Chapter 15: Caring for the Postpartal Woman and Her Family Flashcards
(123 cards)
1
Q
Postpartum care
A
begins immediately after childbirth
- the nurse assists the new mother in learning how to care for herself and her baby
- fourth stage of labor
- 6-week period (puerperium)
2
Q
Puerperium
A
postpartum
the 6 week period
-nursing assessments for the mother, the newborn, and the family
3
Q
Nursing Actions to help Achieve the Healthy People 2020 national initiative
A
center on close observation to identify hemorrhage and related complications during the critical first hour after childbirth
- ongoing education and support for women and families
- teaching about normal physiological changes during the puerperium, signs of danger, contraceptive methods, and benefits of breastfeeding empowers them to make informed decisions and choices
4
Q
Drawbacks to a shortened hospital stay approach
A
-a longer (greater than 24 hour) hospital stay provides more rest and recuperation time for the mother; a greater opportunity for postpartal education about self and infant care, and time for infant observation and assessment for anomalies, defects, or other problems and improved maternal outcomes
5
Q
Advantages for early hospital discharge
A
- decreased risk of nosocomial infections for the mother and infant
- reduced medical expenses
- opportunity for enhanced infant-family bodning
6
Q
Ensuring Safety for Mother and Infant
A
- check identification bracelets
- protect the infant from abduction
7
Q
Ensuring Safety: Check Identification Bracelets
A
safety and security must be maintained at all times during hospitalization
- placement of identification bands on both the mother and infant shortly after birth
- on bringing the infant to the mother, verify that the bracelets match
- at discharge, nurse retain both the infants parents identification bracelets as part of the permanent record
8
Q
Ensuring Safety: Protect the infant from abduction
A
must educate on various measures implemented to protect the safety of the infant
- in most facilities, infants may be transported only in a bassinet and parents are prohibited from carrying the infant in the halls
- when identification bracelets are used, they are matched before giving the infant to the mother
- instructed to give the infant only to properly identified hospital personnel
- after birth, admission photographs and footprints are taken and affixed to the permanent record
- some facilities use an umbilical cord clamp equipped with an embedded infant security alarm; the clamp, which remains in place until discharge, activates an alarm if the infant is removed from the hospital unit or if the clamp is cut or disengaged
- use of an infant electronic radio transmitter tag; a matching maternal tag is also available to ensure that the mother is correctly matched with her infant
- when two or more infants have a similar or same last name, the infants crib and charts indicate the mothers first name and a label that designates “Name alert”
- when there are multiple births, the infants cribs may be labeled with the infants name followed by a letter of the alphabet (e.g. A, B, C)
- some facilities use color-coding systems
9
Q
Early Maternal Assessment
A
- Vital Signs
- Fundus, Lochia, Perineum, Hemorrhoids
10
Q
Early Maternal Assessment: Vital Signs
A
> After Vaginal Birth:
- monitored q 15 minutes during the first hour
- q 30 minutes for second hour
- once during the third hour
- then q 8 hours until discharge or until stable
> Cesarean birth:
- every 30 minutes x 4 hours
- then every hour x 3
- then every 4 to 8 hours
11
Q
Vital Signs: Temperatre
A
98.6-100.4 degrees F
-during the first 24 hours, some may experience increased temp up to 100.4; r/t exertion and dehydration that accompany labor
>increase fluids
-greater than 101.0 degrees F = infection
12
Q
Vital Signs: Pulse
A
50-90 bpm
-heart rates of 50-70 bpm (bradycardia) commonly occur during the first 6 to 10 days postpartum
>if tachycardia occurs, could be a result of prolonged/difficult labor, blood loss, temperature elevation, or infection
13
Q
Vital Signs: Respirations
A
12-20 respirations/min
- slightly elevated can occur because of pain, fear, excitement, exertion, or excessive blood loss
- abnormal: tachypnea, abnormal lung sounds, SOB, chest pain, anxiety, or restlessness; may be indicative of pulmonary edema or emboli
- decreased respiratory rate may occur after an extremely high spinal block or epidural narcotic after a cesarean birth
14
Q
Vital Signs: Blood Pressure
A
Consistent with baseline BP during the first trimester
- elevated (anxiety, preeclampsia, essential hypertension, renal disease
- decreased (hemorrhage)
- an increase in systolic BP of 30 mm Hg or an increase in diastolic of 15 mm Hg, when associated with headaches and visual changes, may be a sign of gestational hypertension
- orthostatic hypotension can occur when person moves from a supine to sitting position
15
Q
Vital Signs: Pain
A
“fifth vital sign”
-recognized and treated in a timely manner
16
Q
Assessment: Fundus
A
within a few minutes after the birth, the firmly contracted uterine fundus should be palpable through the abdominal wall halfway between the umbilicus and the symphysis pubis
-1 hour later, the fundus should have risen to the level of the umbilicus where it remains for the following 24 hours
-fundus decreases 1 fingerbreadth (1 cm) per day in size
>immediately after birth; midline, firmly contracted and palpable through the abdominal wall midway between the umbilicus and symphysis pubis
>Abnormal: Boggy (full bladder, uterine bleeding)
17
Q
Why is Uterine assessment crucial during the first hour postpartum
A
- first hour represents the most dangerous time for the patient
- nurse conducts frequent uterine assessments
- relaxation of the uterus (atony) results in rapid, life-threatening blood loss because no permanent thrombi have yet formed at the placental site
18
Q
Assessment: Lochia
A
puerperal discharge of blood, mucus, and tissue
- Normal progression: lochia rubra (1-2 inch stain on pad, may contain small clots), consistent with a heavy menstrual period for the first 2 hours, then should usually steadily decrease, fleshy odor
- Abnormal: large amounts, clots (hemorrhage), foul-smelling (infection)
19
Q
Assessment: Episiotomy or Incision
A
> Normal: no redness, edema, ecchymosis (bruising), or discharge; edges well approximated
Abnormal: redness, edema, ecchymosis, discharge, non-approximated edges (infection)
20
Q
Assessment: Hemorrhoids
A
- Normal: none, or if present, small
- Abnormal: tender, enlarged and tense (inflammed)
21
Q
Assessment: Bladder
A
- Normal: able to spontaneously empty bladder within 6 to 8 hours, urine output at least 150 mL/hour; bladder not palpable after voiding
- Abnormal: unable to empty bladder (urinary retention), presence of urgency, frequency, dysuria (UTI)
22
Q
What if there is Lower extremity Homan’s signs
A
pain with palpation, warmth, tenderness (thrombophlebitits)
23
Q
What if there is Costovertebral angle tenderness (CVAT)
A
kidney infection
24
Q
The perineal Assessment
A
the fundus, lochia, and perineum need to be assessed every 15 minutes during the immediate postpartum period
- assist the patient to a Sims’ (side-lying) position with back facing the nurse
- provide privacy and adequate lighting
- gently lifts the buttock cheeks to visualize the perineum (REEDA; Redness, Edema, Ecchymosis, Drainage/Discharge, and Approximation)
- some edema of the vulva and perineum is common during the first few postpartum days but, excessive swelling, discoloration, incisional separation, or discharge other than lochia and complaints of pain or discomfort should be reported
- note and document number, appearance, and size (cm) of hemorrhoids
25
Hemorrhoids
may be present before pregnancy or develop during pregnancy; can become enlarged because of pressure on the lower bowel during the second stage of labor (delivery)
- application of ice packs and/or pharmaceutical preparations (topical anesthetic ointments, witch hazel pads) help to relieve discomfort
- frozen tea peripads for hemorrhoids and labia swelling; the tannic acid decreases edema and is soothing
- assist the patient to a side-lying position in bed, teach her to sit on flat, hard surfaces and to tighten her buttocks before sitting; soft surfaces and pillows such as donut rings should be avoided because they separate the buttocks and decrease venous flow, intensifying the pain
- if develop during pregnancy, usually disappear within a few weeks after childbirth
26
BUBBLE -HE Mneumonic
```
Breasts
Uterus
Bladder
Bowel
Lochia
Episiotomy
Homans sign
Emotion
```
27
Assessment: Breasts
-inspection of nipples: everted, flat, inverted?
-breast tissue: soft, filling, firm?
-temperature and color: warm, pink, cool, red streaked?
>during pregnancy and lactation they change in size and weight
28
How to Assess the breasts
ensure privacy and asks patient to remove bra; chest area is covered with a sheet or towel, and instructed to raise her arms and rest her hands on her head
- nurse inspects and palpates each breast for size, shape, tenderness, and color; during the first 2 postpartal days= breast tissue soft to touch, by 3rd day= begin to feel firm and warm ("filling"), on 4th and 5th day= breastfeeding mothers breast should feel firm before infant feeding then become soft once baby is satiated; noticeable changes in breast firmness are indicative of milk transfer
- occasionally, small, firm nodules can be palpated in the "filling" breasts; result from incomplete feeding during previous feeding; disappear after satisfactory feeding but location should be monitored and noted; persistence of any breast mass can = fibrocystic disease or malignant growths unrelated to pregnancy
- documents appearance of nipples, noticing the presence of fissures, cracks, blood, or dried milk and whether they are erect or inverted
29
Assessment: Uterus
-Location (midline or deviated to right or left side)
-tone (firm, firm with massage, boggy)
>immediately after expulsion of the placenta, the uterus contracts to prevent hemorrhage
30
Involution
term that describes the process whereby the uterus returns to the nonpregnant state
- results from a decrease in the size of the myometrial cells of the myometrium (muscle layer of uterus)
- phagocytosis contributes to this process by removing elastic and fibrous tissue from the uterus
31
What does the Uterus do immediately after the delivery of the placenta?
to prevent hemorrhage, rapid uterine contractions seal off the placental site, effectively pinching off the massive network of maternal blood vessels that were attached to the placenta
32
Subinvolution
failure of the uterus to return to nonpregnant state
- from multiple births, hydramnios, prolonged labor or difficult birth, infection, grand multiparity, or excessive maternal analgesia
- a full bladder or retained placental tissue may prevent the uterus from sustaining the contractions needed to prevent hemorrhage or to facilitate involution
33
Exfoliation
scaling off of dead tissue
- the placental site heals by this process
- new endometrial tissue is generated at the site from the glands and tissue that remain in the lower layer of the decidua after separation of the placenta
- results in a uterine lining that contains no scar tissue , which could impede implantation in future pregnancies
- regeneration is complete by the 16th postpartum day, except at the placental site, where regeneration is usually not complete until 6 weeks after childbirth
34
How to Perform a Uterine Assessment
- supine position so that the height of the uterus is not influenced by an elevated position
- abdomen observed for contour to detect distension and presence of striae or diastasis (separation), which appears as a slightly indented groove in the midline; when present, the width and length of a diastasis are recorded in fingerbreadths
- uterus fundus is palpated by placing one hand immediately above the symphysis pubis to stabilize the uterus and the other hand at the level of the umbilicus ; nurse presses inward and downward with the hand positioned on the umbilicus until the fundus is located; it should feel like a firm, globular mass located at or slightly above the umbilicus during the first hour after birth
35
Proper technique for uterine palpation
uterus should never be palpated without supporting the lower uterine segment (symphysis pubis)
-failure to do so may result in uterine inversion and hemorrhage
36
What doe the uterus do immediately after childbirth
immediately after childbirth, the uterus rapidly contracts to facilitate compression of the intramyometrial blood vessels
>the fundus can be palpated midline, midway between the symphysis pubis and the umbilicus
37
The fundus is assessed for what?
- consistency (firm, soft, or boggy)
- location (should be midline)
- height (1 fingerbreadths)
38
After how many days will the uterus have descended into the pelvis and no longer palpable?
10 days
| -descends at a rate of 1 fingerbreadth (cm) per day
39
After pains
(afterbirth pains)
-intermittent uterine contractions that occur during the process of involution
>discomfort or similar to menstrual cramps
>often severe for 2 to 3 days after childbirth
-when the uterus maintains a constant contraction, the pain cease
-breastfeeding and administration of exogenous oxytocin produce afterpains because both cause powerful uterine contractions
>Interventions: prone position with a small pillow placed under her abdomen, sitz baths (for warmth), ambulation, and mild analgesics
40
Breastfeeding and afterpains
analgesics such as ibuprofen (Advil or Motrin) or naproxen (Aleve and Anaprox) are administered to lessen the discomforts of afterpain
-breastfeeding women should take pain medication 30 minutes before nursing the baby to achieve maximum pain relief and to minimize the amount of medication that is transferred in the breast milk
41
What medications can be give for afterbirth pains?
-ibuprofen (Advil or Motrin)
-naproxen (Aleve and Anaprox)
>breastfeeding women take 30 minutes prior to feedings
42
Bladder after childbirth
- voiding should occur within 6 to 8 hours spontaneously
- output of 150 mL/hr. to avoid urinary retention and stasis
- generalized edema is often present in early puerperium; r/t fluid accumulation that normally occurs during pregnancy combined with IV fluids frequently administered during labor and birth
- maternal diuresis occurs immediately after birth and output reaches up to 3000 mL each day by the 2nd to 5th postpartum days
43
Changes in bladder caused by pregnancy
- decreased bladder tone is normal during pregnancy; results from the effects of progesterone on the smooth muscle
- edema from pressure of the presenting part
- mucosal hyperemia (increased amount of blood in the vessels)
- prolonged labor, use of forceps, analgesia, and anesthesia may intensify the changes in the postpartum period
- pressure caused by the fetal head pressing on the bladder during labor can result in trauma and a transient loss of bladder sensation during the first few postpartum days or weeks; can result in incomplete bladder emptying and overdistention
44
Bladder and urethral trauma
- not uncommon during the intrapartal period and may be associated with a decreased flow of urine immediately after a vaginal birth
- an increase in the voided volume, the total flow time (how long it takes to empty the bladder), and the time to peak urine flow (maximum urinary flow rate) begins to occur during the first postpartum day
- urine volume and flow time should return to prepregnant state by 2 to 3 days after childbirth
45
Risks for postpartum urinary retention
- epidural anesthesia, catheterization before birth, and an instrument-facilitated birth
- can also result from bladder hypotonia after childbirth because the weight of the gravid uterus no longer limits bladder capacity
46
What can cause uterine atony and lead to hemorrhage?
an overdistended bladder, which displaces the uterus above and to the right of the umbilicus
47
How to percuss the bladder
- nurse places one finger flat on the abdomen over the bladder and taps it with the finger of the other hand
- full bladder= resonance sound
- empty bladder= dull, thudding sound
48
Interventions to help postpartum mom void
spontaneous voiding returns within 6 to 8 hours
-until this time: enhance attempts to void
>assisting patient to toilet
>providing privacy in an unhurried environment
>turning on the bathroom faucet
>sitz bath
49
Bowel
- GI system becomes more active after childbirth
- often feels hungry and thirsty after food and fluid restrictions that accompany intrapartal experience
- hormone Relaxin, which reaches high circulating levels during pregnancy, depresses bowel motility
- the relaxed condition of the intestinal and abdominal muscles, combined with the continued effects of progesterone on smooth muscles, diminishes bowel motility: results in constipation during early puerperium
- after childbirth, bowel movements are delayed until the second or third puerperal day
50
What can be associated with painful defecation
- hemorrhoids
- perineal trauma
- presence of episiotomy
51
Strategies to help prevent constipation
- early ambulation
- abundant fluids
- high-fiber diet
52
Nursing Interventions to Facilitate normal bowel function during the Puerperium
- drink 6-8 8oz glasses of water everyday to keep stool soft
- eat high-fiber diet that includes fruit and vegetables, oat and bran cereal, whole-grain bread, and brown rice
- avoid ignoring urge to defecate
- avoid straining to have a bowel movement
- early ambulation
- stool softeners or laxatives as ordered
- after discharge, OTC medications may be helpful for hemorrhoidal symptoms of pain, itching, or swelling but consult with caregiver before using medications
53
Lochia
superficial layer of the endometrium becomes necrotic and sloughs off in the uterine discharge; lochia
- composed of erythrocytes, epithelial cells, blood, fragments of decidua, mucus, and bacteria
- characteristics of lochia is indicative of woman's status in the progress of involution
54
Lochia Rubra
during the first few days postpartum, the lochia consists mostly of blood, which gives it a characteristic red color known as lochia rubra
-also contains elements of amnion, chorion, decidua, vernix, lanugo, and meconium (if fetus has passed any stool in utero)
55
Lochia serosa
- after 3 to 4 days
- pinkish-brownish
- contains blood, wound exudates, erythrocytes, leukocytes, and cervical mucosa
56
Lochia alba
-10 to 14 days, the uterine discharge has a reduced fluid content and composed of leukocytes
-white or yellow-white thick discharge
-also contains decidual cells, mucus, bacteria, and epithelial cells
>present until 3rd week after childbirth but can persist for 6 weeks
57
Normal Pattern of Lochia Flow
from lochia rubra to serosa to alba; should not be reversed
- a return of lochia rubra after it has turned pink or white may indicate retained placental fragments or decreased uterine contractions and new bleeding
- not contain large clots; may indicate presence of retained placental fragments that are preventing closure to maternal uterine blood sinuses
58
Odor of Lochia
similar to that of menstrual blood
| -offensive odor= infection
59
Assessment of Lochia Flow: documentation
- Scant: blood only on tissue when wiped or 1-inch (2-5cm) stain on peripad
- Light: less than 4-inch (10 cm) stain on peripad
- Moderate: less than 6 inch (15 cm) stain
- Heavy: peripad saturated within 1 hour
60
Episiotomy
1-2 inch surgical incision made in the muscular area between the vagina and the anus (the perineum) to enlarge the vaginal opening before birth
-Midline: straight incision extending toward anus
-Mediolateral: extends downward and to the side
>episiotomy edges become fused (edges have been sealed) by the first 24 hours after birth
>asses for redness, edema, ecchymosis, discharge, and approximation (REEDA) and document
61
Hematoma after episiotomy
severe hemorrhage after episiotomy is possible
-complaints of excessive perineal pain should alert the nurse the possibility of a perineal, vulvar, vaginal, or ischiorectal hematoma (blood-filled swelling that occurs from damage to blood vessel)
62
How to assess for perineal hematoma
- look for discoloration of perineum
- listen for complaints or expression of severe perineal pain
- observe for edema of the area
- listen for expression of need to defecate (hematoma may cause rectal pressure)
- gently palpate the area, and observe for the patients degree of sensitivity to the area by touch
- call physician or nurse-midwife to report findings immediately, the bleeding that has produced the hematoma must be promptly identified and halted
63
Early episiotomy care
- apply ice bag or cold pack on the perineum for the first 24 hours (wrapped in a towel or disposable paper cover to prevent a thermal injury); promotes local anesthesia and vasoconstriction while reducing edema and the incidence of peripheral bleeding
- after 24 hours, use of moist heat (sitz bath) between 100 and 105 degrees F for 20 minutes, 3 to 4 times a day; increases circulation to the perineum, enhances blood flow to the tissues, reduces edema, and promotes healing
- dry heat in a pack may also be used; use washcloth or gauze pad between pack and skin to prevent potential burn
64
Pain: Why is heat not applied to the abdomen?
because of the potential for uterine relaxation and bleeding
65
Muscular aches and cramps r/t physical exertions expended during labor and delivery can be relieved with?
- back rubs and massage
| - acetaminophen (Tylenol)
66
Episiotomy pain can be associated with what?
sitting, walking, bending, urinating, and defecating
| >application of cold for the first 24 hours, heat (after 24 hours), topical anesthetics (creams, sprays), and sitz baths
67
Sitz bath
portable unit with a reservoir that fits on the toilet
- when filled with warm water, the swirling action of the fluid soothes the tissue, reduces inflammation by promoting vasodilation to the area, and provides comfort and healing
- used for 20 minutes, 3 to 4 times a day
- can contain medicine
- relieve pain, itching, or muscle spasms
68
How does the nurse assess and document pain behavior?
- location of the pain
- type of pain: stabbing, burning, throbbing, or aching
- duration of pain: intermittent or continuous
69
Nursing Interventions for pain
administration of analgesics and patient education about other measures
-suggest nonpharmacological methods for pain relief such as imagery, therapeutic touch, relaxation, distraction, and interaction with infant
-administer prescribed agents such as ibuprofen, propoxyphene napsylate/acetaminophen (Darvocet-N), or oxycodone/acetaminophen (Percocet)
-OTC medications or alternatives such as tea tree oil for self-care after discharge
>acetaminophen or ibuprofen may be equally as effective as narcotic analgesics
-reassure patient that pain and discomfort should not persist beyond 5 to 7 days and that episiotomy sutures are made of an absorbable material, they do not need to be removed
70
What can has also been believed, when applied to the perineum, to help relieve the pain of an episiotomy?
tea tree oil
>provide cooling to the wound, enhance comfort, and promote healing
>if redness, increased swelling, burning, or other signs of allergic reaction occur, discontinue application immediately
71
Homan's Sign
screening tool for deep venous thrombosis (DVT)
>patients legs should be extended and relaxed with knees flexed, the examiner grasps the foot and sharply dorsiflexes it
>positive= resistance or discomfort in the calf or popliteal region
-other leg is assessed in same manner
-presence of thrombosis
-no longer a component of assessment; can lead to emboli if clot is dislodged during the assessment
>a negative sign does not rule out DVT
72
If suggestive of a DVT, what else must you do besides Homan's Sign?
venography and real-time and color doppler ultrasound
73
DVT clinical signs
- pain in the calf
- erythema (superficial reddening of skin)
- warmth greater in one calf than the other
- unequal calf circumference
74
Emotions
- not unusual to have periods of happiness that are intermingled with sadness, insecurity, and depression
- continued assessment of woman's emotional status
- provide information regarding "baby blues"; these are temporary and common
75
Blood Volume After child birth
-decrease in blood volume correlates with the blood loss experienced during delivery
-during next few days, blood loss increases further as a result of diuresis
-500 mL of blood loss that typically occurs in vaginal delivery (1000 in cesarean), results in a 1 gram (2 gram for cesarean) drop in hemoglobin
>as the bodys excess fluid is excreted, the hematocrit may rise because of hemoconcentration; returned to pre-pregnancy levels by 4 to 6 weeks
76
White blood cell count after childbirth
- increases during labor and the immediate postpartum period
| - returns to normal within 6 days
77
Plasma fibrinogen (clotting factor) after childbirth
remain elevated for first few postpartal weeks
| -hematological system returns to normal by 3rd to 4th postpartal week
78
Circulating levels of estrogen and progesterone after childbirth
decrease after delivery of placenta
- the decrease signals the anterior pituitary gland to produce prolactin in readiness for lactation
- in formula feeding women, prolactin levels return to normal by the third to fourth postpartal week
79
After childbirth and the delivery of the placenta what happens to certain hormones?
hormones like human placental lactogen, cortisol, growth hormone, and insulinase fall
- during early postpartum, the decline in these levels reduces the anti-insulin effects that occur during pregnancy; insulin requirements are reduced for insulin dependent women "honeymoon phase"
- for many diabetics, glucose levels remain in normal range (without intervention) for the first few days after childbirth
80
Neurological System after childbirth
-fatigue and discomfort common
-anesthesia and analgesia may cause transient maternal neurological changes such as numbness in the legs or dizziness; safe guard patient as priority
-headaches require further assessment; after spinal or epidural anesthesia, headaches may result from the leakage of cerebrospinal fluid into the extradural space
-labor induced stress or gestational hypertension cause headaches
-sitting upright may cause a headache
-headaches accompanied by double or blurred vision, photophobia, epigastric or abdominal pain, and proteinuria may be signs of developing or worsening preeclampsia
>implement environmental interventions: reducing room lighting and noise and limiting visitors
81
What are signs that indicate developing or worsening preeclampsia?
headaches accompanied by double or blurred vision, photophobia, epigastric or abdominal pain, and proteinuria
82
Renal System, Fluid, and Electrolytes
- renal plasma flow, glomerular filtration rate, plasma creatinine, and blood urea nitrogen return to normal by the second to third month after childbirth
- glucose excretion increases in pregnancy by 100-fold ;return to normal after first postpartal week
- pregnancy associated proteinuria (up to 1- on a urine dipstick or less than 300 mg in 24 hours) is common during pregnancy and returns to normal by 6 weeks
83
Sodium levels after childbirth
there is a rapid, sustained natriuresis (large amount of sodium in the urine) and diuresis as the sodium and water retention of pregnancy is reversed
- reversal is pronounced during 2nd to 5th puerperal day
- bodys fluid and electrolyte balance restored by third postpartal week
84
Respiratory System after childbirth
- after delivery of the placenta and decline in levels of progesterone, respiratory system return to prepregnant state
- the immediate decrease in intra-abdominal pressure associated with the birth of the baby allows for increased expansion of the diaphragm and relief from the dyspnea associated with pregnancy
- system returns to normal by third postpartal week
85
Cardiovascular system
during pregnancy, the heart is displaced slightly upward and to the left
- as involution occurs, it returns to normal position
- cardiac output is increased for 1 to 2 hours postpartum and remains high for 48 hours; normal within 2 to 4 weeks
- by 2 weeks cardiac output decreases by 30% then reaches prepregnant values 6 to 12 weeks postpartum
86
What happens if physiological diuresis does not occur?
increased risk of pulmonary edema
| >3-kg weight loss occurs during the first week postpartum
87
Rho(D) Immune Globulin
non-sensitized women who are Rh(-) negative and have given birth to a Rh(+) positive infant should receive 300 mcg of Rho(D) immune globulin (RhoGAM) within 72 hours after given birth
>should be given whether or not mother received RhoGAM during antepartum period
88
Rubella Vaccine
- if nonimmune, MMR vaccine should be administered
- avoid pregnancy for 1 month (because of the teratogenic effects associated with congenital rubella syndrome)
- may briefly experience rubella-type symptoms such as lymphadenopathy (enlarged lymph nodes), arthralgia (joint pain), and low-grade fever
- may be given to breastfeeding mothers
- signed consent form before given
89
Diastasis recti abdominis
term used to define the separation between the two rectus abdominis muscle that can occur from pregnancy
-during early postpartal period, abdominal wall may not be protected to withstand additional stress from increased activities; maintain correct posture with activities for at least 12 weeks and perform modified sit ups to strengthen abdominal muscles
90
Activity and Rest
- early postpartum ambulation is key in preventing thromboembolic events
- begin with mild exercises; Kegel exercises to strengthen pelvic floor
- non-ambulating patients should begin with leg exercises
- exercising methods increase gradually
- obtain adequate sleep and frequent rest periods
91
Nourishment
- weight loss of 10 to 12 lb occurs after childbirth due to the collective weight from baby, placenta, and amniotic fluid
- an additional 5lbs is lost in result of puerperal diuresis and uterine involution
- eat a balanced nutritious diet with multivitamin supplements
- iron only recommended if hemoglobin is low
92
Elimination
- occur within 4 hours
- empty bladder every 4 to 6 hours and expect to excrete large volumes
- intake and output recorded during first 24 hours
93
Teaching about Perineal Care ("pericare")
-fill the squeeze/ peri-bottle with tap water. water should feel comfortably warm on wrist
-sit on toilet with the bottle positioned between your legs so that water can be squirted directly on perineum; aim bottle opening at your perineum and spray so that water moves front to back; no not separate the labia and do not spray the water into your vagina; empty entire bottle over perineum
-gently pat the area dry with toilet paper or cotton wipes; move from front to back, use each wipe once, then drop in toilet
-grasping the bottom side or ends of a clean peripad, apply it front to back
-stand before flushing the toilet
>rinse perineum with fresh water after use of toilet and before a new perineal pad is applied
94
Pericare for Cesarean Births
- nurse performs
- place a plastic-covered pad under patients buttocks
- supine position; removes peripad in a front-to-back direction
- bedpan positioned under buttocks; movement associated with lifting the buttocks helps to expel clots and/or pooled blood in vaginal canal; serves as good time to assess fundus for tone; uterine palpation helps patient expel additional blood or clots
- nurse uses peri-bottle filled with warm water (or other solution according to policy) and gently squirts perineum front-to-back while allowing water to collect in bed pan
- labia not separated
- gently dry area and peri-pad is applied from front-to-back
95
Encourage Breastfeeding in women with diabetes mellitus
during the intrapartal and postpartal periods, insulin requirements decrease rapidly
-maternal insulin dose be decreased to avoid hypoglycemia
-encourage breastfeeding and be aware that insulin requirements decrease with lactation
>maternal snack before breastfeeding may prevent it
96
Breastfeeding benefits for mothers
- decreased risk of breast, ovarian, and uterine cancer
- decreased risk of type 2 diabetes mellitus
- lactational amenorrhea (missed period) (LAM) (although breastfeeding is not considered an effective form of contraception)
- enhanced involution (caused by uterine contractions triggered by the release of oxytocin) and decreased risk of postpartum hemorrhage
- enhanced postpartum weight loss
- increased bone density
- enhanced bonding with infant
97
Breastfeeding benefits for Infant
>human breastmilk is infant food choice; bacteriologically safe, fresh, and readily available, and balanced to meet the infants needs
- enhanced immunity through the transfer of maternal antibodies; decreased incidence of infections including otitis media, pneumonia, UTI, bacteremia, and bacterial meningitis
- enhanced maturation of GI tract
- decreased risk of sudden infant death syndrome (SIDs)
- decreased likelihood of developing insulin-dependent (Type 1 ) diabetes
- decreased risk of childhood obesity
- enhanced jaw development
- protective effects against certain childhood cancers
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Breastfeeding is Contraindicated in what situations?
- infants with galactosemia (because of an ability to digest the lactose in the milk)
- mothers with active tuberculosis or HIV infection
- mothers with active herpes lesions on the nipples
- mothers who are receiving medications such as lithium or methotrexate
- mothers who are exposed to radioactive isotopes (e.g. during diagnostic testing)
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Supporting Women in Their feeding choice
- decision to breastfeed is always one that must be made by the women
- choice based on what pleases her and what makes her feel most comfortable
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Board-certified lactation consultant (IBCLC)
health-care professional who specializes in the clinical management of breastfeeding
-nurse should refer women who experience breastfeeding pain or other difficulties to a IBCLC
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Care of the Breasts during lactation
- wash the nipples with warm water
- soap should be avoided; have drying effect and cause cracked nipples
- avoid breast creams; may block the Montgomery tubercles on the areolae; other contain alcohol, a drying agent
- avoid creams and oils that contain vitamin E because the infant may absorb toxic amounts
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Latch-on
proper attachment of the infant to the breast for feeding
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Optimal time to breastfeed
when the baby is in a quiet alert state
>crying is usually a late sign of hunger and achieving satisfactory latch-on is difficult
>most alert during first 1 to 2 hours after a unmedicated birth
>bathing the neonate before the first feeding should be avoided; the smell of amniotic fluid on the infant matches the smell of the mother and serves as a "homing device" for the baby
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Benefits of the breast crawl (TBC)
when placed skin-to-skin on the mother's trunk, the newborn's movement toward the maternal breast is the initiation and establishment of effective breastfeeding
-promotes the physical stabilization (i.e. temperature regulation, heart and respiratory rates, and blood glucose) of a healthy newborn
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Infant Feeding Readiness Cues
- begins to stir
- bobs the head against the mattress or mother's neck/shoulder
- makes hand-to-mouth or hand-to-hand movements
- exhibits sucking or licking
- exhibits rooting
- demonstrates increased activity; arms and legs flexed; hands in a fist
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To assist the mother whose infant will not awaken to breastfeed
the nurse may ask:
- have you tried to unwarp the baby's swaddling? (doing this will increase skin-to-skin contact and help to awaken the infant and promote feeding)
- have you tried to rest with the baby by your breast? (doing this may allow the infant to feel and/or smell the breast, which may promote feeding)
- are you familiar with feeding cues? Watching for feeding cues may help you to recognize when your baby is ready to breastfeed. Examples are vocalizations, movements of the mouth, and moving the hand toward the mouth. Hunger-related crying is a late sign of hunger and should not be used as the cue for feeding
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Optimal Breastfeeding Experience
-hold the baby so that his nose is aligned with the nipple and watch for open mouth gape
-at the height of the gape, when the mouth is open widest, aim the bottom lip as far away as possible from the base of the nipple; the infants chin and the lower jaw meet the breast first and the nipple is pointed to the roof of the mouth
-most of the areola should be visible from the infants top lip but not from the bottom; top and bottom lips should be flanged outward
>no slurping or clicking sounds or dimpling of the cheeks
>report a tugging sensation but no pain or pinching
>feedings that last less than 10 minutes or longer than 40 minutes are not satisfactory
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Assessing milk let-down
- mother presents a tingling sensation in the nipples (not always present)
- the infants quick, shallow sucking pattern transitions to a slower, more drawing pattern
- exhibits audible swallowing
- reports uterine cramping; increased lochia present
- mother feels relaxed during feeding
- opposite breast may leak milk
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Breastfeeding: Properly latched on
the tip of the infants nose, cheeks, and chin should all be touching the breast
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How to know if there was a good feeding?
- infant coming off the breast without assistance
- "drunken stupor" look
- nipple should be everted and round, never flat or pinched on any side
- no pain from mother
- infant should appear satiated
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Nipple Confusion
may result when breastfed infants receive supplemental feedings (bottle-fed)
- require different skills
- avoid bottle feeding until breastfeeding is well established (usually 3 to 4 weeks)
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Evaluation of Nourishment: Infant weight gain
-weight loss greater than 7% should be carefully evaluated to make sure he is being fed frequently enough and the feeding technique is effective
(weight loss of 7% is NOT an "automatic" reason to supplement breastfeeding for formula)
-once the mothers milk production increases and the volume of milk consumed increases; infants gain 15 to 30 g or 1/2 to 1 oz per day
-as long as the baby continues to feed well and is gaining weight, the mother can be reassured
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Loss of excessive weight or failure to begin a steady pattern of weight gain indicates what?
the mother is not producing adequate milk or the infant is not ingesting adequate milk
-can also be from the infant having other organic problems (rarely)
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Common Positions for Breastfeeding
- cradle hold position
- football hold position
- side-lying position
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Cradle hold position
- infant is cradled in the arm, close to the maternal breast
| - infants abdomen is placed against the mothers abdomen with the mothers other hand supporting the breast
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Cross-cradle hold
similar to cradle hold
| -infant laying in opposite direction
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Football hold
infants back and shoulders are held in the palm of the mothers hand
- infant is tucked up under the mothers arm, keeping hip, shoulder, and ear in alignment
- mother supports the breast to touch the infants lips
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Side-lying Hold
facing each other
- can place pillow behind infants back for support
- nipple should be placed in easy reach
- frequent mother-baby checks (because of accidental suffocation)
- ensure that newborns not left with fatigued mother in side-lying position
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Breast shells for flat, inverted, or sore nipples
plastic "nipple cups" or inserts that fit into the bra
- may help nipples become more protuberant
- may be used to prevent sore nipples from making contact with woman's clothing or bra
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Problems that result in Ineffective Breastfeeding
- sore nipples
| - breast engorgement
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Breast Engorgement
excessive swelling and overfilling of the breast and areola and is a response to an increase in blood flow and an increase in milk production
-occur from infrequent feeding or ineffective emptying of collecting ducts
-lasts about 24 hours
-range from minimal (complain of breast fullness to discomfort) to severe (pain, tenderness, hardness, warmth to touch; shiny, taut appearance; areolae become firm, nipples may flatten)
>Treatment: removal of milk (via breastfeeding or pumping) to decrease stasis, which reduces swelling and discomfort (feeding q 2-3 hours)
>a non-prescription anti-inflammatory drug such as ibuprofen (Motrin or Advil) can be taken for the pain and swelling r/t engorgement; take before breastfeeding in anticipation of post-feeding discomfort
>wear a well-fitted supportive bra
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Infant Feedings
- q 2-3 hours to minimize stasis of milk
| - feed at each breast at least 15 to 20 minutes until at least one breast softens after the feeding
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How to reduce swelling and enhance milk flow
-warm compresses and perform hand expression; softens areola, initiates let-down reflex, and allows infant to more easily grab the areola
-massage breast
-taking a warm shower
-lean over a bowl of warm water
-hand-expressing some milk before nursing
>because breast swelling is r/t increased blood flow, cold ice packs may be used after breastfeeding or pumping to constrict blood flow and reduce the edema
