POSTPARTUM MANAGEMENT

Out Line:

• Introduction of post partum care• Physical and psychosocial post partum care• Examples of physical &psychosocial midwifery

diagnosis in the post partum care • Expected out comes for post partum care • Physiological needs during post partum• Cultural aspects and beliefs about post partum

Out -line

• Post partum care • Discharge teaching • Follow up after discharge

Introduction

• The goal of midwifery care in the immediate post partum period is to assist women and their partners during their initial transition to parenting

Cont---

• The midwives provided care that focuses on:• The woman physiologic recovery• Psychological well being• Her ability to care for her self and her

newborn

Post partum physical assessment

• Physical assessment- Vital signs- Evaluation of breast-Uterine fundus-Lochia (amount ,color, odor)-perineum area

Cont—physical assessment

-Bladder and bowel function -Energy level -Appetite

Cont-

• Check laboratory test immediate for -Hb, hematocrite ,urine analysis

• Check signs of potential complication

Signs of potential complications

• Temperature --- more than 38 c after the first 24hrs

• Pulse--- tachycardia ,marked Brady cardia

• Blood pressure---hypotension or hyper

Cont-signs

• Energy level ---lethargy ,extreme fatigue• Uterus---deviated from the mid line ,boggy

consistency, remains above the umbilicus after 24 hrs

• Lochia---heavy, foul odor ,bright red bleeding that is not lochia

Cont-

• Perineum---pronounced edema, not intact, signs of infection, marked discomfort

• Breasts ---redness, heat, cracked and fissured nipples, inverted nipples, palpable mass

Cont--

• Elimination -urine: inability to void, urgency, frequency,

dysuria -bowel: constipation, diarrhea

Midwife DX

• Acute pain RT• Risk for constipation RT• Disturbed sleep pattern RT• Ineffective breast feeding RT• Risk for infection RT

Expected out come of care

• Remain free from infection • Demonstrate normal involution and lochial

characteristic

Cont—Expected

• Demonstrate normal bladder and bowel elimination patterns

• Protect the health of future pregnancies and children

Physical care during post

partum period

Physical care

• Prevention of infection by: -apply hand washing techniques to prevent

cross- infection - maintenance of clean environment -bed linens should be changed as needed

Cont--

-disposable pads should be changed frequently-Supervision of use equipment to prevent

contamination as common sitz bath

Episiotomy ,laceration care:

• Wash hand before and after cleaning perineum and changing pads

• Wash perineum with mild soap and warm water at least once daily

• Cleanse from urethra to anal area • Apply peripad from front to back • Change pad with each void or defecation (more than

4 times /day)

Cont--episiotomy

• Assess amount and character of lochia with each pad change

• Apply covered ice pack to perineum from front to back

• Timing---------? 1- during first 2 hrs to decreased edema formation and

increased comfort 2- after the 2 hrs to provide anesthetic effect

Prevention of excessive bleeding :

• Most frequent cause of excessive bleeding after child birth is uterine atony

• Uterine atony means the failure of uterine muscle to contract firmly

• Accurate visual estimation of blood loss is an important nursing responsibility

Cont---

• Loss of blood is usually described subjectively as :

• scant----less than 2.5cm• Light----less than or equal 10 cm• Moderate—more than 10 cm• Heavy (profuse)—one pad saturated within 2

hrs

Cont--

• Most objective estimate of blood loss include weighting blood clots and items saturated with blood

• Using devices that catch and measure blood flowing from the vagina

• Establishing the milliliters of blood it takes to

saturate perineal pads being used

Evidence

• RCT Found that drape estimation of blood loss is more accurate than visual estimation in detection of post partum hemorrhage

• (patella ,drape estimation vs visual assessment for estimating post partum hemorrhage ,International J of Gyaecology,2006)

Cont-

• midwife must alert if:• A perineal pad saturated in 15 minute or less

or pooling of blood under the buttocks are in indications of excessive blood loss

Cont—

• The most important intervention to prevent excessive bleeding is to:

1-maintenance good uterine tone 2-preventing bladder distention

Maintenance uterine atony

• Gently massaging of the uterine fundus until it’s firm to restore good tone

• Under standing the causes and dangers of

uterine atony and the purpose of fundal massage can help the women to be more cooperative

Evidence

• CRT found that intermittent uterine massage after delivery is effective in reducing post partum hemorrhage and stimulate uterine contraction

• (Abdel-A Leem, uterine massage and post partum blood loss, J of Obstetrics' and Gynecology,2006)

Cont –maintenance

• Teaching the woman to do fundal self massage enables her to maintain some control and decreased her anxiety

Cont--

• midwife should be alert if :• The uterus remains boggy even after massage

and expulsion of clots which indicated the major warning sign of uterine atony

Prevention of bladder distention:

• Full bladder causes the uterus to be displaced above the umbilicus and well to one side of the mid line in the abdomen

• Also prevents the uterus from contracting normally

Cont-

• midwife intervention focus on : -helping the woman to empty her bladder as

soon as possible by assist to bathroom or onto bed pan if she unable to ambulate

The mother should void spontaneously within 6-8 hrs after giving birth

Cont-

• Having the woman listen to running water, placing her hands in warm water or pouring water from a squeeze bottle over her perineum can stimulate voiding if the woman isn’t able to void spontaneously

physiological needs during

post partum period

Physiological needs

1-Comfort -causes of discomfort: -after birth pains -episiotomy -perineal lacerations -hemorrhoids -breast engorgement

Cont-physiological needs

• Management:• First, the mide assess the type and severity of

pain to choose an appropriate intervention• Inspect and palpate areas of pain for redness,

swelling ,discharge and observe body and facial tension

• Non pharmacologic interventions include:• Warmth, distraction, deep

breathing ,therapeutic touch, relaxation and inter action with the infant may deceased the after pains discomfort

Cont-

• for episiotomy, perineal laceration discomfort:• Encouraging the woman to lie on her side • Use pillow when sitting • Use ice pack

Cont-

• For breast engorgement discomfort -heat- ice compresses according to breast or

bottle feeding -cold cabbage leaves to breasts -wearing of well fitted support bra

Cont--management

• Pharmacologic management include:

-narcotic or non narcotic medication -topical application of antiseptic or anesthetic

ointment or sprays

CONT

2-Rest & sleep • Causes of fatigue: -excitement and exhilaration after birth -long labor -infant behavior and demands -Breast feeding

Cont-rest& sleep• Management• Establish woman's routine sleep patterns and

compare with current sleep pattern ,exploring things that interfere with sleep to determine scope of problem and direct intervention

• Provide asleep -promoting environment to mother

as quiet environment • The nurse can help the family limit visitors and

provide comfortable bed for partner

Cont-sleep& rest

• Administer sedation or pain med to enhance quality of sleep

• Teach woman's to use infant nap time as time

for her to nap and decreased fatigue

Ambulation:

• Early ambulation is successful in reducing the incidence of thrombo embolism and promote the woman's more rapid recovery of strength

• Nurse should be consider the base line of BP, amount of bld loss, type ,timing of analgesic when assisting woman to ambulate

Exercise:

• Begin soon after birth • Woman should be encouraged to start with

simple exercise and gradually progress to more strenuous ones

Evidence

• Exercise in the post partum period is shown to produce a more relax mother-child relation ship ,combat depression and improve perception of the new relation ship

• Exercise help new mother sleep better and have less anxiety

• ( Shelby, exercise in the post partum period ,J of health,2006)

cont

• Kegel pelvic exercise are extremely important to strengthen muscle tone and maintaining urinary Continence

• Woman must learn to perform the kegel exercises correctly ……..??

Cont—exercise

• The health care provider can teach and assess the woman's techniques during the pelvic examination at the 6 weeks check up by – inserting tow fingers intra vaginally and checking whether the pelvic floor muscle correctly contract or relax

Evidence

• Correct contraction of pelvic muscles at least 10 sec and then relaxing and repeating it for 10-20 times help in strengthening the muscle and promote the healing of perennial tissues during post partum period

• Incorrect pelvic muscle exercise lead to increased risk of incontinence

• (Pauline C ,Women's knowledge, practices and intentions regarding correct pelvic floor exercises ,2002)

nutrition

• Most woman display a good appetite and eat well

• Nutritious snacks are usually welcomed • Cultural dietary preferences must be

respected • Prenatal vitamins and iron supplement are

often continued until 6 weeks post partum

Cont--

• Increased fluid &fruit intake to promote bowel patterns

Breast feeding

• The first 2 hrs after birth are an excellent time to encourage the mother to breast feeding

• The infant is an alert state and ready to feeding

Evidence

• Infants who are breast feed are better prepared to fight off infections and allergens as they grow

(Shealy K, The CDC Guide to breast feeding intervention ,2005)

Health promotion of future pregnancies and children

• Prevention of RH iso immunization by:

-injection of RH immune globulin (a solution of gamma globulin that contains RH antibodies) within 72 hrs after birth

cont

- to prevent sensitization in the RH-negative woman who has had afeto maternal transfusion of RH positive red bld cells

- -RH immune globulin promote lysis of fetal RH positive bld cells before mother forms her own antibodies

cont

• Administration of 300mg(1 Vail) of RH immunoglobulin IM is usually sufficient to prevent maternal sensitization

• Can you given RH before the child birth ??

Rubella vaccine

• For women who have not had rubella (10%-20%)

• Injection of rubella vaccine S/C is recommended before discharge

• Breast feeding mother can be vaccinated ….?

Cont

• The live attenuated rubella virus is not communicable--- so the woman who breast feeding can vaccinated

• Woman must under stand that they must practice contraception to avoid pregnancy for 2-3 months after being vaccinated…….???

Psychosocial assessment during post partum

Impact the birth experience

• By inviting the partners to review the events and describe how they feel ,helps the nurse to assess how they under stand what happened and how well they have been able to put their child birth experience into perspectives

Maternal self-image

• Assess how this new mother feels about herself and her body during the post partum

• Her feels may reflect of her behavior and adaptation

to parenting

Maternal adaptation

• The majority 50%-70% of new mother have a psychological reaction after birth that is often referred to as post partum blues or baby blues

• The cause unknown but may well be a transient response to the rapid role changes that occur as women adapt to mother hood

Cont--

• Symptoms very widely from woman to woman include insomnia, irritability ,anxiety, mood swings.

• These symptoms usually appear within first week after birth and generally disappear by 10 days of post partum

Cont--

• Extra rest ,physical and emotional support ,sympathetic under standing from family and friend are usually sufficient to help women cope with this reaction

Parent-infant interaction

• Assess the mothers and fathers reaction to and inter action with the new baby

• positive parent –infant interaction include: taking pleasure in their infant

• In the tasks done for and with him or her • Under standing their infants emotional states and

providing comfort

Family structure and functioning

• Nurse can help to ease the new mothers return to home by:-

-identifying possible conflicts among family members -helping the woman plan strategies for dealing with

these problems before discharge

Impact of cultural diversity

• Nurses are likely to come contact with women from different countries and cultures

• Nurse must remember that all cultures have developed safe and satisfying methods of caring for new mothers and babies

Midwifery DX

• Impaired parenting RT• Anxiety RT• Risk for situational low self -esteem RT

Expected out of comes

• Identify measures that promote a healthy personal adjustment in the post partum period

• Maintain healthy family functioning based on cultural norms and personal expectations

Cultural considerations

• Arabic women eat special meals designed to restore their energy

• They are expected to stay at home for 40 days after delivery to avoid illness resulting from exposure to the out side air

Cont -

• Chinese ,Mexican, Korean and south east woman may wish to eat only warm foods and drink hot drinks to replace blood loss and to restore the balance of hot and cold in their bodies

cont

• Stay warm and avoiding bathing ,exercises and hair washing for 7-30 days after child birth

• Haitian women may request to take the placenta home to bury or burn

Psychosocial care

• midwife function in the roles of teacher ,encouragement and support rather than doer

• Promotion of parenting skills, family member adjustment to the newest member

• Considered cultural issues

Parent-infant attachment is influenced by:

– Involvement with woman’s own family. – Stability of relationships and home environment. – Mother’s ability to trust. – Mother’s level of self-esteem. – Mother’s ability to enjoy herself. – Mother’s knowledge of expectations of

childbearing and child rearing. – Positive reaction to present pregnancy.

Parenting process : is a process of role attainment and role transition that being during pregnancy .the transition ends when the parent develops a sense of comfort and confidence in performing the parental role .the parenting process requires cognitive and affective skill and knowledge

-parental attachment ,bonding and acquaintance :

Attachment :is the process whereby parents come to love and accept a child and a child comes to love and accept a parent, it is linear process beginning during pregnancy ,intensifying during the early postpartum period

Bonding : it is a sensitive period in the first minutes and hours after birth when mother and fathers must have close contact with their infants

Mternal psychological adaptation

• Phases of Psychologic adjustment includes: – Taking-in. – Taking-hold. – Maternal role attainment. – Possibility of postpartum blues.

Maternal adjustment :

1-dependent (taking –in):

.during the first 24-48 hr’s .focus: self and meeting of basic need

.reliance to others to meet needs comfort ,rest,closenes ,nourishment

.exited and talkative .desire to review birth experience

2-dependent-independent (taking –hold) :

.Start second or third day ;lasts 10 days to several weeks

.focus: care of baby and competent mothering

.desire to take charge . Still need for nurturing and acceptance by others

.eagerness to learn and practice –optimal period for teaching by nurses

.handling of physical discomfort and emotional changes

.possible experience with “blues ’’

3 -Interdependent (letting go ) :

.focus: forward movement of family as unit with interacting members

..reassertion of relationship with partner

.resumption of sexual intimacy

.resolution of individual roles

Discharge

• Discharge planning begins at the time of admission to the unit

• reflected in the plan of care developed for each individual woman by:

• Teaching for self care• Signs of complications • Basic instruction regarding resumption of

intercourse, prescribed med

Evidence

• Women who have episiotomies or spontaneous perineal laceration complain of increased perineal pain ,decreased sexual satisfaction after giving birth and delayed return of sexual activity compared with women who give birth with intact perineum

• (Thompson J ,Prevalence and persistence of health problems after child birth,birth,2002)

Cont--

• Routine mother- baby check up• contraception

Prescribed medication

• Many health care provider routinely have women continue to take their vitamins and iron during the 6- weeks post partum specially

• in the breast feeding • Women with lower hematocrite level

Cont--med

• Prescribed pain relief med as analgesic and non steroidal anti inflammatory med

Contraception cultural

• Saudi Arabian and Hispanic women will likely choose the rhythm method

• Muslim couples may practice contraception by mutual consent as long as is not harm to the women as foam and condoms ,the diaphragm ,natural family planning

• Arabic women value large families and sons are especially prized

• During the hospital stay, a concerted effort should be made to provide family planning education.

• Steroidal contraception and its effects on lactation should be discussed.

• If the woman does not nurse her child, menses usually return within 6 to 8 weeks.

• At times, however, it is difficult clinically to assign a specific date to the first menstrual period after delivery.

• A minority of women bleed small to moderate amounts intermittently, starting soon after delivery.

Promoting Breast-feeding

• Assist the woman and infant in the breast-feeding process.– Have the mother wash her hands before feeding

to help prevent infection.– Encourage the mother to assume a comfortable

position, such as sitting upright in the bed or in a chair, or lying on her side.

– Have the woman hold the baby so that he or she is facing the mother.

• Common positions for holding the baby are the cradle hold, with the baby's head and body supported against the mother's arm, with buttocks resting in her hand; the football hold, in which the baby's legs are supported under the mother's arm, and the head is at the breast, resting in the mother's hand; and lying on the side with the baby lying on his/her side facing the mother

– Teach the woman to bring the baby close to her, to prevent back, shoulder, and arm strain.

– Have the woman cup the breast in her hand in a C position, with bottom of the breast in the palm of her hand and the thumb on top.

– Have the woman place her nipple against the side of the baby's mouth, and when the mouth opens, guide the nipple and the areola into the mouth.

• The baby should latch on so that as much of the areola as possible is in his mouth.

• If the baby has latched on to the nipple only, take the baby off the breast by putting the tip of the mother's finger in the corner of the baby's mouth to break the suction, and then reposition on the breast to prevent nipple pain and trauma.

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– Encourage the woman to alternate the breast with which she begins feeding at each feeding to ensure emptying of both breasts and stimulation for maintaining milk supply.

– Advise the mother to use each breast at each feeding. Begin with approximately 10 minutes at each breast, then increase the time at each breast, allowing the infant to suck until he or she stops sucking actively.

– Pinning a safety pin to the bra as a reminder of which breast to start with at the next feeding is helpful.

– Have the mother breast-feed frequently and on demand (every 2 to 4 hours) to help maintain the milk supply.

– Have the mother air dry her nipples for approximately 15 to 20 minutes after feeding to help prevent nipple trauma.

– Have the mother burp the infant at the end of the feeding to help release the air in the stomach and to make the infant less fretful.

• Alert the mother that uterine cramping may occur, especially in multiparous women, because of the release of oxytocin, which can be worse in women with lessened uterine tone.

• Commonly referred to as afterpains.• Teach the mother to provide for adequate rest and to avoid

tension, fatigue, and a stressful environment, which can inhibit the letdown reflex and make breast milk less available at feeding.

• Advise the woman to avoid taking medications and drugs without health care provider approval because many substances pass into the breast milk and may affect milk production or the infant.

Early Discharge

• The issue of third-party payers dictating inappropriately short lengths of hospital stays following labor and delivery is now regulated by Federal law.

• In 2003, the norms are hospital stays of up to 48 hours following uncomplicated vaginal delivery and up to 96 hours following uncomplicated cesarean delivery (American Academy of Pediatrics and the American College of Obstetricians and Gynecologists, 2002).

Follow- up after discharge

• Home visit• Home visit to new mothers and babies within

few days of discharge can help bridge the gap between hospital care and routine visits to health care providers

• Arrangements must be made to ensure that the neonate receives appropriate follow-up care.

• Any neonate discharged early should be term, normal, and have stable vital signs.

• All laboratory studies should be normal, including direct Coombs test, bilirubin, hemoglobin and hematocrit, and blood glucose.

• Abnormal maternal serological tests (e.g., syphilis and hepatitis B surface antigen) should be addressed.

• Initial hepatitis B vaccine should be administered, and all screening tests required by law should be performed.

• These always include testing for hypothyroidism and phenylketonuria (PKU).

• If subsequent PKU retesting is required after the neonate has consumed milk, the mother must be so instructed.

• Finally, the importance of subsequent neonatal and well-baby care should be stressed and an emphasis placed on infant immunizations.

Evidence

• RCT found that post partum home visits significantly increased exclusive breast feeding and reduce the need for more expensive health care

(Hyam N,Effect of post natal home visit on maternal/infant out come in Syria 2008)

Late Maternal Morbidity

• Glazener and co-workers (1995) surveyed health problems in 1249 British mothers after discharge and up to 18 months.

• Of these, only 3 percent required readmission to the hospital within 8 weeks of delivery.

• 87 percent had milder health problems during the first 8 weeks and 76 percent continued to have a variety of problems for up to 18 months.

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