Module 7. Discuss postpartum psychosocial changes, discharge, education, postpartum complications...

Maternal/Child Health Nursing

Module 7

Discuss postpartum psychosocial changes, discharge, education, postpartum complications and infections

objectives

Mostly water loss◦Diaphoresis, diuresis

Role of breastfeeding in weight loss

Teach importance of extra calorie intake in breastfeeding

Teach importance of nutrient-rich foods in postpartum period

Weight loss after childbirth

Maternal discharge from hospital◦12 hours-2 days postpartum: uncomplicated vaginal deliveries Length of stay may be increased by psychosocial adaptation difficulties , very young mothers or mothers considered at-risk for developing postpartum issues

◦3-7 days for Cesarean section deliveries or complex vaginal deliveries

Mother/baby nursing care

• May add inpatient time for: instrumentation, surgery, interventions, infection, interruption of physiologic/psychosocial systems, complications

• Mother/baby dyad care vs separate nursery Bonding, breastfeeding, care roles,

perceptions /expectations of families and staff members

Mother/baby nursing care

◦ Nursing plan of care: Recovery stage Readiness for home/return to

responsibilities Adult assistance available Mother or family’s ability to care for

mother/infant Teaching: care tasks, self-care,

recognition of danger signs, safety and security

Discussion of social services, follow-up appointments

Mother/baby nursing care

Expected changes◦Rubin’s Restorative/Adaptive Phases 1st: Taking in: Mom focuses on: Maternal recovery: food, fluids, restorative sleep

Birth experience: discussion, “re-living”

Infant, but willing to let others do things for her and may not yet perform infant care tasks

Maternal psychosocial changes

Rubin’s restorative/adaptive Phases: 2nd: Taking hold: Mom focuses on: Infant care, shows initiative Self-care responsibilities May be self-critical of “performance”

Maternal psychosocial changes

Rubins’ restorative/adaptive phases: 3rd: Letting go: Mom focuses on:

Letting go of expectations or idealized experience to incorporate real child into real family situation

Often done by both parents or mother and other caregiver

Maternal psychosocial changes

◦Postpartum blues “baby blues”: common, onset days 2-7, lasting about a week, mood swings, fades quickly

Rapid hormonal shifts Needs reassurance: may feel required to be happy

s/s: anxiety, mood swings, sadness, irritability, crying, decreased concentration, trouble sleeping

Maternal psychosocial changes

◦Cesarean birth (and other interventions) Response may vary if unplanned Anxiety, guilt/blame, need for education, requires adjustment to recovery, scar, self-image, post-operative as well as postpartum adjustment required

Maternal psychosocial changes

If family had ideal birth planned which didn’t include interventions, assess for unresolved feelings toward birth experience

Maternal psychosocial changes

Monitor pain and coping◦Affects recovery, baby care, breastfeeding, rest, mood, anxiety, adaptation, care of other children, partner interaction, self-care

Maternal psychosocial changes

Evaluate learning◦Is Mom getting the education she needs for her situation?

◦Does she seem unwilling or afraid to ask questions?

◦Are pain medications or untreated pain affecting her discharge goals?

Maternal psychosocial changes

◦Monitor moods and expectations◦Report issues, changes to provider◦Home care: Doula care, home visits by lactation consultant, midwife

Health problems likely to be admitted to hospital

Maternal psychosocial changes

Unexpected changes:◦Postpartum depression Generally lasting more than a week, more severe and persistent S/S: Appetite loss, insomnia, intense irritability/anger, overwhelming fatigue, loss if interest in sex, lack of joy in life, feelings of shame, inadequacy, guilt; more severe mood swings, difficult bonding, withdrawal, thoughts of self-harm or harming baby

Maternal psychosocial changes

Postpartum depression: Should be seen by healthcare

provider if increasing in severity, continuing past two weeks, interrupt ADLs and/or baby care, include thoughts of harm

Maternal psychosocial changes

Treatments◦Counseling, antidepressants, hormone therapy

◦May need evaluation for postpartum hypothyroidism

◦Appropriate depression treatment usually helps within a few months

◦Severe S/S may benefit from electroconvulsive therapy

◦Healthy lifestyle support and expectations

Maternal psychosocial changes

◦Postpartum psychosis (severe depression) Attempts to harm to self/baby hallucinations confusion/disorientation paranoia Requires EMERGENCY treatment

Maternal psychosocial changes

◦Infant with a problem Requires additional stabilization away from mother

NICU Feeding problems “Rule out” tests (even if normal result)

Family may need help accepting real baby

Maternal psychosocial changes

No discussion of labor/birth

No interaction with baby

Refusal to discuss contraception or learn care

Negative self-references (“ugly”)

Signs of potential psychosocial problems

Excessive self-preoccupation Marked depression Lack of support Negative partner/family reaction to baby

Signs: potential psych problems

Expresses disappointment over baby’s sex

Sees baby negatively: “messy,” “unattractive”

Baby reminds mother of someone she doesn’t like

Signs of potential psychosocial problems

Newborns’ and Mothers’ Protection Act of 1996◦Insurance must cover minimum in-hospital stay after delivery 48 hours after vaginal 96 hours after C-section

◦Providers may consult with mothers for earlier discharge

Discharge

Assessment: ◦Subjective/objective data: pain, status, appetite, breastfeeding, etc.

◦Breasts: size, color; cracked or bleeding nipples? Does breastfeeding hurt? Proper support?

◦Uterus: cramping? Prolapse?◦Bladder: palpate position, signs retaining urine if output decreased

Postpartum nursing management

◦Bowels: last BM? Constipation? abdominal discomfort/gas? diarrhea? Response to pain meds and foods

◦Lochia: quantity, color◦Fundus: position? Firmness?◦Episiotomy: s/s infection, healing, tenderness

◦Vital signs: changes in baseline, changes expected with medications

Postpartum nursing management

Assessment (cont’d)◦Lower extremities Homan’s sign

◦Bonding/attachment◦Parenting and family education◦Activity◦Comfort◦Self-care

Postpartum nursing management

◦Fundus Teach how to massage, how “firm” feels, about involution

◦Lochia: red, pink/brown, white Increase or change should be reported to provider

◦Perineum Cleansing Report pain, swelling, bleeding

Postpartum teaching

◦Breasts Breastfeeding/bottle-feeding Support, nipple care

◦Nutrition Fresh fruits, vegetables, enough iron and protein rich foods

Calorie increases needed◦Sexuality Avoid sex, tampons, douching for at least six weeks

Postpartum teaching

• exercise◦Avoid

moderate/heavy lifting unless cleared by provider

◦Daily, moderate exercise as tolerated Thromboses Healing Mood

Postpartum teaching

Emotions◦The difference between “baby blues”, postpartum depression, postpartum psychosis

◦Support services available◦Discuss Mom’s expectations

Cesarean birth◦Incision care, lifting restrictions, prescriptions and safety, breastfeeding adaptations

Postpartum teaching

Report to healthcare provider: s/s infection, medication questions, baby care issues, anything of concern

Reassure parents, answer questions, anticipate baby care questions and concerns

Teach baby care safety, reinforce feeding information, ensure written reinforcement of follow-up appointments and contact numbers

Postpartum teaching

Safety: infant must ride in rear-facing car seat until both 1 year old and 20 pounds

Make sure parents have car seat installation instructions

Postpartum teaching

Rh and gamma globulin◦Rhogam IM for Rh-negative mom within 72 hours of birth of Rh-positive baby

◦Prevents Rh-negative mom from forming antibodies to Rh-positive babies in future

Rubella immunization (mom)◦Should be given if not already immune

Health promotion

Wound infection◦Abdominal incision, perineal lacerations, tears or incisionsEdema, erythema, exudateCondition of site (sutures? Tape? Dressing?)

Infections

Metritis◦Also called “endometritis”

◦Tender, enlarged uterus

◦Prolonged, severe cramping

infections

Metritis (cont’d)◦Foul lochia◦Fever, systemic signs infection◦Failure of uterus to involute properly◦Uterine cavity swab may be cultured◦Antibiotics (IV, then PO)◦Assess for signs of spread: abnormal lochia progression, N/V, absent bowel sounds

Infections

Mastitis

◦Infection of breast: skin break maybe not apparent Ineffective latch

◦Often seen in 2nd, 3rd weeks postpartum

◦Usually unilateral (one-sided)◦Staphylococcus aureus often causative organism

Infections

mastitis

mastitis◦Often triggered by engorgement, milk stasis Skipped feeding, infant sleeps through night, breastfeeding stopped suddenly

◦May prevent emptying of breastmilk -> further stasis and infection, swelling, feeding problems

infections:

Mastitis (cont’d)◦Flulike symptomsTemp 101.1F or higherFatigue, achiness, chills, malaise, headache, localized area redness/inflammation

◦Antibiotics, antifungals

Infections

Mastitis: ◦Emptying of breasts: feeds or pumping or both Feeds no less frequent than every 2-3 hours, avoid supplement feedings, keep area clean, dry

◦Supportive bra◦5% may develop abscess: surgical drainage, antibiotics

infections

Urinary tract:◦May be related to impaired bladder emptying

◦Encourage PO fluids, correct antibiotic use, regular emptying of bladder

Infections

Disseminated intravascular coagulation (DIC)◦Disruption in clotting cascade◦May be seen with abruptio placentae, incomplete abortion, hypertensive disease, infections, prolonged retained dead fetus

Thromboembolytic conditions

DIC◦Rare in first-trimester abortion◦The body’s attempts to correct excessive blood loss may lead to too much thrombin production

◦This triggers fibrinogen to convert to fibrin, leading to many small clots in small blood vessels

Thromboembolytic conditions

Thromboembolytic conditions

DIC ◦Small vessels may become obstructed -> ischemia, damage to vital organs

◦Small clots trap platelets -> generalized hemorrhage

◦Since DIC is a secondary diagnosis, cure depends upon fixing the underlying problem

Thromboembolytic conditions

• DIC S/S: sudden onset of chest pain,

dyspnea, restlessness, cyanosis, coughing up bloody, frothy mucus -> profound circulatory shock s/s, maternal/fetal death

Thromboembolytic conditions

Assessment: ◦Nosebleeds, petechiae from B/P cuff, bleeding gums, excessive bleeding from sites of slight trauma (IV sites, IM/SQ injection sites, shaving nicks, urinary catheter insertion)

◦Report to provider immediately!

Thromboembolytic conditions

◦V/S, FHR, I&O, etc.◦Labs: H&H, PT, PTT, platelet counts, fibrinogen levels

◦IV administration of blood, fibrinogen, heparin; 02 by mask, delivery of fetus

Thromboembolytic conditions