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Post Partum Care & Teaching

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Presentation on theme: "Post Partum Care & Teaching"— Presentation transcript:

1 Post Partum Care & Teaching
Presented by: Anna Mackey, RN BSN Authors: Tina Schmidt, RN & Evelyn Hom, RN, MSN, CNS

2 Objectives 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.

3 Postpartum Period Puerperium – Latin “puer” means child and “parere” means to bring forth Immediate PP – “Fourth Stage Labor” birth to two hours Long 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)

4 Uterus and Involution Uterus after delivery=weighs about 1,000 gms
(2lb 4oz) Fundal height Immediately PP = Midway between umbilicus and symphysis pubis One hour PP = At the umbilicus or slightly below umbilicus 12 hours PP = 1 cm above umbilicus 24 hours PP = 1 cm below umbilicus Day 2 to day 7 = Decreases about 1 cm/day Day 7 = Just palpable at the symphysis Day = Non palpable Week 6 = Returns to non-pregnant size Involution= 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!

5 Reasons for Delayed Involution
Multiple gestation Polyhydramnios (AFI > 25) Prolonged labor Grand multiparity (> 5) Prolonged or excessive analgesia Extended period of use of prostaglandins or Oxytocin for labor induction and augmentation Retained placenta Uterine fibroids Cesarean birth

6 Uterine “After-pains”
Painful uterine contractions that occur after delivery of the baby Intensity associated with: Uterine tonics – Oxytocin administered post partum Breastfeeding Conditions producing over distension of the uterus Multiple fetuses Polyhydramnios LGA and macrosomic fetus Intensity greatest immediate PP and diminishes 1st wk

7 Uterine“After-pains”
Nursing Care: Pain medication Educate patient that: Normal for involution process During breast feeding that it is a positive sign baby is properly latched and getting colostrum

8 Lochia Composed of endometrial tissue, blood and mucous. Clots:
Can be normal part of lochia if small and patient has had some pooling Should be decreasing in size and amount as patient moves through postpartum period A slight increase in flow is normal when? First gets out of bed in morning, ambulating, breastfeeding.

9 Stages of Lochia Rubra Dark red or brownish with clots
Contains blood and tissue fragments Fleshy smell Duration: 1-3 days Abnormal Findings: Foul smell, numerous or large clots, quickly saturates pad.

10 Stages of Lochia Serosa
Pink, brown tinged, serosanguineous consistency Contains blood, ertyhrocytes, leukocytes, mucous and decidua Fleshy odor Duration: 3-10 days Abnormal Findings: Foul smell; quickly saturates pad; serosa

11 Stages of Lochia Alba Yellowish-white
Contains mostly leuckocytes, as well as decidua, mucous, bacteria and epithelial cells. No strong odor Duration: days Abnormal Findings: Foul smell, saturated pad, pink or red lochia, discharge beyond 6 weeks

12 Lochia Average amount 240-270 mL (8-9 oz) Scant = one inch
Light = 4 inches Moderate = 6 inches Heavy = Saturate one pad in one hour Hemorrhage = Saturate one pad in 15 minutes Blood loss is commonly underestimated by about half! Weigh/measure 1ml blood=1gram What are some reasons for increased bleeding immediately PP? Uterine Atony Inversion or prolapse of Uterus

13 Cardiovascular Heart position returns to normal from being shifted by diaphragm and uterus within about 2 weeks Cardiac output decreases rapidly following delivery returning to normal by 2-3 weeks PP Varicosities improve with the decrease in cardiac output

14 Blood Volume Changes Vaginal Delivery: normal blood loss = 500mL
C/S: normal blood loss = 1000mL Normal blood loss during first week PP is another 800 mL Return to non-pregnant circulating volume in 3-4 weeks post delivery The large increase in blood volume during pregnancy allows women to sustain significant blood loss at birth.

15 Lab Values: Hct, Hgb For 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 delivery The decrease in plasma volume is greater than the loss of red blood cells- increases HCT immediately after

16 Lab Values: WBC WBC’s- may increase to 20,000/mm3 or more during 1st 10 days PP Average PP WBC is 14, ,000/mm3 Slightly higher with cesarean delivery and traumatic deliveries due to body’s inflammatory response An increase of more than 30% over a 6-hour period is indicative of infection CBC with differential is indicated if the WBC count has significantly increased or the patient has a risk factor or is symptomatic for infection increase in predominantly granulocytes

17 Vital Signs BP - should be similar to intrapartum values
High BP may suggest PIH Low BP may suggest orthostatic hypotension or a late sign of hypovolemia and/or hemorrhage Pulse - bradycardia normal immediate PP(40-80 bpm) Tachycardia – abnormal and suggests hemorrhage or infection Respiratory Rate - usually normal 16-24/min Temperature – Normal slight elevation 1st 24 hrs PP > degrees F indicates infection

18 Teaching Activity/Exercise
Do not overdo…Only care for self and baby Lochia guides activity level Limit stairs/lifting Gradual resumption of activity Start kegels and walking right away PP exercises for abdomen— Seek advice from provider. Usually after 6 weeks pp.

19 Cervix Edematous immediately PP 1 week PP- about 1cm
Easily distensible several days PP Internal OS closes by 2 weeks PP Abnormal Finding: Presence of free flowing bright red blood Cervical laceration

20 Vagina Rugae reappears 3 weeks postpartum
Return to near pre-pregnant state 6-8 weeks post partum Normal mucus production returns with ovulation Need to educate patient - nothing in the vagina for 6 weeks post partum Rugae-ridges in the mucous membranes

21 Menstrual Cycle Non-lactating: Lactating:
40-45% will resume at 6-8 wks 75% will resume at 12 weeks 100% will resume within 6 months Lactating: As early as 12 wks or as late as 18 months

22 Ovulation Non-lactating: 50% will be anovulatory first few cycles
of menses Lactating: 80% will be anovulatory first few cycles

23 Teaching Sexuality Nothing in the vagina for first 4-6 weeks:
“No intercourse. No tampons. No douching” Increased risk for acquiring STD’s Women can still ovulate without menses! Lowered interest due to hormones/fatigue Dry vaginal mucosal lining…Use lubrication Let-down reflex may occur during intercourse

24 Perineum Episiotomy is normally without redness, discharge, or edema
Intact perineum may still have edema and/or ecchymosis secondary to pressure at delivery May experience burning with urination Healing takes place in 1-2 weeks

25 Lacerations 1st degree: through the skin and structures superficial to the muscles 2nd degree: above plus through the muscles of the perineum 3rd degree: above plus through the anal sphincter muscle 4th degree: above plus through the anterior rectal wall

26 Teaching Perineal Care
Good hygiene – hand washing, peri-bottle and frequent pad changes Comfort measures Ice first 24 hours Sitz baths after 24 hours Witchhazel Stitches dissolve in 1-2 weeks, Itching normal as skin heals Infection uncommon, watch for symptoms: fever, abnormal discharge, foul smelling discharge Monitor for dehiscence of repair

27 Hemorrhoids Grape-like clusters at the anus
May not be visible or palpable until straining for BM Should shrink in in about three weeks Teach: Avoid constipation and straining Soft diet with foods or drink that normally help the patient have bowel movements Sitz baths and witchhazel See provider if still a problem after 3 weeks

28 Respiratory System Pulmonary function returns to normal in 6-8 weeks as diaphragm descends Acid/base balance returns to pre-pregnant levels by 3 weeks PP Oxygen Saturations should be above 95% Patients at risk for pulmonary compromise: Fluid overloaded Preeclamptic patients, particularly those on Magnesium Sulfate Cardiac Patients Asthmatics Smokers Patients with preexisting pneumonia or URI

29 GI System Appetite is strong immediately PP period
Decreased GI motility can lead to constipation BM should resume 2-3 days PP Average weight loss of 12 lbs at delivery plus 5 lbs in first week due to diuresis Cesarean birth: Greater incidence of distension, discomfort, constipation and illeus R/T trauma and manipulation of bowel

30 GI System Teaching Eat 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 breastfeeding Interventions to prevent constipation: ambulation, increase fluids and high fiber, stool softeners, laxatives, foods and fluids that usually make patient have BM Having BM will not cause them to tear repairs Call provider if no BM by 4th day PP

31 Urinary System Fluid 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

32 Urinary System Teaching
Common to feel numb first few days PP, so empty bladder frequently Tricks 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 sutures Lean forward on toilet – puts pressure on bladder Sound of running/trickling water Peppermint oil Blowing bubbles in cup of warm water Shower, sitz bath (warm water increases urge to void)

33 Urinary System Teaching
Teach patient symptoms of UTI Urgency Frequency Dysuria Fever, chills Back or lower abdominal pain Decrease in Level of Consciousness – confusion Increase in fatigue / lethargy

34 Musculoskeletal System
Diastasis recti (rectus muscle) may separate 2-4 cm. Will resolve by 6 wks. Most common in black patients Joint stabilization returns in 6-8 wks post partum Teach caution when starting a vigorous exercise program or stomach exercises prior to 6 wk PP follow-up visit. Need to consult with care provider

35 Integumentary System Hyperpigmentation of face (chloasma), abdomen (linea negra) and areaolas gradually lighten and may or may not disappear Stretch marks will gradually fade Hair loss will occur within 6 weeks Diaphoresis for first several weeks, especially at night (night sweats)

36 Immune System Rh 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.

37 Breasts Prolactin – Initiates milk production
Oxytocin – Milk “let-down reflex” Milk removal from breast (by breast feeding or pumping)– facilitates continued milk production Lactating: Colostrum: 1st week PP Transitional milk: between 7-14 days Mature milk comes in after 2 weeks

38 Breasts Non-lactating: breast changes of pregnancy regress in 1-2 weeks postpartum Teach: Well fitting support bra 24 hours a day for 2 weeks No heat or warm water/shower on breasts No stimulation of breasts Ice packs to breast maximum 20 minutes at a time No longer use lactation suppressive medications due to rebound engorgement

39 Engorgement Symptoms Engorgement begins at 2nd - 3rd day and subsides in hours Tender, swollen, and firm breasts (including the areola) making it difficult for infant to latch – like trying to latch on to a basketball Slight fever (<100.4 F)

40 Engorgement Interventions to prevent engorgement:
Encourage early feedings Encourage frequent feedings Minimum 8 feedings/ 24 hours Minimum minutes per breast Avoid supplement for infant unless medically indicated Assess and ensure correct positioning and latch

41 Engorgement Nursing Care: Wear a well fitting support bra
Warm compresses or shower prior to feeding Gentle massage of breasts from axilla towards nipple to stimulate letdown Express milk by hand or pump to soften areola tissue to assist infant in latch Ice packs to axilla for a maximum 20 minutes at a time after feeding

42 Psychological System Role Changes: Grieve the loss of old role and acquire new role and expectations Acquiring the Role of Mother (Rubin, 1975) Taking in phase: days 1-2; passive, dependent, wants care for self; asks many questions Taking hold phase: 4 -5 wks; begins to focus on needs of infant, receptive to teaching, high fatigue Letting go phase: 5+ wks; sees infant as separate individual, refocuses on relationship with partner, may return to work/uses babysitter

43 Attachment Definition: The enduring emotional bond between parent and infant (Klaus & Kennell, 1976) Essential to infant’s growth and survival The 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

44 Attachment Behaviors Observable maternal attachment behaviors:
Touching Holding Gazing Cuddling Kissing En face position Observable Paternal attachment behaviors: “Engrossment”: to stare for long periods of time

45 Attachment Behaviors Observable infant attachment behaviors
(before 8 weeks): Cuddling into mother Following with eyes and gazing Providing clear feeding cues and needs cues Crying Grasping Smiling Babbling

46 Assessing Attachment Maternal 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

47 Assessing 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

48 Assessing Attachment Infant factors to consider
Gestational age, multiple birth, admission to SCN/NICU, transferred to tertiary setting, physical anomalies, gender, temperament, degree of alertness

49 Prenatal Mal-Attachment Behaviors
Excessive moodiness Emotional withdrawal Excessive preoccupation with own personal appearance – ignoring infant Numerous physical complaints Failure to prepare for infants arrival during last trimester (although had opportunity and resources)

50 Postnatal Mal-Attachment Behaviors
Negative comments about baby’s appearance Disappointment about baby’s gender Failure to look at, touch, or handle infant Failure to respond to signaling behaviors Failure to name infant Failure to meet infant’s physical needs

51 Nursing Interventions to Support Attachment
Encourage early and frequent eye-to-eye and skin-to-skin contact Provide opportunity, time, environment for attachment Encourage and praise parents in caring for own infant Instruct infant behaviors and cues Reassure some negative feelings normal Educate significant other about danger signs Provider and Community Health Follow-up Social work referral if needed

52 Culturally Appropriate Care
US - postpartum is seen as time of wellness and early ambulation is expected Japan - remain inside for 1st 100 days, no bath or hair wash for 1 week Korea - avoid exposure to cold, eat warm foods Mexico - keep warm, eat warm foods to help dry the womb; avoid baths for 1 week Mexican- 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 days Onset sudden Incidence 50-80% of all PP women Possible cause: onset of PP Blues coincides with drop in estrogen and progesterone Usually self-limiting (if woman is given support from family and friends) Sleep helps relieve symptoms PP 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 PP Confused thinking, mood swings, delusions, paranoia, disorganized behavior, impaired function. Considered a psychiatric emergency

54 “Baby Blues” - Characteristics
Mood swings Irritability or anger Crying for no apparent reason Mild anxiety Difficulty sleeping Fatigue Discomfort

55 Assessment of SVD patient
1st hour - every 15 minutes x 4 2nd hour - every 30 minutes x 2 2-24 hours - every 4 hours >24 hours - every 8 hours

56 Assessment of C-Section patient
1st hour - every 15 minutes x 4 2-3 hours - every 30 minutes x 4 3-24 hours - every 2-4 hours >24 hours - every 4-8 hours

57 Assessment PP Patient General appearance How she ambulates
Vital Signs TPR, BP Assess pain level HA, musculoskeletal, back, breasts, nipples, uterus, bladder, incision, perineum, hemorrhoids, calf tenderness General appearance How she ambulates Self-care activities Head Facial edema Conjunctival hemorrhage (from pushing) LOC/Sensation Cardio/Pulmonary: AUSCULTATE Neuro: DTR’s

58 Assessment PP Patient Breasts Fullness Nipples Erectility
Breast support Breast surgery scars Nipples Erectility Flat/inverted Intact or cracked Presence of milk Ecchymosis Bleeding

59 Assessment PP Patient Uterus How to position patient Uterine support
Firmness Location of fundus Tenderness Massage C/S incision site Dressing dry/intact Incision - edges well approximated, staples intact Redness, edema, ecchymosis, oozing Drains intact, amount drainage

60 Assessment PP Patient Bladder/output Voiding pattern Distended bladder
Dysuria GI/Elimination Bowel sounds, flatus Bowel movements Perineum Positioning patient during assessment Episiotomy, lacerations Sutures well approximated Edema, ecchymosis, hematoma, discharge Perineum assessment REEDA- redness, edema, ecchymosis, discharge, approximation of edges of episiotomy

61 Assessment PP Patient Extremities Homan’s sign
Edema, warmth, redness of extremity Calf tenderness Lab Values CBC - note H & H, WBC and Platelets UA

62 D/C Teaching Follow-up
Follow-up for SVD usually 6 weeks PP Follow-up for C-Section usually in 4-5 days if staples/sutures not out; If out, days and again at 6-8 weeks Phone number to OB/Ped providers and Lactation Consultant Symptoms/concerns when to call provider

63 D/C Teaching When to Call Provider
Chest pain/coughing Increased perineal pain prolonged baby blues or depression C/S incision that feels hot to touch, oozing or reddened Nausea and vomiting Headache not relieved by medications Fever over 100.4 Chills Symptoms of UTI Saturating >1 pad/hr Bright red flow return Foul smelling lochia Abdominal tenderness Severe leg pain/edema

64 References AWHONN’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;

65 The End

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