OB Chapter 20: Postpartum Adaptations
Describe the influence of these hormones on lactation: a. estrogen b. progesterone c. prolactin d. oxytocin
a&b: Prepare the breast for lactation c. Prolactin initiates milk production in the alveoli. d. Oxytocin is necessary for milk ejection or "letdown" from the alveoli into the lactiferous ducts.
Homans Sign
> Discomfort in the calf with passive dorsiflexion of the foot is a positive Homans sign and may indicate deep vein thrombosis. > A positive Homans sign should be reported to the health care provider, along with redness, tenderness, or warmth of the leg. Assessment of Homans sign can be confusing because a deep venous thrombosis may not produce calf pain with dorsiflexion. In addition, women may report pain that is caused by strained muscles from positioning and pushing during delivery.
List signs and symptoms that the woman should report to her physician or nurse-midwife
> Fever > Localized area of redness, swelling, or pain in either breast > Persistent abdominal tenderness > Feelings of pelvic fullness or pressure > Persistent perineal pain > Frequency, urgency, or burning on urination > Abnormal change in character of lochia (increased amount, resumption of bright red color, passage of clots, foul odor) > Localized tenderness, redness, edema, or warmth of the legs > Redness, separation of or foul drainage from an abdominal incision
Hemorrhage Risk Factors
> Grand multi-parity (five or more) > Overdistention of the uterus (large baby, twins, hydramnios) > Rapid or prolonged labor > Retained placenta > Placenta previa or previous placenta accreta or abruptio placentae > Drugs (tocolytics, magnesium sulfate, general anesthesia,prolonged use of oxytocin) > Operative procedures (cesarean birth, vacuum extraction, forceps) > Uterine fibroids > History of postpartum hemorrhage > Preeclampsia >Coagulation defects
Worsening of preeclampsia
> Headache, proteinuria, blurred vision, photophobia, and abdominal pain may indicate development or worsening of preeclampsia.
Uterine Involution
1. contraction of muscle fibers 2. catabolism (process of converting cells into simpler compounds) 3. regeneration of uterine epithelium
Lochia Rubra
> 1- 3 days after childbirth, lochia consists almost entirely of blood, with small particles of decidua and mucus. > Normal discharge: Bloody; small clots; fleshy, earthy odor, red or red/brown. >Abnormal discharge: Large clots; saturated perineal pads; foul odor
Initial Assessment Postpartum
> 1-2 hours after childbirth > Vital signs > Skin color > Location and firmness of the fundus > Amount and color of lochia > Perineum (edema, episiotomy, lacerations, hematoma) > Presence, degree, and location of pain > Intravenous (IV) infusion (type of fluid; rate of administration; type and amount of added medications; patency of the IV line; and redness, pain, or edema of the site) > Urinary output (time and amount of last void or catheterization, presence of a catheter, color and character of urine) > Status of abdominal incision and dressing, if present > Level of feeling and ability to move if regional anesthesia was administered
Lochia Alba
> 11th- 21st day, the erythrocyte component decreases. The discharge becomes white, cream or light yellow. (Normal discharge) > Present in most women until the 3rd week after childbirth but may persist until the 6th week. (Abnormal discharge)
Lochia Serosa
> 4-10 days > Normal discharge: Amt of blood decreases by the fourth day, and the color changes from red to pink or brown-tinged. >Abnormal discharge: Excessive amount; foul smell; continued recurrent reddish color
Lochia: Important guidelines
> A constant trickle, dribble, or oozing of lochia indicates excessive bleeding and requires immediate attention. > Excessive lochia in the presence of a contracted uterus suggests lacerations of the birth canal. The health care provider must be notified so that lacerations can be located and repaired. >Foul odor suggests endometrial infection. Additional signs include: maternal fever, tachycardia, uterine tenderness, and pain. >Absence of lochia, like the presence of foul odor may also indicate infection. (If cesarean, lochia may be scant because endometrial lining was removed, however it should not be entirely absent.)
Spinal Headaches
> After spinal anesthesia, they may be most severe when the woman is in an upright position and are relieved by a supine position. They should be reported to the appropriate health care provider, usually an anesthesiologist.
Describe postpartum blues. What is the best response to them?
> Aka as baby blues or maternity blues. > This condition begins in the 1st week and usually lasts 2-10 days. > It should last no longer than 2 weeks. It is characterized by insomnia, irritability, fatigues, tearfulness, mood instability, and anxiety. > Mother;s benefit greatly when empathy and support are freely given by the family and the health care team. >Postpartum blues must be distinguished from postpartum depression and postpartum psychosis, which are disabling conditions and require therapeutic management for full recovery.
Topical Medications
> Anesthetic sprays decrease surface discomfort and allow more comfortable ambulation. The mother is instructed to hold the nozzle of the spray 6 to 12 inches from her body and direct it toward the perineum. The spray should be used after perineal care and before clean pads are applied. Astringent compresses should be placed directly over the hemorrhoids to relieve pain. Hydrocortisone ointments may also be applied over the hemorrhoids to increase comfort.
New parents may not recognize signals from the infant that he/she has had enough stimulation and now needs to rest. What signals should the nurse teach parents to recognize?
> Avoidance cues include looking away, splaying the fingers, arching the back, and fussiness.
Headache
> Bilateral and frontal headaches are common in the first postpartum week and may be a result of changes in fluid and electrolyte balance.
Explain how a full bladder at birth can lead to postpartum hemmorrhage
> Bleeding may increase because the uterine ligaments, which were stretched during pregnancy, allow the uterus to be displaced upward and laterally by the full bladder. The displacement results in decreased uterine muscle contraction (uterine atony). >A full bladder interferes with the ability of the uterus to contract firmly and occlude open vessels at the placental site. This allows them to bleed freely.
What is the significance of bradycardia during the early postpartum period?
> Blood volume and cardiac output increase as blood from the uteroplacental unit returns to the central circulation and as excess extracellular fluid enters the vascular compartment for excretion. Because stroke volume increases, pulse decreases.
Describe the processes of bonding and attachment. Similarities and differences in these processes.
> Bonding describes the initial, rapid attraction felt by the parents toward their newborn infant. It is a one-way process, from parent to infant. > Attachment describes a longer-term, two-way process that binds parent and infant. Attachment is facilitated by positive feedback from the infant and by mutually satisfying experiences.
Sitz baths
> Cool water may be used during the first 24 hours to reduce pain from edema. Warm water increases circulation and promotes healing and may be most effective after 24 hours. Nurses must place the emergency bell within easy reach in case the mother feels faint during the sitz bath.
Focused Assessment After Vaginal Birth: Blood Pressure
> If the BP is 140/90 mm Hg or higher, preeclampsia may be present. >A decrease may indicate dehydration or hypovolemia resulting from excessive bleeding. > Hypotension may also indicate hypovolemia. Careful assessments for hemorrhage (location and firmness of the fundus, amount of lochia, pulse rate for tachycardia) should be made if the postpartum BP is significantly less than the prenatal base- line blood pressure.
What teaching should you provide the postpartum woman to prevent constipation?
> Increase activity progressively, drink adequate fluids (at least 8 glasses of water daily), and add dietary fiber (found in fruits and vegetables and whole grain cereals, bread, and pasta) to prevent constipation. Prunes are a natural laxative.
Signs of a distended bladder
> Location of fundus above baseline level > Fundus displaced from midline > Excessive lochia > Bladder discomfort > Bulge of bladder above symphysis > Frequent voidings of less than 150mL of urine, which may indicate urinary retention with overflow
Describe the changes in lochia and when the aforementioned changes occur.
> Lochia rubra contains blood, mucus, and bits of decidua; is red in color; and has a duration of approximately 3 days. Lochia serosa contains serous exudate, erythrocytes, leukocytes, and cervical mucus; it is a pinkish color; and its duration is from the 4th to the 10th day. Lochia alba contains leukocytes, decidual cells, epithelial cells, fat, cervical mucus, and bacteria; it is white or colorless; its duration varies from the 11th day until the 3rd to 6th week.
Describe progression of maternal touch
> Maternal progression is from finger-tipping to palm touch to enfolding the infant and bringing him/her close to the body.
Infection Risk Factors
> Operative procedures (cesarean birth, vacuum extraction, forceps) > Multiple cervical examinations > Prolonged labor > Prolonged rupture of membranes > Manual extraction of placenta or retained fragments > Diabetes > Catheterization > Bacterial colonization of lower genital tract
What nursing measures can help the mother of twins attach to her babies?
> Parents attach to each infant separately as they get to know each infant's unique characteristics. > Nurses must help the parents relate to each infant as an individual rather than as part of a unit by pointing out the individual responses and characteristics of each infant.
Perineal Care
> Perineal care consists of squirting warm water over the perineum after each voiding or bowel movement. This is important for all postpartum women whether the birth was vaginal or by cesarean. The bottle should not touch the perineum. Perineal care cleanses, provides comfort, and prevents infection. The perineum is gently patted rather than wiped dry.
What makes any pregnant and postpartum woman at risk for venous thrombosis? What factors increase this risk?
> Pregnant and postpartum women have higher fibrinogen levels, which increase the ability to form clots. Factors that lyse clots are decreased, however. Some women have another risk in addition to this baseline risk; those who have varicose veins, a history of thrombophlebitis, or a cesarean birth.
Discuss which postpartum mothers would be appropriate candidates for Rho(D) immune globulin and rubella vaccine
> Rh0 (D) immune globulin may be necessary if the mother is Rh negative, the newborn is RH positive, and the mother is not already sensitized. >Rho(D): mother is Rh- and newborn is Rh+; rubella vaccine-if her prenatal rubella antibody screening showed non-immune
Lochia Amount
> Scant: Less than a 2.5-cm (1-inch) stain on the perineal pad > Light: 2.5- to 10-cm (1- to 4-inch) stain >Moderate: 10- to 15-cm (4- to 6-inch) stain >Heavy: Saturated perineal pad >Excessive: Saturated peripad in 15 minutes
Early postpartum period
> The 1st week
Immediate postpartum period
> The first 24 hours postpartum
Ice packs
> The ice pack is wrapped in a washcloth or paper before it is applied to the perineum. It should be left in place until the ice melts. It is then removed for 10 minutes before a fresh pack is applied. Some peripads have cold packs in them. Condensation from ice may dilute lochia and make it appear heavier than it actually is.
Criteria for discharge
> The mother has no complications, and assessments (including vital signs, lochia, fundus, urinary output, incisions, ambulation, ability to eat and drink, and emotional status) are normal. > Pertinent laboratory data including hemoglobin or hematocrit have been reviewed, and Rho(D) immune globulin has been administered, if necessary. > The mother has received instructions on self-care, deviations from normal, and proper response to danger signs and symptoms. > The mother demonstrates knowledge, ability, and confidence to care for herself and her baby. > The mother has received instructions on postpartum activity, exercises, and relief measures for common post- partum discomforts. > Arrangements have been made for postpartum care. > Family members or other sources of support are available to the mother for the first few days after discharge.
Describe progression of maternal verbal behaviors
> The mother progresses from calling the infant "it" to referring to the infant as "he" or "she" to using the infant's given name
Sitting Measures
> The mother should be advised to squeeze her buttocks together before sitting and to lower her weight slowly onto her buttocks. This measure prevents stretching of the perineal tissue and avoids sharp impact on the traumatized area. Sitting slightly to the side is helpful to prevent the full weight from resting on the episiotomy site.
Describe the proper technique to massage a soft fundus. How should the nurse expel clots?
> The non-dominant hand must support and anchor the lower uterine segment if it is necessary to massage an uncontracted uterus. Uterine massage is not necessary if the uterus is firmly contracted. >Begin palpation at the umbilicus, and palpate gently until the fundus is located. This helps determine the firmness and location of the fundus. It should be firm, in the midline, and approximately at the level of the umbilicus. > If the fundus is difficult to locate or is "boggy" (soft), keep the non-dominant hand above the woman's symphysis pubis and massage the fundus with your dominant hand until the fundus is firm. The non-dominant hand anchors the lower segment of the uterus and prevents inversion while the uterus is massaged. The uterus contracts in response to tactile stimulation. > After massaging a boggy fundus until it is firm, press firmly to expel clots. Do not attempt to expel clots before the fundus is firm because this would increase the possibility of causing the uterus to invert. Keep one hand pressed firmly just above the symphysis (over the lower uterine segment) throughout. Removing clots allows the uterus to contract properly.
How should the nurse respond to the parent who is disappointed in the sex of the new born?
> The nurse should help the parent or parents acknowledge their feelings and deal with them to facilitate their attachment with the child.
How can the nurse help the new father adapt to his role?
> The nurse should involve the father in infant care teaching and decisions. Father's may not know what to expect from newborns and benefit from information about growth and development. A review of any prenatal teaching is helpful as well.
Late postpartum period
> The second week through the sixth week
Perineum: REEDA
> Used as a reminder that the site of an episiotomy or a perineal laceration should be assessed for 5 signs >R (redness) >E (edema) >E (ecchymosis, bruising) >D (discharge) >A (approximation)
Rubella vaccine
>Women are advised not to become pregnant for at least 28 days after receiving rubella vaccine.
A newborn is rooming in with his teenage mother, who is watching TV. The nurse notes that the baby is awake and quiet. The best nursing action is to: a. pick the baby up and point out his alert behaviors to the mother b. tell the mother to pick up her baby and talk with him while he is awake c. focus care on the mother, rather than the infant so she can recuperate d. encourage the mother to feed the infant before he begins crying
A
A woman who is 4 hours postpartum ambulates to the bathroom and suddenly has a large gush of lochia rubra. The nurse's first action should be to: a. determine whether the bleeding slows to normal or remains large b. observe vital signs for signs of hypovolemic shock c. check to see what her previous lochia flow has been d. identify the type of pain relief that was given when she was in labor
A
A young mother is excited about her first baby. Choose the best teaching to help her obtain adequate rest after discharge a. plan to sleep or rest any time the infant sleeps b. do all housecleaning while the infant sleeps c. cook several meals at once and freeze for later use d. tell family and friends not to visit for the 1st month
A
Twelve hours after birth, a mother lies in bed resting. Although she will be discharged in another 12 hours, she does not ask about her baby or provide any care. What is the probable reason for her behavior? a. she is still in the taking-in phase of maternal adaptation b. she shows behaviors that may lead to postpartum depression c. she is still affected by medications given during labor d. she may be dissatisfied with some aspect of the newborn
A
When checking a woman's fundus 24 hours after cesarean birth of her third baby, the nurse finds her fundus at the level of her umbilicus, firm, and in the midline. The appropriate nursing action related to this assessment is to: a. document the normal assessment b. determine when she last urinated c. limit her intake of oral fluids d. massage her fundus vigorously
A
A woman who is 18 hours postpartum says she is having "hot flashes" and "swears all the time". The appropriate nursing response is to: a. report her signs and symptoms of hypovolemic shock b. tell her that her body is getting rid of unneeded fluid c. notify her nurse-midwife that she may have an infection d. limit her intake of caffeine-containing fluids
B
Choose the best independent nursing action to aid episiotomy healing in the woman who is 24 hours postpartum a. antibiotic cream applications to the area b. warm sitz baths taken four times per day c. maintaining cold packs to the area at all times d. checking the leukocyte level
B
A woman who is 3 hours postpartum has had difficulty urinating. She finally urinates 100 ml. The initial nursing action is to: a. insert an indwelling catheter b. have her drink additional fluids c. assess the height of her fundus d. chart the urination amt
C
The best nursing encouragement for parents to care for their infant is to: a. stay out of the room for as long as possible b. have the grandmother nearby as a backup c. give positive feedback when they provide care d. correct their performance whenever they make a mistake
C
To help the postpartum woman to avoid constipation, the nurse should teach her to: a. avoid intake of foods such as milk, cheese, or yogurt b. take a laxative for the first 3 postpartum days c. drink at least 2500 ml of non-caffeinated fluids daily d. limit her walking until the episiotomy is freely healed
C
When teaching the postpartum woman about Peripads, the nurse should tell her that: a. she can change to tampons when the initial perineal soreness goes away b. pads having cold packs within them usually hold more lochia than regular pads c. blood-soaked pads must be returned in a plastic bag to the hospital after discharge d. the pads should be applied and removed in a front- to- back direction
D
A new father is reluctant to "spoil" his newborn when she cries by picking her up. The best nursing response is to: a. teach him that she will eventually stop crying if he waits b. take the baby to the nursery to allow the parents to rest c. pick the baby up and rock her until she sleeps again d. tell the father that the baby cries to communicate a need
D
Choose the sign or symptom that the new mother should be taught to report a. occasional uterine cramping when the infant nurses b. oral temp that is 37.2d C (99dF) in the morning c. descent of the fundus one finger-breadth each day d. reappearance of red lochia after it changes to serous
D
To prevent breast engorgement, the nurse should teach the non-breastfeeding postpartum woman to: a. maintain loose-fitting clothing over her breasts b. pump the breasts briefly if they become painful c. limit fluid intake to suppress milk production d. wear a well-fitting bra or breast binder constantly
D
Phase Taking In Maternal behaviors and Nursing considerations
Rubin's Puerperal Phases Maternal Behaviors > The mother is focused primarily on her own need for fluid, food, and sleep. >A major task for the mother during this time is to integrate her birth experience into reality. To do this she discusses her labor and delivery in detail with visitors or on the telephone. This process helps the mother realize that the pregnancy is over and the newborn is an individual separate from her.
Assess: Fundus, Lochia, Bladder, Perineum, VS, Breasts, Lower extremities What do you assess and expected findings Deviations from normal, cause, and nursing actions
Expected > Fundus: Firmly contracted and at or near the level of the umbilicus. Deviation: > If the uterus is above the expected level or shifted (usually to the right) from the middle of the abdomen (midline position), the bladder may be distended. The location of the fundus should be rechecked after the woman has emptied her bladder. Expected: > Lochia: The odor of lochia is usually described as "fleshy," "earthy," or "musty." Deviation: > A foul odor suggests endometrial infection, and assessments should be made for additional signs of infection. These signs include maternal fever, tachycardia, uterine tender- ness, and pain. Absence of lochia, like the presence of a foul odor, may also indicate infection. If the birth was cesarean, lochia may be scant because some of the endometrial lining was removed. Lochia should not, however, be entirely absent. Expected: >Perineum: Redness of the wound may indicate the usual inflammatory response to injury. Deviation: > If accompanied by excessive pain or tenderness, however, it may indicate the beginning of localized infection. Ecchymosis or edema indicates soft tissue damage that can delay healing. There should be no discharge from the wound. Rapid healing requires that the edges of the wound be closely approximated. Expected: >Breasts: For the first day or two after delivery, the breasts should be soft and non-tender. Deviation: > The skin should be inspected for dimpling or thickening, which, although rare, can indicate a breast tumor. Expected: > Lower extremities: The legs are examined for varicosities and signs or symptoms of thrombophlebitis. Deviations: > Indications of thrombophlebitis include localized areas of redness, heat, edema, and tenderness. Pedal pulses may be obstructed by thrombophlebitis and should be palpated with each assessment.
First 24 hours: Respiratory
If the respiratory rate is less than 12 to 14 breaths per minute or the pulse oximeter shows persistent oxygen saturation less than 95%, the nurse should: > Notify the anesthesiologist immediately. >Elevate the head of the bed to facilitate lung expansion and ask the woman to breathe deeply. > Administer oxygen, and apply a pulse oximeter (if not already in place) to measure oxygen saturation. >Follow facility protocol to administer narcotic antagonists, such as naloxone hydrochloride (Narcan). > Observe for recurrence of respiratory depression, because the effect of naloxone lasts only approximately 30 minutes. > Recognize that naloxone reduces the level of pain relief.
Phase Taking Hold Maternal behaviors and nursing considerations
Maternal Behaviors > The mother becomes more independent. She exhibits concern about managing her own body functions and assumes responsibility for her own care. When she feels more comfortable and in control of her body, she shifts her attention to the behaviors of the infant. Nursing Considerations > The nurse must be careful not to take over care of the infant. The mother should be encouraged to perform as much of the care taking as possible as she assumes the mothering role. Fathers should also be encouraged to participate in care taking as they take on a new role. The nurse should praise each attempt, even if the parents' early care is awkward.
Phase Letting Go Maternal behaviors and nursing considerations
Maternal Behaviors > Time of relinquishment for the mother and often for the father. Some mothers and fathers are disappointed by the size, gender, or characteristics of the infant who does not "match up" with the fantasy baby of pregnancy. They must relinquish the infant of their fantasies and accept the real infant. Nursing Considerations > Both parents may benefit, however, if given the opportunity to discuss unexpected feelings and to realize that these feelings are common.
Urinary Catheterization
Necessary if > She is unable to void. > The amount voided is less than 150 mL and the bladder can be palpated. > The fundus is elevated or displaced from the midline.
Reciprocal Attachment Behaviors
Newborn infants have the ability to: > Make eye contact and engage in prolonged, intense, mutual gazing > Move their eyes and attempt to "track" the parent's face > Grasp and hold the parent's finger > Move synchronously in response to rhythms and patterns of the parent's voice (called entrainment) > Root, latch on to the breast, and suckle > Be comforted by the parent's voice or touch
Describe additional nursing assessments and care for the woman who gave birth by cesarean: a. respiratory, b. abdomen, c. intake and output
a. Respiratory: Observe respiratory rate and depth ( every 30 min to 1 hour if epidural narcotics were used); monitor for apnea for epidural narcotic administration; auscultate breath sounds for retained secretions; assist the mother to turn, cough, and deep breathe; use incentive spirometer. b. Abdomen: Assess for return of peristalsis by auscultating bowel sounds; observe for abdominal distention; observe surgical dressing for intactness and drainage; observe incision line after dressing removal for signs of infection (REEDA); palpate fundus gently. c. Intake & Output: Monitor IV line for rate of flow and site condition; observe urine for amount, color, and clarity.
Describe postpartum change in the: a. Uterine Muscle b. Uterine Muscle Cells c. Uterine Lining
a. Stretched uterine muscle fibers contract and gradually regain their former size and contour b. Number of uterine muscle cells remain the same, but each cell decreases in size through catabolism c. Outer area of endometrium (decidua) is expelled with the placenta. Remaining decidua separates into two layers: the superficial layer is shed in lochia and the basal layer regenerates new endothelium