module 7. discuss postpartum psychosocial changes, discharge, education, postpartum complications...
TRANSCRIPT
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Maternal/Child Health Nursing
Module 7
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Discuss postpartum psychosocial changes, discharge, education, postpartum complications and infections
objectives
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Mostly water loss◦Diaphoresis, diuresis
Role of breastfeeding in weight loss
Teach importance of extra calorie intake in breastfeeding
Teach importance of nutrient-rich foods in postpartum period
Weight loss after childbirth
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Maternal discharge from hospital◦12 hours-2 days postpartum: uncomplicated vaginal deliveries Length of stay may be increased by psychosocial adaptation difficulties , very young mothers or mothers considered at-risk for developing postpartum issues
◦3-7 days for Cesarean section deliveries or complex vaginal deliveries
Mother/baby nursing care
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• May add inpatient time for: instrumentation, surgery, interventions, infection, interruption of physiologic/psychosocial systems, complications
• Mother/baby dyad care vs separate nursery Bonding, breastfeeding, care roles,
perceptions /expectations of families and staff members
Mother/baby nursing care
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◦ Nursing plan of care: Recovery stage Readiness for home/return to
responsibilities Adult assistance available Mother or family’s ability to care for
mother/infant Teaching: care tasks, self-care,
recognition of danger signs, safety and security
Discussion of social services, follow-up appointments
Mother/baby nursing care
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Expected changes◦Rubin’s Restorative/Adaptive Phases 1st: Taking in: Mom focuses on: Maternal recovery: food, fluids, restorative sleep
Birth experience: discussion, “re-living”
Infant, but willing to let others do things for her and may not yet perform infant care tasks
Maternal psychosocial changes
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Rubin’s restorative/adaptive Phases: 2nd: Taking hold: Mom focuses on: Infant care, shows initiative Self-care responsibilities May be self-critical of “performance”
Maternal psychosocial changes
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Rubins’ restorative/adaptive phases: 3rd: Letting go: Mom focuses on:
Letting go of expectations or idealized experience to incorporate real child into real family situation
Often done by both parents or mother and other caregiver
Maternal psychosocial changes
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◦Postpartum blues “baby blues”: common, onset days 2-7, lasting about a week, mood swings, fades quickly
Rapid hormonal shifts Needs reassurance: may feel required to be happy
s/s: anxiety, mood swings, sadness, irritability, crying, decreased concentration, trouble sleeping
Maternal psychosocial changes
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◦Cesarean birth (and other interventions) Response may vary if unplanned Anxiety, guilt/blame, need for education, requires adjustment to recovery, scar, self-image, post-operative as well as postpartum adjustment required
Maternal psychosocial changes
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If family had ideal birth planned which didn’t include interventions, assess for unresolved feelings toward birth experience
Maternal psychosocial changes
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Monitor pain and coping◦Affects recovery, baby care, breastfeeding, rest, mood, anxiety, adaptation, care of other children, partner interaction, self-care
Maternal psychosocial changes
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Evaluate learning◦Is Mom getting the education she needs for her situation?
◦Does she seem unwilling or afraid to ask questions?
◦Are pain medications or untreated pain affecting her discharge goals?
Maternal psychosocial changes
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◦Monitor moods and expectations◦Report issues, changes to provider◦Home care: Doula care, home visits by lactation consultant, midwife
Health problems likely to be admitted to hospital
Maternal psychosocial changes
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Unexpected changes:◦Postpartum depression Generally lasting more than a week, more severe and persistent S/S: Appetite loss, insomnia, intense irritability/anger, overwhelming fatigue, loss if interest in sex, lack of joy in life, feelings of shame, inadequacy, guilt; more severe mood swings, difficult bonding, withdrawal, thoughts of self-harm or harming baby
Maternal psychosocial changes
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Postpartum depression: Should be seen by healthcare
provider if increasing in severity, continuing past two weeks, interrupt ADLs and/or baby care, include thoughts of harm
Maternal psychosocial changes
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Treatments◦Counseling, antidepressants, hormone therapy
◦May need evaluation for postpartum hypothyroidism
◦Appropriate depression treatment usually helps within a few months
◦Severe S/S may benefit from electroconvulsive therapy
◦Healthy lifestyle support and expectations
Maternal psychosocial changes
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◦Postpartum psychosis (severe depression) Attempts to harm to self/baby hallucinations confusion/disorientation paranoia Requires EMERGENCY treatment
Maternal psychosocial changes
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◦Infant with a problem Requires additional stabilization away from mother
NICU Feeding problems “Rule out” tests (even if normal result)
Family may need help accepting real baby
Maternal psychosocial changes
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No discussion of labor/birth
No interaction with baby
Refusal to discuss contraception or learn care
Negative self-references (“ugly”)
Signs of potential psychosocial problems
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Excessive self-preoccupation Marked depression Lack of support Negative partner/family reaction to baby
Signs: potential psych problems
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Expresses disappointment over baby’s sex
Sees baby negatively: “messy,” “unattractive”
Baby reminds mother of someone she doesn’t like
Signs of potential psychosocial problems
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Newborns’ and Mothers’ Protection Act of 1996◦Insurance must cover minimum in-hospital stay after delivery 48 hours after vaginal 96 hours after C-section
◦Providers may consult with mothers for earlier discharge
Discharge
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Assessment: ◦Subjective/objective data: pain, status, appetite, breastfeeding, etc.
◦Breasts: size, color; cracked or bleeding nipples? Does breastfeeding hurt? Proper support?
◦Uterus: cramping? Prolapse?◦Bladder: palpate position, signs retaining urine if output decreased
Postpartum nursing management
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◦Bowels: last BM? Constipation? abdominal discomfort/gas? diarrhea? Response to pain meds and foods
◦Lochia: quantity, color◦Fundus: position? Firmness?◦Episiotomy: s/s infection, healing, tenderness
◦Vital signs: changes in baseline, changes expected with medications
Postpartum nursing management
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Assessment (cont’d)◦Lower extremities Homan’s sign
◦Bonding/attachment◦Parenting and family education◦Activity◦Comfort◦Self-care
Postpartum nursing management
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◦Fundus Teach how to massage, how “firm” feels, about involution
◦Lochia: red, pink/brown, white Increase or change should be reported to provider
◦Perineum Cleansing Report pain, swelling, bleeding
Postpartum teaching
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◦Breasts Breastfeeding/bottle-feeding Support, nipple care
◦Nutrition Fresh fruits, vegetables, enough iron and protein rich foods
Calorie increases needed◦Sexuality Avoid sex, tampons, douching for at least six weeks
Postpartum teaching
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• exercise◦Avoid
moderate/heavy lifting unless cleared by provider
◦Daily, moderate exercise as tolerated Thromboses Healing Mood
Postpartum teaching
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Emotions◦The difference between “baby blues”, postpartum depression, postpartum psychosis
◦Support services available◦Discuss Mom’s expectations
Cesarean birth◦Incision care, lifting restrictions, prescriptions and safety, breastfeeding adaptations
Postpartum teaching
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Report to healthcare provider: s/s infection, medication questions, baby care issues, anything of concern
Reassure parents, answer questions, anticipate baby care questions and concerns
Teach baby care safety, reinforce feeding information, ensure written reinforcement of follow-up appointments and contact numbers
Postpartum teaching
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Safety: infant must ride in rear-facing car seat until both 1 year old and 20 pounds
Make sure parents have car seat installation instructions
Postpartum teaching
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Rh and gamma globulin◦Rhogam IM for Rh-negative mom within 72 hours of birth of Rh-positive baby
◦Prevents Rh-negative mom from forming antibodies to Rh-positive babies in future
Rubella immunization (mom)◦Should be given if not already immune
Health promotion
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Wound infection◦Abdominal incision, perineal lacerations, tears or incisionsEdema, erythema, exudateCondition of site (sutures? Tape? Dressing?)
Infections
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Metritis◦Also called “endometritis”
◦Tender, enlarged uterus
◦Prolonged, severe cramping
infections
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Metritis (cont’d)◦Foul lochia◦Fever, systemic signs infection◦Failure of uterus to involute properly◦Uterine cavity swab may be cultured◦Antibiotics (IV, then PO)◦Assess for signs of spread: abnormal lochia progression, N/V, absent bowel sounds
Infections
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Mastitis
◦Infection of breast: skin break maybe not apparent Ineffective latch
◦Often seen in 2nd, 3rd weeks postpartum
◦Usually unilateral (one-sided)◦Staphylococcus aureus often causative organism
Infections
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mastitis
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mastitis◦Often triggered by engorgement, milk stasis Skipped feeding, infant sleeps through night, breastfeeding stopped suddenly
◦May prevent emptying of breastmilk -> further stasis and infection, swelling, feeding problems
infections:
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Mastitis (cont’d)◦Flulike symptomsTemp 101.1F or higherFatigue, achiness, chills, malaise, headache, localized area redness/inflammation
◦Antibiotics, antifungals
Infections
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Mastitis: ◦Emptying of breasts: feeds or pumping or both Feeds no less frequent than every 2-3 hours, avoid supplement feedings, keep area clean, dry
◦Supportive bra◦5% may develop abscess: surgical drainage, antibiotics
infections
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Urinary tract:◦May be related to impaired bladder emptying
◦Encourage PO fluids, correct antibiotic use, regular emptying of bladder
Infections
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Disseminated intravascular coagulation (DIC)◦Disruption in clotting cascade◦May be seen with abruptio placentae, incomplete abortion, hypertensive disease, infections, prolonged retained dead fetus
Thromboembolytic conditions
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DIC◦Rare in first-trimester abortion◦The body’s attempts to correct excessive blood loss may lead to too much thrombin production
◦This triggers fibrinogen to convert to fibrin, leading to many small clots in small blood vessels
Thromboembolytic conditions
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Thromboembolytic conditions
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DIC ◦Small vessels may become obstructed -> ischemia, damage to vital organs
◦Small clots trap platelets -> generalized hemorrhage
◦Since DIC is a secondary diagnosis, cure depends upon fixing the underlying problem
Thromboembolytic conditions
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• DIC S/S: sudden onset of chest pain,
dyspnea, restlessness, cyanosis, coughing up bloody, frothy mucus -> profound circulatory shock s/s, maternal/fetal death
Thromboembolytic conditions
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Assessment: ◦Nosebleeds, petechiae from B/P cuff, bleeding gums, excessive bleeding from sites of slight trauma (IV sites, IM/SQ injection sites, shaving nicks, urinary catheter insertion)
◦Report to provider immediately!
Thromboembolytic conditions
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◦V/S, FHR, I&O, etc.◦Labs: H&H, PT, PTT, platelet counts, fibrinogen levels
◦IV administration of blood, fibrinogen, heparin; 02 by mask, delivery of fetus
Thromboembolytic conditions