Presentation on theme: "Post Partum Care & Teaching"— Presentation transcript:
1Post Partum Care & Teaching Presented by: Anna Mackey, RN BSNAuthors: Tina Schmidt, RN & Evelyn Hom, RN, MSN, CNS
2Objectives 1. Discuss psychological changes during the puerperium. Discuss the role of the postpartum nurse in providing care and instruction to women during the puerperium.Describe the emotional/ psychological needs of postpartum women.
3Postpartum PeriodPuerperium – Latin “puer” means child and “parere” means to bring forthImmediate PP – “Fourth Stage Labor”birth to two hoursLong term PP – “Fourth Trimester” period of time from the delivery of the placenta to return of woman’s reproductive system to its non-pregnant state (typically 6 weeks)
4Uterus and Involution Uterus after delivery=weighs about 1,000 gms (2lb 4oz)Fundal heightImmediately PP = Midway between umbilicus and symphysis pubisOne hour PP = At the umbilicus or slightly below umbilicus12 hours PP = 1 cm above umbilicus24 hours PP = 1 cm below umbilicusDay 2 to day 7 = Decreases about 1 cm/dayDay 7 = Just palpable at the symphysisDay = Non palpableWeek 6 = Returns to non-pregnant sizeInvolution= contractions, autolysis of myometrial cells and regeneration of the epithelium. Translation decrease in size of uterus as well as healing the area where the placenta was implanted.Historically measured in finger-breadths below the umbilicus. It is more accurately described in centimeters.What speeds up uterine involution???-Breastfeeding!
5Reasons for Delayed Involution Multiple gestationPolyhydramnios (AFI > 25)Prolonged laborGrand multiparity (> 5)Prolonged or excessive analgesiaExtended period of use of prostaglandins or Oxytocin for labor induction and augmentationRetained placentaUterine fibroidsCesarean birth
6Uterine “After-pains” Painful uterine contractions that occur after delivery of the babyIntensity associated with:Uterine tonics – Oxytocin administered post partumBreastfeedingConditions producing over distension of the uterusMultiple fetusesPolyhydramniosLGA and macrosomic fetusIntensity greatest immediate PP and diminishes 1st wk
7Uterine“After-pains” Nursing Care:Pain medicationEducate patient that:Normal for involution processDuring breast feeding that it is a positive sign baby is properly latched and getting colostrum
8Lochia Composed of endometrial tissue, blood and mucous. Clots: Can be normal part of lochia if small and patient has had some poolingShould be decreasing in size and amount as patient moves through postpartum periodA slight increase in flow is normal when? First gets out of bed in morning, ambulating, breastfeeding.
9Stages of Lochia Rubra Dark red or brownish with clots Contains blood and tissue fragmentsFleshy smellDuration: 1-3 daysAbnormal Findings:Foul smell, numerous or large clots, quickly saturates pad.
10Stages of Lochia Serosa Pink, brown tinged, serosanguineous consistencyContains blood, ertyhrocytes, leukocytes, mucous and deciduaFleshy odorDuration: 3-10 daysAbnormal Findings:Foul smell; quickly saturates pad; serosa
11Stages of Lochia Alba Yellowish-white Contains mostly leuckocytes, as well as decidua, mucous, bacteria and epithelial cells.No strong odorDuration: daysAbnormal Findings:Foul smell, saturated pad, pink or redlochia, discharge beyond 6 weeks
12Lochia Average amount 240-270 mL (8-9 oz) Scant = one inch Light = 4 inchesModerate = 6 inchesHeavy = Saturate one pad in one hourHemorrhage = Saturate one pad in 15 minutesBlood loss is commonly underestimated by about half! Weigh/measure 1ml blood=1gramWhat are some reasons for increased bleeding immediately PP?Uterine AtonyInversion or prolapse of Uterus
13CardiovascularHeart position returns to normal from being shifted by diaphragm and uterus within about 2 weeksCardiac output decreases rapidly following delivery returning to normal by 2-3 weeks PPVaricosities improve with the decrease in cardiac output
14Blood Volume Changes Vaginal Delivery: normal blood loss = 500mL C/S: normal blood loss = 1000mLNormal blood loss during first week PP is another 800 mLReturn to non-pregnant circulating volume in 3-4 weeks post deliveryThe large increase in blood volume during pregnancy allows women to sustain significant blood loss at birth.
15Lab Values: Hct, HgbFor every 500 ml of blood loss, the hemoglobin will drop gram/dl and the hematocrit will drop 3 - 4%Hct rises immediately after delivery due to blood volume loss & dehydration( %)Returns to normal 4-5 wks ( %)PP anemia is common. Anemia usually considered when Hgb less than 10 and Hct is less than 30%Clotting Factors remain elevated in early PP period, return to normal in 4-5 wks post deliveryThe decrease in plasma volume is greater than the loss of red blood cells- increases HCT immediately after
16Lab Values: WBCWBC’s- may increase to 20,000/mm3 or more during 1st 10 days PPAverage PP WBC is 14, ,000/mm3Slightly higher with cesarean delivery and traumatic deliveries due to body’s inflammatory responseAn increase of more than 30% over a 6-hour period is indicative of infectionCBC with differential is indicated if the WBC count has significantly increased or the patient has a risk factor or is symptomatic for infectionincrease in predominantly granulocytes
17Vital Signs BP - should be similar to intrapartum values High BP may suggest PIHLow BP may suggest orthostatic hypotension or a late sign of hypovolemia and/or hemorrhagePulse - bradycardia normal immediate PP(40-80 bpm)Tachycardia – abnormal and suggests hemorrhage or infectionRespiratory Rate - usually normal 16-24/minTemperature – Normal slight elevation 1st 24 hrs PP> degrees F indicates infection
18Teaching Activity/Exercise Do not overdo…Only care for self and babyLochia guides activity levelLimit stairs/liftingGradual resumption of activityStart kegels and walking right awayPP exercises for abdomen— Seek advice from provider. Usually after 6 weeks pp.
19Cervix Edematous immediately PP 1 week PP- about 1cm Easily distensible several days PPInternal OS closes by 2 weeks PPAbnormal Finding:Presence of free flowing bright red bloodCervical laceration
20Vagina Rugae reappears 3 weeks postpartum Return to near pre-pregnant state6-8 weeks post partumNormal mucus production returns with ovulationNeed to educate patient - nothing in the vagina for 6 weeks post partumRugae-ridges in the mucous membranes
21Menstrual Cycle Non-lactating: Lactating: 40-45% will resume at 6-8 wks75% will resume at 12 weeks100% will resume within 6 monthsLactating:As early as 12 wks or as late as 18 months
22Ovulation Non-lactating: 50% will be anovulatory first few cycles of mensesLactating: 80% will be anovulatory first few cycles
23Teaching Sexuality Nothing in the vagina for first 4-6 weeks: “No intercourse. No tampons. No douching”Increased risk for acquiring STD’sWomen can still ovulate without menses!Lowered interest due to hormones/fatigueDry vaginal mucosal lining…Use lubricationLet-down reflex may occur during intercourse
24Perineum Episiotomy is normally without redness, discharge, or edema Intact perineum may still have edema and/or ecchymosis secondary to pressure at deliveryMay experience burning with urinationHealing takes place in 1-2 weeks
25Lacerations1st degree: through the skin and structures superficial to the muscles2nd degree: above plus through the muscles of the perineum3rd degree: above plus through the anal sphincter muscle4th degree: above plus through the anterior rectal wall
26Teaching Perineal Care Good hygiene – hand washing, peri-bottle and frequent pad changesComfort measuresIce first 24 hoursSitz baths after 24 hoursWitchhazelStitches dissolve in 1-2 weeks,Itching normal as skin healsInfection uncommon, watch for symptoms: fever, abnormal discharge, foul smelling dischargeMonitor for dehiscence of repair
27Hemorrhoids Grape-like clusters at the anus May not be visible or palpable until straining for BMShould shrink in in about three weeksTeach:Avoid constipation and strainingSoft diet with foods or drink that normally help the patient have bowel movementsSitz baths and witchhazelSee provider if still a problem after 3 weeks
28Respiratory SystemPulmonary function returns to normal in 6-8 weeks as diaphragm descendsAcid/base balance returns to pre-pregnant levels by 3 weeks PPOxygen Saturations should be above 95%Patients at risk for pulmonary compromise:Fluid overloadedPreeclamptic patients, particularly those on Magnesium SulfateCardiac PatientsAsthmaticsSmokersPatients with preexisting pneumonia or URI
29GI System Appetite is strong immediately PP period Decreased GI motility can lead to constipationBM should resume 2-3 days PPAverage weight loss of 12 lbs at delivery plus 5 lbs in first week due to diuresisCesarean birth: Greater incidence of distension, discomfort, constipation and illeus R/T trauma and manipulation of bowel
30GI System TeachingEat well balanced diet of all foods in moderation. Increase intake by 500 calories/day for breastfeeding (approx ½ sandwich)Consult provider if plan to diet prior to 6 wks PP or while breastfeedingInterventions to prevent constipation: ambulation, increase fluids and high fiber, stool softeners, laxatives, foods and fluids that usually make patient have BMHaving BM will not cause them to tear repairsCall provider if no BM by 4th day PP
31Urinary SystemFluid shifts common- edema and swelling (patient may weigh more!)Uterus that is elevated and laterally displaced may indicate filling bladder or urinary retention.Full bladder will cause increased lochia.Diuresis begins at 12 hours-48 hours PP and continues for about one week.Kidney function normal by 4 wks PP (GFR returns to pre-pregnant rate, )Increased risk for UTI first 6 wks PP
32Urinary System Teaching Common to feel numb first few days PP, so empty bladder frequentlyTricks to assist voiding:Ice to perineum to prevent swelling (first 24 hrs to reduce edema and for analgesic affect)Administer analgesic prior to void if have suturesLean forward on toilet – puts pressure on bladderSound of running/trickling waterPeppermint oilBlowing bubbles in cup of warm waterShower, sitz bath (warm water increases urge to void)
33Urinary System Teaching Teach patient symptoms of UTIUrgencyFrequencyDysuriaFever, chillsBack or lower abdominal painDecrease in Level of Consciousness – confusionIncrease in fatigue / lethargy
34Musculoskeletal System Diastasis recti (rectus muscle) may separate 2-4 cm. Will resolve by 6 wks. Most common in black patientsJoint stabilization returns in 6-8 wks post partumTeach caution when starting a vigorous exercise program or stomach exercises prior to 6 wk PP follow-up visit. Need to consult with care provider
35Integumentary SystemHyperpigmentation of face (chloasma), abdomen (linea negra) and areaolas gradually lighten and may or may not disappearStretch marks will gradually fadeHair loss will occur within 6 weeksDiaphoresis for first several weeks, especially at night (night sweats)
36Immune SystemRh Sensitivity / Isoimmunization: Administer anti (D) Immune Globulin within 72 hours PP to prevent formation of maternal antibodies against Rh positive fetal blood cells and destroy Rh positive cells.Rubella titer less than 1:8 ratio: Administer Rubella Virus Vaccine prior to discharge. Instruct patient to avoid pregnancy next 3 months.
37Breasts Prolactin – Initiates milk production Oxytocin – Milk “let-down reflex”Milk removal from breast (by breast feeding or pumping)– facilitates continued milk productionLactating:Colostrum: 1st week PPTransitional milk: between 7-14 daysMature milk comes in after 2 weeks
38BreastsNon-lactating: breast changes of pregnancy regress in 1-2 weeks postpartumTeach:Well fitting support bra 24 hours a day for 2 weeksNo heat or warm water/shower on breastsNo stimulation of breastsIce packs to breast maximum 20 minutes at a timeNo longer use lactation suppressive medications due to rebound engorgement
39EngorgementSymptomsEngorgement begins at 2nd - 3rd day and subsides in hoursTender, swollen, and firm breasts (including the areola) making it difficult for infant to latch – like trying to latch on to a basketballSlight fever (<100.4 F)
40Engorgement Interventions to prevent engorgement: Encourage early feedingsEncourage frequent feedingsMinimum 8 feedings/ 24 hoursMinimum minutes per breastAvoid supplement for infant unless medically indicatedAssess and ensure correct positioning and latch
41Engorgement Nursing Care: Wear a well fitting support bra Warm compresses or shower prior to feedingGentle massage of breasts from axilla towards nipple to stimulate letdownExpress milk by hand or pump to soften areola tissue to assist infant in latchIce packs to axilla for a maximum 20 minutes at a time after feeding
42Psychological SystemRole Changes: Grieve the loss of old role and acquire new role and expectationsAcquiring the Role of Mother (Rubin, 1975)Taking in phase: days 1-2; passive, dependent, wants care for self; asks many questionsTaking hold phase: 4 -5 wks; begins to focus on needs of infant, receptive to teaching, high fatigueLetting go phase: 5+ wks; sees infant as separate individual, refocuses on relationship with partner, may return to work/uses babysitter
43AttachmentDefinition: The enduring emotional bond between parent and infant (Klaus & Kennell, 1976)Essential to infant’s growth and survivalThe mother-infant bond is the basis on which all subsequent attachments are formed and plays major role in infant developing a sense of self (Bowlby, 1969)Patterns of attachment vary with culture
44Attachment Behaviors Observable maternal attachment behaviors: TouchingHoldingGazingCuddlingKissingEn face positionObservable Paternal attachment behaviors:“Engrossment”: to stare for long periods of time
45Attachment Behaviors Observable infant attachment behaviors (before 8 weeks):Cuddling into motherFollowing with eyes and gazingProviding clear feeding cues and needs cuesCryingGraspingSmilingBabbling
46Assessing AttachmentMaternal factors to consider that might impede attachment:Length of labor, analgesia used, type of delivery, high risk pregnancy, physical health, age extremes, intelligence, wanted or unwanted pregnancy, past experience with own mother, gravida/para, socioeconomic status, degree of maternal support available, relationship with FOB, prolonged separation from infant, how well infant matches maternal/parental expectations
47Assessing Attachment Paternal Factors to Consider How involved with the pregnancy/baby, maturity level, age, past experience with infants, own expectations for infant, relationship with infant’s mother, relationship with own father
48Assessing Attachment Infant factors to consider Gestational age, multiple birth, admission to SCN/NICU, transferred to tertiary setting, physical anomalies, gender, temperament, degree of alertness
49Prenatal Mal-Attachment Behaviors Excessive moodinessEmotional withdrawalExcessive preoccupation with own personal appearance – ignoring infantNumerous physical complaintsFailure to prepare for infants arrival during last trimester (although had opportunity and resources)
50Postnatal Mal-Attachment Behaviors Negative comments about baby’s appearanceDisappointment about baby’s genderFailure to look at, touch, or handle infantFailure to respond to signaling behaviorsFailure to name infantFailure to meet infant’s physical needs
51Nursing Interventions to Support Attachment Encourage early and frequent eye-to-eye and skin-to-skin contactProvide opportunity, time, environment for attachmentEncourage and praise parents in caringfor own infantInstruct infant behaviors and cuesReassure some negative feelings normalEducate significant other about danger signsProvider and Community Health Follow-upSocial work referral if needed
52Culturally Appropriate Care US - postpartum is seen as time of wellness and early ambulation is expectedJapan - remain inside for 1st 100 days, no bath or hair wash for 1 weekKorea - avoid exposure to cold, eat warm foodsMexico - keep warm, eat warm foods to help dry the womb; avoid baths for 1 weekMexican- prefer touch over staring-believe this prevents unintentional harm by others.Korean-may insist on rooming in, primary focus is allowing mother to rest with newborn.Pakistani-rely on family to take care of newborn, not actively involved with care. Husband not involved with care.
53“Baby Blues” The mildest form of PP depression Typical onset 3rd-8th day PP, lasts daysOnset suddenIncidence 50-80% of all PP womenPossible cause: onset of PP Blues coincides with drop in estrogen and progesteroneUsually self-limiting (if woman is given support from family and friends)Sleep helps relieve symptomsPP depression diagnosis criteria= symptoms present for 2 weeks (typical onset within 1 month of birth)PP Psychosis= Occurs in 1 out of 500 mothers; Rapid onset: within 2-4 weeks PPConfused thinking, mood swings, delusions, paranoia, disorganized behavior, impaired function.Considered a psychiatric emergency
54“Baby Blues” - Characteristics Mood swingsIrritability or angerCrying for no apparent reasonMild anxietyDifficulty sleepingFatigueDiscomfort
55Assessment of SVD patient 1st hour - every 15 minutes x 42nd hour - every 30 minutes x 22-24 hours - every 4 hours>24 hours - every 8 hours
56Assessment of C-Section patient 1st hour - every 15 minutes x 42-3 hours - every 30 minutes x 43-24 hours - every 2-4 hours>24 hours - every 4-8 hours
57Assessment PP Patient General appearance How she ambulates Vital SignsTPR, BPAssess pain levelHA, musculoskeletal, back, breasts, nipples, uterus, bladder, incision, perineum, hemorrhoids, calf tendernessGeneral appearanceHow she ambulatesSelf-care activitiesHeadFacial edemaConjunctival hemorrhage (from pushing)LOC/SensationCardio/Pulmonary: AUSCULTATENeuro: DTR’s
58Assessment PP Patient Breasts Fullness Nipples Erectility Breast supportBreast surgery scarsNipplesErectilityFlat/invertedIntact or crackedPresence of milkEcchymosisBleeding
59Assessment PP Patient Uterus How to position patient Uterine support FirmnessLocation of fundusTendernessMassageC/S incision siteDressing dry/intactIncision - edges well approximated, staples intactRedness, edema, ecchymosis, oozingDrains intact, amount drainage
60Assessment PP Patient Bladder/output Voiding pattern Distended bladder DysuriaGI/EliminationBowel sounds, flatusBowel movementsPerineumPositioning patient during assessmentEpisiotomy, lacerationsSutures well approximatedEdema, ecchymosis, hematoma, dischargePerineum assessmentREEDA- redness, edema, ecchymosis, discharge, approximation of edges of episiotomy
61Assessment PP Patient Extremities Homan’s sign Edema, warmth, redness of extremityCalf tendernessLab ValuesCBC - note H & H,WBC and PlateletsUA
62D/C Teaching Follow-up Follow-up for SVD usually 6 weeks PPFollow-up for C-Section usually in 4-5 days if staples/sutures not out; If out, days and again at 6-8 weeksPhone number to OB/Ped providers and Lactation ConsultantSymptoms/concerns when to call provider
63D/C Teaching When to Call Provider Chest pain/coughingIncreased perineal painprolonged baby blues or depressionC/S incision that feels hot to touch, oozing or reddenedNausea and vomitingHeadache not relieved by medicationsFever over 100.4ChillsSymptoms of UTISaturating >1 pad/hrBright red flow returnFoul smelling lochiaAbdominal tendernessSevere leg pain/edema
64ReferencesAWHONN’s Compendium of Postpartum Care. Johnson and Johnson Inc.; 2006.Chin, MD, FACOG. On Call Obstetrics and gynecology. W.B. Saunders Co. Philadelphia; 1997.Jones, RNC, MSN, Marion W. Postpartum Complications. Health Education Innovations, Inc.;Mattson, PhD, RNC, CTN, Susan and Smith, PhD, RNC, Judy E. Core Curriculum for Maternal-Newborn Nursing, AWHONN, 2nd Ed. ; W.B. Saunders Co. Philadelphia;Rice-Simpson, RNC, MSN and Creehan, RNC, MS, MA, ACCE, Patricia A. Perinatal Nursing. AWHONN; Lippencott, Philadelphia;