The Postpartum Period The Postpartum Family: Needs and Care Chapter 22 Maternal-Newborn & Child Nursing London, Ladewig, Ball & Bindler Prepared by Mary Ann Gagen Professor of Nursing

The Postpartum Family: Needs and Care Clinical Pathway: For the Postpartum Period, pp 464 - 466

Nursing Management During the Early Postpartum Period Nursing Diagnosis Constipation r/t fear of tearing stitches AEB … Family process alteration r/t inclusion of new member Infection, HR for, r/t altered primary defenses during the postpartum period Urinary elimination pattern alteration r/t sensory impairment during labor AEB… Knowledge deficit r/t PP self-care AEB…Skin integrity impairment r/t surgical incision AEB… Pain r/t PP physiologic changes AEB… Discuss: Assess; cluster data; problem list; formulate diagnosis; prioritize

PP Nursing Management, cont’d Promotion of Maternal Physical Well-being Uterine status Table 22-1, p 467 Drug Guide, p 468 Promotion of Comfort and Relief of Pain Perineal discomfort Hemorrhoidal discomfort Afterpains Immobility Postpartum diaphoresis Table 22-3: Common PP drugs, p 470 Uterine assessment q 8 hrs after 4th stage (1st 4 hrs PP) for: bogginess, positioning, heavy lochia, clots. Ongoing monitoring of the lochia for amt, color, odor, etc. See Table 22-1, p 467 May need Pitocin or Methyergonovine Maleate (Methergine) to stimulate uterine contractions Perineal discomfort – wear glves, wash hands /a & /p, and always move front to back. Provide ice packs to reduce edema & provide numbing. Prepare: glove /c ice chips, wrap in paper towel; apply 20 mins on, 10 mins off, for 24 hrs. Sitz baths – tid, to promote comfort & circulation; 105º max (pelvic congestions); abt 20 mins.; may faint; at home: clean tub to prevent infecion. Topical agents – Dermoplast, Americaine, Witch Hazel compresses (Tucks without glycerine); pt needs to WASH HANDS. Perineal care – use “peri-bottles” /p elimination; blot front to back/c tissue. REMEMBER: pt may not know how to apply perineal pad (tampon user); net underwear (looks like a dish cloth) to keep pad snug & prevent irritation to episiotomy site. Remind client to tighten buttocks /a sitting down Refer to TEACHING ABOUT episiotomy care. Hemorrhoidal discomfort – sitz baths, topical anesthetic ointments, suppositories, or Witch Hazel/Tucks. Digital replacement; adequate fluids, fruits, & vegs; stool softeners Afterpains - > mutiparas, breastfeeding moms; relieved by prone position, sitz, ambulation, or analgesic. Breastfeeding: med 1 hr/a nursing. Immobility – joint & muscle pain; early ambulation helpful; assist 1st few times: fatique, meds,blood loss, etc. Diaphoresis – clean gown, linen ∆, frequent fluids

The Postpartum Family: Needs and Care, cont’d Suppression of lactation in the nonnursing mother Promotion of rest and activity Pharmacologic interventions Suppression through mechanical inhibition: well-fitting bra within 6 hrs delivery; continuous for 5 – 7 days, remove only for showers; ice packs qid – 20 mins; teach: avoid stimulation & heat; shower back. Don’t give meds to “dry up” breasts Rest/activity/exercises – encourage rest; sleep when baby sleeps. Relaxin – hormone during breastfeeding; both get sleepy. Cultural considerations: how PP is viewed: natural process vs illness. Gradually ↑ ambulation & activity; avoid heavy lifting (toddler at home!!), excessive stairs; light housekeeping 2nd week; return to work 6 wks. Exercise: Figure 22-1, pp 472 – 473; may start in hospital Pharmacologic interventions: Rubella: titer < 1:10, give vaccine PP /a dc. Informed consent, avoid pregnancy 3 mos; contraceptive counseling advised RH Immune Globulin: RhoGAM within 72 hrs to prevent sensitization from fetomaternal transfusion of Rh-positive fetal RBCs. TEACHING vital! Chapter 13:pp 280 – 283. Figure 13-3, p 281

The Postpartum Family: Needs and Care, cont’d Promotion of maternal psychologic well-being Effective parent education Parent – infant attachment Promotion of family wellness Time of emotional stress: need to “tell her story”; feelings of inadequacy d/t “not coping well” in L&D. Mother must adjust to loss of fantasized child & accept child born, esp if birth defects, wrong sex. Review the stages: taking-in & taking-hold; “let-down” feeling may be surprising to new mother. Parent education: assess learning needs thru observation. Plan & implement logically, in non-threatening manner, & respect family’s cultural values & beliefs. Various methods: Channel 42, handouts, breastfeeding classes, 1-to-1. TIMING IS CRUCIAL! More receptive /f 1st 24hrs. Family wellness: most facilities have mother-baby or couplet care; rooming-in. Learning in a supportive environment; allows father, siblings, friends to help. Flexibility: mother needs respite & can return baby to nursery. Reactions of siblings: visit to mother-baby unit assures sibling that mother is well & still loves them. Arriving home: requires adjustment; have father carry newborn so Mom can hug older children. Use of doll. Expect anger & need for regression. Let child help. Parent-Infant attachment: support parents in childbirth & childrearing goals; postpone eye prophylaxis 1 hr – promote eye contact; provide privacy; enc integration of siblings; help identify & understand negative feelings; support, support, support! Table 22-4: Parent Attachement Behaviors, p 476 Cultural considerations: developing cultural competence: enc class stories

Nursing Management after Cesarean Birth Promotion of maternal physical well-being Promotion of parent-infant interaction after Cesarean birth Chances of pulmonary infections greater. Assess pain: incisional, gas pains, referred shoulder pain, uterine contractions, pain from elimination Administer pain meds 1st 24 – 72 hrs; promote comfort; TC&DB. Duromorph or PCA. General anesthesia: abdominal distension: ambulation, liquid diet 1st 24- 48 hrs or return of BS; avoid straws, carbonated drinks; rectal suppositories; lying on Left die → passage of flatus. Mother/baby separated /p C-sec → anger, withdrawal, depression indicates grief response to loss of fantasized birth experience; by 2nd or 3rd day → “taking-hold” period. Reactions to C-sec: depends on woman’s perception & definition of experience. PP Adolescent: assess support; Social Services referral; benefits from Beta or similar group classes. contraception essential part of teaching Woman relinquishing infant: potential for emotional crises in decision-making; ambivalence; seeing the newborn aids the grieving process; relinquishing is a painful act of love. Anticipate potential for problems if decision is made to parent an unwanted child.

Discharge Information Signs of possible complications PP self care “Hot-line”, agencies, support groups for special needs Nutrition PP appointment Birth certificate Basic infant care S & Sx infant problems Home visit/follow-up call

Sexual Activity and Contraception Resumption of sexual activity Teaching about… pg 700 Contraception Chapter 3, pp 47 – 56 Teaching about … pg 56 Previously, couples were discouraged from sexual intercourse until after 6 wks chek-up. Now couples resume once episiotomy heals & lochia flow stops, usually end of 3rd week. Advise: vaginal dryness, KY-Y jelly needed as lubricant. Change in position may ease discomfort. Nursing mothers should nurse prior to lovemaking. Interference such as baby crying, poor self-image with PP body, etc. Return to prepregnant levels of sexual varies by couple and may take a few monts to year. Patient Teaching: Clients will ask questions. If patient receives Rubella vaccine, teach avoid pregnancy for 3 months. Vaccine can be teratogenic. Methods: Any method of birth control is safer statistically than pregnancy & giving birth Fertility Awareness: natural family planning; periodic abstinence & recording of certain events during cycle; cooperation of partner important. Only method approved by Roman catholic Church. Failure rate: 25%; no protection against HIV, STDs. BBT or Basal body temperature: upon awakening, prior to any activity, take temp; based on temp drops before ovulation & rises & remains up. Couples avoid intercourse that day + 3 days. Record keeping. Calendar 0r rhythm method: ovulation 14 days (+ or – 2 days) before start of next menstrual period. Sperm are viable 48 – 72 hrs, ovum 24 hrs. Record cycles 6 – 8 mos. Fertile period is 18 days from END of shortest recorded cycle . EX: cycle is 24 – 28 days; fertile time is day 6 – 17, abstinence necessary. Least reliable of fertility awareness method. Cervical mucus or ovulation method or Billings method. At ovulation, cervical mucus (estrogen-dominant) is clearer, more stretchable , called spinnbarkeit. Mucus assessed daily; abstain from intercourse 1st sign of slippery, clear to 4 days after last wet mucus. Can be used by women with irregular cycles: based on hormonal changes. Coitus interruptus – withdrawal; doesn’t protect against STIs or HIV; failure rate 19%; requires self-control & preejaculatory fluid contains sperm. Better than nothing! Douching - facilitates conception ↑ sperm into birth canal Barrier methods: male & female condoms, spermicides, diaphragms, cervical caps. Can protect against spread of STIs; spermicides failure rate is 26%, messy; condoms failure rate 14%, latex allergies, lack of knowledge on correct usage; diaphragm protects, allergy , objection to insertion of a device, toxic shock, need to refit q 2 years or with weight change Intrauterine devices – small T-shaped devices loaded with either copper or a progestational agent; Failure rate 0.1% to 2.0%, risk for PID, uterine perforation, infection Hormonal methods - over 30 kinds including combined estrogen-progestin steroidal medications or progestin-only agents which are administered orally, subdermally, patch, or by implantation; emergency contraception using high doses of OCPs;r no protection against STIs, most effective form, not suitable for heavy smokers, 35+ women with HTN, hx of vascular disease, familial DM Emergency contraception: 2 kits: Preven & Plan B, “morning after” pill Sterilization, male & female: permanent; Nurses must be aware of informed consent for voluntary sterilization Clinical interruption – abortion - purposeful interruption of a pregnancy before 20 wks gestation; legal in US since 1973. 1st trimester: D&C, minisuction, or vacuum curettage. 2nd trimester: D & E (dilatation & extraction), hypertonic saline, prostaglandins; Complications of bleeding or infection, religious & moral considerations mifepristone (RU 486): may be used medically to induce abortion during 1st 7 wks, up to 49 days/p conception; returns in 2 days for misoprostol to induce contractions to expel embryo/fetus; returns to MD 12 days to confirm successful abortion.

Questions?

Test question The laboratory results of a postpartum woman are as follow: blood type, A; Rh status, positive (+); rubella titer, 1:4; Hct, 30%; How would the nurse best interpret this data? a. a blood transfusion should be given b. Rubella vaccine should be given c. A Kleinhauer-Betke test should be performed d. Rh immune globulin is necessary within 72 hours of birth B

Keep going… Which of the following clients is most likely to experience strong afterpains? a. She is a G4P4004 b. She is bottle-feeding her baby c. She exhibited oligohydraminos d. She had a baby that weighed 5lb 3oz A