Postpartum Care: Chapter 15, 16, 22 PDF

“If we’re growing, we’re always going to be out of our comfort zone.” John Maxwell POSTPARTUM Dr. Gina Wilding  When does the postpartum period begin? Chapter 15: Postpartum...

“If we’re growing, we’re always going to be out of our comfort zone.” John Maxwell POSTPARTUM Dr. Gina Wilding  When does the postpartum period begin? Chapter 15: Postpartum Adaptations WELCOME TO POSTPARTUM Chapter 16: Nursing Management During the Postpartum Period Chapter 22: Nursing Management of the Postpartum Woman at Risk FOCUSED POSTPARTUM ASSESSMENT BUBBLEEE WITH POSTPARTUM ADAPTATIONS  POSTPARTUM FOCUSED ASSESSMENT Breasts 1. Assess the breasts for fullness/engorgement 2. Assess the nipple for signs of irritation, cracks, bleeding 3. Assess for discomfort 4. Assess for mastitis Uterus 1. Assess for tone (firm or boggy) 2. Assessment for position ( midline or deviated to side) (above, at or below the umbilicus 3. Assess for discomfort Bladder 1. Assess for ability to void 2. Assess for retention of urine 3. Assess for signs of urinary tract infection (dysuria, frequency) 4. Assess hydration Bowels 1. Listen to bowel sounds 2. Palpate the abdomen 3. Assess for constipation 4. Assess for hemorrhoids  POSTPARTUM FOCUSED ASSESSMENT Lochia 1. Assess lochia each time the uterus is assessed 2. Assess the amount, color, and odor of bleeding 3. Assess for clots Episiotomy/Perineum/Epidural 1. Assess perineum, episiotomy, or laceration using REEDA (redness, edema, ecchymosis, discharge Site and approximation) 2. Assess for discomfort 3. Assess peri-care 4. Assess epidural site Extremities/Legs 1. Assess for s/s of deep vein thrombosis 2. Assess for return of sensation following an epidural 3. Assess edema Emotional Status 1. Assess interaction with baby and family 2. Assess sleep, mood, appetite, eye contact (culturally) POSTPARTUM VITAL SIGNS/ASSESSMENT Frequency Normal Ranges Timeframe Frequency Vital Sign Normal During first hour Every 15 minutes Temperature Up to 100.4 F During second hour Every 30 minutes Pulse 60-80 bpm During first 24 hours Every 4 hours Respirations 12-20 bpm After 24 hours Every 8 hours Blood Pressure 85/60 – 140/90 Pain Aim for 0-2 Is the following statement true or false? During the first 24 hours postpartum, a slight elevation in temperature is considered normal. a. True b. False a. True Some women experience a slight elevation in temperature during the first 24 hours postpartum; this may be the result of dehydration secondary to fluid loss during labor. POSTPARTUM MATERNAL ADAPTATIONS Uterine Involution  Lochia – 3 stages Cardiovascular  Afterpains  Pulse and Blood Pressure  Worse with multiple births  Coagulation  Oxytocin released in pituitary  Blood Cellular Components Cervix Musculoskeletal Vagina Integumentary Perineum Respiratory Urinary Endocrine Gastrointestinal UTERUS INVOLUTION Three processes: Contraction of muscle Pre-pregnancy fibers (after pains) (70g) Catabolism – shrinks myometrial cells Pregnancy (1100g) Regeneration of uterine epithelium Postpartum (1000g) 1 week postpartum (500g) Not palpable abdominally usually 6 weeks postpartum by day 10 -14 (60g) UTERUS INVOLUTION Involution Subinvolution - Prolonged labor - Complicated birth - Complete expulsion of amniotic membranes and placenta - Incomplete expulsion of amniotic membranes and placenta - Uncomplicated labor and birth - Uterine infection - Breastfeeding - Overdistention of uterine muscles - Early ambulation - Full bladder - Anesthesia - Short interval between childbirth  UTERUS ASSESSMENT AND INTERVENTIONS Assessment Interventions - Boggy  Massage fundus until firm  Empty bladder - Assess for tone  Administer uterotonic  Firm or boggy - Deviated and/or above umbilicus - Assess for position  Massage fundus and monitor bleeding  Midline or deviated to side  Assess bladder fullness and empty if needed  Above, at or below the umbilicus  Assess for other causes - Assess for pain - Pain  Provide comfort measures - Assess for endometritis infection  Develops 2-4 days up to 6 weeks pp  Provide pain medication  Lower abd pain, fever, odorous lochia, anorexia, nausea, - Document assessment, interventions and evaluation fatigue of interventions - Assess risk factors for postpartum hemorrhage and - Educate on normal and abnormal to notify nurse endometritis infection LOCHIA Stages Timing Color Consists Of Danger Signs Anytime Lochia Rubra First 3 to 4 days Deep red Mucus, tissue Reassess if rubra debris, blood starts again once it has stopped Lochia Serosa Days 3 to 10 Pinkish brown Leukocytes, Heavy bleeding decidual tissue, red blood cells, serous Offensive odor (not fluid fleshy) Lochia Alba Days 10 to 14, up Creamy white or Leukocytes, Discharge present to 3-6 weeks light brown decidual tissue, fluid content LOCHIA ASSESSMENT AND INTERVENTION Assessment Intervention - Assess lochia each time the uterus is - If excessive bleeding or clots assessed  Assess uterus and massage fundus  Assess bladder fullness and empty - Assess lochia prn, “I felt a gush”  Administer uterotonic medications - Assess the amount, color, and odor of  Evaluate risk factors for causes of PPH lochia - If foul odor, - Assess for clots  Notify provider  May indicate infection - Assess for risk factors of excessive bleeding/infection - Educate about expected amount and when to notify the nurse -Document assessment, interventions, and evaluation of interventions 5 CAUSES OF POSTPARTUM HEMORRHAGE 1. Tone: Uterine atony, distended bladder 2. Tissue: Retained placenta and clots, uterine subinvolution 3. Trauma: Lacerations, hematoma, inversion, rupture 4. Thrombin: Coagulopathy (preexisting or acquired)  Von Willebrand Disease – prolonged bleeding time  DIC – Disseminated intravascular coagulation – abnormally activated clotting system (video)  Have to fix the underlying problem along with support measures 5. Traction: Too much pulling on umbilical cord  Uterine inversion or cord detachment CERVIX AND VAGINA Cervix Vagina Immediately: partly dilated, bruised, Immediately: Swollen, relaxed and few swollen, partially in vagina rugae Gradually closes, but never the same as Rugae returns in 3 weeks pre-pregnancy Prepregnant state by 6 to 8 weeks PP Prepregnant state by 6 weeks PP Will be less gaping, but will always be Internal os closed by 2 weeks. slightly larger than pre pregnancy Changes to mucus will return with ovulation (dryness and intercourse discomfort until ovulation)  Immediately – 2 days: swollen and bruised Complete healing lac or epis: 4 to 6 months Muscle tone can be permanently affected Dependent on degree or extension Pelvic floor dysfunction Ice packs Peri-bottle Witch hazel pads Anesthetic sprays Sitz baths (not so much) Practice pelvic floor muscle training (PFMT) exercises PERINEUM Thankfully forgiving  Assessment Intervention Assess perineum Assess episiotomy or laceration REEDA (redness, edema, ecchymosis, Good hand hygiene discharge, and approximation) Turn client to her side to assess perineum Assess for pain Report signs of infection to provider Assess peri-care Provide peri bottle, prn comfort medications Assess ability to void Dermaplast, tucks, Ibuprofen etc Assess epidural site Educate about good hand hygiene and Assess surgical incision peri-care, anticipatory guidance for Assess for risk factors and symptoms for appearance, healing, pain infection Document assessment, interventions and Separation of wound edges, erythema, evaluation of interventions tenderness, fever, purulent drainage PERINEUM/EPISIOTOMY/LACERATION/EPIDURAL/INCISION ASSESSMENT AND INTERVENTION Is the following statement true or false? After birth, the cervix returns to its prevaginal delivery birth shape. A. True B. False FALSE After delivery, the cervix closes but never regains its prevaginal delivery birth appearance. It is no longer circular but appears as a jagged slit – like opening.  CARDIAC Pulse: decreases 60-80 bpm. Increase: hypovolemia, dehydration, BP: decreases day hemorrhage 1&2, then increases day 3 to Cardiac 7. Pre-pregnancy displacement by ~6weeks reverses with (hypotension: uterus involution infection or Nursing hemorrhage) Assessment: Hematocrit stable: reflects plasma loss, if Monitor VS – unstable: may reflect hemorrhage identify changes or abnormal early (Due to birth Cardiac output related blood loss: elevated few days Vaginal then decreases 500ml/Cesarean non-pregnant level 1000ml) ~3 months Blood volume drops rapidly PP and is normal ~4 weeks CARDIAC Coagulation  Pregnancy changes:  Favor coagulation – increases risk for blood clots in order to minimize blood clots  Reduced fibrinolysis, pooling/stasis blood in lower limbs  Postpartum changes:  Hypercoagulable state increases with birth, increasing risk of blood clots  3 per 1000 births experience pulmonary embolism Nursing  Return to pre-pregnancy levels after 3 weeks Assessment: - Assess heart Blood Cellular Components sounds, rhythm and  RBC rate  Production ceases postpartum - Assess for signs  H/H decrease slightly in 1st 24 hours of bleeding, DVT,  Rise slowly over 2 weeks PE  WBC - Evaluate RBC  Increases during labor and WBC  Remains elevated 4 to 6 days, then returns to normal EXTREMITIES ASSESSMENT AND INTERVENTION Assessment Interventions - Assess for signs of superficial venous - Prevention thrombosis and deep vein thrombosis  Antiembolism stockings, ambulation, compression devices,  Aching in leg relieved with elevation anticoagulation therapy  Edema, redness, warmth, tenderness in affected leg - Notify provider of possible thromboembolism - Assess for progression to pulmonary embolism - Education for prevention, treatment in acute  Dyspnea, chest pain, hypotension, syncope, SOB setting and long term, prophylaxis in - Assess for risk factors of blood clots subsequent pregnancies, signs to be seen immediately - Assess for generalized edema  Long term anticoagulation medication (heparin, lovenox, oral) - Assess for return of sensation following  Avoidance of hormonal contraception epidural/spinal - Assist to restroom or use bed pan until sensation returns Is the following statement true or false? The drop in maternal blood volume after birth leads to a similar drop in hematocrit A. True B. False FALSE Despite the decrease in blood volume, the hematocrit level remains relatively stable and may even increase, reflecting the predominant loss of plasma  Nursing Assessment: - Assess for urinary Urinary Gastrointestinal output, distension Pregnancy: - Assess appetite,  Increased Glomerular Filtration Rate/ Renal Plasma BS, gas/BM  Return to normal 6 weeks PP Diuresis:  Begins within 12 hours of birth, continues up to 1 week  IV fluids and Oxytocin (antidiuretic) in labor Pregnancy:  Retention of fluids in pregnancy  Increased progesterone levels: relaxes smooth muscle and  Decreased aldosterone decrease bowel tone Incomplete emptying Postpartum:  Oxytocin  Decreased progesterone levels and no longer gravid abdomen  Perineal lacerations  Anesthesia (decreased bladder tone) Constipation:  Decreased peristalsis  Hematoma  Decreased intra-abdominal pressure  Swelling, poor bladder tone, numbness  Low fiber diet  Insufficient fluid intake Nursing management: Urine retention Bladder distention UTI  Diminished muscle tone - Provide/encourage Bladder distention Displacement of uterus/atony PPH fluids and food - Encourage ambulation URINARY ASSESSMENT AND INTERVENTION Assessment Interventions - Assess for ability to void - Assess for urine retention  Inability to void within 6 hours after vaginal - Encourage fluids, ambulation birth  By palpation of bladder and/or bladder scan - Perform bladder catheterization if needed and ordered - Assess for signs of urinary tract  Strict sterile technique infection  Fever, urinary frequency, urgency, dysuria, CVT - Alert provider of any abnormal tenderness, odorous urine assessments - Assess hydration status - Document assessment, interventions and evaluation of interventions - Assess risk factors for infection and retention BOWEL ASSESSMENT AND INTERVENTION Assessment Interventions - Assess for active bowel sounds - Encourage ambulation early and frequently - Assess for passing of gas and/or BM - Encourage high fiber meals and increase  May not occur for 1-3 days PP hydration - Palpate abdomen - Alert provider of any abnormal  Soft, distended, tenderness assessments - Assess for appetite - Provide ordered stool softener, tucks, etc. - Assess for constipation - Document assessment, interventions and evaluation of interventions - Assess for hemorrhoids - Assess risk factors for constipation  Nursing Assessment: - Assess gait, Musculoskeletal/ Respiratory Endocrine abdominal tone and strength Pregnancy: - Assess lung sounds,  Elevated relaxin, estrogen, and progesterone relax joints respirations Postpartum:  Decrease of these hormones, return to pre-pregnancy state by 6 to 8 weeks Placenta:  May experience hip and joint pain  Once delivered, placenta hormones are cleared quickly Muscles: Estrogen:  Abdominal muscles stretch, can separate (diastasis recti)  Decreased estrogen begin breast engorgement and diuresis  Poor tone postpartum, need exercise and support  Lowest at 1 week pp. Remain low while breastfeeding. Will increase by week 2, if not breastfeeding. Respiratory:  Normal range: 16 to 24 bpm Other hormones:  Diaphragm adjusts to normal position  HCG: undetectable after 1 week  Shortness of breath resolves  hPL: undetectable after 1 day  Returns to prepregnant state by 1 to 3 weeks pp  Progesterone: undetectable after 3 days (returns with first menses) Prolactin:  Secreted by anterior pituitary, remain elevated while Nursing management: breastfeeding - Promote ambulation  Decline within 2 weeks if not breastfeeding - Encourage/educate breastfeeding BREASTFEEDING AAP recommendation: exclusive breastfeeding to 6 months + complimentary foods and breastfeeding to 12+ months Optimal, however some women can not or should not breastfeed  Some medications (antithyroid), street drugs, HIV positive, metabolic disease of newborn Support mother’s choice Return of menses: Dependent on frequency and duration of breastfeeding Anywhere from 2 – 18 months  Without stimulation of LACTATION breast oxytocin and prolactin decrease Prolactin, progesterone and estrogen trigger colostrum Oxytocin helps Prolactin level increase with eject the milk from alveoli to Postpartum sucking and secretes milk the nipple (4-5 days PP) Branches form lobules and Pregnancy: Estrogen alveoli. Each breast stimulates Increase gains nearly 1 ductal system vessels lb by term Skin to skin: Breast crawl helps initiate breastfeeding Progesterone stimulates production system PHYSIOLOGY OF LACTATION  ~30 % US women do not breastfeed More who stop by 2 weeks PP No universal guideline for lactation suppression These women will have engorgement, leaking, discomfort Engorgement usually subsides in 2 to 3 days with recommendations below Return of menses: 7 to 9 weeks PP Current recommendations: Tight, supportive bra at all times Apply ice intermittently Avoid sexual stimulation Avoid nipple stimulation Avoid milk expression LACTATION SUPPRESSION BREAST ASSESSMENT AND INTERVENTION Assessment Interventions - If not breastfeeding: provide lactation suppression support and education - Assess for size, contour, symmetry - Administer prn medications (ie. Lansinoh, Ibuprofen) - Assess for fullness/engorgement - Educate on stimulation of contractions with suckling - Assess nipples - Notify provider of abnormal findings  Cracks, redness, fissures, bleeding - Provide education regarding symptoms and treatment of mastitis - Assess for desire to breast or formula feed  Complete all of the antibiotics  Continue to empty the affected breast - Assess for pain  Hydrate and rest - Assess for mastitis - Provide education and support regarding breastfeeding (takes time)  Redness, pain, fever, flu-like symptoms, abscess  Lactation consultant if available  Benefits - Assess for risk factors for difficulty  Timing/amount of colostrum and milk breastfeeding, mastitis - Document assessment, interventions and evaluation of interventions QUESTION For the woman who is not breast-feeding her newborn, which measure would be most appropriate to relieve engorgement? a. Warm showers b. Nipple stimulation c. Ice to the breasts d. Manually expressing milk ANSWER TO QUESTION c. Ice to the breasts For the woman who is not breast-feeding, measures to relieve engorgement include applying ice to the breasts for 15 to 20 minutes every other hour. Warm showers promote the let-down reflex are encouraged for the woman who is breast-feeding and experiencing engorgement. Any stimulation of the breasts, such as nipple stimulation or manual milk expression, is to be avoided for the woman who is not breast-feeding.  MATERNAL ADAPTATIONS TO PARENTHOOD Phase Timing Taking-in phase Lasts1to 2 days Relives events surrounding - Dependent/passive behaviors birthing process - Retelling birth story - Interacting with newborn, touching and claiming them Taking-hold phase Starts day 2 or 3 Strong interest in care for - Dependent and Independent behavior and lasts for several her infant by herself - Concerned over care of herself and weeks newborn - Concerned with ability to do so Letting-go phase Reestablishes relationships -Adapts to role as mother with others - More confident in care for infant - Lifestyle includes infant and is based in reality ATTACHMENT AND PERINATAL MOOD DISORDERS Bonding: relationship developed in first 30 – 60 days  Unidirectional: from parent to newborn Attachment: relationship formed between a parent and newborn  Bidirectional: parent and newborn share  Skin to skin, breastfeeding, smells, vocalizations, eye contact 85% of new mothers experience “baby blues”  Mild depressive symptoms lasting through day 10 -14 1 in 10 partners develop postpartum depression BABY BLUES VS POSTPARTUM DEPRESSION Time frame Depressive Symptom Relief Partner Symptoms Baby blues Up to 2 weeks PP Mild Independently Postpartum Usually starts in Worsening Persist without Up to 50% of Depression first 6 weeks and intervention (up to partners have worsens with time 6 months) depressive symptoms Postpartum Anytime in first Includes Hospitalized for Psychosis year, commonly in infanticide and weeks to months first 3 months PP suicide  Assessment Intervention Screen with validated tool, ie. EPDS Active listening about birth, parenting, concerns Assess for risk factors for perinatal mood Recognition of findings and direct disorders conversations with the client Assess physical findings: sleep, appetite, Notify provider and social worker with energy concerns Assess affect and interactions with newborn Educate about Baby blues and perinatal mood and significant other disorders Assess support at home Provide resources Document assessment, interventions, and evaluation of interventions EMOTIONAL ASSESSMENT AND INTERVENTION POSTPARTUM DANGER SIGNS NCLEX QUESTION REVIEW