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