Post Natal Care

POST NATAL CARE

Introduction

More than 60% of maternal deaths take place during postpartum period. The first 48 hours are most crucial because Most maternal and neonatal complications are occur during this period. The puerperium is the period beginning after delivery and ending when the woman’s body has returned as closely as possible to its prepregnant state.

The period lasts approximately 6 weeks. The postnatal care starts after the childbirth to 6 weeks

Aims of Postnatal Care

Prevention of sepsis at placental site

Newborn care

Initiation of breast feeding

Nursing Assessment

Immediate Postpartum Assessment. The first 1 hour after delivery of the placenta (fourth stage of labor) is the critical period; post partum hemorrhage is most likely to occur at this time.

Components of Postnatal Care

Postnatal check up includes Pulse, BP, RR. Temp and Pallor. Monitor vital signs every 4 hours during the first 24 hours, then every 8 to 12 hours

BUBBLE-HE is a acronym used to denote the components of the postpartum maternal nursing assessment.

•  B: Breast

•  U: Uterus

•  B: Bladder

•  B: Bowels

•  L: Lochia

•  E: Episiotomy and perineum

•  H: Homan’s

•  E: Emotional status

B- Breast: Assess for breast engorgement and condition of nipples if breast-feeding.

·           Size, Shape, Firmness, Redness, Symmetry

·           Check the Breasts for - nodules, lumps

·            Check the Nipples - assess for eversion, flat, inverted, cracking, bleeding, pain, blisters

·           Individualize teaching for breasts for breastfeeding

·           Check the breasts for signs of engorgement (swollen, tender, tense, shiny breast tissue). If breasts are engorged and the woman is breast-feeding:

•  Allow warm to hot wet towel to cover the breasts and massage to improve comfort.

•  Express some milk manually or by breast pump to improve comport and make nipple more available for infant feeding.

•  Feeding the infant.

•  A mild analgesic may be used to enhance comfort

U: Uterine Assessment

Abdomen : Monitoring of involution process

Check firmness of the fundus at regular intervals.

Palpating the uterine fundus Firm or “Boggy” – not palpable by 10 days.

Ask for “afterpains” (the pain occurs due to uterine contraction towards involution after delivery).

B: Bladder

Observe for the woman’s first void within 6 to 8 hours after delivery.

Palpate the abdomen for bladder distention if the woman is unable to void or complains of fullness after voiding. a. Uterine displacement from the midline suggests bladder distention

 Instruct the woman to void every several hours and after meals to keep her bladder empty.

B: Bowels

Bowels in shock just moved into some strange positions. So plenty of fiber , fluids and Take a stool softener- to avoid harm to the episiotomy or trauma to the C-section incision

L: Lochia

Inspect the perineum regularly for frank bleeding.

•            Note color, amount, and odor of the lochia.

•            Count the number of perineal pads that are saturated in each 8 hour period.

•            Calculate the amount of bleeding

•            Check for lochia (vaginal discharge after delivery)

The Characteristics of Lochia

E: Episiotomy and Perineum

Assess perineal incisions (episiotomy wound) for signs of infection and healing by REEDA Assessment

•  R: Redness

•  E: Edema

•  E: Ecchymosis

•  D: Discharge

•  A: Approximation

Assess for lacerations/edema/hemorrhoids 

Assess for complications/hematoma

Nursing Intervention Sitz Bath: A rotating fluid that moves the water, may fit over the commode or one can be performed with no special equipment using the bathtub other than a bathing ring. Turn tub on and allow drain to open and use a ring for circulating water. It’s very shallow and only bathes the perineal area.

H: Homan’s Sign

•            Assess for Signs of DVT by the Homan’s Sign (Deep Vein Thrombosis)

•            Inspect legs for signs of thromboembolism, and assess Homan’s sign A

•            Positive Homan’s sign is indicative of DVT, although it’s not the most reliable indicator

Performing the Homan’s Test

•            Most commonly performed with the supine position while laying in bed

•            The calf is flexed at a 90° angle

•            The nurse manipulates the foot in a dorsiflexion movement

•            If pain is felt in the calf, the Homan’s Sign is said to be positive

E: Emotional Status

•            Fluctuations in estrogen levels are blamed for the emotional roller-coaster that many moms experience after birth

•            High levels of stress, increased responsibility, and sleep deprivation exacerbate the emotion

•            Bonding refers to the interactions between the mother and baby Caregiving of self and baby is an indicator of emotional status.

Preventing Infection

•            Observe for elevated temperature above 38°C.

•            Evaluate episiotomy/perineum for redness, ecchymosis, edema, discharge (colour, amount, odour) and approximation of the skin.

•            Assess for pain, burning sensation, and frequency of urination.

•            Administer antibiotics as ordered.

Reducing Fatigue

·           Provide a quiet and minimally disturbed environment.

·           Organize nursing care to keep interruptions to a minimum.

·           Encourage the woman to minimize visitors and phone calls.

·           Encourage the woman sleep while the baby is sleeping. (8-10 hours sleep).

·           Early ambulation.

·           Avoid strenuous activities for 6 weeks.

Minimizing Pain

•            Instruct the woman to apply ice packs to the perineal area for the first 24 hours for perineal trauma or edema.

•            Initiate the Sitz bath for perineal discomfort after the first 24 hours. Educate to do three times a day for 15 to 20 minutes.

•            Instruct the woman to contract her buttocks before sitting to reduce perineal discomfort.

•            Assist the woman in the use of positioning cushions and pillows while sitting or lying.

•            Administer pain medication as indicated.

Minor Ailments in Postnatal Period

•            After pains

•            Retention of urine

•            Pain at site of perineum

•            Engorgement of breast

•            Treatment of Anaemia

Postnatal Exercise

•            Pelvic floor exercise

•            Abdominal tightening

•            Pelvic tilting or rocking

•            Hip hitching

•            Foot and Leg Exercise

Immediate postpartum exercises can be performed in bed.

•            Toe Stretch (tightens calf muscles)- While lying on your back, keep your legs straight and point your toes away from you, then pull your legs toward you and point your toes toward your chest. Repeat 10 times.

•            Pelvic  floor  exercise  (tightens  perineal muscles)-Contract your buttocks for the count of 5 and relax. Contract your buttocks and press thighs together for the count of 7 and relax. Contract buttocks, press thighs together, and draw in anus for the count of 10 and relax.

Care of New Born

•            Keeping baby warm

•            Maintain Hygiene

•            Cord care

•            Breast feeding

•            Immunization

Health Education

Postpartum Care and Hygiene

Advise the mother to wash perineum daily and after passing urine and stools. Change perineal pads every 4 - 6 hours. Wash hands frequently and take bath daily.

Nutritional Advice

Increase intake of fluid and food especially iron and protein rich foods like green leafy vegetables, jaggery, lentils, eggs and meat. Increase intake of milk and milk products like curd, cheese etc. Calorie need per day 2200+700 =2900 Kcal Advise adequate rest.

IFA Supplementation

Women with normal Hb are advised to take 1 IFA tablet daily for 3 months. If Hb below 11 gm/dl, advise her to take 2 IFA tabs daily and repeat Hb after 1 month.

Family planning advise

Counsel couple regarding contraception.

Breastfeeding

Advise the mother for exclusive breast feeding on demand, atleast 6 to 8 times during day & 2-3 times during night. Educate that breast feeding is best and Pre-Lacteal feeds must be avoided.

Breast feeding Problems

•            Cracked /sore nipples -Advise the mother to apply hind milk for soothing effect, ensure correct positioning and attachment of baby.

•            Engorged breasts - Advise the mother to continue breast feeding and to put warm compresses.

Registration of Birth

Emphasize the importance of registration of birth with local panchayat.

It is a legal document and it is required for many purposes.

Warning Signs of Puerperium

Advise the mother to report if following symptoms occur

•  Fever, Convulsions

•  Excessive bleeding

•  Severe abdominal pain

•  Difficulty in breathing

•  Foul smelling lochia

Educate about the Immunization for the child

Advise about the importance of postnatal exercises

At 6 weeks following delivery - Ask the mother for the following

Has vaginal bleeding stopped?

Has menstrual cycle returned?

Is there any foul smelling vaginal discharge?

Any problems regarding breast feeding?

Any other complaints?

Give relevant advice & refer to doctor if needed.