overwhelming sadness (Buultjens & Liamputtong, 2007). They may burst into tears easily or feel let down or irritable. This temporary feeling after birth has long been known as the “baby blues.” This phenomenon may be caused by hormonal changes, particularly the decrease in estrogen and progesterone that occurs with delivery of the placenta. For some women, it may be a response to dependence and low self-esteem caused by exhaustion, being away from home, physical discomfort, and the tension engendered by assuming a new role, especially if a woman is not receiving support from her partner. The syndrome is evidenced by tearfulness, feelings of inadequacy, mood lability, anorexia, and sleep disturbance. Anticipatory guidance and individualized support from health care personnel are important to help the parents understand that this response is normal. You can assure a  woman that sudden crying episodes may occur; otherwise, she may have difficulty understanding what is happening to her. Her support person also needs assurance, or he can think the woman is unhappy with him or their new baby or is keeping some terrible secret about the baby from him. Phases of the Puerperium Reva Rubin, a nurse, divided the puerperium into three separate phases (Rubin, 1977). Taking-In Phase A time when the new parents review their pregnancy and the labor and birth, a time of reflection. During this 2- to 3-day period, a woman is largely passive. This dependence results partly from her physical discomfort because of after pains; partly from her uncertainty in caring for her newborn; and partly from the extreme exhaustion that follows childbirth. Taking-Hold Phase After a time of passive dependence, a woman begins to initiate action. Now, she begins to take a strong interest. , it is always best to give a woman brief demonstrations of baby care and then allow her to care for her child herself—with watchful guidance. Letting-Go Phase In the third phase, called letting-go, a woman finally redefines her new role. She gives up the fantasized image of her child and accepts the real one; she gives up her old role of being childless or the mother of only one or two (or however many children she had before this birth). Nursing Care of a Woman and Family during the first 24 hours after birth 1, Provide Pain Relief for After pains. Pain from uterine contractions can be intense, but you can assure a woman that this type of discomfort is normal and rarely lasts longer than 3 days. If necessary, either ibuprofen  (such as Motrin), which has anti-inflammatory properties, or a common analgesic such as acetaminophen (such as Tylenol) is effective for pain relief. As with any abdominal pain, heat to the abdomen should be avoided, because it could cause relaxation of the uterus and subsequent uterine bleeding. 2. Relieve Muscular Aches. Many women feel sore and aching after labor and birth because of the excessive energy they used for pushing during the pelvic division of labor. They describe feeling as if they have “run for miles.” A woman may need a mild analgesic such as acetaminophen for the pain. A backrub is effective for relieving an aching back or shoulders. Carefully assess a woman who states that she has pain on standing. Pain in the calf of the leg on standing (a position that dorsiflexes the foot) is a sign similar to Homans’ sign suggesting thrombophlebitis may be present. 3. Administer Cold and Hot Therapy. Applying an ice or cold pack to the perineum during the first 24 hours reduces perineal edema and the possibility of hematoma formation, thereby reducing pain and promoting healing and comfort. Be certain not to place ice or plastic directly on the woman’s perineum. Wrap an ice bag first in a towel or disposable pad, to decrease the chance of a thermal burn (risk of injury increases because the perineum has decreased sensation from edema after birth). Commercial cold packs combined with perineal pads also are available. For a low-cost alternative, a rubber glove may be partially filled with ice chips, provided latex allergy is not a concern. Ice to the perineum after the first 24 hours is no longer therapeutic. After this time, healing increases best if circulation to the area is encouraged by the use of heat. Dry heat in the form of a perineal hot pack or moist heat with a sitz bath is an effective way to increase circulation to the perineum, provide comfort, reduce edema, and promote healing. 4. Promote Perineal Exercises. Some women find that carrying out perineal exercises three or four times a day can greatly relieve perineal edema. The exercise consists of contracting and relaxing the muscles of the perineum 5 to 10 times in succession, as if trying to stop voiding (Kegel exercises). This aids comfort by improving circulation to the area and decreasing edema. When repeated frequently, Kegel exercises also help a woman regain her prepregnant muscle tone and help prevent urinary incontinence (Hay-Smith & Dumoulin, 2009). 5. Give Episiotomy Care. Although relatively small in size, episiotomy sutures can cause considerable discomfort, because the perineum is an extremely tender area and the muscles of the perineum are involved in so many activities such as sitting, walking, stooping, squatting, bending, urinating, and defecating. Most women expect labor to be painful. They usually do not anticipate the pulling pain from perineal stitches in the postpartal period, discomfort that interferes with their rest and sleep, with eating, and with being able to sit and hold their baby comfortably. Because the perineal area heals rapidly, you can assure a woman that this discomfort is normal and does not usually last longer than 5 or 6 days.  6. Administer Sitz Baths. A sitz bath is a portable basin that fits on a toilet seat. A reservoir filled with water provides a constant supply of swirling water to the basin. The movement of water soothes healing tissue, decreases inflammation by causing vasodilation in the area, and thereby effectively reduces discomfort and promotes healing. Sitz baths usually use water that is maintained at 100° to 105° F (38° to 41° C). Be certain that the water in a sitz bath is not too hot before you help a woman to use it; it should feel pleasantly warm, not hot. 7. Provide Perineal Care. Postpartal women are particularly prone to perineal infection because lochia, if allowed to dry and harden on the vulva and perineum, furnishes a rich bed for bacterial growth, which then can spread to the uterus. Because the vagina lies inclose proximity to the rectum, there is also always the danger that bacteria will spread from the rectum to the vagina. Interruption in skin integrity from an episiotomy also increases the client’s risk for infection. Teach a woman to include perineal care as part of her daily bath or shower and after every voiding or bowel movement. If the woman is on bed rest during the first hour after birth, you will need to provide perineal care for her. 8. Promote Rest in the Early Postpartal Period Few women are prepared for the degree of fatigue they experience after childbirth. Try to do all procedures swiftly yet gently, to allow as much time for sleep as possible. If a woman has discomfort from hemorrhoids, perineal stitches, or afterpains, be sure she has pain relief so that she can rest comfortably or sleep. Urge her not to fall asleep in a narrow hospital bed with her new infant. Sharing bed space is controversial even in a large bed (Horsley et al., 2007). 9. Assess Peripheral Circulation. To determine whether peripheral circulation is adequate, assess a woman’s thigh for skin turgor. Assess for edema at the ankle and over the tibia on the lower leg. Although this technique is not totally reliable, assess for thrombophlebitis by dorsiflexing a woman’s ankle and asking her if she notices pain in her calf on that motion (Homans’ sign). Assess also for redness in the calf area, because thrombophlebitis can be present even with a negative Homans’ sign. Continue to assess for adequate peripheral circulation once every 8 hours during the woman’s stay in a health care facility. If you suspect thrombophlebitis, do not massage the area—doing so could cause an embolus. Be certain to allow a woman to dangle her legs on the edge of the bed for a few minutes to prevent. Dizziness before she gets up for the first time. Then, assist her as needed to take the few steps to a nearby bathroom. Remain with her to be certain that dizziness does not occur. After this, she may be up on her own as she wishes. As a rule, women who ambulate quickly feel stronger and healthier by the end of their first week and have fewer bowel, bladder, and circulatory complications than those who do not. 10. Prevent/Alleviate Breast Engorgement.  If a woman is breastfeeding, encouraging her newborn to suck at the breast is the main treatment for relief of the tenderness and soreness of primary breast engorgement. Many women find the application of warm compresses or standing under a warm shower beneficial to relieve engorgement discomfort. Good support from a bra also offers relief because it prevents unnecessary strain on the supporting muscles of the breasts, positions the breasts in good alignment, and diminishes the amount of engorgement caused by blocked milk ducts. If the woman has not packed a bra in her suitcase, ask her to arrange to have one brought from home. Cold compresses, applied to the breasts three or four times a day during the period of engorgement, or an oral analgesic, or both, provide relief. Wearing a snug-fitting bra and avoiding nipple stimulation may help. Restricting fluid and pumping milk from the breasts are not effective measures and are to some degree harmful, so these actions should be avoided. 11. Promote Breast Hygiene. Breast care during the postpartal period includes cleanliness and support. These issues are the same whether or not a woman is breastfeeding. Teach a woman to wash her breasts daily with clear water at the time of her bath or shower and then dry them with a soft towel. She should avoid using soap, because it tends to dry and crack the nipples, possibly leading to fissures and breast abscess. It is not necessary for women to wash their breasts more often than daily, because excessive washing means unnecessary manipulation. 12. Teach Methods to Promote Uterine Involution. All during the postpartal period, lying on the abdomen gives support to abdominal muscles and may aid involution, because it tips the uterus into its natural forward position. If this puts too much pressure on sore breasts, placement of a small pillow under the abdomen usually solves the problem. It may be dangerous for a woman to assume a knee–chest position until at least the third week after birth. In a knee–chest position, the vagina tends to open. Because the cervical os remains open to some extent until the third week, there is a danger that air will enter the vagina and the open cervix, penetrate the open blood sinuses inside the uterus, enter the circulatory system, and cause an air embolism. BUBBLE-HE BUBBLE-HE is a acronym used to denote the components of the postpartum maternal nursing assessment. This method enhances the standard physical assessment process typically performed on hospitalized patients by the RN, such as those on a Medical-Surgical floor. For stable patients, vital signs are taken every 15 minutes during the first hour following delivery and then gradually less frequently. While performing the BUBBLE-HE, the RN often uses the assessment time to provide for patient education. 8-POINT POSTPARTUM ASSESSMENT INSTRUCTIONS 1. Breast a.Gently palpate each breast b.If you feel nodules in the breast, the ducts may not have been emptied at last. c. Stroke downward towards the nipple, then gently release the milk by manual. d.If nodules remain, notify the doctor.  e.Take this opportunity to explain the process of milk production, what to do about engorgement, how to perform self breast examinations, and answer any questions she may have about breastfeeding.  What is the contour?  Are the breast full, firm, tender, shiny?  Are the veins distended?  Is the skin warm?  Does the patient complain of sore nipples?  Are breasts so engorged that she requires pain medication? 2. Uterus a. Palpate the uterus b. Have the patient feel her uterus as you explain the process of involution c..If uterus is not involution properly, check for infection, fibroids and lack of tone. d. Uterus should the firm decrease approximately one finger breadth below e. Unsatisfactory involution may result if there are retained secundines or the bladder not completely empty 3. Bladder a. Inspect and palpate the bladder simultaneously while checking the height of the fundus. b. An order from the physician is necessary cauterization may be done. An order for culture and sensitivity test since definitive treatment may be required. c. Talk to mother about proper perineal care. Explain that she should wipe from front to back after voiding and defecating. d. Bladder distention should not be present after recent emptying. e. When bladder distention does occur, a pouch over the bladder area is observed, felt upon palpation; mother usually feels need to urinate. f. It is imperative that the first three post-partum voiding be measured and should be at least 150cc. Frequent small voiding with or without pain and burning may indicate infection or retention. 4. Bowel Function a.Question patient daily about bowel movements. She must not become constipated. If her bowels have not functioned by the second postpartum day, the doctor may start her on a mild laxative b..Encourage patient to drink extra fluids. c. Have patient select fruits and vegetables from her menu 5. Lochia a.Assess the amount and type of lochia on pad in relations to the number of postpartum days. First 3 days of postpartum, you should find a very red lochia similar to the menstrual flow (lochia ruba). b.During the next few days, it should become wateryserous (lochia serosa). Onthe tenth day, it c. should become thin and colorless (lochia alba).  d..Inform the mother about what changes she should expect in the lochia and when it should cease. e.Tell the mother when her next menstrual period will probably begin and when she can resume sexual relations. f. Discuss family planning at this time. g.Notify the doctor if the lochia looks abnormal in to color or contains clogs other than small ones. 6. Episiotomy a. Inspect episiotomy thoroughly using flashlight if necessary, for better visibility. b. Check rectal area. If hemorrhoids are present, the doctor may want to start on sitz bath and local analgesic medication. Reassure patient and answer questions she may have regarding pain, cleanliness, and coitus. c. Check episiotomy for proper wound healing, infection, inflammation and suture sloughing. d. Is the surrounding skin warm to touch? e. Does the patient complain of discomfort? Notify the doctor if any occurs 7. Homan’s Sign a.Press down gently on the patient’s knee (legs extended flat on bed) ask her to flex her foot b.Pain or tenderness in the calf is a positive Homan’s sign and indication of thrombophlebitis. Physician should be notified immediately. 8. Emotional Status A. Throughout the physical assessment, notice and evaluate the mother’s emotional status. B. Explain to the mother and to her family that she may cry easily for a while and that her emotions may shift from high to low. The changes are normal and are probably caused by the tremendous hormonal changes occurring in her body and by her realization of new responsibilities that accompany each child’s birth. C. Does the patient appear dependent or independent? Is she elated or despondent? What does she say about family?Are there other nonverbal responses? Pavone, M. E., Purinton, S. C., & Petersen, S. M. (2007). Postpartum care and breastfeeding. In K. B. Fortner, et al. (Eds.). The Johns Hopkins manual of gynecology and obstetrics. Philadelphia: Lippincott Williams & Wilkins. https://www.bcbs.com/sites/default/files/file-attachments/health-of-americareport/ HoA_Maternal_Health.pdf  PUERPERIUM/Postpartum – 6 weeks period after giving birth Engorgement - swell with blood, water, or another fluid Involution - return of the reproductive organs to their non-pregnant state. Lochia - Uterine flow, consisting of blood, fragments of decidua, white blood cells, mucus Sitz bath - type of therapy done by sitting in warm, shallow water. A survey conducted by Blue Cross Blue Shield, The Health of America Report® about TRENDS IN PREGNANCY AND CHILDBIRTH COMPLICATIONS IN THE U.S, Published June 17, 2020, has the following findings: In 2018, nearly one in 10 women who delivered a baby was diagnosed with postpartum depression (PPD). That number is up almost 30% from 2014. Postpartum depression diagnoses were most prevalent in women aged 18-24. Some of this increase could be attributed to a greater awareness of the condition and more screening. Pre-existing behavioral health conditions are linked with a greater risk for postpartum depression. More than two thirds of women diagnosed with postpartum depression had at least one other behavioral health diagnosis before becoming pregnant, and more than 1 in 4 women had two or more pre-existing behavioral health conditions. Make a reflection paper about the relationship of age and pre-existing behavioral health conditions in developing postpartum depression. Textbook: Pilliteri, Silbert-Flagg. (2018). Maternal and Child Health Nursing: Care of the Childbearing and Childrearing Family. (8 th Ed.) Wolters Kluwer Devakumar (2019). Oxford Textbook of Global Health of Women, Newborns, Children, and Adolescents. PB Publishing. Murray (2019). Foundations of Maternal-Newborn and Women’s Health Nursing, 7th edition. Elsevier. Flagg (2018). Maternal and Child Health Nursing: Care of the Childbearing and Chilrearing Family. Wolters Kluwer Wolters Kluwer. Audrey Berman, Shirlee J. Snyder, Geralyn Frandsen. (n.d.). Fundamentals of Nursing by Kozier and Erbs (10th ed.). Pearson. Maternal and Child Health. (n.d.). https://apha.org/topics-and-issues/maternal-and- child-health Maternal, newborn and adolescent health. (n.d.). https://www.who.int/maternal_child_adolescent/en/ Rosalinda Parado Salustiano. (2009). Dr. RPS Maternal & Newborn Care: A Comprehensive Review Guide and Source Book for Teaching and Learning. C & E Publishing, Inc.