Postpartum Nursing Care PATHOPHYSIOLOGICAL AND PSYCHOSOCIAL CHANGES OF

Postpartum Nursing Care PATHOPHYSIOLOGICAL AND PSYCHOSOCIAL CHANGES OF POSTPARTUM ASSESSMENT AND CARING INTERVENTIONS LABORATORY VALUES OF THE POSTPARTUM CLIENT MEDICATIONS USED IN POSTPARTUM PHYSIOLOGY OF BREASTFEEDING AND THE BREASTFEEDING CLIENT FORMULA FEEDING DISCHARGE TEACHING

Pathophysiology of Postpartum Involution - rapid reduction in size of uterus and return to prepregnant state Subinvolution = failure to descent Uterus is at level of umbilicus within 6 to 12 hours after childbirth - decreases by one finger breadth per day Exfoliation - allows for healing of placenta site and is important part of involution – may take up to 6 weeks Enhanced by uncomplicated labor and birth complete expulsion of placenta or membranes breastfeeding early ambulation

FIGURE 23– 1 Involution of the uterus. A, Immediately after expulsion of the placenta, the top of the fundus is in the midline and approximately halfway between the symphysis pubis and the umbilicus. B, About 6 to 12 hours after birth, the fundus is at the level of the umbilicus. The height of the fundus then decreases about one fingerbreadth (approximately 1 cm) each day.

Pathophysiology of Postpartum Uterus rids itself of debris remaining after birth through discharge called lochia Lochia changes: Bright red at birth Rubra - dark red (2 – 3 days after delivery) Serosa – pink (day 3 to 10 after delivery) Alba – white Clear If blood collects and forms clots within uterus, fundus rises and becomes boggy (uterine atony)

Ovulation and Menstruation/Lactation Return of ovulation and menstruation varies for each postpartal woman Menstruation returns between 6 and 10 weeks after birth in nonlactating mother - Ovulation returns within 6 months Return of ovulation and menstruation in breastfeeding mother is prolonged related to length of time breastfeeding continues Breasts begin milk production a result of interplay of maternal hormones

Pathophysiology of Bowel Elimination Intestines sluggish because of lingering effects of progesterone and decreased muscle tone Spontaneous bowel movement may not occur for 2 to 4 days after childbirth Mother may anticipate discomfort because of perineal tenderness or fear of episiotomy tearing Elimination returns to normal within one week After cesarean section, bowel tone return in few days and flatulence causes abdominal discomfort

Pathophysiology of Urinary tract Increased bladder capacity, decreased bladder tone, swelling and bruising of tissue Puerperal diuresis leads to rapid filling of bladder urinary stasis increases chance of urinary tract infection If fundus is higher than expected on palpation and is not in midline, nurse should suspect bladder distension

FIGURE 23– 2 The uterus becomes displaced and deviated to the right when the bladder is full.

Laboratory Values White blood cell count often elevated after delivery Leukocytosis Elevated WBC to 30, 000/mm 3 Physiologic Anemia Blood loss – 200 – 500 Vaginal delivery Blood loss 700 – 1000 ml C/S RBC should return to normal w/in 2 - 6 weeks Hgb – 12 – 16, Hct – 37% - 47% Activation of clotting factors (PT, PTT, INR) predispose to thrombus formation - hemostatic system reaches non-pregnant state in 3 to 4 weeks Risk of thromboembolism lasts 6 weeks

Weight Loss 10 – 12 pounds w/ delivery 5 pounds with diuresis Return to normal weight by 6 – 8 weeks if gained 25 - 30 pounds Breastfeeding will assist with weight loss even with extra calorie intake

Psychosocial Changes Taking in - 1 to 2 days after delivery Mother is passive and somewhat dependent as she sorts reality from fantasy in birth experience Food and sleep are major needs Taking hold - 2 to 3 days after delivery Mother ready to resume control over her life She is focused on baby and may need reassurance

Psychosocial Changes Maternal Role Attachment Woman learns mothering behaviors and becomes comfortable in her new role Four stages to maternal role attainment Anticipatory stage - During pregnancy Formal stage - When baby is born Informal stage - 3 to 10 months after delivery Personal stage - 3 to 10 months after delivery Father-Infant Interaction Engrossment Sense of absorption Preoccupation - Interest in infant

Postpartum Assessment Vital signs: Temperature elevations should last for only 24 hours – should not be greater than 100. 4°F Bradycardia rates of 50 to 70 beats per minute occur during first 6 to 10 days due to decreased blood volume Assess for BP within normal limits: Notify MD for tachycardia, hypotension, hypertension Respirations stable Breath sounds should be clear Complete systems assessment BUBBLEHE assessment Postpartum chills or shivers are common

Breasts Assessment Assess if mother is breast- or bottle-feeding - inspect nipples and palpate for engorgement or tenderness – should not observe redness, blisters, cracking

Breasts Assessment Breasts should be soft, warm, non-tender upon palpation Secrete colostrum for 1 st 2 -3 days –yellowish fluid protein and antibody enriched to offer passive immunity and nutrition Milk comes in around 3 – 4 days – feel firm, full, tingly to client

Uterus Assessment Monitor uterus and vaginal bleeding, every 30 minutes x 2 for first PP hour, then hourly for 2 more hours, every 4 hours x 2, then every 8 hours or more frequently if there is bogginess, position out of midline, heavy lochia flow Determine firmness of fundus and ascertain position approximate descent of 1 cm or 1 fingerbreadth per day If boggy (soft), gently massage top of uterus until firm – notify health care provider if does not firm Displaced to the right or left indicates full bladder – have client void and recheck fundus

Uterus Assessment FIGURE 23– 6 Measurement of descent of fundus for the woman with vaginal birth. The fundus is located two finger-breadths below the umbilicus. Always support the bottom of the uterus during any assessment of the fundus.

Bladder and Bowel Assessment Anesthesia or edema may interfere with ability to void – palpate for bladder distention - may need to catheterize – measure voided urine Assess frequency, burning, or urgency Diuresis will occur 12 – 24 hours after delivery – eliminate 2000 – 3000 ml fluid, may experience night sweats and nocturia Bowel: Assess bowel sounds, flatus, and distention

Lochia – Rubra Assessment Lochia = blood mucus, tissue vaginal discharge Assess amount, color, odor, clots If soaking 1 or > pads /hour, assess uterus, notify health care provider Total volume – 240 – 270 ml Resume menstrual cycle within 6 – 8 weeks, breast feeding may be 3 months

Episiotomy, Lacerations, C/S Incisions Inspect the perineum for episiotomy/lacerations with REEDA assessment Inspect C/S abdominal incisions for REEDA R = redness (erythema) E = edema E = ecchymosis D = drainage, discharge A = approximation

Episiotomy

Postpartum Nursing Interventions Relief of Perineal Discomfort Ice packs for 24 hours, then warm sitz bath Topical agents - Epifoam Perineal care – warm water, gently wipe dry front to back

FIGURE 24– 1 A sitz bath promotes healing and provides relief from perineal discomfort during the initial weeks following birth.

Hemorrhoids, Homan’s Sign Assess for hemorrhoids Relief of hemorrhoidal discomfort may include Sitz baths Topical anesthetic ointments Rectal suppositories Witch hazel pads - Tucks Extremities Assess for pedal edema, redness, and warmth Check Homan's sign – dorsiflex foot with knee slightly bent

FIGURE 23– 9 Homans’ sign: With the woman’s knee flexed, the nurse dorsiflexes the foot. Pain in the foot or leg is a positive Homans’ sign.

Emotional Status/Bonding Assessment Describe level of attachment to infant Determine mother's phase of adjustment to parenting Postpartum Blues Transient period of depression Occurs first few days after delivery Mother may experience tearfulness, anorexia, difficulty sleeping, feeling of letdown Usually resolves in 10 to 14 days Causes: Changing hormone levels, fatigue, discomfort, overstimulation Psychologic adjustments Unsupportive environment, insecurity

Postpartum Nursing Interventions After pains Uterine contractions as uterus involutes Relief of after pains Positioning (prone position) Analgesia administered an hour before breastfeeding Encourage early ambulation - monitor for dizziness and weakness

Medications Bleeding oxytocin (Pitocin) – watch for fluid overload and hypertension methylergonovine (Methergine) – causes hypertension prostaglandin F (Hemabate, carboprost) – n/v, diarrhea Pain Medications NSAIDS – GI upset Oxycodone/acetaminophen (Percocet) – dizziness, sleepiness PCA – Morphine for C/S – respiratory distress docusate (Senna) – causes diarrhea Rubella Vaccine – titer 1: 10, do NOT get pregnant for 3 months Rh Immune Globulin (Rho. GAM) – Rh negative mother – do not administer rubella vaccine for 3 months

Mother and Family Needs Nurse can assist in restoration of physical well- being by Assessing elimination patterns Determining mother's need for sleep and rest Encourage regular diet as tolerated and increasing fluids Identify available support persons - involve support person and siblings in teaching as appropriate Determine family's knowledge of normal postpartum care and newborn care

Breastfeeding Pathophysiology Before delivery, increased estrogen stimulates duct formation, progesterone promotes development of lobules and alveoli After delivery, estrogen and progesterone decrease, prolactin increases to promote milk production by stimulating alveoli Newborn suck releases oxytocin to stimulate letdown reflex

Composition of Breast Milk Breast milk is 90% water; 10% solids consisting of carbohydrates, proteins, fats, minerals and vitamins Composition can vary according to gestational age and stage of lactation Helps meet changing needs of baby Foremilk – high water content, vitamins, protein Hindmilk - higher fat content

Immunologic and Nutritional Properties Secretory Ig. A, immunoglobulin found in colostrum and breast milk, has antiviral, antibacterial, antigenic-inhibiting properties Contains enzymes and leukocytes that protect against pathogens Composed of lactose, lipids, polyunsaturated fatty acids, amino acids, especially taurine Cholesterol, long-chain polyunsaturated fatty acids, and balance of amino acids in breast milk help with myelination and neurologic development

Advantages of Breastfeeding Provides immunologic protection Infants digest and absorb component of breast milk easier Provides more vitamins to infant if mother's diet is adequate Strengthens mother-infant attachment No additional cost Breast milk requires no preparation AAP= Only food for 6 months, w/ foods for 12 months

Disadvantages of Breastfeeding Many medications pass through to breast milk Father unable to equally participate in actual feeding of infant Mother may have difficulty being separated from infant

Breastfeeding Mother Breastfeeding mother needs to know How breast milk is produced How to correctly position infant for feeding Procedures for feeding infant Number of times per day breastfed infant should be put to the breast How to express and store breast milk How and when to supplement with formula How to care for breasts Medications that pass through breast milk Support groups for breastfeeding Review signs and symptoms of engorgement, plugged milk ducts, mastitis

Breastfeeding Assessment

Figure 29– 2 Four common breastfeeding positions. A, Football hold. B, Lying down. C, Cradling. D, Across the lap.

Formula Preparations Three categories of formulas based on cow milk proteins, soy protein-based formulas, specialized or therapeutic formulas - all are enriched with vitamins, particularly vitamin D Most common cow milk protein-based formulas attempt to duplicate same concentration of carbohydrates, proteins, fats as 20 kcal/oz same as breast milk

Bottle-Feeding Advantages Provides good nutrition to infant Father can participate in infant feeding patterns

Bottle-Feeding Disadvantages May need to try different formulas before finding one that is well-tolerated by infant Proper preparation necessary for nutrition adequacy

Bottle-Feeding Mother Bottle-feeding mother needs to know Types of formula available and how to prepare each type Procedure for feeding infant How to correctly position infant for bottle-feeding How to safely store formula How to safely care for bottles and nipples Amount of formula to feed infant at each feeding How often to feed infant Expected weight gain

Bottle Feeding Mother Teach to wear a binder or tight-fitting sports bra day and night for two weeks. Do not allow hot water from shower to run over breasts Avoid manual stimulation Apply cabbage leaves (dries up breast) Use acetaminophen for discomfort

Cesarean Section Needs Assess vital signs Assess breasts Assess location and firmness of uterine fundus Assess lochia Assess incision site – REEDA Assess breath sounds Assess indwelling urinary catheter - color and amount of urine noted Assess bowel sounds: present, hypoactive or hyperactive

Cesarean Section Needs Cesarean birth is major abdominal surgery - if general anesthesia used, abdominal distension may cause discomfort, assess for bowel obstruction Position client on left side, include exercises, early ambulation, increase po intake, avoid carbonated beverages, avoid straws - may need enemas, stool softeners, antiflatulent meds Pulmonary infections may occur related to immobility and use of narcotics because of altered immune response TCDB, use incentive spirometer q 2 hours

Pain and Comfort Administer analgesics within the first 24 to 72 hours - allows woman to become more mobile and active Comfort is promoted through proper positioning, back rubs, and oral care - reduce noxious stimuli in environment Encourage visits by family and newborn, which provides distraction from painful stimuli Encourage non-pharmacologic methods of pain relief (breathing, relaxation, and distraction) - encourage rest

Attachment After a Cesarean Birth Physical condition of mother and newborn and maternal reactions to stress, anesthesia, and medications may impact mother-infant attachment By second or third day, cesarean birth mother moves into "taking-hold period" Emphasize home management and encourage mother to allow others to assume housekeeping responsibilities Stress how fatigue prolongs recovery and may interfere with attachment process

Discharge Instructions S/S complications Referral numbers PP Exercises Nutrition Rest PP appointment Avoid overexertion Birth certificate info Sexual activity Infant care Hygiene Infant complications Sitz baths Infant follow-up Incision care Family bonding

Discharge Teaching New mother should gradually increase activities and ambulation after birth Avoid heavy lifting, excessive stair climbing, strenuous activity, vacuuming Resume light housekeeping by second week at home Delay returning to work until after 6 -week postpartum examination

Discharge Teaching Recommend exercise to provide health benefits to new mother Nurse should encourage client to begin simple exercises while on nursing unit Inform her that increased lochia and pain may necessitate a change in her activity

Sexual Activity and Contraception Sleep deprivation, vaginal dryness, and lack of time together may impact resumption of sexual activity Usually sexual intercourse is resumed once episiotomy has healed and lochia has stopped (about 3 – 6 weeks) Breastfeeding mother may have leakage of milk from nipples with sexual arousal due to oxytocin release

Contraception Information on contraception should be part of discharge planning Nursing staff need to identify advantages, disadvantages, risk factors, any contraindications Breastfeeding mothers concerned that contraceptive method will interfere with ability to breastfeed - they should be given available options – progesterone only

Parent-Infant Attachment Tell parents it is normal to have both positive and negative feelings about parenthood Stress uniqueness of each infant Provide time and privacy for the new family Include parents in nursing intervention

Reaction of Siblings Sibling visits reassure children their mother is well Father may need to hold new baby, so mother can hug older children Suggest to parent that bringing doll home allows young child to "care for" and identify with parents

Infant Care New mother and family should know basic infant care Information about tub baths Cord treatment, When to anticipate cord will fall off Family should be comfortable in feeding and handling infant, as well as safety concerns Immunizations When to call the doctor

Discharge Teaching Nurse should review with new mother any information she has received regarding postpartum exercises, prevent of fatigue, sitz bath and perineal care, etc. - nurse should spend time with parent to determine if they have any lastminute questions before discharge Printed information about local agencies and support groups should be given to new family

Types of Follow-Up Care Telephone calls - nurses must listen carefully and ask open ended questions Return visits - Within one week after first visit Telephone follow-up - Within 3 days of discharge Baby care/postpartum classes New mother support groups Need to have a caring attitude in these activities

Main Purpose of the Home Visit Assessment Status of mother and infant Adaptation and adjustment of family to new baby Determine current informational needs Teaching Self-care Infant Care Opportunity to answer additional questions related to infant care and feeding Counseling Provide emotional support to mother and family Referrals

Maternal Assessments at Home Vital signs: Should be at prepregnancy level Weight: Expect weight to be near prepregnancy level at 6 weeks postpartum Condition of breasts Condition of abdomen, including healing cesarean incision if applicable Elimination pattern: should return to normal by 4 to 6 weeks postpartum

Maternal Assessment Lochia Should progress from lochia rubra to lochia alba If not breastfeeding, menstrual pattern should return about 6 weeks postpartum Fundus Uterus should return to normal size by 6 weeks postpartum Perineum: Episiotomy and lacerations should show signs of healing

Breastfeeding Assessment Nipple soreness - Peaks on days 3 and 6, then recedes Cracked nipples Allow nipples to air dry after breastfeeding Nurse frequently Alternate breasts Change infant's position regularly Breast engorgement, plugged ducts Effect of alcohol and medications Return to work Weaning

Family Assessment Bonding: Appropriate demonstration of bonding should be apparent Level of comfort: parents should display appropriate levels of comfort with the infant Siblings should be adjusting to new baby Parental role adjustment Parents should be working on division of labor Changes in financial status Communication changes Readjustment of sexual relations Adjustment to new daily tasks Contraception: Parents understand need to choose and use a method of contraception

Relinquishing a Baby Many reasons why a woman decides she cannot parent her baby Emotional crisis may arise as woman attempts to resolve her concerns As she faces these concerns, social pressures against giving up baby Mother may need to complete grieving process to work through her decision - she may have made considerable adjustments to her lifestyle to give birth

Relinquishing a Baby (cont’d) Nursing staff need to honor any special requests after birth and encourage mother to express her feelings Seeing newborn may assist mother in grieving process Some mothers may request early discharge or transfer to another unit