Unit 3: Postpartum PDF

Unit 3: Postpartum Maternal and Child Course Nursing Notebook MCN Puerperium begins after delivery of the placenta lasts appr...

Unit 3: Postpartum Maternal and Child Course Nursing Notebook MCN Puerperium begins after delivery of the placenta lasts approximately 6 weeks woman’s body begins to return to its pre-pregnant state includes the changes in all aspects of the mother’s life that occur during the first year after a child’s birth. The true postpartum period may last between 9 and 12 months Maternal Psychological Adaptation in the early 1960s, Reva Rubin identified three phases that a mother goes through to adjust to her new maternal role Rubin’s maternal role framework can be used to monitor the client’s progress as she “tries on” her new role as a mother. Taking-In Phase Characterized by dependent behavior During the first 24 to 48 hours after giving birth, mothers often assume a very passive role in meeting their own basic needs, allowing the nurse to make Unit 3: Postpartum 1  decisions for them Recounts their labor experience — allows them to integrate the birth experience into reality Typically lasts 1-2 days, only phase observed by nurses because of the shortened postpartum stays that are the norm today May be prolonged when a cesarean birth has been necessary. Women may have difficulty assimilating the unfamiliar and intrusive procedures and may have negative perceptions of the birth experience These women need continued attention and sensitive care that considers their physical and psychological needs Taking-Hold Phase Characterized by dependent and independent maternal behavior Starts on the 2nd to 3rd day postpartum, may last several weeks Mother is particularly concerned about her health, the infant’s condition, and her ability to care for the infant Shows independence by caring for herself and learning to care for her newborn but still requires assurance that she is doing well May verbalize anxiety about her competence as a mother The taking-hold phase, which extends over several days, has been called the teachable, reachable, referable moment. Letting-Go Phase The mother reestablishes relationships with other people Adapts to parenthood through her new role as a mother Assumes responsibility and care for the newborn with more confidence Unit 3: Postpartum 2  The focus of this phase is to move forward by assuming the parental role and to separate herself from the symbiotic relationship that she and her newborn had during pregnancy Maternal Role Attainment Role Attainment a process by which the mother achieves confidence in her ability to care for her infant and becomes comfortable with her identity as a mother Begins during pregnancy and continues for several months after childbirth Four Stages 1. Anticipatory Stage a. begins during pregnancy when the mother chooses a physician, nurse- midwife, and a location for the birth b. may attend childbirth classes c. seeks out role models to help her learn the maternal role 2. Formal Stage a. begins with the birth of the infant b. continues for approximately 4 - 6 weeks c. behaviors are guided by others such as health professionals, close friends, and parents d. parents become acquainted with their infant so they can mesh their caregiving with infant cues 3. Informal Stage a. begins when mothers have learned the appropriate responses to their infants’ cues and signals Unit 3: Postpartum 3  b. develops maternal role that fits them rather than following textbooks or health professionals’ directives 4. Personal Stage a. attained when mother feels sense of harmony b. Maternal role attainment — an end point when the woman adjusts to motherhood Most mothers do not feel competent and self-confident in the mothering role until about 4 months after childbirth. Bonding and Attachment Behaviors Bidirectional (Parent to Infant, Infant to Unidirectional (Parent to Infant) Parent) En face Parents respond to the infants cry Infant responds to the parents’ comforting Calls baby by name measures Parents stimulate and entertain the infant Cuddles baby close to chest while awake Parents become “cue sensitive” to the Talks/sings to baby infant’s behavior Kisses the baby Breastfeeds the baby or holds the baby close Emotional and Physiological Adjustments During the Puerperium First 3 months after birth most vulnerable emotional period for mothers Unit 3: Postpartum 4  Rapid hormonal changes during the first few postpartal days and weeks may give rise to mood disorders. The most common of these is often termed “the blues” Other less common puerperal mood disorders include post-partum depression and post-partum psychosis. Maternal Blues/Baby Blues considered a normal reaction to the dramatic changes that occur after childbirth, including abrupt withdrawal of the hormones estrogen, progesterone, and cortisol Women experience a range of symptoms that include tearfulness, mood swings, insomnia, fatigue, anxiety, difficulty concentrating, irritability and poor appetite. Usually begins during the first few postpartal days, peaks on the fifth day, then subsides over the next several days Does not affect the woman’s ability to care for herself or her newborn and family Treated with support and reassurance Referral to a health care provider is appropriate for women whose symptoms persist for more than ten days, as this pattern is suggestive of postpartum depression. Partner Psychological Adaptations Engrossment Father’s developing bond with the newborn—a time of intense absorption, preoccupation, and interest Unit 3: Postpartum 5  Three-Stage Role Development Process 1. Expectations a. has preconceptions about what home life will be like with a newborn 2. Reality a. occurs when fathers or partners realize that their expectations are not realistic b. feelings change from elation to sadness, ambivalence, jealousy, and frustration 3. Transition to mastery a. father makes a conscious decision to take control regardless of his preparedness Postpartum Assessment When is postpartum assessment performed: During the first hour: Every 15 minutes During the second hour: Every 30 minutes During the first 24 hours: Every 4 hours After 24 hours: Every 8 hours B — BREASTS Inspect for size, contour, asymmetry, engorgement, or erythema check the nipples flat/inverted nipples — makes breastfeeding difficult cracked, blistered, fissured, bruised, or bleeding nipples — baby is improperly positioned on the breast Unit 3: Postpartum 6  palpate the breasts use gentle, light touch for breastfeeding women to avoid breast stimulation as milk is starting to come in, the breasts become firmer. this is known as “filling”. engorged breasts are hard, tender, and taut palpate breasts for any nodules, masses, or areas of warmth, which may indicate a plugged duct that may progress to mastitis if not treated promptly discharge that is not colostrum (creamy yellow) or foremilk (bluish white) should be described and documented U — UTERUS Involution — return of the uterus to its pre-pregnancy size and condition. after birth, the uterus is about the size of a grapefruit, fundus halfway between the umbilicus and symphysis pubis fundus should be midline and should feel firm boggy or relaxed uterus — sign of uterine atony (soft or weak uterus after childbirth) can be the result of bladder distension, which displaces the uterus upward and to the right, or retained placental fragments. Either situation predisposes the woman to hemorrhage height of uterine fundus decreases by 1 cm/day Unit 3: Postpartum 7  Normal Findings: 1. Fundus should feel firm and should stay firm even after massage is stopped. 2. Fundus should be at the level of the umbilicus and midline. B — BLADDER Diuresis, as much as 3000 mL, may follow for several days after childbirth, decreasing by the third day Some women may not sense the need to void even if their bladder is full. Women who received regional anesthesia during labor are at risk for bladder distension and for difficulty voiding Decreased bladder tone is normal during pregnancy, results from the effects of progesterone on the smooth muscle, edema from pressure of the presenting part An overdistended bladder may displace the uterus above and to the right of the umbilicus and cause uterine atony and lead to hemorrhage B — BOWEL Gastrointestinal system becomes more active after childbirth Unit 3: Postpartum 8  Peptide hormone, relaxin, which reaches high circulating levels during pregnancies, depresses bowel motility The relaxed condition of the intestinal and abdominal muscles, combined with the continued effects of progesterone on the smooth muscles, diminishes bowel motility; this commonly results to constipation during the early puerperium. L — LOCHIA This is discharge from the uterus that consists of blood from the vessels of the placental site and debris from the decidua Total volume: 240 to 270 mL Women who had cesarean birth will have less lochia discharge but stages and color changes remain the same Lochia Rubra during first few days of postpartum consists mainly of blood; red Lochia Serosa after 3-4 days pinkish brownish Lochia Alba white/yellow-white thick discharge Episiotomy 1 to 2 inch surgical incision made in the muscular area between the vagina and the anus to enlarge the vaginal opening before birth Perineal lacerations are classified in degrees to describe the amount of tissue involved: 1. 1st degree — involves superficial vaginal mucosa or perineal skin Unit 3: Postpartum 9  2. 2nd degree — involves the vaginal mucosa, perineal skin, fascia, muscles of the perineum 3. 3rd degree — 2nd degree but extends into or through the external anal sphincter 4. 4th degree — extends through the external anal sphincter and into the rectal mucosa Assess episiotomy using REEDA R — REDNESS E — EDEMA E — ECCHYMOSIS D — DRAINAGE OR DISCHARGE A — APPROXIMATION OF THE EPISIOTOMY Unit 3: Postpartum 10  S — SEXUALITY H — HOMAN’S SIGN used in the assessment for deep venous thrombosis (DVT) in the leg if calf pain is elicited, a positive Homan’s sign is present E — EMOTIONAL STATUS B — BONDING S — SPIRITUAL/SUPPORT SYSTEM Vital Signs 1. Temperature a. normal in the first 24 hours b. some may experience slight fever due to dehydration from fluid loss during childbirth c. temperature should be normal after 24 hours with replacement of fluids d. abnormal temperature after 24 hours may indicate infection and must be reported. Continue monitoring until an infection can be ruled out through Unit 3: Postpartum 11  cultures and blood studies 2. Pulse a. relative bradycardia may be noted due changes in blood volume and cardiac output b. may range from 50 - 70 bpm c. usually stabilizes to pre-pregnancy levels within 10 days d. tachycardia suggests anxiety, excitement, fatigue, pain, excessive blood loss, infection, or underlying cardiac problems 3. Respiration a. should be within the normal range of 16 - 20 breaths per minute b. any change in respiratory rate may indicate pulmonary edema, atelectasis, or pulmonary embolism and must be reported c. lungs should be clear on auscultation 4. Blood Pressure a. Postpartum BP should be compared with the pre-delivery period so deviations can be quickly identified b. increase from baseline may be caused by pain or anxiety i. if BP is 140/90 mm Hg or higher — preeclampsia may be present c. decrease may indicate dehydration or hypovolemia resulting from excessive bleeding d. may also vary based on the woman’s position, get BP in the same position every time. e. orthostatic hypotension — occurs when woman moves rapidly from a lying or sitting position to a standing position 5. Pain a. have mother rate paint from 0 to 10 points b. many postpartum orders will have the nurse pre-medicate the woman routinely for afterbirth pains rather than wait for her to experience them Unit 3: Postpartum 12  first c. goal of pain management: have the woman’s pain scale rating maintained between 0 to 2 points at all times, especially after breastfeeding d. prevent pain by administering analgesics Systemic Changes During Puerperium Menstruation occurs about 6 weeks after birth in non-breastfeeding mothers and up to 24 weeks in breastfeeding mothers Luteinizing hormone of anterior pituitary is activated after placenta is expelled; prolactin stimulates milk production Oxytocin initiates let down reflex — makes the milk that is already in the breast flow for the current feed, and helps the baby to get the milk easily Absence of sucking inhibits oxytocin and prolactin release. Let down reflex diminishes, inhibiting milk production Circulatory System Blood volume returns to pre-pregnant state after 3 weeks Cardiac output declines by 30% in the first two weeks, reaches normal levels by 6 - 12 weeks If deep vein thrombosis develops, heparin followed by warfarin may be prescribed) WBCs may increase to 30,000/mm3 if labor was lengthy, returns to normal values within 6 days Excretory System Factors that contributes to rapid filling of the bladder within 12 hours of birth: 1. Large amounts of intravenous fluids given during labor 2. Decreasing antidiuretic effect of oxytocin Unit 3: Postpartum 13  3. Buildup and retention of extra fluids during pregnancy 4. Decreasing production of aldosterone — a hormone that decreases sodium retention and increases urine production some women may have difficulty feeling the sensation to void after giving birth if they received an anesthetic block during labor urinary retention and bladder distention can cause displacement of the uterus from the midline to the right and can inhibit the uterus from contracting properly, increasing the risk for postpartum hemorrhage urinary retention is a major cause of uterine atony which allows excessive bleeding Integumentary System profuse diaphoresis (sweating) a mechanism to reduce the amount of fluids retained during pregnancy and restore pre-pregnant body fluid levels Musculoskeletal System Hormones relaxin and progesterone contribute to the relaxation of the soft tissues in the maternal pelvis, creating room for the birthing process Assessing LATCH audible swallowing type of nipple comfort of mother hold or position of the baby Unit 3: Postpartum 14 Unit 3: Postpartum 15