Post Partum Period
Chapters 15 & 16
High Risk Chapter 22
Mary L. Dunlap MSN
Fall 2015
Post Partum
• Begins immediately after child birth
through the 6th post partum week
• Reproductive track returns to
nonpregnant state
• Adaptation to the maternal role and
modification to the family system
Safety for Mother and Infant
• Prevent infant abductions
• Check ID bands
• Educate mother about safety
measures
Infant ID Bands
Security Band
Clinical Assessment
• Receive report
• Review Antepartum and Intrapartum
history
• Determine educational needs
• Consider religious and cultural factors
• Assess for language barriers
Post Partum Assessment
BUBBLE-EE
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Breast
Uterus
Bladder
Bowel
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Lochia
Episiotomy
Extremities
Emotion
Vital signs
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Temperature
Pulse
Blood pressure
Respirations
Pain Assessment
• Determine source/location and pain
level
• Interventions- based on pain
• Document location, type, pain level
and intervention
• Reassess in 30 min and document
pain level
Breast
Initial assessment
• Inspect for size, contour, and
asymmetry
• Note if nipples are flat, inverted or erect
Ongoing assessments
• Check for cracks, redness, or fissures
• Engorgement
• Mastitis
Breast Care
Lactating Mother
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Supportive bra
Clean areola & nipples with water
Air dry
Express colostrum apply to areola &
nipple
• Change breast pads frequently
Breast Care
Non-Lactating Mother
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Avoid stimulation
Wear support bra 24hrs
Ice packs or cabbage leaves
Mild analgesic for discomfort
Assessment of Uterus
• After birth midline between umbilicus
and the symphysis pubis
• Within 1h returns to the umbilicus
• Descends 1 cm/day
• Consistency- firm/boggy
• Height- measured in fingerbreadths
• Fundal massage procedure 22.1 p 753
Nursing care
• Boggy fundus- massage until firm
• Medications- Pitocin, Methergine,
Hemabate
• Teach new mom to massage her
fundus
Afterpains
• Intermittent uterine contractions due to
involution
• Primiparous-mild
• Multipara- more pronounced
• Breastfeeding causes an increase in
contractions due to release of oxytocin
Nursing Interventions
• Patient in a prone position and place
a small pillow to support her abdomen
• Ambulation
• Medicate with a mild analgesic
Bladder
• Monitor for bladder distention and
displacement of uterus
• Assess for voiding difficulty
• Monitor output
• Postpartum Diuresis
Nursing care
• Encourage frequent voiding every 4-6
hours
• Monitor intake and output for 24 hrs
• Early ambulation
• Void within 4-6 hrs after birth
• Catheterize if unable to void
Preventing Stress Incontinence
• Vaginal delivery causes direct pelvic
muscle trauma and disruption of fascial
support contributing to the development
of urinary stress incontinence.
• Prevention strategies: Loss weight, avoid
bladder irritates, decrease fluid intake
• Kegal exercises
Teaching Guidelines 16.3. 502 pg
Bowel
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Relaxin depresses bowel motility
Progesterone ↓ muscle tone
Diminished intra-abdominal pressure
Incontinence if sphincter lacerated (4th
degree)
• Spontaneous BM 2nd to 3rd post partum
day
• Normal bowel pattern 8-14 days
Nursing Care
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Increase fiber in diet
6-8 glasses of water or juice
Stool softener- especially 4th degree
Laxative
Sitz bath for discomfort
Medications for hemorrhoids
Lochia
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Rubra
Serosa
Alba
Documentation
Lochia Assessment
Scant
• 1-2 in
• About 10 ml
Small
• 2-4 in
• About 10-25 ml
Moderate
• 4-6in
• About 25-50 mL
Heavy
• Saturated pad greater than 6 in
• About 50-80 mL within 1 hr.
Nursing Care
• Educate on the stages of lochia
• Increase in lochia, foul odor or return to
Rubra lochia is not normal
• Change Peri pad frequently
• Peri care after each voids to decrease
risk of infections
Episiotomy
• 1-2 inch incision in the muscular area
between the vagina and the anus
• Assess REEDA
• Lacerations
• Episiotomy care
Nursing Care
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Peri care
Ice packs
Dry heat
Topical medications
Sitz bath
Teaching guidelines 16.1 p. 499
Extremities
• Increases the risk of thromboembolic
disorders
• Risk factors venous stasis, altered
coagulation and vascular damage
due to birth process increase risk of
clot formation
Assess for Thrombosis
• Homan’s sign
• Assess extremities
• Monitor for signs of PE
Post Partum Assessment
• Post Partum Assessment Video
Emotional Status
• Bonding is a vital component of the
attachment process. It helps establish
parent infant attachment and a
healthy loving relationship.
• Bonding takes during the first 30 to 60
min. after birth
Emotional Status
Bonding process helps to lay the
foundation for nurturing care
• Touch- skin to skin
• Eye contact
• Breastfeeding
• Engrossment
• Factors that interrupt bonding
Engrossment
Seven Behaviors
• Visual awareness
• Tactile awareness
• Perception NB is perfect
• Focus is on NB
• Aware of NB’s distinct features
• Extreme Elation
• Increase sense of self esteem- proud
Tactile Awareness
Bonding
Factors that may interfere with bonding
process
• Stress over finances
• Lack of support
• Cultural beliefs
• Interruption of process-sick child NICU
Transitioning to parenthood
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Difficult and challenging
Provide emotional support
Accurate information
Nursing goal create a supportive
teaching environment
Assuming the mothering role
Rubin’s three phases
• Taking –in
• Taking –hold
• Letting-go
Taking in Phase
Fathers Development Process
Three stages
• Expectations
• Reality
• Transition to Mastery
Maternal Physiological
Adaptations
Hematological System
• Decrease in blood volume
• Elevated WBC
• Increased Fibrinogen
Hormonal Levels
• Estrogen and Progesterone decrease
• Anterior pituitary → prolactin for
lactation
• Expulsion of the placenta- placental
lactogen, cortisol, growth hormone,
and insulinase levels decrease
• “Honeymoon phase”- insulin needs
decrease
Neurological System
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Maternal fatigue
Transient neurological changes
Headaches
Carpel tunnel improvement
Integumentary System
• Darken pigmentation gradually fades
• Hair regrowth returns to normal in 612 months
• Striae( stretch marks) fade to silvery
lines
Immune System
Rubella
• Administer to nonimmune mothers
• Safe for nursing mothers
• Avoid pregnancy for 1 month
• Flu-type symptoms may occur
Immune System
• Rho (D) immune globulin
• Mother Rh negative, infant Rh
positive
• Negative coombs’ test
• 300 mcg of RhoGam within 72 hrs
after delivery
• Card issued to mother
Reproductive System
• Involution of uterus
• Healing of placental site
• Vaginal changes
Menstruation and Ovulation
Nonlactatating mother
• Menstruation returns in 7-9 wks, can
take up to 3mo.
• First cycle may be anovulatory
Lactating mother
• Delayed ovulation and menstruation
Musculoskeletal System
• Relaxation of pelvic joints, ligaments,
and soft tissue
• Muscle fatigue and general body
aches from labor and delivery of
newborn
• Rectus abdominis diastasis
Postpartal Surgical Patient
• Tubal ligation
• Cesarean birth
Breast Feeding
• American Academy of Pediatrics (AAP)
recommends infants be breastfed
exclusively for first 6 months of life
• Breastfeeding should continue for at
least 12 months
• If infants are weaned before 12 months,
they should receive iron-fortified infant
formula
Breast Feeding
• Optimal method of feeding infant
• Breast milk- Bacteriologically safe,
fresh, readily available
• Milk transition: Colostrum,
Transitional milk & mature milk
• Breastfeeding benefits 18.2 p 583
• Nursing Care Plan 18.1 pg 587
Contraindications to Breastfeeding
• Maternal cancer therapy/ radioactive
isotopes
• Active tuberculosis
• HIV
• Maternal herpes simplex lesion
• Galactosemia in infant
• Cytomegalovirus (CMV)
• Maternal substance abuse
Breast Feeding
Keys to successful breast-feeding
• Initiate first feeding within first hr.
• No supplements
• Feed on demand, unrestricted at least
8-12 feeds in 24hrs
• Avoid artificial nipples
• Mother and newborn to stay together
Breastfeeding
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Cue signs
Latch-on
Assess for milk let down
Scoring tool table 18.6 p 509
Cue Signs
• Rooting
Latch on
• Open mouth gape
• Infant tip of nose,
cheeks and chin
touching breast
THE
LATCH
SCORING
TOOL
Parameters
0 Point
1 Point
2 Point
L
LATCH
Sleepy infant
No latch achieved
Hold nipple in
infants mouth to
latch & suck
Stimulate to suck
Latches on
rhythmic sucking
A:
Audible swallow
none
Few with
stimulation
Spontaneous and
Intermittent
T
Type of nipple
Inverted
Flat
Protruding
C
Comfort of nipple
Engorged
cracked bleeding
sever discomfort
Filling, reddened,
small blisters
Mild to mod.
discomfort
Soft nontender
H
Positioning
Nurse must hold
infant to breast
Minimal
assistance then
mother takes over
No help needed
Breastfeeding
Positions
• Cradle hold
• Foot ball
• Side lying
Cradle Hold
Foot Ball Hold
Foot Ball Hold
Side Lying
Breastfeeding
• A newborns stomach is the size of a
small marble and can hold 5-7 cc’s.
This is matches the amount of
colostrum produced
• From 7-10 days it increases to the
size of a golf ball and can hold 1.5 to
2 oz
Breastfeeding
• Newborns nurse on average 8-12
times/24hrs
• Feed by cue signs about every 1-3
hours
• Should have no more than one 4 hr
period
• Teaching Guidelines 18.4 pg.588
Milk Expression
• Manually
• Manual or handheld breast pump
• Electric breast pump
• Hand Express
Manual Pump
Electric Hand Held
• Electric Pump
Electric Pump
Breast Milk Storage
• Room temperature- 4 hrs
• Refrigerator- 5-7 days
• Deep freezer- 6-7 months
Ineffective Breastfeeding
• Incorrect latch-on
• Inverted nipples
• Breast engorgement
Special Considerations
• Sleepy baby- use gentle stimulate to
bring to alert state
• Fussy baby- use calming techniques
• Slow weight gain- evaluate
breastfeeding
Formula Feeding
• Formula preparation
• Periodically check nipple integrity
• Bottle preparation
Teaching Guidelines 18.5 p. 591
Discharge Teaching
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Fundus and Lochia
Episiotomy care
Incision care
Signs of PP infection- table 22.3 p 761
Elimination
Nutrition Box 16.4 p 504
Discharge Teaching
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Exercise- 16.2 p 501
Activity
Pain management
Sexual activity
Contraception
Blues
Community resources
Postpartum Women at Risk
Chapter 22
Postpartum Hemorrhage
• Blood loss >500 ml of blood after a
vaginal birth
• 1000 ml of blood after cesarean section
• Major hemorrhage >2,500 mL
• Transfusion of >5 units
• Any amount of bleeding that places
mother in hemodynamic jeopardy
• Table 22.1 pg 748
Postpartum Hemorrhage
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5 T’s- factors associated with PPH
Tone
Tissue
Trauma
Thrombin
Traction
Table 22.2 pg. 751
Tone / Atony
• Altered muscle tone due to
overdistention
• Prolonged or rapid labor
• Infection
• Anesthesia
Tissue
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Retained placental fragments
Uterine inversion
Clots
Subinvolution
Trauma
• Cervical lacerations
• Vaginal lacerations
• Hematomas of vulva, vagina or
peritoneal areas
Trauma
Hematoma
• Localized collection of blood in
connective or soft tissue under the
skin( caused by laceration to blood
vessel)
• Risk factors
• Signs and symptoms
• Management
Thrombin
• Disorders of the clotting mechanism
• This should be suspected when
bleeding persists without an
identifiable cause
Management of PPH
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Frequent VS q 15 min times 1 hr.
Fundal massage
Administer medications
Monitor blood loss for amount
Maintain IV
Type & cross match
Empty bladder
Fundal Massaging
• Procedure 22.1
pg. 753
Uterotonic Drugs
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Oxytocin (Pitocin)
Misoprostol (Cytotec)
Dinoprostone (Prostin E2)
Methylergonovine maleate (Methergine)
Prostaglandin (Hemabate)
Drug Guide 22.1 pg.754
Management of PPH
• Balloon Tamponade Catheter
Post Partum Hemorrhage
• PPH Simulation
• PPH Noell
Thromboembolic Conditions
• Thrombosis (blood Clot) can cause
inflammation of the blood vessel
(Thrombophlebitis) which can cause
Thromboembolism (obstruction of
blood vessel)
Assessment Superficial
• Tenderness and pain in extremity
• Warm and pinkish red color over
thrombus area
• Palpable- feels bumpy and hard
• Increased pain when ambulating
Nursing Care
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NSAIDs for pain
Bed rest elevate affected leg
Warm compresses
Elastic stockings
No anticoagulants required
Assessment For Deep Vein
Thrombosis
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Calf swelling
Warmth
Tenderness
Pedal edema
Diminished peripheral pulses
Color blue
Homan’s sign
Nursing Care
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Bed rest
Elevate effected leg
Continuous moist heat
TED hose both legs
Analgesics PRN
Anticoagulation therapy
Thrombosis
Patient Education
• Anticoagulation Teaching Guidelines
22.1 pg. 758
• Eliminate risk factors
• Continue using Compression stockings
• Avoid constrictive clothing & prolonged
standing
• Danger signs
Pulmonary Embolism
• Abrupt onset: chest pain, dyspnea,
diaphoresis, syncope, anxiety
• ABC response
Postpartum Infections
• Temp of 100.4 or higher after the first
24 hrs. for 2 successive days of the
first 10 PP days
• Temp of 102.2 or greater within first
24 hrs.- sever pelvic sepsis Group A
or B streptococcus
Postpartum Infections
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Endometritis
Wound infection
UTI
Mastitis
Septic Pelvic Thrombophlebitis
Box 22.1 Risk Factors
Table 22.3 pg. 761 signs & symptoms
Metritis
• Involves the endometrium, decidua
and adjacent myometrium of the
uterus
• Lower abdominal tenderness or pain
• Temperature
• Foul-smelling lochia
Nursing Care
• Administer broad spectrum antibiotic
• Provide analgesia
• Provide emotional support
Wound Infection
• Sites- Cesarean incision, episiotomy
and genital tract laceration
• Drainage
• Edema
• Tenderness
• Separation of wound edges
Nursing Care
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Aseptic wound management
Frequent perineal pad changes
Good hand washing
Administer antibiotics
Analgesics
Urinary Tract Infection
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Burning and pain on urination
Lower abdominal pain
Low grade fever
Flank pain
Proteinuria, hematuria, bacteriuria,
nitrates and WBC
Nursing Care
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Frequent emptying of bladder
Increase fluid intake
Antibiotics
Analgesics
Peri care
Mastitis
• Infection of the breast (one sided)
• Seen first 2 weeks after delivery
• Most common organism staphylococcus
aureus
• Infected nipple fissure - to ductal system
involvement- edema obstructs milk flow
in a lobe- mastitis
Mastitis Symptoms
• Flu like symptoms
• Tender, hot, red area on one breast
• Breast distention with milk
Nursing Management
• Empty the breast by increasing the
frequency of nursing or pumping
• Control infection- Antibiotics
• Analgesics
• Warm/ice compresses
• Assess infants mouth for thrush
Postpartum Infection
Education
• Continue antibiotics
• Monitor temperature and notify provider if
temp greater then 100.4
• Watch for signs and symptoms of a
recurrence
• Practice good hand washing
• Teaching Guidelines 22.2 pg. 765
Postpartum Affective Disorders
• Plummeting levels of estrogen and
progesterone after delivery contribute
to the mood disorders
• Disorders based on their severity:
Postpartum blues
Postpartum depression
Postpartum psychosis
Postpartum Blues
Transient periods of depression during
the first 1 to 2 weeks postpartum
• Tearfulness
• Sad feeling
• Confusion
• Insomnia
• Feel overwhelmed
Nursing Care
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Remind mom that the “Blues” are normal
Encourage rest
Utilize relaxation techniques
Share her feelings with her partner
If symptoms do not resolve and progress
to depression medical treatment needs
to be sought
Postpartum Depression
• Gradual onset and is evident within first 6
wks.
• Cause combination of body, mind, and
lifestyle
• Symptoms- sleep disturbances, guilt, fatigue,
feelings of hopelessness Box 22.2 pg. 771
• Screening tools
Postpartum Depression
Management same as that for major
depression
• Antidepressants
• Antianxiety
• Psychotherapy
• Marriage counseling if that is part of the
causes
Postpartum Psychosis
• Emergency psychiatric condition which
could put the women at risk for suicide
& infanticide
• Detect within 3 wks. of giving birth
• Symptoms: delusions, hallucinations,
agitation, inability to sleep, bizarre
irrational behavior
Postpartum Psychosis
Management
• Usually hospitalized for several months
• Psychotropic drugs
• Individual psychotherapy
• Support group therapy