1. Gloria Nwagwu MSN, FNP-BC, RN Chapter 15 Caring for the Postpartal Woman and Her Family

2. Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Susan Ward Shelton Hisley Susan Ward Shelton Hisley Question? The most effective and least expensive treatment of puerperal infection is prevention. What is important in this strategy? a. Large doses of vitamin C during pregnancy b. Prophylactic antibiotics c. Strict aseptic technique, including handwashing, by all health care personnel d. Limited protein

3. Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Susan Ward Shelton Hisley Susan Ward Shelton Hisley Fourth Trimester Begins immediately after childbirth Puerperium—first 6 weeks after birth Close observation—identify hemorrhage and complications during first critical hour Ongoing education and support

4. Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Susan Ward Shelton Hisley Susan Ward Shelton Hisley Safety for Mother and Infant Prevent infant abductions Check ID bands Educate mother about safety measures

5. Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Susan Ward Shelton Hisley Susan Ward Shelton Hisley Early Maternal Assessment Vital signs Temperature—below 100.4 o F (38 o C) Pulse—bradycardia Blood pressure Respirations

6. Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Susan Ward Shelton Hisley Susan Ward Shelton Hisley Fundus Immediate postpartum—halfway between the symphysis pubis and the umbilicus 1 hour postpartum—level of the umbilicus or one fingerbreadth above Then, descends one fingerbreadth each day Assess lochia

7. Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Susan Ward Shelton Hisley Susan Ward Shelton Hisley Perineal Assessment Sim’s position REEDA Hemorrhoids Teach regarding comfort measures If severe, teach how to manually reposition

8. Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Susan Ward Shelton Hisley Susan Ward Shelton Hisley Postpartum Assessment Guide

9. Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Susan Ward Shelton Hisley Susan Ward Shelton Hisley BUBBLE-HE Breasts Uterus Bladder Bowel Lochia Episiotomy

10. Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Susan Ward Shelton Hisley Susan Ward Shelton Hisley Other Important Components Maternal pain Homans’ sign Mother’s emotional status Infant bonding

11. Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Susan Ward Shelton Hisley Susan Ward Shelton Hisley Breast Assessment Firmness, filling Nodules Fissures, cracks Blood Dried milk Erect or inverted nipples

12. Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Susan Ward Shelton Hisley Susan Ward Shelton Hisley Assessment of Uterus Placental expulsion usually occurs within 15 minutes after birth Uterine contractions control bleeding Technique for uterine palpation Involution Subinvolution

13. Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Susan Ward Shelton Hisley Susan Ward Shelton Hisley Fundal Assessment Location immediately after birth Descends 1 cm/day Consistency Location Height Measured in fingerbreadths

14. Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Susan Ward Shelton Hisley Susan Ward Shelton Hisley Afterpains Occur during process of involution More pronounced in multipara Nursing care Explain cause Prone position with abdominal pillow Sitz baths Encourage ambulation Administer mild analgesics

15. Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Susan Ward Shelton Hisley Susan Ward Shelton Hisley Bladder Spontaneous void within 6 to 8 hours pp Monitor first voiding Anticipate maternal diuresis Urinary output may reach 3000 mL/day Urine volume, flow returns to pre-pregnant levels within 2 to 3 days pp

16. Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Susan Ward Shelton Hisley Susan Ward Shelton Hisley Assessment Findings: Bladder Incomplete emptying Overdistention Urinary retention Nursing interventions Support and enhance attempts to void

17. Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Susan Ward Shelton Hisley Susan Ward Shelton Hisley Bowel Hunger and thirst after childbirth Relaxin—depresses bowel motility Strategies to prevent constipation Early ambulation Abundant fluids High-fiber diet

18. Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Susan Ward Shelton Hisley Susan Ward Shelton Hisley Lochia Characteristic indicative of status in process of involution Lochia rubra Lochia serosa Lochia alba Document amount

19. Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Susan Ward Shelton Hisley Susan Ward Shelton Hisley Episiotomy 1 to 2 inch surgical incision Assess REEDA Ice for first 24 hours Moist heat—Sitz bath Dry heat—hot packs

20. Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Susan Ward Shelton Hisley Susan Ward Shelton Hisley Pain Assessment Determine source Document location, type, and duration Administer Tylenol or Ibuprofen Sitz bath Educate regarding nonpharmacological measures

21. Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Susan Ward Shelton Hisley Susan Ward Shelton Hisley Assess for DVT Homans’ sign Dorsiflex foot and ask about pain Clinical assessment Erythema, unequal calf circumference, heat Clinical signs are NOT reliable

22. Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Susan Ward Shelton Hisley Susan Ward Shelton Hisley Emotional Status Wide range of emotions May be sad during first 1 to 2 weeks pp Ongoing assessment and education Educate regarding “baby blues”

23. Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Susan Ward Shelton Hisley Susan Ward Shelton Hisley Maternal Physiological Adaptations Continued Assessment of the Patient

24. Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Susan Ward Shelton Hisley Susan Ward Shelton Hisley Hematological System Decrease in blood volume Blood loss Diuresis White blood count increased x 5 to 6 days Fibrinogen increased Returns to normal by third to fourth week

25. Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Susan Ward Shelton Hisley Susan Ward Shelton Hisley Hormonal Levels Estrogen and progesterone decrease Anterior pituitary—prolactin Placental lactogen, cortisol, growth hormone, and insulinase levels decrease Insulin needs decrease—“Honeymoon phase”

26. Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Susan Ward Shelton Hisley Susan Ward Shelton Hisley Neurological System Altered sleep patterns—maternal fatigue Numbness in legs, dizziness Safety for infant and mother Headaches Assess quality and location, and carefully monitor vital signs Implement environmental interventions

27. Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Susan Ward Shelton Hisley Susan Ward Shelton Hisley Renal System, Fluid and Electrolytes GFR, Creatinine, and BUN return to pre-pregnant levels within 2 to 3 months Urinary glucose Proteinuria Rapid, sustained natriuresis and diuresis Output may reach 3000 mL/day

28. Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Susan Ward Shelton Hisley Susan Ward Shelton Hisley Respiratory System Respiratory alkalosis and compensated metabolic acidosis may persist Decrease in intra-abdominal pressure Relief from dyspnea

29. Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Susan Ward Shelton Hisley Susan Ward Shelton Hisley Integumentary System Hormonal changes cause skin alterations Most disappear Striae gravidarum

30. Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Susan Ward Shelton Hisley Susan Ward Shelton Hisley Cardiovascular System Delivery of the baby, expulsion of the placenta, and loss of amniotic fluid can create cardiovascular instability Cardiac output remains elevated Physiological diuresis

31. Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Susan Ward Shelton Hisley Susan Ward Shelton Hisley Immune System Rh o (D) immune globulin (RhoGAM) Rubella vaccination Nonimmune status Signed consent form Avoid pregnancy for 1 month Flu-type symptoms may occur

32. Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Susan Ward Shelton Hisley Susan Ward Shelton Hisley Reproductive System Involution of uterus Healing of placental site Vaginal changes Labia majora and labia minora flaccid

33. Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Susan Ward Shelton Hisley Susan Ward Shelton Hisley Menstruation and Ovulation Nonlactating women Menstruation returns in 6 to 8 weeks First cycle may be anovulatory Lactating women Delayed ovulation and menstruation Educate—ovulation can precede menstruation, need contraception

34. Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Susan Ward Shelton Hisley Susan Ward Shelton Hisley Gastrointestinal System Decreased gastric motility Decreased muscle tone in abdominal wall Constipation Stool softeners

35. Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Susan Ward Shelton Hisley Susan Ward Shelton Hisley Musculoskeletal System Laxity of pelvic joints and ligaments Relaxation of soft tissues Muscle fatigue Body aches Rectus abdominis diastasis Correct posture Modified sit-ups

36. Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Susan Ward Shelton Hisley Susan Ward Shelton Hisley Enhancing Cultural Sensitivity Conduct cultural assessments Expand knowledge and understanding Culturally influenced beliefs Common health care practices Customs and rituals

37. Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Susan Ward Shelton Hisley Susan Ward Shelton Hisley Question? To provide optimum care for the postpartum woman, the nurse understands that the most common causes of subinvolution are: a. Postpartum hemorrhage and infection. b. Multiple gestation and postpartum hemorrhage. c. Uterine tetany and overproduction of oxytocin. d. Retained placental fragments and infection.

38. Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Susan Ward Shelton Hisley Susan Ward Shelton Hisley Promoting Recovery and Self-Care

39. Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Susan Ward Shelton Hisley Susan Ward Shelton Hisley Activity and Rest Early postpartum ambulation Mild exercises Kegel Increase gradually Encourage frequent rest periods Obtain adequate sleep

40. Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Susan Ward Shelton Hisley Susan Ward Shelton Hisley Nourishment Weight loss Appetite Balanced diet Multivitamin supplement Iron if hemoglobin low

41. Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Susan Ward Shelton Hisley Susan Ward Shelton Hisley Elimination Void every 4 to 6 hours Monitor intake and output x 24 hours Increased risk of infection Urinary retention Constipation

42. Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Susan Ward Shelton Hisley Susan Ward Shelton Hisley Perineal Care Risk of infection Teach perineal hygiene Hand washing Tampons contraindicated Cesarean births Nurse provides perineal care until ambulatory

43. Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Susan Ward Shelton Hisley Susan Ward Shelton Hisley Ice Packs Reduce edema and pain Vasoconstriction and numbing Apply for 20 minutes every 2 to 4 hours First 24 hours

44. Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Susan Ward Shelton Hisley Susan Ward Shelton Hisley Afterbirth Pain Intermittent uterine contractions during involution Breastfeeding (release of oxytocin) Duration: 2 to 3 days Mild analgesics

45. Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Susan Ward Shelton Hisley Susan Ward Shelton Hisley Special Considerations Women with HIV/AIDS Gloves, safety glasses Discourage breastfeeding Patient teaching for infant safety

46. Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Susan Ward Shelton Hisley Susan Ward Shelton Hisley Postpartal Surgical Patient Tubal ligation Cesarean birth Incisional wound Recovery from anesthesia Respiratory care

47. Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Susan Ward Shelton Hisley Susan Ward Shelton Hisley Infant Feeding Choices Breastfeeding Bottle feeding Educate Support

48. Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Susan Ward Shelton Hisley Susan Ward Shelton Hisley Physiology of Lactation Breast structure Lactogenesis Milk ejection reflex—“let down” reflex

49. Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Susan Ward Shelton Hisley Susan Ward Shelton Hisley Assisting the Breastfeeding Mother Strategies for Success

50. Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Susan Ward Shelton Hisley Susan Ward Shelton Hisley Breastfeeding Initiating the feeding Achieving proper latch-on Assessing for milk let-down Assuming a position of comfort Assessing for infant weight gain

51. Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Susan Ward Shelton Hisley Susan Ward Shelton Hisley Ineffective Breastfeeding Incorrect latch-on (nipple trauma) Breast engorgement Complementary care Ethnocultural considerations Collecting and storing breast milk

52. Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Susan Ward Shelton Hisley Susan Ward Shelton Hisley Expressing Breast Milk Manual—hand Electric pump Types of breast pumps Storage of breast milk Weaning

53. Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Susan Ward Shelton Hisley Susan Ward Shelton Hisley Formula Feeding Safe Practices

54. Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Susan Ward Shelton Hisley Susan Ward Shelton Hisley Family and Infant Bonding Transition to parenthood Assuming the mothering role Rubin’s phases Paternal bonding Factors that interrupt bonding

55. Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Susan Ward Shelton Hisley Susan Ward Shelton Hisley Adjustment of Other Family Members Siblings Tips for parents Grandparents

56. Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Susan Ward Shelton Hisley Susan Ward Shelton Hisley Emotional Events During the Puerperium First 3 months most vulnerable period Baby blues Postpartum depression Postpartum psychosis Physiological response—tiredness, fatigue

57. Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Susan Ward Shelton Hisley Susan Ward Shelton Hisley Discharge Planning and Teaching Maternal Self-Care

58. Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Susan Ward Shelton Hisley Susan Ward Shelton Hisley Maternal Self-Assessment Fundus and lochia Hygiene Abdominal incision Body temperature Elimination Nutrition

59. Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Susan Ward Shelton Hisley Susan Ward Shelton Hisley Maternal Self-Assessment Fatigue Weight loss Exercise Pain management Mood Sexual activity and contraception

60. Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Susan Ward Shelton Hisley Susan Ward Shelton Hisley Special Needs Populations Adolescent mothers Woman placing infant for adoption Older mothers

61. Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Susan Ward Shelton Hisley Susan Ward Shelton Hisley Community Resources Support groups Home visits Telephone follow-up Outpatient clinics