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  1. 1. Maternal and Child Health NursingPostpartum MATERNAL and CHILD HEALTH NURSING POSTPARTUM Lecturer: Mark Fredderick R. Abejo RN, MAN_____________________________________________________________________________ .I. PHYSIOLOGICAL MATERNAL CHANGESA. LOCHIA – discharge from the uterus during the first 3 weeks after delivery.Increasing Lochia as the day passes by may indicate Heparin Intoxication.LOCHIAL CHANGESLOCHIA RUBRA • Dark red discharge occurring in the first 2-3 days. • Contains epithelial cells, erythrocytes and decidua. • Characteristic human odor.LOCHIA SEROSA • Pinkish to brownish discharge occurring 3-10 days after delivery. • Serosanguineous discharge containing decidua, erythrocytes, leukocytes, cervical mucus and microorganisms. • Has a strong odor.LOCHIA ALBA • Almost colorless to creamy yellowish discharge occurring from 10 days to 3 weeks after delivery. • Contains leukocytes, decidua,epithelial cells, fat, cervical mucus, cholesterol crystals, and bacteria. • Has no odor.B. UTERUS • Process of involution takes 4-6 weeks to complete. • Weight decreases from 2 lbs to 2 oz. • Fundus steadily descends into true pelvis; Fundal height decreases about 1 fingerbreadth (1 cm)/day; by 10-14 days postpartum, cannot be palpated abdominally.MCHN Abejo
  2. 2. Maternal and Child Health NursingPostpartumC. Uterine Involution 1. Description a. The rapid decrease in the size of the uterus as it returns to the nonpregnant state b. Clients who breastfeed may experience a more rapid involution 2. Assessment a. Weight of the uterus decreases from 2 pounds to 2 ounces in 6 week b. Endometrium regenerates c. Fundus steadily descends into the pelvis d. Fundal height decreases about 1 fingerbreadth (1 cm) per day E. By 10 days postpartum, uterus cannot be palpated abdominallyNOTE: Deviation of the fundus to the right or left and location of the fundus above the umbilical are signs that thebladder is distendedNOTE: Height of the Umbilicus on the First Postpartum DayThe height is usually SLIGHTLY below the umbilicus about 24 hours after delivery. The top of the umbilicus isnormally MIDWAY between the umbilicus and the symphysis pubis.D. Breasts 1. Breasts continue to secrete colostrum 2. A decrease in estrogen and progesterone levels after delivery stimulates increased prolactin levels, which promote breast milk production. 3. Breasts become distended with milk on the third day 4. Engorgement occurs in 48 to 72 hours in non breast feeding mothers.NOTE:Bradycardia is a normal physiologic change for 6-10 days postpartumE. Gastrointestinal tract 1. Women are usually very hungry after delivery 2. Constipation can occur 3. Hemorrhoids are commonII. POSTPARTUM NURSING INTERVENTIONS Monitor Vital Signs NOTE: Maternal temperature during the first 24 hours following delivery may rise to 100. 4` F (38`C) as a result of dehydration. The nurse can reassure the new mother that these symptoms are normal. Postpartum Exercise Supine Position with the knee’s flexed, and then inhale deeply while allowing the abdomen to expand and exhale while contracting the abdominal muscles. The purpose of this exercise is to strengthen the abdominal muscles. Examples are reaching for the knees; push ups and sits ups on the first postpartum day. Assess height, consistency, and location of the fundus Monitor color, amount, and odor of lochia Assess lochia and color volume Give RhoGAM to mother if ordered. RhoGAM promotes lysis of fetal Rh (+) RBCs. Administer RhoGam as prescribed within 72 hours postpartum to the Rh-negative client who has given birth to an Rh-positive neonate. Rhogam (D) immune globulin is given by intramuscular injection Check episiotomy and perineum for signs of infection. Promote successful feeding. Non-nursing woman- tight bra for 72 hours, ice packs, minimizes breast stimulation. Nursing woman- success depends on infant sucking and maternal production of milk. “Postpartum Blues” (3-7 days) – Normal occurrence of “roller coaster” emotionsMCHN Abejo
  3. 3. Maternal and Child Health NursingPostpartum Sexual activities- abstain from intercourse until episiotomy is healed and lochia ceased around 3-4 weeks. Remind that Assess height, consistency, and location of the fundus breastfeeding does not give adequate protection. Assess breasts for engorgement Monitor episiotomy for healing ( assess dehiscence & evisceration) Assess incisions or dressings of cesarean birth client ( prone to infection) Monitor bowel status ( prone to constipation) Monitor I &0 Encourage frequent voiding (prevent urinary retention which will predispose the mother to uterus displacement & infection) Encourage ambulation ( to prevent thromboplebitis & paralytic ileus Assess bonding with the newborn infant ( to prevent failure to thrive)NOTE: A positive bonding experience is indicated when the mother turns her face toward the baby to initiate eye-to-eyecontact. Observation of new mothers has shown that a fairly regular pattern of maternal behaviors is exhibited atfirst contact with the newborn. The mother follows a progression of touching activities from fingertip explorationtoward palmar contact to enfolding the infant with the whole hand and arm. The mother also increase the timespent in the en face position. The mother arranges herself or the newborn so that her face and eyes are in the sameplane as in her infant.III. POSTPARTUM DISCOMFORTSA. Perineal discomfort Apply ice packs to the perineum during the first 24 hours to reduce swelling after the first 24 hours, applywarmth by sitz bathsB. Episiotomy 1. Instruct the client to administer perineal care after each voiding 2. Encourage the use of an analgesic spray as prescribed 3. Administer analgesics as prescribed if comfort measures are unsuccessfulC. Breast discomfortPREVENTION: The BEST PREVENTION TECHNIQUE IS TO EMPTY THE BREST REGULARLY AND FREQUENTLYWITH FEEDINGS. The 2nd is EXPRESSING A LITTLE MILK BEFORE NURSING, MASSAGING THE BREASTSGENTLY OR TAKING A WARM SHOWER BEFORE FEEDING MAY HELP TO IMPROVE MILK FLOW. Placingas much of the areola as possible into the neonate’s mouth is one method. Other methods include changing positionwith each nursing so that different areas of the nipples receive the greatest stress from nursing and avoiding breastengorgement, which make I difficult for the neonate to grasp. In addition, nursing more frequently, so that aravenous neonate is not sucking vigorously at the beginning of the feedings, AND FEEDING ON DEMAND toprevent over hunger is helpful. AIRDRYING THE NIPPLES AND EXPOSING THEM TO THE LIGHT HAVE ALSOBEEN RECOMMENDED. Warm Tea bags, which contain tannic acid also, will sooth soreness. WEARING ASUPPORTIVE BRASSIERE DOES NOT PREVENT BREAST ENGORGEMENT. APPLYING ICE and LANOLINDOES NOT RELIEVE BREAST ENGORGEMENT.MCHN Abejo
  4. 4. Maternal and Child Health NursingPostpartumINTERVENTION: Measures that help relieve nipple soreness in a breast-feeding client include lubricating the nipples with afew drops of expressed milk before feedings, applying ice compresses just before feedings, letting the nipples air dryafter feedings, and avoiding the use of soap on the nipples.NOTE: Specific nursing care for breast Engorgement 1. Breastfeed frequently 2. Apply warm packs before feeding 3. Apply ice packs between feedingsNOTE: Specific Nursing Care for Cracked nipples 1. Expose nipples to air for 10 to 20 minutes after feeding 2. Rotate the position of the baby for each feeding 3. Be sure that the baby is latched on to the areola, not just the nippleNOTE: Do not use soap on the breasts, as it tends to remove natural oils, which increases the chance of crackednipplesIV. POST PARTUM COMPLICATIONSA. HEMORRHAGE CAUSES SIGNS OF HEMORRHAGE MANAGEMENTThe #1 cause of POSTPARTUM Boggy uterus (does not Fluid replacementHEMORRHAGE IS RETAINED respond to massage) Emergency layPLACENTAL FRAGMENTS. OxygenUterine atony and vaginal & A boggy uterus would be Vital signscervical tears are associated with palpable above the umbilicus and Perineal pad countearly postpartum hemorrhage would be soft and poorly Psychological support contracted.The #2 cause is OVER- Abnormal clots unusual Massaging the lower abdomenDISTENTION OF THE UTERUS pelvic discomfort or headache after delivery is done to maintainfrom more than (10) pounds, Excessive or bright-red a firm uterus, which will aid inOTHERS ARE: 4000 gms, bleeding the clumping down of bloodneonate, excessive oxytocin use, Signs of shock vessels in the uterus, therebyPolyhydramnios and Placental preventing any further bleeding.Disorders. Early Hemorrhage starts on the first 24 hours, or more than 500 “BOGGY UTERUS ml of blood on the first 24 hrs in Uterine atony means that theYou should assess for uterine a Normal spontaneous delivery.. uterus is not firm or it is notatony after a c-section delivery. contracting. The nurse shouldThis is more common after a c- gently massage the uterus whichsection than after a vaginal will contract the uterus and makedelivery. it firm. Clients who are predisposed are usually MULTIPLE GESTATION, POLYHYDRAMNIOS, PROLONGED LABOR and LGA (LARGE GESTATIONAL AGE fetus.B. THROMBOPLEBITIS Inflammation of the vein caused by a clot The positive Homan’s sign indicate is possibility of thrombophlebitis or a deep venous thrombosis that is present in the lower extremities. When assessing for Homan’s sign ask the patient to stretch her kegs out with the knee slightly flexed while dorsiflex the foot. A positive sign is present when pain is felt at the back of the knee or calf. It is normal for a patient on magnesium sulfate to feel tired because it acts as a central nervous depressant and often makes the patient drowsy.MCHN Abejo
  5. 5. Maternal and Child Health NursingPostpartum MANIFESTATION MANAGEMENT CURATIVE Edematous extremities Preventive Immobilize extremity Fever with chills Analgesics Pain and redness in affected Anticoagulant area Thrombolytics Positive Homan’s signC. INFECTION PREDISPOSING FACTORS MANIFESTATION MANAGEMENT Rupture of membranes over Fever Antibiotics 24 hours before delivery Chills Oxytocin Retained placental Poor appetite Analgesics fragments General body malaise Maintain hygiene Internal fetal monitoring Abdominal pain Semi-fowlers positions Vaginal infection Foul-smelling lochia Vital signs Early ambulations Puerperial infection is an Assess lochia infection of the genital tract. Bright red blood is a normal Early signs and symptoms of puerperial infection include lochial finding in the first 24 chills, fever, and flu-like symptoms. It can occur up to one hours after delivery. Lochia month after delivery. should never contain large clots, tissue fragments, or membranes. A foul odor may signal infection, as may absence of lochia.D. MASTITISMCHN Abejo
  6. 6. Maternal and Child Health NursingPostpartum ASSESSMENT MANAGEMENT Elevated temperature, chills,  Instruct the mother in good hand washing and breast general aching, malaise and hygiene techniques localized pain  Apply heat or cold to site as prescribed Engorgement, hardness and  Maintain lactation in breastfeeding mothers reddening of the breasts Nipple soreness and fissures  Encourage manual expression of breast milk or use Inflammation of the breast as a of breast pump every 4 hours result of infection  Encourage mother to support, breasts by wearing a Primarily seen in breastfeeding supportive bra mothers 2 to 3 weeks after  Administer analgesics & antibiotics as prescribed delivery but may occur at any time during lactationE. Postpartum Mood Disorders MOOD DISORDERS ASSESSMENTPostpartum Blues Onset: 1-10 days postpartum lasting 2 weeks or less Fatigue Weeping anxiety Mood instabilityPostpartum Depression Onset: 3-5 days lasting more than 2 weeks ConfusionNormal processes during Fatiguepostpartum include the withdrawal Agitationof progesterone and estrogen and Feeling of hopelessness and shame “let down feeling”lead to the psychological response Alterations in mood “roller coaster emotions”known as "the blues." Appetite and sleep disturbance Postpartum depression is apsychiatric problem that occurs According to Rubin, dependence and passivity are typical during the taking-later in postpartum and is in period, which may last up to 3 days after delivery. A client experiencingcharacterized by more severe postpartum depression demonstrates anxiety, confusion, or other signs andsymptoms of inadequacy. symptoms consistently. Maternal role attainment occurs over 3 to 10 months.Because the clients behavior is Attachment also is an ongoing process that occurs gradually.normal, notifying her physician andconducting a home assessmentarent necessary. Onset: 3-5 days postpartumPostpartum Psychosis Symptoms of depression plus delusions Auditory hallucinations HyperactivityPOSTPARTUM WARNING S/S TO REPORT TO THE PHYSICIAN  Increased bleeding, clots or passage of tissue.  Bright red vaginal bleeding anytime after birth.  Pain greater than expected.  Temperature elevation to 100.4º F.  Feeling of full bladder accompanied by inability to void.  Enlarging hematoma.  Feeling restless accompanied by pallor; cool, clammy skin; rapid HR; dizziness; and visual disturbance.  Pain, redness, and warmth accompanied by a firm area in the calf.  Difficulty breathing, rapid heart rate, chest pain, cough, feeling of apprehension, pale, cold, or blue skin colorMCHN Abejo
  7. 7. Maternal and Child Health NursingPostpartumV. Psychological Adaptation Psychological AdaptationTaking-in Phase Postpartum blues: overwhelming sadnessTaking-hold Phase Postpartum depressionLetting-Go Postpartum PsychosesRubins Postpartum Phases of Regeneration (POSTPARTUM PSYCHOSOCIAL ADAPTATION)“TAKING IN” PHASE (DEPENDENT) First 3 Days During this time, food and sleep are a major focus for the client. In addition, she works through the birthexperience to sort out reality from fantasy and to clarify any misunderstandings. This phase lasts 1 to 3 days afterbirth. The primary concern is to meet her own needs. • Takes place 1-2 days postpartum • Mother is passive and dependent; concerned with own needs. • Verbalizes about the delivery experience. • Sleep/food important. • Mother focuses on her own primary needs, such as sleep and food Important for the nurse to listen and to help the mother interpret the events of delivery to make them more meaningful Not an optimum time to teach the mother about baby care “TAKING HOLD” PHASE (DEPENDENT/INDEPENDENT)The client is concerned regarding her need to resume control of all facets of her life in a competent manner. At thistime, she is ready to learn self-care and infant care skills. • 3-10 days postpartum • Mother strives for independence and begins to reassert herself. • Mood swings occur. May cry for no reason. • Maximal stage of learning readiness. • Mother requires reassurance that she can perform tasks of motherhood. • Begins to assume the tasks of mothering • An optimum time to teach the mother about baby care.“LETTING GO” PHASE (INTERDEPENCE) • 10 to 6 weeks postpartum • Realistic regarding role transition. • Shows pattern of life-style that includes the new baby but still focuses on entire family as a unit. • Accepts baby as separate person. Mother may feel deep loss over separation of the baby from part of the body and may grieve over the loss Mother may be caught in a dependent/independent role, wanting to feel safe and secure yet wanting to make decisions Teenage mothers need special consideration because of the conflict taking place within them as part of adolescenceMCHN Abejo