#100 nursestarts

BEFORE THE SEMESTER STARTS, WE ARE REQUIRED TO HAVE OUR LABORATORY EXAMS, SUCH AS:

1. X-RAY
2. FECALYSIS
3. SEROLOGY
4. DRUG TEST
5. BLOOD TEST

WE NEED TO PASS THE ORIGINAL LAB. RESULTS TO OUR COORDINATORS. THEY WOULD BE CHECKING THESE RESULTS IF WE COULD BE ALLOWED TO HAVE OUR DUTY IN THEIR AFFILIATED HOSPITALS.

IF YOU ARE POSITIVE IN ANY OF THESE RESULTS YOU ARE NOT ALLOWED TO HAVE DUTY IN HOSPITALS.

continuation: Caring for the Postpartal Woman and Her Family

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.

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

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).