Postpartum Care

Engorgement

Vascular, lymphatic congestion from increased blood, lymph supply to breast ØClinical Manifestations ----Breast distention ----Hardness, tenderness, heat ----Appear red, tense, shiny ØInterventions ----Complete emptying with each feeding ----Heat/warmth prior to feeding, cold compresses after feeding --------Fresh, green cabbage leaves

BUBBLE-HE (Postpartum Assessment)

-Breasts -Uterine Fundus -Bladder Function -Bowel Function -Lochia -Episiotomy (Perineum) -Homan's Sign (Legs) -Emotions

BUBBLE-HE (Postpartum Assessment)-Uterus

-Involution: Return of uterus to its pre-pregnancy state through contractions of smooth uterine muscle ----Uterine consistency ----Uterine placement ----Fundal height -@delivery: Firm, Midline, at the U -Should descend into pelvis approximately 1-2 cm/day -Should not be palpable after 2 weeks PP -To guard against uterine inversion, use both hands to support and fix the uterus in a safe position: ----Place one hand against the patient's abdomen at the symphysis pubis level. ----Place the other hand at the top of the fundus, cupping it. ----If the uterus seems soft &/or boggy, gently massage the fundus with a circular motion until it becomes firm. ----Observe for lochia flow during massage. Watch for bleeding, clots, & tissue expulsion.

Complications r/t Uterus

-Uterine atony •Inability of uterine muscles to contract adequately after birth -Subinvolution •Uterus remains enlarged with continued discharge Do not to express clots prior to uterus becoming firmly contracted. Pushing on an uncontracted uterus can invert the uterus and result in extensive hemorrhage.

Postpartum Psychosis

Andrea Yates •Drowned her 5 children (ages 7, 5, 3, 2, 6 months) in "altruistic homicide" in June 2001 "It was the seventh deadly sin. My children weren't righteous. They stumbled because I was evil...they could never be saved. They were doomed to perish in the fires of hell." •Convicted of capital murder & originally faced life in prison •Overturned conviction in 2006 & found not guilty by reason of insanity

BUBBLE-HE (Postpartum Assessment)-Homan's Sign

Assess for pain with dorsiflexion. Complication: DVT ØPrevention ---Early ambulation, SCDs ---Elevate legs when sitting ---Prevent dehydration (2-3 L fluid) ØManagement ---Facilitate bed rest ---Do not massage affected limb ---Administer anticoagulants (Heparin, Warfarin)

BUBBLE-HE (Postpartum Assessment)-Breasts

Breasts - Is the patient breastfeeding? ØProduction of natural oxytocin, which prevents PPH ----Stimulate uterine contractions-->Normal & beneficial ØMilk Production ----Colostrum - "Liquid gold" ----Milk comes in 3-5 days ØInspect size, symmetry, shape ----Note: Redness, bruising, open wounds/cracked nipples, pain --------Engorgement --------Mastitis ØPalpate for fullness, tenderness, lumps ----Breast Cancer

Postpartum Hemorrhage (PPH)

Defined as •> 500 mL blood loss after vaginal delivery •> 1,000 mL blood loss after Cesarean section ØRisk Factors •Uterine atony, overdistended uterus •Use of oxytocin, magnesium sulfate •High parity •Retained placenta fragments ØClinical Findings •Uterine atony ("boggy") •Blood clots larger than quarter •Pad saturation in <15 min •Tachycardia, hypotension ØInterventions •Firmly massage fundus •Initiate IV fluids (isotonic), blood products if necessary •Provide oxygen via nasal cannula •Assess for source of bleeding ----Placental detachment? ----Uterus? ----Cervical Lacerations? Hematomas? ØMedications •Oxytocin •Methylergonovine maleate (Methergine) ----Given IM (may be given IV for severe bleeding) ----Side Effects: Severe cramping, nausea ----Avoid if hypertensive, heavy smoker (r/t excessive vasoconstriction) •Carboprost tromethamine (Hemabate) ----Given deep IM ----Side Effects: Nausea, vomiting, diarrhea ----Avoid if asthma (r/t bronchoconstriction caused by hypersensitivity) •Misoprostol (Cytotec) ----Rectal suppository ----Side Effects: Nausea, vomiting, diarrhea

Role Attainment

Dependent (taking-in): 24-48 hours •Passive - Need therapeutic communication, active listening •Reflection of pregnancy, labor & birth experience •Relies on others for care r/t physical discomfort, role uncertainty, exhaustion following childbirth Dependent-independent (taking-hold): Day 2-10 •Active - Need demonstration, teach-back method •Focus on infant, improving competency & role •Will still need praise, positive reinforcement Interdependent (letting-go): Can extend through childhood •Reality - Gives up "fantasized image" through grief (if needed), readjustment of relationships •Independent care of infant, family •Focus on family unit Paternal •Expectations & transition •Confronting reality •Creating role of involved father Role Attainment - Interventions •Skin-to-skin •Rooming-in •Early initiation of breastfeeding, identification of feeding cues •Participation in infant care •Frequent praise, support, reassurance •Encourage expression of feelings

Mastitis

Infection of breast with transmission of infected organism entering through cracked nipples ØClinical Manifestations ----Painful, tender localized hard mass and reddened area (unilateral) ----Flu-like symptoms (fever, chills, fatigue) ØInterventions ----Antibiotic administration ----Continue breastfeeding if possible, manual expression if necessary ----Increase fluid intake to at least 3,000 mL/day ----Warm/cold compresses for pain relief

BUBBLE-HE (Postpartum Assessment)-Emotional State

Issues with maternal role attainment ØLack of mother-infant bonding ---Apathy when infant cries or ignores infant entirely ---Disgust when infant voids, stools, spits up ---Expresses disappointment in infant ---Does not seek close physical proximity to infant ØManifestations of mood swings, conflict about maternal role, personal insecurity ---Feelings of being "down" ---Feelings of inadequacy ---Flat affect, being withdrawn ---Feeling unable to care for infant

Postpartum Infections

Occur up to 28 days following birth or abortion, usually within first 10 days, indicated by 2 consecutive days of fever (> 100.4°) ØEndometritis (uterine infection) - most common •Begins at placental attachment site, spreads to encompass entire uterine endometrium •Clinical Manifestations - Usually begins Day 2-5 (incubation period) ----Uterine tenderness, enlargement ----Flu-like symptoms, including chills, fatigue, loss of appetite ----Dark brown, malodorous lochia •Interventions ----Collect vaginal, blood cultures ----Administer antibiotics (Clindamycin) ----Provide comfort measures ØWound infections •Sites include Cesarean incisions, episiotomies, lacerations, & trauma wounds present in birth canal •Clinical Manifestations ----Warmth, erythema, tenderness, pain, edema ----Seropurulent drainage ----Wound dehiscence, evisceration ØUTIs •Interventions ----Obtain clean-catch sample ----Administer antibiotics ----Recommend cranberry and prune juice

Retained Placenta

Placenta or placental fragments remain in uterus > 30 minutes (i.e. prolonged Stage 3), preventing uterine involution ØClinical Findings •Uterine atony, subinvolution, inversion •Excessive bleeding, clots larger than quarter •Malodorous lochia, vaginal discharge ØComplications •Postpartum hemorrhage •Infection ØInterventions •Manual separation & removal by MD •Dilation & Curettage (D&C)

BUBBLE-HE (Postpartum Assessment)-Lochia

ØAssess for color, amount, consistency.

BUBBLE-HE (Postpartum Assessment)-Bladder

ØAssess for distention, urinary retention, incontinence, & infection. ØIncreased output ~ 12 hours PP •Excessive diuresis (> 3,000 mL/day) normal within first 2-3 days after delivery •Will need to increase fluids to accommodate loss, prevent dehydration ØEncourage q 2-3 hour emptying •< 150 mL/void? Possible bladder distention •Catheterize (if necessary) to relieve bladder distention

BUBBLE-HE (Postpartum Assessment)-Episiotomy/Laceration

ØAssess perineum for erythema, edema, hematoma. ---Hematoma: Collection of clotted blood within tissues that appears as bulging bluish mass ØAssess episiotomy/laceration for degree of the tear (whether "natural" or medical), drainage, & approximation of wound edges.

Client Education

ØAvoid sitting for long periods to prevent thromboembolism. ØAvoid heavy lifting, strenuous exercise, excessive stair-climbing for at least 3 weeks. •Wait till follow-up visit if Cesarean section ØEncourage high-protein diet to aid in tissue repair. •Non-lactating: Total 1,800-2,200 kcal/day •Lactating: Additional 300-500 calories/day ØEncourage hydration •2-3 L/day ØEncourage Kegel exercises to strengthen pelvic muscles. •10 times at 8-10x/day ØAvoid vaginal insertion, including intercourse, for 2-4 weeks. •Ovulation return: Approx. 6 months if lactating ----27-75 days if not lactating ØPostpartum follow-up •Vaginal: 4-6 weeks •Cesarean section: 2 weeks ØNotify PCP for S/S of postpartum complications •Chills or fever (100.4°) for > 2 days •Change in vaginal discharge (not following expected progression) •Episiotomy, laceration, incisional pain •Pain or tenderness in abdominal, pelvic areas •Breasts with localized pain or tenderness •Calves with localized pain, tenderness, redness, swelling •Urination with burning, pain, frequency, urgency •Emotional needs- signs of postpartum depression or psychosis

Complications r/t Uterus - Uterine Inversion

ØCauses •Vigorous fundal pressure •Excessive traction applied to umbilical cord •Short umbilical cord ØFindings •Pain in lower abdomen ----Complete - Large, red, rounded mass that protrudes outside of introitus ----Partial - Palpation of smooth mass through dilated cervix

Pulmonary Embolism

ØClinical Manifestations •Apprehension •Pleuritic chest pain, dyspnea, tachypnea •Hemoptysis •Peripheral edema •Distended neck vein •Elevated temperature •Hypotension •Hypoxia ØManagement •Place in semi-Fowler's position to facilitate breathing •Administer oxygen by mask •Thrombolytic therapy (Alteplase, streptokinase)

BUBBLE-HE (Postpartum Assessment)-Bowel

ØConstipation 2-3 days after birth •Decreased intestinal muscle tone during labor, prelabor diarrhea/dehydration ØDiscomfort ("Fear to push") ----Perineal tenderness, lacerations, hemorrhoids What measures would you anticipate?

Coagulopathies

ØIdiopathic thrombocytopenic purpura (ITP) •Autoimmune disorder in which life span of platelets is decreased by antiplatelet antibodies •Results in severe hemorrhage following Cesarean section or lacerations ØDisseminated intravascular coagulation (DIC) •Acquired disorder of blood clotting in which fibrinogen levels fall below effective limits ----Risk for internal, external bleeding as well as damage to organs due to ischemia caused by microclots •Risk Factors ----Placental abruption ----Amniotic fluid embolism ----Severe Pre-Eclampsia, Eclampsia, HELLP Syndrome ----Fetal death in utero (at least 6 weeks retained) ØClinical Manifestations •Easy bruising, bleeding from IV site (early) •Unusual spontaneous bleeding from gums, nose (epistaxis) •Oozing, trickling, flow of blood from incision, laceration •Petechiae, ecchymosis •Hematuria •Tachycardia, hypotension, diaphoresis ØIntervention •Stop underlying cause! •Administer low-dose Heparin to stop clotting cascade •Administer blood products (FFP, platelets) to restore clotting function

Postpartum Vaccinations

ØRho(D) immune globulin •Administered IM within 72 hours of delivery for Rh(-) woman who gave birth to Rh(+) infant to prevent sensitization in future pregnancies •Kleihauer-Betke test: Determines amount of fetal blood in maternal circulation if large amount of fetomaternal transfusion is expected ØRubella •SQ injection to protect future pregnancies •Should not get pregnant for 1 month ØVaricella •Second dose at 4-8 weeks •Should not get pregnant for 1 month ØTDAP

After Recovery: "4th Trimester"

•Approximate 6 week interval after childbirth •Physical & psychological changes ----Involution of uterus & vagina ----Production of milk for lactation ----Restoration of normal menstrual cycle ----Beginning the parenting role

Stage 3 - What happens to the placenta?

•Cultural Considerations ----Waste product for medical disposal ----Bury the placenta (Cambodia, Indonesia, Native Americans) ----Cook the placenta, ground it into powder, consume (China) ----Make necklaces for child to wear (Australia) ----Left on rooftops for birds to consume (Yemen) ----Make print by patting off excess blood •Lotus Birth ----Leaving placenta attached to infant until umbilical cord dries & separates naturally, which generally happens 3-10 days after birth

Stage 3 of Labor - Birth to placental delivery

•Placental separation ----Active bleeding on maternal surface of placenta with separation •Placental expulsion ----Spontaneous delivery or gentle pressure/massage by PCP ----Manual extraction •Inspected after delivery ----Intact, no retained parts •Expected blood loss: 300-500 mL for vaginal delivery 800-1,000 mL for Cesarean section

Goals of Postpartum Care

•Prevent postpartum hemorrhage ----Greatest risks: hemorrhage, shock, infection •Assist with client's recovery •Identify deviations in expected recovery process •Provide comfort measures, pain relief •Educate client about self-care, newborn •Promote infant-family bonding

Stage 4 - Immediate postpartum recovery

•Stabilization of mother (& infant) ----Assess fundus & lochia every 15 min. for first hour. ----Assess fundus & lochia every 30 min. for second hour. ----Massage fundus & administer oxytocics to maintain uterine tone. ----Encourage voiding & breastfeeding (per mom's desire). Expected Findings ØPostpartum chill ----Uncontrollable shaking immediately following birth ØAfterpains ----Uncomfortable uterine cramping ØBenign temperature elevation (usually due to dehydration) ØHypercoagulable state

Allison's Story

•Struggled in silence •Military wife, lack of community •Suicide is leading cause of death for women in 1st year postpartum •Ask a new mom how are YOU doing?