Postpartum Period Maternal and Child Health Nursing PDF

POSTPARTUM PERIOD Maternal and Child Health Nursing BSN 2C | Prof. Marie Vic C. Cañonaso | SEM 1 2024 PHYSICAL CARE OF THE POSTPARTUM MOTHER Immediately after delivery, the fundus of the uterus can...

POSTPARTUM PERIOD Maternal and Child Health Nursing BSN 2C | Prof. Marie Vic C. Cañonaso | SEM 1 2024 PHYSICAL CARE OF THE POSTPARTUM MOTHER Immediately after delivery, the fundus of the uterus can be palpated through the abdominal wall, halfway Providing comfort and relief from any discomfort from between the umbilicus and the symphysis pubis. One deliver, including emotional support. hour later, the uterus is at the level of the umbilicus and will remain for approximately the next 24 hours. Per day, it decreases one fingerbreadths or 1 cm. After 10 days, HEALTHY PEOPLE 2030 RELATED TO POSTPARTUM it recedes under the pubic bone and is not palpable. Reduce the maternal mortality rate to no more than 15.7/100,000 live births from a baseline of 17.4/100,000. ADDITIONAL NOTES Increase the proportions of infants who are breastfed exclusively through 6 months of age from 24.9% to ✓ Contraction may be ineffective if there is retained placenta 42.4%. or membranes. Fundus SPECIFIC BODY CHANGES ON THE MOTHER It is normally located in the midline of the abdomen. The post-partal period or puerperium is in the 4th Can be felt slightly to the right because the bulk forced it trimester of pregnancy. to the side during pregnancy. Puerperium (puer means child and parere means to o Assess the fundal height shortly after a woman has emptied her bladder for most accurate bring forth) refers to 1 6-week period after childbirth. results. Reproductive tract returns to the normal, nonpregnant state (involution). The first hour after birth is potentially the most dangerous UTERUS ASSESSMENT time for a woman. Mother should be in supine position. Maternal changes include: Palpate the fundus. o Retrogressive Place one hand on the base of the uterus, just above ▪ Reproductive System Changes the symphysis pubis, and the other at the umbilicus. ▪ Hormonal Changes Press in and downward with the hand at the umbilicus o Progressive until you “bump” against a firm globular mass in the ▪ Production of Milk for Lactation abdomen: the uterine fundus. ▪ Restoration of the Normal Menstrual o Never palpate the uterus without supporting Cycle the lower segment because it may cause ▪ Beginning of the Maternal Role uterine inversion. Uterine inversion occurs when the uterine fundus collapses into the endometrial cavity, turning the uterus RETROGRESSIVE partially or completely inside out. o It should not cause pain as long as it is done REPRODUCTIVE ORGAN CHANGES gently. Uterine involution is the rapid decrease Assess for the consistency, location, and height. in the size of the uterus as it returns to o Consistency: firm, soft, or boggy the non-pregnant state. The two o Location: midline processes of uterine involution are: o Height: measured in fingerbreadths from the o The area where the placenta distance under the umbilicus (-) or even was implanted is sealed off to slightly above it prevent bleeding. ▪ A well-contracted uterus is firm and o The organ is reduced to its can be compared with a grapefruit approximate pre-gestational in both size and tenderness. size. ▪ A uterus that is not contracted is Subinvolution is the failure of the uterus to return to the boggy (soft or flabby). pre-pregnant state after 6 weeks. The conditions that can Assess the fundus every 10-15 minutes immediately cause delay of involution include multiple birth fetuses, after birth for the first hour. hydramnios, exhaustion from prolonged labor, grand o If the uterus is not firm, massage. If the multiparity, and physiologic effects of excessive uterus does not grow firm with massage, analgesia. notify the woman’s physician or nurse midwife, administer PRN oxytocin as ordered, or place the woman’s infant at breast. ▪ The possible reason why the uterus does not contract is The weight of the uterus is 1000 g immediately after birth because of a clot, retained and 500 g at the end of the first week. After 6 weeks placental fragment, or full bladder. when involution is complete, it becomes 50 g. o If the uterus is totally relaxed, fundal  UTERUS ASSESSMENT LOCHIA pressure may cause uterine inversion that infection. may lead to rapid hemorrhage and The discharge should smell like normal menstrual emergency hysterectomy. A uterine flow. sonogram may be ordered to help detect any problem. Absence Lochia should never be absent during the first 1-3 weeks. ADDITIONAL NOTES ✓ Afterpains are intermittent cramping similar to that of a Assessment menstrual period. It is more noticeable in multiparas rather Discharge decreases daily in amount. than primiparas, women who have given birth to large Weigh the perineal pad before and after use (1 g = 1 babies or multiple births, and most intensely with mL of blood flow). breastfeeding. The comfort measure for this is pain Identify the amount of time between pad changes to reliever. Heat to the abdomen should be avoided because determine most accurately the lochial flow. it could cause relaxation of the uterus and subsequent o Inspect the lochia discharge once every 15 uterine bleeding. minutes for the first hour and then according to the institution’s policy (usually hourly for the next 4 hours and then every 8 hours LOCHIA after that). It is a vaginal discharge from the layer adjacent to the uterine cavity that becomes necrotic. Health Teaching Consist of blood, fragments of decidua, white blood Mother should wash her hands after handling pads. cells, mucus, and some bacteria. Must use only her own personal care equipment so that she does not contract or spread infection. Assessment of Lochia Change perineal pads frequently as she begins self- Amount care because lochia is an excellent medium for Consistency bacterial growth. Pattern (Color) o It is important not to use tampons until after Odor she returns for her post-partal check-up to Absence diminish the risk of infection and possibly toxic shock syndrome. Amount Vary from woman to woman. Cervix Increase in amount during Immediately after birth, the cervix is soft and malleable ambulation and exertion is a and both internal and external OS are open. result of vaginal discharge of At the end of seven days, external OS has narrowed to pooled lochia, not a true the size of a pencil opening, the cervix feels firm and increase in amount. non-gravid, and muscle begins to regenerate. The o Saturating a cervical OS is stellate (star-shaped). perineal pad in less than 1 hour is considered an Vagina abnormally heavy Vaginal outlet remains slightly more distended (swollen) flow and should be than before. reported. Feels soft, with few rugae, and its diameter is greater than normal. Hymen is permanently torn. Consistency Should contain no exceedingly large clots. Large ADDITIONAL NOTES clots denote poor contraction. Clot may indicate retained placental fragments. ✓ Kegels exercise helps increase the strength and tone of vagina. Pattern Lochia rubra: 1-3 days; red, mostly blood Perineum Lochia serosa: days 4-10; pink or brownish Develops edema and Lochia alba: about the 10th day until 6 weeks after generalized tenderness birth – present in most women until the 3rd week after immediately after birth. birth; colorless or white Ecchymosis occurs from o A red flow after a pink or white flow may ruptured capillaries. indicate retained placental fragments. Ecchymosis is a discoloration o Pattern of lochia should not reverse. It of the skin resulting from should be rubra > serosa > alba or RSA. bleeding underneath, typically caused by bruising. Odor Incision line is usually fused by 24 hours. Should not have an offensive odor. Odor would mean  o Inform the woman that the suture will dissolve EPISIOTOMY in 10 days. mean there is no pain. In assessing the perineum: o Mother should be in Sim’s position. Comfort Measures ▪ If she has a mediolateral incision, ask Ice packs during the first 24 hours and warm packs her to turn so the incision is on the after 24 hours. Be careful of thermal burn. bottom buttock because this tends to cause less pain and offers better Use a gentle pillow or donut. visibility. Administer perineal care after each voiding. ▪ Gently lift the upper buttock and Promote perineal exercise 3-4 times a day. inspect the perineum. Do Kegels exercises. Contracting and relaxing the o Observe for ecchymosis, hematoma, erythema, muscles of the perineum 5 to 10 times in succession, edema, intactness, and presence of drainage as if trying to stop voiding. and bleeding from episiotomy stitches. Encourage the woman to lie on her side. Do perineal heat application. EPISIOTOMY Do sitz bath. Episiotomy is a cut (incision) made in the tissue between the vaginal opening and the anus during ADDITIONAL NOTES childbirth. ✓ A sitz bath is a type of therapy done by sitting in warm, Episiotomy Wound Assessment (REEDA) shallow water. It is also useful when assessing a cesarean incision for healing. Some comfort measures on perineal comforts or pain are o R: Redness as follows: ▪ Redness without excessive o Pharmacologic tenderness is probably the normal ▪ Soothing anesthetic cream or spray inflammation associated with cortisone-based cream healing, but pain with the redness ▪ Witch hazel-impregnated pads is more likely to indicate infection. (mainstay for relief of both perineal o E: Edema and hemorrhoidal discomfort) ▪ Mild edema is common, but severe ❖ Do not use aspirin because it edema interferes with healing. interferes with blood clotting o E: Ecchymosis and leads to hemorrhage. ▪ Also refers to bruising. o Non-Pharmacologic ▪ A few small superficial bruises are ▪ Warmth common. Large bruises interfere ▪ Distraction with normal healing. ▪ Imagery o D: Discharge ▪ Therapeutic Touch ▪ No discharge from the perineal ▪ Relaxation suture line should be present. ▪ Interaction with the Client o A: Approximation of Edges of Episiotomy ❖ Unrelieved pain might Wound indicate the presence of a ▪ Approximation refers to the previously unidentified or intactness of the suture line. untreated problem. ▪ The suture line should not be ❖ The nurse should carefully separated. monitor all women receiving ▪ If intact, it is almost impossible to opioids because respiratory distinguish the laceration or depression and decrease episiotomy from surrounding skin intestinal motility are side folds. effects. Perineal care is very important to avoid infection. Episiotomy Care o Teach client to include perineal care as part of Inspect and palpate her daily bath or shower and after voiding or areas. bowel movement. If woman is on bed rest, the Observe for body nurse should do the perineal care. tension, guarded o This is a clean and not a sterile procedure. movements, and o Differs per agency policy on solutions and facial tension. articles used. o Discomfort is normal and does not usually ▪ Wash hands and pull on clean gloves. last longer than 5 to 6 days. ▪ Place a plastic-covered pad under the o BP, PR, and RR may be elevated in woman’s buttocks. response to acute pain. ▪ With the woman lying in a supine o Diaphoresis (excessive sweating) may position, remove the pad from the accompany severe pain. front to back. o A lack of objective sign does not necessarily  ▪ Use a clean gauze square or a clean An increase in leukocyte portion of a washcloth with soap and number is a defense against water for each stroke. infection and aid in healing. ▪ Wash from front to back, from the The increase is in response pubis to the rectum. to inflammation, pain, and ▪ Rinse the area in same manner, and stress, and it protects the dry it. mother from infection as her tissues heal. The white blood cell count returns to normal ADDITIONAL NOTES by 12 days postpartum. ✓ Self-care does not eliminate a nurse’s responsibility for WBC count maybe as high checking a woman’s perineum to assess its condition and as 30,000 cells/mm. the amount and type of lochial flow. Bilateral ankle edema should not progress above the knees. SYSTEMIC CHANGES Activation of blood clotting factors, immobility, and sepsis Hormonal System predispose the woman to thromboembolism. Pregnancy hormones begin to decrease as soon as the Homans sign is a calf pain on dorsiflexion of the foot. placenta is delivered completely. o Level of human chorionic gonadotropin (hCG) Gastrointestinal System and human placental lactogen (hPL) are almost Digestion and absorption begin to be active again. negligible by 24 hours. Woman feels hungry and thirsty almost immediately after o Progestin, estrone, and estradiol are at pre- birth. pregnancy state by week 1. Bowel sounds are active but passage of stool through o Follicle-stimulating hormone (FSH) remains low the bowel maybe slow due to relaxin effect. for about 12 days and then begins to rise as a o Relaxin is a hormone new menstrual cycle is initiated. which softens and lengthens the cervix Urinary System and pubic symphysis 2000 to 3000 mL of fluid are excess in the body during for preparation of the pregnancy. infant’s birth during There is an increase in daily UO (from 1500 mL to 3000 pregnancy. mL / day during the 2nd to 5th day after birth). o Assess the rectal area for the presence of Kidney function returns to normal within a month after swollen rectal veins. birth. A spontaneous bowel evacuation may not occur 2 to 3 Diuresis usually begins within the first 12 hours after days after birth. delivery. Transient loss of bladder tone and edema surrounding CONSTIPATION the urethra occurs. Factors That May Cause Constipation during the Diaphoresis is another way of the body to rid itself of Postpartum Period excess fluid. Medications Some comfort measures include the following: Abdominal muscles are stretched o Encourage to continue drinking a healthy A cesarian incision adds to this difficulty amount of fluids daily, especially if she is breastfeeding. Hemorrhoids or soreness and swelling of the o Assess a woman’s abdomen frequently. A perineum woman should void within 4-8 hours after birth. Slight dehydration and little food intake during labor. A full bladder is a hard or firm area just above the symphysis pubis. Its sound is resonance and it displaces Interventions for Complications the uterus. Early ambulation Hydronephrosis is the increasing of the size of the Encourage mother to eat high soluble fiber foods, ureters. It remains present for about 4 weeks after birth. especially fruits Adequate fluid intake Circulatory System Stool softener as ordered The average blood loss is: o 300 to 500 mL for NSVD. Integumentary System o 500 to 1000 mL for CS. Striae Gravidarum Blood volume returns to its normal pre-pregnancy level o Stretch marks on the abdomen by 1st or 2nd week postpartum. o Still appear reddened There is a 1 g decrease in hemoglobin value in 250 mL Chloasma of blood loss. Thus, a 4-point decrease in hematocrit/250 o Excessive pigmentation of the face and neck mL of blood loss is equal to 1000 mL. o Barely detectable by 6 weeks’ time Plasma fibrinogen level remains the same to protect the Linea Nigra patient against hemorrhage but increase the risk of o Excessive pigmentation on the abdomen thrombus formation. o Barely detectable in 6 weeks’ time  Diastasis Recti ❖ Compare a woman’s PR with o Overstretching and separation of the abdominal the normal range of the post- musculature partal period, not with the ▪ If the separation is large, the area will normal PR in the general appear bluish in the abdominal midline population. o Blood Pressure EFFECTS OF RETROGRESSIVE CHANGES ▪ A decrease in BP can indicate bleeding. Exhaustion ▪ An elevation above 140 mmHg Weight Loss systolic or 90 mmHg diastolic may Vital Sign Changes indicate the development of post- partal hypertension of pregnancy. ADDITIONAL NOTES ❖ Compare a woman’s pressure with her pre- ✓ Six weeks after birth is the baseline post-partal weight. pregnancy level, if possible, rather than with standard BP ranges. Weight Loss ❖ Oxytocics can increase BP. But if BP is more than 140/90 Diuresis and Diaphoresis 5 lbs or 2-4 kg mmHg, withhold the agent Lost at Birth 12 lbs or 5.8 kg and notify the primary caregiver. Lochia Flow 2-3 lbs or 1 kg ORTHOSTATIC HYPOTENSION Vital Sign Changes Dizziness that occurs on standing due to lack of Changes in the postpartum period reflect the internal adequate blood volume to maintain nourishment of adjustments that occur as a woman’s body returns to its brain cells. pre-pregnant state. Taken every 15 minutes during the first hour and 30 Assessment minutes for the next 2 hours. Assess the woman’s BP and pulse while she is lying o Temperature supine. ▪ Never taken rectally. Raise the head of the bed fully upright. Wait 2-3 ▪ Slight increase during the first 24 minutes and reassess. hours after birth because of the If the pulse rate is increased by more than 20 dehydration that occurred during beats/min and BP is 15-20 mmHg lower than labor. formerly, the woman might be susceptible to ❖ Encourage to increase fluid dizziness and fainting when she ambulates. intake. ▪ A temperature higher than 38 °C Interventions (100.4 °F), excluding the first 24-hour Sit up slowly and “dangle” on the side of her bed period, is considered febrile by the before attempting to walk. Joint Commission on Maternal Support her during ambulation to avoid possibility of Welfare. a fall. ▪ A temperature of 100.4°F (38°C) or o Caution mother not to carry newborn until higher during the first 12 hours after cardiovascular stabilizes. delivery could indicate an infection but may not. ❖ A postpartum infection is usually diagnosed after 24 PROGRESSIVE hours have passed since LACTATION delivery and the woman has had a temperature of Formation of breast milk. 100.4°F or higher on two Lactation process is identified by four phases of occasions at least 6 hours lactogenesis (human milk production). apart. Infection is a major o Lactogenesis I (Milk Synthesis): Process cause of post-partal mortality begins around 16 weeks gestation. and morbidity. o Lactogenesis II: It is triggered by the delivery of o Pulse the placenta. It occurs from birth to 5-10 days ▪ Slightly slower than usual. postpartum. This is often termed “transitional ▪ Stroke volume increases between 60- milk.” 70 beats/min. o Lactogenesis III: Occurs from day 10 until ▪ By the end of the first week, PR will weaning postpartum. have returned to normal. o Lactogenesis IV: Occurs after complete ❖ Rapid, thready pulse is a weaning and the breasts involute to their pre- sign of hemorrhage. lactation state.  Colostrum is a thin, watery pre-lactation secretions. It in about 2 days. Apply cold compress to the breasts 3-4 continues to be excreted the first 2 postpartum days. times a day. Use oral analgesics. Wear a snug-fitting bra. Let down reflex, also known as milk ejection reflex, is due Avoid nipple stimulation. Restricting fluid and pumping to an increase of prolactin level through suckling of infant milk from the breasts are not effective measures. and emptying of the breast. Milk production is a supply- meets-demand system. Mastitis The hormones involved are oxytocin and prolactin. Mastitis is the infection of the breast during lactation. The symptoms include localized pain, swelling, redness lumps in breast, fever, chills, and tachycardia. The treatment includes antibiotic as ordered, ice/warm compress, proper breast support, and discontinuation on breastfeeding on affected breast. Breast Hygiene Wash breasts daily with clear water and dry with soft towel. Avoid the use of soap. Insert clean gauze squares or commercial nursing pads in the bra to absorb discharge of colostrum or milk. Change it as often as necessary. If it remains wet, fissures may form and lead to infection. Signs of Poor Attachment RETURN OF MENSTRUAL FLOW Continuous milk production (lactogenesis) will depend It occurs at 6 to 10 weeks postpartum in non- on an infant’s successful latch, ability to suck, and breastfeeding mother. transfer milk effectively. Lactation amenorrhea is the absence of menstruation for o The mouth is not widely opened. 3-4 months in some women. The entire lactation period o The tongue is far back inside the mouth and will be experienced by breastfeeding mothers. definitely would not be seen. After birth, intense tremors that resemble shivering from o The lower lip is not turned outwards. a chill are common. They may result from a sudden o The chin is not close to the breast. release of pressure on pelvic nerves after birth. It is a o As much areola is visible above the baby’s response to a fetus-to-mother transfusion that occurred mouth as below it. during placental separation and a reaction to maternal o The lips may be pointing forwards (pursed). adrenaline production during labor and birth and to Emphasize the importance of breast hygiene before and epidural anesthesia. after breastfeeding. o Useful interventions include warm blankets and Encourage and support breastfeeding. informing that chills or tremors are common, are self-limiting, and last only a short while. ADDITIONAL NOTES ✓ For the first 2 days after birth, an average woman notices little changes in her breasts from the way they were during pregnancy. On the third day after birth, her breasts become full and feel tense or tender as milk forms within breast ducts and replaces colostrum. Engorgement Engorgement is when a woman’s breasts become fuller, larger, and firmer as blood and lymph enter the area to contribute fluid to the formation of milk. PSYCHOLOGICAL CHANGES ON THE MOTHER Primary engorgement is the feeling of tension in the breasts on the 3rd or 4th day postpartum. Breast tissue PHASES OF THE PUERPERIUM may appear reddened as if an acute inflammatory or Taking-In Phase (Dependent) infectious process were present and some moms experience increased tenderness or throbbing. It fades It is a time for reflection (1 to 3-day period) and largely as the infant begins effective sucking. It has a stronger passive (passive-dependence). discomfort for non-breastfeeding mothers. o Prefers having a nurse attend to her and make For breastfeeding mothers, encouraging her newborn to decisions for her. attempt to latch at the breast is the main treatment for o Wants to talk about her pregnancy, especially relief of tenderness and soreness. Apply warm compress about her labor and birth experience. or stand under a warm shower to relieve discomfort. o Holds her new child with a sense of wonder. Manual expression helps relieve engorgement. Wear o Rest to regain her physical strength and supportive bra. experience a calm atmosphere around her. For non-breastfeeding mothers, accumulation of milk The reasons for the dependence include: inhibits further milk formation and engorgement subsides  o Partly from physical discomfort due to perineal Sibling Visitation stitches, afterpains, or hemorrhoids. A chance to visit the hospital and see the new baby and o Partly from her uncertainty in caring for her their mother reduces feelings that their mother cares newborn. more about the new baby than about them. o Partly from extreme exhaustion during The visit can help to relieve some of the impact of childbirth. separation and also help to make the baby a part of the The interventions include: family. o Encourage her to talk about the birth. o Encourage the mother to express her feelings regarding the difference from the anticipated ADDITIONAL NOTES birth plan. ✓ Sudden unexpected postnatal collapse occurs if the newborn’s airway becomes compromised or obstructed, Taking-Hold Phase (Dependent-Independent) which can cause respiratory distress and neurologic If the mother give birth without anesthesia, she may damage and may lead to death. Intervention includes reach this phase in a matter of hours after birth. continuous monitoring and observation and thorough o Woman begins to initiate action. instruction on safe infant positioning. o Prefers to get her own washcloth and to make her own decisions. PHYSIOLOGICAL NEEDS: EMOTIONAL RESPONSE o Has a strong interest in caring for the child. Still feels insecure about her ability to care. Involves assessing the parent’s reactions to the birth The interventions include: experience, feelings about themselves, and interactions o Give a woman brief demonstrations of baby with the new baby and other family members. care and then allow her to care for her child It sometimes indicates serious actual or potential herself with watchful guidance. problems that must be addressed. o Give positive reinforcement (praise for the Guided, supportive interactions, such as pointing out things she does well). parental behaviors and infant responses, enhance positive parent-infant interaction. Letting-Go Phase (Interdependent) Helping parents sort out their feelings about being a A woman who has reached this phase is well into her mother or father and about their new responsibilities new role. through anticipatory guidance also strengthens parent- o The woman finally redefines her new role. infant bonding. o Gives up the fantasized image of her child and Facilitating early skin-to-skin bonding between infant and accepts the real one. mother has shown to improve breastfeeding durations o Gives up her role of being childless or the and outcomes and the emotional stability of both infant mother of one or two. and mother. Transition to Parenthood ATTACHMENT/BONDING It is the period from the decision to conceive through the Woman has successfully linked with her newborn. first months of having a child. It is the process by which a parent comes to love and The three stages of transition to fatherhood includes accept a child, and a child comes to love and accept the expectations (stage 1), reality (stage 2), and transition to parents. mastery (stage 3). Skin-to-skin contact soon after birth facilitates the early Nurses’ important role to facilitate parental attachment attachment and binding phase. includes: o Enhance positive parent-infant contacts by En Face Position heightening parental awareness of an infant’s En face position is looking directly at the newborn’s face, response and ability to communicate. with direct eye contact. o Bolster the parent’s confidence and ego by This is a sign that a woman is beginning effective using positive, non-judgmental approaches and attachment. by providing encouragement and praise for parenting efforts. Engrossment o Identify actual and potential problems and Fathers observed staring at a newborn for long intervals. collaborate with other health care professionals It is the father’s absorption, preoccupation, and interests who will provide care for the parents after in the infant. discharge. Rooming In MATERNAL CONCERNS DURING POSTPARTAL PERIOD Occurs when the infant remains in the woman’s room and the mother and child are together 23 out of 24 hours ABANDONMENT a day. A sensation very close to jealousy; competitive feelings. Hours before, the mother is the center of attention. Everyone is asking about her health and well-being but with the new baby, everyone is interested and asks about the baby and not about her/mother anymore.  The father may express the same feeling. POSSIBLE COMPLICATIONS DURING POSTPARTUM o Use welcome words for a woman to hear. o Help them realize that parenthood involves POST PARTAL HEMORRHAGE some compromise in favor of the baby’s One of the most important causes of maternal mortality interests. is associated with childbearing. o Make infant care a shared responsibility that It can be early or late postpartum hemorrhage. can help alleviate these feelings and make both o Early postpartum hemorrhage occurs within 24 partners feel equally involved in the baby’s hours after delivery. care. o Late postpartum hemorrhage occurs after 24 o Point out positive parenting behaviors. hours after delivery and anytime during the 6- week postpartum. DISILLUSIONMENT Traditionally, postpartum hemorrhage is defined as blood Disappointment usually because of the physical loss of 500 mL or more following a vaginal birth. With a appearance of the baby, gender, and size of the baby. cesarean birth, hemorrhage is present when there is o Reassure parents that this can be a part of a 1000 mL blood loss or a 10% decrease in the hematocrit normal parent-child bonding process. level. o Handle the child warmly. The greatest danger is in the first 24 hours because of o Comment on the child’s good points, such as the grossly denuded and unprotected area left after long fingers, lovely eyes, and good appetite detachment of placenta. (consider the cultural beliefs). The four main causes of post-partal hemorrhage are o Nurse should tip a scale toward acceptance or uterine atony, lacerations, retained placental fragments, at least help a person involved to take a clearer and DIC (disseminated intravascular coagulation). look at his or her situation and begin to cope The four Ts of postpartum hemorrhage is a common with the new circumstances. mnemonic for the etiology of hemorrhage experienced in the puerperium. POST PARTAL BLUES / BABY BLUES o Tone (Uterine Atony) o Trauma (Laceration) It is evidenced by: o Tissue (Retained Placental Fragments) o Tearfulness, feelings of inadequacy, mood o Thrombin (DIC) liability, anorexia, and sleep disturbance Prevention of excessive bleeding includes: o Response to dependence and low self-esteem o A perineal pad saturated in 15 minutes or less caused by exhaustion, being away from home, and pooling of blood under the buttocks are physical discomfort, and emotional instability indications of excessive blood loss, requiring o Hormonal changes immediate assessment, intervention, and o Other reasons, such as problems at home, notification of the physician or nurse-midwife. husband may have been laden off from his job, o Constant trickle of vaginal flow or a woman is financial concerns, or illness of other family soaking through a pad every 60 minutes is members losing more than the average amount of blood. Feelings of overwhelming sadness. They may burst into tears easily or feel let down or PERINEAL PAD SATURATION AFTER BIRTH irritable. o Inform the woman and her support person that Scant < 2.5 cm. sudden crying episodes are normal. Light < 10 cm. o Anticipatory guidance and individualized support from health care personnel are Moderate > 10 cm. important to help the parents understand that Heavy One pad saturated within 1-2 hours this response is normal. o Give the woman a chance to verbalize her Objective estimates of blood loss include measuring feelings. serial hemoglobin or hematocrit values, weighing blood o Give her a sense of control over her life by clots and items saturated with blood (1 mL = 1 g). allowing her to make many decisions. o Observe for the respirations, pulse, skin o Keeping the line of communication open is very conditions, urinary output, and level of important for proper assessment of the consciousness. feelings, either it can be handled best with ▪ The two most important interventions discussion and concerned understanding or it for preventing excessive bleeding are should be referred to the social service maintaining good uterine tone and department. preventing bladder distention. ▪ If the uterus is not contracting, the ADDITIONAL NOTES initial management is to gently massage the uterus until it is firm. ✓ If a mother appears to have a level of depression that is ▪ Initiate IV infusion therapy, including beyond baby blues and/or has a history of previous starting a second IV line if necessary. postpartal depression (PPD), a closer observation and ▪ Administer oxytocics as ordered. referral is indicated immediately. ▪ Starting oxygen therapy via facemask. ▪ Inserting indwelling catheter for strict MIO (monitoring of intake and output).  ▪ Administer blood products as o Hematomas appropriate. The preconception or antepartal factors include: ▪ Assisting with packing of uterus, o History of previous venous thrombosis, UTI, evacuating hematoma, or suturing mastitis, pneumonia, or DM lacerations as indicated. o Alcoholism ▪ Prepare for emergency hysterectomy o Immunosuppression as needed. o Anemia ▪ Keep the client and family informed of o Malnutrition the condition and measures being Therapeutic management includes the use of performed. appropriate antibiotic after culture and sensitivity test. E. Coli organisms are commonly cultured post-partally. ADDITIONAL NOTES Interventions include: o Articles should be sterile. ✓ Blood pressure is not a reliable indicator of impending o Change bed linens as needed. shock from early hemorrhage. o Follow the standard procedure. ✓ Hysterectomy is a surgical procedure to remove the womb o Good hand washing technique to prevent cross (uterus). contamination. o Maintain a clean environment. Puerperal Infection o Each maternity client should have her own bedpan. It is any clinical infection of the genital canal that occurs o Perineal supplies should not be shared. within 28 days after miscarriage, induced abortion, or o Proper perineal care. childbirth. o Proper care of the episiotomy site and any Puerperal sepsis is also related to the lack of trained perineal lacerations prevents infection in the assistance at delivery, to poor obstetric facilities, and to genitourinary area and aids the healing the number of invasive interventions. process. Unclean delivery practices, prolonged rupture of o Use of intravenous antibiotics, such as membranes and/or labour are important factors in the ampicillin, gentamicin, and cefixime. development of subsequent sepsis. o Mother should take the full course of antibiotic Organisms commonly cultured postpartally include to prevent infection from recurring. group B streptococci, staphylococci, and aerobic gram- Toxic shock syndrome is a staphylococcal infection negative bacilli, such as Escherichia coli. introduced through the vagina. Its symptoms include The features of puerperal infection include: elevated temperature, diarrhea, vomiting, muscle aches, o Fever (oral temperature is 38.5°C / 101.3°F or and a sunburn-like rash. higher) on any two of the first ten days postpartum (not counting the first 24 hours after birth) ADDITIONAL NOTES o Pelvic pain and abdominal tenderness ✓ Nursing diagnosis may include health-seeking behaviors o Abnormal vaginal discharge (lochia) with a foul- related to care of the newborn, fear related to lack of smelling odor preparation for childcare, risk for deficient fluid volume o Delay in uterine involution (< 2 cm/day during related to postpartal hemorrhage, risk for coping the first eight days) impairment related to an additional family member, risk for The conditions that increase a woman’s risk for complications in human lactation / breastfeeding, or postpartal infection include: uncertainty regarding the infant’s well-being if there are o Rupture of membranes more than 24 hours congenital anomalies. after birth o Retained placental fragments o Postpartal hemorrhage o Preexisting anemia POSTPARTUM DISCHARGE INSTRUCTIONS o Prolonged and difficult labor, particularly NURSING CARE OF MOTHERS DURING POSTPARTUM instrument births o Internal fetal heart monitoring Limitations in movement o Local vaginal infection was present at the time Assistance in going to the bathroom (frequency of of birth urination) o Uterus was explored after birth for retained Provide privacy but remain in close proximity placenta or abnormal bleeding site Protection from falls o CS Provision of adequate clothing o Chorioamnionitis Wound care for episiotomy ▪ Bacteria infects the chorion and amnion (the membranes that surround Exercise the fetus) and the amniotic fluid (in Postpartum exercise can begin soon after birth. which the fetus floats). The woman should be encouraged to start with simple o Bladder catheterization exercises and gradually progress to more strenuous o Multiple vaginal examinations after rupture of ones. membranes o Epidural anesthesia o Episiotomy or lacerations Abdominal breathing First day after birth Coitus Chin to chest Excellent for the second day Safe as soon as lochial discharge has returned to alba and episiotomy is healed. Perineal contraction Third day Couples may safely resume sexual activity by (Kegel’s exercise) approximately 2 weeks postpartum. Arm raising Fourth day Abdominal crunches 10th or 12th day after birth Hygiene Take either a tub bath or shower. Maintaining Adequate Nutrition Continue to apply cream or ointment as ordered. Postpartal menu planning should include a diet between Cleanse perineum from front to back. 2200 to 2700 calories/day, high in protein, vitamins, and Pre-pregnancy hormone has not yet completely returned minerals. so the vaginal cells may not be as thick as before. For Additional 500 calories and additional 500 mL of fluid the first 6 weeks to 6 months, the vagina does not each day to encourage the production of high-quality lubricate well. breastmilk. Adequate supply of roughage is important for peristaltic CONTRACEPTION action of the bowel. Postpartal Examination / Follow Up o Teach client to continue to eat nutritious diet after she returns home. She should notify her nurse-midwife or physician if she o If the client has any prenatal vitamins or noticed an increase in amount of lochial discharge or supplementary iron preparations left over from lochia serosa or alba returns to lochia rubra. pregnancy, she should continue until supply is Woman should return for an examination 4-6 weeks used. postpartum for uncomplicated birth. o A physician or nurse-midwife will prescribe a Very important to ensure involution is complete. supplement. Women who have had a cesarean birth are often seen for follow up 2 weeks after hospital discharge. Adequate Fluid If an appointment has not been made before discharge, the woman is encouraged to call her physician to Encourage women to drink adequate fluid to help rid schedule an appointment. wastes from the body. Encourage her to drink at least three to four 8 oz glasses Accurate Documentation and Reporting (BUBBLEHE) each day and 6-8 glasses if breastfeeding. Breasts Uterus ADDITIONAL NOTES Bladder ✓ Fluid restriction does little to affect breast engorgement or Bowel weight loss thus should be discouraged. Lochia Episiotomy Measures to prevent complication include ensuring Homan’s Sign adequate uterine contraction, adequate monitoring, Emotional Status prompt referral for complications, and early ambulation. MATERNAL IMMUNIZATION ADDITIONAL NOTES Rubella (German Measles) ✓ Other comfort measures include initiation of lactation, relief A subcutaneous injection of rubella vaccine is of discomforts like breast engorgement and nipple sores, recommended before discharge for women who have and hygienic measures. not had rubella or woman who are serologically not immune. Woman must practice contraception to avoid pregnancy HEALTH TEACHINGS for 2 to 3 months after being vaccinated. Work The mother who is not immune is given the vaccine in Avoid heavy work for at least 3 weeks after birth (lifting the immediate postpartum period. The vaccine prevents or straining). Explore with a woman what she considers infection with the rubella virus during subsequent heavy work. pregnancies, which could cause birth defects. It is usually advised that a woman not return to an outside job for at least 3 weeks (or better, 6 weeks) not Immunization Rho(D) Immune Globulin only for her own health but also for her bonding with her Injection of Rh immune globulin (a solution of gamma newborn. globulin that contains Rh antibodies) within 72 hours after birth prevents sensitization in the Rh-negative Rest woman who has had a fetomaternal transfusion of Rh- One rest period each day is important. positive fetal RBC. She can rest during the day if her newborn is sleeping Administration of 300 mcg of Rh immune globulin unless she has other children or aged parents to care for. prevents maternal sensitization. Explore the possibility of having a family member or RhoGAM is given to the mother, not the newborn, by neighbor to relieve her. intramuscular injection into the deltoid muscle.  FAMILY PLANNING The woman may still be fertile even if she has not had a period since childbirth because she may ovulate but not Reproductive life planning includes all the decisions an menstruate while breastfeeding. individual or couples make about having children, including if and when to have children, how many Coitus Interrupts children to have, and the length of time between having children. Also called withdrawal method. Counselling may include the topics of avoiding Ejaculation may occur before withdrawal is complete conception, increasing fertility, and/or what to do if and, despite the caution used, some spermatozoa may contraception has failed. be deposited in the vagina. Things to consider include personal values, ability to use 82% effective. the method correctly, if the method will affect sexual enjoyment, financial factors, if the couple’s relationship FERTILITY AWARENESS METHODS is short term or long term, prior experiences with Methods relying on detecting when a person will be contraception, future plans, and expectations about capable of impregnation (fertile) so they can use periods menstrual cycle patterns while on birth control. of abstinence during that time. Healthy people 2030 goals related to reproductive life Fertile period exists about 5 days before ovulation to 1 planning include: day after. Typical length of sperm survival is anywhere o Increase the proportion of adolescent males from 3 to more than 5 days. Length of ovum is ripe for who used a condom the last time they had sex. fertilization is about 1 day. o Increase the proportion of adolescents who use birth control the first time they have sex. Standard Days Method with Cycle Beads o Increase the proportion of adolescent females who used effective birth control the last time Cycle should be regular (26-32 days long). they had sex. Less effective is the cycle is < 26 days or > 32 days. o Increase the proportion of adolescents who Identified days 8-19 of the cycle as fertile period. have never had sex. o Reduce the proportion of unintended pregnancies. o Decrease the proportion of pregnancies conceived within 18 months of a previous birth. An ideal contraceptive should be safe, effective, compatible with religious and cultural beliefs and personal preferences of user and partner, free of bothersome side effects, convenient to use and easy to obtain, affordable and needing few instructions for use, and free of effects on future pregnancies after discontinuation. NATURAL CONCEPTION ADDITIONAL NOTES It is called periodic abstinence methods. ✓ Marquette model involves the use of an electric hormonal Methods that involve no introduction of chemical or fertility monitor that measures urine metabolites of foreign material into the body. estrogen and luteinizing hormone. Methods to avoid pregnancy by avoiding sex on the days woman may conceive. Billing’s Method Abstinence Cervical mucus ovulation-detection method and Creighton Model Ovulation Method were utilized. Refraining from sexual relations. All the days in which the mucus is copious, or at least 3 Has a theoretical 0% failure rate and is also the most days after the peak day, are considered to be fertile days. effective way to prevent STIs. Woman must be conscientious about assessing her Has high failure rate. vaginal secretions every day. Spinnbarkeit is the elastic quality that is characteristic of Lactation Amenorrhea Method (LAM) mucus of the uterine cervix especially shortly before There is some natural suppression of ovulation if the ovulation. woman is breastfeeding. As a rule, after 6 months of breastfeeding, the woman CERVICAL MUCUS CHARACTERISTICS should be advised to choose another method of contraception. Postmenstrual Mucus Scant LAM is effective if the infant is: Preovulation Mucus Cloudy, yellow or white, sticky o Under 6 months of age Ovulation Mucus Clear, wet, sticky, slippery o Being totally breastfed at least every 4 hours during the day and every 6 hours at night Postovulation Fertile Mucus Thick, cloudy, sticky o Receives no supplementary feedings Postovulation, Postfertile Scant Mucus  Assessment technique includes: Other causes of temperature fluctuations include o Good handwashing infection, fatigue (less than 3 hours of sleep/night), o Start observation from last day of menstrual awakening late, and anxiety. flow o Assess cervical mucus several times each day Calendar Rhythm Method for several cycles Also called rhythm method. o Mucus can be obtained from vaginal introitus The woman should keep a diary of 6 menstrual cycle. o Record findings on the same record on which The beginning of the fertile period is estimated by BBT is entered subtracting 18 days from the length of the shortest cycle. The end of the fertile period is determined by subtracting 11 days from the length of the longest cycle. ADDITIONAL NOTES ✓ If the shortest cycle is 24 days and longest cycle is 30 days (24 – 18 = 6 and 30 – 11 = 19). Very regular cycles of 28 days each, the formula indicates the fertile days (28 – 18 = 10 and 28 – 11 = 17). Based on the example, to avoid conception, the couple would abstain from day 6 through 19 or day 10 through 17 because ovulation occurs on the Basal Body Temperature Methods 14 (minus/plus 2 days). Start counting from the 1st day of BBT is the lowest the menstruation. body temperature of a Two-Day Method healthy person, taken A person assesses for vaginal secretions daily. immediately after Checks for cervical secretions at least twice a day. waking and o If they notice secretions of any type, color, or before getting out consistency either “today” or “yesterday,” today of bed. is considered a fertile day. Just before the day of ovulation, a slight decrease in o If they feel secretions for 2 days in a row, avoid temperature occurs (approximately 0.05°C). There is a coitus that day and the day following. rise of 0.2°C at the time of ovulation. o If no secretions are noticed today and As soon as a woman notices a slight dip in temperature yesterday (two consecutive days without followed by an increase, she knows she has ovulated. secretions), pregnancy is unlikely today. She refrains from having coitus (sexual relations) for the o If no secretions are noticed either today or next 3 days (the possible life of the discharged ovum). yesterday, pregnancy is likely today. Avoid unprotected sex today to avoid pregnancy. Results in 12 days per month in which they should avoid Symptothermal Method coitus. Combination of at least two methods, usually cervical mucus changes with BBT, in addition to heightened ARTIFICAL METHODS awareness of secondary cycle phase-related symptoms, such as increased libido, mid-cycle abdominal pain, Barrier Method pelvic fullness or tenderness, and vulvar fullness. Work by the placement of a chemical or other barrier o Basal Body Temperature between the cervix and advancing sperm so that sperm o Fertile Cervical Mucus cannot enter the uterus or fallopian tubes and fertilize the o Symptoms ovum. It is a combination of CMM and BBT and is more Lack the hormonal side effects associated with COCs. effective. Failure rate is higher and sexual enjoyment is lessened. Observe for other signs of ovulation, such as o Spermicide mittelschmerz (midcycle abdominal pain). ▪ An agent that causes the death of spermatozoa before they can enter the cervix. ▪ It is a chemical barrier method and is often used in combination with other physical barrier methods. ▪ Gels or creams are easily inserted into the vagina before coitus with the provided applicator. The woman should do this no more than 1 hour The couple must abstain from intercourse until 3 days before coitus. Must be inserted 15 after the rise in temperature or the fourth day after the minutes before coitus. peak of mucus change. ▪ Film of glycerin impregnated with a Recommended that the couple combine this method with spermicidal agent that is folded and calendar method. inserted vaginally.  ▪ Cocoa butter and glycerin-based ▪ A diaphragm should be kept in place vaginal suppositories containing a for at least 6 hours after coitus – spermicide. sperm stay viable in the vagina for that o Sponges duration. ▪ Foam-impregnated synthetic sponges ▪ May be left in place for as long as 24 blocked sperm access to the cervix. hours. ▪ Easy to insert. ▪ If it stays longer than 24 hours, the ▪ Should remain in place for 6 hours statis of fluid may cause cervical after intercourse to ensure sperm inflammation or urethral irritation. destruction. ▪ It has a higher risk for UTI; not ▪ Contraindicated in women with acute effective if the uterus is prolapsed, cervicitis. retroflexed, or anteflexed to some ▪ Failure rate is 20%. degrees that the cervix is also ▪ Some women find the vaginal leakage displaced in relation to the vagina; after use of these products intrusion to the vagina by a cystocele bothersome. or rectocele makes it difficult to insert; o Condom and should not be used in the ▪ It is a latex rubber or synthetic sheath presence of cervicitis. that is placed over the erect penis o Cervical Cap before coitus begins. ▪ Made of soft rubber, are shape like a ▪ The male condom is a thin, thimble, and fit snugly over the uterine stretchable sheath that covers the cervix. penis before genital, oral, or anal ▪ Many women cannot use cervical contact and is removed when the caps because their cervix is too short penis is withdrawn from the partner’s for the cap to fit properly. orifice after ejaculation. It provides a ▪ Tend to dislodge more readily than barrier for STIs (particularly diaphragms. gonorrhea, chlamydia, and ▪ Should not exceed 48 hours. trichomonas) and HIV transmission. ▪ Must be fitted by a health care One of the few “male-responsibility.” provider. Always be worn during coitus between ▪ Contraindication include an partners who do not maintain a abnormally short or long cervix; a monogamous relationship. previous abnormal Pap smear; a Contraindicated to sensitive to latex. history of TSS; an allergy to latex or Ideal failure rate of 2% and a true spermicide; a history of PID, cervicitis, failure rate of about 15% because of or papillomavirus infection; history of breakage or spillage. cervical CA; and undiagnosed vaginal ▪ The female condom is a sheath made bleeding. of latex or polyurethane, prelubricated o Intrauterine Device with a spermicide. The inner ring ▪ It is a small, T-shaped device with (closed end) covers the cervix, and bendable arms placed inside the the outer ring (open end) rests against uterine cavity. the vaginal opening. Male and female ▪ Creates a local sterile inflammatory condoms should not be used together. condition that prevents implantation Failure rate is 5% and 15%. Did not and fertilization. gain popularity because women have ▪ IUD must be fitted by a physician, found them difficult to use. nurse practitioner, or nurse-midwife. o Diaphragm ▪ Perform Pap test and pelvic exam ▪ It is a circular rubber disk that is placed first. over the cervix before intercourse to ▪ Inserted before the client has had mechanically halt the passage of coitus after a menstrual flow. sperm. ▪ Regularly checked after menstruation ▪ Washable and reusable and need to make sure the IUD string is in place inspection for holes, tears, or other and obtain a yearly pelvic exam. problems before each use. ▪ Insertion can be done immediately ▪ Needs to be filled with spermicidal jelly after birth (does not affect uterine cream before vaginal insertion. involution). ▪ Is prescribed and fitted initially by a ▪ Insertion procedure can be done in an physician, nurse practitioner, or nurse- ambulatory setting. midwife to ensure correct fit. ▪ Its advantages include long-term ▪ Will last for 2 years. protection from pregnancy, ▪ Woman should return for a second immediately return to fertility when fitting if any of these occurs: removed, appropriate for women who pregnancy, miscarriage, cervical are at risk for complications surgery (D & C), therapeutic abortion, associated with COCs, and does not or gained weight of 15 lbs. require daily attention or interfere with sexual enjoyment.  ▪ Its disadvantages include increase ▪ Progestin-only pills (mini pills) contain risk for pelvic inflammatory disease only progestin and without estrogen (PID) shortly after placement, content, ovulation may occur. unintentional expulsion of the device, Four ways to set a start date: infection such as uterine perforation, o Sunday Start: Take the first pill on the first and offers no protection against HIV or Sunday after the beginning of a menstrual flow. other STIs. o Quick Start: Begin pills as soon as they are prescribed. o First Day Start: Begin pills on the first day of ADDITIONAL NOTES menses. ✓ Common signs of PID are fever, lower abdominal ▪ After childbirth, a woman should start tenderness, and pain on intercourse. the contraceptive on a day (or Sunday) closest to 2 weeks after birth. ▪ Side effects include some spotting or Take the pill at the same time each day or 21 days to uterine cramping the first 2 hours or 3 maintain adequate hormonal levels for contraception weeks after IUD insertion; as long as and enhance compliance. Menstrual flow will begin this is present, she should use another during the 7 days on which she is taking the placebo form of contraception, such as vaginal tablets or on the pill-free days. foam; and some have heavier than o 21 days = 21 active pills and 7 days pill-free usual menstrual flow for 2 or 3 months o 28 pills = 21 active pills and 7 placebos and experience more dysmenorrhea. COCs must be prescribed by a physician, nurse ▪ Contraindications include woman practitioner, or nurse-midwife after a pelvic exam and whose uterus is distorted in shape; Papanicolaou (Pap) smear. woman with severe dysmenorrhea, Pills are not effective for the first 7 days; she should be menorrhagia, or a history of ectopic advised to use a second form of contraception on the pregnancy; woman with valvular initial 7 days. disease; and woman with anemia are Contraindications include: also not usually considered to be o History of thromboembolic disorder candidates for IUD use. o Cerebrovascular or coronary artery disease o Beast cancer or other estrogen-dependent HORMONAL CONTRACEPTION tumors o Impaired liver function Administered orally, transdermally, or vaginally by o Liver tumor implantation, injection, or by the intrauterine route. o Smoking if the woman is older than 35 years of age (> 15 cigarettes/day) o Headache with focal neurologic symptoms Side effects include nausea, weight gain, headache, breast tenderness, breakthrough bleeding (spotting outside the menstrual period), monilial vaginal infections, mild hypertension, mood swings, and depression. After a woman stops taking a COC, she may not be pregnant for 1 to 2 months and possibly 6 to 8 months. It can be stimulated by clomiphene citrate or Clomid therapy. ADDITIONAL NOTES ✓ The World Health Organization (WHO) recommends women who experiences migraines with an aura or those Oral Contraceptive who take certain drugs for seizures avoid the use of oral Also known as the pill or COCs (Combined or contraceptives as these women may be at an increased Contraceptives). risk for cerebrovascular accident. Regular ingestion of COCs suppresses the action of the hypothalamus and anterior pituitary gland, leading to