Care of Postpartum Patients

University of Cebu

COLLEGE OF NURSING

Cebu City, Philippines

Resource Unit

“CARE OF POSTPARTUM PATIENTS”

Presented by:

Lopez, ChenyMarababol, Maria Cyril

Minguito, Velly JaneMiralles, Jeremiah JohnMontesclaros, Donita

Pino, IreneRivera, Nikki SheryleeRomanillos, Mhargie

Ruiz, Maria EvangelineTampus, Dan PatrickTarucan, Neil Israel

Verano, Britney Arlene

Submitted to:

Ms. Jean P. BernalClinical Instructor

GENERAL OBJECTIVE: After 1 hours and of varied teaching methodologies, the BSN 3 students will be able to gain basic

knowledge, beginning skills, and a positive attitude on the concept of CARE OF POSTPARTUM PATIENTS.

SPECIFIC

OBJECTIVES

CONTENT TIME

ALLOTMENT

METHODOLOGY RESOURCES EVALUATION

Specifically, the BSN 3 students will be able to:

1. Identify the concepts of care of the postpartum women.

o Efforts such as the Safe Motherhood Initiative and the World Health Organization (WHO) Making Pregnancy Safer Division and strategies to meet the United Nations Millennium Development Goals are supporting worldwide activities to reduce maternal and newborn mortality. Despite these efforts, hundreds of thousands of women and babies die or become disabled due to complications of pregnancy and childbirth every year.

o Half of the maternal deaths occur within 24 hours of childbirth with postpartum hemorrhage (PPH) being the leading direct cause of maternal death in most developing countries.  Many of the cases of PPH result from

5 minutesLecture – discussion

1. Human

Resources:

Time and

effort of the

group

Active

participation

of the class.

2. Material

Resources:

Oral Recitation

(question and

answer)

problems during and immediately after the third stage of labor.

o 75 percent of all neonatal deaths take place in the first week and 50 percent within 24 hours after birth. The postpartum/postnatal period, especially the early phase, is also the most neglected part of the pregnancy, delivery, and postpartum continuum of care. It stands to reason, therefore, that newborns may stand a better chance of surviving if they receive care during the period when they are at the greatest risk of dying.

o Since the health and survival of the newborn are closely tied to that of the mother, it is important to integrate maternal and newborn health care into training programs, wherever possible. Although it is not feasible to integrated aspects of maternal and newborn care, this set of materials links selected aspects, including active management of the third stage of labor with care of the baby at birth, immediate postnatal care of the woman and

Computer

Papers

Chairs

Pens

Microphone

3. Book and

Internet

Resources:

(See Bibliography)

2. Define the following terms:

the baby, and counseling the woman/mother to care for herself and her newborn. 

o Ongoing research in various settings continues to identify the best approaches for preventing and managing postpartum bleeding and its complications as well as caring for the newborn and woman in the immediate postpartum period. By developing national guidelines, training skilled birth attendants, improving work environments of skilled providers, ensuring the application of infection prevention principles, and supporting the development of improved access to care, more women will have access to these interventions.

o POSTPARTUM PERIOD - Includes the six-week period after childbirth up to the mother's postpartum check-up with her health care provider

2 minutes

Lecture – discussion

3. Anatomy of the Reproductive Organ

4. Identify the goal of treatment for postpartum women.

o POSTPARTUM CARE -Postpartum care encompasses management of the mother, newborn, and infant during the postpartal period.

o POSTPARTUM BLUES - Postpartum blues, also known as the "baby blues," refers to the period of emotional highs and lows that commonly occur in those first days after birth.

o (See Appendix A)

o Pain relief: If you delivered the baby normally through the birth canal, pain in the area between the rectum and vagina is common. To relieve the pain and prevent infection, you can sit in a warm bath, put cold packs on the area, or put warm water on the area with a squirt bottle or sponge. It is also important to wipe yourself from the front to back after a bowel movement to prevent infection.

8 minutes

3 minutes

Lecture – discussion

Lecture – discussion

5. Elaborate drugs use for pain relief for postpartum.

o Constipation and hemorrhoids: It is common to be constipated or have discomfort from hemorrhoids after delivery. Ointments and sprays can be used to help reduce swelling in the area of the rectum. For constipation try eating foods rich in fiber and drinking lots of liquids.

o ASPIRIN

Aspirin is a pain reliever with anti-inflammatory effects. Even at low doses, it reduces the tendency of the blood to clot, and is therefore useful to prevent heart attacks and strokes. The anti-clotting effect means aspirin is best avoided in injuries that tend to bleed. Its anti-inflammatory effects make it useful for tendonitis. The most well-known brand is Bayer. Aspirin can irritate the stomach. The pills should be taken with food (if possible) to prevent stomach upset. Aspirin should be avoided by persons with active ulcers, and by those on anticoagulants (blood

7 minutes

Lecture – discussion

thinners). Aspirin decreases the tendency of the blood to clot for many days after a single dose.

There's a limit to the amount of pain relief you can get with aspirin. Beyond two tablets (650 mg), little further relief of pain occurs. Aspirin can easily cause poisoning if doses are doubled. Do not take higher doses without the advice of your physician.

Usual dose: Two tablets (650 mg) every 4 hours, up to 4 times daily.

o ACETAMINOPHEN

Is a non-aspirin pain reliever. It is quite well-tolerated by the stomach, so it's unlikely to cause nausea or abdominal pain. The most well-known brand of acetaminophen is Tylenol.Acetaminophen can be used for the pain of insect stings, burns, abrasions, as well as bruises, and sprains. Acetaminophen has NO anti-inflammatory activity. It has no anticoagulant effect. It does not cause ulcers or irritate the

6. Identify the appropriate diet for postpartum mothers

stomach.

There's a limit to the amount of pain relief you can get with acetaminophen. Beyond 1000 mg (two extra-strength tablets), no further relief of pain occurs. Because acetaminophen is poisonous in large doses, it's important not to exceed the recommended dose.

Usual dose: 2 tabs (650 mg) every 4 hours, up to four times daily.

o The basic postpartum diet is a simple but healthy and wholesome one. It can best be summed up by the following guidelines: Eat foods that supply your

body with essential fatty acids, like fresh salmon, nuts, and seeds.

Eat whole, preferably organic, foods – whole grains, fresh vegetables and fruits, unprocessed meats, nuts, and seeds, for example.

Avoid refined sugars and

10 minutes

Lecture – discussion

flour, during pregnancy and postpartum.

Eat foods that supply your body with antioxidants (mainly fresh fruits and vegetables).

Eat slowly and chew your food thoroughly.

Eat a source of nutrient -laden fiber, such as ground flaxseeds.

o Eat Foods that Supply Your Body with Essential Fatty Acids

Fatty acids are the final breakdown product of fats in the diet – the part of the fats you eat that is either stored or used in the cells for energy. Fatty acids were once viewed as nothing more than a source of stored calories, but modern research has shown that the quality of fatty acids in the body has profound effects on human health. Diseases related to inflammation, hormone imbalances, the immune system, behavioral problems, and the heart can often be partially or

completely resolved if essential fatty acid levels are balanced through dietary changes or supplementation.

o Omega-3 Fatty Acids

When you are pregnant, the developing fetus requires large amounts of two specific fatty acids, arachidonic acid (AA) and docosahexaenoic acid (DHA), to build brain and nerve cell membranes. Once a baby reaches about six months of age, his or her body will be able to make DHA and AA from other fatty acids, but while still in utero and in the first six months of life, these fats must be supplied in exact form by the mother's body – first through the placenta, then through breast milk. More than half of the nerve connections in baby's brain form during the first year of life, and the integrity of these connections is dependent upon the fatty acid supply from the mother. Ideally, mother's milk supplies DHA and AA to her baby through nursing for at least a

year.

The fats you eat are transformed into hormone-like messenger molecules called prostaglandins, and how the balance of essential fats in your diet dictates the balance of prostaglandins in your body. These fats are also needed for proper brain and nervous system function in people of all ages, but are needed more than ever during gestation and in your baby's infancy, when those systems are undergoing their fastest period of growth.

The omega-3 fat docosahexaenoic acid, or DHA, is the most important structural and cognitive (brain-function-related) fat for your brain and for your baby's brain. The placenta draws DHA from the mother's body like a vacuum cleaner, and the milk ducts continue to drain her stores for as long as her baby nurses. If you do not keep replenishing your supply, your emotional and physical well-being will most

7. Formulate a nursing care plan for postpartum women.

likely be compromised in the postpartum period and beyond.

o Vital signs

Nursing Considerations

Temp of 100.4°F during first 24 h after delivery considered normal. Encourage fluids.

If temp is above 100.48°F, check the following for possible infection:

Lacerations Sutures Breasts lochia (foul odor of lochia may

indicate infection) urine

Pulse elevation may be first sign of hemorrhage.

Decreased pulse rate (as low as 50) is considered normal during first postpartal week.

15 minutes

Lecture – discussion

Decreased BP and/or narrowed pulse pressure are signs of shock.

Orthostatic hypotension is common during the early postpartal period. The patient should rise slowly from lying or sitting to prevent "blackouts" or falls.

Assess BP every hour if patient has been preeclamptic.

o Intake and output

Nursing consideration

Accurate I&O for at least 12 h (uri-nary retention may occur).

o Head

Nursing consideration

Assess for headache resulting from anesthesia or elevated B

Visual light flashes may indicate preeclampsia

o Lungs

Nursing consideration

Check for adventitious sounds.

Prolonged bed rest, labor, vomiting, or anesthesia may predispose to pneumonia (women who have had spinal or epidural anesthesia may have difficulty coughing or clearing the lower airway until anesthesia wears off).Chest pain and dyspnea are common symptoms of pulmonary embolism.

o Breasts

Nursing consideration

Colostrum appears within first 12 hours.

Breast milk appears by about 72 hours.

Breast engorgement occurs on

the 3rd or 4th postpartal day and should resolve spontaneously within 36 h.

Assess for infection (warm, painful, reddened area).

Assess for irritation of nipples.

Bra should be worn by all women during the postpartal period.

o Abdomen

Nursing consideration

Assess fundus. Should be firm and at umbilicus immediately after delivery, then fall 1 cm (1 fingerbreadth) each day for next 10 days.

If fundus is boggy, assess first for bladder fullness, and have patient void if indicated.

If fundus is boggy and bladder is empty, massage top of fundus

with fingers held together. (Patient may be taught to massage fundus.)

Auscultate to assess peristalsis. Assess daily for BM. (Analgesics and other aspects of labor and delivery make constipation very common.) Increase fiber and fluid intake to prevent constipation.

Encourage early ambulation.

o Perineum

Nursing consideration

Assess episiotomy for edema, bleeding, or redness.

Assess for hematoma (purplish mass may be seen at introitus of vagina) if patient complains of severe perineal pain or a feeling of fullness in the vagina.

Assess for hemorrhoids.

Assess lochia. Patients who report or are observed to have heavy

bleeding should be placed on pad count.

A continuous flow of bright red lochia or the passage of large and/or frequent clots is abnormal and indicates hemorrhage. Occasional passage of clots in the absence of heavy flow may be normal.

Lochia should progress as follows:

Lochia rubra: Dark red, 2—3 days

Lochia serosa: Paler, brownish pink, 4-10 days

Lochia alba: Whitish or yellowish, up to 3 wks

Lochia should be odorless.

o Lower Extremities

Nursing considerations

Assess veins for redness and extreme warmth (signs of phlebitis).

Assess for pain while dorsiflexing foot.

Pain indicates positive Homans’ sign, which is sign of thrombophlebitis.

Ambulation and/or early leg exercises help prevent venous stasis and clot formation.

o Psyche

Nursing considerations

Assess mood. Mild "let-down feeling" is usually considered normal.

Watch for signs of parent-infant bonding:

Parents hold baby so that mutual gazing can occur ("enface" position).

Parents talk to baby.

Parents stroke baby.

Parents make positive statements about baby.

Parents give baby cherished name.

o DIAGNOSIS: Risk for uterine infection related to lochia and episiotomy.

PLANNING: Major patient goals include verbalize understanding of risk factors, identify interventions and demonstrate techniques to prevent risk of infection, achieve timely wound healing, and continue to be free from any symptoms of infection during postpartum.

IMPLEMENTATION:

INDEPENDENT:

Vital signs, lochia (character, amount, odor and presence of

clots), fundal height and status of episiotomy were monitored.RATIONALE: Alterations from normal maybe signs of infection, retained fragments or sub involution of the uterus.

Proper perineal care and hy-giene were reinforced.RATIONALE: Appropriate self care of the perineum in postpartum patients reduces the risk of bacterial invasion. Antiseptic feminine wash or clean warm water may be used.

Emphasized early ambulation and beginning postpartal exer-cise with resumption of normal activities as tolerated.RATIONALE: Mothers who had NSVD are allowed to ambulate 4 – 8 hours after childbirth.Circulation of blood is promoted through regular movements thus it helps in the healing process; Prevents

constipation, circulatory problems, and urinary problems; Promote rapid recovery; Hastens drainage of lochia; Improve GI and urinary function; and a sense of well-being.

Encourage to eat foods that are rich in protein and vitamin C.RATIONALE: Vitamin C is known to prevent infection; Citrus fruits are rich in vitamin C. Protein is needed for tissue repair and regeneration; meat products, nuts, and legumes are rich in sources of which.

Enough rest and sleep was also advised.RATIONALE: This promotes healing by reducing basal metabolic rate and allowing oxygen and nutrients to be utilized for tissue growth, healing, and regeneration.

DEPENDENT:

Intake of antibacterial medica-tion such as amoxicillin and cephalexin as per doctor’s or-der and advise.RATIONALE: Antibiotics are used to treat and prevent infections caused by susceptible pathogens in skin structure infections.

EVALUATION:

Expected patient outcomes:

No redness or anomalous dis-charge is present at epi-siotomy line; lochial dis-charge has no foul odor; tem-perature is not greater than 40⁰c.

Include verbalize understand-ing of risk factors.

Identify interventions and demonstrate techniques to

prevent risk of infection, achieve timely wound heal-ing.

Continue to be free from any symptoms of infection during postpartum.

o Nursing Diagnosis: Acute Pain related to after pains, or episiotomy discomfort.

Goals:

Client states degree of pain is tolerable

Demonstrates knowledge of measures for adequate pain relief.

Implementation:

Assess the location, severity, and duration of the patient’s pain.

Rationale: Excessive perineal / vaginal pain may indicate hematoma formation / lacera-

tions, or infection.

Position the woman in a prone position, with a small pillow un-der her lower abdomen.Rationale: The prone position applies pressure to the uterus and thus stimulates contractions. When the uterus maintains a constant contraction, the after pains cease.

Provide sitz bath as ordered.Rationale: The warmth of the water in the sitz bath provides comfort, decreases pain, and promotes circulation to the tissues. This promotes healing and reduces the incidence of infection.

Administer analgesics as or-dered.Rationale: For pain relief.

Encourage use of relaxation techniques, such as focused

breathing, imaging.Rationale: To distract attention and reduce tension.

Provide information about the cause of after pains.Rationale: This will reduce client’s discomfort.

o Nursing Diagnosis: Risk for impaired urinary elimination or constipation related to loss of bladder and bowel sensation after child birth.

Goals: Patient will maintain normal bowel and bladder function during the postpartum period.

Implementation:

Ambulate the patient to the bathroom to void as soon as possible after delivery.Rationale: To help prevent bladder distention. Patients usually find it easier to void on the commode.

Apply ice to the perineum dur-ing the first 24 hours, then heat as ordered.Rationale: Minimizing edema will prevent urinary retention caused by obstruction.

Monitor the position of the fun-dus.Rationale: A fundus that is raised and displaced to the right suggests a full bladder.

Administer stool softeners or laxatives, as ordered.Rationale: Patients often need medication to help keep stools soft and to stimulate peristalsis.

Encourage a high – fiber diet.Rationale: Fiber provides bulk in the intestine and promotes normal bowel function.

Encourage the patient to con-sume fluids.Rationale: Inadequate fluid

8. Develop a discharge plan for postpartum women.

intake predisposes the patient to harder stool formation.

Encourage the patient to walk.Rationale: Walking stimulates intestinal peristalsis.

o (See Appendix A)

Lecture – discussion

10 minutes

APPENDIX A

ANATOMICAL STRUCTURES (INTERNAL & EXTERNAL)

Figure 1: External

Figure 2: Internal

APPENDIX BDISCHARGE PLAN

PATIENT’S OUTCOME CRITERIA NURSING ORDERAs soon as the patient is discharged from the hospital, she and her significant others will be able to:

A. Assessment

Asses for signs and symptoms of infection.

Asses for continuity of pain felt on the traumatized area of the perineum.

Assess for inadequate rest and sleep pattern periods.

B. Planning

Plan for consultation to ensure recuperation.

Plan for the schedules of immunization for the newborn.

C. Implementation Medication

Comply the entire medication regimen correctly and completely.

ExercisePatient should practice relaxation techniques.

TreatmentFollow the schedule for medication administration.

Health teachingPerform measures that help promote healthy lifestyle.

Out patient referralComply schedules for check up.

DietEat nutritious and rich in fiber foods for early recovery and avoid the risk of constipation.

SpiritualAttend mass every Sunday and do not forget to pray everyday.

D. EvaluationEvaluate the patient’s understanding of all the treatment regimens and planned actions.

note for redness, swelling and tenderness on the perineal area.

perform pain destruction method.

encourage enough rest and sleeping periods

instruct patient to follow schedules for visits.

instruct patient to comply all the immunizations needed for the newborn.

remind the patient of the medication schedules.

for early recovery from labor.

encourage patient to watch out and remember all take home medications ordered by the doctor.

take enough hours of sleep each day at about 8hours/day.

encourage patient to follow the given schedules especially on the immunization of the newborn.

discuss with the patient the basic food groups and the right food to eat.

encourage patient and the family to attend mass every Sunday and to pray together everyday.

encourage the patient to ask questions to things which she did not understand.

ask the patient questions to know that she really understand.

BIBLIOGRAPHY

BOOKS:

Doenges, Marilynn E., Moorhouse, Mary Frances., Murr, Alice C. 2008. Nurse’s Pocket Guide. 11th edition. Pennsylvania: F.A. Davis Company, Philadelphia

Doenges, Marilynn E., Moorhouse, Mary Frances., Murr, Alice C. 2008. Nurse’s Pocket Guide. 11th edition. Pennsylvania: F.A. Davis Company, Philadelphia

Duell, Mary Ellen L. 1989. Maternal – Newborn Nursing. Canada: Aspen Publishing Company, Toronto.

Klossner, N. Jayne, Hatfield, Nancy. 2006. Introductory Maternity & Pediatric Nursing. Lippincott Williams & Wilkins.

London, Marcia L., et.al. 2007. Fundamentals of Maternal and Child Nursing Care. Volume 1. Singapore: Pearson Education South Asia Pte Ltd. 23-25 First Lock Yang Road, Jurong

Pillitteri, Adele. 2007. Maternal & Child Health Nursing: Care of Childbearing & Childrearing Family. 2007. 5th edition. Volume 1. Lippincott Williams & Wilkins.

INTERNET RESOURCES:

http://www.nlm.nih.gov/medlineplus/postpartumcare.html:

http://nursingcrib.com/nursing-care-plan/risk-for-uterine-infection-rt-lochia-and-episiotomy/

http://www.motherhood-cafe.com/postpartum-blues.html

http://www.motherhood-cafe.com/postpartum-period.html

http://findarticles.com/p/articles/mi_gGENH/is_20050229/ai_2699003628/

http://www.tajpharma.com/postpartum-care-diseasesindex-taj-pharmaceuticals.htm

http://www.utahmountainbiking.com/firstaid/painmeds.htm

http://pregnancy.familyeducation.com/recovery/postpartum-diet/35973.html