POst Partum Notes - Maternity and Pediatric Nursing PDF

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CH. 16 Postpartum Notes & HighlightsPostpartum assessment typically is performed as follows: During the first hour: every 15 minutes During the second hour: every 30 minutes During the first 24 hours: every 4 hours After 24 hours: every 8 hours Postpartum assessment of the mother typically i...

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CH. 16 Postpartum Notes & Highlights Postpartum assessment typically is performed as follows: • During the first hour: every 15 minutes • During the second hour: every 30 minutes • During the first 24 hours: every 4 hours • After 24 hours: every 8 hours Postpartum assessment of the mother typically includes vital signs, pain level, and a systematic head-to-toe review of body systems. The acronym BUBBLE-EE— breasts, uterus, bladder, bowels, lochia, episiotomy/ perineum, extremities, and emotional status

Some women experience a slight fever, up to 38°C (100.4°F), during the first 24 hours. This elevation may be the result of dehydration because of fluid loss during labor. A temperature above 38°C (100.4°F) at any time or an abnormal temperature after the first 24 hours may indicate infection and must be reported Tachycardia in the postpartum woman can suggest anxiety, excitement, fatigue, pain, excessive blood loss, infection, or underlying cardiac problems. Further investigation is warranted to rule out complications.

Inspect the breasts for size, contour, asymmetry, engorgement, or erythema. Check the nipples for cracks, redness, fissures, or bleeding, and note whether they are erect, flat, or inverted. Flat or inverted nipples can make breast- feeding challenging for both mother and infant. Cracked, blistered, fissured, bruised, or bleeding nipples in the breast-feeding woman are generally indications that the baby is improperly positioned on the breast. For women who are not breast-feeding, use a gentle, light touch to avoid breast stimulation, which would exacerbate engorgement. Duct that may progress to mastitis if not treated promptly. Any discharge from the nipple should be described and documented if it is not colostrum (creamy yellow) or foremilk (bluish white). Assess the fundus (top portion of the uterus) to determine the degree of uterine involution. If possible, have the woman empty her bladder before assessing the fundus. The fundus should be midline and should feel firm. A boggy or relaxed uterus is a sign of uterine atony. This can be the result of bladder distention, which displaces the uterus upward and to the right, or retained placental fragments. Either situation predisposes the woman to hemorrhage. One to 2 hours after birth, the fundus typically is between the umbilicus and the symphysis pubis. Approximately 6 to 12 hours after birth, the fundus usually is at the level of the umbilicus Normally, the fundus progresses downward at a rate of one fingerbreadth (or 1 cm) per day after childbirth On the first postpartum day, the top of the fundus is located 1 cm below the umbilicus and is recorded as U-1. Similarly, on the second postpar- tum day, the fundus would be 2 cm below the umbilicus and should be recorded as U2, and so on. If the fundus is not firm, gently massage the uterus using a circular motion until it becomes firm. Considerable diuresis—as much as 3,000 mL—may follow for several days after childbirth, decreasing by the third day Palpation of a rounded mass suggests bladder distention. Also percuss the area: a full bladder is dull to percussion. If the bladder is full, lochia drainage will be more than normal because the uterus cannot contract to suppress the bleeding.

Assess lochia in terms of amount, color, odor, and change with activity and time. Foul-smelling lochia suggests an infection, and large clots suggest poor uterine involution, necessitating additional intervention. To determine the amount of lochia, observe the amount of lochia saturation on the perineal pad and re- late it to time Typically, the amount of lochia is described as follows:    

Scant: a 1- to 2-inch lochia stain on the perineal pad or approximately a 10-mL loss Light or small: an approximately 4-inch stain or a 10- to 25-mL loss Moderate: a 4- to 6-inch stain with an estimated loss of 25 to 50 mL Large or heavy: a pad is saturated within 1 hour after changing it

Report any abnormal findings, such as heavy, bright- red lochia with large tissue fragments or a foul odor. If excessive bleeding occurs, the first step would be to massage the boggy fundus until it is firm to reduce the flow of blood. Document all findings. Urge the woman to notify her health care provider if lochia rubra returns after the serosa and alba transitions have taken place. To assess the episiotomy and perineal area, position the woman on her side with her top leg flexed upward at the knee and drawn up toward her waist. The normal episiotomy site should not have redness, discharge, or edema. The majority of healing takes place within the first 2 weeks, but it may take 4 to 6 months for the episiotomy to heal completely Lacerations are classified based on their severity and tis- sue involvement:     

First-degree laceration—involves only skin and superficial structures above muscle Second-degree laceration—extends through perineal muscles Third-degree laceration—extends through the anal sphincter muscle Fourth-degree laceration—continues through anterior rectal wall

Assess the episiotomy and any lacerations at least every 8 hours Large areas of swollen, bluish skin with complaints of severe pain in the perineal area indicate pelvic or vulvar hematomas. Redness, swelling, increasing discomfort, or purulent drainage may indicate infection. Both findings need to be reported immediately. Ice can be applied to relieve discomfort and reduce edema; sitz baths also can promote comfort and perineal healing Three factors predispose women to thromboembolic disorders during pregnancy: o stasis (compression of the large veins because of the gravid uterus), o altered coagulation (state of pregnancy) o and localized vascular damage (may occur during birthing process). Risk factors associated with thromboembolic conditions include: • • • • • • • • • • • • •

Anemia Diabetes mellitus Cigarette smoking Obesity Preeclampsia secondary to exaggeration of hypercoagulable state Hypertension Varicose veins Pregnancy Oral contraceptive use Cesarean birth Previous thromboembolic disease Multiparity Inactivity Advanced maternal age

Edema in the affected leg (typically the left), along with warmth and tenderness, may also be noted Women with an increased risk for this condition during the postpartum period should wear antiembolism stockings or use sequential compression devices to reduce their risk of thrombophlebitis (ambulation as well)

Applications of Cold and Heat Commonly, an ice pack is the first measure used after a vaginal birth to relieve perineal discomfort from edema, an episiotomy, or laceration. It is applied during the fourth stage of labor and can be used for the first 24 hours to re- duce perineal edema and to prevent hematoma formation, thus reducing pain and promoting healing. Usually the ice pack is applied for 20 minutes and removed for 10 minutes after the first 24 hours, a sitz bath with warm water may be prescribed and substitute for th ice pack to reduce swelling and promote comfort for an episiotomy, perineal trauma, or inflamed hemorrhoids. Before using a sitz bath the woman should cleanse the perineum with peribottle or take a shower using mild soap. Topical Preparations Benzocaine These agents numb the perineal area and are used after cleansing the area with water via the peribottle and/or a sitz bath. For hemorrhoid discomfort, cool witch hazel pads, such as Tucks Pads, can be used. The pads are placed at the rectal area, between the hemorrhoids and the perineal pad. These pads cool the area, help relieve swelling, and minimize itching. Pharmacologic measures include: dibucaine, or steroids (hydrocortisone) Analgesics - drugs are secreted in breast milk. Nearly all medications that the mother takes are passed into her breast milk; however, the mild

analgesics (e.g., acetaminophen or ibuprofen) are consid- ered relatively safe for breast-feeding mothers Assisting With Elimination A full bladder interferes with uterine contraction and may lead to hemorrhage, because it will displace the uterus out of the midline. If the woman has difficulty voiding, pouring warm water over the perineal area, hearing the sound of running tap water, blowing bubbles through a straw, taking a warm shower, drinking fluids, or placing her hand in a basin of warm water may stimulate voiding. If these actions do not stimulate urination within 4 to 6 hours after giving birth, catheterization may be needed. Palpate the bladder for distention and ask the woman if she is voiding in small amounts (less than 100 mL) frequently (retention with overflow). If catheterization is necessary, use sterile technique to reduce the risk of infection. Promoting Activity, Rest, and Exercise Be sure that the mother recognizes her need for rest and sleep and is realistic about her expectations. Some suggestions include the following:   

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Nap when the infant is sleeping, because getting un- interrupted sleep at night is difficult. Reduce participation in outside activities and limit the number of visitors. Determine the infant’s sleep–wake cycles and attempt to increase wakeful periods during the day so the baby sleeps for longer periods at night. Eat a balanced diet to promote healing and to increase energy levels. Share household tasks to conserve your energy. Ask the father or other family members to provide infant care during the night periodically so that you can get an uninterrupted night of sleep. Review your family’s daily routine and see if you can “cluster” activities to conserve energy and promote rest.

Self-Care Measures o Ways to prevent infection during postpartum period o Frequently change perineal pads, applying and removing them from front to back to prevent spreading contamination from the rectal area to the genital area. o Avoid using tampons after giving birth to decrease the risk of infection. o Shower once or twice daily using a mild soap. Avoid using soap on nipples. o Use a sitz bath after every bowel movement to cleanse the rectal area and relieve enlarged hemorrhoids. o Use the peribottle filled with warm water after urinating and before applying a new perineal pad. o Avoid tub baths for 4 to 6 weeks, until joints and balance are restored, to prevent falls. o Wash your hands before changing perineal pads, after dis- posing of soiled pads, and after voiding Sexuality and contraception Typically, sexual intercourse can be resumed once bright-red bleeding has stopped and the perineum is healed from an episiotomy or lacerations. This is usually by the third to the sixth week postpartum. They recommend that postpartum women do not use combined hormonal contraceptives during the first 21 days after childbirth because of the high risk for VTE during this period. During days 21-42 postpartum women without any risk factors for EVT can start using estrogencontaining contraceptives, but women with risk factors should not use them until day 42. Maternal Nutrition In general, nutrition recommendations for the postpartum woman include the following: 

Eat a wide variety of foods with high nutrient density.

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Eat meals that require little or no preparation.

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Avoid high-fat fast foods.

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Drink plenty of fluids daily—at least 2,500 mL (approximately 84 oz). Avoid fad weight-reduction diets and harmful substances such as alcohol, tobacco, and drugs. Avoid excessive intake of fat, salt, sugar, and caffeine. Eat the recommended daily servings from each food group

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Nutrition for Breast Feeding Mother 1. To meet the needs for milk production, the woman’s nutritional needs increase as follows:  Calories: +500 cal/day for the first and second 6 months of lactation  Protein: +20 g/day, adding an extra 2 cups of skim milk  Calcium: +400 mg daily—consumption of four or more servings of milk  Fluid: +2 to 3 quarts of fluids daily (milk, juice or water); no sodas  Iodine: 290mcg daily- daily products, seafood, iodine salt.

When teaching the mother about bottle-feeding, provide the following guidelines:    

Make feeding a relaxing time, a time to provide both food and comfort to your newborn. Use the feeding period to promote bonding by smiling, singing, making eye contact, and talking to the infant. Always hold the newborn when feeding. Never prop the bottle. Use a comfortable position when feeding the new- born. Place the newborn in your dominant arm, which is supported by a pillow. Or have the newborn in a semi-upright position supported in the crook of your

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arm (this position reduces choking and the flow of milk into the middle ear) Tilt the bottle so that the nipple and the neck of the bottle are always filled with formula. This prevents the infant from taking in too much air. Stimulate the sucking reflex by touching the nipple to the infant’s lips. Refrigerate any powdered formula that has been combined with tap water. Discard any formula not taken; do not keep it for future feedings. Burp the infant frequently, and place the baby on his or her back or side for sleeping. Use only iron-fortified infant formula for first year

Alleviating Breast Engorgement Encourage the woman to use ice packs, to wear a snug, supportive bra 24 hours a day, and to take mild analgesics such as acetaminophen. Encourage her to avoid any stimulation to the breasts that might fos- ter milk production, such as warm showers or pumping or massaging the breasts Postpartum Blues The postpartum woman may report feelings of emotional lability, such as crying one minute and laughing the next Postpartum blues: this condition is the mildest form of emotional disturbance associated with The mother maintains contact with reality consistently and symptoms tend to resolve spontaneously without therapy within 1 to 2 weeks.

Preparing for discharge: A shortened hospital stay may be indicated if the following criteria are met:

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Mother is afebrile and vital signs are within normal range. Lochia is appropriate amount and color for stage of recovery. Hemoglobin and hematocrit values are within normal range. Uterine fundus is firm; urinary output is adequate. ABO blood groups and RhD status are known and, if indicated, anti-D immunoglobulin has been administered. Surgical wounds are healing and no signs of infection are present. Mother is able to ambulate without difficulty. Food and fluids are taken without difficulty. Self-care and infant care are understood and demonstrated. Family or other support system is available to care for both. Mother is aware of possible complications

Immunizations: Prior to discharge, check the immunity status for rubella for all mothers and give a subcutaneous injection of rubella vaccine if they are not serologically immune (titer less than 1:8). Be sure that the client signs a consent form to receive the vaccine. Nursing mothers can be vaccinated because the live, attenuated rubella virus is not communicable. Inform all mothers receiving immunization about adverse effects (rash, joint symptoms, and a low-grade fever 5 to 21 days later) and the need to avoid pregnancy for at least 28 days after being vaccinated because of the risk of teratogenic effects

CH.22 Nursing Management of the postpartum woman at risk

Postpartum hemorrhage is a potentially life-threatening complication that can occur after both vaginal and cesarean births. Postpartum hemorrhage is defined as a blood loss greater than 500 mL after vaginal birth or more than 1,000 mL after a cesarean birth The most common cause of postpartum hemorrhage is uterine atony, failure of the uterus to contract and re- tract after birth & also obstretic lacesarions, episiotomy, uterine inversion and rupture, retained placenta fragments, coagulation disorders, and hematomas of the vulva, vagina, or subperitoneal areas Any factor that causes the uterus to relax after birth will cause bleeding— even a full bladder that displaces the uterus. typical signs of hemorrhage (e.g., falling blood pressure, increasing pulse rate, and decreasing urinary output) do not appear until as much as 1,800 to 2,100 mL of blood has been Always remember the four causes of postlost partum hemorrhage and the appropriate intervention for each:

A helpful way to remember the causes of 1. Uterine atony—massage and oxytocics; postpartum hemorrhage is by using the “ 2. Retained placental tissue—evacuation and oxytocics; 3. Lacerations or hematoma—surgical repair; Tone: uterine atony, distended bladder 4. Thrombosis (bleeding disorders)—blood Tissue: retained placenta and clots; uter products. Trauma: Lacerations, hematoma, invers 5 uterine inversion: by too much cord traction

Thrombin: Coagulopathy (preexisting or acquired)

Uterus overdistention can be caused by: multifetal gestation, fetal macrosomia,

polyhydramnios, fetal abnormality, or placental fragments. Other causes might include prolonged or rapid, forceful labor, especially if stimulated; bacterial toxins (e.g., chorioamnionitis, endo- myometritis, septicemia); use of anesthesia, especially halothane; and magnesium sulfate used in the treatment of preeclampsia

Contraindications to Medications: Pitocin: never give diluted as a bolus injection intravenously Cytotec: Allergy, active cardiovascular disease, pulmonary or hepatic disease Prostin: E2- active cardiac, Pulmonary, Renal, or hepatic disease Methergine: if the woman is hypertensive DO NOT ADMINISTER Hemabate: contraindicated with asthma due to risk of bronchial spams. Venous Thromboembolitic Conditions Risk factors: use of oral contraceptives before the pregnancy, smoking, employment that necessitates prolonged standing, history of thrombosis, thrombophle- bitis, or endometritis, or evidence of current varicosities. Also look for other factors that can increase a woman’s risk, such as prolonged bed rest, diabetes, obesity, cesarean birth, progesterone-induced distensibility of the veins of the lower legs during pregnancy, severe anemia, varicose veins, advanced maternal age (older than 35), and multi- parity Preventing Thrombotic Conditions: o Developing public awareness about risk factors, symp- toms, and preventive measures o Preventing venous stasis by encouraging activity that causes leg muscles to contract and promotes venous return (leg exercises and walking) o Using intermittent sequential compression devices to produce passive leg muscle contractions until the woman is ambulatory o Elevating the woman’s legs above her heart level to promote venous return o Stopping smoking to reduce or prevent vascular vasoconstriction o Applying compression stockings and removing them daily for inspection of legs o Performing passive range-of-motion exercises while in bed o Using postoperative deep-breathing exercises to improve venous return by relieving the negative thoracic pressure on leg veins o Reducing hypercoagulability with the use of warfarin, aspirin, and heparin o Preventing venous pooling by avoiding pillows under knees, not crossing legs for long periods, and not leav- ing legs up in stirrups for long periods o Padding stirrups to reduce pressure against the popliteal angle o Avoiding sitting or standing in one position for pro- longed periods S&S Pulmonary Embolism: o Using a bed cradle to keep linens and blankets Sudden onset of shortness off extremities of breath ‘ Severe chest pain Apprehensive & diaphrotetic Tachypnea Tachycardiab

o Avoiding trauma to legs to prevent injury to the vein wall o Increasing fluid intake to prevent dehydration o Avoiding the use of oral contraceptives S&S DVT Pain or tenderness in extremety Redness in the area Warm to touch Pain on ambulation or bears down Postpartum Infection Postpartum infection is defined as a fever of 38°C or 100.4°F or higher after the first 24 hours after childbirth, occurring on at least 2 of the first 10 days after birth, exclusive of the first 24 hours Risk Factors: surgical birth prolonged rupture of membranes multiple vagina examinations inadecuate hand higyeme internal...