Care of the postpartum family --> OB exam 2

Postpartum physical adaption--> weight loss

- 10-12 lbs after delivery of neonate and placenta - 5 lbs from puerperal diuresis - return to prepregnancy by 6-8 weeks postpartum

Antepartum measures to decrease risk of thromboembolic disease

- advise woman to avoid sedentary lifestyle and to exercise as much as possible (walking is ideal) - recommend plenty of fluids to avoid dehydration - advise to quit smokin g - teach to avoid prolonged standing or sitting in one postion or sitting with legs crossed - encourage elevation of less when sitting - teach to avoid tight knee high hose or other constrictive garments - encourage frequent breaks during long care trips to walk around, thereby prevention prolonged venous stasis

Physical assessment --> perineum

- assess in sims position/ buttocks lifted - assess wound (laceration or episiotomy) --> *reeda scale* = redness, edema, ecchymosis/brusing, discharge/drainage and approximation --> mild bruising not unusual but excessive bruising/ tenderness may indicated hematoma --> should have minimal pain --> asses for hemorrhoids: size, number, pain or tenderness

Nursing care of the postpartum mother with a history of sexual abuse

- be conscious that these clients may experience more anxiety and stress with hospital procedures. interactions with infamilie staff and being touched - clients have difficulties trusting staff (take time to establish rapport) - often feel uncomfortable when asked to share private info or be assessed (nurse, before d/c, should privately ask all postpartum clients whether they feel safe returning to home enviornment) - higher rates of postpartum depression ---> through screen PRIOR to s/c ---> support groups

PHYSICAL ASSESSMENT --> elimination

- bladder distention not unusual bc of postpartum increased diuresis ---> assess for distention frequently ----> if unable to void 8 hrs, <100CC per void, or distention with inability to void occurs, straight Cath is indicated - C/S often have indwelling catheter bc anesthesia affects ability to void and utilized to avoid distention - distention complications = hemorrhage or infection - educate client that they should not have pain with urination or feel like not fully emptying bladders - first BM usually 2-3 days postpartum after vaginal birth ---> constipation prevention: stool softeners, ambulation, fluids, fiber rich foods (constipation can lead to straining and increased pain)

Postpartum physical adaption--> afterpains

- caused by intermittent uterine contractions - more common in multiparas - populations in which uterus markedly distended (ex: multiple pregnancy, polyhydraminos, cloys or placental fragments) have higher change of afterpains - ocytocic agents and breastfeeding makes afterpains worse TX - warm pack to abdomen - analgesics, ambulation and prone position with pillow SELF CARE TEACHING - cause of pain and tx options to relieve afterpains discomfort

PTSD

- development of characteristic symptoms follow exposure to one or more traumatic events .. examples= labor, delivery, loss of baby - 4-6% prevalence -RISK FACTORS - history of prior trauma and/or psychiatric history and women who undergo emergency C/S S&S - feeling numb - seeming dazed and unaware of environment, irritable - intrusive thoughts and flashes - difficulty thinking and sleeping g - avoidance of anything reminding her of event CLINICAL THERAPY - psychiatric meds (ex; lithium for psychosis), support groups, electroconvulsive therapy and removal of baby (for psychosis)

physical assessment --> nutrition

- dietary requirements of non breastfeeding mother's decrease and return to pre-pregnancy levels (300 calories less than during pregnancy) - breast-feeding mothers have increased dietary needs (200 calories over pregnancy requirement or 500 calories over pre-pregnancy, orin supplements) CLIENT SELF TEACHING - calorie recommendations - continue taking prenatal vitamin and/or iron supplement

Wound infection clinical therapy

- dx based on history, physical exam and blood test - localized wound receives generalized antibiotics and analgesics ---> metririts receives IV antibiotics - wound with pus/drainage or infected stitch will have been opened and drainaged - irrigated/cleaned or wound packed with dressing change multiple times/day ---> aseptic technique ---> wound packing allows removal of dead tissue ---> wet to dry

Postpartum physical adaption--> postpartum diaphoresis

- elimination of excess fluid and waste - perspiration at night common - offer fresh, dry gowns/linens and shower/sponge bath - encourage increased fluid intake

INTRAPARTUM measures to decrease risk of thromboembolic disease

- encourage ambulation unless contraindicated in early labor - later, encourage leg exercises - do not gatch bed or use poles under knees - pad stirrups - ensure correct positioning in stirrups that minimizes pressure eon the popliteal area - limit time in sirrups as much as possible - after c/s, initiate leg an foot exercises as soon as possible (in recovery) - use antremplism stockings for women at risk for DVTs

Physical assessment --> lungs

- encourage cough and deep breathing, incentive spirometer with c/s - monitoring for pulmonary edema ---> preterm labor and preeclampsia women at higher risk ---> c/s women at higher risk for pneumonia

Postpartum measures to decrease risk of thromboembolic disease

- encourage early ambulation - for women on bedrest, advise or assist with turning and leg exercises every 2 hours (women may be encourage to rotate ankles and to "write baby's name in air with toes") - encourage fluids to avoid dehydration - advise no smoking g - use anti embolism stockings with those at risk. Pneumatic compression stockings may be orders after c/s birth until ambulation occurs - advise agianst prolonged sitting and crossing legs - avoid knee gatch in hospital bed - encourage elevation in legs while sitting

Nursing intervention to assist mother in process

- encourage skin to skin contact - instructing about newborn/infant caregiving - building awareness of and responsiveness to newborn/infant interactive capabilities - promoting maternal-newborn attachment - preparing the own for the maternal social role - encouraging interactive therapeutic nurse-client relationship

Discharge assessment and follow-up

- ensure client is up-to-date on immunizations and has prescriptions *TDAP* = usually administered during pregnancy, if not, recommended before hospital discharge *MMR/RUBELLA VACCINE* - administer postpartum to non immune client - educate client that immediate postpartum period ideal time for administration bc A. vaccine is live and not recommended during pregnancy and B. more likely to adhere to CDC recorded 3 month period to avoid pregnancy after administration - educate that all caregivers should have current immunizations *RHOGAM* = administered during pregnancy and postpartum for RH - negative clients with RH positive babies (given within 72 hrs post-delivery to prevent sensitization) ACCESS TO AND FILLED PRESCRIPTIONS FOR ANALGSICS - Tylenol and NSAIDS (ibuprofen or toreador) - narcotics such as tramadol and opioids (hydrocodone or oxycodone) --- *client self care teaching* = side effects of meds and when to call provider - ensure client has access to follow up care ---> help coordinate postpartum appointment ---> educate on importance of follow-up appointments - discuss family planning and contraception before discharge

Physical assessment - REST AND SLEEP

- fatigue common (esp. with long labor/birth - fatigue often factor in mother's apparent disinterest, therefore, psychological assessment should be done after mother naps and more than once ---> can affect ability to delve attachment with baby ---> ideally, one support person stays in room, with client/baby to promote postpartum rest - nursing interventions= identify cause for lack of rest and intervene if able ---> cluster care ---> encourage limited visitors CLIENT SELF-TEACHING - "sleep when baby sleeps" - utilize family and friends for support/assistance, delegate/postpone unnecessary tasks or chores, and to contact provider if client experiences unrelenting fatigue beyond initial postpartum period

discharge assessment and follow up

- home visit or follow-up phone call recommenced 304 days after birth --> provides new mothers with a source of support and an opportunity to ask questions - some problems to evaluate: infections, hypertensive issues, substance abuse, depression, poor newborn feeding, excessive weight loss. and jaundice - include entire family, for, it provides an opportunity to assess for disturbed family patterns ---> also allow family opportunities to ask nurse questions and voice concerns

Nursing care of LGBTQ postpartum mothers

- include non birth parent in education, care, and decision-making of the postpartum family -Ensure inclusively of same-sex parents, do not assume/ask - take cues from the couple - respectful acknowledgement - culturally sensitive communication

Mastitis

- inflammation of the breast, with out without bacterial infection, that occurs primarily in lactating women - onset is 3-4 weeks postpartum and with any decrease n nursing frequency - incidence: 20% of breastfeeding mothers S&S - flu-like symptoms - warm-reddened painful area of breast - breastfeeding is NOT contraindicative, only risk to newborn is thrush; if causative organism for mastitis is candidiasis albicans

Postpartum physical adaption--> postpartum chills

- intense tremors that resemble shivering immediately after birth - caused by hormones, anesthesia, and release of pressure on the pelvic nerves - apply warm blanket, educate client, and encourage client to relax muscles

Lower extremities

- joint/muscle pain not uncommon; esp. with long labor - return of sensation to legs post anesthesia - edema -assess for thrombophelebtitis sharp dorsiflexion/homan's sign - nurse education to client --> prevention with easy ambulation ---- assist with postpartum ambulation first few times ---- dizziness not uncommon ---- should ensure client is stead, without dizziness and able to sit without assistance before first shower ----- s&s of DVT

Promotion of maternal comfort and well being

- monitor uterine status - relief of perineal discomfort - relief of hemorrhoid discomfort - relict of afterpains - relief of discomfort from immobility and muscle strain - postpartum diaphroesis - lactation suppression for non breastfeeding mother - pharmacological interventions (immunizations, rhogham, analgesics) - support of maternal psychosocial well-being

Postpartum psychosis

- most serious psychiatric disorders but RARE - a medical emergency bc of suicide and infanticide risk RISK FACTORS = history of bipolar disorder and postpartum psychosis S&S - sleep disturbances - depersonalization - confusion - hallucinations - psychomotor imbalances CLINICAL THERAPY - psychiatric meds (ex; lithium for psychosis), support groups, electroconvulsive therapy and removal of baby (for psychosis)

Physical assessment --> breasts

- supportive and properly fitted bra if breastfeeding - assess warmth, tenderness, and redness of breast (even not breastfeeding mothers) - assess nipples, red, sore, everted/inverted, cracked - monitoring for engorgement, mastitis, and the infections ---> for engorgement: heat/pump & massage, hand expression/ice in breastfeeding mothers ---> educate mother on s/s of complications - with lactation suppression, for non-breastfeeding mothers, engorgment is possible --> *client self-care* = non pharmacological techniques (supportive bra, avoid breast stimulation, and application of cold packs/cabbage leaves and pharmacological analgesics, s&s of mastisit s ------> breast stimulation avoided until feeling of fullness dissipates (usually 7-10 days )

Nursing implications with uterine stimulants

- note expected duration of action of drug being administer and take care to recheck fundus at the time for adequate tone = when the drug is ineffective and the fundus remains atonic (boggy or uncontracted) and bleeding continues, massage the fundus. If massage fails to cause sustained contraction, consider the status of the urinary bladder. If uterine tone is not retired after the bladder is empty and fundal massage has been performed, notify the physician/CNS immediately - monitor woman for signs of knows side effects of the drug: report to healthcare provider is side effects occur - remind the woman and her support person that uterine cramping is an expected result of these drugs and the meds are available for discomfort. Administer analgesic meds as needed for pain relief. Provide nonpharmacologci comfort measures. IF analgesic meds ordered is insuffiecnt for pain relief, notify provider. - provide info to woman and family regarding importance of not smoking during methergine administration (nicotine from cigs leads to constructed vessels and may lead to HTN) and signs of toxicity WHEN PROSTAGLADIN IS USED - check temp every 1-2 hrs. Administer antipyretic meds as ordered for prostaglandin-induced fever - auscultate breath sounds frequently for signs of adverse respiratory effects -assess for N/V and diarrhea. Administer antiemetic and antidiarrheal meds as ordersd

The postpartum family: needs and care

- nursing education, of physical, and psychological postpartum adaptations, is crucial to facilitate family adjustment ---> must include signs of life-threatening complications and who to seek care in education - client teaching includes how to perform self0care and provide effective newborn care - nursing care goal is to aid client and family in meeting individualized needs - late maternal mortality = maternal deaths that occur more than 42 days but less than 1 year after termination of pregnancy ---> incidence has risen in the US in last 35 years - be flexible with nursing care, especially for routine/non-urgent nursing tasks

Nursing care of the obese postpartum mother

- obesity can double risk of postpartum hemorrhage ---> carefully monitor fundus and lochia - higher risk for airway obstruction of hypoxia --> monitor O2 levels; especially with clients taking opioids - higher risk for pneumonia ---> early ambulation and incentive spirometer with C/S - educate client on the benefits of breastfeeding g --> children born to obese parents are at higher risk of developing obesity --> breastfeeding decreases risk for childhood obesity - use of mirror to educate client on wound care/healing - healthcare provider should be sensitive to special needs of obese of obese clients to promote dignity --> correct =sized bed, BP cuff, transport equipment, gowns sensitive devices with ambulation, shower chair, etc.

Nursing care of the women who relinquishes her newborn

- one who chooses to place her newborn for adoption OR one who has conceived via traditional or gestation means and is acting as a surrogate mother with the intention of placement of the newborn with another mother RELINQUISMENT OCCURS FOR MANY REASONS - stigma of single parenthood - unable to financially care fo child - multiple children already - life circumstances - psychosocial issues: rape, incest, conception outside the women current intimate relationship,.IPV, cultural normal, family disapproval, or threat of abandonment by her intimate partner or family id they mother keeps the child

Postpartum blues

- period of depression that can occur postpartum S&S - mood swings - anger - weepiness - anorexia - difficulty sleeping - feeling of letdown (ask why she's crying often responds "I dont know) --> can occur soon after delivery until 10-14 days postpartum --> symptoms persist longer of get worse evaluate for postpartum depression --> primiparas at higher risk --> screening tools should be used during pregnancy and postpartum - hormones, unsupportive environment/insecurty, fatigue, and pain potential causes CLIENT SELF CARE TEACHING - normal psychological changes ini postpartum period, signs and symptoms, when to call healthcare provider; involving family/support person during education is crucial

Nursing care of the postpartum mother with special needs

- physical, developmental and intellectual disabilities as well as chronic conditions must be considered when caring for the postpartum client ---> nurse should perform a needs assessment ---> assist with coordinating care to address identified needs

Uterine inversions

- prolapse of the uterine fundus to or though the cervix so that the uterus is, in effect, turned inside out after birth, is a rare but life-threatening cause of associated postpartum hemorrhage - associated with weak muscle, relaxed uterus from anesthesia or dugs, abnormal placental adherence to uterus, manual removal of placenta, or "cord tugging" - treatment: manual repositioning of uterus in pelvis by doctor

Uterine Atony

- relaxation of the uterus, accounts for 80% of PPH RISK FACTORS: uterine distention (ex; twins), prolonged labor, oxytocin in labor. grandmultiparity, anesthesia, magnesium sulfate, Procardia, terbutaline, prolonged 3rd stage of labor, pre eclampsia, retained placental fragments --> identification and appropriate monitoring of high risk clients crucial for prevention - the *T Mnemonic* when evaluating bleeding = *TONE, TRUAME, TISSUS EAND THROMBIN*

Promotion of maternal physical well=being after cesarean birth

- skin to skin contact essential if client and baby are healthy --> nurse should assist with process; encourage support person to be hands on as well -client feelings of "missing out" or guilt associated with an unplanned C/S ---> allow client an opportunity to verbalize and work thru feeling s ---> offer positive support and provide factual info about their situation ---> a support person at the delivery and opportunities for them to take pictures allows client to relive the experience or fill in gaps ---> encourage client to discuss the possibility of a vaginal birth after cesarean (VBAC) with their provider

Perineum client self-care teaching

- stitches will dissolve in a few weeks - cleanse perineum with peri bottle after elimination - gentle when wiping - change peri pads frequently - reliefs of perineal discomfort --> perineal ice packs first 24hrs -----> applied 10-20 min at a time --> sitz bath with warm water after 24 hrs (increase circulation also helps with wound healing) ---> if using clean bathtub only sit in 2-6 inches of water ----> soak 15-20 min --> topical agents: witch hazels/benzocaine spray/dibucaine ---> wash hands before and after application --> analgesics for pain; stool softeners - no submerged baths - signs and symptoms of infection - Hemorrhoid relief --> side lying position --> tighten buttocks when sitting down --> avoid prolonged sitting --> high-fiber diet

Nursing care of the adolescent postpartum mother

- teen mothers have fewer social, educational and financial resources to assist with transition to motherhood - higher rates of postpartum depression - newborns have higher rates of low birth weight, preterm brith, and death in infancy (extra teaching support, and referrals, and followup recommended for any special concerns) - may need special assistance with postpartum hygiene and care - be sensitive to needs and ensure client understand reasons for assessments and cares - nurse a crucial role model to adolescent parents when responding to and caring for baby (embarrassed and intimidated nay initiate exams) - ensure adolescent parents have the knowledge and can demonstrate skills to care for self and newborn before discharge (adolescent client's, adult support system can assets, but, parent must be able to demonstrate competency) (provide clients positive feedback to increase confidence and self-esteem) - provider client with education on local support resources for adolescent parents

Initial postpartum experience within the muslin

- traditionally in the Muslim community, labor and delivery is the business of women with DAYAHS (midwives). Therefore, ALL-FEMALE ATTENDANTS ARE PREFERRED at brith, whether they be doctors, nurses, midwives, doulas or female realties. However, it is permissible in islam for male doctors to attend to a pregnant woman. There is no islamic teaching that prohibits fathers from attending the birth of their child; this is left up to personal choice - the *call to prayer (adman)* are the beautiful words that call the muslim community to prayer 5 times a day and are also the first words the muslim baby will hear. The father or a family elder will whisper these words in the baby's ears shortly after birth.

Clinical Therapy for DVT and pulmonary embolism

- venous US and D-dimer assays diagnostic of DVT - *immediate* tretemtn with anticoagulants (heparin therapy) ---> if need anticoagulation therapy more than 6 weeks postpartum, transition to warfarin - strict bed rest - elevation of affected limb - compression stockings - analgesics - closely monitoring for bleeding (hematuria, fecal occult blood)

Physical assessment --> abdomen/fundus

- void before fundal check: can cause uterus displacement or uterine atony - evaluate fundus in relation to umbilical ---> to right = most common cause is full bladder ---> fibroids or hernia other causes fro deviations to right or left ---> above umbilicus = concern for bleeding/clots - if funds is not firm, perform final massage and should firm with massage ---> fundus still boggy, concern for postpartum hemorrhage ---> boddy uterus feels like sponge versus firm uterus feels like a grapefruit ---> *clent self-care education* = how to asses their fundus (firmness, postion, and massage to promote contraction) - inspect cesaren incision for approximation, healing, infection, and bleeding

Coagulation disorders

- von williebrand disease, thrombocytopenia, or disseminated intravascular coagulation (DIC) - consider if postpartum bleeding persists with no identifiable cause

Postpartum depression continued

-can occur at any point is first postpartum year; greatest risk around 4th week - risk for suicide; higher risk with psychosis - screen for PPD with postpartum depression screening scale and edinburg postnatal depression scale ---> score of 12 or higher = PPD TREATMENT - psychotherapy - antidepressants (ssri) - combination (certain meds contraindicative for breastfeeding)

Blood products

1. CYROPRECIPITATE - use in PPH = correct deficiencies of factor VIII, XIII, vonWilliebrand factor + fibrinogen - volume/unit = 10-15 mL - infusion info = increases fibrinogen levels 5-10 mg/dL per unit transfused 2. FRESH FROZEN PLASMA - use in PPH = contains all clotting factors - volume/unit = 250 ml - infusion info= thawed for use. must use within 24 hours of thaw/ Infuse blood filter or component filter. May give at 200 mL/hour unless fluid overload 3. PACKED RED BLOOD CELLS - use in PPH= contains RBCs and plasma. Increase O2 capacity of blood without adding volume- used for acute blood loss - volume/unit = 300 mL - infusion info = filter required for administration. Infusion rate +/- 4 hours/unit within 1 hours. Expected to increase hemoglobin by 1 g/dL and hematocrit by 3% per unit transfused 4. PLATLETS (SINGLE DONOR POOLED) - use in PPH = control or prevent blood loss associated with deficiency in platelets and for prophylactic use for those with platelet counts <10,000 - volume/unit = 200 mL (6U) - infusion info = give within 4 hours of preparation. Use competent filter for administration. Increases platelets by 30,000-60,000 units per unit transfused

PHYSICAL AND DEVELOPMENTAL TASKS NEW MOTHS ACCOMPLISH POSTPARTUM

1. restore physical condition 2. develop competence in caring for and meeting needs of her baby 3. establish a relationship with her new baby - adapt to altered lifestyles and family structure resulting from the addition of a new member

Transition from labor to postpartum

3RD STAGE OF LABOR - after delivery of fetus until delivery of placenta - shortest stage - placenta and amniotic membranes examined for intactness - cord blood obtained 4TH STAGE OF LABOR - first 2 hours after birth - immediate recovery - maternal organs undergo initial change - frequent assessments required POSTPARTUM PERIOD - after completion of the 3rd stage of labor; period during which the woman readjusts, physically and psychologically, from pregnancy and birth. IT begins immediately after the birth and continues approximately 6 weeks or until the body has returned to a near non pregnant stage

Involution of the uterus

A. immediately after delivery of the placenta the top of the funds is midline and approximately 2/3 to 3/4 of the way btwn the symphysis pubis and the umbilicus B. About 6-12 hours after birth, the funds is at the level of 9or one finger breadth below) the umbulicus. The high of the fundus then decreases about one finger breadth (approx.1 cm each day)

Postpartum physical adaption--> abdomen and lactation

ABDOMEN - uterine ligaments stretched and takes postpartum period to recover, also responses to exercises - diastisis recti abdominis - striae/stretch marks generally fast with time LACTATION - interplay of hormones lead to establishes milk production GI SYSTEM - hunger and thirst immediate postpartum period common - sluggish bowels - delayed elimination and constipation for fear related pain with bearing down ---> stool softness recommended ---> early ambulation to reduce incidence of constipation - Increased gas pain ---> treated with ambulation and meds such as simethicone URINARY TRACT - at risk of distention and difficulty voiding ---> anesthesia block affect functioning of bladder and even higher risk of distention and voiding issues - puerperal diuresis causes rapid filling of bladder - urinary stasis increases increases risk of infection and hemorrhage

Nursing care management for postpartum hemorrhage

ASSESSMENT - assess for increased risk of hemorrhage - monitor for increased bladder distention - visualize bleeding (pad counts or weight pads to monitor bleeding) - examine perineal area for signs of hematoma if client verbalized pain at site ---> ice can prevent hematoma if applied immediately after trauma as well as reduce hematoma size ---> sitz bath/heat provides pain relief and aids fluid reabsorption *once bleeding stops* - frequent vital signs to monitor for hypovolemia DIAGNOSIS - deficient fluid volume related to blood loss secondary to uterine atony, lacerations, hematoma, or retained placental fragments - risk for ineffective peripheral tissue perfusion related to hypovolemia - risk for bleeding related to lack of info about signs of delayed postpartum hemorrhage PLAN AND IMPLEMENTATION - call for help; initiate rapid response team - massage to firm fundus and remove clots - initiate or verify IV access (large bore perferred- 18G needle) - weigh pads to accurately monitor blood loss (1g-1ml) - vital signs at least q15 minutes (low BP, high HR, low pulse ox, high temp) - O2 client has desaturation to promote peripheral tissue oxygenation - void or catheterize to eliminate over distention if applicable - replace volume with normal saline or LR (if vital signs unstable, blood products more appropriate intervention) ( monitor urine output to evaluate adequacy of fluid replacement and renal function) - elevate legs 30 degrees to promote circulation and venous return PLAN AND IMPLEMENTATION - verify client is typed and crossed blood is available - draw labs, CBC> coagulation studies (PT, PTT, fibrinogen), BMP, and type and screen (if not already completed) - consider ECG - prepare for additional interventions - pain meds for fungal massage and uterotonic meds - keep NPO in case surgery needed - provide emotional support to woman and family EVALUATION - signs of postpartum hemorrhage are detected quickly and managed effectively - maternal-newborn attachment is maintain successfully - able to identify abnormal changes that might occur follow discharge and understands the importance of notifying her healthcare provider if they develop

Nursing management for postpartum urinary tract infection

ASSESSMENT - bladder distention - displaced and/or boggy uterus - increased bleeding - cramping, backache, restlessness DIAGNOSIS - risk for infection related to urinary stasis secondary to over distention of the bladder - urinary retention related to decreased bladder sensitivity and normal postpartum diuresis NURSING PLAN AND IMPLEMENTATION - encourage client to void frequently (assist to bathroom or provide bedpan/bedside commode) - provide pain meds and perineal ice packs/sitz bath to encourage less painful voiding - tricks for difficulties voiding: running water, blow through straw, or peppermint - sterile catheterization (if indicated) EVALUATION - voids adequately to meet the demands of the increased fluid shifts in postpartum period - does not develop infection du ego stasis of urine - actively incorporated self-care measures to decrease bladder overdisention

Nursing management for postpartum thromboembolic disease

ASSESSMENT - edema of leg or ankle - low-grade fever with subsequent chills and high grade fever - tenderness or pain in leg, inguinal area, or abdomen (esp. with palpation) - palpable cord - color changes to affected limb - homan's sign - limb pale/cool to touch - diminished pedal pulses on affected limb DIAGNOSIS - ineffective peripheral tissue perfusion related to obstructed venous return - acute pain related to tissue hypoxia and edema secondary to vascular obstruction - risk for impaired parenting related to decreased maternal-newborn interaction secondary to bedrest and IV lines - interrupted family processes related to illness of family member - deficient knowledge related to self-care after discharge on anticoagulant therapy NURISNG PLAN AND IMPLEMENTATION - provide appropriate comfort measures - monitor for signs of a pulmonary embolism - assess for bleeding from heparin therapy - educate client and support person on plan of care and signs/symptoms to report to provider - prevention is key: avoid prolonged standing sitting or crossing legs, encourage walking, compression stockings, SCDS if client not mobile EVALUATION - seeks treatment for her thrombophlebitis early and is managed successfully w/out further complications - at discharge able to explain the purpose, dosage regimen, and necessary precautions associated with any prescribed medications, such as anticoagulants - can discuss self-care measures and ongoing therapies (such asthma house of compression stockings) that are indicated - has bonded successfully with her newborn and is able to care for the baby effectively

Nursing managment for the postpartum woman with a psychiatric disorder

ASSESSMENT - identify risk factors - obtain personal/prental/family health history - provide screening tools - observe for objective signs of depression - recognize risk for suicide (SAL= specific plan, accessible weapon , is method lethal? DIAGNOSIS - ineffective coping related to postpartum depression - risk for impaired parenting related to postpartum mental illness - risk for self-directed violence against self (suicide), newborn, and other children related to depression NRUSING PLAN AND IMPLEMENTATION - antepartum education, to parents, offer realistic info and guidance for parenthood (decreases risk for postpartum depression) - encourage membership with a support group - educate mother, partner, and family of postpartum blues, S&S of depression and when to call a healthcare provider - educate mother Ron risk factors/contraindication of breastfeeding with certain psychiatric meds - support family and monitor family relationships EVALUATION - sings of depression are identified and she receives therapy quickly - newborn is cared for effectively by the partner of other support person until the mother is able to provide care - mother and newborn will remain safe - newborn is integrated into the family

Nursing management of wound infection

ASSESSMENT - perineum and wound assessment every 8-12 Horus - reeda scale; S/S of infection - >30% increase in WBCS over 6 hours NURSING DX - risk or injury related to the spread of infection - acute pain related to the presence of infection - risk for impaired parented related to delayed parent-newborn attachment secondary to woman's pain and other symptoms of infection as well as possible separation of the newborn from the mother NURSNG PLAN AND IMPLEMENTATION - standard precautions and aseptic technique reduced infection risk - educate on risk for infection. S/S, prevention. wound care, and pelvic rest since may puerperal infections occur after discharge - assist in maintaining frequent breastfeeds/pumping if applicable --->monitor baby for S/S of thrush - encourage father-neonatal bonding if mother is seriously ill EVALUATION - infection is quickly assessed and treatment instituted successfully without further complications - understands the nature of the infection and purpose of therapy; carrels out any ongoing antibiotics therapy necessary after discharge - maternal-newborn attachment is maintain

Postpartum physical adaption--> neuro changes

HEADCHE - some causes include cerebrospinal fluid leakage or stress MIGRAINE HEADACHES - prevalence returns to pre-pregnancy baseline postpartum EPIPPETICS HIGHER RISK FOR SEIZURES POSTPARTUM - make sure they are taking their anti epileptic drugs

Lower extremities --> physical assessment

CLIENT SELF-CARE EDUCATION - monitor for sings of weakness and dizziness (if noted, sit down and call out for assistance) - advance activity as tolerated (avoid heavy lifting, excessive stir climbing and strenuous activity. Resume normal activities by 4-5 weeks postpartum) - POSTPARTUM EXERCISES --- begin kegels right after birth to help with vaginal tone and prevent urinary leakage --- short walks --- abdominal exercises to retina muscles --- reassess exercises if increased lochia or pain --- vigorous exercise only after cleared at 6 week postpartum visit

Lochia

CHARACTER - rubes, serosa, alba AMOUNT - should never exceed moderate, average 6 partially saturated peri pads/ day normal ODOR - non offensive and never foul PRESENCE OF CLOTS -small clots non unusual bc of pooling blood in vagina; large clots abnormal - if client reports heavy bleeding but not visualized, ask client to apply fresh pad and reassess in one hour ---> if continued bleeding weight pads and soiled lined --> 1g = 1 mL blood loss CLIENT SELF CARE EDUCATION - normal lochia (amount and color); when to call doctor's office/hospital (saturating more than one standard pad/hour)

Postpartum physical adaption--> cardiovascular changes

CARDIAC OUTPUT (CO) - hypervolemia/increased cardiac out immediately - return to pre-delivery levels 1 hr post delivery - returns to pre-pregnancy level by 6-12 weeks PP DIURESIS - increases postpartum - failure to duirese increases risk for pulmonary edema and cardiac issues ---> preeclampsia and preexisting cardiac problems at higher risk for these complications

Postpartum URINARY TRACT INFECTION

CAUSES - postpartum increased diuresis - increased bladder capacity - decreased bladder sensitivity from stretching or trauma - bacterial shedding with urinary stasis - contamination from catheterization - inhibited neural control of bladder following anesthesia RISK FACTORS (of urinary retention/over distention of bladder) - nulliparirty - assisted childbirth (forceps or vacuum assisted birth) - prolonged labors CLINICAL THERAPY - straight Cath x1 - bladder scan to evaluate volume of urine in bladder - reoccurrence of distention, indwelling catheter for 24hrs often indicated

Health promotion education CONTENT

CONENT OF TEACHING •Expected physiologic changes •Activity level •Self-care •Maternal nutrition •Exercise •Sexuality and contraception •Emotional responses to childbearing •Newborn care •Newborn safety •Newborn immunizations •Signs of maternal and newborn complications •Emergency contact information •Psychosocial support •Specific follow-up for high-risk clients (gestational diabetes mellitus, etc.) •Healthcare team roles and recommended follow-up appointments. CRITICAL TEACHING CONCEPTS - headache - leg pain - abnormal vaginal bleeding - swelling of face or extremities - chest pain or SOB - thoughts of harming self or baby - oral temp of 100.4 or higher - excessive incisional pain or discharge

Promotion of family wellness and shared parenting --> CONTRACEPTION and RESUMPTION OF SEXUAL ACTIVITY

CONTRACPETION - info made viable to couple before discharge from hospital - stress that pregnancy can occur before first menstrual period returns - stress that pregnancy can occur before first menstrual period returns RESUMPTION OF SEXUAL ACTIVITY - couples are advised to abstain from intercourse until the perineum is healed and the lochia flow has stopped (usually 3-6 weeks postpartum) - vaginal dryness common; water-based lubricant encouraged initially during intercourse ---> often continues throughout lactation bc of low estrogen levels - warn breastfeeding mothers that milk ejection may occur during intercourse/orgasms

S&S of engorgement, plugged duct, and mastitis

ENGORGEMENT -onset: gradual; postpartum -location = entire breast - heat/swelling = breast is hot and swollen - temp = less than 38.4C (101.1) - pain = entire breast - general symptoms = none PLUGGED DUCT - onset: gradual; after feedings - location: one side of breast - heat/swelling: little or no heat; there may be swelling - temp: less than 38.4 (101.1) - pain: mild pain on affected side - general symptoms: none MASTITIS - onset: sudden' usually after 10 days - location: generally one side of breast - heat/swelling: swelling on affect side' skin is red and hot - temp: greater than 38.4 (101.1) - pain: intense pain on affected side - general s&S: similar to the flu

Postpartum hemorrhage (PPH)

DEFINED = - cumulative blood loss greater than or equal to 1,000 mL of blood loss accompanied by S&S of hypovolemia within 24 Horus after the birth processs (includes intrapartum blood loos) regardless of route of delivery ---> definitie disgnosis of a drop in maternal hematocrit levels of 10% or more from redelivery baseline or excessive bleeding that causes hemodynamic instability or the need for a blood transfusion ---> accounts for 10% of maternal morbidity and mortality in the US EARLY/PRIMARY HEMORRHAGE: occurs first 24 hours after childbirth;more common LATE/SECONDARY HEMORRHAGE: occurs 24 hours to 12 weeks postpartum PHYSIOLOGY - when placenta separates from uterine all, the many uterine vessels that have carried blood to and from the placenta are served abruptly. To stop the blood flow, after expulsion of the placenta is contraction of interlacing uterine muscles to occlude the spaces that previously brought blood into the placenta. Absence of prompt and sustained uterine contraction (uterine atony) can cause significant blood loss)

Clinical therapy for mastitis

DIAGNOSIS - diagnosed based on presenting signs and symptoms - cultue and sensitivity of breastmilk performed if client does not respond to antibiotics or has reoccurring mastitis ---> >100,00 leukocytes = mastitis TREATMENT - antibiotics - frequent and complete emptying of breast (breastfeed or pump) - rest and increased fluids - supportive bra - heat/ice - NSAIDS - monitor for abscess formation (erythema, extreme pain, and duration on upper outer portions of affect breast) - probiotics to promote health flora and decrease risk for Candida albicans PREVENTION - regular drainage of both breasts ASSESSMENT - daily assessment of breast including skin color, surface temperature, nipple condition and presence of pain - if infection present, assess for cracked nipples, poor hygiene, engorgement, supplemental feedings, change in routine or feeding pattern, abrupt weaning, or lack of breast support DIAGNOSIS - risk for trauma related to lack of information about appropriate breastfeeding practices - ineffective breastfeeding related to pain secondary to development of mastitis

Community based nursing care

EDUCATION OPPORTUNITES - nutrion counseling - breastfeeding assistance - maternal exercise - newborn/infant care - newborn/infant development - parenting courses HEALTHCARE PROGRAM OPPORTUNITIES - well-baby clinic - immunization clinical - lactation centers - family planning agencies - new mother support groups

Promotion of family wellness and shared parenting

FAMILY CENTERED CARE - approach to health care based on the concept that a hospital can provide professional services to mothers, fathers, and babies in a homelike environment that would enhance the integrity of the family unit MOTHER/BABY (COUPLET) CARE - family centered approach for maternal-child nursing where both the mother and her baby are cared for by the same nurse, with the baby remaining at the mother's bedside ---> skin to skin immediately after delivery if mother/baby stable (uninterrupted until completion of 1st feed) ---> crib placed within arms reach ---> conducive to recommenced on-demand feeding ---> provide parent with supplies necessary to perform newborn cares ---> nursery amiable if parents request baby not remain at bedside SIBLING REACTION - hospital visitation encouraged, opportunity to see mother and meet baby before discharge - need reassurance that they are still special RESUMPTION OF SEXUAL ACTIVITY - couples are advised to abstain from intercourse until the perineum is healed and the lochia flow has stopped (usually 3-6 weeks postpartum) - vaginal dryness common; water-based lubricant encouraged initially during intercourse ---> often continues throughout lactation bc of low estrogen levels - warn breastfeeding mothers that milk ejection may occur during intercourse/orgasms to parents - regression of sibling is not uncommon

Development of family attachment pt. 2

FATHER-NEWBORN INTERACTIONS - father's attraction and feelings towards newborn are similar to mother's attachment - *engrossment* = sense of absorption, preoccupation, and interest in baby demonstrated by father - be conscious of cultural difference of father involvement and paternal role SIBLINGS AND OTHERS - rooming-in and open visiting hours encourages participation of attachment for other family members/siblings with newborn CULTURAL INFLUENCES IN POSTPARTUM PERIOD - be conscious that the postpartum period may look different for different cultures

Psychological assessment

FEELINGS OF BEING OVERWHELMED ARE NOT UNCOMMON - client may ask for lots of resources or be passive and quiet - nurse should ask questions in non-judgmental, supportive way - monitor for s&s of ineffective coping g - evaluate if early attachment is present - identify, intervene/refer ineffective coping because can lead to child abuse or neglect

Late postpartum hemorrhage --> subinvolution

Failure of a part of the uterus to return to its normal size after functional enlargement, such as failure of uterus to return to normal size after pregnancy Retention of placental tissue = potential cause -- assessment will note fundal height greater than anticipated -- often discovered 46- weeks postpartum (with first postpartum checkup) - lochia not progressing normally in color or amount -- backache, leukorrhea and foul smelling lochia if infection causing sub involution TREATMENT - methergine 0.2mg Q3-4 hrs for 24-34 hrs; antibiotics if infections present, curettage if retained placenta suspected and methergine not effective

PHYSICAL ASSESSMENT

GENRAL PRINCIPLES - always do vital sings first; will let you know if you need to incorporate additional assessment - ask woman to void before assessment - pre-medicate if applicable - incorporate teaching into assessment *BUBBLE-HE* - breasts - uterus - bladder - bowel - lochia - episiotomy - homan's sign - emotional

Clinical Therapy for postpartum hemorrhage

GOAL - stop hemorrhage - correct hypovolemia - treat the underlying cause FUNDAL MASSAGE - utilized if uterus isn to firm and contracted -- may expel clots and correct cause -- consider pain med if additional massage/interventions needed BIMANUAL MASSAGE (Clinicial only) - first compress body of uterus from below; other hand massages funds from above utilized if bleeding continues - manual sweep may also be performed at this stage UTERINE STIMULANTS - help contract the atonic uterine muscle - oxytocin, cytotec, methergine nad hemabate/prostagladin most common - ***prophylactic IV/IM oxytocin most effective; given right after cord clamping ***

Common postpartum concerns

GUSH OF BLOOD THAT SOMETIMES OCCURS WHEN SHE FIRST ARISES - there is normal pooling of blood in the vagina when the woman lies down to eat or sleep - gravity causes blood to flow out when she stands PASSING CLOTS - blood pools at top of the vagina and forms clots that are passed upon rising or sitting on the toilet NIGHT SWEATS - normal physiologic occurrence that results as body attempts to eliminate excess fluids that were present during pregnancy. May be aggravated by plastic mattress pad AFTERPAINS - more common in multiples. Caused by contraction and relaxation of uterus. Increased by oxytocin, breastfeeding. Relived with mild analgesics and time "LARGE STOMACH" AFTER BIRTH ADN FAILURE TO LOSE ALL WEIGHT GAINED DURING PREGNANCY - the baby, amniotic fluid, and placenta account for only a portion of the weight gained during pregnancy. The remainder takes approximately 6 weeks to lose. Abdomen also appears larger bc of decreased muscle tone. Postpartum exercises will help

Promotion of maternal physical well=being after cesarean birth -->IMMOBILITY

IMMOBILITY - risk for pulmonary infection ---> cough/deep breath and IS - risk for abdominal distention --> simethicone --> ambulate when able -- > general anesthesia client at higher risk --> lie on left side; promotes gas expulsion - risk for DVT of embolism ---> SCDS until ambulating regularly ---> unless contraindicated, dangle legs over side of bed within 12 hours postpartum ---> when awake, alert, and complete sensation and strength, up with assistance (up no laster Hahn 24 hr, at least 2-3 days)

Postpartum physical adaption--> reproductive system

INVOLUTION OF THE UTERUS - rapid reduction in size of the uterus and its return to pre-pregnant state ---> excess tissue that involved placenta and no longer needed sloughs off ---> exfoliation part of the healing process, prevents uterine scarring that can affect future pregnancies and implantation - factors that slow it= prolonged labor, anesthesia, full bladder, retained placenta CHANGE IN FUNDAL POSTION - at umbilicus 6-12 hours postpartum - above umbilicus and or body (not firm) = sing of excessive bleeding - above umbilicus and deviated to right = sing of full bladder. Empy and reassess

Other Causes for early postpartum hemorrhage

LACERATIONS OF THE GENITAL TRACT (PERINEUM, NAGINA, OR CERVIX) - risk factors: nulliparity, epidural, precipitous childbirth, macrosomia, instrument assisted birth, and oxytocin use - if bright red blood, with firmly contracted uterus observed, suspect laceration - treatment: sture/repair laceration RETAIN PLACENTAL FRAGMENTS - often occurs when partial separation of placenta from uterus, during fundal massage, before spontaneous placental separation (not best practice) ---> wait to fundal massage until after placental separation - inspect delivered placenta for intactness and for any missing fragments - uterine exploration/"sweep" indicative if missing fragment s - sonography can be diagnostic for retained fragments -TREATMENT: uterotonic agents or curettage (if sweep is not successful)

Postpartum physical adaption--> reproductive system continued

LOCHIA - maternal discharge of blood, mucus, and tissue from the uterus - rubra (day 2-4), serosa (day 7-10), alba (day 10-21) CERVICAL CHANGES - an be bruised or have lacerations - external os of cervix will close slowly, shape altered permanently VAGINAL CHANGES - edematous and bruising evident, rugae no longer present PERINEAL CHANGES - bruising/swelling; check approximation for any laceration or epistomies - completed healed by 4-6 months REOCCURRENCE OF OVULATION ADN MENSTRUATION - returns 7-12 weeks for non-lactating women and 3 months to as late as 3 years for lactating women

Development of family attachment

MATERNAL-NEWBORN ATTACHMENT BEHAVIOR - factors influencing include: level of trust and self-esteem, capacity for enjoying herself, adequacy of knowledge about childbearing and childrearing, prevailing mood or usual feeling tone, and reactions to the present pregnancy INITAL ATTACHMENT BEHAVIOR - familiarizes self with baby - touching activities - en face position = mother positions baby and self face-to-face and eye-to-eye contact - greets newborn and talking in high pitched voice - responds verbally to noises newborn makes *AQUANTANCE PHASE* = getting to know baby first day or two *MUTUAL REGULATION PHASE* = balance is sought between needs of mother and baby *RECIPROCITY*= mutual regulation achieved and mother/baby interaction mutually gratifying

Factors affecting development of postpartum mastitis

MILK STASIS - failure to change postion of baby to allow emptying of all lobes - failure to alternated breasts at feeding - poor suck - poor letdown ACTION STHAT PROMOTE ACCESS/MULTIPLICATION OF BACTERIA - poor Gand hygiene technique - improper breast hygiene - failure to air dry breasts after breastfeeding - use of plastic lined breast pads that trap moisture against nipple BREAST/NIPPLE TRAUMA - incorrect positioning for breastfeeding g - poor latch-on - failure to rotate position on nipple - incorrect or aggressive pumping technique - cracked nipples OBSTRUCTION OF DUCTS - restrictive clothing - constricting bra - underwire bra CHAING IN MUMBE ROF FEEDINGS/FAILURE TO EMPTY BREASTS - attempted weaning - missed feeding - prolonged sleeping of baby, including sleeping though the nigh t - favoring side of nipple soreness LOWERED MATERNAL DEFENSES - fatigue - stress - poor diet

Early postpartum period

NURSING DIAGNOSIS - impaired urinary elimination - imparted skin integrity - acute pain, acute - risk for infection - risk for constipation - readiness for enhanced knowledge - readiness for enhanced coping - readiness for enhanced breastfeeding EXPECTED OUTCOMES - mother and baby remain healthy, safe and free of injury or complication s -verbalized comfort - tells birth story and verbalizes feelings and concerns regarding the event - reviews educational resources for self and newborn/infant care - performs appropriate self and newborn/infant care and practices - parent and newborns demonstrate positive bonding behaviors - verbalizes understanding of and demonstrates successful breastfeeding/ breast care or mother describes accurate formula prep, demonstrates safe bottle feeding techniques, and verbalized understanding of lactation suppression care - verbalizes sources of support to assist in newborn care and family responsibilities - states plan for follow-up healthcare for self and newborn - identifies s&s of maternal or newborn complications and when to call healthcare provider ** ADDITIONAL OUTCOMES FOR THE C/S BIRTH MOTHER INCLUDES: - expresses understanding of reason for the c/s birth and verbalizes feelings r/t the event - maintains desired comfort level (pain less than 4) - maintains mobility (up ini chair 12 hours; ambulates within 24)

Nursing management for mastitis

NURSING PLAN AND IMPLEMENTATION - educate prenatally on proper breastfeeding techniques - initiate breastfeeding soon after birth and encourage frequent feeding - refer to lactation if having feeding difficulties - educate on proper hygiene - educate on regular emptying of breast and problem solving plugged ducts/ enorgement to avoid mastitis - educate that mastitis can reoccur - client understands the importance to take full course of antibiotics EVAULTION - aware of the sings and symptoms of mastitis - reports signs and symptoms of mastitis early and it is treated successfully - can continue breastfeeding if she chooses - understand self-care measures she can use to prevent recurrence of mastitis

Uterine stimulants used to prevent and manage uterine atony

OXYTOCIN (PITOCIN) Misoprostil Methergine Prostagladin LOOK AT SLIDE 48 !!!

Postpartum depression

POSTPARTUM BLUES - mildest condone of disrupted mood, affect up to 85% of postpartum mothers PSTPARTUM DEPRESSION (PPD) - 10-20% of women develop PPD RISK FACTORS - history of depression - history of PPD or bipolar illness (recurrence rates are ≥ 20%) - stressful life events - primiparity - ambivalence about maintaining the pregnancy - lack of social support and/or stable and supportive relationship with parents (esp. her father, as a child) or partner - dissatisfaction with herself - complications of delivery - loss of newborn - age (adolescents)

Postpartum nursing assessment: risk factors

PREECLAMPSIA - blood pressure - ↑ CNS irritability --> ↑risk for seizure - ↑need for bed rest --> ↑ risk for thrombophlebitis DIABETES - need for insulin regulation - episodes of hypoglycemia or hyperglycemia - ↓healing CARDIAC DISEASE - increased maternal exhaustion CESAREAN BIRTH - ↑healing needs - ↑pain from incision -↑ risk of infection -↑length of hospital stay -exacerbation of carpal tunnel syndrome OVERDISTENTION OF UTERUS (MULTIPLE GESTATION, POLYHYDRAMINOS) - ↑risk of throbophlebitis -↑ risk of problems breastfeeding -↑risk of hemorrhage - ↑ risk of anemia - ↑stretching of abdominal muscles - ↑incidence and severity of afterpains ABRUPTIO PLACENTAE, PLECENTA PREVIA - hemorrhage --> anemia - ↓uterine contractility after birth --> ↑infection risk PRECIPITOUS LABOR (LESS THAN 3 HOURS) - ↑risk of lacerations to birth canal--> hemorrhage PROLONGED LABOR (GREATER THAN 24 HOURS) - exhaustion - increased risk for hemorrhage - nutritional and fluid depletion - increased bladder atony and/or trauma - increased pain and bruising from prolonged time in stirrups DIFFICULT BIRTH - exhaustion - ↑risk of perineal lacerations - ↑risk of hematomas - ↑risk of hemorrhage --> anemia EXTENDED PERIOD OF TIME IN STIRRUPS AT BIRTH - ↑risk of thrombophlebitis RETAINED PLACENTA - ↑risk of hemorrhage - ↑risk of infection

Postpartum reproductive tract or wound infection

PUREPERAL INFECTION= infection of the reproductive tract associated with childbirth that occurs up to 6 weeks postpartum; 11% of pregnancy-related deaths PERITONITIS - infection involving the peritoneal cavity PUERPERAL MORBIDITY - a temp of 38C of higher (taken by mouth 4x per day) on any 2 of the first 10 days after birth, not including the first 24 hours - rupture of membranes and labor as well as alkaline Ph postpartum allows opportunity for normal vaginal flora/microorganisms to bacterially contaminate uterine cavity - postpartum perineal wound infections are more common with 3rd and 4th degree tears bc of rectum involvement

Post partum complications

RISK FACTOS - c/s, prolonged ROM, prolonged labor, bladder cauterization, hemorrhage - mastitis - ARU - UTI - thrombophlebitis - hematoma, abscess formation - endometritis - perineal cellulitis *maintain semi-fowlers position to localize infection*

Postpartum psychologic adaptations --> social support

SOCIAL SUPPORT - family relationships important for psychological well-being - often positive impact; but can also be source of stress - lack of social support/netwrok and risk for isolation ---> increase risk for postpartum depression and child abuse/neglect ---> support groups especially helpful for new mothers

Postpartum psychologic adaptations

TAKING IN PERIOD - first several days - passive, somewhat dependent, follows suggestions, hesitates with decisions, preoccupied with own needs - food and sleep = major needs TAKING HOLD PERIOD - post part day 2 or 3 - ready to resume control of mothering and life, critical- judges own ability to care for baby. - nurse should measure and encourage independence --> client more receptive to teaching during this period BECOMING A MOTHER (BAM) - transition process of becoming a mother and chaining in mother-child relationship 1. commitment, attachment, and preparation (pregnancy) 2. acquantince, learning, and physical restoration (first 2-6 weeks after birth) 3. moving toward a new normal (2 weeks to 4 months) 4. Achievement of the maternal identity (around 4 months)

Postpartum physical adaption--> vital sings

TEMPERATURE - increase up to 38C first 24 hours related to exertion, dehydration, and mother's milk coming in BLOOD PRESSURE - transient rise immediate postpartum common then return to pre-pregnancy baseline within couple days - orthostatic hypotension - low or decreasing BP is a sign of hypovoleimia - low or decreasing BP is a sign of hypovolemia and/or hemmorage - elevation potential causes= certain meds such as excessive use of oxytocin and persistent or now onset preeclampsia HEART RATE - *puerperal bradycardia* = HR 50-70 ---> common 6-10 days postpartum - tachycardia could be sign of hypovolemia, infection, fear or pain

Health promotion education

TIMING - must be efficient and effective bc of shortened postpartum days in hospital METHOD - structured group classes - individualized instruction - printed materials - online materials - education television channels - approved streaming videos produced by professional organizations ** most learners absorb more info when printed material is accompanied by verbal explanation, observation followed by hands-on practice increases learning and promotes client confidence when performing self and newborn care EVALUATION - client discussion and return demonstration (teach-back( best practice for evaluating client and family learning ---> follow up education/reinforcement if necessary

Adoption

TRADITIONAL = the birth mother terminates her parental rights and gives consent for another person to adopt her child - common terms: open, semi-open,. closed - if adoptive parents involved = important to remember that biological mother is legal guardian until paperwork is completed and client is d/c home - collaborate with social workers and agencies --> consult facility resource experts --> follow adoption policies --> know state's rights of birth father (if applicable) NURSING INTERVENTIONS - psychosocial support or postpartum client throughout active listening and being present; support person to client if no support person present; respect whatever amount of contact client desires with newborn; look to client cure for when significant other and/or adoptive parents are present

Promotion of maternal physical well=being after cesarean birth --> PAIN

TYPES - incisional, gas (shoulder), contraction, epidural, voiding, defecation, and constipation pain - Analgesics, as ordered, help manage pain --> neuraxial analgesia (through epidural) provides pain relief for 24 hrs postpartum --> PCA (often morphine) for first 24 hrs --> oral analgesics -Non pharmacological interventions = repositioning, abdominal binder or holding polo to abdomen with cough/sneeze/movement,rest/ avoid prolonged activity, head and distraction - encourage support person to assist with neonatal cares - instruct and assist client with positioning when feeding newborn

Clinical therapy for postpartum hemorrhage

UTERINE TAMPONADE - if uterine stimulants don't work - Bakri Ballon to buy time for fluid and blood replacement and visualize any continuous bleeding ---> inserted into uterine cavity ---> 300-500 mL of saline fills balloon, providing pressure to uterine wall (do not perform a fundal massage with ballon in place, only check fundal height and bleeding) ---> removed after 24 hrs if bleeding continued UTERINE ARTERY EMBOLISM - if tamponade not successful - percutaneous catheter relaxes small particles that embolisms/blocks blood vessels - performed via interventional radiology (IR) SURGICAL MANAGMENT - exploratory laparotomy ---> compression sutures or ligation of uterine artery - hysterectomy definition surgical treatment of uterine bleeding = LAST RESORT

Postpartum thromboembolic disease

VENOUS THROMBOSIS - formation of blood clot at an area of impeded blood flow in a superficial or deep vein THROMBOPHLEBITIS - when clot forms as a response to inflammation in the vein wall PULMONARY EMBOLISM - when clot, formed in deep leg veins, is carried to pulmonary artery SUPERFICIAL VEIN DISEASE - clot involved saphenous vein; more common in women with pre-existing varicose veins and seen 3-4 days postpartum MAJOR CAUSES RELATED OT PREGNANCY 1. HYPERCOAGULABILITY OF BLOOD (protects mom from excessive blood loss during delivery) --- increased blood clotting factors --- postpartum thrombocytosis (increased platelets and adhesiveness) --- release of thromboplastin substances from decidua, placenta, and fetal membranes with delivery ---- increase in fibrinolysis inhibitors (less platelets being inhibited) 2. VENOUS STASIS RELATED TO COMPRESSION OF COMMON ILLIAC VEIN BY GRAVID UTERUS 3. INJURY TO EPITHELIUM *outside layer) OF BLOOD VESSEL RISK FACTORS - c/s, prolonged immobility, obesity, smoker, trauma to extremity (stirrups), ama, diabetes, anemia

Other causes for early postpartum hemorrhage

VULVAR, VAGINAL, ADN PELVIC HEMATOMS - caused by injury to blood vessel from birth-trauma - soft tissue opportunistic for large (250-500CC) and rapid hematoma development RISK FACTORS - trauma to area, primiparity, macrosomia, prolonged second stage, preeclampsia, clotting disorder, and history of vulvuar varicosities ---> small hematomas, that are non expanding, ice first 24hrs and then heart ---> large hematomas requires evacuation via incision and drainage, ligation of blood vessel, sometimes vaginal packing --> antibiotics often ordered

Postpartum physical adaption--> blood values

WHITE BLOD CELLS (WBC) - elevated postpartum (25-30K) - returns to normal by end of 1st week HEMOGLOBIN AND HEMATOCRIT (H&H) - difficult to interpret bc of changing blood volume postpartum - average blood loss/devlery = 200-500 ml vaginal or 1000 ml cesarean delivery - general rule : 2-3 point drop hematocrit for every 500 mL blood loss PLATLETS - falls as a result of placental separation, normal approx: 150-450K - returns to normal by six weeks postpartum HEMOSTATIC SYSTEM (BLOOD MAKE UP) AS A WHOLE RETURNS TO NORMAL BY 6 WEEKS - deep veins take longer to return to hemostasis; coupled with increased coagulation makes postpartum client an increased risk for DVT

Postpartum enodmetriris (metritis)

inflammation of the endometrium portion of the uterine lining INCIDENCE: 1-3% of women who give birth vaginall and in 30 to 50% of those who give birth by c/s after an extended period of labor and ruptured membranes -- most common postpartum infection; presumed cause of postpartum fever until determined otherwise RISK FACTORS - C/s, PROM, prolonged labor preceding c/s, multiple vaginal eliminations during labor, compromised health status, use of fetal scalp electrode or intrauterine pressure catheter for internal monitoring during labor ASSESSMENT - foul smelling lochia, fever (usually btwn 38.3 and 40C, (101 and 104)), uterine tenderness on palpation, lower abdominal pain, tachycardia, and chills PREVENTION - prophylactic antibiotics for c/s during surgery