Transcript PP Care and Assessment

Post Partum Care & Teaching
Presented by: Anna Mackey, RN BSN
Authors:
Tina Schmidt, RN & Evelyn Hom, RN, MSN, CNS
Objectives
1. Discuss psychological changes during
the puerperium.
2. Discuss the role of the postpartum
nurse in providing care and instruction
to women during the puerperium.
3. Describe the emotional/ psychological
needs of postpartum women.
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Postpartum Period
Puerperium – Latin “puer” means
child and “parere” means to bring forth
Immediate PP – “Fourth Stage Labor”
birth to two hours
Long term PP – “Fourth Trimester”
period of time from the delivery of the
placenta to return of woman’s
reproductive system to its nonpregnant state (typically 6 weeks)
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Uterus and Involution
Uterus after delivery=weighs about 1,000 gms
(2lb 4oz)
Fundal height
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Immediately PP = Midway between umbilicus and
symphysis pubis
One hour PP = At the umbilicus or slightly below
umbilicus
12 hours PP = 1 cm above umbilicus
24 hours PP = 1 cm below umbilicus
Day 2 to day 7 = Decreases about 1 cm/day
Day 7 = Just palpable at the symphysis
Day 10-14 = Non palpable
Week 6 = Returns to non-pregnant size
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Reasons for Delayed Involution
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Multiple gestation
Polyhydramnios (AFI > 25)
Prolonged labor
Grand multiparity (> 5)
Prolonged or excessive analgesia
Extended period of use of prostaglandins or
Oxytocin for labor induction and augmentation
Retained placenta
Uterine fibroids
Cesarean birth
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Uterine “After-pains”
Painful uterine contractions that occur
after delivery of the baby
Intensity associated with:
 Uterine tonics – Oxytocin
administered post partum
 Breastfeeding
 Conditions producing over
distension of the uterus
Multiple fetuses
 Polyhydramnios
 LGA and macrosomic fetus
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Intensity greatest immediate PP and
diminishes 1st wk
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Uterine“After-pains”
Nursing Care:
 Pain
medication
 Educate patient that:
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Normal for involution process
During breast feeding that it is a positive
sign baby is properly latched and getting
colostrum
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Lochia
Composed of endometrial tissue, blood
and mucous.
Clots:
Can be normal part of lochia if small and
patient has had some pooling
 Should be decreasing in size and amount as
patient moves through postpartum period
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Stages of Lochia
Rubra
 Dark red or brownish with clots
 Contains blood and tissue fragments
 Fleshy smell
 Duration: 1-3 days
Abnormal Findings:
Foul smell, numerous or large clots,
quickly saturates pad.
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Stages of Lochia
Serosa
 Pink, brown tinged, serosanguineous
consistency
 Contains blood, ertyhrocytes,
leukocytes, mucous and decidua
 Fleshy odor
 Duration: 3-10 days
Abnormal Findings:
Foul smell; quickly saturates pad; serosa
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Stages of Lochia
Alba
Yellowish-white
 Contains mostly leuckocytes, as well as
decidua, mucous, bacteria and epithelial
cells.
 No strong odor
 Duration: 10-14 days
Abnormal Findings:
Foul smell, saturated pad, pink or red
lochia, discharge beyond 6 weeks
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Lochia
Average amount 240-270 mL (8-9 oz)
Scant = one inch
 Light = 4 inches
 Moderate = 6 inches
 Heavy = Saturate one pad in one hour
 Hemorrhage = Saturate one pad in 15
minutes
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Cardiovascular
Heart position returns to normal
from being shifted by diaphragm
and uterus within about 2 weeks
Cardiac output decreases rapidly
following delivery returning to
normal by 2-3 weeks PP
Varicosities improve with the
decrease in cardiac output
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Blood Volume Changes
Vaginal Delivery: normal blood
loss = 500mL
C/S: normal blood loss = 1000mL
Normal blood loss during first
week PP is another 800 mL
Return to non-pregnant circulating
volume in 3-4 weeks post delivery
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Lab Values: Hct, Hgb
For every 500 ml of blood loss, the
hemoglobin will drop 1-1.5 gram/dl and the
hematocrit will drop 3 - 4%
Hct rises immediately after delivery due to
blood volume loss & dehydration(28 - 35 %)
Returns to normal 4-5 wks (37 - 47%)
PP anemia is common. Anemia usually
considered when Hgb less than 10 and Hct
is less than 30%
Clotting Factors remain elevated in early PP
period, return to normal in 4-5 wks post
delivery
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Lab Values: WBC
WBC’s- may increase to 20,000/mm3 or more
during 1st 10 days PP
 Average PP WBC is 14,000 - 16,000/mm3
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Slightly higher with cesarean delivery and traumatic
deliveries due to body’s inflammatory response
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An increase of more than 30% over a 6-hour
period is indicative of infection
 CBC with differential is indicated if the WBC
count has significantly increased or the patient
has a risk factor or is symptomatic for infection
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Vital Signs
BP - should be similar to intrapartum values
 High BP may suggest PIH
 Low BP may suggest orthostatic hypotension or
a late sign of hypovolemia and/or hemorrhage
Pulse - bradycardia normal immediate PP(40-80
bpm)
 Tachycardia – abnormal and suggests
hemorrhage or infection
Respiratory Rate - usually normal 16-24/min
Temperature – Normal slight elevation 1st 24 hrs PP
> 100.4 degrees F indicates infection
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Teaching Activity/Exercise
Do not overdo…Only care for self
and baby
Lochia guides activity level
Limit stairs/lifting
Gradual resumption of activity
Start kegels and walking right
away
PP exercises for abdomen—
Seek advice from provider.
Usually after 6 weeks pp.
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Cervix
 Edematous
immediately PP
 1 week PP- about 1cm
 Easily distensible several days PP
 Internal OS closes by 2 weeks PP
Abnormal Finding:
Presence of free flowing bright red
blood
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Vagina
 Rugae
reappears 3 weeks
postpartum
 Return to near pre-pregnant state
6-8 weeks post partum
 Normal mucus production returns with
ovulation
 Need to educate patient - nothing in
the vagina for 6 weeks post partum
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Menstrual Cycle
Non-lactating:
40-45% will resume at 6-8 wks
 75% will resume at 12 weeks
 100% will resume within 6
months
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Lactating:
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As early as 12 wks or as late as
18 months
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Ovulation
Non-lactating: 50% will be
anovulatory first few cycles
of menses
Lactating: 80% will be
anovulatory first few cycles
of menses
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Teaching Sexuality
Nothing in the vagina for first 4-6 weeks:
“No intercourse. No tampons. No
douching”
Increased risk for acquiring STD’s
Women can still ovulate without
menses!
Lowered interest due to
hormones/fatigue
Dry vaginal mucosal lining…Use
lubrication
Let-down reflex may occur during
intercourse
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Perineum
Episiotomy is normally without redness,
discharge, or edema
Intact perineum may still have edema
and/or ecchymosis secondary to
pressure at delivery
May experience burning with urination
Healing takes place in 1-2 weeks
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Lacerations
1st degree: through the skin and
structures superficial to the muscles
2nd degree: above plus through the
muscles of the perineum
3rd degree: above plus through the anal
sphincter muscle
4th degree: above plus through the
anterior rectal wall
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Teaching Perineal Care
Good hygiene – hand washing, peri-bottle
and frequent pad changes
Comfort measures
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Ice first 24 hours
Sitz baths after 24 hours
Witchhazel
Stitches dissolve in 1-2 weeks,
Itching normal as skin heals
Infection uncommon, watch for symptoms:
fever, abnormal discharge, foul smelling
discharge
Monitor for dehiscence of repair
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Hemorrhoids
Grape-like clusters at the anus
May not be visible or palpable until straining for
BM
Should shrink in in about three weeks
Teach:
 Avoid constipation and straining
 Soft diet with foods or drink that normally help
the patient have bowel movements
 Sitz baths and witchhazel
 See provider if still a problem after 3 weeks
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Respiratory System
Pulmonary function returns to normal in 6-8
weeks as diaphragm descends
Acid/base balance returns to pre-pregnant levels
by 3 weeks PP
Oxygen Saturations should be above 95%
Patients at risk for pulmonary compromise:
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Fluid overloaded
Preeclamptic patients, particularly those on Magnesium
Sulfate
Cardiac Patients
Asthmatics
Smokers
Patients with preexisting pneumonia or URI
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GI System
Appetite is strong immediately PP period
Decreased GI motility can lead to
constipation
BM should resume 2-3 days PP
Average weight loss of 12 lbs at delivery plus
5 lbs in first week due to diuresis
Cesarean birth: Greater incidence of
distension, discomfort, constipation and illeus
R/T trauma and manipulation of bowel
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GI System Teaching
Eat well balanced diet of all foods in moderation.
Increase intake by 500 calories/day for
breastfeeding (approx ½ sandwich)
Consult provider if plan to diet prior to 6 wks PP or
while breastfeeding
Interventions to prevent constipation: ambulation,
increase fluids and high fiber, stool softeners,
laxatives, foods and fluids that usually make patient
have BM
Having BM will not cause them to tear repairs
Call provider if no BM by 4th day PP
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Urinary System
Fluid shifts common- edema and swelling
(patient may weigh more!)
Uterus that is elevated and laterally
displaced may indicate filling bladder or
urinary retention.
Full bladder will cause increased lochia.
Diuresis begins at 12 hours-48 hours PP
and continues for about one week.
Kidney function normal by 4 wks PP (GFR
returns to pre-pregnant rate, )
Increased risk for UTI first 6 wks PP
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Urinary System Teaching
Common to feel numb first few days PP, so empty
bladder frequently
Tricks to assist voiding:
 Ice to perineum to prevent swelling (first 24 hrs to
reduce edema and for analgesic affect)
 Administer analgesic prior to void if have sutures
 Lean forward on toilet – puts pressure on bladder
 Sound of running/trickling water
 Peppermint oil
 Blowing bubbles in cup of warm water
 Shower, sitz bath (warm water increases urge to
void)
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Urinary System Teaching
Teach patient symptoms of UTI
 Urgency
 Frequency
 Dysuria
 Fever,
chills
 Back or lower abdominal pain
 Decrease in Level of Consciousness
– confusion
 Increase in fatigue / lethargy
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Musculoskeletal System
Diastasis recti (rectus muscle) may
separate 2-4 cm. Will resolve by 6 wks.
Most common in black patients
Joint stabilization returns in 6-8 wks post
partum
Teach caution when starting a vigorous
exercise program or stomach exercises
prior to 6 wk PP follow-up visit. Need to
consult with care provider
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Integumentary System
Hyperpigmentation of face (chloasma),
abdomen (linea negra) and areaolas
gradually lighten and may or may not
disappear
Stretch marks will gradually fade
Hair loss will occur within 6 weeks
Diaphoresis for first several weeks,
especially at night (night sweats)
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Immune System
Rh Sensitivity / Isoimmunization: Administer
anti (D) Immune Globulin within 72 hours
PP to prevent formation of maternal
antibodies against Rh positive fetal blood
cells and destroy Rh positive cells.
Rubella titer less than 1:8 ratio: Administer
Rubella Virus Vaccine prior to discharge.
Instruct patient to avoid pregnancy next 3
months.
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Breasts
Prolactin – Initiates milk
production
Oxytocin – Milk “let-down reflex”
Milk removal from breast (by
breast feeding or pumping)–
facilitates continued milk
production
Lactating:
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Colostrum: 1st week PP
Transitional milk: between 7-14
days
Mature milk comes in after 2 weeks
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Breasts
Non-lactating: breast changes of pregnancy regress
in 1-2 weeks postpartum
Teach:
 Well fitting support bra 24 hours a day for 2 weeks
 No heat or warm water/shower on breasts
 No stimulation of breasts
 Ice packs to breast maximum 20 minutes at a time
 No longer use lactation suppressive medications
due to rebound engorgement
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Engorgement
Symptoms
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Engorgement begins at
2nd - 3rd day and
subsides in 24 - 36 hours
Tender, swollen, and firm
breasts (including the
areola) making it difficult
for infant to latch – like
trying to latch on to a
basketball
Slight fever (<100.4 F)
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Engorgement
Interventions to prevent engorgement:
 Encourage early feedings
 Encourage frequent feedings
Minimum 8 feedings/ 24 hours
 Minimum 10 - 15 minutes per breast
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Avoid supplement for infant unless
medically indicated
 Assess and ensure correct positioning and
latch
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Engorgement
Nursing Care:
 Wear a well fitting support bra
 Warm compresses or shower prior to
feeding
 Gentle massage of breasts from axilla
towards nipple to stimulate letdown
 Express milk by hand or pump to soften
areola tissue to assist infant in latch
 Ice packs to axilla for a maximum 20
minutes at a time after feeding
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Psychological System
Role Changes: Grieve the loss of old role and
acquire new role and expectations
Acquiring the Role of Mother (Rubin, 1975)
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Taking in phase: days 1-2; passive, dependent, wants
care for self; asks many questions
Taking hold phase: 4 -5 wks; begins to focus on needs
of infant, receptive to teaching, high fatigue
Letting go phase: 5+ wks; sees infant as separate
individual, refocuses on relationship with partner, may
return to work/uses babysitter
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Attachment
Definition: The enduring emotional bond
between parent and infant (Klaus & Kennell,
1976)
Essential to infant’s growth and survival
The mother-infant bond is the basis on which
all subsequent attachments are formed and
plays major role in infant developing a sense
of self (Bowlby, 1969)
Patterns of attachment vary with culture
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Attachment Behaviors
Observable maternal attachment behaviors:
 Touching
 Holding
 Gazing
 Cuddling
 Kissing
 En face position
Observable Paternal attachment behaviors:
 “Engrossment”: to stare for long periods of
time
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Attachment Behaviors
Observable infant attachment behaviors
(before 8 weeks):
 Cuddling into mother
 Following with eyes and gazing
 Providing clear feeding cues and needs
cues
 Crying
 Grasping
 Smiling
 Babbling
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Assessing Attachment
Maternal factors to consider that might impede
attachment:
Length of labor, analgesia used, type of delivery,
high risk pregnancy, physical health, age
extremes, intelligence, wanted or unwanted
pregnancy, past experience with own mother,
gravida/para, socioeconomic status, degree of
maternal support available, relationship with
FOB, prolonged separation from infant, how well
infant matches maternal/parental expectations
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Assessing Attachment
Paternal Factors to Consider
 How involved with the
pregnancy/baby, maturity level, age,
past experience with infants, own
expectations for infant, relationship
with infant’s mother, relationship with
own father
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Assessing Attachment
Infant factors to consider
 Gestational
age, multiple birth, admission
to SCN/NICU, transferred to tertiary
setting, physical anomalies, gender,
temperament, degree of alertness
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Prenatal Mal-Attachment
Behaviors
Excessive moodiness
Emotional withdrawal
Excessive preoccupation with own
personal appearance – ignoring infant
Numerous physical complaints
Failure to prepare for infants arrival
during last trimester (although had
opportunity and resources)
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Postnatal Mal-Attachment
Behaviors
Negative comments about baby’s
appearance
Disappointment about baby’s gender
Failure to look at, touch, or handle infant
Failure to respond to signaling
behaviors
Failure to name infant
Failure to meet infant’s physical needs
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Nursing Interventions to
Support Attachment
Encourage early and frequent eye-to-eye and
skin-to-skin contact
Provide opportunity, time, environment for
attachment
Encourage and praise parents in caring
for own infant
Instruct infant behaviors and cues
Reassure some negative feelings normal
Educate significant other about danger signs
Provider and Community Health Follow-up
Social work referral if needed
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Culturally Appropriate Care
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US - postpartum is seen as time
of wellness and early ambulation
is expected
 Japan - remain inside for 1st 100
days, no bath or hair wash for 1
week
 Korea - avoid exposure to cold,
eat warm foods
 Mexico - keep warm, eat warm
foods to help dry the womb; avoid
baths for 1 week
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“Baby Blues”
The mildest form of PP depression
Typical onset 3rd-8th day PP, lasts 2 - 3
days
Onset sudden
Incidence 50-80% of all PP women
Possible cause: onset of PP Blues
coincides with drop in estrogen and
progesterone
Usually self-limiting (if woman is given
support from family and friends)
Sleep helps relieve symptoms
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“Baby Blues” - Characteristics
Mood swings
Irritability or anger
Crying for no apparent reason
Mild anxiety
Difficulty sleeping
Fatigue
Discomfort
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Assessment of SVD patient
1st hour - every 15 minutes x 4
2nd hour - every 30 minutes x 2
2-24 hours - every 4 hours
>24 hours - every 8 hours
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Assessment of C-Section
patient
1st hour - every 15 minutes x 4
2-3 hours - every 30 minutes x 4
3-24 hours - every 2-4 hours
>24 hours - every 4-8 hours
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Assessment PP Patient
Vital Signs
TPR, BP
Assess pain level
HA, musculoskeletal,
back, breasts,
nipples, uterus,
bladder, incision,
perineum,
hemorrhoids, calf
tenderness
General appearance
How she ambulates
Self-care activities
Head
Facial edema
Conjunctival
hemorrhage (from
pushing)
LOC/Sensation
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Assessment PP Patient
Breasts
Fullness
Breast support
Breast surgery scars
Nipples
Erectility
Flat/inverted
Intact or cracked
Presence of milk
Ecchymosis
Bleeding
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Assessment PP Patient
Uterus
How to position
patient
Uterine support
Firmness
Location of fundus
Tenderness
Massage
C/S incision site
Dressing dry/intact
Incision - edges well
approximated,
staples intact
Redness, edema,
ecchymosis, oozing
Drains intact,
amount drainage
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Assessment PP Patient
Bladder/output
Voiding pattern
Distended bladder
Dysuria
GI/Elimination
Bowel sounds, flatus
Bowel movements
Perineum
Positioning patient
during assessment
Episiotomy,
lacerations
Sutures well
approximated
Edema, ecchymosis,
hematoma, discharge
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Assessment PP Patient
Extremities
Homan’s sign
Edema, warmth,
redness of extremity
Calf tenderness
Lab Values
CBC - note H & H,
WBC and Platelets
UA
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D/C Teaching Follow-up
Follow-up for SVD usually 6 weeks PP
Follow-up for C-Section usually in 4-5
days if staples/sutures not out; If out,
10-14 days and again at 6-8 weeks
Phone number to OB/Ped providers and
Lactation Consultant
Symptoms/concerns when to call
provider
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D/C Teaching
When to Call Provider
Fever over 100.4
Chills
Symptoms of UTI
Saturating >1 pad/hr
Bright red flow return
Foul smelling lochia
Abdominal tenderness
Severe leg pain/edema
Chest pain/coughing
Increased perineal pain
prolonged baby blues or
depression
C/S incision that feels hot
to touch, oozing or
reddened
Nausea and vomiting
Headache not relieved by
medications
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References
AWHONN’s Compendium of Postpartum Care. Johnson
and Johnson Inc.; 2006.
Chin, MD, FACOG. On Call Obstetrics and gynecology.
W.B. Saunders Co. Philadelphia; 1997.
Jones, RNC, MSN, Marion W. Postpartum Complications.
Health Education Innovations, Inc.; 1996.
Mattson, PhD, RNC, CTN, Susan and Smith, PhD, RNC,
Judy E. Core Curriculum for Maternal-Newborn Nursing,
AWHONN, 2nd Ed. ; W.B. Saunders Co. Philadelphia;
2000.
Rice-Simpson, RNC, MSN and Creehan, RNC, MS, MA,
ACCE, Patricia A. Perinatal Nursing. AWHONN;
Lippencott, Philadelphia; 2003.
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The End