The Postpartum Period

Objectives Nursing Care of the Postpartum Patient Normal Postpartum Period Nursing Care of the Postpartum Patient Physical Changes During the Postpartum Period Psychosocial Changes During the Postpartum Period High-Risk Postpartum Period Nursing Care of the High-Risk PP Patient Postpartum Hemorrhage Postpartum Infections Thromboembolic Disorders Postpartum Psychiatric Disorders

Physiological Changes Reproductive System Involution of uterus; descends 1-2 cm each day. Cannot not be palpated after the 9th postpartum day. Normal estrogen levels return by 10 weeks. Ovulation occurs in 10-12 weeks for non-lactating women; 12-16 weeks for lactating women. Lochia occurs in 3 stages.

Uterine Involution

Stages of Lochia Lochia rubra. Bright red and lasts for the first three days Lochia serosa. Pinkish and watery. Present from day 3 to day 10 Lochia alba. Whitish tan color. Appears after the 10th day and can last as long as six weeks

Assessing Lochia Amount (1gm=1mL)

Physiological Changes Breasts Colostrum is secreted immediately after delivery Milk production begins 3-5 days after delivery

Physiological Changes Cardiovascular System -Blood volume decreases after day 3, as the excess fluid accumulated in pregnancy is eliminated -Diaphoresis eliminates much of the fluid via the skin. -Clotting factors remain elevated (increasing risk of DVT) but returns to normal by the third week.

Physiological Changes Urinary System -Diuresis begins within 12 hours of birth -Helps eliminate excess fluid. Output may be 3,000 mL/day during the first week -Bladder tone is restored by the end of the first week -Edema of the perineum may cause difficult voiding and urinary retention during the first 24 hours. An epidural also may cause retention.

Physiological Changes Gastrointestinal System -Normal bowel function returns by the end of the first week -Stool softeners should be used if episiotomy present -In the immediate postpartum period, patient may be very hungry and thirsty

Physiological Changes Vital Signs -Vital signs do not change much under normal circumstances -Temperature may rise slightly during first 24 hours due to dehydration during labor; hormone changes -Encourage fluids to rehydrate -Pulse decreases to pre-pregnancy rate by 8-10 weeks -Respiration rate decreases to normal prebirth range by 6-8 weeks -Blood pressure usually not altered; orthostatic hypotension may occur during first 48 hours

Nonpathologic Leukocytosis Nonpathological leukocytosis often occurs during labor and in the immediate postpartum period WBC 25,000-30,000/mm3 WBC values typically return to normal levels by the end of the first postpartum week Leukocytosis combined with the normal increase in erythrocyte sedimentation rate (ESR) may obscure the diagnosis of acute infection CBC with diff will confirm a true infection James, 2008

Nursing Interventions -Provide warm blankets for “postpartum chill” during the first 2 hours. Normal response -Replace fluids and food to replace fluid loss and boost energy -Perform physical assessment: B/P, pulse, temperature, lochia, fundal height/firmness, bladder, perineal healing, and nipples/breasts -Ice pack to perineum/episiotomy

Don’t Forget Bladder Assessment -If the bladder is full, it will displace the uterus upward and to the side -A full bladder will prevent the uterus from contracting (involuting) and will increase the risk of hemorrhage

Postpartum Nursing Interventions -Monitor bowel function -Assess for urinary retention and bladder distention -Provide nutrition counseling/teaching -Provide education regarding breast care -Provide education regarding breast or bottle-feeding techniques -Assess family interaction/bonding -Teach Kegel exercises

Pharmacologic Management -Analgesics Acetaminophen and codeine for episiotomy pain Nonsteroidal anti-inflammatory drugs such as ibuprofen for cramping pain (afterpains) -Stool softeners -Benzocaine spray (Dermoplast) -Tucks/Witch hazel pads -Lansinoh breast cream

Products for Perineum Pain Relief

Sitz Bath

Administration of RhoGAM -If mother is Rh negative, we must determine the infant’s blood type to determine if there is a Rh incompatibility -Cord blood is sent to the lab -If the infant is Rh positive, the mother must receive RhoGAM within 72 hours of birth -This will destroy antibodies she may have created and therefore protect her next fetus -Dose: 300 mcg I.M. or I.V.

Administration of Rubella Vaccine -Also known as German measles -Given to postpartum patients who are rubella non-immune (titer < than 1:10). -Not given while pregnant as it has teratogenic effects on the fetus therefore patients instructed not to get pregnant for 1-3 months after injection -Safe for breastfeeding mothers -Vaccine made of goose eggs…possible allergy? -Administered at discharge; 0.5 mL s.c. upper arm

Postpartum Complications Maladaptation Bonding issues Postpartum depression/“baby blues” Physical exhaustion Constipation Breast problems

-If weaned prior to 12 months, use iron-fortified formula. Breastfeeding -American Academy of Pediatrics recommends exclusive breastfeeding for the first 6 months of life – then continue until 12 months of age. -If weaned prior to 12 months, use iron-fortified formula. -Stats: (CDC, 2009) 74% breastfed at birth <14% at 6 months

Breastfeeding Stats

Breastfeeding Benefits for Baby Enhances GI maturation Antibodies Less allergies/asthma Less SIDS Resistance to lymphoma and Type 1 diabetes mellitus Increased cognitive development

Breastfeeding Benefits for Mom: Decreased risk of ovarian, uterine, breast CA Decreased risk of postpartum hemorrhage Faster weight loss Some protection against osteoporosis Facilitates bonding Convenient – no supplies needed, less expense Requires an additional 500 calories per day

Breastfeeding: Imprinting -Breastfeeding should be initiated within one hour of birth because infant is in alert state -This prompt feeding will “imprint” in the baby’s memory. Baby will remember how to breastfeed once he/she comes out of the sleepy state -Studies show that this prompt feeding facilitates greater breastfeeding success

Breastfeeding and Hormones -After delivery estrogen and progesterone drops which triggers release of prolactin -Prolactin prepares breast to produce and release milk. Prolactin is produced in response to infant suckling so milk is constantly produced. -Oxytocin is essential to lactation – responsible for “let down” reflex **Breastfeeding stimulates uterine contractions which decreases risk of bleeding/postpartum hemorrhage

Breast Care Client Teaching -Shower daily but no soap on nipples; use lanolin cream after nursing -Air dry nipples to prevent excess moisture; use bra pads to absorb leaking milk. Change frequently to prevent infection -Heat/massage should be used just before feeding to increase milk flow -Feed on demand. No time limitation. Not necessary to have infant nurse on both sides with each feeding -Mastitis is infection of the breast due to block milk duct/break in tissue. Antibiotics, moist heat, analgesics and continued breastfeeding are required

Breast Care Client Teaching: Bottle-feeding Mothers -Drugs are no longer used to dry up the milk. Adverse cardiovascular side effects -Use supportive bra or binder for first 72 hours (around the clock) to prevent milk production in non-nursing mothers -Cabbage leaves can be placed in bra; helps dry up milk; enzymes in cabbage cause milk production to end -Ice packs to breasts decrease milk flow

Engorgement of the Breasts -Milk comes in but infant is not expressing the milk due to poor nursing technique -Breasts become engorged with milk; breasts become very hard, making it difficult for baby to latch -Pumping or hand expression of milk will help soften the breasts. However, pumping must be limited to 5 minutes; just enough to soften the breasts and allow baby to attach. Too much pumping will increase milk production and add to the engorgement problem

Engorgement of the Breasts -For engorgement, use mild analgesics. Use cold compresses or ice packs to relieve engorgement discomfort (20 minutes 4 times per day) -Frequent breastfeeding sessions will help decrease engorgement

Assessing Breastfeeding Success: L.A.T.C.H. Score Successful Breastfeeding Score = >8/10 Score (0-2) Latch Audible Swallowing Type of Nipple Comfort Hold

Pumping -Stimulates milk production when the infant cannot nurse because of prematurity or illness -Mother should pump for 15 minutes every 3-4 hours while awake -Storage: Breastmilk is good for 5 days in refrigerator; good for 5 months when frozen

Phases of Maternal Postpartum Adjustment Taking-In Phase Day 1. Patient very dependent. Emphasis on self. Requires much assistance. Desire to review birth experience Taking-Hold Phase Day 2 or Day 3. Lasts 10 days to several weeks. Less dependent. Patient more eager to learn about infant; providing more infant and self care. Desire to take charge. Still need for acceptance and nurturing by others Letting-Go Phase Independent. Providing all infant care. Emphasis shifts to entire family. Reassertion of relationship with partner. Sexual intimacy resumes. Resolution of individual roles.

En Face Positioning A mother seeks eye-to-eye contact with her baby

Discharge Teaching -C/Section patients to see their MD in 2 weeks -Vaginal delivery mothers to follow-up in 6 wks -Patient to report any of the following: Foul smell from the vagina or C-Section surgical site Abnormal bleeding/clots from vagina/C-S site Constant uterine tenderness; prolonged perineal pain Tenderness, swelling, warmth in the legs (DVT?) Tenderness, pain, swelling in the breasts (mastitis?) Temperature greater than 100.4 F/38 .0 C

THE COMPLICATED POSTPARTUM EXPERIENCE

Complications in the PP Period -Postpartum hemorrhage -Postpartum infections -Thromboembolic disorders -Psychiatric disorders -Perinatal loss

Maternal Mortality

Hemorrhage Vaginal birth >500 mLs. C-Section birth >1,000 mLs Causes: Uterine atony Common in multipara women as uterus has lost its tone and ability to contract. Also seen in women carrying twins, large baby, polyhydramnios Retained placenta Small section of placenta is retained or entire placenta has implanted deeply into the uterine wall (accreta). Continues to receive blood supply Cervical lacerations Fundus will be firm but a steady flow of blood will continue until laceration is repaired. Common with large babies; precipitous deliveries Hematoma Due to broken blood vessel in perineum. Patient will report extreme pain, rectal pressure and an urge to have a bowel movement

Uterine Atony

Signs of Postpartal Hemorrhage -Excessive or bright red bleeding -A boggy fundus that does not respond to massage -Abnormal clots -Persistent bleeding despite a firmly contracted uterus -Increased pulse or decreased B/P -Decreased level of consciousness

Postpartum Hemorrhage: Effective Nursing Interventions *Assess the fundus carefully. If boggy, atony is the likely cause. Massage to restore tone and help constrict the blood vessels. If the fundus is already firm, there may be another reason for the bleeding (i.e. cervical tear, retained placenta) *If fundus is displaced up and to the right or left, the bladder is full. This will prevent involution of the uterus. Assist the pt. to the bathroom or perform a prompt bladder catheterization *Provide bolus of IV fluids with Pitocin. (Standing order in OB) *Consider oxygen 8-10 l/min via mask if blood loss is excessive *Quantify blood loss. Obtain vital signs. Report situation to the attending physician and anticipate orders for methergine, hemabate, cytotec, etc….

Hypovolemic Shock in the Maternity Patient

Placental Bleeding Causes

Hemorrhage Nursing Interventions: -Massage fundus for firmness, height, position -Assess bladder for fullness/distention; empty bladder -Assess for signs of shock -Weigh peri pads to estimate blood loss (1gm=1mL) -Monitor vital signs, urinary output, LOC -Elevate legs 15-30 degrees -O2 by mask at 8-10 L/min if loss is excessive -Replace fluids and administer uterine stimulants -Administer blood replacement as per MD orders

HEMORRHAGE: Pharmacologic Management # 1: Pitocin (oxytocin): 10-40 units/L IV or 10-20 U IM # 2: Methergine (methylergonovine maleate): 0.2 mg IM q 2-4 hr. Once stable, 0.2 mg PO Q 6 hr X 24 hours # 3: Hemabate (prostin 15M/carboprost): 250 mcg IM or intra-myometrically OR #4: Cytotec (misoprostol): 800-1,000 mcg rectally

Pitocin

Methergine

Hemabate

Postpartum Infections Reproductive tract infections Endometritis Chorioamnionitis Wound infections Breast infections Mastitis Urinary tract infections

Thromboembolic Disorders -Superficial thrombophlebitis -Deep vein thrombosis (DVT) -Pulmonary embolism (amniotic fluid embolism) -Disseminated Intravascular Coagulation (DIC)

Deep Vein Thrombosis

Disseminated Intravascular Coagulation (DIC) -A form of clotting that is diffuse and consumes large amounts of clotting factors -Widespread external, internal bleeding or both -DIC is always a secondary diagnosis therefore must treat the condition that triggered DIC

DIC: Nursing Management REMAIN CALM! -Vital signs q 1-15 min until stable -Assess for shock with vital signs -Fetal monitoring if undelivered -Monitor uterine activity -Accurate I & O -Quantify blood loss; hang blood products -Explain situation to patient & family

Postpartum Psychiatric Disorders 1) Postpartum Blues Affects 50-70% of new mothers Mild, temporary depression; weepy, may feel overwhelmed, insecure in own abilities Occurs within a few days of birth 2) Postpartum Depression 3) Postpartum Psychosis

Psychiatric Disorders Postpartum Depression Usually occurs around 4th week Persistent Unable to cope; social withdrawal Despondency Insomnia; fatigue May have thoughts of death/suicide Postpartum Psychosis Hallucinations Delusions, phobias Disorganization Emotional lability Bizarre or violent behavior; mania Changes in appetite; sleep patterns May harm/kill infant

Perinatal Loss -Approximately 15 - 20% of all pregnancies end in miscarriage -Miscarriages combined with stillbirths, newborn deaths and SIDS equals approximately 1/3 of all pregnancies

Nursing Interventions: -Encourage verbalization of feelings -Discuss grieving process -Prepare patient for side effects of induction -Liberal use of analgesia and anesthesia -Offer opportunity to see, touch, hold infant -Prepare family for appearance of infant -Provide a Memory Box: tangible remembrances (lock of hair, gown, pictures, foot prints)

Perinatal Loss -Discuss autopsy and explain benefits -Discuss plans for funeral or memorial services -Offer spiritual support from clergy -Offer baptism or blessing -Provide information re: support groups -Provide written grief materials -Follow-up with a bereavement counselor, social worker, clergy

“Resolve Through Sharing” National perinatal loss support group Picture of leaf or white rose placed on patient’s door to alert health care team of perinatal loss Best RN response? “I’m so sorry for your loss” Avoid saying: “You can have another baby” “Your baby is in heaven” “It just wasn’t meant to be”