Postpartum Period PDF

POSTPARTUM PERIOD  POSTPARTUM PERIOD Puerperium – the first 6 weeks after delivery/birth - the fourth trimester of pregnancy - the time of maternal changes that are both: * retrogressive ( involution of u...

POSTPARTUM PERIOD  POSTPARTUM PERIOD Puerperium – the first 6 weeks after delivery/birth - the fourth trimester of pregnancy - the time of maternal changes that are both: * retrogressive ( involution of uterus and vagina ) * progressive ( production of milk for lactation, restoration of the normal menstrual cycle and beginning of parenting role National health goals: * Reduce the maternal mortality rate * Reduce the proportion of births occurring within 24 months of a previous birth * Increase the proportion of mothers who breastfeed their babies in the early postpartum period Assessment - by: * health interview * physical examination * analysis of laboratory data Psychological assessment: * was she disappointed or happy about the sex of her baby * is she glad to be through with the pregnancy * does she hold and talk her infant * do you observe her crying * observe for self-care * is she depressed Nursing diagnosis: * Health-seeking behavior related to care of newborn. * Risk for impaired parenting related to disappointment in the sex of the child. * Fear related to lack of preparation for child care * Risk for deficient fluid volume related to postpartal hemorrhage. Special needs 1. Prevention and early detection and treatment of complications and disease 2. provision of advice and services on : * breastfeeding * birth spacing * immunization * maternal nutrition  Psychological changes after delivery Rubin’s postpartum phase a. Taking-in phase - a time when the new parents review their pregnancy and the labor and birth - a time of reflection - 2-3 day period - woman is passive - prefers having a nurse minister to her (bringing her a bath towel or a clean nightgown) and make decisions for her - her dependence is due to * perineal stitches, afterpains or hemorrhoids; * partly from her uncertainty in caring for her newborn * partly from the extreme exhaustion that follows childbirth - wants to talk about her pregnancy, labor and birth - encouraging her to talk about the birth helps her integrate it into her life experiences a. Taking-in phase - her dependence is due to * perineal stitches, afterpains or hemorrhoids; * partly from her uncertainty in caring for her newborn * partly from the extreme exhaustion that follows childbirth - wants to talk about her pregnancy, labor and birth - encouraging her to talk about the birth helps her integrate it into her life experiences b. Taking-hold phase/Transition phase - after passive dependence, the woman begins to initiate action - begins to make her own decisions - may reach this second phase in a matter of hours after birth for women without anesthesia - has strong interest in taking care of her child - it is always best to give a woman brief demonstration of baby care and then allow her to care for her child herself – with watchful guidance - with strong independence, still feels insecure about her ability to care for her new child - needs praise for the things she does well to give her confidence, continues from hospital to home c. Letting-go phase - called letting go - woman redefines her new role - she gives up fantasized image of her child and accepts the real one - gives up from being childless  Physiologic adaptations after delivery Cardiovascular system a. blood loss b. reduction in blood volume c. increase blood volume during pregnancy enters the maternal circulation d. blood volume returns to nonpregnant levels 1-2 week after delivery  Physiologic adaptations after delivery Integumentary sytem a. skin changes during pregnancy gradually disappears b. striae albicantes c. hyperpigmentation of the areola may not disappear completely  Physiologic adaptations after delivery Gastrointestinal system a. hungry b. bowel movement maybe delayed resulting to constipation  Physiologic adaptations after delivery Urinary system a. diuresis begins 12 hours after delivery b. acetone in the urine right after labor c. bladder and urethra are traumatized d. bladder tone regained after 1 week e. assess bladder Effects of bladder distention : * hemorrhage * infection * increased discomfort * atony of bladder wall * overflow incontinence  Sign of full bladder : * suprapubic swelling with resonant sound on percussion * high fundus * increase lochia Measures to induce voiding : * provide privacy * let woman listen to a sound of running water * pour warm water over the perineum * assist woman to bathroom or offer bedpan * place woman’s hand on warm water * practice kegel’s exercise * increase fluid intake * catheterization Measures to prevent infection : * flush perineum, wipe from front to back * apply perineal pad from front to back * liberal fluid intake * use decoction of guava leaves * perilight treatment * report S/S of UTI o frequency of urination/ urgency of urination o painful urination o suprapubic pain  Physiologic adaptations after delivery Reproductive system Uterus Uterine involution 1. uterine involution 2. diminution of uterine size 3. new endometrium 4. uterus does not return to its original size 5. breastfeeding promote involution Physiologic adaptations after delivery Fundus 1. fundus is assessed frequently for firmness, position and height 2. palpate fundus 3. height of fundus UTERINE INVOLUTION UTERINE INVOLUTION Uterine contractions 1. UC during the postpartum period prevent bleeding 2. afterpains 3. afterpains are present for 2 – 3 days after childbirth 4. nursing measures : * explain * keep bladder empty * prone position * massage uterus gently * never apply heat to abdomen * administer analgesics as ordered Lochia 1. lochia is a uterine discharge after delivery 2. lochia is never absent 3. color and pattern a. Lochia rubra b. Lochia serosa c. Lochia alba 4. amount - scant amount - light amount - moderate amount - heavy amount 5. presence of clots 6. smell 7. Signs of abnormal lochia SIGNS POSSIBLE CAUSE Foul smell Infection Large clots Retained fragments Excessive amount with Lacerations of birth canal contracted uterus Return to rubra after Retained fragments serosa or alba Infection A reddish color in lochia that persists for more than 2 weeks indicates retained fragments Bleeding after 6 weeks Subinvolution of the uterus Infection Placental site 1. heals in 6 weeks 2. bleeding maternal vessels in placental site are sealed off by thrombosis and uterine contractions > healing is achieved by exfoliation – involves complete regrowth of endometrium > the remaining decidual lining undergoes necrosis, is sloughed off and is shed in the lochia Cervix 1. soft, edematous and relax 2. regains prepregnent firmness after first 6 weeks postpartum External os - does not return to it original prepregnant condition Internal os - assumes a slit like appearance 3. external os is closed by the end of first week and will not admit a finger Vagina 1. soft and swollen after childbirth 2. lacerations and episiotomy are usually healed after 2 weeks 3. after 3-4 weeks, rugae reappear but not numerous 4. vagina returns to prepregnant condition after 6-8 weeks 5. hymen is converted to myrteformes carucles Perineum 1. traumatized, swollen, discolored and painful, often with lacerations and episiotomy 2. observe for signs of infection * edema * redness * purulent discharge * gaping at suture line 3. discomfort of episiotomy does not last for more than 1 week Non-absorbable suture - is removed on the 5th and 6th day Absorbable sutures - not removed and are absorbed  1. perineal muscle tone is regained by 6 weeks 2. perineal care : Purpose : to prevent infection to ease woman to eliminate odor Instructions : flush with warm water from front to back pat dry from front to back change perineal pad observe incision for signs of infection (redness, swelling, unusual discharge) apply topical agents reduce hemorrhoids tighten buttocks before sitting  Ice packs – lessen discomfort  Sitz bath- application of heat to perineum to promote circulation by vasodilation, thereby promoting healing o perineum is immersed in 45 inches of water with temperature of 102 to 105 F for 3-5 times a day for no more than 20 minutes Perineal lamp - perilight - promote vasodilation and perineal healing PERINEAL CARE SITZ BATH PERILIGHT TREATMENT / HEAT LAMP TREATMENT POSTPARTUM PSYCHIATRIC DISORDERS Causes: - currently unknownIt - multifactorial with many contributory factors. Current beliefs on the causes on its cause include the following views:  stress responsibilities of child rearing  Sudden hormonal changes  Low free serum tryptophan levels  Postpartum thyroid dysfunction POSTPARTUM PSYCHIATRIC DISORDERS Risk Factors:  Unwanted pregnancy  Feeling unloved by mate  Below 20 years old  Single mother  Medical indigenge  Low self-esteem  Dissatisfaction with extent of education  Economic problems with housing or income  Poor relationship with husband or boyfriend  Being part of a family with 6 or more siblings  Limited parental support (either as a child or as an adult)  DIFFERENTIATION OF PPB, PPD, PPP Characte- Postpartum Postpartum Postpartum ristics Blues Depression Psychosis Incidence 70% to 80% of 7% to 20% of new mothers 1% to 2% of mothers per new mothers 1000 live births 26% in adolescent mothers Onset Three to five days Usually within six months Usually within two to four after childbirth after childbirth weeks following childbirth Sympto Periodic crying Anorexia, weight loss, Early symptoms may ms spells, sadness, insomnia, fear of harming resemble depression and confusion, the baby, neglect of then suddenly escalate to insomnia and personal care, self- delirium, hallucinations, anxiety destructive, feelings of anger towards self and worthlessness, guilt, baby, bizarre behavior, fatigue, hypochondria, and manifestations of mania, low self-esteem and thoughts of hurting self or baby Contact Maintained Intact but can be Loss of touch with reality, with consistency disoriented; sense of severe regressive reality suicidal thoughts and breakdown, high risk of depersonalization when suicide and/or infanticide severe  1. Postpartum Blues: - Is a transient disorder that occurs 2-3 days after delivery, peaking on the fifth day and usually resolves within 10-14 days. - It is characterized by mild mood swings that begin to develop after the patient arrives home from the hospital and tends to be worse in primis. Cause: Hormonal changes after delivery Risk Factors: * History of depression * Pre-existing psychosocial impairment 1. Postpartum Blues: Management: * PPB is self limiting. Medication is not required. * Supportive care and education is important: > The feelings are normal and common. Provide reassurance > Encourage woman to discuss her feelings > Recommend to seek assistance in baby care and other household chores * If symptoms do not disappear within 10 days or become increasingly severe, refer for psychiatric evaluation and counseling.  2. Postpartum Depression - is a more prolonged effective disorder that often occurs during the first month after delivery and lasts for weeks to months. - PPD generally lasts for 3-6 months, with 25% of patients still affected at 1 year. - The signs and symptoms are similar to other major mood disorders.  2. Postpartum Depression Risk Factors:  Postpartum blues  History of postpartum depression  History of mood disorder or premenstrual dysphoric disorder (not necessarily the milder and less- specific premenstrual syndrome)  Family history of depression, bipolar illness, and/or anxiety  Marital dissatisfaction  Anxiety/depression during pregnancy  Infant-related stressors, such as problematic temperament in the baby  Adverse life events or stressors  Inadequate support from family or friends  2. Postpartum Depression Management : 1. Screening: Edinburgh Postnatal Depression Scale - a 10-item self-report test - It is not a diagnostic tool as diagnosis of postnatal depression - requires clinical evaluation. * 5X more sensitive than routine clinical evaluation * Responses are scored 0, 1, 2, 3 with max. score of 30 * A score of >12 indicates postpartum  2. Postpartum Depression Management : 2. Individual counseling - more effective than group sessions 3. Group therapy : effective when the patient is recovering from severe depression 4. Therapeutic communication: * Tell her depression occurs in many other women after delivery and in most cases, the signs and symptoms resolves. This provides reassurance and hope for recovery. * Provide opportunity to express feeling verbally or by other creative outlets. * Allow to ventilate feelings of guilt and resentment. Avoid being judgmental at this time. Discuss patient’s feelings in an atmosphere of trust and acceptance. 2. Postpartum Depression Management : 5. Provide assistance in performing activities of daily living. 6. Support groups: Beneficial during the recovery phase to help reduce feelings of isolation, anger and guilt. 7. Monitor for signs of suicidal tendencies when depression sets it and when the patient begins to recover from depression. - When a woman with severe postpartum depression becomes suicidal, she may consider killing her infant and young children, not from anger but from a desire not to abandon them.  2. Postpartum Depression Management : 8. Medications: SSRI’s such as Paxil, Celexa, Effexor, Lexapro, Zoloft, Prozac and Trazadone or Wellbutrin for insomnia. a. Selective serotonine reuptake inhibitors (SSRI’s) or secondary amines. - can be used by nursing mothers without adverse effects on the infant.  Avoid alcohol, barbiturates, and over-the-counter medications (including herbal preparations) during medication because these substances may interact with the antidepressant medications.  Instruct patient of the expected side effects and not to discontinue taking the medication if she experience them.  Instruct patient not to increase, decrease or discontinue medication without advice from physician or nurse.  Tell patient that the medications may take 2-3 weeks before taking effect and improvement in her mood can be felt.  Instruct to stop breastfeeding when antidepressant drugs are passed on the breastmilk such as doxepin.  Antidepressant medication is continued until 9-12 months after remission of signs and symptoms with tapering of dose during the last 1-2 months. b. There is no clinical indication for women treated with tricyclic antidepressants (TCAs), other than doxepin, to stop breastfeeding, provided the infant is healthy and its progressed monitored. c. Lithium is known to impair thyroid and renal function in adults. In view of the significant risks to the infant of a breastfeeding mother taking lithium, mothers should be encouraged to avoid breastfeeding. If a decision is made to proceed, close monitoring of the infant, including serum lithium levels, should be made. d. Electroconvulsive therapy for patients with severe PPD because it is one of the most effective treatments available for major depression. 3. Postpartum Psychosis (PPP) - Is the most severe and the rarest postpartum psychiatric disorder. - It is characterized by a group of severe and varied disorders with mania, depression or schizoaffective disorder that elicit psychotic symptoms which could endanger the patient or the newborn. - The signs and symptoms are similar to other psychotic disorders and typically appear during the first two to four weeks after delivery that generally lasts for three months. - Puerperal psychosis has better prognosis than other psychotic disorder. Recurrence may occur in about 10-25% of cases.  3. Postpartum Psychosis (PPP) Risk Factors:  Previous puerperal psychosis  History of manic-depressive disorder  Obsessive personality  Family history of mood disorder  Prenatal stressors (lack of partner, low socioeconomic status) 3. Postpartum Psychosis (PPP) Management: 1. When a woman exhibits signs of PPP such as hallucinations and delusions, it is a medical emergency that requires hospitalization for immediate psychiatric evaluation and treatment. 2. Removal of infant from the mother for safety considerations. 3. Medications: Antipsychotic medications, Sedatives 4. Electroconvulsive therapy is the last resort if other treatment fails. ECT is usually instituted if waiting for the therapeutic effects of medications will endanger the life of the mother or infant. 5. Psychotherapy: Often long term psychotherapy is required.