Postpartum Care: Jose Rizal University

NUR C207 Care of Mother, Child and Adolescent (Midterm) By Gina M. Dumawal RN, MAN Postpartum Care The Postpartal Period Begins with the termination of labor & ending with the uterine involution (6 - wk period after birth). It is also known as puerperium (from latin word puer, “child” &...

NUR C207 Care of Mother, Child and Adolescent (Midterm) By Gina M. Dumawal RN, MAN Postpartum Care The Postpartal Period Begins with the termination of labor & ending with the uterine involution (6 - wk period after birth). It is also known as puerperium (from latin word puer, “child” & parere, “to bring forth”). This is a time of maternal changes that are: a) retrogressive - involution of the uterus & vagina b) progressive - production of milk for lactation, restoration of the normal menstrual cycle & beginning of a parenting role. The period is popularly termed the fourth trimester of pregnancy.  Physiologic Changes of Postpartal Period Retrogressive physiologic changes – reproductive system as well as other systemic changes. > Involution - process whereby the reproductive organs return to their non-pregnant state. Reproductive System Changes ❑ The Uterus; Two process of uterine involution: 1) Placental site is sealed off to prevent bleeding. 2) The organ is reduced to its approximate pre-gestational size. ❖ Height - fundus of the uterus may be palpated halfway between the umbilicus and symphysis pubis w/ in a few minutes after birth. > remains at the level of umbilicus for 24hrs. > 2nd postpartum day – 1fingerbreadth below the umbilicus then decreases 1 fingerbreadth/day ❖ Consistency - firm, round, smooth; not “boggy” ❖ Location - fundus is normally in the midline of the abdomen. By day 10, uterus almost back to pre-pregnant state and no longer palpated in abdomen.  Physiologic Changes of Postpartal Period Reproductive System Changes ❑The Uterus  Physiologic Changes of Postpartal Period Reproductive System Changes (cont.) Lochia: uterine discharge similar to menstrual flow consisting of blood, fragments of decidua, WBC’s, mucus and some bacteria. 1. Lochia rubra - (1-3days after birth) discharge consist of blood with only small particles of decidua and mucus. 2. Lochia serosa - (3-10days) pink and brownish color consist of blood, mucus, and invading leukocytes. 3. Lochia alba - (10-14days & may last 6wks) amount of the flow decreases and becomes colorless or white. The Cervix: By the end of 7days, the external os is narrowed to the size of a pencil opening & the cervix feels firm & non-gravid. The Vagina: After vaginal birth, the vagina is soft w/ few rugae. Its diameter is considerably greater than normal. The hymen is permanently torn & and heals w/ small separate tags of tissue. The Perineum: May developed edema & generalized tenderness. Portions of the perineum may show ecchymosis from the rupture of surface capillaries.  Physiologic Changes of Postpartal Period Systemic Changes The Hormonal System - Pregnancy hormones begin to decrease as soon as the placenta is delivered (hCG & hPL). - FSH remains low for about 12 days postpartum then begins to rise as new menstrual cycle is initiated. - Menses resumes by 4-5 wks if not breastfeeding, 2-18 months if breastfeeding. - Anterior pituitary- prolactin increases for lactation  Physiologic Changes of Postpartal Period Systemic Changes (cont.) The Urinary System Assess a woman’s abdomen frequently in the postpartal period because full bladder displaces the uterus. Hydronephrosis or increased size of ureters during pregnancy remains present for about 4 weeks after birth. Bladder Changes: edema and hyperemia, extravasation overdistension with incomplete emptying urethral trauma may cause dysuria ❖Note: transient glycosuria, proteinuria & ketonuria are normal in immediate postpartum period.  Physiologic Changes of Postpartal Period Systemic Changes (cont.) The Circulatory System Blood vol. returns to normal by 1- 2 weeks after birth. > Ave. blood vol: pre-pregnant = 4000cc pregnant state = 5250cc. >  Hct (4point for every 250ml bld lost) during delivery >  Hgb (1g for every 250ml bld lost) during delivery >  Leucocytes (15,000 to 30,000 mm3) >  Fibrinogen (1st postpartal wk) - risk of thrombophlebitis Hct gradually rises reaching prepregnancy level by 6 weeks after birth. HR remains increase x 24-48 hrs postpartum.  Physiologic Changes of Postpartal Period Systemic Changes (cont.) The Gastrointestinal System Digestion & absorption begin to be active again soon after birth. Presence of hemorrhoids due to pelvic-stage pushing. Bowel sounds are active but passage of stool may be slow due to the effect of relaxin that depresses bowel motility. BM difficult / painful d/t lacerations/hemmorhoids. Constipation r/t decreased peristalsis - decreased intra abdominal pressure Spontaneous BM returned on the 2nd – 3rd post partum day Physiologic Changes of Postpartal Period Systemic Changes (cont.) The Integumentary System Striae gravidarum appear reddened on abdomen. Fade by 3-6 months; pearly white marks may remain in lighter skinned & darker marks in darker skinned patients. Chloasma & linea nigra become barely detectable in 6 weeks’ time (gradually fades). Abdominal wall & ligaments that support the uterus usually require 6 weeks to return to their former state. - Modified sit-ups strengthen abdomen. Physiologic Changes of Postpartal Period Effects of Retrogressive Changes The overall effects of postpartal retrogressive changes are exhaustion and weight loss. Exhaustion Sleep & rest patterns disrupted during 3rd trimester & continue to be disrupted during postpartum period. excitement anxiety discomfort baby feedings  Physiologic Changes of Postpartal Period Effects of Retrogressive Changes (cont.) Weight Loss ❖ Average wt. loss 12 lb. [infant & placenta] ❖ 5 lbs. - diuresis & diaphoresis on the 2nd - 5th day after birth. ❖ 2-3 lbs. - lochial flow ❖ Total = approx. 19-20 lbs. {depends on total wt. gain} ❖ The weight a woman reaches at 6 weeks after birth becomes her baseline postpartal weight unless she takes active measures to lose the weight.  Physiologic Changes of Postpartal Period Other Changes Vital Sign ❖Temperature > slightly  w/in 1st 24 hrs postpartum - DHN during labor. If the elevation in temperature lasts longer than a few hours, (T = 100.4 or >) postpartum infection is suspected. Temp. also rises 3rd - 4th day with filling of breast milk ❖Pulse PR is slightly slower than normal due to increased stroke volume (between 60 & 70 bpm). By the end of 1st week, the PR will return to normal. Evaluate PR in postpartal period - rapid & thready pulse could be a sign of hemorrhage / infection. Physiologic Changes of Postpartal Period Other Changes (cont.) Vital Sign Changes ❖Blood Pressure Monitor BP during postpartal period -  can indicate bleeding. Elevation above 140 mm Hg systolic - postpartal pregnancy- induced HPN, an unusual complication of puerperium. To prevent BP from rising too high, always measure it before administering oxytoxic agents. Orthostatic hypotension or dizziness that occurs on standing is a major complication due to blood lost.  Physiologic Changes of Postpartal Period Progressive Changes Lactation First 2 days - excretes colostrum. 3rd day, breasts become full & feel tense or tender as milk forms within breast ducts. Breast milk forms in response to  estrogen & progesterone that follows delivery of the placenta. Breast distention becomes marked & often accompanied by a feeling of heat or throbbing pain. Breast tissue may appear reddened, simulating an acute inflammatory process. The feeling of tension in the breasts on the 3rd or 4th day after birth is termed primary engorgement.  Physiologic Changes of Postpartal Period Progressive Changes (cont) Return of Menstrual Flow After delivery, FSH levels rise causing ovulation. Non breastfeeding - menses resumes 6-10 wks after birth. Breastfeeding- menses may not return for 3 or 4 months (lactational amenorrhea) or, in some women, for the entire lactation period. Parenting Role > Dev’t of parental love & positive family relationships: a) Rooming In; infant stays in room with mom 24hrs. (partial or complete) b) Sibling Visitation: encourage siblings to visit to promote family togetherness. Psychological Changes of Postpartal Period Phases of the Puerperium Reva Rubin, a nurse, divided the puerperium into 3 separate phases. 1: Taking - In phase (first 2-3days) > a time of reflection regarding new role > may have expressed little interest in caring for her child. > woman is largely passive & dependent > talks about birth experience 2: Taking - Hold phase (2 days to 1 wk) > times of renewed action & forward movement > a woman begins to initiate action, caring for self & newborn > begins to take a strong interest in caring for her child > moving from dependence to independence 3: Letting - Go phase (from 1 wk onwards) > the woman finally redefines her hew role. > readjustment, focus on entire family (partner & infant) > woman gives up fantasy image of baby and accepts real child.  Postpartum Monitoring V/S Monitoring Temperature > elevations should last for only 24 hours – should not be greater than 100.4°F > Elevated Temperature - sign of dehydration and infection Respirations > stable, and breath sounds should be clear Pulse Rate > Bradycardia (normal finding) rates of 60 to 70 bpm occur during first 6 to10 days due to decreased blood volume. > Tachycardia Infection, hemorrhage, pain, and anxiety  Postpartum Monitoring V/S Monitoring (cont.) Blood Pressure > Lowered Blood Pressure - orthostatic hypotension or shock > Elevated Blood Pressure - pregnancy-induced hypertension Monitoring of Uterine Involution Location of the Uterus > Midline, halfway between the umbilicus and symphysis pubis immediately after birth then descends 1 cm/day. > Consistency- firm/boggy > Full bladder raises fundal height, gives false reading and displaced the uterus to the right or left side of the abdomen.  The uterus becomes displaced and deviated to the right when the bladder is full.  Monitoring Uterine Involution Monitor uterus and vaginal bleeding: > every 15” X 1hr > every 30 minutes x 2hrs for first postpartum hour > hourly for 2 more hours > every 4 hours x 2 times > every 8 hours or more frequently if there is bogginess, position out of midline and heavy lochial flow. > If boggy, gently massage top of uterus until firm – notify health care provider if does not firm Delay in uterine involution: > retained placenta/clots > multiparous patient [grand multipara] > exhaustion > multi-fetuses. > C/S involutes slower; d/t surgery & less initiation of breast feeding after delivery.  Monitoring Uterine Involution Assessment of Uterus Presence of cramping or “afterpains” caused by contractions. > Primigravida--uterus contracted unless clots or tissue remain in uterus. > Multipara--uterus contracts & relaxes at intervals causing “afterpains”. ❖Afterpains more severe when breasfeeding in both primiparas and multiparas because of release of oxytocin. Monitoring Amount and Pattern of Lochia Assessment of Lochia Assess amount, color, odor, clots Total flow lasts about 3-6 wks Amount Estimate of Drainage Number of Pads Color Rubra = ”red” [1-3 days after birth] Serosa = “pink” [3-10 days] Alba = “white” [10-14 days, may last up to 6 weeks] If soaking 1 or > pads /hr, assess uterus, notify health care provider Should not be bright red; could be postpartum hemorrhage.  Monitoring Emotional Response ◼ Abandonment: feelings that occur after birth of child; woman no longer center of attention. ◼ Disappointment: infant does not meet expectations of mother or father. (Eg. eye color; sex.) ◼ Postpartum blues > Reduction of progesterone, delayed prolactin release & changes in other placental hormones may trigger emotional instability. > Body image changes & dependency needs may contribute. > Over concern (infant & self) & emotional lability are “normal” during the first 5-10 days after delivery. > Occurs in 50% of women.  Monitoring Responses to Drug Therapy  Bleeding  oxytocin (Pitocin) – watch for fluid overload and hypertension  methylergonovine (Methergine) – causes hypertension  prostaglandin F (Hemabate, carboprost) – diarrhea  Pain Medications  NSAIDs – GI upset  Oxycodone/acetaminophen (Percocet) – dizziness, sleepiness  docusate (Senna) – causes diarrhea  Rubella Vaccine – titer 1:10, do NOT get pregnant for 3 months  Rh Immune Globulin (RhoGAM) – Rh negative mother – do not administer rubella vaccine for 3 months  Monitoring Episiotomy Healing Episiotomy care Inspect the perineum for episiotomy/lacerations with REEDA assessment > Redness > Edema > Ecchymosis > Drainage/discharge > Approximation  Possible Postpartum Complication Postpartum Hemorrhage -- Blood loss of >500 ml after a vaginal birth -- 1000 ml (or more) of blood after cesarean section -- Uterine Atony - most common cause Causes of early postpartum hemorrhage: Laceration Atony Retained placental tissue Ruptured uterus You pulled too hard on the umbilical cord  Possible Postpartum Complication ❑Factors associated with PPH Tone/Atony > Altered muscle tone due to overdistention > Prolonged or rapid labor > Infection > Anesthesia Trauma > Cervical lacerations > Vaginal lacerations > Hematomas of vulva, vagina or perineal areas (localized collection of blood in connective or soft tissue under the skin)  Possible Postpartum Complication ◼ Laceration; Management > analgesics > application of ice pack > topical creams > hot Sitz bath. > nothing into rectum - no rectal temps, suppositories or enemas with 4th degree to avoid further damage. > increase fluids to promote BM > Kegels exercise  Possible Postpartum Complication ❑Factors associated with PPH Tissue > Retained placental fragments > Uterine inversion > Subinvolution Thrombin > Disorders of the clotting mechanism > This should be suspected when bleeding persists without an identifiable cause.  Possible Postpartum Complication Postpartum Hemorrhage Signs & Symptoms > saturate > one pad/hr > “boggy” uterus > increased lochia w/ clots > severe perineal pain (w/ hematoma) > tachycardia > hypotension Management of Postpartum Hemorrhage Frequent VS Fundal massage Administer medications Monitor amount of blood loss Maintain IV Type & cross match (blood) Keep bladder empty Inspect placenta for missing parts Administer oxytocics  Possible Postpartum Complication Postpartum Infections Types of infections > Reproductive tract: - back ache - abdominal pain - foul smelling lochia or purulent discharge > Wound infection: - erythema - warmth - swelling & tenderness - drainage A fever of 100.4 or higher after the first 24 hrs for 2 successive days of the first 10 postpartum days. > Endometritis > Wound infection > UTI > Mastitis > Septic Pelvic Thrombophlebitis  Possible Postpartum Complication Postpartum Infections (cont.) Endometritis > Involves the endometrium & adjacent myometrium of the uterus > Lower abdominal tenderness or pain > Temperature elevated > Foul-smelling lochia Nursing Care > Administer broad spectrum antibiotic > Provide analgesia > Provide emotional support Wound Infection > Sites- Cesarean incision, episiotomy & genital tract laceration > Drainage > Edema > Tenderness > Separation of wound edges Nursing Care > Aseptic wound management (hand washing) > Frequent perineal pad changes > Administer medications (analgesics / antibiotics)  Possible Postpartum Complication Postpartum Infections (cont.) Urinary Tract Infection > Burning and pain on urination > Lower abdominal pain > Low grade fever > Flank pain > Protienuria, hematuria, bacteriuria and WBC Nursing Care > Frequent emptying of bladder > Increase fluid intake > Antibiotics & Analgesics  Possible Postpartum Complication Postpartum Infections (cont.) Mastitis > Infection of the breast (one sided) seen 2-3 wks after delivery > Caused by staphylococcus aureus > Infected nipple fissure to ductal system involvement- edema obstructs milk flow in a lobe- mastitis Symptoms > Flu like symptoms > Tender, hot, red area on one breast > Breast distention with milk  Possible Postpartum Complication Postpartum Infections (cont.) Mastitis; Nursing Management > Empty the breast by increasing the frequency of nursing or pumping > Antibiotics & Analgesics Postpartum Infection Education > Continue antibiotics > Monitor temp & notify provider if temp >100.4F > Watch for signs and symptoms of a recurrence > Practice good hand washing  Possible Postpartum Complication Postpartum Infections (cont.) Thrombophlebitis and Thrombosis > Thrombosis (blood Clot) can cause inflammation of blood vessel (thrombophlebitis) which can cause thromboembolism (obstruction of blood vessel) Assessment > Tenderness and pain in extremity > Warm and pinkish red color over thrombus area > Palpable- feels bumpy and hard > Increased pain when ambulating  Possible Postpartum Complication Postpartum Infections Thrombophlebitis and Thrombosis; Nursing Care > NSAIDs for pain > Bed rest elevate affected leg > Warm compresses > Elastic stockings Deep Vein Thrombosis Assessment; > Located from foot to pelvis - can dislodge & caused PE > Calf swelling > Warmth & tenderness > Pedal edema > Diminished peripheral pulses  Possible Postpartum Complication Postpartum Infections (cont.) Deep Vein Thrombosis; Nursing Care > Bed rest > Elevate effected leg > Continuous moist heat > Analgesics PRN > Anticoagulation therapy  Postpartum Nursing Diagnoses Health-seeking behaviors r/t care of newborn Fear r/t lack of preparation for child care Risk for deficient fluid volume r/t postpartal hemorrhage Pain r/t uterine cramping Risk for infection (uterine) r/t lochia & denuded uterine surface Disturbed sleep pattern r/t exhaustion from & excitement of childbirth Imbalanced nutrition, less than body requirements, r/t lack of knowledge about postpartal needs Risk for impaired urinary elimination or constipation r/t loss of bladder and bowel sensation after childbirth Pain r/t primary breast engorgement Health-seeking behaviors r/t future breast health Health-seeking behaviors r/t client’s desire to return to pre-pregnant weight and appearance Risk for impaired parenting r/t inadequate bonding behavior after childbirth Nursing Care During Postpartum Period Postnatal care (Daily care of the mother) 1. Clean perineum & apply sterile pad 2. Make her comfortable 4. Allow her to rest 5. Record vital sign 6. Check for any bleeding Assessment > postpartal woman history > physical examination > analysis of laboratory findings  Nursing Care During Postpartum Period Assessment Breasts – soft, filling, firm, nipples Uterus – consistency, position, height Bladder – voiding pattern Bowels – bowel sounds, hemorrhoids, BM Lochia – type, amt, clots, odor Episiotomy – laceration, bruising, swelling Homan sign – present or not Emotional status – bonding, blues Nursing Care During Postpartum Period Interventions Prevention of Complications Reduce Discomfort ADL Nutrition Rest & Sleep Ambulation Bathing Kegel Exercises  Nursing Care During Postpartum Period Promoting Comfort Perineal care Rest Adequate fluid intake Prevent constipation Assess peripheral circulation Prevent/alleviate breast engorgement, Breast hygiene Promote uterine involution Relief of Discomfort Afterpains Muscular aches Episiotomy care Perineal exercises Hot, cold therapy, Sitz baths End of Slides