POST PARTUM Lecture 8 1

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 8-10 days. “INVOLUTION”. Pt. in danger of hemorrhage uterus until involution is complete. Oxytocin released > uterine contx’s. 2

Fundus: assess for firmness. Palpate > delivery. Remains @ umbilicus X 24 hrs. Soft aka “boggy” - danger of hemorrhage. Massage uterus! Uterus descends one finger breadth every day. Delivery day, uterus @ 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

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

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

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

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

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

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

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

↓ 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., 2000-3000 ml. of fluid accumulates in body - Client loses 5- 10 lbs. of water weight in 1st wk. How? Diaphoresis & diuresis…. 11

Circulatory System: Blood volume ^ 30 – 50% in pregnancy. With diuresis & blood loss @ delivery, blood volume returns to normal in 1-2 wks. Blood loss for NSVD = 300 cc. & C/S = 500 cc. Non pregnant: HCT=37 - 47% & HGB=12 - 16g/dL Pregnant: HCT=32 -42 % & 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

Can cause ^ thrombus formation. ^ Blood volume: provides adequate exchange of nutrients in placenta & compensates for blood loss during delivery. HR remains ^ x 24-48 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

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

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

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 = 100.4 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 100.4 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

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

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 15-20 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

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 - 2-3 lbs. Total = approx. 19-20 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

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 2 - 3. Occur on day 1 esp. if woman is multip. Can occur later, depends on recovery process or cultural beliefs. 20

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, separation @ birth (NICU) 21

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

PP Depression: 30% of women exp. this. Therapy & medication may be necessary. Hx of depression & anxiety prior to pregnancy puts mother @ 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

MANIFESTATIONS OF POSTPARTUM DEPRESSION  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

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. 631-422-2255 www.postpartumNY.org MANIFESTATIONS OF POSTPARTUM PSYCHOSIS s/s depression s/s manic auditory hallucinations delusions guilt worthlessness 25

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 & BREAST FEEDING 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

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

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

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

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 - 15-20 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

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

Supply & Demand Response - Every time woman breast feeds, more prolactin produced which then produces ^milk. Time Interval to ↑ milk volume. It takes approx. 30-60 min. to fill up breast after nursing. Assessment: Antepartum Changes Breasts enlarge [each breast gains ~ 0.5 - 0.9 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

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 24-36 hrs– why? Analgesics [Tylenol 650 mg. q 4 - 6 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

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

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

Health Teaching Rooting – sign of hunger Breast feed q 2-3 hrs. for 20-30 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

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

NURSING MANAGEMENT OF POST PARTUM CLIENT 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

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

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 100.4 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

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. 100.0 Rectal or greater] 4. S/S inflammation/ infection @ cord stump [yellow drng.] 5. Bleeding @ 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