Nursing Care of the Family During the Postpatum Period

Key Points Postpartum care is family centered and modeled on the concept of health. Cultural beliefs and practices affect the maternal and family response to the postpartum period. The nursing care plan includes assessments to detect deviations from normal, comfort measures to relieve discomfort or pain, and safety measures to prevent injury or infection.

Key Points (cont) Common nursing interventions in the postpartum period focus on preventing excessive bleeding, bladder distention, and infection; providing nonpharmacologic and pharmacologic relief of discomfort associated with the episiotomy, lacerations, or breastfeeding; and instituting measures to promote or suppress lactation. Teaching and counseling measures are designed to promote the woman’s feelings of competence in self-management and infant care.

Key Points (cont) Meeting the psychosocial needs of new mothers involves taking into consideration the composition and functioning of the entire family. Early discharge classes, telephone follow-up, home visits, warm lines, and support groups are effective means of facilitating physiologic and psychologic adjustments in the postpartum period.

Learning Objectives Describe components of a systematic postpartum assessment. Recognize signs of potential complications in the postpartum woman. Formulate a nursing care plan for a woman in the postpartum period. Explain the influence of cultural beliefs and practices on postpartum care.

Learning Objectives (cont) Identify psychosocial needs of the woman in the early postpartum period. Prepare a plan for postpartum teaching for self-management. Describe the nurse’s role in these postpartum follow-up strategies: home visits, telephone follow-up, warm lines and help lines, support groups, and referrals to community resources.

Nursing Care of the Postpartum Woman Goal of nursing care in the immediate postpartum period is: to assist women and their partners during their initial transition to parenting

Nursing Care of the Postpartum Woman Fourth Stage of Labor The first two hours after birth Maternal organs start to undergo readjustments to the nonpregnant state Nurse’s role during the fourth stage of labor is: Identify and manage promptly any deviations from the normal processes that may occur Promote and support parent-infant attachment

Nursing Care of the Postpartum Woman Fourth stage of Labor Assessment During the first hour in the recovery room, physical assessments of the mother are frequent All factors but temperature are assessed every 15 minutes for the first hour and then every thirty minutes in the second hour Temperature is assessed at the beginning and end of the recovery period Postpartum women experience intense tremors or shivering Provide warm blankets

Nursing Care of the Postpartum Woman Physiologic Assessments Temperature First 24 hours every 4 hours Every 8 hours after that till discharge Pulse, Respirations, and Blood Pressure Every 15 minutes-first hour of delivery Every 30 minutes for the next 2 hours after delivery Then every 4 hours for the first 24 hours Then every 8 hours till discharge

1.Retake the temperature in 15 minutes 2.Notify the physician A postpartum nurse is taking the vital signs on a woman who delivered a healthy newborn 4 hours ago. The nurse notes that the mother’s temperature is 100.2º F. Which of the following actions would be most appropriate? 1.Retake the temperature in 15 minutes  2.Notify the physician  3.Document the finding  4.Increase hydration by encouraging oral fluids 

Nursing Care of the Postpartum Woman Physiologic Assessments Fundus, Lochia, and Bladder Assess every 15 minutes for the first hour Assess ever 4 hours for the next two hours after delivery Then assess every 8 hours until discharge Perineum Assess once the first hour after delivery Then assess every four hours for the first 24 hours Then after 24 hours of delivery assess every 8 hours until discharge

2.Lie flat on her back with the knees and legs flat and straight  A nurse is preparing to perform a fundal assessment on a postpartum client. The nurse first asks the client to: 1.Turn on her side  2.Lie flat on her back with the knees and legs flat and straight  3.Urinate and empty her bladder  4.Massage the fundus gently

2.Document the findings and reassess in 1 hour 3.Massage the fundus A nurse is assessing the fundal height on a postpartum woman and notes that the fundus feels flaccid and soft. The nurse would immediately: 1.Contact the physician  2.Document the findings and reassess in 1 hour  3.Massage the fundus  4.Ask the client to ambulate

1.Increases during ambulation 2.Increases during sleep A nurse is providing information about lochia flow to a woman who just delivered a newborn. The nurse tells the woman that the amount of lochia flow: 1.Increases during ambulation  2.Increases during sleep  3.Is scant immediately following delivery  4.Increases in amount on the third postpartum day 

2.Encourage increased oral intake of fluids When performing a postpartum assessment on a client, the nurse notes the presence of clots in the lochia. The nurse examines the clots and notes that they are larger than 1 cm. Which of the following nursing actions is most appropriate? 1.Document the findings  2.Encourage increased oral intake of fluids  3.Reassess the client in 2 hours  4.Notify the physician

2.Lie flat on her back with the knees and legs flat and straight A nurse is preparing to perform a fundal assessment on a postpartum client. The nurse first asks the client to: 1.Turn on her side  2.Lie flat on her back with the knees and legs flat and straight  3.Urinate and empty her bladder  4.Massage the fundus gently

Nursing care of the Postpartum Woman Physiologic Assessments Breasts, Legs Assess every four hours in the first twenty-four hours Then assess every 8 hours thereafter until discharge

Nursing Care of the Postpartum Woman Laws Related to Discharge Newborn’s and Mother’s Health Protection Act of 1996 Provided minimum federal standards for health plan coverage for mothers and their newborns New mothers and newborns could remain in the hospital for a minimum of 48 hours after a normal vaginal delivery New mothers and newborns could remain in the hospital for a minimum of 96 hours after a normal cesarean birth Healthcare providers expressed concern that some medical problems do not show up for 24 hours after birth and that new mothers have not sufficiently learned how to care for their newborn health problems such as jaundice related to breastfeeding difficulties There also was concern that the shortened hospital stays would increase maternal hospital readmissions for infection, hypertension, and hemorrhage I women who gave birth vaginally Enactment of federal and various state maternity length-of-stay bills to ensure adequate care for both mother and newborn

Nursing Care of the Postpartum Woman Routine Laboratory Test Hemoglobin Hematocrit Rubella Rh status

Nursing Care of the Postpartum Woman Nursing Diagnoses Alteration in comfort related to afterpains, episiotomy, laceration, hemorrhoids, breast engorgement, surgical incision Sleep pattern disturbances Health seeking behaviors regarding self-care, newborn care, health maintenance, prevention of infections, or complications Altered parenting Potential for infection/hemorrhage

Nursing care of the Postpartum W- Woman Couplet Care Also called mother and baby care or single-room maternity care Nurse functions as the primary nurse for both the mother and baby, even if the baby is in the nursery Rooming-in Mother and baby room together Mother and nurse share the care of the infant

Nursing Care of the Postpartum Woman Plan of Care Perineal Care Pouring a stream of water over the vulva and perineum after voiding or defecation Wiping from front to back after voiding or defecation Change peri-pad with each voiding or defecation Cold therapy for 24 to 48 hours Ice packs Cold packs Heat therapy

Nursing Care of the Postpartum Woman Plan of Care Perineal Care Sitz bath 2-3 times a day Warm packs Medications Anesthetic sprays, epifoam, witch hazel pads (tucks) Sitting with perineal sutures Bring buttocks together and contract pelvic floor muscles

2.“I will use warm water to rinse the perineum after elimination.” A nurse has provided instructions to a postpartum woman regarding care of the episiotomy site to prevent an infection. Which statement by the woman indicates a need for further instructions? 1.“I will wipe my perineum from front to back after voiding and defecation.”  2.“I will use warm water to rinse the perineum after elimination.”  3.“I will change the perineal pad three times a day.”  4.“I will perform warm sitz baths three times a day.”

Nursing Care of the Postpartum Woman Plan of Care Prevention of Excessive Bleeding Uterine Atony Failure of the uterine muscle to contract firmly Most frequent cause of excessive bleeding after childbirth Two most important interventions for preventing excessive bleeding are: Maintaining good uterine tone Preventing bladder distention

Nursing Care of the Postpartum Patient Plan of Care Maintenance of Uterine Tone Fundal massage Teaching patient to do fundal self- massage IV oxytocin, such as pitocin Oral or IM medications (drugs that stimulate contraction of the uterine smooth muscle) such as methergine, cytotec, and hemobate

Nursing Care of the Postpartum Woman Plan of care Prevention of Bladder Distention Full bladder causes the uterus to be displaced above the umbilicus well to one side of the midline of the abdomen Prevents uterus from contracting normally Focus on helping the woman to empty her bladder spontaneously as soon as possible

1.Diuresis 2.Stress incontinence 3.Urge incontinence 4.Retention In the immediate postpartum period, the nurse monitors the new mother for which risk related to the urinary system? 1.Diuresis  2.Stress incontinence  3.Urge incontinence  4.Retention 

Nursing Care of the Postpartum Woman Prevention of Bladder Distention Techniques to help the woman void Assist woman to the bathroom Have woman listen to running water Pouring water from a squeeze bottle over her perineum Assisting woman into the shower or sitz bath

Nursing Care of the Postpartum Woman Afterbirth pains Menstrual-like cramps felt by many women as the uterus contracts after childbirth Warmth Distraction Deep breathing Imagery Therapeutic touch and relaxation Interaction with the infant may decrease the discomfort associated with these uterine contractions

Nursing Care of the Postpartum Woman Plan of Care Ambulation Early ambulation is successful in reducing the incidence of thromboembolism and in promoting the woman’s more rapid recovery of strength Orthostatic hypotension Women with varicosities are encouraged to wear support hose

Nursing Care of the Postpartum Woman Plan of Care Ambulation Thrombus is suspected Warmth, redness, or tenderness in the suspected leg Notify MD immediately Confine woman to bed with affected limb elevated on pillows

Nursing Care of the Postpartum Woman Fatigue Common in the postpartum period Interventions must be planned to meet the woman’s individual need for sleep and rest Support and encouragement in mother’s behaviors help reduce anxiety Hospital and nursing routines also may be adjusted to meet individual needs

Nursing Care of the Postpartum Woman Plan of Care Bladder After giving birth the woman should void spontaneously within 6 to 8 hours Several of the first voidings should be measured to document adequate emptying of the bladder A volume of 150 ml is expected for each voiding

Nursing Care of the Postpartum Woman Plan of Care Educating the woman about measures to avoid constipation Adequate roughage Plenty of fluids Exercise Decreased narcotic usage Stool softeners and laxative use fort

4. Within 2 weeks postpartum  A postpartum nurse is providing home care instructions to a woman following delivery of a healthy newborn. The nurse tells the mother that she should expect normal bowel elimination to return: 1. 1 day postpartum  2. 3 days postpartum  3. 7 days postpartum  4. Within 2 weeks postpartum 

Nursing Care of the Postpartum Woman Plan of Care Breast Care Breastfeeding First 2 hours after birth Infant is an alert state Aids in the contraction of the uterus Hygiene Avoid soap, alcohol, and other drying agents Cleans nipple with clear water Apply lanolin for sore or cracked nipples

Lactation Benefits of breast feeding Mother Infant Promotes bonding Helps weight loss Stimulates uterine contractions Decreases risk of thromboembolism Protects against breast cancer Some contraceptive protection Readily available Infant

Breast feeding benefits Con’t Infant Milk contains natural components to facilitate immune system and anti-inflammatory agents Nutrients are easily tolerated and digested No artificial colorings, flavors, preservatives Active & passive protection against viral and bacterial pathogens Promotes better tooth and jaw development Protects against food allergies Not likely to over feed

Lactation Nutritional needs Calories Protein Fluid Increase calorie intake by 500 cal/day -6 mo 2300-2700 cal/day while breast feeding Protein Needs additional 20 gm Extra 2 c. of milk = 16g protein Fluid 2-3 quarts per day Water, milk, fruit juice Encourage 1 glass of fluid with each nursing of infant Vitamins and minerals Balanced supplement for less than 1800 cal/da

1.100 calories per day 2.300 calories per day 3.500 calories per day A nurse is providing nutritional counseling to a new mother who is planning to breast-feed her newborn. The nurse instructs the mother that her calorie needs need to increase by: 1.100 calories per day  2.300 calories per day  3.500 calories per day  4.1000 calories per day

A home care nurse visits a client who delivered a healthy newborn infant 2 days ago. The mother is complaining of breast discomfort and the nurse notes that the mother is experiencing breast engorgement. The nurse provides instructions to the mother regarding relief of the engorgement. Which statement by the mother indicates a need for further instructions? 1.“I should feed my infant at least every 2½ hours for 15 to 20 minutes on each side.”  2.“I should avoid breast-feeding during the time of breast engorgement.”  3.“I should apply moist heat to both breasts for about 20 minutes before a feeding.”  4.“I should gently massage the breasts during a feeding from the outer areas to the nipples.” 

Nursing Care of the Postpartum Woman Lactation Suppression Wearing a well-fitted support bra or binder Avoid any breast stimulation Severe breast engorgement Ice packs to the breast Cabbage leaves Mild analgesics

Nursing Care of the Postpartum Woman Rubella –women who have not had rubella Titer of 1:8 or enzyme immunoassay level less than 0.8 Given sub Q Women are cautioned to avoid pregnancy for 28 days

Nursing Care of the Postpartum Woman Varicella Vaccine Women with no immunity Avoid pregnancy for 28 days A second dose is given at the postpartum follow-up visit (4 to 8 weeks after the first dose

Nursing Care of the Postpartum Womman Varicella Vaccination Before discharge in women with no immunity Second dose 4-6 weeks postpartum Tetanus-Diphtheria-Acellular Pertussis Vaccine (Tdap)

Nursing Care of the Postpartum Woman Prevention of RH Isoimmunization Injection of Rh immune globulin (Rhogam) must be given within 72 hours after birth to prevent sensitization in the RH-negative woman who has had a fetomaternal transfusion of Rh-positive red blood cells Administration of 300 mcg (1 vial) of Rh immune globulin is usually sufficient to prevent maternal sensitization

Nursing Care of the Postpartum Woman Prevention of RH Isoimmunization Large fetomaternal transfusions Kleihauer-Betke- which detects the amount of fetal blood in maternal circulation More than 30 ml of fetal blood is present in maternal circulation, the dosage of Rh immune globulin must be increased

Nursing Care of the Postpartum Woman Cultural Variations Mother” beliefs about postpartal care influenced by her culture and personal values Many cultures emphasize certain postpartal routines or rituals for mother and baby Some Hispanics, African, and Asian cultures may avoid cold after birth Rest and seclusion Hygiene

Nursing Care of the Postpartum Woman Follow-Up After Discharge Home Visits Telephone follow-up Warm lines Support groups Referral to community resources