5. Postpartum

Postpartum

Basic Definitions

Transfer From the Recovery Area

At the end of the fourth stage of labor the woman changes from an intrapartum to a postpartum status. She can remain in the same room with the same care provider or be transferred to a postpartum room in the same or another nursing unit and change care providers. This is an excellent time to review intrapartum events and plan appropriate postpartum care for her and her newborn.

Information that must be communicated to the postpartum nurse includes the following:

ent Name and age of patient

ent Identity of the primary health care provider

ent Gravidity and parity

ent Time of birth

ent Duration of labor and time of rupture of membranes

ent Whether labor was induced or augmented

ent Type of birth (vaginal, operative vaginal [forceps- or vacuum-assisted], cesarean)

ent Anesthetic used

ent Any medications given

ent Intravenous (IV) infusion of any fluids

ent Physiologic status since birth

ent Description of fundus, lochia, bladder, and perineum

ent Laboratory results

ent Blood type and Rh status

ent Group B streptococci status

ent Status of rubella immunity

ent Human immunodeficiency virus (HIV) test result (if positive)

ent Hepatitis B test result (if positive)

ent Syphilis (serology) test result (if positive)

ent Other infections identified during pregnancy (i.e., chlamydia, gonorrhea) and whether these were treated before the birth

ent Sex and weight of infant

ent Any abnormalities noted

ent Chosen method of feeding

ent Name of pediatric care provider

ent Assessment of initial parent-infant interaction

Most of this information is also documented for the nursing staff in the newborn nursery. Other specific information about the newborn that must be communicated to the nursery staff includes the following:

Management of Physical Needs

Assessment

ent Initial postpartum assessment, performed on admission to the postpartum unit (or when woman changes to postpartum status)

ent Vital signs including blood pressure

ent Emotional status

ent Energy level

ent Degree of physical discomfort, hunger, thirst

ent Intake and output assessment (if IV infusion or a urinary catheter is in place)

ent Incisional dressing condition (cesarean birth)

ent Ongoing assessment, performed at least once on each shift throughout her hospital stay; the following components should be included in each assessment:

ent BUBBLE-HE is an acronym for the assessment components.

B Breasts (soft, filling, firm; include condition of nipples)

U Uterine fundus (location, consistency)

B Bowel function (presence or absence of bowel movement)

B Bladder function (volume, color)

L Lochia

ent Lochia rubra—bright or dark red blood—lasts 3 to 4 days

ent Lochia serosa—pink or brown—lasts up to 2 weeks

ent Lochia alba—thin, yellow to white, can last 4 to 6 weeks

E Episiotomy (perineum)

H Homans sign (legs)

E Emotions

SAFETY ALERT

A perineal pad saturated in 15 minutes or less and pooling of blood under the buttocks are indications of excessive blood loss, requiring immediate assessment, intervention, and notification of the physician or nurse-midwife.

NURSING ALERT

The nurse always checks under the mother’s buttocks as well as on the perineal pad. Blood may flow between the buttocks onto the linens under the mother. Although the amount on the perineal pad is slight, excessive bleeding may go undetected.

ent Signs of potential physiologic complications are listed in the box on p. 208.

ent Routine laboratory tests

ent Hematocrit (on first postpartum day) if ordered

ent Rubella status (if no results available on admission to the postpartum unit)

ent Rh status (if no results available on admission to the postpartum unit)

General Care

Newborn Safety

Prevention of Infection

Prevention of Excessive Bleeding

Promotion of Comfort and Rest

Comfort

NURSING ALERT

The nurse should carefully monitor all women receiving opioids because respiratory depression and decreased intestinal motility are side effects.

Rest
Promotion of Ambulation and Exercise

Teaching for Self-Management

Kegel Exercises

Description and Rationale

Kegel exercise, or pelvic muscle exercise, is a technique used to strengthen the muscles that support the pelvic floor. This exercise involves regularly tightening (contracting) and relaxing the muscles that support the bladder and urethra. By strengthening these pelvic muscles, a woman can prevent or reduce accidental urine loss.

Technique

The woman needs to learn how to target the muscles for training and how to contract them correctly. One suggestion for teaching is to have the woman pretend she is trying to prevent the passage of intestinal gas. Have her use this tightening motion on the muscles around her vagina and the upper pelvis. She should feel these muscles drawing inward and upward. Other suggested techniques are to have the woman pretend she is trying to stop the flow of urine in midstream or to have her think about how her vagina is able to contract around and move up the length of the penis during intercourse.

The woman should avoid straining or bearing-down motions while performing the exercise. She should be taught how bearing down feels by having her take a breath, hold it, and push down with her abdominal muscles as though she were trying to have a bowel movement. Then the woman can be taught how to avoid straining down by exhaling gently and keeping her mouth open each time she contracts her pelvic muscles.

Specific Instructions

Other Suggestions for Implementation

Sources: Sampselle, C. (2003). Behavior interventions in young and middle-aged women: Simple interventions to combat a complex problem. American Journal of Nursing, 103(Suppl), 9-19; Sampselle, C. (2000). Behavioral interventions for urinary incontinence in women: Evidence for practice. Journal of Midwifery & Women’s Health, 45(2), 94-103; Sampselle, C., Wyman, J., Thomas, K., Newman, D., Gray, M., Dougherty, M., et al. (2000). Continence for women: A test of AWHONN’s evidence-based protocol. Journal of Obstetric, Gynecologic and Neonatal Nursing, 29(1), 312-317.

SAFETY ALERT

Have a hospital staff or family member present the first time the woman gets out of bed after birth because she may feel weak, dizzy, faint, or lightheaded.

Promotion of Healthy Nutrition

Promotion of Normal Bowel and Bladder Patterns

Breastfeeding Promotion/Lactation Suppression

Breastfeeding Promotion

During the first 3 days of life the breastfed infant receives colostrum, a very concentrated, high-protein fluid containing enzymes, antiinfective agents, hormones, and growth factors. As the baby adjusts to extrauterine life and the digestive tract is cleared of meconium, intake increases from 15 to 30 ml of colostrum per feeding in the first 24 hours to 60 to 90 ml of milk by the end of the first week.

Assisting with Breastfeeding

Positioning

Three of the four basic positions are shown in Figure 5-1.

Initially it is best to use the position that most easily facilitates latch while allowing maximal comfort for the mother.

Before discharge from the hospital, assist the mother to try all four positions so that she will feel confident in her ability to vary positions at home.

Regardless of the position used, the mother should be comfortable.

Latch

ent To facilitate latch:

ent In preparation for latch during early feedings, have the mother manually express a few drops of colostrum or milk and spread it over the nipple.

ent The latch process is shown in Figure 5-2.

ent Mother supports her breast in one hand with the thumb on top and four fingers underneath at the back edge of the areola. The breast is compressed slightly.

ent With the baby held close to the breast and the mouth held directly in front of the nipple, mother tickles the baby’s lower lip with the tip of her nipple, stimulating the mouth to open.

ent When the mouth is open wide and the tongue is down, the mother quickly “hugs” the baby to the breast, bringing the baby onto the nipple.

ent In general, with correct latch, the baby’s mouth should cover the nipple and an areolar radius of approximately 2 to 3 cm all around the nipple.

ent When latched correctly, the baby’s cheeks and chin are touching the breast. Depressing the breast tissue around the baby’s nose to create breathing space is not necessary (Fig. 5-3).

ent When the baby is nursing appropriately, the following occur:

ent Mother reports a firm tugging sensation on her nipples but no pinching or pain.

ent Baby sucks with cheeks rounded, not dimpled.

ent Baby’s jaw glides smoothly with sucking.

ent Swallowing is usually audible.

ent Any time the signs of adequate latch and sucking are not present, the baby should be taken off the breast and latch attempted again.

ent To prevent nipple trauma as the baby is taken off the breast, instruct the mother to break the suction by inserting a finger in the side of the baby’s mouth between the gums and leaving it there until the nipple is completely out of the baby’s mouth (Fig. 5-4).

Milk Ejection or Let-down

As the baby begins sucking on the nipple, the milk-ejection, or let-down, reflex is stimulated. The following signs indicate that milk ejection has occurred:

Frequency of Feedings
Duration of Feedings

NURSING ALERT

If a baby seems to be feeding effectively and the urine output is adequate but the weight gain is not satisfactory, the mother may be switching to the second breast too soon. The high-lactose, low-fat foremilk can cause the baby to have explosive stools, gas pains, and inconsolable crying. Feeding on the first breast until it softens ensures that the baby receives the higher fat hindmilk, which usually results in increased weight gain.

Related posts:

  1. 8. Selected Newborn Complications
  2. 7. The Newborn
  3. 1. Pregnancy
  4. 2. Selected Pregnancy Complications

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Jul 18, 2016 | Posted by in NURSING | Comments Off on 5. Postpartum

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