Postpartum Nursing Care Review PDF

POSTPARTUM NURSING CARE - Puerperium -- post partum - Immediately after birth - About 6 weeks - 4^th^ trimester - Transition to motherhood - Body returns to pre-pregnant state - Involution - Reproductive System Changes - Uterus:...

POSTPARTUM NURSING CARE - Puerperium -- post partum - Immediately after birth - About 6 weeks - 4^th^ trimester - Transition to motherhood - Body returns to pre-pregnant state - Involution - Reproductive System Changes - Uterus: - Involution - Term that describes rapid reduction in size of uterus and returns to pre-pregnant state - Height of fundus decreases by one fingerbreadth 1 cm/day after birth - 6-12 hours after birth @ umbilicus - Immediately after birth: halfway between umbilicus and symphysis pubis - Uterus becomes displaces and deviated to the right when the bladder is full - What can impede the normal process of involution? - Over distention - Prolonged labor - Anesthesia - Infection - Incomplete expulsion of placenta or membranes - Healing of placental site: - Enhanced by: - Uncomplicated labor and birth - Complete expulsion of placenta or membranes - Manual removal of placenta during a C/S - Breastfeeding -- release of oxytocin to help uterus contract - Early ambulation - Afterpains usually last 2-3 days - Usually worse in multipara - Skin to skin & breastfeeding increases frequency & severity due to relase of body's own oxytocin - Assessment of Lochia - Amount - 1 gram = 1mL - Quantitate blood loss for first 2 hours immediately following birth (if low risk) - Should not be soaking 1 pad/hour (**problem!**) - Consistency - Clots? - Nickle sized normal - Larger than plus or golf ball should be investigated - Pattern - **Rubra** -- **red** -- day 1-3 - **Serosa** -- **pink** -- day 3-10 - **Alba** -- **white** -- day 10-14 up to 6 weeks - once it starts changing it should never change back! - Odor - Musty, stale smell - Absence - Never in the 1-3 weeks - Can be a sign of infection - Sometimes scant after c/s but never absent - Average volume of lochia is 225ml - Discharge is greater in the AM due to laying down all night and blood kind of pooling in the vaginal canal - If blood collects and forms clots within uterus, fundus rises and becomes boggy! - Massage the fundus - Cervical changes - Flabby formless and may be bruised - Typically, 2cm 1^st^ few days then fingertip by end of 1 week - External OS changes in shape; changes from dimple to transverse slit "fish mouth" - Vagina - Edematous and may be bruised (rugae absent) - May have superficial lacerations - Size decreased and rugae return in 3-4 weeks - 6 weeks: non-lactating women vagina: normal - Lactating women have hypo-estrogenic vaginal state - Pale mucosal pink decreased rugae and lubrication (painful intercourse) - Kegel exercises will improve vaginal tone - Perineum - Appears edematous with some bruising - Edges of episiotomy or laceration should be well approximated - Hemorrhoids are common, but not a normal finding - Initial healing of repaired tissue occurs in 2-3 weeks - Complete healing may take up to 4-6 months - Discomfort may be notes during this time - Cramping due to uterus contracting down - Vaginal discomfort - Comfort measures: - Ice pack - Sitz bath - Tucks pads - Dermoplast or Americaine spray - Pat dry - Administer analgesics - Pillows for splinting - When sitting; squeeze butt checks together - Ovulation and Menstruation/lactation - Return of ovulation and menstration varies for each postpartum women - Non-lactating mothers: - Menstruation: usually returns by 7 weeks after brith - Ovulation: mean time to return 70-75 days as wearly as 27 days in some - Lactating mothers: - Return of ovulation and menstruation in breastfeeding mothers are prolonged related to length of time breastfeeding continues - Breast begin milk production -- milk production is a result of interplay of maternal hormeones - If mother breastfeeds for \< month: return to menstruation/ovulation is compareable to non-lacting mothers - Vitals & Blood values - Pulse: - \> 100 may indicate hypovolemia, infection, fear, pain and needs further assessment - Bradycardia: - 40-50 beats per min occur during PP r/t decreased cardiac effort, increased stroke volume, and decreased blood volume - B/P: - monitor for HTN or hypotension - May have a transient rise in BP - Temp: - afebrile with exception of 1st 24 hours - Up to 100.4 may be d/t exertion and dehydration of labor - If higher than 100.4 assess for causes - WBC - Often elevated after birth - 20 -- 25 - Activation of clotting factors - Predispose to thrombus formation - Hemostatic system reaches non-pregnant state in 3-4 weeks - Risk of thromboembolism lasts for 6 weeks - Hypercoagulable state: protective mechanism to protect from PPH (postpartum hemorrhage) - Blood Loss\*\* - Average for vaginal: 200-500mL - Average for C/S: 1000ml - drop in HCT: signals abnormal blood loss - rule of thumb: 2-3% point drop in HCT = 500mL blood loss - blood values are difficult to interpret the 1^st^ 48 hours d/t hemodynamic changes - **first 1-2 days** - hemoconcentration - **rise** in hematocrit - extracellular fluid excreted - diuresis - **Day 3-4** - interstitial fluid is mobilized - causes hemodilution - HBG and HCT **decrease** by the end of 1^st^ PP week - Cardio: - Increased fluid volume is now being lost - Decreases Cardiac output - Normal by 6-12 weeks - Weight loss: - Initial loss of 10-12lbs - Infant - Placenta - Amniotic fluid - 6-8 weeks PP may have returned to pre-pregnant weight - diaphoresis - Elimination of excess fluid and waste products - Sweating, especially at night, may awake soaked - 3kg weight loss - If does not have - Pulmonary edema - Cardiac problems - CHF - GI - Hungry and thirsty after birth - intake driven by type of birth and anesthesia - intestines sluggish because of lingering effects of progesterone and decreased muscle tone - spontaneous bowel movement may not occur for 2-3 days after childbirth - mother may anticipate discomfort because of perineal tenderness or fear of episiotomy tearing - may use stool softeners to help make more comfortable - elimination returns to normal within one week - after cesarean section, bowel tone returns in few days and flatulence causes abdominal discomfort - Urinary Tract - Increased bladder capacity - Decreased bladder tone & sensation - Increased swelling and bruising of tissue - Over-distention - Incomplete emptying - Buildup of residual urine - Puerperal diuresis leads to rapid filling of bladder - Urinary stasis increases change of UTI - If fundus Is higher than expected on palpation and is not in midline, nurse should suspect bladder distension - Abdominal muscles: - Diastasis recti abdominins - Separation of abdominal muscles may be present from pregnancy - Worse with increasing number of pregnancy, less pregnancy spacing, type and amount of pshyical exercise and physical condition of mother - May be more pronounces in C/S as manually separated to access the uterus - Response to exercise in 2-3 months - Neurological - Headache from fluid shift - Leaking of CSF fluid - Pre-eclampsia headache - Immune - Temp may be 100.4 first 24 hours from exertion and dehydration then normal range - Temp also increased first 24 hours after mother's milk comes in 100-102 - Any other elevated temp present outside these reasons suspect infection - Chills - Intense tremors/shivering immediately after birth - Often happens - Theories: sudden release of pelvic nerves, response to fetus to mother transfusion? With placental separation, maternal epinephrine produced during labor and birth, reaction to anesthesia? - No fever = no concern with chill - Provide warm blankets, kangaroo care, reassure is normal - Psychological Changes - Maternal Infant Bonding - A process by which infant and parent get to know each other - Skin to skin - Time alone - Claiming - Family - Co-parenting adaptation -- transition to fatherhood - Expectations and intentions - Confronting reality - Creating the role of involved parent - Reaping rewards - LGBTQ families - Levels of isolation - Inadequately viewed - Stigma - Legal and relationship concerns with birth certificate - Sibling Adaptation - Assess for positive or adverse reactions to infant - Touring unit, sibling to baby gift giving, 1-1 parent time - Include in infant care, doll for preschool age - May have aggression, attention seeking behaviors, increase in independence or dependence - Phases of maternal role attainment - Taking in Phase: dependent - **Self-focused** - Passive dependent - 1^st^ 24-48 hours - Follows suggestions and hesitates to make decisions. Focuses on her needs - May need to talk about labor and birth or very quiet - Sorting through reality vs fantasy of labor and birth - Food and sleep are major needs - Taking Hold Phase: dependent-independent - **Baby and caregiving focused** - Usually begins day 2-3 but varies, can last 10 days to several weeks - Resuming control for her baby - Wants to learn and practice - Dealing with physical and emotional discomforts, experience baby blues - Shift concerns to technique or quality of milk if breastfeeding - Sensitive to feeling unsure or tentative with baby and can feel demoralized if nurse or family is more proficient - Spit up feels as personal failure - Wants to take charge but needs acceptance and reassurance they are doing well - Letting Go Phase: interdependent - **Family focused** - Family as a unit - Resuming and integrating pre-pregnant roles - Phases of Maternal Attachment - Acquaintance Phase - "in face" position - response verbally to sounds of infant - fingertip exploration - claiming - Phase of mutual regulation - Adjustment between needs of mother and needs of infant - Reciprocity - Mutually gratifying interaction among mother, infant, and father - Other feelings - Jealousy - Disappointment - Postpartum blues and anxiety - Mood swings - Anger - Weepiness - Decreased appetite - Difficulty sleeping - Feeling of let-down - Can lead to PPD and other mood disorders - Post Partum Assessment & Care - Immediate care - Comfort measures - Vital signs - Fundal assessment - Lochia check - Bladder function - Bubblehep - Breast - Breast or bottle-feeding - Palpate for engorgement or tenderness - Size, shape of breast - Any abnormalities (redness, swelling, heat, or pain) - Nipples: assess for fissures, cracks, soreness, flat or inversion - Assess bra - Uterus - Empty bladder prior - Determine firmness of fundus and locate position - Normally midline if body -\> massage - Correlate position with approximate descent of 1cm per day - C/S - Still palpate fundus - Observe dressing for drainage, odor, skin surrounding for S/S of infection - Bowel - Assess bowel sounds, flatus, and distention - Bladder - Assess frequency, burning, or urgently - Palpate for bladder distention - Lochia - Lochia changes - If saturation of perineal pad in 15 mins or less can indicate excessive bleeding - Don't want to saturate pad in an hour - **Ask**... when did you change your pad? - Episiotomy/Perineum - Inspect abdominal inscisions for reeda - Redness, edema, ecchymosis, drainage, approximation - Inspect perneuma for reeda - Foud odor, hardened area, erythema, heat & edema -\> infection - Homan's/Hemorrhoids - Side lying - Hemorrhoids size, number, and pain/tenderness - Assess for pedal edema, redness, and warm - Emotion - Physical fatigue often affects other adjustments and functions of new mothers - Pain - Afterpains: - Intermittent uterine contractions - Analgesics within first 24-72 hours - Use pain scale - Comfort is promoted through proper positioning, back rubs, warm/coolness, and oral care - Encourage visits by family and newborn, which provides distraction from painful stimuli - Encourage non-pharmacologic methods of pain relief - Encourage rest - Pain first, may need to premedicate - Ask her how she is feeling before assessment, emotional state - Ask if she needs to use bathroom before assessment - Uterine Stimulants - Oxytocin - Methylergonovine maleate (methergine) - Prostaglandin - Carboprost tromethamine (Hemabate) - Prostin/15m - PGF - Dinoprostone (Prostin E2) - Mistoprostol (Cytotec) - CHART 30 PG 672 - Intermediate Care - Vitals - Assess progress of involution - Nutrition - Rest/sleep - Urinary elimination - Bowel elimination - Homan's sign - Early ambulation - Hygiene - Breast assessment & Care - Perineal care - After pains - Meds - Weight loss - Teach for knowledge deficit - Cesarean Section Assessment and Care - Major abdominal surgery - Abdominal distension can cause discomfort - Left side lying, include exercises, early ambulation, avoid carbonated drinks and straws - May need enemas and stool softeners - Pulmonary infections may occur because of - Immobility - Use of narcotics - Altered immune response - Encourage CTDB every 2 hours - Incentive spirometer - Splint incision with pillow - Start ambulation when sensation and stability returns - Discharge Criteria - Normal vs - Involution of uterus - Appropriate lochia - Without infection -- afebrile - Perineum intact - Voiding - Passing gas - Knowledge of S/S of infection - Ability to perform pericare - Ability to perform self-care - Ability to care for newborn - Receive RhoGAM/rubella - Update immunizations - PE & appropriate discharge teaching - Labs Assessed - Admin RhoGAM and rubella - H&H - Referrals - Follow up post up appointments - WIC - Mental health - Urology for baby if need circ - Audiology for baby if failed hearing - Teaching - Discuss fatigue, nutrition, family adjustment and psychologic status - Community resources if any challenges identified - Warning s/s to call provider - Family planning - No intercourse for 6 weeks - May have decreased lubrication, intercourse needs to be approached slowly - Safe haven laws - Edinburgh Postnatal Depression Screen - Done as screening - Asks only about feelings in the last week - Outpatient, home visit, pediatrician appointments and at 6-8 weeks postpartum follow up visit - Referral if score higher than 9 or answer question 10 with 1 point or higher (suicidal ideation) - Main reason for home visit: - Assess the status of the mother and infant - Adaptation and adjustment of the family to the new baby - Determine current informational needs - Provide teaching as needed - Answer additional questions related to infant care and feeding - Provide emotional support to mother and family The Patient at Risk in Post-Partum - Post-partum Complications - Bleeding - Hemorrhage - Lacerations - Retained placental fragments - Hematoma - Infection - Endometritis - Mastitis - Cardiovascular - DVT - Embolism - Hypertensive disorders - Post-partum Hemorrhage - Drop in maternal HCT of 3% or \> from pre-birth baseline or excessive bleeding that causes hemodynamic instability or requires blood transfusion - \> 500 ml (vaginal) - \>1000 ml (C/S) - May also occur intra-abdominally and as hematomas - Early: - 1^st^ to 24 hours after birth - Late: - 24 hours after birth to 12 weeks after birth - S/S may not occur until 10-30% of blood lost d/t increase blood volume of pregnancy - S/S: - Excessive or bright red bleeding - Saturation fo more than 1 pad per hour - Boggy fundus that does not response to massage - Abnormal clots - High temp - Any unusual pelvic discomfort or backache - Persistent bleeding in the presence of firmly contracted ureters - Rise in the level of the fundus of the uterus - Increase pulse or decreased BP - Hematoma formation or bulging/shiny skin in the perineal area - Decreased level of consciousness - The 4 T's - Tone - Tissue - Trauma - Thrombin - Tone: Uterine Atony - Lack of uterine muscle tone - Caused by conditions that over-distend uterus and affect uterine contractibility - Most common cause of early PP hemorrhage - Perform fundal massage and check for clots! \#1 action - Administer uterine stimulants as ordered to monitor for side effects - Contributing factors: - Overdistention of uterus - Multiple gestation, hydramnios - Dysfunction or prolonged labor - Induction or augmentation of labor - Pitocin - Grand multiparity - G 6, 8, 9 - Medications - MgSO4 - Anesthesia - Ca+ channel blockers - Prolonged 3^rd^ stage - \> 30 mins to deliver placenta - Preeclampsia - Operative birth - Vacuum or forceps - Asian or Hispanic Heritage - Retained placental fragments - Placenta previa or accrete - Distended bladder - Obesity - Assessment Findings: - Uterus larger than normal and boggy with institute massage - Prolonged lochia discharge -- discharges hasn't slowed -- rubrua at day 4 - Irregular or excessive bleeding - Tachycardia & hypotension -- late sign? - Pallor of skin and mucous membranes; cool clammy skin with loss of turgor - Nursing Interventions: - Empty bladder - Institute fundal massage - Record amount of bleeding - VS frequently - Use of oxytocic's - Oxytocin, methergine, Hemabate, ergotrate, Cytotec - Initiate/maintain IVF - Uterine tamponade -- looks like a catheter, fills up with water and puts pressure on uterus. - Surgery -- in rare cases -- hysterectomy - Transfusions if required - Medications: - Oxytocin - First line - Mixed with IV fluids - Methergine or Hemabate - 2^nd^ line - Methergine: - IM -- can cause HTN - Don't use methergine if pt has HTN - Hemabate: - IM - Can cause n/v/d - Don't give if pt has asthma - Tissue: Retained placental Fragments - Placenta or fragments not delivered within 30 mins of delivery - Commonly occurs when fundus is massaged prior to spontaneous placental separation - Suspect if patient is bleeding with firm fundus and no laceration - Inspect placenta thoroughly after birth for intactness - Fundal exploration may be performed after birth if missing fragments noted - May be seen in early or late PP hemorrhages - Most common cause of late PP Hemorrhage - Risk Factors: - Partial separation of normal placenta - Excessive traction of umbilical cord prior to complete separation of placenta - Placental tissue abnormally adherent to wall of uterus - Preterm birth esp. between 20-24 weeks - Physical Assessment Findings: - Uterine atony, subinvolution or inversion - Excessive bleeding or blood clots \> quarter size - Return of lochia rubra after progressing to lochia alba - Foul odor lochia or vaginal discharge - Elevated temp - Treatment: - Manual removal or D/C of fragments - Nursing prep for procedure - Trauma: Lacerations, episiotomy - Bright red bleeding with firm uterus - Suspect if mother is bleeding heavily in presence of firmly contracted fundus - Contact HCP to suture laceration - Predisposing factors: - Nulliparity -- 1^st^ pregnancy - Epidural anesthesia - Precipitous birth -- 3 hours or less -- fast birth - Forceps or birthday - Forceps or vacuum assisted birth - Macrosomia -- big baby - Oxytocin used - Lacerations: - 1^st^ degree: superficial tear confined to epithelial layer - 2^nd^ degree: extend into perineal body, but not into external anal sphincter - 3^rd^ degree: involve superficial or deep injury to external anal sphincter - 4^th^ degree: extends completely through the rectal mucosa - Trauma: hematoma - Bleeding into the tissues -- usually vulva or vagina due to traumatic birth - Symptoms: - Swelling - Severe pain at the stie or rectal pain - Inability to void - Bulging and/or discoloration on vulva - Treatment: - Ice packs - Pain meds - Pts may report unrelieved pain even with pain meds - Last resort: - Evacuation and cauterization - Late PP Hemorrhage - Generally, occurs within from 24 hours to 12 weeks after birth - Frequently due to subinvolution - Failure of uterus to return to normal size - Fundal heigh \> than expected - Much less common than early - Contributing factors: - Deficiency of immunologic factors - Faulty implantation in less vascular lower uterine segment - Retained placental fragments (most common cause) - Infections - Nursing management: - Goal: stop hemorrhage -- correct hypovolemia & treat underlying cause - Identify any risk factors prenatal and upon admission - Early recognition and management of complications - Frequent assessments after birth - Boggy uterus aggressive massage -- 1^st^ line of treatment - Monitor for s/s shock - Pain assessments: after regional anesthesia has subsided monitor for perineal pain (associated with hematomas) usually "intense" - May also have rectal pressure (posterior vagina) - May have difficulty urinating (upper vagina) - Perineal assessments: - Ecchymosis, edema, tenseness of tissue overlying the hematoma, bulging mass at introitus & extreme tenderness to palpation - Perform pad counts -- weigh pads - This included everything during delivery as well - All lines, blood, gauze, etc - VS q 15 mins - Maintain IV access if risk factors present - Monitor bladder status (keep empty) - Monitor and evaluate labs (H&H) - Monitor mental status - Administer meds per HCP order - If risk of PP hemorrhage, type, and cross match for blood - Assess for s/s hemorrhage: fatigue, pallor, H/A, thirst, B/P, and pulse changes - Monitor urinary output - Recognition; readiness; response; record - Puerperal Infection - Infection of reproductive tract associated with childbirth - Occurs up to 6 weeks PP - Endometritis (uterine lining): most common - Peritonitis can occur (uncommon) - Puerperal morbidity - Contamination with bacteria can occur once membranes rupture - Alkaline pH vaginally postpartum favors growth of aerobes - Risk Factors: - C-section especially with extended labor with ROM - Diabetes - Endometritis & Metritis - Endometritis: inflammation of endometrium portion of uterine lining (most common) - Metritis: inflammation of endometrium portion of uterine wall - May occur 1-3% during vaginal births - Aerobic & anaerobic organisms can cause metritis - S/S - Vaginal discharge is bloody - May be scant or profuse (tomato soup consistency) - May have odor - Uterine tenderness/pelvic pai - "Sawtooth" temp spikes - Classic S/S: - Tachycardia - Chills - Foul smelling lochia - Pelvic pain - Treatment: - Endometritis rates have falling d/t prophylactic administration of abx with c-section - Obtain hx and perform physical exam - Blood cultures, lochia cultures, UA - Do this before ever giving ABX - Abx admin - Start broad abx until cultures come back - Usually, penicillin's or cephalosporins - Will continue abx until afebrile for 24-48 hours - Nursing management: - Assessment of perineum, lochia, incision q 8 hours - Admin meds - Vs - Adequate fluid intake - Evaluate labs - Instruct on good perineal care - Proper hand washing - Promote comfort - Thromboembolic disease - May occur antepartum but usually a PP complication - **Venous thrombosis**: can be superficial or deep vein, usually in legs - **Thrombophlebitis**: thrombus formed in response to inflammation in vein wall - **Pulmonary embolus**: rare, life threatening condition occurs when thrombi formed in deep vein dislodges and is carried to pulmonary artery. - **Virchow's Triad**: - Alteration in blood flow - Endothelial damage - Hypercoagubility - Risk Factors: - c/s - immobility - obesity - cig smoker - previous hx - varicose veins - trauma to extremity - DM - AMA - Inherited coag disorders - Multiparity - Anemia - Malignancy - Exogenous hormone use - Superficial thombophlebitits - More common PP than during pregnancy - Usually saphenous vein - More common with women with preexisting varices - S/S: PP day 3 or 4 - Tenderness in portion of vein, local heat & redness, normal temp or low grade, slight increase pulse - Tender palpate cord may be noted along portion of vein - PE rare - Treatment: - Bed, rest, elevation of limb, local heat application, analgesics, support hose - DVT - More frequently seen with a hx of thrombosis - OB complications that increase incidence - Preeclampsia - Operative brith - Polyhydramnios - S/S - Edema of ankle & leg - Initial low grade temp then high temp with chills - Pain/tenderness - Palpate cord, change in limb color, diff in limb circumference - Diagnosis: - Hx & PE - Compression venous ultrasonography - D-dimer - Tx: - Unfractured heparin or LMWH - Strict bedrest - Leg elevation - Analgesics - If fever, abx is given - Do not dislodge the clot! - Avoid compression stockings and sequential devices - Nursing care of Women with Thromboembolic Disease - Assess leg for s/s - Evaluate need to antiembolism stockings - Promote hydration - Avoid prolonged stirrup use - Progressive ambulation after acute phase - Encourage leg exercises, leg elevation - If on anticoagulant therapy: maintain safe administration of meds, comfort measures, monitor for side effects, physical assessment and assess for increase in PP bleeding - Have antidote for heparin available! - Protamine sulfate!! - High Risk Pregnancy - 16% of maternal deaths d/t hypertensive disorders - Can happen in post-partum! - Gestational Hypertension - Chronic essential hypertension - Preeclampsia - Eclampsia - \*\*\* take notes MATH - Mag - Convert lbs. to kg - 11/6 study sesh Review - Ductus arteriosus - Foramen ovale - Close at birth - When they close and how long it takes them to close - If they don't close, what will you see - Liver breaks down RBCs - Jaundice is d/t liver can't get rid of bilirubin bc its not mature enough - Phototherapy - No lotion - No clothes -- worry about temp - Eyes covered - increased risk of jaundice - Bruising during birth causes - Mom with DM - Cephalhematoma - Caped - Precipitous birth - Bowel changes of baby - Voiding for first week of life - Breastfeeding position - Folic acid for iron deficiency