OB: postpartum

what is 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

vag: faster milk come in

some women overprod. or under prod.

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

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

• 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

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

what to do if you have BIRTH?

call you healthcare provider

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