Postpartum Nursing Care PDF

The Family After Birth Postpartum Nursing Care Chapter 12 Postpartum  Puerperium or “4th trimester”  Period during woman adjusts physically and psychologically to the process of childbirth  Time from birth until body returns to a (near) pre-pregnant state  ~6weeks ...

The Family After Birth Postpartum Nursing Care Chapter 12 Postpartum  Puerperium or “4th trimester”  Period during woman adjusts physically and psychologically to the process of childbirth  Time from birth until body returns to a (near) pre-pregnant state  ~6weeks  ~40 days Cultural Influences  Special cultural practices most evident at significant life events, such as birth  Nurses role  Support physically safe and culturally meaningful event  https://www.youtube.com/watch?v=CCa50OS6jyo Involution  Return uterus to pre-pregnant size & condition  Uterus shrinks as cells become smaller  Pre-pregnant size in 5-6 weeks  Bleeding controlled by contracting uterine muscle fibers  May be felt as afterpains  Uterine lining is shed as lochia  Placental site fully heals in 6-7 weeks  Fundal Position  Fundus = top portion of uterus  Immediately after birth – between pubis and umbilicus  1 hour after birth – at or slightly above the umbilicus  Descends 1 fingerbreadth (1 cm) per day  Below pubis by day 10  If bladder is full - fundus rises above the umbilicus & deviates to the side Fundal Position Assessing the Fundus Nursing Care  Assess  Fundal height  Amount, color, characteristics of lochia  Keep uterus contracted  Massage if poorly contracted  Meds - oxytocin, methylergonovine  Patient teaching Afterpain  Intermittent uterine contractions  Causes  Oxytocin  Breastfeeding  More common & severe in multiparas  Interventions  comfort measures  massage fundus  ibuprofen  Lochia  Discharge of debris from uterus  Lochia rubra  Dark red  First 3 days after birth  Lochia serosa  Pinkish  3rd to 10th days  Lochia alba  Colorless or white  10th to 21st day after birth Lochia  Fleshy or menstrual odor  Not foul  Excessive to soak a pad in 15 min  May gush on arising  Vaginal pooling - normal  Persistence, return or increase of rubra  May indicate delayed involution or hemorrhage Cervix & Vagina  Stretched, edematous, & bruised  May have tears  Bright red trickle of blood when fundus is firm  Suggest water-soluble gel for intercourse  Vaginal tone can be improved by doing Kegel’s exercises Perineum  Edematous, tender, & bruised  Episiotomy  Laceration, or perineal tear  Hemorrhoids may worsen from pressure during birth Perineum  Assess in sidelying position  Check for -  Bruising, erythema,  Edema  Hematoma  Intactness  Pain  Hemorrhoids Perineal Care  Ice  1st12 - 24 hours  Reduce edema, bruising, & pain  Heat  After 24 hours  Sitz bath (fig. 12-5)  Comfort & hygiene  Topical preparations Ovulation & Menstruation  Non-nursing  5 weeks  Nursing  Usually delayed – 8 weeks  Notes  First periods may or may not be ovulatory  Ovulation returns with or without menstration Ovulation & Menstruation  Ovulation frequently returns prior to the first period  Woman must practice birth control with first post partum intercourse if she doesn’t desire an immediate pregnancy  Breast feeding is not a reliable form of birth control  Breasts  Breasts  Increasein size with milk production  May become engorged by the 3rd day  Hard & painful  See Pg 217  Nursing care  Assess  Supportive bra (without plastic or wires)  flaps that open if breastfeeding  tight bra or binder & ice if not breastfeeding  Clean with plain water GI & Skin  Skin  Pigment changes reverse  Striae fade but don’t disappear  GI  Hungry  Constipation a problem  Cardiovascular System  Normal physical signs  Increase cardiac output despite blood loss  Blood diverted from uterus to circulation  Increased blood clotting  Lab values vary; look at patient (P, BP, dizzy)  Chill (without fever)  Orthostatic hypotension  Nursing care  VS (P), assess for DVT, ambulate, hygiene...  Urinary System  Increased output  Rid fluid; large urinary output & diaphoresis  Decreased sensation or soreness  Full bladder can interfere with uterine contraction  Nursing care  Keep bladder emptying  Help her void or  Straight cath Musculoskeletal  Abdomen  Loose & flabby  Responds well to exercise  Diastasis recti = separation of abdominal muscle wall  Exercises  Walk  Head lift, pelvic tilt, abd tightening  Kegel exercise Immune System  Rh immune globulin - RhoGAM  Given to mother within 72 hours of birth of Rh+ infant to Rh- woman  Rubella  Immunize during immediate postpartum period if non-immune  Avoid pregnancy for next month  Will prevent risk in future pregnancy Cesarean Recovery  Uterus - check fundus gently  Lochia - expect less  Incision  Assess dressing  May shower  Urinary catheter removed within 24 hours  Be sure she is able to void within 6 - 8 hours  “DTV” CS Wound  REEDA -  redness  edema  ecchymosis  discharge  approximation  REEDA acronym also useful for assessing the perineum  Cesarean Recovery  Respiratory  Incentive spirometer, ambulate  Splint incision to cough  Prevent DVT  Leg exercises, TED hose, early ambulation  SCD, heparin  Pain management  Epidural narcotics - check resp q1hr, pulse ox  PCA  Short term narcotic exposure is not harmful to infant; mom in pain is!  Psychological Adaptation  Hormonal changes  Changes in body image  Accepting self as a mother  Moods  Elation  Depression  Fatigue  Overwhelmed Emotional Care  Postpartum blues  Conflicting feelings normal  Fathers - feeling parallel new mother  Sibling - reaction varies with age  Grandparents - may be involved or remote  Grieving parents  Listen, allow choice of setting, memory packet  Discharge Planning  Discharge teaching begins before admission, in childbirth classes  Follow-up apps for mom & baby  OB – 2 & 6 weeks  Ped - 1 week  Provide phone contact (hospital &/or MD)  Hygiene - shower & peri care  Avoid douche, tampons, & tub bath  Sexual Relations  May resume when  1) lochia stops  2) she feels physically healed & emotionally ready  Use effective birth control measure  Birthcontrol with 1st PP intercourse  Ovulation can occur even if breastfeeding  Do not get pregnant within 1st month of receiving rubella vaccine  Vaginal dryness may occur Self-care Teaching  Watch for danger signs of:  Hemorrhage  Infection (T > 38o C or 100.4o F, pain)  Thrombosis  Provide written material  tosupplement verbal teaching & demonstration  Infant car safety  “Firstride, every ride”  Approved, new, rear facing seat  Not in seat with airbag Postpartum Complications Chapter 13 Postpartum Hemorrhage  Leading cause of maternal mortality worldwide  Blood loss > 500ml after vaginal birth  >1000ml after cesarean birth  Because of extra blood volume during pregnancy (1 - 2 L)  Woman tolerates blood loss better than otherwise expected  Hypovolemic Shock  Volume of blood depleted  cannot fill circulatory system, can be fatal  Signs (body’s attempt to get O2 to vital organs)  Skin cool & clammy  Tachycardia  Drop in BP with narrow pulse pressure  Anxiety, confusion, restlessness, lethargy  Decreased urine output  Primary or Early Postpartum Hemorrhage 1st 24 hours  Uterine atony  Most common cause of early PPH  Signs  increased bleeding, clots  boggy (soft) fundus  Risk factors - #1 Birth!  Full bladder  Overdistension, multiparity  Abnormal labor  prolonged, precipitate, oxytocin, interventions  Medications that relax affect uterus  Mg, tocolytics; or oxytoctics Medical Management  Stop blood loss  Contract uterus - massage & drugs  IV fluid to replace volume  Blood transfusion to replace RBCs  Give oxygen to increase O2 sat.  Monitor with pulse oximeter  Indwelling catheter empty bladder & monitor renal function  OR for D&C, packing or hysterectomy Uterine Atony  Nursing care  Massage the uterus until firm  Don’t over-massage  Save pads  Empty the bladder  Have infant breastfeed  Meds  Oxytocin (IV)  Methergine (PO) (side effect - HTN)  Rarely hysterectomy is needed  Keep NPO until bleeding controlled Secondary or Late Postpartum Hemorrhage  After 24 hours until 6 weeks  Causes  Retention of placental fragments  Subinvolution of uterus (next slide)  Treatment  Meds (oxytocin, Methergine, etc.)  Curettage  scraping or vacuuming inner surface of uterus  Teach prior to discharge  Subinvolution of Uterus  Slower than expected return to normal  Abnormal placental attachment  Retained placental fragment  Infection  S & S (lack of expected changes)  Fundus too high, persistent lochia rubra  Pelvic pain, heaviness, fatigue  Treatment  Methergine, antibiotics, D & C  Teach about normal changes and abnormal signs to report prior to DC Trauma - Laceration  Causes  Instrumentation  Large baby, abnormal presentation  S&S  Continuous bright red bleeding  Firm fundus  Treatment  Notify physician  May require surgical repair  Keep NPO Hematoma  Collection of blood within tissue  Bulging bluish-purplish mass  Severe pain, pressure  Signs of shock from concealed blood loss  Treatment  Small  May resolve without treatment  Ice  Large  Incision and drainage (keep NPO) Infections  Signs  Temp 38oC (100.4oF)  x2 days, after 24 hours  Local;redness, edema, pain, odor  Systemic; fever, malaise, achiness, anorexia, very elevated WBCs  Additional risk factors  CS, forceps, vacuum, frequent vag exams  Prolonged ROM, labor  Hemorrhage or anemia, poor nutrition Treatment of Infection  General nursing care & teaching  Hygiene - handwashing & peri care  Promote rest & nutrition  Observe for S & S  Teach patient S & S, what to report  Antibiotics  Takeall antibiotics even after symptoms go away Endometritis - Uterine Infection  S&S  Systemic*  Uterine tenderness, enlargement, cramping, foul smelling lochia  Complications - can spread to other organs  Treatment  C&S  Antibiotics (IV)  Nursing monitoring & care Wound Infection  Surgical incision, episiotomy or laceration  REEDA  Redness, warmth, edema, pain, pus, separation of suture line  Treatment C &S  Antibiotics (PO) – can allow to breastfeed  Analgesics, sitz bath  Teach prevention Urinary Tract Infection  Risks  Catheterization  Prolonged labor  S & S - pain, urgency, fever, burning,…  Treatment  Antibiotics (PO)  Increase fluid  Teach prevention – peri care  Mastitis - Breast Infection  Organisms enter cracks in nipple  Usually occurs 2 - 3 weeks after birth  S&S  Redness, fever, heat, tenderness, heaviness, enlarged axillary nodes, possible purulent drainage, malaise  Treatment  Antibiotics, I & D if abscess forms  Encourage breastfeeding, don’t wean; review proper technique, pump Thromboembolic Disorders  Precipitating factors to thrombosis  *Increased clotting factors  *Venous stasis  Vein wall injury  Risk up to 12 weeks PP  Prevention  Ambulation  Compression  Prophylactic heparin  Don’t cross legs  Care when using stirrups Thromboembolic Disorders  Signs  Superficial - Painful, hard, red, warm vein. Visible  DVT - Pain, calf tenderness, edema, discoloration, + Homan’s sign  Greatest risk - pulmonary embolus  Treatment  Anticoagulant  Heat, leg elevation, analgesics  Patient teaching – Prevention, S&S, meds  Postpartum Depression  Signs & symptoms  Upto 4 months after giving birth  Sad, moody, crying, anxiety, …  Lack of motivation to self/baby care  Lack of pleasure, preoccupation with death  In touch with reality  Associated factors (cause unknown)  Past history of depression  Inadequate social support  Low self esteem, unplanned pregnancy, stress Postpartum Depression  Treatment  Psychotherapy  Antidepressant medications  Increased social supports  Include family in care  Nursing care  Identify symptoms  Help identify sources of emotional support  Listen & offer reassurance Postpartum Psychosis  Psychiatric disorder  Impaired sense of reality  Rare but dangerous to mother & infant  Suicide & infanticide possible  Abrupt onset 2 day – 2 weeks PP  Treatment  Psychiatric professional  Emergency hospitalization Postpartum Care Summary  Be aware of high risk patients  Monitor for signs outside of normal  Excess bleeding, pain, enlarged uterus  Be aware infections can spread  Teach new mothers about normal changes and signs of complications  Careful listening to identify mood disorders Presentation(s)  Groups of 2-3 persons  Presentations approximate 20min  Power-Point  Topic of Your Choice  No Duplicate Topics  Questions/ Answers may be used on the Final Exam Topic Choices  Gestational Diabetes  Cervical Insufficiency  Pre-Eclampsia  Post Partum Hemorrhage  Prolapsed Umbillical Cord FOR EACH Topic, Cover Presentation Should Start with a Scenario: Ex. All oral presentations should start with age, gravidity, parity, if pregnant gestational age and dating criteria, and finally chief complaint. For example (ID/CC): Ms. X is a 24 year old Gravida 2 Para 1001 at 39 weeks by last menstrual period who presents from clinic with elevated blood pressure. For Each Topic Cont.  Describe possible alterations in health  Health promotions and disease prevention  Risk Factors  Expected Finidings (ex. Labs, assessment, pt. complaints)  Laboratory Tests  Diagnostic procedures  Nuring Care Concerns For Each Topic Cont.  Therapeutic Procedures/Interventions  Medications If Any  Client Education  Interprofessional Care  Complications  Safety Considerations If Any  5 Questions That ARE FINAL EXAM Worthy