1. Chapter 9
The Family After Birth

2. Puerperium Known as postpartum period Six weeks following childbirth
Sometimes referred to as the fourth trimester of pregnancy
The puerperium is a time of transition for both the new mother and her family.
Complete the following:
Pregnancy: 40 weeks as Puerperium:______
1. 5 weeks
2. 6 weeks
3. 2 months
4. 1 year
GOAL: The student will learn what Puerperium means and what is included in that period.

3. Cultural Influences The nurse must adapt care to fit
Health beliefs
Values
Practices
Use an interpreter where appropriate
Should not be a family member or in cultural/religious conflict with the patient/family
Dietary practices
Nurses must use caution not to stereotype clients based upon outward appearances.
The nurse must remain flexible when planning the care to be provided.
Review the resources that might be available on the nursing unit to meet unique patient concerns relating to language barriers.
What resources are available for nurses to review cultural practices?
GOAL: The student will learn how the patient’s culture influences the Peurperium period.

4. Reproductive System Changes PP
Uterus
Involution
Uterine lining
Descent of uterine fundus
Afterpains
Lochia
Rubra
Serosa
Alba
Cervix
Vagina
Stress importance of discussing when to resume vaginal intercourse postpartum with health care provider
Breasts
Engorgement
Nursing care
Immediately after delivery, the mother begins to experience changes in her reproductive system.
The nurse must provide a comprehensive assessment of the patient’s reproductive system.
What are normal and abnormal findings from the nursing assessment of the reproductive system?
During post-partum discharge teaching a woman expresses that "since she is breastfeeding her newborn" she will not require birth control. The nurse will:
1. Inform the physician
2. Tell the woman she will require birth control when she is weaning the baby.
3. Inform her that breastfeeding is not a form a birth control.
4. Inform her that she must use oral contraceptives in supplement to breastfeeding.
GOAL: The student will learn how the patient’s culture influences the Peurperium period.

5. Reproductive System (cont.)
Perineum
Episiotomy
REEDA assessment
Redness
Edema
Ecchymosis
Discharge
Approximation
Nursing care and patient teaching
Cold packs
Topical and systemic medications
Nonpharmacological pain relief methods
Return of ovulation and menstruation
Menstrual cycle typically resumes in 6-8 weeks if not breastfeeding
Return of ovulation is delayed if breastfeeding; however, it can occur at any time after birth (pregnancy is possible)
GOAL: The student will learn how the patient’s culture influences the Peurperium period.

6. Cardiovascular System
Cardiac output and blood volume
Coagulation
Blood values
Chills
Orthostatic hypotension
Nursing care
Review pg
During pregnancy, the woman experiences a 50% increase in circulating blood volume.
Physiological changes during labor and delivery cause further cardiac changes.
Review the pathophysiology that is responsible for the changes in blood coagulation and laboratory values.
It is considered normal for a woman's blood pressure to increase during pregnancy.
1. True
2. False
GOAL: The student will learn how the patient’s cardiovascular system is affected during the Peurperium period.

7. Urinary System
A full bladder can displace the uterus and lead to postpartum hemorrhage
The woman who voids frequent, small amounts of urine may have increased residual urine because her bladder does not fully empty
Residual urine in the bladder may promote the growth of microorganisms
During pregnancy, the bladder experiences a reduction in tone.
During labor, administering intravenous fluids and anesthesia could impact urinary elimination.
Review the assessment of the urinary bladder during the postpartum period.
For what signs and symptoms should the nurse assess?
What should be reported?
GOAL: The student will learn how the patient’s urinary system is affected during the Peurperium period. .

8. Gastrointestinal System
Constipation
To help alleviate this problem, encourage woman to
Increase fluid and fiber intake
Increase activity, such as walking
After delivery, gastrointestinal function returns to normal rapidly.
The patient might have concerns regarding the first bowel movement.
What information concerning bowel health should be provided to the patient?
When will pharmacological interventions be employed?
GOAL: The student will learn how the patient’s gastrointestinal system is affected during the Peurperium period.

9. Integumentary System
Hyperpigmentation of the skin changes as hormone levels decrease
Linea nigra disappears
Striae fade to silver
GOAL: The student will learn how the patient’s integumentary system is affected during the Peurperium period.

10. Musculoskeletal System
Diastasis recti (separation of the longitudinal abdominal muscles)
Hypermobility of the joints
Exercises
Abdominal muscle tightening
Head lift
Pelvic tilt
Kegel exercises
Many women might not be realistic concerning their appearance in the immediate postpartum period.
What information should be given to the woman during the prenatal period concerning her physical appearance after delivery?
At what point in the pregnancy should this information be provided?
GOAL: The student will learn how the patient’s musculoskeletal system is affected during the Peurperium period.

11. Immune System Prevent blood incompatibilities and infection
RhoGAM if woman is Rh negative and baby is Rh positive
Give mother immunization for rubella if she is not immune
Titer < 1:8 requires immunization
Assessment of the woman’s blood type and immune status is completed during the pregnancy. If concerns are identified, they are monitored closely during the pregnancy.
Review the Rh status of the father in the identified scenario.
RhoGAM is a product obtained from the hospital’s blood bank. Discuss precautions that are indicated when administering this agent.
Discuss the administration of the rubella vaccine.
GOAL: The student will learn how the patient’s Immune system is affected during the Peurperium period.

12. Changes After Cesarean Birth and Adaptation of Nursing Care
Same as with normal vaginal delivery except
Monitoring of abdominal dressing
Lochia generally less
Urinary catheter
Respiratory care
Prevention of thrombophlebitis
Interventions for pain
The mother who delivers via cesarean section may experience feelings of failure because of her inability to deliver vaginally.
How should the nurse address these concerns?
GOAL: The student will learn the changes that occur post-c-section, during the Peurperium period, and the adaptation of nursing care.

13. Emotional Care
The birth of an infant brings about physical changes in the mother but also causes many emotional and relationship changes in all family members.
GOAL: The student will learn how the patient’s emotions are affected during the Peurperium period.

14. Mother Rubin’s Psychological Changes of the Puerperium
Phase 1
Phase 2
Phase 3
Postpartum blues
Postpartum depression
Fatigue
Review each of Rubin’s phases.
What is the primary focus and task for each of the phases?
What are signs and symptoms the patient is not progressing normally through each of the phases?
Which of the following groups of signs and symptom are the most representative of postpartum "blues"?
1. Crying, loss of appetite, constipation, abdominal pain, and anxiety.
2. Crying, loss of appetite, difficulty sleeping, and anxiety.
3. Crying, increased appetite, urinary retention, anxiety, and fear of the unknown.
4. Crying, despondency, poor concentration, diarrhea, and anxiety.
GOAL: The student will learn how the patient’s emotions are affected during the Peurperium period.

15. Father Engrossment Four phases of adjustment
Having expectations and personal intentions
Confronting reality and overcoming frustrations
Creating one’s own personal father role
Reaping rewards of fatherhood
The relationship between the father and mother will have the greatest impact on the father’s responses to the infant.
What additional factors will influence the father’s actions/reactions?
GOAL: The student will learn how the Father’s emotions are affected during the Peurperium period.

16. Other Family Members Siblings Grandparents
Age-dependent on how older sibling will respond to new baby
Preparation important
Grandparents
Today’s method of obstetrical care incorporates the needs and desires of the entire family into the birthing experience.
What interventions can the nurse perform to promote inclusion of the siblings and grandparents into the plan of care?
GOAL: The student will learn how the family’s emotions are affected during the Peurperium period.

17. Grieving Parents Therapeutic communication and nursing care
Stages of the grief process
Shock and disbelief
Anger
Guilt
Sadness and depression
Gradual resolution of sadness
The support of the nurses is vital to the family during the grief process.
What can the nurse do to offer emotional support?
Discuss the types of questions and responses that should be avoided.
GOAL: The student will learn how the patient’s emotions are affected during the Peurperium period when incurring a loss.

18. Parenthood Can affect communication between partners
Division of responsibility can be source of conflict
Fatigue increases irritability
Loss of freedom and decreased socializing may cause couple to feel loneliness
GOAL: The student will learn how parenthood affects a couple, during the Peurperium period.

19. Family Care Plan
Studying the family as the patient can offer insight into community-based care
GOAL: The student will learn how the patient , the family, is cared for during the Peurperium period.

20. Data Collection for the Family Care Plan
Demographic information
Family composition
Occupation
Cultural group
Religious/spiritual affiliation
Developmental tasks
Health concerns
Communication patterns
Decision making
Family values
Socialization
Coping patterns
Housing
Cognitive abilities
Support system
Response to care
The development of a successful plan of care requires the nurse to be comprehensive in scope.
In addition to the patient interview, what are other sources of data?
GOAL: The student will learn how the patient , the family, is cared for during the Peurperium period.

21. Phase 2 Nursing Care of the Newborn
Supporting thermoregulation
Evaporation
Conduction
Convection
Radiation
Observing bowel and urinary function
Identifying the infant
Security measures
Umbilical cord care
GOAL: The student will learn the 2nd phase nursing care of the newborn.

22. Phase 2 Nursing Care of the Newborn (cont.)
Observing for anomalies
Obtaining vital signs
Weighing and measuring
Gestational age evaluation
Skin
Vernix
Hair
Ears
Breast tissue
Genitalia
Sole creases
After delivery, the infant must have a complete assessment.
Abnormal findings must be reported.
Discuss normal findings for each category.
What other security measures may need to be implemented?
GOAL: The student will learn the 2nd phase nursing care of the newborn.

23. Hypoglycemia
A blood glucose below 40 mg/dL in the term infant indicates hypoglycemia
The infant must have a source of energy to successfully adapt to life outside of the uterus.
GOAL: The student will learn what neonatal hypoglycemia is and how it is assessed and evaluated.

24. Risk for Neonatal Hypoglycemia
Preterm/postterm
Diabetic mother
LGA/SGA
IUGR
Asphyxiated
Cold stress
Mother had tocolytics during labor process
Review the underlying pathophysiology responsible for the increased potential for hypoglycemia in infants with these scenarios.
GOAL: The student will learn what neonatal hypoglycemia is and how it is assessed and evaluated.

25. Signs and Symptoms of Hypoglycemia in the Newborn
Jitteriness
Poor muscle tone
Sweating
Respiratory difficulty
Low temperature
Poor sucking
High-pitched cry
Lethargy
Seizure
The key to successful management of hypoglycemia requires early intervention.
Review the actions that should be taken by the nurse to provide care to the hypoglycemic infant.
Discuss charting for this occurrence.
GOAL: The student will learn what neonatal hypoglycemia is and how it is assessed and evaluated.

26. Screening Tests Heel stick performed on day of discharge PKU
Hypothyroidism
Galactosemia
Thalassemia
Sickle cell
Maple syrup urine disease
Homocystinuria
Screening tests are routinely performed to assess for abnormalities which are known to cause physical or mental disabilities.
The tests required will vary by state.
What screening tests are required by your state?
After birth, nurses are reminded to wear gloves until the initial bath has been completed.
Generally, the newborn spends most of its time in the mother’s room. This provides an ideal time for teaching the parents infant care.
GOAL: The student will learn about the screening tests performed on the newborn and why.

27. Recognizing Hunger in the Newborn
Hand-to-mouth movements
Mouth and tongue movement
Sucking motions
Rooting movements
Clenched fists
Kicking of legs
Crying (a late sign)
One of the primary needs of the newborn involves providing nutrition.
It is important for parents and nurses to be aware of the signs of hunger manifested by the newborn.
GOAL: The student will learn how to recognize the signs of hunger in the newborn.

28. GOAL: The student will learn the basics of breastfeeding.
Choosing whether to breastfeed
Physiology of lactation
Hormonal stimulation
Prolactin
Oxytocin
Composition of milk
Foremilk
Hindmilk
Phases of milk production
Colostrum
Transitional
Mature
Selection of a method of feeding is often an area of concern for new mothers.
It is helpful to provide as much information as possible to assist in the decision-making process.
GOAL: The student will learn the basics of breastfeeding.

29. Assisting the Mother to Breastfeed
Advantages of breastfeeding are
Promotes mother-infant bonding
Maintains infant temperature
Suckling stimulates oxytocin release to contract mother’s uterus
Cultural use of galactogogues
As a point of class discussion, inquire about why some women might choose not to breastfeed.
The cultural use of galactogogues refers to the use of “breast milk stimulators.” These are interventions taken by the mother to facilitate lactation. Nurses must be culturally respectful of these practices.
What are commonly used breast milk stimulators?
GOAL: The student will learn the advantages of breastfeeding.

30. Positions for Breastfeeding
Positions for nursing.
Cradle hold.
Football hold.
Side-lying position.
Which of the positions would be most comfortable for a mother after a cesarean section?
GOAL: The student will learn the different positions for breastfeeding.

31. Breastfeeding Techniques
Positions of the mother’s hands
Latch-on
Suckling patterns
Removing the infant from the breast
Essential factors in breastfeeding involve:
1. Proper body alignment
2. Correct grasp of the areola
3. Proper hand positions of the mother on the breast
The mother should wash her hands before breastfeeding.
Attempting to express some colostrum on the nipple prior to breastfeeding will increase the erectness of the nipples.
Which breast should the mother use to initiate breastfeeding?
GOAL: The student will learn breastfeeding techniques to help the patient.

32. Latch-on
What actions can the mother take to cause the infant to open the mouth and turn toward the breast?
GOAL: The student will learn breastfeeding techniques to help the patient.

33. Removing Infant From Breast
Correctly removing the infant from the breast requires the mother to “break suction.”
The mother should break the suction before removing the infant from the breast.
She can break the suction by inserting a finger in the corner of the infant’s mouth.
The infant should never be pulled away from the breast without first breaking suction.
What problems can result if the mother does not break suction?
GOAL: The student will learn breastfeeding techniques to help the patient.

34. Evaluating Intake of Infant
Let-down reflex occurs
A tingling sensation with milk dripping from nipple
Infant nurses for 15 minutes per breast 8 to 10 times per day
An audible swallow is heard
Infant appears relaxed after feeding
Infant has 6-8 wet diapers per day
Infant passes several stools per day
Breast feels soft after feeding
GOAL: The student will learn breastfeeding techniques to help the patient.

35. Preventing Problems Frequency and duration of feedings
The sleepy infant
The fussy infant
Flat or inverted nipples
Supplemental feedings and other
Nipple confusion of the infant
Breast engorgement
Nipple trauma
Breast hygiene
Breastfeeding problems can cause emotional distress for the new mother.
It is vital for the nurse to assess for complications/concerns related to breastfeeding.
Discuss the manifestations for each of the identified problems.
What nursing interventions could help the mother work through the problems listed?
Audience Response Question #1
A woman with flat nipples will not be able to breastfeed.
1. True
2. False
GOAL: The student will learn breastfeeding techniques to help the patient.

36. Special Breastfeeding Situations
Multiple births
Premature birth
Delayed feedings
Special breastfeeding challenges can be overcome with nursing assistance.
Identify potential problems/concerns with each of the situations presented.
GOAL: The student will learn breastfeeding techniques to help the patient.

37. Storing and Freezing Breast Milk
Milk at room temperature for more than 4 hours increases potential for bacterial contamination
Container size should hold no more than one feeding
Safely stored or frozen in glass or hard plastic containers
Milk can be stored in refrigerator at 4° C (390F) for 24 hours or in the freezer at –4° C (-200F) for up to 3 months (although freezing breast milk can destroy some antimicrobial factors)
Can be thawed in refrigerator for 24 hours prior to using
Microwaving of breast milk is not advised because it destroys immune factors in the milk
Important points to stress with class and when teaching mother/caregiver.
Milk stored in the refrigerator compartment should be stored toward the back of the refrigerator.
Milk stored in the freezer should also be stored toward the back as the temperature is more constant in this area.
GOAL: The student will learn breastfeeding techniques to help the patient.

38. Maternal Nutrition
Mother needs an additional 500 calories over the nonpregnant diet
8-10 glasses of fluids per day
Some foods eaten by mother may cause a change in the taste of the milk or cause the infant to develop gas (flatus)
Medications taken by the mother may be secreted in the breast milk
Dietary changes might be required if certain substances are found to cause distress in the infant.
Discuss common foods that can be a source of problems when eaten by the breastfeeding mother.
GOAL: The student will learn breastfeeding techniques to help the patient.

39. Weaning Gradual weaning is preferred There is no “best time” to wean
Technique of weaning
Eliminate one feeding at a time
Omit daytime feedings first
Eliminate the favorite feeding last
Infant will need “comfort nursing” if tired or ill
Breast pumping not advised in order to decrease the milk supply cycle
Abrupt weaning can cause engorgement, mastitis, and discomfort in the mother, and the infant could become distressed.
As solid foods are gradually introduced into the diet, the infant will gradually lose interest in breastfeeding.
GOAL: The student will learn breastfeeding techniques to help the patient.

40. GOAL: The student will learn about formula feeding.
Types of formulas
Ready to feed
Concentrated liquid
Powdered
Regardless of type, it is important to follow manufacturer’s instruction on preparation and storage of formula products
The mother who decides to formula feed her infant will require education from the nurse concerning this method.
Formulas are available in a variety of stages of preparation.
What are the necessary steps to prepare each type of commercial formula?
GOAL: The student will learn about formula feeding.

41. Feeding the Infant with Formula
Feed every 3 to 4 hours because formula is digested more slowly than breast milk
Do not microwave formula
Do not prop bottle
Involve partner and family in bottle feeding of infant
Many women desire to warm their infant’s formula. This is not necessary.
Why should the use of the microwave be avoided?
Although bottle propping may seem like a timesaver for the mother, it must be avoided. Why?
GOAL: The student will learn breastfeeding techniques to help the patient.

42. Postpartum Self-Care Teaching
Ample written materials regarding mother and newborn care should be provided and reviewed
Follow-up appointments
Hygiene
Sexual intercourse
Diet and exercise
Danger signs to watch for and report
Newborn follow-up care
Infant safety seats
Reassure mother that hospital staff is available by telephone should any questions arise
Childbirth and the addition of a new family member will require education for both the mother and father.
What is the best time to begin discharge teaching?
Discuss ideal times for providing discharge education.
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