Nursing Care of the Family During the Postpartum Period Chapter 19 Nursing Care of the Family During the Postpartum Period All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.

Nursing Care of the Postpartum Woman Components of nursing care Assist mother with rest and recovery after birth Assessment of physiologic and psychologic adaptation Prevention of complications Education regarding self-management and infant care Support of mother and her partner during transition to parenthood All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.

Transfer from Recovery Area In traditional setting, woman is moved to postpartum room after recovery In labor, delivery, recovery, and postpartum (LDRP) setting, woman and infant remain together in room where birth occurred Postanesthesia recovery Regardless of obstetric status, no woman should be discharged from recovery area until completely recovered from anesthesia All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.

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Planning for Discharge Length of stay is dependent upon: Physical condition of the mother and newborn Mental and emotional status of the mother Social support at home Educational needs for self-management Financial constraints All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.

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Planning for Discharge (Cont.) Newborns’ and Mothers’ Health Protection Act of 1996 Allows for a minimum of 48 hours stay after a vaginal birth and 96 hours after cesarean birth Criteria for discharge American Academy of Pediatrics recommendations All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.

Care Management Physical Needs Couplet or mother-baby care Ongoing physical assessment Routine lab tests Nursing interventions Infant security Prevention of infant abduction All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.

Care Management Physical Needs (Cont.) Prevention of infection Prevention of excessive bleeding Uterine atony Maintenance of uterine tone Fundal massage Prevention of bladder distention All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.

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All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.

Care Management Physical Needs (Cont.) Promotion of comfort Nonpharmacologic interventions Pharmacologic interventions Promotion of rest Postpartum fatigue Promotion of ambulation Reduction of venous thromboembolism Promotion of exercise All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.

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Care Management Physical Needs (Cont.) Promotion of nutrition Promotion of normal bladder function Promotion of normal bowel function Promotion of breastfeeding Baby-Friendly Hospital Initiative Lactation suppression All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.

Planning Future Pregnancies Rubella vaccination If woman is not immune, vaccination is recommended Varicella vaccination Tetanus-diphtheria-acellular pertussis (Tdap) Rh isoimmunization Rh immune globulin should be given within 72 hours for R-negative women who deliver an Rh-positive infant All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.

Care Management Psychosocial Needs Effect of the birth experience Maternal self-image Adaptation to parenthood and parent-infant interactions Family structure and functioning Impact of cultural diversity All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.

Case Study Ms. Roth is a 19-year-old at 28 weeks with an unexpected pregnancy. She began prenatal care at 20 weeks and presented to labor and delivery triage yesterday c/o abdominal pain and vaginal bleeding. On examination she was found to be 7 cm dilated, 100% effaced with bulging membranes. On US the fetus was found to be breech and fetal heart monitoring revealed persistent decelerations with contraction. Plans were made to prepare for an emergent cesarean birth. All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.

Case Study (Cont.) A female infant was delivered 24 hours ago. Apgar scores were 3/5/8. NCCC team was present at birth and baby is in stable condition on oxygen tent in NCCC. Ms. Roth is also in stable condition. The surgery was uncomplicated and she is now getting up with assistance to go to the bathroom with saline lock. Her pain is managed with PO medications. Her mother spent the night with her last night, but has gone home to get ready for work. The father of the baby (FOB) is not involved at this time. In report the night nurse notes that the patient has had a “flat affect.” You are now assuming care for Ms. Roth on the mother-baby unit. All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.

Case Study (Cont.) Based on the report, what are some of the priorities of care? Post c/s care Start with basic medical-surgical nursing care and build on your assessment skills. Include focused postpartum assessment. Assess wound. Encourage patient to ambulate. Discuss return to bowel activity. Assess for bowel sounds, flatus and appetite. Is patient voiding freely on her own? Hydration status? Edema? Teaching of self-care and anticipation of healing process.   Pain Teach patient to rate pain on scale. Teaching should include importance of managing pain steadily in order to ambulate and begin self-care. Teach patient about the medications available to her and the effects they may have. Psychological support The patient has experienced a surprising and challenging chain of events including unexpected pregnancy without the continued support of her partner, painful contractions that led to a surgical birth, and the birth of a preterm infant now in intensive care. The nurse plays an important role as a teacher, listener, and caregiver. Validating her experience by recognizing what a difficult time she has had may be a way to begin conversation with the patient. Open-ended questions including asking her about her experience leading up to her hospitalization, feelings about pregnancy, relationship with FOB, learning about her support system, and level of understanding about the condition of her baby would all be appropriate. The nurse can offer to help the mother visit the baby, teach her about breast-pumping, and offer lactation consultation. The nurse should also be sure that a social work consult has been initiated. Importance of skin-to-skin time and/or visitation with the baby should also be included to assist with bonding and maternal and infant well-being. Pumping The mother’s plans for feeding the baby should be assessed. Discussion should include information on how many mothers of preterm infants begin with pumping regardless of their feeding intentions at the beginning of the pregnancy. Teaching about the added importance of providing human milk to the preterm baby should be included. Help with pumping and teaching regarding use of equipment and storage of colostrum/milk should be included. Other concerns to address In the coming day or two the nurse should include teaching and support for the mother as she adapts to the reality of having a preterm baby in the intensive care unit. This includes planning for logistics such as breast pump rental, transportation for visits with the baby, conflicts with work or school, adjusting to the role of mother, risk for postpartum depression, risk for disturbed body image after surgery, and childbearing. The nurse should refer the mother to social work, postpartum follow-up, and nursing staff in the intensive care nursery in order to provide continuity of care and support after discharge. All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.

All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.

All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.

Discharge Teaching Self-management and signs of complications Sexual activity/contraception Prescribed medications Routine mother and baby checkups Activities of daily living at home All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.

Discharge Teaching (Cont.) Follow-up after discharge Home visits Telephone follow-up Warm lines Support groups Referral to community resources All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.

Question Childbirth may result in injuries to the vagina and uterus. Pelvic floor exercises also known as Kegel exercises will help to strengthen the perineal muscles and encourage healing. The nurse knows that the client understands the correct process for completing these conditioning exercises when she reports: “I contract my thighs, buttocks, and abdomen.” “I do 10 of these exercises every day.” ANS: D Feedback A Incorrect: Each contraction should be as intense as possible without contracting the abdomen, buttocks, or thighs. B Incorrect: Guidelines suggest that these exercises should be done 24 to 100 times per day. Positive results are shown with a minimum of 24 to 45 repetitions per day. C Incorrect: The best position to learn Kegel exercises is to lie supine with knees bent. A secondary position is on the hands and knees. D Correct: The woman can pretend that she is attempting to stop the passing of gas or the flow of urine midstream. This will replicate the sensation of the muscles drawing upward and inward. DIF: Cognitive Level: Analysis OBJ: Client Needs: Health Promotion and Maintenance TOP: Nursing Process: Evaluation All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.

Question (Cont.) “I stand while practicing this new exercise routine.” “I pretend that I am trying to stop the flow of urine midstream.” All Elsevier items and derived items © 2014, 2010, 2006, 2002 , Mosby, Inc., an imprint of Elsevier Inc.