POSTPARTUM ASSESSMENT AND NURSING CARE

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POSTPARTUM ASSESSMENT AND NURSING CARE

• CHAPTER 13

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POSTPARTUM PERIOD

• Puerperium-6 wks.-from childbirth to return of
  uterus and other organs to pre-pregnant state.
• Immediate postpartum- first 24 hours
• Early postpartum-first week
• Late postpartum-after the first week-6th week

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GOALS OF POSTPARTUM CARE

• Assist and support recovery -educate mom about
  self-care and infant care
• After the initial dangers of hemorrhage and shock
  are past, the primary danger is infection
• REVIEW Clinical Pathway 13-1Postpartum Care

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INVOLUTION OF THE UTERUS

• Rapid reduction in size and return of the uterus
  to the pre-pregnant state
• Exfoliation is a unique healing process enables
  the placental site to heal without scarring.
  Future ova will implant in an unscarred uterus.
• Endometrial regeneration - 3 wks. Placental site-
  6 wks.

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DESCENT OF THE UTERINE FUNDUS

• Fundal height-measured in fingerbreadths or cm in
  relation to the umbilicus, used to assess the
  rate of uterine involution, figure 13-1,A B,
  and procedure 13-1
• Afterpains-occur first 2-3 days pp and uterine
  cramping occurs when breastfeeding. Muscles
  contract and relax

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CHARACTERISTICS OF LOCHIATable 13-1

• LOCHIA RUBRA- days 1-3- RED
• LOCHIA SEROSA- days 4-9 PINKISH BROWN
• LOCHIA ALBA- day 10-3wks.-WHITE

• Fig 13-2 AMOUNT size of area stain on peri pad
  in 1 hour
• Scant - 2 inch (10ml)
• Small or slight -4 inch (10-25ml)
• Moderate -6 inch ( 25-50ml)
• Heavy or large - gt 6 inch (50-80ml)
• Excessive pad saturated within 15 minutes

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Changes in the Reproductive System

• Vagina
• within 6 weeks the vagina almost returns to
  its prepregnancy form
• Perineum
• depends on whether there has been an episiotomy
  done. May be very edematous
• if done use the acronym, REEDA for assessment
• R-redness, E-edema, E-ecchymosis or bruising,
  D-discharge, A-approximation of the wound
• skill 13-2 assessing the perineum

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Changes in the Musculoskeletal System

• Lower extremeties
• due to venous stasis the woman is at risk for
  blood clots, do Homans sign

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CARDIOVASCULAR SYSTEM CHANGES

• EXCESS BLOOD VOLUME IS DISPOSED OF IN TWO WAYS
• DIURESIS-(POLYURIA) 3000 ML. PER DAY POSSIBLE
• DIAPHORESIS-(PROFUSE SWEATING)

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VITAL SIGNS

• FIRST 24 HOURS-100.4F. NORMAL DUE TO EXERTION AND
  DEHYDRATION. AFTER 24 HR. SHOULD BE AFEBRILE- IF
  NOT, MAY BE INFECTION REPORT TO M.D.
• PULSE 50-70, IF ELEVATED MAY MEAN EXCESSIVE BLOOD
  LOSS, INFECTION, PAIN, ANXIETY, CV DISEASE

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BLOOD PRESSURE

• SHOULD REMAIN STABLE
• DECREASE- EXCESSIVE BLOOD LOSS
• INCREASE W/ HEADACHE MAY PIH, A LEADING CAUSE
  OF MATERNAL DEATH- MONITOR AND CALL M.D.

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CHANGES IN THE URINARY SYSTEM

• BLADDER- LOSES MUSCLE TONE HAS INCREASED
  CAPACITY
• URETHRA, BLADDER, URINARY MEATUS BECOME EDEMATOUS
  TRAMATIZED
• DIMINISHED AWARENESS DUE TO ANESTHESIA, BLADDER
  FILLS DISPLACES THE UTERUS

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FAST FOCUS 13-1,SIGNS OF DISTENDED BLADDER

• FUNDUS ABOVE UMBILICUS
• FUNDUS TO ONE SIDE
• BULGE OF BLADDER ABOVE SYMPHYSIS
• EXCESSIVE LOCHIA
• TENDERNESS OVER BLADDER AREA
• FREQUENT VOIDINGS -LESS THAN 150CC

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Changes In the GI system

• CONSTIPATION
• Decreased peristalsis from progesterone
• lack of solid food and limited fluid intake
• fear of pain from hemorrhoids and episiotomy
• common problem in PP period
• stool softeners and laxatives prescribed and
  administered

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ENDOCRINE CHANGES

• AFTER EXPULSION OF PLACENTA, ESTROGEN
  PROGESTERONE LEVELS DECREASE
• LACTATION BEGINS IS MAINTAINED WITH THE INFANT
  SUCKLING
• MENSTRUAL CYCLE FUNCTION RETURNS

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SUPPRESSION OF LACTATION

• IF NOT BREASTFEEDING, AVOID ANY BREAST
  STIMULATION- NO INFANT SUCKLING OR PUMPING OF
  BREASTS
• A SUPPORTIVE BRA MAY HELP WITH ENGORGEMENT
• MENSES -NONLACTATING-7-9 WKS.
• LACTATING-APPROX. 3 MO.

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WEIGHT LOSS

• Immediate loss- 10-12 lbs from loss of fetus,
  placenta amniotic fluid
• 5 or more lbs from diuresis and diaphoresis
• 5 to7 lbs are stored for lactation needs, if not
  lactating, may not lose this extra wt as quickly
• exercises are encouraged to lose the wt gained
  during pregnancy to increase muscle tone

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RUBINS TAKING-IN AND TAKING-HOLD PHASES

• Taking-in birth to as much as 2 days PP,
  Passive, dependent behavior. Focuses on her needs
  and health of infant
• Taking-hold asserts independence, participates
  in infant care, becomes exhausted and verbalizes
  anxiety
• third stage is letting-go maternal role, maybe
  PP BLUES

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MATERNAL ROLE-ACCORDING TO MERCER

• ANTICIPATORY STAGE-during pregnancy
• FORMAL STAGE- infant is born
• INFORMAL STAGE-mother makes her own choices about
  mothering
• PERSONAL STAGE-at 3-10 months, does what she is
  comfortable with

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POSTPARTUM BLUES

• OCCURS FIRST FEW DAYS
• TEARFULNESS, INSOMNIA, LACK OF APPETITE, A
  FEELING OF LET-DOWN
• SUPPORT, GUIDANCE, AND REASSURANCE ARE HELPFUL,
  IF INTENSE MOOD SWINGS, FURTHER EVALS ARE
  NECESSARY

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CARE MANAGEMENT AFTER DELIVERY

• First 1-2 hours recovery period
• every 15 minutes v/s, fundal assessment,
  amount of bleeding
• Once taken to the PP unit
• baseline assessment
• assessment of clients level of knowledge
  continuation of teaching as applicable

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Postpartum Check

• Table 13-3
• Ambulation encouraged, but needs assistance for
  the 1st time out of bed
• Postpartum Chill women often experience a
  shaking, uncontrollable chill immediately after
  birth. Unknown cause. Assure mother that this
  is normal will pass

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PROMOTING COMFORT

• Sit on a pillow
• Use an ice pack
• Moist or dry heat
• Topical applications may be ordered
• Cleanse perineum with a squeeze bottle
• warm showers, sitz baths, skill 13-4

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PARENT-INFANT ATTACHMENT

• FAST FOCUS13-2
• CUDDLES INFANT
• MAKES EYE CONTACT
• SPEAKS SINGS TO INFANT
• ADMIRES INFANT, CALLS BY NAME
• STROKES AND MASSAGES INFANT

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SIBLING PREPARATION FOR BABY

• Box 13-1
• ENCOURAGE TO FEEL FETUS MOVE
• TAKE ON PRENATAL VISIT
• INCREASE INVOLVEMENT OF FATHER WITH THE CHILD
• GIVE A GIFT TO CHILD WHEN BABY COMES HOME

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Postpartum Discharge InstructionsTable 13-4

• WASH BREASTS WITH CLEAR WATER TO REDUCE DRYING,
  CRACKING OF NIPPLES-AIR DRY FOR 15 MIN.
• WASH PERI AREA FRONT TO BACK APPLY PADS FRONT TO
  BACK
• DO NOT RUB OR MASSAGE LEGS FOR RISK OF EMBOLI OR
  THROMBI

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AMBULATION

• REDUCES RISK OF INFECTION OR THROMBOSIS
• LESSENS CHANCE OF RESPIRATORY, CIRCULATORY, AND
  URINARY PROBLEMS
• LESSENS CONSTIPATION
• PROMOTES RETURN OF STRENGTH

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NUTRITIONAL STATUS

• THREE WELL-BALANCED MEALS QD
• HIGH FIBER DIET
• INCREASE CALORIES BY 500 PER DAY IF BREASTFEEDING
• INCREASE FLUIDS, MILK SUPPLY
• AVOID GAS-FORMING FOODS

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Postpartum Discharge Instructions

• Start slowly with activities, most will return to
  normal by 4-5 weeks-back to work 6 wk
• Sexual intercourse when lochia has ceased,
  episiotomy is healed, and when woman is
  ready(from 3-6 weeks)
• Contraception begin prior to 1st intercourse
  may become pregnant even if havent had 1st
  menses yet breastfeeding NOT an effective form
  of birth control

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Postpartum Discharge Instructions

• Follow up care within 2-6 weeks of delivery see
  fast focus 13-3 PP Danger Signs
• Newborn care
• prior to dc from hospital ensure these things
  are known how to take babys temp, give bath,
  feed, change burp the baby, care for the cord,
  when to go for follow up, immunization plan,
  have a car seat

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PP EXERCISES

• TIGHTENING BUTTOCKS-AVOIDS DIRECT TRAUMA TO
  PERINEUM
• KEGEL EXERCISES-PERINEAL TIGHTENING, PROMOTES
  HEALING
• PELVIC TILT-RELIEVES STRAIN ON LOWER BACK,
  STRENGTHENS BACK MUSCLES

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VACCINES

• RUBELLA VACCINE MAY BE GIVEN DURING POSTPARTUM
  PERIOD TO PROTECT NEXT FETUS. MUST NOT GET
  PREGNANT FOR 3 MONTHS!
• RH NEG.WOMAN MAY RECEIVE RHOGAM WITHIN 72 HOURS
  FOR HEALTH OF NEXT CHILD IF INFANT IS RH POSITIVE