Post Partum Period Mary L. Dunlap MSN, APRN Fall 10

Post Partum Begins immediately after child birth through the 6th post partum week Reproductive track returns to nonpregnant state Adaptation to the maternal role and modification to the family system

Safety for Mother and Infant Prevent infant abductions Check ID bands Educate mother about safety measures ID band placed on baby in delivery room in front of parents and they verify information ID bands need to be checked when taking child to mother ( this will prevent unauthorized removal of baby and inadvertent mix up or switching of newborns Parents need to be aware of the unit routine Name alert

Clinical Assessment Review Antepartum and Intrapartum history Receive report Determine educational needs Consider religious and cultural factors Assess for language barriers

Post Partum Assessment BUBBLE-HE Lochia Episiotomy Legs Emotion Breast Uterus Bladder Bowel Table 15-2 pg. 437 Additional assessment- pain bonding

Early Assessment Vital signs Temperature Pulse Blood pressure Respirations V.S.- q 15 1 hr- q 30- 2nd hr –q1hr for 3rd hr then q 4-8 hrs per policy Temperature Initial 24hrs up to 100.4 due to exertion/dehydration of labor and increased breast vascularity Temp above 100.4 may be indicative of an infection Pulse- 50-70 first 6-10 days due to physiological changes Tachycardia – prolonged labor, blood loss, infection, elevated temperature Blood pressure- should be the same as 1st trimester- if decreased hemorrhage- if elevated PIH Respirations- normal 12-20 if Tachypnea ,S.O.B.,restlessness could be signs/symptoms of PE

Breast Assessment Inspect for size, contour, asymmetry and engorgement Nipples check for cracks, redness, fissures Note if nipples are flat, inverted or erect Evaluate for mastitis Estrogen stimulates the formation of new ducts, the elongation of existing glands Progesterone stimulates formation of lobules ( produce the breast milk) First 2 postpartum days- soft to touch 3rd day- begin to fell firm and warm ( filling is beginning) 4th – 5th day firm before nursing then softer ( milk transfer) if taught and painful poor transfer of milk

Nursing Care Lactating Mother Supportive bra Correct position Correct latch-on technique Warm showers Expose to air

Nursing Care Non-Lactating Mother Avoid stimulation Wear support bra 24hrs Ice packs or cabbage leaves Mild analgesic for discomfort

Assessment of Uterus Location immediately after birth Descends 1 cm/day Consistency- firm/boggy Location Height- measured in fingerbreadths Placental expulsion within 15 min of birth- fundus then midline between umbilicus and symphysis pubis After 10 days can no longer palpate it has descended into the pelvis Involution- returns the uterus to the nonpregnant state 1000 g/ after delivery 500 g/ end of 1st week 300 g/ end of 2nd wk 100 g after that Factors that facilitate involution – complete expulsion of placenta/membranes- breastfeeding- early ambulation Subinvolution- failure of uterus to return to nonpregnant state- can be due to Overdistention of the uterus (multiple births, Hydramnios) prolonged labor infection grand multiparty full bladder retained placental tissue anesthesia ( relaxation of the muscles Fig 15-1 and 2 pg. 475 assessment technique and picture of Fundal heights Table 15-4 pg. 476 assessment and documentation of involution

Nursing care Boggy fundus- massage until firm Medications- Pitocin, Methergine, Hemabate Teach new mom to massage her fundus

Afterpains Intermittent uterine contractions due to involution Primiparous-mild Multipara- more pronounced Uncomfortable for 2-3 days post partum The after pains cease once the uterus is contracted down to normal size. Breast feeding and exogenous oxytocin increases pain

Nursing Interventions Patient in a prone position and place a small pillow under her abdomen Ambulation Medicate with a mild analgesic

Bladder Spontaneous void 6-8 hrs Monitor output Postpartum Diuresis monitor output- due to decrease tone, pressure from presenting part, analgesia/anesthesia delivery process can cause urinary retention- small frequent voiding less than 150 Assess for full bladder by percussion- full resounding sound -empty dull thud pt c/o inability to void – frequent voids still feel they pt has to void Assess for bruising/swelling around meatus Postpartum Diuresis-up to 3000 each day 2nd to 5th pp days Causes- fluid from labor, decrease production of aldosterone (retains sodium) Decrease Pitocin (antidiuretic)

Nursing care Encourage frequent voiding every 4-6 hours Monitor intake and output for 24 hrs Early ambulation Void within 4 hrs after birth Catheterize if unable to void Table 15-5 signs and symptoms and nursing interventions

Bowel Anatomy returns to normal location Relaxin depresses bowel motility Diminished intraabdominal pressure Incontinence if sphincter lacerated Spontaneous BM 2nd – 3rd post partum day Diminished abdominal wall tone analgesics

Nursing Care Increase fiber in diet 6-8 glasses of water or juice Stool softener Laxative Sitz bath for discomfort Medications for hemorrhoids Box 15-1 pg. 477 Nursing interventions

Lochia Mixture of erythrocytes, epithelial cells, blood, fragments of decidua, mucus and bacteria As involution proceeds it is the necrotic sloughed off decidua 240-270 ml Cesarean less Present for 3-6 weeks

Lochia Rubra Serosa Alba Documentation Rubra- dark red first 3-4 days Serosa- pinkish brown 4th to 14th days Alba- yellowish-whitish 14th day and can last up to 3-6 wks Documentation – color, odor, amount, presence of clots color returns to Rubra or if clots develop may indicate retained placental fragments Odor is similar to menstrual flow if it becomes fowl smelling – infection Amount scant 1-2 in 10 ml small 4in 10-25 ml moderate 4-6in 25-50 heavy saturated pad fig 15-3 pg 478

Nursing Care Educate mother on the stages of lochia Caution mother that an increase, foul odor or return to rubra lochia is not normal Instruct patient to change peri pad frequently Peri care after each void

Episiotomy 1-2 inch incision in the muscular area between the vagina and the anus Assess REEDA Episiotomy care R- redness E -edema E- ecchymosis D- discharge A- approximation Pt c/o excessive pain evaluate for a hematoma and if present notify MD!!!

Nursing Care Peri care Ice packs Sitz baths Dry heat Topical medications Nursing interventions- ice 24hrs Sitz bath 3-4 x/day 20 min warm H2O ( procedure 15-1 pg 480 ) Dry heat (lamp, hot packs) Change pad frequently Peri care after each void Topical medication

Pain Assessment Determine source Document location, type and duration Interventions Location Type- stabbing, burning, throbbing, aching, cramping Duration- intermitted/continuous Interventions- Nonpharmacologic positioning, ice , Sitz baths, positioning Medications

Assess for DVT Homans’ sign Clinical assessment Homans’- legs extended and relaxed with knees flexed grasp foot and sharply dorsiflexes foot no pain or discomfort should be expressed Pain is only present 50% of the time Clinical assessment- redness warmth in calf unequal calf circumference( not always reliable ) Venography- real time and color Doppler

Postpartum Blues Transient periods of depression during the first 1 to 2 weeks postpartum Tearfulness Sad feeling Confusion Insomnia

Nursing Care Remind mom that the “Blues” are normal Encourage rest Utilize relaxation techniques Share her feelings with her partner If symptoms do not resolve and progress to depression medical treatment needs to be sought PP Depression- appears 2 wks after child birth symptoms- sleep disturbances, guilt, fatigue, feelings hopelessness/worthlessness sever cases thoughts of suicide PP Psychosis- delusions, hallucinations, agitation, inability to sleep, bizarre irrational behavior

Maternal Physiological Adaptations

Hematological System Decrease in blood volume Elevated WBC Increased Fibrinogen Decrease in blood volume (due to blood loss/Diuresis)- 500 ml loss vaginal 1gram loss hemoglobin 1000 ml loss c/sec 2 gram loss hemoglobin Due to Diuresis Hematocrit may rise due to hemoconcentration but should return to normal by 4-6 wks PP. Elevated WBC’s- due to labor process returns to normal within 6 days Increased Fibrinogen- protects against hemorrhage dose increase risk for thrombus formation- returns to nonpregnant status 3-4 pp wk

Hormonal Levels Estrogen and Progesterone decrease Anterior pituitary-prolactin for lactation Expulsion of the placenta- placental lactogen, cortisol, growth hormone, and insulinase levels decrease “Honeymoon phase”- insulin needs decrease Honeymoon phase”- insulin needs decrease due to the reduction in these hormones which reduces the anti-insulin effects glucose levels remain in a normal range (without intervention) for a few days PP

Neurological System Maternal fatigue Transient neurological changes Headaches Carpel tunnel improvement Maternal fatigue due to altered sleep pattern Transient neurological changes-anesthesia/analgesia can cause transient numbness in the legs or dizziness Headaches- R/O spinal vs. PIH Carpel tunnel- as swelling decreases improvement should be noted

Renal GFR, Creatinine, and BUN return to prepregnant levels within 2-3 months Urinary glucose levels return to nonpregnant levels by 2nd PP wk Protienuria resolves by the 6th PP wk Natriuresis / Diuresis Natriuresis/Diuresis- large amount of NA in the urine/water retention is reversed

Integumentary System Darken pigmentation gradually fades Hair regrowth returns to normal in 6-12 months Striae( stretch marks) fade to silvery lines High levels of estrogen cause hair to go into a rest period- after del.hair falls out and then satblizes

Cardiovascular System Heart returns to normal position Cardiac output elevated above prelabor levels up to 48 hrs. PP Delivery of baby, expulsion of the placenta, loss of amniotic fluid can create cardiovascular instability and cardiac output can be elevated for up to 48hrs (strain on heart)

Immune System Rubella Administer to nonimmune mothers Safe for nursing mothers Avoid pregnancy for 1 month Flu-type symptoms may occur Nonimmune- titer less than 1:8 vaccine should be administered

Immune System Rho (D) immune globulin Mother Rh negative, infant Rh positive Negative coombs’ test 300 mcg of RhoGam within 72 hrs after delivery Card issued to mother Larger doses may be needed if hemorrhage or exchange of maternal-fetal blood occured

Reproductive System Involution of uterus Healing of placental site Vaginal changes Involution- prepregnancy state by 3 wks Placental site heals without forming a scar- important because this would limit future implantation sites Vaginal changes- cervical external os never closes Vaginal returns to prepregnancy state by 6-8wks but will be a bit larger (Kegal exercises) Labia majora/labia minora remain flaccid

Menstruation and Ovulation Nonlactactating mother Menstruation returns in 6-8 wks First cycle may be anovulatory Lactating mother Delayed ovulation and menstruation Lactating –menses depends on feeding frequency and duration( exclusively breast feed) 2-18 months High levels of prolactin delay ovulation by inhibiting ovarian response to FSH Educate mom that she can ovulate prior to menses so she needs to use BC

Musculoskeletal System Relaxation of pelvic joints, ligaments, and soft tissue Muscle fatigue and general body aches from labor and delivery of newborn Rectus abdominis diastasis Relaxation of pelvic joints, ligaments, and soft tissue- teach patient to be careful when she goes home no heavy/lifting pushing can cause damage to back and hips returns to normal state in 6-8 wks Rectus abdominis diastasis-split between the 2 rectus abdominis muscles Instruct the patient to be careful since the abdominal Wall may not be able to deal with additional stress 1) correct posture when lifting , carrying or bathing the baby for 12 weeks 2) Modified sit-ups to strengthen abdominal muscles

Multicultural Nursing Care Enhance Cultural Sensitivity Understand cultural influences on the post partum period Provide culturally appropriate care

HIV/AIDS Gloves safety glasses Discourage breast feeding Avoid contact personal body fluid with infants mucous membranes

Postpartal Surgical Patient Tubal ligation Cesarean birth Tubal encourage ambulation and bonding as soon as possible will be sore from procedure medicate as needed if general anesthesia used encourage C&D Cesarean section at risk for DVT ambulate as soon as possible, do leg exercises in bed, compression stockings, pain management, need to C&D If it was unplanned pt may have feelings of disappointment, failure, inadequacy, guilt, hostility towards staff, Encourage bonding as soon as possible, provide emotional support Increase risk for hemorrhage, wound infection, UTI from Foley, DVT, PE, pneumonia

Breast Feeding Optimal method of feeding infant Breast milk- Bacteriologically safe, fresh, readily available Box 15-3 pg.489 Breastfeeding benefits Contraindications to breastfeeding Infants with milk intolerance- Galactosemia Mothers with active TB- HIV Active herpes lesion on nipple Mothers on lithium/methotrexate Mothers exposed to radioactive isotopes

Breastfeeding Lactogenesis- secretion of milk Milk ejection reflex- “let down” reflex Lactogenesis-once the placenta is delivered decrease in estrogen and progesterone- increase secretion prolactin from the anterior lobe of pituitary it stimulates the alveoli (MILK PRODUCING CELLS) to secrete milk Infant suckling- releases oxytocin from posterior pituitary- this contracts smooth muscle myoepithelial cells surrounding the alveoli to eject milk from the alveoli into the lactiferous ducts milk ejection

Breastfeeding Cue signs- Box 15-4 pg. 492 Latch-on- Fig 15-8 pg 492 Assess for milk let down Cue signs (signs of readiness)- most alert first 1-2 hrs after delivery Latch-on ( fig 15-8 & 9) – proper attachment of infant to breast 1) open mouth gape 2) infants tip of nose, cheeks, and chin should all be touching the breast Assess for milk let down- tingling sensation in the nipple audible swallowing 2:1 or 1:1 5:1 or higher non-nutritive sucking can led to poor wt gain uterine cramping & increased lochia mother feels relaxed opposite breast may leak milk

Breastfeeding Positions Cradle hold Foot ball Side lying Fig 15-10 pg 494 Feedings that last longer than 40 min and less than 10 min are not satisfactory Infant may lose an average of 5% of birth wt- wt loss more than 7% evaluate feedings Satisfactory-infant falls off without assistance drunken stupor look nipple everted and round never flat or pinched on one side Once breast milk production is established infant gains 15-30g or ½ to 1 oz /day continues for first several months

Ineffective Breastfeeding Incorrect latch-on Inverted nipples Breast engorgement Incorrect latch on – causes sore nipples, pain when nursing, ineffective emptying of breast poor milk production Inverted nipples- difficulty with latch on- ice, pump, role nipples Engorgement- excessive swelling and over filling of the breast- can be caused by infrequent feedings or ineffective emptying of breast last about 24 hrs 3-5th day PP when milk comes in Nursing interventions- warm compresses hand expression of milk before feeding to help with latch on nurse q 2-3 hrs for 15-20 min After nursing cold compresses/ ice packs cabbage leaves anti-inflammatory medications supportive bra with no underwire

Collection and Storage Breast Milk Room temperature- 4 hrs Refrigerator- 5-7 days Deep freezer- 6-7 months Use oldest milk first Thawing- place in warm water never microwave- creates hot spots and decreases anti-infective properties Thawed milk never refreeze

Formula Feeding Formula preparation Periodically check nipple integrity Bottle preparation Formula preparation- follow directions do not add more water than asked for will be diluted and can cause failure to thrive Periodically check nipple integrity- if it flows to freely more than one drop at a time can cause chocking Bottle preparation- wash in hot soapy water rinsed in hot water washed and then run through dish washer washed and then boiled in water for 5-10 min

Family and Infant Bonding Transitioning to parenthood Assuming the mothering role Parental bonding Factors that interrupt bonding

Transitioning to parenthood Difficult and challenging Provide emotional support Accurate information Nursing goal create a supportive teaching environment Primiparous- limited experience – social isolation from family & friends lack of knowledge and confidence Nursing goal create a supportive teaching environment – Use principles of family centered care 1) assess knowledge/skill level 2) provide support through communication/listening 3) Empower them-recognize their own strengths 4) Encourage parents to participate in the decision making process 5) Provide learning opportunities

Assuming the mothering role Rubin’s three phases Taking –in Taking –hold Letting-go Table 15-6 pg. 499 Taking in- first 1-2 days PP- relieves events of birth talkative Taking-hold- 2nd-3rd PP day can last up to several wks- caring for self & newborn- Great time to teach Letting –go- 2-6th wk PP- Focus is on entire family, partner- infant is now an individual Due to technology women know their infants prior to birth (3D)

Bonding Bonding process helps to lay the foundation for nurturing care Touch- skin to skin Eye contact Breastfeeding Fathers- encourage them to assume an active role in bonding process ( change diapers, skin to skin holding, feedings) Factors that may interrupt the bonding process Stress over finances Lack of support Cultural beliefs Interruption of process-sick child NICU Siblings- may regress in behavior help the child to accept the newborn (pg 501

Discharge Planning and Teaching Self Care

Discharge Teaching Fundus and Lochia Episiotomy care Incision care Signs of infection- box 15-5 pg 505 Elimination

Discharge Teaching Nutrition Exercise Pain management Sexual activity Contraception Sexual activity- may be resumed after 6 wk pp exam-safe once lochia transitioned to Alba and episiotomy Has healed pt may have some discomfort since the vagina may not be as thick as before-lubricating gel Contraception- may ovulate before menses use some form of BC

Community Resources Support groups Home visits Telephone follow-up Outpatient Clinics

Postpartum Complications

Postpartum Hemorrhage Blood loss of more than 500 ml of blood after a vaginal birth 1000 ml of blood after cesarean section Any amount of bleeding that places mother in hemodynamic jeopardy 1ml = 1g Early= within first 24 hrs Late- more than 24hrs less than 6 wks Greatest likely hood first 4 hrs

Postpartum Hemorrhage LARRY- common causes of early PPH Laceration Atony Retained placental tissue Ruptured uterus You pulled to hard on the cord

Postpartum Hemorrhage 4 Ts- factors associated with PPH Tone Trauma Tissue Thrombin

Postpartum Hemorrhage Tone/Atony Altered muscle tone due to overdistention Prolonged or rapid labor Infection Anesthesia Box 16-1 pg 513

Postpartum Hemorrhage Trauma Cervical lacerations Vaginal lacerations Hematomas of vulva, vagina or peritoneal areas Box 16-2 pg 514

Postpartum Hemorrhage Tissue Retained placental fragments Uterine inversion Subinvolution Retained placental fragments- check placenta after delivery- if lobes are missing the uterus will need to be explored Uterine inversion- turned inside out can be caused by abnormal adherence of placenta excessive traction on UC vigorous manual removal of placenta Precipitous delivery Subinvolution- incomplete involution of uterus- infection distended bladder

Postpartum Hemorrhage Thrombin Disorders of the clotting mechanism This should be suspected when bleeding persists without an identifiable cause Low fibrinogen levels Idiopathic thrombocytopenia (ITP) Acquired pathology HELLP syndrome- Hemolysis, Elevated Liver enzymes, Low Platelets

Management of PPH Frequent VS Fundal massage Administer medications- Box 16-1 Monitor blood loss for amount Maintain IV Type & cross match Empty bladder Aggressive management to prevent Hypovolemic shock- if healthy can tolerate a 1000 ml blood loss Management will depend on cause May not see a change in B/P or pulse until large amount of blood is lost look at MAP decrease in this measurement may be first sign of problem

Hematoma Localized collection of blood in connective or soft tissue under the skin Risk factors Signs and symptoms Management Caused by laceration to blood vessel- can led to large blood loss and pain Risk factor- lacerations episiotomies difficult or prolonged second stage Signs and symptoms- Unremitting pain & pressure discoloration & bulging of tissue if not treated can led to shock Management-notify provider less than 3-5 cm palliative TX- ice 24 hrs Sitz baths after 24 hrs greater than 5 cm- I & D

Postpartum Infections A fever of 100.4 or higher after the first 24 hrs for 2 successive days of the first 10 PP days Fever of 102.2 or greater within first 24 hrs- sever pelvic sepsis Group A or B streptococcus

Postpartum Infections Endometritis- Table 16-2 pg 521 Wound infection- Table 16-3 pg. 523 UTI- Table 16-4 pg. 524 Mastitis- Table 16-5 pg 525 Septic Pelvic Thrombophlebitis-Table 16-6 pg 526

Endometritis Involves the endometrium, decidua and adjacent myometrium of the uterus Lower abdominal tenderness or pain Temperature Foul-smelling lochia

Nursing Care Administer broad spectrum antibiotic Provide analgesia Provide emotional support

Wound Infection Sites- Cesarean incision, episiotomy and genital tract laceration Drainage Edema Tenderness Separation of wound edges

Nursing Care Aseptic wound management Frequent perineal pad changes Good hand washing Administer antibiotics Analgesics

Urinary Tract Infection Burning and pain on urination Lower abdominal pain Low grade fever Flank pain Protienuria, hematuria, bacteriuria, nitrates and WBC

Nursing Care Frequent emptying of bladder Increase fluid intake Antibiotics Analgesics

Mastitis Infection of the breast (one sided) Seen 2-3 weeks after delivery Caused by staphylococcus aureus Infected nipple fissure - to ductal system involvement- edema obstructs milk flow in a lobe- mastitis

Mastitis Symptoms Flu like symptoms Tender, hot, red area on one breast Breast distention with milk

Nursing Management Empty the breast by increasing the frequency of nursing or pumping Antibiodics Analgesics

Postpartum Infection Education Continue antibiotics Monitor temperature and notify provider if temp greater then 100.4 Watch for signs and symptoms of a recurrence Practice good hand washing

Thrombophlebitis and Thrombosis Thrombosis (blood Clot) can cause inflammation of the blood vessel (thrombophlebitis) which can cause thromboembolism (obstruction of blood vessel) This is due to hypercoagulable state, venous stasis and vein injury

Assessment Superfical Tenderness and pain in extremity Warm and pinkish red color over thrombus area Palpable- feels bumpy and hard Increased pain when ambulating

Nursing Care NSAIDs for pain Bed rest elevate affected leg Warm compresses Elastic stockings

Assessment Deep Vein Located from foot to pelvis- can dislodge and cause PE Calf swelling Warmth Tenderness Pedal edema Diminished peripheral pulses

Nursing Care Bed rest Elevate effected leg Continuous moist heat TED hose both legs Analgesics PRN Anticoagulation therapy

Pulmonary Embolism Abrupt onset: chest pain, dyspnea, diaphoresis, syncope, anxiety ABC response