Ricci chapter 16

Physical assessment

Breasts 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 breast-feeding challenging for both mother and infant. Cracked, blistered, fissured, bruised, or bleeding nipples in the breast-feeding 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, and document your findings. For women who are not breast-feeding, use a gentle, light touch to avoid breast stimulation, which would exacerbate engorgement. Lactogenesis (the onset of milk secretion) is 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 breast-feeding, the prolactin levels fall and return to normal levels within 2 to 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). Over the first week, the breast milk matures and contains all necessary nutrients in the neonatal period. The breast milk continues to change throughout the period of breast-feeding to meet the changing demands of the growing infant. Uterus 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 (Fig. 16.2). The fundus should be midline and should feel firm. A boggy or relaxed uterus is a sign of uterine atony (loss of muscle tone in the uterus). This can be the result of bladder distention, which displaces the uterus upward and to the right, or retained placental fragments. Either situation predisposes the woman 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 (1 fingerbreadth is approximately equal to 1 cm). One to 2 hours after birth, the fundus typically is between the umbilicus and the symphysis pubis. Approximately 6 to 12 hours after birth, the fundus usually is 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. FIGURE 16.2 Palpating the fundus. Normally, the fundus progresses downward at a rate of one fingerbreadth (or 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 (Cunningham et al., 2014). On the first postpartum day, the top of the fundus is located 1 cm below the umbilicus and is recorded as u/1. Similarly, on the second postpartum day, the fundus would be 2 cm below the umbilicus and should be recorded as u/2, and so on. Health care agencies differ according to how fundal heights are charted, so follow their protocols for this. If the fundus is not firm, gently massage the uterus using a circular motion until it becomes firm. Bladder Considerable diuresis—as much as 3,000 mL/day—begins within 12 hours after childbirth and continues for several days. A single voiding may be 500 mL or more. By 21 days postpartum, the diuresis is usually complete (Jordan et al., 2014). However, 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. Urinary retention as a result of decreased bladder tone and emptying can lead to urinary tract infections. It is imperative that nurses monitor clients for signs of urinary tract infections, including fever, urinary frequency and/or urgency, difficult or painful urination, and tenderness over the costovertebral angle (Wilson et al., 2015). Women who received regional anesthesia during labor are at risk for urinary tract infections due to continuous urinary catheterization to prevent urinary retention during labor, which is thought to delay fetal descent. 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 for voiding problems by asking the woman the following 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? 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. Take Note! Note the location and condition of the fundus; a full bladder tends to displace the uterus up and to the right. 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 (Mattson & Smith, 2016). Document all urine output. Bowels Spontaneous bowel movements may not occur for 1 to 3 days after giving birth because of a decrease in muscle tone in the intestines as a result of elevated progesterone levels. Normal patterns of bowel elimination usually return within a week after birth (Verghese, Futaba, & Latthe, 2015). 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 typically is soft, nontender, and nondistended. Bowel sounds are 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 a common problem during the postpartum period and many women do not offer this information unless asked about it. Normal assessment findings are active bowel sounds, passing gas, and a nondistended abdomen. Lochia Assess lochia in terms of amount, color, odor, and change with activity and time. To assess how much a woman is bleeding, ask her how many perineal pads she has used in the past 1 to 2 hours and how much drainage was on each pad. For example, did she saturate the pad completely, or was only half of the pad covered with drainage? Ask about the color of the drainage, odor, and the presence of any clots. 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, necessitating additional intervention. To determine the amount of lochia, observe the amount of lochia saturation on the perineal pad and relate it to time (Fig. 16.3). Also, 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 breast-feeds (oxytocin release causes uterine contractions). A woman who saturates a perineal pad within 30 to 60 minutes is bleeding much more than one who saturates a pad in 2 hours. FIGURE 16.3 Assessing lochia. Typically, the amount of lochia is described as follows: Scant: a 1- to 2-in lochia stain on the perineal pad or approximately a 10-mL loss Light or small: an approximately 4-inch stain or a 10- to 25-mL loss Moderate: a 4- to 6-in stain with an estimated loss of 25 to 50 mL Large or heavy: a pad is saturated within 1 hour after changing it (Bope & Kellerman, 2015) 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 any abnormal findings, such as heavy, bright-red lochia with large tissue fragments or a 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. Document all findings. Women who had a cesarean birth will have less lochia discharge than those who had a vaginal birth, 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. Anticipatory guidance to give the woman at discharge should include information about lochia and the expected changes. Urge the woman to notify her health care provider if lochia rubra returns after the serosa and alba transitions have taken place. This is abnormal and 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. Episiotomy/Perineum and Epidural Site If the woman has an episiotomy, which is not routinely done currently, 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. If necessary, use a penlight to provide adequate lighting during the assessment. Wearing gloves and standing at the woman's side with her back to you, gently lift the upper buttock to expose the perineum and anus (Fig. 16.4). Inspect the episiotomy for irritation, ecchymosis, tenderness, or hematomas. Assess for hemorrhoids and their condition. FIGURE 16.4 Inspecting the perineum. 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. The majority of healing takes place within the first 2 weeks, but it may take 4 to 6 months for the episiotomy to heal completely (King et al., 2015). Lacerations to the perineal area sustained during the birthing process that were identified and repaired also need to be assessed to determine their healing status. Lacerations are classified based on their severity and tissue involvement: First-degree laceration: involves only skin and superficial structures above muscle Second-degree laceration: extends through perineal muscles Third-degree laceration: extends through the anal sphincter muscle Fourth-degree laceration: continues through anterior rectal wall Assess the episiotomy and any lacerations at least every 8 hours to detect hematomas or signs of infection. Large areas of swollen, bluish skin with complaints of severe pain in the perineal area indicate pelvic or vulvar hematomas. Redness, swelling, increasing discomfort, or purulent drainage may indicate infection. Both findings need to be reported immediately. A white line running the length of the episiotomy is a sign of infection, as is swelling or discharge. Severe, intractable pain, perineal discoloration, and ecchymosis indicate a perineal hematoma, a potentially dangerous condition. Report any unusual findings. Ice can be applied to relieve discomfort and reduce edema; sitz baths also can promote comfort and perineal healing (see "Promoting Comfort" in the Nursing Interventions section). If the woman has had an epidural during her labor, assessment of the epidural wound site is important as well as checking for any side effects of the medication injected such as itching, nausea and vomiting, or urinary retention. Visual inspection of the epidural site and an accurate documentation of intake and output are essential. Extremities Pregnancy is associated with an increased risk of venous thromboembolism (VTE), which includes pulmonary embolism and deep vein thrombosis. During pregnancy, the state of hypercoagulability protects the mother against excessive blood loss during childbirth and placental separation. However, this hypercoagulable state can increase the risk of thromboembolic disorders during pregnancy and postpartum. Three factors predispose women to thromboembolic disorders during pregnancy: stasis (compression of the large veins because of the gravid uterus), altered coagulation (state of pregnancy), and localized vascular damage (may occur during the birthing process). All of these factors increase the risk of clot formation and having it 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. Take Note! Pulmonary embolism occurs in up to 3 per 1000 births and is a major cause of maternal mortality (Kim et al., 2015). Pulmonary emboli typically result from dislodged deep vein thrombi in the lower extremities. Risk factors associated with thromboembolic conditions include: 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 Advanced maternal age > 35 years (Kline & Kabrhel, 2015) Because of the subtle presentation of thromboembolic disorders, the physical examination may not be enough to detect them. An accurate diagnosis of pulmonary embolism is needed because it requires (1) prolonged therapy (≤9 months of heparin during pregnancy), (2) prophylaxis during future pregnancies, and (3) avoidance of oral contraceptive pills. The woman may report lower extremity tightness or aching when ambulating that is relieved with rest and elevation of the leg. Edema in the affected leg (typically the left), along with warmth and tenderness, and a low-grade fever may also be noted. 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 (Sucker & Zotz, 2015). Women with an increased risk for this condition during the postpartum period should wear antiembolism 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. (Ricci 525-529) Ricci, Susan. Lippincott CoursePoint for Ricci: Essentials of Maternity, Newborn and Women's Health Nursing, 4th Edition. CoursePoint, 10/1/2016. VitalBook file.

Promoting nutrition

The postpartum period can be a stressful one for myriad reasons, such as fatigue, the physical stress of pregnancy and birth, and the nonstop work required to take care of the newborn and to meet the needs of other family members. As a result, the new mother may ignore her own nutrition needs. Whether she is breast-feeding or bottle-feeding, encourage the new mother to take good care of herself and eat a healthy diet so that the nutrients lost during pregnancy can be replaced and she can return to a healthy weight. In general, nutrition recommendations for the postpartum woman include the following: Eat a wide variety of foods with high nutrient density. Eat meals that require little or no preparation. Avoid high-fat fast foods. Drink plenty of fluids daily—at least 2,500 mL (approximately 84 oz). Avoid fad weight-reduction diets and harmful substances such as alcohol, tobacco, and drugs. Avoid excessive intake of fat, salt, sugar, and caffeine. Eat the recommended daily servings from each food group (Box 16.4). Nutrition for the Breast-Feeding Mother The breast-feeding mother's nutritional needs are higher than they were during pregnancy. The mother's diet and nutritional status influence the quantity and quality of breast milk. Recently, the American Academy of Pediatrics (2014a) recommended that breast-feeding women consume foods that contain iodine, an element that is crucial to healthy brain development and may be lacking in their present diets. Iodine is necessary to produce thyroid hormone, which in turn helps brain development. To meet the needs for breast milk production, the woman's nutritional needs increase as follows: (Ricci 542-543) Calories: +500 cal/day for the first and second 6 months of lactation Protein: +20 g/day, adding an extra 2 cups of skim milk Calcium: +400 mg daily—consumption of four or more servings of milk Iodine: 290 μg daily—dairy products, seafood and iodized salt Fluid: +2 to 3 quarts of fluids daily (milk, juice, or water); no sodas Some foods eaten by the breast-feeding mother may affect the flavor of the breast milk or cause gastrointestinal problems for the infant. Not all infants are affected by the same foods. It is suggested that the mother identify the food item that may be causing a problem for the infant and reduce or eliminate her intake of it. Nutritional needs for breast-feeding mothers are based on the nutritional content of breast milk and the energy expended to produce it. If intake of calories exceeds the energy expended, weight gain occurs. The highest incidence of obesity in women occurs during the childbearing years. Women need to be made aware that weight gained during their reproductive years will have a negative impact on their health as they age. Nurses can assist women in their postpartum weight management program by assessing their readiness to change to lose their pregnancy weight gain; assessing their breast-feeding status, dietary intake, and activity levels; and assessing them for stress and depressive symptoms, which might hinder their weight loss (Green, 2016). (Ricci 543) Ricci, Susan. Lippincott CoursePoint for Ricci: Essentials of Maternity, Newborn and Women's Health Nursing, 4th Edition. CoursePoint, 10/1/2016. VitalBook file.

Promoting adjustment and well being

The postpartum period involves extraordinary physiologic, psychological, and sociocultural changes in the life of a woman and her family. Adapting to the role of a parent is not an easy process. The postpartum period is a "getting-to-know-you" time when parents begin to integrate the newborn into their lives as they reconcile the fantasy child with the real one. This can be a very challenging period for families. Nurses play a major role in assisting families to adapt to the changes, promoting a smooth transition into parenthood. Appropriate and timely interventions can help parents adjust to the role changes and promote attachment to the newborn (Fig. 16.7). For couples who already have children, the addition of a new member may bring role conflict and challenges. The nurse should provide anticipatory guidance about siblings' responses to the new baby, increased emotional tension, child development, and meeting the multiple needs of the expanding family. Although the multiparous woman has had experience with newborns, do not assume that her knowledge is current and accurate, especially if some time has elapsed since her previous child was born. Reinforcing information is important for all families. Promoting Parental Roles Parents' roles develop and grow when they interact with their newborn (see Chapter 15 for information on maternal and paternal adaptation). The pleasure they derive from this interaction stimulates and reinforces this behavior. With repeated, continued contact with the newborn, parents learn to recognize cues and understand the newborn's behavior. This positive interaction contributes to family harmony. Nurses need to know the stages parents go through as they make their new parenting roles fit into their life experience. Assess the parents for attachment behaviors (normal and deviant), adjustment to the new parental role, family member adjustment, social support system, and educational needs. To promote parental role adaptation and parent-newborn attachment, provide the following nursing interventions: Provide as many opportunities as possible for parents to interact with their newborn. Encourage parents to explore, hold, and provide care for their newborn. Praise them for their efforts. p. 547 p. 548 FIGURE 16.7 Examples of family members carrying out roles to promote adjustment and well-being. A. An aunt admiring the newest member of the family. B. A father holding his newborn closely on his chest. C. Grandparents welcoming the newest little one to the family circle. Model behaviors by holding the newborn close, calling the newborn's name, and speaking positively. Speak directly to the newborn in a calm voice, while pointing out the newborn's positive features to the parents. Evaluate the family's strengths and weaknesses and readiness for parenting. Assess for risk factors such as lack of social support and the presence of stressors. Observe the effect of culture on the family interaction to determine healthy family dynamics. Monitor parental attachment behaviors to determine whether alterations require referral. Positive behaviors include holding the newborn closely or in an en face position, talking to or admiring the newborn, or demonstrating closeness. Negative behaviors include avoiding contact with the newborn, calling it names, or showing a lack of interest in caring for the newborn (see Table 16.1). Monitor the parents' coping behaviors to determine alterations that need intervention. Positive coping behaviors include positive conversations between the partners, both parents wanting to be involved with newborn care, and lack of arguments between the parents. Negative behaviors include not visiting, limited conversations or periods of silence, and heated arguments or conflict. Identify the support systems available to the new family and encourage them to ask for help. Ask direct questions about home or community support. Make referrals to community resources to meet the family's needs. Arrange for community home visits in high-risk families to provide positive reinforcement of parenting skills and nurturing behaviors with the newborn. Provide anticipatory guidance about the following before discharge to reduce the new parents' frustration: Newborn sleep-wake cycles (they may be reversed) Variations in newborn appearance and developmental milestones (growth spurts) How to interpret crying cues (hunger, wet, discomfort) and what to do about them Sensory enrichment/stimulation (colorful mobile) Signs and symptoms of illness and how to assess for fever Important phone numbers, follow-up care, and needed immunizations Physical and emotional changes associated with the postpartum period Need to integrate siblings into care of the newborn; stress that sibling rivalry is normal and offer ways to reduce it Ways to make time together for the couple In addition, nurses can help fathers to feel more competent in assuming their parental role by teaching and providing information (Fig. 16.8). Education can dispel any unrealistic expectations they may have, helping them to cope more successfully with the demands of fatherhood and thereby fostering a nurturing family relationship. Explaining Sibling Roles It can be overwhelming to a young child to have another family member introduced into his or her small, stable world. Although most parents try to prepare siblings for the arrival of their new little brother or sister, many young children experience stress. They may view the new infant as competition, or fear that they will be replaced in the parents' affection. All siblings need extra attention from their parents and reassurance that they are loved and important. Many parents need reassurance that sibling rivalry is normal. Suggest the following to help parents minimize sibling rivalry: FIGURE 16.8 Father participating in newborn care. Expect and tolerate some regression (thumb sucking, bedwetting). Explain childbirth in an appropriate way for the child's age. Encourage discussion about the new infant during relaxed family times. Encourage the sibling(s) to participate in decisions, such as the baby's name and toys to buy. Take the sibling on a tour of the maternity suite. Buy a T-shirt that says "I'm the [big brother or big sister]." Spend "special time" with the child. Read with the child. Some suggested titles include: Things to Do With a New Baby (Ormerod, 1984); Betsy's Baby Brother (Wolde, 1975); The Berenstain Bears' New Baby (Berenstain, 1974); and Mommy's Lap (Horowitz & Sorensen, 1993). Plan time for each child throughout the day. Role-play safe handling of a newborn, using a doll. Give the preschooler or school-age child a doll to care for. Encourage older children to verbalize emotions about the newborn. Purchase a gift that the child can give to the newborn. Purchase a gift that can be given to the child by the newborn. Arrange for the child to come to the hospital to see the newborn (Fig. 16.9). Move the sibling from his or her crib to a youth bed months in advance of the birth of the newborn. Show the older sibling photos of the baby growing in mommy's belly. Let them pat the baby beneath the bulge, talk to baby, and feel the baby kick. Make the older sibling feel important by giving them a title "mommy's helper." p. 549 p. 550 FIGURE 16.9 Sibling visitation. Encourage grandparents to pay attention to the older child when visiting. Tell the older sibling that their friends come and go, but siblings are forever. Encourage "Do unto others as you would have them do unto you" (Sears & Sears, 2015c). (Ricci 547-550) Ricci, Susan. Lippincott CoursePoint for Ricci: Essentials of Maternity, Newborn and Women's Health Nursing, 4th Edition. CoursePoint, 10/1/2016. VitalBook file. Discussing Grandparents' Role Grandparents can be a source of support and comfort to the postpartum family if effective communication skills are used and roles are defined. The grandparents' role and involvement will depend on how close they live to the family, their willingness to become involved, and cultural expectations of their role. Just as parents and siblings go through developmental changes, so too do grandparents. These changes can have a positive or negative effect on the relationship. Newborn care, feeding, and child-rearing practices have changed since the grandparents raised the parents. New parents may lack parenting skills but nonetheless want their parents' support without criticism. A grandparent's "take-charge approach" may not be welcome by new parents who are testing their own parenting roles, and family conflict may ensue. However, many grandparents respect their adult children's wishes for autonomy and remain "resource people" for them when requested. (Ricci 550) Ricci, Susan. Lippincott CoursePoint for Ricci: Essentials of Maternity, Newborn and Women's Health Nursing, 4th Edition. CoursePoint, 10/1/2016. VitalBook file. Nurses can assist in the grandparents' role transition by assessing their communication skills, role expectations, and support skills during the prenatal period. Find out whether the grandparents are included in the couple's social support network and whether their support is wanted or helpful. If they are, and it is, then encourage the grandparents to learn about the parenting, feeding, and child-rearing skills their children have learned in childbirth classes. This information is commonly found in "grandparenting" classes, which introduce new parenting concepts and bring the grandparents up to date on today's childbirth practices. Teaching About Postpartum Blues The postpartum period is typically a happy yet stressful time, because the birth of an infant is accompanied by enormous physical, social, and emotional changes. The postpartum woman may report feelings of emotional lability, such as crying one minute and laughing the next (see Chapter 15 for postpartum blues discussion). Although postpartum blues is usually benign and self-limited, these mood changes can be frightening to the woman. It is prudent to ask two questions—about having pleasure and interest in things, or feeling predominately down, depressed, or hopeless. Once postpartum blues are determined to be the likely cause of her mood symptoms, the nurse can offer anticipatory guidance that these mood swings are commonly experienced and usually resolve spontaneously within a week and offer reassurance. Women should also be counseled to seek further evaluation if these moods do not resolve within two weeks, as postpartum depression may be developing (King et al., 2015). Take Note! Postpartum blues have been regarded as brief, benign, and without clinical significance, but several studies have proposed a link between blues and subsequent depression in the 6 months following childbirth (Cristescu et al., 2015). Postpartum blues require no formal treatment other than support and reassurance because they do not usually interfere with the woman's ability to function and care for her infant. Nurses can ease a mother's distress by encouraging her to vent her feelings and by demonstrating patience and understanding with her and her family. Suggest that getting outside help with housework and infant care might help her to feel less overwhelmed until the blues ease. Provide telephone numbers she can call when she feels down during the day. Making women aware of this disorder while they are pregnant will increase their knowledge about this mood disturbance, which may lessen their embarrassment and increase their willingness to ask for and accept help if it does occur. The postpartum woman also is at risk for postpartum depression and postpartum psychosis; these conditions are discussed in Chapter 22. (Ricci 550-551) Ricci, Susan. Lippincott CoursePoint for Ricci: Essentials of Maternity, Newborn and Women's Health Nursing, 4th Edition. CoursePoint, 10/1/2016. VitalBook file.

Promoting Activity, Rest, & Exercise

The postpartum period is an ideal time for nurses to promote the importance of physical fitness, help women incorporate exercise into their lifestyle, and encourage them to overcome barriers to exercise. The lifestyle changes that occur postpartum may affect a woman's health for decades. Early ambulation is encouraged to reduce the risk of thromboembolism and to improve strengthening. Many changes occur postpartum, and caring for a newborn alters the woman's eating and sleeping habits, work schedules, and time allocation. Postpartum fatigue is common during the early days after childbirth, and it may continue for weeks or months. Having adequate sleep is critical for new mothers because shorter sleep time, a high percentage of sleep disturbances, and greater fatigue are associated with depressive symptoms in postpartum women (Bhati & Richards, 2015). Working partners with newborns experience fatigue during early parenthood and are unable to recover due to interrupted and poor sleep patterns. This sleep deficit can compromise their work safety (Parfitt & Ayers, 2014). For women, it affects the mother's relationships with significant others and her ability to fulfill household and child care responsibilities. Be sure that the mother recognizes her need for rest and sleep and is realistic about her expectations. Some suggestions include the following: Nap when the infant is sleeping, because getting uninterrupted sleep at night is difficult. Reduce participation in outside activities and limit the number of visitors. Determine the infant's sleep-wake cycles and attempt to increase wakeful periods during the day so the baby sleeps for longer periods at night. Eat a balanced diet to promote healing and to increase energy levels. Share household tasks to conserve your energy. Ask the father or other family members to provide infant care during the night periodically so that mothers can get an uninterrupted night of sleep, if they are not breast-feeding. Review your family's daily routine and see if you can "cluster" activities to conserve energy and promote rest. The demands of parenthood may reduce or prevent exercise in even the most committed person. A targeted exercise program and proper body mechanics can help new mothers deal with the physical challenges of motherhood. Emphasize the benefits of a regular exercise program, which include: Helps the woman to lose pregnancy weight Reduces the risk of obesity later in life Increases overall postpartum well-being Increases energy level so the woman can cope with her new responsibilities Speeds the return to prepregnant size and shape Reduces risk of postpartum depression Reduces risk of constipation Reduces mental fatigue Provides an outlet for stress (Covan, 2015) Overweight and obesity are epidemic in the United States. Obesity is a risk factor for numerous conditions, including diabetes, hypertension, high cholesterol, stroke, heart disease, cancer and arthritis. More than one third of American women are overweight (ACOG, 2014). Although the average gestational weight gain is small (approximately 25 to 35 lb), excess weight gain and failure to lose weight after pregnancy are important predictors of long-term obesity. The postpartum period is a vulnerable time for excessive weight retention, particularly for the increasing number of women who are overweight at the start of their pregnancy and subsequently find it difficult to lose the additional weight gained during pregnancy. Breast-feeding and exercise may help to control weight in the long term (Neville et al., 2014). p. 538 p. 539 Take Note! Women who are unable to return to a healthy weight by 6 months postpartum increase their risk factors for the development of chronic diseases including metabolic syndrome, obesity, and cardiovascular disease (Brekke et al., 2014). Encourage women to lose their pregnancy weight by 6 months postpartum, and refer those who don't to community weight-loss programs. The postpartum woman may face some obstacles to exercising, including physical changes (ligament laxity), competing demands (newborn care), lack of information about weight retention (inactivity equates to weight gain), and stress incontinence (leaking of urine during activity). A healthy woman with an uncomplicated vaginal birth can resume exercise in the immediate postpartum period. Advise the woman to start slowly and increase the level of exercise over a period of several weeks as tolerated. Infant strollers/carriers may be an option for some women, allowing them to walk with their newborns for exercise. Jogging strollers can be used later when the infant is 6 to 12 months old and can hold his or her head up. Also, exercise videos and home exercise equipment allow mothers to work out while the newborn naps. Exercising after giving birth promotes feelings of well-being and restores muscle tone lost during pregnancy. Routine exercise should be resumed gradually, beginning with pelvic floor exercises on the first postpartum day and, by the second week, progressing to abdominal, buttock, and thigh-toning exercises. Most postpartum women fail to meet national guidelines for physical activity which may elevate their risk for morbidity and contribute to the intergenerational impact of obesity on their offspring (Downs, Evenson, & Chasan-Taber, 2014). Walking is an excellent form of early exercise as long as the woman avoids jarring and bouncing movements, because joints do not stabilize until 6 to 8 weeks postpartum. Exercising too much too soon can cause the woman to bleed more and her lochia may return to bright red. If this occurs, instruct the woman to stop exercising and rest lying down until the bleeding slows. This increase in bleeding should be a warning to the woman that she is over doing it and needs to slow down her exercise routine. Recommended exercises for the first few weeks postpartum include abdominal breathing, head lifts, modified sit-ups, double knee roll, and pelvic tilt (Teaching Guidelines 16.2). The number of exercises and their duration is gradually increased as the woman gains strength. (Ricci 538-539) Ricci, Susan. Lippincott CoursePoint for Ricci: Essentials of Maternity, Newborn and Women's Health Nursing, 4th Edition. CoursePoint, 10/1/2016. VitalBook file.

Providing and promoting comfort

The postpartum woman may have discomfort and pain from a variety of sources, such as an episiotomy, perineal lacerations, backache as a result of the epidural, pain from a full bladder, an edematous perineum, inflamed hemorrhoids, engorged breasts, afterbirth pains secondary to uterine contractions in breast-feeding and multiparous mothers, and sore nipples if breast-feeding. Relieving the underlying problem is the first step in pain management. Most practices traditionally employed for postpartum discomforts are not evidence based, so both nonpharmacologic and pharmacologic measures are often used in tandem (King et al., 2015). Applications of Cold and Heat COLD Commonly, an ice pack is the first measure used after a vaginal birth to relieve perineal discomfort from edema, an episiotomy, or a laceration. An ice pack seems to minimize edema, reduce inflammation, decrease capillary permeability, and reduce nerve conduction to the site. It is applied during the fourth stage of labor and can be used for the first 24 hours to reduce perineal edema and to prevent hematoma formation, thus reducing pain and promoting healing. Ice packs are wrapped in a disposable covering or clean washcloth and are applied to the perineal area. Usually the ice pack is applied intermittently for 20 minutes and removed for 10 minutes. Many commercially prepared ice packs are available, but a surgical glove filled with crushed ice and covered can also be used if the mother is not allergic to latex. Ensure that the ice pack is changed frequently to promote good hygiene and to allow for periodic assessments. HEAT The peribottle is a plastic squeeze bottle filled with warm tap water that is sprayed over the perineal area after each voiding and before applying a new perineal pad. Usually the peribottle is introduced to the woman when she is assisted to the bathroom to freshen up and void for the first time—in most instances, once vital signs are stable after the first hour. Provide the woman with instructions on how and when to use the peribottle. Reinforce this practice each time she changes her pad, voids, or defecates, making sure that she understands to direct the flow of water from front to back. The woman can take the peribottle home and use it over the next several weeks until her lochia discharge stops. The peribottle can be used by women who had either vaginal or cesarean births to provide comfort and hygiene to the perineal area. After the first 24 hours, a sitz bath with room temperature water may be prescribed and substituted for the ice pack to reduce local swelling and promote comfort for an episiotomy, perineal trauma, or inflamed hemorrhoids. The change from cold to room temperature therapy enhances vascular circulation and healing. When compared with an infrared light to promote healing and reduce perineal pain, sitz baths were significantly more effective in promoting episiotomy wound healing (Sukhwinder et al., 2014). Before using a sitz bath, the woman should cleanse the perineum with a peribottle or take a shower using mild soap. FIGURE 16.6 Sitz bath setup. Most health care agencies use plastic disposable sitz baths that women can take home. The plastic sitz bath consists of a basin that fits on the commode; a bag filled with warm water is hung on a hook and connected via a tube onto the front of the basin (Fig. 16.6). Teaching Guidelines 16.1 highlights the steps in using a sitz ba (Ricci 536) Advise the woman to use the sitz bath several times daily to provide hygiene and comfort to the perineal area. Encourage her to continue this measure after discharge. Some facilities have hygienic sitz baths called Suri-Gators in the bathroom that spray an antiseptic, water, or both onto the perineum. The woman sits on the toilet with legs apart so that the nozzle spray reaches her perineal area. Keep in mind that tremendous hemodynamic changes are taking place within the mother during this early postpartum period, and her safety must be a priority. Fatigue, blood loss, the effects of medications, and lack of food may cause her to feel weak when she stands up. Assisting the woman to the bathroom to instruct her on how to use the peribottle and sitz bath is necessary to ensure her safety. Many women become light-headed or dizzy when they get out of bed and need direct physical assistance. Staying in the woman's room, ensuring that the emergency call light is readily available, and being available if needed during this early period will ensure safety and prevent accidents and falls. Recent reviews of the use of postpartum local cooling and warming interventions for perineal pain found limited evidence supporting their effectiveness. Additional studies are needed in the area of perineal pain and healing in order to develop evidence-based interventions in the future (Mooventhan & Nivethitha, 2014). Topical Preparations Several treatments may be applied topically for temporary relief of perineal pain and discomfort. One such treatment is a local anesthetic spray such as benzocaine topical. These agents numb the perineal area and are used after cleansing the area with water via the peribottle and/or a sitz bath. Postpartum women are predisposed to hemorrhoid development due to pressure during vaginal birth, constipation, relaxation of the smooth muscles in vein walls, and impaired blood return, all related to increased pressure from the heavy gravid uterus. Nonpharmacologic measures to reduce hemorrhoid discomfort include ice packs, ice sitz baths, and application of cool witch hazel pads, such as Tucks®. The pads are placed at the rectal area, between the hemorrhoids and the perineal pad. These pads cool the area, help relieve swelling, and minimize itching. Pharmacologic methods used to reduce hemorrhoid pain include local anesthetics (dibucaine) or steroids (hydrocortisone acetate). Prevention or correction of constipation, encouraging the use of the sidelying position, proper toileting habits, assuming positions that minimize putting pressure on the hemorrhoids, and not straining during defecation will be helpful in reducing discomfort (King et al., 2015). Nipple pain is difficult to treat, although a wide variety of topical creams, ointments, and gels are available to do so. This group includes beeswax, glycerin-based products, petrolatum, lanolin, and hydrogel products. Many women find these products comforting. Beeswax, glycerin-based products, and petrolatum all need to be removed before breast-feeding. These products should be avoided in order to limit infant exposure because the process of removal may increase nipple irritation. Applying expressed breast milk to nipples and allowing it to dry has been suggested to reduce nipple pain. Usually the pain is due to incorrect latch-on and/or removal of the nursing infant from the breast. Early assistance with breast-feeding to ensure correct positioning can help prevent nipple trauma. Analgesics Analgesics such as acetaminophen and oral nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen or naproxen are prescribed to relieve mild postpartum discomfort. For moderate to severe pain, a narcotic analgesic such as codeine or oxycodone in conjunction with aspirin or acetaminophen may be prescribed. Instruct the woman about adverse effects of any medication prescribed. Common adverse effects of oral analgesics include dizziness, light-headedness, nausea and vomiting, constipation, and sedation (Skidmore-Roth, 2015). Also inform the woman that the drugs are secreted in breast milk. Nearly all medications that the mother takes are passed into her breast milk; however, the mild analgesics (e.g., acetaminophen or ibuprofen) are considered relatively safe for breast-feeding mothers (King et al., 2015). Administering a mild analgesic approximately an hour before breast-feeding will usually relieve afterpains and/or perineal discomfort. (Ricci 537) Ricci, Susan. Lippincott CoursePoint for Ricci: Essentials of Maternity, Newborn and Women's Health Nursing, 4th Edition. CoursePoint, 10/1/2016. VitalBook file.

Counseling about sexuality and contraception

Pregnancy and childbirth are special periods in a woman's life that involve significant physical, hormonal, psychological, social, and cultural changes that may influence her own sexuality as well as the health of a couple's sexual relationship. This is often a time period filled with excitement, changes, and challenges. Mothers often face changes in their own sexuality in their adjustment to motherhood. Sexuality is an important part of every woman's life. Women want to get back to "normal" as soon as possible after giving birth, but a couple's sexual relationship cannot be isolated from the psychological and psychosocial adjustments that both partners are going through. Childbirth is a significant life transition that has a measurable impact on postpartum women's sexual function. There are physical (perineal pain), psychological (depression), and contextual factors (motherhood) that contribute to the change in many women's sex lives after experiencing childbirth. Postpartum women may hesitate to resume sexual relations for a number of reasons. Many postpartum women have fatigue, weakness, loss of sexual desire, perception of decreased attractiveness, change in body appearance, vaginal bleeding, perineal discomfort, hemorrhoids, sore breasts, decreased vaginal lubrication resulting from low estrogen levels, and dyspareunia. Fatigue, the physical demands made by the infant, and the stress of new roles and responsibilities may stress the emotional reserves of couples. New parents may not get much privacy or rest, both of which are necessary for sexual pleasure (Whittock, 2015). Men may feel they now have a secondary role within the family, and they may not understand their partner's daily routine. The delicate nature of postpartum sexuality makes it difficult for couples to discuss. These issues, combined with the woman's increased investment in the mothering role, can strain the couple's sexual relationship. Although couples are reluctant to ask, they often want to know when they can safely resume sexual intercourse after childbirth. Typically, sexual intercourse can be resumed once bright-red bleeding has stopped and the perineum is healed from an episiotomy or lacerations. This is usually by the third to the sixth week postpartum. However, there is no set, prescribed time at which to resume sexual intercourse after childbirth. There is no scientific basis for the traditional recommendation to delay sexual activity until the six week postpartum check-up. Each couple must set their own time frame when they feel it is appropriate to resume sexual intercourse. Despite fears and myths about sexual activity during pregnancy, maintaining a couple's sexual interactions throughout pregnancy and the postpartum period can promote sexual health and well-being and a greater depth of intimacy. Postpartum sexual health and sexual problems are common, which receive little attention from health care providers during the postpartum period, need to be addressed (Halford, Petch, & Creedy, 2015). When counseling the couple about sexuality, determine what knowledge and concerns the couple have about their sexual relationship. Inform the couple that fluctuations in sexual interest are normal. Reassure the breast-feeding mother that she may notice a let-down reflex during orgasm and find her breasts are very sensitive when touched by her partner. Also inform the couple about how to prevent discomfort. Precoital vaginal lubrication may be impaired during the postpartum period, especially in women who are breast-feeding. Use of water-based gel lubricants (K-Y® jelly, Astroglide) can help. Pelvic floor exercises, in addition to preventing stress incontinence, can also enhance sensation. Initiation of contraception during the postpartum period is important to prevent unintended pregnancy and short birth intervals, which can lead to negative health outcomes for mother and infant. Contraceptive options should be included in the discussions with the couple so that they can make an informed decision before resuming sexual activity. Many couples are overwhelmed with the amount of new information given to them during their brief hospitalization, so many are not ready for a lengthy discussion about contraceptives. Presenting a brief overview of the options, along with literature, may be appropriate. It may be suitable to ask them to think about contraceptive needs and preferences and advise them to use a barrier method (condom with spermicidal gel or foam) until they choose another form of contraception. This advice is especially important if the follow-up appointment will not occur for 4 to 6 weeks after childbirth, because many couples will resume sexual activity before this time. Some postpartum women ovulate before their menstrual period returns and thus need contraceptive protection to prevent another pregnancy. Recently, the CDC assessed evidence regarding the safety of estrogen-containing contraceptive methods use during the postpartum period. They recommend that postpartum women not use combined hormonal contraceptives during the first 21 days after childbirth because of the high risk for VTE during this period. During days 21 to 42 postpartum, women without risk factors for VTE generally can initiate estrogen-containing contraceptives, but women with risk factors for VTE (e.g., previous VTE or recent cesarean delivery) generally should not use these methods. After 42 days postpartum, no restrictions on the use of combined hormonal contraceptives based on postpartum status apply (Centers for Disease Control and Prevention [CDC], 2015a). Open and effective communication is necessary for effective contraceptive counseling so that information is clearly understood. Provide clear, consistent information appropriate to the woman and her partner's language, culture, and educational level. This will help the couple select the best contraceptive method. Research supports that postpartum education about contraception leads to more contraception use and fewer unplanned pregnancies and that both short-term and multiple-contact interventions had effects. The use of contraceptives was highest when contraceptive counseling was provided prenatally and again in the postpartum period (Zapata et al., 2015). (Ricci 541-542) Ricci, Susan. Lippincott CoursePoint for Ricci: Essentials of Maternity, Newborn and Women's Health Nursing, 4th Edition. CoursePoint, 10/1/2016. VitalBook file.

Psychological assessment

Psychosocial assessment of the postpartum woman focuses on emotional status and bonding and attachment. 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. Remember Raina and her "quiet" husband, the Muslim couple? The postpartum nurse informs Raina that her doctor, Nancy Schultz, has been called away for emergency surgery and won't be available the rest of the day. The nurse explains that Dr. Robert Nappo will be making rounds for her. Raina and her husband become upset. Why? Is culturally competent care being provided to this couple? Bonding and Attachment Nurses can be instrumental in promoting 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. Remember, however, that mothers from different cultures may behave differently from what is expected in your own culture. For example, Native American mothers tend to handle their newborns less often and use cradle boards to carry them. Native American mothers and many Asian American mothers delay breast-feeding until their milk comes in, because colostrum is considered harmful for the newborn (Bowers & Ceballos, 2015). Do not assume that different behavior is wrong. Meeting the newborn for the first time after birth can be an exhilarating experience for parents. Although the mother has spent many hours dreaming of her unborn and how he or she will look, it is not until after birth that they meet face to face. They both need to get to know one another and to develop feelings for one another. Bonding is 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 really a continuation of the relationship that began during pregnancy (Sears & Sears, 2015a). It is affected by a multitude of factors, including the parent's 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 holder. Take Note! The length of time necessary for bonding depends on the health of the infant and mother, as well as the circumstances surrounding the labor and birth (Tester-Jones et al., 2015). Attachment is the development of strong affection between an infant and a significant other (mother, father, sibling, and caretaker). 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 (Sette, Coppola, & Cassibba, 2015). This tie between two people is psychological rather than biologic, and it does not occur overnight. The process of attachment follows a progressive or developmental course that changes over time. Attachment is an individualized and multifactorial process that differs based on the health of the infant, the mother, environmental circumstances, and the quality of care the infant receives. 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 him or her (Mattson & Smith, 2016). It occurs through mutually satisfying experiences. 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 caretaking behaviors, emotional attentiveness to infant's needs, staying close to, touching, kissing, cuddling, choosing the en face (face-to-face) position while holding or feeding the newborn, expressing pride in the newborn and exchanging gratifying experiences with the infant (McComish, 2015). 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 the 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 very 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 (Fig. 16.5). Generally, research on attachment has found that the process is similar for partners as for mothers, but the pace may be different. Like mothers, partners manifest attachment behaviors during pregnancy. Indeed, Baltes et al. (2014) found that the best predictors of early postnatal attachment for fathers or significant others were those who viewed the paternal caregiving role as important and also had greater marital quality. Higher levels of paternal sensitivity were associated with better infant-father attachment. Becoming a father or significant partner requires the person to build on the experiences he/she has had throughout childhood and adolescence. Fathers or significant other partners develop an emotional tie with their infants in a variety of ways. They seek and maintain closeness with the infant and can recognize characteristics of the infant. Another study further described paternal attachment as a permanent, cyclical concept characterized by changes in response to the child's developmental stage. When children have a secure, supportive, and sensitive relationship with their fathers or mother's significant other, they are generally better adjusted than those that have a nonsupportive relationship (Lickenbrock & Braungart-Rieker, 2015). FIGURE 16.5 En face position. 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 can occur if a mother's physical and emotional states are adversely affected by exhaustion, pain, and the absence of a support system; if she has an infant in NICU and is separated from it; or had a traumatic birth experience, anesthesia, or an unwanted outcome, such as an ill infant (Lee et al., 2014). Take Note! Touch is a basic instinctual interaction between a parent and his or her infant and has a vital role in the infant's early development. Parents provide a variety of tactile stimulation while addressing their infant's daily care routines (Hugill, 2015). The developmental task for the infant is learning to differentiate between trust and mistrust. If the mother or caretaker is consistently responsive to the infant's care, meeting the baby's physical and psychological needs, the infant will likely learn to trust the caretaker, 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 (Klebanov & Travis, 2015). "Becoming" a parent may take 4 to 6 months. The transition to parenthood, according to Mercer (2006), involves four stages: Commitment, attachment, and preparation for an infant during pregnancy Acquaintance with and increasing attachment to the infant, learning how to care for the infant, and physical restoration during the first weeks after birth Moving toward a new normal routine in the first 4 months after birth Achievement of a parenthood role around 4 months p. 530 p. 531 The stages overlap, and the timing of each is affected by variables such as the environment, family dynamics, and the partners (Mercer, 2006). FACTORS AFFECTING ATTACHMENT Attachment behaviors are influenced by three major factors: Parents' background (includes the care that the parents received when growing up, cultural practices, relationship within the family, experience with previous pregnancies and planning and course of events during pregnancy, postpartum depression) Infant (includes the infant's temperament and health at birth) Care practices (the behaviors of physicians, midwives, nurses, and hospital personnel, care and support during labor, first day of life in separation of mother and infant, and rules of the hospital or birthing center) (Lewis & Rudolph, 2014). Attachment occurs more readily with the infant whose temperament, health, appearance, and gender fit the parent's expectations. If the infant does not meet these expectations, attachment can be delayed (Lickenbrock & Braungart-Rieker, 2015). Factors associated with the health care facility or birthing unit can also hinder attachment. These include: Separation of infant and parents immediately after birth and for long periods during the day Policies that discourage unwrapping and exploring the infant Intensive care environment, restrictive visiting policies Staff indifference or lack of support for parent's caretaking attempts and abilities Concept Mastery Alert Grief After Delivery of a Child with Special Needs It is important for the mother to visit the child in the special care nursery, but the priority is to assist the mother in dealing with the grief that accompanies giving birth to a child with special needs. The mother must first mourn the loss of the "perfect child." CRITICAL ATTRIBUTES OF ATTACHMENT The terms bonding and attachment are often used interchangeably, even though they involve different time frames and interactions. Attachment stages include proximity, reciprocity, and commitment. Proximity refers to the physical and psychological experience of the parents being close to their infant. This attribute has three dimensions: Contact: The sensory experiences of touching, holding, and gazing at the infant are part of proximity-seeking behavior. Emotional state: The emotional state emerges from the affective experience of the new parents toward their infant and their parental role. Individualization: Parents are aware of the need to differentiate the infant's needs from themselves and to recognize and respond to them appropriately, making the attachment process also, in some way, one of detachment. Reciprocity is the process by which the infant's abilities and behaviors elicit parental response. Reciprocity is described by two dimensions: complementary behavior and sensitivity. Complementary behavior involves taking turns and stopping when the other is not interested or becomes tired. An infant can coo and stare at the parent to elicit a similar parental response to complement his or her behavior. Parents who are sensitive and responsive to their infant's cues will promote their development and growth. Parents who become skilled at recognizing the ways their infant communicates will respond appropriately by smiling, vocalizing, touching, and kissing. Commitment refers to the enduring nature of the relationship. The components of this are twofold: centrality and parent role exploration. In centrality, parents place the infant at the center of their lives. They acknowledge and accept their responsibility to promote the infant's safety, growth, and development. Parent role exploration is the parents' ability to find their own way and integrate the parental identity into themselves (Sears & Sears, 2015b). POSITIVE AND NEGATIVE ATTACHMENT BEHAVIORS Positive bonding behaviors include maintaining close physical contact, making eye-to-eye contact, speaking in soft, high-pitched tones, and touching and exploring the infant. Table 16.1 highlights typical positive and negative attachment behaviors. (Ricci 529-531) Ricci, Susan. Lippincott CoursePoint for Ricci: Essentials of Maternity, Newborn and Women's Health Nursing, 4th Edition. CoursePoint, 10/1/2016. VitalBook file.

Vital signs assessment

Temperature Use a consistent measurement technique (oral, axillary, or tympanic) to get the most accurate readings. Typically, the new mother's temperature during the first 24 hours postpartum is within the normal range or a low-grade elevation. Some women experience a slight fever, up to 100.4° F (38° C), during the first 24 hours. This elevation may be the result of dehydration because of fluid loss during labor. Temperature should be normal after 24 hours with replacement of fluids lost during labor and birth (Green, 2016). 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. Abnormal temperature readings warrant continued monitoring until an infection can be ruled out through cultures or blood studies. An elevated temperature can identify maternal sepsis, which results in significant maternal morbidity and mortality worldwide. To improve the outcome, it is essential that nurses be vigilant in obtaining accurate values and monitoring their client's temperature. Pulse Pulse rates of 60 to 80 beats per minute (bpm) at rest are normal during the first week after birth. This pulse rate is called 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 now. The elevated stroke volume leads to a decreased heart rate (Creasy et al., 2014). 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 to rule out complications. Respirations Respiratory rates in the postpartum woman should be within the normal range of 12 to 20 bpm at rest. Pulmonary function typically returns to the prepregnant state after childbirth when the 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. Lungs should be clear on auscultation. Blood Pressure Assess the woman's blood pressure and compare it with her usual range. Report any deviation from this range. Immediately after childbirth, the blood pressure should remain the same as during labor. An increase in blood pressure could indicate gestational hypertension, whereas a decrease could indicate shock or orthostatic hypotension or dehydration, a side effect of epidural anesthesia. Blood pressure readings should not be higher than 140/90 mm Hg or lower than 85/60 mmHg (King et al., 2015). Blood pressure also may vary based on the woman's position, so assess blood pressure with the woman in the same position every time. Be alert for orthostatic hypotension, which can occur when the woman moves rapidly from a lying or sitting position to a standing one. Pain Pain, the fifth vital sign, is assessed along with the other four parameters. Question the woman about the type of pain and its location and severity. Have the woman rate the pain using a numeric scale from 0 to 10 points. Nursing care should focus on providing comfort measures to ease pain which might include perineal care, clean gown, mouth care, providing warm blankets, ensuring adequate fluid intake to facilitate healing, reposition frequently, and encouraging rest between assessments (Nagtalon-Ramos, 2014). Many postpartum orders will have the nurse premedicate the woman routinely for afterbirth pains rather than wait for her to experience them first. The goal of pain management is to have the woman's pain scale rating maintained between 0 and 2 points at all times, especially after breast-feeding. This 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. (Ricci 524-525) Ricci, Susan. Lippincott CoursePoint for Ricci: Essentials of Maternity, Newborn and Women's Health Nursing, 4th Edition. CoursePoint, 10/1/2016. VitalBook file.

Supporting women's choice of infant feeding

The AAP, WHO, ANA, IOA, USDHHS, ADA, and USPSTF have all released position statements in support of breast-feeding and nurses, should be encouraging it as part of evidence-based practice (Edelman, Kudzma, & Mandle, 2014). Although there is considerable evidence that breast-feeding has numerous health benefits for both mother and infant, many mothers choose to feed their infants formula for the first year of life. Nurses must be able to deliver sound, evidence-based information to help the new mother choose the best way to feed her infant and must support her in her decision. Research findings indicate that parents do listen to nurse's instruction on feeding practices (Stagg & Ustianov, 2015). Many factors affect a woman's choice of feeding method, such as culture, employment demands, support from significant others and family, and knowledge base. Although breast-feeding is encouraged, be sure that couples have the information they need to make an informed decision. Whether a couple chooses to breast-feed or bottle-feed the newborn, support and respect their choice. Women Who Should Not Breast-Feed Certain women should not breast-feed. Drugs such as antithyroid drugs, antineoplastic drugs, alcohol, herpes infection on the breasts, or street drugs (methamphetamines, cocaine, PCP, marijuana) enter the breast milk and would harm the infant, so women taking these substances should not breast-feed. To prevent HIV transmission to the newborn, women who are HIV positive should not breast-feed. Other contraindications to breast-feeding include a newborn with an inborn error of metabolism such as galactosemia or phenylketonuria (PKU), active tuberculosis, or a mother with a serious mental health disorder that would prevent her from remembering to feed the infant consistently (Denne, 2015). Providing Assistance With Breast-Feeding and Bottle-Feeding First-time mothers often have many questions about feeding, and even women who have had experience with feeding may have questions. Regardless of whether the postpartum woman is breast-feeding or bottle-feeding her newborn, she can benefit from instruction. PROVIDING ASSISTANCE WITH BREAST-FEEDING Lippincott's Maternity Nursing Video Series: Assisting the Client with Breastfeeding Click to Show The AAP (2014b) recommends breast-feeding for all full-term newborns. Exclusive breast-feeding is sufficient to support optimal growth and development for approximately the first 6 months of life. Breast-feeding should be continued for at least the first year of life and beyond for as long as mutually desired by mother and child. Educating a mother about breast-feeding will increase the likelihood of a successful breast-feeding experience. At birth, all newborns should be quickly dried, assessed, and, if stable, placed immediately in uninterrupted skin-to-skin contact (kangaroo care) with their mother. This is good practice whether the mother is going to breast-feed or bottle-feed her infant. Numerous benefits of kangaroo care have been reported related to physiological (thermoregulation, cardiorespiratory stability), behavioral (sleep, breast-feeding duration, and degree of exclusivity), domains, as an effective therapy to relieve procedural pain, and improve neurodevelopment. In addition, kangaroo care provides the newborn with optimal physiologic stability, warmth, and opportunities for the first feed (Campbell-Yeo et al., 2015). p. 543 p. 544 The benefits of breast-feeding for infants are clear (see Chapter 18). To promote breast-feeding, the Baby-Friendly Hospital Initiative, an international program of the World Health Organization and the United Nations International Children's Emergency Fund (UNICEF), was started in 1991. This global health promotion initiative was put forth to improve maternal-infant health by improving rates of exclusive breast-feeding. As part of this program, the hospital or birth center should take the following 10 steps to provide "an optimal environment for the promotion, protection, and support of breast-feeding": Have a written breast-feeding policy that is communicated to all staff. Educate all staff to implement this written policy. Inform all women about the benefits and management of breast-feeding. Show all mothers how to initiate breast-feeding within 30 minutes of birth. Give no food or drink other than breast milk to all newborns. Demonstrate to all mothers how to initiate and maintain breast-feeding. Encourage breast-feeding on demand. Allow no pacifiers to be given to breast-feeding infants. Establish breast-feeding support groups and refer mothers to them. Practice rooming-in 24 hours daily (Cleminson et al., 2015; CDC, 2015a; World Health Organization [WHO], 2014a). The nurse is responsible for protecting, promoting and supporting breast-feeding when appropriate. For the woman who chooses to breast-feed her infant, the nurse or lactation consultant will need to spend time instructing her about how to do so successfully. Many women have the impression that breast-feeding is simple. Although it is a natural process, women may experience some difficulty in breast-feeding their newborns. Nurses can assist mothers in smoothing out this transition. Assist and provide one-to-one instruction to breast-feeding mothers, especially first-time breast-feeding mothers, to ensure correct technique. Suggestions are highlighted in Teaching Guidelines 16.4 (see Evidence-Based Practice 16.2). (Ricci 543-544) Tell mothers that they need to believe in themselves and their ability to accomplish this task. They should not panic if breast-feeding does not go smoothly at first; it takes time and practice. Additional suggestions to help mothers relax and feel more comfortable breast-feeding, especially when they return home, include the following: Select a quiet corner or room where you won't be disturbed. Use a rocking chair to soothe both you and your infant. Take long, slow deep breaths to relax before nursing. Drink while breast-feeding to replenish body fluids. Listen to soothing music while breast-feeding. Cuddle and caress the infant while feeding. Set out extra cloth diapers within reach to use as burping cloths. Allow sufficient time to enjoy each other in an unhurried atmosphere. Involve other family members in all aspects of the infant's care from the start. Contact a local La Leche or Nursing Mother's group for continued guidance/support. (Ricci 544-545) Ricci, Susan. Lippincott CoursePoint for Ricci: Essentials of Maternity, Newborn and Women's Health Nursing, 4th Edition. CoursePoint, 10/1/2016. VitalBook file. Because obesity in America is increasing in all walks of life, it is important for nurses to be knowledgeable about how it impacts breast-feeding and ways to support the obese mother. Research shows that mothers who are obese (BMI > 30) are less likely to initiate lactation, have difficulties with latching on, have delayed lactogenesis, experience mechanical challenges, and are prone to early cessation of breast-feeding (Shannon, Chao, & Ramos, 2015). Obesity rates are highest among African American women, who have the lowest rate of breast-feeding initiation and shortest duration when compared with Hispanic and White women. Women who are overweight and obese have lowered prolactin responses to infant sucking, thus milk production may be inhibited. Lactation plays a significant role in preventing future obesity in both the mother and the infant (Masho, Cha, & Morris, 2015). p. 545 p. 546 Nurses can assist in managing obesity-related lactation challenges by keeping the mother and newborn together to facilitate early and frequent sucking to trigger prolactin and oxytocin production, which will help negate the obesity-related blunting of the prolactin response. Suggesting a sandwich technique to insert the mother's breast into the newborn's mouth to elicit sucking might be helpful for the mother with large breasts. In the sandwich technique, the mother is taught to grasp her breast by making a "C" with her thumb and index finger. The thumb stabilizes the top of the breast while the remaining four fingers support her breast from below. Massage or pumping the breast may soften and extend the nipple for easier infant latch-on. In short, nurses can make a difference by observing lactation, assessing infant hydration and satisfaction, and reassuring the mother about her breast-feeding capacity. PROVIDING ASSISTANCE WITH BOTTLE-FEEDING If the mother or couple has chosen to bottle-feed their newborn, the nurse should respect and support their decision. Discuss with the parents what type of formula they will use. Commercial formulas are classified as cow's milk-based (Enfamil, Similac), soy protein-based (Isomil, Prosobee, Nursoy), or specialized or therapeutic formulas for infants with protein allergies (Nutramigen, Pregestimil, Alimentum). Commercial formulas can also be purchased in various forms: powdered (must be mixed with water), condensed liquid (must be diluted with equal amounts of water), ready to use (poured directly into bottles), and prepackaged (ready to use in disposable bottles). Breast milk is a dynamic fluid with compositional changes occurring throughout the period of lactation that reflects the growth rate and developmental needs of the infant. Infant formula, in contrast, has a static composition, intended to meet the nutritional requirements of infants from birth to 12 months of age (Lönnerdal & Hernell, 2015). Nurses need to bring this information to the attention of mothers who choose to formula feed their infants that changes may be needed in different stages of growth to meet the nutritional needs of their infant. Newborns need about 108 cal/kg or approximately 650 cal/day (Dudek, 2014). Therefore, explain to parents that a newborn will need 2 to 4 ounces to feel satisfied at each feeding. Until about age 4 months, most bottle-fed infants need six feedings a day. After this time, the number of feedings declines to accommodate other foods in the diet, such as fruits, cereals, and vegetables (Dudek, 2014). For more information on newborn nutrition and bottle feeding, see Chapter 18. When teaching the mother about bottle-feeding, provide the following guidelines: Wash hands with soap and water and dry using a clean or disposable cloth. Make sure all bottles, nipples and other utensils are clean. Make feeding a relaxing time, a time to provide both food and comfort to your newborn. Use the feeding period to promote bonding by smiling, singing, making eye contact, and talking to the infant. Powdered formula mixes more easily and the lumps dissolve faster if you use room-temperature water. Store any formula prepared in advance in the refrigerator to keep bacteria from growing. Do not microwave formula; the microwave won't heat it evenly, causing hot spots. Always hold the newborn when feeding. Never prop the bottle. Use a comfortable position when feeding the newborn. Place the newborn in your dominant arm, which is supported by a pillow. Or have the newborn in a semi-upright position supported in the crook of your arm. (This position reduces choking and the flow of milk into the middle ear.) Tilt the bottle so that the nipple and the neck of the bottle are always filled with formula. This prevents the infant from taking in too much air. Stimulate the sucking reflex by touching the nipple to the infant's lips. Refrigerate any powdered formula that has been combined with tap water. Discard any formula not taken; do not keep it for future feedings. Burp the infant frequently, and place the baby on his or her back for sleeping. Use only iron-fortified infant formula for the first year (Moses, 2014). (Ricci 545-546) Ricci, Susan. Lippincott CoursePoint for Ricci: Essentials of Maternity, Newborn and Women's Health Nursing, 4th Edition. CoursePoint, 10/1/2016. VitalBook file.

Introduction

The postpartum period is a time of major adjustments and adaptations not just for the mother, but for all members of the family. It is during this time that parenting starts and a relationship with the newborn begins. A positive, loving relationship between parents and their newborn promotes the emotional well-being of all. This relationship endures and has profound effects on the child's growth and development. Take Note! 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 the parents to learn new skills and to integrate the new member into the family. Once the infant is born, each system in the mother's body takes several weeks to return to its nonpregnant state. The physiologic changes in women during the postpartum period are dramatic. Nurses should be aware of these changes and should be able to make observations and assessments to validate normal occurrences and detect any deviations. This chapter describes the nursing management of the woman and her family during the postpartum period. (See Chapter 21 for a detailed discussion of the postpartum care of the woman undergoing a surgical birth.) 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 (see Chapter 15 for a detailed discussion of these adaptations). The chapter outlines physical assessment parameters for new mothers and newborns. It also focuses on bonding and attachment behaviors; nurses need to be aware of these behaviors so they can perform appropriate interventions. Family members are also assessed to determine how well they are making the transition to this new stage. Based on assessment findings, the nurse plans and implements care to address the family's needs. Steps to address physiologic needs such as comfort, self-care, nutrition, and contraception are described. Ways to help the woman and her family adapt to the birth of the newborn are also discussed (Fig. 16.1). Because of today's shortened lengths of stay, the nurse may be able to focus only on priority needs and may need to arrange for follow-up in the home to ensure that all the family's needs are met. (Ricci 522) Ricci, Susan. Lippincott CoursePoint for Ricci: Essentials of Maternity, Newborn and Women's Health Nursing, 4th Edition. CoursePoint, 10/1/2016. VitalBook file.

Providing cultural care

As the face of America is becoming more diverse, nurses must be prepared to care for childbearing families from various cultures. In many cultures, women and their families are cared for and nurtured by their community for weeks and even months after the birth of a new family member. Overall, the culturally competent care for all childbearing families include understanding of traditional folk beliefs; involvement and support by family members; respect; presence of a significant other; breast-feeding and eating healthy; observing the principles of hot and cold; avoidance of sexual intercourse postnatally; encouragement; empowerment; their spiritual dimensions as important; avoidance of evil spirits; and the hope that nurses will anticipate the needs of the mother and infant (McFarland & Wehbe-Alamah, 2015). Box 16.3 highlights some of the major cultural variants during the postpartum period. (Ricci 532-534) Nurses need to remember that childbearing practices and beliefs vary from culture to culture. To provide appropriate nursing care, the nurse should determine the client's preferences before intervening. Cultural practices may include dietary restrictions, certain clothes, taboos, activities for maintaining mental health, and the use of silence, prayer, or meditation. Restoring health may involve taking folk medicines or conferring with a tribal healer. A language barrier might interfere with communication between the woman and health providers, followed by health care provider's lack of cultural sensitivity, leading to a woman's reluctance in using health services (Santiago & Figueiredo, 2015). Providing culturally diverse care within our global community is challenging for all nurses, because they must remember that one's culture cannot be easily summarized in a reference book, but must be viewed through one's own life experiences. (Ricci 534) Ricci, Susan. Lippincott CoursePoint for Ricci: Essentials of Maternity, Newborn and Women's Health Nursing, 4th Edition. CoursePoint, 10/1/2016. VitalBook file.

Assisting with self care measures

Demonstrate and discuss with the woman ways to prevent infection during the postpartum period. Because she may experience lochia drainage for as long as a month after childbirth, describe practices to promote well-being and healing. These measures include: Frequently change perineal pads, applying and removing them from front to back to prevent spreading contamination from the rectal area to the genital area. Avoid using tampons after giving birth to decrease the risk of infection. Shower once or twice daily using a mild soap. Avoid using soap on nipples. Use a sitz bath after every bowel movement to cleanse the rectal area and relieve enlarged hemorrhoids. Use the peribottle filled with warm water after urinating and before applying a new perineal pad. Avoid tub baths for 4 to 6 weeks, until joints and balance are restored, to prevent falls. Wash your hands before changing perineal pads, after disposing of soiled pads, and after voiding (Mattson & Smith, 2016). To reduce the risk of infection at the episiotomy site, reinforce proper perineal care with the client, showing her how to rinse her perineum with the peribottle after she voids or defecates. Stress the importance of always patting gently from front to back and washing her hands thoroughly before and after perineal care. For hemorrhoids, have the client apply witch hazel-soaked pads (Tucks®), ice packs to relieve swelling, or hemorrhoidal cream or ointment if ordered. (Ricci 540-541) Ricci, Susan. Lippincott CoursePoint for Ricci: Essentials of Maternity, Newborn and Women's Health Nursing, 4th Edition. CoursePoint, 10/1/2016. VitalBook file.

Preventing Stress Incontinence

Fifty percent of all parous women develop some degree of pelvic prolapse in their lifetime that is associated with stress incontinence. Stress incontinence causes reduced quality of life and withdrawal from fitness and exercise activities typically. Research suggests that having a vaginal delivery results in direct pelvic muscle trauma and disruption of fascial supports, and also causes damage to the levator ani muscle and pudendal nerve injury. Offering pelvic floor muscle exercise instruction to all women during their first pregnancy and again after having a vaginal birth is recommended by the National Institute for Health and Care Excellence (NICE) guidelines. Nurses can offer them as a first-line intervention in the prevention of urinary incontinence postpartum (Hall & Woodward, 2015). The more vaginal deliveries a woman has had, the more likely she is to have stress incontinence. Stress incontinence can occur with any activity that causes an increase in intra-abdominal pressure. Postpartum women might consider low-impact activities such as walking, biking, swimming, or low-impact aerobics so they can resume physical activity while strengthening the pelvic floor. Suggestions to prevent stress incontinence are: Start a regular program of pelvic floor muscle exercises after childbirth. Lose weight if necessary; obesity is associated with stress incontinence. Avoid smoking; limit intake of alcohol and caffeinated beverages, which irritate the bladder. Adjust fluid intake to produce a 24-hourly urine output of 1,000 to 2,000 mL. Use either an intravaginal or intra-urethral device that puts pressure onto the urethra so that urine will not leak when bladder pressure rises (Laliberte, 2015). Pelvic floor exercises (Kegel exercises) help to strengthen the pelvic floor muscles if done properly and regularly (Ciaghi, Bianco, & Guarese, 2015). These pelvic floor strengthening exercises were originally developed by Dr. Arnold Kegel in the 1940s as a method of controlling incontinence in women after childbirth. The principle behind these exercises is that strengthening the muscles of the pelvic floor improves urethral sphincter function. While providing postpartum care, instruct women on primary prevention of stress incontinence by discussing the value and purpose of pelvic floor muscle exercises. Approach the subject sensitively, avoiding the term incontinent. The terms leakage, loss of urine, or bladder control issues are more acceptable to most women. (Ricci 539-540) Ricci, Susan. Lippincott CoursePoint for Ricci: Essentials of Maternity, Newborn and Women's Health Nursing, 4th Edition. CoursePoint, 10/1/2016. VitalBook file.

Nursing interventions

In terms of postpartum hospital stays today, "less is more." If the woman had a vaginal delivery, she may be discharged within 48 hours or sooner. If she had a cesarean birth, she may remain hospitalized for up to 72 hours. This shortened stay leaves little time for nurses to prepare the woman and her family for the many changes that will occur when she returns home (see Nursing Care Plan 16.1). Research shows that mothers feel unprepared, uninformed, and unsupported during the postpartum period as they struggle with physical and emotional issues, infant caregiving, breast-feeding concerns, and lifestyle adjustments (Walker, Murphey, & Nichols, 2015). Nurses need to focus on: pain and discomfort, immunizations, nutrition, activity and exercise, infant care, lactation instruction, discharge teaching, sexuality and contraception, and follow-up with the limited time they have with their clients. Planning home visits to reinforce postpartum instructions may enhance maternal-infant wellness (see Evidence-Based Practice 16.1). (Ricci 531-532) Ricci, Susan. Lippincott CoursePoint for Ricci: Essentials of Maternity, Newborn and Women's Health Nursing, 4th Edition. CoursePoint, 10/1/2016. VitalBook file.

Nursing assessment during the postpartum period

Many adaptations and adjustments must be made to accommodate the new family member. The nurse's focus is on assistance for families to maximize their adjustment, surveillance for maladaptation, and education, consultation, collaboration as needed. Comprehensive nursing assessment begins within an hour after the woman gives birth and continues through discharge. Take Note! Nurses need a firm grasp of normal findings to be able to recognize abnormal findings and intervene appropriately. This postpartum assessment includes vital signs and physical and psychosocial assessments. It also includes assessing the parents and other family members, such as siblings and grandparents, for attachment and bonding with the newborn. Although the exact protocol may vary among facilities, postpartum assessment typically is performed as follows: During the first hour: every 15 minutes During the second hour: every 30 minutes During the first 24 hours: every 4 hours After 24 hours: every 8 hours (Jordan et al., 2014; Mattson & Smith, 2016). During each assessment, keep in mind risk factors that may lead to complications, such as infection or hemorrhage, during the recovery period (Box 16.1). Early identification is critical to ensure prompt intervention. The postpartum period is a time of transition for women. The end of the pregnancy and childbirth initiates physiologic changes as many body systems return to their nonpregnant state. Nurses need to be aware of the normal physiologic and psychological changes that take place in clients' bodies and minds in order to provide comprehensive care during the postpartum period. In addition to client and family teaching, one of the most significant responsibilities of the postpartum nurse is to recognize potential complications after childbirth. As with any assessment, 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. Postpartum assessment of the mother typically includes vital signs, pain level, epidural site inspection for infection, and a systematic head-to-toe review of body systems. The acronym BUBBLE-EEE—breasts, uterus, bladder, bowels, lochia, episiotomy/perineum/epidural site, extremities, and emotional status—can be used as a guide for this head-to-toe review (Cunningham et al., 2014). (Ricci 523) Ricci, Susan. Lippincott CoursePoint for Ricci: Essentials of Maternity, Newborn and Women's Health Nursing, 4th Edition. CoursePoint, 10/1/2016. VitalBook file.

Ensuring safety

One of the safety concerns during the postpartum period is orthostatic hypotension. When the woman rapidly moves from a lying or sitting position to a standing one, her blood pressure can suddenly drop, causing her pulse rate to increase. She may become dizzy and faint. Be aware of this problem and initiate the following safeguards: Check blood pressure first before ambulating the client. Elevate the head of the bed for a few minutes before ambulating the client. Have the client sit on the side of the bed for a few moments before getting up. Help the client to stand up, and stay with her. Ambulate alongside the client and provide support if needed. Frequently ask the client how her head feels. Stay close by to assist if she feels light-headed. Additional topics to address orthostatic hypotension that may concern infant safety include instructing the woman to place the newborn back in the crib on his or her back if she is feeling sleepy to prevent a fall. If the woman falls asleep while holding the infant, she might drop him or her. Also, instruct mothers to keep the door to their room closed when their infant is in their room with them. They should check the identification of anyone who enters their room or who wants to take the infant out of the room. This will prevent infant abduction. (Ricci 541) Ricci, Susan. Lippincott CoursePoint for Ricci: Essentials of Maternity, Newborn and Women's Health Nursing, 4th Edition. CoursePoint, 10/1/2016. VitalBook file.

Teaching about breast care

Regardless of whether or not the mother is breast-feeding her newborn, urge her to wear a very supportive, snug bra 24 hours a day to support enlarged breasts and promote comfort. A woman who is breast-feeding should wear a supportive bra throughout the lactation period. A woman who is not nursing should wear it until engorgement ceases, and then should wear a less restrictive one. The bra should fit snugly while still allowing the mother to breathe without restriction. All new mothers should use plain water to clean their breasts, especially the nipple area; soap is drying and should be avoided. Assessing the Breasts Instruct the mother how to examine her breasts daily. Daily assessment includes the milk supply (breasts will feel full as they are filling), the condition of the nipples (red, bruised, fissured, or bleeding), and the success of breast-feeding. The fullness of the breasts may progress to engorgement in the breast-feeding mother if feedings are delayed or breast-feeding is ineffective. Palpating both breasts will help identify whether the breasts are soft, filling, or engorged. A similar assessment of the breasts should be completed on the nonlactating mother to identify any problems, such as engorgement or mastitis. Alleviating Breast Engorgement Breast engorgement usually occurs during the first week postpartum. It is a common response of the breasts to the sudden change in hormones and the presence of an increased amount of milk. Reassure the woman that this condition is temporary and usually resolves within 72 hours. ALLEVIATING BREAST ENGORGEMENT IN THE BREAST-FEEDING WOMAN If the mother is breast-feeding, encourage frequent feedings, at least every 2 to 3 hours, using manual expression just before feeding to soften the breast so the newborn can latch on more effectively. Advise the mother to allow the newborn to feed on the first breast until it softens before switching to the other side. See Chapter 18 for more information on alleviating breast engorgement and other common breast-feeding concerns. ALLEVIATING BREAST ENGORGEMENT AND SUPPRESSING LACTATION IN THE BOTTLE-FEEDING WOMAN If the woman is bottle-feeding, explain that breast engorgement is a self-limiting phenomenon that disappears as increasing estrogen levels suppress milk formation (i.e., lactation suppression). Encourage the woman to use ice packs, to wear a snug, supportive bra 24 hours a day, and to take mild analgesics such as acetaminophen. Encourage her to avoid any stimulation to the breasts that might foster milk production, such as warm showers or pumping or massaging the breasts. Medication is no longer given to hasten lactation suppression because these agents had limited effectiveness and adverse side effects. Teaching Guidelines 16.5 provides tips on lactation suppression. (Ricci 546-547) Ricci, Susan. Lippincott CoursePoint for Ricci: Essentials of Maternity, Newborn and Women's Health Nursing, 4th Edition. CoursePoint, 10/1/2016. VitalBook file.

Preparing for discharge

The World Health Organization (WHO) recommends that the length of stay in the health care facility should be individualized for each mother and baby, but should be at least 24 hours after birth (2014b). A shortened hospital stay may be indicated if the following criteria are met: Mother is afebrile and vital signs are within normal range. Lochia is appropriate amount and color for stage of recovery. Hemoglobin and hematocrit values are within normal range. Uterine fundus is firm; urinary output is adequate. ABO blood groups and RhD status are known and, if indicated, anti-D immunoglobulin has been administered. Surgical wounds are healing and no signs of infection are present. Mother is able to ambulate without difficulty. Food and fluids are taken without difficulty. Self-care and infant care are understood and demonstrated. Family or other support system is available to care for both. Mother is aware of possible complications (WHO, 2014b). Providing Immunizations Prior to discharge, check the immunity status for rubella for all mothers and give a subcutaneous injection of rubella vaccine if they are not serologically immune (titer less than 1:8). Be sure that the client signs a consent form to receive the vaccine. The rubella vaccine should not be given to any woman who is immune compromised, and the immune status of her close contacts needs to be determined before any vaccine is administered to her to prevent a more virulent case of the vaccine-preventable illness or potential death. With the recent increase in the number of pertussis in infants younger than three months of age, the CDC is also recommending vaccination with (Tdap) (combination of diphtheria, pertussis, and tetanus vaccines) for the mother during her postpartum stay (CDC, 2015b). Nursing mothers can be vaccinated because the live, attenuated rubella virus is not communicable. Inform all mothers receiving immunization about adverse effects (rash, joint symptoms, and a low-grade fever 5 to 21 days later) and the need to avoid pregnancy for at least 28 days after being vaccinated because of the risk of teratogenic effects (CDC, 2015b). Rh Status If the client is Rh negative, check the Rh status of the newborn. Verify that the woman is Rh negative and has not been sensitized, that her indirect Coombs' test (antibody screen) is negative, and that the newborn is Rh positive. Mothers who are Rh negative and have given birth to an infant who is Rh positive should receive an injection of Rh immunoglobulin within 72 hours after birth to prevent a sensitization reaction in the Rh-negative woman who received Rh-positive blood cells during the birthing process. Administering RhoGAM prevents initial isoimmunization in Rh-negative mothers by destroying fetal erythrocytes in the maternal system before maternal antibodies can develop and maternal memory cells become sensitized. This is a classic passive immunization technique. The usual protocol for the Rh-negative woman is to receive two doses of Rh immunoglobulin (RhoGAM), one at 28 weeks' gestation and the second dose within 72 hours after childbirth. The standard dose of Rho(D) immune globulin (RhoGAM) is 300 mcg given intramuscularly, which prevents the development of antibodies for an exposure of up to 15 mL of fetal red blood cells (King et al., 2015). A signed consent form is needed after a thorough explanation is provided about the procedure, including its purpose, possible adverse effects, and effect on future pregnancies. RhoGam contains actual Rh antibodies produced by people who have become sensitized. It is therefore, a blood product. Each dose contains enough Anti-D to suppress the immune response of 15 mL of Rh positive red blood cells (Jordan et al., 2014). Jehovah's Witnesses and others who belong to religions prohibiting the use of blood products should consult their conscience and possibly ecclesiastical leaders about the use of RhoGam. Nurses need to respect whatever their decision is. Ensuring Follow-Up Care New mothers and their families need to be attended to over an extended period of time by nurses knowledgeable about mother care, infant feeding (breast-feeding and bottle-feeding), infant care, and nutrition. Although continuous nursing care stops on discharge from the hospital or birthing center, extended episodic nursing care needs to be provided at home. Some of the challenges faced by families after discharge are described in Box 16.5. Many new mothers are reluctant to "cut the cord" after their brief stay in the health care facility and need expanded community services. Women who are discharged too early from the hospital run the risk of uterine subinvolution, discomfort at an episiotomy or cesarean site, infection, fatigue, and maladjustment to their new role. Postpartum nursing care should include a range of family-focused care, including telephone calls, outpatient clinics, and home visits. Typically, public health nurses, community and home health nurses, and the health care provider's office staff will provide postpartum care after hospital discharge. (Ricci 551-552) Ricci, Susan. Lippincott CoursePoint for Ricci: Essentials of Maternity, Newborn and Women's Health Nursing, 4th Edition. CoursePoint, 10/1/2016. VitalBook file. PROVIDING TELEPHONE FOLLOW-UP Telephone follow-up typically occurs during the first week after discharge to check on how things are going at home. Calls can be made by perinatal nurses within the agency as part of follow-up care or by the local health department nurses. One disadvantage of a phone call assessment is that the nurse cannot see the client and thus must rely on the mother or the family's observations. The experienced nurse needs to be able to recognize distress and give appropriate advice and referral information if needed. PROVIDING OUTPATIENT FOLLOW-UP For mothers with established health care providers such as private pediatricians and obstetricians, visits to the office are arranged soon after discharge. For the woman with an uncomplicated vaginal birth, an office visit is usually scheduled for 4 to 6 weeks after childbirth. A woman who had a cesarean birth frequently is seen within 2 weeks after hospital discharge. Hospital discharge orders will specify when these visits should be made. Newborn examinations and further diagnostic laboratory studies are scheduled within the first week. Take Note! The hospital stay of the mother and her healthy term newborn should be long enough to allow identification of early problems and to ensure that the family is able and prepared to care for the infant at home (WHO, 2014b). Outpatient clinics are available in many communities. If family members run into a problem, the local clinic is available to provide assessment and treatment. Clinic visits can replace or supplement home visits. Although these clinics are open during daytime hours only and the staff members are unfamiliar with the family, they can be a valuable resource for the new family with a problem or concern. PROVIDING HOME VISIT FOLLOW-UP Home visits are usually made within the first week after discharge to assess the mother and newborn. During the home visit, the nurse assesses for and manages common physical and psychosocial problems. In addition, the home nurse can help the new parents adjust to the change in their lives. The postpartum home visit usually includes the following: Maternal assessment: general well-being, vital signs, breast health and care, abdominal and musculoskeletal status, voiding status, fundus and lochia status, psychological and coping status, family relationships, proper feeding technique, environmental safety check, newborn care knowledge, and health teaching needed (Fig. 16.10 shows sample assessment forms.) Infant assessment: physical examination, general appearance, vital signs, home safety check, child development status, any education needed to improve parents' skills The home care nurse must be prepared to support and educate the woman and her family in the following areas: Breast-feeding or bottle-feeding technique and procedures Appropriate parenting behavior and problem solving Maternal/newborn physical, psychosocial, and culture-environmental needs Emotional needs of the new family Warning signs of problems and how to prevent or eliminate them Sexuality issues, including contraceptive use Immunization needs for both mother and infant Family dynamics for smooth transition Links to health care providers and community resources (Ricci 552) Ricci, Susan. Lippincott CoursePoint for Ricci: Essentials of Maternity, Newborn and Women's Health Nursing, 4th Edition. CoursePoint, 10/1/2016. VitalBook file.

Assisting with elimination

The bladder is edematous, hypotonic, and congested immediately postpartum. Consequently, bladder distention, incomplete emptying, and inability to void are common. A full bladder interferes with uterine contraction and may lead to hemorrhage, because it will displace the uterus out of the midline. Encourage the woman to void. Often, assisting her to assume the normal voiding position on the commode facilitates this. If the woman has difficulty voiding, pouring warm water over the perineal area, hearing the sound of running tap water, blowing bubbles through a straw, taking a warm shower, drinking fluids, providing her with privacy, or placing her hand in a basin of warm water may stimulate voiding. If these actions do not stimulate urination within 4 to 6 hours after giving birth, catheterization may be needed. Palpate the bladder for distention and ask the woman if she is voiding in small amounts (less than 100 mL) frequently (retention with overflow). If catheterization is necessary, use sterile technique to reduce the risk of infection. Decreased bowel motility during labor, high iron content in prenatal vitamins, postpartum fluid loss, and the adverse effects of pain medications and/or anesthesia may predispose the postpartum woman to constipation. In addition, the woman may fear that bowel movements will cause pain or injury, especially if she had an episiotomy or a laceration that was repaired with sutures. Usually a stool softener, such as docusate, with or without a laxative might be helpful if the client has difficulty with bowel elimination. Other measures, such as ambulating and increasing fluid and fiber intake, may also help. Nutritional instruction might include increasing fruits and vegetables in the diet; drinking plenty of fluids (8 to 12 cups daily) to keep the stool soft; drinking small amounts of prune juice and/or hot liquids to stimulate peristalsis; eating high-fiber foods such as bran cereals, whole grains, dried fruits, fresh fruits, and raw vegetables; and walking daily. (Ricci 537-538) Ricci, Susan. Lippincott CoursePoint for Ricci: Essentials of Maternity, Newborn and Women's Health Nursing, 4th Edition. CoursePoint, 10/1/2016. VitalBook file.