postnatal care
TRANSCRIPT
CARE OF POSTNATAL MOTHER
PREPARED BY LEKSHMI AJITHLALM.Sc Nursing
Definition 6 weeks period following the child birth during which the body tissues especially the pelvic organs revert back approximately to the pre pregnant state both
anatomically and physiologically. 6 week interval between the birth of the
new born and the return of reproductive organs to their normal nonpregnant state.
period of six weeks which begins as soon as placenta is expelled
CHARECTERISTICS OF PUERPERIUM
Reproductive organs return to the non pregnancy state.
Other physiological changes of pregnancy are reversed.
Lactation is stabilised. Reestablishment of menstruation. Foundation of relationship between parents and
infant
is laid Mother recovers from stress of pregnancy &
delivery Mother begins to assume responsibility for care and
nurturing of the infant.
Physiology of the Puerperium
UterusAnatomic changesPhysiological changes
ContractionsAfter painsPlacental siteMuscles& blood vesselsEndometrial regeneration
Lochia
Uterine Changes
Changes in the Cervix & Lower Uterine Segment
Cervical opening contracts slowly and for a few days immediately after labor
by the end of the 1st wk → it has narrowed
As the opening narrows the cervix thickens and a canal reforms.
Bilateral depression at the site of lacerations remain as permanent changes that characterize the parous cervix
Peritoneum and Abdominal wall
Broad & round ligaments : much more lax than nonpregnant : require considerable time to recover from stretching & loosening
Abdominal wall : return to normal → requires several weeks (aided by exercise) : usually resumes its prepregnancy state except for silvery striae
Physiology of the PuerperiumCardiovascular changes Cardiac output remains elevated for at least 48
hours postpartum Changes of pregnancy reversed over three
weeks Marked increase stroke volume immediately
post partum 500-1000ml blood loss in normal delivery leukocytosis and thrombocytosis occur
during and after labor
Hormones ChangeLowest level
hPL decreases<24 hr
Estrogen decreasesDay7
Progesterone decreasesDay7
FSH decreasesDay10-12
LH decreasesDay10-12
Prolactin decreasesDay14
Growth
hormone
Stays low through day3
Thyroid No change
Corticosteroids decreasesDay7
Plasma Renin decreases<2hr
Angiotensin II decreases<2hr
Mammary Glandes
Breast Anatomy
Breast Feeding
Medications & Breast FeedingDrugs absolutely contraindicated in
breast feeding. Chemotherapeutic or cytotoxic agents all drugs used recreationally (including alcohol and nicotine) radioactive nuclear medicine tracers lithium carbonate chloramphenicol phenylbutazone Atropine Thiouracil
Iodides and mercurials.
Medications & Breast Feeding
Drugs to strongly avoid or consider bottle feeding.
Antipsychotics, antidepressants, meteronidazole,tetracycline, sulfonamides, diazepam, salicylates, corticosteroids ,phenytoin, phenobarbital,
or warfarin. Drugs safe to use in normal doses. Acetaminophen, insulin, diuretics, digoxin, beta-blockers, penicillins, cephalosporins, erythromycin, birth control pills, OTC cold preparations, and
narcotic analgesics (short term in normal doses). Lactation-suppressing drugs. Levodopa, anticholinergics, bromocriptine, trazodone, and large-dose estradiol birth control pills.
PSYCHOLOGY OF PUERPERIUM
POST PARTUM BLUES POST PARTUM DEPRESSION POST PARTUM PSYCHOSIS
PARENTING PROCESS
PARENTING PROCESS DEFINITION
A Process Of Role Attainement And Role Transition That Begins During Pregnancy.The Transitionends When The Parent Develops A Sense Of Comfort And Confidence In Performing The Parenting Roles-sank (1991)
RECIPROCAL ATTACHMENT BEHAVIOURS
Make eye contact and engage in prolonged ,intense mutual gazing
Move their eyes and attempts to track their parent’s face.
Grasp the parents finger and holds onMove synchronously in response to
rhythms and patterns of parent’s voiceRoot, suck and finally latch on to the
breastsBe comforted by parents touch or voice.
THEORIES OF ATTACHMENT
Psycho analytic
Ethologic Learning theory
FACILITATING BEHAVIOURS parent
Gazes, looks into physical characteristics of the infant, eye contact
Identifies infant as an unique individual Touches; progresses from fingertip to
fingers to palms Talks to, coos or sings to infant Express pride in infant Relates infant’s behaviour to familiar
events
INHIBITING BEHAVIOURS
Turns away from infant, ignores infant’s presence
Avoids infant; refuses to hold infant when given opportunity
Identifies infant with someone parent dislikes Fails to move from fingertip touch Frowns at the infant Express disappointment Do not incorporate infant into life.
FACILITATING BEHAVIOURS -infant
Visually alert; eye-to-eye contact; tracking or following of parent’s face
Smiles Vocalisation; crying only when hungry or wet Grasp reflex Anticipatory approach behaviours for feeding; sucks well Enjoys being cuddled Easily consolable Activity and regularity somewhat predictable Differential crying, smiling and vocalizing; recognizes
and prefers parents Approaches through locomotion Cling to parents; puts arm around parent’s neck
INHIBITING BEHAVIOURS
Sleepy; eyes closed most of the time; gaze aversion
Resemblance to person parent dislikes; hyperirritability ‘jerky movements touched
Bland facial expression; infrequent smiles Crying for hours Exaggerated motor reflex Feeds poorly ,regurgitates often Resists holding and cuddling Inconsolable Shows no preference for parents
PHASES OF PUERPERIUM
1.Taking - in phase
2.Taking - hold phase
3.Letting - go phase
MATERNAL ROLE ATTAINMENT
Anticipatory stageFormal stageInformal stagePersonal stage
FACTORS AFFECTING FAMILY ADAPTATION
Physical discomfort and fatigue- resolve within one or two days
knowledge of the infant’s needs Previous experiences Expectations for the new born Maternal age Maternal temperament Temperament of the infant Availability of a strong support system Unanticipated events- caesarean birth, pre term
infant, ill infant or birth of more than one infant. Cultural influence
WHEEL OF FAMILY CENTRED POSTPARTUM NEW BORN CARE
early parent infant
contact
demand feeding
flexible care
routine
individual care
father's are not
considered as visitors
parenting education
sibling and grand parent
education
ASSESSMENT OF EARLY ATTACHMENT
1. Is the mother attached to her new born?2. Is the mother inclined to nurture her
infant?3. Does the mother act consistently?4. Is she sensitive to new born’s needs as
they arise?5. Does she seem pleased with her baby’s
appearance and sex?6. Are there any cultural factors that might
modify the mother’s response?
GUIDELINES FOR INTERVENTION
1. Determine the childbearing and childrearing goals of the infant’s mother and father and use them in planning nursing care
2. Arrange the health care setting so that a individual nurse client relationship can be developed and maintained throughout pregnancy and during the early months of post partum.
3. Enhance the couple’s relationship and increase their communication capacity during the pregnancy.
4. Use anticipatory guidance from conception through the post partum period to prepare for expected problems of adjustment.
GUIDELINES FOR INTERVENTION contd
5. Include parents in planning, implementing and evaluating nursing interventions
6. Initiate and support measures to support and alleviate parental fatigue.
7. Help parents to identify, understand and accept positive and negative feelings related to overall parenting experience.
8. Remove barriers to voluntary contact among family members and infant.
9. Support and assist parent in determining the unique needs of the infant
STRATEGIES TO PROMOTE ROLE OF FATHER IN PREGNANCY AND CHILDBIRTH
Include father in all prenatal visits Encourage his participation in parenting and
prenatal classes. Address concerns of fathers relating to
childbirth and infant care. Encourage discussion of changes in role and
parenting issues Facilitate father’s presence at labour and
birth and assist for the role he wishes. Encourage father to hold his new born. Include the father in well baby checks Facilitate discussion in sharing responsibility
for infant care.
MANAGEMENT OFPUERPERIUM
Hospital Care
Care at Home
MANAGEMENT OF PUERPERIUMObjectives
Ensuring that postnatal care is related to needs of each individual mother.
Promoting a relaxed environment in which mother can take adequate rest &freedom from unnecessary stress.
Identifying potential problems & ensuring prompt & appropriate treatment
Enabling parents to become confident in the care of infant
Hospital CareAttention immediately after labor
for the first hour after delivery - BP & PR : should be taken every 15 minutes
monitor amount of vaginal bleeding
Fundus should be palpated to ensure that it is well contracted
Breast feeding
Nutrition
Hygienic care
Postnatal care
Ambulation & exercise Rest & sleep. Care of breast Nutrition Emotional needs Prevention of infections Management of after pains Immunizations
Complications of Puerperium Blood loss
Early post partum hemorrhage Uterine Atony
Retained products of conception
Lacerations Uterine rupture
Complications of Puerperium Infections
Endomyometritis Foul smelling lochia and tender uterus
within first few days post partum Increased risk with c-section, PROM, Multiple
exams during labor, & long labor Polymicrobial including anaerobes (Ecoli,
Gardnerella, Peptostreptococcus) Treat with Gentamycin/Clindomycin (Gold
Standard), extended spectrum penicillin or cephalosporin
Breast complicationsBreast fever
For the first 24 hours after development of lacteal secretion,
: breasts to become distended, firm, & nodular ← exaggeration of normal venous & lymphatic
engorgement of the breast Puerperal fever from breast engorgement is
common : 37.8~39 , seldom persists for longer than ℃
4~16 hours Treatment- brassiere, ice bag, analgesics, pumping
or manual expression
Breast complications contd….
Mastitis Parenchymatous infection of mammary glands
seldom appear before the end of the 1st week postpartum not until the
3rd or 4th week.
unilateral, breast becomes hard, reddened and painful
Signs : chills (1st), rigor, fever, tachycardia
Etiology
Staphylococcus aureus (most common)
※ breast abscess : caused by group B streptococcus
- almost always from nursing infant's nose & throat
→ the organism enters the breast through the nipple at the site of a fissure or abrasion
Breast complications contd….
Treatment swab and culture & sensitivity antimicrobial therapy
: penicillin or cephalosporin : MRSA →vancomycin for about 7-
10days Continue breast feeding
: early Treatment & continued lactation is successful in avoiding abscess formation
Breast abscess surgical drainage (essential) & general anesthesia
PRINCIPLES OF POSTNATAL CARE
Promoting physical and psychological well being of the mother, her baby and the family
The identification of deviation from normal physiological or psychological progress with appropriate prompt referral
Encouraging sound methods of infant care and feeding and promoting of effective parent infant relationships.
Supporting and strengthening the women and her partner’s confidence thus facilitating their transition to the parenting role.
POINTS REDNESS EDEMA ECHYMOSIS
DISCHARGE
APPROXIMATION
0 none none none none closed
1 within .25cmof incision B/L
perineal, less than 1 cm from incision
within .25cmof incision B/L
Serum Skin separation 3 mm or less
2 within .5cmof incision B/L
Perineal &or vulvar between 1-2 cm from incision
within .25cmof incision B/LOr .5 cm unilaterally
Serosanguinous
Skin &subcutaneous fat separation
3 Beyond .5cmof incision B/L
Perineal &or vulvar between 2 cm from incision
Greater than 1 cm B/L or 2 cm unilaterally
Bloody purulent
Skin &subcutaneous fat & fascial separation
REEDA SCALE
NURSING DIAGNOSES1. Pain related to involution of uterus, trauma to
perineum, and episiotomy2. Risk for infection related to child birth trauma
to the tissues episiotomy and presence of lochia3. Risk for fluid volume deficit related to blood
loss after childbirth recovery4. Constipation related to post child birth
discomfort and child birth trauma to the tissues.5. Urinary retention related to post child birth
discomfort and child birth trauma to the tissues.
6. Sleep pattern disturbance related to discomforts of the post partum period, infant care and hospital routine.
7.Risk for imbalanced nutrition less than body requirement related to lack of knowledge regarding post partal diet and increased requirements
8.Risk for complications9.Knowledge deficit related to care of
puerperium, care of new born and family planning methods.
HEALTH EDUCATION
POSTNATAL CARE Rest and sleep Early ambulation Personal hygiene Care of breast Care of perineum Prevention of infection Postnatal diet and fluid intake Postnatal exercise Family planning
HEALTH EDUCATION contd
B. CARE OF BABYC. HOME CARE AND DISCHARGE
Rest and sleepEarly ambulationPersonal hygiene
Care of breastCare of perineumPrevention of infection
HEALTH EDUCATION contd
Postnatal diet and fluid intake Postnatal exercise Family planning Avoidance of coitus Postnatal check up
POST NATAL CHECK UP
OBJECTIVES TIME ACTIVITIES
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