Women's Health and Neonatal Nursing - Exam #4

Respiratory System Adaptations

> 16-24 breaths per minute > As the abdominal organs resume their nonpregnant positions, the diaphragm returns to its usual position. > Anatomic changes in the thoracic cavity and rib cage caused by increasing uterine growth resolve quickly. > Symptoms such as shortness of breath and rib aches are relieved. > Tidal volume, minute volume, vital capacity, and functional residual capacity return to pregnant values (1-3 weeks)

Physical Assessment

> BUBBLE-E -> Breasts, Uterus, Bladder, Bowel, Lochia, Epidural/Perineal/Episotomy, Extremities

Bonding versus Attachment

> Bonding - Close emotional attraction to a newborn by the parents that develops the first 30 to 60 minutes after birth - Unidirectional, from parent to infant - a component of the attachment process > Attachment - Development of a strong affection between an infant and a significant other (mother, father, sibling, caretaker) - Goes in both directions - This tie between two people is psychological rather than biologic, and it does not occur overnight.

BUBBLE-EE

> Breasts > Uterus > Bladder > Bowel > Lochia > Episiotomy/Perineum/Epidural Site > Extremities > Emotional Status

Psychosocial Assessment

> Emotional Status > Bonding and Attachment

Nursing Assessment Timeframes

> First Hour: Every 15 minutes > Second Hour: Every 30 Minutes > 24 Hours: Every 4 hours > After 24 Hours: Every 8 Hours

Assess for Voiding Problems (Questions)

> Have you (voided, urinated, gone to the bathroom) yet? > Have you noticed any burning or discomfort with urination? > Do you have any difficulty passing your urine? > Do you feel that your bladder is empty when you finish urinating? > Do you have any signs of infection such as urgency, frequency, or pain? > Are you able to control the flow of urine by squeezing your muscles? > Have you noticed any leakage of urine when you cough, laugh, or sneeze?

Lactation

> Lactation is secretion of milk by the breasts. > It is caused by progesterone, estrogen, prolactin, and oyxtocin. > Appears within 4 to 5 days of childbirth.

Suppressing Lactation

> No universal guide > 30% of women do not breastfeed their infants > Wear a tight supportive bra 24 hours daily > Apply ice to breasts for 15-20 minutes every other hour > Avoid sexual stimulation > Do not stimulate the breasts by squeezing or manually expressing milk from the nipples.. > Avoid exposing the breasts to warmth (hot shower) > Engorgement usually subsides within 2-3 days

Risk Factors for Postpartum Hemorrhage

> Precipitous labor (less than 3 hours) > Uterine atony > Placenta previa or abruptio placenta > Labor induction or augmentation > Operative procedures (vacuum extraction, forceps, cesarean birth) > Retained placental fragments > Prolonged third stage of labor (more than 30 minutes) > Multiparity, more than three births closely spaced > Uterine overdistention (large infant, twins, hydramnios)

Extremities

> Pregnancy is associated with an increased risk of venous thromboembolism (VTE), including PE and DVT > State of hypercoagulability protects the mother against excessive blood loss during childbirth and placental separation > 3 Factors for Thromboembolic Disorders: Stasis (compression of large veins because of the gravid uterus); Altered Coagulation (state of pregnancy); and Localized Vascular Damage (during birthing process) > Clot may form and travel to the lungs > While inspecting the woman's extremities, also determine the degree of sensory and motor function return (recovery from anesthesia) by asking the woman if she feels sensation at various areas the nurse touches and also by observing her ambulation stability. > A PE typically results from a dislodged DVT in the lower extremities > Blood clots may not be detected during physical examination. When DVT progresses to PE, it may do so without any signs or symptoms. > S/S of PE: hypotension, syncope, chest pain, dyspnea > An accurate diagnosis of PE is needed because it requires (1) prolonged therapy (at least 9 months of heparin after pregnancy); (2) prophylaxis during future pregnancies; and (3) avoidance of oral contraceptive pills > S/S of DVT: Lower extremity tightness or aching when ambulating that is relieved with rest and elevation of leg; edema in affected leg (usually left); warmth and tenderness; low grade fever > A duplex ultrasound (two-dimensional ultrasound and Doppler ultrasound that compresses the vein to assess for changes in venous flow) in conjunction with the physical findings frequently is needed for a conclusive diagnosis > Women with an increased risk for this condition during the postpartum period should wear antiembolism or graduated compression stockings or use sequential compression devices to reduce the risk of venous stasis by preventing blood from pooling in the calves of the legs. > Encouraging the client to ambulate after childbirth reduces the incidence of thrombophlebitis.

Breastfeeding

> Skin-to-skin contact during the first hour following birth is the gold standard to initiate breastfeeding > A newborn's instinct is to seek nourishment after birth. A newborn moves on their mother's abdomen up to her breast instinctively.

More about the 4 Stages for BAM

> The woman's work in the first stage is to make a commitment to the pregnancy and to the safe birth and care of her unborn child. > During the second stage while the mother is placing the infant in her family context and learning how to care for her infant, her attachment and attitude toward her infant, and her self-confidence and/or sense of competence in mothering consistently indicate an interdependence of these two variables.

Reproductive System Adaptations

> Uterine Involution

Engorgement

> a postnatal physiologic painful condition in which distention and swelling of the breast tissue occurs as a result of an increase in blood and lymph supply as a precursor to lactation > peaks in 3-5 days postpartum and subsides within the following 24-36 hours > If milk is not removed as it is formed, the alveolar space can become overdistended, causing tender, swollen, and painful breasts > Engorgement can occur from infrequent feeding or ineffective emptying of the breasts and typically lasts about 24 hours. > Prolactin causes increased swelling and vascularity 2-4 days after birth > If engorged, the breasts will be hard and tender to touch. > Frequent emptying of the breasts helps minimize discomfort and resolve engorgement. Standing in a warm shower or applying warm compresses immediately before feedings will help to soften the breasts and nipples in order to allow the newborn to latch on more easily. > Treatments: heat or cold applications, cabbage leaf compresses, breast massage and milk expression, ultrasound, breast pumping, and antiinflammatory agents > Antiinflammatory -> reduces discomfort and swelling > Between feedings, applying cold compresses to the breasts helps reduce swelling.

Taking-Hold Phase

> the second phase of maternal adaptation, is characterized by dependent and independent maternal behavior. > This phase typically starts on the 2nd to 3rd day postpartum and may last several weeks. > As the client regains control over her bodily functions during the next few days, she will be taking hold and becoming preoccupied with the present. > She will be particularly concerned about her health, the infant's condition, and her ability to care for them. > She demonstrates increased autonomy and mastery of her own body's functioning, and a desire to take charge with support and help from others. > She will show independence by caring for herself and learning to care for her newborn, but she still requires assurance that she is doing well as a mother. She expresses a strong interest in caring for the infant by herself.

BAM

Becoming a mother

Hematomas

Large areas of swollen, bluish skin with complaints of severe pain in the perineal area indicate pelvic or vulvar hematomas. > Severe, intractable pain, perineal discoloration, and ecchymosis indicate a perineal hematoma, a potentially dangerous condition

Healthy People 2030 (Breastfeeding)

Objective: Increase the proportion of infants who are breastfed exclusively through 6 months. Rationale: Will provide infants with the most complete form of nutrition, improving their health, growth and development, and immunity. Will improve maternal and child health via breastfeeding's beneficial effects.

Engrossment

The partner's developing bond with the newborn—a time of intense absorption, preoccupation, and interest

(T/F) A danger sign is the reappearance of bright-red blood after lochia rubra has stopped. Reevaluation by a health care provider is essential if this occurs.

True

(T/F) Afterpains are usually stronger during breastfeeding because oxytocin released by the sucking reflex strengthens the contractions. Mild analgesics can reduce this discomfort.

True

(T/F) Failure to maintain and restore perineal muscular tone can lead to urinary incontinence later in life for many women.

True

(T/F) If rectus muscle tone is not regained through exercise, support may not be adequate during future pregnancies.

True

(T/F) If the fundus is not firm, gently massage the uterus using a circular motion until it becomes firm.

True

(T/F) It is not uncommon for women to have a temperature elevation up to 100.4°F in the first 24 hours postpartum due to mild dehydration. There may also be a slight decrease in blood pressure. The nurse should be most concerned about a blood pressure elevation because preeclampsia may occur during the early postpartum period.

True

(T/F) Ovulation may occur before menstruation. Therefore, breastfeeding is not a totally reliable method of contraception unless the mother exclusively breastfeeds, has had no menstrual period since giving birth, and has an infant younger than 6 months.

True

(T/F) Parenting is a skill that is often learned by trial and error with varying degrees of success. Successful parenting, a continuous and complex interactive process, requires parents to learn new skills and integrate the new member into the family.

True

(T/F) Prolactin and oxytocin result in milk production if stimulated by sucking. If the stimulus is not present, as with a woman who is not breastfeeding, breast engorgement and milk production will subside within days postpartum.

True

Subinvolution

delayed or absent involution

MRA

maternal role attainment

4 Stages for Establishment of Maternal Identity in BAM

1. Commitment, attachment to the unborn baby, and preparation for delivery and motherhood during pregnancy 2. Acquaintance/attachment to the infant, learning to care for the infant, and physical restoration during the first 2 to 6 weeks following birth 3. Moving toward a new normal 4. Achievement of a maternal identity through redefining self to incorporate motherhood (around 4 months); the mother feels self-confident and competent in her mothering and expresses love for and pleasure interacting with her infant

7 Behaviors of Engrossment

1. Visual awareness of the newborn—the partner perceives the newborn as beautiful. 2. Tactile awareness of the newborn—the partner has a desire to touch or hold the newborn and considers this activity pleasurable. 3. Perception of the newborn as perfect—the partner does not "see" any imperfections. 4. Strong attraction to the newborn—the partner focuses all their attention on the newborn when in the room. 5. Awareness of distinct features of the newborn—the partner can distinguish the newborn from others in the nursery. 6. Extreme elation—the partner feels a "high" after the birth of the child. 7. Increased sense of self-esteem—the partner feels proud, "bigger," more mature, and older after the birth of the child

Lacerations

> 1st Degree: involves only skin and superficial structures above muscle > 2nd Degree: extends through perineal muscles > 3rd Degree: extends through anal sphincter muscle > 4th Degree: extends through anterior rectal wall

Fostering Maternal Role Attainment

> 3 Interventions 1. First, instructions about infant care and the infant's capabilities are more effective if they are specifically focused on that particular mother's infant. 2. Second, mothers prefer live classes rather than videos so they can ask questions. In short, interactive nurse-client relationships are associated with positive maternal growth. 3. Third, identifying barriers that reduce skin-to-skin periods of mother-to-infant contact during the postpartum hospital stay and intervening to reduce them have implications for both maternal role development and breastfeeding success, if the mother has chosen this method. Providing times for skin-to-skin contact has a positive impact on the long-term health of both the mother and baby. > Nurses who interact with clients long-term during pregnancy, childbirth, and well-child care help build maternal competence.

Vagina

> After birth, mucosa is edematous, relaxed, and thin with few rugae > As ovarian function returns and estrogen production resumes, the mucosa thickens and rugae return in approximately 3 weeks. > Returns to prepregnant state by 6-8 weeks > Will always remain a bit larger than it had been before pregnancy > Normal mucus production and thickening of the vaginal mucosa usually return with ovulation. The vaginal decreases in size and regains tone. > Edema and vascularity decrease by 3-4 weeks > The vaginal epithelium is generally restored by 6 to 8 weeks postpartum > Localized dryness and coital discomfort (dyspareunia) plague many women until menstruation returns. Water-soluble lubricants can reduce discomfort during intercourse.

Risk Factors for Thromboembolic Condition

> Anemia > Diabetes mellitus > Cigarette smoking > Obesity > Preeclampsia > Hypertension > Severe varicose veins > Pregnancy > Multiple pregnancies > Cardiovascular disease > Sickle cell disease > Postpartum hemorrhage > Oral contraceptive use > Cesarean birth > Severe infection > Previous thromboembolic disease > Multiparity > Bed rest or immobility for 4 days or more > Maternal age older than 35

Integumentary System Adaptations

> As estrogen and progesterone levels decrease, the darkened pigmentation on the abdomen (linea nigra), face (melasma), and nipples gradually fades. > Hair loss may be experienced. Approximately 90% of hairs are growing at any one time, with the other 10% entering a resting phase > Because of the high estrogen levels present during pregnancy, an increased number of hairs go into the resting phase. The most common period for hair loss is within 3 months after birth, when estrogen returns to normal levels and more hairs are allowed to fall out. > This hair loss is temporary, and regrowth generally returns to normal levels in 4 to 6 months in two thirds of women and by 15 months in the remainder, though hair may be less abundant than before pregnancy > Striae gravidarum (stretch marks) that develop on the breasts, abdomen, and hips gradually fade to silvery lines. These do not fade, however. > Profuse diaphoresis (sweating) is common in early postpartum. > Many women will wake up drenched with perspiration during the puerperium. This postpartum diaphoresis is a mechanism to reduce the amount of fluids retained during pregnancy and restore prepregnant body fluid levels. > It is common, especially at night during the first week after birth. Reassure the client that this is normal and encourage her to change her night clothes to prevent chilling.

Lochia (Physical Assessment)

> Assess amount, color, odor, and change with activity and time. Ask about the presence of clots. > Ask how many perineal pads she has used in the past 1-2 hours and how much drainage was on each pad. > Lochia has a definite musky scent, with an odor similar to that of menstrual flow without any large clots (fist size). > Foul-smelling lochia suggests an infection, and large clots suggest poor uterine involution > To determine the amount of lochia, observe the amount of lochia saturation on the perineal pad and relate it to time. Take into consideration the specific type of peripad used, because some are more absorbent than others. > Lochia flow will increase when the woman gets out of bed (lochia pools in the vagina and the uterus while she is lying down) and when she breastfeeds (oxytocin release causes uterine contractions). > The total volume of lochial discharge varies in women based on their parity, but the amount decreases daily. > Check under the woman by turning her to either side to make sure additional blood is not hidden and not absorbed on her perineal pad. This also a good time to assess for the presence and condition of hemorrhoids since the nurse is visually inspecting the perineum. > Report heavy, bright red lochia with large tissue fragments or foul odor. If excessive bleeding occurs, the first step would be to massage the boggy fundus until it is firm to reduce the flow of blood. > Women who had cesarean births will have less lochia discharge than those who had vaginal births, but stages and color changes remain the same. > Although the woman's abdomen will be tender after surgery, the nurse must palpate the fundus and assess the lochia to make sure they are within the normal range and that there is no excessive bleeding. > Urge the woman to notify her health care provider if lochia rubra returns after the serosa and alba transitions have taken place. This may indicate subinvolution or that the woman is too active and needs to rest more. > Lochia is an excellent medium for bacterial growth. Explain to the woman that frequent changing of perineal pads, continued use of her peribottle for rinsing her perineal area, and hand hygiene before and after pad changes are important infection control measures.

Uterus (Physical Assessment)

> Assess the fundus (top portion of the uterus) to determine the degree of uterine involution. > If possible, have the woman empty her bladder before assessing the fundus and auscultate her bowel sounds prior to uterine palpation. > If the client has had a cesarean birth and has a patient-controlled anesthesia (PCA) pump, instruct her to self-medicate prior to fundal assessment to decrease her discomfort. > Using a two-handed approach with the woman in the supine position with her knees flexed slightly and the bed in a flat position or as low as possible, palpate the abdomen gently, feeling for the top of the uterus while the other hand is placed on the lower segment of the uterus to stabilize it > The fundus should be midline and firm. A boggy uterus is a sign of uterine atony (loss of muscle tone in the uterus). This can be due to bladder distention, which displaces the uterus upward and to the right, or retained placental fragments. These factors can lead to hemorrhage. > Once the fundus is located, place your index finger on the fundus and count the number of fingerbreadths between the fundus and the umbilicus (one fingerbreadth is approximately equal to 1 cm). > 1-2 hours after birth, the fundus is usually between the umbilicus and the symphysis pubis. > 6-12 hours after birth, the fundus is usually at the level of the umbilicus. > If the fundal height is above the umbilicus, which would be an abnormal finding, investigate this immediately to prevent excessive bleeding. Frequently, the woman's bladder is full, thus displacing the uterus up and to either side of the midline. Ask the woman to empty her bladder, and reassess the uterus again. > Normally, the fundus progresses downward at a rate of 1 cm per day after childbirth and should be nonpalpable by 10 to 14 days postpartum. > By day 14, the uterus has descended below the rim of the symphysis pubis and is no longer palpable > On the first postpartum day, the top of the fundus is located 1 cm below the umbilicus and is recorded as u/1.

Emotional Status

> Assess the woman's emotional status by observing how she interacts with her family, her level of independence, energy levels, eye contact with her infant (within a cultural context), posture and comfort level while holding the newborn, and sleep and rest patterns. > Be alert for mood swings, irritability, or crying episodes.

Parental Attachment Behaviors

> Attachment = formation of a relationship between a parent and newborn through a process of physical and emotional interactions. > Maternal attachment has the potential to affect both child development and parenting > Attachment begins before birth, during the prenatal period when acceptance and nurturing of the growing fetus takes place. > It continues after giving birth as parents learn to recognize the newborn's cues, adapt to the newborn's behaviors and responses, and meet the newborn's needs. > Oxytocin plays an essential role in the chemistry aspect of bonding, and its effects can be enhanced by skin-to-skin contact; breastfeeding; eye contact; social vocalizations; maternal and milk odors, which are soothing for the newborn; and newborn massage during the first postpartum hour. > Early and sustained contact between newborns and their parents is vital for initiating this relationship. > Nurses play a crucial role in assisting the attachment process by promoting early parent-newborn interactions. > nurses can facilitate skin-to-skin contact (kangaroo care) by placing the infant onto the bare chests of mothers and their partners to enhance parent-newborn attachment. This activity will enable them to get close to their newborn and experience an intense feeling of connectedness and evoke feelings of being nurturing parents. > Encouraging breastfeeding is another way to foster attachment between mothers and their newborns. > Finally, nurses can encourage nurturing activities and contact such as touching, talking, singing, comforting, changing diapers, feeding—in short, participating in routine newborn care. > Nurses need to minimize parent-newborn separation by promoting parent-newborn interactions through kangaroo care, breastfeeding, and participation in their newborn care.

Attachment

> Attachment = the development of strong affection between an infant and a significant other (mother, father, sibling, and caregiver). > This attachment is reciprocal; both the significant other and the newborn exhibit attachment behaviors. > The attachment relationship formed between the infant and primary caregiver influences the child's view of the world and future relationships > Does not occur overnight (psychological) > The process of attachment follows a progressive or developmental course that changes over time. > It is affected by health of the infant, the mother, environmental circumstances, and the quality of care the infant receives > It is individualized > The newborn responds to the significant other by cooing, grasping, smiling, and crying. > Nurses can assess for attachment behaviors by observing the interaction between the newborn and the person holding them > Maternal attachment begins during pregnancy as the result of fetal movement and maternal fantasies about the infant and continues through the birth and postpartum periods. > Attachment behaviors include seeking; physical caregiving behaviors; emotional attentiveness to the infant's needs; staying close to, touching, kissing, cuddling, and choosing the en face position (face-to-face) while holding or feeding the newborn; expressing pride in the newborn; and exchanging gratifying experiences with the infant > In a high-risk pregnancy, the attachment process may be complicated by premature birth (lack of time to develop a relationship with the unborn baby) and by parental stress due to fetal and/or maternal vulnerability. > Bonding is a vital component of the attachment process and is necessary in establishing parent-infant attachment and a healthy, loving relationship. > During this early period of acquaintance, mothers touch their infants in a characteristic manner. Mothers visually and physically "explore" their infants, initially using their fingertips on the infant's face and extremities and progressing to massaging and stroking the infant with their fingers. This is followed by palm contact on the trunk. Eventually, mothers draw their infant toward them and hold the infant. > This process is similar for partners, with a different pace. Like mothers, partners manifest attachment behaviors during pregnancy. Partners develop emotional ties with their infants in a variety of ways. They seek and maintain closeness with the infant and can recognize characteristics of the infant.

Attachment

> Attachment is a process; it does not occur instantaneously, even though many parents believe in a romanticized version of attachment, which happens right after birth. > A delay in the attachment process occurs if a mother's physical/emotional states are affected by exhaustion, pain, and the absence of a support system; if she has an infant in neonatal intensive care unit (NICU) and is separated from them; or had a traumatic birth experience, substance abuse, anesthesia, or an unwanted outcome, such as an ill infant > The developmental task for the infant is learning to differentiate between trust and mistrust. If the mother or caregiver is consistently responsive to the infant's care, meeting the baby's physical and psychological needs, the infant will likely learn to trust the caregiver, view the world as a safe place, and grow up to be secure, self-reliant, trusting, cooperative, and helpful. > However, if the infant's needs are not met, the child is more likely to face developmental delays, neglect, and child abuse.

Bonding

> Bonding = the close emotional attraction to a newborn by the parents that develops during the first 30 to 60 minutes after birth. > It is unidirectional, from parent to infant. It is thought that optimal bonding of the parents to a newborn requires a period of close contact within the first few minutes to a few hours after birth. > Bonding is a continuation of the relationship that began during pregnancy > It is affected by the parents' socioeconomic status, family history, role models, support systems, cultural factors, and birth experiences. > The mother initiates bonding when she caresses her infant and exhibits certain behaviors typical of a mother tending her child. > The infant's responses to this, such as body and eye movements, are a necessary part of the process. During this initial period, the infant is in a quiet, alert state, looking directly at the person holding them.

Bowels (Physical Assessment)

> Constipation is most common GI problem > Causes: Local pelvic floor trauma, taking pain medications, lack of dietary fiber, fluids, and infant care > Spontaneous bowel movements may not occur for 1-3 days after giving birth because of a decrease in muscle tone in the intestines as as result of elevated progesterone levels. > Normal patterns of bowel elimination usually return within a week after birth. > Often women are hesitant to have a bowel movement due to pain in the perineal area resulting from an episiotomy, lacerations, or hemorrhoids. Some are fearful that they may "rip their stitches" should they strain. > Nurses should reassure their clients that stool softeners and/or laxatives to treat constipation have been prescribed for them to reduce discomfort. > Inspect the woman's abdomen for distention, auscultate for bowel sounds in all four quadrants prior to palpating the uterine fundus, and palpate for tenderness. > The abdomen should be soft, nontender, and nondistended. Bowel sounds should be present in all four quadrants. > Ask the woman if she has had a bowel movement or has passed gas since giving birth, because constipation is common during the postpartum period, and many women do not offer this information unless asked about it.

Cultural Considerations for Postpartum Period

> Cultures vary in their postpartum beliefs, practices, and customs. > Therefore, nurses must be open, respectful, nonjudgmental, and willing to learn about ethnically diverse populations. > Somali Women -> highly regarded in society for their roles as mothers. They stay at home and refrain from sexual activity for 30 days. At the end of 40 days, there is a celebration and this typically marks the first time the mother and infant have left the home since childbirth. > Arab and Somali women breastfeed their babies for extended periods of time

Pulse and Blood Pressure

> Decrease in cardiac output and stroke volume > Pulse lowers to 60-80 BPM within the first few weeks postpartum. > Lowered pulse is due to the increased blood flow that flows back the heart and to central circulation since there is no longer a placenta to perfuse. > This increase in central circulation brings about an increased stroke volume and allows a slower heart rate to provide ample maternal circulation. > Cardiac output returns to prepregnant levels by 3 months after childbirth > Tachycardia is abnormal: may be a sign of hypovolemia, dehydration, or hemorrhage > Since there is an increase in blood volume during pregnancy, a considerable loss of blood may be tolerated. > In most instances of postpartum hemorrhage, blood pressure and cardiac output remain increased because of the compensatory increase in heart rate. Thus, a decrease in blood pressure and cardiac output are not expected changes during the postpartum period. > Blood pressure falls in the first 2 days, then increases 3-7 days after childbirth. It returns to prepregnancy levels by 6 weeks. > A significant increase accompanied by headache might indicate preeclampsia and requires further investigation. > Decreased blood pressure may suggest an infection or a uterine hemorrhage.

Bladder

> Diuresis (3000 mL/day) begins within 12 hrs after childbirth and continues for several days. It usually stops at 21 days. > many postpartum women do not sense the need to void even if their bladder is full. In this situation, the bladder can become distended and displace the uterus upward and to the side, which prevents the uterine muscles from contracting properly and can lead to excessive bleeding. > Postpartum urinary retention = the inability to empty the bladder within 6 hours after a vaginal birth. > Urinary retention can be caused by decreased bladder tone and emptying. It can lead to UTIs and postpartum hemorrhaging. > Monitor for S/S of UTI: Fever, urinary frequency or urgency, difficult or painful urination, tenderness over the costovertebral angle. > Women who received regional anesthesia during labor are at risk for UTIs (due to continuous urinary catheterization) > They also experience difficulty voiding and loss of sensation and must wait until it returns to feel a full bladder which might be several hours after childbirth. > Assess the bladder for distention and adequate emptying after efforts to void. > Palpate the area over the symphysis pubis. If empty, the bladder is not palpable. > Palpation of a rounded mass suggests bladder distention. > Also percuss the area; a full bladder is dull to percussion. If the bladder is full, lochia drainage will be more than normal because the uterus cannot contract to suppress the bleeding. > After the woman voids, palpate and percuss the area again to determine adequate emptying of the bladder. > If the bladder remains distended, the woman may be retaining urine in her bladder, and measures to initiate voiding should be instituted. Be alert for signs of infection, including infrequent or insufficient voiding (less than 200 mL), discomfort, burning, urgency, or foul-smelling urine

Musculoskeletal System Adaptations

> During Pregnancy: Increased ligament laxity, weight gain, change in center of gravity, carpal tunnel syndrome. > This changes revert back during the postpartum period. > During pregnancy, relaxin, estrogen, and progesterone relax the joints. After birth, these levels decline, resulting in a return of all joints to their prepregnant state (except the feet). > Parous women may note a permanent increase in shoe size. > Women commonly experience fatigue and activity intolerance and have a distorted body image for weeks after birth secondary to declining relaxin and progesterone levels, which cause hip and joint pain that interferes with ambulation and exercise. > Lower back pain and injury to joints can be prevented with good body mechanics and correct positioning, > Within 6-8 weeks, joints are completely stabilized and return to normal. > During pregnancy, stretching of the abdominal wall muscles occurs to accommodate the enlarging uterus. This leads to a loss in muscle tone and separation of the longitudinal muscles (rectus abdominis) of the abdomen. > After birth, muscle tone is diminished and the abdominal muscles are soft and flabby. Specific exercises are necessary to help the woman regain muscle tone. Fortunately, diastasis responds well to exercise, and abdominal muscle tone can be improved.

Introduction to Nursing Management During the Postpartum Period

> During postpartum, parenting starts and a relationship with the newborn begins. > A positive, loving relationship between parents and the newborn promotes the emotional well-being of all. This relationship endures and has profound effects on the child's growth and development. > Nursing management during the postpartum period focuses on assessing the woman's ability to adapt to the physiologic and psychological changes occurring at this time > Family members are also assessed to determine how well they are making the transition to this new stage.

Urinary System Adaptations

> During pregnancy, glomerular filtration rate and renal plasma flow increase significanty. This return to normal within 6 weeks of birth (decrease). > Gradual return of bladder tone and normal size and function of the bladder, ureters, and renal pelvis (all of which were dilated during pregnancy) > Many women have difficulty feeling the sensation to void after giving birth if they received an anesthetic block during labor (which inhibits neural functioning of the bladder) or if they received oxytocin to induce or augment labor (antidiuretic effect) > Urination may be impeded by: Perineal lacterations, generalized swelling and bruising of the perineum and tissues surrounding the urinary meatus, hematomas, decreased bladder tone (regional anesthesia), diminished sensation of bladder pressure due to swelling, poor bladder tone, and number effects of regional anesthesia > Difficulty voiding can lead to urinary retention, bladder distention, and ultimately urinary tract infection. > Urinary retention and bladder distention can cause displacement of the uterus from the midline to the right and can inhibit the uterus from contracting properly, which increases the risk of postpartum hemorrhage. > Frequent voiding of small amounts (less than 150 mL) suggests urinary retention with overflow, and catheterization may be necessary to empty the bladder to restore tone. > Postpartum diuresis also occurs due to: large amounts of IV fluids given during labor; a decreasing antidiuretic effect of oxytocin as its level declines; the buildup and retention of extra fluids during pregnancy; and a decreasing production of aldosterone. > Diuresis begins within 12 hours after birth and continues through 1st week. Normal function returns within a month.

Colostrum

> During pregnancy, prolactin, estrogen, and progesterone cause synthesis and secretion of colostrum, > Contains proteins and carbohydrates, but no milk fat > Creamy/yellow

Breastfeeding

> During the first 2 days after birth, the breasts are soft and nontender. > the woman may also report a tingling sensation in both breasts, which is the "let-down reflex" that occurs immediately before or during breastfeeding. > After this time, breast changes depend on whether the mother is breastfeeding or taking measures to prevent lactation.

Endocrine System Adaptations

> Estrogen and progesterone drop quickly after placenta delivery > Decreased estrogen levels -> breast engorgement and diuresis > Estrogen is lowest after a week postpartum > For the woman who is not breastfeeding, estrogen levels begin to increase by 2 weeks after birth. > For the breastfeeding woman, estrogen levels remain low until breastfeeding frequency decreases. > hCG, human placental lactogen, and progesterone decline rapidly after birth. > The hCG levels are nonexistent at the end of the first postpartum week, and hPL is undetectable within 1 day after birth > Progesterone levels are undetectable by 3 days after childbirth, and production is reestablished with the first menses. > Prolactin -> secreted by anterior pituitary gland (involved with lactation). Levels decrease within 2 weeks for woman who is not breastfeeding. They remain elevated for lactating women.

Weight Loss after Childbirth

> Excessive weight gain and postpartum weight retention increase risk of obesity > Lactation is usually not sufficient for mothers to return to the prepregnant weight. > The rate and amount of weight loss in the postpartum period us determined by existing weight, body mass index (BMI), diet, age, and activity level

Postpartum Danger Signs

> Fever >100.4°F (38°C) > Foul-smelling lochia or an unexpected change in color or amount > Large blood clots or bleeding that saturates a peripad in an hour > Severe headaches or blurred vision > Visual changes, such as blurred vision or spots, or headaches > Calf pain with dorsiflexion of the foot > Swelling, redness, or discharge at the episiotomy, epidural, or abdominal sites > Dysuria, burning, or incomplete emptying of the bladder > Shortness of breath or difficulty breathing without exertion > Depression or extreme mood swings

Ovulation and Return of Menstruation

> Four hormones important in postpartum: estrogen, progesterone, prolactin, and oxytocin > Estrogen levels drop at birth and reach their lowest after a week > Progesterone quiets the uterus to prevent preterm birth during pregnancy. Its increased levels prevent lactation before birth. Levels also decreased dramatically after birth and are undetectable 72 hours after birth > Progesterone levels are reestablished with first menstrual cycle. > Oxytocin stimulates contractions during breastfeeding session (as long as 20 minutes after each feeding). It also acts on the breast by eliciting milk let-own reflex during breastfeeding. >Prolactin stimulates milk production. In women who breastfeed, prolactin remains elevated for 6 weeks. Prolactin decreases in nonlactating women by 3 week. > High levels of prolactin have been found to delay ovulation by inhibiting ovarian response to follicle-stimulating hormone > The timing of menses and ovulation after birth differs between breastfeeding women and who are not breastfeeding > For nonlactating women, menstruation may resume by 7-9 weeks, most take 3 months (anovulatory -> ovulation does not occur) > For lactating women, this can be anywhere from 2-18 months. > The return of menses in the lactating woman depends on breastfeeding frequency and duration. It can return any time after childbirth, depending on whether the woman is exclusively breastfeeding or supplementing with formula.

Sexual Health

> Hormones, physical and psychological changes, parenting roles, infant care, breastfeeding, insomnia, fatigue, customs, beliefs, and traditions are all factors that influence sexual functioning in the postpartum period. > Problems may include sexual drive, arousal, orgasmic disorders, and uncomfortable intercourse.

Cervix

> Immediately after birth, the cervix extends into the vagina and remains partly dilated, bruised, and edematous. > Returns to prepregnant state by week 6 > Gradually closes but never regains its prepregnant appearance > Immediately after childbirth, the cervix is shapeless and edematous and is easily distensible for several days. > The internal os gradually closes and returns to normal by 2 weeks, while the external os widens and never appears the same after childbirth. > The external o becomes a jagged slit-like opening (fish mouth) instead of a circle

Social Support and Cultural Considerations

> In today's mobile society, extended families may live far away and may be unable to help care for the new family. > As a result, many new parents turn to health care providers for information as well as physical and emotional support during this adjustment period. > Nurses can be an invaluable resource by serving as mentors, teaching about self-care measures and baby care basics, and providing emotional support. > Nurses can "mother" the new mother by offering physical care, emotional support, information, and practical help. > The postpartum period is noted for traditional practices related to rest, healing, and consumption of food and drink. In many cultures, mothers and mothers-in-law have a great deal of influence over the new mother, so nurses need to be aware of the client's culture and help them integrate their beliefs and practices into contemporary health care practice > The skill set needed by nurses to provide culturally humble care to postpartum clients and their families includes understanding their beliefs, experiences, and family environment; facilitating their language through appropriate use of interpreters so that the information provided can be understood; and compassionately respecting clients and their human rights > Ex: many Chinese cultures value traditions and the involvement of elders in the extended family

Breastfeeding

> Includes motions of infant's jaw, undulation of the tongue, and breast milk ejection reflex > RECOMMENDATION: exclusive breastfeeding for 6 months followed by the introduction of appropriate complementary foods and continued breastfeeding to 1 year and beyond > Nurses have an important role in promoting, supporting, and protecting breastfeeding. > Proper positioning, latching-on, sucking, and swallowing are the foundation for successful breastfeeding. > During pregnancy, the breasts increase in size and functional ability in preparation for breastfeeding > Estrogen stimulates growth of milk collection (ductal system) > Progesterone stimulates growth of milk production system. > Within the first month of gestation, the ducts of the mammary glands grow branches, forming more lobules and alveoli. These structural changes make the breasts larger, more tender, and heavy. > Each breast gains nearly 1 lb in weight by term, the glandular cells fill with secretions, blood vessels increase in number, and the amount of connective tissue and fats cells increase. > Prolactin, released by the anterior pituitary gland, triggers synthesis and secretion of milk after the woman gives birth. > After birth takes place, the high levels of estrogen and progesterone are abruptly withdrawn, resulting in prolactin being able to stimulate the glandular cells to secrete milk instead of colostrum. This takes place within 4-5 days after birth. > Oxytocin allows milk to be ejected from the alveoli to the nipple. Sucking by the newborn will release milk. > A decrease in the quality of stimulation causes a decrease in prolactin surges and thus a decrease in milk production. > Prolactin levels increase in response to nipple stimulation during feedings.

Breasts (Physical Assessment)

> Inspect the breasts for size, contour, asymmetry, engorgement, or erythema. > Check the nipples for cracks, redness, fissures, or bleeding, and note whether they are erect, flat, or inverted. > Flat or inverted nipples can make breastfeeding challenging for both mother and infant. > Cracked, blistered, fissured, bruised, or bleeding nipples in the breastfeeding woman are generally indications that the baby is improperly positioned on the breast. > Palpate the breasts lightly to ascertain if they are soft, filling, or engorged. For women who are not breastfeeding, use a gentle, light touch to avoid breast stimulation, which would exacerbate engorgement. > Lactogenesis (onset of milk secretion) = initially triggered by the delivery of the placenta, which results in falling levels of estrogen and progesterone with the continued presence of prolactin. If the mother is not breastfeeding, prolactin levels fall and return to normal within 2-3 weeks. > As milk is starting to come in, the breasts become firmer; this is charted as "filling." > Engorged breasts are hard, tender, and taut > Ask the woman if she is having any nipple discomfort. > Palpate the breasts for any nodules, masses, or areas of warmth, which may indicate a plugged duct that may progress to mastitis if not treated promptly. > Any discharge from the nipple should be described and documented if it is not colostrum (creamy yellow) or foremilk (bluish white).

After Pains

> Involution requires uterine contractions > Immediately after birth and delivery of the placenta, the uterus begins to contract constricting the intramyometrial vessels and impeding blood flow (prevents hemorrhage) > Inadequate myometrial contractions will result in atony which will result in an early postpartum hemorrhage > These painful uterine contractions are often called afterpains. > All women experience afterpains, but they are more acute in multiparous and breastfeeding women, secondary to repeated stretching of the uterine muscles from multiple pregnancies or stimulation during breastfeeding with oxytocin released from the pituitary gland. > Breastfeeding and administration of exogenous oxytocin both cause powerful and painful uterine contractions. > Afterpains usually respond to oral analgesics.

Uterine Involution

> Involution: the uterus returns to its normal size. Involves retrogressive changes that return it to its nonpregnant size and condition. > 3 Retrogressive Processes: 1. Contraction of muscle fibers to reduce those previously stretched during pregnancy. 2. Catabolism, which shrinks enlarged individual myometrial cells. 3. Regeneration of the uterine epithelium from the lower layer of the decidua after the upper layers have been sloughed off and shed during lochia discharge. > Weights 1000 g after birth. Weights 500g after 1 week postpregnancy. By 6 weeks, it weights 60g. > During the first 12 hours postpartum, the fundus of the uterus is located at the level of the umbilicus. > The uterus typically descends from the level of the umbilicus at a rate of 1 cm (1 fingerbreadth) per day. > By 3 days, the fundus lies two to three fingerbreadths below the umbilicus (or slightly higher in multiparous women) > By the end of 10 days, the fundus usually cannot be palpated because it has descended into the true pelvis. > If these changes do not occur (due to placental fragments or infection), then subinvolution of uterus occurs. > Factors that Support Involution: complete expulsion of amniotic membranes and placenta at birth, a complication-free labor and birth process, breastfeeding, and early ambulation. > Factors that Inhibit Involution: Prolonged labor and difficult birth, incomplete expulsion of amniotic membranes and placenta, uterine infection, overdistention of uterine muscles (multiple gestation, hydramnios, or a large fetus), a full bladder (displaces uterus and interferes with contractions), anesthesia (relaxes uterine muscles), and close childbirth spaces (frequent and repeated distention decreases tone and causes muscular relaxation)

Lochia

> Lochia = vaginal discharge that occurs after birth and continues for approximately 4-8 weeks. > It results from involution, during which the superficial layer of the decidua basalis becomes necrotic and is sloughed off. > It is used to measure the process of involution and the restoration of the endometrium > Immediately after childbirth: Bright red and consists of blood, fibrinous products, decidual cells, and red and white blood cells > Lochia from the uterus is alkaline but becomes acidic as it passes through the vagina > Each day, the amount of bleeding should be less and lighter in color. The color changes result from the changing composition of the tissue that is sloughed and expelled during the endometrial restoration process. > Women with C. section tend to have less flow since uterine debris are removed manually along with delivery of placenta by the physician.

3 Stages of Lochia

> Lochia Rubra = deep-red mixture of mucus, tissue debris, and blood that occurs for first 3-4 days. As uterine bleeding subsides, it becomes paler and more serous. > Lochia Serosa = pinkish brown and is expelled 3-10 days postpartum. Mostly consists of leukocytes, decidual tissue, red blood cells, and serous fluid. > Lochia Alba = discharge is creamy white or light brown and consists of leukocytes, decidual tissue, and reduced fluid content. Occurs from days 10-14, but can last 3-6 weeks postpartum in some women. > Lochia at any stage should have a fleshy smell. An offensive odor is a sign of infection )endometritis)

Mood Disorders

> Many people consider childbirth a time of happiness and well-being, but it is common for women to experience changes in their mood during this time. > This can include being fatigued, irritable, and worried, and frequently these feelings become severe enough to require medical intervention. > Perinatal mood disorders are one of the most common complications to occur during the postpartum period, impairing maternal caregiving skills. > Can be divided into three entities (with increasing severity): Maternal Baby Blues; Postpartum Depression; Postpartum Psychosis > Up to 85% of new mothers suffer from the short-lived postpartum mood disorder called the "baby blues" or "maternal blues," which are characterized by mild depressive symptoms, anxiety, irritability, mood swings, loss of appetite, trouble sleeping, tearfulness (often for no discernible reason), increased sensitivity, and fatigue (peaks at 4-5 days and may last from hours to days. Usually resolves by day 10).

Cardiovascular System Adaptations

> Maternal hemodynamics are altered > Possible cardiovascular instability > During pregnancy, the heart is displaced slightly upward and to the left. This is reversed during involution. > Cardiac output remains high for the first few days postpartum and then gradually declines to nonpregnant values within 3 months of birth. > Blood volume (increased during pregnancy) drops rapidly after birth -> returns to normal within 4 weeks > The decrease in cardiac output and blood volume is due to blood loss (500 mL vaginal birth and 1000 mL C. section) > Cardiac Output -> returns to normal within 24-72 hours; rapidly falls over the next 2 weeks; and then returns to nonpregnant levels 6-8 weeks postpartum > Blood plasma volume is further reduced through diuresis, which occurs between days 2 and 5. > Despite the decrease in blood volume, the hematocrit level remains relatively stable and may even increase, reflecting the predominant loss of plasma. (An acute decrease in hematocrit is not an expected finding and may be a sign of hemorrhage)

Maternal Psychological Adaptations

> Mood Disorders > Phases of Maternal Adaptation to Parenthood

Stage 1: Expectations

> New partners pass through stage 1 (expectations) with preconceptions about what home life will be like with a newborn. > Many partners may be unaware of the dramatic changes that can occur when this newborn comes home to live with them. > For some, it is an eye-opening experience.

Coagulation

> Normal physiologic changes of pregnancy, including alterations in hemostasis that favor coagulation, reduced fibrinolysis, and pooling and stasis of blood in the lower limbs, place women at risk for blood clots. > This changes return to prepregnant levels after 3 weeks postpartum > They are important for minimizing blood loss at childbirth > Risk Factors for Coagulation Disorders: Smoking, obesity, immobility, infection, postpartum bleeding, and emergency surgery > Elevated clotting factors remain during the early postpartum period. Giving birth stimulates hypercoagulability even further. It remains this way for 2 to 3 weeks. > This hypercoagulable state, combined with vessel damage during birth and immobility, places the woman at risk for thromboembolism (blood clots) in the lower extremities and the lungs.

Bonding and Attachment

> Nurses can promote attachment by assessing attachment behaviors (positive and negative) and intervening appropriately if needed. > Nurses must be able to identify any family discord that might interfere with the attachment process. > Mothers from different cultures may behave differently from what is expected in one's own culture. > Ex: some Native American mothers may handle their newborns less often and use cradle boards to carry them. Some Native American mothers and many Asian American mothers delay breastfeeding until their milk comes in, because colostrum is believed to be harmful for the newborn > Do not assume that a behavior different from those of the predominant culture is wrong.

Nursing Assessment in the Postpartum Period

> Nurses need to carry out a thorough assessment of maternal discomfort and attempt to implement both preventive and therapeutic measures to reduce any discomfort to improve the mother's quality of life > The nurse's focus is on assistance for families to maximize their adjustment, surveillance for maladaptation, education, consultation, and collaboration as needed > Comprehensive nursing assessment begins within an hour after the woman gives birth and continues through discharge. > Includes vital signs, physical assessment, psychosocial assessment > It also includes assessing the parents and other family members, such as siblings and grandparents, for attachment and bonding with the newborn. > one of the most significant responsibilities of the postpartum nurse is to recognize potential complications after childbirth. > always review the woman's medical record for information about her pregnancy, labor, and birth. Note any preexisting conditions, any complications that occurred during pregnancy, labor, birth, and immediately afterward, and any treatments provided.

Risk Factors for Postpartum Infection

> Operative procedure (forceps, cesarean birth, vacuum extraction) > History of diabetes, including gestational-onset diabetes > Prolonged labor (more than 24 hours) > Use of indwelling urinary catheter > Anemia (hemoglobin <10.5 mg/dL) > Multiple vaginal examinations during labor > Prolonged rupture of membranes (>24 hours) > Manual extraction of placenta > Compromised immune system (HIV-positive)

Partners vs. Maternal Responses

> Partners have their own unique way of relating to their newborns and can become as nurturing as mothers. > A partner's nurturing responses may be less automatic and slower to unfold than a mother's, but they are capable of a strong bonding attachment to their newborns > Encouraging partners to express their feelings by seeing, touching, and holding the newborn and by cuddling, talking to, and feeding them will help cement this new relationship.

Phases of Maternal Adaptation to Parenthood

> Pregnancy is a time of great change and heightened vulnerability, and a mother faces tremendous challenges as she undergoes this transition. > Motherhood is often portrayed as idealized, romanticized, and joyful. However, a large proportion of women do not feel this way and instead experience postnatal psychological distress. > Society has constructed many ideal images of motherhood, creating sometimes unrealistic standards for women to live up to, frequently setting them up for disappointment. > In the early 1960s, Reva Rubin identified three phases that a mother goes through to adjust to her new maternal role. > Rubin's maternal role framework can be used to monitor the client's progress as she "tries on" her new role as a mother. >The absence of these processes or inability to progress through the phases satisfactorily may impede the appropriate development of the maternal role > Maternal role attainment is an interactional and developmental process occurring over time in which the mother becomes attached to her infant, acquires competence in her caregiving tasks, and feels a sense of harmony > Mothers today are able to go through the phases faster, are less passive than the past, and are more knowledgeable.

Summary of Breast Milk Production

> Prolactin levels increase at term with a decrease in estrogen and progesterone levels. > Estrogen and progesterone levels decrease after the placenta is delivered. > Prolactin is released from the anterior pituitary gland and initiates milk production. > Oxytocin is released from the posterior pituitary gland to promote milk let-down. > Infant sucking at each feeding provides continuous stimulus for prolactin and oxytocin release

Introduction to Postpartum Period

> Puerperium Period = begins after delivery of the placenta and lasts about 6 weeks (4th trimester) > Body begins to return to its prepregnant state -> can last up to a year

Gastrointestinal System Adaptations

> Quickly returns to normal because the gravid uterus is no longer filling the abdominal cavity and producing pressure on the abdominal organs > Progesterone levels decline (cause relaxation of smooth muscle and diminished tone) > For several days after birth, the women experience decreased bowel tone and sluggish bowels. Decreased persitalsis occurs due to analgesics, surgery, diminished intra-abdominal pressure, low-fiber diet, insufficient fluid intake, and diminished muscle tone. > Also, episitomies, perineal lacerations, or hemorrhoids may cause fear or pain to the perineum with the first bowel movement and women may attempt to delay it. > Constipation is a common problem during postpartum. A stool softener can be prescribed. > Most women are hungry and thirsty after childbirth, commonly related to nothing-by-mouth (NPO) restrictions and the energy expended during labor. Their appetite returns to normal immediately after giving birth.

Blood Cellular Components

> Red blood cell production ceases early in puerperium > This causes hemoglobin and hematocrit levels to decrease slightly in the first 24 hours > During the next two weeks, both levels rise slowly. > WBC (increases during labor) remains elevated for 4-6 days, but then falls to 6,000 to 10,000. This white blood cell elevation can complicate a diagnosis of infection.

Amount of Lochia Scale

> Scant: 1-2 inch stain on the pad and 10 mL loss > Light/Small: 4 inch stain or a 10-25 mL loss > Moderate: 4-6 inch stain with an estimated loss of 25-50 mL > Large/Heavy: pad is saturated within 1 hour of changing it

Three-Stage Role Development Process (Partners)

> Stage 1: Expectations > Stage 2: Reality > Stage 3: Transition to Mastery > Occurs during the first three weeks on the transition to parenthood.

3 Phases to Parenthood

> Taking-In Phase > Taking-Hold Phase > Letting-Go Phase

Vital Signs Assessment

> Temperature: - Use a consistent measurement technique - Mother's within 24 hours may experience low-grade fever (100.4) due to dehydration from fluid loss during labor - Temperature should return to normal after 24 hours with replacement of fluids. - A temperature above 100.4°F (38°C) at any time or an abnormal temperature after the first 24 hours may indicate infection and must be reported. - If temperature is elevated, cultures should be collected. - An elevated temperature is a sign of maternal sepsis, which can be fatal. - Oral, axillary, tympanic > Pulse: - Normal: 60 to 80 BPM (Puerperal Bradycardia) - During pregnancy, the heavy gravid uterus causes a decreased flow of venous blood to the heart. After giving birth, there is an increase in intravascular volume. The cardiac output is most likely caused by an increased stroke volume from the venous return. The elevated stroke volume leads to a decreased heart rate - Tachycardia in the postpartum woman can suggest anxiety, excitement, fatigue, pain, excessive blood loss or delayed hemorrhage, infection, or underlying cardiac problems. Any pulse rate higher than 100 BPM warrants further investigation. > Respirations: - Should be 12-20 breaths per minute - Diaphragm descends and the organs revert to their normal positions - Any change in respiratory rate out of the normal range might indicate pulmonary edema, atelectasis (a side effect of epidural anesthesia), or pulmonary embolism and must be reported. > Blood Pressure: - Assess BP and compare with normal range. Report any deviation from this range. - BP should remain that same as labor after immediately after childbirth. - Increase -> sign of gestational hypertension - Decrease -> sign of shock or orthostatic hypotension or dehydration, a side effect of epidural anesthesia. - BP should not be greater than 140/90 or less than 85/60. - Assess BP in same position every time. > Pain: - Type of pain, location, severity - 0-10 - Provide perineal care, a clean gown, mouth care, providing warm blankets, ensuring adequate fluid intake to facilitate healing, repositioning frequently, and encouraging rest between assessments - Many postpartum orders will have the nurse premedicate the woman routinely for afterbirth pains rather than waiting for her to experience them first. - Goal: pain scale to be between 0 to 2 (at all times) - This goal can be accomplished by assessing the woman's pain level frequently and preventing pain by administering analgesics. - If the woman has severe pain in the perineal region despite use of physical comfort measures, check for a hematoma by inspecting and palpating the area. If one is found, notify the health care provider immediately.

Partner Psychological Adaptations

> The transition to parenthood is influenced by many factors, including participation in childbirth, relationships with significant others, competence in child care, the family role organization, the individual's cultural background, and the method of infant feeding. > Nurses can play a key role in supporting a partner's transition to parenthood by keeping partners informed about birth and postpartum routines, reporting on their newborn's health status, and reviewing infant development. > They can also contribute by creating participative space for new partners during the postpartum period. This can be achieved, for example, by helping partners take on the new role by supporting and promoting their degree of involvement in the process. They can also be encouraged to actively participate in caring for and maintaining contact with the newborns.

Psychological Adaptations

> The transition to parenthood, while an exciting time to celebrate the life of a new child, causes parents to face new challenges such as physical exhaustion, role overload, and less time for themselves and each other. > Parenting involves caring for infants physically and emotionally to foster the growth and development of responsible, caring people. > research finds no biologically based differences between mothers and partners in sensitivity to infants, capacity to provide care, or acquisition of parenting skills. > 1/10 partners develop postpartum depression ans 1/9 mothers do > Early parent-infant contact after birth improves attachment behaviors

Breast Crawl

> This instinct occurs when a newborn, left undisturbed and skin-to-skin on the mother's trunk following birth, moves toward the mother's breast for the purpose of locating and self-attaching for the first feeding. > From there, the newborn uses leg and arm movements to propel toward the breast. > Upon reaching the sternum, the newborn will bounce the head up and down and side to side. As the newborn approaches the nipple, the mouth opens and after several attempts, latch-on and suckling take place. > Newborns have senses and skills that enable early initiation of feeding at the breast. > Encouraging use of the breast crawl can be the first step in health promotion for every newborn.

Episiotomy/Perineum and Epidural Site

> To assess the episiotomy, and perineal area, position the woman on her side with her top leg flexed upward at the knee and drawn up toward her waist. > Use a penlight to provide adequate lighting > Wear gloves and stand at the woman's side with her back to you, lift the upper buttock to expose the perineum and anus. > Inspect the episiotomy for irriration, ecchymosis, tenderness, or hemotomas. Assess for hemorrhoids and their conditions. > During the early postpartum period, the perineal tissue surrounding the episiotomy is typically edematous and slightly bruised. > The normal episiotomy site should not have redness, discharge, or edema. > Healing mostly takes place within 2 weeks, but may take 4-6 months to heal completely. > Assess the episiotomy and any lacerations at least every 8 hours to detect hematomas or signs of infection. > Redness, swelling, increasing discomfort, or purulent drainage may indicate infection. > A white line running the length of the episiotomy is a sign of infection, as is swelling and discharge. > Treatments: Ice (discomfort and reduces edema)' sitz baths (promote comfort and healing) > Assess epidural site and check for any side effects of the medication such as itching, nausea and vomiting, or urinary retention.

Balance of Hot and Cold

> Vietnamese women view the postpartum period as a cold state (duong) and protect themselves with warmth. Cultural practices include warm water for hygiene and stimulation of lactation, consuming warm foods, and staying indoors. > In the United States, childbearing and recovery are viewed as healthy states, and mothers receive little formal support for both their recovery and infant care. > In China, childbearing and postpartum are viewed as states that disturb the normal health balance between yin and yang. In order to restore balance in health, postpartum women engage in practices for a month related to the maternal role, physical activity, maintenance of body warmth, and certain food consumption that will restore balance. Postpartum confinement negatively correlates with aerobic endurance and positively correlates with depression. > Many cultures believe good health requires the balancing of hot and cold substances. Because childbirth involves the loss of blood, which is considered hot, the postpartum period is considered cold, so the mother must balance that with the intake of hot food. > Cold foods (such as fruits and veggies) should be avoided. > Western practices frequently use cold packs or sitz baths to reduce perineal swelling and discomfort. These practices are not acceptable to women of many cultures and can be viewed as harmful. > Hot-Cold Beliefs: Latin American, African, and Asian > Postpartum nurses need to understand these diverse cultural beliefs and provide creative strategies for encouraging hygiene (sponge baths, perineal care), exercise, and balanced nutrition while remaining respectful of the cultural significance of different practices. The best approach is to ask each woman to describe what cultural practices are important to her and plan accordingly.

Postpartum Assessment

> Vital Signs > Pain Level > Epidural Site (for infection) > Head-to-Toe Review of Body Systems

Uterine Atony

> inability of the uterus to contract effectively > major cause is urinary retention > can lead to excessive bleeding

Stage 2: Reality

> occurs when partners realize that their expectations in stage 1 are not in line with reality. > Their feelings change from elation to sadness, ambivalence, jealousy, and frustration. Many wish to be more involved in the newborn's care and yet do not feel prepared to do so. > Some find parenting fun but at the same time do not feel fully prepared to take on that role. > A partner's stress, irritability and frustration in the days, weeks, and months after the birth of the child can turn into depression, just like that experienced by the mother. > Unfortunately, partners rarely discuss their feelings or ask for help, especially during a time when they are supposed to be the "strong one" for the new mother. > Depression in partners can lead to marital conflicts, reckless or violent behavior, withdrawn parental interactions with the newborn, poor job performance, and substance abuse. In addition, it can have a detrimental effect on the child's future development, such as depression and defiant behavior > Risk Factors for Postpartum Depression: previous history of depression, financial problems, a poor relationship with the mother, and an unplanned pregnancy > Symptoms appear between 1-3 weeks after birth and include feelings of high stress, anxiety, discouragement, fatigue, headaches, and resentment toward the infant and the attention they are getting > Partners experiencing these symptoms should understand that it is not a sign of weakness, and professional help can be helpful.

Transnational Parenting

> practiced by Chinese women > a process of sending their American-born child to China to be raised by extended family there.

Diastasis Recti

> separation of rectus abdominis muscles during pregnancy > common in women who have poor abdominal muscle tone before pregnancy

Perineum

> stretches during childbirth to allow passage of newborn > often edematous and bruised for the first day or two after birth > With lacerations or episiotomy -> complete healing may take 4-6 months (hematoma or infection is possible) > The muscle tone may or may not return to normal, depending on the extent of injury to muscle, nerve, and connecting tissues > Perineal lacerations may extend into the anus and cause considerable discomfort for the mother when she is attempting to defecate or ambulate. > Swollen hemorrhoids may be present > Interventions: Ice packs, pouring warm water over the area via a peribottle, witch hazel pads, anesthetic sprays, and sitz baths > Supportive tissues of the pelvic floor are stretched during the childbirth process, and restoring their tone may take up to 6 months. > Pelvic relaxation can occur in any woman experiencing a vaginal birth. > Pelvic floor dysfunction is one of the most common complications of childbirth following a vaginal birth, and it can have a significant impact on the woman's quality of life as she ages. > Nurses should encourage all women to practice pelvic floor muscle training exercises (PFMT) to improve pelvic floor tone, strengthen the perineal muscles, and promote healing.

Global Health of Childbearing Women

> the health of women is remaining stagnant or growing worse in many parts of the world > The increase in global health awareness for improving health and affecting social change is key in the global health landscape today. > The issues of disrespect and abuse during and after childbirth and the need for respectful maternity care are key elements that need to be addressed to improve outcomes. > Nurses can make a difference outside their own countries' borders by advocating for all women globally through their governmental political systems and encouraging those governments to offer help and save lives.

Stage 3: Transition to Mastery

> the partner makes a conscious decision to take control and be at the center of the newborn's life regardless of preparedness. > This adjustment period is similar to that of the mother's letting-go phase when she incorporates the newest member into the family.

Letting-Go Phase

> the third phase of maternal adaptation, the woman reestablishes relationships with other people. > She adapts to parenthood in her new role as a mother. She assumes the responsibility and care of the newborn with a bit more confidence > the focus of this phase is to move forward by assuming the parental role and to separate herself from the symbiotic relationship that she and her newborn had during pregnancy. > She establishes a lifestyle that includes the infant. The mother relinquishes the fantasy infant and accepts the real one. > Mothers' perceptions of their competence and/or confidence in mothering and their expressions of love for their infants are affected by age, relationship with the father or partner, socioeconomic status, birth experience, stress, available support, personality traits, self-concept, child-rearing attitudes, role strain, health status, preparation during pregnancy, relationships with their own mothers, depression, and anxiety. > Infant factors on MRA/BAM: appearance, responsiveness, temperament, and health status

Taking-In Phase

> the time immediately after birth when the client needs sleep, depends on others to meet her needs, and relives the events surrounding the birth process. > phase is characterized by dependent behavior > During the first 24 to 48 hours after giving birth, mothers often assume a passive role in meeting their own basic needs for food, fluids, and rest, allowing the nurse to make decisions for them concerning activities and care. > They spend time recounting their labor experience to others. Such actions help the mother integrate the birth experience into reality; the pregnancy is over and the newborn is now a unique individual, separate from herself. > When interacting with the newborn, new mothers spend time claiming the newborn and touching them, commonly identifying specific features in the newborn, such as "he has my nose" or "his fingers are long like his father's > Generally takes 1-2 days. Most often, it is the only phase seen in the hospital due to shortened postpartum stays.