Chapter 15: Caring for the Postpartal Woman and Her Family Flashcards
Postpartum care
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)
Puerperium
postpartum
the 6 week period
-nursing assessments for the mother, the newborn, and the family
Nursing Actions to help Achieve the Healthy People 2020 national initiative
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
Drawbacks to a shortened hospital stay approach
-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
Advantages for early hospital discharge
- decreased risk of nosocomial infections for the mother and infant
- reduced medical expenses
- opportunity for enhanced infant-family bodning
Ensuring Safety for Mother and Infant
- check identification bracelets
- protect the infant from abduction
Ensuring Safety: Check Identification Bracelets
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
Ensuring Safety: Protect the infant from abduction
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
Early Maternal Assessment
- Vital Signs
- Fundus, Lochia, Perineum, Hemorrhoids
Early Maternal Assessment: Vital Signs
> 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
Vital Signs: Temperatre
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
Vital Signs: Pulse
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
Vital Signs: Respirations
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
Vital Signs: Blood Pressure
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
Vital Signs: Pain
“fifth vital sign”
-recognized and treated in a timely manner
Assessment: Fundus
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)
Why is Uterine assessment crucial during the first hour postpartum
- 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
Assessment: Lochia
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)
Assessment: Episiotomy or Incision
> Normal: no redness, edema, ecchymosis (bruising), or discharge; edges well approximated
Abnormal: redness, edema, ecchymosis, discharge, non-approximated edges (infection)
Assessment: Hemorrhoids
- Normal: none, or if present, small
- Abnormal: tender, enlarged and tense (inflammed)
Assessment: Bladder
- 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)
What if there is Lower extremity Homan’s signs
pain with palpation, warmth, tenderness (thrombophlebitits)
What if there is Costovertebral angle tenderness (CVAT)
kidney infection
The perineal Assessment
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
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
BUBBLE -HE Mneumonic
Breasts Uterus Bladder Bowel Lochia Episiotomy Homans sign Emotion
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
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
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
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
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
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
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
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
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
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
The fundus is assessed for what?
- consistency (firm, soft, or boggy)
- location (should be midline)
- height (1 fingerbreadths)
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
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
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
What medications can be give for afterbirth pains?
-ibuprofen (Advil or Motrin)
-naproxen (Aleve and Anaprox)
>breastfeeding women take 30 minutes prior to feedings
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
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
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
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
What can cause uterine atony and lead to hemorrhage?
an overdistended bladder, which displaces the uterus above and to the right of the umbilicus
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
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
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
