Postpartum Phase Lecture 2024 PDF

Chapter 17 Nursing Care of a Postpartal Family 1  Objectives: 1.Describe the psychological and physiologic changes that occur in a postpartal woman and her family. 2.Assess the physiologic and psychological changes of the postpartal woman and her family. 3.Formulate nursing dia...

Chapter 17 Nursing Care of a Postpartal Family 1  Objectives: 1.Describe the psychological and physiologic changes that occur in a postpartal woman and her family. 2.Assess the physiologic and psychological changes of the postpartal woman and her family. 3.Formulate nursing diagnoses related to physiologic and psychological transitions of the postpartal period. 4.Develop expected outcomes for a postpartal woman and family related to the changes during this period as well as manage seamless transitions across differing healthcare settings. Copyright © 2018 Wolters Kluwer · All Rights Reserved  Objectives: 5.Using the nursing process, plan nursing care. 6.Implement nursing care to aid the progression of physiologic and psychological transitions occurring in a postpartal woman and family. 7.Evaluate outcome criteria for achievement and effectiveness of care. 8.Integrate knowledge of postpartal women and families with the interplay of nursing process to promote quality maternal and child health nursing care. Copyright © 2018 Wolters Kluwer · All Rights Reserved  Postpartum or Puerperium Period of 6 wks after delivery during which the reproductive system and the body returns to normal immediate--first 24 hrs early--first week late--2nd to 6th week 4th Trimester of Pregnancy 4  Postpartum or Puerperium  It is a time of maternal changes that are both retrogressive (involution of the uterus and vagina) and progressive (production of milk for lactation, restoration of the normal menstrual cycle, and beginning of a parenting role). 5 Psychological Changes The new mother must move from dependent to independent in a short time Reva Rubins three stages of the Postpartum (Puerperium):  Taking in  Taking hold  Letting go (taking over) 6 Taking in phase Focused on self (not infant) dependent on others for help in care needs assistance decision making difficult comfort-rest-food needs paramount relives delivery experience Usually occurs 2 – 3 days PP 7 Taking Hold Phase  Moving from dependence to independence   energy level   focus on infant  self care, focus on bowels, bladder, breastfeeding  responds to instruction, praise  Lasts from 3rd day to 2 weeks PP 8 Letting Go Phase Giving up previous role (role transition) See self as separate from infant Give up fantasy delivery and baby Readjustment of relationships necessary from 2wk 9 Letting Go Phase  She gives up the fantasized image of her child and accepts the real one;  she gives up her old role of being childless or the mother of only one or two (or however many children she had before this birth).  This process requires some grief work and readjustment of relationships, similar to what occurred during pregnancy. 10 Postpartum Psychological Adaptations, Maternal Concerns Maternal concerns and feelings Typical issues identified by postpartal women that they would like to hear discussed are:  breast soreness; regaining their figure; regulating the demands of a job, housework, their partner, and their children; coping with emotional tension and sibling jealousy; and how to combat fatigue. 12/15/24 POSTPARTUM PHASE 11 Postpartum Psychological Adaptations, Maternal Concerns Abandonment Disappointment Postpartal blues Postpartum depression 12/15/24 POSTPARTUM PHASE 12  Psychological Changes of the Postpartal Period Maternal concerns and feelings  Abandonment Examination of these competitive feelings can help a couple realize that parenthood involves some compromise in favor of the baby’s interests. Making infant care a shared responsibility can help alleviate these feelings and make both partners feel equally involved in the baby’s care. You can help parents or partners move past this competitive stage by pointing out positive parenting behaviors, positive self-care behaviors, and the warm infant response to their behaviors. Abandonment Mother feels less important and abandoned  the baby becomes everyone’s chief interest. The father may express the same feeling  Bec. mother spends more time with their infant. 14  Psychological Changes of the Postpartal Period Maternal concerns and feelings  Disappointment All during pregnancy, they pictured a chubby- cheeked, curly-haired, smiling girl or boy. They may have instead a thinner baby, without any hair, who seems to cry constantly, or may have a congenital condition. This can make it difficult to feel positive immediately toward a child who does not meet their expectations.  Psychological Changes of the Postpartal Period Maternal concerns and feelings  Disappointment You can never change the sex, size, or look of a child, but in the short time you care for a postpartal family, it is possible for a key person such as a nurse to tip a scale toward acceptance or at least help a person involved to take a clearer look at his or her situation and begin to cope with the new circumstances. Handle the child warmly, to show you find the infant satisfactory or even special. Comment on the child’s good points, such as long fingers, lovely eyes, and healthy appetite.  Psychological Changes of the Postpartal Period  Maternal concerns and feelings  Postpartal blues During the postpartal period, as many as 50% of women experience some feelings of overwhelming sadness or “baby blues” (Baselice & Lawson, 2012). They may burst into tears easily or feel let down and irritable. This phenomenon may be caused by hormonal changes, particularly the decrease in estrogen and progesterone that occurred with delivery of the placenta. Postpartal blues Described as overwhelming sadness that occurs in most women during the first week or two after birth. May be manifested by mood swings, anger, weepiness, anorexia, difficulty sleeping, and a feeling of letdown. Hormonal changes and psychological adjustments are thought to be the main causes. 12/15/24 POSTPARTUM PHASE 18 Postpartum blues Reduction of progesterone, delayed prolactin release and changes in other placental hormones may trigger emotional instability. Body image changes and dependency needs may contribute. 19 Postpartum blues Overconcern re: infant and self, and emotional lability are “normal” during the first 5-10 days after delivery Usually resolve naturally in 2 to 3 weeks with support and reassurance. If symptoms persist, the client should be evaluated for postpartum depression. 12/15/24 POSTPARTUM PHASE 20  Psychological Changes of the Postpartal Period Maternal concerns and feelings  Postpartal blues Severe psychosis also can occur in women during this time (Heron, Gilbert, Dolman, et al., 2012). If a mother appears to have a level of depression that is beyond baby blues and/or has a history of previous postpartal depression (PPD), closer observation and referral is indicated immediately.  Psychological Changes of the Postpartal Period Maternal concerns and feelings  Postpartal blues Breastfeeding has been shown to help elevate baby blues and counteract the effects of the hormonal drop that occurs after childbirth. For some women, it may be a response to dependence and low self-esteem caused by exhaustion, being away from home, physical discomfort, and the tension engendered by assuming a new role, especially if a woman is not receiving support from her partner.  Psychological Changes of the Postpartal Period  Maternal concerns and feelings  Postpartal blues In addition to crying, the syndrome is evidenced by feelings of inadequacy, mood lability, anorexia, and sleep disturbance. Anticipatory guidance and individualized support from healthcare personnel are important to help the parents understand that this unexpected response is normal. Be certain support persons also receive assurance of this type, or they can think the woman is unhappy with them or the new baby or is keeping some terrible news about the baby secret.  Psychological Changes of the Postpartal Period  Maternal concerns and feelings  Postpartal blues Give the woman a chance to verbalize her feelings and make as many decisions as she wants to help her gain a sense of control and move past this strange postpartal emotion. Women are at greater risk (19% to 48%) for moderate to severe depression after childbirth requiring formal counseling, especially if they are economically stressed or have a comorbid condition such as diabetes (Farr, Dietz, Williams, et al., 2011). Postpartum Depression Rejection of infant, or fears that she may harm infant call for immediate intervention. Remind mom during postpartum teaching that these feelings sometimes occur and help is available 25  MANIFESTATIONS OF POSTPARTUM DEPRESSION  interest in surroundings  interest in food unable to feel pleasure fatigue sleep disturbance panic attacks obsessive thinking  hygiene  ability to concentrate odd food cravings irritability rejection of infant Postpartum Depression PPD: Teaching relaxation therapy rest & nutrition frequent contact with other adults Resource: The Post Partum Resource Center of New York, Inc. 631-422-2255 www.postpartumNY.org 27 Disappointment May be experienced by the parents when their baby does not meet their expectations.  Handle the child warmly  Comment on the child’s good points 28  PHYSIOLOGIC CHANGES PPP Retrogressive Changes  Include those physiologic changes related specifically to the reproductive system as well as other systemic changes  THE UTERUS  Involution of the uterus involves two processes: 1)The area where the placenta was implanted is sealed off to prevent bleeding. 2)The organ is reduced to its approximate pregestational size. 29  PHYSIOLOGIC CHANGES PPP THE UTERUS  Involution of the uterus involves two processes: 1) The area where the placenta was implanted is sealed off to prevent bleeding.  is accomplished by rapid contraction of the uterus immediately after delivery of the placenta.  With time, thrombi form within the uterine sinuses and permanently seal the area. 30  PHYSIOLOGIC CHANGES PPP THE UTERUS  Involution of the uterus involves two processes: 2) The organ is reduced to its approximate pregestational size. 31 PHYSIOLOGIC CHANGES PPP UTERUS Estrogen & progesterone Atrophy of myometrial cells Decrease in uterine size & weight 32  PHYSIOLOGIC CHANGES PPP THE UTERUS  INVOLUTION  Reproductive organs return to their non- pregnant state.  Woman is in danger of hemorrhage until involution is complete (6 weeks).  Healing of placental site. 33  PHYSIOLOGIC CHANGES PPP UTERUS  Factor that promote uterine involution: 1)Breastfeeding  Release of oxytocin stimulates uterine contractions. 2)Factors that delay uterine involution: a) Over distention of uterus from hydramnios and multiple fetuses. b) Use of analgesia during labor c) Exhaustion due to prolonged & difficult labor. d) Multiparity 34  PHYSIOLOGIC CHANGES PP UTERUS  Progressive reduction in uterine weight:  Right after delivery: 1,000 g  1 week after delivery: 500 g  2 weeks after delivery: 300 g  6 weeks after delivery: 50 g 35  PHYSIOLOGIC CHANGES PPP Retrogressive Changes UTERUS  uterine contraction begins immediately after placental delivery.  Within a few minutes after birth  the fundus of the uterus is palpable through the abdominal wall, halfway between the umbilicus and the symphysis pubis,.  One hour later  it will rise to the level of the umbilicus, where it remains for approximately the next 24 hours. 36  PHYSIOLOGIC CHANGES PPP Retrogressive Changes UTERUS  From then on, it decreases by one fingerbreadth, or 1 cm, per day;  for example, on the first postpartal day, it will be palpable 1 cm below the umbilicus.  By the 9th or 10th day  can no longer be detected by abdominal palpation 37 38  PHYSIOLOGIC CHANGES PPP Retrogressive Changes UTERUS  Fundus Palpate the uterus and assess for: 1)Firmness 2)Position 3)Height Empty the bladder first. 39 Palpating the Uterus Nursing care r/t uterine changes  Palpate fundus at frequent intervals  q. 15” X 1hr  q. 1hr X 2  q. 2hr X 2  q. 4 hrs up to 24-48 hrs. post delivery  Massage if not firm  Deviation to the sides and above umb. may signal full bladder 41 Nursing care r/t uterine changes  Occasionally, the fundus can be felt slightly to the right  because the bulk of the sigmoid colon forced it to that side during pregnancy and it tends to remain in that position.  Assess fundal height shortly after a woman has emptied her bladder for most accurate results  because a full bladder can keep the uterus from contracting, pushing it upward and increasing the risk of excess bleeding. 42  PHYSIOLOGIC CHANGES PPP  UTERUS  Afterpains  Strong uterine contractions that cause uncomfortable cramps.  Uterine contractions prevent bleeding.  Present 2 – 3 days after childbirth.  Nursing measures to relieve afterpains: 1)Explain the cause & purpose of afterpains 2)Keep bladder empty 3)Instruct woman to assume PRONE POSITION. 4)NEVER APPLY HEAT on abdomen  Relaxes uterus leading to hemorrhage 5)Administer analgesics as ordered (NO ASPIRIN). 43  Cramping or “Afterpains”  Primiparas  uterus tonically contracted unless clots or tissue remain in uterus.  Multipara  uterus contracts and relaxes at intervals causing “afterpains”.  Afterpains tend to be noticed most by multiparas than by primiparas and by women who have given birth to large babies or multiple births.  More severe when breasfeeding in both primiparas and multiparas. 44  PHYSIOLOGIC CHANGES PPP  LOCHIA  Uterine discharge after delivery consisting of blood, fragments of decidua, white blood cells, mucus, and some bacteria  LOCHIA RUBRA  From delivery up to 3rd day.  Bright red and may contain small clots.  Consists of blood, fragments of decidua, and mucus  LOCHIA SEROSA  4th to 10th day  Pinkish to brownish in color  Consists of blood, mucus, and invading leukocytes 45  PHYSIOLOGIC CHANGES PPP LOCHIA  10–14 day (may last 6 weeks pp)  White or Cream to yellowish in color  Largely mucus; leukocyte count high 46 Scant amount Light amount Moderate Heavy amnt Blood only on < 4 inch (10 amnt Saturated tissue when cm) stain on < 6 inch (15.2 peripad within wiped peripad cm) stain on 1 hr. < 1 inch stain peripad on peripad 47 Physiologic Changes CERVIX  Soft, edematous and relaxed  By end of 7 days, external os has narrowed to size of a pencil opening, appears slit-like, feels firm and non- gravid. 48 Physiologic Changes VAGINA  Right after childbirth, vagina is smooth & swollen  Lacerations and episiotomy are usually healed after 2 weeks.  After 3 – 4 weeks, rugae reappear, but not as numerous as before pregnancy.  Returns to prepregnant condition after 6 – 8 weeks.  Kegel exercise help improve circulation to reduce edema and hasten return of vaginal muscle tone. 49 Physiologic Changes PERINEUM  Swollen, ecchymosis from ruptured capillaries, painful immediately after delivery.  Perineal muscle tone is regained by 6 weeks.  Instruct woman on the following: 1)Perineal care 2)Perineal hygiene 50 Evaluate Episiotomy or Perineal lac. for REEDA Redness Edema Ecchymosis Drainage Approximation 51 Physiologic Changes PERINEUM  Perineal Care: 1) Ice packs Applied on the perineum for the 1st 24 hrs. for 20 min. 2) Sitz Bath Done after 24 hrs. following delivery to promote circulation by vasodilation. Done 3 – 4x/day for 20 min. 52 Physiologic Changes PERINEUM  Perineal Care: 3) Perilite exposure Place woman in dorsal recumbent position, drape thighs, and place lamp between legs. Use 25 – 40 watt bulb Lamp should be 12 – 18 inches away from the perineum. Use perineal heat lamp for 20 min., 3x/day. 53 Physiologic Changes Progressive Changes The Hormonal System  Pregnancy hormones decrease with delivery of placenta.  Levels of human chorionic gonadotropin (hCG) and human placental lactogen (hPL) are almost negligible by 24 hours.  By week 1, progestin, and estrogen (estradiol) are all at prepregnancy levels (estriol may take an additional week before it reaches prepregnancy levels). 54  Physiologic Changes Progressive Changes The Hormonal System  4 major naturally occurring estrogens: 1)Estrone (E1) 2)Estradiol (E2)  Predominant and most potent estrogen during reproductive years. 3)Estriol (E3)  During pregnancy is synthesized by the placenta in very high quantities. 4)Estetrol (E4) 55 Physiologic Changes Progressive Changes The Hormonal System Follicle-stimulating hormone (FSH) remains low for about 12 days and then begins to rise as a new menstrual cycle is initiated. Menses resumes by 6 - 10 wks. if not Br. Fdg. 56 Physiologic Changes Progressive Changes MENSTRUATION & OVULATION  Woman who is NOT BREASTFEEDING:  Menstrual flow return 6 – 10 weeks after birth, and ovulate by 8 – 10 weeks after delivery.  A woman who BREASTFEEDS CONSISTENTLY, and uses no supplemental feeding  Menstruation and ovulation may return in 6 months (Lactational amenorrhea) 57 Breast Changes LACTATION Estrogen and Progesterone Stimulates prolactin production Milk production Breast engorgement 58 Suppression of Lactation Avoid breast stimulation Ice Tight bra Do not pump or express milk Hormonal suppression (rarely) 59 LACTATION & BREAST FEEDING Lactation starts regardless if pt. is breastfeeding or not. Entirely up to mother Must feel comfortable doing so. Advantages of Breast Feeding: Promotes bonding between mother & baby. High nutritional value for infant. Promotes uterine involution thru release of oxytocin from posterior pituitary. Reduces cost of feeding & preparation time. Contraindications to Breast Feeding: Mother receiving meds not appropriate for Breast fdg. [Lithium] Exposure to radioactive compounds [thyroid testing];  pump & dump breast milk x 48 hrs.  Flush in toilet. Breast Cancer; HIV  Physiology of Lactation Early pregnancy, ↑ estrogen (placenta) stimulates growth of milk glands & size of breasts. Colostrum: middle of pregnancy & day 1-3 PP, Thin, watery pre-lactation secretion. Rich in antibodies; passes to baby in 1-3 days. Breasts begin to get tender; fill up w. milk.  Physiology of Lactation Breast milk by 3rd to 4th day in response to: falling levels of estrogen & progesterone > delivery of placenta. ^ production of prolactin by anterior pituitary Milk ducts become distended & fluid turns bluish-white  Physiology cont. Infant suckling on breast produces more prolactin, which in turn stimulates more milk production. Finally, oxytocin released > delivery of placenta causing mammary glands to send milk to nipples [let down reflex]. Progesterone, estrogen levels drop after delivery which leads to ↑ milk production. The Urinary System: Loss of bladder tone d/t swelling & anesthesia ; urinating difficult. May not feel urge to void. Hydronephrosis [enlargement of ureters] occurs after delivery & to 4 wks. PP. DIURESIS! ↓ bladder sensitivity - ↑ risk for bladder infection - urinary stasis. Avoid bladder damage - assess bladder q 1-2 hrs. til pt. voids. The Urinary System: During preg., 2,000-3,000 ml. of fluid accumulates in body - Client loses 5- 10 lbs. of weight in 1st wk. PP.  extensive diaphoresis (excessive sweating) and diuresis (excess urine production) begin almost immediately after birth to rid the body of this fluid. The Urinary System: This easily increases the daily urine output of a postpartal woman from a normal level of 1,500 ml to as much as 3,000 ml/day during the second to fifth day after birth. This marked increase in urine production causes the bladder to fill rapidly. The Urinary System: Decreased woman’s ability to sense when she has to void  Because during a vaginal birth, the fetal head exerts a great deal of pressure on the bladder and urethra as it passes on the bladder’s underside, this may leave the bladder with a transient loss of tone that, together with the edema surrounding the urethra. The Urinary System: A woman who has had epidural anesthesia can feel no sensation in the bladder area until the anesthetic has worn off.   Circulatory System:  Blood volume ↑30 – 50% in pregnancy.  With diuresis & blood loss @ delivery, blood volume returns to normal in 1-2 wks. Blood loss for NSVD = 300 – 500 cc. C/S = 500 – 1,000 cc. Non pregnant:  HCT=37 - 47%  HGB=12 - 16g/dL Pregnant:  HCT=32 - 42 %   HCT drops by 4 % & HGB drops by 1 g. for every 250cc. of blood client loses. Patient should not be anemic entering delivery Possible blood transfusion with large blood loss. Average blood volume:  pre-pregnant = 4000cc;  pregnant state = 5250cc.  ↑Blood volume during pregnancy:  provides adequate exchange of nutrients in placenta & compensates for blood loss during delivery. HR remains ↑ x 24-48 hrs. PP With diuresis, HCT levels rise  [↑hemoconcentration] reach pre- preg level by 6 wks.  Plasma fibrinogen  ↑50% during pregnancy & remains elevated 6 wks. PP. [↑estrogen levels]  Can cause ↑thrombus formation.  Assess pts. legs/calves for s/s thrombophlebitis (Homan’s sign)  Rise in leukocytes  WBC ↑ protective measure to prepare for stress of delivery. As high as 20-25,000. Gastrointestinal System: NSVD: bowels sounds. Eat right away. C/S: bowel sounds hypoactive 1st 8 hrs. Epidural/spinal: po clear liquid after delivery, advance diet if +BS. General anesthesia: usually NPO for 6-8 hrs. Gastrointestinal System: BM - difficult/painful d/t lacerations/ hemorrhoids. C/S - BM 3rd - 4th day.  GI activity slowed d/t surgery. Can go home without BM if + flatus.  Integumentary System:  Stretch marks  [striae gravidarum] appear reddened on abdomen.  Fade by 3-6 months;  Pearly white marks may remain in lighter skinned pts. & darker marks in darker skinned pts.  Modified sit-ups strengthen abdomen VITAL SIGNS PP  Temperature: slightly ↑  dehydration during labor 1st 24 hrs.  Returns to normal within 24 hrs. T = 100.4 (38°C) or > PP infection suspected. Temp. also rises 3rd - 4th day with filling of breast milk (breast engorgement) Observe for s/s infection - nurse usually 1st to detect ↑ temp. [universal sign of infection 100.4 x 2 VITAL SIGNS PP Pulse: HR ↑ slightly x 1st hr. Stroke volume (vol. of blood pumped from the left ventricle per beat) & cardiac output also ↑ x 1st hr. then decreases 8-10 wks., returns to pre-pregnant state. Rapid, thready pulse:  sign of PP hemorrhage, infection Blood Pressure - Monitor carefully. 1st trimester Heart works faster to handle volume. BP remains same. 2nd trimester BP drops slightly d/t lowered peripheral resistance in blood vessels as placenta expands rapidly. Heart beats faster more efficiently d/t blood volume. Pre-pregnant BP 120/80. Pregnant BP 114/65. 3rd trimester BP back to pre-pregnant value.  BP Complications ↓ BP [90/60 or less] with dizziness is “Orthostatic hypotension”; could signify hemorrhage. Take BP/pulse lying/sitting/standing. Compare values. Orthostatic: If BP drops 15-20 mmHg and pulse increases 20 bpm or more. Caution for falls. ↑ BP [140/90 or >] could signify PP pre-eclampsia. Notify physician. Could develop into serious complication. Oxytocic meds [Pitocin] rapid delivery could ↑BP  Other Changes Exhaustion:  Common  Frequent rest periods  RN coordinates nursing care & infant feeding times  provide maximum rest time.  Other Changes Average Weight Loss:  12 lb. [infant & placenta]  5 lbs. - diuresis & diaphoresis in wk. that follows.  Lochial flow - 2-3 lbs.  Total = approx. 19-20 lbs. {depends on total wt. gain}  At 6 wks. wt. may still be above pre-preg. weight. Return of Menses: > after delivery FSH levels rise causing ovulation No Breast Fdg.- menses resumes ~ 6 wks. Lactation delays menses for several months NURSING MANAGEMENT OF POST PARTUM CLIENT Assessment – minimum of twice daily Vital signs Emotional Status Breasts Fundus, lochia, & perineum Voiding & bowel function - flatus, BM Legs [+ Homan’s sign, ankle edema ] S/S complications [PP hemorrhage, NURSING MANAGEMENT OF POST PARTUM CLIENT Nursing Care Safety Prevent hemorrhage- massage uterus on admission and q 4 for first 8 hrs. Prevent falls – assess when getting out of bed for 1st 8 hrs. Assist when necessary. Check labs for low Hct & Hgb. Bowel function (1-3 days to resume). Stool softeners, as ordered Encourage ambulation Increase dietary fiber Provide adequate fluid intake Health teaching & discharge planning Reinforce self care -hand washing, perineal care, Self-breast exam q month; S/S PP Depression Comfort Measures Ice , Sitz Baths, Topical Anesthetics Analgesia, Kegels for NSVD; modified sit-ups for NSVD (10th – 12th day PP), Breast Care