Cesarean Section Delivery Heather Brigance, MSN, ARNP, CNM 1 C Section Information and Video: http://pennmedicine.adam.com/content. aspx?productId=14&pid=14&gid=000134 2 Cesarean Section Delivery Cesarean section is the delivery of the infant through an abdominal surgical incision. Cesarean birth delivery rate reported at 32% about 1/3 births! Maternal risk is higher than with a vaginal birth There is increased risk for infection, bleeding There is an increase in length of hospitalization Increased recovery time Increased pain for the mother There is an increase in the financial cost There is an increased maternal mortality and morbidity risk in subsequent pregnancies Neonates are at higher risk for respiratory complications Healthy People 2020 calls for lowering c-section rates 3 Indications for C-Section: Fetal Distress Non reassuring fetal heart rate patterns Cephalopelvic Disproportion (CPD) The fetal head (cephalo-) and the maternal pelvis (pelvic) are disproportionate (don’t fit) True CPD is rare – pelvic deformities, very large fetus, fetal head anomalies like hydrocephalus or tumor, conjoined twins Fetal position Breech/ face/ transverse presentations Active genital herpes lesions or + history with prodromal symptoms Failure to progress in labor – case by case Maternal illness Severe unstable hypertension, severe anemia, infection 4 Emergency / medical indication… Placenta Previa Symptoms: • Painless episodic vaginal bleeding after 20 weeks, usually bright red • Can be without bleeding • Identified on ultrasound • No vaginal exams / no intercourse • Monitor for blood loss Vital signs • CBCs https://www.youtube.com/ watch?v=dFkIoeiN_lo • 5 Prolapsed Cord Cord compression causes fetal hypoxia Immediate intervention required Manual decompression O2 via mask Knee-chest position or bed in Trendelenberg position Urgent/ stat cesarean delivery May administer tocolytic as ordered by CNM/OB https://youtu.be/ZrIvF1H 6 mYNA Placental Abruption Risk factors Hypertension Seizures Uterine rupture Trauma Smoking Cocaine use Coagulation defects History of abruption Placental pathology Abruptio placentae is separation of the placenta from the uterine wall before delivery leading to fetal hypoxia Symptoms Vaginal bleeding dark red (can be concealed) Maternal abdominal pain/ tenderness to palpation Firm/rigid uterus Fetal distress Late decelerations Decreased utero-placental blood flow https://www.youtube.com/watch?v=CLI43qRqcj w 7 Uterine Rupture Risk factors: Signs and Symptoms Prior cesarean(s) Sudden fetal distress Prior uterine surgery Prior D&C Acute and continuous abdominal pain Vaginal bleeding Prior rupture Uterine anomalies Irregular abdominal contour Multiparity Loss of fetal station Induction with excessive stimulation Crack cocaine use https://www.youtube.com/watch?v= 3NOVCpIDWdE Management Emergency cesarean – only 10-30 minutes before major fetal morbidity occurs 8 Planning for C-section All childbirth classes discus the possibility of c-section Pre-op Care Obtain informed consent/ Pre-op checklist NPO to prevent maternal aspiration Antacid given to prevent acid aspiration pneumonia IV started with large gauge IV ( 18-20 gauge) Isotonic fluid NS or Lactated Ringers Foley catheter inserted to prevent bladder trauma Abdominal skin prep Antibiotic prophylaxis Nursery team and warmer in OR to receive newborn 9 Anesthesia Regional blocks most commonly used Epidural Anesthetic or analgesic can be administer into the epidural space Catheter can be left in place for pain control after surgery Major side effect – hypotension Spinal Injection of an anesthetic in the subarachnoid space Monitor that sensation has returned to lower extremities Major side effect – hypotension and headache 10 General Anesthesia Reversible state in which the patient loses consciousness as a result of the inhibition of neuronal impulses in the brain Multiple agents are used: IV sedatives, hypnotics, muscle relaxants and analgesics Work rapidly BUT cross the placenta Inhaled anesthetic gases 11 Procedure Skin incision/ uterine incision Classic vertical vs low transverse incision 12 Oxytocin (Pitocin) Synthetic (exogenous) hormone that stimulates uterine contractions Give IV piggyback into IV fluids after delivery Goal is promote uterine involution and prevent postpartum hemorrhage Encourage breastfeeding as soon as possible after delivery for endogenous oxytocin release Enhances bonding 13 Stimulates maternal oxytocin release from the posterior pituitary to enhance uterine involution Post-op Assessment A-B-C’S AIRWAY patent BREATHING Adequate gas exchange MONITOR Pulse Ox Breath sounds Respiratory rate & rhythm CIRCULATION Vital signs Blood loss Monitor lochia, fundus, and incision site Monitor urine output – should be greater than 30 ml/ hour Skin color 14 Promote bonding with baby as soon as possible Baby may go to nursery and receive care as needed DVT prophylaxis SCDs Antiembolic hose/socks Heparin or enoxaparin (Lovenox) SC TCDB and incentive spirometer Early ambulation May be initially NPO If positive bowels sounds clear liquid diet usually started Diet advanced as + flatus / bowel sounds Foley catheter usually removed within 12-24 hours of delivery if output is good Patient due to void 6-8 hours after removal 15 Pain Control Frequently have PCA pump post op Morphine or hydromorphone (Dilaudid) May have a basal rate of medication and addition doses as needed in time interval Pumps are programmed according to orders Settings checked by 2 nurses Controlled substance Waste must be witnessed Only patient to push administration button Monitor: Vital signs and O2 sats Level of consciousness Pain scale Amount of medication infused Discontinue if resp. rate <12 Narcan – antidote 16 IV fluids and pain meds usually stopped when: Vital signs are stable Fundus is firm/ bleeding is WNL Adequate urine output Tolerating po fluids IV lock may be left in place as a safety measure PO pain meds given prn Opiates – oxycodone + acetaminophen (Percocet), hydrocodone + acetaminophen (Vicodin), oxycodone ER (OxyContin) Good for surgical pain SE – hypotension, respiratory depression, drowsiness, urinary retention, constipation NSAIDS – ibuprofen Good for uterine cramping 17 Incision Assessment Is there a surgical dressing? If there is a dressing covering the incision, then the dressing itself must be assessed until removal. Is it clean, dry and intact? Is dressing removed by MD or CNM or by RN with order? If no dressing, how is incision closed? Staples, sutures, steri-strips, dermabond? Is the incision well approximated? Is there any drainage? Odor? 18 Surgical Site Complications: Redness, edema, drainage, bruising, bleeding, approximation, ecchymosis… 19 VBAC (pronounced v-back) Vaginal Birth After Cesarean Labor and vaginal birth after a cesarean TOLAC= Trial Of Labor After Cesarean Approved by ACOG in 2004 with low transverse uterine incisions and no other contraindications Risks of cesarean outweigh risks of VBAC Greatest risk of VBAC is uterine rupture Almost all women are delivered by elective repeat cesarean instead of VBAC. Why? 20 WHY? Some women elect cesarean over experiencing labor Can be scheduled at a “convenient” time Threat of lawsuit if there are any complications for mom or baby Although the risk of uterine rupture is very low overall, the rate of fetal mortality in this emergency is very high Necessary staff not available for immediate cesarean delivery at facility 21 Care of the Post Partum Patient Heather Brigance, MSN, CNM 22 Post Partum Care Postpartum = puerperium the period after delivery to the return of the maternal organs to pre-pregnant state AKA The 4th Trimester – about 6 weeks Some include the changes in all aspects of the mother’s life that occur in the first year after childbirth. This could be 9-12 months 23 Vital Signs Alterations in vital signs may indicate complications Temperature elevation to 100.4°F (38°C) usually due to normal processes should last for only 24 hours. Related to dehydration. Encourage fluid intake >100.4 may indicate infection Pulse drops to 40-80 for about the first week CBC and cultures usually done tachycardia can indicate blood loss, hypovolemia, pain, anxiety, infection Blood pressure should remain stable decreased may indicate hemorrhage increased may indicate PIH (pregnancy-induced hypertension) Respirations should remain normal – 16-20 24 Pain Assessment Assess location and use pain scale to assess pain severity What is the patient’s acceptable level of pain? Usually 0-2, especially if breast feeding Examine complaints of abdominal pain, perineal and rectal pain Assess for perineal hematomas, bruising Assess for hemorrhoids Treat pain with appropriate medications NSAID for cramping (ibuprofen) Topicals for perineal pain Opiates for more severe pain – post-op CS pain 25 Post Partum Danger Signs Fever > 100.40 F Change in color, amount or odor of lochia Visual changes, blurred vision, spots or headaches Calf pain with dorsiflexion Edema, redness or discharge at episiotomy site Dysuria, burning, or incomplete emptying of bladder Shortness of breath Depression or extreme mood swings 26 BUBBLEE Assessment Systematic head to toe physical is done with additional focus on: B = Breast U = Uterus B = Bladder B = Bowel L = Lochia E = Episiotomy/Laceration/ C-Section Incision E = Emotional 27 Breast Changes Prolactin Secreted by anterior pituitary – promotes milk production Oxytocin Secreted by the posterior pituitary in response to infant sucking nipple Causes uterine contractions and the letdown reflex Letdown Reflex triggered by thoughts of baby, baby crying, sexual orgasm can be suppressed by fear, pain, embarrassment once lactation is well established prolactin production decreases and oxytocin and sucking causes milk production, regular nursing and increasing baby demands increases milk production 28 Assess the Nipples Assess for inverted, flat or everted nipples, soreness and cracking Is baby latching on correctly? If not it may cause sore nipples Clean breasts with warm water, air dry, no soap Use shield if irritated by clothing Change breast pads frequently if leaking milk Apply protective cream prn Colostrum lubricates nipples lanolin cream (Lansinoh) 29 Assess breasts Are they soft, filling, firm? Does patient have a supportive, well-fitting bra? Engorgement Breasts become full and firm, warm, and tender to painful usually seen 2-4 days after delivery patient may have elevated temperature </= 100.4 patient may experience this at home so patient teaching is important 30 Treatment of Engorgement Breastfeeding Mom Supportive bra Encourage frequent feedings q 1 .5 -3 hrs. Change baby’s feeding position to empty breasts Warm compresses/ shower Manual expression of milk or pump Analgesics Maintain good nutrition/ fluid intake Non-breastfeeding Mom (prevention) Suppression of lactation by compression within 6 hours after birth & 24 hours / day for 5 days binder or tight bra No nipple stimulation Avoid warm shower to breasts Ice packs to axilla/ breasts 15 min. q 1hr. Analgesics for pain There are no medications to suppress lactation Should subside within 48 hours 31 Mastitis Inflammation/ infection of breasts Seen primarily in breastfeeding women Usually seen within 2 weeks of lactation Usually due to cracked nipples/ bacteria from infant’s mouth Also poor hygiene – hand washing* Can occur from stasis of milk, nipple trauma caused by poor latch, improper positioning, aggressive pumping Prevention with good nursing/ pumping techniques, handwashing Clean breast pump with soap and hot water after each use Frequent feedings Proper latch and removal Overall good health 32 Signs & Symptoms of Mastitis: breast tenderness, redness, streaking, warmth, palpable mass fever, chills, malaise Treatment: Antibiotics if initial treatment fails culture breast milk may be community-acquired MSRA (CA-MRSA) newborn may also need antibiotic treatment Usually should continue to breastfeed during treatment Increased fluid intake Warm moist heat Analgesics Can pump & dump to maintain supply and supplement with formula until infection resolved if necessary Breast abscess can occur 33 (n.d.) Mosby's Medical Dictionary, 8th edition. (2009). Retrieved February 6 2017 from http://medical-dictionary.thefreedictionary.com/mastitis 34 Breastfeeding Breast Milk Composition changes over time Colostrum Present 2-3 days after birth Yellowish or creamy-appearing fluid Thicker than mature milk High in protein, fat-soluble vitamins, and minerals Contains high levels of immunoglobulins or antibodies Source of passive immunity for the newborn Transitional milk After colostrum for approximately 2 weeks postpartum Contains colostrum and milk More calories than colostrum 35 Mature Milk Appears bluish in color and is not as thick as colostrum Contains approximately 20-23 cal/ oz. Contains all required nutrients Composition of mature milk varies according to time during feeding Fore-milk Obtained at beginning of the feeding High in water content Contains vitamins and protein Hind-milk Released after initial letdown of milk Higher fat concentration 36 Advantages of Breast Feeding For Baby Strengthens immune system Helps positive bacterial growth in GI tract Less GI upset, colic, constipation, diarrhea Decreased respiratory infections, asthma, and otitis media Decreased SIDS Promotes mother-baby bonding Less overfeeding and decreased risk of obesity No preparation, ready when baby is ready Protection from food allergies For Mother Faster uterine involution and control of bleeding Can facilitate maternal postpartum weight loss Lower risk of breast cancer Decreased cost 37 Contraindications of Breastfeeding Maternal HIV/ AIDS Women receiving chemo or radioactive isotopes Women with active HSV lesions on breast Women with active tuberculosis Maternal medications may or may not be contraindication. May need to pump and dump. Newborn jaundice may include a brief suspension of breastfeeding or supplementation with formula. 38 Disadvantages of Breastfeeding 9 to 12 feedings every day may be considered inconvenient and stressful Exclusion of the father from nurturing involved in feeding infant Breastfeeding after returning to work may be difficult 39 Latch Scoring Tool Parameters 0 Points 1 Point 2 Points L: Latch Sleepy, no latch achieved Must hold nipple and stimulate to suck Grasps nipple tongue down , rhythmic sucking A: Audible swallow None Few with stimulation Spontaneous and intermittent T: Type of nipple Inverted Flat Everted C: Comfort of nipple Engorged, cracked, bleeding, severe discomfort Filling, red, small blisters, mild to mod discomfort Soft, non tender H: Hold Nurse must hold infant Minimal assist No assistance by nurse The higher the score the less intervention required 40 To Facilitate Successful Breastfeeding Privacy Comfortable position Initiate breast feeding as soon as possible Position baby comfortably close to mother Position baby so nose is at level of the nipple Nose is at level of the nipple Gums are on areola Both breasts offered at each feeding to stimulate supply Breast feed every 1 .5 - 3 hrs. 41 Drink plenty of fluid during nursing Begin with 1st breast – nurse 10-15 minutes Burp baby when changing breasts and at end of feeding At next feeding begin with the breast that was used 2nd Utilize rooting reflex Latching on properly prevents sore nipples Break the seal of baby’s mouth before removing from breast prevents sore nipples If not nursing baby off breast Take acetaminophen or ibuprofen before nursing for cramps 42 Mother should be taught the signs of milk transfer to infant Audible swallowing Milk appearing in baby's mouth Breast feeling soft after feeding Milk leaking from opposite breast Newborn gains weight Has six or more wet diapers per day 43 Encouraging a Sleepy Baby to Breastfeed Unwrap baby Provide skin-to-skin contact between mom and baby Have mom rest with baby near her breast Encourage mom to watch for feeding cues Hand-to-mouth activity Fluttering eyelids Vocalization but not necessarily crying Mouthing activities 44 Breast Pumping May be necessary when Mother and baby are separated: Baby in NICU Work Travel Can be done with manual or electric pump Milk must be labeled and stored correctly. It can be refrigerated for up to 5 days It can be frozen for 3-6 months Deep freeze 6-12 months http://kellymom.com/bf/pumpingmoms/milkstorage/ milkstorage/ 45 External Supports The father or other partner is the most important support person Baby provides support in form of positive feedback La Leche League International www.LLLI.org Provide education about breastfeeding Assistance to women who are breastfeeding Provides printed materials Offers one-to-one peer counseling Local lactation consultants 46 Drugs and Breastfeeding Drugs will cross into breast milk but in a smaller concentration < 1% of maternal dose Risk vs. benefit Tell provider who may prescribe medications that client is breastfeeding May need to pump and dump Observe infant for any adverse reactions Foods can also affect newborn Caffeine, chocolate can stimulate Gaseous foods can cause gas Drugs and Lactation Data Base http://toxnet.nlm.nih.gov/newtoxnet/lactmed.htm 47 48 Uterine Changes Involution The rapid decrease in size of the uterus after birth due to a decrease in estrogen and progesterone Contractions of the uterus helps to stop the bleeding at site of placental detachment The uterus returns to being a pelvic organ and not palpable within 10 days The uterus returns to the pre-pregnant size in 5-6 weeks 49 Involution Enhanced by Easy delivery Breast feeding (oxytocin secretion) Complete emptying of uterus Early ambulation Involution prolonged by Prolonged labor Anesthesia Analgesics Multi-parity or over distension from multiple gestations or a large fetus Full bladder Incomplete emptying of uterus 50 Involution is assessed by measuring Fundal height 51 To check fundus: Have pt. void, do pericare, and assess lochia If post-op, have pt. self medicate with PCA first Lie patient flat Support lower uterus and palpate upper part of uterus Assess the height of the fundus to the umbilicus (U+or-…) Is it firm, midline? Displaced to side may indicate full bladder Soft or boggy uterus (uterine atony)needs deep massage until it firms up If uterus is boggy, pt. will also have excessive bleeding – assess VS after massage Notify CNM/MD, may order meds Pt. should know how to check her fundus 52 Within 1-2 hours after delivery the fundus should be firm, at midline and between umbilicus and symphosis pubis Within 6-12 hrs. the uterus rises to the level of the umbilicus (U), and should be firm and midline Uterus should involute or descend 1 cm or FB (finger breadth) daily Documented = firm, midline, @U or U-1, U-2, etc Involution will be faster in breast feeding moms 53 Afterpains Cramps experienced for 2-3 days after delivery Intensified by : breastfeeding in multips multiple gestation prolonged labor with a full bladder Encourage frequent voiding Medicate with acetaminophen/ibuprofen prn Warm blanket / heating pad 20 min on/off 54 For Uterine Atony Massage boggy uterus Give medications as ordered Medicate for cramps Monitor VS, fundus, bleeding Expected outcome? 55 Medications for Uterine Atony oxytocin IM may be given or IV may be started methylergonvine maleate (Methergine) IM or PO Stimulates smooth muscle contraction and also causes vasoconstriction Side effects: hypertension, cramps, N&V, palpitations, seizures Check B/P and document prior to administering Hold if B/P > 140/90 carboprost tromethamine (Hemabate) IM Hold if client has asthma misoprostol (Cytotec) – given rectally 56 BLADDER ASSESSMENT Frequent urination enhances uterine involution Pt should void within 6-8 hrs. after delivery and the q 2-4 hrs. (may need cath after 8 hours) Postpartum diuresis = up to 3000 ml/day shift from plasma resolution of edema IV fluids Decreases by day 3 urine output = fluid volume Assess for urinary retention 20 to perineal trauma, edema, medications, and anesthesia Assess for S&S of UTI Post C/S – D/C foley – DTV 6-8 hrs To measure urine, subtract amount of peri-wash used 57 The uterus becomes displaced and deviated to the right when the bladder is full. Have patient void and reassess fundus. 58 Bowel Assessment Are bowel sound present? Is pt passing gas? (especially post C/S) Fear of pain on first evacuation May not have BM for 2-3 days Normal pattern returns within 2 weeks Encourage pt to: Avoid straining Increase fluids – 2000ml./ day Increase fiber – fruits and veggies, whole grains Increase activity Suppository may stimulate peristalsis/ evacuation Stool softeners frequently given Simethicone (Mylicon) chewable tabs for gas 59 Lochia Fluid discharge from uterus after delivery Total volume=approximately 150-400 ml amt in morning due to pooling amt may be seen with exertion/ breastfeeding there should be no foul odor Lochia rubra – day 1-3 or 4, may see a few small clots Lochia serosa – approximately day 4-10 amount will daily pinkish-brown Lochia alba occurs after day 10 – 2wks light brown/ yellow/ whitish contains mostly WBC’s, fat, bacteria, mucous when this lochia stops cervix is closed Assessment of lochia is important to detect hemorrhage and infection 60 Patient should be taught what to expect and what to report as abnormal Large clots need further evaluation check fundus, bladder, VS document color/ amt scant = 1-2” stain in 1 hr. light/small = < 4” stain on pad in 1 hour moderate= < 4-6” stain on pad in 1 hr. heavy/ large= > 6” or saturation in 1 hr.= 100 ml. C/S will have less lochia but pooling can occur due to bed rest 61 Episiotomy, Perineum, C-S Assess perineum after pt. has been up to the bathroom and done pericare. Best position is sidelying to view peri area & rectum. Lithotomy is alternative Assess perineum as well as episiotomy site and C-Section incision for: Redness, Edema, Ecchymosis, Drainage, Approximation of episiotomy or surgical repairs There should be minimal tenderness, no foul odor, no discharge or edema Assess rectum for hemorrhoids Document number, size and presence of pain 62 Assessing the perineum and rectum 63 Classifications of Lacerations 1st degree laceration 2nd degree laceration extends through perineal muscles 3rd degree laceration involves only skin and superficial structures above muscle extends through the anal sphincter muscle 4th degree laceration continues through anterior rectal wall 64 Patient Teaching During Assessment Discuss care with patient Sutures will dissolve Always cleanse perineal area from front to back using cleanser / water after each trip to BR Clean pad should also be applied from front to back Ice pack to perineum on 20 minutes, off 10 minutes for 1st 24 hours Warm sitz baths 24 hours after delivery to promote healing, prevent infection. 20 mins- tid or prn Teach patient how to set up and use at home Stay with pt. 1st time- may feel light headed/faint Keep call bell in reach Topical agents: Epifoam, Dermoplast spray, Tuck’s pads (witch hazel) Nupercain ointment 65 A Sitz bath promotes healing and provides relief from perineal discomfort during the initial weeks following birth. 66 Extremities Assessment for thrombophlebitis (DVT) clotting factors & venous return predispose the patient to DVT Patient may c/o lower extremity pain or aching when walking or Homan's sign may be positive Check pedal pulses Check legs for edema, redness, warmth Notify practitioner and keep the patient on bed rest Venous doppler ultrasound is done for diagnosis Treatment is usually anticoagulation therapy Prevention with TEDS and SCDs, early ambulation 67 Emotional Status: Rubin’s Maternal Phases Taking In and Taking Hold Taking In = first 24-48 hours Immediately after delivery and for 1-2 days Focus on self, sleep, food, comfort. Will relive and tell of birth experience Will seek help of others Taking Hold = 2-3 days post partum- several weeks Resumes control over life may still have some dependence Concerned about self and newborn Reassurance that mother is doing a good job Letting Go Lasts 10 days to 6 weeks Mothering functions established Sees infant as a unique individual 68 Bonding and Attachment En face position= Face to face with newborn. Maintain close proximity to newborn and interact. Newborn responds and parents respond to infant. Helps newborn in establishing Trust vs. Mistrust 69 Engrossment Father or significant other’s involvement with the infant 70 Postpartum Blues Postpartum “blues” Transient period of depression Mild to severe symptoms 2-7 days post partum 50-80% of new mothers experience postpartum blues Causes: Changing hormone levels, stress of new role, insecurity, fatigue, discomfort, overstimulation Clinical manifestations: Mood swings, tearfulness, anorexia, difficulty sleeping, feeling of letdown Should not interfere with ability to care for newborn Edinburgh Post Natal Depression Scale Measures risk for post partum depression http://www.fresno.ucsf.edu/pediatrics/downloads/edinburghscale.pdf 71 Nursing Interventions: Important for nurse to recognize signs and symptoms Allow the patient to verbalize fears, concerns Encourage patient and family that these are normal feelings. Family should provide physical and emotional support Give accurate info Good patient teaching Help to improve self esteem If excessive or prolonged depression beyond 4 weeks refer to healthcare provider 72 Physiological Changes Blood Values Labs should return to pre-pregnant state by 4-6 weeks. Risk of thromboembolism lasts 6 weeks. WBC is normally elevated after delivery. Should return to normal after 1 week Can complicate diagnosis of infection Platelets may decrease as a result of placental separation Should be >100,000 H&H may decrease from blood loss, diuresis Diuresis occurs first 2-5 days, resulting weight loss = 3 kg. Failure to diurese - assess for pulmonary edema Diaphoresis- profuse sweating (frequently at night) Normal and part of elimination of additional plasma volume 73 Weight Loss Post Partum Weight Loss Initial loss from birth= 10-12 lbs. Infant, placenta, amniotic fluid Post Partum diaphoresis/ diuresis = 5 lbs. Should return close to pre-pregnant weight in 6 weeks if weight gain was within norm! 74 Nutrition Non-nursing mother should reduce caloric intake by 300 kcal and return to pre-pregnancy levels of nutrients. Nursing mother should increase caloric intake by 200 kcal over pregnancy requirements Total 500 kcal increase over pre-pregnancy status Increased calcium and fluids (2-3 L/day) Adequate protein Avoid caffeine and gas-causing foods Teach client to take iron supplements for 4 to 6 weeks after delivery to prevent anemia. Prenatal vitamins are frequently continued 75 Integumentary Changes Linea nigra, and the hyperpigmentation of the breasts and face will begin to fade. Striae usually fade gradually to 76 silvery lines. Promotion of Maternal Rest Organize nursing care to avoid frequent interruptions Encourage rest periods while baby napping or 1 to 2 naps per day Encourage rest to decrease problems of establishing breastfeeding pattern Encourage delegation of household tasks to other family members if possible 77 Resumption of Activity Gradually increase ambulation and activity over 6 weeks after delivery Teach client to avoid Heavy lifting (heavier than baby) Excessive stair climbing Strenuous activity Return to work after final postpartum examination FMLA= Family Medical Leave Act Allows mothers and fathers 12 weeks of unpaid medical leave to care for new baby There are qualifications for this 78 Sexual Activity Resume sexual intercourse once laceration/ episiotomy is healed and lochia flow has stopped ~6 weeks Provide anticipatory guidance Measures to decrease discomfort Breastfeeding mother Use water-soluble lubricant Breastfeed prior to sexual intercourse to reduce milk flow with orgasm Factors that may inhibit sexual experience Baby crying Body unattractive to mother or partner Sleep deprivation Physiologic responses due to hormonal changes Decreased libido 79 Reoccurrence of Ovulation and Menstruation Return of menses is variable Non-nursing moms 40% menstruate in 1st 6- 10 weeks. Breastfeeding moms Return of menses 2-18 months depending on frequency of breastfeeding. 50% of theses ovulate and 50% anovulatory May or may not ovulate 5-15% of nursing women become pregnant unintentionally prior to their first menstrual period 80 81 Birth Control discussion and plan are essential for every new mom Abstinence x 6 weeks Always emphasize safe sex 82 83 Postpartum Exercises Exercise will help promote wellness, increase energy levels, muscle tone and help lose pregnancy weight Start slow and gradually increase as tolerated Signs of too strenuous activity Increased lochia Increased pain Prevent stress incontinence Kegel exercises 84 Immunizations Rhogam should be given to all Rh NEGATIVE moms with Rh POSITIVE BABY within 72 hours of delivery to prevent antibody formation. Antepartal dose at 28 weeks to all Rh negative moms Ruebella vaccine should be given if mom has negative antibodies or low titer levels= < 1:8. Pt should avoid pregnancy for 3 months Contraception information Tetanus, Diptheria and Pertussis- TDAP If not immunized within the last 10 years Pertussis immunization important when in close contact with children/ newborns 85 Promotion of Family Wellness Mother-baby, or couplet care Allows time to bond with baby En face position – face to face/eye to eye contact Allows time to learn and practice care of infant Sibling role Reassurance of mother's love and well-being Opportunity to become familiar with infant May see sibling regression Grandparent role May be role transition for grandparents Can be source of support 86 87 Discharge Teaching Printed information on care of mother and infant Warning signs of complications of mother and infant When to contact the primary care provider Information on resources and support groups Appointment for follow-up care of mother and infant Birth certificate information Plan for follow-up home visit or telephone call 88 On-going Discharge Instructions Clients should be instructed “Pelvic rest” x 6 weeks No sexual intercourse, douching, tampons, tub baths No aspirin or aspirin containing products Breast care Diet – increased fluids, fruits, fiber, Fe-rich foods Activity /Exercise No heavy lifting x 6 weeks, regular exercise after 6 weeks Call provider for any sign of infection, vaginal bleeding, T 100.4, foul odor or vaginal discharge or other warning signs BABY CARE 89
