Chapter 19 - Nursing Care of the Family During the Postpartum Period - Test 1

Case Management - Maintenance of Uterine Tone

A major intervention to restore good tone is stimulation by gently massaging the uterine fundus until firm. Fundal massage can cause a temporary increase in the amount of vaginal bleeding seen as pooled blood leaves the uterus. Clots can be expelled. The uterus can remain boggy even after massage and expulsion of clots. Fundal massage can be a very uncomfortable procedure. Understanding the causes and dangers of uterine atony and the purpose of fundal massage can help the woman cooperate. Teaching the woman to massage her own fundus enables her to maintain some control and decreases her anxiety. When uterine atony and excessive bleeding occur, additional interventions likely to be used are administration of intravenous fluids and oxytocic medications.

Transfer From The Recovery Area

After the initial recovery period has been completed, the woman may be transferred to a postpartum room in the same or another nursing unit. In facilities with labor, delivery, recovery, postpartum rooms, the woman stays in the same room; the nurse who provides care during the recovery period usually continues caring for the woman. In many settings women who have received general or regional anesthesia must be cleared for transfer from the recovery area by a member of the anesthesia care team. In other settings nurse makes the determination. Postanesthesia Recovery: Regardless of obstertric status, no woman should be discharged from recovery area until completely recovered from anesthesia.

Components of nursing care

Assist mother with rest and recovery after birth. Assessment of physiologic and psychologic adaptation. Prevention of complications. Education regarding self-management and infant care. Support of mother and her partner during transition to parenthood.

Care Management - Nursing Interventions

Based on the available data and assessment findings, the nurse plans with the woman which nursing measures are appropriate and which are to be given priority. The nursing plan of care includes periodic assessments to detect deviations from normal physical changes, measures to relieve discomfort or pain, safety measures to prevent injury or infection, and teaching and counseling measures designed to promote the woman's feelings of competence in self-management and newborn care.

Care Management - Promotion of Comfort

Common causes of discomfort include afterbirth pains, perineal lacerations or episiotomy, hemorrhoids, sore nipples, and breast engorgement. The woman's description of the type and severity of her pain is the best guide in choosing an appropriate intervention. To confirm the location and extent of discomfort, the nurse inspects and palpates areas of pain as appropriate for redness, swelling, discharge, and heat and observes for body tension, guarded movements, and facial tension. Blood pressure, pulse, and respirations can be elevated in response to acute pain. Diaphoresis can accompany severe pain. A lack of objective signs does not necessarily mean there is no pain. Nursing interventions are intended to eliminate the pain sensation entirely or reduce it to a tolerable level that allows the woman to care for herself and her baby.

Care Management - Nonpharmacologic Interventions

Distraction, imagery, therapeutic touch, relaxation, acupressure, aromatherapy, hydrotherapy, massage therapy, music therapy, and transcutaneous eletrical nerve stimulation. Contractions - applying warmth or lying prone may be helpful. Interaction with the infant may also provide distraction and decrease discomfort.

Planning for Discharge

From their initial contact with the postpartum woman, nurses prepare the new mother for the time when she will return home. Planning for discharge begins with the first interaction between the nurse, the woman, and her family and continues until they leave the hospital or birthing facility. The length of stay after giving birth depends on many factors, including the physical condition of the mother and the newborn, mental and emotional status of the mother, social support at home, patient education needs for self-management and infant care, and financial constraints. Women who give birth in birthing centers may be discharged within a few hours, after the woman's and infant's conditions are stable. Mothers and newborns who are at low risk for complications may be discharged from the hospital within 24 to 36 hours after vaginal birth. This short time frame is often called early postpartum discharge, shortened hospital stay, or 1-day maternity stay. Early discharge was popular in the late 1980s and early 1990s, but concerns related to the health and well-being of mothers and newborns led to legislation promoting longer hospital stays. The passage of the Newborns' and Mothers' Health Protection Act of 1996 provided minimum federal standards for health plan coverage for mothers and their newborns. Under the Act all health plans are required to allow the new mother and newborn to remain in the hospital for a minimum of 48 hours after an uncomplicated vaginal birth and for 96 hours after a cesarean birth, unless the attending provider in consultation with the mother decides on early discharge.

Case Management - Infant Security

Nurses discuss infant security precautions with the mother and her family because infant abductions are an ongoing concern. Security devices such as access control to the unit, close-circuit television, computer monitoring systems, and electronic infant security systems in which tamper-proof tags are placed on the neonate immediately after birth and removed at the time of hospital discharge.

Case Management - Prevention of Infection

Nurses in the postpartum setting are acutely aware of the importance of preventing infection in their patients. One important means of preventing infection is maintenance of a clean environment. Bed linens should be changed as needed. Disposable pads should be changed frequently. Women should wear shoes when walking about to avoid contaminating the linens when the return to bed. A sitz bath or heat lamp used by more than one patient must be scrubbed after each woman's use. Personnel must be conscientious about their hand hygiene to prevent cross-infection. Standard precautions must be practiced. Staff members with colds, coughs, or skin infections must follow hospital protocol when in contact with postpartum patients. In many hospitals staff with open herpetic lesions, strep throat, conjuctivitis, upper respiratory infections, or diarrhea are encouraged to avoid contact with mothers and infants by staying home until the condition is no longer contagious. Perineal lacerations and episiotomies can increase the risk of infection as a result of interruption in skin integrity. Proper perineal care helps prevent infection in the genitourinary area and aids the healing process. Educating the woman to wipe from front to back after voiding or defecating is a simple first step. In many hospitals a squeeze bottle filled with warm water or an antiseptic solution is used after each voiding to cleanse the perineal area. The woman should change her perineal pad from front to back each time she voids or defecates and wash her hands thoroughly before and after doing so.

Care Management - Ongoing Physical Assessment

Ongoing assessments are performed throughout hospitalization. In addition to vital signs, physical assessment of the postpartum woman focuses on evaluation of the breasts, uterine fundus, lochia, perineum, bladder and bowel function, vital signs, and legs.

Care Management - Routine Laboratory Tests

Several laboratory tests may be performed in the immediate postpartum period. Hemoglobin and hematocrit values are often evaluated on the first postpartum day to assess blood loss during birth, especially after cesarean birth. In some hospitals a clean-catch or catheterized urine specimen may be obtained and sent for routine urinalysis or culture and sensitivity, especially if an indwelling urinary catheter was inserted during the intrapartum period. In addition, if the woman's rubella and Rh status are unknown, tests to determine her status and need for possible treatment should be performed at this time.

Criteria for Discharge

The AAP recommends that the hospital stay for a mother with a healthy term newborn should be of sufficient length to identify early problems and determine that the mother and family are prepared and able to care for the neonate at home. The health of the mother and her newborn should be stable; the mother should be able and confident to provide care for her infant; there should be adequate support systems in place and access to follow-up care. It is essential that nurses consider the individual needs of the woman and her newborn and provide care that is coordinated to meet these needs to provide timely physiologic interventions and treatment to prevent morbidity and hospital readmission.

Case Management - Prevention of Excessive Bleeding

The most frequent cause of excessive bleeding after childbirth is uterine atony. The two most important interventions for preventing excessive bleeding are maintaining good uterine tone and preventing bladder distention. if uterine atony occurs, the relaxed uterus distends with blood and clots, blood vessels in the placental site are not clamped off, and excessive bleeding results. Although the cause of uterine atony is not always clear, it often results from retained placental fragments. Excessive blood loss after birth can also be caused by vaginal or vulvar hematomas or unrepaired lacerations of the vagina or cervix. These potential sources might be suspected if excessive vaginal bleeding occurs in the presence of a firmly contracted uterus. Accurate visual estimation of blood loss is an important nursing responsibility. Blood loss is usually described subjectively as scant, light, moderate, or heavy. Although postpartal blood loss may be estimated by observing the amount of staining on a perineal pad, it is difficult to judge the amount of locial flow based only on observation of perineal pads. More objective estimates of blood loss include measuring serial hemoglobin or hematocrit values, weighing blood clots and items saturated with blood, and establising the milliliters it takes to saturate perineal pads being used. When excessive bleeding occurs, vital signs are monitored closely. Blood pressure is not a reliable indicator of impending shock from early postpartum hemorrhage because compensatory mechanisms prevent a significant drop in blood pressure until the woman has lost 30% to 40% of her blood volume. Respirations, pulse, skin condition, urinary output, and level of consciousness are more sensitive means of identifying hypovolemic shock. The frequent physical assessments performed during the fourth stage of labor are designed to provide prompt identification of excessive bleeding. Nurses maintain vigilance for excessive bleeding throughout the hospital stay as they perform periodic assessment of the uterine fundus and lochia.

Care Management - Physical Needs

The nursing plan of care includes both the postpartum woman and her infant. It is also family centered, considering the needs and concerns of the family and focusing on family unity. Although in some hospitals the nursery nurse retains primary responsibility for the infant, most perinatal settings use the couplet or mother/baby model of care. Nurses in these settings have been educated in both mother and infant care and function as primary nurses for both mother and infant, even if the infant is kept in the nursery. This approach is a variation of rooming-in, in which the mother and infant room together and mother and nurse share the care of the infant. The organization of the mother's care must take the newborn's feeding and care needs into consideration.

Care Management - Prevention of Bladder Distension

Uterine atony and excessive bleeding after birth can be the result of bladder distention. A full bladder caused the uterus to be displaced above the umbilicus and well to one side of the midline in the abdomen. It also prevents the uterus from contracting normally. Women can be at risk of bladder distention resulting from urinary retention based on intrapartum factors. These risk factors include epidural anesthesia, extensive vaginal or perineal lacerations, episiotomy, intrument-assisted birth, or prolonged labor. Women who have had indwelling catheters such as with cesarean birth can experience some difficulty as the intially attempt to void after the catheter is removed. Nurses who are aware of these risk factors can be proactive in preventing complications.