Chapter 9 The Family after Birth

Chapter 9 The Family after Birth
Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Puerperium (p. 199) 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. Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Adapting Care to Specific Groups and Cultures (p. 199)
The nursing care provided must be adapted to the circumstances of the mother and infant. The nurse caring for the childbearing family has a responsibility to provide culturally sensitive care. The special needs of each patient group must be incorporated into the care provided. Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Nursing Considerations for Specific Groups of Patients (pp. 199-200)
Adolescents Single women Families at or below the poverty level Families who have twins (or more) Identify the unique concerns for adolescents, single women, families at or below the poverty level, and families who are expecting multiples. What is the best manner in which to approach each of the groups identified? Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Cultural Influences on Postpartum Care (p. 200)
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 patients 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? Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Using Interpreters (p. 200)
Aids in the woman being able to understand and provide optimal care to her infant Interpreter should not be a family member or from a group that is in social or religious conflict Why is it important not to use family to interpret sensitive information? Because the family member may selectively interpret information the nurse is providing. Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Postpartum Changes in the Mother (p. 200)
Immediately after delivery, the mother experiences multiple physiological changes. It is important for the nurse to assess all body systems and not just focus on the reproductive system changes. Why must the nurse assess all body systems in the postpartum period? What should the nurse monitor for? Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Reproductive System (pp. 200-206)
Uterus Involution-decrease 1 cm/day-if uterus is boggy-massage Uterine lining Descent of uterine fundus-should be at umbilical area and firm; if C section should palpate from the side of uterus to midline Afterpains-more in multiparas; breastfeeding due to oxytocin Lochia Rubra-red immediately after delivery up to 3 days Serosa-pinkish 3rd to 10th day Alba –colorless 10th to 21st day Report if lochia changes to bright red color Cervix Vagina Stress importance of discussing with health care provider when to resume vaginal intercourse postpartum 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. Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Reproductive System (cont.) (pp. 203-206)
Perineum Episiotomy REEDA assessment Nursing care and patient teaching Cold packs-first 12 to 24 hours after 24 hours, heat pack or sitz bath Cleaning of perineum-after each voiding or bowel movement; front to back including placing of pad; blotted dry Topical and systemic medications Nonpharmacological pain relief methods-air ring; small egg crate pad 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) What are normal and abnormal findings from the nursing assessment of the reproductive system? Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Breasts (p. 206) First 2-3 days postpartum, breasts are full but soft
Day 3, breasts become firm, lumpy due to increased blood flow and milk production Engorged breasts occur in both nursing and nonnursing mothers Nipples should be assessed for redness and cracking and washed with plain water Support bra should be worn Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Cardiovascular System (pp. 206-207)
Cardiac output and blood volume Coagulation Blood values Chills Orthostatic hypotension Nursing care 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. Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Urinary System (pp ) 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 affect 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? Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Gastrointestinal System (p. 208)
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? Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Integumentary System (p. 208)
Hyperpigmentation of the skin changes as hormone levels decrease Linea nigra disappears Striae fade to silver Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Musculoskeletal System (pp. 208-209)
Diastasis recti 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? Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Immune System (p. 209) Prevent blood incompatibilities and infection
RhoGAM if woman is Rh negative and baby is Rh positive; needs to be administered within 72 of delivery 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. Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Adaptation of Nursing Care Following Cesarean Birth (pp. 209-211)
Same as with normal vaginal delivery except Monitoring of abdominal dressing Lochia generally less Urinary catheter Respiratory care Prevention of thrombophlebitis Pain management 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? Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Emotional Care (p. 211) The birth of an infant brings about physical changes in the mother but also causes many emotional and relationship changes in all family members Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Mothers (p. 211) Rubin’s Psychological Changes of the Puerperium Phase 1-Taking in Phase-mother passive letting others do for her; has interest in child, but prefers others take care of child; focus on food, fluids, sleep Phase 2-Taking Hold Phase-becomes interested in infant; critical about her abilities; concern about her body functions and assume self care; interested in learning Phase 3-Letting go phase-work through giving up previous life style; give up fantasy about child and experience 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? Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Fathers (p. 212) 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? Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Other Family Members (pp. 212-213)
Siblings 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? Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Grieving Parents (pp. 213-214)
Therapeutic communication and nursing care Always listen to parents; if child is poor parents may express desire to have baptism done; in emergency the nurse may perform baptism and minister or priest if notified 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. Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Parenthood (p. 214) 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 lonely Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Family Care Plan (p. 214) Studying the family as well as the patient can offer insight into community-based care Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Data Collection for the Family Care Plan (p. 214)
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? Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Neonatal Transition to Extrauterine Life (p. 214)
Phase 1: Period of reactivity, 0-30 minutes after birth Phase 2: Decreased responsiveness, 30 minutes to 2 hours after birth Phase 3: Second period of reactivity, 2 to 8 hours after birth Phase 1 was presented in Chapter 6. Phase 3 will be presented in Chapter 12. Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Phase 2 Nursing Care of the Newborn (pp. 215-217)
Supporting thermoregulation Table 9-3 Evaporation-liquids from skin Conduction-direct contact to cold surface Convection-by drafts Radiation-loss by being close to cold object by not in direct contact Observing bowel and urinary function Security measures-always ensure that identification bands are checked each time baby and parent are reunited Identifying the infant Gestational age evaluation Skin Vernix Hair Ears Breast tissue Genitalia Sole creases Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Phase 2 Nursing Care of the Newborn (cont.) (pp. 217-219)
Observing for injuries or anomalies Obtaining vital signs Weighing and measuring length and head circumference Umbilical cord care-assessed for 2 arteries and 1 vein-”AVA”; keeping cord clean and dry; diaper fastened low to allow air circulation; will become dry and brownish black as dries; clamp removed when cord end is dry and crisp-about 24 hours; redness or moist, foul smelling Screening tests 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? Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Hypoglycemia (p. 219) A blood glucose below 45 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. Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Risk for Neonatal Hypoglycemia (p. 219)
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. Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Signs and Symptoms of Hypoglycemia in the Newborn (p. 219)
Jitteriness Poor muscle tone Sweating Respiratory difficulty Low temperature Poor suck 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. Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Promoting Bonding and Attachment (p. 220)
Bonding: strong emotional tie that forms soon after birth between parents and newborn Attachment: affectionate tie occurring over time with increased interaction Need to learn infant’s communication cues, e.g., hunger, wet diaper Nursing assessments should include observing for these to occur Some parents are not able to bond with their child and a referral to social services may be needed for a more detailed assessment and intervention plan. Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Nursing Interventions to Aid in Bonding and Attachment (pp. 220-222)
Calling the infant by name Holding the infant en face Providing skin-to-skin contact Talking in gentle, high-pitched tones Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Breastfeeding (p. 222) 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. Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Assisting the Mother to Breastfeed (pp. 223-224)
Advantages of breastfeeding are Promotes mother-infant bonding Maintains infant temperature Sucking stimulates oxytocin release to contract mother’s uterus Cultural use of galactogogues As a point of class discussion, inquire 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? Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Breastfeeding Techniques (p. 225)
Positions of the mother’s hands-if mother had C section show mother the football hold in order to minimize pain at incision site Latch-on Suckling patterns Removing the infant from the breast Essential factors in breastfeeding involve: Proper body alignment Correct grasp of the areola 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? Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Evaluating Intake of Infant (p. 226)
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-alternating breast at each feeding 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 Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Preventing Problems (p. 227)
Frequency and duration of feedings Typically every 2 to 3 hours during early weeks The sleepy infant The fussy infant Flat or inverted nipples Supplemental feedings—should not be offered supplemental feedings or water when breastfeeding infant 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? Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Recognizing Hunger in the Newborn (p. 227)
Hand-to-mouth movements Mouth and tongue movements 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. Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Special Breastfeeding Situations (pp. 228-229)
Multiple births Premature birth Breast surgery Delayed feedings Special breastfeeding challenges can be overcome with nursing assistance. Identify potential problems/concerns with each of the situations presented. Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Storing and Freezing Breast Milk (pp. 229-230)
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 (39° F) for 24 hours or in the freezer at –4° C (–20° F) 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. Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Maternal Nutrition (p. 230)
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. Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Weaning (p. 230) 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. Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Formula Feeding (p. 231) 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? Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Safety Alert (p. 231) Overdilution or underdilution of concentrated liquid or powdered formulas can result in serious illness Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Feeding the Infant (p. 231) Feed every 3 to 4 hours because formula is digested more slowly than breast milk Do not microwave formula Do not prop bottle Hold bottle so nipple is always full of formula. Involve partner and family in bottle feeding of infant To help mother with engorged breasts explain to wear a snug fitting bra around the clock to help with discomfort 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? Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Discharge Planning (pp. 231-232)
Begins on admission Due to quickness of discharge from hospital, teaching often begins before mother is psychologically ready to learn Care maps be used Provide sufficient teaching materials for mother to refer to after discharge Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Postpartum Self-Care Teaching (pp. 232-233)
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 discharge 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. Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Newborn Discharge Care (pp. 233-234)
Discharge planning for the newborn begins shortly after birth If discharged before 72 hours old, a follow-up visit with the pediatrician is recommended within 2 days of discharge Well baby checks start around 6-8 weeks of age Immunization information may be provided Car seat safety: seat should be in back seat and facing the rear until 2 years of age Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Chapter 9 The Family after Birth

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