Unit 5: Postpartum Part 2 (Ch 22 and 33)

processes of parent-infant relationships

• attachment

• bonding

• proximity

• mutuality

• acquaintance

• claiming process

bonding

the emotions and feelings experienced by the mother (or parent) in relation to the infant

attachment

two-way interaction between the mother (or primary caregiver) and the infant that develops during the first year of the infant’s life

proximity

staying close to the infant

mutuality

the infant’s behaviors and characteristics elicit a corresponding set of parental behaviors and characteristics

acquaintance

eye contact, touching, talking, and exploring to become acquainted with their infant

claiming

• the identification of the new infant

• The child is first identified in terms of likeness to other family members, then in terms of differences, and finally in terms of uniqueness

early interaction

• skin to skin with mom or partner

• helps with bonding and breastfeeding

couplet care / rooming in / dyading

• promotes?

• drawbacks?

• mom and bay stay in the same room for the length of hospital stay

• promotes bonding and learning but mom is required to be with baby 24/7

• she may lose rest

biorhythmicity

• the fetus is in tune with the mother’s natural rhythms, such as her heartbeat

en face is when

• baby is 12 inches from mom making eye contact

entrainment

• allows for?

• what are the babies doing

• Newborns move in time with the structure of adult speech

• allows babies to begin to acquire speech

• They wave their arms, lift their heads, and kick their legs, seemingly “dancing in tune” to a parent’s voice.

Reciprocity

• baby’s part

• mom’s part

• Reciprocity is a type of body movement or behavior that provides the observer with cues

• newborn fusses and cries, the mother responds by picking up and cradling the infant,

• the baby becomes quiet and alert and establishes eye contact, and the mother verbalizes, sings, and coos while the baby maintains eye contact

• back and forth

  
  

synchrony

• the “fit” between the infant’s cues and the parent’s response

• synchronous interaction is mutually rewarding

• specific cry in response to different situations such as boredom, loneliness, hunger, and discomfort

• Parents learn to interpret

• parent may need assistance in interpreting these cries, along with trial-and-error interventions, before synchrony develops

common issues parents face

• sexual intimacy

• division of responsibilities

• financial concerns

• balancing work and parental responsibilities

• social activities

adolescent moms are more at risk for

• more at risk for preeclampsia, anemia, infection, preterm birth, LGW

• PPD, IPV, substance abuse

• lack of prenatal care

babies of adolescent moms are more at risk for

• growth and development issues

• language and speech delays / cognitive delays

• neglect and abuse

issues with adolescent dads

• may not live with mom & baby

• limited education

• live in poverty

• cannot help financially

advanced maternal age issues

• may lack time & energy

• may have less support

• may also be taking care of their own parents

same sex couples at risk for

• lack of support bc of attitude of caregiver

visually impaired parents

• need oral teaching by health care providers

• needs an orientation to the hospital room that allows the parent to move about the room independently. For example, “Go to the left of the bed and trail the wall until you feel the first door. That is the bathroom.”

• need explanations of routines.

• need to feel devices and to hear descriptions of the devices.

• chance to ask questions.

• need the opportunity to hold and touch the infant after birth.

• Nurses need to demonstrate infant care by touch and to follow with, “Now show me how you would do it.”

• Nurses need to give instructions such as “I’m going to give you the baby. The head is to your left side.

hearing impaired parents

• Before initiating communication, be aware of the parent’s preferences and capabilities. Do they wear a hearing aid? Do they read lips? Do they wish to have an interpreter

• Make certain that the parent sees you approaching to avoid startling the parent.

• Before speaking, be directly in front of the parent and have their full attention.

• Avoid standing in front of a light or a window while speaking to the parent.

• If the parent relies on lip-reading, sit close enough so that the parent can easily see your lip movements.

• Speak clearly with a regular voice volume and lip movements while maintaining eye contact.

• Speak in short, simple sentences to facilitate understanding.

• If the parent does not understand something, it is better to find a different way to say what needs to be communicated rather than repeating the same words over and over.

• Written / visual messages aid in communication. A small white or black erasable board can be useful.

• Give educational materials to the hearing-impaired parent and ask them to read the materials before doing parent teaching. They can refer to the materials after discharge.

• When doing parent teaching, it is helpful for a hearing person (partner or family member) to be present.

• Allow ample time to communicate with the hearing-impaired parent; being in a rush can evoke stress and create barriers to effective communication.

Strategies for Facilitating Sibling Acceptance of a New Baby in Prenatal period

• Take your child on a prenatal visit. Let the child listen to the fetal heartbeat and feel the infant move.

• Involve the child in preparations for the infant, such as helping to decorate the infant’s room.

• Move the child to a bed (if still sleeping in a crib) at least 2 months before the infant is due.

• Read books, show videos or DVDs, and/or take your child to sibling preparation classes, including a hospital tour.

• Answer your child’s questions about the coming birth and what babies are like and any other questions.

• Take your child to the homes of friends who have newborns so that the child has realistic expectations of what babies are like

Strategies for Facilitating Sibling Acceptance of a New Baby During the Stay in the Birth Facility

• Have someone bring the child to the birth facility to visit you and the infant (unless you plan to have the child attend the birth).

• When the child arrives, make sure your arms are open to embrace the child.

• Do not force interactions between the child and the infant. Often the child will be more interested in seeing you and being reassured of your love.

• Help the child explore the infant by showing how and where to touch the infant.

• Give the child a gift (from you, from the father or your partner, and the infant).

Strategies for Facilitating Sibling Acceptance of a New Baby Going Home

• Have the grandmother or another adult available to focus on the child during discharge from the birth facility and on the trip home.

• Have someone else carry the infant from the car so that you can hug the child first.

Strategies for Facilitating Sibling Acceptance of a New Baby after the baby is home

• Arrange a special time for the child to be alone with each parent.

• Do not exclude the child during infant feeding times. The child can sit with you and the infant and feed a doll or drink juice or milk or sit quietly with a game. You can read aloud to the child while you are feeding the infant.

• Prepare small gifts for the child so that when the infant receives gifts, the child will not feel left out. The child can also help open the infant’s gifts.

• praise the child for acting age appropriately (so that being an infant does not seem better than being older).

Postpartum Hemorrhage (PPH)

• 2 defining factors

• leading cause of

• when is it recognized

• (1) cumulative blood loss ≥1000 mL or

• (2) bleeding associated with signs/symptoms of hypovolemia within 24 hours of the birth process regardless of type of birth

• Leading cause of maternal morbidity and mortality

• Often unrecognized until mother has profound symptoms

Early, acute, or primary PPH occurs when

• occurs within 24 hours of the birth

Late or secondary PPH occurs when

• occurs more than 24 hours but less than 6 weeks after the birth

Estimated vs quantitative blood loss

• how much is blood loss underestimated by

• EBL is looked at and estimated, under estimated by 50%

• QBL is weighed - (blood and any pads or chucks with blood on them)

uterine atony is the ?

• #1 cause of PPH

• aka marked hypotonia of uterus

• inadequate uterine contractions

• uterus remains flaccid and rapid blood loss follows

uterine atony is asscoiated with

• Overdistended uterus

• Macrosmic (Large) fetus

• Multiple fetuses

• polyhydramnios

• high parity

causes of pph other than uterine atony

• Anesthesia and analgesia

• Previous history of uterine atony

• High parity

• Obesity

• Prolonged labor, oxytocin-induced labor

• Chorioamnionitis

• Trauma during labor and birth

• Forceps-assisted birth

• Vacuum-assisted birth

• Cesarean birth

• Unrepaired lacerations of the birth canal

• Ruptured uterus

• Inversion of the uterus

• Placenta accreta syndrome/morbidly adherent placenta (placenta accreta, increta, or percreta)

• Coagulation disorders

• Placental abruption

• Placenta previa

• Manual removal of retained placenta

• Magnesium sulfate administration during labor or postpartum period

• Uterine subinvolution

• Hypertensive disorders

• Intrauterine fetal demise

• Failure to progress during second stage of labor

if the blood is dark red

• it originated from veins, usually varicosities

if the blood is bright red

• it is from arteries

• deep lacerations of the cervix or genital tract

• increased risk if vacuum or forceps used

• can be trickle of blood or full blown hemorrhage

if there is increased bleeding during placenta separation

• indicative of incomplete placental separation

if there is increased bleeding after placenta separation

• it is either uterine atony or prolapsed uterus

late or secondary PPH Is indicative of

• caused by

• s/s?

• subinvolution

• uterus didn’t contract back down

• from retained placenta/ endometriosis/ pelvic infection

• Signs and symptoms include prolonged lochial discharge, irregular or excessive bleeding, and sometimes hemorrhage

subinvolution tx

• D&curettage

• antibitoics if infection

• methergine - oxytocic drug

retained placenta

• how long do we give the placenta to expel

• if it doesn’t come out? what may we give her during this procedure?

• what drug works best

• after 30 mins of the placenta is not out it can cause PPH

• may need manual removal - needs anesthesia & tocolytic to relax uterus so doc can remove easier

• terbutaline works fastest

risk of giving tocolytic for manual removal

• what can we give to combat?

• increases risk of uterine atony bc it relaxes uterus

• pitocin, cytotec, hemabate can be given to stimulate contractions after the procedure

unusual placental adherence (placenta accreta)

• 3 degrees

• r/o?

• placenta accreta - slight penetration of myometrium

• placenta increta - deep penetration of myometrium

• placenta percreta - perforation of myometrium and uterine serosa, may involve adjacent organs

• r/o PPH and previa for all 3

who is at a higher risk for placenta accreta

• hx of uterine surgery like a c-section

• fibroids

• advanced maternal age

dx of placenta accreta

• when we know?

• what do we prepare for ?

• ultrasound

• if we know prior to brith she needs a c-section

• prepare for blood transfusion

• prepare for possible hysterectomy if placenta cannot come off of uterine wall (usually with intcreta and percreta)

if we do not know of placenta accreta

• big r/o PPH

• bleeding may not happen until placenta is coming out/ attempted manual removal

precipitous delivery

• onset of labor to birth is less than 3hrs

• this causes r/o lacerations → pph

other risk factors for tearing

• abnormal fetus presentation/ positioning

• abnormal uterine tissue

• varicosities

• previous scarring

hematoma

• how can we identify it?

• may cause/

• tx?

• collection of blood

• may not be vaginal bleeding, but she will have persistent, abnormal perinuem/ vaginal pain especially with palpation when we assess the perimuem

• may cause PPH

• must be surgically evacuated

Inversion of the Uterus

• can be caused by

• tx?

• can be caused by fundal pressure (either to get baby out or by fundal massage without supporting hand)

• caused by traction/ pulling if cord

• Potentially life threatening

• OB emergency, needs surgery

s/s of hypovolemic shocks 7

• consequences?

• rapid and shallow RR

• rapid pulse

• cool, clammy, pale skin

• urine output less than 30ml in 1 hour (won’t see unless there is a foley)

• drop in LOC, lethargic , anxiety

• decreased BP an H&H - late signs!

• decreases venous pressure

• may cause death via organs not being perfused and lack of O₂

what do we do if she is PPH due to uterine atony

• in this order:

• firm & continuous fundal massage

• catheterize/ empty bladder if fundus firms up

• asses for lacerations

• ensure venous access

• IV - 10-40 units of pitocin/ hemabate/ cytotec

• may need oxygen

• draw labs - H&H, CBC, blood typing , coag factors

• prepare for blood transfusion/ fluid

• last resort - surgery

what do we do if she is PPH due to retained placenta (we ruled out uterine atony)

• in this order

• anticipate anesthesia - needs manual removal

• tocolytic (tubertaline) as ordered

• manual removal

• combat r/o pph due to tocolytic use with oxytotic meds

what do we do if she is PPH due to suspected coagulopathy (ruled out uterine atony and retained placenta)

• asses for underlying cause

• start O₂

• anticipate fluids/ blood transfusion

• anticipate antibiotics, vasodilators, uterotonic agents

• may need surgery

aftermath of pph

• may delay milk

• increases risk of ppd

When postpartum bleeding is continuous and there is no identifiable source what should be suspected

• an inherited or acquired coagulopathy should be suspected.

Idiopathic thrombocytopenic purpura (ITP)

• Autoimmune disorder in which antiplatelet antibodies decrease the life span of platelets

von Willebrand disease (vWD)

• A type of hemophilia

• Deficiency or defect in blood clotting protein

causes of VTE

• what doubles the risk

• what do we assess

• venous stasis and hypercoagualtion

• c-section doubles risk

• asses calf circumfrence, pain, color

Superficial venous thrombosis

• prophylaxis?

• involvement of the superficial saphenous venous system

• most common VTE

• anticoagulant therapy (heparin, lovenox, SCD)

Deep venous thrombosis (DVT)

• what do we do?

occurs most often in the lower extremities; involvement varies but can extend from the foot to the iliofemoral region

• bed rest, elevate limb, call MD

• anticoagulant therapy (heparin, lovenox)

• NO SCD

Pulmonary embolism (PE)

complication of DVT occurring when part of a blood clot dislodges and is carried to the pulmonary artery, where it occludes the vessel and obstructs blood flow to the lungs

• rapid response emergency

C-section doubles what risk

• risk of VTE

postpartum infection

• when ?

• temp?

• first 24hrs?

• Any clinical infection of the genital tract that occurs within 28 days after miscarriage, induced abortion, or birth

• presence of a fever of 100.4 F or more on 2 consecutive days of the first 10 postpartum days (not including the first 24 hours after birth bc we know temp can rise, but we still notify MD)

endometritis

• tx?

• Infection of the lining of the uterus

• Most common postpartum infection

• Management: IV broad-spectrum antibiotic therapy

wound infections

• rate after c-section

• management?

• Often develop after mothers are discharged home

• Rates of wound infection after cesarean birth are 3% to 5%

• Management: cleaning and drying site, look for s/s of infection and approximation

UTIs

• Occur in 2% to 4% of postpartum women

• void q2-3hrs to avoid