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    puerperium puerperium Presentation Transcript

    • Unit-IV Physiology and management of normal puerperium
    • Introduction  The puerperium is a period of approximately 6 weeks which commences following completion of third stage of labour. During this time the women recovers from stresses of pregnancy & delivery & the physiological adaptations which occur during pregnancy subside, facilitating the restoration of the non pregnant state.
    • Definitions  The puerperium is defined as the 6 weeks period commencing after the completion of third stage of labour. -E.M SYMONDS  The puerperium is refers to the 6 weeks period following child birth, when considerable adjustments occur before return to the pre pregnant state. -PHILIP N. BAKER  Puerperium is defined as the time from delivery of the placenta through the first few weeks after the delivery. (cont….)
    •  The postpartum period is the period of time following the delivery of the child during which the body tissues, especially the reproductive system reverts back to the pre-pregnant state, both anatomically and physiologically.  It is the period of adjustment after pregnancy and delivery when anatomical and physiological changes of pregnancy are reversed and the body returns to the normal non pregnant state.. (reproductive tract returns to its normal, non-pregnancy state)
    • Stages of puerperium  The post partum period has been divided into:  The immediate puerperium, the first 24 hours after parturition; when acute post anesthetic or post delivery complications may occur.  The early puerperium, which extends until the first week post partum.  The remote puerperium, which includes the period of time required for involution of the genital organs through the sixth weeks postpartum.
    • Uterus Reproductive system Involution:-is the return of the uterus to a nonpregnant state after childbirth Involution process begins immediately after expulsion of the placenta with contraction of uterine smooth muscles At the end of third stage of labor, the uterus is in the midline, about 2cm below the level of the umbilicus and weighs 1000g By 24 hours postpartum the uterus is about the same size it was at 20 gestational weeks The fundus descends about 1 to 2cm every 24 hours, and by the sixth postpartum day it is located halfway between the symphysis pubis and the umbilicus. -The uterus lies in the true pelvis within 2 weeks after childbirth.
    •  Involution of the uterus  return to the pelvis by about 2 weeks  be at normal size by 6 weeks  the weight changes of uterus  1000g immediately after birth (excluding the fetus, placenta, membrane and amniotic fluid.  500g 1 weeks after birth  300g 2 weeks after birth  50g 6 weeks after birth  The  The endometrial lining rapidly regenerates (16 days) placental site undergoes a series of changes in the postpartum period
    • Its fundus level approximates that of a 20 week pregnancy at the level of umbilicus, at the end first post partum week it is palpable at the symphysis pubis -Autolysis:-it is a self destruction of excess hypertrophied tissue. -Subinvolution:-is the failure of the uterus to return to a nonpregnant state. -The most common causes of subinvolution are retained placenta fragments and infection
    • Contraction The hormone oxytocin strengths and coordinates uterine contraction, which compress blood vessels and promotes homeostasis During the first 1 to 2 postpartum hours, uterine contractions may decrease in intensity and become uncoordinated
    • Exogenous oxytocin is usually administered immediately after expulsion of the placenta to maintain the uterus firm and contracted. Mothers are encouraged to put the baby to breast immediately after birth to stimulate the release of oxytocin.
    • Placental site -Immediately after the expulsion of the placenta and membranes, vascular constriction and thrombosis cause the placental site to be reduced to an irregular nodular and elevated area. Upward growth of endometrium causes the sloughing of necrotic tissues and prevents scar formation. Endometrial regeneration is completed by postpartum day 16, except the placental site is not complete until 6 weeks after birth.
    • Lochia It is the uterine discharge that occurs after birth. Lochia is initially bright red changing later to a pinkish red or reddish brown -For the first 2 hours after birth the amount of lochia should be about that of a heavy menstrual period, after that time the lochial flow should steadily decrease.
    • Lochia passes through 3 stages:1-lochia rubra:-it consists of blood, decidual and trophoplastic debris It lasts 3-4 days after childbirth . 2-lochia serosa:-it consists of old blood, serum, leukocytes, and tissue debris. the flow becomes pink or brown. It is expelled 3-10 days postpartum
    • 3-lochia alba:-it consists of leukocytes, decidua, epithelial cells, mucus, and bacteria. it is yellow to white in color. Lochia alba may continue to drain for up to and beyond 6 weeks after childbirth. The amount of lochia is usually increases with ambulation, and breastfeeding. Persistence of lochia rubra early in the postpartum period suggests continued bleeding as a result of retained fragments of the placenta or membranes. The another common source of vaginal bleeding is vaginal or cervical laceration.
    • After Pain After expulsion of fetus and placenta the uterus contracts to regain its normal size, weight and site, this called involution of uterus. Oxytocin is released from posterior lobe of the pituitary gland in response to the sucking, which facilitate uterine contraction.  Characteristic of after pain:  Occur during the 1st 2-3 days of puerperium  Abdominal pains (like cramps) and back pain.  Strong, regular, and coordinated.  The intensity, frequency and regularity of contraction decrease after the 1st postpartum day.  Primigravida--uterus tonically contracted unless clots or tissue remain in uterus.  Multipara--uterus contracts and relaxes at intervals causing “afterpains”. More severe when breasfeeding in both primiparas and multiparas. 
    • Constipation  It is common in the first few days of puerperium and is due to many factors. The woman‘s food intake is interrupted, there may be dehydration during labor, the abdominal muscles are lax and perineal lacerations make defecation painful.
    •  Cervix It is soft immediately after birth -The cervix up to the lower uterine segment remains edematous, and thin for several days after birth. The cervical os which is dilated to 10cm during labor closes gradually, it may still possible to introduce 2 fingers into cervical os for the first 4-6 postpartum days.  The external cervical os never regains its prepregnancy appearance, it is no longer shaped like a fish mouth.  It return to its normal state at 4 weeks after birth
    • Vagina and perineum -The greatly distended, smooth walled vagina gradually returns to its prepregnancy size by 6-10 weeks after childbirth. -The mucosa remains atrophic in lactating woman at least until menstruation begins again. -Thickening of vaginal mucosa occurs with the return of ovarian function.
    • The reduced estrogen levels also responsible for causing a decreased amount of vaginal lubrication, so localized dryness and dyspareunia may persist until ovarian function returns and menstruation resumes. -Initially the introitus is erythematous and edematous especially in the area of the episiotomy or laceration repair.
    • If episiotomy and laceration have been carefully repaired, hematomas are prevented or treated early. - usually healing should occur within 2-3 weeks - Hemorrhoids usually decrease in size within 6 weeks of childbirth.
    • Pelvic muscular support The supporting structure of the uterus and vagina may be injured during childbirth. the supportive tissues of the pelvic floor that are torn or stretched during childbirth may require up to 6 months to regain tone Women are encouraged to do kegel exercises after birth to strengthen perineal muscles and promote healing
    •  Perineum  Swelling completely gone within 1-2 weeks The muscle tone may or may not return to normal, depending on the extent of injury. 
    • The muscular walls of the pelvic organs  The voluntary muscles of the pelvic floor and pelvic supports gradually regain their tone during the puerperium. Tearing or overstretching of the musculature or fascia at the time of delivery predispose to genital hernias. Over distention of the abdominal wall during pregnancy may result in rupture of the elastic fibers, persistent striae, and diastases of the recti muscles. Involution of the abdominal musculature may require 6-7 weeks and vigorous exercises are not recommended until after that time.
    • Breasts Anatomy A ducts B lobules C dilated section of duct to hold milk D nipple E fat F pectoralis major muscle G chest wall/rib cage Enlargement: A normal duct cells B basement membrane C lumen (center of duct)
    • Physiology of Lactation
    •  During pregnancy estrogen and progesterone secreted by the placenta prepare the breasts for lactation. The estrogen inhibits milk production until the end of pregnancy. In the 3rd trimester of pregnancy colostrum is present and remains for the first 3 days postpartum.
    •  By the 3rd stage of labor (delivery of the placenta), the hormonal production is reduced, and during the next 48 hrs, the blood level of estrogen and progesterone fall. This stimulates the anterior pituitary gland to produce the lactogenic hormone (prolactin hormone) which acts on the acini cells in the breast, and milk is formed.
    • The milk is pushed along the lactiferous ducts and some is stored in the ampullae which lie just under the areola. When the infant sucks, he takes the nipple and the areola into his mouth, and partly by a vacuum which is created mostly by a chewing action of his jaws, milk is pushed into his mouth and he swallows. As the ampulla and lower ducts are emptied, milk is pushed from the alveoli by contraction of the myoepithelial cells. So, the act of sucking by the infant is the stimulus that provokes lactation.
    •  This effects a neuro-hormonal reflex mechanism which activates the anterior pituitary lobe to produce lactotropin, and the posterior pituitary lobe to produce oxytocin which reaches the breast through the blood stream, leading to contraction of myoepithelial cells, and the expulsion of milk.
    • Oxytocin also stimulates uterine contractions causing after pains and lochial discharge during breastfeeding.  With the onset of milk the breasts become larger firmer, heavier, and full of milk that can be expressed on pressure, or may escape spontaneously. This procedure is associated with a considerable local throbbing pain extending the axillae. 
    •  Characteristics of breast milk. It is suited to the infant’s needs, easily digestible, germ-free, fresh, warm and contains antibodies, vitamins, calcium, lactose, casein protein, fat, mineral salt and water. It is also readily available, and costs little.
    • Types of Breast milk Breast milk at different stages of lactation is defined by different terms. Colostrum: is a thick, sticky and light yellowish in colour which is produced during the first few days after delivery. Although secreted in small quantities (30-90ml), it is sufficient to meet the caloric needs of a normal newborn in the first few days of life.
    •  Transition milk :During a period of 1-2 weeks that follow the colostrum stage the milk increases in quantity and changes in appearance and composition as per the baby's needs, protein contents decrease while fat and sugar contents increase. At this time the breasts feel full, hard and heavy.
    • Mature milk: This milk is thinner and watery but contains all the nutrients essential for optimum physical and mental development of the child. Mature milk changes even during the length of a single feed to exactly suit the needs of a baby.
    • The mature milk consists of Foremilk and Hind milk:  Foremilk :The milk which comes at the start of a feed. It has a low level of fat and is high in lactose, sugar, protein, vitamins, mineral and water. It satisfies the baby's thirst and is produced in larger amounts than hind milk.
    •   Hind milk: which comes later in a feed, is richer in fat which makes it look whiter and thicker than foremilk. It satisfies the babies hunger and supplies much of the energy of a breastfeed. It should be noted that a baby needs both the foremilk and the hind milk for appropriate weight gain. Also, babies who are fed both foremilk and hind milk sleep well. Preterm milk: is a milk produced by a woman who has delivered prematurely.This milk has more proteins, minerals, immunoglobulin and lactoferrin than the mature milk, making it suitable for the needs of a preterm baby.The preterm milk is ideal food for low birth weight babies.Term milk is produced by a woman who has a full term delivery. Its composition is suitable for normal term baby
    • Breast feeding in the correct position Art and technique of breast feeding Step 1: Find a comfortable position for your self. You may lie down; sit on a chair on the bed or on the floor to feed your baby. Most important is that you must feel comfortable and your back must be supported
    • Step 2: Hold your baby in your arm so that her head and neck rest in the bend of their elbow , the back along forearm and the buttocks in your hands if your feeding on your right breast your right arm should be used to cradle your baby.
    • Step 3: Turn the baby's entire body towards yours so that the baby's tummy touches your tummy. The babies head and neck should be supported Step 4: Raise the baby to the level of your breast so that the babies mouth can easily reach the nipple and the areola. This could be made possible by putting a pillow below your arm or raising your thigh if your sitting crossed leg on the floor.
    • Make sure that the baby is not exclusively clothed so that the baby can be brought really close to you. Some times you may need to tuck your babies arm away. So that it does not come in the way.You may use your free hand to hold your breast or to fondle your baby once your baby is really attached. Step 5: When the nipple touches, the baby's lips or the cheek, your baby's mouth will reflexively open to draw the nipple and part of the areola in to form a teat. this is known as "attachment to the breast" the lactiferous sinuses which are the storehouses of milk are situated beneath the areola. 
    • To effectively suckle milk from the breast, both the nipple and the areola should go into the baby's mouth. Proper attachment is the key to successful breast feeding, improper attachment is responsible for most of the problems related to breast feeding like sore nipple, congested breast and inadequate milk supply  Body position: The mother should feed her baby in any comfortable position such as lying or sitting with good eye contact. Good and bad body positions are shown in Fig. a & b. 
    • A B
    • Pic . a: Good body position Baby’s head and neck is straight or bend slightly back. Baby’s body is turned towards the mother. Baby’s body is close to the mother facing breast. Baby’s whole body is supported. Mother baby eye contact is there
    • Pic . b: Bad body position Baby’s head and neck not straight. Baby’s body is turned away from the mother. Baby’s body is away from the mother. Baby’s body is not supported. There is no eye contact between the mother and baby
    • Attachment attachment refers to the emotional connection between a patient and her infant. This attachment is reciprocal; both the mother and the infant exhibit attachment behaviors. The infant responds to the patient by cooing, grasping, smiling, and crying.
    • However, these behaviors are nondiscriminatory before approximately 8 weeks. Nurses can assess for attachment behaviors by observing the interaction between the mother and her infant. Behaviors indicating a positive attachment include:  Touching  Holding  Kissing  Cuddling  Talking and singing  Choosing the "en face" position  Expressing pride in the infant
    • Endocrine system Placental hormones Expulsion of the placenta results in dramatic decreases of hormones produced by placenta. The placental enzyme insulinaze causes the diabetogenic effects of pregnancy to be reversed, resulting in significantly lower blood sugar levels in the immediate postpartum period - Estrogen and progesterone levels decrease markedly after expulsion of the placenta, reaching their lowest levels 1 week into the postpartum period. - 2- Decreased estrogen level associated with; breast engorgement, and diuresis of excess extracellular fluid that has accumulated during pregnancy.
    • The estrogen levels in nonlactating women begin to increase by 2 weeks after birth, and higher by postpartum day 17. Pituitary hormones and ovarian function:-Lactating and nonlactating women differ in the time of the first ovulation. -The persistence of elevated serum prolactin levels in breast feeding women appears to the responsible for suppressing ovulation In women who breast feed, prolactin levels remain elevated into the sixth week after birth. Serum prolactin levels are influenced by the frequency of breastfeeding, the duration of each feeding, and the degree to which supplementary feedings are used. Prolactin levels decline in nonlactating women, reaching the prepregnant range by third week About 70% of nonlactating women resume menstruation by 3 months after birth.
    • -The mean time to ovulation in women breast feed is about 6 months. -The resumption of ovulation and the return of menses in lactating women are determined by breastfeeding patterns. -The first menstrual flow after childbirth is usually heavier than normal, within 3-4 cycles, the amount of menstrual flow returned to woman’s prepregnant volume
    • Abdomen -Abdominal muscles protrude during the first days after birth. -During the first 2 weeks after birth the abdominal wall is relaxed and it takes approximately 6 weeks to return almost to its nonpregnant state -The skin regains most of its previous elasticity, but some striae may present -The return of muscle tone depends on previous tone, proper exercise, and the amount of adipose tissue.
    • Urinary system The diminishing steroids levels after birth may explain the reduced renal function that occurs during the pueriperium. Urine components BUN level increases during puerperium as autolysis of the involuting uterus occurs. This breakdown of excess protein in the uterine muscle cells results in a mild (+1)proteinurea for 1-2 days after childbirth
    • Postpartal diuresis -Within 12 hours of birth, women begin to lose the excess tissue fluid that has accumulated during pregnancy. -One mechanism responsible for reducing these retained fluids is the profuse diaphoresis that often occurs for the first 2-3 days after childbirth -The fluid loss through increased urinary output accounts for weight loss of approximately 2.25kg during the puerperium
    • Urethra and bladder If trauma to the urethra and bladder occur during the birth process, the bladder wall becomes hyperemic and edematous, often with small areas of hemorrhage. Birth-induced trauma increased bladder capacity and the effects of conduction anesthesia combine to cause a decrease in the urge to void. In addition to pelvic soreness from the forces of labor, vaginal laceration, or an episiotomy which they reduce the voiding reflex. Decreased voiding, along with postpartal diuresis may result in bladder distention. -Distended bladder pushes the uterus up and to the side and this prevents the uterus from firmly contracting which may cause excessive bleeding. -Bladder tone is usually restored 5-7days after childbirth .
    • Gastrointestinal system Appetite The mother is usually hungry shortly after giving birth. Bowel evacuation A spontaneous bowel evacuation may be delayed until 2-3 days after childbirth. This can be explained by decreased muscle tone of the intestines during labor and the immediate puerperium, prelabor diarrhea, lack of food, or dehydration
    • GI/hepatic function GI tone and motility decreases in the early postpartum period, commonly causing constipation. -Normal bowel function returns approximately 2 to 3 days postpartum. -Liver function returns to normal approximately 10 to 14 days postpartum. -Gall bladder contractility increases to normal, allowing for expulsion of small gallstones
    • Cardiovascular function Most dramatic changes occur in this system. Cardiac output decreases rapidly and returns to normal by 2 to 3 weeks postpartum. Hematocrit increases and increased red blood cell (RBC) production stops. Leukocytosis with increased white blood cells (WBCs) common during the first postpartum week. Blood volume The blood volume which increase during pregnancy is eliminated within the first 2 weeks after birth, with return to nonpregnant values by 6 weeks postpartum.
    • Cardiac output Immediately after the birth, the pulse rate, stroke volume and cardiac output remain elevated or increase for 30 to 60 minutes as the blood that shunted through uteroplacental circuit suddenly returns to the maternal systemic venous circulation
    • Vital Signs Temperature:  The temperature is slightly elevated: 0.5 degrees for the first 24 hours and up to 38 degrees is known. This rise in temperature is due to the absorption of waste products of muscular contractions of labor.  Transient rise in temperature later on is due to: • Milk engorgement (by the 4th day postpartum). • Constipation. • Nervous excitation. • Infection. 
    •  The  The pulse: pulse is full and slow (about 60-70 B/mm) and is known as physiological bradycardia (for 24-48 hrs after labor). It is due to: • The rest period after labor . • The increase in the circulating blood volume on account of the elimination of the placental pool. • The pulse should remain below 100 B/mm if all is going well. A rapid pulse may be brought on by pain, visitors, excitement, exhaustion, the nursing infant, hemorrhage or infection.
    •  Respiration:  This is in the usual relation with pulse and temperature. Because of a reduction in the size of the uterus and relaxation of the abdominal wall respiration is more abdominal in character. Deviation from the normal may suggest pneumonia or embolism.
    •  Blood  No Pressure: change is counted, but if hypotension is present, postpartum hemorrhage may be suspected. If hypertension is present (over 140/90 mm Hg) postpartum toxemia may be suspected.
    • Blood and Fluid Changes Marked leukocytosis and thrombocytosis occur during and after labor The leukocyte count sometimes reaches 30,000L, with the increase . There is also a relative lymphopenia and an absolute eosinopenia. Normally, during the first few postpartum days, hemoglobin concentration and hematocrit fluctuate moderately. If they fall much below the levels present just prior to labor, a considerable amount of blood has been lost By 1 week after delivery, the blood volume has returned nearly to its nonpregnant level.
    • Respiratory function -Returns to normal by approximately 6 to 8 weeks postpartum. -Basal metabolic rate increases for 7 to 14 days postpartum, secondary to mild anemia, lactation, and psychological changes-
    • Neurological system Discomfort and fatigue are common. Afterpains and discomfort from the delivery, lacerations, episiotomy, and muscle aches are common. Frontal and bilateral headaches are common and are caused by fluid shifts in the first week postpartum. The elimination of physiologic edema through the diuresis that occurs after childbirth relieves carpal tunnel syndrome by easing the compression of the median nerve.
    • Musculoskeletal function -Generalized fatigue and weakness is common. -Decreased abdominal tone is common. -Diastasis recti heals and resolves by the 4th to 6th week postpartum. -Until healing is complete, abdominal exercises are contraindicated
    • Integumentary system - Chloasma of pregnancy usually disappears at the end of pregnancy. - Hyperpigmentation of the areolae and linea nigra may not regress completely after childbirth, and it may be permanent in some women. - Stretch marks on breasts, abdomen, hips, and thighs may fade but usually do not disappear - Hair growth slows during postpartum period, and some women may actually experience hair loss. Immune system No significant changes occur during postpartum period
    • psychological changes during Postpartum Phases of the Maternal Role: Emotional changes in the mother during the postpartum period (restorative process) as described by Reva Rubin pass through three phases. They are:  Taking-in phase.  Taking-hold phase.  Letting-go phase. 
    • Taking-in Phase (Turning in):  It takes 2-3 days, during which time the mother’s first concern is with her own needs (sleep and food). The woman reacts passively, mostly dependent on others to meet her needs. She initiates little activity on her own. She is quite talkative during this phase about every detail of her labor and delivery experience.
    • Taking-Hold Phase (Taking Responsibility as a Mother):  It starts the 3rd day postpartum. The emphasis is placed on the present. She becomes impatient and is driven to organize herself and her life. She progresses from the passive individual to the one who is in command of the situation. This phase lasts about 10 days. Once the mother has taken control of her physical being and accepted her role as a mother, she is able to extend her energies to her mate and other children.
    • Letting-go Phase: As her mothering functions become more established the mother enters the letting-go phase. This generally occurs when the mother returns home. In this phase there are two separations that the mother must accomplish. One is to realize and accept physical separation from the infant. The other is to relinquish her former role as a childless person and accept the enormous implications and responsibilities of her new situation. She must adjust her life to the relative dependency and helplessness of her child. 
    • Bonding:  also known as attachment: process by which parents form emotional relationship with infant over time; influenced by many factors: family, stability of home environment, nurturing she received as child. Certain characteristics important: level of trust, level of self esteem, reactions to present pregnancy; interest in child rearing.
    • Postpartum Blues (Depression) Definition  Rubin defined postpartum depression as the gap between the ideal and reality: the new mother’s self-expectation may exceed her capabilities, resulting in cyclic feelings of depression.  During Postpartum, and for no apparent reason that the mother can think of, she may experience a let-down feeling accompanied by irritability and tears. Occasionally her appetite and sleep patterns are disturbed. These are the usual manifestations of the postpartum or “infant” blues .
    • This depression is usually temporary and may occur in the hospital. It is thought to be related, in part, to hormonal changes, and in part, to the ego adjustment that accompanies role transition. Discomfort, fatigue and exhaustion certainly contribute to this condition. Crying often relieves the tension, but if the parents are not knowledgeable about the condition the mother may feel rather guilty for being depressed.  Understanding and anticipatory guidance will help the parent be aware that these feelings are a normal accompaniment to this role transition. 
    • Predisposing Factors         The first pregnancy. A pregnancy in late child bearing years. Ambivalence toward the woman’s own mother. Social isolation. Long or hard labor. Anxiety regarding finances. Marital disharmony. Crisis in the extended family
    • The Emotional Needs of the Woman during Postpartum Recognition of the effort made during labor: approval of behavior during labor as well as in the immediate postpartum period.  Support and encouragement in her care for the infant.  Attention from family members particularly from the husband: this is very significant as most of the attention in the immediate postpartum period is directed suddenly toward the newborn. 
    • Someone to listen and help them solve their dependency-independency conflict.  Physical needs of comfort, nourishment and hygiene should be properly fulfilled. 
    • A good method to remember how to check the postpartum changes is the use of the acronym BUBBLERS:  B: Breast.  U: Uterus.  B: Bladder.  B: Bowel.  L: Lochia.  E: Episiotomy.  R: Emotional response.  S: Homans' sign. 
    • Nursing Management of the Postpartum Period Introduction Nursing care during the postpartum provides the means by which the parturient can restore her physical and emotional health, as well as gain experience in caring for her new born infant.
    • Components of Care during the Postpartum Period Care of the mother: Immediate care. Subsequent daily care. Care of the newborn infant. 
    • Objectives of Care during the Postpartum Period. Immediate care of the mother:  Secure physical and mental rest, restore normal good muscle tone and maintain normal body functions.  Provide proper adequate nutrition.  Guard against infection.
    • Teach the mother how to care for herself and the infant.  Foster and maintain family ties and adjust the parents to their new role.  To encourage breastfeeding 
    • Nursing Assessment The first hour, after placental separation and birth, is under the management of the labor ward nurse:  Observation of bleeding signs and symptoms by: Palpating the fundus of the uterus through the abdominal wall. Normally,
    • Inspecting the perineum and perineal pad for obvious signs of bleeding. Taking and recording vital signs every 15 minutes for the first hour after labor.  Observation of legs for signs and symptoms of deep vein thrombosis (DVT): pain, warmth, tenderness, swollen reddened vein that feels hard or solid and positive Homan’s sign
    • Postnatal Exercises Pelvic floor exercise  Abdominal tightening  Pelvic tilting or rocking  Rectus gap  Hip hitching  Foot and Leg Exercise 
    • Nursing Diagnosis Based on Assessment. Potential for :  Postpartum bleeding.  Deep vein thrombosis.  Infection.
    • Nursing Plan and Implementation Palpate the uterus: if it remains firm, well contracted and does not increase in size, it is neither necessary nor desirable to stimulate it. If it becomes soft and boggy because of relaxation, the fundus should be massaged immediately until it becomes contracted again. 
    • If the uterus is atonic, blood which collects in the cavity should be expressed with firm, but gentle, force in the direction of the outlet. This is done only after the fundus has been first massaged because it may result in inversion of the uterus and lead to serious complications.  Administer oxytocin (e.g. ergometrine 5 mg.TM) as ordered to control bleeding and to promote involution.  Continue checking of vital signs.  Encourage urination because full bladder impedes involution and may cause atony of the uterus leading to excessive bleeding. 
    •       Check lochial discharge for color, amount, consistency and presence of clots. Perineal care is performed under aseptic technique to prevent infection. Offer food to mother if the policy permits, and after vital signs are stable. Breast care may be employed. General hygiene: shower may be permissible to clean, comfort and refresh the mother (after vital signs are stable) according to the hospital policy. Encourage early initiation of breastfeeding to stimulate involution, lactation and to enhance emotional bonding.
    • Correct dehydration promptly by offering fluid intake (orally), or starting IV fluid as ordered.  Start leg exercises and early ambulation, especially following operative delivery.  Administer prophylactic anticoagulant therapy as ordered. 
    • Nursing Care Plan and Implementation After admission to the postnatal ward, subsequent daily care is implemented as follows: General Aspects of Care  Check vital signs 2 times daily (morning and evening); observe for symptoms of hypovolemic shock and hemorrhage (fainting).  A temperature of 380C, or above, for two consecutive days after the first 24 hrs. is considered an early sign of puerperal infection.  Bradycardia is a normal physiological phenomenon. 
    • Palpate the uterus to assess firminess, level of fundus, and rate of involution of the uterus.  Administer oxytocin medication as ordered to promote involution.  Check lochia for color, amount, odor, consistency and presence of blood clots. 
    • Observe perineum and suture line - if present - for redness, ecchymosis, edema or gapping. Check healing and cleanliness.  Provide for sufficient periods of rest and sleep in order to maintain physical and mental health, as well as to promote lactation (8 hr. night-time sleep and 2 hr. afternoon-nap are needed).  Proper positioning. During the first 8 hrs after labor, the mother is allowed to sleep in any comfortable position. After that, prone position or either lateral positions should be encouraged in order to facilitate involution, and to help drainage of lochia. Sitting position is also recommended since it promotes contraction of the abdominal muscles, aids pelvic circulation, and helps drainage of lochia. Knee-chest position is indicated in certain conditions because it prevents RVF of the uterus and hastens its involution. 
    •     On the other hand, both supine and semi-sitting positions should be avoided. Prevent infection: complete aseptic and antiseptic precautions should be followed during the early postpartum period to prevent infection. Monitor laboratory reports for Hb, HCT, and WBC. Observe for postpartum blues, which may be caused by a drop in hormonal levels on the 4th or 5th day.
    •       Meet the mother’s needs to enable her to meet the infant’s needs. Assist the mother with self-care and care of the infant as needed. Stress the importance of postpartum examination, visits and follow up to assess involution, general health and wellbeing of the mother. Evaluate client’s response and revise plan as necessary. Discuss community resources that provide maternal services. Regular and frequent examination for early detection of complications such as engorged breast, cracked nipples, mastitis and breast abscess.
    • Promote bladder and bowel function: Bladder: Marked diuresis is expected for 2-3 days following delivery: voiding should be encouraged within 6-8 hrs after labor. If no urine is passed after 12 hrs., usually occurs due to lax abdominal and bladder walls, spasm of the bladder sphincter secondary to pain from an episiotomy wound or lacerations and bruising of the urethra during delivery. Being at bed rest for long periods of time with decreased movements of the body also contribute to the inability to pass urine. initiate simple nursing measure to induce voiding. If failed, catheterization, under complete aseptic technique is performed.  Bowel: there may be no bowel action for a couple of days because the bowel has probably been emptied during labor. Glycerin suppository may be used to relieve constipation. 
    • Diet: Provide diet high in proteins and calories to restore tissues. A daily requirement of 3000-3500 cal/day is needed in the form of a well balanced diet rich in class proteins, calcium, iron, vitamin A, thiamine, riboflavin, and ascorbic acid. Liberal amounts of fluids are required (e.g. milk, juice ... etc.). Roughage and green vegetables are provided to prevent constipation. Care of the perineum: The acronym REEDA is often used to assess an episiotomy or laceration of the perineum. REEDA stands for redness, edema, ecchymosis, discharge, and approximation. Redness is considered normal with episiotomies and lacerations—however, if there is significant pain present, further assessment is necessary. 
    • Excessive edema can delay wound healing and the use of ice packs during the immediate postpartum period is generally indicated.  Inspect and observe for presence of episiotomy, lacerations, edema, pain or ulceration.  Only sterile vaginal pads should be used  Keep the area clean and dry by employing perineal care.  use a sitz bath to aid in perineal healing.To avoid infection  Teach the mother principals of selfcare.
    • Medication : Antibiotics must be prescribed if an episiotomy has been done or the vaginal tissues manipulated excessively. Ergometrine can be given to help in contracting the uterus better. Laxatives may be given if the patient suffers from constipation (very common at this stage). Supplements of calcium, iron and Vit B-complex tablets may be given.  If Rh negative mother, assess need for administration of RhO GAM.  Give rubella vaccine if indicated. 
    • Homan's Sign (DVT): Homan's sign can be obtained by dorsiflexion of the foot.The presence of pain when eliciting the Homan's sign, is indicative of a deep vein thrombosis (DVT). is important to note that that a DVT may be present despite a negative Homan's sign so nurses must monitor patients for other signs of a DVT. Specifically, the lower extremities should be assessed for the following:  presence of hot, red, painful, and edematous areas, all indicative of a DVT. 
    •   Assess the legs for adequate circulation by checking the pedal pulses and noting temperature and color, Pedal edema is normally present for several days after delivery as fluids in the body shift. However, lasting edema should be reported for further assessment. Get patients to ambulate as soon as possible after delivery to improve circulation and prevent the development of thrombi. Teach them not to cross their legs for long periods of time and to keep the legs elevated while
    • Care of the newborn infant: Nursing assessment: Observing the general condition.  Checking the cord.  Checking the infant’s physical needs: cleanliness, feeding, warmth, sleep, protection from unsuitable environment.  Checking psychological needs: bonding, attachment. 
    • Nursing diagnosis: Potential for: Cord abnormalities: bleeding, discharge, hernia.  Heat loss, hypothermia.  Hazardous environmental factors.  Psychological disturbance due to lack of bonding and attachment.  Nursing plan and implementation:       Carry out partial or complete bath to ensure cleanliness and comfort. Use proper clothing to keep the infant warm. Perform cord dressing. Encourage early, on demand and exclusive breastfeeding. Ensure adequate hours of sleep. Protect from environmental hazards.
    • Discuss infant care with mother: cleanliness, handling, clothing, cord care, feeding, bonding, diapering, circumcision of male infant, immunization, registration, and community resources.  Encourage early skin to skin contact, bonding and attachment 
    • Contraceptive Methods Sex is not advisable for at least 6 weeks after delivery, i.e. in the postpartum period, as the tissues are fragile at this time and need time to recover. But, if necessary, barrier contraceptives like condoms should be used.  barrier contraceptives are the ideal birth control method which should be used for the first 6 months after childbirth. This is because other birth control methods like oral contraceptive pills can cause a decrease in the milk production of the breasts.  After 6 months, when the baby can be started on supplementary food, oral contraceptive pills can be prescribed. It is also possible to use intra-uterine devices like Copper-T after this period. 
    • Minor Discomforts during the Postpartum Period Minor Complaints They are minor complaints felt by the parturient during postpartum period. Simple nursing measures (interventions) are needed to alleviate these complaints. After-pains  It is a spasmodic colicky pain in the lower abdomen during the early postpartum. days due to vigorous contractions of the uterus. It is more common and more severe in multiparas due to weak muscle tone. Conditions with increased intra abdominal pressure e.g. polyhydraminos, multiple pregnancy, large size infant.
    •  Predisposing factors:  Presence of blood clots, piece of membranes or placental tissue.  Breastfeeding increases after-pain.  Nursing management:  Simple uterine Massage.  Reassurance and simple explanation of the cause. Proper positioning (prone, sitting).  Offering warm drinks.  Mild sedatives on doctor’s orders (before feeding).  Avoid full bladder.  Encourage abdominal muscle exercises and pelvic floor muscle exercises.
    • Urinary Retention It is the inability to excrete urine, i.e. urine is accumulated within the urinary bladder. A common complaint during the first few days after labor.  Causes:  Laxity of the abdominal muscles.  Inability to micturate in the recumbent position.  Reflex inhibition due to stitched perineum or bruised urethra.  Atony of the bladder.  Compression of the urethra by edema or haematoma. 
    •  Treatment:  Urine should be passed approximately 8-12 hrs. after delivery. If not, the following measures should be attempted: ◦ Perineal care with warm water. ◦ Privacy and reassurance. ◦ Warm bedpan. ◦ Listening to the sound of running water. ◦ Hot-water bottle over the symphysis pubis.  If these measures fail, catheterization should be performed using complete aseptic technique.
    • Constipation An abnormal infrequent and difficult evacuation of feces may occur during the first few days postpartum.  Nursing management: health teaching should consider the following:  Diet rich in roughage.  Increase fluid intake.  Milk before bedtime.  Exercises.  After 72 hrs a glycerin suppository, or mild laxative, may be administered as ordered.
    • Engorged Breast    It is an accumulation of increased amounts of blood and other body fluids as well as milk in the breasts.This condition occurs frequently about the 3rd day postpartum, especially in primiparas. It is due to lymphatic and venous engorgement, and is relieved when milk comes out. Causes: Inadequate and/or infrequent breastfeeding. Inhibited milk ejection reflex.
    •  Signs and symptoms:  Breasts are firm, heavy (due to blocked ducts), swollen, tender and hot (37.80C).  Pain may be present leading to irritability and insomnia. The mother may refuse to nurse the infant.  Nursing management: Apply moist warm packs to the involved breast 2-3 minutes before each feeding.  Massage and manual expression of milk to relieve areolar engorgement before feeding. This facilitates attachment. 
    • Massaging the Breast Stroking the Breast
    • Cold application after feeding.  A well-fitting bra should be used to provide support and comfort.  Mild analgesics may be ordered. Syntocinon inhalation may be prescribed. In severe cases, administration of 2 doses of diuretic (as Lasix 40 mg) is effective. 
    • Cracked Nipple  Fissured nipple occurs in about half of the nursing mothers at one time or another. Nipple tenderness and soreness are usually the result of trauma and irritation.  Causes  Improper antenatal care. Improper technique of breastfeeding. Unnecessary prolonged lactation. Flat or large size nipple excoriation. The use of irritating substances e.g. soaps, lotions. Conditions as candidiasis, and contact dermatitis. Engorgement of the breast. Blond and redheaded women usually have delicate skin that may be predisposed to cracking.       
    •  Signs and symptoms: Irritation of the nipple in the form of minute blisters, or petechial spots.  Persistent pain and tenderness.  Bleeding.  Inflammation signs.  Nursing management:         Proper technique of breastfeeding should be followed. Apply moist heat and massage before feeding (3-5 mm). Frequent, short feedings. Air/sun exposure. Avoid engorged breast. Avoid irritating materials. Use supportive bra. Mild analgesic and panthenol ointment may be used. Treatment of candidiasis and dermatitis.
    • Perineal Discomfort       It usually occurs due to presence of tears, lacerations, episiotomy and edema. Nursing management: Frequent perineal care under aseptic technique. (the area should be kept clean and dry). Soaks of magnesium sulphate compresses in case of edema. Expose to dry heat (electric lamp) will help the healing process. Health education that includes: ◦ Perineal self care. ◦ Position (lateral with a pillow between thighs). ◦ Diet: rich in protein. ◦ Sources of strain such as coughing, constipation and carrying heavy objects should be avoided. ◦ Encourage pelvic floor muscle exercises. ◦ Avoid infection. ◦ The use of cotton underwear
    • Postpartum Blues (Depression)  Reva Rubin defined postpartum blues as “the gap between the ideal and reality: the new mother’s expectations may exceed her capabilities, resulting in cyclic feelings of depression”.This condition is usually temporary and may occur in the hospital.The condition is partly due to hormonal changes, and partly due to the ego adjustment that accompanies role transition.  Manifestations:    Disturbed appetite and sleeping patterns. Discomfort, fatigue and exhaustion. Episodes of crying for no apparent cause. The mother may experience a let down feeling accompanied by irritability and tears which often relieves the tension. Guilt feeling at being depressed.
    •  Predisposing factors:  The first pregnancy or pregnancy in late childbearing age. Social isolation. Ambivalence toward the woman’s own mother. Prolonged, hard labor. Anxiety regarding finances. Marital disharmony. Crisis in the family.      Nursing management: Reassurance, understanding, and anticipatory guidance will help the parents become aware that these feelings are a normal accompaniment to this role transition.
    • Postpartum Visits The First Visit  This visit is carried out 3-4 weeks after labor in order to assess the degree of involution of the body in general, and of the genital tract in particular. General and local examinations are performed. The client’s condition is evaluated through various medical and nursing activities that include:  Measuring and recording of blood pressure.  Estimation of the hemoglobin percentage, and aggressive treatment of anemia, if present.  Urine analysis for sugar and albumen.  Thorough examination of the breasts and nipples for early detection and treatment of abnormalities.
    • Examination of abdominal muscles, perineum, perineal wounds and nature of lochia to asses the degree of involution of these parts, and to exclude the presence of infection.  Careful and thorough examination of: size of the uterus, its position, adnexal masses, tenderness, the condition of the cervix (such as lacerations or erosions) as well as the condition of the pelvic floor. Management of any lesion should be readily started  The Second Visit This visit is done at the end of the 6 postpartum week. It is carried out along the same lines as the first postnatal visit with the institution of more active treatment for certain lesions:  If retroversion flexion (RVF) is still present a pessary must be inserted.  Cervical erosion may call for cauterization.  Subinvolution calls for more energetic treatment. 
    • Health teaching items at this time include advice in relation to:  Sexual intercourse, which should be prohibited during the first six postpartum weeks, and allowed after that, provided that the woman is in good health, with a perfectly healed genital tract.  Spacing of pregnancies and counseling about the appropriate contraceptive method, which should be prescribed and may be started at once.  If prolapse of the genital tract is present, it should be treated by pelvic floor muscle exercises and/or the insertion of a ring pessary.The patient should be advised to abstain from bearing down. Chronic cough and constipation should be treated for this purpose. However, operative treatment is not considered before the lapse of six months when total involution of the genital tract is established. 
    • Health education to puerperal women at this time should also include instructions related to the possibility of encountering menstrual irregularities during the following months. These irregularities range from complete amenorrhea to oligo-menorrhea, hypomenorrhae or polymenorrhea. Bleeding is expected at the end of the 6th puerperal week in the majority of patients. In non-lactating mothers, however, menstruation usually appears after 6-8 weeks. On the other hand, lactating women may have great variations in this respect: about 1/3 of them will start menstruation 3 months postpartum, and by the 6 month more than half of them will menstruate. 
    • The Third Visit      This is performed at the end of 3 months (12 weeks) by which time complete involution of the genital tract has occurred. General and local examinations are carried out, and any discovered lesion should be dealt with: Cervical erosions must be cauterized. Persistent RVF and/or prolapse should be managed properly. If lactational amenorrhea is present, the client should be instructed that this is not a bar against another pregnancy, and suitable contraceptive measures should be instituted.
    • Discharge Instructions Patients and their families should be instructed to call the healthcare provider if the patient has any of the following:  Fever  Foul-smelling lochia  Large blood clots, or bleeding that saturates a pad in 1 hour
    • Discharge or severe pain from incisions  Hot, red, painful areas on the breasts or legs  Bleeding and severe pain in the nipples  Severe headaches or blurred vision  Chest pain or dyspnea without exertion  Frequent, painful urination 
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