Ch 16: Nursing Management during PP

how long is a typical hospital stay for PP?

48 hrs but varies depending on facility, mode of delivery, & health status

PP inf risk factors (5)

- operative procedure

- hx of DM

- prolonged labor

- indwelling cath

- anemia

PP hemorrhage risk factors

- operative procedure

- short labor

- uterine atony

- placental previa

- labor induction

placental previa

placenta attaches lower then normal

PP thromboembolism risk factors (4)

- immobility

- operative procedure

- hx of blood clots

- clotting disorders

whats most important to assess right after birth?

signs of PP hemorrhage & checking fundus firmness & position

nursing assessment timing hr 1 PP

q15 mins

nursing assessment timing hr 2 PP

q30 mins

nursing assessment timing hr 3-24 PP

q4 hrs

nursing assessment timing hr 24-72 PP

q8 hrs

pain goal for PP pts

keep pain at 0-2

typical pulse PP

decreases in first few days (puerperal bradycardia)

typical temp PP

can be elevated due to increased WBC but should be

what can being tachy mean during PP?

delayed hemorrhage, inf, anxiety -> >100 requires further investigation

typical RR PP

should be WNL

what can an abnormal RR during PP signify?

pulmonary edema, atelectasis, PE

typical BP PP

should be within pts normal limit -> >140/90 requires further investigation

PP lab work (5)

- HGB/HCT

- urinalysis

- rubella status

- Rh status

- newborn core blood if mother Rh-

focused PP assessment (BUBBLE) (9)

- breasts

- uterus

- bowel

- bladder

- lochia

- extremities

- perineum

- emotional needs

- teaching

nursing assessment danger signs (8)

- fever >100.4

- foul smelling lochia

- severe headaches/blurred vision

- calf pain

- sudden weight gain

- rapid HR

- dysuria

- mood swings

breast assessment (2)

- note size & shape

- nipples

breast assessment complications (3)

- flat/inverted nipples -> trouble breastfeeding

- cracked, blistered, bleeding nipple

- mastitis

uterine assessment

- fundal assessment for involution (empty bladder before)

- fundus location

- palpate symphysis pubis

normal findings of uterus (3)

- fundus midline & firm

- fundus on midline

- symphysis pubis non palpable 10-14 days PP

abnormal findings of uterus

- boggy uterus

- fundus above umbilicus

- non-firm fundus -> massage until it is

lochia assessment (2)

- uterine bleeding

- amt, composition, smell, quality

extremities assessment

bilateral comparison for edema, pain, & redness -> increased risk for VTE due to increase blood clots

perineum assessment (4)

- pain

- lacerations -> assess for inf & hematoma

- care

- slightly bruised is normal

pain interventions for perineum

ice & sitz bath

sign of hematomas in the perineum

swollen, bluish, & severe pain

sign of inf in the perineum

red, swelling, purulent drainage

normal findings of bladder/bowel PP (3)

- stool pass 2-3 days post birth

- diuresis 12 hrs after PP

- soft, non-tender, & non-distended abdomen

most common bowel/bladder issues PP

constipation & urinary retention

cause of PP constipation

decreased abdominal muscle tone & pain when pushing

cause of PP urinary retention

decreased sensation to void & decreased bladder tone -> regular voiding

what can contribute to UTIs PP?

regional analgesia

bonding

unidirectional emotional attraction to baby & develops 30-60 mins after birth -> vital to attachment

what does bonding require?

contact w newborn within 1st few mins of birth

attachment

the progression of a strong affection between infant & parent -> reciprocal interaction

sign of attachment

en face -> face to face position

pharmacologic tx for PP comfort (3)

- ibuprofen/naproxen -> afterpains

- antiseptic or anesthetic ointment -> perirenal trauma

- opioids -> severe pain

nonpharm tx for PP comfort (5)

- heating pad

- prone positioning

- ice pack, sitz bath, & peri bottle -> peri trauma

- nipple cream & correct latch -> nipple soreness

- ice & warm shower -> engorgement

sitz bath

bath in room temp water

when should you cath PP mothers?

if not voiding within 4-6 hrs post birth

constipation tx PP (3)

- stool softener

- ambulating

- increase fluid & fiber intake

PP incomplete emptying cause

bladder is edematous, hypotonic, & congested

ways to assist w elimination (3)

- warm water on peri-renal area

- sounds of running tap

- increase fluid intake

postpartum fatigue

common during early days of PP & can last for weeks or months

PP sleep recommendations (4)

- nap when infant sleeps

- reduce outside activities

- balanced diet

- increase wake periods during day -> increase night sleep

PP exercise benefits (4)

- lost pregnant weight

- decrease PP depression risk

- maintain CV fitness

- decrease mental fatigue

PP exercise recommendations (4)

- start slow then gradually increase

- avoid bouncing

- start w pelvic floor muscle exercises

- if increase in bleeding -> decrease exercise

exercise recommendations for uncomplicated vaginal birth

light exercise immediately PP

recommended exercises for PP (5)

- abdominal breathing

- head lifts

- modified sit ups

- double knee roll

- pelvic tilt

PP stress incontinence

involuntary leakage of urine due to pelvic muscle trauma -> vaginal delivery disrupts fascia & damages muscles/nerves

what increases risk of PP stress incontinence?

vaginal deliveries

1st line tx for stress incontinence

exercising pelvic floor muscles -> 10 second contractions

other considerations to help w stress incontinence (4)

- increase physical activity daily

- scheduled voiding w gradual increase of time in between

- lose weight

- avoid constipation

perirenal care to prevent inf (5)

- change peri pad frequently

- apply & remove pads front to back

- avoid tampons

- shower 1-2 times/day w mild soap

- sitz bath after BM

interventions for orthostatic hypotension in PP pt (3)

- check for decreased HGB/HCR before ambulating pt

- elevate HOB before getting up

- put newborn in crib if lightheaded

when can PP pts have sex again?

once bright red bleeding stops & perineum is healed -> usually 3-6 weeks but full recovery can take up to 6 months

hormonal contraception PP

can't take until 6 weeks postpartum & lactation is well established

progesterone only contraception

preferred for PP pts

progesterone & estrogen combined contraception

not preferred -> decreases quantity & quality of milk & increases risk of DVT

lactating nutrition recommendations (3)

- variety of fruits & vegetables

- 1/2 of grains should be whole grains

- low fat or fat free milk

nutritional needs for lactating persons

increase calories, calcium, iodine, omega 3 fatty acids, & fluids

what are nutritional needs based on?

the nutritional content of breast milk & energy expanded to produce it

non-lactating nutrition recommendations (5)

- 1/2 of plate fruit & vegetables

- red, orange, & dark green vegetables

- skim or 1% milk

- whole grains

- seafood & beans 2 times/week

what can having a BMI >30 affect during PP? (3)

- less likely to initiate lactation

- difficulty latching

- early cessation of breastfeeding

when is breast feeding recommended by the American Academy of Pediatrics?

first 6 months of life

Steps to promote breastfeeding according to the Baby-Friendly Hospital Initiative (5)

- immediate skin to skin contact

- staff education

- support for parents

- c hold

- massage breast

contraindication's for breast feeding (6)

- taking opioids, cocaine, or phencyclidine

- HIV

- active herpes on breast

- newborn w galactosemia

- mpox or brucellosis

- active TB or varicella

types of commercial formula (4)

- cow milk based

- soy protein based

- specialized

- therapeutic

how much formula should you feed a newborn?

2-4 oz each feeding usually 6 times/day

- start to decrease at 4 months to accomadate solids

prep & storage guidelines for formula (4)

- if powdered use room temp water

- don't microwave

- nipple & neck should be filled w formula

- prepared formula -> discard within 1 hr after feeding infant

breast care for breastfeeding & bottle feeding pts (3)

- supportive bra

- watch for & manage engorgement

- lactation suppression

when should non breastfeeding mothers wear supportive bras?

until engorgement ceases

ways to prevent engorgement in breast feeding mothers (4)

- frequent feedings

- manual expression -> softens nipples before feedings

- massage breast

- feed on one breast until soft then switch

ways to prevent engorgement in bottle feeding mothers (3)

- use ice packs

- wear supportive bra

- avoid breast stimulation -> warm water, massages

how long does it take for lactation suppression?

5-7 days

risk factors for delayed or impaired bonding (5)

- premature

- PP mental health condition

- decreased social support

- infant illness

- substance use

interventions for bonding & attachment (3)

- early contact

- extended contact

- communication through touch, eye, contact, & voice

interventions & expectations for sibling adaptations (4)

- expect regression

- encourage sibling involvement

- plan time for each child

- explain child birth appropriately

postpartum blues education (3)

- d/t rapid decrease in hormones

- reassure commonly experienced & usually resolve in a week

- if it doesn't resolve in 2 weeks possible PP depression

PP discharge criteria (5)

- no signs of inf

- bleeding controlled

- infant is okayd by pediatrician

- education complete

- family/support available

PP immunizations (3)

- rubella

- rhogan

- tdap & flu

which PP pts get rubella?

non immune clients (titers

when is rhogan immunization doses given?

IM -> 28 wks gestation then 72 hrs post birth

which PP pts get rhogam?

Rh- mother & Rh+ infant