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POST PARTUM POST PARTUM Lecture 8 Lecture 8. Puerperium: “to bring forth” 6 wk > childbirth. “4th trimester” - transition for woman/family (pregnancy.

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Presentation on theme: "POST PARTUM POST PARTUM Lecture 8 Lecture 8. Puerperium: “to bring forth” 6 wk > childbirth. “4th trimester” - transition for woman/family (pregnancy."— Presentation transcript:

1 POST PARTUM POST PARTUM Lecture 8 Lecture 8

2 Puerperium: “to bring forth” 6 wk > childbirth. “4th trimester” - transition for woman/family (pregnancy ends/parenting role begins) “4th trimester” - transition for woman/family (pregnancy ends/parenting role begins) I. Physiological Changes of Post Partum Period I. Physiological Changes of Post Partum Period A. Reproductive System Changes: UTERUS: contx’s begin > birth & delivery of placenta 1. placental site seals 2. Entire uterus contracts & reduces gradually for 8-10 days. “INVOLUTION”. Pt. in danger of hemorrhage uterus until involution is complete. Oxytocin released > uterine contx’s.

3 Fundus: assess for firmness. Palpate > delivery.  umbilicus X 24 hrs. Soft aka “boggy” - danger of hemorrhage. Massage uterus! Uterus descends one finger breadth every day. Delivery day, umbilicus Delivery day, umbilicus 1st day PP uterus 1 FB ↓ Umbilicus 1st day PP uterus 1 FB ↓ Umbilicus 2nd day PP uterus 2 FB ″ and so forth. 2nd day PP uterus 2 FB ″ and so forth. Support lower segment of uterus when palpating to prevent uterine eversion. Support lower segment of uterus when palpating to prevent uterine eversion.

4 By day 10, uterus almost back to pre-pregnant size & position in pelvic cavity. [1000 grams → 50 grams] No longer palpated in abdomen. By day 10, uterus almost back to pre-pregnant size & position in pelvic cavity. [1000 grams → 50 grams] No longer palpated in abdomen. Full bladder raises fundal height, gives false reading. Full bladder raises fundal height, gives false reading. Natural oxytocin released with breast feeding. ^ contractions. 2FB ↓ umb. on 1st day PP. Natural oxytocin released with breast feeding. ^ contractions. 2FB ↓ umb. on 1st day PP. Breast fdg.offers little protection against hemorr. Breast fdg.offers little protection against hemorr.

5 Delay in uterine involution: retained placenta/clots - effective contraction of uterus not possible. Risk of PP Hemorr. Delay also with: multiparous pt. [grand multip ] multiparous pt. [grand multip ] exhaustion exhaustion multi-fetuses. multi-fetuses. C/S involutes slower; d/t surgery & less initiation of breast feeding > delivery. C/S involutes slower; d/t surgery & less initiation of breast feeding > delivery. After-birth pains = cramping caused by contractions more in multi-parous women than in primips. more in multi-parous women than in primips. With Br. Fdg. because of release of oxytocin. With Br. Fdg. because of release of oxytocin.

6 2. LOCHIA Placenta separates from spongy layer of uterus - decidua BASALIS. Placenta separates from spongy layer of uterus - decidua BASALIS. Inner layer of decidua remains & forms new layer of endometrium. Outer becomes necrotic & sheds. Inner layer of decidua remains & forms new layer of endometrium. Outer becomes necrotic & sheds. Consists of blood, fragments of decidua, mucus, bacteria. Consists of blood, fragments of decidua, mucus, bacteria. 1st 3 days = rubra =”red” [blood] 1st 3 days = rubra =”red” [blood] >3 days = serosa = “pink” >3 days = serosa = “pink” 10th day – alba - “white” [up to 3 wks] 10th day – alba - “white” [up to 3 wks] Total flow lasts about 4-5 wks Total flow lasts about 4-5 wks Should not be bright red; could be PP hemorrhage. Should not be bright red; could be PP hemorrhage.

7 3. CERVIX Neck; remains slightly opened & contracts > delivery. Neck; remains slightly opened & contracts > delivery. In 7 days, opening narrow as pencil. Os remains slit-like. In 7 days, opening narrow as pencil. Os remains slit-like. 4. VAGINA Slightly distended after birth. Kegel exercises ^muscle tone and strength. Important for lacerations. Slightly distended after birth. Kegel exercises ^muscle tone and strength. Important for lacerations. 5. PERINEUM Can be edematous/ecchymotic Can be edematous/ecchymotic Ice x 24 hrs. then heat [Sitz] Ice x 24 hrs. then heat [Sitz] Topical anesthetics creams/sprays apply for comfort. Topical anesthetics creams/sprays apply for comfort. Perineal massage relaxes perineum before delivery. Perineal massage relaxes perineum before delivery. May prevent episiotomy/laceration. May prevent episiotomy/laceration. Teach Kegels - tightening & releasing of perineal muscles. Improves circulation & healing of epis/lac. Teach Kegels - tightening & releasing of perineal muscles. Improves circulation & healing of epis/lac.

8 Complications of Perineum: Hematomas [blood from bleeding vessel] Hematomas [blood from bleeding vessel] Area of swelling on one side of perineum. Area of swelling on one side of perineum. If small, absorbs in few days; apply ice & give analgesics. If small, absorbs in few days; apply ice & give analgesics. If large bleed, to OR for evacuation & vaginal packing. If large bleed, to OR for evacuation & vaginal packing. Common - forceps deliveries Common - forceps deliveries Perineal Care - use warm water; wipe from front to back. Perineal Care - use warm water; wipe from front to back.

9 Laceration size of baby, timing of delivery, tension on perineum. size of baby, timing of delivery, tension on perineum. Sutured & treated as episiotomies. Sutured & treated as episiotomies. Analgesics, ice, topical creams, Sitz bath. Analgesics, ice, topical creams, Sitz bath. 1st degree = from base of vagina to base of labia minora. 1st degree = from base of vagina to base of labia minora. 2nd “ = from base of vagina to mid perineum 2nd “ = from base of vagina to mid perineum 3rd = entire perineum to anal sphincter 3rd = entire perineum to anal sphincter 4th = entire perineum through anal sphincter & some rectal tissue. 4th = entire perineum through anal sphincter & some rectal tissue. Nothing into rectum - no rectal temps., suppositories, or enemas with 4 th degree to avoid further damage. Nothing into rectum - no rectal temps., suppositories, or enemas with 4 th degree to avoid further damage. Colace TID, ^ po fluids to promote BM. Ice X 24 hrs., Sitz baths TID; topicals. KEGELS! Colace TID, ^ po fluids to promote BM. Ice X 24 hrs., Sitz baths TID; topicals. KEGELS!

10 SYSTEMIC CHANGES - Body returns to SYSTEMIC CHANGES - Body returns to pre-pregnant state by 6 wks. Hormonal System:  Pregnancy hormones decrease w. delivery of placenta.  HCG & HPL disappear by 24 hrs. FSH rises 12 days - to begin new menstrual cycle. Menses resumes by 4-5 wks. if not Br. Fdg. 12 days - to begin new menstrual cycle. Menses resumes by 4-5 wks. if not Br. Fdg.

11 The Urinary System: The Urinary System: Loss of bladder tone d/t swelling & anesthesia ; urinating difficult. May not feel urge to void. Loss of bladder tone d/t swelling & anesthesia ; urinating difficult. May not feel urge to void. Hydronephrosis [enlargement of ureters] occurs after delivery & to 4 wks. PP. DIURESIS! Hydronephrosis [enlargement of ureters] occurs after delivery & to 4 wks. PP. DIURESIS! ↓ bladder sensitivity - ↑ risk for bladder infection - urinary stasis. ↓ bladder sensitivity - ↑ risk for bladder infection - urinary stasis. Avoid bladder damage - assess bladder q 1-2 hrs.til voids qs. Teach voiding q 2 – 3 hours. Avoid bladder damage - assess bladder q 1-2 hrs.til voids qs. Teach voiding q 2 – 3 hours. Palpate abdomen gently, note location of fundus. Palpate abdomen gently, note location of fundus. When do you suspect full bladder? During preg., ml. of fluid accumulates in body - Client loses lbs. of water weight in 1 st wk. During preg., ml. of fluid accumulates in body - Client loses lbs. of water weight in 1 st wk.How?

12 Circulatory System: Blood volume ^ 30 – 50% in pregnancy. With diuresis & blood delivery, blood volume returns to normal in 1-2 wks. Blood loss for NSVD = 300 cc. & C/S = 500 cc. Blood loss for NSVD = 300 cc. & C/S = 500 cc. Non pregnant: HCT= % & HGB= g/dL Non pregnant: HCT= % & HGB= g/dL Pregnant: HCT= % & HGB = 11.5 – 14g/dL Pregnant: HCT= % & HGB = 11.5 – 14g/dL HCT drops by 4 pts. & HGB drops by 1 g. for every 250cc. of blood client loses. HCT drops by 4 pts. & HGB drops by 1 g. for every 250cc. of blood client loses. Patient should not be anemic entering delivery Patient should not be anemic entering delivery Possible blood transfusion with large blood loss. Possible blood transfusion with large blood loss. Average blood volume: pre-pregnant = 4000cc; Average blood volume: pre-pregnant = 4000cc; pregnant state = 5250cc. pregnant state = 5250cc.

13 ^ Blood volume: provides adequate exchange of nutrients in placenta & compensates for blood loss during delivery. ^ Blood volume: provides adequate exchange of nutrients in placenta & compensates for blood loss during delivery. HR remains ^ x hrs. PP HR remains ^ x hrs. PP With diuresis, HCT levels rise [^ hemoconcentration] reach pre-preg level by 6 wks. With diuresis, HCT levels rise [^ hemoconcentration] reach pre-preg level by 6 wks. Plasma fibrinogen ^^ 50% during pregnancy & remains elevated 6 wks. PP. [^ estrogen levels] WHY? Can cause ^ thrombus formation.  Assess pts. legs/calves for s/s thrombus. Rise in leukocytes; WBC ^ protective measure to prepare for stress of delivery. As high as 20-25,000. Rise in leukocytes; WBC ^ protective measure to prepare for stress of delivery. As high as 20-25,000.

14 Gastrointestinal System: NSVD: bowels sounds. Eat right away. NSVD: bowels sounds. Eat right away. C/S: bowel sounds hypoactive 1st 8 hrs. C/S: bowel sounds hypoactive 1st 8 hrs. Epidural/spinal: po clears after delivery, advance diet if +BS. Epidural/spinal: po clears after delivery, advance diet if +BS. General anesthesia: usually NPO for ~ 6-8 hrs. General anesthesia: usually NPO for ~ 6-8 hrs. Duramorph/astromorph can cause N/V up to 12 hrs. Duramorph/astromorph can cause N/V up to 12 hrs. antiemetic meds. [Reglan/Zofran]. antiemetic meds. [Reglan/Zofran]. BM - difficult/painful d/t lacerations/hemmorhoids. BM - difficult/painful d/t lacerations/hemmorhoids. C/S - BM 3rd - 4th day. GI activity slowed d/t surgery. C/S - BM 3rd - 4th day. GI activity slowed d/t surgery. Can go home without BM if + flatus. Can go home without BM if + flatus.

15 Integumentary System: Stretch marks [striae gravidarum] appear reddened on abdomen. Fade by 3-6 months; Pearly white marks may remain in lighter skinned pts. & darker marks in darker skinned pts.  Modified sit-ups strengthen abdomen

16 VITAL SIGNS PP Temperature: slightly ^ - dehydration during labor 1 st 24 hrs. Returns to normal within 24 hrs. T = or > PP infection suspected. T = or > PP infection suspected. Temp. also rises 3rd - 4th day with filling of breast milk Temp. also rises 3rd - 4th day with filling of breast milk Observe for s/s infection - nurse usually 1st to detect ↑ temp. [universal sign of infection x 2 readings, on days 2-10 PP] Observe for s/s infection - nurse usually 1st to detect ↑ temp. [universal sign of infection x 2 readings, on days 2-10 PP] Pulse: HR ^ slightly x 1st hr. Stroke volume & cardiac output also ^ x 1 st hr. then decreases Stroke volume & cardiac output also ^ x 1 st hr. then decreases 8-10 wks.,returns to pre-pregnant state wks.,returns to pre-pregnant state. Rapid, thready pulse- sign of PP hemorrhage, infection Rapid, thready pulse- sign of PP hemorrhage, infection

17 Blood Pressure - Monitor carefully. 1st trimester 1st trimester Heart works faster to handle ^ volume. BP remains same. 2nd trimester 2nd trimester BP drops slightly d/t lowered peripheral resistance in blood vessels as placenta expands rapidly. Heart beats faster, more efficiently d/t ^ blood volume. Pre-pregnant BP 120/80. Pregnant BP 114/65. 3rd trimester 3rd trimester BP back to pre-pregnant value.

18 BP Complications ↓ BP ↓ BP [90/60 or less] with dizziness is “Orthostatic hypotension”; could signify hemorrhage. Take BP/pulse lying/sitting/standing. Compare values. Take BP/pulse lying/sitting/standing. Compare values. Orthostatic: If BP drops mmHg and pulse increases 20 bpm or more. Caution for falls. Orthostatic: If BP drops mmHg and pulse increases 20 bpm or more. Caution for falls. Needs IV fluids. Take VS. Report to MD > order for CBC. Needs IV fluids. Take VS. Report to MD > order for CBC. ↑ BP ↑ BP [140/90 or >] could signify PP pre-eclampsia. Notify MD. Could develop into serious complication. Notify MD. Could develop into serious complication. Oxytocic meds [Pitocin] > delivery could ^ BP Oxytocic meds [Pitocin] > delivery could ^ BP

19 Other Changes Other Changes Exhaustion:  Common  Frequent rest periods  RN coordinates nursing care & infant feeding times  provide maximum rest time. Weight Loss:  Average wt. loss 12 lb. [infant & placenta]  5 lbs. - diuresis & diaphoresis in wk. that follows.  Lochial flow lbs.  Total = approx lbs. {depends on total wt. gain}  At 6 wks. wt. may still be above pre-preg. weight. Return of Menses: > delivery FSH levels rise causing ovulation No Br. Fdg.- menses resumes ~ 6 wks. No Br. Fdg.- menses resumes ~ 6 wks. Lactation delays menses for several months (6 mos) Lactation delays menses for several months (6 mos)

20 PSYCHOLOGICAL CHANGES OF POST PARTUM PERIOD: ADJUSTMENTS Taking-In Phase:  time of reflection for client regarding new role  may be passive or excited  talks at length about birth experience  on phone with family/friends recounting birth experience.  Usually lasts 1-2 days.  Delayed d/t pain r/t vaginal or C/S. Taking-Hold Phase:  woman makes own decisions regarding self & infant care.  Usually day Occur on day 1 esp. if woman is multip.  Can occur later, depends on recovery process or cultural beliefs.

21 Letting Go Phase :  Woman gives up fantasy image of baby and accepts real child. real child.  Occurs within few weeks of getting home  Needs time to adjust to new experience. Bonding:  Expressing maternal love & attachment toward new baby. Develops gradually.  Enface position: close eye contact with infant.  Healthy bonding - kissing, touching, counting fingers & toes, cooing, etc. Factors Interfering with Bonding: difficult labor, birth (NICU) Factors Interfering with Bonding: difficult labor, birth (NICU)

22 Other Maternal Feelings of Post Partum Period Abandonment: feelings that occur > birth of child; woman no longer center of attention. Abandonment: feelings that occur > birth of child; woman no longer center of attention. Disappointment: infant does not meet expectations of mother/father. Eg. eye color; sex. Disappointment: infant does not meet expectations of mother/father. Eg. eye color; sex. Post Partum Blues: d/t normal hormonal changes; Post Partum Blues: d/t normal hormonal changes; Drop in estrogen/progesterone; lasts 1st few days of PP period. Occurs in 50% of women.

23 PP Depression: 30% of women exp. this. Therapy & medication may be necessary. Therapy & medication may be necessary. Hx of depression & anxiety prior to pregnancy puts higher risk for developing this. Hx of depression & anxiety prior to pregnancy puts higher risk for developing this. Can manifest itself up to 1 year > birth. Can manifest itself up to 1 year > birth. Screening tool: Edinburgh PP depression tool Screening tool: Edinburgh PP depression tool Always refer to social worker to assess for degree of depression. Always refer to social worker to assess for degree of depression. Ask: is mother able to take infant home without danger to self or baby? Ask: is mother able to take infant home without danger to self or baby? Studies show breast feeding helps reduce symptoms d/t oxytocin “feel good” effect Studies show breast feeding helps reduce symptoms d/t oxytocin “feel good” effect

24 MANIFESTATIONS OF POSTPARTUM DEPRESSION  interest in surroundings  interest in surroundings  interest in food  interest in food unable to feel pleasure unable to feel pleasure fatigue fatigue health c/o health c/o sleep disturbance sleep disturbance panic attacks panic attacks obsessive thinking obsessive thinking  hygiene  hygiene  ability to concentrate  ability to concentrate odd food cravings odd food cravings irritability irritability rejection of infant rejection of infant

25 PPD: Teaching relaxation therapy relaxation therapy rest & nutrition rest & nutrition frequent contact with other adults frequent contact with other adultsResource: The Post Partum Resource Center of New York, Inc MANIFESTATIONS OF POSTPARTUM PSYCHOSIS s/s depression s/s depression s/s manic s/s manic auditory hallucinations auditory hallucinations delusions delusions guilt guilt worthlessness worthlessness

26 Development of Parental Love & Positive Family Relationships: Rooming In: most hospitals offer this; infant stays in room with mom 24hrs. (partial or complete) Rooming In: most hospitals offer this; infant stays in room with mom 24hrs. (partial or complete) Sibling Visitation: encourage siblings to visit to promote family togetherness. Sibling Visitation: encourage siblings to visit to promote family togetherness.

27 LACTATION & BREAST FEEDING Lactation starts regardless if pt. is breastfeeding or not. Lactation starts regardless if pt. is breastfeeding or not. Entirely up to mother Entirely up to mother Must feel comfortable doing so. Must feel comfortable doing so. Advantages to Breast Feeding: Promotes bonding between mother & baby. Promotes bonding between mother & baby. High nutritional value for infant. High nutritional value for infant. Promotes uterine involution thru release of Promotes uterine involution thru release of oxytocin from posterior pituitary. oxytocin from posterior pituitary. Reduces cost of feeding & preparation time. Reduces cost of feeding & preparation time.

28 Nurse has major role as educator of benefits & methods of breast feeding. Ways to teach new moms about lactation: videos videos handouts handouts hands on demo hands on demo lactation specialist [in clinical settings] lactation specialist [in clinical settings] Offer support Offer support Contraindications to Breast Feeding: Mom receiving meds not appropriate for Br. fdg. [Lithium] Mom receiving meds not appropriate for Br. fdg. [Lithium] Exposure to radioactive compounds [thyroid testing]; pump & dump breast milk x 48 hrs. Flush in toilet. Exposure to radioactive compounds [thyroid testing]; pump & dump breast milk x 48 hrs. Flush in toilet. Breast Cancer; HIV Breast Cancer; HIV

29 Physiology of Lactation Physiology of Lactation Body prepares for lactation during pregnancy; stores fat & nutrients; provide energy, vitamins, minerals in breast milk. Early pregnancy, ↑ estrogen (placenta) stimulates growth of milk glands & size of breasts. Early pregnancy, ↑ estrogen (placenta) stimulates growth of milk glands & size of breasts. Colostrum: middle of pregnancy & day 1-3 PP, Colostrum: middle of pregnancy & day 1-3 PP, Thin, watery pre-lactation secretion. Rich in antibodies; passes to baby in 1-3 days. Thin, watery pre-lactation secretion. Rich in antibodies; passes to baby in 1-3 days. Breasts begin to get tender; fill up w. milk. Breasts begin to get tender; fill up w. milk. Breast milk by 3 rd to 4 th day in response to: falling levels of estrogen & progesterone > delivery of placenta. falling levels of estrogen & progesterone > delivery of placenta. ^ production of prolactin by anterior pituitary ^ production of prolactin by anterior pituitary Milk ducts become distended & fluid turns bluish-white Milk ducts become distended & fluid turns bluish-white

30 Physiology cont. Infant suckling on breast produces more prolactin, which in turn stimulates more milk production. Infant suckling on breast produces more prolactin, which in turn stimulates more milk production. Finally, oxytocin released > delivery of placenta causing mammary glands to send milk to nipples [let down reflex]. Finally, oxytocin released > delivery of placenta causing mammary glands to send milk to nipples [let down reflex]. Progesterone levels drop after delivery which leads to ↑ milk production. Progesterone levels drop after delivery which leads to ↑ milk production.

31 Anatomy of Lactation Colostrum: protein, sugar, fat, water, minerals, vitamins, maternal antibodies. Provides total nutrition for infant Provides total nutrition for infant Transitional breast milk by 3 – 4th day. Transitional breast milk by 3 – 4th day. Mature breast milk by 10th day. Mature breast milk by 10th day. Each breast lobes of glandular tissue -alveoli. Each breast lobes of glandular tissue -alveoli. Acinar or alveolar cells of glands form milk. Acinar or alveolar cells of glands form milk. Each alveolus ends in a ductule. Each alveolus ends in a ductule. Each alveoli produces milk, ejects it into ductules aka let down reflex; milk transported to lactiferous sinus and ejected into infant’s mouth. Each alveoli produces milk, ejects it into ductules aka let down reflex; milk transported to lactiferous sinus and ejected into infant’s mouth.

32 Pathway of Droplet of Milk: Milk → mammary ducts → reservoirs behind nipples [lactiferous sinuses] → infant’s mouth Milk → mammary ducts → reservoirs behind nipples [lactiferous sinuses] → infant’s mouth Foremilk: constantly accumulating. “Let-down reflex” –lets foremilk be available right away. “Let-down reflex” –lets foremilk be available right away. Triggered by sound of baby crying Triggered by sound of baby crying Hind milk: forms after let-down reflex. Has most calories; Feed until breast empty. Feed until breast empty. Breast Milk: Provides complete nutrition for 1st 6 mos of life. > 6 months, iron-fortified cereal. > 6 months, iron-fortified cereal. Breast milk easier to digest than formula. Breast milk easier to digest than formula. Iron in breast milk absorbed better than iron in formula. Iron in breast milk absorbed better than iron in formula.

33 Supply & Demand Response - Every time woman breast feeds, more prolactin produced which then produces ^milk. Time Interval to ↑ milk volume. It takes approx min. to fill up breast after nursing. Time Interval to ↑ milk volume. It takes approx min. to fill up breast after nursing. Assessment: Antepartum Changes Breasts enlarge [each breast gains ~ lb. or more] Breasts enlarge [each breast gains ~ lb. or more] Glands enlarge Glands enlarge Increased blood flow to breasts, causing blood vessels to enlarge & become more visible. Increased blood flow to breasts, causing blood vessels to enlarge & become more visible. Areola [dark circle around nipple] enlarges and darkens Areola [dark circle around nipple] enlarges and darkens Small bumps on areola [Montgomery’s tubercles] enlarge and produce oils to soften nipples and keep them clean. Small bumps on areola [Montgomery’s tubercles] enlarge and produce oils to soften nipples and keep them clean. Teach moms no soap on nipples;may ^ irritation. Teach moms no soap on nipples;may ^ irritation. Lanolin; tea bags [wet] [tanic acid] on sore nipples. Lanolin; tea bags [wet] [tanic acid] on sore nipples.

34 Common Problems: Engorgement : milk enters on 3rd - 4th day; C/S - prior to D/C  breasts hard, painful to touch.  Warm soaks, hot showers, express milk manually, breast feed q 2-3 Pumping produces more milk. Cabbage leaves; diuretic property. Pumping produces more milk. Cabbage leaves; diuretic property. nursing bra. nursing bra. tight bra and ice packs x hrs– why? tight bra and ice packs x hrs– why? Analgesics [Tylenol 650 mg. q hrs.prn] Analgesics [Tylenol 650 mg. q hrs.prn] Sore/Cracked/Bleeding Nipples  Common - from improper positioning or not enough areola in infant’s mouth; may continue to feed; up to mom. Reposition infant. Reattempt nursing.  Rest the nipple; apply lanolin ointment prn.  Apply tea bag [tanic acid] natural healing property.

35 Plugged Duct  firm nodule under arm; temporarily blocked duct; relieved by infant sucking. Evaluate carefully since may be malignant growth. Warm compresses prn. Mastitis –  “inflammation”; milk duct/gland becomes infected. Poss. antibiotic therapy. Manual expression, continue to breast feed, frequent warm compresses.

36 Nursing Care : Promote successful breast feeding: Encourage first feeding [L&D, PP; establish pt’s. Encourage first feeding [L&D, PP; establish pt’s. desire to breast feed] desire to breast feed] Emptying of breasts ~ 20 minutes Emptying of breasts ~ 20 minutes Teach: start on breast where she left off - maintains good supply. Teach: start on breast where she left off - maintains good supply. Rest, relaxation, ↑ fluids by four 8 oz glasses/day. Rest, relaxation, ↑ fluids by four 8 oz glasses/day. Not enough fluids, ^ anxiety may lower milk production. Not enough fluids, ^ anxiety may lower milk production. Nutritional Counseling: ^ 500 calories/day. Nutritional Counseling: ^ 500 calories/day.

37 Health Teaching Rooting – sign of hunger Rooting – sign of hunger Breast feed q 2-3 hrs. for minutes Breast feed q 2-3 hrs. for minutes Teach “latching”: nipple and part of areola to prevent nipple irritation. Listen for swallowing. Teach “latching”: nipple and part of areola to prevent nipple irritation. Listen for swallowing. Nursing Bra Nursing Bra Feeding & Burping [bottle fed infants] upright position Feeding & Burping [bottle fed infants] upright position Nipple care: no soap; nipple creams -Lansinoh Nipple care: no soap; nipple creams -Lansinoh Avoid drugs, alcohol, smoking Avoid drugs, alcohol, smoking

38 FORMULA FEEDING Feeding Skills Position upright position- support head and shoulders] Position upright position- support head and shoulders] Formula [Similac, Enfamil, Isomil; all have iron] Formula [Similac, Enfamil, Isomil; all have iron] milk or soy based milk or soy based Burp Burp Safety Tips never prop bottle; choking or ear infection. never prop bottle; choking or ear infection. ^ amt. ½-3/4 oz./day; feed q 3 – 4 hrs. x 24 hrs. ^ amt. ½-3/4 oz./day; feed q 3 – 4 hrs. x 24 hrs. Discharge Follow up: Telephone calls & home visits [if needed] Telephone calls & home visits [if needed] Help line; Support groups [La Leche] Help line; Support groups [La Leche]

39 NURSING MANAGEMENT OF POST PARTUM CLIENT Assessment – minimum of twice daily Vital signs Vital signs Emotional Status Emotional Status Breasts Breasts Fundus, lochia, & perineum Fundus, lochia, & perineum Voiding & bowel function - flatus, BM Voiding & bowel function - flatus, BM Legs [+ Homan’s sign, ankle edema ] Legs [+ Homan’s sign, ankle edema ] S/S complications [PP hemorrhage, infection, ↑ BP ] S/S complications [PP hemorrhage, infection, ↑ BP ] Nursing Care Safety Prevent hemorrhage- massage uterus on admission and q 4 for first 8 hrs. Prevent hemorrhage- massage uterus on admission and q 4 for first 8 hrs. Prevent falls – assess when getting out of bed for 1st 8 hrs. Assist when necessary. Check labs for low H&H. Prevent falls – assess when getting out of bed for 1st 8 hrs. Assist when necessary. Check labs for low H&H.

40 Bowel function (1-3 days to resume). Stool softeners, as ordered [Colace] Stool softeners, as ordered [Colace] Encourage ambulation Encourage ambulation Increase dietary fiber Increase dietary fiber Provide adequate fluid intake Provide adequate fluid intake Health teaching & discharge planning Reinforce self care -hand washing, peri care, Reinforce self care -hand washing, peri care, Self-breast exam q month; S/S PPD Self-breast exam q month; S/S PPD Comfort Measures Ice, Sitz Baths, Topical Anesthetics Ice, Sitz Baths, Topical Anesthetics Analgesia, Kegels for NSVD; modified sit-ups for Analgesia, Kegels for NSVD; modified sit-ups for NSVD & C/S, Breast Care NSVD & C/S, Breast Care

41 Birth Control Plans Birth Control Plans Family Planning options [condoms, depo, OC’s, IUD] Exercises Keep 6 week PP appt. Maternal Warning Signs to Report a) Heavy Vaginal Discharge [poss. hemorrhage] a) Heavy Vaginal Discharge [poss. hemorrhage] b) Pelvic or perineal pain [traveling clot] b) Pelvic or perineal pain [traveling clot] c) Fever [temp or greater = infection] c) Fever [temp or greater = infection] d) Burning sensation during urination [UTI] d) Burning sensation during urination [UTI] e) Swollen area on leg ; painful, red, or hot e) Swollen area on leg ; painful, red, or hot f) Breast: painful, red, hot area [mastitis] f) Breast: painful, red, hot area [mastitis]

42 Infant care Infant care a] Bathing, cord care, circumcision care, diapering a] Bathing, cord care, circumcision care, diapering b] Feeding, burping, scheduling feedings [mom can keep chart] b] Feeding, burping, scheduling feedings [mom can keep chart] c] Temperature, skin color [dusky], newborn rash, jaundice c] Temperature, skin color [dusky], newborn rash, jaundice d] Stool & voiding [BM’s ; 6 or more voids/day] d] Stool & voiding [BM’s ; 6 or more voids/day] e] Back to Sleep [SIDS] Newborn warning signs: 1. Diarrhea, constipation 1. Diarrhea, constipation 2. Colic, repeated vomiting esp. projectile vomiting 2. Colic, repeated vomiting esp. projectile vomiting 3. Fever [temp Rectal or greater] 3. Fever [temp Rectal or greater] 4. S/S inflammation/ cord stump [yellow drng.] 4. S/S inflammation/ cord stump [yellow drng.] 5. circumcision site 5. circumcision site 6. Rash, jaundice 6. Rash, jaundice 7. Deviation from normal patterns [long period of sleep >5 hrs.; projectile 7. Deviation from normal patterns [long period of sleep >5 hrs.; projectile vomiting, etc. R/O sepsis; intestinal obstruction] vomiting, etc. R/O sepsis; intestinal obstruction]


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