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39 Cards in this Set
- Front
- Back
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Care of the Postpartum Patient
Postpartal Adaptation • Uterus |
– Involution – return of the uterus to the non-pregnant state, if not it’s called sub-involution, should decrease about 1 fingerbreath each postpartum day, by day 6 it should be halfway there and not palpable by the 9th day, mother may experience after pains, especially when breast feeding due to the release of oxytocin
– Lochia – discharge of blood and debris following delivery, smaller amount present after a cesarean, should not move backwards in stages unless something is wrong and could indicate something like infection, continued serosa or alba could be endometriosis, could be indicative of lacerations, when lochia stops it means the cervix is closed – cannot have sex until then |
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Factors that influence involution
• Enhance involution |
– Uncomplicated L&D
– Breastfeeding – Early ambulation |
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Factors that influence involution
• Slow involution |
– Prolonged labor
– Difficult delivery – Overdistended uterus – Grand multiparity – Retained placental fragments – Full urinary bladder – Infection |
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Lochia
Rubra |
Bright red, bloody, may have small clots, characteristic fleshy odor (animallike scent), 1-3 days post partum, heavy to moderate flow
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Lochia
Serosa |
Pink to pink brown, serous, no clots, usually no odor (unless poor hygiene), 5-7 days post partum, decrease in flow
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Lochia
Alba |
Cream to yellowish, may be brownish, usually no odor (unless poor hygiene, 1-3 weeks post partum, scant flow
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Postpartal Adaptation
– Cervix |
can appear bruised with small lacerations, should regain shape by first week but external shape is permanently changed, should have diaphragm refitted
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Postpartal Adaptation
Vagina |
edemetus and bruised, should be normal within 6 weeks if not lactating, if breast feeding it may be pale and need increased lubrication
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Postpartal Adaptation
Perineum |
may be edemetus with bruising, episotomy may need to heal
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Postpartal Adaptation
Ovulation and Menstruation |
varies for each woman, non-lactating will usually return 6-8 weeks, if breast feeding it is prolonged and determined by length of time she breastfeeds and if formula supplements are used, if breastfeeding for less than one month it returns about the same as a non-breast feeder
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Postpartal Adaptation
– Abdominal wall |
loose and flabby but will respond to exercise within 2-3 months
• Diastasis recti – responds well to exercise • Striae - will not completely go away but will shrink and turn white/silver and be less noticeable |
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Postpartal Adaptation
– Cardiovascular |
occurs rapidly, bp should be similar to third trimester of pregnancy, if there’s a decrease below that we worry about hemorrhage, if it increases we are worried about pregnancy induced HT up to 6 weeks postpartum, will see a slight bradycardia which is normal, tachycardia is not normal and is a cause for concern
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Postpartal Adaptation
– Hematologic |
should return to normal by 6 weeks, coagulation is enhanced, h&h should remain close to the same as it was upon admission, if it decreases it could indicate hemorrhage, WBC’s will be high
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Postpartal Adaptation
– Urinary |
increased bladder capacity, decreased sensation, could lead to retained urine and incomplete emptying and build up of residual urine, if she had an epidural it will be even worse, output will increase because she needs to get rid of 3-4 liters of extracellular fluid within first day, fluid is lost during perspiration (often at night), every patient will have a cath order if she doesn’t urinate soon after delivery
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Postpartal Adaptation
– GI |
sluggish bowels, decreased peristalsis, fear of first bowel movement will cause constipation
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Postpartal Adaptation
– Endocrine |
lactation causes release of oxytocin to release prolactin, makes milk and let down reflex, colostrim is first milk, rich in proteins and immunoglobulins, usually always there but lacking in volume, needs to breastfeed q2-3hrs to promote the production of regular milk, engorged breast in 2-3days, RH negative mothers who delivery RH positive baby will need Rogham within 72hrs, if she’s non-rubella immune she needs to be immunized right before she leaves because her temperature will increased and she can’t be discharged
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Psychosocial Aspects
• Maternal Adjustment – Reva Rubin |
• Taking In – less than 12hrs at times, mother is preoccupied with her own needs, passive and dependent, hesitant to make decisions, sleep and food are priority, might not be ready to care for baby yet
• Taking Hold – ready to resume control over their body and mothering, anticipatory guidance is good now • Letting Go – won’t start until around 6 weeks postpartum, sees the baby as an individual |
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Psychosocial Aspects
• Maternal Adjustment Attachment |
bonding, begins during pregnancy, mother’s a fathers do this, watch to see if mother picks up on infant cues or makes negative remarks about the baby
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Nursing Care in the Postpartum
• Preparation for Assessment |
– Evaluate prenatal and intrapartal history for risk factors
– Provide privacy and have client void – Position client in bed with head flat – Proceed in head to toe fashion |
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Vital Signs
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• Temperature
– May be elevated initially after delivery • Exertion of labor and dehydration – Above 100.4 after first 24 hrs could mean infection • Pulse – Slight bradycardia (50-70) normal • Decrease in workload of heart – Persistant tachycardia (>100)- report • Respirations – Normal range – Watch for signs of pulmonary edema or pulmonary emboli • Blood pressure – Elevation with headache or visual disturbance = PIH – Slow progressive decrease with ^pulse = hemorrhage |
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Nursing Care in the Postpartum
• Assessment |
– BUBBLE-DEB
• Breasts • Uterus • Bladder • Bowel • Lochia • Epis/perineum • DVT • Emotional Status • Bonding |
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Nursing Care in the Postpartum
• Breast |
– Breast or bottle feeding? Need firm bra for support to prevent excessive swelling
– Palpate for engorgement or tenderness – Inspect nipples • Redness • Cracks • Erectility – if flat or inverted it could cause problems with breastfeeding |
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Nursing Care in the Postpartum
• Uterus |
– Nondominant hand over symphysis pubis, dominant hand over fundus
– Determine firmness, height of fundus, position in relation to midline – Measure height in fingerbreaths above, at, or below umbilicus – Inspect any abdominal incisions, if uterus is not palpable she needs to empty her bladder |
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Nursing Care in the Postpartum
• Bladder |
– Should void within 4-6 hours after delivery
– Assess frequency, burning, or urgency – Completely emptying bladder? – Palpate for bladder distention |
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Nursing Care in the Postpartum
• Bladder |
– Should void within 4-6 hours after delivery
– Assess frequency, burning, or urgency – Completely emptying bladder? – Palpate for bladder distention |
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Nursing Care in the Postpartum
• Bowel |
– Assess for passage of flatus
– Inspect for signs of distention – Auscultate bowel sounds in all 4 quadrants for post-op patients |
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Nursing Care in the Postpartum
• Lochia |
– Inspect
• Type – rubra, serosa, alba • Quantity – should partially saturate 6-8 pads per day, if she saturates a pad in an hour that is probably too much and could indicate a hemorrhage • Odor • Clots – Is this appropriate for PPD and type of delivery? |
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Nursing Care in the Postpartum
• Episiotomy or perineum |
– Edema or bruising in intact perineum
– Signs of hematoma – REEDA for incisions (epis/lac repair) – Hemorrhoids |
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Nursing Care in the Postpartum
• DVT |
– Inspect for pedal edema, redness, or warmth
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Nursing Care in the Postpartum
• Emotional Status |
– Are client’s emotions appropriate for situation?
– Phase of postpartal adjustment • Taking-in • Taking-hold • Letting-go – Assess for postpartum blues • Bonding – Touch – Enface position – Engrossment by father • Role Adaptation |
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• Promote nutrition and fluid intake
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– Non-lactating
– Lactating – everytime she breastfeeds she should be drinking something |
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• Deal with sexuality issues
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– Intercourse – no sex until lochea has stopped and episiotomy has healed, may need extra lubrication
– Contraception – do not rely on breastfeeding for birth control |
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Concerns of Adolescents
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Superimposed crisis on ongoing developmental crisis of adolescence
Completing cognitive task of learning to think more abstractly- Formal Operations consider more complex moral questions anticipate future events anticipate needs and feelings of others Teenagers are often awkward in social situations May mistrust authority May be preoccupied with own appearance |
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Concerns of Adolescents
Interventions |
Nurse needs to be aware of own feelings
Focus on a positive activity first Focus on Mom and not just the baby Start with her immediate concerns first Ask about the labor How does she feel about it Learn about home life What preparations have been made? Who will help? What about school? Consider feelings toward father of baby Probably not married Is there an ongoing relationship? If not, birth may be painful reminder of hurtful experience May expect boyfriend to come back now Baby may look a lot like father Disinterest may be a result of a number of factors Observe interactions Does she respond to infants needs? Tend not to initiate activity at first May be waiting for okay from nurse Positive reinforcement Avoid criticism Open discussion about contraception Future Goals Repeat rate as high as 40% in 1st year and 70 % by the 3rd year |
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Postpartum Psychiatric Disorder
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Adjustment reaction
Postpartum blues Postpartum Major Mood Disorder Postpartum depression Postpartum Psychosis Risk Factors Decreased levels of Estrogen and Progesterone Change in roles Added responsibilities Hostilities towards family Physical problems Sleep cycle disturbances Prevention Prenatal Education Identify helpful resources Maintain outside interests |
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Postpartum Psychiatric Disorder
Postpartum Blues |
Adjustment reaction with depressed mood
50-80% Characterized by: Mild depression interspersed with happier feelings Episodic tearfulness without reason Feel overwhelmed, unable to cope Occur within a few days of birth and self-limiting (1-10 days) Interventions Need to validate feelings Provide reassurance |
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Postpartum Psychiatric Disorder
Postpartum Depression |
Occurs in 8-26%
Anytime in 1st year postpartum Most often around 4th week At time of first menses or weaning Risk factors: History of pp depression or bipolar illness Body image and eating disorders Lack of social support or lack of stable relationships (parents, partner) PP Depression - Symptoms Sadness, frequent crying, appetite changes, insomnia, difficulty concentrating or making decisions, obbsessive thought of inadequacy, lack of interest in usual activities, lack of concern about personal appearance Feel like “I’m in a fog” PP Depression Disrupts the family Requires interventions to resolve Differentiated by number, intensity, and persistence of symptoms Consistently present for at least 2 weeks Not mood swings PP Depression - Treatment Medications Zoloft, Paxil, Prozac Individual or group psychotherapy |
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Postpartum Psychiatric Disorder
Postpartum Psychosis |
Rare but receives much attention
Basically severe depression due to dealing with a crisis Evident within first 3 months postpartum 10-25% recurrence rate in subsequent pregnancies Symptoms Agitation, hyperactivity, insomnia, mood lability, difficulty remembering or concentrating, irrationality, poor judgment, delusions, and hallucinations Infant is evil or better off dead Emergency due to risk of suicide or infantcide |
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Nursing Care for PP Psychiatric Disorder
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Observe client with baby and family
Sensitivity to infant cues Help client to verbalize feelings Provide anticipatory guidance Education Identify resources Recognize early signs of problems Support positive parenting behaviors Refer the client to social services if needed |
