Caring for the Postpartal Woman and Her Family part 1

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.