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POST PARTUM Lecture 8 1.

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Presentation on theme: "POST PARTUM Lecture 8 1."— Presentation transcript:

1 POST PARTUM Lecture 8 1

2 Puerperium: “to bring forth” 6 wk > childbirth.
“4th trimester” - transition for woman/family (pregnancy ends/parenting role begins) 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 days. “INVOLUTION”. Pt. in danger of hemorrhage uterus until involution is complete. Oxytocin released > uterine contx’s. 2

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 1st day PP uterus 1 FB ↓ Umbilicus 2nd day PP uterus 2 FB ″ and so forth. Support lower segment of uterus when palpating to prevent uterine eversion. 3

4 Full bladder raises fundal height, gives false reading.
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. Natural oxytocin released with breast feeding. ^ contractions . 2FB ↓ umb. on 1st day PP. Breast fdg.offers little protection against hemorr. 4

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 ] exhaustion multi-fetuses. 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 . With Br. Fdg. because of release of oxytocin. 5

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

7 Neck; remains slightly opened & contracts > delivery.
3. CERVIX Neck; remains slightly opened & contracts > delivery. 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. 5. PERINEUM Can be edematous/ecchymotic Ice x 24 hrs. then heat [Sitz] Topical anesthetics creams/sprays apply for comfort. Perineal massage relaxes perineum before delivery. May prevent episiotomy/laceration. Teach Kegels - tightening & releasing of perineal muscles. Improves circulation & healing of epis/lac. 7

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

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

10 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. 10

11 ↓ bladder sensitivity - ↑ risk for bladder infection - urinary stasis.
The Urinary System: 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! ↓ 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. 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 1st wk. How? Diaphoresis & diuresis…. 11

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. Non pregnant: HCT= % & HGB= g/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. Patient should not be anemic entering delivery Possible blood transfusion with large blood loss. Average blood volume: pre-pregnant = 4000cc; pregnant state = 5250cc. 12

13 Can cause ^ thrombus formation.
^ Blood volume: provides adequate exchange of nutrients in placenta & compensates for blood loss during delivery. HR remains ^ x hrs. PP 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. To prevent hemorrhage. 13

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

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 15

16 T = 100.4 or > PP infection suspected.
VITAL SIGNS PP Temperature: slightly ^ - dehydration during labor 1st 24 hrs. Returns to normal within 24 hrs. T = or > PP infection suspected. 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] Pulse: HR ^ slightly x 1st hr. Stroke volume & cardiac output also ^ x 1st hr. then decreases 8-10 wks.,returns to pre-pregnant state. Rapid, thready pulse- sign of PP hemorrhage, infection 16

17 Blood Pressure - Monitor carefully. 1st trimester
Heart works faster to handle ^ volume. BP remains same. 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 BP back to pre-pregnant value. REVIEW: 17

18 BP Complications ↓ BP [90/60 or less] with dizziness is “Orthostatic hypotension”; could signify hemorrhage. Take BP/pulse lying/sitting/standing. Compare values. 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. ↑ BP [140/90 or >] could signify PP pre-eclampsia. Notify MD. Could develop into serious complication. Oxytocic meds [Pitocin] > delivery could ^ BP 18

19 RN coordinates nursing care & infant feeding times
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. Lactation delays menses for several months (6 mos) 19

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. 20

21 Woman gives up fantasy image of baby and accepts
Letting Go Phase: Woman gives up fantasy image of baby and accepts 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) 21

22 Other Maternal Feelings of Post Partum Period
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 . Post Partum Blues: d/t normal hormonal changes; Drop in estrogen/progesterone; lasts 1st few days of PP period. Occurs in 50% of women. 22

23 PP Depression: 30% of women exp. this.
Therapy & medication may be necessary. Hx of depression & anxiety prior to pregnancy puts higher risk for developing this. Can manifest itself up to 1 year > birth. Screening tool: Edinburgh PP depression tool 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? Studies show breast feeding helps reduce symptoms d/t oxytocin “feel good” effect 23

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

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

26 Development of Parental Love & Positive Family Relationships:
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. 26

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

28 Nurse has major role as educator of benefits & methods of
breast feeding. Ways to teach new moms about lactation: videos handouts hands on demo lactation specialist [in clinical settings] Offer support Contraindications to Breast Feeding: 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. Breast Cancer; HIV 28

29 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. Colostrum: middle of pregnancy & day 1-3 PP, Thin, watery pre-lactation secretion. Rich in antibodies; passes to baby in 1-3 days. Breasts begin to get tender; fill up w. milk. Breast milk by 3rd to 4th day in response to: falling levels of estrogen & progesterone > delivery of placenta. ^ production of prolactin by anterior pituitary Milk ducts become distended & fluid turns bluish-white 29

30 Physiology cont. 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]. Progesterone levels drop after delivery which leads to ↑ milk production. 30

31 Anatomy of Lactation Colostrum: protein, sugar, fat, water, minerals, vitamins, maternal antibodies. Provides total nutrition for infant Transitional breast milk by 3 – 4th day. Mature breast milk by 10th day. Each breast lobes of glandular tissue -alveoli. Acinar or alveolar cells of glands form milk. 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. 31

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

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. Assessment: Antepartum Changes Breasts enlarge [each breast gains ~ lb. or more] Glands enlarge Increased blood flow to breasts, causing blood vessels to enlarge & become more visible. 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. Teach moms no soap on nipples;may ^ irritation. Lanolin; tea bags [wet] [tanic acid] on sore nipples. 33

34 Engorgement : milk enters on 3rd - 4th day; C/S - prior to D/C
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. nursing bra. tight bra and ice packs x hrs– why? 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. Constrict ducts & stop flow & production of breast milk. 34

35 Plugged Duct Mastitis –
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. 35

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

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

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

Assessment – minimum of twice daily Vital signs Emotional Status Breasts Fundus, lochia, & perineum Voiding & bowel function - flatus, BM Legs [+ Homan’s sign, ankle edema ] S/S complications [PP hemorrhage, infection, ↑ BP ] Nursing Care Safety 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. 39

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

41 Family Planning options [condoms, depo, OC’s, IUD] Exercises
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] b) Pelvic or perineal pain [traveling clot] c) Fever [temp or greater = infection] d) Burning sensation during urination [UTI] e) Swollen area on leg ; painful, red, or hot f) Breast: painful, red, hot area [mastitis] 41

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

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