Transcript Maternal-Child Nursing Care Optimizing Outcomes for Mothers

Chapter 15
Caring for the Postpartal Woman and Her
Family
Gloria Nwagwu MSN, FNP-BC, RN
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Susan Ward
Shelton Hisley
Question?
 The most effective and least expensive treatment of puerperal
infection is prevention. What is important in this strategy?
 a. Large doses of vitamin C during pregnancy
 b. Prophylactic antibiotics
 c. Strict aseptic technique, including handwashing, by all
health care personnel
 d. Limited protein
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Fourth Trimester
 Begins immediately after childbirth
 Puerperium—first 6 weeks after birth
 Close observation—identify hemorrhage and
complications during first critical hour
 Ongoing education and support
Susan Ward
Shelton Hisley
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Safety for Mother and Infant
 Prevent infant abductions
 Check ID bands
 Educate mother about safety measures
Susan Ward
Shelton Hisley
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Early Maternal Assessment
 Vital signs
 Temperature—below 100.4oF (38oC)
 Pulse—bradycardia
 Blood pressure
 Respirations
Susan Ward
Shelton Hisley
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Susan Ward
Shelton Hisley
Fundus
 Immediate postpartum—halfway between the symphysis
pubis and the umbilicus
 1 hour postpartum—level of the umbilicus or one
fingerbreadth above
 Then, descends one fingerbreadth each day
 Assess lochia
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Perineal Assessment
 Sim’s position
 REEDA
 Hemorrhoids
 Teach regarding comfort measures
 If severe, teach how to manually reposition
Susan Ward
Shelton Hisley
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Susan Ward
Shelton Hisley
Postpartum Assessment Guide
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
BUBBLE-HE
 Breasts
 Uterus
 Bladder
 Bowel
 Lochia
 Episiotomy
Susan Ward
Shelton Hisley
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Other Important Components
 Maternal pain
 Homans’ sign
 Mother’s emotional status
 Infant bonding
Susan Ward
Shelton Hisley
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Breast Assessment
 Firmness, filling
 Nodules
 Fissures, cracks
 Blood
 Dried milk
 Erect or inverted nipples
Susan Ward
Shelton Hisley
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Susan Ward
Shelton Hisley
Assessment of Uterus
 Placental expulsion usually occurs within 15 minutes after
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birth
Uterine contractions control bleeding
Technique for uterine palpation
Involution
Subinvolution
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Fundal Assessment
 Location immediately after birth
 Descends 1 cm/day
 Consistency
 Location
 Height
 Measured in fingerbreadths
Susan Ward
Shelton Hisley
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Afterpains
 Occur during process of involution
 More pronounced in multipara
 Nursing care
 Explain cause
 Prone position with abdominal pillow
 Sitz baths
 Encourage ambulation
 Administer mild analgesics
Susan Ward
Shelton Hisley
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Susan Ward
Shelton Hisley
Bladder
 Spontaneous void within 6 to 8 hours pp
 Monitor first voiding
 Anticipate maternal diuresis
 Urinary output may reach 3000 mL/day
 Urine volume, flow returns to pre-pregnant levels within 2
to 3 days pp
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Assessment Findings: Bladder
 Incomplete emptying
 Overdistention
 Urinary retention
 Nursing interventions
 Support and enhance attempts to void
Susan Ward
Shelton Hisley
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Bowel
 Hunger and thirst after childbirth
 Relaxin—depresses bowel motility
 Strategies to prevent constipation
 Early ambulation
 Abundant fluids
 High-fiber diet
Susan Ward
Shelton Hisley
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Susan Ward
Shelton Hisley
Lochia
 Characteristic indicative of status in process of involution
 Lochia rubra
 Lochia serosa
 Lochia alba
 Document amount
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Episiotomy
 1 to 2 inch surgical incision
 Assess REEDA
 Ice for first 24 hours
 Moist heat—Sitz bath
 Dry heat—hot packs
Susan Ward
Shelton Hisley
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Pain Assessment
 Determine source
 Document location, type, and duration
 Administer Tylenol or Ibuprofen
 Sitz bath
 Educate regarding nonpharmacological measures
Susan Ward
Shelton Hisley
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Assess for DVT
 Homans’ sign
 Dorsiflex foot and ask about pain
 Clinical assessment
 Erythema, unequal calf circumference, heat
 Clinical signs are NOT reliable
Susan Ward
Shelton Hisley
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Emotional Status
 Wide range of emotions
 May be sad during first 1 to 2 weeks pp
 Ongoing assessment and education
 Educate regarding “baby blues”
Susan Ward
Shelton Hisley
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Susan Ward
Shelton Hisley
Maternal Physiological Adaptations
 Continued Assessment of the Patient
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Hematological System
 Decrease in blood volume
 Blood loss
 Diuresis
 White blood count increased x 5 to 6 days
 Fibrinogen increased
 Returns to normal by third to fourth week
Susan Ward
Shelton Hisley
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Susan Ward
Shelton Hisley
Hormonal Levels
 Estrogen and progesterone decrease
 Anterior pituitary—prolactin
 Placental lactogen, cortisol, growth hormone, and insulinase
levels decrease
 Insulin needs decrease—“Honeymoon phase”
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Susan Ward
Shelton Hisley
Neurological System
 Altered sleep patterns—maternal fatigue
 Numbness in legs, dizziness
 Safety for infant and mother
 Headaches
 Assess quality and location, and carefully monitor vital signs
 Implement environmental interventions
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Susan Ward
Shelton Hisley
Renal System, Fluid and Electrolytes
 GFR, Creatinine, and BUN return to pre-pregnant levels within 2
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to 3 months
Urinary glucose
Proteinuria
Rapid, sustained natriuresis and diuresis
Output may reach 3000 mL/day
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Susan Ward
Shelton Hisley
Respiratory System
 Respiratory alkalosis and compensated metabolic acidosis
may persist
 Decrease in intra-abdominal pressure
 Relief from dyspnea
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Integumentary System
 Hormonal changes cause skin alterations
 Most disappear
 Striae gravidarum
Susan Ward
Shelton Hisley
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Susan Ward
Shelton Hisley
Cardiovascular System
 Delivery of the baby, expulsion of the placenta, and loss of amniotic
fluid can create cardiovascular instability
 Cardiac output remains elevated
 Physiological diuresis
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Immune System
 Rho (D) immune globulin (RhoGAM)
 Rubella vaccination
 Nonimmune status
 Signed consent form
 Avoid pregnancy for 1 month
 Flu-type symptoms may occur
Susan Ward
Shelton Hisley
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Reproductive System
 Involution of uterus
 Healing of placental site
 Vaginal changes
 Labia majora and labia minora flaccid
Susan Ward
Shelton Hisley
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Menstruation and Ovulation
 Nonlactating women
 Menstruation returns in 6 to 8 weeks
 First cycle may be anovulatory
 Lactating women
 Delayed ovulation and menstruation
 Educate—ovulation can precede menstruation, need
contraception
Susan Ward
Shelton Hisley
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Gastrointestinal System
 Decreased gastric motility
 Decreased muscle tone in abdominal wall
 Constipation
 Stool softeners
Susan Ward
Shelton Hisley
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Musculoskeletal System
 Laxity of pelvic joints and ligaments
 Relaxation of soft tissues
 Muscle fatigue
 Body aches
 Rectus abdominis diastasis
 Correct posture
 Modified sit-ups
Susan Ward
Shelton Hisley
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Enhancing Cultural Sensitivity
 Conduct cultural assessments
 Expand knowledge and understanding
 Culturally influenced beliefs
 Common health care practices
 Customs and rituals
Susan Ward
Shelton Hisley
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Susan Ward
Shelton Hisley
Question?
 To provide optimum care for the postpartum woman, the nurse
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understands that the most common causes of subinvolution are:
a. Postpartum hemorrhage and infection.
b. Multiple gestation and postpartum hemorrhage.
c. Uterine tetany and overproduction of oxytocin.
d. Retained placental fragments and infection.
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Promoting Recovery
and Self-Care
Susan Ward
Shelton Hisley
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Activity and Rest
 Early postpartum ambulation
 Mild exercises
 Kegel
 Increase gradually
 Encourage frequent rest periods
 Obtain adequate sleep
Susan Ward
Shelton Hisley
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Nourishment
 Weight loss
 Appetite
 Balanced diet
 Multivitamin supplement
 Iron if hemoglobin low
Susan Ward
Shelton Hisley
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Elimination
 Void every 4 to 6 hours
 Monitor intake and output x 24 hours
 Increased risk of infection
 Urinary retention
 Constipation
Susan Ward
Shelton Hisley
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Perineal Care
 Risk of infection
 Teach perineal hygiene
 Hand washing
 Tampons contraindicated
 Cesarean births
 Nurse provides perineal care until ambulatory
Susan Ward
Shelton Hisley
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Ice Packs
 Reduce edema and pain
 Vasoconstriction and numbing
 Apply for 20 minutes every 2 to 4 hours
 First 24 hours
Susan Ward
Shelton Hisley
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Afterbirth Pain
 Intermittent uterine contractions during involution
 Breastfeeding (release of oxytocin)
 Duration: 2 to 3 days
 Mild analgesics
Susan Ward
Shelton Hisley
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Special Considerations
 Women with HIV/AIDS
 Gloves, safety glasses
 Discourage breastfeeding
 Patient teaching for infant safety
Susan Ward
Shelton Hisley
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Postpartal Surgical Patient
 Tubal ligation
 Cesarean birth
 Incisional wound
 Recovery from anesthesia
 Respiratory care
Susan Ward
Shelton Hisley
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Infant Feeding Choices
 Breastfeeding
 Bottle feeding
 Educate
 Support
Susan Ward
Shelton Hisley
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Physiology of Lactation
 Breast structure
 Lactogenesis
 Milk ejection reflex—“let down” reflex
Susan Ward
Shelton Hisley
Maternal-Child Nursing Care
Assisting the
Breastfeeding Mother
Optimizing Outcomes for Mothers, Children, & Families
 Strategies for Success
Susan Ward
Shelton Hisley
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Breastfeeding
 Initiating the feeding
 Achieving proper latch-on
 Assessing for milk let-down
 Assuming a position of comfort
 Assessing for infant weight gain
Susan Ward
Shelton Hisley
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Ineffective Breastfeeding
 Incorrect latch-on (nipple trauma)
 Breast engorgement
 Complementary care
 Ethnocultural considerations
 Collecting and storing breast milk
Susan Ward
Shelton Hisley
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Expressing Breast Milk
 Manual—hand
 Electric pump
 Types of breast pumps
 Storage of breast milk
 Weaning
Susan Ward
Shelton Hisley
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Formula Feeding
 Safe Practices
Susan Ward
Shelton Hisley
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Family and Infant Bonding
 Transition to parenthood
 Assuming the mothering role
 Rubin’s phases
 Paternal bonding
 Factors that interrupt bonding
Susan Ward
Shelton Hisley
Maternal-Child Nursing Care
Adjustment of
Other Family Members
Optimizing Outcomes for Mothers, Children, & Families
 Siblings
 Tips for parents
 Grandparents
Susan Ward
Shelton Hisley
Maternal-Child Nursing Care
Emotional Events
During the Puerperium
Optimizing Outcomes for Mothers, Children, & Families
 First 3 months most vulnerable period
 Baby blues
 Postpartum depression
 Postpartum psychosis
 Physiological response—tiredness, fatigue
Susan Ward
Shelton Hisley
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Susan Ward
Shelton Hisley
Discharge Planning and Teaching
 Maternal Self-Care
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Maternal Self-Assessment
 Fundus and lochia
 Hygiene
 Abdominal incision
 Body temperature
 Elimination
 Nutrition
Susan Ward
Shelton Hisley
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Maternal Self-Assessment
 Fatigue
 Weight loss
 Exercise
 Pain management
 Mood
 Sexual activity and contraception
Susan Ward
Shelton Hisley
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Special Needs Populations
 Adolescent mothers
 Woman placing infant for adoption
 Older mothers
Susan Ward
Shelton Hisley
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Community Resources
 Support groups
 Home visits
 Telephone follow-up
 Outpatient clinics
Susan Ward
Shelton Hisley