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Chapter 9 The Family after Birth Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. Puerperium (p. 199) Known as postpartum period Six weeks following childbirth Sometimes referred to as the fourth trimester of pregnancy Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 2 Adapting Care to Specific Groups and Cultures (p. 199) The nursing care provided must be adapted to the circumstances of the mother and infant. Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 3 Nursing Considerations for Specific Groups of Patients (pp. 199-200) Adolescents Single women Families at or below the poverty level Families who have twins (or more) Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 4 Question 1 Complete the following: Pregnancy : 40 weeks as Puerperium : ______ 1) 2) 3) 4) 5 weeks 6 weeks 2 months 1 year Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 5 Cultural Influences on Postpartum Care (p. 200) The nurse must adapt care to fit Use an interpreter where appropriate Health beliefs Values Practices Should not be a family member or in cultural/religious conflict with the patient/family Dietary practices Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 6 Using Interpreters (p. 200) Aids in the woman being able to understand and provide optimal care to her infant Interpreter should not be a family member or from a group that is in social or religious conflict Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 7 Postpartum Changes in the Mother (p. 200) Immediately after delivery, the mother experiences multiple physiological changes. It is important for the nurse to assess all body systems and not just focus on the reproductive system changes. Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 8 Reproductive System (pp. 200-206) Uterus Involution Uterine lining Descent of uterine fundus Afterpains Lochia Rubra Serosa Alba Cervix Vagina Stress importance of discussing with health care provider when to resume vaginal intercourse postpartum Breasts Engorgement Nursing care Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 9 Reproductive System (cont.) (pp. 203-206) Perineum Episiotomy Nursing care and patient teaching REEDA assessment Cold packs Topical and systemic medications Nonpharmacological pain relief methods Return of ovulation and menstruation Menstrual cycle typically resumes in 6-8 weeks if not breastfeeding Return of ovulation is delayed if breastfeeding; however, it can occur at any time after birth (pregnancy is possible) Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 10 Question 2 During postpartum discharge teaching, a woman expresses that “since she is breastfeeding her newborn” she will not require birth control. The nurse will: 1) inform the physician. 2) tell the woman she will require birth control when she is weaning the baby. 3) inform her that breastfeeding is not a form a birth control. 4) inform her that she must use oral contraceptives in supplement to breastfeeding. Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 11 Breasts (p. 206) First 2-3 days postpartum, breasts are full but soft Day 3, breasts become firm, lumpy due to increased blood flow and milk production Engorged breasts occur in both nursing and nonnursing mothers Nipples should be assessed for redness and cracking and washed with plain water Support bra should be worn Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 12 Cardiovascular System (pp. 206-207) Cardiac output and blood volume –blood loss 500mL vaginal/1000mL in cesarean birth. Body rids excess fluids through diuresis and diaphoresis Coagulation – blood clotting factors higher during pregnancy and 4 to 6 weeks post. Blood values – hg and hct –fluid shift affects count – 8 week post fluid balance returns to normal. Elevated WBCs returns to normal by 12 days postpartnum Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 13 Cardiovascular System (pp. 206-207) Chills- not feeling “cold” but tremors possible adrenaline response from birth process Orthostatic hypotension – resistance to the blood flow in pelvis drops Nursing care – “Safety Alert” – patients should ask for assistance the first time they get out of bed Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 14 Question 3 It is considered normal for a woman’s blood pressure to increase during pregnancy. 1) True 2) False Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 15 Urinary System (pp. 207-208) A full bladder can displace the uterus and lead to postpartum hemorrhage The woman who voids frequent, small amounts of urine may have increased residual urine because her bladder does not fully empty Residual urine in the bladder may promote the growth of microorganisms Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 16 Gastrointestinal System (p. 208) Constipation To help alleviate this problem, encourage woman to • Increase fluid and fiber intake • Increase activity, such as walking Medications may slow peristalsis. Hemorrhoids, soreness, dehydration and little food intake may have affect. Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 17 Integumentary System (p. 208) Hyperpigmentation of the skin changes as hormone levels decrease Linea nigra disappears Striae fade to silver Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 18 Musculoskeletal System (pp. 208-209) Diastasis recti Longitudinal ab muscles from chest to symphysis pubis are separated Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 19 Musculoskeletal System (pp. 208209) Hypermobility of the joints that occurs during pregnancy will stabilize within 6 weeks after delivery Exercises Abdominal muscle tightening Head lift Pelvic tilt Kegel exercises Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 20 Immune System (p. 209) Prevent blood incompatibilities and infection RhoGAM if woman is Rh negative and baby is Rh positive Give mother immunization for rubella if she is not immune. This will prevent infection in future pregnancies which could cause birth defects. Mother may breastfeed after immunization. • Titer < 1:8 requires immunization Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 21 Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 22 Adaptation of Nursing Care Following Cesarean Birth (pp. 209-211) Same as with normal vaginal delivery except Monitoring of abdominal dressing Lochia generally less because surgical sponges have removed contents of the uterus. Urinary catheter removed within 24 hours of birth Respiratory care – if confined in bed, turn and cough every 2 hours Prevention of thrombophlebitis Pain management – some epidural narcotics may cause respiratory depression. Give analgesia immediately after breastfeeding to minimize passage to breast milk. Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 23 Emotional Care (p. 211) The birth of an infant brings about physical changes in the mother but also causes many emotional and relationship changes in all family members Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 24 Mothers (p. 211) Rubin’s Psychological Changes of the Puerperium (Table 9-2) Phase 1 Phase 2 Phase 3 Postpartum blues Postpartum depression Fatigue Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 25 Question 4 Which of the following groups of signs and symptom are the most representative of postpartum “blues”? 1) Crying, loss of appetite, constipation, abdominal pain, and anxiety. 2) Crying, loss of appetite, difficulty sleeping, and anxiety. 3) Crying, increased appetite, urinary retention, anxiety, and fear of the unknown. 4) Crying, despondency, poor concentration, diarrhea, and anxiety. Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 26 Fathers (p. 212) Engrossment Four phases of adjustment Having expectations and personal intentions Confronting reality and overcoming frustrations Creating one’s own personal father role Reaping rewards of fatherhood Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 27 Other Family Members (pp. 212-213) Siblings Age-dependent on how older sibling will respond to new baby Preparation important Grandparents – proximity and attitude towards involvement with care Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 28 Grieving Parents (pp. 213-214) Therapeutic communication and nursing care Stages of the grief process Shock and disbelief Anger Guilt Sadness and depression Gradual resolution of sadness Memory packet, code on parent’s door indicating to staff the family is grieving lost of their infant Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 29 Parenthood (p. 214) Can affect communication between partners Division of responsibility can be source of conflict Fatigue increases irritability Loss of freedom and decreased socializing may cause couple to feel lonely Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 30 Family Care Plan (p. 214) The “patient” is the entire family. Studying the family as well as the patient can offer insight into community-based care Nursing care plan 9-2 page 215 Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 31 Neonatal Transition to Extrauterine Life (p. 214) Phase 1: Period of reactivity, 0-30 minutes after birth Phase 2: Decreased responsiveness, 30 minutes to 2 hours after birth Phase 3: Second period of reactivity, 2 to 8 hours after birth Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 32 Phase 2 Nursing Care of the Newborn (pp. 215-217) Supporting thermoregulation Evaporation Conduction Convection Radiation Observing bowel and urinary function Security measures Identifying the infant Gestational age evaluation Skin Vernix Hair Ears Breast tissue Genitalia Sole creases Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 33 Phase 2 Nursing Care of the Newborn (cont.) (pp. 217-219) Observing for injuries or anomalies Obtaining vital signs- normal RR 30 to 60 counted for one full minute, HR 110 to 160 Temp is taken axillary, BP, 65 to 95 systolic, 30 to 60 diastolic Weighing and measuring length and head circumference Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 34 Umbilical Cord Care Two arteries, one vein Keep cord dry, exposed to air Keep the upper end of diaper folded down below the cord so it doesn’t rub Observe site for redness, discharge or foul odor Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 35 Hypoglycemia (p. 219) Newborns use glucose stored in their bodies until they receive regular feedings A blood glucose below 45 mg/dL in the term infant indicates hypoglycemia Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 36 Risk for Neonatal Hypoglycemia (p. 219) Preterm/postterm Diabetic mother LGA/SGA Asphyxiated Cold stress Mother had tocolytics (slow down labor) during labor process Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 37 Signs and Symptoms of Hypoglycemia in the Newborn (p. 219) Jitteriness Poor muscle tone Sweating Respiratory difficulty Low temperature Poor suck High-pitched cry Lethargy Seizure Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 38 Screening Tests Mandatory vary by state PKU (protein enzyme) test Phenylketonuria to prevent severe mental retardation Hypothyroidism, galactosemia, sickle cell, thalassemia, maple syrup urine disease and homcysteinuria. Pulse oximetry testing becoming mandatory to detect congenital heart disease Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 39 Promoting Bonding and Attachment (p. 220) Bonding: strong emotional tie that forms soon after birth between parents and newborn Attachment: affectionate tie occurring over time with increased interaction Need to learn infant’s communication cues, e.g., hunger, wet diaper Nursing assessments should include observing for these to occur Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 40 Nursing Interventions to Aid in Bonding and Attachment (pp. 220-222) Calling the infant by name Holding the infant en face Providing skin-to-skin contact Talking in gentle, high-pitched tones Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 41 Breastfeeding (p. 222) Choosing whether to breastfeed Pros – easier to digest, provides natural immunity, maternal weight loss, promotes the uterus to pre-pregnant state HIV and human T cell lymphotropic viruses Hep A and Hep B not contraindicated with vaccines Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 42 Breastfeeding (cont) Physiology of lactation Hormonal stimulation • Prolactin • Oxytocin Composition of milk Foremilk- first milk the infant obtains Hindmilk – later milk higher fat content too short a feeding doesn’t allow the infant to obtain hindmilk Phases of milk production Colostrum- first few days with immunoglobins, protein Transitional – 7 to 10 days increased lactose, fat and calories Mature – 14 days, Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 43 Assisting the Mother to Breastfeed (pp. 223-224) Advantages of breastfeeding are Promotes mother-infant bonding Maintains infant temperature Sucking stimulates oxytocin release to contract mother’s uterus Table 9-4 – wash hands before feeding, nurse 10 minutes before changing to other breast, nurse after birth and every 2-3 hours thereafter Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 44 Positions for Breastfeeding (pp. 224-225) Cradle hold Football Hold Side-lying Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 45 Latch-On (p. 225) Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 46 Removing Infant From Breast (p. 226) Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 47 Evaluating Intake of Infant (p. 226) Let-down reflex occurs A tingling sensation with milk dripping from nipple Infant nurses for 15 minutes per breast 8 to 10 times per day An audible swallow is heard Infant appears relaxed after feeding Infant has 6-8 wet diapers per day Infant passes several stools per day Breast feels soft after feeding Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 48 Preventing Problems (p. 227) Frequency and duration of feedings Typically every 2 to 3 hours during early weeks The sleepy infant The fussy infant Flat or inverted nipples Supplemental feedings Nipple confusion of the infant Breast engorgement Nipple trauma Breast hygiene Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 49 Recognizing Hunger in the Newborn (p. 227) Hand-to-mouth movements Mouth and tongue movements Sucking motions Rooting movements Clenched fists Kicking of legs Crying (a late sign) Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 50 Special Breastfeeding Situations (pp. 228-229) Multiple births – one or both at a time Premature birth - good for immulogic reasons Breast surgery – silicone breasts implants should not affect feedings Delayed feedings – pump milk with pump Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 51 Storing & Freezing Breast Milk (pp. 229-230) Milk at room temperature for more than 4 hours increases potential for bacterial contamination Container size should hold no more than one feeding Safely stored or frozen in glass or hard plastic containers Milk can be stored in refrigerator at 4° C (39° F) for 24 hours or in the freezer at –4° C (–20° F) for up to 3 months (although freezing breast milk can destroy some antimicrobial factors) Can be thawed in refrigerator for 24 hours prior to using Microwaving of breast milk is not advised because it destroys immune factors in the milk 52 Maternal Nutrition (p. 230) Mother needs an additional 500 calories over the nonpregnant diet 8-10 glasses of fluids per day Some foods eaten by mother may cause a change in the taste of the milk or cause the infant to develop gas (flatus) Medications taken by the mother may be secreted in the breast milk Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 53 Weaning (p. 230) Gradual weaning is preferred There is no “best time” to wean Technique of weaning Eliminate one feeding at a time Omit daytime feedings first Eliminate the favorite feeding last Infant will need “comfort nursing” if tired or ill Breast pumping not advised in order to decrease the milk supply cycle Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 54 Formula Feeding (p. 231) Types of formulas Ready to feed Concentrated liquid Powdered Regardless of type, it is important to follow manufacturer’s instruction on preparation and storage of formula products Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 55 Safety Alert (p. 231) Overdilution or underdilution of concentrated liquid or powdered formulas can result in serious illness Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 56 Feeding the Infant (p. 231) Feed every 3 to 4 hours because formula is digested more slowly than breast milk Do not microwave formula Do not prop bottle Involve partner and family in bottle feeding of infant Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 57 Discharge Planning (pp. 231-232) Begins on admission Due to quickness of discharge from hospital, teaching often begins before mother is psychologically ready to learn Provide sufficient teaching materials for mother to refer to after discharge Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 58 Postpartum Self-Care Teaching (pp. 232-233) Ample written materials regarding mother and newborn care should be provided and reviewed Follow-up appointments Hygiene Sexual intercourse Diet and exercise Danger signs to watch for and report Newborn discharge care Infant safety seats Reassure mother that hospital staff is available by telephone should any questions arise Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 59 Newborn Discharge Care (pp. 233-234) Discharge planning for the newborn begins shortly after birth If discharged before 72 hours old, a follow-up visit with the pediatrician is recommended within 2 days of discharge Well baby checks start around 6-8 weeks of age Immunization information may be provided Car seat safety: seat should be in back seat and facing the rear until 2 years of age Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 60
