Post Partum Period

1
Post Partum Period

• Mary L. Dunlap MSN, APRN
• Fall 10

2
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

3
Safety for Mother and Infant

• Prevent infant abductions
• Check ID bands
• Educate mother about safety measures

4
Clinical Assessment

• Review Antepartum and Intrapartum history
• Receive report
• Determine educational needs
• Consider religious and cultural factors
• Assess for language barriers

5
Post Partum AssessmentBUBBLE-HE

• Lochia
• Episiotomy
• Legs
• Emotion

• Breast
• Uterus
• Bladder
• Bowel

6
Early Assessment

• Vital signs
• Temperature
• Pulse
• Blood pressure
• Respirations

7
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

8
Nursing Care Lactating Mother

• Supportive bra
• Correct position
• Correct latch-on technique
• Warm showers
• Expose to air

9
Nursing CareNon-Lactating Mother

• Avoid stimulation
• Wear support bra 24hrs
• Ice packs or cabbage leaves
• Mild analgesic for discomfort

10
Assessment of Uterus

• Location immediately after birth
• Descends 1 cm/day
• Consistency- firm/boggy
• Location Height- measured in fingerbreadths

11
Nursing care

• Boggy fundus- massage until firm
• Medications- Pitocin, Methergine, Hemabate
• Teach new mom to massage her fundus

12
Afterpains

• Intermittent uterine contractions due to
  involution
• Primiparous-mild
• Multipara- more pronounced

13
Nursing Interventions

• Patient in a prone position and place a small
  pillow under her abdomen
• Ambulation
• Medicate with a mild analgesic

14
Bladder

• Spontaneous void 6-8 hrs
• Monitor output
• Postpartum Diuresis

15
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

16
Bowel

• Anatomy returns to normal location
• Relaxin depresses bowel motility
• Diminished intraabdominal pressure
• Incontinence if sphincter lacerated
• Spontaneous BM 2nd 3rd post partum day

17
Nursing Care

• Increase fiber in diet
• 6-8 glasses of water or juice
• Stool softener
• Laxative
• Sitz bath for discomfort
• Medications for hemorrhoids

18
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

19
Lochia

• Rubra
• Serosa
• Alba
• Documentation

20
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

21
Episiotomy

• 1-2 inch incision in the muscular area between
  the vagina and the anus
• Assess REEDA
• Episiotomy care

22
Nursing Care

• Peri care
• Ice packs
• Sitz baths
• Dry heat
• Topical medications

23
Pain Assessment

• Determine source
• Document location, type and duration
• Interventions

24
Assess for DVT

• Homans sign
• Clinical assessment

25
Postpartum Blues

• Transient periods of depression during the first
  1 to 2 weeks postpartum
• Tearfulness
• Sad feeling
• Confusion
• Insomnia

26
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

27
Maternal Physiological Adaptations
28
Hematological System

• Decrease in blood volume
• Elevated WBC
• Increased Fibrinogen

29
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

30
Neurological System

• Maternal fatigue
• Transient neurological changes
• Headaches
• Carpel tunnel improvement

31
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

32
Integumentary System

• Darken pigmentation gradually fades
• Hair regrowth returns to normal in 6-12 months
• Striae( stretch marks) fade to silvery lines

33
Cardiovascular System

• Heart returns to normal position
• Cardiac output elevated above prelabor levels up
  to 48 hrs. PP

34
Immune System

• Rubella
• Administer to nonimmune mothers
• Safe for nursing mothers
• Avoid pregnancy for 1 month
• Flu-type symptoms may occur

35
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

36
Reproductive System

• Involution of uterus
• Healing of placental site
• Vaginal changes

37
Menstruation and Ovulation

• Nonlactactating mother
• Menstruation returns in 6-8 wks
• First cycle may be anovulatory
• Lactating mother
• Delayed ovulation and menstruation

38
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

39
Multicultural Nursing Care

• Enhance Cultural Sensitivity
• Understand cultural influences on the post partum
  period
• Provide culturally appropriate care

40
HIV/AIDS

• Gloves safety glasses
• Discourage breast feeding
• Avoid contact personal body fluid with infants
  mucous membranes

41
Postpartal Surgical Patient

• Tubal ligation
• Cesarean birth

42
Breast Feeding

• Optimal method of feeding infant
• Breast milk- Bacteriologically safe, fresh,
  readily available
• Box 15-3 pg.489 Breastfeeding benefits

43
Breastfeeding

• Lactogenesis- secretion of milk
• Milk ejection reflex- let down reflex

44
Breastfeeding

• Cue signs- Box 15-4 pg. 492
• Latch-on- Fig 15-8 pg 492
• Assess for milk let down

45
Breastfeeding

• Positions
• Cradle hold
• Foot ball
• Side lying
• Fig 15-10 pg 494

46
Ineffective Breastfeeding

• Incorrect latch-on
• Inverted nipples
• Breast engorgement

47
Collection and Storage Breast Milk

• Room temperature- 4 hrs
• Refrigerator- 5-7 days
• Deep freezer- 6-7 months

48
Formula Feeding

• Formula preparation
• Periodically check nipple integrity
• Bottle preparation

49
Family and Infant Bonding

• Transitioning to parenthood
• Assuming the mothering role
• Parental bonding
• Factors that interrupt bonding

50
Transitioning to parenthood

• Difficult and challenging
• Provide emotional support
• Accurate information
• Nursing goal create a supportive teaching
  environment

51
Assuming the mothering role

• Rubins three phases
• Taking in
• Taking hold
• Letting-go
• Table 15-6 pg. 499

52
Bonding

• Bonding process helps to lay the foundation for
  nurturing care
• Touch- skin to skin
• Eye contact
• Breastfeeding

53
Discharge Planning and Teaching

• Self Care

54
Discharge Teaching

• Fundus and Lochia
• Episiotomy care
• Incision care
• Signs of infection- box 15-5 pg 505
• Elimination

55
Discharge Teaching

• Nutrition
• Exercise
• Pain management
• Sexual activity
• Contraception

56
Community Resources

• Support groups
• Home visits
• Telephone follow-up
• Outpatient Clinics

57
Postpartum Complications
58
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

59
Postpartum Hemorrhage

• LARRY- common causes of early PPH
• Laceration
• Atony
• Retained placental tissue
• Ruptured uterus
• You pulled to hard on the cord

60
Postpartum Hemorrhage

• 4 Ts- factors associated with PPH
• Tone
• Trauma
• Tissue
• Thrombin

61
Postpartum HemorrhageTone/Atony

• Altered muscle tone due to overdistention
• Prolonged or rapid labor
• Infection
• Anesthesia
• Box 16-1 pg 513

62
Postpartum HemorrhageTrauma

• Cervical lacerations
• Vaginal lacerations
• Hematomas of vulva, vagina or peritoneal areas
• Box 16-2 pg 514

63
Postpartum HemorrhageTissue

• Retained placental fragments
• Uterine inversion
• Subinvolution

64
Postpartum HemorrhageThrombin

• Disorders of the clotting mechanism
• This should be suspected when bleeding persists
  without an identifiable cause

65
Management of PPH

• Frequent VS
• Fundal massage
• Administer medications- Box 16-1
• Monitor blood loss for amount
• Maintain IV
• Type cross match
• Empty bladder

66
Hematoma

• Localized collection of blood in connective or
  soft tissue under the skin
• Risk factors
• Signs and symptoms
• Management

67
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

68
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

69
Endometritis

• Involves the endometrium, decidua and adjacent
  myometrium of the uterus
• Lower abdominal tenderness or pain
• Temperature
• Foul-smelling lochia

70
Nursing Care

• Administer broad spectrum antibiotic
• Provide analgesia
• Provide emotional support

71
Wound Infection

• Sites- Cesarean incision, episiotomy and genital
  tract laceration
• Drainage
• Edema
• Tenderness
• Separation of wound edges

72
Nursing Care

• Aseptic wound management
• Frequent perineal pad changes
• Good hand washing
• Administer antibiotics
• Analgesics

73
Urinary Tract Infection

• Burning and pain on urination
• Lower abdominal pain
• Low grade fever
• Flank pain
• Protienuria, hematuria, bacteriuria, nitrates and
  WBC

74
Nursing Care

• Frequent emptying of bladder
• Increase fluid intake
• Antibiotics
• Analgesics

75
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

76
Mastitis Symptoms

• Flu like symptoms
• Tender, hot, red area on one breast
• Breast distention with milk

77
Nursing Management

• Empty the breast by increasing the frequency of
  nursing or pumping
• Antibiodics
• Analgesics

78
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

79
Thrombophlebitis and Thrombosis

• Thrombosis (blood Clot) can cause inflammation of
  the blood vessel (thrombophlebitis) which can
  cause thromboembolism (obstruction of blood
  vessel)

80
Assessment Superfical

• Tenderness and pain in extremity
• Warm and pinkish red color over thrombus area
• Palpable- feels bumpy and hard
• Increased pain when ambulating

81
Nursing Care

• NSAIDs for pain
• Bed rest elevate affected leg
• Warm compresses
• Elastic stockings

82
Assessment Deep Vein

• Located from foot to pelvis- can dislodge and
  cause PE
• Calf swelling
• Warmth
• Tenderness
• Pedal edema
• Diminished peripheral pulses

83
Nursing Care

• Bed rest
• Elevate effected leg
• Continuous moist heat
• TED hose both legs
• Analgesics PRN
• Anticoagulation therapy

84
Pulmonary Embolism

• Abrupt onset chest pain, dyspnea, diaphoresis,
  syncope, anxiety
• ABC response