Transcript Lecture 5 Post Partum Period Fall 10 Teachers copy

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
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Breast
Uterus
Bladder
Bowel
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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
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Supportive bra
Correct position
Correct latch-on technique
Warm showers
Expose to air
Nursing Care
Non-Lactating Mother
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Avoid stimulation
Wear support bra 24hrs
Ice packs or cabbage leaves
Mild analgesic for discomfort
Assessment of Uterus
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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
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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
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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
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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
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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
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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
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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
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Transitioning to parenthood
Assuming the mothering role
Parental bonding
Factors that interrupt bonding
Transitioning to parenthood
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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
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Fundus and Lochia
Episiotomy care
Incision care
Signs of infection- box 15-5 pg 505
Elimination
Discharge Teaching
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Nutrition
Exercise
Pain management
Sexual activity
Contraception
Community Resources
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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
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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
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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
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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
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Aseptic wound management
Frequent perineal pad changes
Good hand washing
Administer antibiotics
Analgesics
Urinary Tract Infection
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Burning and pain on urination
Lower abdominal pain
Low grade fever
Flank pain
Protienuria, hematuria, bacteriuria,
nitrates and WBC
Nursing Care
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Frequent emptying of bladder
Increase fluid intake
Antibiotics
Analgesics
Mastitis
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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
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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
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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