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Post Partum Period Chapters 15

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Title: High Risk Pregnancy Author: Phillip Dunlap Last modified by: Dunlap, Mary Created Date: 9/23/2007 1:25:12 PM Document presentation format: On-screen Show (4:3) – PowerPoint PPT presentation

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Title: Post Partum Period Chapters 15


1
Post Partum PeriodChapters 15 16High Risk
Chapter 22
  • Mary L. Dunlap MSN
  • Fall 2015

2
Post Partum
  • Begins immediately after child birth through the
    6th post partum week
  • Reproductive track returns to nonpregnant state
  • Adaptation to the maternal role and modification
    to the family system

3
Safety for Mother and Infant
  • Prevent infant abductions
  • Check ID bands
  • Educate mother about safety measures

4
Infant ID Bands
5
Security Band
6
Clinical Assessment
  • Receive report
  • Review Antepartum and Intrapartum history
  • Determine educational needs
  • Consider religious and cultural factors
  • Assess for language barriers

7
Post Partum AssessmentBUBBLE-EE
  • Breast
  • Uterus
  • Bladder
  • Bowel
  • Lochia
  • Episiotomy
  • Extremities
  • Emotion

8
Vital signs
  • Temperature
  • Pulse
  • Blood pressure
  • Respirations

9
Pain Assessment
  • Determine source/location and pain level
  • Interventions- based on pain
  • Document location, type, pain level and
    intervention
  • Reassess in 30 min and document pain level

10
Breast
  • Initial assessment
  • Inspect for size, contour, and asymmetry
  • Note if nipples are flat, inverted or erect
  • Ongoing assessments
  • Check for cracks, redness, or fissures
  • Engorgement
  • Mastitis

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13
Breast Care Lactating Mother
  • Supportive bra
  • Clean areola nipples with water
  • Air dry
  • Express colostrum apply to areola nipple
  • Change breast pads frequently

14
Breast CareNon-Lactating Mother
  • Avoid stimulation
  • Wear support bra 24hrs
  • Ice packs or cabbage leaves
  • Mild analgesic for discomfort

15
Assessment of Uterus
  • After birth midline between umbilicus and the
    symphysis pubis
  • Within 1h returns to the umbilicus
  • Descends 1 cm/day
  • Consistency- firm/boggy
  • Height- measured in fingerbreadths
  • Fundal massage procedure 22.1 p 753

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20
Nursing care
  • Boggy fundus- massage until firm
  • Medications- Pitocin, Methergine, Hemabate
  • Teach new mom to massage her fundus

21
Afterpains
  • Intermittent uterine contractions due to
    involution
  • Primiparous-mild
  • Multipara- more pronounced
  • Breastfeeding causes an increase in contractions
    due to release of oxytocin

22
Nursing Interventions
  • Patient in a prone position and place a small
    pillow to support her abdomen
  • Ambulation
  • Medicate with a mild analgesic

23
Bladder
  • Monitor for bladder distention and displacement
    of uterus
  • Assess for voiding difficulty
  • Monitor output
  • Postpartum Diuresis

24
Nursing care
  • Encourage frequent voiding every 4-6 hours
  • Monitor intake and output for 24 hrs
  • Early ambulation
  • Void within 4-6 hrs after birth
  • Catheterize if unable to void

25
Preventing Stress Incontinence
  • Vaginal delivery causes direct pelvic muscle
    trauma and disruption of fascial support
    contributing to the development of urinary stress
    incontinence.
  • Prevention strategies Loss weight, avoid bladder
    irritates, decrease fluid intake
  • Kegal exercises
  • Teaching Guidelines 16.3. 502 pg

26
Bowel
  • Relaxin depresses bowel motility
  • Progesterone ? muscle tone
  • Diminished intra-abdominal pressure
  • Incontinence if sphincter lacerated (4th degree)
  • Spontaneous BM 2nd to 3rd post partum day
  • Normal bowel pattern 8-14 days

27
Nursing Care
  • Increase fiber in diet
  • 6-8 glasses of water or juice
  • Stool softener- especially 4th degree
  • Laxative
  • Sitz bath for discomfort
  • Medications for hemorrhoids

28
Lochia
  • Rubra
  • Serosa
  • Alba
  • Documentation

29
Lochia Assessment
30
Scant
  • 1-2 in
  • About 10 ml

31
Small
  • 2-4 in
  • About 10-25 ml

32
Moderate
  • 4-6in
  • About 25-50 mL

33
Heavy
  • Saturated pad greater than 6 in
  • About 50-80 mL within 1 hr.

34
Nursing Care
  • Educate on the stages of lochia
  • Increase in lochia, foul odor or return to Rubra
    lochia is not normal
  • Change Peri pad frequently
  • Peri care after each voids to decrease risk of
    infections

35
Episiotomy
  • 1-2 inch incision in the muscular area between
    the vagina and the anus
  • Assess REEDA
  • Lacerations
  • Episiotomy care

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38
Nursing Care
  • Peri care
  • Ice packs
  • Dry heat
  • Topical medications
  • Sitz bath
  • Teaching guidelines 16.1 p. 499

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40
Extremities
  • Increases the risk of thromboembolic disorders
  • Risk factors venous stasis, altered coagulation
    and vascular damage due to birth process increase
    risk of clot formation

41
Assess for Thrombosis
  • Homans sign
  • Assess extremities
  • Monitor for signs of PE

42
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43
Post Partum Assessment
  • Post Partum Assessment Video

44
Emotional Status
  • Bonding is a vital component of the attachment
    process. It helps establish parent infant
    attachment and a healthy loving relationship.
  • Bonding takes during the first 30 to 60 min.
    after birth

45
Emotional Status
  • Bonding process helps to lay the foundation for
    nurturing care
  • Touch- skin to skin
  • Eye contact
  • Breastfeeding
  • Engrossment
  • Factors that interrupt bonding

46
Engrossment
  • Seven Behaviors
  • Visual awareness
  • Tactile awareness
  • Perception NB is perfect
  • Focus is on NB
  • Aware of NBs distinct features
  • Extreme Elation
  • Increase sense of self esteem- proud

47
Tactile Awareness
48
Bonding
  • Factors that may interfere with bonding process
  • Stress over finances
  • Lack of support
  • Cultural beliefs
  • Interruption of process-sick child NICU

49
Transitioning to parenthood
  • Difficult and challenging
  • Provide emotional support
  • Accurate information
  • Nursing goal create a supportive teaching
    environment

50
Assuming the mothering role
  • Rubins three phases
  • Taking in
  • Taking hold
  • Letting-go

51
Taking in Phase
52
Fathers Development Process
  • Three stages
  • Expectations
  • Reality
  • Transition to Mastery

53
Maternal Physiological Adaptations
54
Hematological System
  • Decrease in blood volume
  • Elevated WBC
  • Increased Fibrinogen

55
Hormonal Levels
  • Estrogen and Progesterone decrease
  • Anterior pituitary ? prolactin for lactation
  • Expulsion of the placenta- placental lactogen,
    cortisol, growth hormone, and insulinase levels
    decrease
  • Honeymoon phase- insulin needs decrease

56
Neurological System
  • Maternal fatigue
  • Transient neurological changes
  • Headaches
  • Carpel tunnel improvement

57
Integumentary System
  • Darken pigmentation gradually fades
  • Hair regrowth returns to normal in 6-12 months
  • Striae( stretch marks) fade to silvery lines

58
Immune System
  • Rubella
  • Administer to nonimmune mothers
  • Safe for nursing mothers
  • Avoid pregnancy for 1 month
  • Flu-type symptoms may occur

59
Immune System
  • Rho (D) immune globulin
  • Mother Rh negative, infant Rh positive
  • Negative coombs test
  • 300 mcg of RhoGam within 72 hrs after delivery
  • Card issued to mother

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61
Reproductive System
  • Involution of uterus
  • Healing of placental site
  • Vaginal changes

62
Menstruation and Ovulation
  • Nonlactatating mother
  • Menstruation returns in 7-9 wks, can take up to
    3mo.
  • First cycle may be anovulatory
  • Lactating mother
  • Delayed ovulation and menstruation

63
Musculoskeletal System
  • Relaxation of pelvic joints, ligaments, and soft
    tissue
  • Muscle fatigue and general body aches from labor
    and delivery of newborn
  • Rectus abdominis diastasis

64
Postpartal Surgical Patient
  • Tubal ligation
  • Cesarean birth

65
Breast Feeding
  • American Academy of Pediatrics (AAP) recommends
    infants be breastfed exclusively for first 6
    months of life
  • Breastfeeding should continue for at least 12
    months
  • If infants are weaned before 12 months, they
    should receive iron-fortified infant formula

66
Breast Feeding
  • Optimal method of feeding infant
  • Breast milk- Bacteriologically safe, fresh,
    readily available
  • Milk transition Colostrum, Transitional milk
    mature milk
  • Breastfeeding benefits 18.2 p 583
  • Nursing Care Plan 18.1 pg 587

67
Contraindications to Breastfeeding
  • Maternal cancer therapy/ radioactive isotopes
  • Active tuberculosis
  • HIV
  • Maternal herpes simplex lesion
  • Galactosemia in infant
  • Cytomegalovirus (CMV)
  • Maternal substance abuse

68
Breast Feeding
  • Keys to successful breast-feeding
  • Initiate first feeding within first hr.
  • No supplements
  • Feed on demand, unrestricted at least 8-12 feeds
    in 24hrs
  • Avoid artificial nipples
  • Mother and newborn to stay together

69
Breastfeeding
  • Cue signs
  • Latch-on
  • Assess for milk let down
  • Scoring tool table 18.6 p 509

70
Cue Signs
  • Rooting

71
  • Latch on
  • Open mouth gape
  • Infant tip of nose,
  • cheeks and chin
  • touching breast

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THE LATCH SCORING TOOL
Parameters 0 Point 1 Point 2 Point
L LATCH Sleepy infant No latch achieved Hold nipple in infants mouth to latch suck Stimulate to suck Latches on rhythmic sucking
A Audible swallow none Few with stimulation Spontaneous and Intermittent
T Type of nipple Inverted Flat Protruding
C Comfort of nipple Engorged cracked bleeding sever discomfort Filling, reddened, small blisters Mild to mod. discomfort Soft nontender
H Positioning Nurse must hold infant to breast Minimal assistance then mother takes over No help needed
75
Breastfeeding
  • Positions
  • Cradle hold
  • Foot ball
  • Side lying

76
  • Cradle Hold

77
Foot Ball Hold
78
Foot Ball Hold
79
Side Lying
80
Breastfeeding
  • A newborns stomach is the size of a small marble
    and can hold 5-7 ccs. This is matches the amount
    of colostrum produced
  • From 7-10 days it increases to the size of a golf
    ball and can hold 1.5 to 2 oz

81
Breastfeeding
  • Newborns nurse on average 8-12 times/24hrs
  • Feed by cue signs about every 1-3 hours
  • Should have no more than one 4 hr period
  • Teaching Guidelines 18.4 pg.588

82
Milk Expression
  • Manually
  • Manual or handheld breast pump
  • Electric breast pump

83
  • Hand Express

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Manual Pump
86
Electric Hand Held
87
  • Electric Pump

88
Electric Pump
89
Breast Milk Storage
  • Room temperature- 4 hrs
  • Refrigerator- 5-7 days
  • Deep freezer- 6-7 months

90
Ineffective Breastfeeding
  • Incorrect latch-on
  • Inverted nipples
  • Breast engorgement

91
Special Considerations
  • Sleepy baby- use gentle stimulate to
  • bring to alert state
  • Fussy baby- use calming techniques
  • Slow weight gain- evaluate breastfeeding

92
Formula Feeding
  • Formula preparation
  • Periodically check nipple integrity
  • Bottle preparation
  • Teaching Guidelines 18.5 p. 591

93
Discharge Teaching
  • Fundus and Lochia
  • Episiotomy care
  • Incision care
  • Signs of PP infection- table 22.3 p 761
  • Elimination
  • Nutrition Box 16.4 p 504

94
Discharge Teaching
  • Exercise- 16.2 p 501
  • Activity
  • Pain management
  • Sexual activity
  • Contraception
  • Blues
  • Community resources

95
Postpartum Women at RiskChapter 22
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Postpartum Hemorrhage
  • Blood loss gt500 ml of blood after a vaginal birth
  • 1000 ml of blood after cesarean section
  • Major hemorrhage gt2,500 mL
  • Transfusion of gt5 units
  • Any amount of bleeding that places mother in
    hemodynamic jeopardy
  • Table 22.1 pg 748

98
Postpartum Hemorrhage
  • 5 Ts- factors associated with PPH
  • Tone
  • Tissue
  • Trauma
  • Thrombin
  • Traction
  • Table 22.2 pg. 751

99
Tone / Atony
  • Altered muscle tone due to overdistention
  • Prolonged or rapid labor
  • Infection
  • Anesthesia

100
Tissue
  • Retained placental fragments
  • Uterine inversion
  • Clots
  • Subinvolution

101
Trauma
  • Cervical lacerations
  • Vaginal lacerations
  • Hematomas of vulva, vagina or peritoneal areas

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Trauma
  • Hematoma
  • Localized collection of blood in connective or
    soft tissue under the skin( caused by laceration
    to blood vessel)
  • Risk factors
  • Signs and symptoms
  • Management

104
Thrombin
  • Disorders of the clotting mechanism
  • This should be suspected when bleeding persists
    without an identifiable cause

105
Management of PPH
  • Frequent VS q 15 min times 1 hr.
  • Fundal massage
  • Administer medications
  • Monitor blood loss for amount
  • Maintain IV
  • Type cross match
  • Empty bladder

106
Fundal Massaging
  • Procedure 22.1
  • pg. 753

107
Uterotonic Drugs
  • Oxytocin (Pitocin)
  • Misoprostol (Cytotec)
  • Dinoprostone (Prostin E2)
  • Methylergonovine maleate (Methergine)
  • Prostaglandin (Hemabate)
  • Drug Guide 22.1
    pg.754

108
Management of PPH
  • Balloon Tamponade Catheter

109
Post Partum Hemorrhage
  • PPH Simulation
  • PPH Noell

110
Thromboembolic Conditions
  • Thrombosis (blood Clot) can cause inflammation of
    the blood vessel (Thrombophlebitis) which can
    cause Thromboembolism (obstruction of blood
    vessel)

111
Assessment Superficial
  • Tenderness and pain in extremity
  • Warm and pinkish red color over thrombus area
  • Palpable- feels bumpy and hard
  • Increased pain when ambulating

112
Nursing Care
  • NSAIDs for pain
  • Bed rest elevate affected leg
  • Warm compresses
  • Elastic stockings
  • No anticoagulants required

113
Assessment For Deep Vein Thrombosis
  • Calf swelling
  • Warmth
  • Tenderness
  • Pedal edema
  • Diminished peripheral pulses
  • Color blue
  • Homans sign

114
Nursing Care
  • Bed rest
  • Elevate effected leg
  • Continuous moist heat
  • TED hose both legs
  • Analgesics PRN
  • Anticoagulation therapy

115
Thrombosis
  • Patient Education
  • Anticoagulation Teaching Guidelines 22.1 pg. 758
  • Eliminate risk factors
  • Continue using Compression stockings
  • Avoid constrictive clothing prolonged standing
  • Danger signs

116
Pulmonary Embolism
  • Abrupt onset chest pain, dyspnea, diaphoresis,
    syncope, anxiety
  • ABC response

117
Postpartum Infections
  • Temp of 100.4 or higher after the first 24 hrs.
    for 2 successive days of the first 10 PP days
  • Temp of 102.2 or greater within first 24 hrs.-
    sever pelvic sepsis Group A or B streptococcus

118
Postpartum Infections
  • Endometritis
  • Wound infection
  • UTI
  • Mastitis
  • Septic Pelvic Thrombophlebitis
  • Box 22.1 Risk Factors
  • Table 22.3 pg. 761 signs symptoms

119
Metritis
  • Involves the endometrium, decidua and adjacent
    myometrium of the uterus
  • Lower abdominal tenderness or pain
  • Temperature
  • Foul-smelling lochia

120
Nursing Care
  • Administer broad spectrum antibiotic
  • Provide analgesia
  • Provide emotional support

121
Wound Infection
  • Sites- Cesarean incision, episiotomy and genital
    tract laceration
  • Drainage
  • Edema
  • Tenderness
  • Separation of wound edges

122
Nursing Care
  • Aseptic wound management
  • Frequent perineal pad changes
  • Good hand washing
  • Administer antibiotics
  • Analgesics

123
Urinary Tract Infection
  • Burning and pain on urination
  • Lower abdominal pain
  • Low grade fever
  • Flank pain
  • Proteinuria, hematuria, bacteriuria, nitrates and
    WBC

124
Nursing Care
  • Frequent emptying of bladder
  • Increase fluid intake
  • Antibiotics
  • Analgesics
  • Peri care

125
Mastitis
  • Infection of the breast (one sided)
  • Seen first 2 weeks after delivery
  • Most common organism staphylococcus aureus
  • Infected nipple fissure - to ductal system
    involvement- edema obstructs milk flow in a lobe-
    mastitis

126
Mastitis Symptoms
  • Flu like symptoms
  • Tender, hot, red area on one breast
  • Breast distention with milk

127
Nursing Management
  • Empty the breast by increasing the frequency of
    nursing or pumping
  • Control infection- Antibiotics
  • Analgesics
  • Warm/ice compresses
  • Assess infants mouth for thrush

128
Postpartum Infection Education
  • Continue antibiotics
  • Monitor temperature and notify provider if temp
    greater then 100.4
  • Watch for signs and symptoms of a recurrence
  • Practice good hand washing
  • Teaching Guidelines 22.2 pg. 765

129
Postpartum Affective Disorders
  • Plummeting levels of estrogen and progesterone
    after delivery contribute to the mood disorders
  • Disorders based on their severity
  • Postpartum blues
  • Postpartum depression
  • Postpartum psychosis

130
Postpartum Blues
  • Transient periods of depression during the first
    1 to 2 weeks postpartum
  • Tearfulness
  • Sad feeling
  • Confusion
  • Insomnia
  • Feel overwhelmed

131
Nursing Care
  • Remind mom that the Blues are normal
  • Encourage rest
  • Utilize relaxation techniques
  • Share her feelings with her partner
  • If symptoms do not resolve and progress to
    depression medical treatment needs to be sought

132
Postpartum Depression
  • Gradual onset and is evident within first 6 wks.
  • Cause combination of body, mind, and lifestyle
  • Symptoms- sleep disturbances, guilt, fatigue,
    feelings of hopelessness Box 22.2 pg. 771
  • Screening tools

133
Postpartum Depression
  • Management same as that for major depression
  • Antidepressants
  • Antianxiety
  • Psychotherapy
  • Marriage counseling if that is part of the causes

134
Postpartum Psychosis
  • Emergency psychiatric condition which could put
    the women at risk for suicide infanticide
  • Detect within 3 wks. of giving birth
  • Symptoms delusions, hallucinations, agitation,
    inability to sleep, bizarre irrational behavior

135
Postpartum Psychosis
  • Management
  • Usually hospitalized for several months
  • Psychotropic drugs
  • Individual psychotherapy
  • Support group therapy
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