OB Post partum
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What are the most common causes of maternal death? What is the top cause in the US?
- Hemorrhage, hypertension, sepsis, abortion, other direct, indirect
- #1 in the US is pulmonary embolism
How long does the post partum period last?
First 4 hours after birth until the woman is stable
What does BUBBLEHEP stand for?
- Homan's Signs
- Emotional State
How would you assess the mother's breasts?
- Ask the mother, are they soft, filling, or hard?
- Assess for pain or discomfort in nipples or when breast feeding
What teaching should be done if the mother chooses the breast feed?
- Wear a supportive bra (without under wire) and you may need nipple pads for leaking milk
- Assess for engorgement and teach that ice packs and frozen cabbage leaves can relieve pain
- Assess proper technique, including alternating breasts, feeding q3hrs or on demand, holding baby in cradle, foot ball hold, or in side lying position, as well as bringing the baby to the breast instead of bringing the breast to the baby
- Break the seal of breast feeding by putting a finger in the baby's mouth
- If nipples are sore, use lanolin cream (wool allergy?) and allow to air dry (do not use soap)
What teaching should be done if the mother choses the bottle feed?
- The breasts may engorge but DO NOT EMPTY BREASTS
- Avoid nipple stimulation, such as in the shower or with loose clothes
- Use ice packs or frozen cabbage leaves to relieve pain
- Generally resolves in 24-48 hours
- Feed baby in a slight upright position and do not prop bottle
- Baby will drink 5-10 ml q2-3hrs for the first few days, then feed on demand
- Follow formula recommendations on the bottle or can
What are some interventions for engorgement and cracked/sore nipples?
- Use ice packs, frozen cabbage leaves, and NSAIDs for pain
- Use lanolin cream for sore or cracked nipples and allow they to air dry (may let a little milk drip). Do not use soap or wash nipples before and after feeding as it dries the nipples out
How would you assess the fundus of the uterus?
- Hold one hand over the bottom of the uterus above the pubic symphysis to prevent uterine prolapse and use deep palpation about the umbilicus with the other hand to feel the top of the fundus. It should feel hard due to the clamping of the uterus
- If the uterus is not firm, but firms up with a little massage, pitocin may be needed to help clamp the uterus and prevent hemorrhage
- If the uterus is displaced to one side, the bladder needs to be emptied as it can prevent the uterus from clamping down and returning to its place
- The location of the fundus is measured in finger-breathes (1cm =1 finger breath)
- The woman may experience cramping pains which can be relieved by Motrin (ibuprofen)
What is expected descent of a firm uterus (in hours & days)?
- At birth, it should be palapted either 1cm above or at the umbilicus
- With every 24 hours, it should descend 1-2 cm
- By the 6th day, it should be halfway between the umbilicus and the pubic symphysis
- By day 10, it should have returned into the true pelvis and not be palpable
What is a boggy fundus and what interventions can be done?
- A boggy fundus is a uterus which is not clamping down and is at risk for hemorrhage
- Gentle massage can help firm the fundus
- Oxytocin is put into the IV (high) to clamp the uterus and prevent hemorrhage
How often should a woman be assessed during the post partum period?
- First hour: q15 min
- Second hour: q30 min
- Next 22 hours: q4hrs
- After 24 hours: once per shift
How would you assess the bladder? Why is it important to empty the bladder frequently?
- If the uterus is displaced from midline, the bladder needs to be emptied so the uterus can clamp and descend
- Does the mother have burning or pain? Where? (could be related to episotomy/tear or UTI)
- I/O monitored post c-birth
- First void after birth should be measured regardless
How would you assess the bowels post partum? What interventions should take place?
- Listen for bowel sounds, ask about passing gas
- It may take 2-3 days before first BM (after discharge)
- Mother may have hemorrhoids from pregnancy (Assess)
- Give docusate sodium (stool softener) to reduce strain and simethicone (gas x) to help with gassiness
- Increase fluids and fiber in diet to help with BMs
- Encourage ambulation to help move digestive track
How would you assess lochia?
- Assess peri pad color, the amount, and how much in a given time
- Lochia may be rubra, serosa, or alba
- Amount may be scant, light, moderate
- Heavy is saturating 1 pad per hour
- Excessive is saturating a pad in 15min and is an EMERGENCY (hemorrhage)
- Small clots may be present
- Lochia may increase with activity or breast feeding (which produces oxytocin and clamping of the uterus)
- Cesarean births have less lochia in the first 24 hours
- *absence of lochia is not normal and signifies possibility of retained clots
What kind of lochia is expected during the first month post partum?
- 1-3 days: Rubra (red)
- 3-10th day: Serosa (pink)
- 10-21st day: Alba (clear, colorless, white)
Why do we perform Homan's sign post partum?
- To assess for DVTs r/t to increased fibrinogen during pregnancy and bedrest during labor
- Homan's sign is not a reliable sign of DVT
- Assess for leg or chest pain
- Lung sounds should be assessed as PE is the highest cause of maternal death in the US
How do you assess an episiotomy or tear?
What are your main concern?
- Assess for redness, edema, ecchimosis, drainage and approximation of the wound
- Assess the peri area by having the mother roll onto her side and lift the buttocks gently
- An episiotomy may be mediolateral or midline, but is becoming less common
- Lacerations or tears vary in degree from 1-4, but 3 and 4 are into the rectum
- Main concerns are pain (treated with narcotics), infection (wound care), and difficult/fear of BM (docusate sodium)
How do you assess and care for a cesarean incision?
- Most common is low transverse above pubic bone
- May also be medial from top to bottom of tummy
- Keep the incision clean and dry
- Teach splinting techniques and for mother to walk upright
- Assess dressing and maintain wound care
- Provide adequate pain management
How do you assess the maternal emotional state?
- NEVER ASK THE MOTHER- observation only
- Are they bonding?
- Is there a history of depression or post partum depression?
- Is there a history of other psych illness?
How do you assess for post partum pain?
- Assess the location and type of pain (do not assume!)
- Pains scale rated by client
- Offer medication by the choice of the client, reassess 30-60 min later
What are some non-pharmacological ways to manage post partum pain?
- Ice (such as to the perineum or breasts)
- Sitz bath
- Body mechanics
- Position changes
How is post partum pain pharmacologically managed? What medication is she likely to go home with?
- Narcotics- morphine, stadol
- Perocet (Acetamenophin & Oxycodone)
- Motrin (Ibuprofen)
Why would Rhogam be given? When would you give it?
- Rhogam is give if Mom is Rh- at 28 weeks or if preg is terminated, trauma occurs, or amniocentesis is done
- If the baby is Rh+ at birth, the mother receives a second dose within 72 hours
- The goal is to PREVENT the production of Rh antibodies in the mother, which can attack the RBCs of future pregnancies if the fetus is Rh-
What immunizations are offered post partum?
- MMR (Rubella): If non-immune when tested during pregnancy (first visit, titer of 1:8 or greater indicates immunity), offered prior to discharge. Encouraged not to get pregnant again for 4 weeks
- Tdap: pertussis is the big one that is bad for babies
- Hep B: baby receives first dose at birth
- Varicella: chicken pox
- Flu shot: if in season
What factors influence the transition to parenthood?
- Previous life experience
- Relationship b/t parents
- Support System
- Desire to be a Parent
- Age of Parents
How does a mother transition to parenthood?
- Commitment, attachment, and preparation for the infant during pregnancy
- Acquaintance with and increasing attachment to the infant, learning to care for the infant, and physical restoration during the early weeks after birth
- Moving toward a new normal during the first four months
- Achievement of a maternal identity around 4 mo
What are the three maternal phases transitioning to motherhood?
- Taking-in phase: period of dependent behaviors 24-48 hrs after birth
- Taking-hold phase: movement from dependent to independent behaviors lasting up to weeks after delivery
- Letting-go phase: movement from independent behaviors to the new phase of motherhood. Usually fluid with the taking-hold phase
How does a father transition to fatherhood?
- Men may picture themselves as a father during pregnancy, but may not come to the reality until the baby is born
- The father's involvement is strongly influenced by the mother
- The father may not feel they have adequate parenting skills and will need assistance with feeding, bathing, and changing diapers
What is the difference between bonding and attachment?
- Bonding: emotional feeling that begins in pregnancy or shortly after birth. It is unidirectional from the parent to the child
- Attachment: Emotional attachment between the parents/care givers and child that is bidirectional. This has a lifelong impact on the developing person
What are some expected bonding behaviors?
- Hold the infant close
- Refer to infant by name or gender
- Respond to the infant's needs
- Speak positively about the infant
- Are interested in learning about the infant
- Ask appropriate questions about caring for the infant
- Appear comfortable holding or caring for the infant
What are some maladaptive bonding behaviors?
- Referring to the infant as "it"
- Avoiding eye contact with the infant (may be cultural)
- Does not respond to the infant's cries
- Emotionally unavailable to the infant
- Allow others to care for the infant
- Shows no interest in the infant (may be cultural)
- Poor feeding techniques (propping bottle, not being patient during feeding)
- Irritable or uncomfortable with breastfeeding
How can the nurse promote bonding?
- Early & Prolonged contact with the infant
- Rooming in
- Couplet Care
- Positive reinforcement of parental care of infant
- Encourage the parents to talk about birth and feelings of parenthood
- Encourage breastfeeding (when desired)
What measures can be taken to promote bonding if the infant is in the NICU?
- Take pictures of the infant or have webcam on infant for parents. Parents may be able to call NICU with questions
- Assist parents to NICU
- Involve parents in care of the infant in the NICU (feeding, changing)
- Family rooms in the NICU
What teaching is included in discharge planning? When are postpartum appointments scheduled for?
- Teach care of self and infant
- Educate about medications at home
- Discuss resuming sexual relations and methods of birth control
- Discuss eating a well balanced diet and nutritional needs if baby is breast feeding
- Mom will have 6 week appointment
- Infant seen within the first week
- Appointments may be made prior to discharge
After discharge, what danger signs should prompt the woman to call her HCP immediately?
- Persistent or bright red Lochia
- Foul smelling Lochia
- Prolonged afterpains, pelvic or abdominal pains, constant backache
- s/s of UTI
- Pain, redness, or tenderness in calf
- Localized breast tenderness or redness (mastitis)
- Discharge, pain, redness, or separation of suture line
- Prolonged and pervasive feelings of depression or being let dow/ generally not enjoying life
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