Chapter 16: Nursing Management During the Postpartum Period (OB)

What is bonding?

What is attachment?

Bonding:
- Close emotional attraction to a newborn by the parents that develop the first 30 to 60 minutes after birth
- Unidirectional, from parent to infant

Attachment:
- Development of a strong affection between an infant and a significant other (mother, father, sibling, caregiver)

When is postpartum assessment performed?

During the first hour: every 15 minutes

During the second hour: every 30 minutes

During the first 24 hours: every 4 hours

After 24 hours: every hour

How are vital signs after giving birth?

Temperature: slight elevation during first 24 hours; normal afterward

Pulse: 40 to 80 bpm at rest during 1st week after birth = puerperal bradycardia

Respirations: 12 to 20 breaths per minute at rest

Blood pressure: within usual range (should not be higher than 140/90 or lower than 85/60)

Pain: goal between 0 and 2 on pain scale

What are risk factors for postpartum infection?

Operative procedure (forceps, cesarean birth, vacuum extraction)

History of diabetes, including gestational-onset diabetes

Prolonged labor (more than 24 hours)

Use of indwelling urinary catheter

Anemia (hemoglobin <10.5 mg/dL)

Multiple vaginal examinations during labor

Prolonged rupture of membranes (>24 hours)

Manual extraction of placenta

Compromised immune system (HIV-positive)

What are risk factors for postpartum hemorrhage?

Precipitous labor (less than 3 hours)

Uterine atony

Placenta previa or abruptio placenta

Labor induction or augmentation

Operative procedures (vacuum extraction, forceps, cesarean birth)

Retained placental fragments

Prolonged third stage of labor (more than 30 minutes)

Multiparity, more than three births closely spaced

Uterine overdistention (large infant, twins, hydramnios)

What are postpartum danger signs?

Fever >100.4°F (38°C)

Foul-smelling lochia or an unexpected change in color or amount

Large blood clots or bleeding that saturates a peripad in an hour

Severe headaches or blurred vision

Visual changes, such as blurred vision or spots, or headaches

Calf pain with dorsiflexion of the foot

Swelling, redness, or discharge at the episiotomy, epidural, or abdominal sites

Dysuria, burning, or incomplete emptying of the bladder

Shortness of breath or difficulty breathing without exertion

Depression or extreme mood swings

What physical assessment is done during the postpartum period?

Breasts (size, contour, engorgement)

Uterus (height of fundus, firmness)

Bladder (voiding, bladder emptying)

Bowels (bowel sounds, distention)

Lochia (amount, color, odor)

Episiotomy and perineum (lacerations, hematoma)

Extremities

Emotional status

What are positive vs negative attachment behaviors in the infant?

Positive:
Smiles; is alert; demonstrates strong grasp reflex to hold parent's finger; sucks well, feeds easily; enjoys being held close; makes eye-to-eye contact; follows parent's face; appears facially appealing; is consolable when crying

Negative:
Feeds poorly, regurgitates often; cries for long periods, colicky and inconsolable; shows flat affect, rarely smiles even when prompted; resists holding and closeness; sleeps with eyes closed most of time; stiffens body when held; is unresponsive to parents; doesn't pay attention to parents' faces

What are positive vs negative attachment behaviors in the parent?

Positive:
Makes direct eye contact; assumes en face position when holding infant; claims infant as family member, pointing out common features; expresses pride in infant; assigns meaning to infant's actions; smiles and gazes at infant; touches infant, progressing from fingertips to holding; names infant; requests to be close to infant as much as allowed; speaks positively about infant

Negative:
Expresses disappointment or displeasure in infant; fails to "explore" infant visually or physically; fails to claim infant as part of family; avoids caring for infant; finds excuses not to hold infant close; has negative self-concept; appears uninterested in having infant in room; frequently asks to have infant taken back to nursery to be cared for; assigns negative attributes to infant and calls infant inappropriate, negative names

What aspects of the emotional status should be assessed?

Interactions with family

Level of independence

Energy levels

Eye contact with infant

Posture and comfort level with infant

Sleep and rest patterns

Be alert for mood swings, irritability, or crying episodes

What is proximity in the critical attributes of attachment?

Proximity refers to the physical and psychological experience of the parents being close to their infant. This attribute has three dimensions:

Contact: The sensory experiences of touching, holding, and gazing at the infant are part of proximity-seeking behavior.

Emotional state: The emotional state emerges from the affective experience of the new parents toward their infant and the parental role.

Individualization: Parents are aware of the need to differentiate the infant's needs from themselves and to recognize and respond to them appropriately, making the attachment process also, in a way, one of detachment

What is reciprocity in the critical attributes of attachment?

Process by which the infant's abilities and behaviors elicit parental response. Reciprocity is described by two dimensions: complementary behavior and sensitivity.

Complementary behavior involves taking turns and stopping when the other is not interested or becomes tired. An infant can coo and stare at the parent to elicit a similar parental response to complement their behavior.

Parents who are sensitive and responsive to their infant's cues will promote their development and growth. Parents who become skilled at recognizing the ways their infant communicates will respond appropriately by smiling, vocalizing, touching, and kissing

What is commitment in the critical attributes of attachment?

Commitment refers to the enduring nature of the relationship. The components of this are twofold: centrality and parent role exploration.

In centrality, parents place the infant at the center of their lives. They acknowledge and accept their responsibility to promote the infant's safety, growth, and development.

Parent role exploration is the parents' ability to find their own way and integrate the parental identity into themselves

What are the Stages in the Transition to Parenthood?

Commitment, attachment, preparation for an infant during pregnancy

Acquaintance with and attachment to the infant, learning how to care for the infant; physical restoration in first
weeks after birth

Moving toward a new normal routine in the first 4 months after birth

Achievement of a parenthood role around 4 months

What factors affect attachment?

Parent's background

Infant temperament and health at birth

Care practices

Separation immediately after birth

Policies discouraging exploring infant

Intensive care environment

Staff indifference or lack of support for parents

What teaching topics are done for the postpartum period?

Pain and discomfort

Immunizations

Nutrition

Activity and exercise

Lactation

Discharge teaching

Sexuality and contraception

Follow-up

Nursing Management in Postpartum Period: Nursing Interventions #1

Providing optimal cultural care (see Box 16.3)

Promoting comfort:
- Cold (first measure after vag birth, can be used up to 24 hours, + used intermittently for 20 mins on and 10 mins off) and heat applications
- Topical preparations (benzocaine, witch hazel pads, products for nipple pain, and expressed breast milk)
- Analgesics (NSAIDs/Ibuprofen + naproxen + acetaminophen)

Assisting with elimination:
Promoting voiding + Promoting bowel elimination)

Nursing Management in Postpartum Period: Nursing Interventions #2

Promoting activity, rest, and exercise: - Early ambulation
- Rest periods
- Exercise program; recommended exercises; Kegel exercises

Assisting with self-care measures

Ensuring safety

Counseling about sexuality and contraception

Nursing Management in Postpartum Period: Nursing Interventions #3

Promoting nutrition:
- General recommendations (see Box 16.4)
- Needs for the breast-feeding woman

Supporting choice of newborn feeding method:
- Assistance with breast-feeding + bottle feeding

How to ensure safety during ambulation:

Check blood pressure first

Elevate head of bed for a few minutes before ambulating

Have client sit on side of bed for a few moments first

Help client stand up and stay with her

Ambulate alongside client and provide support if needed

Frequently ask client how her head feels

Stay close by to assist if she feels lightheaded

How is breast engorgement alleviated in breast-feeding women?

If the mother is breast-feeding, encourage frequent feedings at least every 2 to 3 hours, using manual expression just before feeding to soften the breast so the newborn can latch on more effectively. Advise the mother to allow the newborn to feed on the first breast until it softens before switching to the other side

How is breast engorgement and suppression of lactation alleviated in bottle-feeding women?

If the woman is bottle feeding, explain that breast engorgement is a self-limiting phenomenon that disappears as increasing estrogen levels suppress milk formation (i.e., lactation suppression)

Encourage the woman to use ice packs, to wear a snug, supportive bra 24 hours a day, and to take mild analgesics such as acetaminophen. Encourage her to avoid any stimulation to the breasts that might foster milk production, such as warm showers or pumping or massaging the breasts

Medication is no longer given to hasten lactation suppression because these agents had limited effectiveness and adverse side effects

What is postpartum blues?

Transient emotional disturbances

Characterized by anxiety, irritability, insomnia, crying, loss of appetite, and sadness

Symptoms usually begin 2 to 4 days after childbirth and resolve by day 8

Blues typically resolve with restorative sleep

Postpartum depression and psychosis are more serious and require professional referral

What criteria should be met when preparing for discharge?

within normal range.

Lochia is appropriate amount and color for stage of recovery.

Hemoglobin and hematocrit values are within normal range.

Uterine fundus is firm; urinary output is adequate.

ABO blood groups and RhD status are known and if indicated, anti-D immunoglobulin has been administered.

Surgical wounds are healing, and no signs of infection are present.

Mother is able to ambulate without difficulty.

Food and fluids are taken without difficulty.

Self-care and infant care are understood and demonstrated.

Family or other support system is available to care for both.

Mother is aware of possible complications

How are immunizations given prior to discharge?

Prior to discharge, check the immunity status for rubella for all mothers and give a subcutaneous injection of rubella vaccine if they are not serologically immune (titer less than 1:8)

Do not give vaccine to immunocompromised mom + the immune status of her close contacts needs to be determined b/f administration

Tdap + inactivated flu can also be given. Nursing mothers can be given rubella (not pregnant women)

Adverse effects: rash, joint symptoms, + low grade fever 5-21 ays later
- Pts should avoid pregnancy for at least 28 days after vaccine d/t risk of teratogenic effects

How is telephone follow up done after discharge?

Telephone follow-up typically occurs during the first week after discharge to check on how things are going at home. Calls can be made by perinatal nurses within the agency as part of follow-up care or by the local health department nurses

One disadvantage of a phone call assessment is that the nurse cannot see the client and thus must rely on the mother or the family's observations. The experienced nurse needs to be able to recognize distress and give appropriate advice and referral information if needed.

How are outpatient follow-ups done after discharge?

For mothers with established health care providers such as private pediatricians and obstetricians, visits to the office are arranged soon after discharge. For the woman with an uncomplicated vaginal birth, an office visit is usually scheduled for 4 to 6 weeks after childbirth

A woman who had a cesarean birth is typically seen within 2 weeks after hospital discharge. Hospital discharge orders will specify when these visits should be made. Newborn examinations and further diagnostic laboratory studies are scheduled within the first week.

How are home visits done after discharge?

Early discharge in combination with home visit follow-up programs has shown safe outcomes for both the mother and infant. Home visits are usually made within the first week after discharge to assess the mother and newborn

Postpartum home visits usually include:

Maternal assessment: general well-being, vital signs, breast health and care, abdominal and musculoskeletal status, voiding status, fundus and lochia status, psychological and coping status, family relationships, proper feeding technique, environmental safety check, newborn care knowledge, and health teaching needed

Infant assessment: physical examination, general appearance, vital signs, home safety check, child development status, any education needed to improve parents' skills

What challenges do families face after discharge?

Lack of role models for breast-feeding and infant care.

Lack of support from the new mother's own mother if she did not breast-feed.

Increased mobility of society, which means that extended family may live far away and cannot help care for the newborn and support the new family.

Nonsupportive, overwhelmed, and fatigued partner.

Feelings of isolation and limited community ties for women who work full-time.

Shortened hospital stays; parents may be overwhelmed by all the information they are given in the brief hospital stay.

Prenatal classes usually focus on the birth itself rather than on skills needed to care for themselves and the newborn during the postpartum period.

Limited access to education and support systems