POSTPARTUM

COMPETENCY APPRAISAL OB

RLE 2

BUBBLESHE

BREASTS
BY: RYAN AMOR

LACTATION
-Formation of breast milk -Begins in a postpartal woman
DELIVERY OF THE PLACENTA
ESTROGEN AND PROGESTERONE LEVELS

HORMONES
Prolactin- hormone for production
of breast milk

Oxytocin- hormone for excretion or

ejection of milk

COLOSTRUM
-first lacteal secretion
-present at the time of delivery -produced by the 3rd and 4th postpartum day

-yellow sticky fluid more protein, less sugar, less fat than mature milk.

Mature Milk
-Foremilk: watery milk coming from full breast (low in fat, high in carbohydrates)

-Hindmilk: creamy milk coming from a nearly empty breast (rich in fats and calories)

Prolactin

Oxytocin
Contractility of myoepithelial cells

Milk Flow

MILK

LET-DOWN REFLEX

The average amount of milk produced in 24 hours increases with time: -First week- 6-10 oz -1-4 weeks- 20 oz -After 4 weeks- 30 oz

Amount of supply depends on how often the mother nurse or pumps ( the more the mother nurses, the more milk is produced)

Engorgement
-feeling of tension (heat or throbbing pain)

-occurs on the 3rd -4th day

-Due to expanding veins and pressure of new breast milk contained with them

Engorgement management:
-Nurse often (not going more than 3 hours without nursing and not skipping night feedings) -Well-fitted bra -Warm compress/shower -Chilled cabbage leaves (placed on breast with nipple exposed) -Acetaminophen or ibuprofen for pain -Pumping or manually expressing breast milk

BREASTFEEDING
-Feed newborn per demand (breastfeeding or bottlefeeding) -at least every two hours and intervals should not exceed 5 hours

-From birth to at least 2 years

-Exclusive breastfeeding until 6 months of age -Correct latching on -Large part of the breast and areola need to enter the babys mouth -Nipple should be at the back of the babys throat with the babys tongue lying flat in its mouth

Latching On

-10-20 minutes each breast

-Cradling position
-Oral contraceptives are contraindicated in lactating mothers

BREAST CARE:
-Wash breast daily at bath or shower time
-Soap or alcohol should never be used on the breast -Wash hands before and after every feeding -Insert clean OS squares or piece of cloth in the brassiere

ABNORMAL FINDINGS Mastitis

-Inflammation of the breast -Staphylococcus aureus or Haemophilus parainfluenzae from the infants nose and throat. Candida albicans is another cause. -Usually occurs in the 2nd or 4th week of pregnancy. -Contributing factors include clogged milk ducts, lowered maternal defences due to fatigue or stress, unclean hands, and cracked or fissured nipples. -A breast abscess may be a complication.

MASTITIS

Nursing Assessment:
-Examine the breast for localized redness, tenderness, and swelling -Inspect nipple for fissures or cracks -Assess mothers general physical status. -Assess mothers dietary and sleep patterns and level of stress. -Assess feeding history for precipitating factors such as ineffective emptying of breasts, engorgement -Inspect babys mouth for white patches surrounded by redness on the buccal membrane

Nursing Interventions:
-Handwashing technique -Handwashing before handling breasts or nipples, cleansing of breast with water only, wearing supportive bra at all times and changing bra and breast pads frequently -Reinforce mothers knowledge about breastfeeding techniques -Administer oral antifungals as ordered and pain medications usually before breastfeeding -Teach mother to increase feeding frequency, increase fluid intake, be on bed rest

Nipple inversion

Inverted nipples appear to be indented in your areola, instead of standing up above the surface of your breast. Nursing management: -Roll the nipple gently between the fingertips to increase protractility -Use special breast shields such as woolrich -Use hand to shape nipple when beginning to nurse -Apply ice for a few minutes prior to feeding to improve nipple erection

Inadequate letdown
-Massage breasts prior to nursing -Feed in a quiet, private place, away from distraction -Take a warm shower before nursing to relax and stimulate letdown

Nipple soreness
-Ensure that infant is correctly positioned at the breast with the infants ear, shoulder and hip in straight alignment -Rotate breastfeeding positions

Involution of the uterus

Reduction in size of uterus and return to it

prepregnant size Enhanced by:

Uncomplicated birth Breastfeeding Early ambulation

After expulsion of placenta, uterus is contracted.

Grapefruit size Located midway between symphysis and

umbilicus

Involution of the uterus. A, Immediately after delivery of the placenta, the fundus is midline and halfway between the symphysis pubis and the umbilicus. B, About 6 to 12 hours after birth, the fundus is at the level of the umbilicus. It then descends one finger breadth (approximately 1 cm) each day.

Stays at the level of umilicus for 1 day, then decrease in size about 1 finger breatdth/day. Within 10 days to 2 weeks it is again a pelvic organ Placental site takes up to 6 weeks to heal.

Displacement: full bladder

Let the patient void to avoid pressure on uterus

Not firm fundus: boggy

-Full bladder, presence of clots or diminished

contractility in multigravidas

Massage fundus gently until firm If uterus does not contract, massage more vigorously

FIGURE 236 Measurement of descent of fundus for the woman with vaginal birth. The fundus is located two finger-breadths below the umbilicus. Always support the bottom of the uterus during any assessment of the fundus.

If bogginess remains or returns, notify physician. Note height of uterus in reltaion to umbilicus
Eg. Uterus firm, in the midline 1FB (up arrow) U

Bladder

Marked diuresis to eliminate excess fluids

(Urine output from 1500ml/day to as much as 3000ml/day

2nd-5th after birth)

Difficulty voiding

Abdominal pressure and trauma to trigone of the bladder Dec. bladder sensation Use of anesthesia agents during birth Increased bladder capacity

Assess voiding frequency, burning, or urgency

At least 250-300 ml every 4-6 hrs Ask symptoms of urinary tract infection *urgency,

frequency, dysuria

Adequate fluid intake Voiding may be initiated by:

Pouring warm and cool water alternately over the

vulva Encourage the client to go to the comfort room Let her listen to the sound of running water If these measures fail, catheterization, done gently and aseptically, is the last resort on doctors order. (if there is resistance to the catheter when it reaches the internal sphincter, ask patient to breathe through the mouth while rotating the catheter before moving it inward again.)

Bowel Elimination
Constipation: delayed bowel evacuation post partially may be due to:
1. 2. 3. 4. 5. Decrease muscle tone Lack of food during labor Administration of enema prior to labor Dehydration Fear of pain from perineal tenderness due to episiotomy, lacerations, or hemorrhoids NSD: Normally last for a day or two C-section: Will reach up to 3 to 4 days

Bowel Elimination
Teachings for preventing and easing constipation Do not ignore the urge to move your bowels Eat high-fiber foods such as whole-grain, beans, fresh fruits and vegetables

Bowel Elimination
6 - 8 glasses of water and/or especially prune juice Ambulate or exercise

Bowel Elimination
Stool Softeners

Lochia Discharge
Uterine discharge consisting of blood, deciduas, WBC, mucus and some bacteria. It should approximate menstrual flow. Increases with activity and decreases with breastfeeding.

Musty, stale odor but not offensive Any fowl smell indicated infections Is about 225ml, amount decreases each passing day

Lochia Discharge
Discharge is greater in the morning because of pooling in the vagina and uterus while sleeping Multiparous mothers have more lochia than primi gravida

Less amount for those who underwent cesarean birth

Lochia Discharge
Types of Lochia 1.) Lochia Rubra Dark red in color within first 23days Epithelial cells, erythrocytes, leukocytes, and deciduas Human Odor 3.) Lochia Alba 2.) Lochia Serosa Pinkish to brownish discharge Colorless to creamy within 4 - 9 days yellowish discharge Serosanguineous discharge, occurring from 10 days to 3 erythrocytes, leukocytes, cervical weeks after delivery mucus Leukocytes, deciduas, Odorless epithelial cells, cervical mucus, cholesterol crystal and bacteria Strong odor due to bacteria

Evaluation Lochia Discharge

Scant - Perineal pad stains less than 1 - 2 inch in length after 1 hour Small (light) Perineal pad stain less than 4 inches in length after 1 hour, 10 - 25ml lochia Moderate - Perineal pad has a stain less than 6 inches in length within 1 hour, 25 to 50ml lochia

Heavy - Perineal pad has a stain larger than 6 inches in length within 1 hour, 50 to 80ml lochia

Episiotomy/Perineum
Appears edematous and bruised after delivery caused by episiotomy and some degree of laceration
Assessment of infection and inflammation REEDA (Redness, edema, ecchymosis, discharge, approximation of sutures) Prevention of lacerations Massage Warm Compress Manual Support (Ritgens Maneuver) Birthing in a lateral position

Episiotomy/Perineum
Assessment of Laceration

1st degree - lacerations extend through the skin and superficial layers of the perineum 2nd degree - through perineal muscles 3rd degree - through anal sphincters 4th degree - through anterior rectal wall (damaging to the perineum)

QuickTime and a decompressor are needed to see this picture.

Episiotomy/Perineum
To Relieve Pain Sims Position - Minimizes strain on the suture line Perineal heat lamp or warm sitz bath - vasodilates and increases blood supply and therefore promotes healing Ice or cold therapy immediately after delivery to decrease edema and provide anesthesia, therefore apply moist or dry heat therapy to promote comfort and healing Topical or Oral Analgesics

SKIN

Chloasma

fades completely months after giving birth avoid prolonged exposure to sunlight

SKIN

Stretch marks

scarring on the skin with an off-color hue become lighter in color but may not disappear completely

HOMANS SIGN
Increased risk for thrombophlebitis, thrombus formation and inflammation involving a vein Assess for Homans sign

(+) calf pain = (+) Homans sign

HOMANS SIGN

Management:

Low-dose heparin Early ambulation Avoid crossing legs, constrictive clothing/undergarment

EMOTIONAL

Rubins (1997) three stages of Psychological Adaptation

Taking-In

1-2 days after delivery energy is focused on bodily concerns mother must have adequate rest and uninterrupted sleep 2-4 days after delivery concerned with ability to parent successfully and to accept new responsibilities focused on regaining control over bodily functions masters newborn skills

Taking-Hold

EMOTIONAL

Letting Go
after new mother returns home redefines new role gives up fantasized image of child and accepts her real child

EMOTIONAL

Maternal-Infant Bonding

Emotional connection between mother and child

Positive attachment: touching, kissing, holding, cuddling, talking and singing, expressing pride in the infant

EMOTIONAL

Malattachment behaviors vary but may include:

refusing to look at the infant refusing to touch or hold the infant refusing to name the infant has negative comments about the infant refusing to respond or negatively responds to infants cues

EMOTIONAL

Postpartum Blues

baby blues, normal part of postpartum experience, but lasts only for a few days manifested by tearfulness, irritability, insomnia due hormonal fluctuations
a serious & debilitating depression, occurring within first 9 months after delivery, often within the initial weeks or months

Postpartum Depression