14.1-7. Post partum

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Post Partum Period

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Post Partum

• Begins after child birth through the 6 th postpartum week

• Reproductive track returns to nonpregnant state•

Adaptation to the maternal role and modificationto the family system

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Safety for Mother and Infant

• Prevent infant abductions• Check ID bands• Educate mother about safety measures

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Clinical Assessment

• Review Antepartum and Intrapartum history• Determine educational needs• Consider religious and cultural factors• Assess for language barriers

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Post Partum AssessmentBUBBLE-HE

• Breast• Uterus• Bladder• Bowel

• Lochia•

Episiotomy• Legs• Emotion

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Breast Assessment•

Inspect for size, contour, asymmetry andengorgement• Nipples check for cracks, redness, fissures• Note if nipples are flat, inverted or erect• Evaluate for mastitis

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Nursing CareLactating Mother

• Supportive bra• Correct position• Correct latch-on technique• Warm showers• Expose to air

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Nursing CareNon-Lactating Mother

• Avoid stimulation• Wear support bra 24hrs•

Ice packs or cabbage leaves• Mild analgesic for discomfort

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Assessment of Uterus• Location immediately after birth• Descends 1 cm/day• Consistency- firm/boggy•

Location Height- measured in fingerbreadths

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Nursing care

• Boggy fundus- massage until firm• Medications- Pitocin, Methergine, Hemabate• Teach new mom to massage her fundus

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Afterpains

• Intermittent uterine contractions due toinvolution

• Primiparous-mild• Multipara- more pronounced

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Nursing Interventions

• Patient in a prone position and place a smallpillow under her abdomen

• Ambulation• Medicate with a mild analgesic

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Bladder

• Spontaneous void 6-8 hrs• Monitor output• Postpartum Diuresis

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Nursing care

• Encourage frequent voiding every 4-6 hours• Monitor intake and output for 24 hrs• Early ambulation• Void within 4 hrs after birth• Catheterize if unable to void

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Bowel

• Anatomy returns to normal location• Relaxin depresses bowel motility• Diminished intraabdominal pressure• Incontinence if sphincter lacerated• Spontaneous BM 2 nd – 3 rd post partum day

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Nursing Care

• Increase fiber in diet• 6-8 glasses of water or juice• Stool softener• Laxative• Sitz bath for discomfort• Medications for hemorrhoids

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Lochia• Mixture of erythrocytes, epithelial cells, blood,

fragments of decidua, mucus and bacteria• As involution proceeds it is the necrotic sloughed

off decidua•

240-270 ml• Cesarean less• Present for 3-6 weeks

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Lochia

• Rubra• Serosa• Alba• Documentation

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Nursing Care

• Educate mother on the stages of lochia• Caution mother that an increase, foul odor or

return to rubra lochia is not normal• Instruct patient to change peri pad frequently• Peri care after each void

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Episiotomy

• 1-2 inch incision in the muscular area betweenthe vagina and the anus

• Assess REEDA• Episiotomy care

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Nursing Care

• Peri care• Ice packs• Sitz baths• Dry heat• Topical medications

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Pain Assessment

• Determine source• Document location, type and duration• Interventions

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Postpartum Blues•

Transient periods of depression during the first 1to 2 weeks postpartum• Tearfulness• Sad feeling• Confusion• Insomnia

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Nursing Care

• Remind mom that the“

Blues”

are normal• Encourage rest• Utilize relaxation techniques• Share her feelings with her partner• If symptoms do not resolve and progress to

depression medical treatment needs to be

sought

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Maternal PhysiologicalAdaptations

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Neurological System

• Maternal fatigue• Transient neurological changes• Headaches• Carpel tunnel improvement

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Renal •

GFR, Creatinine, and BUN return to prepregnantlevels within 2-3 months• Urinary glucose levels return to nonpregnant

levels by 2 nd PP wk• Protienuria resolves by the 6 th PP wk• Natriuresis / Diuresis

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Immune System

Rubella• Administer to nonimmune mothers• Safe for nursing mothers• Avoid pregnancy for 1 month• Flu-type symptoms may occur

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Reproductive System

• Involution of uterus• Healing of placental site• Vaginal changes

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Menstruation and Ovulation

Nonlactactating mother• Menstruation returns in 6-8 wks• First cycle may be anovulatoryLactating mother• Delayed ovulation and menstruation

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Multicultural Nursing Care

• Enhance Cultural Sensitivity• Understand cultural influences on the post

partum period• Provide culturally appropriate care

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HIV/AIDS

• Gloves safety glasses• Discourage breast feeding• Avoid contact personal body fluid with infants

mucous membranes

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Postpartal Surgical Patient

• Tubal ligation• Cesarean birth

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Breastfeeding

• Optimal method of feeding infant• Breast milk- Bacteriologically safe, fresh, readily

available

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• Lactogenesis- secretion of milk• Milk ejection reflex-

“

let down”

reflex• Latch-on• Assess for milk let down

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Breastfeeding

Positions• Cradle hold• Foot ball• Side lying

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Ineffective Breastfeeding

• Incorrect latch-on• Inverted nipples• Breast engorgement

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Collection and StorageBreast Milk

• Room temperature- 4 hrs• Refrigerator- 5-7 days• Deep freezer- 6-7 months

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Formula Feeding

• Formula preparation• Periodically check nipple integrity• Bottle preparation

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Family and Infant Bonding

• Transitioning to parenthood• Assuming the mothering role• Parental bonding• Factors that interrupt bonding

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Transitioning to parenthood

• Difficult and challenging• Provide emotional support• Accurate information• Nursing goal create a supportive teaching

environment

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Bonding

• Bonding process helps to lay the foundation fornurturing care

• Touch- skin to skin• Eye contact• Breastfeeding

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Discharge Teaching•

Fundus and Lochia• Episiotomy care• Incision care•

Signs of infection• Elimination

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• Nutrition•

Exercise• Pain management• Sexual activity• Contraception

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Community Resources

• Support groups• Home visits• Telephone follow-up• Outpatient Clinics

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Postpartum Complications

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Postpartum Hemorrhage

• Blood loss of more than 500 ml of blood after avaginal birth

• 1000 ml of blood after cesarean section• Any amount of bleeding that places mother in

hemodynamic jeopardy

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LARRY- common causes of early PPH• Laceration• Atony•

Retained placental tissue• Ruptured uterus• You pulled to hard on the cord

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• 4 Ts- factors associated with PPH• Tone• Trauma• Tissue• Thrombin

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PPH - Tone/Atony

• Altered muscle tone due to overdistention• Prolonged or rapid labor• Infection• Anesthesia

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PPH - Trauma

• Cervical lacerations• Vaginal lacerations•

Hematomas of vulva, vagina or peritoneal areas

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PPH - Tissue

• Retained placental fragments• Uterine inversion•

Subinvolution

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PPH - Thrombin

• Disorders of the clotting mechanism• This should be suspected when bleeding

persists without an identifiable cause

f

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Management of PPH• Frequent VS• Fundal massage• Administer medications• Monitor blood loss for amount• Maintain IV• Type & cross match• Empty bladder

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P I f i

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Postpartum Infections

• A fever of 100.4 or higher after the first 24 hrs for2 successive days of the first 10 PP days

• Fever of 102.2 or greater within first 24 hrs-sever pelvic sepsis Group A or B streptococcus

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E d i i

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Endometritis

• Involves the endometrium, decidua and adjacentmyometrium of the uterus

• Lower abdominal tenderness or pain• Temperature• Foul-smelling lochia

N i C

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Nursing Care

• Administer broad spectrum antibiotic• Provide analgesia• Provide emotional support

W d I f i

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Wound Infection

• Sites- Cesarean incision, episiotomy and genitaltract laceration

• Drainage• Edema• Tenderness• Separation of wound edges

N i C

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Nursing Care

• Aseptic wound management• Frequent perineal pad changes• Good hand washing• Administer antibiotics• Analgesics

U i T t I f ti

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Urinary Tract Infectio n

• Burning and pain on urination• Lower abdominal pain• Low grade fever• Flank pain• Protienuria, hematuria, bacteriuria, nitrates and

WBC

N i C

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Nursing Care

• Frequent emptying of bladder• Increase fluid intake• Antibiotics• Analgesics

M titi

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Mastitis

• Infection of the breast (one sided)• Seen 2-3 weeks after delivery• Caused by staphylococcus aureus• Infected nipple fissure - to ductal system

involvement- edema obstructs milk flow in alobe- mastitis

M titi S t

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Mastitis Symptoms

• Flu like symptoms• TBreast distention with milk• ender, hot, red area on one breast

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Postpartum Infection

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pEducation

• Continue antibiotics• Monitor temperature and notify provider if temp

greater then 100.4•

Watch for signs and symptoms of a recurrence• Practice good hand washing

Thrombophlebitis and

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Thrombophlebitis andThrombosis

• Thrombosis (blood Clot) can cause inflammationof the blood vessel (thrombophlebitis) which cancause thromboembolism (obstruction of bloodvessel)

Assessment Superfical

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Assessment Superfical

• Tenderness and pain in extremity• Warm and pinkish red color over thrombus area• Palpable- feels bumpy and hard• Increased pain when ambulating

Nursing Care

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Nursing Care

• NSAIDs for pain• Bed rest elevate affected leg• Warm compresses• Elastic stockings

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Pulmonary Embolism

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Pulmonary Embolism

• Abrupt onset: chest pain, dyspnea, diaphoresis,syncope, anxiety

• ABC response

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