Post Partal Assessment

POST PARTAL ASSESSMENT

POSTPARTAL ASSESSMENT

ALERT : Assess client for post partal complications. The puerperium is the period of time spanning the first 6 weeks after delivery. It is the period of time in which the body adjust both physically and psychologically to the process of childbearing.

Physiological Changes

UTERUS

Uterine involution: process by which the uterus return to its prepregnant condition.

Immediately after delivery, top of fundus is several finger breadths above the umbilicus.

Twelve hours after delivery, fundus is one finger breadth above the umbilicus.

Fundus recedes/descends into the pelvis approximately one finger breadth per day.

By day 10, fundus is below the symphisis pubis and not palbable.

Afterpains: alternate contractions and relaxation of the uterine muscle.

Lochia

Lochia rubra - dark red discharge; occurs the first 3 days.

Lochia serosa - pinkish, serosangineous discharge;last 3-10 days

Lochia alba - creamy or yellowish discharge; occurs after the

-Tenth day and may last a week or two.

When lochia subsides, uterus is considered closed; postpartal infection is less likely.

CERVIX

May be stretched and swollen

Small lacerations may be apparent.

External os closes slowly; at the end of the first week after delivery, the opening is at the fingertip size.

VAGINA

Does not return to its original prepregnant state.

Rugae reappear in 3 weeks.

Labia majora and minora are more flabby.

PERINEUM

May be bruised and tender.

Pelvic floor and ligaments are stretched.

Muscle tone is restored by kegel exercises .

OVULATION AND MENSTRUATION

Non-breast-feeding women.

Menstruation resumes in 6 weeks

Ovulation; 50% may ovulate during the first cycle.

Lactating women

Varies

45% resume menstruation within 12 weeks after delivery.

ABDOMEN

Soft and flabby

Possible separation of the abdominal wall; diastasis recti.

Muscle tone can be restored within 2 to 3 months with exercise.

BREAST

Anterior pituitary releases prolactin, which stimulates secretion of milk.

Engorgement may occur approximately 36-48 hours after delivery.

Colostrum (thin, yellowish fluid) is released.

Contains antibodies(immunoglobulin A is 90% of the immunoglobulin present) along with more protein, fat- soluble vitamins (E,A,K) and more minerals such as sodium and zinc.

Colustrum has a laxative effect o the newborn; promotes expulsion of bilirubin-laden meconium.

Also encourages the colonization of the intestines with Lactobacillus bifidus, which are bacteria that inhibit the growth of pathogenic bacteria, fungi, and parasites.

GASTROINTESTINAL SYSTEM

Immediately after delivery, hunger is common.

Gastrointestinal tract is sluggish and hypoactive because of decrease muscle tone and peristalsis.

Constipation may ba a problem.

URINARY TRACT

Risk for urinary tract infection is increased, if client was catheterized during labor and delivery.

May have bruising and swelling caused by trauma around the urinary meatus.

Increased bladder capacity, along with decreased sensitivity to pressure leads to urinary retention.

Diuresis occurs during the first 2 days after delivery.

Bladder distention may displace the uterus, leading to a boggy uterus and increase risk for atony.

VITAL SIGNS

Temperature maybe slightly elevated after a long labor; should return to normal within 24 hours.

Blood pressure maybe slightly decreased after delivery; however it should remain stable.

Pulse rate slows after delivery; puerperal bradycardia rate is 50-70 beats per minute;usually returns to normal after 10 days.

BLOOD VALUES

Leukocytosis is present; WBC count of 20-30,000/min

Hemoglobin and hematocrit values and red blood cell count return to normal within 2-6 weeks.

Pregnancy induced increase in coagulation factors during the first week after delivery leads to increased risk of development of thrombophlebitis and thromboembolism.

WEIGHT LOSS

Initial 10-12 lb loss is from the weight of the infant, placenta, and amniotic fluid.

Diuresis leads to an additional 5 lb weight loss.

6-8 weeks after delivery; return to normal prepregnant weight if an average if an average of 25-30 lbs. was gained.

ATTACHMENT: PSYCHOLOGICAL RESPONSE

Phases:

Taking-in phase

First few days after delivery.

Characterized by passiveness and dependency.

Mother is preoccupied with her own needs; food attention, and physical comforts and care.

Talkative

Taking-hold phase

Occurs about 2-3 days after delivery; characterized by increase in physical well being.

Emphasis on the present; woman takes hold of the task of mothering; requires reassurance.

Very receptive to teaching.

. Letting –go (Independent)

Characteristics

Usually evident by fifth or sixth weeks

Show pattern of life style that includes new baby but still focuses on entire family as unit

Reestablishment of husband –wife

Mother may still fell tired and overwhelmed by responsibility and conflicting demands on her time and energies

Psychosocial Changes

A. Adoption to Parenthood

Motor skills – new parents must learn new physical skill to care for the infants (e.g. feeding holding, burping, changing diapers, skin care)

Attachment skills

a. Bonding

-The development of a caring relationship with the baby, which includes:

- Claiming- identifying the way in which the baby looks or acts like members of the family

- Identification – establishing the baby’s unique nature (assigning the baby his/her own name)

- Attachment – is facilitated by positive feedback between baby and caregivers

b. Sensual Response

*Touch – important communication with the baby

Eye to eye contact – forms a trusting relationship

Voice – baby respond to higher pitched voice that parent use in talking to the baby

Odor – baby quickly identify their own mothers breast milk and scent.

POSTPARTUM NURSING CARE Nursing alert!!! Perform postpartum assessment and instruct client on postpartum care. Goal : To initiate routine postpartum assessment 1. General observations of mood, activity level, and feeling of wellness; routine vital sign assessment. 2. Inspection of breast; Check for beginning engorgement and presence of cracks in nipples, any pain or tenderness, progress of breast feeding. 3. Check uterine fundus; determine height of fundus in relation to umbilicus; should feel firm and globular. 4. Assess for bladder distention, especially during the first 24-48 hours after delivery.

5. Perineal area: -observe episiotomy site : evaluate healing status of episiotomy, apply anesthetic sprays or ointments to reduce pain -Determine whether hemorrhoids are present, and if so provide relief measures. -Lochia: record the color,odor, and amount of discharge -Lower extremities: assess for thrombophlebitis; -Abdomen and perineum: Initiate strengthening exercises for both abdominal wall and perineum. (e.g. kegels)

Goal : To provide comfort and relief of pain . Episiotomy : ice packs for first few hours, followed by peri light, hot sitz baths. Perineal care : use of “peri bottles” to squirt warm water over perineum (front to back) to prevent contaminations and avoid use of toilet tissue. Afterpains; use of analgesics (preferably 1 hour before feeding, especially for breastfeeding mothers.) hemorroidal pain . Sitzs baths, analgesic, rectal suppositories, Encourage lying on side and avoidance of prolonged sitting. Stool softener or laxatives may be indicated; client usually has a normal bowel movement usually by second or third day postpartum. Breast engorgement ; well fitting bra should be worn to provide support.

Goal : To promote maternal-infant attachment and facilitate integration of the newborn into the family unit.

Use infant’s name when talking about him or her.

Serve as a role model; be cautious not to appear too expert in handling the infant because it may lead to feelings of discouragement in the mother.

Assist parents in problem solving and meeting their infants needs. Explain ways to distinguish different types of cries- those related to hunger, illness, or discomfort.

Encourage parents to provide as much of the care to the infant as possible while in the hospital.

Accept parents emotions and encourage expression of feelings.

Help parents understand sibling behavior to plan for the arrival of the new family member.

Goal: To establish successful infant feeding patterns .

Non-lactating mother

-Provide supportive bra

-Explain proper position for feeding.

-Formulas; ready to feed in disposable bottles, often with disposable nipples.

Lactating mothers

Avoid the use of nipple creams, ointments or any topical preparations.

Teach mother to avoid using sunlamps or hair dryer to dry nipples.

Application of expressed breast milk to nipples after each feeding has a bacteriostatic effect and may protection to damaged skin.

Asses breast for engorgement, nipple inversion, cracking, inflammation, or pain.

Types of feeding positions

Cradle position, side lying, football or clutch position, and modified clutch positions.

Teach mother to:

Bring infant to level of the breast; don’t lean over.

Turn infant completely on side with arms embracing the breast on either side

Bring infant in as close as possible with legs wrapped around the mothers waist and the tip of the nose touching the breast.

Bring infants lips to nipple; when infant opens mouth to the widest point, draw the infant the rest of the way on to the nipple for him to latch on.

Break the suction by placing a clean finger in the side of the infants mouth before removing the infant from the breast.

Infant should be put to breast 8-12 times per day.

EVALUATING BREASTFEEDING

How do you know that an infant is getting enough breast milk?

Hear infant swallow and make “ka” or “ah” sounds.

See smooth nutritive suckling, smooth series of sucking and swallowing with occasional rest periods, not the short, choppy sucks that occur when the baby is falling asleep.

Breast gets softer during the feeding

Breast-feeding 8-12 times per day; more milk is produced with frequent breast-feeding.

Infant has at least 2-6 wet diapers per day for 1st 2 days after birth; 6-8 diapers per day by the 5th day.

Infant has at least 3 bowel movements daily during the 1st month and often more.

Infant is gaining weight and is satisfied after feedings.

COMPLICATIONS OF THE PUERPERIUM

HEMORRHAGE

Assessment;

Risk factors:

Precipitous labor

2. dystocia

3. premature separation of placenta

4. forceps delivery

5. multiple pregnancy

6. large fetus

7. polyhydramnios

Causes:

1. Uterine atony

2. Lacerations

3. Retained placental tissue

Clinical manifestations:

Early postpartal hemorrhage; blood loss greater than 500ml after 24 hours after delivery.

Late postpartal hemorrhage; blood loss greater than 500ml after the first 24 hours.

Symptoms of shock; weak, rapid pulse; low blood pressure; pallor; restlessness; etc.

Treatment:

Medical:

Uterine atony: oxytoxic medications, bimanual compression of the uterus.

Fluid and blood replacement.

Surgical:

Lacerations; suturing the bleeding edges

Retained placenta; dilatation and curettage to remove retained placenta.

Hysterectomy for uncontrolled bleeding.

NURSING INTERVENTIONS

Goal : To control and correct the cause of the hemorrhage

Uterine atony

Massage uterus to stimulate contractions.

Administer oxytocin

Lacerations:

Inspect perineal area

Hematoma formation

Vulvar hematoma may appear as a discoloration of the perineal area

Any complaint of pain in the perineal area should prompt careful inspection.

Retained placenta:

Inspect placenta at the time of delivery for intactness.

Never force the expulsion of the placenta.

Goal: To maintain adequate circulating blood volume to prevent shock and anemia. Type and crossmatch blood for women at high risk for development of postpartum hemorrhage. Anticipate replacement of IV fluids and blood. Check hematocrit and hemoglobin levels. Treat for shock Monitor vital signs and amount of lochia. Goal: To prevent postpartal infection . Maintain aseptic technique Administer prophylactic antibiotics. Monitor vital signs.

PUERPERAL INFECTION

Puerperal infection is also called childbirth fever.

Assessment

Predisposing factor:

Antepartal infection

Premature rupture of the membranes

Prolonged labor

Laceration

Anemia: postpartal hemorrhage

Poor aseptic technique.

Temp elevation from 38oC, if taken at least 4 times daily on any 2 of the first 10 postpartum days with the exemption of the first 24 hours.

Symptoms vary according to system involved.

Area of involvement is characterized by five cardinal symptoms of inflammation ( redness, pain, edema, and loss of functions)

Tachycardia, chills, and abdominal tenderness are common.

Headache, malaise, deep pelvic pain.

Profuse, foul smelling lochia

Area involved:

Uterus is most often affected: endometritis.

May have localized infection of the perineum, vulva, and vagina.

Local infection may extend via the lymphatics into the pelvic organ resulting in:

thrombophlebitis

salpingitis

oophoritis

peritonitis

septicemia

Urinary system

a. pyelitis

b.Cystitis

Treatment:

Antibiotics

Antipyretics

Diatary; high protein, high calorie, high vitamin diet.

Encourage intake of 3000-4000 ml of fluids per day.

Nursing interventions :

Goal: To prevent puerperal infection .

Maintain meticulous aseptic technique during labor and delivery.

Assess and treat antepartal infection.

Detect anemia: check hematocrit during prenatal visits.

Avoid prolonged labor.

Goal: To promote mother’s resistance to infection .

Administer antibiotic, antipyretic,

Encourage good nutrition

Isolate client from other maternity clients

Use semi-fowlers position to promote free drainage of lochia and prevent upward extension of infection into pelvis.

MASTITIS

Mastitis is the invasion of the breast tissue by pathogenic organisms.

Assessment:

Predisposing factors :

-Fissured nipples

-Erosion of the areola

-Mastitis is most frequently caused by staphylococci, which are transmitted from the nasopharynx of the nursing infant.

Occurs most often between the first and fourth weeks of the postpartal period.

Chills and tachycardia.

Red, swollen, painful breast

Fever

Treatment:

Antibiotics

Antipyretics

Analgesics

Nursing Interventions:

Goal : To prevent the complication of mastitis .

Teach mother to care for breast and nipples.

Explain importance of wearing bra that provides adequate support.

Goal: To promote comfort and maintain lactation .

Frequent breast-feeding, starting on the affected side.

Breast massage before and during each feeding to thoroughly drain any blockages ( a breast pump may be used if the infant is unable to do this.)

Encourage good nutrition and adequate rest.

Application of moist heat; increased intake of fluids and vitamin C.

Administer antibiotics, as ordered.

THROMBOPHLEBITIS

General Information:

Formation of a thrombus when the vein wall is inflamed.

May seen in the legs or pelvis.

May result from injury, infection, or the normal increase in circulating clotting factors in the pregnant and newly delivered woman.

Assessment findings :

Pain/discomfort in the area of thrombus (legs, pelvis, abdomen)

If in the leg, pain, edema, redness over affected area.

Elevated body temperature and chills.

Peripheral pulses may be decreased.

If in a deep vein, legs may be cool and pale

Nursing Interventions:

Maintain bed rest with legs elevated on pillow.

Never raise knee gatch on bed.

Apply moist heat as ordered.

Administer analgesics as ordered.

Provide bed cradle to keep sheets off leg.

Administer anticoagulant therapy as ordered. (usually heparin), and observe for signs of bleeding.

Apply elastic support hose if ordered, with daily inspection of legs with hose removed.

Teach client not to massage legs.

Allow client to express fears and reactions to conditions .

SUBINVOLUTION

General Information:

-Failure of the uterus to revert to prepregnant state through gradual reduction in size and placement.

-May be caused by infection, retained placental fragments, or tumors in the uterus.

Assessment findings:

Uterus remains enlarged.

Fundus higher in the abdomen than anticipated.

Lochia does not progress from rubra to serosa to alba.

If caused by infection, possible leucorrhea and backache.

Nursing Intervention:

Teach client to recognize unusual bleeding patterns

Teach client the usual pattern of uterine involution.

Instruct client to report abnormal bleeding to physician.

Administer oxytoxic medications if ordered.

CYSTITIS AND PYELITIS

Cystitis and pyelitis occur as a result of trauma to the bladder mucosa, the temporary loss of the bladder tone, and an increased bladder capacity. All three lead to distention and incomplete emptying of urine, predisposing the postpartum client cystitis and pyelitis.

Postpartum Depression

Mother experience a “let down” feeling after giving birth

Doubts about ability to cope effectively with the demands of childbearing

This depression is mild and transient beginning 2-3 days after delivery and resolving within 1-2 weeks

4. Mild depression may lead to POSTPARTUM PSYCHOSIS, a pathologic condition

Assessment

Assess maternal and paternal physical and emotional status

Determine what parents know about infant care

Evaluate impact of parents cultural background

Assess readiness for parenthood, emotional maturity, pregnancy planned or unplanned, financial status, jobs

Assess physical conditions of mother prior to pregnancy during labor and delivery and puerperium

Assess physical condition of infant at birth (e.g. prematurely, congenital defects)

Assess opportunities for early parent – infant, interaction

Evaluate parental knowledge of normal growth and development

Nursing Diagnoses

Knowledge deficit

Self-care deficit

Alteration in Family process

Potential alteration in Parenting

Disturbance in self-concept, Role Performance

Planning and Implementation

Provide time for parents to be alone with baby in crucial early time after delivery

Identify learning needs of parents

Plan teaching to include both parents where possible

Help parents realize that fatigue is normal at this time

Help parents identify and strengthen their own coping mechanism

Help parents identify resource available to them

Promote positive self-esteem on part of parents as they learn new roles

Provide initiatory guidance after discharge

Prepare for discharge, reinforce physicians instructions about activities, rest, diet, drugs, exercise, resumption of sexual intercourse, return to postpartum examinations

Evaluation

Mother demonstration increasing levels of competence in carrying out tasks of newborn care

Mother appears relaxed and secure in her interaction with infant

Couple plan time together

Mother does not appear unduly depressed or anxious

Postpartum Psychosis

A more serious and rare condition is postpartum psychosis . It affects about 1 in 1,000 women who give birth and occurs within the first month after labor and delivery. It may include hallucinations, such as hearing voices or seeing things, or feelings of paranoia. A woman can have irrational ideas about her baby — such as that the baby is possessed or that she has to hurt herself or her child. This condition can be extremely serious and disabling, and new mothers who are experiencing these symptoms need medical attention right away.

Women who have other psychiatric illnesses, such as bipolar disorder or schizoaffective disorder, may be at greater risk of developing postpartum psychosis. Postpartum psychosis requires immediate medical attention and, often, a brief hospitalization. If you or someone you know is experiencing symptoms, don't delay getting medical attention.