CARE OF POSTNATAL MOTHER

PREPARED BY LEKSHMI AJITHLALM.Sc Nursing

Definition 6 weeks period following the child birth during which the body tissues especially the pelvic organs revert back approximately to the pre pregnant state both

anatomically and physiologically. 6 week interval between the birth of the

new born and the return of reproductive organs to their normal nonpregnant state.

period of six weeks which begins as soon as placenta is expelled

CHARECTERISTICS OF PUERPERIUM

Reproductive organs return to the non pregnancy state.

Other physiological changes of pregnancy are reversed.

Lactation is stabilised. Reestablishment of menstruation. Foundation of relationship between parents and

infant

is laid Mother recovers from stress of pregnancy &

delivery Mother begins to assume responsibility for care and

nurturing of the infant.

Physiology of the Puerperium

UterusAnatomic changesPhysiological changes

ContractionsAfter painsPlacental siteMuscles& blood vesselsEndometrial regeneration

Lochia

Uterine Changes

Changes in the Cervix & Lower Uterine Segment

Cervical opening contracts slowly and for a few days immediately after labor

  by the end of the 1st wk → it has narrowed

As the opening narrows the cervix thickens and a canal reforms.

Bilateral depression at the site of lacerations remain as permanent changes that characterize the parous cervix

Peritoneum and Abdominal wall

Broad & round ligaments      : much more lax than nonpregnant      : require considerable time to recover from stretching & loosening

Abdominal wall     : return to normal → requires several weeks (aided by exercise)    : usually resumes its prepregnancy state except for silvery striae

Physiology of the PuerperiumCardiovascular changes Cardiac output remains elevated for at least 48

hours postpartum Changes of pregnancy reversed over three

weeks Marked increase stroke volume immediately

post partum 500-1000ml blood loss in normal delivery leukocytosis and thrombocytosis occur

during and after labor

Hormones ChangeLowest level

hPL decreases<24 hr

Estrogen decreasesDay7

Progesterone decreasesDay7

FSH decreasesDay10-12

LH decreasesDay10-12

Prolactin decreasesDay14

Growth

hormone

Stays low through day3

Thyroid No change

Corticosteroids decreasesDay7

Plasma Renin decreases<2hr

Angiotensin II decreases<2hr

Mammary Glandes

Breast Anatomy

Breast Feeding

Medications & Breast FeedingDrugs absolutely contraindicated in

breast feeding. Chemotherapeutic or cytotoxic agents all drugs used recreationally (including alcohol and nicotine) radioactive nuclear medicine tracers lithium carbonate chloramphenicol phenylbutazone Atropine Thiouracil

Iodides and mercurials.

Medications & Breast Feeding

Drugs to strongly avoid or consider bottle feeding.

Antipsychotics, antidepressants, meteronidazole,tetracycline, sulfonamides, diazepam, salicylates, corticosteroids ,phenytoin, phenobarbital,

or warfarin. Drugs safe to use in normal doses. Acetaminophen, insulin, diuretics, digoxin, beta-blockers, penicillins, cephalosporins, erythromycin, birth control pills, OTC cold preparations, and

narcotic analgesics (short term in normal doses). Lactation-suppressing drugs. Levodopa, anticholinergics, bromocriptine, trazodone, and large-dose estradiol birth control pills.

PSYCHOLOGY OF PUERPERIUM

POST PARTUM BLUES POST PARTUM DEPRESSION POST PARTUM PSYCHOSIS

PARENTING PROCESS

PARENTING PROCESS DEFINITION

A Process Of Role Attainement And Role Transition That Begins During Pregnancy.The Transitionends When The Parent Develops A Sense Of Comfort And Confidence In Performing The Parenting Roles-sank (1991)

RECIPROCAL ATTACHMENT BEHAVIOURS

Make eye contact and engage in prolonged ,intense mutual gazing

Move their eyes and attempts to track their parent’s face.

Grasp the parents finger and holds onMove synchronously in response to

rhythms and patterns of parent’s voiceRoot, suck and finally latch on to the

breastsBe comforted by parents touch or voice.

THEORIES OF ATTACHMENT

Psycho analytic

Ethologic Learning theory

FACILITATING BEHAVIOURS parent

Gazes, looks into physical characteristics of the infant, eye contact

Identifies infant as an unique individual Touches; progresses from fingertip to

fingers to palms Talks to, coos or sings to infant Express pride in infant Relates infant’s behaviour to familiar

events

INHIBITING BEHAVIOURS

Turns away from infant, ignores infant’s presence

Avoids infant; refuses to hold infant when given opportunity

Identifies infant with someone parent dislikes Fails to move from fingertip touch Frowns at the infant Express disappointment Do not incorporate infant into life.  

FACILITATING BEHAVIOURS -infant

Visually alert; eye-to-eye contact; tracking or following of parent’s face

Smiles Vocalisation; crying only when hungry or wet Grasp reflex Anticipatory approach behaviours for feeding; sucks well Enjoys being cuddled Easily consolable Activity and regularity somewhat predictable Differential crying, smiling and vocalizing; recognizes

and prefers parents Approaches through locomotion Cling to parents; puts arm around parent’s neck 

INHIBITING BEHAVIOURS

Sleepy; eyes closed most of the time; gaze aversion

Resemblance to person parent dislikes; hyperirritability ‘jerky movements touched

Bland facial expression; infrequent smiles Crying for hours Exaggerated motor reflex Feeds poorly ,regurgitates often Resists holding and cuddling Inconsolable Shows no preference for parents

PHASES OF PUERPERIUM

1.Taking - in phase

2.Taking - hold phase

3.Letting - go phase

MATERNAL ROLE ATTAINMENT

Anticipatory stageFormal stageInformal stagePersonal stage

FACTORS AFFECTING FAMILY ADAPTATION

Physical discomfort and fatigue- resolve within one or two days

knowledge of the infant’s needs Previous experiences Expectations for the new born Maternal age Maternal temperament Temperament of the infant Availability of a strong support system Unanticipated events- caesarean birth, pre term

infant, ill infant or birth of more than one infant. Cultural influence

WHEEL OF FAMILY CENTRED POSTPARTUM NEW BORN CARE

early parent infant

contact

demand feeding

flexible care

routine

individual care

father's are not

considered as visitors

parenting education

sibling and grand parent

education

ASSESSMENT OF EARLY ATTACHMENT

1. Is the mother attached to her new born?2. Is the mother inclined to nurture her

infant?3. Does the mother act consistently?4. Is she sensitive to new born’s needs as

they arise?5. Does she seem pleased with her baby’s

appearance and sex?6. Are there any cultural factors that might

modify the mother’s response?

GUIDELINES FOR INTERVENTION

1. Determine the childbearing and childrearing goals of the infant’s mother and father and use them in planning nursing care

2. Arrange the health care setting so that a individual nurse client relationship can be developed and maintained throughout pregnancy and during the early months of post partum.

3. Enhance the couple’s relationship and increase their communication capacity during the pregnancy.

4. Use anticipatory guidance from conception through the post partum period to prepare for expected problems of adjustment.

GUIDELINES FOR INTERVENTION contd

5. Include parents in planning, implementing and evaluating nursing interventions

6. Initiate and support measures to support and alleviate parental fatigue.

7. Help parents to identify, understand and accept positive and negative feelings related to overall parenting experience.

8. Remove barriers to voluntary contact among family members and infant.

9. Support and assist parent in determining the unique needs of the infant

STRATEGIES TO PROMOTE ROLE OF FATHER IN PREGNANCY AND CHILDBIRTH

Include father in all prenatal visits Encourage his participation in parenting and

prenatal classes. Address concerns of fathers relating to

childbirth and infant care. Encourage discussion of changes in role and

parenting issues Facilitate father’s presence at labour and

birth and assist for the role he wishes. Encourage father to hold his new born. Include the father in well baby checks Facilitate discussion in sharing responsibility

for infant care.

MANAGEMENT OFPUERPERIUM

Hospital Care

Care at Home

MANAGEMENT OF PUERPERIUMObjectives

Ensuring that postnatal care is related to needs of each individual mother.

Promoting a relaxed environment in which mother can take adequate rest &freedom from unnecessary stress.

Identifying potential problems & ensuring prompt & appropriate treatment

Enabling parents to become confident in the care of infant

Hospital CareAttention immediately after labor

for the first hour after delivery    - BP & PR : should be taken every 15 minutes

monitor amount of vaginal bleeding

Fundus should be palpated to ensure that it is well contracted

Breast feeding

Nutrition

Hygienic care   

Postnatal care

Ambulation & exercise Rest & sleep. Care of breast Nutrition Emotional needs Prevention of infections Management of after pains Immunizations

Complications of Puerperium Blood loss

Early post partum hemorrhage Uterine Atony

Retained products of conception

Lacerations Uterine rupture

Complications of Puerperium Infections

Endomyometritis Foul smelling lochia and tender uterus

within first few days post partum Increased risk with c-section, PROM, Multiple

exams during labor, & long labor Polymicrobial including anaerobes (Ecoli,

Gardnerella, Peptostreptococcus) Treat with Gentamycin/Clindomycin (Gold

Standard), extended spectrum penicillin or cephalosporin

Breast complicationsBreast fever

For the first 24 hours after development of lacteal secretion,

: breasts to become distended, firm, & nodular        ← exaggeration of normal venous & lymphatic

engorgement of the breast            Puerperal fever from breast engorgement is

common           : 37.8~39 , seldom persists for longer than ℃

4~16 hours   Treatment- brassiere, ice bag, analgesics, pumping

or manual expression     

Breast complications contd….

  Mastitis Parenchymatous infection of mammary glands

seldom appear before the end of the 1st week postpartum not until the

3rd or 4th week.

unilateral, breast becomes hard, reddened and painful 

Signs : chills (1st), rigor, fever, tachycardia

Etiology

Staphylococcus aureus (most common) 

※ breast abscess : caused by group B streptococcus

- almost always from nursing infant's nose & throat

  → the organism enters the breast through the nipple at the site of a fissure or abrasion      

Breast complications contd….

Treatment swab and culture & sensitivity  antimicrobial therapy

       : penicillin or cephalosporin       : MRSA →vancomycin for about 7-

10days Continue breast feeding

     : early Treatment & continued lactation is successful in avoiding abscess formation

Breast abscess surgical drainage (essential) & general anesthesia

PRINCIPLES OF POSTNATAL CARE

Promoting physical and psychological well being of the mother, her baby and the family

The identification of deviation from normal physiological or psychological progress with appropriate prompt referral

Encouraging sound methods of infant care and feeding and promoting of effective parent infant relationships.

Supporting and strengthening the women and her partner’s confidence thus facilitating their transition to the parenting role.

POINTS REDNESS EDEMA ECHYMOSIS

DISCHARGE

APPROXIMATION

0 none none none none closed

1 within .25cmof incision B/L

perineal, less than 1 cm from incision

within .25cmof incision B/L

Serum Skin separation 3 mm or less

2 within .5cmof incision B/L

Perineal &or vulvar between 1-2 cm from incision

within .25cmof incision B/LOr .5 cm unilaterally

Serosanguinous

Skin &subcutaneous fat separation

3 Beyond .5cmof incision B/L

Perineal &or vulvar between 2 cm from incision

Greater than 1 cm B/L or 2 cm unilaterally

Bloody purulent

Skin &subcutaneous fat & fascial separation

REEDA SCALE

NURSING DIAGNOSES1. Pain related to involution of uterus, trauma to

perineum, and episiotomy2. Risk for infection related to child birth trauma

to the tissues episiotomy and presence of lochia3. Risk for fluid volume deficit related to blood

loss after childbirth recovery4. Constipation related to post child birth

discomfort and child birth trauma to the tissues.5. Urinary retention related to post child birth

discomfort and child birth trauma to the tissues.

6. Sleep pattern disturbance related to discomforts of the post partum period, infant care and hospital routine.

7.Risk for imbalanced nutrition less than body requirement related to lack of knowledge regarding post partal diet and increased requirements

8.Risk for complications9.Knowledge deficit related to care of

puerperium, care of new born and family planning methods.

HEALTH EDUCATION

POSTNATAL CARE Rest and sleep Early ambulation Personal hygiene Care of breast Care of perineum Prevention of infection Postnatal diet and fluid intake Postnatal exercise Family planning

HEALTH EDUCATION contd

B. CARE OF BABYC. HOME CARE AND DISCHARGE

Rest and sleepEarly ambulationPersonal hygiene

Care of breastCare of perineumPrevention of infection

HEALTH EDUCATION contd

Postnatal diet and fluid intake Postnatal exercise Family planning Avoidance of coitus Postnatal check up

POST NATAL CHECK UP

OBJECTIVES TIME ACTIVITIES

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