Post Partum Care PDF

NCM 107 Post Partum Care Excerpt From: Virginia A. Jupiter PhDNed, PhD, MAN, RN  Puerperium 6 weeks after the birth of an infant Previously post-partum care was focused on mother and newborn, now father/partner, siblings, grandparents are included. Family adapta...

NCM 107 Post Partum Care Excerpt From: Virginia A. Jupiter PhDNed, PhD, MAN, RN  Puerperium 6 weeks after the birth of an infant Previously post-partum care was focused on mother and newborn, now father/partner, siblings, grandparents are included. Family adaptation-family roles and relationships must be reorganized with the birth of a baby Bonding- rapid process of attachment (parent to child only) taking place during the sensitive period of the first 30-60 minutes after birth Attachment- a long term process that begins during pregnancy and intensifies during the post-partum, establishes an enduring bond between parent and child and develops through reciprocal behaviors. Claiming process- family identifies likeness, differences and unique qualities of the infant  Factors affecting family adaptation 1. Parental fatigue 2. Previous experience with a newborn 3. Parents expectations of the newborn 4. Knowledge of and confidence in providing for newborn needs 5. Temperament of the newborn 6. Temperament of the parents 7. Age of the parents 8. Available support system 9. Unexpected events  Maternal physiologic changes A. Reproductive System 1. Uterus *Involution- the return of the uterus to its pre-pregnant size Muscle fiber contraction- to control bleeding Catabolism- return to normal uterine cell size Regeneration- healing - endometrium-2-3 weeks, placental site-6 weeks Uterine fundal descent Immediately after birth- between umbilicus and symphysis pubis Level of umbilicus for about 12 hours 1cm or 1 finger breadth each day for 10 days Breast feeding causes afterpains- caused by strong uterine contraction and let-down reflex  Maternal physiologic changes Lochia- vaginal discharge after birth Rubra (reddish)- first 3 days-blood, small pieces of decidua, mucus Serosa (pinkish brown)- 4th -10th day-serous exudates from cervical mucus, erythrocytes and leukocytes Alba (yellowish white)- after 10th day-6 weeks- leukocytes, epithelial cells, decidua, mucus, serum and bacteria Cervix 18 hours after birth- firm, shorten and regain its form After 2 weeks- cervical os is closed Maternal physiologic changes Vagina 6 weeks – complete involution and regain the contour it had before pregnancy Dyspareunia- painful coitus due to decrease vaginal lubrication cause by decreased level of estrogen Perineum Episiotomy- surgical incision of the perineum 1st degree- skin and mucus membrane 2nd degree- skin and mucus membrane and muscle 3rd degree- skin and mucus membrane, muscle and rectal sphincter 4th degree- skin and mucus membrane, muscle, rectal sphincter and rectal mucosa  Maternal physiologic changes 2. Endocrine System After placental expulsion- decrease in hPL, estrogen and cortisol- reverse the diabetogenic effect of pregnancy- check mother’s blood sugar Lactation Prolactin- initiate milk production 2-3 days after infant’s birth “Let-down reflex” is neurohormonal reflex Menstrual cycle FSH in BF and NBF mothers are the same BF- increased Prolactin level (6 weeks- 6 months)causes ovaries NOT to respond to FSH and ovulation does not occur NBF- Prolactin level returns to pre-pregnant level within 2 weeks- ovulation takes place after 27 days – 2 months Maternal physiologic changes 3. Breasts Colostrum- produce in last few weeks of pregnancy -yellowish fluid rich in antibodies and high in protein Produce milk 2-3 days after birth Engorgement-distended, swollen and warm, occur 3-4 days after birth -spontaneously disappear 24-48 hours when breast are not emptied Lactation ceases within a week  Maternal physiologic changes 4. Gastrointestinal System After giving birth most mothers are hungry and thirsty- asked for extra food- due to the energy expended during labor and birth- DAT after recovery from anesthesia Bowel movement difficulty due to: -peristalsis decreased (increased progesterone level during pregnancy) -pre-labor diarrhea -lack of food during labor -dehydration -perineal trauma, episiorrhaphy, hemorrhoids -mother’s anticipation of discomfort Maternal physiologic changes 5. Cardiovascular System Blood loss averages 500 ml (1 L in CS) Vital signs T- may rise 38° C due to dehydration - back to normal after 24 hours, may slightly increase when BF PR- may be elevated 24-48 hours after delivery, but must not exceed 100bpm - may return to pre-pregnant rate after 8 weeks RR- pre-pregnant rate returns 6-8 weeks after delivery (diaphragm descends) BP- small increase, last for 4 days - orthostatic hypotension- due to rapid decrease in intra-abdominal pressure resulting from visceral blood vessel dilatation.  Maternal physiologic changes Blood Volume 3 physiologic changes protect from excessive blood loss a. Loss of uteroplacental circulation (when the placenta is expelled) reduces the maternal vascular bed by 10-15% b. stimulus for vasodilation is removed with the loss of placental endocrine functions c. movement of extravascular water, stored during pregnancy, into the blood vessel increases blood volume Diuresis -3 L of urine/day for 2-3 days ,Diaphoresis at night 2-3 days after delivery Maternal physiologic changes Blood Values WBC- rises up to 20,000-30,000 mm³ (n=up to 12,000mm³) 10-12 day after delivery Hemoglobin and hematocrit- slightly increase by 3-7 days after delivery due to large loss of plasma volume Coagulation Î level of clotting factor and fibrinogen for few days as protection for post-partum hemorrhage, but has a great risk for thrombus formation Varicosities Varices of the legs, anus, vulvar are empty rapidly immediately after delivery Maternal physiologic changes 6. Urinary System Hypotonia of the bladder and dilation of the ureters- 2-8 weeks Bladder distention- causes uterine atony UTI- due to bladder stasis Mild proteinuria , ketonuria, and elevated BUN for 1-2 days- cause by catabolic process of uterine involution 7. Musculoskeletal Joints, ligaments and cartilage ligament stabilizes 6-8 weeks after birth due to the decreasing level of hormone relaxin (except on the feet- increase shoe size) Abdominal muscles- returns in pre pregnant state in 6 weeks Maternal physiologic changes 8. Integumentary System Areas of hyperpigmentation- lighten in color immediately after birth due to declined Melanocyte-stimulating Hormone Spider angioma and palmar erythema fade due to decreasing estrogen level Fine hair disappears but course hair remains Streia, linea nigra, dark areola remains 9. Neurologic System Fatigue, afterpains, episiotomy and breast engorgement create maternal discomfort Spinal headache- leakage of CSF in extradural space PIH- blurring of vision, photophobia, abdominal pain with headache  Maternal physiologic changes 10. Weight Loss 6 months to 1 year to return to pre-pregnant weight approximately13 lbs loss- infant, placenta, BOW, and blood loss (post delivery) 8-9 lbs loss due to diaphoresis, diuresis and involution of reproductive organs POSTPARTUM PSYCHOLOGICAL ADAPTATION 1. TAKING- IN PHASE = 1 – 3 DAYS POSTPARTUM WHEN MOTHER RELIES ON OTHERS TO CARE FOR HER & HER NEWBORN.PREOCCIPIED WITH SELF & OWN NEEDS ( FOOD & SLEEP), CLIENT MAY VERBALIZE HER FEELINGS REGARDING RECENT DELIVERY. HESITANT ABOUT MAKING DECISIONS.  POSTPARTUM PSYCHOLOGICAL ADAPTATION 2. TAKING – HOLD PHASE = 4 – 7 DAYS POSTPARTUM WHEN MOTHER BEGINS TO INITIATE ACTIONS & DECISIONS;DEPENDENCY /INDEPENDENCY; READY FOR MOTHERING ROLE; POST-PARTUM BLUES – (AN OVERWHELMING FEELING OF SADNESS THAT CANNOT BE ACCOUNTED FOR) MAY BE OBSERVED. COULD BE DUE TO HORMONAL CHANGES, FATIGUE OR FEELINGS OF INADEQUACY IN TAKING CARE OF A NEW BABY. Management - EXPLAIN THAT IT IS NORMAL & THAT CRYING COULD BE THERAPEUTIC. BUT IF POSTPARTUM BLUES EXTEND BEYOND TWO WEEKS, IT COULD LEAD TO POSTPARTUM DEPRESSION & POSTPARTUM PSYCHOSIS ;THEREFORE CONSTANT MONITORING SHOULD BE DONE TO THE MOTHER. IMPLICATION: PROVIDE PSYCHOLOGICAL SUPPORT. POSTPARTUM PSYCHOLOGICAL ADAPTATION 3. LETTING –GO PHASE = 10 DAYS - WOMAN ATTAINS COMPLETE INDEPENDENCE; ASSUMING NEW ROLES AND RESPONSIBILITIES