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Maternal and Child Health Nursing Postpartum

MATERNAL and CHILD HEALTH NURSING POSTPARTUM Lecturer: Mark Fredderick R. Abejo RN, MAN

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I. PHYSIOLOGICAL MATERNAL CHANGES A. LOCHIA discharge from the uterus during the first 3 weeks after delivery. Increasing Lochia as the day passes by may indicate Heparin Intoxication.

LOCHIAL CHANGES LOCHIA RUBRA Dark red discharge occurring in the first 2-3 days. Contains epithelial cells, erythrocytes and decidua. Characteristic human odor. LOCHIA SEROSA Pinkish to brownish discharge occurring 3-10 days after delivery. Serosanguineous discharge containing decidua, erythrocytes, leukocytes, cervical mucus and microorganisms. Has a strong odor. LOCHIA ALBA Almost colorless to creamy yellowish discharge occurring from 10 days to 3 weeks after delivery. Contains leukocytes, decidua,epithelial cells, fat, cervical mucus, cholesterol crystals, and bacteria. Has no odor.

B. UTERUS Process of involution takes 4-6 weeks to complete. Weight decreases from 2 lbs to 2 oz. Fundus steadily descends into true pelvis; Fundal height decreases about 1 fingerbreadth (1 cm)/day; by 10-14 days postpartum, cannot be palpated abdominally.

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Maternal and Child Health Nursing Postpartum

C. Uterine Involution 1. Description a. The rapid decrease in the size of the uterus as it returns to the nonpregnant state b. Clients who breastfeed may experience a more rapid involution 2. Assessment a. Weight of the uterus decreases from 2 pounds to 2 ounces in 6 week b. Endometrium regenerates c. Fundus steadily descends into the pelvis d. Fundal height decreases about 1 fingerbreadth (1 cm) per day E. By 10 days postpartum, uterus cannot be palpated abdominally NOTE: Deviation of the fundus to the right or left and location of the fundus above the umbilical are signs that the bladder is distended NOTE: Height of the Umbilicus on the First Postpartum Day The height is usually SLIGHTLY below the umbilicus about 24 hours after delivery. The top of the umbilicus is normally MIDWAY between the umbilicus and the symphysis pubis.

D. Breasts 1. Breasts continue to secrete colostrum 2. A decrease in estrogen and progesterone levels after delivery stimulates increased prolactin levels, which promote breast milk production. 3. Breasts become distended with milk on the third day 4. Engorgement occurs in 48 to 72 hours in non breast feeding mothers. NOTE: Bradycardia is a normal physiologic change for 6-10 days postpartum

E. Gastrointestinal tract 1. Women are usually very hungry after delivery 2. Constipation can occur 3. Hemorrhoids are common

II.

POSTPARTUM NURSING INTERVENTIONS Monitor Vital Signs NOTE: Maternal temperature during the first 24 hours following delivery may rise to 100. 4` F (38`C) as a result of dehydration. The nurse can reassure the new mother that these symptoms are normal. Postpartum Exercise Supine Position with the knees flexed, and then inhale deeply while allowing the abdomen to expand and exhale while contracting the abdominal muscles. The purpose of this exercise is to strengthen the abdominal muscles. Examples are reaching for the knees; push ups and sits ups on the first postpartum day. Assess height, consistency, and location of the fundus Monitor color, amount, and odor of lochia Assess lochia and color volume Give RhoGAM to mother if ordered. RhoGAM promotes lysis of fetal Rh (+) RBCs. Administer RhoGam as prescribed within 72 hours postpartum to the Rh-negative client who has given birth to an Rh-positive neonate. Rhogam (D) immune globulin is given by intramuscular injection Check episiotomy and perineum for signs of infection. Promote successful feeding. Non-nursing woman- tight bra for 72 hours, ice packs, minimizes breast stimulation. Nursing woman- success depends on infant sucking and maternal production of milk. Postpartum Blues (3-7 days) Normal occurrence of roller coaster emotions

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Maternal and Child Health Nursing Postpartum

Sexual activities- abstain from intercourse until episiotomy is healed and lochia ceased around 3-4 weeks. Remind that Assess height, consistency, and location of the fundus breastfeeding does not give adequate protection. Assess breasts for engorgement Monitor episiotomy for healing ( assess dehiscence & evisceration) Assess incisions or dressings of cesarean birth client ( prone to infection) Monitor bowel status ( prone to constipation) Monitor I &0 Encourage frequent voiding (prevent urinary retention which will predispose the mother to uterus displacement & infection) Encourage ambulation ( to prevent thromboplebitis & paralytic ileus Assess bonding with the newborn infant ( to prevent failure to thrive) NOTE: A positive bonding experience is indicated when the mother turns her face toward the baby to initiate eye-to-eye contact. Observation of new mothers has shown that a fairly regular pattern of maternal behaviors is exhibited at first contact with the newborn. The mother follows a progression of touching activities from fingertip exploration toward palmar contact to enfolding the infant with the whole hand and arm. The mother also increase the time spent in the en face position. The mother arranges herself or the newborn so that her face and eyes are in the same plane as in her infant.

III.

POSTPARTUM DISCOMFORTS

A. Perineal discomfort Apply ice packs to the perineum during the first 24 hours to reduce swelling after the first 24 hours, apply warmth by sitz baths B. Episiotomy

1. Instruct the client to administer perineal care after each voiding 2. Encourage the use of an analgesic spray as prescribed 3. Administer analgesics as prescribed if comfort measures are unsuccessful C. Breast discomfort PREVENTION: The BEST PREVENTION TECHNIQUE IS TO EMPTY THE BREST REGULARLY AND FREQUENTLY WITH FEEDINGS. The 2nd is EXPRESSING A LITTLE MILK BEFORE NURSING, MASSAGING THE BREASTS GENTLY OR TAKING A WARM SHOWER BEFORE FEEDING MAY HELP TO IMPROVE MILK FLOW. Placing as much of the areola as possible into the neonates mouth is one method. Other methods include changing position with each nursing so that different areas of the nipples receive the greatest stress from nursing and avoiding breast engorgement, which make I difficult for the neonate to grasp. In addition, nursing more frequently, so that a ravenous neonate is not sucking vigorously at the beginning of the feedings, AND FEEDING ON DEMAND to prevent over hunger is helpful. AIRDRYING THE NIPPLES AND EXPOSING THEM TO THE LIGHT HAVE ALSO BEEN RECOMMENDED. Warm Tea bags, which contain tannic acid also, will sooth soreness. WEARING A SUPPORTIVE BRASSIERE DOES NOT PREVENT BREAST ENGORGEMENT. APPLYING ICE and LANOLIN DOES NOT RELIEVE BREAST ENGORGEMENT.

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Maternal and Child Health Nursing Postpartum

INTERVENTION: Measures that help relieve nipple soreness in a breast-feeding client include lubricating the nipples with a few drops of expressed milk before feedings, applying ice compresses just before feedings, letting the nipples air dry after feedings, and avoiding the use of soap on the nipples. NOTE: Specific nursing care for breast Engorgement 1. Breastfeed frequently 2. Apply warm packs before feeding 3. Apply ice packs between feedings NOTE: Specific Nursing Care for Cracked nipples 1. Expose nipples to air for 10 to 20 minutes after feeding 2. Rotate the position of the baby for each feeding 3. Be sure that the baby is latched on to the areola, not just the nipple NOTE: Do not use soap on the breasts, as it tends to remove natural oils, which increases the chance of cracked nipples

IV. A.

POST PARTUM COMPLICATIONS HEMORRHAGE SIGNS OF HEMORRHAGE Boggy uterus (does not respond to massage) A boggy uterus would be palpable above the umbilicus and would be soft and poorly contracted. Abnormal clots unusual pelvic discomfort or headache Excessive or bright-red bleeding Signs of shock Early Hemorrhage starts on the first 24 hours, or more than 500 ml of blood on the first 24 hrs in a Normal spontaneous delivery.. MANAGEMENT Fluid replacement Emergency lay Oxygen Vital signs Perineal pad count Psychological support Massaging the lower abdomen after delivery is done to maintain a firm uterus, which will aid in the clumping down of blood vessels in the uterus, thereby preventing any further bleeding. BOGGY UTERUS Uterine atony means that the uterus is not firm or it is not contracting. The nurse should gently massage the uterus which will contract the uterus and make it firm. Clients who are predisposed are usually MULTIPLE GESTATION, POLYHYDRAMNIOS, PROLONGED LABOR and LGA (LARGE GESTATIONAL AGE fetus.

CAUSES The #1 cause of POSTPARTUM HEMORRHAGE IS RETAINED PLACENTAL FRAGMENTS. Uterine atony and vaginal & cervical tears are associated with early postpartum hemorrhage The #2 cause is OVERDISTENTION OF THE UTERUS from more than (10) pounds, OTHERS ARE: 4000 gms, neonate, excessive oxytocin use, Polyhydramnios and Placental Disorders.

You should assess for uterine atony after a c-section delivery. This is more common after a csection than after a vaginal delivery.

B. THROMBOPLEBITIS Inflammation of the vein caused by a clot The positive Homans sign indicate is possibility of thrombophlebitis or a deep venous thrombosis that is present in the lower extremities. When assessing for Homans sign ask the patient to stretch her kegs out with the knee slightly flexed while dorsiflex the foot. A positive sign is present when pain is felt at the back of the knee or calf. It is normal for a patient on magnesium sulfate to feel tired because it acts as a central nervous depressant and often makes the patient drowsy.

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Maternal and Child Health Nursing Postpartum

MANIFESTATION Edematous extremities Fever with chills Pain and redness in affected area Positive Homans sign

MANAGEMENT Preventive

CURATIVE Immobilize extremity Analgesics Anticoagulant Thrombolytics

C. INFECTION PREDISPOSING FACTORS Rupture of membranes over 24 hours before delivery Retained placental fragments Internal fetal monitoring Vaginal infection MANIFESTATION Fever Chills Poor appetite General body malaise Abdominal pain Foul-smelling lochia Puerperial infection is an infection of the genital tract. Early signs and symptoms of puerperial infection include chills, fever, and flu-like symptoms. It can occur up to one month after delivery. MANAGEMENT Antibiotics Oxytocin Analgesics Maintain hygiene Semi-fowlers positions Vital signs Early ambulations Assess lochia Bright red blood is a normal lochial finding in the first 24 hours after delivery. Lochia should never contain large clots, tissue fragments, or membranes. A foul odor may signal infection, as may absence of lochia.

D. MASTITIS

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Maternal and Child Health Nursing Postpartum

ASSESSMENT Elevated temperature, chills, general aching, malaise and localized pain Engorgement, hardness and reddening of the breasts Nipple soreness and fissures Inflammation of the breast as a result of infection Primarily seen in breastfeeding mothers 2 to 3 weeks after delivery but may occur at any time during lactation

MANAGEMENT Instruct the mother in good hand washing and breast hygiene techniques Apply heat or cold to site as prescribed Maintain lactation in breastfeeding mothers Encourage manual expression of breast milk or use of breast pump every 4 hours Encourage mother to support, breasts by wearing a supportive bra Administer analgesics & antibiotics as prescribed

E. Postpartum Mood Disorders MOOD DISORDERS Postpartum Blues ASSESSMENT Onset: 1-10 days postpartum lasting 2 weeks or less Fatigue Weeping anxiety Mood instability Onset: 3-5 days lasting more than 2 weeks Confusion Fatigue Agitation Feeling of hopelessness and shame let down feeling Alterations in mood roller coaster emotions Appetite and sleep disturbance According to Rubin, dependence and passivity are typical during the takingin period, which may last up to 3 days after delivery. A client experiencing postpartum depression demonstrates anxiety, confusion, or other signs and symptoms consistently. Maternal role attainment occurs over 3 to 10 months. Attachment also is an ongoing process that occurs gradually.

Postpartum Depression Normal processes during postpartum include the withdrawal of progesterone and estrogen and lead to the psychological response known as "the blues." Postpartum depression is a psychiatric problem that occurs later in postpartum and is characterized by more severe symptoms of inadequacy. Because the client's behavior is normal, notifying her physician and conducting a home assessment aren't necessary. Postpartum Psychosis

Onset: 3-5 days postpartum Symptoms of depression plus delusions Auditory hallucinations Hyperactivity

POSTPARTUM WARNING S/S TO REPORT TO THE PHYSICIAN Increased bleeding, clots or passage of tissue. Bright red vaginal bleeding anytime after birth. Pain greater than expected. Temperature elevation to 100.4 F. Feeling of full bladder accompanied by inability to void. Enlarging hematoma. Feeling restless accompanied by pallor; cool, clammy skin; rapid HR; dizziness; and visual disturbance. Pain, redness, and warmth accompanied by a firm area in the calf. Difficulty breathing, rapid heart rate, chest pain, cough, feeling of apprehension, pale, cold, or blue skin color

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Maternal and Child Health Nursing Postpartum

V.

Psychological Adaptation

Psychological Adaptation

Taking-in Phase Taking-hold Phase Letting-Go

Postpartum blues: overwhelming sadness Postpartum depression Postpartum Psychoses

Rubin's Postpartum Phases of Regeneration (POSTPARTUM PSYCHOSOCIAL ADAPTATION) TAKING IN PHASE (DEPENDENT) First 3 Days During this time, food and sleep are a major focus for the client. In addition, she works through the birth experience to sort out reality from fantasy and to clarify any misunderstandings. This phase lasts 1 to 3 days after birth. The primary concern is to meet her own needs. Takes place 1-2 days postpartum Mother is passive and dependent; concerned with own needs. Verbalizes about the delivery experience. Sleep/food important. Mother focuses on her own primary needs, such as sleep and food Important for the nurse to listen and to help the mother interpret the events of delivery to make them more meaningful Not an optimum time to teach the mother about baby care TAKING HOLD PHASE (DEPENDENT/INDEPENDENT) The client is concerned regarding her need to resume control of all facets of her life in a competent manner. At this time, she is ready to learn self-care and infant care skills.

3-10 days postpartum Mother strives for independence and begins to reassert herself. Mood swings occur. May cry for no reason. Maximal stage of learning readiness. Mother requires reassurance that she can perform tasks of motherhood. Begins to assume the tasks of mothering An optimum time to teach the mother about baby care.

LETTING GO PHASE (INTERDEPENCE) 10 to 6 weeks postpartum Realistic regarding role transition. Shows pattern of life-style that includes the new baby but still focuses on entire family as a unit. Accepts baby as separate person. Mother may feel deep loss over separation of the baby from part of the body and may grieve over the loss Mother may be caught in a dependent/independent role, wanting to feel safe and secure yet wanting to make decisions Teenage mothers need special consideration because of the conflict taking place within them as part of adolescence

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Abejo