POST PARTUM

Lecture 8

Puerperium: to bring forth 6 wk > childbirth. 4th trimester - transition for woman/family (pregnancy ends/parenting role begins)

I. Physiological Changes of Post Partum PeriodA. Reproductive System Changes:UTERUS: contxs begin > birth & delivery of placenta1. placental site seals 2. Entire uterus contracts & reduces gradually for 8-10 days. INVOLUTION. Pt. in danger of hemorrhage uterus until involution is complete. Oxytocin released > uterine contxs.

Fundus: assess for firmness. Palpate > delivery. Remains @ umbilicus X 24 hrs. Soft aka boggy - danger of hemorrhage. Massage uterus! Uterus descends one finger breadth every day. Delivery day, uterus @ umbilicus 1st day PP uterus 1 FB Umbilicus 2nd day PP uterus 2 FB and so forth.Support lower segment of uterus when palpating to prevent uterine eversion.

By day 10, uterus almost back to pre-pregnant size & position in pelvic cavity. [1000 grams 50 grams] No longer palpated in abdomen.

Full bladder raises fundal height, gives false reading. Natural oxytocin released with breast feeding. ^ contractions . 2FB umb. on 1st day PP. Breast fdg.offers little protection against hemorr.

Delay in uterine involution: retained placenta/clots - effective contraction of uterus not possible. Risk of PP Hemorr.Delay also with:multiparous pt. [grand multip ] exhaustion multi-fetuses.C/S involutes slower; d/t surgery & less initiation of breast feeding > delivery.

After-birth pains = cramping caused by contractionsmore in multi-parous women than in primips .With Br. Fdg. because of release of oxytocin.

2. LOCHIAPlacenta separates from spongy layer of uterus - decidua BASALIS. Inner layer of decidua remains & forms new layer of endometrium . Outer becomes necrotic & sheds. Consists of blood, fragments of decidua, mucus, bacteria. 1st 3 days = rubra =red [blood] >3 days = serosa = pink10th day alba - white [up to 3 wks]Total flow lasts about 4-5 wks Should not be bright red; could be PP hemorrhage.

3. CERVIX Neck; remains slightly opened & contracts > delivery.In 7 days, opening narrow as pencil. Os remains slit-like . 4. VAGINASlightly distended after birth. Kegel exercises ^muscle tone and strength. Important for lacerations.

5. PERINEUMCan be edematous/ecchymoticIce x 24 hrs. then heat [Sitz]Topical anesthetics creams/sprays apply for comfort. Perineal massage relaxes perineum before delivery. May prevent episiotomy/laceration. Teach Kegels - tightening & releasing of perineal muscles. Improves circulation & healing of epis/lac.

Complications of Perineum:Hematomas [blood from bleeding vessel] Area of swelling on one side of perineum.If small, absorbs in few days; apply ice & give analgesics. If large bleed, to OR for evacuation & vaginal packing.Common - forceps deliveriesPerineal Care - use warm water; wipe from front to back.

Laceration size of baby, timing of delivery, tension on perineum. Sutured & treated as episiotomies. Analgesics, ice, topical creams, Sitz bath.1st degree = from base of vagina to base of labia minora.2nd = from base of vagina to mid perineum3rd = entire perineum to anal sphincter4th = entire perineum through anal sphincter & some rectal tissue.Nothing into rectum - no rectal temps., suppositories, or enemas with 4th degree to avoid further damage. Colace TID, ^ po fluids to promote BM. Ice X 24 hrs., Sitz baths TID; topicals. KEGELS!

SYSTEMIC CHANGES - Body returns to pre-pregnant state by 6 wks.Hormonal System: Pregnancy hormones decrease w. delivery of placenta. HCG & HPL disappear by 24 hrs. FSH rises 12 days - to begin new menstrual cycle. Menses resumes by 4-5 wks. if not Br. Fdg.

The Urinary System: Loss of bladder tone d/t swelling & anesthesia ; urinating difficult. May not feel urge to void. Hydronephrosis [enlargement of ureters] occurs after delivery & to 4 wks. PP. DIURESIS! bladder sensitivity - risk for bladder infection - urinary stasis.Avoid bladder damage - assess bladder q 1-2 hrs.til voids qs. Teach voiding q 2 3 hours.Palpate abdomen gently, note location of fundus. When do you suspect full bladder?During preg., 2000-3000 ml. of fluid accumulates in body - Client loses 5- 10 lbs. of water weight in 1st wk.How?

Circulatory System: Blood volume ^ 30 50% in pregnancy. With diuresis & blood loss @ delivery, blood volume returns to normal in 1-2 wks. Blood loss for NSVD = 300 cc. & C/S = 500 cc.

Non pregnant: HCT=37 - 47% & HGB=12 - 16g/dLPregnant: HCT=32 -42 % & HGB = 11.5 14g/dLHCT drops by 4 pts. & HGB drops by 1 g. for every 250cc. of blood client loses. Patient should not be anemic entering deliveryPossible blood transfusion with large blood loss.Average blood volume: pre-pregnant = 4000cc; pregnant state = 5250cc.

^ Blood volume: provides adequate exchange of nutrients in placenta & compensates for blood loss during delivery. HR remains ^ x 24-48 hrs. PPWith diuresis, HCT levels rise [^ hemoconcentration] reach pre-preg level by 6 wks.Plasma fibrinogen ^^ 50% during pregnancy & remains elevated 6 wks. PP. [^ estrogen levels] WHY? Can cause ^ thrombus formation.Assess pts. legs/calves for s/s thrombus.Rise in leukocytes; WBC ^ protective measure to prepare for stress of delivery. As high as 20-25,000.

Gastrointestinal System:

NSVD: bowels sounds. Eat right away.C/S: bowel sounds hypoactive 1st 8 hrs. Epidural/spinal: po clears after delivery, advance diet if +BS.General anesthesia: usually NPO for ~ 6-8 hrs. Duramorph/astromorph can cause N/V up to 12 hrs. antiemetic meds. [Reglan/Zofran] .

BM - difficult/painful d/t lacerations/hemmorhoids.C/S - BM 3rd - 4th day. GI activity slowed d/t surgery. Can go home without BM if + flatus.

Integumentary System: Stretch marks [striae gravidarum] appear reddened on abdomen. Fade by 3-6 months; Pearly white marks may remain in lighter skinned pts. & darker marks in darker skinned pts. Modified sit-ups strengthen abdomen

VITAL SIGNS PPTemperature: slightly ^ - dehydration during labor 1st 24 hrs. Returns to normal within 24 hrs.T = 100.4 or > PP infection suspected. Temp. also rises 3rd - 4th day with filling of breast milk Observe for s/s infection - nurse usually 1st to detect temp. [universal sign of infection 100.4 x 2 readings, on days 2-10 PP]Pulse: HR ^ slightly x 1st hr. Stroke volume & cardiac output also ^ x 1st hr. then decreases8-10 wks.,returns to pre-pregnant state. Rapid, thready pulse- sign of PP hemorrhage, infection

Blood Pressure - Monitor carefully.

1st trimester Heart works faster to handle ^ volume. BP remains same.

2nd trimesterBP drops slightly d/t lowered peripheral resistance in blood vessels as placenta expands rapidly. Heart beats faster, more efficiently d/t ^ blood volume. Pre-pregnant BP 120/80. Pregnant BP 114/65.

3rd trimesterBP back to pre-pregnant value.

BP Complications

BP [90/60 or less] with dizziness is Orthostatic hypotension; could signify hemorrhage. Take BP/pulse lying/sitting/standing. Compare values. Orthostatic: If BP drops 15-20 mmHg and pulse increases 20 bpm or more. Caution for falls.Needs IV fluids. Take VS. Report to MD > order for CBC.

BP [140/90 or >] could signify PP pre-eclampsia. Notify MD. Could develop into serious complication.Oxytocic meds [Pitocin] > delivery could ^ BP

Other Changes Exhaustion: CommonFrequent rest periods RN coordinates nursing care & infant feeding times provide maximum rest time.

Weight Loss: Average wt. loss 12 lb. [infant & placenta] 5 lbs. - diuresis & diaphoresis in wk. that follows. Lochial flow - 2-3 lbs. Total = approx. 19-20 lbs. {depends on total wt. gain}At 6 wks. wt. may still be above pre-preg. weight.

Return of Menses: > delivery FSH levels rise causing ovulationNo Br. Fdg.- menses resumes ~ 6 wks. Lactation delays menses for several months (6 mos)

PSYCHOLOGICAL CHANGES OF POST PARTUM PERIOD: ADJUSTMENTS

Taking-In Phase: time of reflection for client regarding new rolemay be passive or excitedtalks at length about birth experienceon phone with family/friends recounting birth experience. Usually lasts 1-2 days. Delayed d/t pain r/t vaginal or C/S.

Taking-Hold Phase: woman makes own decisions regarding self & infant care. Usually day 2 - 3. Occur on day 1 esp. if woman is multip. Can occur later, depends on recovery process or cultural beliefs.

Letting Go Phase: Woman gives up fantasy image of baby and accepts real child. Occurs within few weeks of getting home Needs time to adjust to new experience.

Bonding: Expressing maternal love & attachment toward new baby. Develops gradually. Enface position: close eye contact with infant.Healthy bonding - kissing, touching, counting fingers & toes, cooing, etc.

Factors Interfering with Bonding: difficult labor, separation @ birth (NICU)

Other Maternal Feelings of Post Partum Period

Abandonment: feelings that occur > birth of child; woman no longer center of attention. Disappointment: infant does not meet expectations of mother/father. Eg. eye color; sex .Post Partum Blues: d/t normal hormonal changes; Drop in estrogen/progesterone; lasts 1st few days of PP period. Occurs in 50% of women.

PP Depression: 30% of women exp. this. Therapy & medication may be necessary. Hx of depression & anxiety prior to pregnancy puts mother @ higher risk for developing this. Can manifest itself up to 1 year > birth. Screening tool: Edinburgh PP depression tool

Always refer to social worker to assess for degree of depression.Ask: is mother able to take infant home without danger to self or baby?Studies show breast feeding helps reduce symptoms d/t oxytocin feel good effect

MANIFESTATIONS OF POSTPARTUM DEPRESSION interest in surroundings interest in foodunable to feel pleasurefatiguehealth c/osleep disturbancepanic attacksobsessive thinking hygiene ability to concentrateodd food cravingsirritabilityrejection of infant

PPD: Teachingrelaxation therapyrest & nutritionfrequent contact with other adults

Resource: The Post Partum Resource Center of New York, Inc. 631-422-2255 www.postpartumNY.org

MANIFESTATIONS OF POSTPARTUM PSYCHOSISs/s depression s/s manic auditory hallucinationsdelusionsguiltworthlessness

Development of Parental Love & Positive Family Relationships:

Rooming In: most hospitals offer this; infant stays in room with mom 24hrs. (partial or complete)Sibling Visitation: encourage siblings to visit to promote family togetherness.

LACTATION & BREAST FEEDING

Lactation starts regardless if pt. is breastfeeding or not. Entirely up to mother Must feel comfortable doing so.

Advantages to Breast Feeding: Promotes bonding between mother & baby. High nutritional value for infant. Promotes uterine involution thru release of oxytocin from posterior pituitary. Reduces cost of feeding & preparation time.

Nurse has major role as educator of benefits & methods of breast feeding. Ways to teach new moms about lactation: videos handouts hands on demo lactation specialist [in clinical settings] Offer support

Contraindications to Breast Feeding:Mom receiving meds not appropriate for Br. fdg. [Lithium]Exposure to radioactive compounds [thyroid testing]; pump & dump breast milk x 48 hrs. Flush in toilet.Breast Cancer; HIV

Physiology of Lactation

Body prepares for lactation during pregnancy; stores fat & nutrients; provide energy, vitamins, minerals in breast milk.

Early pregnancy, estrogen (placenta) stimulates growth of milk glands & size of breasts. Colostrum: middle of pregnancy & day 1-3 PP, Thin, watery pre-lactation secretion. Rich in antibodies; passes to baby in 1-3 days. Breasts begin to get tender; fill up w. milk.

Breast milk by 3rd to 4th day in response to:falling levels of estrogen & progesterone > delivery of placenta. ^ production of prolactin by anterior pituitary Milk ducts become distended & fluid turns bluish-white

Physiology cont.Infant suckling on breast produces more prolactin, which in turn stimulates more milk production. Finally, oxytocin released > delivery of placenta causing mammary glands to send milk to nipples [let down reflex]. Progesterone levels drop after delivery which leads to milk production.

Anatomy of LactationColostrum: protein, sugar, fat, water, minerals, vitamins, maternal antibodies. Provides total nutrition for infant Transitional breast milk by 3 4th day. Mature breast milk by 10th day. Each breast - 15-20 lobes of glandular tissue -alveoli. Acinar or alveolar cells of glands form milk.Each alveolus ends in a ductule.Each alveoli produces milk, ejects it into ductules aka let down reflex; milk transported to lactiferous sinus and ejected into infants mouth.

Pathway of Droplet of Milk:

Milk mammary ducts reservoirs behind nipples [lactiferous sinuses] infants mouth

Foremilk: constantly accumulating. Let-down reflex lets foremilk be available right away. Triggered by sound of baby crying Hind milk: forms after let-down reflex. Has most calories; Feed until breast empty. Breast Milk: Provides complete nutrition for 1st 6 mos of life. > 6 months, iron-fortified cereal. Breast milk easier to digest than formula. Iron in breast milk absorbed better than iron in formula.

Supply & Demand Response - Every time woman breast feeds, more prolactin produced which then produces ^milk.Time Interval to milk volume. It takes approx. 30-60 min. to fill up breast after nursing. Assessment: Antepartum ChangesBreasts enlarge [each breast gains ~ 0.5 - 0.9 lb. or more]Glands enlargeIncreased blood flow to breasts, causing blood vessels to enlarge & become more visible.Areola [dark circle around nipple] enlarges and darkensSmall bumps on areola [Montgomerys tubercles] enlarge and produce oils to soften nipples and keep them clean.Teach moms no soap on nipples;may ^ irritation.Lanolin; tea bags [wet] [tanic acid] on sore nipples.

Common Problems:

Engorgement : milk enters on 3rd - 4th day; C/S - prior to D/Cbreasts hard, painful to touch. Warm soaks, hot showers, express milk manually, breast feed q 2-3Pumping produces more milk. Cabbage leaves; diuretic property. nursing bra. tight bra and ice packs x 24-36 hrs why? Analgesics [Tylenol 650 mg. q 4 - 6 hrs.prn]

Sore/Cracked/Bleeding Nipples Common - from improper positioning or not enough areola in infants mouth; may continue to feed; up to mom. Reposition infant. Reattempt nursing. Rest the nipple; apply lanolin ointment prn.Apply tea bag [tanic acid] natural healing property.

Plugged Ductfirm nodule under arm; temporarily blocked duct; relieved by infant sucking. Evaluate carefully since may be malignant growth. Warm compresses prn.Mastitis inflammation; milk duct/gland becomes infected. Poss. antibiotic therapy. Manual expression, continue to breast feed, frequent warm compresses.

Nursing Care : Promote successful breast feeding:

Encourage first feeding [L&D, PP; establish pts. desire to breast feed]Emptying of breasts ~ 20 minutes Teach: start on breast where she left off - maintains good supply.Rest, relaxation, fluids by four 8 oz glasses/day. Not enough fluids, ^ anxiety may lower milk production.Nutritional Counseling: ^ 500 calories/day.

Health TeachingRooting sign of hungerBreast feed q 2-3 hrs. for 20-30 minutes Teach latching: nipple and part of areola to prevent nipple irritation. Listen for swallowing. Nursing BraFeeding & Burping [bottle fed infants] upright positionNipple care: no soap; nipple creams -LansinohAvoid drugs, alcohol, smoking

FORMULA FEEDING

Feeding SkillsPosition upright position- support head and shoulders]Formula [Similac, Enfamil, Isomil; all have iron] milk or soy basedBurp Safety Tipsnever prop bottle; choking or ear infection. ^ amt. -3/4 oz./day; feed q 3 4 hrs. x 24 hrs.

Discharge Follow up: Telephone calls & home visits [if needed] Help line; Support groups [La Leche]

NURSING MANAGEMENT OF POST PARTUM CLIENT

Assessment minimum of twice daily Vital signs Emotional Status Breasts Fundus, lochia, & perineum Voiding & bowel function - flatus, BM Legs [+ Homans sign, ankle edema ] S/S complications [PP hemorrhage, infection, BP ]

Nursing CareSafety Prevent hemorrhage- massage uterus on admission and q 4 for first 8 hrs. Prevent falls assess when getting out of bed for 1st 8 hrs. Assist when necessary. Check labs for low H&H.

Bowel function (1-3 days to resume). Stool softeners, as ordered [Colace] Encourage ambulation Increase dietary fiber Provide adequate fluid intake Health teaching & discharge planning Reinforce self care -hand washing, peri care, Self-breast exam q month; S/S PPDComfort Measures Ice , Sitz Baths, Topical Anesthetics Analgesia, Kegels for NSVD; modified sit-ups for NSVD & C/S, Breast Care

Birth Control PlansFamily Planning options [condoms, depo, OCs, IUD]ExercisesKeep 6 week PP appt.

Maternal Warning Signs to Report a) Heavy Vaginal Discharge [poss. hemorrhage] b) Pelvic or perineal pain [traveling clot] c) Fever [temp 100.4 or greater = infection] d) Burning sensation during urination [UTI] e) Swollen area on leg ; painful, red, or hot f) Breast: painful, red, hot area [mastitis]

Infant care

a] Bathing, cord care, circumcision care, diapering b] Feeding, burping, scheduling feedings [mom can keep chart] c] Temperature, skin color [dusky], newborn rash, jaundice d] Stool & voiding [BMs ; 6 or more voids/day]e] Back to Sleep [SIDS]

Newborn warning signs: 1. Diarrhea, constipation 2. Colic, repeated vomiting esp. projectile vomiting 3. Fever [temp. 100.0 Rectal or greater] 4. S/S inflammation/ infection @ cord stump [yellow drng.] 5. Bleeding @ circumcision site 6. Rash, jaundice 7. Deviation from normal patterns [long period of sleep >5 hrs.; projectile vomiting, etc. R/O sepsis; intestinal obstruction]

**********************Diaphoresis & diuresis.****To prevent hemorrhage.********REVIEW:**********************************Constrict ducts & stop flow & production of breast milk.****************