POST PARTUMPOST PARTUM

Lecture 8Lecture 8

PuerperiumPuerperium: “to bring forth” 6 wk > childbirth. : “to bring forth” 6 wk > childbirth. ““4th trimester” - transition for woman/family 4th trimester” - transition for woman/family

(pregnancy ends/parenting role begins)(pregnancy ends/parenting role begins)

I. I. Physiological Changes of Post Partum PeriodPhysiological Changes of Post Partum PeriodA. A. Reproductive System Changes:Reproductive System Changes:

UTERUS:UTERUS: contx’s begin > birth & delivery of contx’s begin > birth & delivery of placentaplacenta

1. placental site seals 1. placental site seals 2. Entire uterus contracts & reduces gradually for 8-2. Entire uterus contracts & reduces gradually for 8-

10 days. “INVOLUTION”. Pt. in danger of 10 days. “INVOLUTION”. Pt. in danger of hemorrhage uterus until involution is complete. hemorrhage uterus until involution is complete.

Oxytocin released > uterine contx’s.Oxytocin released > uterine contx’s.

FundusFundus: : assess for firmness. Palpate > delivery. assess for firmness. Palpate > delivery. Remains @ umbilicus X 24 hrs. Soft aka “boggy” Remains @ umbilicus X 24 hrs. Soft aka “boggy”

- danger of hemorrhage. - danger of hemorrhage.

MassageMassage uterus! uterus!

Uterus descends one finger breadth every Uterus descends one finger breadth every day.day.

Delivery day, uterus @ umbilicusDelivery day, uterus @ umbilicus 1st day PP uterus 1 FB ↓ Umbilicus1st day PP uterus 1 FB ↓ Umbilicus 2nd day PP uterus 2 FB ″ and so forth.2nd day PP uterus 2 FB ″ and so forth. Support lower segment of uterus when Support lower segment of uterus when

palpating to prevent uterine eversion.palpating to prevent uterine eversion.

By day 10, uterus almost back to pre-By day 10, uterus almost back to pre-pregnant size & position in pelvic cavity. pregnant size & position in pelvic cavity. [1000 grams→ 50 grams] No longer [1000 grams→ 50 grams] No longer palpated in abdomen. palpated in abdomen.

Full bladder raises fundal height, gives Full bladder raises fundal height, gives false reading. false reading.

Natural oxytocin released with breast Natural oxytocin released with breast feeding. ^ contractions . 2FB ↓ umb. on feeding. ^ contractions . 2FB ↓ umb. on 1st day PP. 1st day PP.

Breast fdg.offers little protection against Breast fdg.offers little protection against hemorr. hemorr.

Delay in uterine involution: retained placenta/clots Delay in uterine involution: retained placenta/clots - -

effective contraction of uterus effective contraction of uterus not possiblenot possible. Risk of . Risk of PP Hemorr.PP Hemorr.

Delay also with:Delay also with: multiparous pt. [grand multip ] multiparous pt. [grand multip ] exhaustion exhaustion multi-fetuses.multi-fetuses. C/S involutes slower; d/t surgery & less initiation C/S involutes slower; d/t surgery & less initiation

of breast feeding > delivery. of breast feeding > delivery.

After-birth painsAfter-birth pains = cramping caused by contractions = cramping caused by contractions more in multi-parous women than in primips .more in multi-parous women than in primips . With Br. Fdg. because of release of oxytocin.With Br. Fdg. because of release of oxytocin.

2. 2. LOCHIALOCHIA Placenta separates from spongy layer of uterus - Placenta separates from spongy layer of uterus -

decidua BASALIS. decidua BASALIS. Inner layer of decidua remains & forms new layer Inner layer of decidua remains & forms new layer

of endometrium . Outer becomes necrotic & of endometrium . Outer becomes necrotic & sheds. sheds.

Consists of blood, fragments of decidua, mucus, Consists of blood, fragments of decidua, mucus, bacteria. bacteria.

1st 3 days = rubra =”red” [blood]1st 3 days = rubra =”red” [blood] >3 days = serosa = “pink”>3 days = serosa = “pink” 10th day – alba - “white” [up to 3 wks]10th day – alba - “white” [up to 3 wks] Total flow lasts about 4-5 wks Total flow lasts about 4-5 wks Should not be bright red; could be PP Should not be bright red; could be PP

hemorrhage.hemorrhage.

3. 3. CERVIX CERVIX Neck; remains slightly opened & contracts > Neck; remains slightly opened & contracts >

delivery.delivery. In 7 days, opening narrow as pencil. Os remains In 7 days, opening narrow as pencil. Os remains

slit-like .slit-like . 4.4. VAGINA VAGINA Slightly distended after birth. Kegel exercises Slightly distended after birth. Kegel exercises

^muscle tone and strength. Important for ^muscle tone and strength. Important for lacerations. lacerations.

5.5. PERINEUM PERINEUM Can be edematous/ecchymoticCan be edematous/ecchymotic Ice x 24 hrs. then heat [Sitz]Ice x 24 hrs. then heat [Sitz] Topical anesthetics creams/sprays apply for Topical anesthetics creams/sprays apply for

comfort. comfort. Perineal massage relaxes perineum before Perineal massage relaxes perineum before

delivery. delivery. May prevent episiotomy/laceration.May prevent episiotomy/laceration. Teach Kegels - tightening & releasing of perineal Teach Kegels - tightening & releasing of perineal

muscles. Improves circulation & healing of muscles. Improves circulation & healing of epis/lac.epis/lac.

Complications of Perineum:Complications of Perineum: Hematomas [blood from bleeding Hematomas [blood from bleeding

vessel] vessel] Area of swelling on one side of Area of swelling on one side of

perineum.perineum. If small, absorbs in few days; apply If small, absorbs in few days; apply

ice & give analgesics. ice & give analgesics. If large bleed, to OR for evacuation & If large bleed, to OR for evacuation &

vaginal packing.vaginal packing. Common - forceps deliveriesCommon - forceps deliveries Perineal Care - use warm water; wipe Perineal Care - use warm water; wipe

from front to back.from front to back.

Laceration Laceration size of baby, timing of delivery, tension on size of baby, timing of delivery, tension on

perineum. perineum. Sutured & treated as episiotomies. Sutured & treated as episiotomies. Analgesics, ice, topical creams, Sitz bath.Analgesics, ice, topical creams, Sitz bath. 1st degree = from base of vagina to base of labia 1st degree = from base of vagina to base of labia

minora.minora. 2nd “ = from base of vagina to mid perineum2nd “ = from base of vagina to mid perineum 3rd = entire perineum to anal sphincter3rd = entire perineum to anal sphincter 4th = entire perineum through anal sphincter & 4th = entire perineum through anal sphincter &

some rectal tissue.some rectal tissue. Nothing into rectum - no rectal temps., Nothing into rectum - no rectal temps.,

suppositories, or enemas with 4suppositories, or enemas with 4thth degree to avoid degree to avoid further damage. further damage.

Colace TID, ^ po fluids to promote BM. Ice X 24 Colace TID, ^ po fluids to promote BM. Ice X 24 hrs., Sitz baths TID; topicals. KEGELS!hrs., Sitz baths TID; topicals. KEGELS!

SYSTEMIC CHANGES - Body returns to SYSTEMIC CHANGES - Body returns to

pre-pregnant state by 6 wks.pre-pregnant state by 6 wks.

Hormonal SystemHormonal System: : Pregnancy hormones decrease w. Pregnancy hormones decrease w.

delivery of placenta. delivery of placenta. HCG & HPL disappear by 24 hrs. FSH HCG & HPL disappear by 24 hrs. FSH

rises rises

12 days - to begin new menstrual cycle. 12 days - to begin new menstrual cycle. Menses resumes by 4-5 wks. if not Br. Menses resumes by 4-5 wks. if not Br. Fdg.Fdg.

The Urinary SystemThe Urinary System: : Loss of bladder tone d/t swelling & anesthesia ; Loss of bladder tone d/t swelling & anesthesia ;

urinating difficult. May not feel urge to void. urinating difficult. May not feel urge to void. Hydronephrosis [enlargement of ureters] occurs Hydronephrosis [enlargement of ureters] occurs

after delivery & to 4 wks. PP. DIURESIS!after delivery & to 4 wks. PP. DIURESIS! ↓ ↓ bladder sensitivity - ↑ risk for bladder bladder sensitivity - ↑ risk for bladder

infection - urinary stasis.infection - urinary stasis. Avoid bladder damage - assess bladder q 1-2 Avoid bladder damage - assess bladder q 1-2

hrs.til voids qs. Teach voiding q 2 – 3 hours.hrs.til voids qs. Teach voiding q 2 – 3 hours. Palpate abdomen gently, note location of Palpate abdomen gently, note location of

fundus. fundus. When do you suspect full bladder?When do you suspect full bladder? During preg., 2000-3000 ml. of fluid During preg., 2000-3000 ml. of fluid

accumulates in body - Client loses 5- 10 lbs. of accumulates in body - Client loses 5- 10 lbs. of water weight in 1water weight in 1stst wk. wk.

How?How?

Circulatory SystemCirculatory System: Blood volume ^ 30 – 50% : Blood volume ^ 30 – 50% in pregnancy. in pregnancy.

With With diuresis & blood lossdiuresis & blood loss @ delivery, blood @ delivery, blood volume volume

returns to normal in 1-2 wks. returns to normal in 1-2 wks. Blood loss for NSVD = 300 cc. & C/S = 500 Blood loss for NSVD = 300 cc. & C/S = 500

cc.cc.

Non pregnant: HCT=37 - 47% & HGB=12 - 16g/dLNon pregnant: HCT=37 - 47% & HGB=12 - 16g/dL Pregnant: HCT=32 -42 % & HGB = 11.5 – 14g/dLPregnant: HCT=32 -42 % & HGB = 11.5 – 14g/dL HCT drops by 4 pts. & HGB drops by 1 g. for every HCT drops by 4 pts. & HGB drops by 1 g. for every

250cc. of blood client loses. 250cc. of blood client loses. Patient should not be anemic entering deliveryPatient should not be anemic entering delivery Possible blood transfusion with large blood loss.Possible blood transfusion with large blood loss. Average blood volume: pre-pregnant = 4000cc; Average blood volume: pre-pregnant = 4000cc; pregnant state = 5250cc.pregnant state = 5250cc.

^ Blood volume: provides adequate exchange of ^ Blood volume: provides adequate exchange of nutrients in placenta & compensates for blood nutrients in placenta & compensates for blood loss during delivery. loss during delivery.

HR remains ^ x 24-48 hrs. PPHR remains ^ x 24-48 hrs. PP With diuresis, HCT levels rise [^ With diuresis, HCT levels rise [^

hemoconcentration] reach pre-preg level by 6 hemoconcentration] reach pre-preg level by 6 wks.wks.

Plasma fibrinogenPlasma fibrinogen ^^ 50% during pregnancy & ^^ 50% during pregnancy & remains elevated 6 wks. PP. [^ estrogen levels] remains elevated 6 wks. PP. [^ estrogen levels] WHY?WHY?

Can cause ^ thrombus formation.Can cause ^ thrombus formation. Assess pts. legs/calves for s/s thrombus.Assess pts. legs/calves for s/s thrombus. Rise in leukocytes; WBC ^ protective measure to Rise in leukocytes; WBC ^ protective measure to

prepare for stress of delivery. As high as 20-prepare for stress of delivery. As high as 20-25,000.25,000.

Gastrointestinal SystemGastrointestinal System: :

NSVD: bowels sounds. Eat right away.NSVD: bowels sounds. Eat right away. C/S: bowel sounds hypoactive 1st 8 hrs. C/S: bowel sounds hypoactive 1st 8 hrs. Epidural/spinal: po clears after delivery, advance Epidural/spinal: po clears after delivery, advance

diet if +BS.diet if +BS. General anesthesia: usually NPO for ~ 6-8 hrs. General anesthesia: usually NPO for ~ 6-8 hrs. Duramorph/astromorph can cause N/V up to 12 Duramorph/astromorph can cause N/V up to 12

hrs. hrs. antiemetic meds. [Reglan/Zofran] . antiemetic meds. [Reglan/Zofran] .

BM - difficult/painful d/t lacerations/hemmorhoids.BM - difficult/painful d/t lacerations/hemmorhoids. C/S - BM 3rd - 4th day. GI activity slowed d/t C/S - BM 3rd - 4th day. GI activity slowed d/t

surgery. surgery. Can go home without BM if + flatus.Can go home without BM if + flatus.

Integumentary System: Stretch marks Integumentary System: Stretch marks

[striae gravidarum] appear reddened [striae gravidarum] appear reddened on on

abdomen. Fade by 3-6 months; abdomen. Fade by 3-6 months;

Pearly white marks may remain in Pearly white marks may remain in lighter lighter

skinned pts. & darker marks in darker skinned pts. & darker marks in darker skinned pts. skinned pts.

Modified sit-ups strengthen Modified sit-ups strengthen abdomenabdomen

VITAL SIGNS PPVITAL SIGNS PPTemperature: slightly ^ - dehydration during labor Temperature: slightly ^ - dehydration during labor

11stst 24 hrs. Returns to normal within 24 hrs. 24 hrs. Returns to normal within 24 hrs. T = 100.4 or >T = 100.4 or > PP infection suspected. PP infection suspected. Temp. also rises 3rd - 4th day with filling of Temp. also rises 3rd - 4th day with filling of

breast milk breast milk Observe for s/s infection - nurse usually 1st to Observe for s/s infection - nurse usually 1st to

detect ↑ temp. detect ↑ temp. [universal sign of infection 100.4 [universal sign of infection 100.4 x 2 readings, on days 2-10 PP]x 2 readings, on days 2-10 PP]

Pulse: HR ^ slightly x 1st hr. Pulse: HR ^ slightly x 1st hr. Stroke volume & cardiac output also ^ x 1Stroke volume & cardiac output also ^ x 1stst hr. hr.

then decreasesthen decreases 8-10 wks.,returns to pre-pregnant state. 8-10 wks.,returns to pre-pregnant state. Rapid, thready pulse- sign of PP hemorrhage, Rapid, thready pulse- sign of PP hemorrhage,

infection infection

Blood Pressure -Blood Pressure - Monitor carefully. Monitor carefully.

1st trimester1st trimester Heart works faster to handle ^ volume. BP remains Heart works faster to handle ^ volume. BP remains

same. same.

2nd trimester2nd trimesterBP drops slightly d/t lowered peripheral resistance BP drops slightly d/t lowered peripheral resistance

in blood in blood vessels as placenta expands rapidly. Heart beats vessels as placenta expands rapidly. Heart beats

faster, faster, more efficiently d/t ^ blood volume. more efficiently d/t ^ blood volume. Pre-pregnant BP 120/80. Pregnant BP 114/65. Pre-pregnant BP 120/80. Pregnant BP 114/65.

3rd trimester3rd trimesterBP back to pre-pregnant value. BP back to pre-pregnant value.

BP ComplicationsBP Complications

↓ ↓ BP BP [90/60 or less] with dizziness is “Orthostatic [90/60 or less] with dizziness is “Orthostatic

hypotension”; could signify hemorrhage. hypotension”; could signify hemorrhage. Take BP/pulse lying/sitting/standing. Compare Take BP/pulse lying/sitting/standing. Compare

values. values. Orthostatic: If BP drops 15-20 mmHg and pulse Orthostatic: If BP drops 15-20 mmHg and pulse

increases 20 bpm or more. Caution for falls.increases 20 bpm or more. Caution for falls. Needs IV fluids. Take VS. Report to MD > order for Needs IV fluids. Take VS. Report to MD > order for

CBC.CBC.

↑ ↑ BP BP [140/90 or >] could signify PP pre-eclampsia. [140/90 or >] could signify PP pre-eclampsia. Notify MD. Could develop into serious Notify MD. Could develop into serious

complication.complication. Oxytocic meds [Pitocin] > delivery could ^ BP Oxytocic meds [Pitocin] > delivery could ^ BP

Other Changes Other Changes ExhaustionExhaustion: : CommonCommon Frequent rest periods Frequent rest periods RN coordinates nursing care & infant feeding times RN coordinates nursing care & infant feeding times provide maximum rest time. provide maximum rest time.

Weight LossWeight Loss: : Average wt. loss 12 lb. [infant & placenta] Average wt. loss 12 lb. [infant & placenta] 5 lbs. - diuresis & diaphoresis in wk. that follows. 5 lbs. - diuresis & diaphoresis in wk. that follows. Lochial flow - 2-3 lbs. Lochial flow - 2-3 lbs. Total = approx. 19-20 lbs. {depends on total wt. Total = approx. 19-20 lbs. {depends on total wt.

gain}gain} At 6 wks. wt. may still be above pre-preg. weight.At 6 wks. wt. may still be above pre-preg. weight.

Return of Menses:Return of Menses: > delivery FSH levels rise causing > delivery FSH levels rise causing ovulationovulation

No Br. Fdg.- menses resumes ~ 6 wks. No Br. Fdg.- menses resumes ~ 6 wks. Lactation delays menses for several months (6 mos)Lactation delays menses for several months (6 mos)

PSYCHOLOGICAL CHANGES OF POST PARTUM PSYCHOLOGICAL CHANGES OF POST PARTUM PERIOD: ADJUSTMENTSPERIOD: ADJUSTMENTS

Taking-In PhaseTaking-In Phase: : time of reflection for client regarding new roletime of reflection for client regarding new role may be passive or excitedmay be passive or excited talks at length about birth experiencetalks at length about birth experience on phone with family/friends recounting birth on phone with family/friends recounting birth

experience. experience. Usually lasts 1-2 days. Usually lasts 1-2 days. Delayed d/t pain r/t vaginal or C/S.Delayed d/t pain r/t vaginal or C/S.

Taking-Hold PhaseTaking-Hold Phase: : woman makes own decisions regarding self & infant woman makes own decisions regarding self & infant

care. care. Usually day 2 - 3. Occur on day 1 esp. if woman is Usually day 2 - 3. Occur on day 1 esp. if woman is

multip. multip. Can occur later, depends on recovery process or Can occur later, depends on recovery process or

cultural beliefs.cultural beliefs.

Letting Go PhaseLetting Go Phase: : Woman gives up fantasy image of baby and accepts Woman gives up fantasy image of baby and accepts real child. real child. Occurs within few weeks of getting home Occurs within few weeks of getting home Needs time to adjust to new experience.Needs time to adjust to new experience.

Bonding:Bonding: Expressing maternal love & attachment toward Expressing maternal love & attachment toward

new baby. Develops gradually. new baby. Develops gradually. Enface positionEnface position: close eye contact with infant.: close eye contact with infant. Healthy bonding - kissing, touching, counting Healthy bonding - kissing, touching, counting

fingers & toes, cooing, etc.fingers & toes, cooing, etc.

Factors Interfering with BondingFactors Interfering with Bonding: difficult labor, : difficult labor, separation @ birth (NICU) separation @ birth (NICU)

Other Maternal Feelings of Post Partum PeriodOther Maternal Feelings of Post Partum Period

Abandonment: Abandonment: feelings that occur > birth of feelings that occur > birth of child; woman no longer center of attention. child; woman no longer center of attention.

Disappointment:Disappointment: infant does not meet infant does not meet expectations of mother/father. Eg. eye expectations of mother/father. Eg. eye color; sex .color; sex .

Post Partum Blues:Post Partum Blues: d/t normal hormonal d/t normal hormonal changes; changes;

Drop in estrogen/progesterone; lasts 1st few Drop in estrogen/progesterone; lasts 1st few days of days of

PP period. Occurs in 50% of women. PP period. Occurs in 50% of women.

PP Depression:PP Depression: 30% of women exp. this. 30% of women exp. this. Therapy & medication may be necessary.Therapy & medication may be necessary. Hx of depression & anxiety prior to Hx of depression & anxiety prior to

pregnancy puts mother @ higher risk for pregnancy puts mother @ higher risk for developing this. developing this.

Can manifest itself up to 1 year > birth. Can manifest itself up to 1 year > birth. Screening tool: Edinburgh PP depression Screening tool: Edinburgh PP depression

tool tool

Always refer to social worker to assess for Always refer to social worker to assess for degree of depression.degree of depression.

Ask: Ask: is mother able to take infant home without is mother able to take infant home without danger to self or baby?danger to self or baby?

Studies show breast feeding helps reduce Studies show breast feeding helps reduce symptoms d/t oxytocin “feel good” effectsymptoms d/t oxytocin “feel good” effect

MANIFESTATIONS OF POSTPARTUM MANIFESTATIONS OF POSTPARTUM DEPRESSIONDEPRESSION

interest in surroundingsinterest in surroundings interest in foodinterest in food unable to feel pleasureunable to feel pleasure fatiguefatigue health c/ohealth c/o sleep disturbancesleep disturbance panic attackspanic attacks obsessive thinkingobsessive thinking hygienehygiene ability to concentrateability to concentrate odd food cravingsodd food cravings irritabilityirritability rejection of infantrejection of infant

PPD: TeachingPPD: Teaching relaxation therapyrelaxation therapy rest & nutritionrest & nutrition frequent contact with other adultsfrequent contact with other adults

Resource: Resource: The Post Partum Resource Center of New York, The Post Partum Resource Center of New York,

Inc. Inc. 631-422-2255 631-422-2255 www.postpartumNY.org

MANIFESTATIONS OF POSTPARTUM MANIFESTATIONS OF POSTPARTUM PSYCHOSISPSYCHOSIS

s/s depression s/s depression s/s manic s/s manic auditory hallucinationsauditory hallucinations delusionsdelusions guiltguilt worthlessnessworthlessness

Development of Parental Love & Development of Parental Love & Positive Family Relationships:Positive Family Relationships:

Rooming In: most hospitals offer this; infant Rooming In: most hospitals offer this; infant stays in room with mom 24hrs. (partial or stays in room with mom 24hrs. (partial or complete)complete)

Sibling Visitation: encourage siblings to visit to Sibling Visitation: encourage siblings to visit to promote family togetherness. promote family togetherness.

LACTATION & BREAST FEEDINGLACTATION & BREAST FEEDING

Lactation starts regardless if pt. is Lactation starts regardless if pt. is breastfeeding or not. breastfeeding or not.

Entirely up to mother Entirely up to mother Must feel comfortable doing so. Must feel comfortable doing so.

Advantages to Breast Feeding:Advantages to Breast Feeding: Promotes bonding between mother & Promotes bonding between mother &

baby. baby. High nutritional value for infant.High nutritional value for infant. Promotes uterine involution thru release of Promotes uterine involution thru release of

oxytocin from posterior pituitary.oxytocin from posterior pituitary. Reduces cost of feeding & preparation Reduces cost of feeding & preparation

time.time.

Nurse has major role as educator of benefits & Nurse has major role as educator of benefits & methods of methods of

breast feeding. breast feeding. Ways to teach new moms about lactation: Ways to teach new moms about lactation: videosvideos handoutshandouts hands on demo hands on demo lactation specialist [in clinical settings] lactation specialist [in clinical settings] Offer support Offer support

Contraindications to Breast Feeding:Contraindications to Breast Feeding: Mom receiving meds not appropriate for Br. fdg. Mom receiving meds not appropriate for Br. fdg.

[Lithium][Lithium] Exposure to radioactive compounds [thyroid Exposure to radioactive compounds [thyroid

testing]; pump & dump breast milk x 48 hrs. testing]; pump & dump breast milk x 48 hrs. Flush in toilet.Flush in toilet.

Breast Cancer; HIVBreast Cancer; HIV

Physiology of LactationPhysiology of Lactation

Body prepares for lactation during pregnancy; stores Body prepares for lactation during pregnancy; stores fat fat

& nutrients; provide energy, vitamins, minerals in & nutrients; provide energy, vitamins, minerals in breast milk.breast milk.

Early pregnancy, ↑ estrogen (placenta) stimulates Early pregnancy, ↑ estrogen (placenta) stimulates growth of milk glands & size of breasts. growth of milk glands & size of breasts.

Colostrum: middle of pregnancy & day 1-3 PP, Colostrum: middle of pregnancy & day 1-3 PP, Thin, watery pre-lactation secretion. Rich in Thin, watery pre-lactation secretion. Rich in

antibodies; passes to baby in 1-3 days. antibodies; passes to baby in 1-3 days. Breasts begin to get tender; fill up w. milk. Breasts begin to get tender; fill up w. milk.

Breast milk by 3Breast milk by 3rdrd to 4 to 4thth day in response to: day in response to: falling levels of estrogen & progesterone > falling levels of estrogen & progesterone >

delivery of placenta. delivery of placenta. ^ production of prolactin by anterior pituitary ^ production of prolactin by anterior pituitary Milk ducts become distended & fluid turns bluish-Milk ducts become distended & fluid turns bluish-

whitewhite

Physiology cont.Physiology cont.

Infant sucklingInfant suckling on breast produces on breast produces more prolactin, which in turn stimulates more prolactin, which in turn stimulates more milk production. more milk production.

Finally, Finally, oxytocinoxytocin released > delivery of released > delivery of placenta causing mammary glands to placenta causing mammary glands to send milk to nipples [let down reflex]. send milk to nipples [let down reflex].

Progesterone levels drop after delivery Progesterone levels drop after delivery which leads to ↑ milk production.which leads to ↑ milk production.

Anatomy of LactationAnatomy of LactationCColostrum:olostrum: protein, sugar, fat, water, minerals, protein, sugar, fat, water, minerals,

vitamins, maternal antibodies. vitamins, maternal antibodies. Provides total nutrition for infant Provides total nutrition for infant Transitional breast milk by 3 – 4th day. Transitional breast milk by 3 – 4th day. Mature breast milk by 10th day. Mature breast milk by 10th day. Each breast - 15-20 lobes of glandular tissue -Each breast - 15-20 lobes of glandular tissue -

alveoli. alveoli. Acinar or alveolar cells of glands form milk.Acinar or alveolar cells of glands form milk. Each alveolus ends in a ductule.Each alveolus ends in a ductule. Each alveoli produces milk, ejects it into Each alveoli produces milk, ejects it into

ductules aka let down reflex; milk transported ductules aka let down reflex; milk transported to lactiferous sinus and ejected into infant’s to lactiferous sinus and ejected into infant’s mouth.mouth.

Pathway of Droplet of Milk:Pathway of Droplet of Milk:

Milk → mammary ducts → reservoirs behind nipples Milk → mammary ducts → reservoirs behind nipples [lactiferous sinuses] → infant’s mouth[lactiferous sinuses] → infant’s mouth

FForemilk:oremilk: constantly accumulating. constantly accumulating. ““Let-down reflexLet-down reflex” –lets foremilk be available right ” –lets foremilk be available right

away. away. Triggered by sound of baby cryingTriggered by sound of baby crying Hind milk:Hind milk: forms after let-down reflex. Has most forms after let-down reflex. Has most

calories; calories; Feed until breast empty. Feed until breast empty. Breast Milk:Breast Milk: Provides complete nutrition for 1st 6 mos Provides complete nutrition for 1st 6 mos

of life. of life. > 6 months, iron-fortified cereal. > 6 months, iron-fortified cereal. Breast milk easier to digest than formula. Breast milk easier to digest than formula. Iron in breast milk absorbed better than iron in Iron in breast milk absorbed better than iron in

formula. formula.

Supply & Demand ResponseSupply & Demand Response - Every time woman - Every time woman breast breast

feeds, more prolactin produced which then feeds, more prolactin produced which then produces ^milk.produces ^milk.

Time Interval to ↑ milk volumeTime Interval to ↑ milk volume. It takes approx. . It takes approx. 30-60 min. to fill up breast after nursing. 30-60 min. to fill up breast after nursing.

Assessment: Antepartum ChangesAssessment: Antepartum Changes Breasts enlarge [each breast gains ~ 0.5 - 0.9 lb. Breasts enlarge [each breast gains ~ 0.5 - 0.9 lb.

or more]or more] Glands enlargeGlands enlarge Increased blood flow to breasts, causing blood Increased blood flow to breasts, causing blood

vessels to enlarge & become more visible.vessels to enlarge & become more visible. Areola [dark circle around nipple] enlarges and Areola [dark circle around nipple] enlarges and

darkensdarkens Small bumps on areola [Montgomery’s tubercles] Small bumps on areola [Montgomery’s tubercles]

enlarge and produce oils to soften nipples and enlarge and produce oils to soften nipples and keep them clean.keep them clean.

Teach moms no soap on nipples;may ^ irritation.Teach moms no soap on nipples;may ^ irritation. Lanolin; tea bags [wet] [tanic acid] on sore Lanolin; tea bags [wet] [tanic acid] on sore

nipples.nipples.

Common ProblemsCommon Problems::

Engorgement : Engorgement : milk enters on 3rd - 4th day; C/S - prior to milk enters on 3rd - 4th day; C/S - prior to D/CD/C

breasts hard, painful to touch. breasts hard, painful to touch. Warm soaks, hot showers, express milk manually, breast Warm soaks, hot showers, express milk manually, breast

feed q 2-3feed q 2-3 Pumping produces more milk. Cabbage leaves; diuretic Pumping produces more milk. Cabbage leaves; diuretic

propertyproperty. . nursing bra. nursing bra. tight bra and ice packs x 24-36 hrs– tight bra and ice packs x 24-36 hrs– why?why? Analgesics [Tylenol 650 mg. q 4 - 6 hrs.prn]Analgesics [Tylenol 650 mg. q 4 - 6 hrs.prn]

Sore/Cracked/Bleeding Nipples Sore/Cracked/Bleeding Nipples Common - from improper positioning or not enough areola Common - from improper positioning or not enough areola

in infant’s mouth; may continue to feed; up to mom. in infant’s mouth; may continue to feed; up to mom. Reposition infant. Reattempt nursing. Reposition infant. Reattempt nursing.

Rest the nipple; apply lanolin ointment prn.Rest the nipple; apply lanolin ointment prn. Apply tea bag [tanic acid] natural healing property.Apply tea bag [tanic acid] natural healing property.

Plugged DuctPlugged Duct firm nodule under arm; temporarily firm nodule under arm; temporarily

blocked duct; relieved by infant sucking. blocked duct; relieved by infant sucking. Evaluate carefully since may be malignant Evaluate carefully since may be malignant growthgrowth. . Warm compresses prn.Warm compresses prn.

Mastitis – Mastitis – ““inflammation”; milk duct/gland becomes inflammation”; milk duct/gland becomes

infected. Poss. antibiotic therapy. Manual infected. Poss. antibiotic therapy. Manual expression, continue to breast feed, expression, continue to breast feed, frequent warm compresses. frequent warm compresses.

Nursing Care : Nursing Care : Promote successful breast feeding:Promote successful breast feeding:

• Encourage first feeding [L&D, PP; establish pt’s. Encourage first feeding [L&D, PP; establish pt’s. desire to breast feed]desire to breast feed] Emptying of breasts ~ 20 minutes Emptying of breasts ~ 20 minutes • Teach: start on breast where she left off - Teach: start on breast where she left off -

maintains good supply.maintains good supply.• Rest, relaxation, ↑ fluids by four 8 oz glasses/day. Rest, relaxation, ↑ fluids by four 8 oz glasses/day. • Not enough fluids, ^ anxiety may lower milk Not enough fluids, ^ anxiety may lower milk

production.production.• Nutritional Counseling: ^ 500 calories/day. Nutritional Counseling: ^ 500 calories/day.

Health TeachingHealth Teaching Rooting – sign of hungerRooting – sign of hunger Breast feed q 2-3 hrs. for 20-30 minutes Breast feed q 2-3 hrs. for 20-30 minutes Teach “latching”: nipple and part of areola to Teach “latching”: nipple and part of areola to

prevent nipple irritation. Listen for swallowing. prevent nipple irritation. Listen for swallowing. Nursing BraNursing Bra Feeding & Burping [bottle fed infants] upright Feeding & Burping [bottle fed infants] upright

positionposition Nipple care: no soap; nipple creams -LansinohNipple care: no soap; nipple creams -Lansinoh Avoid drugs, alcohol, smokingAvoid drugs, alcohol, smoking

FORMULA FEEDINGFORMULA FEEDING

Feeding SkillsFeeding Skills Position upright position- support head and Position upright position- support head and

shoulders]shoulders] Formula [Similac, Enfamil, Isomil; all have iron] Formula [Similac, Enfamil, Isomil; all have iron] milk or soy basedmilk or soy based Burp Burp Safety TipsSafety Tips never prop bottle; choking or ear infection.never prop bottle; choking or ear infection. ^ amt. ½-3/4 oz./day; feed q 3 – 4 hrs. x 24 hrs.^ amt. ½-3/4 oz./day; feed q 3 – 4 hrs. x 24 hrs.

Discharge Follow up: Discharge Follow up: Telephone calls & home visits [if needed] Telephone calls & home visits [if needed] Help line; Support groups [La Leche]Help line; Support groups [La Leche]

NURSING MANAGEMENT OF POST PARTUM CLIENTNURSING MANAGEMENT OF POST PARTUM CLIENT

Assessment – minimum of twice daily Assessment – minimum of twice daily Vital signsVital signs Emotional Status Emotional Status Breasts Breasts Fundus, lochia, & perineumFundus, lochia, & perineum Voiding & bowel function - flatus, BMVoiding & bowel function - flatus, BM Legs [+ Homan’s sign, ankle edema ]Legs [+ Homan’s sign, ankle edema ] S/S complications [PP hemorrhage, infection, ↑ BP ] S/S complications [PP hemorrhage, infection, ↑ BP ]

Nursing CareNursing CareSafetySafety Prevent hemorrhage- massage uterus on admission and q 4 Prevent hemorrhage- massage uterus on admission and q 4

for first 8 hrs. for first 8 hrs. Prevent falls – assess when getting out of bed for 1st 8 hrs. Prevent falls – assess when getting out of bed for 1st 8 hrs.

Assist when necessary. Check labs for low H&H.Assist when necessary. Check labs for low H&H.

Bowel functionBowel function (1-3 days to resume). (1-3 days to resume). Stool softeners, as ordered [Colace]Stool softeners, as ordered [Colace] Encourage ambulationEncourage ambulation Increase dietary fiberIncrease dietary fiber Provide adequate fluid intake Provide adequate fluid intake

Health teaching & discharge planningHealth teaching & discharge planning Reinforce self care -hand washing, peri Reinforce self care -hand washing, peri

care,care,

Self-breast exam q month; S/S PPDSelf-breast exam q month; S/S PPDComfort MeasuresComfort Measures Ice , Sitz Baths, Topical AnestheticsIce , Sitz Baths, Topical Anesthetics Analgesia, Kegels for NSVD; modified sit-Analgesia, Kegels for NSVD; modified sit-

ups forups for NSVD & C/S, Breast Care NSVD & C/S, Breast Care

Birth Control PlansBirth Control PlansFamily Planning options [condoms, depo, OC’s, IUD]Family Planning options [condoms, depo, OC’s, IUD]ExercisesExercisesKeep 6 week PP appt.Keep 6 week PP appt.

Maternal Warning Signs to ReportMaternal Warning Signs to Report a) Heavy Vaginal Discharge [poss. a) Heavy Vaginal Discharge [poss.

hemorrhage]hemorrhage] b) Pelvic or perineal pain [traveling clot]b) Pelvic or perineal pain [traveling clot] c) Fever [temp 100.4 or greater = c) Fever [temp 100.4 or greater =

infection]infection] d) Burning sensation during urination d) Burning sensation during urination

[UTI][UTI] e) Swollen area on leg ; painful, red, or e) Swollen area on leg ; painful, red, or

hot hot f) Breast: painful, red, hot area [mastitis]f) Breast: painful, red, hot area [mastitis]

Infant careInfant care

a] Bathing, cord care, circumcision care, diaperinga] Bathing, cord care, circumcision care, diapering b] Feeding, burping, scheduling feedings [mom can keep chart]b] Feeding, burping, scheduling feedings [mom can keep chart] c] Temperature, skin color [dusky], newborn rash, jaundicec] Temperature, skin color [dusky], newborn rash, jaundice d] Stool & voiding [BM’s ; 6 or more voids/day]d] Stool & voiding [BM’s ; 6 or more voids/day]e] Back to Sleep [SIDS]e] Back to Sleep [SIDS]

Newborn warning signs:Newborn warning signs: 1. Diarrhea, constipation1. Diarrhea, constipation 2. Colic, repeated vomiting esp. projectile vomiting2. Colic, repeated vomiting esp. projectile vomiting 3. Fever [temp. 100.0 Rectal or greater]3. Fever [temp. 100.0 Rectal or greater] 4. S/S inflammation/ infection @ cord stump [yellow drng.] 4. S/S inflammation/ infection @ cord stump [yellow drng.] 5. Bleeding @ circumcision site 5. Bleeding @ circumcision site 6. Rash, jaundice6. Rash, jaundice 7. Deviation from normal patterns [long period of sleep >5 hrs.; 7. Deviation from normal patterns [long period of sleep >5 hrs.;

projectile projectile vomiting, etc. R/O sepsis; intestinal obstruction] vomiting, etc. R/O sepsis; intestinal obstruction]