Nurs 2410 Family Nursing: Postpartum & Postpartum Complications PDF

NURS 2410 FAMILY NURSING Week 7 - Postpartum & Postpartum Complications 1  POSTPARTUM PHYSIOLOGICAL ADAPTATIONS 2 Physical Changes Betweenbirth & return of the reproductive organs to their nonpregnant state (lasts approx...

NURS 2410 FAMILY NURSING Week 7 - Postpartum & Postpartum Complications 1  POSTPARTUM PHYSIOLOGICAL ADAPTATIONS 2 Physical Changes Betweenbirth & return of the reproductive organs to their nonpregnant state (lasts approximately 6 weeks) Physiological changes consist of uterine involution; lochia flow; cervical involution; decrease in vaginal distention; alteration in ovarian function and menstruation; and cardiovascular, urinary tract, breast, and gastrointestinal tract changes. Risks are hemorrhage, shock and infection 3 Assessment BP & HR q15min for first 2 hrs Temp q4h for the first 8 hours and then q8h Assessment pneumonic BUBBLE Breasts Uterus (fundal height, uterine placement & consistency) Bowel Bladder Lochia (color, consistency & amount (COCA)) Episiotomy (redness, edema, ecchymosis, approximation (REEDA)) Vital signs 4 Breasts Colostrum is secreted during pregnancy through 2-3 days after birth Milk is produced 3-5 days after birth Determine if the client plans to breastfeed Engorgement is a result of lymphatic circulation, milk production, and temporary vein congestion. The breast will appear tight, tender, warm, and full Do not plan to breastfeed: will resolve on its own, but breast binders or support bras can be used, or an ice pack or cabbage leaves can be applied. Plan to breastfeed that breast care and frequent feedings will prevent or manage engorgement. Observe for erythema, breast tenderness, cracked nipples & indications of mastitis (infection in milk duct of the breast with concurrent flu-like symptoms) 5 Breastfeeding Promote breastfeeding within 1-2 hours after birth Assist with positioning: football, cradle, modified cradle & sideling Properlatch: newborn takes in part of the areola & nipple to prevent nipple soreness Breastfeedingcauses release of oxytocin which stimulates uterine contraction 6 Uterus Decreases in size from 1,000 g at 3rd stage of labor to 60-80 g 6 weeks postpartum Fundal height descends into pelvis 1 cm per day Immediatelyafter birth: midline & 2 cm below umbilicus 1 hr after delivery: fundus should rise to the level of the umbilicus 24hrs: descents 1-2 cm/day and should be between symphysis pubis & umbilicus 2 weeks: uterus should lie within true pelvis & should not be palpable 7 Uterus Assessment Palpation: cup one and just above the symphysis pubis to support lower segment of uterus and with the other hand, palpate the abdomen to locate fundus Determine fundal height: fingerbreadths (cm) to fundus and the umbilicus Determine if fundus is midline or displaced Determine whether fundus is firm or boggy Document If above the umbilicus, document as +1, U+1, 1/U. If below the umbilicus, document as -1, U-1, U/1. Administeroxytocic IM or IV after placenta is delivered to promote uterine contractions & prevent hemorrhage 8 Bowel Forceps, vacuum assisted delivery & anal sphincter lacerations increase risk of temporary postpartum anal incontinence that resolves within 6 months Physical changes Increased appetite, constipation, hemorrhoids Assessment Assess bowel sounds BM might not occur 2-3 days after delivery Assess for discomfort from perineal tenderness, episiotomy, lacerations & hemorrhoids Assess rectal area for varicosities (hemorrhoids) Encourage early ambulation, increased fluids & intake of high fiber foods Administer stool softener to prevent constipation 9 Bladder Distended bladder can cause infection, uterine atony & displacement to one side Postpartum diuresis begins within 12 hrs after delivery 3,000 mL/day is normal within 2-3 days after delivery Assess for evidence of distended bladder Fundal height above the umbilicus or baseline level Fundus displaced from the midline over to the side Bladder bulges above the symphysis pubis Excessive lochia Tenderness over the bladder area Have the client void within 6-8 hours after delivery & place catheter if unable to Measure the first few voids after delivery to assess for bladder emptying 10 Lochia Postbirth uterine discharge that contains blood, mucus & uterine tissue Amount is similar to a heavy menstrual period about 2 hrs after delivery 3 stages Lochia rubra: Dark red color, bloody consistency, fleshy odor, can contain small clots, transient flow increases during breastfeeding and upon rising. Lasts 1 to 3 days after delivery. Lochia serosa: Pinkish brown color and serosanguineous consistency. Can contain small clots and leukocytes. Lasts from approximately day 4 to day 10 after delivery. Lochia alba: Yellowish white creamy color, fleshy odor. Can consist of mucus and leukocytes. Lasts from approximately day 10 up to 6 weeks postpartum. 11 Lochia Assessment Assess Amount: q15 for first 1 hr, q1h for 4 hours, q4-8h Color, odor & consistency Assess for pooled lochia on the pad under buttocks Massaging or ambulation can result in gush of lochia If a C/S was performed there will be decreased bleeding Abnormal Bright red blood from the vagina: cervical or vaginal tear Saturation of 1 pad in 15 mins: hemorrhage Foul odor: infection Heavy lochia rubra beyond 3 days: retained placental fragments Continued lochia serosa or alba beyond normal length: endometritis with fever, pain or abdominal tenderness Education: change pads frequently, hand hygiene, do not use tampons 12 Cervix, Vagina & Perineum Cervix can be edematous, bruised & have small lacerations 2-3 days after postpartum: cervix shortens & regains its form Vaginagradually returns to size & reappearance of rugae & thickening of vaginal mucosa Muscle tone is never restored completely Breastfeeding increases the incidence of vaginal dryness & atrophy Perineum soft tissue can be erythematous & edematous Hematomas & hemorrhoids can be present 13 Cervix, Vagina & Perineum Assessment Assess Cervical, vagina & perineum for erythema, edema & hematoma Assess episiotomy and lacerations for approximation, drainage, quantity, and quality. A bright red trickle of blood from the episiotomy site in the early postpartum period is a normal finding Healing occurs 2-3 weeks & complete healing occurs within 4-6 months Ice packs to the perineum for the first 24 hours Hot packs, moist heat & sitz bath (BID for 20 mins) to increase circulation & promote healing Administer acetaminophen & ibuprofen or codeine/hydrocodone Apply witch hazel compresses for hemorrhoids Use peri bottle to clean after voiding 14 Vital Signs BP usually unchanged ↑ BP: postpartum hypertension ↓ BP: bleeding Orthostatic hypotension within 48 hours postpartum can occur ↑ HR, stroke volume & cardiac output for the first 1 hour postpartum then gradually decreases 6-8 weeks Puerperal bradycardia (40 BPM) due to ↑ stroke volume ↑ temp (38 C or 100.4 F) from dehydration & labor in the first 24 hours after labor Elevation after first 24 hrs can indicate infection 15 Cardiovascular System ↓ in blood volume 300-500 mL blood loss during average vaginal 500-1000 mL blood loss during average C/S Diaphoresis & diuresis Weight loss due to lochia, delivery & diuresis (10 lbs or 8.6 kg) during first 5 days Labs ↓ Hematocrit 20,000-25,000 WBC is common in 4-7 days after birth (postpartum leukocytosis) ↑ fibrinogen during pregnancy & remain elevated: thrombus formation & thromboembolism 16 Musculoskeletal Joints return to their prepregnant state & are completely stabilized The feet can remain permanently increased in size Muscle tone begins to restore Abdominal exercises can’t be started until 4-6 weeks after C/S Postpartumstretching can be started with gradual progression to more strenuous ones Ambulate soon after delivery Perform Kegel exercises to strengthen pelvis muscles 17 Immune System Rubella:client who is nonimmune or has negative titer should receive vaccine during postpartum period Client should not get pregnant 1 month following immunization RH– clients who have RH + newborns must be given RHOGAM within 72 hours after delivery Varicella:client who has no immunity should be administered varicella vaccine Client should not get pregnant 1 month following immunization Tetanus-diphtheria-acellularpertussis vaccine: if client has not received, administer prior to discharge 18 Psychosocial Client can experience many different emotions due to hormonal changes Monitor for postpartum blue & depression Assess Emotional status, observe for bonding with infant Monitor for postpartum blue/depression: decreased appetite, difficulty sleeping, decreased interaction with others, lack of communication Encourage skin to skin with baby after delivery Encourage rooming in with the baby in client’s room at all times Provide support & initiate referrals as needed for counseling 19 BABY FRIENDLY CARE 20  Lack of Parent Infant Parent Infant Bonding Bonding Holds the infant face‑to‑face (en face Apathy when the infant cries position), maintaining eye contact Disgust when the infant voids, stools, Identifies the infant’s unique or spits up characteristics and relates them to Expresses disappointment in the infant those of other family members Turns away from the infant Names the infant, indicating bonding is occurring Does not seek close physical proximity to the infant Touches the infant and maintains close physical proximity and contact Does not talk about the infant’s unique features Provides physical care for the infant (feeding, diapering) Handles the infant roughly Responds to the infant’s cries Ignores the infant entirely Smiles at, talks to, and sings to the Does not include the infant in the infant family context 21 Perceives infant behavior as uncooperative Nursing Action Encourage skin to skin or en face position immediately after birth Promote rooming‑in as a quiet and private environment that enhances the family bonding process Promote early initiation of breastfeeding and encourage the client to recognize infant readiness cues. Encourage parents to bond with the infant through cuddling, bathing, feeding, diapering, and watching the infant Encourage parents to express feelings, fears, and anxieties about caring for the infant. 22 Coparent Adaptation Encourage Nursing Action Using skin‑to‑skin contact, Provide education about infant holding the infant, and care with each parent or engaging in eye‑to‑eye contact caregiver, and encourage a with the infant. hands‑on approach Observing the infant for Assist the co-parent to similarities to the parent’s own transition to the parental role features. by providing guidance and Talking, singing, and reading to encouraging equal participation the infant in infant care. 23 Sibling Adaptation Assessfor positive responses Nursing Actions from the sibling. Take the sibling on a tour of the Interest and concern for the infant obstetric unit. Encourage the parents to do the Increased independence following. Assess Let the sibling be one of the first to see for adverse responses the infant. from the sibling. Provide a gift from the infant to give the Indications of sibling rivalry and sibling. jealousy Arrange for one parent to spend time Regression in toileting and sleep with the sibling while the other parent habits is caring for the infant. Aggression toward the infant Allow older siblings to help in providing care for the infant. Increased attention‑seeking Provide preschool‑aged siblings with a behaviors and whining doll to care for. 24 CLIENT EDUCATION & DISCHARGE TEACHING 25  Perineal Care Cleanse the perineal area from front to back with warm water after each voiding and bowel movement. Blot perineal area from front to back. Remove and apply perineal pads from front to back. Breast Care Wear a well-fitting bra, do not use underwire Breastfeed infant 8-12 times in a 24 hour period Offer both breasts during feeding & start the feeding with opposite breasts Take a warm shower or apply warm compresses for engorgement Use pump after breastfeeding if breasts are still full Apply breastmilk to nipples to help with soreness 26 Nursing Interventions for Postpartum Care Care for Non-breastfeeding Wear a supportive bra for 72 hours Avoid breast stimulation & avoid running warm water over breasts for extended periods of time Apply cold compresses for 15 mins, cabbage leaves and mild analgesics to help with engorgement Activity Perform Kegel exercises Start with simples exercises & progress to strenuous activity C/S: wait 4-6 weeks to perform abdominal & strenuous exercise & do not lift more than baby’s wt 27 Nursing Interventions for Postpartum Care Nutrition Encourage nonlactating clients to consume 1,800 to 2,200 kcal/day Encourage lactating clients to consume an additional 450-500 calories/day and calcium rich food Sexual Activity Sexual activity can be resumed 2-4 weeks after birth when bleeding has stopped & perineum has healed Contraception Discuss contraception with clients & inform that pregnancy can occur while breastfeeding even though menses has not returned Menses Lactating: might not resume for 6 months or until stopping breastfeeding Nonlactating: 4-10 weeks but ovulation can occur as early as 1 month 28 POSTPARTUM DISORDERS 29 Deep-vein Thrombosis (DVT) Clot in lower extremities that can lead to pulmonary embolism Riskfactors: pregnancy, C/S, PE, immobility, obesity, smoking, multiparty, >35 yo, hx of DVT Expected findings: leg pain & tenderness, unilateral area of swelling, warm & redness, calf tenderness Diagnostics: ultrasound, CT, MRI Medications: heparin, warfarin Education: do not massage leg, use electric razors, avoid aspirin & ibuprofen, soft toothbrush 30 Pulmonary Embolus Complication of DVT. The embolus moved into the pulmonary artery Risk factors: same as DVT Expected findings: chest pain, dyspnea, tachypnea, hemoptysis, tachycardia, cough, crackles, elevated temperature, hypoxia Diagnostics: spiral CT, MRI, embolectomy Medications: same as DVT 31 Coagulopathies Idiopathic thrombocytopenic purpura (ITP): Autoimmune disorder that decreases life span of platelets  hemorrhage RF: genetic Disseminated intravascular coagulation (DIC): Clotting & anticlotting mechanisms occur at the same time  hemorrhage & organ damage from micro clots RF: placenta abruption, amniotic fluid embolism, abortion, fetal death in utero, preeclampsia/eclampsia/HELLP, septicemia, CPR, hemorrhage, hydatiform mole Expected findings: bleeding, petechia, ecchymosis, hematuria, GI bleeding, tachycardia/hypotension & diaphoresis Labs: CBC & type & crossmatch ( ↓ platelets, ↓ fibrinogen levels, ↑ PT, ↑ d- dimer) CORRECT THE UNDERLYING CAUSE 32 Postpartum Hemorrhage >500 mL blood loss after vaginal birth & >1,000 mL after C/S RF:uterine atony, prolonged labor, high parity, ruptured uterus, placenta previa/placenta abruption, precipitous delivery, mg sulfate, inversion of uterus, retained placenta, DIC Expected findings: boggy uterus, blood clots size of quarter, pad saturation in 15 mins, tachycardia/hypotension, pale skin/mucous membranes, oliguria Labs: Hgb & Hct, type & cross Nursing care: Massage the uterus, VS, assess for bladder distension, IV fluids (0.9 NaCl/ RBC/plasma), O2 Medications: oxytocin, methylergonovine, misoprostol, tranexamic acid 33 Uterine Atony Inability of the uterine muscle to contract adequately after birth. RF:retained placenta, prolonged/precipitous labor, oxytocin, overdistension of uterus, mg, anesthesia Expected findings: increased vaginal bleeding, boggy uterus, tachycardia/hypotension Diagnostics: remove placenta fragments, hysterectomy Nursingcare: bladder is empty, fundal height, lochia, fundal massage, VS, IV fluids, O2 Medications: same as postpartum hemorrhage 34 Subinvolution of the Uterus Uterus remains enlarged with continued lochia discharge and can result in postpartum hemorrhage. RF: pelvic infection, endometritis, placental fragments Expected findings: vaginal bleeding, boggy uterus Labs: blood, intracervical & intrauterine bacterial cultures Dilation & curettage (D&C) to remove retained placental fragments Nursing care: fundal check, lochia, VS, bladder Medications: methylergonovine 35 Inversion of the Uterus turning inside out of the uterus and can be partial or complete EMERGENCY  hemorrhage RF:retained placenta, tocolysis, fetal macrosomia, uterine atony, prolonged labor Expected findings: pain in lower abdomen, hemorrhage, red rounded mass through cervix or further, dizziness, hypotension/tachycardia Procedures: manual replacement & positioning Nursing care: pelvic exam, IV fluids, O2, stop oxytocin Medications: terbutaline 36 Retained Placenta placentaor fragments of the placenta remain in the uterus and prevent the uterus from contracting  uterine atony  subinvolution RF: partial separation of placenta, preterm birth Expected findings: bleeding, clots, elevated temperature Labs: Hgb & Hct Diagnostics: manual separation & removal of placenta, D&C if oxytocin are ineffective Nursing care: monitor fundus, lochia, VS, IV fluids, O2 Medications: oxytocin to expel retained placenta, terbutaline used for D&C if oxytocin is unsuccessful 37 Laceration & Hematomas Laceration: tearing of soft tissue in the birth canal Hematoma: collection of clotted blood RF: forceps, vacuum, precipitous birth, cephalopelvic disproportion, size/position of infant Expected findings: Laceration: oozing or trickling of bright red blood Hematoma: pain, pressure sensation in rectum or vagina, difficulty voiding, bulging/bluish mass or red/purple discoloration Nursing care: pain, lochia, VS, identify source of bleeding, ice packs, pain medication, sitz bath Procedures: suturing of episiotomy or laceration 38 POSTPARTUM INFECTIONS 39 Endometritis/Uterine Infection infection of the uterine lining or endometrium Expected findings: pelvic pain, chills, fatigue, loss of appetite, uterine tenderness/enlargement, dark profuse lochia, malodorous/purulent lochia, >38 temp, tachycardia Labs: blood/intracervical/intrauterine bacterial cultures, WBC, RBC Nursing care: collect virginal/blood cultures, IV antibiotics, analgesics Medications: antibiotics 40 Mastitis Infections of the breast that is usually unilateral RF:milk stasis, poor breastfeeding technique, decrease in breastfeeding frequency Expected findings: painful/tender localized hard mass & reddened area in 1 breast, flu like symptoms (chills, fever, headache, body ache), fatigue Labs: blood/intracervical/intrauterine bacterial cultures, WBC, RBC Nursing care: antibiotics Education: wash hands, cleanliness of breast, allow nipples to dry, proper infant position, complete empty of breasts, ice/warm packs, breastfeeding frequency, analgesics, well-fitting bra 41 Wound Infections include cesarean incisions, episiotomies, lacerations, and any trauma wounds present in the birth canal following labor and birth Expected findings: flu like symptoms (body aches, chills, fever, malaise), anorexia/nausea, wound warm/erythema/tender/pain/edema/drainage, >38 temp Labs: blood/intracervical/intrauterine bacterial cultures, WBC, RBC Nursing care: aseptic technique, IV access, IV antibiotics 42 Urinary Tract Infection Expected findings: urgency/frequency/dysuria & discomfort in pelvic area, fever, chills, malaise Diagnostics: urinalysis for WBC, RBC, protein, bacteria Nursing care: urine sample, antibiotics, acetaminophen, perineal hygiene education, increase fluid intake to 3,000 mL/day 43 POSTPARTUM DEPRESSION 44 Postpartum Depression RF: hormonal changes, socioeconomic factors, decrease support system, anxiety, unintended pregnancy, hx of depression, low self-esteem, hx of violence, parent of multiples Postpartum blues: Feelings of sadness, Lack of appetite, Sleep pattern disturbances, Feeling of inadequacies, Crying easily for no apparent reason, Restlessness, insomnia, fatigue, Headache, Anxiety, anger, sadness Postpartum depression: Feelings of guilt and inadequacies, Irritability, Anxiety, Fatigue persisting beyond a reasonable amount of time, Feeling of loss, Lack of appetite, Persistent feelings of sadness, Intense mood swings, Sleep pattern disturbances, wt loss, flat affect, rejection of infant, anxiety/panic attach Postpartum psychosis: Pronounced sadness, Disorientation, Confusion, Paranoia, hallucination, delusions, self-harm or harming the infant 45 Postpartum Depression Nursing care: monitor interactions, monitor mood & affect, reinforce feeling down in postpartum period is normal, encourage client to communicate feelings, reinforce teaching about medications, schedule a follow-up apt, ask if they have thoughts of self-harm Medications: antidepressants, antipsychotics & mood stabilizers 46