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Transcript
Post Partum Period Mary L. Dunlap MSN, APRN Fall 10 Post Partum • Begins immediately after child birth through the 6th post partum week • Reproductive track returns to nonpregnant state • Adaptation to the maternal role and modification to the family system Safety for Mother and Infant • Prevent infant abductions • Check ID bands • Educate mother about safety measures Clinical Assessment • Review Antepartum and Intrapartum history • Receive report • Determine educational needs • Consider religious and cultural factors • Assess for language barriers Post Partum Assessment BUBBLE-HE • • • • Breast Uterus Bladder Bowel • • • • Lochia Episiotomy Legs Emotion Early Assessment Vital signs • Temperature • Pulse • Blood pressure • Respirations Breast Assessment • Inspect for size, contour, asymmetry and engorgement • Nipples check for cracks, redness, fissures • Note if nipples are flat, inverted or erect • Evaluate for mastitis Nursing Care Lactating Mother • • • • • Supportive bra Correct position Correct latch-on technique Warm showers Expose to air Nursing Care Non-Lactating Mother • • • • Avoid stimulation Wear support bra 24hrs Ice packs or cabbage leaves Mild analgesic for discomfort Assessment of Uterus • • • • Location immediately after birth Descends 1 cm/day Consistency- firm/boggy Location Height- measured in fingerbreadths Nursing care • Boggy fundus- massage until firm • Medications- Pitocin, Methergine, Hemabate • Teach new mom to massage her fundus Afterpains • Intermittent uterine contractions due to involution • Primiparous-mild • Multipara- more pronounced Nursing Interventions • Patient in a prone position and place a small pillow under her abdomen • Ambulation • Medicate with a mild analgesic Bladder • Spontaneous void 6-8 hrs • Monitor output • Postpartum Diuresis Nursing care • Encourage frequent voiding every 4-6 hours • Monitor intake and output for 24 hrs • Early ambulation • Void within 4 hrs after birth • Catheterize if unable to void Bowel • • • • • Anatomy returns to normal location Relaxin depresses bowel motility Diminished intraabdominal pressure Incontinence if sphincter lacerated Spontaneous BM 2nd – 3rd post partum day Nursing Care • • • • • • Increase fiber in diet 6-8 glasses of water or juice Stool softener Laxative Sitz bath for discomfort Medications for hemorrhoids Lochia • Mixture of erythrocytes, epithelial cells, blood, fragments of decidua, mucus and bacteria • As involution proceeds it is the necrotic sloughed off decidua • 240-270 ml • Cesarean less • Present for 3-6 weeks Lochia • • • • Rubra Serosa Alba Documentation Nursing Care • Educate mother on the stages of lochia • Caution mother that an increase, foul odor or return to rubra lochia is not normal • Instruct patient to change peri pad frequently • Peri care after each void Episiotomy • 1-2 inch incision in the muscular area between the vagina and the anus • Assess REEDA • Episiotomy care Nursing Care • • • • • Peri care Ice packs Sitz baths Dry heat Topical medications Pain Assessment • Determine source • Document location, type and duration • Interventions Assess for DVT • Homans’ sign • Clinical assessment Postpartum Blues • Transient periods of depression during the first 1 to 2 weeks postpartum • Tearfulness • Sad feeling • Confusion • Insomnia Nursing Care • • • • • Remind mom that the “Blues” are normal Encourage rest Utilize relaxation techniques Share her feelings with her partner If symptoms do not resolve and progress to depression medical treatment needs to be sought Maternal Physiological Adaptations Hematological System • Decrease in blood volume • Elevated WBC • Increased Fibrinogen Hormonal Levels • Estrogen and Progesterone decrease • Anterior pituitary-prolactin for lactation • Expulsion of the placenta- placental lactogen, cortisol, growth hormone, and insulinase levels decrease • “Honeymoon phase”- insulin needs decrease Neurological System • • • • Maternal fatigue Transient neurological changes Headaches Carpel tunnel improvement Renal • GFR, Creatinine, and BUN return to prepregnant levels within 2-3 months • Urinary glucose levels return to nonpregnant levels by 2nd PP wk • Protienuria resolves by the 6th PP wk • Natriuresis / Diuresis Integumentary System • Darken pigmentation gradually fades • Hair regrowth returns to normal in 612 months • Striae( stretch marks) fade to silvery lines Cardiovascular System • Heart returns to normal position • Cardiac output elevated above prelabor levels up to 48 hrs. PP Immune System Rubella • Administer to nonimmune mothers • Safe for nursing mothers • Avoid pregnancy for 1 month • Flu-type symptoms may occur Immune System • Rho (D) immune globulin • Mother Rh negative, infant Rh positive • Negative coombs’ test • 300 mcg of RhoGam within 72 hrs after delivery • Card issued to mother Reproductive System • Involution of uterus • Healing of placental site • Vaginal changes Menstruation and Ovulation Nonlactactating mother • Menstruation returns in 6-8 wks • First cycle may be anovulatory Lactating mother • Delayed ovulation and menstruation Musculoskeletal System • Relaxation of pelvic joints, ligaments, and soft tissue • Muscle fatigue and general body aches from labor and delivery of newborn • Rectus abdominis diastasis Multicultural Nursing Care • Enhance Cultural Sensitivity • Understand cultural influences on the post partum period • Provide culturally appropriate care HIV/AIDS • Gloves safety glasses • Discourage breast feeding • Avoid contact personal body fluid with infants mucous membranes Postpartal Surgical Patient • Tubal ligation • Cesarean birth Breast Feeding • Optimal method of feeding infant • Breast milk- Bacteriologically safe, fresh, readily available • Box 15-3 pg.489 Breastfeeding benefits Breastfeeding • Lactogenesis- secretion of milk • Milk ejection reflex- “let down” reflex Breastfeeding • Cue signs- Box 15-4 pg. 492 • Latch-on- Fig 15-8 pg 492 • Assess for milk let down Breastfeeding Positions • Cradle hold • Foot ball • Side lying • Fig 15-10 pg 494 Ineffective Breastfeeding • Incorrect latch-on • Inverted nipples • Breast engorgement Collection and Storage Breast Milk • Room temperature- 4 hrs • Refrigerator- 5-7 days • Deep freezer- 6-7 months Formula Feeding • Formula preparation • Periodically check nipple integrity • Bottle preparation Family and Infant Bonding • • • • Transitioning to parenthood Assuming the mothering role Parental bonding Factors that interrupt bonding Transitioning to parenthood • • • • Difficult and challenging Provide emotional support Accurate information Nursing goal create a supportive teaching environment Assuming the mothering role Rubin’s three phases • Taking –in • Taking –hold • Letting-go • Table 15-6 pg. 499 Bonding • Bonding process helps to lay the foundation for nurturing care • Touch- skin to skin • Eye contact • Breastfeeding Discharge Planning and Teaching Self Care Discharge Teaching • • • • • Fundus and Lochia Episiotomy care Incision care Signs of infection- box 15-5 pg 505 Elimination Discharge Teaching • • • • • Nutrition Exercise Pain management Sexual activity Contraception Community Resources • • • • Support groups Home visits Telephone follow-up Outpatient Clinics Postpartum Complications Postpartum Hemorrhage • Blood loss of more than 500 ml of blood after a vaginal birth • 1000 ml of blood after cesarean section • Any amount of bleeding that places mother in hemodynamic jeopardy Postpartum Hemorrhage LARRY- common causes of early PPH • Laceration • Atony • Retained placental tissue • Ruptured uterus • You pulled to hard on the cord Postpartum Hemorrhage • • • • • 4 Ts- factors associated with PPH Tone Trauma Tissue Thrombin Postpartum Hemorrhage Tone/Atony • Altered muscle tone due to overdistention • Prolonged or rapid labor • Infection • Anesthesia • Box 16-1 pg 513 Postpartum Hemorrhage Trauma • Cervical lacerations • Vaginal lacerations • Hematomas of vulva, vagina or peritoneal areas • Box 16-2 pg 514 Postpartum Hemorrhage Tissue • Retained placental fragments • Uterine inversion • Subinvolution Postpartum Hemorrhage Thrombin • Disorders of the clotting mechanism • This should be suspected when bleeding persists without an identifiable cause Management of PPH • • • • • • • Frequent VS Fundal massage Administer medications- Box 16-1 Monitor blood loss for amount Maintain IV Type & cross match Empty bladder Hematoma • Localized collection of blood in connective or soft tissue under the skin • Risk factors • Signs and symptoms • Management Postpartum Infections • A fever of 100.4 or higher after the first 24 hrs for 2 successive days of the first 10 PP days • Fever of 102.2 or greater within first 24 hrs- sever pelvic sepsis Group A or B streptococcus Postpartum Infections • • • • • Endometritis- Table 16-2 pg 521 Wound infection- Table 16-3 pg. 523 UTI- Table 16-4 pg. 524 Mastitis- Table 16-5 pg 525 Septic Pelvic Thrombophlebitis-Table 16-6 pg 526 Endometritis • Involves the endometrium, decidua and adjacent myometrium of the uterus • Lower abdominal tenderness or pain • Temperature • Foul-smelling lochia Nursing Care • Administer broad spectrum antibiotic • Provide analgesia • Provide emotional support Wound Infection • Sites- Cesarean incision, episiotomy and genital tract laceration • Drainage • Edema • Tenderness • Separation of wound edges Nursing Care • • • • • Aseptic wound management Frequent perineal pad changes Good hand washing Administer antibiotics Analgesics Urinary Tract Infection • • • • • Burning and pain on urination Lower abdominal pain Low grade fever Flank pain Protienuria, hematuria, bacteriuria, nitrates and WBC Nursing Care • • • • Frequent emptying of bladder Increase fluid intake Antibiotics Analgesics Mastitis • • • • Infection of the breast (one sided) Seen 2-3 weeks after delivery Caused by staphylococcus aureus Infected nipple fissure - to ductal system involvement- edema obstructs milk flow in a lobe- mastitis Mastitis Symptoms • Flu like symptoms • Tender, hot, red area on one breast • Breast distention with milk Nursing Management • Empty the breast by increasing the frequency of nursing or pumping • Antibiodics • Analgesics Postpartum Infection Education • Continue antibiotics • Monitor temperature and notify provider if temp greater then 100.4 • Watch for signs and symptoms of a recurrence • Practice good hand washing Thrombophlebitis and Thrombosis • Thrombosis (blood Clot) can cause inflammation of the blood vessel (thrombophlebitis) which can cause thromboembolism (obstruction of blood vessel) Assessment Superfical • Tenderness and pain in extremity • Warm and pinkish red color over thrombus area • Palpable- feels bumpy and hard • Increased pain when ambulating Nursing Care • • • • NSAIDs for pain Bed rest elevate affected leg Warm compresses Elastic stockings Assessment Deep Vein • Located from foot to pelvis- can dislodge and cause PE • Calf swelling • Warmth • Tenderness • Pedal edema • Diminished peripheral pulses Nursing Care • • • • • • Bed rest Elevate effected leg Continuous moist heat TED hose both legs Analgesics PRN Anticoagulation therapy Pulmonary Embolism • Abrupt onset: chest pain, dyspnea, diaphoresis, syncope, anxiety • ABC response
