1. Nursing Care of Post Partum Mother

2. Physical Changes cardiac & respiratory
Heart position output
Fluid volume VS
Respiratory
Pulmonary function
BMR
Cardiac
Cardiac output – rises for 48 hours PP brady – 50-60bpm normal by 10 days
Fluid volume – diuresis about 3000/d for first few days
VS – temp first day from dehydration
Gastrointestinal
Normal immediately BMR elevated 1-2 wks –”starved”
Gastric motility decreased
BM 2-3 days PP
Constipation r/t hemorrhoids, trauma, dehydration, pain, fear, immobility, meds

3. Physiological Changes GU & Reproductive System
Urinary
Genitalia
Involution of uterus Decent After pains Lochia Cervix, Vagina, Perineum Return of menses

4. Measurement of descent of fundus for the woman with vaginal birth.
The fundus is located two finger breadths below the umbilicus.
Measurement of descent of fundus for the woman with vaginal birth.

5. Involution of the uterus
Involution of the uterus. A, Immediately after delivery of the placenta, the fundus is midline and halfway between the symphysis pubis and the umbilicus. B, About 6 to 12 hours after birth, the fundus is at the level of the umbilicus. It then descends one finger breadth (approximately 1 cm) each day.

6. Suggested guideline for assessing lochia volume.

7. BUBBLEHE Assessment Breasts – Soft, filling, firm, Nipples
Uterus – consistency, position, height, C/S
Bladder – voiding pattern
Bowels – bowel sounds, hemorrhoids, BM
Lochia – type, amt, clots, odor
Episiotomy – laceration, bruising, swelling
Homan sign – present or not
Emotional status – bonding, blues

8. REEDA Scale for Incisions
Redness
Edema
Ecchymosis
Discharge
Approximation

9. Physical Changes PP Gastrointestinal Appetite Gastric motility
BM resumes
Constipation r/t hemorrhoids, trauma, dehydration, pain, fear, immobility, meds
Musculoskeletal
Joint stabilization
Abdominal wall

10. Physical Changes PP
Integumentary
Endocrine
Neurological
Hematological

11. Psychosocial Needs Promoting bonding
Rubin’s Phases Taking in – wants to be taken care of Taking hold – takes charge Letting go – more realistic
p.468

12. Post Partum Blues
Is normal, mild, transient condition affects 50-70% of women
Begins 3-4 days after childbirth, peaks on the 4-5 day and resolves within 2 wks
Symptoms: insomnia, fatigue, tearfulness, mood instability, anxiety
Nursing care: encouraged to rest, take care of self, discuss feelings, it is self-limiting
p. 468

13. Cesarean Care TCDB NPO, ice chips usually 12 hrs Ambulate 12 hours
Foley D/C after 24 hours
IV until tolerating diet
Dressing removed 24hours
Sutures removed 1 week after delivery
When home – rest, good nutrition, mild exercise

14. Nursing Care Review teaching info syllabus p. 38-41
Involution – 6-7 weeks
Decent of uterus midline and descend 1cm/d
Lochia – unique healing – no scar rubra 2-3 days - dark red with small clots serosa 4-10 days – pink to brownish alba 1-6 weeks – cream-white
Cervix – never the same
Perineum – if episiotomy, takes 3-6 weeks

15. Nursing Care - Teaching
Bladder – diuresis first 24 hours
Stomach – resume exercise after Dr says
Menstruations – 6 weeks, delayed with lactating mothers, STILL ovulate
Sex – resume after first menstruation, after episiotomy some loose interest for one year
Rest, Rest, Rest

16. Breastfeeding
Colostrum is produced during pregnancy and immediately after birth, contains antibodies
Replaced in 2-4 days with milk
Teach: clean breast first in shower, proper positioning, release suction with finger, avoid soap on nipples, disposable bra pads, S&S of complications – redness, swelling, fever, tenderness, cracked nipples – (usually mastitis unilateral)

17. LATCH: a breastfeeding charting and documentation tool
LATCH: a breastfeeding charting and documentation tool. LATCH was created to provide a systematic method for breastfeeding assessment and charting. It can be used to assist the mother in establishing breastfeeding and define areas of needed intervention.
LATCH was created to provide a systematic method for breastfeeding assessment and charting.

18. Complications
Hemorrhage – Hgb < 9 requires Tx atony- most common cause is full bladder laceration – bleeding with firm uterus placenta fragments – bleeding returns to rubra or foul odor noted – more common with “Dirty Dunkin”
Infection – Temp above F urinary mastitis
Thrombophlebitis – pain and redness, +Homan – send for venous scan pulmonary embolism – sudden onset chest pain, SOB

19. Post Partum Hemorrhage
Loss of blood more than 500 cc – vaginal birth, C/S 1000 cc lost
Most common cause – uterine atony others are retained placenta fragments, or infection, hematoma, lacerations
Tx – initial is fundal massage
S & S – saturate more than one pad/hr, “boggy” uterus, increased lochia with clots, severe perineal pain (with hematoma), tachycardia, hypotension

20. Manual compression of the uterus and massage with the abdominal hand usually will effectively control hemorrhage from uterine atony.

21. Manual removal of placenta. Performed only by the medical clinician.
The fingers are alternately abducted, adducted, and advanced until the placenta is completely detached.
Manual removal of placenta. Performed only by the medical clinician.

22. Nursing Care of PP hemorrhage
Inspect placenta for missing parts
Administer oxytocics
Maintain IV line
Apply ice to perineum
Keep bladder empty
Massage fundus if boggy
Monitor lochia with amount and type
Discharge teaching: report if return to rubra, fever over 100.4, foul smelling lochia, flu-like symptoms

23. Puerperal Infection
Fever over after the first 24 hours and lasting 2 days or more
Chills, flu-like symptoms, elevated WBC (over 30,000), tachycardia
Types of infections reproductive tract: back ache, abd pain, foul smelling lochia, purulent discharge wound infection: erythema, warmth, swelling, tenderness, drainage.
Puerperal infection is any infection of the reproductive tract that occurs within 28 days after abortion or childbirth. The first symptom is usually a fever.
Common sources of PP infection are endometritis , mastitis, episiotomy or incision infection, UTI and respiratory infections.

24. Mastitis. Erythema and swelling are present in the upper outer quadrant of the breast. Axillary lymph nodes are enlarged and tender.

25. PP Infections UTI: pain, burning, urgency or freq of urine
Mastitis – erythema, warmth in breast, flue-like symptoms
Diagnosis with culture, vag exam, CBC
Nursing care: assess VS, lochia, incisions, attend to pain, ensure food and fluid intake, obtain specimens, monitor response to antibiotic.

26. Thrombophlebitis Inflammation of vessel wall with thrombus
Causes: stasis and hypercoagulability
Types: superficial venous thrombus: reddened, warm, swollen deep vein thrombosis: occurs in larger veins, positive Homan’s, pain
Risk factors: immobility, C/S, PIH, DM, smoking, over 40 yr, multiparity, anemia
Prevent: early ambulation and hydration

27. Nursing Care Thrombophlebitis
Bedrest with leg elevated
Change positions frequently, not flexed knees
Teach no to rub area
Daily measurements of calf and thigh
Support stockings, moist heat application
Assess for complication: embolism, S&S of pulmonary embolism

28. Rh Incompatibility
Antibodies cross placenta and attach to fetal red blood cells destroying them

29. Rh Incompatibility Mother Rh- negative and fetus Rh positive
If Rh positive blood enters system of Rh negative mother reacts by developing antibodies to destroy RBCs with Rh positive antigens
Blood may mix during third stage of labor
First child not effected

30. p. 693
About 15% of white population in US is Rh negative. – lower in African americans and Asians
Rh isoimmunization sequence. Rh-positive father and Rh-negative mother.

31. As the placenta separates, the mother is further exposed to the Rh-positive blood.

32. Anti-Rh-positive antibodies (triangles) are formed.
The body acts as it would any foreign body and develops antibodies to destroy the invading antigen.
Most exposure occurs during the third stage of labor. The first child is not affected. Next pregnancy will cross the placental barrier and destroy fetal blood cells. As fetal blood cells are destroyed, fetal bilirubin levels increase which lead to neurological disease. The fetus is anemic it is termed Erythroblastosis fetalis.
We will discuss RhoGam in Pharm
Anti-Rh-positive antibodies (triangles) are formed.

33. In subsequent pregnancies with an Rh-positive fetus, Rh-positive red blood cells are attacked by the anti-Rh-positive maternal antibodies, causing hemolysis of the red blood cells in the fetus.

34. RhoGAM
Rho (D) immune globulin suppresses the stimulation of active immunity by Rh-positive foreign RBC
Given IM at 28 weeks antepartum and within 72 hours of delivery – 1 vial
Before 13 weeks give ½ dose after amniocentesis, miscarriage, ectopic pregnancy

35. Before Administration
Never administer intravenously
Never administer to a neonate
Never administer to an Rh negative patient who has been previously sensitized to the Rh antigen
Confirm that the mother is Rh negative
Confirm infant is Rh positive and assess direct coombs test
Mother has indirect coombs test to determine the presence of antibodies against fetal blood. If the test is positive, amniocenteses may be performed to determine the fetal Rh factor and degrees of hyperbilirubinemia. When infants are jaundiced the infants blood type and a direct coombs test are performed on eh cord blood A positive coombs test indicates that antibodies from the mother have attached to the infants RBC. Bilirubin levels are followed closely for changes that indicate that treatment should be initiated or changed,

36. Coombs Test
Indirect coombs test on mother to determine the presence of antibodies against fetal blood.
If the test is positive, amniocenteses may be performed to determine the fetal Rh factor and degrees of hyperbilirubinemia.
Direct coombs test is performed on the cord blood. Positive coombs test indicates that antibodies from the mother have attached to the infants RBC. Bilirubin levels are followed closely for changes that indicate that treatment should be initiated or changed.

37. Postpartum Depression/Psychosis
Postpartum depression % - all ethnic groups affected.
Cause unknown, may be r/t hormonal, exhaustion, anger, chronic stress
S&S: starts first 4 wks and last several months, fatigue, loss of self, suicide thoughts crying
TX: combination of psychotherapy, social, meds
Postpartum psychosis- rare, bipolar disorder or major depression, frightening thoughts, delusions of dead baby and hallucinations, need psychiatric Tx, will not resolve itself

38. Infant Care Cord care Diapering feeding Stools Urine Baths
How to take temp