Nursing Care of the Low-Risk Postpartum Family

Clinical Assessment Review antepartum and intrapartum histories Receive report from labor room personnel Client may want to review birth experience Education Consider religious and cultural factors Assess language barriers

Physical Assessment Vital signs Breasts Uterus, level of fundus Amount and type of lochia Uterine pain Bladder

Physical Assessment (continued) Bowels, hemorrhoids Episiotomy Extremities Emotional status

Postpartum Assessment B – Breasts U – Uterus B – Bowel B – Bladder L – Lochia E – Episiotomy/Lacerations

Postpartum Assessment (continued) H – Homans’/Hemorrhoids E – Emotions

Distended Bladder Postpartum

Uterine Involution

Figure 34–1 Involution of the uterus Figure 34–1 Involution of the uterus. (A) Immediately after delivery of the placenta, the top of the fundus is in the midline and approximately two thirds to three-fourths of the way between the symphysis pubis and the umbilicus (B). About 6 to 12 hours after birth, the fundus is at the level of (or one fingerbreadth below) the umbilicus. The height of the fundus then decreases about one fingerbreadth (approximately 1 cm) each day.

Other Assessments Hemodynamic status Integumentary system WBC, H&H, coagulation factors Integumentary system Striae, perspiration, acne, hair loss Musculoskeletal system Diastasis Activity, exercise, and weight loss Sexuality and contraception

Postpartum Changes in Lab Values Nonpathologic leukocytosis occurs in the early postpartum period Blood loss averages 200-500 mL (vaginal), 700-1000 mL (cesarean) Plasma levels reach the prepregnant state by 4-6 weeks postpartum Platelet levels will return to normal by the 6th week Diuresis Cardiac output returns to normal by 6-12 weeks

Immunizations Rubella Rho(D) immune globulin Rubella nonimmune clients Safe for nursing mothers Transient rash, fever, joint symptoms Rho(D) immune globulin Mother Rh negative, infant Rh positive Negative Coombs’ test 300 mcg IM within 72 hours of delivery Card issued to client Coombs: Direct – demonstrates if pts RBCs have been attacked by antibodies in pts own blood. Indirect – maternal anti- Rh antibiodies.

Family Considerations Maternal-infant attachment Maternal adjustment and role attainment Taking-in phase Taking-hold phase Letting-go phase Paternal adjustment Sibling adjustment Grandparent adjustment Taking-in phase: Passive. Accepts help of others. talks about birth experience. Taking-hold phase: becomes more independent & takes interest in and responsibility of own care. welcomes opportunity to learn about behavior of infant & cares for infant. Letting-go phase: gives up carefree lifestule of couple. establishs lifestyle including child.

Postpartum Uterine Changes Decrease in weight 100g Spongy layer of the decidua is sloughed off Basal layer differentiates into two layers Outer layer sloughs off Inner layer begins the foundation for the new endometrium Placental site heals by exfoliation

Postpartum Uterine Changes (continued) Uterine cells will atrophy Uterine debris in the uterus is discharged through lochia Lochia rubra is red (first 2-3 days) Lochia serosa is pink (day 3 to day 10) Lochia alba is white (continues until the cervix is closed)

Factors Retarding Involution Table 34–1 Factors that retard uterine involution.

Postpartal High-Risk Factors Table 34–2 Postpartal high-risk factors.

Postpartal Concerns Table 34–3 Common postpartal concerns.

Lochia Rubra Scant amount Large amount with clots

Lochia Changes Table 35–3 Changes in lochia that cause concern.

Postpartum Cervical and Vaginal Changes Cervix is spongy, flabby, and may appeared bruised External os may have lacerations and is irregular and closes slowly Shape of the external os changes to a lateral slit Vagina may be edematous, bruised with small superficial lacerations Size decreases and rugae reappear within 3-4 weeks Returns to prepregnant state by 6 weeks

Perineal Changes and Return of Menstruation Perineum may be edematous, with bruising Lacerations or an episiotomy may be present Menstruation generally returns between 6 and 10 weeks (nonbreastfeeding)

Postpartum Abdominal and Breast Changes Loose and flabby but will respond to exercise Uterine ligaments will gradually return to their prepregnant state Diastasis recti abdominis Striae will take on different colors based on the mother’s skin color Breasts are ready for lactation

Figure 34–3 Diastasis recti abdominis, a separation of the musculature, commonly occurs after pregnancy.

Postpartum Bowel Changes Bowels will be sluggish Episiotomy, lacerations, or hemorrhoids may delay elimination

Postpartum Bladder Changes Increased bladder capacity Swelling and bruising of tissues around the urethra Decrease in sensitivity to fluid pressure Decrease in sensation of bladder filling Urinary output is greater due to puerperal diuresis Increased chance of infection due to dilated ureters and renal pelves

Postpartum Changes in Vital Signs Temperature may be elevated to 38C for up to 24 hours after birth Temperature may be increased for 24 hours after the milk comes in BP rises early and then returns to normal Bradycardia occurs during first 6-10 days

Postpartum Weight Changes Initial weight loss of 10-12 lbs Postpartum diuresis causes a loss of 5 lbs Return to their prepregnant weight by the 6th to 8th week

Postpartal Nutrition Table 34–5 Daily eating to encourage healthful nutrition during the postpartal period.

Maternal Psychological Adjustment “Taking In” “Taking Hold”

Figure 34–4 The mother has direct face-to-face and eye-to-eye contact in the en face position. SOURCE: © Stella Johnson (www.stellajohnson.com)

Maternal Role Attainment Anticipatory stage Formal stage Informal stage Personal stage

Postpartum Blues Transient periods of depression; sometimes occurs during the first few days postpartum Mood swings Anger Weepiness Anorexia Difficulty sleeping Feeling let down

Causes of Postpartum Blues Changing hormones Lack of supportive enviornment

Cultural Influence in the Postpartum Period Non-Western cultures emphasize postpartum period Food and liquids after birth Hot-cold balance Role of grandmother

Principles of Conducting a Postpartum Assessment Selecting the time that will provide the most accurate data Providing an explanation of the purpose of the assessment Ensuring that the woman is relaxed before starting Recording and reporting the results clearly Body fluid precautions

Breast Assessment Size and shape Abnormalities, reddened areas, or engorgement Presence of breast fullness due to milk presence Assess nipples for cracks, fissures, soreness, or inversion

Abdominal Assessment Position of fundus related to umbilicus Position of fundus to midline Firmness Assess incision for bleeding, approximation, and signs of infection

Figure 34–6 Measuring the descent of the fundus for the woman having a vaginal birth. The fundus is located two fingerbreadths below the umbilicus. Always support the bottom of uterus during any assessment of fundus.

Figure 34–2 The uterus becomes displaced and deviated to the right when the bladder is full.

Assessment of Lochia and Perineum Assess lochia for amount, color, and odor Presence of any clots Wound is assessed for approximation, redness, edema, ecchymosis, and discharge Presence of hemorrhoids Level of comfort/discomfort Efficacy of any comfort measures

Figure 34–8 Intact perineum with hemorrhoids.

Assessment of Extremities, Bowel, and Bladder Homan’s sign Assess calf for redness and warmth Adequacy of urinary elimination Bladder distention and pain during urination Intestinal elimination Maternal concerns regarding bowel movements

Assessment of Psychological Adaptation and Nutrition Adaptation to motherhood Fatigue Nutritional status Cesarean birth Return of bowel function Tolerance of dietary progression

Physical and Developmental Tasks Gain competence in caregiving Confidence is role as parent Return of all physical systems to prepregnant state

Factors that Influence Parent-Infant Attachment Family of origin Relationships Stability of the home environment Communication patterns The degree of nurturing the parents received as children

Nursing Responsibilities for Client Teaching Assess educational needs Develop and implement a teaching plan Evaluate client learning Revise plan as needed

Postpartal Teaching Table 35–1 Areas to include in postpartal teaching.

Postpartal Teaching Table 35–1 (continued) Areas to include in postpartal teaching.

Postpartal Teaching Table 35–1 (continued) Areas to include in postpartal teaching.

Postpartal Teaching Table 35–1 (continued) Areas to include in postpartal teaching.

Postpartal Teaching Table 35–1 (continued) Areas to include in postpartal teaching.

Postpartal Teaching Table 35–1 (continued) Areas to include in postpartal teaching.

Postpartal Uterine Monitoring Table 35–2 Key facts to remember about monitoring postpartal uterine status.

Postpartum Drugs Table 35–4 Essential information for common postpartum drugs.

Postpartum Drugs Table 35–4 (continued) Essential information for common postpartum drugs.

Parent Attachment Table 35–5 Parent attachment behaviors.

Uterine Well-Being and Comfort Measures Assess uterus Assess lochia Afterpains Positioning Ambulation Analgesics

Perineal Well-Being and Comfort Measures Assess perineum Perineal care Ice packs Surgigator® Analgesics

Comfort Measures Diaphoresis Suppression of lactation Well-fitting bra Cold compresses or cabbage leaves Anti-inflammatory medication

Pharmacologic Interventions Rubella vaccine RhoGAM

Emotional Stress Interventions Encourage mothers to tell birth stories Maternal role attainment

Rest and Activity Provide opportunities for rest Encourage frequent rest periods Resumption of activity Avoid heavy lifting Avoid frequent stair climbing Avoid strenuous activity

Postpartal Family Wellness Family-centered care Information Time for interaction Supportive environment

Figure 35–3 The nurse provides discharge instructions to the mother and father before discharge.

Resumption of Sexual Activity Resume after episiotomy healed and lochia stopped Lubrication may be required Contraception Potential limiting factors Fatigue Demands of the infant

Parent-Infant Attachment Incorporate family goals in care plan Postpone eye prophylaxis for 1 hour after delivery Provide private time for the family to become acquainted Encourage skin-to-skin contact Encourage mother to tell her birth story

Parent-Infant Attachment Encourage involvement of the sibling Prepare parents for potential problems with adjustment Initiate and support measures to minimize fatigue Help parents identify, understand, and accept feelings

Care of the Mother after Cesarean Birth Minimize complications Deep breathing and incentive spirometry Ambulation Pain management Rest Minimize gas pains

Pharmacologic Management of Pain Epidural analgesia PCA

Needs after Discharge Increased need for rest and sleep Incisional care Assistance with household chores Infant and self-care Relief of pain and discomfort

Parent-Infant Attachment Factors that hinder attachment Physical condition of the mother and the newborn Maternal reactions to stress Anesthesia Medications Newborn safety

Nursing Care of the Adolescent Postpartum hygiene Contraceptive counseling Newborn care Include family in teaching Positive feedback

Post-discharge Adolescent Needs Child care Transportation Financial support Nonjudgmental emotional support Education regarding newborn care and illness Education regarding self-care

Care of the Mother who Relinquishes her Infant Active listening Provide nonjudgmental support Show concern and compassion Personalize care for the mother

Early Discharge Signs of possible complications Rest and activity Resumption of sexual activity Referral numbers for questions Contact information about local agencies or support groups Bottle or breastfeeding information

Early Discharge (continued) A scheduled postpartal and newborn well-baby visit Procedure for obtaining the birth certificate Newborn care Signs and symptoms of infant complications

Lactation and Newborn Nutrition

American Academy of Pediatrics Recommendations Newborns should be nursed when they show signs of hunger No supplements should be given unless there is a medical indication Exclusive breastfeeding is sufficient for approximately six months

American Academy of Pediatrics Recommendations (continued) Gradual introduction of iron-rich solids should begin after six months Breastfeeding should continue for at least 12 months

Nutrients in Breast Milk Protein Source of amino acids for growth Whey fraction more easily digested and promotes gastric emptying Fat Greatest concentration in hind milk Necessary for brain development Carbohydrates Enhance immunity and brain development

Nutrients in Breast Milk (continued) Water and electrolytes Minerals Trace elements Fat-soluble and water-soluble vitamins

Anatomy of the Breast Clavicle Ribs Pectoralis major muscle Lobes (glandular tissue) Adipose tissue Cooper’s ligament Areola Areola Nipple Nipple Lactiferous duct Opening of lactiferous duct

Lactogenesis Estrogen and progesterone levels fall Prolactin triggers milk production Oxytocin elicits the let-down reflex Milk production depends on supply and demand Feed often (every two to three hours) Avoid supplements Encourage night feedings

Interferences with Lactation Poor nutrition, inadequate fluid intake Maternal anxiety Medical conditions Pendulous breasts Flat or inverted nipples Postoperative pain Deficient knowledge

Promoting Successful Breastfeeding Maternal comfort and relaxation Positioning of mother and infant Correct latching on of the infant Removal of the infant from the breast Burping

Promoting Successful Breastfeeding (continued) Timing Feed immediately after delivery if possible Offer both breasts at each feeding 15 minutes on each breast Offer the breast every two to three hours

Positioning for Breastfeeding

Techniques for Successful Breastfeeding Breaking suction Proper latching-on technique Rooting reflex

Benefits of Breastfeeding Maternal benefits Contraception Less anemia Weight loss Involution of the uterus Prevention against breast and ovarian cancer

Benefits of Breastfeeding (continued) Infant benefits Bonding between mother/infant Optimal nutrition Prevention against infection Enhanced cognitive development Prevention against disease (diabetes, SIDS, asthma)

Nursing Implications: Barriers to Successful Breastfeeding Maternal barriers Diet, medications, smoking, fatigue Prior breast surgery Nipple abnormalities Contraceptives Psychologic issues, modesty Infant barriers Prematurity Illness and disability Hypoglycemia Jaundice Nipple shields Breastfeeding the preterm infant

Assessment for Insufficient Lactation Low urination pattern Low stooling frequency Minimal breast changes after delivery Irritable or sleepy infant Nursing less than seven times a day Weight loss of more than 10% of the birth weight Continued weight loss after day 10 of life Need 6 or more wet diapers per day.

Contraindications to Breastfeeding Maternal disease Hepatitis B, C HIV Maternal medications Infant Severe illness Inborn errors of metabolism

Common Breastfeeding Problems Cracked or sore nipples Change positions Assess for proper latching on Apply breast milk after nursing Cabbage leaves, tea bags Mastitis Antibiotics

Common Breastfeeding Problems (continued) Engorgement Feed frequently, avoid supplements Good support bra Apply warmth (towels, shower) before nursing

Breast Pumps

Resources for Breastfeeding Mothers Lactation consultants La Leche League International Lactation Consultant Association

Formula Feeding Available in powder, concentrate, ready-to-feed forms Ensure that parents know how to mix formula Ensure cleanliness in preparation Cow- or soy-based preparations Monitor for food allergy symptoms Rash, colic, diarrhea, bloody stool, respiratory symptoms

Formula Feeding (continued) Solids usually introduced at about four months One new food at a time Wait at least three days between new foods