N106

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N106

• Nursing Care of
• Post Partum Mother

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Physical Changescardiac respiratory

• Cardiac
• Heartpositionoutput
• Fluid volume
• VS

• Respiratory
• Pulmonary function
• BMR

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Physiological ChangesGU Reproductive System

• Urinary
• Genitalia
• Involution of uterus Decent After
  painsLochiaCervix, Vagina, PerineumReturn of
  menses

4
Measurement of descent of fundus for the woman
with vaginal birth.
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Involution of the uterus. A, Immediately after
delivery of the placenta, the fundus is midline
and halfway between the symphysis pubis and the
umbilicus. B, About 6 to 12 hours after birth,
the fundus is at the level of the umbilicus. It
then descends one finger breadth (approximately 1
cm) each day.
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Suggested guideline for assessing lochia volume.
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BUBBLEHE Assessment

• Breasts Soft, filling, firm, Nipples
• Uterus consistency, position, height, C/S
• Bladder voiding pattern
• Bowels bowel sounds, hemorrhoids, BM
• Lochia type, amt, clots, odor
• Episiotomy laceration, bruising, swelling
• Homan sign present or not
• Emotional status bonding, blues

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REEDA Scale for Incisions

• Redness
• Edema
• Ecchymosis
• Discharge
• Approximation

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Physical Changes PP

• Gastrointestinal
• Appetite
• Gastric motility
• BM resumes
• Constipation r/themorrhoids, trauma,
  dehydration, pain, fear, immobility, meds

• Musculoskeletal
• Joint stabilization
• Abdominal wall

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Physical Changes PP

• Integumentary
• Endocrine
• Neurological
• Hematological

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Psychosocial Needs

• Promoting bonding
• Rubins PhasesTaking in wants to be
  taken care of Taking hold takes
  charge Letting go more realistic

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Post Partum Blues

• Is normal, mild, transient condition affects
  50-70 of women
• Begins 3-4 days after childbirth, peaks on the
  4-5 day and resolves within 2 wks
• Symptoms insomnia, fatigue, tearfulness, mood
  instability, anxiety
• Nursing care encouraged to rest, take care of
  self, discuss feelings, it is self-limiting

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Cesarean Care

• TCDB
• NPO, ice chips usually 12 hrs
• Ambulate 12 hours
• Foley D/C after 24 hours
• IV until tolerating diet
• Dressing removed 24hours
• Sutures removed 1 week after delivery
• When home rest, good nutrition, mild exercise

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Nursing Care

• Review teaching info syllabus p. 38-41
• Involution 6-7 weeks
• Decent of uterus midline and descend 1cm/d
• Lochia unique healing no scarrubra 2-3 days
  - dark red with small clotsserosa 4-10 days
  pink to brownishalba 1-6 weeks cream-white
• Cervix never the same
• Perineum if episiotomy, takes 3-6 weeks

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Nursing Care - Teaching

• Bladder diuresis first 24 hours
• Stomach resume exercise after Dr says
• Menstruations 6 weeks, delayed with lactating
  mothers, STILL ovulate
• Sex resume after first menstruation, after
  episiotomy some loose interest for one year
• Rest, Rest, Rest

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Breastfeeding

• Colostrum is produced during pregnancy and
  immediately after birth, contains antibodies
• Replaced in 2-4 days with milk
• Teach clean breast first in shower, proper
  positioning, release suction with finger, avoid
  soap on nipples, disposable bra pads, SS of
  complications redness, swelling, fever,
  tenderness, cracked nipples (usually mastitis
  unilateral)

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LATCH was created to provide a systematic method
for breastfeeding assessment and charting.
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Complications

• Hemorrhage Hgb lt 9 requires Tx atony- most
  common cause is full bladderlaceration
  bleeding with firm uterusplacenta fragments
  bleeding returns to rubra or foul odor noted
  more common with Dirty Dunkin
• Infection Temp above 100.4 Furinarymastitis
• Thrombophlebitis pain and redness, Homan
  send for venous scanpulmonary embolism sudden
  onset chest pain, SOB

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Post Partum Hemorrhage

• Loss of blood more than 500 cc vaginal birth,
  C/S 1000 cc lost
• Most common cause uterine atonyothers are
  retained placenta fragments, or infection,
  hematoma, lacerations
• Tx initial is fundal massage
• S S saturate more than one pad/hr, boggy
  uterus, increased lochia with clots, severe
  perineal pain (with hematoma), tachycardia,
  hypotension

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Manual compression of the uterus and massage with
the abdominal hand usually will effectively
control hemorrhage from uterine atony.
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Manual removal of placenta. Performed only by
the medical clinician.
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Nursing Care of PP hemorrhage

• Inspect placenta for missing parts
• Administer oxytocics
• Maintain IV line
• Apply ice to perineum
• Keep bladder empty
• Massage fundus if boggy
• Monitor lochia with amount and type
• Discharge teaching report if return to rubra,
  fever over 100.4, foul smelling lochia, flu-like
  symptoms

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Puerperal Infection

• Fever over 100.4 after the first 24 hours and
  lasting 2 days or more
• Chills, flu-like symptoms, elevated WBC (over
  30,000), tachycardia
• Types of infectionsreproductive tract back
  ache, abd pain, foul smelling lochia, purulent
  dischargewound infection erythema, warmth,
  swelling, tenderness, drainage.

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Mastitis. Erythema and swelling are present in
the upper outer quadrant of the breast.
Axillary lymph nodes are enlarged and tender.
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PP Infections

• UTI pain, burning, urgency or freq of urine
• Mastitis erythema, warmth in breast, flue-like
  symptoms
• Diagnosis with culture, vag exam, CBC
• Nursing care assess VS, lochia, incisions,
  attend to pain, ensure food and fluid intake,
  obtain specimens, monitor response to antibiotic.

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Thrombophlebitis

• Inflammation of vessel wall with thrombus
• Causes stasis and hypercoagulability
• Typessuperficial venous thrombus reddened,
  warm, swollendeep vein thrombosis occurs in
  larger veins, positive Homans, pain
• Risk factors immobility, C/S, PIH, DM, smoking,
  over 40 yr, multiparity, anemia
• Prevent early ambulation and hydration

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Nursing Care Thrombophlebitis

• Bedrest with leg elevated
• Change positions frequently, not flexed knees
• Teach no to rub area
• Daily measurements of calf and thigh
• Support stockings, moist heat application
• Assess for complication embolism, SS of
  pulmonary embolism

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Rh Incompatibility

• Antibodies cross placenta and attach to fetal red
  blood cells destroying them

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Rh Incompatibility

• Mother Rh- negative and fetus Rh positive
• If Rh positive blood enters system of Rh negative
  mother reacts by developing antibodies to destroy
  RBCs with Rh positive antigens
• Blood may mix during third stage of labor
• First child not effected

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Rh isoimmunization sequence. Rh-positive father
and Rh-negative mother.
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As the placenta separates, the mother is further
exposed to the Rh-positive blood.
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Anti-Rh-positive antibodies (triangles) are
formed.
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In subsequent pregnancies with an Rh-positive
fetus, Rh-positive red blood cells are attacked
by the anti-Rh-positive maternal antibodies,
causing hemolysis of the red blood cells in the
fetus.
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RhoGAM

• Rho (D) immune globulin suppresses the
  stimulation of active immunity by Rh-positive
  foreign RBC
• Given IM at 28 weeks antepartum and within 72
  hours of delivery 1 vial
• Before 13 weeks give ½ dose after amniocentesis,
  miscarriage, ectopic pregnancy

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Before Administration

• Never administer intravenously
• Never administer to a neonate
• Never administer to an Rh negative patient who
  has been previously sensitized to the Rh antigen
• Confirm that the mother is Rh negative
• Confirm infant is Rh positive and assess direct
  coombs test

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Coombs Test

• Indirect coombs test on mother to determine the
  presence of antibodies against fetal blood.
• If the test is positive, amniocenteses may be
  performed to determine the fetal Rh factor and
  degrees of hyperbilirubinemia.
• Direct coombs test is performed on the cord
  blood. Positive coombs test indicates that
  antibodies from the mother have attached to the
  infants RBC. Bilirubin levels are followed
  closely for changes that indicate that treatment
  should be initiated or changed.

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Postpartum Depression/Psychosis

• Postpartum depression- 15-25 - all ethnic groups
  affected.
• Cause unknown, may be r/t hormonal, exhaustion,
  anger, chronic stress
• SS starts first 4 wks and last several months,
  fatigue, loss of self, suicide thoughts crying
• TX combination of psychotherapy, social, meds
• Postpartum psychosis- rare, bipolar disorder or
  major depression, frightening thoughts, delusions
  of dead baby and hallucinations, need psychiatric
  Tx, will not resolve itself

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Infant Care

• Cord care
• Diapering
• feeding
• Stools
• Urine
• Baths
• How to take temp