Postpartum Care Flashcards
Stages of labour
- 1st stage – time from the **onset **of labor →full cervical dilation (10cm)
- 2nd stage – time from 10cm → **delivery **of the baby
- 3rd stage – time from** delivery** of the baby →the expulsion of the placenta
- 4th stage – immediately after baby’s birth (Postpartum & Newborn Care)
Mnemonics for stages of Labour
S1 - Crowning till 10cm
S2 - 10cm to delivery
S3 - Delivery to expulsion of placenta
S4 - PPC & NBC
What is puerperium?
- Also known as the postnatal/ postpartum period
- Begins immediately from the end of third stage of labour and continues for about 6 weeks or until the body has returned to a near pre-pregnant state.
- The woman experiences numerous physiological & psychological changes.
Initial
Post-partum Assessment includes?
1. Gravida & parity
**2. Delivery details: **
* type & time, length of delivery
* placenta & membranes
* blood loss
* perineal tear/ episiotomy
* Swab count
**3. Duration of labour **
4. Pain relief used
**5. Significant med & surg history: **
any diabetes or hypertension
6. Lab data – Haemoglobin (Hb) level, Hepatitis B status
Post-Partum Physical Assessment
BUBBLE - HE
Breast
Uterus
Bladder
Bowel
Lochia
Episiotomy
Homan sign (lower limbs)
Emotional status
Focused Examination
Post-Partum, apart from BUBBLE-HE
Subsequent Assessment
1. General appearance: Exhausted/ pale/ Listless/ Presence of pain/ discomfort
2. VS (Pain, RR, BP, PR, temp, Spo2)
a. Temp, Respi
* Temp. taken by orally or tympanically (never rectally) (risk of infection & discomfort)
-
Fever during the first 24 hrs after birth because of dehydration that occurred during labor.
Self-limiting if there’s adequate fluid consumption.
Thirst is normal, consuming large qty of fluids is contraindicated for women nauseated from birth analgesic. - Febrile after 24hrs may indicate that a postpartal infection is present
- Engorgement (due to lactogenesis) can cause a rise in temp during 3rd-4th day PP.
(If elevation of temp persist for several hrs, infection might be present = Mastitis) - An infection of the breast during lactation is termed mastitis. Mothers may or may not feel breast pain or experience redness of the breast, but they will often have a high temperature and feel flu-like symptoms such as malaise and fatigue.
Mastitis can interfere with lactation, and sometimes, an infant will refuse to nurse on the affected side. The women’s medical provider must be notified to initiate antibiotic treatment (congruent with breastfeeding). Mothers should be instructed to continue breastfeeding if the infant will breastfeed from the affected side. If the infant refuses, instruct the mother to pump her breasts to maintain flow (and to avoid clogged ducts) and then offer the affected breast after 12 to 24 hours. Once the mastitis is treated, infants often will resume breastfeeding after 12 to 24 hours. Unless specifically directed otherwise, infants are safe to continue to breastfeed while a mother is being treated for mastitis.
* Within normal range
* Temperature labile in first few days:
o -> increase in 1st 24 hrs,
o -> increase in 3rd & 4th day (physiologic milk fever)
* inform doctor if pyrexia > 37.5°C persists (concerns with postpartum infection)
b. Pulse
* A woman’s pulse rate during the PP period is usually slightly slower than usual. During pregnancy, the distended uterus obstructed the amount of venous blood returning to the heart; after birth, to accommodate the increased blood volume returning to the heart, stroke volume increases. This increased stroke volume reduces the pulse rate to between 60 and 70 beats/min. As diuresis diminishes the blood volume and causes blood pressure to fall, the pulse rate increases accordingly.** By the end of the first week, the pulse rate will have returned to normal.**
- Evaluate pulse rate conscientiously in the postpartal period because a rapid and thready pulse during this time could be a sign of hemorrhage.
c. BP
* BP should also be monitored carefully during the postpartal period because a decrease in this can also indicate bleeding. In contrast, an elevation above 140 mmHg systolic or 90 mmHg diastolic may indicate the development of postpartal hypertension of pregnancy, an unusual but serious complication of the puerperium.
* Oxytocics, drugs frequently administered during the postpartal period to achieve uterine contraction, cause contraction of all smooth muscle, including blood vessels. Consequently, these drugs can increase BP. Always measure BP before administering one of these agents; if BP is greater than 140/90 mmHg, withhold the agent and notify the woman’s primary care provider to prevent hypertension and, possibly, a cerebrovascular accident.
- A major complication in women who have lost an appreciable amount of blood with birth is orthostatic hypotension, or dizziness that occurs on standing because of the lack of adequate blood volume to maintain nourishment of brain cells. To test whether a woman will be susceptible to this, assess her blood pressure and pulse while she is lying supine. Next, raise the head of the bed fully upright, wait 2 or 3 minutes, and reassess these values.** If the pulse rate is increased by more than 20 beats/min and blood pressure is 15 to 20 mmHg lower than formerly, the woman might be susceptible to dizziness and fainting when she ambulates. **Inform the woman’s primary care provider of these findings. Advise her to always sit up slowly and “dangle” on the side of her bed before attempting to walk. If she notices obvious dizziness on sitting upright, support her during ambulation to avoid the possibility of a fall.
Caution her not to attempt to walk carrying her newborn until her cardiovascular status adjusts to her blood loss.
- Near pre-pregnant level
- Blood volume returns to pre-pregnant state by 3rd week postnatally
- Marked diuresis in 1st few days postnatally
- Haemoglobin & Haemotocrit (normal limits within 3 – 7 days)
d. Comfort
* Presence of discomfort e.g. pain over perineum/ episiotomy, backache or headache
* Pain Score: administer analgesia as ordered unless contraindicated
e. Resumption of ovulation & menstruation
Mastitis
Infection of the breast due to lactation
Is breastfeeding permitted during the treatment for mastitis?
Yes, unless specifically told otherwise.
Mastitis can interfere with lactation, and sometimes, an infant will refuse to nurse on the affected side. The women’s medical provider must be notified to initiate antibiotic treatment (congruent with breastfeeding). Mothers should be instructed to continue breastfeeding if the infant will breastfeed from the affected side. If the infant refuses, instruct the mother to pump her breasts to maintain flow (and to avoid clogged ducts) and then offer the affected breast after 12 to 24 hours. Once the mastitis is treated, infants often will resume breastfeeding after 12 to 24 hours. Unless specifically directed otherwise, infants are safe to continue to breastfeed while a mother is being treated for mastitis.
Assessment of PP Women
- Temperature.
a. Temp, Respi
* Temp. taken by orally or tympanically (never rectally) (risk of infection & discomfort)
-
Fever during the first 24 hrs after birth because of dehydration that occurred during labor.
Self-limiting if there’s adequate fluid consumption.
Thirst is normal, consuming large qty of fluids is contraindicated for women nauseated from birth analgesic. - Febrile after 24hrs may indicate that a postpartal infection is present
- Engorgement (due to lactogenesis) can cause a rise in temp during 3rd-4th day PP.
(If elevation of temp persist for several hrs, infection might be present = Mastitis) - An infection of the breast during lactation is termed mastitis. Mothers may or may not feel breast pain or experience redness of the breast, but they will often have a high temperature and feel flu-like symptoms such as malaise and fatigue.
Mastitis can interfere with lactation, and sometimes, an infant will refuse to nurse on the affected side. The women’s medical provider must be notified to initiate antibiotic treatment (congruent with breastfeeding). Mothers should be instructed to continue breastfeeding if the infant will breastfeed from the affected side. If the infant refuses, instruct the mother to pump her breasts to maintain flow (and to avoid clogged ducts) and then offer the affected breast after 12 to 24 hours. Once the mastitis is treated, infants often will resume breastfeeding after 12 to 24 hours. Unless specifically directed otherwise, infants are safe to continue to breastfeed while a mother is being treated for mastitis.
* Within normal range
* Temperature labile in first few days:
o -> increase in 1st 24 hrs,
o -> increase in 3rd & 4th day (physiologic milk fever)
* inform doctor if pyrexia > 37.5°C persists (concerns with postpartum infection)
Assessment of PP Women
- Pulse
b. Pulse
* A woman’s pulse rate during the PP period is usually slightly slower than usual. During pregnancy, the distended uterus obstructed the amount of venous blood returning to the heart; after birth, to accommodate the increased blood volume returning to the heart, stroke volume increases. This increased stroke volume reduces the pulse rate to between 60 and 70 beats/min. As diuresis diminishes the blood volume and causes blood pressure to fall, the pulse rate increases accordingly.** By the end of the first week, the pulse rate will have returned to normal.**
- Evaluate pulse rate conscientiously in the postpartal period because a rapid and thready pulse during this time could be a sign of hemorrhage.
Assessment of PP Women
- BP
c. Blood Pressure*
BP should also be monitored carefully during the postpartal period because a decrease in this can also indicate bleeding. In contrast, an elevation above 140 mmHg systolic or 90 mmHg diastolic may indicate the development of postpartal hypertension of pregnancy, an unusual but serious complication of the puerperium.
- Oxytocics, drugs frequently administered during the postpartal period to achieve uterine contraction, cause contraction of all smooth muscle, including blood vessels. Consequently, these drugs can increase blood pressure. Always measure blood pressure before administering one of these agents; if blood pressure is greater than 140/90 mmHg, withhold the agent and notify the woman’s primary care provider to prevent hypertension and, possibly, a cerebrovascular accident.
- A major complication in women who have lost an appreciable amount of blood with birth is orthostatic hypotension, or dizziness that occurs on standing because of the lack of adequate blood volume to maintain nourishment of brain cells. To test whether a woman will be susceptible to this, assess her blood pressure and pulse while she is lying supine. Next, raise the head of the bed fully upright, wait 2 or 3 minutes, and reassess these values.** If the pulse rate is increased by more than 20 beats/min and blood pressure is 15 to 20 mmHg lower than formerly**, the woman might be susceptible to dizziness and fainting when she ambulates. Inform the woman’s primary care provider of these findings. Advise her to always sit up slowly and “dangle” on the side of her bed before attempting to walk. If she notices obvious dizziness on sitting upright, support her during ambulation to avoid the possibility of a fall. Caution her not to attempt to walk carrying her newborn until her cardiovascular status adjusts to her blood loss.
- Near pre-pregnant level
- Blood volume returns to pre-pregnant state by** 3rd week postnatally**
- Marked diuresis in 1st few days postnatally
- Haemoglobin & Haemotocrit (normal limits within 3 – 7 days)
Assessment of PP Women
- Comfort (Pain)
d. Comfort
* Presence of discomfort e.g. pain over perineum/ episiotomy, backache or headache
- Pain Score: administer analgesia as ordered unless contraindicated
Assessment of PP Women
- Resumption of ovulation & menstruation
Non- Breastfeeding Women
- on average, ovulate 40 to 50 days postpartum (6 - 7 wks)
- menstruate within 6 to 9 weeks after birth
Breastfeeding Women
Lactational amenorrhoea
- Ovulation suppressed due to Prolactin
- Depends on frequency of breastfeeding in a day
- Likely to ovulate after 6 months postnatally
Post partum Breast Assessment
a. Assessment
* Breast tissue should feel soft on palpation on the first and second postpartal day. On the third day, it should begin to feel firm and warm (described as filling). On the third or fourth day, breasts appear large and reddened, with taut, shiny skin (engorgement) and, on palpation, feel hard and tense and painful. Because, normally, engorgement causes the entire breast to feel warm or appear reddened, if only one portion of a breast appears this way, inflammation or, possibly, infection of glands or milk ducts (mastitis) is suggested.
It is also normal for the breast to swell into the axillary area due to lymph node swelling and/or breast tissue engorgement. This is called the** tail of Spence area;** reassure the mother that this finding is normal.
- Occasionally, a **firm nodule **is detected on palpation. Usually, this is only a temporarily blocked milk duct preventing milk from flowing forward to the nipple. Often, hand massages and warm compresses will help to soften the nodule area. One of the best interventions for engorgement is an effective latch and to have the newborn breastfeed often from both sides initially while the milk is coming in.
- Note also whether the breast nipples are normally erect and not inverted. Assess for any cracks, fissures, or the presence of caked milk. Avoid squeezing the nipples because this can be painful. Unnecessary nipple manipulation also may increase the risk of mastitis by providing a portal for infection. If the mother is experiencing a painful latch or the newborn is having difficulty latching and transferring milk, a call to the hospital lactation consultant is warranted immediately.
b. Nursing Care for Breasts (PP)
- If breastfeeding: - Feed on demand - Well supported bra - Pump to relieve engorgement - Hot or cold compress to reduce engorgement - NSAIDS
- If bottle-feeding: - Wear well-supported bra - Pain relief - No breast massage
- Prevent/Alleviate Breast Engorgement. If a woman is breastfeeding, encouraging her newborn to attempt to latch at the breast is the main treatment for relief of the tenderness and soreness of primary breast engorgement . Many women find the application of warm compresses or standing under a warm shower beneficial to relieve the discomfort of engorgement. Instructing a mother how to perform manual expression helps to relieve milk engorgement as well. Good support from a bra also offers relief because it prevents unnecessary strain on the supporting muscles of the breasts and positions the breasts in good alignment. Assess the woman for any intense nipple discomfort or pain. If nipple pain is occurring within the first few days postpartum it is often due to an infant’s ineffective latch.
Nipple damage from a mislatch can result in a bacterial or yeast infection of the nipple. Nipple pain must be assessed by a lactation consultant and the women’s provider prior to discharge and preferably as soon as possible. A woman who is not breastfeeding may experience strong discomfort for the first few days. When little or no milk is removed from the breasts, however, the accumulation of milk inhibits further milk formation, and engorgement subsides by the third day. An oral analgesic, wearing a snug-fitting bra, avoiding nipple stimulation, or applying cold compresses three or four times a day can all provide relief. Restricting fluid and pumping milk from the breasts are not effective. - Promote Breast Hygiene. Breast care during the postpartal period includes cleanliness and support and is the same whether or not a woman is breastfeeding. Teach a woman to wash her breasts daily with clear water and gentle soap at the time of her bath or shower and then dry them with a soft towel. It is not necessary for women to wash their breasts more often than daily or use a vast amount of soap because excessive washing means unnecessary skin manipulation. A woman who has a considerable discharge of colostrum or milk from her breasts (whether breastfeeding or not) should insert clean gauze squares or commercial nursing pads into her bra to absorb the moisture, changing them as often as necessary to keep the nipples dry because if the nipples remain wet for any length of time, fissures may form and lead to infection.
