POST PARTUM

Lecture 8

Puerperium: Puerperium: to bring forth 6 wk > childbirth.  4th trimester - transition for woman/family (pregnancy ends/parenting role begins) I. Physiological Changes of Post Partum Period A. Reproductive System Changes: UTERUS: contx s begin > birth & delivery of placenta 1. placental site seals 2. Entire uterus contracts & reduces gradually for 8-10 8days. INVOLUTION . Pt. in danger of hemorrhage uterus until involution is complete. Oxytocin released > uterine contx s.


Fundus: Fundus: assess for firmness. Palpate > delivery.



Remains @ umbilicus X 24 hrs. Soft aka boggy danger of hemorrhage.

Massage uterus! Uterus descends one finger breadth every day.  Delivery day, uterus @ umbilicus  1st day PP uterus 1 FB Umbilicus  2nd day PP uterus 2 FB and so forth.  Support lower segment of uterus when palpating to prevent uterine eversion.

By day 10, uterus almost back to pre-pregnant presize & position in pelvic cavity. [1000 grams 50 grams] No longer palpated in abdomen. Full bladder raises fundal height, gives false reading. Natural oxytocin released with breast feeding. ^ contractions . 2FB umb. on 1st day PP. Breast fdg.offers little protection against hemorr.

Delay in uterine involution: retained placenta/clots effective contraction of uterus not possible. Risk of PP possible. Hemorr. Delay also with:  multiparous pt. [grand multip ]  exhaustion  multi-fetuses. multi C/S involutes slower; d/t surgery & less initiation of breast feeding > delivery. AfterAfter-birth pains = cramping caused by contractions  more in multi-parous women than in primips . multi With Br. Fdg. because of release of oxytocin.

2. LOCHIA  Placenta separates from spongy layer of uterus decidua BASALIS.

 

    

Inner layer of decidua remains & forms new layer of endometrium . Outer becomes necrotic & sheds. Consists of blood, fragments of decidua, mucus, bacteria. 1st 3 days = rubra = red [blood] >3 days = serosa = pink 10th day alba - white [up to 3 wks] Total flow lasts about 4-5 wks 4Should not be bright red; could be PP hemorrhage.

3. CERVIX  Neck; remains slightly opened & contracts > delivery.  In 7 days, opening narrow as pencil. Os remains slit-like . slit4. VAGINA  Slightly distended after birth. Kegel exercises ^muscle tone and strength. Important for lacerations. 5. PERINEUM  Can be edematous/ecchymotic  Ice x 24 hrs. then heat [Sitz]  Topical anesthetics creams/sprays apply for comfort.  Perineal massage relaxes perineum before delivery. May prevent episiotomy/laceration. Teach Kegels - tightening & releasing of perineal muscles. Improves circulation & healing of epis/lac.

Complications of Perineum:  Hematomas [blood from bleeding vessel]  Area of swelling on one side of perineum.  If small, absorbs in few days; apply ice & give analgesics.  If large bleed, to OR for evacuation & vaginal packing.  Common - forceps deliveries  Perineal Care - use warm water; wipe from front to back.

Laceration  size of baby, timing of delivery, tension on perineum.  Sutured & treated as episiotomies.  Analgesics, ice, topical creams, Sitz bath.  1st degree = from base of vagina to base of labia minora.  2nd = from base of vagina to mid perineum  3rd = entire perineum to anal sphincter  4th = entire perineum through anal sphincter & some rectal tissue.  Nothing into rectum - no rectal temps., suppositories, or enemas with 4th degree to avoid further damage.  Colace TID, ^ po fluids to promote BM. Ice X 24 hrs., Sitz baths TID; topicals. KEGELS!

SYSTEMIC CHANGES - Body returns to prepre-pregnant state by 6 wks. Hormonal System: System:  Pregnancy hormones decrease w. delivery of placenta.  HCG & HPL disappear by 24 hrs. FSH rises 12 days - to begin new menstrual cycle. Menses resumes by 4-5 wks. if not Br. Fdg. 4

The Urinary System: System:  Loss of bladder tone d/t swelling & anesthesia ; urinating difficult. May not feel urge to void.  Hydronephrosis [enlargement of ureters] occurs after delivery & to 4 wks. PP. DIURESIS!  bladder sensitivity - risk for bladder infection urinary stasis.  Avoid bladder damage - assess bladder q 1-2 hrs.til 1voids qs. Teach voiding q 2 3 hours.  Palpate abdomen gently, note location of fundus. When do you suspect full bladder?  During preg., 2000-3000 ml. of fluid accumulates in 2000body - Client loses 5- 10 lbs. of water weight in 1st 5wk. How?

Circulatory System: Blood volume ^ 30 50% in System: pregnancy. With diuresis & blood loss @ delivery, blood volume returns to normal in 1-2 wks. 1 Blood loss for NSVD = 300 cc. & C/S = 500 cc.
  

  

Non pregnant: HCT=37 - 47% & HGB=12 - 16g/dL Pregnant: HCT=32 -42 % & HGB = 11.5 14g/dL HCT drops by 4 pts. & HGB drops by 1 g. for every 250cc. of blood client loses. Patient should not be anemic entering delivery Possible blood transfusion with large blood loss. Average blood volume: pre-pregnant = 4000cc; prepregnant state = 5250cc.

^ Blood volume: provides adequate exchange of nutrients in placenta & compensates for blood loss during delivery.  HR remains ^ x 24-48 hrs. PP 24 With diuresis, HCT levels rise [^ hemoconcentration] reach pre-preg level by 6 wks. prePlasma fibrinogen ^^ 50% during pregnancy & remains elevated 6 wks. PP. [^ estrogen levels] WHY? Can cause ^ thrombus formation.  Assess pts. legs/calves for s/s thrombus.  Rise in leukocytes; WBC ^ protective measure to prepare for stress of delivery. As high as 20-25,000. 20

Gastrointestinal System: System:

     

NSVD: bowels sounds. Eat right away. C/S: bowel sounds hypoactive 1st 8 hrs. Epidural/spinal: po clears after delivery, advance diet if +BS. General anesthesia: usually NPO for ~ 6-8 hrs. 6Duramorph/astromorph can cause N/V up to 12 hrs. antiemetic meds. [Reglan/Zofran] . BM - difficult/painful d/t lacerations/hemmorhoids. C/S - BM 3rd - 4th day. GI activity slowed d/t surgery. Can go home without BM if + flatus.

  

Integumentary System: Stretch marks [striae gravidarum] appear reddened on abdomen. Fade by 3-6 months; 3Pearly white marks may remain in lighter skinned pts. & darker marks in darker skinned pts.  Modified sit-ups strengthen abdomen sit-

VITAL SIGNS PP Temperature: slightly ^ - dehydration during labor 1st 24 hrs. Returns to normal within 24 hrs.  T = 100.4 or > PP infection suspected.  Temp. also rises 3rd - 4th day with filling of breast milk  Observe for s/s infection - nurse usually 1st to detect temp. [universal sign of infection 100.4 x 2 readings, on days 2-10 PP] 2Pulse: HR ^ slightly x 1st hr.  Stroke volume & cardiac output also ^ x 1st hr. then
decreases
 

8-10 wks.,returns to pre-pregnant state. preRapid, thready pulse- sign of PP hemorrhage, infection pulse-

Blood Pressure - Monitor carefully. 1st trimester Heart works faster to handle ^ volume. BP remains same. 2nd trimester BP drops slightly d/t lowered peripheral resistance in blood vessels as placenta expands rapidly. Heart beats faster, more efficiently d/t ^ blood volume. PrePre-pregnant BP 120/80. Pregnant BP 114/65. 3rd trimester BP back to pre-pregnant value. pre-

BP Complications
BP [90/60 or less] with dizziness is Orthostatic hypotension; could signify hemorrhage.  Take BP/pulse lying/sitting/standing. Compare values.  Orthostatic: If BP drops 15-20 mmHg and pulse increases 1520 bpm or more. Caution for falls.  Needs IV fluids. Take VS. Report to MD > order for CBC.

BP [140/90 or >] could signify PP pre-eclampsia. pre Notify MD. Could develop into serious complication.  Oxytocic meds [Pitocin] > delivery could ^ BP

Other Changes Exhaustion: Exhaustion:  Common  Frequent rest periods  RN coordinates nursing care & infant feeding times  provide maximum rest time. Weight Loss: Loss:  Average wt. loss 12 lb. [infant & placenta]  5 lbs. - diuresis & diaphoresis in wk. that follows.  Lochial flow - 2-3 lbs.  Total = approx. 19-20 lbs. {depends on total wt. gain} 19 At 6 wks. wt. may still be above pre-preg. weight. preReturn of Menses: > delivery FSH levels rise causing ovulation  No Br. Fdg.- menses resumes ~ 6 wks. Fdg. Lactation delays menses for several months (6 mos)

PSYCHOLOGICAL CHANGES OF POST PARTUM PERIOD: ADJUSTMENTS Taking- Phase: Taking-In Phase:  time of reflection for client regarding new role  may be passive or excited  talks at length about birth experience  on phone with family/friends recounting birth experience.  Usually lasts 1-2 days. 1 Delayed d/t pain r/t vaginal or C/S. TakingTaking-Hold Phase: Phase:  woman makes own decisions regarding self & infant care.  Usually day 2 - 3. Occur on day 1 esp. if woman is multip.  Can occur later, depends on recovery process or cultural beliefs.

Letting Go Phase:


 

Woman gives up fantasy image of baby and accepts real child. Occurs within few weeks of getting home Needs time to adjust to new experience.

Bonding:  Expressing maternal love & attachment toward new baby. Develops gradually.  Enface position: close eye contact with infant. position:  Healthy bonding - kissing, touching, counting fingers & toes, cooing, etc.


Factors Interfering with Bonding: difficult labor, Bonding: separation @ birth (NICU)

Other Maternal Feelings of Post Partum Period Abandonment: feelings that occur > birth of child; woman no longer center of attention.  Disappointment: infant does not meet expectations of mother/father. Eg. eye color; sex .  Post Partum Blues: d/t normal hormonal changes; Drop in estrogen/progesterone; lasts 1st few days of PP period. Occurs in 50% of women.


PP Depression: 30% of women exp. this.  Therapy & medication may be necessary.  Hx of depression & anxiety prior to pregnancy puts mother @ higher risk for developing this.  Can manifest itself up to 1 year > birth.  Screening tool: Edinburgh PP depression tool


Always refer to social worker to assess for degree of depression.

Ask: is mother able to take infant home without danger

to self or baby? Studies show breast feeding helps reduce symptoms d/t oxytocin feel good effect

MANIFESTATIONS OF POSTPARTUM DEPRESSION

            

q interest in surroundings q interest in food unable to feel pleasure fatigue health c/o sleep disturbance panic attacks obsessive thinking q hygiene q ability to concentrate odd food cravings irritability rejection of infant

PPD: Teaching  relaxation therapy  rest & nutrition  frequent contact with other adults Resource: The Post Partum Resource Center of New York, Inc. 631-422631-422-2255 www.postpartumNY.org MANIFESTATIONS OF POSTPARTUM PSYCHOSIS  s/s depression  s/s manic  auditory hallucinations  delusions  guilt  worthlessness

Development of Parental Love & Positive Family Relationships:



Rooming In: most hospitals offer this; infant stays in room with mom 24hrs. (partial or complete) Sibling Visitation: encourage siblings to visit to promote family togetherness.

LACTATION & BREAST FEEDING



 

Lactation starts regardless if pt. is breastfeeding or not. Entirely up to mother Must feel comfortable doing so.

Advantages to Breast Feeding:


 

Promotes bonding between mother & baby. High nutritional value for infant. Promotes uterine involution thru release of oxytocin from posterior pituitary. Reduces cost of feeding & preparation time.

Nurse has major role as educator of benefits & methods of breast feeding. Ways to teach new moms about lactation: videos handouts hands on demo lactation specialist [in clinical settings] Offer support Contraindications to Breast Feeding:  Mom receiving meds not appropriate for Br. fdg. [Lithium]  Exposure to radioactive compounds [thyroid testing]; pump & dump breast milk x 48 hrs. Flush in toilet.  Breast Cancer; HIV

Physiology of Lactation Body prepares for lactation during pregnancy; stores fat & nutrients; provide energy, vitamins, minerals in breast milk.
   

Early pregnancy, estrogen (placenta) stimulates growth of milk glands & size of breasts. Colostrum: middle of pregnancy & day 1-3 PP, 1Thin, watery pre-lactation secretion. Rich in antibodies; prepasses to baby in 1-3 days. 1Breasts begin to get tender; fill up w. milk.

Breast milk by 3rd to 4th day in response to:  falling levels of estrogen & progesterone > delivery of placenta.  ^ production of prolactin by anterior pituitary  Milk ducts become distended & fluid turns bluish-white bluish-

Physiology cont.


Infant suckling on breast produces more prolactin, which in turn stimulates more milk production. Finally, oxytocin released > delivery of placenta causing mammary glands to send milk to nipples [let down reflex]. Progesterone levels drop after delivery which leads to milk production.

Anatomy of Lactation
Colostrum: protein, sugar, fat, water, minerals, vitamins, maternal antibodies.  Provides total nutrition for infant  Transitional breast milk by 3 4th day.  Mature breast milk by 10th day.  Each breast - 15-20 lobes of glandular tissue -alveoli. 15 Acinar or alveolar cells of glands form milk.  Each alveolus ends in a ductule.  Each alveoli produces milk, ejects it into ductules aka let down reflex; milk transported to lactiferous sinus and ejected into infant s mouth.

Pathway of Droplet of Milk:



Milk mammary ducts reservoirs behind nipples [lactiferous sinuses] infant s mouth

Foremilk: constantly accumulating. LetLet-down reflex lets foremilk be available right away.  Triggered by sound of baby crying Hind milk: forms after let-down reflex. Has most calories; letFeed until breast empty. Breast Milk: Provides complete nutrition for 1st 6 mos of life.  > 6 months, iron-fortified cereal. iron Breast milk easier to digest than formula.  Iron in breast milk absorbed better than iron in formula.

Supply & Demand Response - Every time woman breast feeds, more prolactin produced which then produces ^milk.  Time Interval to milk volume. It takes approx. 30-60 volume. 30min. to fill up breast after nursing. Assessment: Antepartum Changes  Breasts enlarge [each breast gains ~ 0.5 - 0.9 lb. or more]  Glands enlarge  Increased blood flow to breasts, causing blood vessels to enlarge & become more visible.  Areola [dark circle around nipple] enlarges and darkens  Small bumps on areola [Montgomery s tubercles] enlarge and produce oils to soften nipples and keep them clean.  Teach moms no soap on nipples;may ^ irritation.  Lanolin; tea bags [wet] [tanic acid] on sore nipples.

Common Problems: Problems: Engorgement : milk enters on 3rd - 4th day; C/S - prior to D/C
     

breasts hard, painful to touch. Warm soaks, hot showers, express milk manually, breast feed q 2-3 2Pumping produces more milk. Cabbage leaves; diuretic property. nursing bra. tight bra and ice packs x 24-36 hrs why? 24Analgesics [Tylenol 650 mg. q 4 - 6 hrs.prn]

Sore/Cracked/Bleeding Nipples


 

Common - from improper positioning or not enough areola in infant s mouth; may continue to feed; up to mom. Reposition infant. Reattempt nursing. Rest the nipple; apply lanolin ointment prn. Apply tea bag [tanic acid] natural healing property.

Plugged Duct


firm nodule under arm; temporarily blocked duct; relieved by infant sucking. Evaluate carefully since may be malignant growth. Warm growth. compresses prn. inflammation; milk duct/gland becomes infected. Poss. antibiotic therapy. Manual expression, continue to breast feed, frequent warm compresses.

Mastitis


Nursing Care : Promote successful breast feeding: Encourage first feeding [L&D, PP; establish pt s. desire to breast feed] Emptying of breasts ~ 20 minutes Teach: start on breast where she left off - maintains good supply. Rest, relaxation, fluids by four 8 oz glasses/day. Not enough fluids, ^ anxiety may lower milk production. Nutritional Counseling: ^ 500 calories/day.

Health Teaching
  

   

Rooting sign of hunger Breast feed q 2-3 hrs. for 20-30 minutes 220Teach latching : nipple and part of areola to prevent nipple irritation. Listen for swallowing. Nursing Bra Feeding & Burping [bottle fed infants] upright position Nipple care: no soap; nipple creams -Lansinoh Avoid drugs, alcohol, smoking

FORMULA FEEDING Feeding Skills  Position upright position- support head and shoulders] position Formula [Similac, Enfamil, Isomil; all have iron]  milk or soy based  Burp Safety Tips  never prop bottle; choking or ear infection.  ^ amt. -3/4 oz./day; feed q 3 4 hrs. x 24 hrs. Discharge Follow up:  Telephone calls & home visits [if needed]  Help line; Support groups [La Leche]

NURSING MANAGEMENT OF POST PARTUM CLIENT Assessment minimum of twice daily  Vital signs  Emotional Status  Breasts  Fundus, lochia, & perineum  Voiding & bowel function - flatus, BM  Legs [+ Homan s sign, ankle edema ]  S/S complications [PP hemorrhage, infection,

BP ]

Nursing Care Safety  Prevent hemorrhage- massage uterus on admission and q 4 for first hemorrhage8 hrs.  Prevent falls assess when getting out of bed for 1st 8 hrs. Assist when necessary. Check labs for low H&H.

Bowel function (1-3 days to resume). (1 Stool softeners, as ordered [Colace]  Encourage ambulation  Increase dietary fiber  Provide adequate fluid intake Health teaching & discharge planning  Reinforce self care -hand washing, peri care, SelfSelf-breast exam q month; S/S PPD Comfort Measures Ice , Sitz Baths, Topical Anesthetics Analgesia, Kegels for NSVD; modified sit-ups for sitNSVD & C/S, Breast Care

Birth Control Plans Family Planning options [condoms, depo, OC s, IUD] Exercises Keep 6 week PP appt. Maternal Warning Signs to Report  a) Heavy Vaginal Discharge [poss. hemorrhage]  b) Pelvic or perineal pain [traveling clot]  c) Fever [temp 100.4 or greater = infection]  d) Burning sensation during urination [UTI]  e) Swollen area on leg ; painful, red, or hot  f) Breast: painful, red, hot area [mastitis]

Infant care a] b] c] d] e] Bathing, cord care, circumcision care, diapering Feeding, burping, scheduling feedings [mom can keep chart] Temperature, skin color [dusky], newborn rash, jaundice Stool & voiding [BM s ; 6 or more voids/day] Back to Sleep [SIDS]

Newborn warning signs: 1. Diarrhea, constipation 2. Colic, repeated vomiting esp. projectile vomiting 3. Fever [temp. 100.0 Rectal or greater] 4. S/S inflammation/ infection @ cord stump [yellow drng.] 5. Bleeding @ circumcision site 6. Rash, jaundice 7. Deviation from normal patterns [long period of sleep >5 hrs.; projectile vomiting, etc. R/O sepsis; intestinal obstruction]