n106 nursing care of post partum mother. physical changes cardiac & respiratory cardiac heart...

N106Nursing Care of

Post Partum Mother

Physical Changescardiac & respiratory

• Cardiac • Heart

positionoutput

• Fluid volume • VS

• Respiratory• Pulmonary function• BMR

Physiological ChangesGU & Reproductive System

• Urinary• Genitalia

Involution of uterusDecentAfter pains

LochiaCervix, Vagina, PerineumReturn of menses

Measurement of descent of fundus for the woman with vaginal birth.

Involution of the uterus. A, Immediately after delivery of the placenta, the fundus is midline and halfway between the symphysis pubis and the umbilicus. B, About 6 to 12 hours after birth, the fundus is at the level of the umbilicus. It then descends one finger breadth (approximately 1 cm) each day.

Suggested guideline for assessing lochia volume.

BUBBLEHE Assessment

• Breasts – Soft, filling, firm, Nipples• Uterus – consistency, position, height, C/S• Bladder – voiding pattern• Bowels – bowel sounds, hemorrhoids, BM• Lochia – type, amt, clots, odor• Episiotomy – laceration, bruising, swelling• Homan sign – present or not• Emotional status – bonding, blues

REEDA Scale for Incisions

• Redness

• Edema

• Ecchymosis

• Discharge

• Approximation

Physical Changes PP

• Gastrointestinal• Appetite• Gastric motility • BM resumes• Constipation r/t

hemorrhoids, trauma, dehydration, pain, fear, immobility, meds

• Musculoskeletal• Joint stabilization• Abdominal wall

Physical Changes PP

• Integumentary• Endocrine• Neurological • Hematological

Psychosocial Needs

• Promoting bonding• Rubin’s Phases

Taking in – wants to be taken care of

Taking hold – takes charge

Letting go – more realistic

Post Partum Blues

Is normal, mild, transient condition affects 50-70% of women

Begins 3-4 days after childbirth, peaks on the 4-5 day and resolves within 2 wks

Symptoms: insomnia, fatigue, tearfulness, mood instability, anxiety

Nursing care: encouraged to rest, take care of self, discuss feelings, it is self-limiting

Cesarean Care

• TCDB

• NPO, ice chips usually 12 hrs

• Ambulate 12 hours

• Foley D/C after 24 hours

• IV until tolerating diet

• Dressing removed 24hours

• Sutures removed 1 week after delivery

• When home – rest, good nutrition, mild exercise

Nursing Care• Review teaching info syllabus p. 38-41• Involution – 6-7 weeks • Decent of uterus midline and descend 1cm/d • Lochia – unique healing – no scar

rubra 2-3 days - dark red with small clotsserosa 4-10 days – pink to brownishalba 1-6 weeks – cream-white

• Cervix – never the same• Perineum – if episiotomy, takes 3-6 weeks

Nursing Care - Teaching

• Bladder – diuresis first 24 hours

• Stomach – resume exercise after Dr says

• Menstruations – 6 weeks, delayed with lactating mothers, STILL ovulate

• Sex – resume after first menstruation, after episiotomy some loose interest for one year

• Rest, Rest, Rest

Breastfeeding

• Colostrum is produced during pregnancy and immediately after birth, contains antibodies

• Replaced in 2-4 days with milk

• Teach: clean breast first in shower, proper positioning, release suction with finger, avoid soap on nipples, disposable bra pads, S&S of complications – redness, swelling, fever, tenderness, cracked nipples – (usually mastitis unilateral)

LATCH was created to provide a systematic method for breastfeeding assessment and charting.

Complications• Hemorrhage – Hgb < 9 requires Tx

atony- most common cause is full bladderlaceration – bleeding with firm uterusplacenta fragments – bleeding returns to rubra or foul odor noted – more common with “Dirty Dunkin”

• Infection – Temp above 100.4 Furinarymastitis

• Thrombophlebitis – pain and redness, +Homan – send for venous scanpulmonary embolism – sudden onset chest pain, SOB

Post Partum Hemorrhage• Loss of blood more than 500 cc – vaginal

birth, C/S 1000 cc lost• Most common cause – uterine atony

others are retained placenta fragments, or infection, hematoma, lacerations

• Tx – initial is fundal massage• S & S – saturate more than one pad/hr,

“boggy” uterus, increased lochia with clots, severe perineal pain (with hematoma), tachycardia, hypotension

Manual compression of the uterus and massage with the abdominal hand usually will effectively control

hemorrhage from uterine atony.

Manual removal of placenta. Performed only by the medical clinician.

Nursing Care of PP hemorrhage• Inspect placenta for missing parts• Administer oxytocics• Maintain IV line• Apply ice to perineum• Keep bladder empty• Massage fundus if boggy• Monitor lochia with amount and type• Discharge teaching: report if return to rubra,

fever over 100.4, foul smelling lochia, flu-like symptoms

Puerperal Infection• Fever over 100.4 after the first 24 hours and

lasting 2 days or more

• Chills, flu-like symptoms, elevated WBC (over 30,000), tachycardia

• Types of infectionsreproductive tract: back ache, abd pain, foul smelling lochia, purulent dischargewound infection: erythema, warmth, swelling, tenderness, drainage.

Mastitis. Erythema and swelling are present in the upper outer quadrant of the breast.

Axillary lymph nodes are enlarged and tender.

PP Infections

• UTI: pain, burning, urgency or freq of urine

• Mastitis – erythema, warmth in breast, flue-like symptoms

• Diagnosis with culture, vag exam, CBC

• Nursing care: assess VS, lochia, incisions, attend to pain, ensure food and fluid intake, obtain specimens, monitor response to antibiotic.

Thrombophlebitis• Inflammation of vessel wall with thrombus

• Causes: stasis and hypercoagulability

• Types:superficial venous thrombus: reddened, warm, swollendeep vein thrombosis: occurs in larger veins, positive Homan’s, pain

• Risk factors: immobility, C/S, PIH, DM, smoking, over 40 yr, multiparity, anemia

• Prevent: early ambulation and hydration

Nursing Care Thrombophlebitis

• Bedrest with leg elevated

• Change positions frequently, not flexed knees

• Teach no to rub area

• Daily measurements of calf and thigh

• Support stockings, moist heat application

• Assess for complication: embolism, S&S of pulmonary embolism

Rh Incompatibility

Antibodies cross placenta and attach to fetal red blood cells

destroying them

Rh Incompatibility

• Mother Rh- negative and fetus Rh positive

• If Rh positive blood enters system of Rh negative mother reacts by developing antibodies to destroy RBCs with Rh positive antigens

• Blood may mix during third stage of labor

• First child not effected

Rh isoimmunization sequence. Rh-positive father and Rh-negative mother.

As the placenta separates, the mother is further exposed to the Rh-positive blood.

Anti-Rh-positive antibodies (triangles) are formed.

In subsequent pregnancies with an Rh-positive fetus, Rh-positive red blood cells are attacked by the anti-Rh-positive maternal antibodies, causing hemolysis of the red blood cells in the fetus.

RhoGAM

• Rho (D) immune globulin suppresses the stimulation of active immunity by Rh-positive foreign RBC

• Given IM at 28 weeks antepartum and within 72 hours of delivery – 1 vial

• Before 13 weeks give ½ dose after amniocentesis, miscarriage, ectopic pregnancy

Before Administration

• Never administer intravenously

• Never administer to a neonate

• Never administer to an Rh negative patient who has been previously sensitized to the Rh antigen

• Confirm that the mother is Rh negative

• Confirm infant is Rh positive and assess direct coombs test

Coombs Test

• Indirect coombs test on mother to determine the presence of antibodies against fetal blood.

• If the test is positive, amniocenteses may be performed to determine the fetal Rh factor and degrees of hyperbilirubinemia.

• Direct coombs test is performed on the cord blood. Positive coombs test indicates that antibodies from the mother have attached to the infants RBC. Bilirubin levels are followed closely for changes that indicate that treatment should be initiated or changed.

Postpartum Depression/Psychosis• Postpartum depression- 15-25% - all ethnic

groups affected. • Cause unknown, may be r/t hormonal,

exhaustion, anger, chronic stress• S&S: starts first 4 wks and last several months,

fatigue, loss of self, suicide thoughts crying• TX: combination of psychotherapy, social,

meds• Postpartum psychosis- rare, bipolar disorder

or major depression, frightening thoughts, delusions of dead baby and hallucinations, need psychiatric Tx, will not resolve itself

Infant Care

• Cord care• Diapering• feeding• Stools• Urine• Baths• How to take temp