OB: postpartum

what is postpartum?

when the body adjusts physically and psychologically to the process of childbearing

when is postpartum?

* 4th trimester
* birth thru 12 wks

focus of postpartum

* healthy, normal life process
* family with center being the mother
* patients young, alert, and conscious

postpartum assessment

B reasts

U terus

B owel

B ladder

L ochia

E pisiotomy/laceration

H emorrhoids

E motional status

E xtremities (edema, DTR)

breast assessment

assess for

* tenderness
* firmness
* warmth
* enlargement
* nipple size, shape, irritation

non-breastfeeding assessment

assess skin appearance, shape, firmness, and warmth

most common discomfort for non- breastfeeding

engorgement

what is engorgement

when milk comes in, usually 2-3 days after delivery; breast get full and painful

prevention/treatment of engorgement

* minimize stimulation (shower from back)
* wear supportive tight bra (sports bra)
* analgesics for pain (moltrin)
* ice packs
* cabbage leaves soaked in ice water

breastfeeding

colostrum → pre milk

* this is extremely healthy for the baby
* is high in fat & protein

breastfeeding assessment

regular breast assessment + nipples: erect, flat, inverted

* if inverted, harder for baby to latch onto

breastfeeding common discomforts

* engorgement
* plugged ducts
* sore/cracked nipples
* mastitis

when does engorgement occur?

onset 2-3 days for 12-24 hours

why does engorgement happen?

* venous congestion
* accumulation of milk/change from colostrum
* missed feedings

treatment/prevention of engorgement

* early and frequent feedings
* proper positioning of infant
* supportive bra
* manual expression of milk
* heat to assist milk ejection reflex
* ice packs after feeding
* pain medication

what are plugged ducts?

area of breast not draining

plugged ducts assessment

palpation of tender breast lumps the size of peas (hard)

plugged ducts treatment/prevention

* warm compresses/showers
* massaging
* frequent feedings
* change positions with each feeding
* check clothing: tight, restrictive bras can clog ducts

plugged ducts expectation

clear in 1-2 feedings

sore/cracked nipples assessment

skin alterations (blister, bruise, scab or crack)

what causes sore/cracked nipples?

* infant not positioned properly
* not rotating infant position
* over-eager infant
* irritation from clothing
* infant thrush infection

sore/cracked nipples treatment/prevention

* proper positioning of areola in infant’s mouth
* change positions, chin away from sore area
* start on unaffected side
* frequent feedings
* expose to air after feeding
* tea bags/breast milk to nipple (colostrum around sore area, expose breast to air after)
* breast shells

advantages of breastfeeding for mom

* increased prolactin and oxytocin production: decreased risk of hemorrhage
* clamps uterus down
* uterus contracts to normal size faster
* reduced risk of some GYN cancers
* lactational amenorrhea
* will not get periods back while breastfeeding but can still get pregnant
* reduces risk of osteoporosis
* burns calories
* decreases PP depression

advantages of breastfeeding for baby

* dec incidence of acute infection
* acute illness: ear inf, intestinal disorders, SIDS
* resp conditions
* chronic illness: juvenile diabetes, Crohn’s disease
* higher hemoglobin values
* serum IgA transferred in breast milk
* lots of antibodies
* **breastmilk changes when sick to protect baby**

disadvantages of breastfeeding

* high level of commitment on family
* not for all mothers
* social acceptance/support
* others cannot be involved in feeding
* milk ejection reflex at inappropriate times

breastfeeding education

* limited time to teach a lot of information while at hospital
* vaginal: 24 hrs
* c-sec: 48 hrs
* learn by doing (trial and error)
* culturally
* acceptance
* support
* family experience
* exposure of breasts

initial breast feeding

* massage and expression
* handling and positioning of breast
* rooting/latching on
* sucking pattern
* hears noise from sucking = not good latch
* evaluation of suck
* lips flanged/wide
* muscle movement near eyes
* hearing swallowing
* breaking suction
* don’t pull off breast = sore/cracked nipples
* finger on side of mouth and then pull out
* rotating breasts

when does milk come?

c-sec: milk comes later bc of fluids, IV, surg. = hormones not tiggered

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vag: faster milk come in

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some women overprod. or under prod.

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pump for more supply = demand from breast = more milk prod.

baby weight loss % concern

>10%

breastfeeding needs/supplies

* pumping/storage
* room temp: 4 hours
* refrig: 4 days
* freezer: 4 mon.
* returning to work
* pumping schedule, place to pump
* weaning baby off
* support groups: la leche league

uterus involution process

* autolysis and contractions
* shedding stuff that was left inside from childbirth
* end of stage 3: placenta out and fundus at umbilicus
* **every 24 hrs: descends -1-2 cm or finger breadth (U/1, U/2)**
* **takes 6-8 wks**

fundus contracting

every 24 hrs: descends -1-2 cm or finger breadth (U/1, U/2)

how long does it take for the fundus to fully contract to pre-preg size?

6-8 wks

how to describe the fundus?

* midline
* firm/boggy
* U/U: at umbilicus
* U/1: 24 hrs, 1 finger breadth below umb.
* 2/U: 2 finger breadths above umbilicus

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if uterus is to the side, bladder is full

uterus assessment

* frequent vitals and fundus exam ^^**q15mins x 2hrs**^^
* assess for
* location
* position (left, right, midline)
* tone (firm, boggy)

uterus: factors that impede involution

* prolonged labor
* anesthesia
* difficult birth
* grand multiparity
* **full bladder**
* incomplete expulsion of placenta &/or membrane (part of placenta)
* infection

active management of 4th stage

* prevent PP hemorrhage
* fundal assessment (q15mins for 2 hrs)
* freq vitals (q15mins for 2 hrs)
* oxytocin infusion for 4 hrs
* quantitative blood loss (QBL: measured, accurate)
* EBL: estimated

uterine atony with active hemorrhage characteristics

not tone, relaxed, boggy

uterus: common discomforts

* ^^afterpains^^
* **causes**
* multiparas: harder to clamp down, muslce atrophy, less elastic, uterus becomes lazy
* breast-feeding: cause contracting of uterus naturally
* oxytocin
* marked distension
* clots or placental fragments retained
* **duration**: 2-3 days
* **treatment**: analgesic (ibuprofen, tylenol), pressure on abdomen, freq urination,

bowel risk factors

* constipation
* dec motility
* taking iron, narcotics for pain = constipation
* pt scared bc of pain, tender, lacerations

bowel assessment

* ausculation, distention
* ask about flatus

bowel: common discomfort

constipation

bowel: cause of constipation

* dec food during labor
* effects of progesterone
* dec muscle tone
* loss of fluid from labor
* fear of pain
* opioids

bowel: treatment/prevention of constipation

* diet: high fiber
* ambulation
* lesen perineal pain
* medications
* laxatives
* stool softners
* privacy
* water

bladder assessment

* palpation
* distention
* amount and frequency of voiding: i/o’s
* sensation
* s/s of UTI

bladder: problems from retention

* displaced uterus
* stasis leading to infection
* discomfort from bladder distention (cramping)

bladder: treatment/prevention

* ^^**assist to normal voiding position**^^
* warm water on perineum
* sitz bath (warm water runs on perineum, bowel in toilet to sit on)
* elevate knees above pelvis (step stool)
* blow thru straw
* cath, bladder scan
* encourage to void q2h

lochia assessment

* esp. first 2h
* during palpation of uterus
* feeling any gushing of blood when pressing on uterus
* amt on pad
* number of perineal pads
* musty, earthy odor
* color

lochia: source

* tissue & bacteria from uterus


* red blood cells

lochia: stages of color

* rubra
* 1st stage
* 0-3 days
* dark red
* few small cots
* serosa
* 2nd stage
* 4-10 days
* pink to brown
* less clots
* alba
* 3rd stage
* 10 days - 6 wks
* creamy or yellowish color
* no clots

lochia: amount

* scant
* less than 1 inch stain
* light
* less than 4 inch
* moderate
* less than 6 inch
* heavy
* saturated pad in 1 hr

lochia patterns

* heavier in mornings
* heavier during nursing
* should see overall decrease in amt and color changes

lochia care

* front to back peri hygiene
* peri bottle with warm water
* pad changes
* sitz bath

episiotomy/lacerations assessment

**R** ed

**E** dema

**E** ccymosis

**D** ischarge

**A** pproximation

episiotomy/lacerations alterations

* bruising
* edema
* hematoma
* incisional alterations
* hemorrhoids

episiotomy/lacerations: peri care

* peri bottle with water water and spray
* shower
* hot or cold sitz bath

episiotomy/lacerations: peri pain treatment

* peri bottle
* cool peri pad
* ice pack

perineum common discomforts

perineal tenderness

* causes
* lacerations
* stretching of perineum during childbirth
* hematoma (less common)
* complain of pressure in vagina

perineum treatments

* ice to perineum /24 hrs
* hard v ^^soft surface^^
* stool softeners
* topical ointments, sprays, foam

perineum laceration: 1st degree

vaginal mucosa torn

perineum laceration: 2nd degree

perineal muscles torn

perineum laceration: 3rd degree

anal sphincter torn

perineum laceration: 4th degree

rectum torn

common discomfort: hemorrhoids

causes

* impaired venous return and/or pressure during delivery, esp. stage 3
* constipation can cause hemorrhoids straining

hemorrhoids treatment

* sitz bath
* tucks pads (witch hazel)
* anesthetic ointment
* manual replacement
* stool softeners
* diet: high fiber, water
* inc fluid intake

emotional status: variety of emotions

* relief
* safe passage
* elation
* disappointment (sex of infant)
* surprise (early, multiple)
* exhaustion
* body image adjustment
* miss being pregnant, doctor’s visits
* miss the attention

emotional status: rubin’s stage

* taking in
* holding on
* letting go

rubin’s stage: taking in

* 1-2 days
* pre-occupied with own needs
* need to review labor and birth
* focus on food and sleep
* dec ability to make decisions

rubin’s stage: taking hold

* 2 days - 6 wks
* beginning to resume control
* inc care of infant
* return home and inc responsibility

rubin’s stage: letting go

* 6 wks for remainder of life
* milestones of letting go: the “firsts”
* babysitter
* daycare
* school
* college
* marriage
* moving away

emotional status: postpartum blues (baby blues)

* sudden emotions
* crying
* mood swings
* change in hormones

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* transient during first 1-2 wks
* 70-80% or more women experience
* cause unknown

emotional status: postpartum blues manifestations

* mood swings
* anger
* weepiness
* anorexia
* difficulty sleeping
* feeling of let down
* lack of attention

PP depression

* severe depression
* 6-12 months
* effects family
* disabling
* doesn’t want to take care of baby

PP depression signs

* depressed mood for at least 2 wks
* weight loss
* insomnia or hypersomnia
* fatigue
* dec ability to concentrate
* feeling worthless or guilty

other assessments: pain

uterine, perineum

other assessments: temperature

w/i 24 hrs → 100.4 = normal

* exhaustion, dehydration

w/i 24 hrs → 100.4 = concern

* fever, infection

> 24 hrs → 100.4+ = fever, infection

other assessments: bp

* stable or slightly inc

unless

* hemorrhage

and/or

* preeclampsia

other assessments: pulse

* puerperal bradycardia
* 50-70 bpm x 3months
* tachycardia
* inc blood loss
* difficult
* prolonged labor and birth
* infection, fever

physiologic changes: cardiovascular

* avg. blood loss 200-500
* hemodynamic changes

physiologic changes: immune system

* WBC returns to normal by day 7
* mild elevation in temp
* rubella/RhoGAM

physiologic changes: urinary

* transient stress incontinence
* bladder

pelvic floor exercises

physiologic changes: endocrine

* estrogen, progesterone, prolactin dec
* diaphoresis = dec estrogen
* body is getting rid of fluids
* pregnancy precautions

ESL/QBL during labor

vaginal: 200-500mL

c-section: 600-1000mL

body’s response to blood loss

* greater loss of plasma volume than blood cells
* hgb and erythrocyte vary until 2-6 wks
* hct rises as extracellular fluid excreted

lab values: leukocytosis

12,000 mm^3

* common WBC 16,000-30,000

lab values: coag. chnges

returns to normal at varying times

lab values: plasma fibrogen

maintained at pregnancy levels x1 wk →inc sed. rates

lab values: Rh status

* Rh neg mom and Rh pos baby
* blood can mix and so when 2nd preg. mom’s antibodies will recognize the antigens and attack 2nd baby = miscarriage
* isoimmunization/hemolytic disease of newborn
* coombs test (from cord blood)
* if antibodies are present, risk for jaundice in baby
* RhoGAM given to all neg moms at 28 wks
* RhoGAM is given w/i 72 hours of giving birth if coombs test comes back with pos baby

lab values: rubella status

* if not immune, administer rubella vaccine
* live vaccine
* can breastfeed
* not become pregnant for 4 wks (teratogenic)

family adjustment

attachment

* infant ties to parent(s) or parent(s) ties to infant

bonding

* often used interchangeably with attachment
* maternal bonding behaviors
* skin to skin contact

nursing support

evaluation

mal-attachment

father role

* variety of emotions
* need to support
* have present with teaching
* participate in care of mom and baby

siblings role

* preparation begins prenatally
* need to know: capabilities of newborn
* support from extended family
* expected behaviors
* helper
* regression
* curiosity

cultural differences in PP

some cultural practices conflict with teaching

* diet
* grandparent may be infant care taker

incorporate cultural practices as much as possible

adolescent preg. piaget

concrete v abstract thought

* factors leading to preg
* high repeat preg
* contraceptive teaching

adolescent preg. erikson

identity v role confusion

* body image
* being mothered to mothering

adolescent preg. needs

* cont. edu
* support

adolescent preg. nursing support

* recognize developmental level
* supportive and not judgemental
* **role modeling highly effective**
* inc mother/infant contact in hospital
* include adolescent father

POST-BIRTH warning signs

**P** ain in chest

**O** bstructed breathing or SOB

**S** eizures

**T** houghts of hurting yourself or you baby

**B** leeding, soaking thru 1 pad/hr, or blood clots, the size of an egg or bigger

**I** ncision that is not healing

**R** ed or swollen leg, that is painful or warm to touch

**T** emp of 100.4 or higher

**H** eadache that does not get better, even after taking meds, or bad headache with vision changes

what to do if you have POST?

call 911

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“I had a baby on (date) and I am having (warning signs)”

what to do if you have BIRTH?

call you healthcare provider

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if you can’t reach provider, call 911 or go to emerg. room