1. Post Partum Period Chapters 15 & 16 High Risk Chapter 22
Mary L. Dunlap MSN
Fall 2015

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

4. Infant ID Bands

5. Security Band

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

7. Post Partum Assessment BUBBLE-EE
Breast
Uterus
Bladder
Bowel
Lochia
Episiotomy
Extremities
Emotion

8. Vital signs
Temperature
Pulse
Blood pressure
Respirations

9. Pain Assessment Determine source/location and pain level
Interventions- based on pain
Document location, type, pain level and intervention
Reassess in 30 min and document pain level

10. Breast Initial assessment Inspect for size, contour, and asymmetry
Note if nipples are flat, inverted or erect
Ongoing assessments
Check for cracks, redness, or fissures
Engorgement
Mastitis

13. Breast Care Lactating Mother
Supportive bra
Clean areola & nipples with water
Air dry
Express colostrum apply to areola & nipple
Change breast pads frequently

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

15. Assessment of Uterus
After birth midline between umbilicus and the symphysis pubis
Within 1h returns to the umbilicus
Descends 1 cm/day
Consistency- firm/boggy
Height- measured in fingerbreadths
Fundal massage procedure 22.1 p 753

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

21. Afterpains Intermittent uterine contractions due to involution
Primiparous-mild
Multipara- more pronounced
Breastfeeding causes an increase in contractions due to release of oxytocin

22. Nursing Interventions
Patient in a prone position and place a small pillow to support her abdomen
Ambulation
Medicate with a mild analgesic

23. Bladder Monitor for bladder distention and displacement of uterus
Assess for voiding difficulty
Monitor output
Postpartum Diuresis

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

25. Preventing Stress Incontinence
Vaginal delivery causes direct pelvic muscle trauma and disruption of fascial support contributing to the development of urinary stress incontinence.
Prevention strategies: Loss weight, avoid bladder irritates, decrease fluid intake
Kegal exercises
Teaching Guidelines pg

26. Bowel Relaxin depresses bowel motility Progesterone ↓ muscle tone
Diminished intra-abdominal pressure
Incontinence if sphincter lacerated (4th degree)
Spontaneous BM 2nd to 3rd post partum day
Normal bowel pattern 8-14 days

27. Nursing Care Increase fiber in diet 6-8 glasses of water or juice
Stool softener- especially 4th degree
Laxative
Sitz bath for discomfort
Medications for hemorrhoids

28. Lochia
Rubra
Serosa
Alba
Documentation

29. Lochia Assessment

30. Scant
1-2 in
About 10 ml

31. Small
2-4 in
About ml

32. Moderate
4-6in
About mL

33. Heavy
Saturated pad greater than 6 in
About mL within 1 hr.

34. Nursing Care Educate on the stages of lochia
Increase in lochia, foul odor or return to Rubra lochia is not normal
Change Peri pad frequently
Peri care after each voids to decrease risk of infections

35. Episiotomy
1-2 inch incision in the muscular area between the vagina and the anus
Assess REEDA
Lacerations
Episiotomy care

38. Nursing Care Peri care Ice packs Dry heat Topical medications
Sitz bath
Teaching guidelines 16.1 p. 499

40. Extremities Increases the risk of thromboembolic disorders
Risk factors venous stasis, altered coagulation and vascular damage due to birth process increase risk of clot formation

41. Assess for Thrombosis Homan’s sign Assess extremities
Monitor for signs of PE

43. Post Partum Assessment
Post Partum Assessment Video

44. Emotional Status
Bonding is a vital component of the attachment process. It helps establish parent infant attachment and a healthy loving relationship.
Bonding takes during the first 30 to 60 min. after birth

45. Emotional Status
Bonding process helps to lay the foundation for nurturing care
Touch- skin to skin
Eye contact
Breastfeeding
Engrossment
Factors that interrupt bonding

46. Engrossment Seven Behaviors Visual awareness Tactile awareness
Perception NB is perfect
Focus is on NB
Aware of NB’s distinct features
Extreme Elation
Increase sense of self esteem- proud

47. Tactile Awareness

48. Bonding Factors that may interfere with bonding process
Stress over finances
Lack of support
Cultural beliefs
Interruption of process-sick child NICU

49. Transitioning to parenthood
Difficult and challenging
Provide emotional support
Accurate information
Nursing goal create a supportive teaching environment

50. Assuming the mothering role
Rubin’s three phases
Taking –in
Taking –hold
Letting-go

51. Taking in Phase

52. Fathers Development Process
Three stages
Expectations
Reality
Transition to Mastery

53. Maternal Physiological Adaptations

54. Hematological System Decrease in blood volume Elevated WBC
Increased Fibrinogen

55. 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

56. Neurological System Maternal fatigue Transient neurological changes
Headaches
Carpel tunnel improvement

57. Integumentary System Darken pigmentation gradually fades
Hair regrowth returns to normal in 6-12 months
Striae( stretch marks) fade to silvery lines

58. Immune System Rubella Administer to nonimmune mothers
Safe for nursing mothers
Avoid pregnancy for 1 month
Flu-type symptoms may occur

59. 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

61. Reproductive System Involution of uterus Healing of placental site
Vaginal changes

62. Menstruation and Ovulation
Nonlactatating mother
Menstruation returns in 7-9 wks, can take up to 3mo.
First cycle may be anovulatory
Lactating mother
Delayed ovulation and menstruation

63. 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

64. Postpartal Surgical Patient
Tubal ligation
Cesarean birth

65. Breast Feeding
American Academy of Pediatrics (AAP) recommends infants be breastfed exclusively for first 6 months of life
Breastfeeding should continue for at least 12 months
If infants are weaned before 12 months, they should receive iron-fortified infant formula

66. Breast Feeding Optimal method of feeding infant
Breast milk- Bacteriologically safe, fresh, readily available
Milk transition: Colostrum, Transitional milk & mature milk
Breastfeeding benefits 18.2 p 583
Nursing Care Plan 18.1 pg 587

67. Contraindications to Breastfeeding
Maternal cancer therapy/ radioactive isotopes
Active tuberculosis
HIV
Maternal herpes simplex lesion
Galactosemia in infant
Cytomegalovirus (CMV)
Maternal substance abuse

68. Breast Feeding Keys to successful breast-feeding
Initiate first feeding within first hr.
No supplements
Feed on demand, unrestricted at least 8-12 feeds in 24hrs
Avoid artificial nipples
Mother and newborn to stay together

69. Breastfeeding Cue signs Latch-on Assess for milk let down
Scoring tool table 18.6 p 509

70. Cue Signs
Rooting

71. Latch on
Open mouth gape
Infant tip of nose,
cheeks and chin
touching breast

74. Hold nipple in infants mouth to latch & suck
THE
LATCH
SCORING
TOOL
Parameters
0 Point
1 Point
2 Point L
Sleepy infant
No latch achieved
Hold nipple in infants mouth to latch & suck
Stimulate to suck
Latches on rhythmic sucking A:
Audible swallow
none
Few with stimulation
Spontaneous and Intermittent T
Type of nipple
Inverted
Flat
Protruding C
Comfort of nipple
Engorged
cracked bleeding
sever discomfort
Filling, reddened, small blisters
Mild to mod. discomfort
Soft nontender H
Positioning
Nurse must hold infant to breast
Minimal assistance then mother takes over
No help needed

75. Breastfeeding
Positions
Cradle hold
Foot ball
Side lying

76. Cradle Hold

77. Foot Ball Hold

78. Foot Ball Hold

79. Side Lying

80. Breastfeeding
A newborns stomach is the size of a small marble and can hold 5-7 cc’s. This is matches the amount of colostrum produced
From 7-10 days it increases to the size of a golf ball and can hold 1.5 to 2 oz

81. Breastfeeding Newborns nurse on average 8-12 times/24hrs
Feed by cue signs about every 1-3 hours
Should have no more than one 4 hr period
Teaching Guidelines 18.4 pg.588

82. Milk Expression Manually Manual or handheld breast pump
Electric breast pump

83. Hand Express

85. Manual Pump

86. Electric Hand Held

87. Electric Pump

88. Electric Pump

89. Breast Milk Storage Room temperature- 4 hrs Refrigerator- 5-7 days
Deep freezer- 6-7 months

90. Ineffective Breastfeeding
Incorrect latch-on
Inverted nipples
Breast engorgement

91. Special Considerations
Sleepy baby- use gentle stimulate to
bring to alert state
Fussy baby- use calming techniques
Slow weight gain- evaluate breastfeeding

92. Formula Feeding Formula preparation
Periodically check nipple integrity
Bottle preparation
Teaching Guidelines 18.5 p. 591

93. Discharge Teaching Fundus and Lochia Episiotomy care Incision care
Signs of PP infection- table 22.3 p 761
Elimination
Nutrition Box 16.4 p 504

94. Discharge Teaching Exercise- 16.2 p 501 Activity Pain management
Sexual activity
Contraception
Blues
Community resources

95. Postpartum Women at Risk Chapter 22

97. Postpartum Hemorrhage
Blood loss >500 ml of blood after a vaginal birth
1000 ml of blood after cesarean section
Major hemorrhage >2,500 mL
Transfusion of >5 units
Any amount of bleeding that places mother in hemodynamic jeopardy
Table 22.1 pg 748

98. Postpartum Hemorrhage
5 T’s- factors associated with PPH
Tone
Tissue
Trauma
Thrombin
Traction
Table 22.2 pg. 751

99. Tone / Atony Altered muscle tone due to overdistention
Prolonged or rapid labor
Infection
Anesthesia

100. Tissue Retained placental fragments Uterine inversion Clots
Subinvolution

101. Trauma Cervical lacerations Vaginal lacerations
Hematomas of vulva, vagina or peritoneal areas

103. Trauma
Hematoma
Localized collection of blood in connective or soft tissue under the skin( caused by laceration to blood vessel)
Risk factors
Signs and symptoms
Management

104. Thrombin Disorders of the clotting mechanism
This should be suspected when bleeding persists without an identifiable cause

105. Management of PPH Frequent VS q 15 min times 1 hr. Fundal massage
Administer medications
Monitor blood loss for amount
Maintain IV
Type & cross match
Empty bladder

106. Fundal Massaging
Procedure 22.1
pg. 753

107. Uterotonic Drugs Oxytocin (Pitocin) Misoprostol (Cytotec)
Dinoprostone (Prostin E2)
Methylergonovine maleate (Methergine)
Prostaglandin (Hemabate)
Drug Guide 22.1 pg.754

108. Management of PPH
Balloon Tamponade Catheter

109. Post Partum Hemorrhage
PPH Simulation
PPH Noell

110. Thromboembolic Conditions
Thrombosis (blood Clot) can cause inflammation of the blood vessel (Thrombophlebitis) which can cause Thromboembolism (obstruction of blood vessel)

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

112. Nursing Care NSAIDs for pain Bed rest elevate affected leg
Warm compresses
Elastic stockings
No anticoagulants required

113. Assessment For Deep Vein Thrombosis
Calf swelling
Warmth
Tenderness
Pedal edema
Diminished peripheral pulses
Color blue
Homan’s sign

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

115. Thrombosis Patient Education
Anticoagulation Teaching Guidelines 22.1 pg. 758
Eliminate risk factors
Continue using Compression stockings
Avoid constrictive clothing & prolonged standing
Danger signs

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

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

118. Postpartum Infections
Endometritis
Wound infection
UTI
Mastitis
Septic Pelvic Thrombophlebitis
Box 22.1 Risk Factors
Table pg. 761 signs & symptoms

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

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

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

122. Nursing Care Aseptic wound management Frequent perineal pad changes
Good hand washing
Administer antibiotics
Analgesics
Perineal- Peri care
Incision- wound care

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

124. Nursing Care Frequent emptying of bladder Increase fluid intake
Antibiotics
Analgesics
Peri care

125. Mastitis Infection of the breast (one sided)
Seen first 2 weeks after delivery
Most common organism staphylococcus aureus
Infected nipple fissure - to ductal system involvement- edema obstructs milk flow in a lobe- mastitis

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

127. Nursing Management
Empty the breast by increasing the frequency of nursing or pumping
Control infection- Antibiotics
Analgesics
Warm/ice compresses
Assess infants mouth for thrush

128. 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
Teaching Guidelines 22.2 pg. 765

129. Postpartum Affective Disorders
Plummeting levels of estrogen and progesterone after delivery contribute to the mood disorders
Disorders based on their severity:
Postpartum blues
Postpartum depression
Postpartum psychosis

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

131. 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

132. Postpartum Depression
Gradual onset and is evident within first 6 wks.
Cause combination of body, mind, and lifestyle
Symptoms- sleep disturbances, guilt, fatigue, feelings of hopelessness Box 22.2 pg. 771
Screening tools

133. Postpartum Depression
Management same as that for major depression
Antidepressants
Antianxiety
Psychotherapy
Marriage counseling if that is part of the causes
Provide support for the father as well

134. Postpartum Psychosis
Emergency psychiatric condition which could put the women at risk for suicide & infanticide
Detect within 3 wks. of giving birth
Symptoms: delusions, hallucinations, agitation, inability to sleep, bizarre irrational behavior

135. Postpartum Psychosis Management
Usually hospitalized for several months
Psychotropic drugs
Individual psychotherapy
Support group therapy