1. Post Partum Period
Mary L. Dunlap MSN, APRN
Fall 10

2. Post Partum
Begins immediately after child birth through the 6th post partum week
Reproductive track returns to nonpregnant state
Adaptation to the maternal role and modification to the family system

3. Safety for Mother and Infant
Prevent infant abductions
Check ID bands
Educate mother about safety measures
ID band placed on baby in delivery room in front of parents and they verify information
ID bands need to be checked when taking child to mother ( this will prevent unauthorized removal of baby and inadvertent mix up or switching of newborns
Parents need to be aware of the unit routine
Name alert

4. Clinical Assessment Review Antepartum and Intrapartum history
Receive report
Determine educational needs
Consider religious and cultural factors
Assess for language barriers

5. Post Partum Assessment BUBBLE-HE
Lochia
Episiotomy
Legs
Emotion
Breast
Uterus
Bladder
Bowel
Table 15-2 pg. 437
Additional assessment- pain bonding

6. Early Assessment Vital signs Temperature Pulse Blood pressure
Respirations
V.S.- q 15 1 hr- q 30- 2nd hr –q1hr for 3rd hr then q 4-8 hrs per policy
Temperature Initial 24hrs up to due to exertion/dehydration of labor and increased breast vascularity
Temp above may be indicative of an infection
Pulse first 6-10 days due to physiological changes Tachycardia – prolonged labor, blood loss, infection, elevated temperature
Blood pressure- should be the same as 1st trimester- if decreased hemorrhage- if elevated PIH
Respirations- normal if Tachypnea ,S.O.B.,restlessness could be signs/symptoms of PE

7. Breast Assessment Inspect for size, contour, asymmetry and engorgement
Nipples check for cracks, redness, fissures
Note if nipples are flat, inverted or erect
Evaluate for mastitis
Estrogen stimulates the formation of new ducts, the elongation of existing glands
Progesterone stimulates formation of lobules ( produce the breast milk)
First 2 postpartum days- soft to touch
3rd day- begin to fell firm and warm ( filling is beginning)
4th – 5th day firm before nursing then softer ( milk transfer) if taught and painful poor transfer of milk

8. Nursing Care Lactating Mother
Supportive bra
Correct position
Correct latch-on technique
Warm showers
Expose to air

9. Nursing Care Non-Lactating Mother
Avoid stimulation
Wear support bra 24hrs
Ice packs or cabbage leaves
Mild analgesic for discomfort

10. Assessment of Uterus Location immediately after birth
Descends 1 cm/day
Consistency- firm/boggy
Location Height- measured in fingerbreadths
Placental expulsion within 15 min of birth- fundus then midline between umbilicus and symphysis pubis
After 10 days can no longer palpate it has descended into the pelvis
Involution- returns the uterus to the nonpregnant state
1000 g/ after delivery
500 g/ end of 1st week
300 g/ end of 2nd wk
100 g after that
Factors that facilitate involution – complete expulsion of placenta/membranes- breastfeeding- early ambulation
Subinvolution- failure of uterus to return to nonpregnant state-
can be due to Overdistention of the uterus (multiple births, Hydramnios)
prolonged labor infection grand multiparty full bladder retained placental tissue
anesthesia ( relaxation of the muscles
Fig 15-1 and 2 pg. 475 assessment technique and picture of Fundal heights
Table 15-4 pg. 476 assessment and documentation of involution

11. Nursing care Boggy fundus- massage until firm
Medications- Pitocin, Methergine, Hemabate
Teach new mom to massage her fundus

12. Afterpains Intermittent uterine contractions due to involution
Primiparous-mild
Multipara- more pronounced
Uncomfortable for 2-3 days post partum
The after pains cease once the uterus is contracted down to normal size.
Breast feeding and exogenous oxytocin increases pain

13. Nursing Interventions
Patient in a prone position and place a small pillow under her abdomen
Ambulation
Medicate with a mild analgesic

14. Bladder Spontaneous void 6-8 hrs Monitor output Postpartum Diuresis
monitor output- due to decrease tone, pressure from presenting part, analgesia/anesthesia delivery process can cause urinary retention- small frequent voiding less than 150
Assess for full bladder by percussion- full resounding sound -empty dull thud
pt c/o inability to void –
frequent voids still feel they pt has to void
Assess for bruising/swelling around meatus
Postpartum Diuresis-up to 3000 each day 2nd to 5th pp days
Causes- fluid from labor, decrease production of aldosterone (retains sodium)
Decrease Pitocin (antidiuretic)

15. Nursing care Encourage frequent voiding every 4-6 hours
Monitor intake and output for 24 hrs
Early ambulation
Void within 4 hrs after birth
Catheterize if unable to void
Table 15-5 signs and symptoms and nursing interventions

16. Bowel Anatomy returns to normal location
Relaxin depresses bowel motility
Diminished intraabdominal pressure
Incontinence if sphincter lacerated
Spontaneous BM 2nd – 3rd post partum day
Diminished abdominal wall tone analgesics

17. Nursing Care Increase fiber in diet 6-8 glasses of water or juice
Stool softener
Laxative
Sitz bath for discomfort
Medications for hemorrhoids
Box 15-1 pg. 477 Nursing interventions

18. Lochia
Mixture of erythrocytes, epithelial cells, blood, fragments of decidua, mucus and bacteria
As involution proceeds it is the necrotic sloughed off decidua ml
Cesarean less
Present for 3-6 weeks

19. Lochia Rubra Serosa Alba Documentation Rubra- dark red first 3-4 days
Serosa- pinkish brown 4th to 14th days
Alba- yellowish-whitish 14th day and can last up to 3-6 wks
Documentation – color, odor, amount, presence of clots
color returns to Rubra or if clots develop may indicate retained placental fragments
Odor is similar to menstrual flow if it becomes fowl smelling – infection
Amount scant 1-2 in 10 ml
small 4in ml
moderate 4-6in 25-50
heavy saturated pad
fig 15-3 pg 478

20. Nursing Care Educate mother on the stages of lochia
Caution mother that an increase, foul odor or return to rubra lochia is not normal
Instruct patient to change peri pad frequently
Peri care after each void

21. Episiotomy
1-2 inch incision in the muscular area between the vagina and the anus
Assess REEDA
Episiotomy care
R- redness
E -edema
E- ecchymosis
D- discharge
A- approximation
Pt c/o excessive pain evaluate for a hematoma and if present notify MD!!!

22. Nursing Care Peri care Ice packs Sitz baths Dry heat
Topical medications
Nursing interventions- ice 24hrs
Sitz bath 3-4 x/day 20 min warm H2O ( procedure 15-1 pg 480 )
Dry heat (lamp, hot packs)
Change pad frequently
Peri care after each void
Topical medication

23. Pain Assessment Determine source Document location, type and duration
Interventions
Location
Type- stabbing, burning, throbbing, aching, cramping
Duration- intermitted/continuous
Interventions- Nonpharmacologic positioning, ice , Sitz baths, positioning
Medications

24. Assess for DVT Homans’ sign Clinical assessment
Homans’- legs extended and relaxed with knees flexed grasp foot and sharply dorsiflexes foot
no pain or discomfort should be expressed
Pain is only present 50% of the time
Clinical assessment- redness warmth in calf unequal calf circumference( not always reliable )
Venography- real time and color Doppler

25. Postpartum Blues
Transient periods of depression during the first 1 to 2 weeks postpartum
Tearfulness
Sad feeling
Confusion
Insomnia

26. Nursing Care Remind mom that the “Blues” are normal Encourage rest
Utilize relaxation techniques
Share her feelings with her partner
If symptoms do not resolve and progress to depression medical treatment needs to be sought
PP Depression- appears 2 wks after child birth
symptoms- sleep disturbances, guilt, fatigue, feelings hopelessness/worthlessness
sever cases thoughts of suicide
PP Psychosis- delusions, hallucinations, agitation, inability to sleep, bizarre irrational behavior

27. Maternal Physiological Adaptations

28. Hematological System Decrease in blood volume Elevated WBC
Increased Fibrinogen
Decrease in blood volume (due to blood loss/Diuresis)-
500 ml loss vaginal 1gram loss hemoglobin
1000 ml loss c/sec 2 gram loss hemoglobin
Due to Diuresis Hematocrit may rise due to hemoconcentration but should return to normal by 4-6 wks PP.
Elevated WBC’s- due to labor process returns to normal within 6 days
Increased Fibrinogen- protects against hemorrhage dose increase risk for thrombus formation- returns to nonpregnant status 3-4 pp wk

29. Hormonal Levels Estrogen and Progesterone decrease
Anterior pituitary-prolactin for lactation
Expulsion of the placenta- placental lactogen, cortisol, growth hormone, and insulinase levels decrease
“Honeymoon phase”- insulin needs decrease
Honeymoon phase”- insulin needs decrease due to the reduction in these hormones which reduces the anti-insulin effects glucose levels remain in a normal range (without intervention) for a few days PP

30. Neurological System Maternal fatigue Transient neurological changes
Headaches
Carpel tunnel improvement
Maternal fatigue due to altered sleep pattern
Transient neurological changes-anesthesia/analgesia can cause transient numbness in the legs or dizziness
Headaches- R/O spinal vs. PIH
Carpel tunnel- as swelling decreases improvement should be noted

31. Renal
GFR, Creatinine, and BUN return to prepregnant levels within 2-3 months
Urinary glucose levels return to nonpregnant levels by 2nd PP wk
Protienuria resolves by the 6th PP wk
Natriuresis / Diuresis
Natriuresis/Diuresis- large amount of NA in the urine/water retention is reversed

32. Integumentary System Darken pigmentation gradually fades
Hair regrowth returns to normal in 6-12 months
Striae( stretch marks) fade to silvery lines
High levels of estrogen cause hair to go into a rest period- after del.hair falls out and then satblizes

33. Cardiovascular System
Heart returns to normal position
Cardiac output elevated above prelabor levels up to 48 hrs. PP
Delivery of baby, expulsion of the placenta, loss of amniotic fluid can create cardiovascular instability and cardiac output can be elevated for up to 48hrs (strain on heart)

34. Immune System Rubella Administer to nonimmune mothers
Safe for nursing mothers
Avoid pregnancy for 1 month
Flu-type symptoms may occur
Nonimmune- titer less than 1:8 vaccine should be administered

35. Immune System Rho (D) immune globulin
Mother Rh negative, infant Rh positive
Negative coombs’ test
300 mcg of RhoGam within 72 hrs after delivery
Card issued to mother
Larger doses may be needed if hemorrhage or exchange of maternal-fetal blood occured

36. Reproductive System Involution of uterus Healing of placental site
Vaginal changes
Involution- prepregnancy state by 3 wks
Placental site heals without forming a scar- important because this would limit future implantation sites
Vaginal changes- cervical external os never closes
Vaginal returns to prepregnancy state by 6-8wks but will be a bit larger (Kegal exercises)
Labia majora/labia minora remain flaccid

37. Menstruation and Ovulation
Nonlactactating mother
Menstruation returns in 6-8 wks
First cycle may be anovulatory
Lactating mother
Delayed ovulation and menstruation
Lactating –menses depends on feeding frequency and duration( exclusively breast feed) 2-18 months
High levels of prolactin delay ovulation by inhibiting ovarian response to FSH
Educate mom that she can ovulate prior to menses so she needs to use BC

38. Musculoskeletal System
Relaxation of pelvic joints, ligaments, and soft tissue
Muscle fatigue and general body aches from labor and delivery of newborn
Rectus abdominis diastasis
Relaxation of pelvic joints, ligaments, and soft tissue- teach patient to be careful when she goes home no heavy/lifting pushing can cause damage to back and hips returns to normal state in 6-8 wks
Rectus abdominis diastasis-split between the 2 rectus abdominis muscles
Instruct the patient to be careful since the abdominal Wall may not be able to deal with additional stress
1) correct posture when lifting , carrying or bathing the baby for 12 weeks
2) Modified sit-ups to strengthen abdominal muscles

39. Multicultural Nursing Care
Enhance Cultural Sensitivity
Understand cultural influences on the post partum period
Provide culturally appropriate care

40. HIV/AIDS Gloves safety glasses Discourage breast feeding
Avoid contact personal body fluid with infants mucous membranes

41. Postpartal Surgical Patient
Tubal ligation
Cesarean birth
Tubal encourage ambulation and bonding as soon as possible will be sore from procedure medicate as needed if general anesthesia used encourage C&D
Cesarean section at risk for DVT ambulate as soon as possible, do leg exercises in bed, compression stockings, pain management, need to C&D
If it was unplanned pt may have feelings of disappointment, failure, inadequacy, guilt, hostility towards staff,
Encourage bonding as soon as possible, provide emotional support
Increase risk for hemorrhage, wound infection, UTI from Foley, DVT, PE, pneumonia

42. Breast Feeding Optimal method of feeding infant
Breast milk- Bacteriologically safe, fresh, readily available
Box 15-3 pg.489 Breastfeeding benefits
Contraindications to breastfeeding
Infants with milk intolerance- Galactosemia
Mothers with active TB- HIV
Active herpes lesion on nipple
Mothers on lithium/methotrexate
Mothers exposed to radioactive isotopes

43. Breastfeeding Lactogenesis- secretion of milk
Milk ejection reflex- “let down” reflex
Lactogenesis-once the placenta is delivered decrease in estrogen and progesterone- increase secretion prolactin from the anterior lobe of pituitary
it stimulates the alveoli (MILK PRODUCING CELLS) to secrete milk
Infant suckling- releases oxytocin from posterior pituitary- this contracts smooth muscle myoepithelial cells
surrounding the alveoli to eject milk from the alveoli into the lactiferous ducts milk ejection

44. Breastfeeding Cue signs- Box 15-4 pg. 492 Latch-on- Fig 15-8 pg 492
Assess for milk let down
Cue signs (signs of readiness)- most alert first 1-2 hrs after delivery
Latch-on ( fig 15-8 & 9) – proper attachment of infant to breast 1) open mouth gape 2) infants tip of nose, cheeks, and chin should all be touching the breast
Assess for milk let down- tingling sensation in the nipple
audible swallowing 2:1 or 1:1 5:1 or higher non-nutritive sucking can led to poor wt gain
uterine cramping & increased lochia
mother feels relaxed
opposite breast may leak milk

45. Breastfeeding Positions Cradle hold Foot ball Side lying
Fig pg 494
Feedings that last longer than 40 min and less than 10 min are not satisfactory
Infant may lose an average of 5% of birth wt- wt loss more than 7% evaluate feedings
Satisfactory-infant falls off without assistance drunken stupor look nipple everted and round never flat or pinched on one side
Once breast milk production is established infant gains 15-30g or ½ to 1 oz /day continues for first several months

46. Ineffective Breastfeeding
Incorrect latch-on
Inverted nipples
Breast engorgement
Incorrect latch on – causes sore nipples, pain when nursing, ineffective emptying of breast poor milk production
Inverted nipples- difficulty with latch on- ice, pump, role nipples
Engorgement- excessive swelling and over filling of the breast- can be caused by infrequent feedings or ineffective emptying of breast
last about 24 hrs 3-5th day PP when milk comes in
Nursing interventions- warm compresses hand expression of milk before feeding to help with latch on
nurse q 2-3 hrs for min
After nursing cold compresses/ ice packs
cabbage leaves
anti-inflammatory medications
supportive bra with no underwire

47. Collection and Storage Breast Milk
Room temperature- 4 hrs
Refrigerator- 5-7 days
Deep freezer- 6-7 months
Use oldest milk first
Thawing- place in warm water never microwave- creates hot spots and decreases anti-infective properties
Thawed milk never refreeze

48. Formula Feeding Formula preparation
Periodically check nipple integrity
Bottle preparation
Formula preparation- follow directions do not add more water than asked for will be diluted and can cause failure to thrive
Periodically check nipple integrity- if it flows to freely more than one drop at a time can cause chocking
Bottle preparation- wash in hot soapy water rinsed in hot water
washed and then run through dish washer
washed and then boiled in water for 5-10 min

49. Family and Infant Bonding
Transitioning to parenthood
Assuming the mothering role
Parental bonding
Factors that interrupt bonding

50. Transitioning to parenthood
Difficult and challenging
Provide emotional support
Accurate information
Nursing goal create a supportive teaching environment
Primiparous- limited experience – social isolation from family & friends
lack of knowledge and confidence
Nursing goal create a supportive teaching environment –
Use principles of family centered care
1) assess knowledge/skill level
2) provide support through communication/listening
3) Empower them-recognize their own strengths
4) Encourage parents to participate in the decision making process
5) Provide learning opportunities

51. Assuming the mothering role
Rubin’s three phases
Taking –in
Taking –hold
Letting-go
Table 15-6 pg. 499
Taking in- first 1-2 days PP- relieves events of birth talkative
Taking-hold- 2nd-3rd PP day can last up to several wks- caring for self & newborn- Great time to teach
Letting –go- 2-6th wk PP- Focus is on entire family, partner- infant is now an individual
Due to technology women know their infants prior to birth (3D)

52. Bonding Bonding process helps to lay the foundation for nurturing care
Touch- skin to skin
Eye contact
Breastfeeding
Fathers- encourage them to assume an active role in bonding process ( change diapers, skin to skin holding, feedings)
Factors that may interrupt the bonding process
Stress over finances
Lack of support
Cultural beliefs
Interruption of process-sick child NICU
Siblings- may regress in behavior help the child to accept the newborn (pg 501

53. Discharge Planning and Teaching
Self Care

54. Discharge Teaching Fundus and Lochia Episiotomy care Incision care
Signs of infection- box 15-5 pg 505
Elimination

55. Discharge Teaching Nutrition Exercise Pain management Sexual activity
Contraception
Sexual activity- may be resumed after 6 wk pp exam-safe once lochia transitioned to Alba and episiotomy Has healed pt may have some discomfort since the vagina may not be as thick as before-lubricating gel
Contraception- may ovulate before menses use some form of BC

56. Community Resources Support groups Home visits Telephone follow-up
Outpatient Clinics

57. Postpartum Complications

58. Postpartum Hemorrhage
Blood loss of more than 500 ml of blood after a vaginal birth
1000 ml of blood after cesarean section
Any amount of bleeding that places mother in hemodynamic jeopardy
1ml = 1g
Early= within first 24 hrs
Late- more than 24hrs less than 6 wks
Greatest likely hood first 4 hrs

59. Postpartum Hemorrhage
LARRY- common causes of early PPH
Laceration
Atony
Retained placental tissue
Ruptured uterus
You pulled to hard on the cord

60. Postpartum Hemorrhage
4 Ts- factors associated with PPH
Tone
Trauma
Tissue
Thrombin

61. Postpartum Hemorrhage Tone/Atony
Altered muscle tone due to overdistention
Prolonged or rapid labor
Infection
Anesthesia
Box 16-1 pg 513

62. Postpartum Hemorrhage Trauma
Cervical lacerations
Vaginal lacerations
Hematomas of vulva, vagina or peritoneal areas
Box 16-2 pg 514

63. Postpartum Hemorrhage Tissue
Retained placental fragments
Uterine inversion
Subinvolution
Retained placental fragments- check placenta after delivery- if lobes are missing the uterus will need to be explored
Uterine inversion- turned inside out can be caused by abnormal adherence of placenta
excessive traction on UC
vigorous manual removal of placenta
Precipitous delivery
Subinvolution- incomplete involution of uterus- infection distended bladder

64. Postpartum Hemorrhage Thrombin
Disorders of the clotting mechanism
This should be suspected when bleeding persists without an identifiable cause
Low fibrinogen levels
Idiopathic thrombocytopenia (ITP)
Acquired pathology HELLP syndrome- Hemolysis, Elevated Liver enzymes, Low Platelets

65. Management of PPH Frequent VS Fundal massage
Administer medications- Box 16-1
Monitor blood loss for amount
Maintain IV
Type & cross match
Empty bladder
Aggressive management to prevent Hypovolemic shock- if healthy can tolerate a 1000 ml blood loss
Management will depend on cause
May not see a change in B/P or pulse until large amount of blood is lost look at MAP decrease in this measurement may be first sign of problem

66. Hematoma
Localized collection of blood in connective or soft tissue under the skin
Risk factors
Signs and symptoms
Management
Caused by laceration to blood vessel- can led to large blood loss and pain
Risk factor- lacerations
episiotomies
difficult or prolonged second stage
Signs and symptoms- Unremitting pain & pressure
discoloration & bulging of tissue
if not treated can led to shock
Management-notify provider
less than 3-5 cm palliative TX- ice 24 hrs Sitz baths after 24 hrs
greater than 5 cm- I & D

67. Postpartum Infections
A fever of or higher after the first 24 hrs for 2 successive days of the first 10 PP days
Fever of or greater within first 24 hrs- sever pelvic sepsis Group A or B streptococcus

68. Postpartum Infections
Endometritis- Table 16-2 pg 521
Wound infection- Table 16-3 pg. 523
UTI- Table 16-4 pg. 524
Mastitis- Table 16-5 pg 525
Septic Pelvic Thrombophlebitis-Table 16-6 pg 526

69. Endometritis
Involves the endometrium, decidua and adjacent myometrium of the uterus
Lower abdominal tenderness or pain
Temperature
Foul-smelling lochia

70. Nursing Care Administer broad spectrum antibiotic Provide analgesia
Provide emotional support

71. Wound Infection
Sites- Cesarean incision, episiotomy and genital tract laceration
Drainage
Edema
Tenderness
Separation of wound edges

72. Nursing Care Aseptic wound management Frequent perineal pad changes
Good hand washing
Administer antibiotics
Analgesics

73. Urinary Tract Infection
Burning and pain on urination
Lower abdominal pain
Low grade fever
Flank pain
Protienuria, hematuria, bacteriuria, nitrates and WBC

74. Nursing Care Frequent emptying of bladder Increase fluid intake
Antibiotics
Analgesics

75. Mastitis Infection of the breast (one sided)
Seen 2-3 weeks after delivery
Caused by staphylococcus aureus
Infected nipple fissure - to ductal system involvement- edema obstructs milk flow in a lobe- mastitis

76. Mastitis Symptoms Flu like symptoms
Tender, hot, red area on one breast
Breast distention with milk

77. Nursing Management
Empty the breast by increasing the frequency of nursing or pumping
Antibiodics
Analgesics

78. Postpartum Infection Education
Continue antibiotics
Monitor temperature and notify provider if temp greater then 100.4
Watch for signs and symptoms of a recurrence
Practice good hand washing

79. Thrombophlebitis and Thrombosis
Thrombosis (blood Clot) can cause inflammation of the blood vessel (thrombophlebitis) which can cause thromboembolism (obstruction of blood vessel)
This is due to hypercoagulable state, venous stasis and vein injury

80. Assessment Superfical
Tenderness and pain in extremity
Warm and pinkish red color over thrombus area
Palpable- feels bumpy and hard
Increased pain when ambulating

81. Nursing Care NSAIDs for pain Bed rest elevate affected leg
Warm compresses
Elastic stockings

82. Assessment Deep Vein
Located from foot to pelvis- can dislodge and cause PE
Calf swelling
Warmth
Tenderness
Pedal edema
Diminished peripheral pulses

83. Nursing Care Bed rest Elevate effected leg Continuous moist heat
TED hose both legs
Analgesics PRN
Anticoagulation therapy

84. Pulmonary Embolism
Abrupt onset: chest pain, dyspnea, diaphoresis, syncope, anxiety
ABC response