Postpartum - Lecture notes 1 PDF

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Summary

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...

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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

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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

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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

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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

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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

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I’m sad for you

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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

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 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

VIII.

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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...