Title | Postpartum - Lecture notes 1 |
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Author | Alexandria Head |
Course | Professional Clin Nursing Iii |
Institution | Columbus State University |
Pages | 9 |
File Size | 75.3 KB |
File Type | |
Total Downloads | 14 |
Total Views | 75 |
Care of Postpartum Patient Fourth stage of labor= recovery time for mom o Lasts 1- 4 hours o Start of physiological & psychological readjust for mom o Internal organs begin process of returning to a pre pregnant state o Begin breastfeeding & parent- infant bonding Postpartum= aft...
Postpartum 1
Care of Postpartum Patient Fourth stage of labor= recovery time for mom o Lasts 1- 4 hours o Start of physiological & psychological readjust for mom o Internal organs begin process of returning to a pre pregnant state o Begin breastfeeding & parent- infant bonding Postpartum= after placenta is delivered- 8 weeks (Time for mom’s body to return to pre pregnant state) Three phases I. Dependent “TAKE IN” = day 1- 2 Focus on themselves & meeting basic needs Passive & dependent on others for getting up and breastfeeding Very excited. Talking about experience. Family visiting. II.
Dependent- independent “TAKING HOLD” = Day 3- 10 Focus is on baby Adjusting to motherhood/ another kid Increased independence and self care Learning to adjust to new normal May begin to experience the blues
III.
Interdependent “LETTING GO” = day 10- forward Focus is on moving past the honey moon phase real life Family may not be as involved Adapted better to new role Sexual intimacy Honey moon phase of neonate real life neonate *which includes crying & diaper changes
PHYSIOLOGICAL MATERNAL CHANGES Uterine involution o Process begins IMMEDIATELY o Fundus drops to umbilicus r/t contractions *s/s= cramping After delivery. Fundus @ umbilicus or 1 cm above Descends roughly 1- 2 cm each day until @ pelvis *approximately day 10 Returns to non pregnant form in 6 weeks Uterus not descending downward, right or left of midline full bladder or blood clot? Should never deviate left or right Should never move back up to umbilicus Should be firm. Not boggy During assessment support uterus by placing other hand @ suprapubic or below incision o Uterine contractions= “after pains” To contract muscle cells, compress uterine blood vessels (AVOIDS PPH), & allowing uterine to shrink Stronger contractions during breastfeeding due to Oxytocin release Oxytocin (Pitocin) (IV or IM) is administered to contract the uterus & prevent PPH Cervical involution o Never regains pre preg appearance *circle slit o Immediately after delivery o Cervical ox closes at least 1- 2cm 1st day after birth o Should be closed within a week
Postpartum 2
Some do not every fully close again AT RISK FOR PRE TERM LABOR
Endocrine system *Immediately after placenta is removed o Rapid drop in progesterone & estrogen Risk of post partum depression o Diuresis o Profuse nocturnal diaphoresis o hCG levels disappear from mom’s circulation o hPL (lactogen that assisted placenta) reduces Ovarian function o NOT breastfeeding= Ovulation occurs 27 DAYS postpartum, menstruation occurs 12 WEEKS o Breastfeeding= ovulation occurs 6 MONTHS after birth *Varies greatly Breastfeeding releases prolactin suppresses ovulation SHOULD NOT BE USED AS BIRTH CONTROL o After ovulation starts back= chance of pregnancy o Breastfeeding helps hormone readjustment Breasts o Colostrum (early milk) can occur throughout pregnancy *3rd trimester (28 weeks- ) Comes out first day after Very thick, nutrient dense fluid with immunity properties o Mature milk *after first couple of days Lactogensis II Breast= tender, more full, warm, firm Not breastfeeding? Do not stimulate the body with warm showers, baby cries, etc.) Keep breasts in a sports bra Breastfeeding? Increase calories by 400- 500 o Trauma to breasts due to dryness or improper nursing techniques risk of infection mastitis Avoid washing with soap *Wash with cream or breast milk o Engorgement= filled up & must be emptied No breastfeeding? Use ice packs, pain medications to endure the pain; eat cabbage Will dry up due to decreased prolactin stimulation (which would stimulate lactogensis II) This may occur with breastfeeding if not on a regular rotation Nutrition o Plenty of fluids to avoid constipation & promote general health High risk of constipation r/t pain meds, lack of activity, possible Mag tx, surgery that will slow down the GI, prenatal and iron vitamins, physiological- hesitant to have a bowel movement (especially if they have hemorrhoids) Tx= Colace with prenatal vitamins o Potential need for iron o Breastfeeding? Continue prenatal vitamin Extra 400- 500 calories a day Extra DHA in diet *eat fish low in mercury
Postpartum 3
Avoid alcohol & verify medications due to crossing over to breast milk Cardiovascular o Pregnancy induced hypervolemia o Normal EBL with vaginal & cesarean deliveries o Remember- Blood volumes increased 40- 60% during pregnancy which helps with blood loss during birth (vag- 500 cc, Cesarean- 1000 cc) o Up to an hour after delivery Cardiac output increases 60- 80% r/t placenta removal pushing blood back into circulation increases work load of the heart o First couple of weeks= CO will decline o 6- 8 weeks postpartum= pre preg CO Genitourinary system o Decrease bladder tone r/t preg and delivery (can be permanent) o Reduce risk of overfilling o Kegel exercises to reduce risk of leaking o Decreased sensation r/t anesthesia (epidural or spinal) o Increase capacity o Displacement o Pitocin SE= antidiuretic once Pit is out of the body patients will void o Patients should independently void in 6 hours after birth If they can not due to epidural, & bladder is full straight cath To allow the uterus to keep contracting & preventing PPH o Average output= 3000 L due to diuresis process Gastrointestinal system o Hunger & thirsty o Bowel movement may take 2- 3 days after delivery o Risk of constipation due to medication & lack of movement o Tx= stool softeners Health promotion Rubella vaccine (MMR) o Not immuned? Receive vaccine o DO NOT GET PREGNANT IN FIRST 28 DAYS AFTER *at risk for congenital anomalies Varicella vaccine- flu Tdap *q 10 years RhoGAM o Baby is Rh+ o Amniocentesis o Miscarriage o Trauma to abdomen o Blood mixing Postpartum goals Cesarean section: Incentive spirometer, SCDs, splinting during coughing/ laughing VS q 4 hrs x 24 hrs, then q 8 hours Assess fundal height and firmness. Monitor lochia flow. Massage if “boggy” or soft Prevent uterine inversion by supporting the uterues @ supra pubic= symphysis pubus Educate about “after pains” = contractions to push uterus down and decrease size Assess bladder for distension Postpartum assessment: BUBBLEHE
Postpartum 4
Breasts. Uterus. Bladder. Bowels. Lochia. Episiotomy/ lacerations. Homan’s sign/ Hemorrhoids. Emotions Lochia= debris remaining in the uterus after birth *is the uterus working by contracting and descending o Day 1- 4: RUBRA= dark red with small clots (quarter size), tissue, & debris o Day 4- 10: SEROSA= light pink- light fleshy brown o Day 10- 6 weeks: ALBA= white- skin color discharge o Alba rubra= Come back to hospital May be r/t lacerations, opened sutures, exercising to early, blood clot due to boggy uterus o Pad assessment over 1-hour period *weigh for quantitative amount < 1 inch= scant < 4 inch= small < 6 inch= moderate saturate pad= heavy 1 gram= 1 cc * remember vaginal PPH= > 500 cc, C sec PPH= > 1000 cc o Clots less than 2- 3 cm= not alarming o Foul odor= infection Lochia o o o o
pattern Lochia pooling r/t first time getting up (ambulation) & breastfeeding Breastfeeding releases oxytocin uterine contractions Color change: smell, amount, odor Notify HCP if lochia is pink (serosa) red (rubra); or has a foul odor
Home o o o
care Postpartum appointment Intercourse after 6 weeks Contraceptives!!!
Postpartum Complications UTI r/t Foley or multiple catheters; bladder not able to empty r/t decreased tone or sensitivity Postpartum hemorrhage (PPH) *look at sheet o Leading cause of maternal morbidity & mortality worldwide o Medical emergency o > 500 cc after vag birth o > 1000 cc after cesarean section o Late sign= > 10% drop in Hematocrit Causes 1. Uterine atony allows hemorrhage to flow into uterus vaginal lacerations o May just be a trickle. So wash with water then assess for CONTINUOUS BRIGHT RED TRICKLE in pattern with heart beat o BIGGEST CLUE= Tone is fine, lochia= dark red, & bright red bleeding r/t laceration retained placental fragments or clots Cervix, labia, or perineum hematoma Full bladder Early vs late Early (immediate primary) hemorrhage= FIRST 24 HOURS POSTPARTUM o r/t retaining placenta (which leaves an open wound) or laceration Late (secondary) hemorrhage= FROM 1ST 24 HOURS- 6 WEEKS AFTER BIRTH
Postpartum 5
Signs of developing Hematoma in Perineum o Intense perineal pain o Swelling & blue/ black discoloration on perineum r/t bruising (blood in vessels stuck) o Pallor, tachycardia, & hypotension o Pressure in vagina, urethra, or bladder o Possible urinary retention or uterine displacement Urinary inversion= uterus turns inside out: complete, incomplete, prolapsed (= out of vagina) o R/t vigorous massage of fundus (due to atony tx); or fast delivery- cord pulling placenta out with it o S/s= pain, hemorrhaging bleeding leading to shock o Tx= HCP placing in proper position Uterine subinvolution= delayed return of uterus to normal size & function o Causes= blood clots, retain placental fragments, infected tissue o S/S= Fundus @ umbilicus or higher, boggy o Remember- Fundus is @ umbilicus after birth. Then decreases 1- 2 cm each day after
Urinary retention o Risk factors= decrease tone, decrease sensitivity r/t anesthesia, collateral bladder trauma during delivery, perineal swelling, or edema o SHOULD VOID WITHIN 6 HOURS OF DELIVERY ON THEIR OWN o Assess for bladder distention & uterus placement @ right or left side of midline Endometritis= infection of lining of uterus o Begins at uterus incision site o S/S= foul smelling lochia, fever, subinvolution= uterus not returning to smaller size Tachycardia, chills, uterine pain (tenderness, back pain, different pain) Wound infections tx= sitz bath in bed pan *helps heal, clean, and reduce pain o Hand washing! o Promote rest Urinary Tract Infections cystitis, pyelonephritis o Tx= antibiotics Mastitis o Unilateral & develops after milk supply has been established o Typically, 1st time breast feeders o CRACK NIPPLES & improper position of baby’s mouth= source of infection ductal system infection o Factors= engorgement & edema that block flow of milk= source for bacteria o Can result in abscess o S/S= pain, red streaks or red patches, chills, fever, body aches o Risk factors= fatigue, stress, poor hygiene o Care Antibiotics
Postpartum 6
Re educate: use breast milk & cream to clean nipples Prevent engorgement by making a schedule for breast feeding Do not skip times to breast feed YOU CAN STILL BREAST FEED to prevent engorgement
Thrombosis= formation of a blood clot/ clots inside a blood vessel caused by thrombophlebitis or partial obstruction of vessel o Caused by venous stasis & hyper coagulation Superficial venous thrombosis (SVT) Deep venous thrombosis (DVT) Pulmonary embolism (PE) o Risk factors= C section, bed rest, obesity, HTN, DM o Prevent with SCDs (especially if on bed rest, post c section, obese) Early ambulation *even with c sections Superficial Venous Thrombosis @ superficial saphenous venous system o Apparent 3rd- 4th day of PP o S/S= pain in lower extremity, warmth, redness, enlarged tender hardened vein o Tx= NSAIDs, rest with elevation of leg, application of heat, elastic compression stockings or compression devices, local thrombectomy with a local anesthetic Heparin with extensive superficial phlebitis
DVT o o o o o
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Foot – iliofemoral region Common during pregnancy & hx of DVT S/S= leg pain, edema, calf tenderness, swelling, redness, and warmth Homan’ sign= calf pain *does walking hurt? May result in pulmonary embolism Tx= anticoagulant therapy *IV heparin for 5- 7 days, bed rest, affected leg elevated, analgesia NEVER MASSAGE Oral anticoagulant therapy (Coumadin) for 3 months PE tx= IV heparin therapy until s/s resolve SubQ heparin or oral anticoagulant therapy for 6 months
Postpartum blues= NORMAL o “Pink period” “baby blues” o occurs in 50- 80% of patients. More severe in primiparas o Occurs within a few days after birth to 10 days- 2 weeks o R/t rapid alteration in estrogen, progesterone, & prolactin levels after birth o Need a strong support system o s/s= mild depression, crying for no reason, feeling anxious, irritable, oversensitive, moody Postpartum depression *after 2 weeks o Intense persistent sadness, fears, angers, anxiety, panic attacks, irritability with severe mood swings o Inadequate, incompetent, guilt o History of mild depression o Occurs in 10- 15% of women
Postpartum 7
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Typically requires tx Will not seek help till “crisis point” Risk factors: Prenatal depression (MDD), Family hx of mood disorders, Low self esteem, Stress of child care, Prenatal anxiety, Life stress, Lack of social support, martial problems, hx of depression, difficult infant, postpartum blues, single, low socioeconomic status, unwanted/ unplanned pregnancy S/S: Irritability, guilt, inadequacy, food cravings with binging, weight gain, difficult falling asleep, awakened easily, violent outbursts, uncontrollable sobbing, severe anxiety, panic attacks, fear, sadness Mother often feels guilty and may be in denial Negative feelings toward the infant or infant rejection/disinterest/annoyance Outbursts directed toward significant other or infant Jealousy May experience obsessive thoughts about harming the infant May appear awkward when caring for the infant
Postpartum psychosis- psychiatric emergency o PP depression with delusions, suicidal &/ or homicidal thoughts- plan? o 30- 50% more likely to develop in future births o average time of onset= 2- 3 weeks PP & within 8 weeks (can occur within days of birth) o S/S: Fatigue, insomnia, restlessness, tearful, inability to move, stand, or work, suspiciousness, confusion, incoherence, irrational statements, disorganized, poor judgment, impulsivity, manic, suicidal/homicidal thoughts, obsessive concerns RT infant’s health o 50% have delusions o 25% have hallucinations (auditory hallucinations telling mom to kill baby in severe cases) o Irrational thoughts about infant o Red flag- mom is very agitated, overactive, confused, complaining or suspicious o May have another episode within 1- 2 years of birth o SUPERVISED visits if mother wishes to see infant Nursing care o Assess for s/s of postpartum blues/ depression/ psychosis o Be an active listener o Caring non- judgmental attitude o Ask questions PP care after a loss o Assess bleeding, VS o @ antepartum floor o may D & C baby o provide remembrance: footprints, handprints, pictures, baby ID band, clothes, lock of hair o Encourage to hold baby o Call child by name o BIGGEST REGRETS: Parents don’t see their baby, don’t hold & spend time with baby, don’t get a picture of baby, don’t know where baby is now due to hospital disposal OKAY TO SAY
I’m sad for you
Postpartum 8
How are you doing with all of this This must be hard for you What can I do for you? I’m sorry I’m here, and I want to listen
NOT OKAY TO SAY Be thankful you can have another child
God had a purpose for her The living must go on I know how you feel It’s God’s will You have to keep on going for her sake You’re young; you can have more children We’ll see you back here next year Now you have an angel in heaven This happened for the best. Something was wrong with the baby anyways Better to happen now, before you knew her
Kaplan review I. 1st action after SVD= Observe lochia flow for signs of hemorrhage 1. Assess LOCHIA 2. Assess fundus 3. Massage fundus & other interventions after assessment II. Sitz baths= to increase circulation to the area & promote wound healing III. Flow of lochia INCREASES during ambulation due to pooling while in bed & gravity INCREASES during breastfeeding due to oxytocin release Day 1- 3= rubra with small clots Day 4- 9= serosa Day 10+= alba Yellow- brown= infection IV. Rh incompatibilities Occurs when mom is Rh - & fetus is Rh + Rh antibodies from mom will attack blood cells of infant give Rhogam to prevent Once prenatally for all Rh – mothers Postpartum only if baby is Rh + PRN for any miscarriages, trauma, or anytime maternal & fetal blood could mix V. Postpartum vital indicative of hemorrhage Tachycardia, low BP, decreasing O2 and temperature VI. Breastfeeding Clean nipples with water (NO SOAP), & expose to air to dry Position nipple so that infants mouth covers a large portion of the areola Rotate sides & position Most drugs cross into breast milk so check with HPC before taking any medication Alcohol= CNS depressant effect on baby Diet= more calories, & same amount of protein, calcium, and fluids VII. Ovulation after delivery Non nursing mothers resume menstruation by 12 weeks after birth Breastfeeding delays menstruation
Postpartum 9
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Ovulation may occur before menstruation in lactating women **BIRTH CONTROL Postpartum depression Precipitated by decrease in estrogen & progesterone Occurs in 3- 7 days after birth Tearfulness, difficulty sleeping, anorexia Encourage verbalization of feelings, evaluate for postpartum depression if feelings persist, & assess potential for suicide Postpartum infection Temperature > 38 C or 100.4 F Chills, tachycardia, abdominal pain, foul smelling lochia, yellow or brown lochia, localized tenderness Encourage ambulation, change peripads frequently, pericare, monitor for s/s infection, administer antibiotics Postpartum nursing interventions Check lochia q 15 minutes Check fundus q 15 minutes *should be at or 1 cm above umbilicus for the 1st 12 hours *Firm & globular Check vital signs q 15 minutes Check urine output & bladder distension will cause excess bleeding o Measure first void o May have urethral edema due to birth/ anesthesia causes urinary retention o May have increased amounts of urine from diaphoresis= body getting rid of retained fluids Rh immune globulin (RhoGAM) Rh – mother’s must receive **especially if father is Rh + Administered 28 weeks to all Rh – mothers within 72 hours of delivery if baby if Rh + Whenever maternal & fetal blood intermingles or other trauma Postpartum hemorrhage Assess lochia and fundus Massage fundus if BOGGY and CALL FOR HELP For uterine atony: Massage, empty bladder, hang PIT, call HCP o Consider Cytotec (Misoprostol), Methergine (Methylergometrine), Hemabate (carboprost), tamponades, or hysterectomy Fundus if firm & still bleeding assess for other causes Weigh pads to get accurate assessment o > 500 cc for vaginal o > 1000 cc for C/S Maintain hemodynamic stability: 2nd IV (for blood), more fluids &/ or blood, H&H count, O2, warm blankets...