Maternal-Child Nursing Care Optimizing Outcomes for Mothers
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Chapter 15 Caring for the Postpartal Woman and Her Family Gloria Nwagwu MSN, FNP-BC, RN Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Susan Ward Shelton Hisley Question? The most effective and least expensive treatment of puerperal infection is prevention. What is important in this strategy? a. Large doses of vitamin C during pregnancy b. Prophylactic antibiotics c. Strict aseptic technique, including handwashing, by all health care personnel d. Limited protein Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Fourth Trimester Begins immediately after childbirth Puerperium—first 6 weeks after birth Close observation—identify hemorrhage and complications during first critical hour Ongoing education and support Susan Ward Shelton Hisley Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Safety for Mother and Infant Prevent infant abductions Check ID bands Educate mother about safety measures Susan Ward Shelton Hisley Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Early Maternal Assessment Vital signs Temperature—below 100.4oF (38oC) Pulse—bradycardia Blood pressure Respirations Susan Ward Shelton Hisley Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Susan Ward Shelton Hisley Fundus Immediate postpartum—halfway between the symphysis pubis and the umbilicus 1 hour postpartum—level of the umbilicus or one fingerbreadth above Then, descends one fingerbreadth each day Assess lochia Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Perineal Assessment Sim’s position REEDA Hemorrhoids Teach regarding comfort measures If severe, teach how to manually reposition Susan Ward Shelton Hisley Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Susan Ward Shelton Hisley Postpartum Assessment Guide Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families BUBBLE-HE Breasts Uterus Bladder Bowel Lochia Episiotomy Susan Ward Shelton Hisley Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Other Important Components Maternal pain Homans’ sign Mother’s emotional status Infant bonding Susan Ward Shelton Hisley Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Breast Assessment Firmness, filling Nodules Fissures, cracks Blood Dried milk Erect or inverted nipples Susan Ward Shelton Hisley Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Susan Ward Shelton Hisley Assessment of Uterus Placental expulsion usually occurs within 15 minutes after birth Uterine contractions control bleeding Technique for uterine palpation Involution Subinvolution Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Fundal Assessment Location immediately after birth Descends 1 cm/day Consistency Location Height Measured in fingerbreadths Susan Ward Shelton Hisley Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Afterpains Occur during process of involution More pronounced in multipara Nursing care Explain cause Prone position with abdominal pillow Sitz baths Encourage ambulation Administer mild analgesics Susan Ward Shelton Hisley Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Susan Ward Shelton Hisley Bladder Spontaneous void within 6 to 8 hours pp Monitor first voiding Anticipate maternal diuresis Urinary output may reach 3000 mL/day Urine volume, flow returns to pre-pregnant levels within 2 to 3 days pp Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Assessment Findings: Bladder Incomplete emptying Overdistention Urinary retention Nursing interventions Support and enhance attempts to void Susan Ward Shelton Hisley Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Bowel Hunger and thirst after childbirth Relaxin—depresses bowel motility Strategies to prevent constipation Early ambulation Abundant fluids High-fiber diet Susan Ward Shelton Hisley Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Susan Ward Shelton Hisley Lochia Characteristic indicative of status in process of involution Lochia rubra Lochia serosa Lochia alba Document amount Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Episiotomy 1 to 2 inch surgical incision Assess REEDA Ice for first 24 hours Moist heat—Sitz bath Dry heat—hot packs Susan Ward Shelton Hisley Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Pain Assessment Determine source Document location, type, and duration Administer Tylenol or Ibuprofen Sitz bath Educate regarding nonpharmacological measures Susan Ward Shelton Hisley Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Assess for DVT Homans’ sign Dorsiflex foot and ask about pain Clinical assessment Erythema, unequal calf circumference, heat Clinical signs are NOT reliable Susan Ward Shelton Hisley Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Emotional Status Wide range of emotions May be sad during first 1 to 2 weeks pp Ongoing assessment and education Educate regarding “baby blues” Susan Ward Shelton Hisley Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Susan Ward Shelton Hisley Maternal Physiological Adaptations Continued Assessment of the Patient Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Hematological System Decrease in blood volume Blood loss Diuresis White blood count increased x 5 to 6 days Fibrinogen increased Returns to normal by third to fourth week Susan Ward Shelton Hisley Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Susan Ward Shelton Hisley Hormonal Levels Estrogen and progesterone decrease Anterior pituitary—prolactin Placental lactogen, cortisol, growth hormone, and insulinase levels decrease Insulin needs decrease—“Honeymoon phase” Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Susan Ward Shelton Hisley Neurological System Altered sleep patterns—maternal fatigue Numbness in legs, dizziness Safety for infant and mother Headaches Assess quality and location, and carefully monitor vital signs Implement environmental interventions Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Susan Ward Shelton Hisley Renal System, Fluid and Electrolytes GFR, Creatinine, and BUN return to pre-pregnant levels within 2 to 3 months Urinary glucose Proteinuria Rapid, sustained natriuresis and diuresis Output may reach 3000 mL/day Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Susan Ward Shelton Hisley Respiratory System Respiratory alkalosis and compensated metabolic acidosis may persist Decrease in intra-abdominal pressure Relief from dyspnea Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Integumentary System Hormonal changes cause skin alterations Most disappear Striae gravidarum Susan Ward Shelton Hisley Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Susan Ward Shelton Hisley Cardiovascular System Delivery of the baby, expulsion of the placenta, and loss of amniotic fluid can create cardiovascular instability Cardiac output remains elevated Physiological diuresis Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Immune System Rho (D) immune globulin (RhoGAM) Rubella vaccination Nonimmune status Signed consent form Avoid pregnancy for 1 month Flu-type symptoms may occur Susan Ward Shelton Hisley Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Reproductive System Involution of uterus Healing of placental site Vaginal changes Labia majora and labia minora flaccid Susan Ward Shelton Hisley Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Menstruation and Ovulation Nonlactating women Menstruation returns in 6 to 8 weeks First cycle may be anovulatory Lactating women Delayed ovulation and menstruation Educate—ovulation can precede menstruation, need contraception Susan Ward Shelton Hisley Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Gastrointestinal System Decreased gastric motility Decreased muscle tone in abdominal wall Constipation Stool softeners Susan Ward Shelton Hisley Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Musculoskeletal System Laxity of pelvic joints and ligaments Relaxation of soft tissues Muscle fatigue Body aches Rectus abdominis diastasis Correct posture Modified sit-ups Susan Ward Shelton Hisley Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Enhancing Cultural Sensitivity Conduct cultural assessments Expand knowledge and understanding Culturally influenced beliefs Common health care practices Customs and rituals Susan Ward Shelton Hisley Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Susan Ward Shelton Hisley Question? To provide optimum care for the postpartum woman, the nurse understands that the most common causes of subinvolution are: a. Postpartum hemorrhage and infection. b. Multiple gestation and postpartum hemorrhage. c. Uterine tetany and overproduction of oxytocin. d. Retained placental fragments and infection. Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Promoting Recovery and Self-Care Susan Ward Shelton Hisley Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Activity and Rest Early postpartum ambulation Mild exercises Kegel Increase gradually Encourage frequent rest periods Obtain adequate sleep Susan Ward Shelton Hisley Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Nourishment Weight loss Appetite Balanced diet Multivitamin supplement Iron if hemoglobin low Susan Ward Shelton Hisley Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Elimination Void every 4 to 6 hours Monitor intake and output x 24 hours Increased risk of infection Urinary retention Constipation Susan Ward Shelton Hisley Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Perineal Care Risk of infection Teach perineal hygiene Hand washing Tampons contraindicated Cesarean births Nurse provides perineal care until ambulatory Susan Ward Shelton Hisley Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Ice Packs Reduce edema and pain Vasoconstriction and numbing Apply for 20 minutes every 2 to 4 hours First 24 hours Susan Ward Shelton Hisley Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Afterbirth Pain Intermittent uterine contractions during involution Breastfeeding (release of oxytocin) Duration: 2 to 3 days Mild analgesics Susan Ward Shelton Hisley Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Special Considerations Women with HIV/AIDS Gloves, safety glasses Discourage breastfeeding Patient teaching for infant safety Susan Ward Shelton Hisley Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Postpartal Surgical Patient Tubal ligation Cesarean birth Incisional wound Recovery from anesthesia Respiratory care Susan Ward Shelton Hisley Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Infant Feeding Choices Breastfeeding Bottle feeding Educate Support Susan Ward Shelton Hisley Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Physiology of Lactation Breast structure Lactogenesis Milk ejection reflex—“let down” reflex Susan Ward Shelton Hisley Maternal-Child Nursing Care Assisting the Breastfeeding Mother Optimizing Outcomes for Mothers, Children, & Families Strategies for Success Susan Ward Shelton Hisley Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Breastfeeding Initiating the feeding Achieving proper latch-on Assessing for milk let-down Assuming a position of comfort Assessing for infant weight gain Susan Ward Shelton Hisley Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Ineffective Breastfeeding Incorrect latch-on (nipple trauma) Breast engorgement Complementary care Ethnocultural considerations Collecting and storing breast milk Susan Ward Shelton Hisley Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Expressing Breast Milk Manual—hand Electric pump Types of breast pumps Storage of breast milk Weaning Susan Ward Shelton Hisley Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Formula Feeding Safe Practices Susan Ward Shelton Hisley Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Family and Infant Bonding Transition to parenthood Assuming the mothering role Rubin’s phases Paternal bonding Factors that interrupt bonding Susan Ward Shelton Hisley Maternal-Child Nursing Care Adjustment of Other Family Members Optimizing Outcomes for Mothers, Children, & Families Siblings Tips for parents Grandparents Susan Ward Shelton Hisley Maternal-Child Nursing Care Emotional Events During the Puerperium Optimizing Outcomes for Mothers, Children, & Families First 3 months most vulnerable period Baby blues Postpartum depression Postpartum psychosis Physiological response—tiredness, fatigue Susan Ward Shelton Hisley Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Susan Ward Shelton Hisley Discharge Planning and Teaching Maternal Self-Care Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Maternal Self-Assessment Fundus and lochia Hygiene Abdominal incision Body temperature Elimination Nutrition Susan Ward Shelton Hisley Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Maternal Self-Assessment Fatigue Weight loss Exercise Pain management Mood Sexual activity and contraception Susan Ward Shelton Hisley Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Special Needs Populations Adolescent mothers Woman placing infant for adoption Older mothers Susan Ward Shelton Hisley Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Community Resources Support groups Home visits Telephone follow-up Outpatient clinics Susan Ward Shelton Hisley
