Highlights of Chapter Nine The Family After Birth

Changes in the uterus; page 200 Involution Returning to pre pregnancy size and condition Descent of Uterine Fundus Once centimeter a day and tucked back in the pelvis by day ten Afterpains Intermittent uterine contractions Occur more often in multiparas or women whose uterus was overly distended Lochia Rubra, serosa, alba. Page 201

Make note of on Page 201!! Summary of Post Partum Assessment on page 201 Nursing tips regarding: Massaging a soft uterus properly Assessing the uterus each shift Teaching mother to assess and massage the uterus See Observing and Massaging the Uterine Fundus Page 2o3

Assessment of amount of lochia Heavier when the mother ambulates because of pooled lochia Small clots normal, large clots need to be reported Women with C section will bleed less Absence of lochia is NOT normal See 9-1 page 202 for estimating the volume of lochia.

Nursing Care Related to the Fundus and Bleeding. Should be assessed once a shift (once recovery period is complete) more often for mothers at high risk for post partum hemorrhage If Mom is bed ridden make sure you roll her over and check her under pad too. Massage a poorly contracted uterus Make sure mom’s bladder stays empty Medication may be necessary to stimulate uterine contractions: Oxytocin or Methergine An infant sucking at the breast assists with contractions

Report any of the following: Fouls smelling lochia Lochia rubra that persists beyond the third day Unusually heavy flow of lochia Lochia that returns to red after it has progressed to serosa or alba

The Cervix The most important thing to remember is that if there is a constant trickle of bright red lochia it probably isn’t lochia but is bleeding from a laceration of the cervix of vagina, particularly if the fundus remains firm.

Vagina Safe to resume sexual intercourse when Bleeding has stopped Episiotomy has healed. Vagina does not lubricate well first 6 weeks after child birth Many health care providers continue to recommend waiting for intercourse for six weeks

Assess the Episiotomy Redness Edema Ecchymosis Drainage Approximation

Nursing Care of the Episiotomy Ice Pack first 12-24 hours CLEAN TECHNIQUE in preparing the ice pack After 24 hours: warmth to episiotomy Perineal care Pads removed in front to back direction Topicals: Epifoam, Benzocaine Witch hazel pads Squeeze buttocks when she sits down. Squeezing the cheeks together before she sits down will protect her episiotomy or lacerated perineum from stretching once she sits.

Ovulation and Menstruation Resumes in 6-8 weeks if not breastfeeding Delayed in breast feeding mother. You may ovulate before your first period Breastfeeding is not considered an adequate form of birth control

BREASTS Milk comes in by the third day (after 48 hours) Engorgement may occur due to Abundance of milk Increased circulation Edema Wear a supportive bra Avoid soap to the nipples Most sore nipples due to poor position of infant on the breast.

Cardiovascular; Output and Blood Volume Blood loss 500 ml in vaginal 1000 ml in c section However still a temporary increase in blood volume due to fluid shift from tissues as well as extra volume needed when pregnant Temporary increase in stroke volume= bradycardia Body rids itself of fluid Diuresis diaphoresis

Blood Coagulation Blood clotting factors are higher Blood clot break down remains the same Prone to blood clot formation Thrombophlebitis Pulmonary embolism Check for both in your assessment

Blood Values Hemodilution of pregnancy continues Hematocrit 33-46% Return to normal by 8 weeks pp (36- 48%) Elevated white blood count is normal 12,000-20,000

"Chills" Sudden release of pressure on the pelvic nerves Vasomotor response involving epinephrine Reassurance and a warm blanket

Orthostatic Hypotension Resistance to blood flow in pelvis drops Blood pressure falls when she sits or stands Careful when getting up.

Assessment/care related to Cardiovascular High pulse must be taken seriously due to expected bradycardia Shock Infection Edema of lower extremities common Edema of upper extremities may be related to pregnancy induced hypertension Check for evidence of thrombosis

Urinary System Mothers may have difficulty with emptying their bladders due to Epidural Birth trauma Keep ahead of distension of the bladder Contributes to uterine atony Residual urine may promote growth of organisms Measure the first two or three voids after birth Should be able to void at least 150 mls; some resources state that under 300 suggest urinary retention and I agree that 150 is too low

Gastrointestinal System Constipation is a problem due to : Medications Stretched abdominal muscles Soreness and swelling of perineum Hemorrhoids Dehydration Encourage Mom to: Drink a lot of fluid Add fiber to her diet Ambulate Take stool softeners/laxatives

Immunity for Mothers RhoGAM for RH negative mothers who have had an RH positive baby Rubella (German measles) immunization for non immune mothers.

Cesarean Section Care. Uterus Lochia Dressing Urinary Catheter Respiratory Thrombophlebitis Pain management

Rubin's Psychological Changes Taking in Taking hold Letting go

Grieving Parents Grieving can even happen when the baby is healthy Grieving can happen when a baby has a birth defect Grieving will happen with a still born Shock and disbelief Anger Guilt Sadness and Depression Gradual resolution

What nurses can do for grieving parents Listen Provide privacy Make sure support systems are in place Assist with rituals Memory packet Code on the door

See danger signs of pregnancy page 233 Post Partum Discharge Follow up at 2 and 6 weeks Hygiene Intercourse See danger signs of pregnancy page 233