Nursing Care of the Postpartal Family

• Postpartum

  The 6 weeks following the 4th stage of labor
• Postpartum care-lab work

  Blood Loss

  CBC

  Hct may drop 2% for each 500 mL of blood loss

  Hgb may drop 1.0-1.5 g/dl per 500 mL of blood loss

  Leukocytosis common

  Increased fibrinogen, clotting factors, platelets

  GBS and Rh status
• B: Breasts

  U: Uterus

  B: Bladder

  B: Bowels

  L: Lochia

  E: Episiotomy/Laceration

  H: Hemorrhoids

  E: Extremities

  H: Hygiene

  E: Emotional assessment/patient education
• Mastitis:

  This is an inflammation or infection of the breast

  Infection may be due to bacterial entry through cracks in nipples

  Symptoms: fever, malaise, unilateral breast pain, and tenderness in the infected area

  Treatment: Antibiotic therapy, analgesia, rest and hydration

  Patient should continue to breast feed or pump her breasts
• Non-Breastfeeding Women

  Assess: breasts for primary engorgement

  Instruct: patient to wear a tight fitting bra 24 hours a day until breasts become soft

  Instruct: (if experiencing engorgement) apply ice to the breast, not to express milk as this will stimulate milk production, avoid heat to the breast, and take analgesia for pain

  Inform: patient that breast engorgement will subside within 48 hours
• Uterus assessment

  Massage fundus until firm

  If uterus remains boggy:

  -Express clots and note bleeding amount

  -Give Pitocin or other uterotonic

  -Empty bladder or insert a foley

  -VS as needed
• Descent of the uterus:

  Involution is about 1 cm per day

  14 days after childbirth, the fundus should no longer be palpable

  Afterpains, or intermittent uterine contractions, cause discomfort for many women

  Subinvolution: process of involution does not occur -> PPH
• Determine position of the uterus:

  A uterus that is shifted to the side is an indication of a distended bladder

  Should be midline
• Signs of a distended bladder:

  -Location of fundus above baseline level

  -Fundus displaced from midline

  -Excessive lochia

  -Bladder discomfort

  -Bulge of bladder above symphysis

  -Frequent voidings of less than 150 mL of urine, may indicate urinary retention with overflow
• Cystitis:

  Bladder inflammation/infection

  Symptoms: frequency, urgency, pain/burning on urination and malaise

  Treatment: antibiotic therapy, increased hydration, rest
• Characteristics of Lochia:

  Lochia Rubra: Days 1-3; bloody

  Lochia Serosa: Days 4-10; pink-brown tinged

  Lochia Alba: Days 11-21; white/cream/light yellow
• Assessment of Lochia

  Scant: < 2.5 cm, 1 inch stain

  Light: 2.5-10 cm, 1-4 inch stain

  Moderate: 10-15 cm, 4-6 inch stain

  Heavy: saturated in 1 hour
• Excessive Bleeding:

  Heavy lochia is a sign of excessive bleeding and/or PPH

  Early postpartum hemorrhage occurs in 1st 24 hours

  -Most common causes of early PPH is uterine atony

  -Other causes: placental anomalies, uterine inversion, retained placental tissue, obstetric lacerations, and coagulation defects

  Late PPH occurs after the 1st 24 hours

  -Causes: atony, infection, subinvolution, and retained placenta
• Nursing interventions for PPH:

  -Starts 2 large bore IVs and administer fluids

  -Uterotonic meds

  -Prepare for hanging blood

  -Monitor VS, pulse ox, and breath sounds

  -Foley to monitor output
• Shock following PPH FIRST signs

  TACHYcardia and LOW BP
• Episiotomy/laceration

  R: Redness

  E: Edema or swelling

  E: Ecchymosis or bruising

  D: Drainage or discharge

  A: Approximation
• Perineal comfort measures:

  -Ice to perineum first 24 hours to decrease edema

  -Encourage to lay on side to decrease pressure

  -Instruct to tighten gluteal muscles as she sits down and relaxes muscles after she is seated to cushion perineum

  -Instruct to wear peri pads snuggly to prevent rubbing

  -Instruct woman to take sitz baths starting 24 hours after delivery twice a day

  -Offer analgesia, topical spray or hydrocortisone cream
• First-degree laceration: involves the superficial vaginal mucous or perineal skin

  Second-degree laceration: involves the vaginal mucosa, perineal skin, and deeper tissues; muscles of perineum

  Third-degree: involves anal sphincter

  Fourth-degree: Extends through the anal sphincter into the rectal mucosa
• Thrombosis/DVT

  • Tenderness and heat over the affected area
  • Leg pain with walking
  • Unilateral swelling
  • Teach patient prevention and detection
• Hygiene

  Diuresis, diaphoresis, shower or peri care
• Orthostatic hypotension

  • Woman are at risk during the first weeks postpartum
  • Instruct patient to slowly rise to a standing position
  • Assist patient when ambulating during the first few hours post birth
  • Assist patient to a sitting position if she becomes dizzy or faint
• Endometritis

  • Most common PP infection
  • Risk factors: prolonged ROM, prolonged labor, cesarean birth, internal fetal/uterine monitor, anemia, malnutrition, PPH, and diabetes
  • Assessment findings: fever of 101 or greater, tachycardia, uterine tenderness, subinvolution, malaise, lower abdominal pain or discomfort, lochia heavy & foul smelling, and lochia is scant & odorless when beta-hemolytic streptococcus is present
• Duramorph

  • Alters perception of painful stimuli; causes generalized CNS depression
  • Common side effects: itching, n/v, respiratory depression, hypotension, urinary retention
  • Nursing actions: monitor VS, RR, & pulse ox
  • Administer anti pruritics, anti-emetics
• Rubella vaccine

  • Prevents fetal exposure to rubella in the first trimester
  • Non-immune women should be immunized before discharge
  • Women taught to avoid pregnancy for 4 weeks after receiving the vaccine
• RhoGam/Rhophylac

  • Administered to Rh negative mothers who give birth to Rh positive babies
  • Prevents production of anti Rh (D) antibodies
  • Adverse reaction: pain at injection site
  • Must be given within 72 hours of birth