Caring for the Postpartal Woman and Her Family

Within a period of one day, most of what has been carefully accumulated over nine months is eliminated as no longer necessary by the body.

LEARNING TARGETS At the completion of this chapter the student will be able to:

·         Discuss the physiological and psychological changes that occur in the postpartal woman.

·         Assess the physiological and psychosocial status of the postpartal woman.

·         Plan holistic nursing care for the postpartal woman and her family that includes strategies for home follow-up.

·         Implement nursing interventions to promote positive breast and formula feeding outcomes for the mother and her infant.

·         Describe effective maternal self-care measures to be implemented during the puerperium.

·         Discuss methods for assessing and treating pain in the postpartal period.

·         Conduct appropriate nursing assessments and plan interventions for the patient who has experienced a cesarean birth.

·         Discuss dimensions of postpartal care for the multicultural family.

·         Plan postpartal nursing care with interventions to assess and foster maternal/infant/family bonding.

Moving toward evidence-based practice:The Influence of Norms on Breastfeeding Decisions

Swanson,V.,&Power, K.G. (2005). Initiation and continuation of breastfeeding: theory of planned behavior. Journal of Advanced Nursing, (50)3, 272–282. Rimal, R.N., & Real, K. (2003). Understanding the influence of perceived norms on behaviors. Communication Theory 13(2), 184–203.

The purpose of this study was to investigate the subjective norms of new mothers in relation to the decision to breast or bottle feed. Norms were defined as “group identity-based codes of conduct that are understood and disseminated through group interaction” (Rimal & Real, 2003). The Theory of Planned Behavior (TPB), a social cognition model, was used as a framework for the study, which explored how attitudes, norms, and perceived behavior control (PBC) predicted mothers’ feeding behaviors at birth.

Specifically, the research was designed to measure changes in norms and attitudes on the selected infant feeding method from birth to 6 weeks postpartum. Follow-up for both breast and bottle-fed infants and a decision to discontinue breastfeeding during this period was examined. The researchers also explored the views held by significant persons in the women’s environment (partner, own mother, and nurses) in relation to the mother’s decision about a method of feeding.

An initial interview and self-administered questionnaire were completed by 203 new mothers after childbirth. At 6 weeks postpartum, 118 of the participants completed a follow-up questionnaire. The sample included primiparous and multiparous women who experienced a vaginal or cesarean birth. At the time of delivery, 103 participants planned to breastfeed;100 planned to bottle feed.

Data analysis revealed the following findings:

• One half of the sample were multiparas; the majority of these mothers chose to use the same feeding method used with their previous children.

• Eight mothers who had breast fed their fi rst child chose to bottle feed the newborn; 11 mothers who had bottle fed their first child chose to breastfeed the newborn.

• Mothers who bottle fed their children tended to be younger, single, less educated, of lower socioeconomic status, and more likely to live in a rental unit.

• At the 6-week follow-up, 48% who initially planned to breastfeed continued to do so; 47% continued to bottle feed; and 12% combined breast and bottle feeding methods.

• Mothers who were breastfeeding reported positive beliefs toward breastfeeding. In addition, mothers who were bottle-feeding also reported positive beliefs.

• No significant differences were found in the mothers’ perceived level of control over their choice of infant feeding methods.

• Both breast-feeding and bottle-feeding mothers were in agreement with social norms as expressed by their partner, mother, close female friends, and nurses or midwives.

• At 6 weeks postpartum, the breastfeeding mothers indicated that significant persons were more in favor of bottle feeding than breastfeeding. Ratings of the bottle-feeding mothers did not change.

• The partners, nurses, and nurse midwives were considered to have the most influence in relation to the mother’s decision about a method of feeding.

• Mothers who discontinued breastfeeding by 6 weeks perceived more overall social pressure to bottle feed.

The researchers concluded that nurses and midwives have a crucial role in communicating positive views on breastfeeding to new mothers.

1. What might be considered as limitations to this study?

2. How is this information useful to clinical nursing practice?

See Suggested Responses for Moving Toward Evidence-Based Practice on the Electronic Study Guide or Davis Plus.

Introduction

Postpartum care begins immediately after childbirth. During this time, the nurse assists the new mother in learning how to care for herself and her baby. This 6-week period of time, also known as the puerperium, is filled with a myriad of changes that require careful nursing assessments for the mother, the newborn, and the family. The nurse’s knowledge and care provided during this “fourth trimester” of pregnancy can have a life-long impact in shaping the future plans and choices for the new family. The Healthy People 2010 national initiative includes several goals that encompass the time period of the early puerperium:

• Reduce the maternal mortality rate to no more than 3.3/100,000 live births from a baseline of 7.1/100,000.

• Reduce the proportion of births occurring within 24 months of a previous birth to 6% from a baseline of 11%.

• Increase to at least 75% the proportion of mothers who breastfeed their babies in the early postpartum period from a baseline of 64% (DHHS, 2000).

Nursing actions to help the nation achieve these goals center on close observation to identify hemorrhage and related complications during the critical first hour after childbirth and ongoing education and support for women and families. Teaching about normal physiological changes during the puerperium, signs of danger, contraceptive methods, and benefits of breastfeeding empowers them to make informed decisions and choices.

Current trends reflect a shortened hospital stay for the new mother and her infant. However, there are several drawbacks to this approach. A longer (greater than 24 hours) hospital stay provides more rest and recuperation time for the mother; a greater opportunity for postpartal education about self and infant care; and time for infant observation and assessment for anomalies, defects, or other problems, and improved maternal outcomes. Early hospital discharge has advantages as well. These include a decreased risk of nosocomial infections for the mother and infant, reduced medical expenses, and an opportunity for enhanced infant—family bonding.

Providing care during this period requires knowledge of the physiological and psychosocial aspects of the puerperium. The transitions that occur as the changes of pregnancy are reversed are considered to be a normal, but distinct, process. Protecting this process requires the nurse who cares for the postpartum patient to be equipped with special knowledge and skills. This chapter will discuss the physiological and psychosocial adaptations that occur during the postpartum period and the nursing assessments and interventions required to promote positive, healthy outcomes.

Ensuring Safety for the Mother and Infant

Early newborn discharge began as a consumer-initiated movement and as an alternative to home births in the 1980s. In the 1990s, third-party payers began to refuse reimbursement for hospital stays that extended beyond 24 hours, particularly after an uncomplicated vaginal birth. Congress responded to the growing concern over the safety of this practice by signing into law the Newborns’ and Mothers’ Health Protection Act of 1996. This legislation prohibits third-party payers from restricting benefits for hospital stays of less than 48 hours after a vaginal birth or less than 96 hours after a cesarean birth. Forty-eight hours is an incredibly short amount of time to assess, assist, and educate new mothers about matters concerning personal, newborn, and family health. Information provided by the postpartum nurse can protect the newborn and his family from unnecessary morbidity and mortality.

Fears surrounding infant abductions have long been common concern among hospital staff and families. These concerns have created the need for the electronic tracking of infants. The growing need for fail-proof mechanisms to ensure infant safety has prompted the development of a variety of systems designed to foil infant abduction attempts. In response to increased litigation and pressure from The Joint Commission, it has become mandatory for hospitals to offer state-of-the-art security protection for their patients, mother/baby units, and visitors.

To meet The Joint Commission mandatory infant safety requirements, hospitals have instituted policies and procedures that nurses and mothers must follow to ensure their newborn’s safety. Infant security experts agree that an informed mother is the baby’s first line of defense while in the hospital as well as after returning home. It is essential that nurses educate new mothers about measures designed to protect their newborns from potential abductors.

Be sure to— Check identification bracelets

The safety and security of the infant must be maintained at all times during hospitalization. This process involves the placement of identification bands on both the mother and infant shortly after birth. On bringing the infant to the mother, it is essential for the nurse to verify that the bracelets match. At discharge, it may be necessary for the nurse to retain both the infant’s and parent’s identification bracelets as part of the permanent record. This safety measure serves a twofold purpose: to prevent the unauthorized removal of the infant from the hospital unit and to prevent the inadvertent mix-up or switching of newborns.

Be sure to— protect the infant from abduction

Protecting the infant from abduction is an extremely important consideration during hospitalization. Personnel, parents, and significant others must be educated regarding the various measures implemented to protect the safety of the infant. Any time the infant is transported from the nursery to the mother’s room, it is essential for staff to follow the hospital’s protocol. In most facilities, infants may be transported only in a bassinet and parents are prohibited from carrying the infant in the halls. When identification bracelets are used, they are matched before giving the infant to the mother. Mothers should be instructed to release the infant only to properly identified hospital personnel. After birth, admission photographs and footprints are most likely taken and affixed to the permanent record. When two or more infants have a similar or same last name, it is common practice for the infants’ cribs and charts to indicate the mother’s first name, and bear a label that designates a “NAME ALERT.” When there are multiple births, the infants’ cribs may be labeled with the infant’s name followed by a letter of the alphabet (i.e., A, B, C, or D).

Hospital personnel are typically required to wear visible photo identification when working in the maternal child unit. All employee photo badges should be similar in appearance to facilitate the ready identification of individuals posing as hospital employees. Visitors may be required to wear identification badges while on the unit. Hospital staff should be empowered to question any suspicious activity or individuals who are present on the maternal child unit.

Now Can You— Discuss strategies to ensure maternal–infant safety?

1. Identify three measures the hospital nurse can implement to ensure the safety of both the infant and the mother? 2. Suggest a strategy to decrease the potential for confusing infants whose last names are similar or identical? 3. Describe two actions that hospital personnel can take to help prevent infant abduction?

Early Maternal Assessment

VITAL SIGNS

During the postpartum period, vital signs are a reflection of the body’s attempts to return to a pre-pregnant state. Vital signs can alert the nurse to the presence of hemorrhage or infection and should be monitored according to hospital policy. After a vaginal birth, vital signs are typically monitored every 15 minutes during the first hour after childbirth, then every 30 minutes during the second hour, once during the third hour, and then every 8 hours until discharge or until they are stable. A different protocol is followed for vital sign assessment after a cesarean birth (e.g., q30min _ 4 hours; then q1h _ 3; then q4–8h).

Temperature

During the fi rst 24 hours postpartum, some women experience an increase in body temperature up to 100.4°F (38°C). The exertion and dehydration that accompany labor are the primary causes for the temperature elevation, and increased fluids usually return the temperature to a normal range. Increased breast vascularity may also cause a transient increase in temperature. After the fi rst 24 postpartal hours have passed, however, the patient should be afebrile. A temperature above 100.4°F (38°C) at this time may be indicative of infection. (See Chapter 16 for further discussion).

Pulse

Heart rates of 50 to 70 beats per minute (bradycardia) commonly occur during the fi rst 6 to 10 days of the postpartum period. During pregnancy, the weight of the gravid uterus causes a decreased fl ow of venous blood to the heart. After childbirth, there is an increase in intravascular volume. The elevated stroke volume leads to a decreased heart rate. Postpartal tachycardia may result from a complication, prolonged labor, blood loss, temperature elevation, or infection.

Blood Pressure

Postpartal blood pressure values should be compared with blood pressure values obtained during the first trimester. Decreased blood pressure may result from the physiological changes associated with the decrease in intrapelvic pressure, or it may be indicative of uterine hemorrhage. An increase in the systolic blood pressure of 30 mm Hg or 15 mm Hg in the diastolic blood pressure, especially when associated with headaches or visual changes, may be a sign of gestational hypertension. Further assessment is indicated.

In the puerperium, plasma renin and angiotensin II levels return to normal, nonpregnant levels. These physiological changes produce a decrease in vascular resistance. Orthostatic hypotension may occur when the patient moves from a supine to a sitting position. Otherwise, maternal blood pressure should remain stable (Cunningham et al., 2005).

Respirations

The respiratory rate should remain within the normal range of 12 to 20 respirations per minute. However, slightly elevated respirations may occur due to pain, fear, excitement, exertion, or excessive blood loss. Careful nursing assessment for causes of an elevated respiratory rate is indicated, along with appropriate interventions. Tachypnea, abnormal lung sounds, shortness of breath, chest pain, anxiety, or restlessness are abnormal findings that must be reported immediately. These signs and symptoms may be indicative of pulmonary edema or emboli. (See Chapter 16 for further discussion.)

Nursing Insight— Promoting comfort during the immediate postpartum period

It is not unusual for women to experience shaking chills during the time immediately after childbirth. This physiological response results from: (1) pressure changes in the abdomen after the reduction in the bulk of the uterus and (2) temperature readjustments after the diaphoresis of labor. Feelings of excitement and exhaustion may also play a role. Nurses should reassure patients of the normalcy of this temporary reaction and offer warm blankets and beverages as comfort measures.

FUNDUS, LOCHIA, PERINEUM

Within a few minutes after birth, the firmly contracted uterine fundus should be palpable through the abdominal wall halfway between the umbilicus and the symphysis pubis. Approximately 1 hour later, the fundus should have risen to the level of the umbilicus, where it remains for the following 24 hours.

Optimizing Outcomes— Uterine assessment crucial during the fi rst hour postpartum

Because the first postpartal hour represents the most dangerous time for the patient, it is essential that the nurse conduct frequent uterine assessments during this time. Relaxation of the uterus (atony) results in rapid, life threatening blood loss because no permanent thrombi have yet formed at the placental site. The fundus then descends one fingerbreadth (1 cm) per day in size. The fundus, lochia (puerperal discharge of blood, mucus, and tissue), and perineum need to be assessed every 15 minutes during the immediate postpartum period. To facilitate the perineal assessment, the nurse assists the patient into a Sim’s (side-lying) position with her back facing the nurse.

Nursing Insight— Perineal assessment

Protecting the patient’s privacy and ensuring adequate lighting are essential components of the perineal assessment. Although some edema of the vulva and perineum is a common finding during the fi rst few postpartum days, excessive swelling, discoloration, incisional separation, or discharge other than lochia should be reported, along with the patient’s complaints of pain or discomfort.

With adequate lighting in place, the nurse gently lifts the buttock cheeks to visualize the perineum. Use of the acronym REEDA guides the nurse to assess for Redness, Edema, Ecchymosis, Drainage or discharge, and Approximation of the episiotomy if present (Table 15-1). The episiotomy and/or laceration repairs should appear intact with the tissue edges closely approximated. Hemorrhoids may also be present. The nurse should note and document the number, appearance, and size (in centimeters) of the hemorrhoids.

Table 15-1 The REEDA Acronym to Guide the Perineal Assessment
Points	Redness	Edema	Ecchymosis	Discharge	Approximation
0	None	None	None	None	Closed
1	Within 0.25 cm of incision bilaterally	Less than 1 cm from incision	1–2 cm from incision	Serum	Skin separation 3 mm or less
2	Within 0.5 cm of incision bilaterally	1–2 cm from incision	0.25–1 cm bilaterally or 0.5–2 cm unilaterally	Serosanguineous	Skin and subcutaneous fat separated
3	Beyond 0.5 cm of incision bilaterally	Greater than 2 cm from incision	Greater that 1 cm bilaterally or 2 cm unilaterally	Bloody, purulent	Skin, subcutaneous fat and fascial separation

HEMORRHOIDS

Hemorrhoids that may be present before pregnancy or develop during pregnancy can become enlarged due to pressure on the lower bowel during the second stage of labor. The application of ice packs and/or pharmaceutical preparations such as topical anesthetic ointments or witch hazel pads helps to relieve discomfort. Frozen tea peripads may also be used as a comfort measure for hemorrhoids and labial swelling. The tannic acid decreases edema and is soothing. Other actions to minimize hemorrhoidal discomfort include assisting the patient to a side-lying position in bed and teaching her to sit on fl at, hard surfaces and to tighten her buttocks before sitting. Soft surfaces and pillows such as donut rings should be avoided because they separate the buttocks and decrease venous flow, intensifying the pain. If the hemorrhoids are severe, the patient can be taught how to manually reposition the hemorrhoids back into the rectum. Hemorrhoids that developed during pregnancy generally disappear within a few weeks after childbirth.

Now Can You— Discuss postpartum vital signs and perineal assessment?

1. Describe the expected vital sign findings during the postpartum period? 2. Identify potential causes for increased blood pressure, pulse, and respirations during the postpartum period? 3. Explain what is meant by the REEDA acronym to facilitate the perineal assessment?

A Concise Postpartum Assessment: Guide to Facilitate Nursing Care

THE BUBBLE-HE MNEMONIC

Use of a systematic assessment process helps the nurse ensure that the special needs of postpartum patients are met. As with all nursing care, a complete head-to-toe assessment must be completed for the postpartum patient who has unique needs not found in any other nursing environment. To assist with the postpartum assessment, the mnemonic BUBBLE-HE is commonly used to guide nursing practice. BUBBLE-HE reminds the nurse to assess the breasts, uterus, bladder, bowel, lochia, and episiotomy.

Assessment of maternal pain, Homans’ sign, the patient’s emotional status and initiation of infant bonding are other important components to be included in the postpartum evaluation (Table 15-2). Medications commonly prescribed during the puerperium are presented in Table 15-3.

Table 15-2 BUBBLE-HE: Components of a Postpartum

Letter	Assess	Assessment Includes
B	Breasts	Inspection of nipples: everted, flat,inverted? Breast tissue: soft, filling, firm? Temperature and color: warm, pink, cool, red streaked?
U	Uterus	Location (midline or deviated to right or left side) and tone (firm, firm with massage, boggy)
B	Bladder	Last time the patient emptied her bladder (spontaneously or via catheter)? Palpable or nonpalpable? Color, odor, and amount of urine?
B	Bowels	Date/time of last BM; presence of fl atus and hunger (unless the colon was manipulated, do not need to auscultate for bowel sounds)
L	Lochia	Color, amount, presence of clots, any free flow?
(I)E	(Incision) Episiotomy	Type as well as other tissue trauma (lacerations, etc.) Assess using REEDA
L/H	Legs (Homans’ sign)	Pain, varicosities, warmth or discoloration in calves; presence of pedal pulses; sensation and movement (after cesarean birth)
E	Emotions	Affect, patient-family interaction, effects of exhaustion
(B)	Bonding	Interaction with infant—”taking in” phase—presence of finger tipping, gazing, enfolding, calling infant by name, identifying unique characteristics

Breasts

A number of physiological changes occur during pregnancy to prepare the breasts for the process of lactation. The mammary glands, or milk producing system, are unlike any other organ system. Throughout the woman’s growth and development, no other human organ undergoes the dramatic changes in size, shape, and function that take place in the breasts (Riordan, 2005). Essentially, the breasts serve no function other than to nourish the child. Breast size has no bearing on the woman’s ability or capacity to nourish her infant. Instead, the infant’s appetite and frequent emptying of the breasts dictate the quantity of milk produced.

A & P review Hormonal Changes to Prepare the Breasts for Lactation

Up until the onset of puberty, the breasts are much the same in males and females and their internal structure is similar: they consist of a collection of ducts that empty into the nipple. In the female, breast tissue responds to the release of the female sex hormones estrogen and progesterone during puberty. Estrogen stimulates the formation of additional ducts, the elongation of existing ducts and the formation of a system of milk secreting glands. These changes are associated with an increase in volume and elasticity of connective tissue, deposition of adipose tissue and increased vascularity. Progesterone stimulates the formation of lobules, the glands in the breast which produce milk.

By the time the breasts are fully formed, typically by the age of 15, breast tissue extends medially from the second or third rib to the sixth or seventh rib, and laterally from the breastbone to the edge of the axillae. Although genetic factors, body size and ethnicity account for some variations, on average, the breasts weigh approximately 200 grams. During pregnancy, each breast increases in size and weight to reach approximately 600 grams and 600 to 800 grams during lactation (Lawrence & Lawrence, 2005).

Until menopause, when menstrual periods cease, the woman’s breast tissue continues to respond to the changing hormonal environment that accompanies each menstrual cycle. Throughout the majority of the woman’s life, the breasts remain in a resting state except for the time during pregnancy and lactation.

Regardless of whether the woman plans to breast or bottle feed, the breasts require careful assessment. After ensuring privacy, the nurse asks the patient to remove her bra. The chest area is covered with a sheet or towel and the woman is instructed to raise her arms and rest her hands on her head. The nurse inspects and palpates each breast for size, shape, tenderness, and color. During the first 2 postpartal days, the breast tissue should feel soft to the touch. By the third day, the breasts should begin to feel firm and warm. This change is described as “filling.” On the fourth and fifth days postpartum, breastfeeding mothers’ breasts should feel firm before infant feeding, then become soft once the baby is satiated. The noticeable changes in breast firmness are indicative of milk transfer.

The process of lactation is established in all postpartum women, regardless of their intention to breast or formula feed. Tense, painful breasts in a breastfeeding mother are indicative of poor transfer of milk to the infant. This finding should prompt a breastfeeding assessment and, when appropriate, referral to an international board-certified lactation consultant. (See discussion later in this chapter.)

Occasionally, small, firm nodules can be palpated in the filling breasts. The nodules result from incomplete emptying of the breasts during the previous feeding. Usually, a nodule arises from a blocked milk duct or from milk contained in a gland that is not fl owing forward to the nipple. Although the nodules typically disappear after a satisfactory feeding, their location should be noted and monitored. Persistence of any breast mass may be indicative of fibrocystic disease or malignant growths unrelated to the pregnancy. The nurse also documents the appearance of the nipples, noting the presence of fissures, cracks, blood, or dried milk, and whether they are erect or inverted.

Uterus

Involution is a term that describes the process whereby the uterus returns to the non-pregnant state. The uterus undergoes a dramatic reduction in size although it will remain slightly larger than its size before the first pregnancy. Immediately after expulsion of the placenta, the uterus rapidly contracts to prevent hemorrhage. The uterus weighs approximately 1000 g in the immediate postpartal period and by the end of the first week, its weight has diminished to 500 g. Uterine size and weight continue to decrease and on average, the uterus weighs 300 g by the end of the second week and thereafter the weight is 100 g or less (Cunningham et al., 2005).

Table 15-3 Commonly Used Medications in the Postpartum Period

Classification	Medication	Dose Safety of Use in Breastfeeding	Indication for Use in Postpartum Phase
Stool softener	Docusate sodium (Colace)	50 mg to 500 mg by mouth daily until bowel movements are normal. Not contraindicated in breast feeding mother.	Used in the treatment of constipation
Stool softener	Bisacodyl (Dulcolax)	10 mg to 30 mg by mouth until bowel movements are normal. Not contraindicated in breast feeding mother.	Used in the treatment of constipation
Topical anesthetic	Lidocaine spray	Spray to perineal area after sitz bath or perineum care. Not contraindicated in breastfeeding mother.	Used on the skin to relieve pain and itching
Hemorrhoid care	Witch hazel (Tucks)	Apply to perineal area after sitz bath or perineum care. Not contraindicated in breast feeding mother.	Used on the skin to relieve the itching, burning, and irritation associated with hemorrhoids
Nonsteroidal anti inflammatory drugs	Ibuprofen (Motrin)	400 mg by mouth every 4–6 hours as needed for pain. Not contraindicated in breastfeeding mother.	Used for the treatment of mild to moderate pain
Opioid analgesics	Darvocet (propoxyphene and acetaminophen)	Take one tablet by mouth every four hours as needed for pain. Not contraindicated in breastfeeding mother.	Used for the treatment of moderate to severe pain
Opioid analgesics	Percocet (oxycodone and acetaminophen)	Take one to two tablets every 4-6 hours as needed for pain. Not contraindicated in breastfeeding mother.	Used for the treatment of moderate to severe pain

After the birth of the infant, placental expulsion spontaneously occurs within 15 minutes in approximately 90% of women. To prevent hemorrhage, rapid uterine contractions seal off the placental site, effectively pinching off the massive network of maternal blood vessels that were attached to the placenta (Cunningham et al., 2005).

The original site of placental implantation covers a surface area that is approximately 8 to 10 cm in size. By the end of the second postpartal week, the site has shrunk to about 3 to 4 cm; complete healing takes approximately 6 to 7 weeks. The uterus is predominantly composed of a muscle layer, the myometrium. The myometrium is covered by serosa and lined by the decidua basalis. The process of uterine involution results from a decrease in the size of the myometrial cells rather than from a decrease in the number of myometrial cells. The decrease in cell size results in myometrial thickening and ischemia from reduced blood flow to the contracted uterus.

Phagocytosis (the engulfment and destruction of cells) contributes to the process of uterine involution by removing elastic and fibrous tissue from the uterus. The process is further hastened by autolysis (self-digestion) that results from migration of macrophages to the uterus. Subinvolution is the failure of the uterus to return to the non-pregnant state. Uterine involution may be inhibited by multiple births, hydramnios, prolonged labor or difficult birth, infection, grand multiparity, or excessive maternal analgesia. In addition, a full bladder or retained placental tissue may prevent the uterus from sustaining the contractions needed to prevent hemorrhage or to facilitate involution. (See Chapter 16 for further discussion.)

The placental site heals by a process called exfoliation. Exfoliation is the scaling off of dead tissue. New endometrial tissue is generated at the site from the glands and tissue that remain in the lower layer of the decidua after separation of the placenta. This physiological process results in a uterine lining that contains no scar tissue, which could impede implantation in future pregnancies. Regeneration of the endometrium is complete by the 16th postpartum day, except at the placental site, where regeneration is usually not complete until approximately 6 weeks after childbirth.

Figure 15-1 To palpate the uterus, the upper hand is cupped over the fundus; the lower hand stabilizes the uterus at the symphysis pubis.

To perform the uterine assessment, the nurse assists the patient to a supine position so that the height of the uterus is not influenced by an elevated position. The patient’s abdomen is observed for contour to detect distention and the presence of striae or a diastasis (separation), which appears as a slightly indented groove in the midline. When present, the width and length of a diastasis are recorded in fingerbreadths. The uterine fundus is palpated by placing one hand immediately above the symphysis pubis to stabilize the uterus and the other hand at the level of the umbilicus (Fig. 15-1). The nurse presses inward and downward with the hand positioned on the umbilicus until the fundus is located. It should feel like a Firm, globular mass located at or slightly above the umbilicus during the first hour after birth.

Clinical alert Proper technique for uterine palpation

The uterus should never be palpated without supporting the lower uterine segment. Failure to do so may result in uterine inversion and hemorrhage.

FUNDUS. Immediately after childbirth, the uterus rapidly contracts to facilitate compression of the intra myometrial blood vessels. The uterine fundus can be palpated midline, midway between the umbilicus and symphysis pubis.

Figure 15-2 Fundal heights postpartum.

Within an hour, the uterus settles in the midline at the level of the umbilicus. Over the course of days, the uterus descends into the pelvis at a rate of about 1 cm/day (one fingerbreadth) (Fig. 15-2). After 10 days, the uterus has descended into the pelvis and is no longer palpable. The fundus is assessed for consistency (firm, soft, or boggy), location (should be midline), and height (measured in finger breadths). During the fundal assessment, the nurse notes whether it is located midline or deviated to one side. On occasion, the fundus can be palpated slightly to the right because of displacement from the sigmoid colon during pregnancy. Assessment of the fundus should be made shortly after the patient has emptied herbladder. A full bladder prevents the uterus from contracting and instead pushes the uterus upward and may deviate it from the midline, due to laxness of the uterine ligaments. A flabby, non-contracted, boggy uterus is associated with increased bleeding. A well-contracted fundus is firm, round, and midline. The nurse documents the location of the fundus according to fingerbreadths above or below the umbilicus (Table 15-4).

Table 15-4 Assessment and Documentation of Uterine Involution
Time	Location of Fundus	Documentation
Immediately after birth	Midline, midway between umbilicus and symphysis pubis
1–2 hours	At the level of the umbilicus	at U (umbilicus)
12 hours	1 cm above umbilicus (1 fingerbreadth)	U + 1
24 hours	1 cm below umbilicus	U - 1
2 days	2 cm below umbilicus (2 fingerbreadths)	U - 1
3 days	3 cm below umbilicus (3 fingerbreadths)	U - 1
7 days	Palpable at the symphysis pubisl
10 days	Not palpable

Afterpains (afterbirth pains) are intermittent uterine contractions that occur during the process of involution. Patients often describe the sensation as a discomfort similar to menstrual cramps. The primiparous woman typically has mild afterpains, if she notices them at all, because her uterus is able to maintain a contracted state. Multiparas and patients with uterine overdistention (e.g., large baby, multifetal gestation, hydramnios) are more likely to experience afterpains, due to the continuous pattern of uterine relaxation and vigorous contractions. When the uterus maintains a constant contraction, the afterpains cease. Breastfeeding and the administration of exogenous oxytocin usually produce pronounced afterpains because both cause powerful uterine contractions. Afterbirth pain is often severe for 2 to 3 days after childbirth.

Nursing interventions for discomfort include assisting the patient into a prone position with a small pillow placed under her abdomen, initiating sitz baths (for warmth), encouraging ambulation, and administrating mild analgesics.

Optimizing Outcomes— Breastfeeding and Afterpains

Analgesics such as ibuprofen (Advil, Motrin) or naproxen (Aleve, Anaprox) are frequently administered to lessen the discomforts of afterpains. Breastfeeding women should take pain medication approximately 30 minutes before nursing the baby to achieve maximum pain relief and to minimize the amount of medication that is transferred in the breast milk.

Now Can you— Discuss changes in the breasts and uterus during the postpartum period?

1. Name each component of the BUBBLE-HE mnemonic for the postpartum assessment? 2. Explain normal breast changes that occur during the first few postpartal days? 3. Explain what is meant by “involution”?

Bladder

After childbirth, spontaneous voiding should occur within 6 to 8 hours and the first few voiding amounts should be monitored. Urinary output of at least 150 mL/hr is necessary to avoid urinary retention or stasis. Generalized edema is often present in the early puerperium. It is related to the fluid accumulation that normally occurs during pregnancy combined with intravenous fluids frequently administered during labor and birth. Maternal diuresis occurs almost immediately after birth and urinary output reaches up to 3000 mL each day by the second to fifth postpartum days.

Decreased bladder tone is normal during pregnancy, and results from the effects of progesterone on the smooth muscle, edema from pressure of the presenting part, and mucosal hyperemia from the increase in blood vessel size. Prolonged labor, the use of forceps, analgesia, and anesthesia may intensify the changes in the immediate postpartum period. Pressure caused by the fetal head pressing on the bladder during labor can result in trauma and a transient loss of bladder sensation during the first few postpartal days or weeks. These changes can result in incomplete bladder emptying and overdistention.

Bladder and urethral trauma is not uncommon during the intrapartal period and may be associated with a decreased flow of urine immediately after a vaginal birth. An increase in the voided volume, the total flow time (how long it takes to empty the bladder) and the time to peak urine flow (the maximum urinary flow rate) begins to occur during the first postpartum day. Urine volume and flow time should return to pre-pregnant levels by 2 to 3 days after childbirth. Epidural anesthesia, catheterization before birth, and an instrument-facilitated birth are associated with an increased risk of postpartum urinary retention. Urethral and bladder trauma and lacerations may accompany vaginal or cesarean birth.

Urinary retention can also result from bladder hypotonia after childbirth since the weight of the gravid uterus no longer limits bladder capacity. Assessment of the maternal bladder is an extremely important component of the nursing evaluation (Table 15-5). An overdistended bladder, which displaces the uterus above and to the right of the umbilicus, can cause uterine atony and lead to hemorrhage.

Table 15-5 Nursing Assessment and Interventions for the Urinary System
Patient’s Signs and Symptoms	Nursing Interventions
Location of fundus above baseline level • Fundus displaced from midline • Excessive lochia • Bladder discomfort • Bulge of bladder above symphysis pubis • Frequent voiding of less than 150 mL of urine; urinary output disproportionate to fluid intake	• Promote hydration • Promote ambulation • Administer an analgesic before voiding, as prescribed • Place ice on perineum to reduce swelling and pain • Encourage the use of a sitz bath • Provide privacy • Turn on the bathroom faucet

Other assessment findings may include presence of the bladder palpated as a hard or firm area just above the symphysis pubis and a urinary output that is disproportionate to the fluid intake. Bladder percussion enhances the assessment. To percuss the bladder, the nurse places one finger fl at on the patient’s abdomen over the bladder and taps it with the finger of the other hand. A full bladder produces a resonant sound. An empty bladder has a dull, thudding sound. Patients may express an urge to void but

be unable to void. Fortunately, spontaneous voiding typically returns within 6 to 8 hours after childbirth. Until this time, the nurse should support and enhance the woman’s attempts to void. Nursing interventions may include assisting the patient to the toilet, providing privacy and a unhurried environment, turning on the lavatory faucet, and assisting the patient into a sitz bath.

Bowel

The gastrointestinal system becomes more active soon after childbirth. The patient often feels hungry and thirsty after the food and fluid restrictions that usually accompany the intrapartal experience. The peptide hormone relaxin, which reaches high circulating levels during pregnancy, depresses bowel motility (Cunningham et al., 2005). The relaxed condition of the intestinal and abdominal muscles, combined with the continued effects of progesterone on the smooth muscles, diminishes bowel motility. These factors commonly result in constipation during the early puerperium. After childbirth, bowel movements are typically delayed until the second or third puerperal day and hemorrhoids (distended rectal veins), perineal trauma, and the presence of an episiotomy may be associated with painful defecation. Early ambulation, abundant fluids, and a high-fiber diet are a few strategies to help prevent constipation (Box 15-1).

Box 15-1 Nursing Interventions to Facilitate Normal Bowel Function During the Puerperium

To facilitate the return of normal bowel function in the puerperium, the nurse should: • Encourage the patient to drink at least six to eight 8-oz. glasses of water every day to help keep the stool soft. • Encourage the patient to eat a high-fiber diet that includes an abundance of fruits and vegetables, oat and bran cereal, whole-grain bread, and brown rice. • Encourage the patient to avoid ignoring the urge to defecate. • Encourage the patient to avoid straining to have a bowel movement. • Encourage the patient to initiate early ambulation. • Administer stool softeners and/or laxatives as ordered. • Explain that after hospital discharge, over-the-counter medications may be helpful for hemorrhoidal symptoms of pain, itching, or swelling but encourage the patient to consult with her caregiver before using such medications.

Lochia

Separation of the placenta and membranes occurs in the spongy or outer layer of the decidua basalis. The uterine decidua basalis reorganizes into the basal and superficial layers. The inner basal layer becomes the foundation from which new layers of endometrium will form. The superficial layer becomes necrotic and sloughs off in the uterine discharge, called lochia. Lochia is composed of erythrocytes; epithelial cells; blood; and fragments of decidua, mucus, and bacteria (Cunningham et al., 2005). The characteristics of the lochia are indicative of the woman’s status in the process of involution.

During the first few days postpartum, the lochia consists mostly of blood, which gives it a characteristic red color known as lochia rubra. Lochia rubra also contains elements of amnion, chorion, decidua, vernix, lanugo, and meconium if the fetus had passed any stool in utero. These components cause the fleshy odor associated with lochia rubra.

After 3 to 4 days, the lochia becomes the pinkish brownish lochia serosa. Lochia serosa contains blood, wound exudates, erythrocytes, leukocytes, and cervical mucosa. After approximately 10 to 14 days, the uterine discharge has a reduced fluid content and is largely composed of leukocytes. This combination produces a white or yellow-white thick discharge known as lochia alba. Lochia alba also contains decidual cells, mucus, bacteria, and epithelial cells. It is present until about the third week after childbirth but may persist for 6 weeks. The pattern of lochia flow, from lochia rubra to serosa to alba, should not reverse. A return of lochia rubra after it has turned pink or white may indicate retained placental fragments or decreased uterine contractions and new bleeding. Lochia should contain no large clots, which may indicate the presence of retained placental fragments that are preventing closure of maternal uterine blood sinuses. The odor of lochia is similar to that of menstrual blood. An offensive odor is indicative of infection.

After assessment of the lochia, the nurse may find it difficult to document the findings correctly. Lochia is typically documented in amounts described as scant, small, moderate, or heavy. The amount of vaginal discharge is not a true indicator of the lochia flow unless the time factor is also considered. For example, a perineal pad (peripad) that accumulates less than 1 cm of lochia in 1 hour is associated with scant flow (Fig. 15-3). Nurses must also be certain to take into account the specific type of peripad used, since some are more absorbent than others. At times, visually assessing the amount of lochia flow can be difficult and inaccurate.

Optimizing Outcomes— Abnormal findings in a postpartal patient

During a routine postpartal assessment conducted 2 hours after childbirth, the nurse records the following vital signs: pulse _ 102 beats/minute; blood pressure _ 130/86 mm Hg; respirations _ 21 breaths/minute; temperature _ 98.9°F (37.1°C). The nurse’s first action is to assess the fundus. With the cupped palm placed directly over the uterine fundus, the nurse uses palpation to assess for the state of contraction (e.g., soft, boggy, or firmly contracted), along with the location and height of the fundus. If soft, the fundus is massaged in a circular motion with the cupped palm until the uterus is well contracted. The nurse inspects the peripad for the lochia amount and color, and the presence of odor. The physician or nurse midwife is notified of the findings. If excessive blood loss has occurred or if the uterus is not well contracted, the nurse administers appropriate prn medication(s) (e.g., Methylergonovine [Methergine]) as ordered.

Episiotomy

An episiotomy is a 1- to 2-inch surgical incision made in the muscular area between the vagina and the anus (the perineum) to enlarge the vaginal opening before birth. The midline episiotomy is a straight incision extending toward the anus. A mediolateral episiotomy extends downward and to the side. Typically, the episiotomy edges have become fused (the edges have sealed) by the first 24 hours after birth. Although the patient’s perineal folds may interfere with full visualization of a midline episiotomy, it is important for the nurse to carefully assess the episiotomy for redness, edema, ecchymosis, discharge, and approximation (REEDA) and then document all findings.

Clinical alert

Hematoma after an episiotomy Severe hemorrhage after an episiotomy is possible. Maternal complaints of excessive perineal pain should alert the nurse to the possibility of a perineal, vulvar, vaginal, or ischiorectal hematoma (a blood-filled swelling that occurs from damage to a blood vessel).

Medication: Methylergonovine Methylergonovine (meth-ill-er-goe-noe-veen) Methergine Pregnancy Category: C Indications: Prevention and treatment of postpartum and post-abortion hemorrhage caused by uterine atony or subinvolution Actions: Directly stimulates uterine and vascular smooth muscle. Therapeutic Effects: Uterine contraction Pharmacokinetics: ABSORPTION: Well absorbed after oral or IM administration ONSET OF ACTION: Oral: 5–10 minutes; IM: 2–5 minutes; IV: Immediately DISTRIBUTION: Oral: 3 hours; IM: 3 hours; IV: 45 minutes. Enters breast milk in small quantities. METABOLISM AND EXCRETION: Probably metabolized by the liver HALF-LIFE: 30–120 minutes Contraindications and Precautions CONTRAINDICATED IN: Hypersensitivity. Should not be used to induce labor. USE CAUTIOUSLY IN: Hypertensive or eclamptic patients (more susceptible to hypertensive and arrhythmogenic side effects); severe hepatic or renal disease; sepsis EXERCISE EXTREME CAUTION IN: Third stage of labor Adverse Reactions and Side Effects: CENTRAL NERVOUS SYSTEM: Dizziness, headache EYES, EARS, NOSE, THROAT: Tinnitus RESPIRATORY: Dyspnea CARDIOVASCULAR: Hypotension, arrhythmias, chest pain, hypertension, palpitations GASTROINTESTINAL: Nausea, vomiting GENITOURINARY: Cramps DERMATOLOGICAL: Diaphoresis Route and Dosage: PO: 200–400 mcg (0.4–0.6 mg) q6–12h for 2–7 days IM, IV: 200 mcg (0.2 mg) after delivery of fetal anterior shoulder, after delivery of the placenta, or during the puerperium; may be repeated as required at intervals of 2–4 hours up to fi ve doses. Nursing Implications: 1. Physical assessment: Monitor blood pressure, heart rate and uterine response frequently during medication administration. Notify the primary health care provider if uterine relaxation becomes prolonged or if character of vaginal bleeding changes. 2. Assess for signs of ergotism (cold, numb fingers and toes, chest pain, nausea, vomiting, headache, muscle pain, weakness) Data from Deglin, J.H, and Vallerand, A.H. (2009). Davis’s drug guide for nurses (11th ed.). Philadelphia: F.A. Davis.

To assess for perineal hematoma, the nurse should: 1. Look for discoloration of the perineum. 2. Listen for the patient’s complaints or expression of severe perineal pain. 3. Observe for edema of the area. 4. Listen for the patient’s expression of a need to defecate (the hematoma may cause rectal pressure). 5. Don sterile gloves, gently palpate the area, and observe for the patient’s degree of sensitivity to the area by touch. 6. Call the physician or nurse-midwife to report the findings immediately. The bleeding that has produced the hematoma must be promptly identified and halted.

Optimizing Outcomes— Early episiotomy care

The nurse should apply an ice bag or commercial cold pack to the perineum during the first 24 hours after childbirth. The ice bag should be wrapped in a towel or disposable paper cover to prevent a thermal injury. Application of cold provides local anesthesia and promotes vasoconstriction while reducing edema and the incidence of peripheral bleeding. Later (after 24 hours), the nurse encourages the use of moist heat (sitz bath) between 100o and 105°F (37.8–40.5oC) for 20 minutes three to four times per day. The sitz bath increases circulation to the perineum, enhances blood flow to the tissues, reduces edema, and promotes healing. Dry heat, in the form of a commercial perineal “hot pack,” may also be used. The packs are “cracked” to generate heat. Women should be cautioned to apply a washcloth or gauze square between the hot pack and their skin to prevent a potential burn.

ASSESSMENT OF PAIN.

Pain, sometimes considered the fifth “vital sign,” must be recognized as an important assessment focus throughout the postpartum period. Nurses play an important role in assessing, planning, and implementing interventions to manage maternal pain effectively.

Pain should be recognized and treated in a timely manner.

The failure to manage pain effectively has been associated with numerous complications, including prolonged recovery, increased length of hospital stay, depression, anxiety, poor coping, and altered sleep patterns.

Discomfort and pain may occur from several sources. Afterpains, which most commonly occur in the multiparous patient, can be quite intense, especially after breastfeeding. Analgesics such as acetaminophen (e.g., Tylenol) or nonsteroidal anti-inflammatory agents (NSAIDs) such as ibuprofen (e.g., Motrin, Advil) are effective and safe for use. Heat is not applied to the abdomen because of the potential for uterine relaxation and bleeding. Muscular aches and cramps related to the physical exertion expended during labor and birth may be relieved with back rubs and massage. When necessary, acetaminophen (e.g., Tylenol) may be used to alleviate the discomfort. Pain occurring in the calf of the leg must be carefully evaluated for thromboembolic disease. Episiotomy pain and discomfort may be associated with sitting, walking, bending, urinating, and defecating. It may interfere with the woman’s ability to comfortably hold and feed her infant. Interventions to decrease discomfort from the episiotomy include the application of cold (first 24 hours) and heat, and the use of topical anesthetic creams, sprays, and sitz baths. The sitz bath is a portable unit with a reservoir that fits on the toilet. When filled with warm water, the swirling action of the fluid soothes the tissue, reduces inflammation by promoting vasodilation to the area, and provides comfort and healing. The nurse prepares and assists the patient to the sitz bath, which should be used for 20 minutes three to four times a day (Procedure 15-1).

Optimizing Outcomes— Enhancing comfort and healing with a sitz bath

A sitz bath is a warm-water bath taken in the sitting position that covers only the perineum and buttocks. It can be placed in the toilet, with the seat raised. Other mechanisms for taking a sitz bath include sitting in a tub filled with 4–6 inches of warm water or the use of a non-portable sitz bath unit (similar to a toilet that fills up with warm water). A sitz bath may be used for either healing or hygiene purposes. The water may contain medication. Sitz baths are used to relieve pain, itching, or muscle spasms.

The patient likely has expectations regarding pain management during the postpartum phase. She should be encouraged to express her requests or concerns regarding pain control. Education regarding the available modalities is essential and will likely enhance the patient’s perception of control, as well as her level of satisfaction with the nursing care received. The nurse should regularly assess for pain and medication side effects and actively involve the patient in her pain management regimen. Use of a standardized pain rating scale enhances the assessment by allowing the patient to select the pain intensity level being experienced.

The nurse assesses and documents the patient’s pain behavior regarding the:

• Location of the pain

• Type of pain: stabbing, burning, throbbing, aching

• Duration of pain: intermittent or continuous

Nursing interventions include the administration of analgesics and patient education about other measures to promote comfort.

• Suggest non-pharmacological methods for pain relief such as imagery, therapeutic touch, relaxation, distraction, and interaction with the infant.

• Provide pain relief by administering prescribed agents such as ibuprofen, propoxyphene napsylate/ acetaminophen (Darvocet-N), or oxycodone/acetaminophen (Percocet).

• Suggest over-the-counter medications and alternative therapies such as tea tree oil for self-care after hospital discharge. Teach the patient that medication such as acetaminophen or ibuprofen may be equally as effective as narcotic analgesics.

• Reassure the patient that the pain and discomfort should not persist beyond 5 to 7 days and that since the episiotomy sutures are made of an absorbable material, they will not need to be removed.

Complementary Care: Tea tree oil to facilitate episiotomy healing

Tea tree (Melaleuca alternifolia) oil applied to the perineum is believed to be beneficial in facilitating healing of the episiotomy site. Melaleuca alternifolia oil has been in use as a botanical medicine in various forms for centuries. For hundreds of years, the Australian aboriginal people have used tea tree oil as an antiseptic, antimicrobial, and anti-inflammatory agent. The anti-inflammatory properties are believed to be particularly helpful in promoting incisional healing (Halon & Milkus, 2004) although allergic contact dermatitis may occasionally occur (Stonehouse & Studdiford, 2007). Postpartum women with episiotomies may be taught to fill an applicator with tea tree oil and then apply the oil directly to the wound. A few drops of the oil provide cooling to the wound, relieve pain, enhance comfort, and promote healing

.

Procedure 15-1 Preparing a Sitz Bath

Purpose To facilitate healing through the application of moist heat.

Equipment • Sitz bath tub/toilet insert with water receptacle • Medications to be added to water or saline, as ordered • Towels for drying the perineal area after the treatment • Clean perineal pad to be applied after the treatment Steps 1. Wash your hands, identify the patient, and explain the procedure. RATIONALE: Hand washing helps to prevent infection. Patient identification ensures that the procedure is performed on the correct patient. Providing an explanation educates the patient and helps to alleviate anxiety. 2. Assess the patient to confirm that she is able to ambulate to the bathroom. RATIONALE: A sitz bath can cause dizziness and increase the potential for injury. It is important to ascertain that the patient can safely ambulate to the bathroom before initiating the procedure. 3. Assemble equipment and ensure that all equipment is clean. RATIONALE: Gathering all equipment before the procedure enhances efficiency. 4. Raise the toilet seat in the patient’s bathroom. 5. Insert the sitz bath apparatus into the toilet. The overflow opening should be directed toward the back of the toilet. 6. Fill the collecting bag with water or saline, as directed, at the appropriate temperature (105°F [41°C]). 7. Test the water temperature. It should feel comfortably warm on the wrist. RATIONALE: Ensuring a correct water temperature reduces the chance of thermal injury. The flow of warm water to the perineum promotes healing by increasing circulation and reducing inflammation. 8. If prescribed, add medications to the solution. 9. Hang the bag overhead to allow a steady stream of water to flow from the bag, through the tubing, and into the reservoir. 10. Assist the ambulating patient to the bathroom. Help with removal of the perineal pad from front to back. Assist the patient to sit in the basin. RATIONALE: Assistance with ambulation reduces the chance for patient injury. Removal of the pad from front to back decreases the risk for infection transmission. Proper placement on the seat ensures comfort and effectiveness of the treatment. 11. Instruct the patient to use the tubing clamp to regulate the flow of water. Ensure that the patient is adequately covered with a robe or blankets to prevent chilling. RATIONALE: The swirling warm water helps to reduce edema and promote comfort. Clothing and extra blankets for warmth prevent chilling and enhance patient comfort. 12. Verify that the call bell is within reach and provide for privacy. RATIONALE: Easy access to the call bell reassures the patient that prompt assistance is readily available when needed. 13. Encourage the patient to remain in the sitz bath for approximately 20 minutes. RATIONALE: After 20 minutes, vasoconstriction occurs and heat is no longer therapeutic. 14. Provide assistance with drying the perineal area and applying a clean perineal pad by grasping the pad by the ends or bottom side. RATIONALE: Holding the pad correctly decreases the risk for contamination and subsequent infection. 15. Assist the patient back to the room. RATIONALE: After the procedure, the patient may be fatigued or light headed from the warm water; assistance minimizes the risk of injury. 16. Assess the patient’s response to the procedure. Reinforce teaching about continued perineal care at home. RATIONALE: Assessment helps to determine the effectiveness of the procedure; teaching enhances understanding and promotes continuity of care after discharge. 17. Record completion of the procedure, the condition of the perineum, and the patient’s tolerance. RATIONALE: Documentation provides evidence of the intervention and an additional opportunity for evaluation of care and the patient’s tolerance of the procedure. Clinical Alert The warm environment associated with a sitz bath may cause the patient to feel light-headed or dizzy. It is important to monitor the patient frequently throughout the intervention to ensure safety and tolerance.

Teach the Patient 1. The benefits of using the sitz bath, which include enhanced hygiene, comfort, and improved circulation2. To use the sitz bath as often as recommended— usually three to four times per day or as needed for discomfort 3. To contact the nursing staff immediately if she becomes light-headed or dizzy 4. To check the temperature of the solution before use. Applying water or solution that is too warm may result in local trauma or burns to the area Note If the patient prefers to prepare a sitz bath in the tub at home, she should be instructed not to use the same water for bathing. Instead, fresh water should be drawn for washing to diminish the potential for infection. Caution: The nurse must check the temperature of the water before administration of the sitz bath to ensure that it is not too warm.

Documentation 6/29/09 1500 Patient reported perineal discomfort. Mild perineal edema noted. Patient assisted into bathroom for sitz bath. Tolerated sitz bath with warm water for 20 minutes. She denied any discomfort or syncope throughout treatment. Perineal care was provided and a new peripad was applied. The patient was assisted back into bed. She denies perineal pain at present. —Olga Sanchez, RN

Homans’ Sign

Homans’ sign is often used in the assessment for deep venous thrombosis (DVT) in the leg. To assess for Homans’ sign, the patient’s legs should be extended and relaxed with the knees flexed. The examiner grasps the foot and sharply dorsiflexes it (Fig. 15-4). No pain or discomfort should be present. The other leg is assessed in the same manner. If calf pain is elicited, a positive Homans’ sign is present. The pain occurs from inflammation of the blood vessel and is believed to be associated with the presence of a thrombosis. Pain on dorsiflexion is indicative of DVT in approximately 50% of patients. Thus, a negative Homans’ sign does not rule out DVT. A diagnosis based solely on the evaluation of clinical signs that include pain in the calf, erythema, warmth greater in one calf than the other, and unequal calf circumference has proven to be unreliable. Instead, specific diagnostic procedures (e.g., venography, real-time and color Doppler ultrasound) should be performed when DVT is suspected. (See Chapter 16 for further discussion.)

Emotional Status

The birth of a child is associated with a range of emotional experiences in the new mother. During the early puerperium, it is not unusual for patients to have periods of happiness that are intermingled with sadness, insecurity, and depression. Continued assessment of the woman’s emotional status is an important nursing action that begins immediately after childbirth and continues throughout the hospital stay. The nurse should offer support to the new mother, which may include listening to her share her labor experience or reassuring her about her ability to effectively care for the newborn. The nurse should also provide information regarding the “baby blues,” and emphasize that these feelings are common and temporary (Horowitz & Goodman, 2005).

Now Can You— Discuss essential components of postpartum nursing care?

1. Identify three types of lochia and explain the characteristics and duration of each? 2. Describe nursing interventions to promote healing, enhance comfort, and prevent infection in the patient with an episiotomy? 3. Discuss the nurse’s role in pain assessment of the postpartal patient?

Figure 15-4 Assessing for Homans’ sign.

Maternal Physiological Adaptations and Continued Assessment of the Patient

HEMATOLOGICAL AND METABOLIC SYSTEMS

During the immediate postpartum period, a decrease in blood volume correlates with the blood loss experienced during delivery. During the next few days after childbirth, the maternal plasma volume decreases even further as a result of diuresis. The 500-mL blood loss that typically accompanies a vaginal birth (1000 mL for a cesarean birth) usually results in a 1 gram (2 grams for a cesarean birth) drop in hemoglobin. It is important for the nurse to remember that as the body’s excess fluid is excreted, the hematocrit may rise due to hemoconcentration. However, the hematocrit should have returned to pre-pregnancy levels by 4 to 6 weeks postpartum.

The white blood cell (WBC) count, which increases during labor and in the immediate postpartum period, returns to normal values within 6 days. Levels of plasma fibrinogen tend to remain elevated during the first few postpartal weeks. Although this alteration exerts a protective effect against hemorrhage, it increases the patient’s risk of thrombus formation. Overall, the hematologic system has usually returned to a nonpregnant status by the third to fourth postpartal week.

Circulating levels of estrogen and progesterone decrease dramatically after delivery of the placenta. The decline in these two hormones signals the anterior pituitary gland to produce prolactin in readiness for lactation. In nonlactating (formula feeding) women, prolactin levels return to normal by the third to fourth postpartal week.

After childbirth and expulsion of the placenta, circulating levels of other hormones, including placental lactogen, cortisol, growth hormone, and insulinase, also fall. During the early postpartum period, the decline in the serum levels of these substances reduces the anti-insulin effects that occur during pregnancy. Hence, insulin requirements are reduced for insulin dependent women during this time, sometimes termed a “honeymoon phase.” For many insulin dependent diabetics, glucose levels remain in a normal range (without intervention) during the first few days after childbirth (Chan & Winkle, 2006).

NEUROLOGICAL SYSTEM

Fatigue and discomfort are common complaints after childbirth. The demands of the newborn frequently create altered sleep patterns that contribute to increased maternal fatigue. Anesthesia and analgesia received during labor and birth may cause transient maternal neurological changes such as numbness in the legs or dizziness. When these changes are present, the nursing priority is to safeguard the patient and her infant and prevent injury from falls.

Complaints of headaches require further nursing assessment. Patients who received epidural or spinal anesthesia may experience headaches, especially when they assume an upright position. After spinal or epidural anesthesia, headaches may result from the leakage of cerebrospinal fluid into the extradural space. Labor-induced stress or gestational hypertension may also cause headaches. It is essential that the nurse assess the quality and location of the headache and carefully monitor maternal vital signs. Headaches that are accompanied by double or blurred vision, photophobia, epigastric or abdominal pain, and proteinuria may be signs of a developing or worsening preeclampsia. Report these findings immediately to the primary health care provider. Implement environmental interventions such as reducing the room lighting and noise levels and limiting visitors. The physiological edema of pregnancy is dramatically reversed during postpartum diuresis. Patients who experienced medial nerve compression and carpel tunnel syndrome during pregnancy often obtain relief of symptoms.

RENAL SYSTEM, FLUID, AND ELECTROLYTES

The renal plasma flow, glomerular filtration rate (GFR), plasma creatinine and blood urea nitrogen (BUN) return to pre-pregnant levels by the second to third month after childbirth. Urinary glucose excretion increases in pregnancy by 100-fold over non pregnant values. These values return to nonpregnant levels after the first postpartal week. Pregnancy-associated proteinuria (up to 1_ on a urine dipstick or less than 300 mg in 24 hours) is common during pregnancy and generally returns to pre-pregnancy values by 6 weeks postpartum (Cunningham et al., 2005).

During the postpartum period, there is a rapid, sustained natriuresis (excessively large amount of sodium in the urine) and diuresis as the sodium and water retention of pregnancy is reversed. The physiological reversal is particularly pronounced during the second to fifth puerperal days. In most women, the body’s fluid and electrolyte balance has been restored to a non pregnant homeostatic state by the third postpartal week. After childbirth, a decrease in levels of oxytocin and estrogen naturally occurs and contributes to diuresis. As the serum levels decline, the diuresis becomes more pronounced. Nurses often note a maternal urinary output that reaches 3000 mL excreted in a 24-hour period. For the postpartum patient, a single voiding may contain 500 to 1000 mL of urine.

Now Can You— Describe early postpartal physiological adaptations in the metabolic, neurological, and renal systems?

1. Explain what is meant by the “honeymoon phase” and why this may occur? 2. Identify possible causes and describe appropriate nursing assessments for patients who complain of headache? 3. Discuss physiological adaptations in the renal system and identify one patient teaching need related to these adaptations?

RESPIRATORY SYSTEM

Respiratory alkalosis and compensated metabolic acidosis occur during labor and may persist into the postpartum period. In most situations, however, after delivery of the placenta and the decline in levels of progesterone, the respiratory system quickly returns to a pre-pregnant state. In addition, the immediate decrease in intra-abdominal pressure associated with the birth of the baby allows for increased expansion of the diaphragm and relief from the dyspnea usually associated with pregnancy. By the third postpartal week, the respiratory system has returned to a pre-pregnant state.

INTEGUMENTARY SYSTEM

Changes in the skin during pregnancy and in the postpartum period are related to the major alterations in hormones. Women may experience alterations in pigmentation, connective and cutaneous tissue, hair, nails, secretory glands, and pruritus. Most pregnancy-related skin changes disappear completely during the postpartum period although some, such as striae gravidarum (stretch marks) fade but

may remain permanently.

Ethnocultural Considerations— Pregnancyrelated skin changes in the puerperium

Although abdominal stretch marks (striae gravidarum) appear more pronounced immediately after childbirth, they tend to fade over the following 6 months. In Caucasian women, striae become pale and white in color; in African American women, they will appear as a slightly darker pigment.

CARDIOVASCULAR SYSTEM

During pregnancy, the heart is displaced slightly upward and to the left. As involution of the uterus occurs, the heart returns to its normal position. Dramatic changes in the maternal hemodynamic system result from birth of the baby, expulsion of the placenta, and loss of the amniotic fluid. These abrupt alterations can create cardiovascular instability during the immediate postpartum period. Despite the usual blood loss (500 mL with a vaginal birth; 1000 mL with a cesarean birth), the maternal cardiac output is significantly elevated above prelabor levels for 1 to 2 hours postpartum and remains high for 48 hours postpartum. The cardiac output returns to pre-pregnant levels within 2 to 4 weeks after childbirth.

On average, a 3-kg weight loss occurs during the first postpartal week. Diuresis takes place between the second and fifth day. A major fl uid shift involves the movement of extracellular fluid back into the venous system for excretion through urine and perspiration. If the physiologic diuresis does not occur, there is an increased risk of pulmonary edema. The cardiac output and stroke volume remain elevated for at least 48 hours after childbirth. Within 2 weeks, the cardiac output has decreased by 30% and then reaches pre-pregnant values by 6 to 12 weeks postpartum in most women (Cunningham et al., 2005).

IMMUNE SYSTEM

The WBC count is increased during labor and birth and remains elevated during the early postpartum period, gradually returning to normal values within 4 to 7 days after childbirth. Depending on the patient’s blood type and immune status, administration of RhoGAM (see below) may be indicated. Women who are rubella susceptible during pregnancy should receive the MMR (measles–mumps– rubella) vaccine at the time of hospital discharge; varicella vaccine should also be encouraged (American College of Obstetricians and Gynecologists [ACOG], 2003).

Rho(D) Immune Globulin

Nonsensitized women who are Rho(D)-negative and have given birth to an Rh(D)-positive infant should receive 300 mcg of Rho(D) immune globulin (RhoGAM) within 72 hours after giving birth. RhoGAM should be given whether or not the mother received RhoGAM during the antepartum period. In some situations, depending on the extent of hemorrhage and exchange of maternal–fetal blood, a larger dose of RhoGAM may be indicated.

Rubella Vaccine

Before discharge, the patient needs to be assessed for rubella immunity. If nonimmune (rubella titer less than 1:8, or antibody negative on the enzyme-linked immunosorbent assay [ELISA]), the MMR vaccine should be administered. The nurse should counsel the patient about the need to avoid pregnancy for 1 month after receiving the vaccine (due to the teratogenic effects associated with congenital rubella syndrome) and advise her that she may briefly experience rubella-type symptoms such as lymphadenopathy, arthralgia, and a low-grade fever. The vaccine may be safely given to breastfeeding mothers. A signed consent form must be obtained before administration of the vaccine (ACOG, 2003).

REPRODUCTIVE SYSTEM

The uterus undergoes a rapid reduction in size (involution) and returns to its pre-pregnant state in about 3 weeks. The former site of the placenta heals by the process of exfoliation, which ensures that the placental site heals without leaving a fibrous scar. Formation of scar tissue would limit areas for future implantation and adversely affect the potential for future pregnancies. After a vaginal birth, the vagina often appears edematous or bruised and superficial lacerations may be present. Although swelling is resolved during the healing process, the vagina does not return to its nulliparous size and the labia majora and labia minora remain more flaccid in the multiparous woman (Cunningham et al., 2005).

During the postpartum phase, the return of ovulation and menstruation varies according to the individual. Menstruation usually resumes within 6 to 8 weeks after childbirth in women who are not breastfeeding. Seventy five percent menstruate by the twelfth postpartal week. The first cycle is often anovulatory. The return of ovulation and menstruation is typically prolonged in lactating women. Those who exclusively breastfeed may not ovulate or menstruate for 3 or more months. It is important to educate patients that since ovulation can precede menstruation, breastfeeding is not a reliable method of contraception.

GASTROINTESTINAL SYSTEM

Owing to hormonal effects, gastric motility is decreased during pregnancy. It is further decreased during labor and in the first few postpartal days due to decreased abdominal wall tone. Abdominal discomfort results from gaseous distention related to decreased motility and abdominal muscle relaxation. Constipation, a common nursing diagnosis for the postpartal patient, is associated with abdominal discomfort and decreased hunger. Straining to pass hard stool can cause hemorrhoids and tear episiotomy sutures. Although spontaneous bowel movements usually resume by the second or third day after childbirth, it is important to educate the patient about strategies to prevent constipation. Stool softeners may be necessary. Additional nursing diagnoses for the postpartal patient focus on a variety of other problems such as pain, fatigue, and sleep disturbances, infant feeding difficulties and knowledge deficit (Box 15-2).

Box 15-2 Common Nursing Diagnoses During the Puerperium

• Breastfeeding, ineffective/effective • Risk for constipation • Sleep-pattern disturbed • Fatigue • Pain, acute • Activity intolerance • Skin integrity, risk for impaired • Knowledge, deficient regarding self-care or care of infant • Risk for infection • Family processes parenting impaired • Risk for situational low self-esteem related to body image changes • Risk for urinary retention

MUSCULOSKELETAL SYSTEM

During pregnancy, the pelvic joints and ligaments have increased laxity. The hormones relaxin and progesterone are believed to contribute to the relaxation of the soft tissues (muscles, ligaments, and connective tissue) in the maternal pelvis to create room for the birthing process. In some women, the loosening of the pelvic joints causes pain and functional limitations.

During the first few days after childbirth, the woman may experience muscle fatigue and general body aches from the exertion of labor and delivery of the baby. Muscle fatigue can be exacerbated by the extended lack of nutrition and fluids throughout the course of labor. The maternal expenditure of glucose during parturition (the act of giving birth) can also add to muscle fatigue and may interfere with the patient’s ability to ambulate and initiate postpartum exercises. The nurse needs to assure the patient that the muscular discomforts are temporary and not indicative of a serious medical problem.

During pregnancy, the abdominal walls are stretched to accommodate the growing fetus. The progressive stretching causes a decrease in the muscle tone of the rectus muscles of the abdomen and results in the soft, flabby, and weak muscles experienced after birth. Rectus abdominis diastasis is a conventional term used to define the split between the two rectus abdominis muscles that can occur from pregnancy. Women should be aware that during the early postpartal period, the abdominal wall may not be sufficiently protected to withstand additional stress from increased activities. Nurses should teach them to maintain correct posture when performing activities such as lifting, carrying, and bathing the baby for at least 12 weeks after birth. Performing modified sit-ups during this time is beneficial in helping to strengthen the abdominal muscles.

Now Can You— Describe postpartal physiological adaptations in the respiratory, cardiovascular, and reproductive systems?

1. Explain why pregnancy-related dyspnea is relieved in the early postpartal period?

2. Describe three intra-postpartal events that cause dramatic changes in the maternal hemodynamic system?

3. Identify when ovulation and menstruation usually occur in the postpartal woman and explain specifi c information that should be given to lactating mothers?

Nursing Care Plan Acute Pain/Discomfort in the Postpartal Patient Nursing Diagnosis: Acute Pain related to tissue damage secondary to childbirth Measurable Short-term Goal: The patient will report decreased pain to a level that is acceptable to her. Measurable Long-term Goal: The patient will report minimal or no pain upon discharge from the hospital. NOC Outcomes: Pain Level (2102) Severity of observed or reportedpain Pain Control (1605) Personal actions to controlpain NIC Interventions: Pain Management (1400) Analgesic Administration (2210) Heat/Cold Application (1380) Nursing Interventions: 1. Perform routine, comprehensive pain assessments to include: onset, location, intensity, quality, characteristics, and aggravating and alleviating factors of the discomfort. Note verbal and nonverbal indications of discomfort. RATIONALE: Routine, comprehensive pain assessments enable the nurse to provide interventions in a timely manner to enhance effectiveness of medications and ensures early identification of complications resulting in painful stimuli. 2. Ask the patient to rate her pain on a standard 0 to 10 pain scale before and after interventions and to identify her own acceptable comfort level on the scale. RATIONALE: Use of a consistent pain scale provides objective measurement of the patient’s perception of pain, the effectiveness of interventions, and the acceptable comfort level for the individual. 3. Identify cultural or personal beliefs about the experience of pain and the use of pain interventions, including prescribed medications. RATIONALE: Expression of pain and use of pain relief interventions may vary according to culture and personal beliefs. Patients may prefer a stoic response to pain or fear becoming addicted to narcotics. 4. Provide factual, nonjudgmental information regarding pain interventions that are available to the patient. Encourage use of culturally based comfort measures when appropriate. RATIONALE: Accurate information and respect for the individual’s experience and preferences empowers the patient and reduces psychic discomfort. 5. Offer an ice pack to the perineum if the patient experienced perineal trauma or episiotomy. Apply for 20 minutes followed by removal for 10 minutes. RATIONALE: Cold therapy causes vasoconstriction and reduces edema resulting in decreased pain. Periodic removal avoids thermal injury. 6. Assist the patient with a sitz bath as ordered if the patient experiences perineal discomfort. RATIONALE: Cool water in the sitz bath decreases pain associated with edema while warm water promotes vasodilation and increased circulation to promote healing and provide comfort. 7. Teach the patient to apply topical medications for perineal or hemorrhoid pain as ordered. RATIONALE: Topical anesthetics, such as Dermoplast spray, produce localized pain relief by inhibiting conduction of sensory nerve impulses. Tucks pads contain witch hazel, which has astringent properties to shrink hemorrhoids and reduce perineal edema. 8. Teach the patient about the sources of pain and the effects of prescribed medications and interventions. Encourage her participation in developing a pain management plan. RATIONALE: Information and involvement increases the patient’s perception of control and increases her personal satisfaction with postpartum pain management.

Care for the Multicultural Family

ENHANCING CULTURAL SENSITIVITY

According to the United States Census Bureau (2001), ethnic and racial diversity in the U.S. population has reached new levels. At present, the population includes 77.1% Caucasians, 12.9% African Americans, 12% Hispanics, 4.2% Asians, 1.5% Native Americans/Alaska Natives, 0.3% Native Hawaiian/other Pacific Islanders, and 2.4% as persons who describe themselves as members of other races. Diversity in the population reaches into the health care sector and has prompted emphasis on cultural awareness in nursing education curricula and mandatory in service offerings for hospital staff.

Culturally competent care involves knowledge of the various dimensions of care, including moving beyond the biomedical needs of the patient. Rather, a holistic approach is one that expands knowledge, changes attitudes, and enhances clinical skills. To provide optimal care in a variety of clinical settings, it is important for health care professionals to conduct cultural assessments and expand their knowledge and understanding of culturally influenced beliefs, common health care practices, customs, and rituals (Taylor, 2005). In preparation for the cultural assessment, health care providers should:

• Assess their own cultural beliefs, identifying personal biases, stereotypes, and prejudices.

• Make a conscious commitment to respect and value the beliefs of others.

• Learn the customs and rituals of the common cultural groups within the community.

• Seek input from patients regarding health-related traditions and practices.

• Evaluate if what is about to be taught is really better than what the patient is already doing for herself.

• Adapt care to meet the special needs of the patient and her family, as long as standards of health and safety are not compromised.

• Include cultural assessment as a routine part of perinatal health care.

CULTURAL INFLUENCES ON THE PUERPERIUM

In certain multicultural populations such as India, Thailand, and China, the woman’s postpartum confinement lasts for 40 days. During this time, prolonged rest with restricted activity is believed to be essential. The postpartum period is an important time for ensuring future good health; thus great emphasis is placed on allowing the mother’s body to regain balance after the birth of a child.

During the 40-day confinement, support for the mother is provided by the female family members, usually the woman’s mother, sister(s), and mother-in law, who perform household chores such as cooking and caring for the siblings and new baby. The woman’s mother or older female relative often prescribes cultural remedies to aid in recovery and promote good health in the future. The female family members also provide the new mother with information on caring for herself and activities to avoid.

Lack of adequate rest and poor diet are believed to result in poor eyesight, varicose veins, digestive disorders, headache, and backache (Davis, 2001).

Certain beliefs regarding hot and cold exist among several multicultural groups. Blood is considered “hot,” and because the postpartum woman loses blood, she is considered to be in a “cold” state. To avoid illness, the mother must restore her health status by moving from a cold to hot state. The mother accomplishes this by:

• Adopting a diet that includes drinking/eating hot foods (foods such as black pepper, ginger, and garlic are believed to improve blood circulation). Sour foods such as lemons, grapefruits, and oranges are discouraged because they are thought to cause urinary incontinence later in life if eaten too early during the puerperium.

• Avoiding the consumption of ice water or cold water. These cold beverages are believed to cause weakness and delay healing.

• Avoiding cold temperatures, which are thought to be detrimental to the mother’s recovery. To maintain warmth, the mother dresses warmly and stays in bed for several days. Bathing, showering, and washing the hair is delayed for 40 days because water cools the body.

• Avoiding drafts by keeping doors and windows closed and avoiding fans and air-conditioning.

CLINICAL IMPLICATIONS OF CULTURALLY APPROPRIATE CARE

To provide sensitive, appropriate care, nurses need to adopt a flexible approach when caring for women who embrace non-Western health beliefs and practices. Inquiring about cultural beliefs, and, when possible, incorporating the beliefs into the plan of care are important strategies to help achieve this goal. For example, to demonstrate sensitivity to beliefs regarding hot and cold, the nurse may offer a warm sponge bath instead of a shower, adjust the thermostat in the room and provide extra blankets for warmth; offer warm drinks instead of cold beverages; and allow female family members as much access to the mother as possible.

Now Can You— Provide culturally sensitive postpartal care?

1. Identify at least five ways that health care providers can enhance cultural sensitivity before conducting a cultural assessment? 2. Describe several cultural beliefs concerning “hot” and “cold” and identify specific nursing interventions that allow women to adhere to these beliefs?

Promoting Recovery and Self-Care in the Puerperium

ACTIVITY AND REST

In the postpartum period, it is important for the new mother to begin ambulating as soon as her condition permits. Despite recent advances in diagnosis and treatment, deep vein thrombosis after birth continues to constitute a leading cause of maternal morbidity and mortality. Venous stasis and hypercoagulation, conditions that exist in pregnancy, are continued into the postpartum period. Early postpartum ambulation is key in preventing maternal thromboembolic events.

The type of birth and overall health status determines how soon the patient is allowed to resume exercise. The woman should be taught to begin with mild exercises, such as Kegel exercises, to strengthen the pelvic floor muscles. Non ambulating patients may begin with leg exercises. All exercise methods should be increased gradually.

Many women enter labor fatigued from the discomforts of pregnancy and lack of satisfying sleep associated with the third trimester. The length of labor and demands of the new mothering role further increase the feelings of exhaustion. During the hospital stay and later at home, all patients should be encouraged to obtain adequate sleep and frequent rest periods to help facilitate an optimal recovery.

NOURISHMENT

A weight loss of approximately 10 to 12 lbs. (4.5 to 5.5 kg) occurs immediately after childbirth, and this amount is directly related to the collective weights of the baby, placenta, and amniotic fluid. An additional 5 lbs. (2.3 kg) is lost over the following week as a result of puerperal diuresis and uterine involution. How quickly the woman returns to her pre-pregnancy weight depends on her physical activity level, eating habits, and lifestyle. Olson, Strawderman, Hinton, and Pearson (2003) noted that women whose weight increase was within the recommended limit of 25 to 30 lbs. (11.4 to 13.6 kg) during pregnancy could anticipate a return to the pre-pregnancy weight by 6 to 8 weeks postpartum. Factors associated with weight changes during the postpartum period include gestational weight gain, frequency of exercise, dietary intake, and breastfeeding for longer than 1 year.

Because of the restriction of food during labor, most patients demonstrate a hearty appetite after childbirth. All parturient women should be encouraged to eat a balanced, nutritious diet with multivitamin supplements. Iron is recommended only if the patient’s hemoglobin is low.

ELIMINATION

Voiding should occur within 4 hours of childbirth. Patients should be encouraged to empty the bladder every 4 to 6 hours and to expect to excrete large volumes of urine. In addition to the extra- to intravascular fl uid shift that follows childbirth, there is a decrease in the production of the adrenal hormone aldosterone. Declining levels of aldosterone are associated with a decrease in sodium retention and an increase in urinary output.

An intake and output record should be maintained to monitor the volume of urine passed during the first 24 hours. The woman who has recently given birth is prone to urinary stasis and retention. Incomplete bladder emptying or urinary retention may result from trauma to urethral tissue sustained during the “pushing phase” of a vaginal birth. Also, patients who were catheterized or who received regional anesthesia during childbirth sometimes experience an absence of the sensation to void. Bladder hypotonia during labor may also lead to postpartal urinary retention or stasis, factors that increase the risk of infection.

Incomplete emptying of the bladder is suspected when the patient experiences urinary frequency and passes 100 to 150 mL of urine with each voiding. The nurse’s assessment includes careful palpation of the lower abdomen to identify a distended or displaced uterus. The uterine fundus is felt above the symphysis pubis with a lateral displacement of the uterus. The nurse also notes an increase in the amount of lochia since the uterus is unable to contract effectively. The bladder is displaced, bulges above the symphysis pubis, and feels “boggy” on palpation. Patients experiencing urinary retention due to absence of the urge to void can be helped by assisted early ambulation to the toilet and other measures such as running the water from the lavatory faucet. If ambulation is not possible, the nurse can pour warm water over the vulva and perineal area to help relax the urethral sphincter. Owing to the risk of urinary infection associated with urinary stasis, catheterization may be necessary if the patient is unable to void.

Constipation commonly occurs because of slowed peristalsis associated with pregnancy hormones and childbirth anesthesia. In addition, perineal discomfort, fear of suture separation at the episiotomy site, and incisional pain (after a cesarean birth) may contribute to decreased frequency in bowel movements. To prevent constipation, nurses should encourage patients to consume foods high in fiber and roughage. Adequate fluid intake that includes drinking at least six to eight glasses of water or juice daily is another important strategy to prevent constipation. Early ambulation is also encouraged to improve peristalsis and relieve abdominal gas pain. If these measures are not effective, the primary care provider may prescribe a stool softener, suppository, or enema to alleviate the symptoms.

PERINEAL CARE

The perineum is susceptible to infection because of impaired tissue integrity resulting from bruising, laceration, or an episiotomy. The proximity of the perineum to the anus increases the risk of the incision becoming contaminated with fecal material; continuous drainage of blood creates a favorable medium for the proliferation of bacteria. To minimize infection, patients should be taught about perineal hygiene. A teaching approach that incorporates a return demonstration, encouragement, and positive reinforcement is most likely to be successful. Instructions should be given about properly cleansing the perineal area and the value of sitz baths, which not only cleanse but also provide relief from discomfort during the first

24 to 48 hours postpartum.

Patients should be educated about the importance of cleansing the perineum after each voiding and bowel movement. Hand washing before and after perineal care (“pericare”) is essential for the prevention of infection. The nurse instructs the patient to gently rinse her perineum with fresh warm water after use of the toilet and before a new perineal pad is applied. The patient is taught to fill the peri-bottle (hand-held squirt bottle) with warm tap water and gently squirt the water toward the front of the perineum and allow the water to flow from front to back. Consistent use of the peri-bottle is soothing, cleansing, and helps to relieve discomfort. Peri-pads should be changed often and secured in the underwear to allow for free drainage of the lochia. Tampons are contraindicated due to the risk of infection.

The nurse provides pericare for patients recovering from cesarean births until they are ambulatory and able to perform personal self-care. To provide pericare for the bedbound patient, a plastic-covered pad is placed under the patient’s buttocks to protect the bed during the procedure. With the woman in a supine position, the nurse carefully removes the perineal pad in a front-to-back direction. This prevents the portion of the pad that touched the rectal area from sliding forward and contaminating the vagina. Next, a bedpan is positioned under the buttocks. The movement associated with lifting the buttocks helps to expel clots and/or pooled blood in the vaginal canal. This also serves as a good time to assess the fundus for tone. Uterine palpation may be beneficial in helping the patient expel additional blood or clots. The nurse uses a peri-bottle fi lled with warm water (or other solution used according to hospital policy) and gently squirts the perineum from front to back while allowing the water to collect in the bedpan. The labia are not separated because they prevent the solution from entering the vagina. The perineal area is then gently dried and a clean peripad is applied from front to back.

Optimizing Outcomes— Teaching about perineal care

To enhance the patient’s understanding about proper perineal care, the nurse provides the following instructions: 1. Fill the squeeze/peri bottle with tap water. The water should feel comfortably warm on your wrist. 2. Sit on the toilet with the bottle positioned between your legs so that water can be squirted directly on the perineum. Aim the bottle opening at your perineum and spray so that the water moves from front to back. Do not separate the labia and do not spray the water into your vagina. Empty the entire bottle over the perineum— this should take approximately 2 minutes. 3. Gently pat the area dry with toilet paper or cotton wipes. Move from front to back, use each wipe once, then drop it in the toilet. 4. Grasping the bottom side or ends of a clean perineal pad, apply it from front to back. 5. Stand before flushing the toilet to prevent the water from the toilet from spraying onto your perineum.

Ice Packs

To reduce perineal swelling and pain that result from bruising, ice packs may be applied every 2 to 4 hours. Application of cold is beneficial because of its vasoconstriction and numbing effects. The ice pack should always be covered and applied from front to back. It should be left in place for no longer than 20 minutes to minimize the complications associated with prolonged vasoconstriction. Patients obtain the most relief when ice packs are applied within the first 24 hours after childbirth.

DISCOMFORT RELATED TO AFTERPAINS

Afterbirth pains describe intermittent uterine contractions that occur during the process of involution. In general, the pains are more pronounced in patients with decreased uterine tone due to overdistention. Uterine overdistention is associated with multiple gestation, multiparity, macrosomia, and hydramnios. Afterpains also tend to be more intense in breastfeeding women because infant suckling and/or pumping the breasts triggers an endogenous release of oxytocin, the hormone that initiates the milk-ejection reflex. Oxytocin causes powerful uterine contractions. Afterbirth pain maybe severe for 2 to 3 days after childbirth. Mild analgesics should provide relief.

SPECIAL CONSIDERATIONS FOR WOMEN WITH HIV/AIDS

Women who have the human immunodeficiency virus (HIV) or acquired immunodeficiency syndrome (AIDS) require special precautionary care during the puerperium. All personnel who come in close contact with the patient should wear latex gloves (unless the patient has a latex allergy). In that situation, nonlatex gloves are used, as well as safety glasses to prevent the transmission of blood and body fluids. Patients need to be taught to avoid contact of personal body fl uids with the infant’s mucous membranes and open skin lesions. Breastfeeding is not advised due to the risk of transmission of HIV to the infant.

Now Can You— Promote recovery and self-care in the puerperium?

1. Identify factors that determine how quickly patients should return to the pre-pregnant weight? 2. Describe the essential components of patient teaching about perineal care? 3. Describe special precautions that should be taken for postpartal HIV-positive women?

Care of the PostpartalSurgical Patient

PERMANENT STERILIZATION (TUBALLIGATION)

A postpartum tubal ligation is a procedure that blocks the fallopian tubes to prevent the woman from becoming pregnant. When requested, the procedure, called a minilaparotomy, is performed after childbirth while the mother is still hospitalized. The size and position of the uterus during the early puerperium facilitates the surgical procedure. When a cesarean birth has been performed, the tubal ligation may be done at the same time. Patients need to be informed that while it is typically considered to be a permanent form of fertility control, there is a small chance that a future pregnancy may occur.

Patients scheduled for a tubal ligation are NPO before the surgical procedure. If epidural anesthesia was used for childbirth, the catheter is often left in place so that the patient can be re-anesthetized easily. When no epidural was previously placed, general anesthesia will most likely be used during surgery.

CARE OF THE PATIENT AFTER A CESAREAN BIRTH

Nursing care of the postoperative postpartum patient is similar to the care provided to all postoperative patients. The nurse must complete the BUBBLE-HE assessment previously discussed. Because the woman is confined to bed until full sensation has returned to the lower extremities, interventions for the prevention of deep vein thrombosis (DVTs) must be implemented. Preventive strategies include leg exercises (flexion and extension of the knee) and application of compression boots as ordered by the physician.

How the patient reacts to her surgery is often tied to the circumstances surrounding the birth—that is, whether the cesarean section (“c-section”) was a planned procedure or an emergency event. Women who experience an emergency or unplanned cesarean birth may suffer from extreme disappointment, feelings of inadequacy, guilt, and personal failure. They may also harbor hostilities directed toward the medical and nursing staff.

After a cesarean birth, especially when unplanned, nurses must be aware of the myriad of potential psychological issues that may arise. Research suggests that women may perceive cesarean birth to be a less positive experience than a vaginal birth. Vaginal birth has been shown to be associated with enhanced maternal satisfaction and perceptions of greater personal control over the birth. Women who experience vaginal birth describe feelings of empowerment, elation, and achievement (Lavender, Hofmeyr, Nielson, Kingdon, & Gyte, 2007). Particularly for unplanned or emergent cesarean deliveries, the experience of cesarean birth may be associated with more negative perceptions of the birthing experience. However, research regarding the psychological outcomes associated with cesarean birth remains mixed (Patel, Murphy, & Peters, 2005).

The benefits of maternal–child interaction during the early postpartal hours are well documented. The first few hours after childbirth constitute a critical time for the initiation of a healthy maternal–infant interaction. For most mothers, a successful vaginal birth is psychologically better tolerated and avoids the need for additional recovery time that is necessary after a cesarean birth. In addition, early breast feeding (for those who wish to breast feed) is more easily implemented after a vaginal birth.

Additional challenges faced by patients during recovery from a cesarean birth include recovery from the anesthesia,a need to cope with incisional and gas pain, and slow ambulation. Mother–infant bonding may be delayed and patients are at an increased risk for hemorrhage, surgical wound infection, urinary tract infections, and DVT.

CARE OF THE INCISIONAL WOUND

The surgical incision requires ongoing nursing assessment after a cesarean birth. The nurse should assess for approximation of the wound edges, and make note of any redness, discoloration, warmth, edema, unusual tenderness, or drainage. If a dry sterile dressing has been applied, the surrounding tissue should be carefully evaluated for evidence of a reaction to the tape used to secure the dressing.

Assessing for and effectively treating incisional pain is also of paramount importance.

RECOVERY FROM ANESTHESIA

Ambulation is encouraged as soon as the patient’s vital signs are stable. If a spinal or epidural anesthesia was used, ambulation is delayed until full sensation has returned to the lower extremities. Common side effects of anesthesia include paresthesias (sensation of pins and needles in the legs) and headache. Assistance is required when the patient gets out of bed for the first time. Nurses should administer pain medication 30 minutes before the patient attempts ambulation. To minimize dizziness from orthostatic hypotension, the nurse should instruct the patient to sit on the side of her bed for several minutes before moving into a standing position.

Respiratory Care

Incisional pain and abdominal distension often cause patients to adopt shallow breathing patterns that can lead to decreased gas exchange and a reduced tidal volume. To facilitate adequate lung functions, patients should be taught how to perform pulmonary exercises. After being placed in a high Fowler’s position, the patient is shown to use a pillow to support her incision and instructed to take a deep breath and cough. Respiratory therapists are often included in the team approach to care for postoperative patients. Expectoration of secretions and deep breathing help prevent common complications including atelectasis and pneumonia. The nurse should administer pain medication 15 to 30 minutes before the patient begins her respiratory exercises.

Abdominal distension and gas pains are common after abdominal surgery and result from delayed peristalsis. Breakdown of digested food in the colon produces a buildup of gas that results in distension and discomfort. Anesthesia also causes a delay in the return of peristalsis and it usually takes several days for the intestinal function to return.

Until bowel sounds are present, the nurse should offer the patient ice chips and small sips of water only. The diet is slowly advanced as tolerated. To minimize gas pains and stimulate the return of peristalsis, frequent ambulation is encouraged.

An indwelling Foley catheter connected to a closed drainage system remains in place for approximately 24 hours after a cesarean birth. While the catheter is in place, the nurse must assess for urine output of at least 150 mL/hr and maintain appropriate perineal care to reduce the risk of urinary tract infection. Once the catheter has been removed, the patient is at risk for urinary retention and her output must be closely monitored. The nurse can help facilitate the return of normal voiding patterns by encouraging early ambulation to the toilet, ensuring privacy, allowing water to run in the lavatory, and pouring warm water on the perineum. If the patient is unable to void within 6 hours, a diagnosis of urinary retention should be considered and catheterization may be necessary.

Now Can You— Provide nursing care for the surgical postpartal patient?

1. Identify nursing assessments appropriate for the postoperative postpartum patient? 2. Describe maternal psychological issues that may accompany a cesarean birth? 3. Discuss nursing interventions to facilitate ambulation and lung expansion?

Facilitating Infant Nourishment: Educating Parents to Make Informed Choices

Holistic care during the puerperium includes educating women and their partners about infant nutrition and providing support to facilitate success with the feeding method chosen. By the time they enter the postpartum phase of childbearing, most women have already made a decision about infant feeding. Providing current, evidence based information, offering clinical guidance, and identifying appropriate resources when needed empowers patients to achieve success in nourishing and nurturing their newborn.

Breastfeeding has long been established as the optimal method of infant feeding and current trends are reflective of the public’s awareness of its value. Today, more women in the United States are breastfeeding their babies than at any time in modern history. While the rate of breastfeeding has increased in all demographic groups, certain populations of women are less likely to breastfeed. These include women younger than 25 years of age; those with a lower income; primiparas; African Americans; those who participate in the special Supplemental Nutrition Program for Women, Infants, and Children (WIC); those with a high school education or less; and those who are employed full time outside of the home (Johnston & Esposito, 2007).

Human breast milk is the ideal infant food choice. It is bacteriologically safe, fresh, readily available and balanced to meet the infant’s needs. According to the American Academy of Pediatrics, “human milk is species-specific, and all substitute feeding preparations differ markedly from it, making human milk uniquely superior for infant feeding” (Gartner et al., 2005). When discussing infant feeding options with parents, nurses can share factual information about the physiological and psychological benefits of breastfeeding (Box 15-3). There are economic benefits as well: breastfeeding reduces the cost of feeding and preparation time. Providing such information may reinforce the mother’s decision to breastfeed or help women and their partners in the decision-making process. The partner’s level of support with the infant feeding method is an important factor in the woman’s decision and success. There are only a few situations in which breast feeding is contraindicated:

• Infants with galactosemia (due to an inability to digest the lactose in the milk)

Box 15-3 Selected Breastfeeding Benefits

FOR MOTHERS • Decreased risk of breast cancer • Lactational amenorrhea (LAM) (although breastfeeding is not considered an effective form of contraception) • Enhanced involution (due to uterine contractions triggered by the release of oxytocin) and decreased risk of postpartum hemorrhage • Enhanced postpartum weight loss • Increased bone density • Enhanced bonding with infant

FOR INFANTS • Enhanced immunity through the transfer of maternal antibodies; decreased incidence of infections including otitis media, pneumonia, urinary tract infections, bacteremia and bacterial meningitis • Enhanced maturation of the gastrointestinal tract • Decreased likelihood of developing insulin-dependent (type 1) diabetes • Decreased risk of childhood obesity • Enhanced jaw development • Protective effects against certain childhood cancers 490 • Mothers with active tuberculosis or HIV infection • Mothers with active herpes lesions on the nipples • Mothers who are receiving certain medications, such as lithium or methotrexate • Mothers who are exposed to radioactive isotopes (e.g., during diagnostic testing)

Despite knowledge of the benefits of breastfeeding some women choose to formula feed. Concerns about convenience, opportunity to involve the father in the baby’s care, and modesty and embarrassment may be factors that influence the mother’s decision. An unsuccessful breastfeeding experience during a previous pregnancy may also play a role. Some women anticipate that breastfeeding will interfere with plans to return to work. Whatever the reasons, the nurse must provide information and support in a caring, non judgmental manner. Postpartal women who planned to bottle feed may still benefit from education about the benefits of breast milk over formula (Miller, Cook, Brooks, Heine, & Curtis, 2007). The nurse’s offer of breastfeeding support and assistance may encourage some women to change their chosen feeding method. The importance of the nurse’s role in the promotion of breastfeeding has been underscored in an AWHONN clinical position statement (1999; available at http://www.awhonn.org/awhonn/content.do?name=05HealthPolicyLegislation/ 5HPositionStatements.htm).

Optimizing Outcomes— Supporting women in their infant feeding choice

Although breast milk provides the best nutrition choice for infants, the decision to breastfeed is always one that must be made by the woman. She should make the choice based on what pleases her and makes her feel most comfortable. If the woman is pleased and comfortable with her choice, the infant will also be pleased and comfortable and both will benefit from the experience.

ENHANCING UNDERSTANDING OF THE PROCESS OF LACTATION

Normal Structure of the Breast

The breast is composed of glandular, connective, and fatty tissue. The lactating breast contains lobes that house the milk production cells called aveoli (alveolus), fatty tissue, and a series of small and main ducts. The ducts converge into 9 to 10 duct openings in the nipple (Fig. 15-5).

According to most published literature, each breast contains 15 to 20 lobes although recent ultrasound studies have demonstrated variations that range from 4 to18 lobes per breast (Ramsay, Kent, Hartmann, & Hartmann, 2005). Each lobe has a small duct that unites with others to form a main duct. The lobes are connected by areolar tissue and blood vessels. The ducts function to collect milk from the alveolus and transport it toward the nipple. The Cooper’s ligaments, along with the fatty adipose tissue, give shape to the breasts and provide support to the ductal system (Fig. 15-6).

The areola, a 15- to 16-mm circular pigmented structure, darkens and enlarges with pregnancy. The Montgomery tubercles are small sebaceous glands in the areola that enlarge during pregnancy. They secrete a waxy substance that acts as a lubricant and contains anti-infective properties that protect the nipples. The nipple, a mass of conical erectile tissue, is located in the center of the areola and projects a few millimeters from the center of the breast. Circular smooth muscles surround the areola and cause the nipple to become erect with stimulation. The main ducts converge and open into the nipple (Riordan, 2005).

Blood and Nerve Supply and Lymphatic Drainage

There is an abundant vascular supply to the breasts. Approximately 60% of the blood supply to the breasts comes from the internal mammary artery. The remainder is supplied by branches of the intercostal, subclavian, and axillary arteries (Lawrence & Lawrence, 2005). Branches from the mammary arteries anastomose around the nipples and areolae and provide blood to those structures.

The fourth, fifth, and sixth intercostal nerves provide innervation to the breasts. The fourth nerve enters into the posterior aspect of the breast (anatomically, in the position of 4 o’clock on the left breast; 8 o’clock on the right breast) and provides maximum sensation to the nipple and the areola. The areola is the most sensitive area of the breast; the nipple itself is the least sensitive area. Damage to the intercostal nerves can result in some loss of sensation to the breast (Riordan, 2005). Loss of sensation may prevent the nipple from protruding and becoming erect in preparation for a baby’s latching-on to breastfeed.

The breasts contain an extensive lymphatic network. The skin covering the breasts houses superficial lymph channels that serve the chest wall and are continuous with the superficial lymphatics of the neck and abdomen. A rich network of lymphatics is also present deep in the breasts. The primary deep lymphatics drain laterally toward the axillae.

Figure 15-5 Cross section of a lactating breast.

The Physiology of Lactation

MILK PRODUCTION AND LET-DOWN.

Lactogenesis, the process by which the breasts secrete milk, is dependent on the release of the hormones prolactin and oxytocin. The process of milk synthesis begins after the delivery of the placenta. This event results in a dramatic decrease in plasma progesterone and estrogen and an increase in the secretion of prolactin from the anterior lobe of the pituitary gland. Prolactin stimulates the alveoli, or milk producing cells, to secrete milk. Stimulation from infant suckling or pumping the breasts triggers the release of oxytocin from the posterior lobe of the pituitary gland.

Oxytocin prompts contraction of the smooth muscle myoepithelial cells surrounding the alveoli to eject milk from the alveoli into the lactiferous (main) ducts (Fig. 15-7). Movement of milk into the large lactiferous ducts for removal is called the “milk ejection reflex” or the “letdown” reflex. Lactating mothers describe “let-down” as a tingling or pins and needles sensation that occurs immediately before or during breastfeeding. Frequent stimulation and release of milk from the breasts are necessary for the continued release of prolactin.

The initiation of milk production is divided into three stages. Stage 1 occurs in late pregnancy and is characterized by the maturation of the alveoli, the proliferation of the secretory alveoli ductal system, and the increase in size and weight of the breast. Stage 2 begins during the postpartum period. Reduced plasma progesterone levels lead to an increase in prolactin levels that cause a copious milk production by the fourth to fifth postpartal day. Stage 3, the establishment and maintenance of the milk supply, is governed by a principle of “supply and demand” and continues until breastfeeding ceases. The “weaning” stage, sometimes referred to as “Stage 4,” begins when breast stimulation ceases. This stage is characterized by a significant reduction in milk volume.

A lack of breastfeeding (in breastfeeding or non breastfeeding mothers), or a failure to empty the breasts by pumping, results in an accumulation of inhibiting peptides, or hormones released from the hypothalamus. Inhibiting peptides act on the breast secretory cells, causing a gradual decrease in milk volume and the eventual death of the epithelial cells.

ASSISTING THE MOTHER WHO CHOOSES TO BREASTFEED: STRATEGIES FOR BREASTFEEDING SUCCESS

The most important information that the nurse can give to a mother is that breastfeeding should not be painful. When the baby is feeding at the breast, the woman should experience a strong tugging sensation and occasional mild discomfort. However, pain associated with breastfeeding is not a normal finding. The nurse should refer women who experience breastfeeding pain or other difficulties to a board-certified lactation consultant (IBCLC) for help and assistance. Although the pediatrician is responsible for the health care of the infant, the IBCLC is a lactation expert who offers the most current, up-to-date, accurate information on breastfeeding using a “hands-on” approach. Mothers should be encouraged to consult with an IBCLC when they have any questions, are having difficulty with the latch-on process, or express concerns about their milk production. Ideally, all breastfeeding mothers should be discharged with an appointment to an IBCLC.

Collaboration in Caring— Partnering with an IBCLC and other community resources

An IBCLC is a health care professional who specializes in the clinical management of breastfeeding. IBCLCs are certified by the International Board of Lactation Consultant Examiners Inc. under the direction of the US National Commission for Certifying Agencies. IBCLCs work in a variety of health care settings including hospitals, pediatric offices, public health clinics, and private practice. The IBCLC credential is primarily an add-on qualification that brings together health professionals from different disciplines who share a common knowledge base in human lactation. Among those who become IBCLCs are midwives, nurses, family practitioners, pediatricians, obstetricians, educators, dietitians, and occupational, speech, and physical therapists. Most of these health care professionals have spent at least 4 years acquiring the experience and education required for certification. Costs for services provided by IBCLCs depend upon the environments in which they work. Charges for inpatients are typically incorporated into the hospital stay. Follow-up visits in a hospital-based lactation department may or may not be included as a benefit for giving birth at that facility. Other consultations are fee-for-service. Most insurance companies do not pay for lactation services unless the service is provided within a physician’s office under the supervision of the physician. Under these circumstances, the office visit charges may apply. Many government sponsored health programs such as the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) provide breastfeeding support services that are staffed by breastfeeding peer counselors. A mother who indicates that she is breastfeeding and is part of the WIC program will be provided with a special food package for herself and for her newborn. The La Leche League, an international support organization for breastfeeding mothers, is another resource that may be available in the community.

Optimizing Outcomes— Care of the breasts during lactation

The nurse should teach breastfeeding mothers to wash the nipples with warm water. Soap, which can have a drying effect and cause cracked nipples, should be avoided. Breast creams are also to be avoided. They may block the natural oil secreted by the Montgomery tubercles on the areolae; others contain alcohol, a drying agent. Creams or oils that contain vitamin E should also be avoided because the infant may absorb toxic amounts of the fat-soluble vitamin.

Initiating the Feeding

The optimal time to breastfeed is when the baby is in a quiet alert state. Crying is usually a late sign of hunger and achieving satisfactory latch-on at this time is difficult.

Latch-on is proper attachment of the infant to the breast for feeding. The neonate is most alert during the first 1 to 2 hours after an unmedicated birth, and this is the ideal time to put the infant to the breast. Bathing the neonate before the first breastfeeding should be avoided. The smell of the amniotic fluid on the infant matches the smells of the mother and serves as a “homing device” for the baby.

Cesarean deliveries and medicated births, including those with epidural anesthesia, may require more mother–infant skin to skin contact before a successful latch-on occurs.

To assist the breastfeeding mother, the nurse must understand that a baby latched on to the breast is not necessarily transferring milk. A baby that breastfeeds effectively cues (shows readiness) for feedings, is in a good feeding position, latches-on (attaches) deeply at the breast, and moves milk forward from the breast and into the mouth. When the infant is properly latched-on to the breast, the tip of his nose, cheeks and chin should all be touching the breast (Fig. 15-8).

To feed effectively, the infant must awaken and let his mother know that he wants to eat. When possible, mother-baby rooming-in creates an optimal situation for breastfeeding. When the infant is in the mother’s room at all times, she is able to observe “feeding-readiness cues” that signal the infant’s readiness to feed (Box 15-4).

“What to say”— To assist the mother whose infant won’t awaken to breastfeed

During hospitalization, nurses provide much information and coaching regarding breastfeeding. One new mother expresses her concern that her infant is too sleepy to breastfeed. The nurse may ask: • Have you tried to unwrap the baby’s swaddling? Doing this will increase skin-to-skin contact and help to awaken the infant and promote feeding. • Have you tried to rest with the baby by your breast? Doing this may allow the infant to feel and/or smell the breast, which may promote feeding. • Are you familiar with feeding cues? Watching for feeding cues may help you to recognize when your baby is ready to breastfeed. Examples of infant feeding cues are vocalizations, movements of the mouth, and moving the hand toward the mouth. Hunger-related crying is a late sign of hunger and should not be used as the cue for feeding.

An optimal breastfeeding experience begins with the mother’s prompt response to her infant’s feeding readiness cues (Cadwell et al., 2006). The mother should hold the baby so that his nose is aligned with the nipple and watch for an open mouth gape. At the height of the gape, when the mouth is open widest, the mother should aim the bottom lip as far away as possible from the base of the nipple.

With this action, the infant’s chin and the lower jaw meet the breast first and the nipple is pointed to the roof of the mouth. To facilitate a proper latch-on, it is desirable that the nipple be aligned with the baby’s nose. This position allows the baby to tilt his head upward slightly so that the chin and lower jaw drops, creating the wide open gape desired. Next, the infant’s mouth should be placed 1 to 2 inches beyond the base of the nipple. Depending on the areola size, most of the areola should be visible from the infant’s top lip but not from the bottom lip. The top and bottom lips should be flanged outward. When properly positioned, there should be no slurping or clicking sounds or dimpling of the cheeks. Also, the mother should report a tugging sensation but no pain or pinching. If any of these are present, the infant should be removed from the breast by instructing the mother to insert her finger into the corner of the baby’s mouth to break the seal. As an alternative, the mother can gently lift up and push back on the baby’s upper lip (Fig. 15-9).

Figure 15-8 When properly latched-on, the tip of the infant’s nose, cheeks and chin should all be touching the breast.

Box 15-4 Infant Feeding-Readiness Cues

The infant demonstrates readiness for feeding when she: • Begins to stir. • Bobs the head against the mattress or mother’s neck/shoulder. • Makes hand-to-mouth or hand-to-hand movements. • Exhibits sucking or licking. • Exhibits rooting. • Demonstrates increased activity; arms and legs flexed; hands in a fist.

Optimizing Outcomes— Assessing for milk let-down

The nurse assesses for cues that indicate that the milk letdown reflex has occurred: • The mother reports a tingling sensation in the nipples (not always present). • The infant’s quick, shallow sucking pattern transitions to a slower, more drawing pattern. • The infant exhibits audible swallowing. • The mother reports uterine cramping; increased lochia may be present. • The mother states she feels extremely relaxed during the feeding. • The opposite breast may leak milk.

Once the baby is latched on correctly, he must suckle and transfer milk. There should be a 2:1 or 1:1 suck/swallow ratio with audible swallowing to indicate that milk transfer is occurring. A 5:1 or higher suck/swallow ratio is indicative of non-nutritive suckling. Non-nutritive suckling can result in poor milk supply and lead to poor infant weight gain. Feedings that last less than 10 minutes or continue for longer than 40 minutes are not satisfactory and require consultation and assessment by a lactation consultant.

Optimal feeding results in the infant coming off the breast without assistance. Once the feeding has ended, the infant should be in a relaxed state with hands open; he may or may not be asleep. After a successful breastfeeding experience, mothers often describe their baby as having a “drunken stupor” look. The nipple should be everted and round, never fl at or pinched on any side. The mother should report no pain and the infant should appear satiated.

Figure 15-9 Infant latch-on. A. Nipple is aligned with the baby’s nose. B, C. As the baby latches to the nipple, the baby’s mouth is placed one to two inches beyond the base of the nipple. D. To remove the baby from the breast, the mother inserts her finger into the corner of the baby’s mouth to break the seal.

EVALUATION OF NOURISHMENT: INFANT WEIGHT GAIN

All newborns are expected to lose weight during the early days of life. A newborn who is feeding frequently and effectively, in general, may lose an average of 5% of his birth weight (American Academy of Pediatrics [AAP], 2004). Any infant who loses more than 7% of his birth weight should be carefully evaluated to make sure that the he is being fed frequently enough and that the feeding technique is effective in transferring milk from the mother’s breast.

An infant weight loss of greater than 7% is not an “automatic” reason to supplement breast feedings with formula. The administration of formula may interfere with the baby’s interest in feeding at the breast and his ability to learn appropriate breastfeeding techniques.

Nursing Insight— Preventing nipple confusion

Nipple confusion may result when breast fed infants receive supplemental feedings. Essentially, the infant exhibits difficulty in knowing how to latch-on to the breast. Nipple confusion occurs because breastfeeding and bottle feeding require different skills. Sucking and swallowing patterns as well as the way the tongue, cheeks, and lips are used vary considerably between breast and bottle feeding. The infant’s tongue is pulled backward when sucking from the breast; it is thrust forward when sucking from a rubber nipple. Parents should be taught to avoid bottles until breast feeding is well established (usually 3 to 4 weeks).

Once the mother’s milk production increases and the volume of milk consumed increases, most infants begin to gain 15 to 30 g or 1/2 to 1 oz. per day (AAP, 2004). This rate of gain continues for the first several months of life. Loss of excessive weight or failure to begin a steady pattern of weight gain indicates that the mother is not producing adequate milk, or the infant is not ingesting adequate milk, or, much less commonly, the infant has other organic problems. In most instances, correcting latch-on difficulties and proper positioning improves milk transfer from the breast to the baby. As long as the baby continues to feed well and is gaining weight the mother can be reassured not to worry.

POSITIONS FOR BREASTFEEDING

Common positions for nursing a baby include cradle hold, cross-cradle hold, football, and side-lying (Fig.15-10). In the cradle hold position, the infant is cradled in the arm, close to the maternal breast. The infant’s abdomen is placed against the mother’s abdomen with the mother’s other hand supporting the breast. The cross cradle hold is similar to the cradle hold, although in this hold, the infant is laying in the opposite direction. In the football hold, the infant’s back and shoulders are held in the palm of the mother’s hand. The infant is tucked up under the mother’s arm, keeping the infant’s hip, shoulder, and ear in alignment. The mother supports the breast to touch the infant’s lips. Once the infant’s mouth is open, the mother pulls the infant toward the breast. In the side-lying position, both the mother and the infant lay on their sides. Facing one another, the mother should place a pillow behind the infant’s back for support. The nipple should be placed within easy reach for the infant with the mother guiding the nipple into the infant’s mouth (Lawrence & Lawrence, 2005).

Figure 15-10 Common positions for breastfeeding. A. Cradle hold position. B. Football hold position. C. Side-lying position.

Now Can You— Discuss the physiology of lactation and assist the breastfeeding mother?

1. Describe the four stages involved in the process of lactation? 2. Discuss techniques the breastfeeding mother can use to promote proper “latch-on”? 3. Explain what the mother should be taught regarding the infant’s weight? 4. Demonstrate four common breastfeeding positions?

PROBLEMS THAT RESULT IN INEFFECTIVE BREASTFEEDING

Sore nipples are related to an incorrect latch-on and positioning of the infant at the breast. If a mother complains of pain when the infant is nursing, it is important to observe the baby for correct latch-on during feeding. The nurse can assess for proper latching by making the following observations when the infant is at the breast: maternal–infant positioning is optimal for feeding; the infant exhibits a flanged lower lip, there is a good seal between the mouth and nipple, and an audible swallow. Successful latch-on is essential to prevent trauma to the nipple. The shape of the nipple at the conclusion of the feeding also provides a good indicator for correct latching. If the nipple shape has changed at the end of the feeding, the nurse should troubleshoot for specific problems and teach the mother about correct latch and positioning techniques.

Optimizing Outcomes— Breast shells for flat, inverted, or sore nipples

Breast shells, which are plastic “nipple cups,” or inserts that fit into the bra, are useful for women with fl at or inverted nipples because they help the nipples to become more protuberant. They may also be used to prevent sore nipples from making contact with the woman’s clothing or bra.

Breast engorgement is described as excessive swelling and overfilling of the breast and areola and is a physiological response to an increase in blood flow and an increase in milk production. Engorgement, which may occur from infrequent feeding or ineffective emptying of the breasts, results in congestion and over distension of the collecting ductal system and obstruction of lymphatic drainage. It typically lasts about 24 hours. Symptoms of engorgement usually occur between the third and fifth day after childbirth (when the milk “comes in”) and vary from minimally engorged (patients complain of breast fullness and discomfort) to severe engorgement, characterized by symptoms of pain, tenderness, hardness and warmth to the touch. With severe engorgement, swelling of the breasts is profuse and extends from the clavicle to the tail of Spence and the lower rib cage. The breasts may have a shiny, taut appearance. The areolae become very fi rm and the nipples may flatten, making it difficult for the infant to latch-on. Back pressure exerted on full milk glands inhibits milk production. Thus, if milk is not removed from the breasts, the milk supply may decrease. Treatment involves relieving the patient’s discomfort by removal of the milk (via breast feeding or pumping) to decrease stasis, which reduces the swelling and discomfort.

Because the infant is very efficient in the removal of milk, frequent feeding (at least every 2 to 3 hours) is advised to minimize the stasis of milk. The infant should feed at each breast at least 15 to 20 minutes until at least one breast softens after the feeding. To help reduce the swelling and enhance milk flow, the nurse should instruct the mother to use warm compresses and perform hand expression before nursing. This action softens the areola, initiates the let-down reflex, and allows the infant to more easily grasp the areola. Massaging the breasts during feedings is also beneficial. Other methods to enhance milk flow and help facilitate infant latch-on include taking a warm shower or leaning over a bowl of warm water and hand-expressing some milk before nursing. Since breast swelling is related to increased blood flow, cold ice packs may be used after breastfeeding or pumping to constrict blood flow and reduce the edema.

Complementary Care— Cabbage leaves to diminish breast swelling

Patients can be taught to place raw cabbage leaves over their breasts between feedings to help reduce swelling. First, several large cabbage leaves are washed, then stored in the refrigerator until they become cool. The leaves are then crushed and placed directly on the breasts for 15 to 20 minutes. This process may be repeated two to three times only; frequent application of the cabbage leaves may decrease the milk supply. Women who are allergic to cabbage, sulfa drugs, or who develop a skin rash should not use cabbage leaves (Lactation Education Resources, 2004).

A nonprescription anti-inflammatory medication such as ibuprofen (e.g., Motrin, Advil) may be taken for the pain and swelling related to engorgement. It may be particularly helpful for the mother to take the medication before breastfeeding in anticipation of post feeding discomfort. Because of the significant increase in breast size during lactation, patients should be advised to wear well fitting supportive bras with no underwire for comfort. Bras that are too small may compress the ducts and obstruct milk flow. If the infant is unable to breastfeed, warm soaks, breast massage and the use of a manual or electric pump for the expression of milk help to reduce milk stasis and swelling.

Ethnocultural Considerations— Cultural influences and interventions for breastfeeding discomfort

When educating mothers regarding management of breastfeeding-related discomfort, the nurse must consider the cultural background of the patient. Many non-Western cultures such as Asian, Latin, and African cultures embrace a hot and cold “humoral theory.” Breastfeeding mothers from these cultures may choose not to utilize a cold modality for the relief of breast engorgement or discomfort. Although the nurse may explain the clinical rationale for applying ice packs to the breasts, the patient is culturally bound to adhere to her beliefs. Nurses must remain sensitive to culturally influenced customs and allow patients to use relief measures that do not conflict with their personal beliefs.

COLLECTING AND STORING BREAST MILK

Collecting and storing breast milk is a necessity for mothers who are separated from their infants due to problems such as prematurity or illness. In other situations, women may elect to return to school or work and wish to have breast milk available for feeding by another individual. Freshly pumped breast milk can be safely stored at room temperature for four hours or refrigerated at 34 to 39°F (0°C) for 5 to 7 days after collection. Milk kept in a deep freezer at 0°F (19°C) can be stored for 6 to 12 months

(Lawrence & Lawrence, 2005).

The oldest milk should be used first, unless the pediatrician recommends the use of recently expressed milk. Women should be taught to thaw breast milk by placing the collection container in the refrigerator. The thawing process may be accelerated by holding the collection container under warm running water or by placing it in a cup, pot, bowl, or basin of warm water. Breast milk should not be allowed to thaw at room temperature, in very hot water, or in the microwave oven. Microwaving the breast milk container can create “hot spots” and use of the microwave oven or heating the container in very hot water may decrease the milk’s anti-infective properties. Breast milk separates during storage. The cream rises to the top, because breast milk is not homogenized. To mix the milk after storage, the collection container should be gently swirled, or rotated; vigorous shaking should be avoided. After the feeding, any milk that remains in the feeding container should be discarded and not saved for a later feeding. Thawed milk should never be refrozen.

Optimizing Outcomes— With manual (hand) and electric expression of breast milk

Performing manual or electric expression of breast milk is sometimes necessary because of medical complications or for occupational reasons. During the early postpartum period, the woman should be encouraged to frequently express her breast milk. This action helps to establish and increase the milk supply for later breastfeeding needs. Once lactation has been established, the mother should be encouraged to express milk, either manually or with an electric breast pump, whichever method is most convenient or effective for her (Miller et al., 2007).

Electric Expression of Breast Milk

Women should be encouraged to avoid pumping the breasts until the infant is breastfeeding comfortably. Although the mother can help her baby learn to take a bottle once breastfeeding has been well established, it is best to wait for 3 to 4 weeks before introducing bottle feeding. The American Academy of Pediatrics (2004) recommends exclusive breastfeeding with no supplements, for the first 6 months of life.

The nurse teaches the woman to use hot, soapy water to wash her hands, all components of the breast pump that will touch her breasts and all collecting bottles before proceeding. Most equipment may also be safely cleaned in an automatic dishwasher. If soap and water are not available, many “quick clean” products may be safely used instead. Collecting bottles should be allowed to air dry on a clean towel.

The woman is encouraged to carefully read the instruction manual and practice pumping when she is rested, relaxed, and when her breasts feel full. The nurse can teach employed mothers to begin to pump and store breast milk 2 to 3 weeks before returning to work. The breasts should be pumped once a day, every day, 7 days a week. The first morning pumping usually produces the largest quantity of milk. If possible, the woman should nurse the baby on one breast while pumping the other breast. The breast milk may be stored in the refrigerator or freezer. The 7-day-a-week pumping schedule should continue even after the woman has returned to work (Tully, 2005).

Many employed mothers use the fresh breast milk they pump while at work for infant feedings the following day. For example, the breast milk pumped at work on Monday should be refrigerated and used on Tuesday. Mothers should be counseled to breastfeed the infant before leaving for work and then adhere to a set schedule of pumping and feeding each day. Breast milk collected (by pumping) on Friday and Saturday can be frozen for future use. Ideally, mothers should pump the breasts for each missed feeding, but two pumpings per work day during an 8-hour work shift is realistic for most women. The breasts should be pumped for 15 to 20 minutes or until the milk flow stops. Breastfeeding should be resumed during the evening and throughout weekends (Johnston & Esposito, 2007).

Types of Breast Pumps

A variety of manual and electric breast pumps are available, and, for most women, the choice is made according to needs, preferences, and financial resources. Hospital grade electric breast pumps are designed for complete mother–baby separation. In these situations, the infant will not be able to breastfeed for an indeterminate period of time due to problems such as prematurity, surgery, or illness. Hospital-grade electric pumps are typically considered to be multiple-user rental equipment. Retail or “personal use” electric breast pumps are excellent alternatives to the rented hospital-grade pump (Fig. 15-11). These single-user electric breast pumps usually work well for the working mother or in situations in which consistent pumping is needed. Occasional use battery powered or manual breast pumps are designed for the mother who needs to have extra milk only once in a while.

INFANT WEANING

When a mother decides to wean the baby from the breast, it is recommended that she begin by eliminating one feeding at a time. Usually the least favorite nursing time is the first one that is discontinued (Cadwell et al., 2006). After waiting for a few days, an alternate feeding time (not the one immediately before or after the one already discontinued) may be eliminated. Mothers should be advised to carefully observe the baby for signs of emotional or physical reactions (i.e., cow’s milk allergy if formula is introduced). Babies sometimes choose to stop nursing although this does not usually occur with infants younger than 1 year of age. The American Academy of Pediatrics (2004) currently recommends breastfeeding for the first 12 months of life.

Figure 15-11 Personal use electric breast pump.

ASSISTING THE MOTHER WHO CHOOSES TO FORMULA-FEED HER INFANT

Information regarding formula choices should be offered to mothers who choose not to breastfeed. Formula preparations come in ready-to-feed cans that can be poured directly into a bottle, liquid concentrates that require dilution before feeding and powder formulas that are mixed with water. A variety of bottles and nipples are also available, and selection is usually based on the parent’s preference. For example, the mother may choose from glass bottles or plastic bottles with angled or straight nipples or convenience bottles with disposable liners. The nurse should remind the parents to periodically check the nipple integrity to ensure that the formula flows freely one drop at a time. If the formula flows too quickly, the nipple should be discarded because it poses a risk for infant choking and aspiration.

Parents should also be advised to read and follow the manufacturer’s instructions explicitly when preparing the formula. For example, no water should be added to the ready-to-feed preparations and care should be taken to correctly dilute the concentrate and powder preparations. Poorly prepared formula that is too concentrated (from adding an incorrect amount of water) may result in infant hypernatremia and dehydration. Formula that is too dilute may cause the infant to demonstrate symptoms of undernourishment and water intoxication.

Bottles and nipples must be thoroughly washed in hot soapy water with dishwashing detergent and then rinsed in hot clean water. They may also be cleaned in an automatic dishwasher. Some parents prefer to sterilize their equipment and a variety of commercial sterilizers that can be placed in a microwave oven are available for purchase at most baby stores. If boiling is the preferred cleaning method, parents should be instructed to wash the bottles, nipples, rings, discs and all other equipment used to prepare the formula in hot soapy water. The items are then well rinsed in hot, clean water, placed in a pot filled with enough water to cover the equipment and boiled for 5 to 10 minutes.

Although formula can be fed to the baby at room temperature, if warmed formula is preferred, the parents are instructed to place the prepared bottle of formula in a bowl of hot (not boiling) water for a few minutes. Alternatively, the prepared bottle of formula can be warmed in an electric bottle warmer available at most baby stores. It is important to emphasize to parents the need for testing the temperature of warmed formula before feeding. Parents are instructed to shake a few drops of formula on the inside of the wrist. The liquid should feel warm, but not hot.

When feeding the baby, parents should choose a comfortable chair, and hold the baby in their arms close to them with the baby’s head higher than the rest of the body to prevent aspiration and minimize ear infection. Holding the baby skin-to-skin and maintaining full eye contact throughout the feeding helps to facilitate the bonding process. To prevent the baby from swallowing too much air, the bottle should be kept in an angled position with the nipple continuously filled with formula. Burping is usually performed midway and at the end of the feeding to remove excess air from the infant’s stomach. To burp the baby properly, parents are taught to either hold the baby over their shoulder or on their lap with the baby’s head supported. The baby’s back is gently rubbed until air is expelled (Fig. 15-12).

Parents should be advised that babies usually spit up during burping and that this is normal. However, the pediatrician must be consulted if the baby vomits large amount of formula with burping or after feeding. Since babies eat more efficiently and take in the desired amount of formula when they are hungry, a “baby-driven” demand feeding schedule rather than a regimented feeding schedule is desirable. The pediatrician can provide guidelines regarding the volume of formula the baby needs.

Safe Practices for Bottle Feeding

When informing parents about the safety of formula, it is important for health care professionals to be aware that liquid formulas have been subjected to high temperatures to make the product sterile. Powdered formulas are not sterile because high temperatures destroy vital nutrients. The microorganism Enterobacter sakazakii, known to cause meningitis, has been identified in powdered formula. To minimize the risk of infection, health care professionals must provide accurate instructions to parents regarding the correct procedure for formula preparation, storage and reconstitution. Instructions given should emphasize the importance of good handwashing techniques before handling the equipment that is to be used to reconstitute the powder. The formula should never be mixed in a blender or stored in large amounts for longer than 24 hours. Cold water should be used to mix the powder, only the amount to be used for each feeding should be prepared, and any unused formula should be discarded. Parents should be cautioned not to use a microwave oven to prepare or warm the formula due to the potential for “hot spots” that can burn the infant’s mouth. They should also be taught to never prop the bottle to allow the infant to feed alone or put the infant to bed with a bottle. These practices may result in choking, ear infections, and tooth decay.

Figure 15-12 One infant burping technique.

Optimizing Outcomes— Safely preparing infant formula

Nurses can provide the following safety instructions to parents who plan to formula feed their infant: • Wash hands before beginning to prepare formula and after any interruptions. • Always shake and wash tops of liquid formula cans before opening. • Reconstitute the formula according to the manufacturer’s recommendations. • Store the ready-to-feed formula according to the manufacturer’s recommendations. • Shake the bottle well before feeding. • Discard any formula that the infant does not drink. • Wash thoroughly/sterilize all equipment used to prepare the infant formula and use a bottle and nipple brush to remove milk residue. • Replace the nipples regularly.

Now Can You— Discuss breast milk storage and assist the mother who is bottle feeding her infant?

1. Explain what the breastfeeding mother should be taught about pumping and storing breast milk? 2. Discuss appropriate cleaning techniques for bottles and nipples? 3. Describe special precautions to be used with powdered formulas?

Promoting Family and Infant Bonding

FACILITATING THE TRANSITION TO PARENTHOOD

The transition to parenthood can be an especially difficult and challenging time for primiparous mothers with limited experience in infant care and for new parents who are experiencing social isolation from family or friends. Feelings of anxiety and inadequacy regarding parenting skills, lack of knowledge and confidence about providing baby care, emotional concerns, depression, and detachment toward the infant are all symptoms not infrequently expressed by first-time mothers. This information underscores the importance patients place on nurses and other health care professionals to provide emotional support and accurate information about self care and baby care.

An essential goal of nursing care at this time is to create a supportive teaching environment that increases the parents’ knowledge and confidence in caring for themselves and their infants. Using the principles of Family-Centered Care as a guideline, nurses can help parents cope with the emotional and physical changes that accompany the childbearing year. To create a supportive teaching environment, the nurse can:

• Perform a needs assessment to identify the parents’ knowledge/skill deficits.

• Utilize good communication and listening skills to provide support.

• Empower the parents by assisting them in recognizing their own strengths.

• Facilitate parents’ actions to participate in the decision making process.

• Provide learning opportunities that move the parents from dependence to independence and self-reliance.

ASSUMING THE MOTHERING ROLE

Rubin (1975) described three distinct phases that are associated with the woman’s assuming the mothering role. She labeled these phases “Taking-in,” “Taking-hold,” and “Letting-go” (Table 15-6). At the time of Rubin’s work, women were traditionally hospitalized for 5-7 days after childbirth and nurses could readily observe their patients’ transitions through each phase. Today, however, with shortened hospital stays, women seem to move through the transitions much more rapidly and often there is overlapping of the phases.

In the first day or two after birth, the mother is exhausted and should be encouraged to rest. During this time she is reflecting and clarifying, or “taking-in” her birth experience. Many mothers want to talk about their labor, discuss with family members the detailed events of the labor, seek clarification if unexpected events occurred, and share joys or disappointments associated with the birth. Mothers who hold specific expectations for their birth experience and are unable to follow a birth plan or who are required to transfer from a birth center to a hospital setting may experience feelings of loss and mourn for the hoped for birth experience.

As the mother’s physical condition improves, she begins to take charge, and enters the taking-hold phase where she assumes care for herself and her infant. At this time, the mother eagerly wants information about infant care and shows signs of bonding with her infant. During this phase, the nurse should closely observe mother–infant interactions for signs of poor bonding and if present, implement actions to facilitate attachment.

Table 15.6 Phases Associated with the Mothering Role
Phase 1: Taking-In	Phase 2: Taking-Hold	Phase 3: Letting-Go
First 1–2 days Second and/or third day First 2–6 weeks postpartum The mother is recovering from the immediate exhaustion of labor. She is relatively dependent on others to meet her physical needs. Characteristics of her behavior include: a) Physical exhaustion b) Elation, excitement, and/or anxiety and confusion. c) Reliving, verbally and mentally, the events of her labor and birth.	Second and/or third day The mother starts to initiate action and to begin some of the tasks of motherhood. She may: a) Ask for help with self-care b) Begin caring for the baby c) Be anxious about her mothering abilities.	First 2–6 weeks postpartum This is the time during which the mother redefines her new role. She: a) Moves beyond the mother–infant symbiosis of pregnancy and early postpartum and begins to see her infant as an emerging individual. b) Starts to focus on issues larger than those associated directly with herself and her newborn. (She begins to focus on her partner, other children, and family issues.)

Critical nursing action Assessing for Maternal–Infant Attachment

·         When observing the mother with her newborn, the nurse should look for clues that indicate successful bonding. The nurse should assess for the following indicators: ·         Does the mother show eagerness to care for her infant? ·         What is her response when the baby cries? ·         Does she make eye contact when holding and feeding her baby?

In the letting-go phase, seen later in the mother’s recovery, the woman begins to see the infant as an individual separate from herself. At this point, she can leave the baby with a sitter, set aside more time for herself, become more involved with her partner, and begin adapting to the realities of parenthood. Maladjustment during this phase may occur with an overprotective mother who has difficulty accepting help with infant care from others and who excludes the partner from her affections.

Across Care Settings: Successful maternal transition into the letting-go phase

During the letting-go phase, the mother may have difficulty with the tasks associated with viewing the infant as a separate individual. This phase occurs after the mother has been discharged from the hospital or birthing center. Postpartum and community health nurses who suspect that patients may have difficulty making a successful transition into this phase must communicate their concerns with the infant’s pediatric care team so that appropriate assessments and interventions can be carried out.

Bonding and Attachment

Bonding is described by Klaus (1982) as the promotion of a unique and powerful relationship between the parent and the infant. Attachment refers to the tie that exists between the parent and infant and is recognized as a feeling that binds one person to another.

MATERNAL

Bonding begins at the moment the pregnancy is confirmed and continues through the birth experience, during the postpartal period and throughout the early years of the child’s life. Bonding is critical for the infant’s survival and development. Providing parents with a model of caring during labor, birth, and in the early postpartum period enhances the bonding process and helps to lay the foundation for the nurturing care that the child will later receive. Touch is recognized as an important communication tool between humans.

Figure 15-13 Bonding is enhanced with mother-infant eye-to-eye contact.

Touch is an essential element in the creation of a loving relationship and lasting attachment between the parents and their child. Nurses can be instrumental in enhancing the bonding process by minimizing the time that the infant is separated from the mother. Fostering a positive mother–child relationship begins in the delivery/birthing room when the infant is placed directly on the mother’s chest and is held skin-to-skin. The nurse should encourage the mother to initiate early eye contact during the first 30 minutes after childbirth when both the mother and her baby are alert (Fig. 15-13). This special quiet time provides an opportunity for connecting and communicating with one another. Early initiation of breastfeeding for mothers who wish to breastfeed and utilizing a rooming-in protocol are important nursing interventions that contribute to a positive maternal-child relationship (Dabrowski, 2007).

Optimizing Outcomes— Providing couplet care as an alternative to rooming-in

Rooming-in is a common strategy to enhance bonding. With this arrangement, the mother and her infant share a room and the mother and her nurse share the care of the infant. Some facilities offer a variation termed couplet care. In these settings, the nurse has been educated in both mother and infant care and serves as the primary nurse for the mother and the infant, even when the infant is kept in the nursery.

PATERNAL

Historically, mothers have been considered to be the major nurturer of children. By tradition, the mother took care of the child’s needs while the father, in the “breadwinner” role, worked and formed little attachment during the infant’s early years. Changes in women’s roles, couples’ participation in childbirth preparation classes, allowing fathers in the delivery room and encouraging early contact with the infant have all been instrumental in promoting and fostering early paternal–infant bonding. Other researchers (St. John, Cameron, & McVeigh, 2005) have documented the benefits of early and ongoing contact between fathers and infants (Fig. 15-14). When the primary caregiver is able to touch, hold, and attach with the newborn infant, this special interaction helps to build the foundation for a nurturing and protective relationship. Fathers should be encouraged to assume an active role in infant bonding by participating in the care giving activities. For example, fathers can change diapers, engage in skin-to-skin holding and infant massage, and feed the bottle-fed infant.

FACTORS THAT MAY INTERRUPT THE BONDING PROCESS

Stress associated with insufficient finances to purchase infant supplies, a chaotic home life, concerns about child care if the mother must return to work, lack of family support, and substance abuse may negatively interfere with the bonding process. An essential nursing role involves identifying obstacles to optimal bonding and coordinating with appropriate community resources such as social services to explore the mother’s eligibility for Medicaid, the Women’s Infants and Children’s (WIC) program, and Healthy Start. Other resources may include counseling and support services, financial aid, and pastoral care.

Adolescent mothers may not demonstrate attachment behaviors because they have unrealistic expectations of the infant’s level of functioning and may not be aware of the infant’s vulnerability. It is important for nurses to create a supportive environment that allows the young mother close and frequent interaction with her infant. The nurse must also provide anticipatory guidance and education about infant care that includes how to recognize and respond appropriately to infant cues. With today’s shortened hospital stays, it becomes imperative that appropriate home follow-up and social work referrals are established before discharge for this vulnerable population.

Figure 15-14 The father gets acquainted with his newborn.

Case Study Adolescent Primipara with a Possible Bonding Difficulty

Sarah, a 17-year-old primipara, gave birth to a healthy 7 lb., 8 oz. (3.4 kg) baby boy yesterday. Although Sarah has been pleasant during her hospitalization, she has expressed little interest in her infant. When the nurses offer to bring the infant to the room, Sarah typically asks them to keep the infant in the nursery so that she can “relax and sleep.” She plans to bottle feed her son but has repeatedly found excuses not to feed the baby. The nursery personnel have been feeding the infant instead. The nurses are becoming very concerned because Sarah is to be discharged home with the infant tomorrow. 1. How would you initially respond to the situation? Based on your understanding of the developmental tasks of adolescence, how will you initiate dialog with Sarah? 2. How can the nurse help Sarah begin to feel comfortable holding her baby and also promote maternal–infant bonding? 3. What other nursing actions are indicated? ◆ See Suggested Answers to Case Studies in text on the Electronic Study Guide or DavisPlus.

Women from diverse cultural groups who reside in extended families may be comfortable enlisting the help of their mother, mother-in-law, or a female relative in caring for the infant while they recuperate from childbirth. It is important for the nurse to explore the mother’s cultural values and mores before reporting a lack of bonding and attachment between the mother and her infant.

An interruption in the bonding process may occur when infants must be separated from their parents for medical or surgical interventions. To promote optimal bonding in these special circumstances, it is important to allow the parents early and frequent access to the infant.

The staff in the neonatal intensive care unit (NICU) can enhance parental attachment and bonding by encouraging the parents to touch, speak to and hold their neonate skin to- skin as soon as is medically safe. If the mother is unable to visit, photographs of the infant should be sent to her as soon as possible and frequent telephone calls made to keep her advised of the infant’s status. The mother must be reassured that the bonding process is ongoing and that lack of early contact will not interfere with the development of a positive relationship with her infant.

ADJUSTMENT OF SIBLINGS TO THE NEWBORN

The arrival of a new baby into the family results in many emotional changes for the siblings. Feelings of hurt and jealously, sibling rivalry, and behavioral regression are all common among younger siblings. For example, a toilet trained toddler may once again require diapers or a 2-yearold who has been weaned may now wish to breastfeed.

Parents should be prepared for these common emotional upheavals and formulate strategies that will help the sibling(s) adjust and accept the baby. Many hospitals offer sibling classes for young (ages 2 to 8) children that introduces the concept of having a new addition to the family and provides parents with specific information about how to make the transition easier.

Family Teaching Guidleines…Helping Older Siblings Adjust to the New Baby

Nurses can be instrumental in arming parents with strategies to help their children accept and adjust to a new infant. The following tips may be useful: ◆ Talk with the child (ren) about their feelings regarding the new baby. Listen and validate their feelings. ◆ Teach the older sibling how to play with the new baby; encourage gentleness. ◆ Help develop the child’s self-esteem by giving him/her special jobs, for example, bringing the diaper when you are changing the baby. Praise each contribution. ◆ Praise age-appropriate behaviors and do not criticize regressive behaviors. ◆ Set aside a special time each day for you to be alone with the older child; remind the child that he/she is loved very much. TOPIC: Warning signs indicative of poor sibling adjustment Professional help may be needed when the child: ◆ Continually avoids or ignores the baby ◆ Shows the baby no affection ◆ Is consistently angry, taunting or demonstrating aggressive behavior towards the baby or other family members ◆ Experiences nightmares and sleeping difficulties Adapted from International Childbirth Education Association (2003).

ADJUSTMENT OF GRANDPARENTS TO THE NEWBORN

Grandparents can provide much support to the new family and the degree of their involvement is often linked to cultural expectations. Many cultures (i.e., Hispanics, Asians, and Caribbeans) strongly value the extended family. In these settings, the grandparents are intimately involved in the fabric of family dynamics and frequently exert a strong influence on child-rearing practices. Grandparents’ classes, offered by most hospitals, usually focus on defining grandparenting roles such as helping with sibling care during the mother’s hospitalization and providing assistance with household activities and cooking and shopping during the fi rst few postpartal weeks. Other class themes include current recommendations concerning infant positioning, feeding and clothing, responding to behavior cues, and positive strategies for assuming a supportive, rather than a parenting role.

Now Can You— Facilitate family bonding with the newborn?

1. Identify and describe Rubin’s three phases associated with assuming the mothering role? 2. Describe strategies to facilitate maternal and paternal bonding? 3. Discuss five specific activities that parents can use to help older siblings adjust to the newborn?

Family Teaching Guidelines... Helping Older Siblings Adjust to the New Baby

Nurses can be instrumental in arming parents with strategies to help their children accept and adjust to a new infant. The following tips may be useful: ◆ Talk with the child(ren) about their feelings regarding the new baby. Listen and validate their feelings. ◆ Teach the older sibling how to play with the new baby; encourage gentleness. ◆ Help develop the child’s self-esteem by giving him/her special jobs, for example, bringing the diaper when you are changing the baby. Praise each contribution. ◆ Praise age-appropriate behaviors and do not criticize regressive behaviors. ◆ Set aside a special time each day for you to be alone with the older child; remind the child that he/she is loved very much.

Emotional and Physiological Adjustments During the Puerperium

EMOTIONAL EVENTS

Many mothers experience a roller coaster of emotions after childbirth. These feelings stem from a number of influences and are often linked to perceptions concerning the fulfillment of expectations surrounding the childbirth experience. A complicated birth, a premature birth or a sick infant, as well as the woman’s parity, age, marital status and stability of family finances are some of the many factors known to shape emotions experienced during the postpartum period.

The first 3 months after birth are recognized as the most vulnerable emotional period for mothers. Insecurity about infant care, the constant demands associated with caring for the baby, sleep deprivation, and minimal social support create the potential for frequent and dramatic mood changes. Rapid hormonal changes during the first few postpartal days and weeks may give rise to mood disorders. The most common of these is often termed “the blues.” Other less common puerperal mood disorders include post partum depression and post partum psychosis.

Maternity Blues/Baby Blues/Postpartum Blues

The “maternity blues” are considered to be a normal reaction to the dramatic changes that occur after childbirth including abrupt withdrawal of the hormones estrogen, progesterone and cortisol. Women experience a range of symptoms that include tearfulness, mood swings, insomnia, fatigue, anxiety, difficulty concentrating, irritability and poor appetite. The symptoms usually begin during the first few postpartal days, peak on the fifth day, and then subside over the next several days. Blues do not affect the woman’s ability to care for herself or her newborn and family.

The “blues” are treated with support and reassurance (Beck, Records, & Rice, 2006). Proactive education to prepare the woman and her family for the possibility of postpartum blues is important. The nurse needs to explore what resources the new mother will have available when she goes home. The discussion should focus on whether the patient has adequate food, clothing, shelter, and transportation, and whether there are relational concerns that need to be addressed before discharge. Incorporating community resources such as the woman’s church, a Mother’s Day Out group, a hobby club, or La Leche League can help the new mother realize she is not alone in the experience of nurturing a newborn, while also caring for herself and her family. Referral to a health care provider is appropriate for women whose symptoms persist for more than ten days, as this pattern is suggestive of postpartum depression.

Postpartum Depression

Postpartum depression, which affects 10% to 13% of women, usually appears around two weeks after childbirth. The symptoms associated with this condition are often insidious and include sleep disturbances, guilt, fatigue, and feelings of hopelessness and worthlessness. In severe instances, suicidal ideation may occur. Patients who demonstrate symptoms of post partum depression must be promptly referred for evaluation and intervention.

Postpartum Psychosis

Postpartum psychosis develops in approximately one or two women for every 1000 births and is unlikely to manifest itself during the early postpartum period. Symptoms include delusions; hallucinations; agitation; inability to sleep; and bizarre, irrational behavior. Before hospital discharge, patients with a history of mood disorders or depression should be referred to appropriate resources for community support and follow-up.

PHYSIOLOGICAL RESPONSES TO EMOTIONAL EVENTS

Tiredness and Fatigue

Postpartum tiredness and fatigue have long been considered a natural physiological and psychological response to the stresses of labor and childbirth coupled with the additional responsibilities of motherhood. Although new mothers are often confident that tiredness will improve upon returning home, this phenomenon is not supported by the nursing literature. Rather, the multiplicity of demands associated with motherhood augments the experience of physical and mental exhaustion. While changes in societal trends in the care of children suggest that fathers are taking a more active role, mothers continue to hold the main responsibility for care. Thus, it is essential for the nurse to encourage new mothers to enlist the support and assistance of family and friends in an effort to promote time for rest and recovery (Runquist, 2007).

Nursing Insight— Persistent fatigue during the puerperium

Feelings of fatigue that extend beyond the 6-week postpartal period may be indicative of a more serious condition. Persistent, pervasive fatigue may be indicative of postpartum depression (Troy, 2003). The woman and her family should be provided with guidelines about normal feelings and reactions during the puerperium and encouraged to report excessive tiredness or fatigue to the health care provider.

Contributors to fatigue and tiredness in the postpartum period include physical, psychological, and situational variables. Physical contributors include the length of labor, maternal hormone shifts, maternal anemia, episiotomy or surgical incision healing, breast feeding, and pain. Psychological contributors include difficulty sleeping, depression, and a non supportive partner. The challenge of managing multiple roles, cultural influences and expectations, a lack of assistance with housework or childcare, having more than one child under the age of 5 in the home, and returning to outside employment are situational variables that can readily lead to fatigue. Insights into the multiple contexts that shape the patient’s environment allow nurses to provide anticipatory guidance regarding fatigue and its relationship with diminished quality of life in the postpartum period (Runquist, 2007).

Postpartal Discharge Planning and Teaching

PROMOTING MATERNAL SELF CARE

Because of early postnatal discharge, all postpartal women must be taught strategies for self-care. A self-assessment sheet completed before discharge helps to identify areas of deficits. When possible, parents are encouraged to attend a discharge teaching class. Topics reviewed usually include infant bathing, breastfeeding, perineal hygiene, physical activity, rest and expected emotional changes. This information is useful because it empowers the family to identify normal events and to promptly recognize complications that should be reported to the health care provider. Many institutions also distribute home care booklets that provide written information about maternal and newborn care and available community resources. Often, home visitation by a community health nurse is arranged before the patient’s discharge. The community health nurse visit typically includes an examination of the mother and infant, an opportunity for discussion about problems or concerns and breastfeeding or formula feeding support. Additional areas of focus during the postpartal visit include education regarding basic maternal and infant care, plans for follow up visits and contraception counseling (Fig. 15-15).

Optimizing Outcomes— When early postpartum discharge is planned

Women and their families may have the option of early discharge with postpartum home care. Maternal criteria for early discharge includes an uncomplicated perinatal course, no evidence of PROM, no difficulties with voiding or ambulation, normal vital signs, hemoglobin _ 10 g and no significant vaginal bleeding. The infant must also meet certain criteria (i.e., full term, normal vs and physical examination, feeding, urinating, stooling, laboratory/screening tests completed). Early follow-up visits are an essential component of safe care for mothers and their infants (AAP Committee on Fetus and Newborn, 2004; Meara, Kotagal, Atherton, & Lieu, 2004).

COMPONENTS OF MATERNAL SELF-ASSESSMENT

Fundus

The woman is taught how to locate and palpate the fundus and how to determine the progression of the fundal height as it involutes into the pelvis. After months of abdominal enlargement, many women are delighted to be able to rest in a prone position. Nurses can explain that lying on the abdomen is beneficial because this position supports the abdominal muscles and aids involution because the uterus is tipped into its natural forward position.

Clinical Alert

Avoiding the knee–chest position

The nurse teaches the patient to avoid a knee-chest position until at least the third postpartal week. This position causes the vagina to open. Since the cervical os is still open to some extent, there is a danger that air can enter the vagina, pass into the cervix and enter the open blood sinuses inside the uterus. Entry of air into the circulatory system can cause an air embolus.

Lochia

The nurse reinforces to the patient that the lochia (vaginal discharge) may continue for 3 to 6 weeks after birth. During this time, it is important for her to examine the peripads for color, amount and odor each time she visits the toilet. The woman should be provided with guidelines concerning the anticipated color and amount of the lochia and reminded to promptly report abnormal findings such as heavy bleeding, the passing of large clots and foul smelling odor.

Hygiene

The patient is advised to continue to use her perineal squeeze bottle until the bleeding stops and to use the prescribed medications and/or sitz bath for episiotomy discomfort. After each visit to the toilet she is reminded to carefully wipe from front to back and thoroughly wash her hands before and after changing the peri pads.

Abdominal Incision

Nurses should instruct the post operative patient to shower as normal and to carefully pat the incision dry. If staples were applied at the incision site, the obstetrician will inform her when to come into the office for removal. Steri-strips used for incision closure should remain undisturbed until they eventually fall off. The woman is advised to avoid the application of cream or powder to the incision site and to notify her obstetrician if she experiences fever or develops signs of incisional infection such as redness, offensive odor or discharge.

Figure 15-15 The postpartum home visit usually involves an examination of the mother and baby. It provides an opportunity for teaching and promotes continuity of care.

Body Temperature

Some women experience a transient increase in body temperature along with breast heaviness on the third to fourth postpartum day when the milk supply is established. They should be reminded that temperatures above 100.4°F (38.0°C) and fl u-like symptoms (e.g., chills, body aches, severe pain) may indicate infection and should be promptly reported to the health care provider.

Urination

Before discharge, all patients should be able to pass urine without difficulty. Women should be taught the signs and symptoms of a urinary tract infection (UTI). Specifically, burning on urination (dysuria), frequent voiding with only a small amount of urine passed, the presence of a “fishy” odor to the urine and lower abdominal or flank pain are symptoms that must be reported to the health care provider. To reduce the likelihood of a urinary tract infection, patients are advised to drink at least eight 8-oz. glasses of water each day, avoid delays in emptying the bladder, wipe the perineum from front-to-back after each use of the toilet, change peripads after toileting, and to wash their hands frequently.

Bowel Function

The nurse teaches about the importance of maintaining good hydration and consuming a healthy diet abundant in fiber and roughage. An exploration of the woman’s dietary preferences facilitates discussion about specific types of foods (e.g., fruits, vegetables, whole-grain cereals) that promote bowel regularity. The patient should consult with her obstetrician or certified nurse midwife if laxatives or other medications become necessary. Stool softeners are usually prescribed for women with third or fourth degree episiotomies or vaginal lacerations.

Nutrition

Most women are concerned about weight increase during the pregnancy and how quickly they can expect to return to their pre-pregnancy weight. A well-balanced diet that includes high-energy foods is essential to recovery in the puerperium. Patients should be counseled about the need for adequate protein to promote tissue repair and healing and encouraged to select a healthy, low-fat diet that contains protein along with carbohydrates, fruits, and vegetables.

Fatigue

Patients should be reminded that since the first six postpartal weeks are devoted to infant care and recovery from childbirth, energy depletion, usually manifested as extreme tiredness and fatigue, often occurs. They should be encouraged to limit visitors and whenever possible to rest when the baby sleeps. Patients may wish to cook easily prepared meals in advance and freeze foods for later use. When possible, the new mother should solicit help from her partner, family members and friends to assist with the household chores, shopping and child care.

Weight Loss

Weight loss at the time of childbirth is precipitous. Within minutes after birth, the parturient woman loses half of the weight gained during the previous nine months. On average, the weight loss amounts to 10 to 12 lbs. (4.5 to 5.5 kg). This loss comes from the infant, the placenta, amniotic fluid, and blood. Rapid dieresis and diaphoresis occur during the second to fifth postpartum days and result in an additional weight loss of about 5 lbs. (2.3 kg). By the sixth to eighth postpartal week, many women will have returned to their prepregnant weight. The amount of weight lost during the puerperium is primarily related to the amount of weight gained during pregnancy and the woman’s level of physical activity.

Exercise

The patient is advised to resume activities gradually, beginning with Kegel exercises to strengthen the pelvic floor muscles. After a vaginal birth, patients may begin modified sit-ups to strengthen the abdominal muscles and perform knee and leg roll exercises to firm the waist. Modified sit-ups are especially beneficial for women with diastasis recti.

Optimizing Outcomes— Postnatal exercises to promote physical fitness

Teaching patients about exercises to help return the body to its pre-pregnant state is an important component of postpartal care. Exercises to strengthen the back, abdominal muscles, thighs, and shoulders are particularly beneficial at this time.

Supple Spine

Begin on all fours. Inhale. Lift your head, keeping your back straight or arching slightly (avoid strain). Then exhale, round your back, tighten abdominals, tuck in tail and head. Repeat the sequence eight times. This exercise strengthens the back and abdominals.

Tighter Abdominals

Lie on your back in a straight line. Then exhale, lowering the back,

vertebra by vertebra. Repeat sequence five times. This exercise helps develop a strong back and abdominals.

Stronger Back

Sit upright, knees bent, feet flat on the floor, back straight, arms forward at shoulder level. Inhale, then exhale and lean back halfway. Inhale again and sit up slowly. Repeat five times. This exercise strengthens the back and abdominals.

Flexible Body

Stand upright with arms raised, elbows slightly relaxed. Inhale, then exhale and bend forward, keeping back straight and swinging arms down and back. Then relax your head and stretch your arms up behind you. Inhale as you swing arms and body up again, returning to your original position. Repeat eight times. Go carefully and do not strain. This exercise is good for thighs, hips, back, arms, shoulders, and neck.

Pain Management

Medications for pain relief (nonsteroidal antiinflamatory medications or analgesics) may be prescribed, especially for postoperative patients. The nurse should ensure that medications prescribed for breastfeeding patients are not contraindicated. Information regarding therapeutic modalities such ice packs, sitz baths, or topical anesthetics may be helpful for the relief of perineal discomfort from hemorrhoids or the episiotomy incision. Patients are instructed to notify their health care provider if pain persists or increases in intensity, and the nurse also reviews other danger signs and symptoms that must be promptly reported (Box 15-5).

Mood

The nurse should provide support and empower the family by discussing the often overwhelming responsibilities associated with newborn care. Information shared with the mother and her partner includes the emotional changes such as feelings of sadness and weepiness that often appear on the second or third postpartal day. Patients can be assured that “mood swings” and periods of unexpected crying, moodiness or anxiety are common and occur in 70% to 80% of women. If the following symptoms persist for more than 2 weeks after childbirth, the woman, her partner, a family member or a support person should contact the health care provider for assistance:

• Crying excessively

• Significant changes in appetite

• Feeling helpless

• Experiencing extreme worry, concern

• Unable to sleep/wanting to sleep all the time

• Unable to care for herself or the baby

• Panic attack

• Fear of harming self or the baby

Box 15-5 Postpartum Discharge Teaching: Danger Signs to Be Reported

An important component of discharge teaching focuses on alerting patients to signs and symptoms that must be reported to the health care provider. The nurse should ensure that the patient is given written information and knows how to reach her care provider. The patient should immediately report: • Temperature greater than 100.4°F (38.0°C), chills, or fl u-like symptoms • Abdominal incision that is red, tender to touch, or painful, or if edges of the incision have separated. • Difficulty initiating urination, urinary frequency or painful urination • Increased vaginal bleeding with or without clots, or foul-smelling vaginal discharge • Persistent pain or marked swelling at the site of a perineal laceration or episiotomy • Swelling or masses in the breasts, red streaks, shooting pain in the breasts, or cracked, bleeding nipples. • Swelling, warmth, tenderness or painful areas in the legs • Blurred vision or persistent headache that is not relieved by pain medication • Overwhelming feelings of sadness or an inability to care for self or the baby

Sexual Activity and Contraception

To maximize healing and prevent infection, patients are discouraged from resuming sexual activity until after the six week postpartum check-up with the obstetrician or midwife. It is important for the nurse to inform the woman and her partner that since ovulation may resume as early as two weeks after childbirth, pregnancy can occur if no contraceptive is used.

Although advised to abstain from sexual intercourse until the postpartum examination, many couples wish to resume intimate relations before this time. Coitus is safe once the woman’s lochia has transitioned to alba and the episiotomy (if present) has healed. This usually occurs after the first week after childbirth. The patient should be warned that she may experience vaginal discomfort because the cells lining the vagina may not be as thick as before, due to a hormone imbalance. A contraceptive foam or lubricating jelly may be used to enhance comfort.

Exploring previously used methods of contraception may be helpful in identifying a starting place for the discussion. The couple’s religion and cultural background often dictates their contraceptive choice. Discussing contraception options with the patient and her partner (if present) before discharge allows the couple time to make informed decisions before resuming sexual intercourse. The breastfeeding mother should be warned that she can become pregnant during lactation and that breastfeeding is not a substitute for birth control. If the breastfeeding patient wishes to use an oral contraceptive the nurse must inform the healthcare provider so that a progesterone-only pill can be prescribed.

PLANNING FOR THE FOLLOW-UP EXAMINATION

Most health care providers schedule a 6-week follow-up appointment (“postpartal check”). Women who have had cesarean births are often scheduled for a return visit to the physician’s office 2 weeks after hospital discharge. It is helpful to indicate the date and time of the return appointment in the patient’s discharge instructions.

The nurse can explain that during the 6-week follow up visit, fundal palpation and a vaginal examination will be performed to evaluate the size of the uterus. The episiotomy or abdominal incision site will be evaluated for healing and a breast examination will be performed. If desired, a contraceptive method or prescription will also be given. The nurse should encourage the patient to discuss any concerns during this visit.

The parents should also schedule a newborn follow-up appointment before hospital discharge. Most physicians and clinics wish to see the infant within the first week or by age 2 weeks.

Now Can You— Promote self-care for the puerperium?

1. Outline postpartal teaching guidelines that include information about self-assessment of the fundus, lochia, hygiene, incisional site, body temperature, and elimination? 2. Demonstrate appropriate exercises for the postpartal patient? 3. Identify at least six symptoms indicative of poor emotional adjustment that, if present for more than 2 weeks, should be reported to the healthcare provider?

Patients with Special Needs During the Puerperium

CARE OF THE ADOLESCENT

The period of adolescence is a time to form important relationships with peers–these close connections help to facilitate self-growth and development. Adolescents who are thrust into an untimely motherhood role must also deal with their own personal and social development. Adjusting to pregnancy and impending motherhood can be emotionally and physically challenging for a mature woman; the adolescent requires special assistance from the nurse.

Many adolescents enter motherhood with unrealistic expectations. They lack mothering and child care skills. Fatigue and sleep deprivation, common in all new mothers, coupled with the responsibility of caring for an infant who requires constant attention often results in limited time for social activities and subsequent social isolation from their peers. Nurses who care for the adolescent mother must be cognizant of personal prejudices or feelings of disapproval and avoid expressing negative feelings toward the teen mother. It is important for the nurse to provide emotional support for the postpartum adolescent that will help her adjust to role changes, foster feelings of positive self esteem and assist her in developing a new identity and sense of self (Logsdon & Koniak-Griffi n, 2005). The nurse must create a supportive environment by recognizing the adolescent as the infant’s primary caregiver, irrespective of her age. The nurse models and facilitates infant caring behaviors that will promote bonding and teaches about infant care and child safety. Before discharge, arrangements should be made for a community health nurse follow-up visit within a week.

“What to say” — When planning the adolescent mother’s hospital discharge

The adolescent mother has unique needs for discharge planning. The nurse can best explore the young patient’s immediate plans for herself and the baby by initiating dialog in a supportive, nonthreatening environment. Examples of appropriate questions that the nurse may ask include the following: “Do you have someone available to offer you help and/or support?” “Do you feel a sense of closeness or attachment to your baby?” “After you leave the hospital, will anyone be helping you to care for your baby?” “Will anyone be taking care of the baby so that you can go back to school?” “Where will you take the baby for follow-up care?”

To facilitate a supportive home and family environment, the community health nurse will conduct a social support assessment to identify the significant family member or other person who will be assisting with parenting responsibilities and financial support. If the adolescent’s mother is identified as the primary support person, the nurse explores the mother’s and grandmother’s expectations in caring for the newborn in order to provide anticipatory guidance regarding each person’s new role before discharge.

A supportive family environment is the single most important element in facilitating the adolescent mother’s successful transition to motherhood. When appropriate, referrals should be made for social services and other community resources such as home health nursing care, pastoral care, teen parent support groups, and economic assistance. Guidance and support provided by these professionals help to reinforce infant care skills and identify additional resources to enable the young mother to complete her education. Professional and family support has proven to be effective in helping adolescents delay a sub sequent pregnancy, stay enrolled in school, find work and complete the developmental tasks of adolescence (Logsdon & Koniak-Griffi n, 2005; Secco et al., 2007).

THE WOMAN WHO IS PLACING HER INFANT FOR ADOPTION

The relinquishment of an infant triggers a host of emotions for the woman and her family. Nurses must be sensitive to the myriad of psychological stressors and social stigmas associated with placing a child for adoption. Depending on hospital policy, the patient may be admitted to the postpartum unit where she can be attended to by nurses who are experienced in perinatal care. The nurse should offer support, a “listening ear”, and a compassionate environment where the patient feels safe in expressing her feelings. The woman will likely experience a range of emotions such as grief, loneliness, and guilt. After birth, the patient should have access to her newborn if she so desires. The opportunity to see, hold, and feed the infant may help her to accept the reality that she has given birth to a healthy child. This affirmation may foster feelings of self-esteem and provide a foundation for emotional healing. Postpartum care may continue well beyond hospital discharge for women who choose to give up the infant. Referrals to various community resources may be appropriate (Cunningham et al., 2005). In some cases, the adoptive couple may come into the hospital to meet the new infant. The new parents will need the same instruction in infant care and safety as the biological parents.

THE OLDER WOMAN

Today, it is not uncommon for women over age 35 to experience their first pregnancy, and when pregnancy occurs among this population, it is deemed “advanced maternal age”.

The older patient may have preexisting medical conditions (e.g., hypertension, diabetes) and experience greater health risks and pregnancy complications such as gestational diabetes and preeclampsia. In these situations, pregnancy and puerperal care involve a collaborative approach that includes a physician with special training in high-risk obstetrics (perinatologist) and medical specialists (e.g., endocrinologist, rheumatologist, cardiologist).

Women experience pregnancy after the age of 35 for a number of reasons. Some postpone pregnancy in order to make advancements in careers; others have struggled with infertility and become pregnant following advanced reproductive techniques while others report contraceptive failure. There is a wide range of attitudes and emotions that accompany parenthood during midlife. Some women believe that delaying motherhood enhances the adaptation to the parental role. They cite qualities such as maturity, patience, and understanding and greater life experiences as positive influences for assuming the parental role. For others, parenthood at an older age can be disruptive to intimate relationships, interfere with career goals, and create a perception of loss of control. Reassurance, support, and referral, when appropriate, help to facilitate transitions during the puerperium for the older couple.

Community Resources for the New Family

SUPPORT GROUPS

The birth of a newborn constitutes a major life transition. For the new parent, attending a support group can provide a venue for sharing experiences and challenges with other new parents. Information about “essential” parenting topics, such infant feeding and nutrition, behavior, sleeping patterns, and strategies for fostering family relationships is readily available during the meetings. Specific support groups may also be available for unique populations, such as single parents, working mothers and parents of infants with special needs. Parents who participated in childbirth education classes together often reunite to form a support group after childbirth.

HOME VISITS

Some facilities routinely schedule home visits for maternal and baby assessment. This visit provides the nurse with an opportunity to assess bonding, conduct patient teaching, answer questions, correct learning deficits, reinforce hospital discharge instructions and make appropriate community referrals.

TELEPHONE FOLLOW-UP

Facilities that offer home follow-up services usually call parents approximately two to three days after discharge. Making personal contact with the family provides early support and reassurance, allows for questions to be answered and discharge instructions to be reviewed and clarified.

OUTPATIENT CLINICS

Outpatient clinics provide another option for facilities that do not offer home visitation. The clinics are often nurse-managed and allow the mother and her baby to receive further information about maternal-infant care. The patients additional questions or concerns can also be dealt with at this time.

A list of community resources and phone numbers is often provided to the couple before discharge. These services may include professional lactation services, nursing mother’s support groups, “Mommy and Me” classes, postnatal exercise classes, parenting education and support groups, medical care, crisis lines/counseling, emergency and financial assistance, and bereavement support.

Now Can You. Care for postpartal patients with special needs and identify community resources for the postpartal family?

1. Identify nursing interventions that foster the postpartal adolescent’s self-esteem and empower her to bond with and care for her infant? 2. Describe nursing interventions to provide appropriate emotional support for the woman who chooses to place her infant for adoption? 3. Identify at least three sources of community support for the postpartal family and discuss the benefits of each?

Summary points

·         During the postpartum period, the nurse assumes the responsibility of facilitating the integration of the newborn into the family unit.

·         The postpartum patient has unique assessment needs that include physical and psychosocial considerations.

·         The new mother should be given the opportunity to discuss her birth experience.

·         The postpartum woman who has experienced a cesarean birth is also considered to be a surgical patient who has special needs for additional nursing care.

·         Effective pain management should be an integral component of the postpartal nursing assessment.

·         The breastfeeding mother should be provided with sufficient support to facilitate success.

·         The nurse should provide anticipatory guidance that includes family members whenever possible. review questions

Multiple Choices

1.     In the preadmission clinic, the perinatal nurse describes the advantages to a short hospital stay as including:

A. Decreased risk of nosocomial infection

B. Increased rest and recuperation

C. Increased opportunity to initiate successful breastfeeding

D. Increased teaching about infant care

2.     In the immediate postpartum period, the perinatal nurse knows that the postpartum woman most often has a:

A. Bradycardia

B. Tachycardia

C. Pulse within the normal adult range

D. Tachycardia then a pulse rate that returns to normal in 4 hours

3.     The postpartum nurse expects a postpartum woman’s bladder function to return to normal within which length of time:

A. 4.6 hours

B. 6.8 hours

C. 2.4 hours

D. 8.12 hours

Fill-in-the-Blank

4.     The perinatal nurse knows that the first 6 weeks after birth is described as the ______.

5.     The perinatal nurse works with the healthcare facility’s unit council to develop policies to promote patient safety. The policy on infant safety particularly focuses on the challenge of two infants/families with the same ______ to ensure that there are specific strategies to protect each family.

6.     The perinatal nurse recognizes that it is common for women using insulin to have ______ insulin requirements postpartum. This finding is due to a ______ in levels of placental lactogen and insulinase.

True or False

7.     The perinatal nurse teaches the student nurse about the use of the acronym REEDA for wound assessment. The “R” stands for Redness and the “A” stands for Approximation of the wound edges.

Select All that Apply

8.     The perinatal nurse teaches a new nurse about the Healthy People 2010 initiative, which includes postpartum teaching that focuses on:

A. Warning signs during the postpartum period

B. Benefits of breastfeeding

C. Use of infant soothers

D. Contraceptive methods

9.     The postpartum nurse recognizes that after birth, the patient is at risk for decreased bladder tone and function if her labor/birth included:

A. Forceps

B. Vacuum extraction

C. Prodromal labor

D. Prolonged second stage

Case Study

10.  The perinatal nurse is assessing Ruth, who has given birth 2 hours ago. The nurse notes a discoloration of the perineum and Ruth complains of pain and rectal pressure. The most appropriate action for the nurse is to:

A. Call the health care provider to assess immediately.

B. Increase IV fluids and request an order for ergonovine (Ergotrate).

C. Reassure Ruth and her family that postpartum pain is normal and medication is available.

D. Apply ice packs to the perineum as quickly as possible.