Postpartum Care CH 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? WELCOME TO Chapter 15: Postpartum Adaptations...

“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? WELCOME TO Chapter 15: Postpartum Adaptations Chapter 16: Nursing Management POSTPARTUM During the Postpartum Period Chapter 22: Nursing Management of the Postpartum Woman at Risk  FOCUSED POSTPARTUM ASSESSMENT WITH BUBBLEEE POSTPARTUM  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/ 1. Assess perineum, episiotomy, or laceration using REEDA (redness, edema, Epidural Site ecchymosis, discharge 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 Every 30 minutes Pulse 60-80 bpm hour Respirations 12-20 bpm During first 24 Every 4 hours Blood Pressure 85/60 – 140/90 hours Pain Aim for 0-2 After 24 hours Every 8 hours 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 Pre- pregnancy muscle fibers (70g) (after pains) Pregnancy Catabolism – (1100g) shrinks myometrial cells Regeneration of Postpartum (1000g) uterine epithelium 1 week postpartum (500g) Not palpable abdominally 6 weeks usually by day 10 postpartum -14 (60g)  UTERUS INVOLUTION Involution Subinvolution - Prolonged labor - Complicated birth - Complete expulsion of - Incomplete expulsion of amniotic membranes and amniotic membranes and placenta placenta - Uterine infection - Uncomplicated labor and birth - Overdistention of uterine - Breastfeeding muscles - Full bladder - Early ambulation - 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 - Assess for position - Deviated and/or above umbilicus  Midline or deviated to side  Massage fundus and monitor bleeding  Above, at or below the umbilicus  Assess bladder fullness and empty if needed  Assess for other causes - Assess for pain - Pain - Assess for endometritis infection  Provide comfort measures  Develops 2-4 days up to 6 weeks pp  Provide pain medication  Lower abd pain, fever, odorous lochia, anorexia, nausea, fatigue - Document assessment, interventions and - Assess risk factors for postpartum hemorrhage evaluation of interventions and endometritis infection - Educate on normal and abnormal to notify nurse LOCHIA Stages Timing Color Consists Danger Of Signs Anytime Lochia Rubra First 3 to 4 Deep red Mucus, tissue Reassess if days debris, blood rubra starts again once it has stopped Lochia Serosa Days 3 to 10 Pinkish brown Leukocytes, Heavy bleeding decidual tissue, red Offensive odor blood cells, (not fleshy) serous fluid Lochia Alba Days 10 to 14, Creamy white Leukocytes, Discharge up to 3-6 or light brown decidual present weeks tissue, fluid content LOCHIA ASSESSMENT AND INTERVENTION Assessment Intervention - Assess lochia each time the - If excessive bleeding or clots  Assess uterus and massage fundus uterus is assessed  Assess bladder fullness and empty  Administer uterotonic medications - Assess lochia prn, “I felt a  Evaluate risk factors for causes of PPH gush” - If foul odor, - Assess the amount, color, and  Notify provider odor of lochia  May indicate infection - Assess for clots - Educate about expected amount and when to notify the nurse - Assess for risk factors of -Document assessment, interventions, and excessive bleeding/infection 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, Immediately: Swollen, relaxed and few rugae bruised, swollen, partially in vagina Rugae returns in 3 weeks Gradually closes, but never the Prepregnant state by 6 to 8 weeks PP same as pre-pregnancy Will be less gaping, but will always Prepregnant state by 6 weeks PP be slightly larger than pre pregnancy Internal os closed by 2 weeks. 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 Ice packs Pelvic floor dysfunction 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, Good hand hygiene ecchymosis, discharge, and Turn client to her side to assess approximation) perineum Assess for pain Report signs of infection to Assess peri-care provider Assess ability to void Provide peri bottle, prn comfort Assess epidural site medications Assess surgical incision Dermaplast, tucks, Ibuprofen Assess for risk factors and etc symptoms for infection Educate about good hand hygiene Separation of wound edges, and peri-care, anticipatory erythema, tenderness, fever, guidance for appearance, healing, purulent drainage pain Document assessment, PERINEUM/EPISIOTOMY/LACERATION/ interventions and evaluation of EPIDURAL/INCISION ASSESSMENT AND interventions 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, BP: decreases dehydration, day 1&2, then hemorrhage increases day Cardiac 3 to 7. Pre- displacement pregnancy by reverses with ~6weeks uterus (hypotension: involution Nursing infection or Assessment: hemorrhage) Hematocrit stable: reflects plasma Monitor VS – loss, if unstable: identify may reflect hemorrhage changes or Cardiac output abnormal early (Due to birth elevated few related blood days then loss: Vaginal decreases non- 500ml/Cesarea pregnant level n 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 Nursing  3 per 1000 births experience pulmonary embolism Assessment:  Return to pre-pregnancy levels after 3 weeks - Assess heart sounds, Blood Cellular Components rhythm and  RBC rate  Production ceases postpartum - Assess for  H/H decrease slightly in 1st 24 hours signs of  Rise slowly over 2 weeks bleeding, DVT,  WBC PE  Increases during labor - Evaluate RBC  Remains elevated 4 to 6 days, then returns to normal and WBC EXTREMITIES ASSESSMENT AND INTERVENTION Assessment Interventions - Assess for signs of superficial venous - Prevention thrombosis and deep vein thrombosis  Antiembolism stockings, ambulation, compression  Aching in leg relieved with elevation devices, 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  Dyspnea, chest pain, hypotension, syncope, SOB acute setting and long term, prophylaxis in subsequent pregnancies, signs to be seen immediately - Assess for risk factors of blood clots  Long term anticoagulation medication (heparin, lovenox, oral) - Assess for generalized edema  Avoidance of hormonal contraception - Assess for return of sensation following - Assist to restroom or use bed pan until epidural/spinal 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 output, Urinary Gastrointestinal distension Pregnancy: - Assess  Increased Glomerular Filtration Rate/ Renal Plasma appetite, BS,  Return to normal 6 weeks PP gas/BM 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  Decreased aldosterone smooth muscle and decrease bowel tone Incomplete emptying  Oxytocin Postpartum:  Decreased progesterone levels and no  Perineal lacerations longer gravid abdomen  Anesthesia (decreased bladder tone)  Hematoma Constipation:  Swelling, poor bladder tone, numbness  Nursing Decreased peristalsis  management: Decreased intra-abdominal pressure Urine retention Bladder distention UTI  Low fiber diet - Provide/encourage  Insufficient fluid intake fluids and food Bladder distention Displacement of uterus/atony PPH  Diminished muscle tone - 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  Strict sterile technique - Assess for signs of urinary tract infection - Alert provider of any abnormal  Fever, urinary frequency, urgency, dysuria, assessments CVT tenderness, odorous urine - Document assessment, - Assess hydration status 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 - Assess for passing of gas and/or frequently BM - Encourage high fiber meals and  May not occur for 1-3 days PP increase 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, - Assess for hemorrhoids interventions and evaluation of interventions - Assess risk factors for constipation  Nursing Assessment: - Assess gait, Musculoskeletal/ Respiratory Endocrine abdominal tone and strength Pregnancy: - Assess lung  Elevated relaxin, estrogen, and progesterone relax sounds, joints respirations Postpartum: Placenta:  Once delivered, placenta hormones are cleared quickly  Decrease of these hormones, return to pre-pregnancy state by 6 to 8 weeks Estrogen:  May experience hip and joint pain  Decreased estrogen begin breast engorgement and diuresis  Lowest at 1 week pp. Remain low while breastfeeding. Will increase by week 2, if not breastfeeding. Muscles:  Abdominal muscles stretch, can separate (diastasis Other hormones: recti)  HCG: undetectable after 1 week  hPL: undetectable after 1 day  Poor tone postpartum, need exercise and support  Progesterone: undetectable after 3 days (returns with first menses) Respiratory:  Normal range: 16 to 24 bpm Nursing Prolactin:  Secreted by anterior pituitary, remain elevated while  Diaphragm adjusts to normalmanagement: position breastfeeding Shortness of breath resolves - Promote  Decline within 2 weeks if not breastfeeding   Returns to prepregnant state ambulation by 1 to 3 weeks pp - 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 breast LACTATION oxytocin and prolactin decrease Prolactin, progestero ne and estrogen trigger Prolactin colostrum Oxytocin level helps eject the milk Postpart increase with from alveoli to the um sucking and secretes nipple milk (4-5 Branches form Pregnan days PP) Estrogen lobules and cy: Each stimulates alveoli. breast gains ductal nearly 1 lb system Increase vessels by term Skin to skin: Breast crawl helps initiate breastfeedi Progestero ng ne 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 - Assess for size, contour, symmetry suppression support and education - Administer prn medications (ie. Lansinoh, - Assess for fullness/engorgement Ibuprofen) - Educate on stimulation of contractions with - Assess nipples suckling  Cracks, redness, fissures, bleeding - Notify provider of abnormal findings - Provide education regarding symptoms and - Assess for desire to breast or formula treatment of mastitis  Complete all of the antibiotics feed  Continue to empty the affected breast  Hydrate and rest - Assess for pain - Provide education and support regarding - Assess for mastitis breastfeeding (takes time)  Lactation consultant if available  Redness, pain, fever, flu-like  Benefits symptoms, abscess  Timing/amount of colostrum and milk - Document assessment, interventions and - Assess for risk factors for difficulty evaluation of interventions breastfeeding, mastitis 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 Phase PARENTHOOD Timing Taking-in phase Lasts1to 2 days Relives events - Dependent/passive behaviors surrounding birthing - Retelling birth story process - Interacting with newborn, touching and claiming them Taking-hold phase Starts day 2 or Strong interest in care - Dependent and Independent 3 and lasts for for her infant by behavior several weeks herself - Concerned over care of herself and newborn - Concerned with ability to do so Letting-go phase Reestablishes -Adapts to role as mother relationships with - More confident in care for others 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 Partner Symptoms Relief Baby blues Up to 2 weeks Mild Independently PP Postpartum Usually starts Worsening Persist Up to 50% of Depression in first 6 without partners have weeks and intervention depressive worsens with (up to 6 symptoms time months) Postpartum Anytime in Includes Hospitalized Psychosis first year, infanticide for weeks to commonly in and suicide months first 3 months PP Assessment Intervention Active listening about birth, parenting, Screen with validated tool, ie. concerns EPDS Recognition of findings and direct Assess for risk factors for conversations with the client perinatal mood disorders Notify provider and social worker with Assess physical findings: sleep, concerns appetite, energy Educate about Baby blues and perinatal mood Assess affect and interactions disorders with newborn and significant Provide resources other Document assessment, interventions, and Assess support at home evaluation of interventions EMOTIONAL ASSESSMENT AND INTERVENTION POSTPARTUM DANGER SIGNS NCLEX QUESTION REVIEW