IX.

CARE OF POST PARTAL MOTHER

Postpartum care encompasses management of the mother, newborn, and infant during the postpartal period. This period usually is considered to be the first few days after delivery, but technically it includes the sixweek period after childbirth up to the mother's postpartum check-up with her health care provider. 1. Post partum hemorrhage Postpartum hemorrhage is defined as excessive blood loss during or after the third stage of labor. The average blood loss is 500 mL at vaginal delivery and 1000 mL at cesarean section. It is also defined as a 10% change in hematocrit between admission and postpartum or the need for transfusion after delivery secondary to blood loss. Early postpartum hemorrhage is described as that occurring within the first 24 hours after delivery. Late postpartum hemorrhage most frequently occurs 1-2 weeks after delivery. The immediate postpartum period occurs most often in the hospital setting, where the majority of women remain in the hospital approximately 2 days after a vaginal delivery and 3-5 days after a cesarean section. During this time, women are recovering from their delivery, as well as beginning to care for the newborn. This period is used both to make sure the mother is stable and to educate her in the care of her baby, especially the first-time mother. While still in the hospital, the mother is monitored for blood loss, signs of infection, abnormal blood pressure, contraction of the uterus, and the ability to void. 2. Post partum infection a. Mastitis - Mastitis is an inflammation of the breast or mammary gland usually caused by streptococcal or staphylococcal infection or staphylococcus aureaus. Staphylococcus aureaus is found on the hands or in the mouths of infants. Bacteria can enter through cracked nipples caused by improper latch-on during breastfeeding. It can be developed due to blocked milk ducts and milk stasis in the breastfeeding clients. Blocked milk ducts and milk stasis occurs as a result of improper latching and inadequate breast emptying. Symptoms of mastitis often mimic

those of the flu and include body aches and a fever of 101F (38.6C) or more. - Both milk stasis and cracked nipples, which contribute to the influx of skin flora, are the underlying factors associated with the development of mastitis. The most common causative organism, isolated in approximately one half of all cases, is Staphylococcus aureus. - Treatment : Milk stasis sets the stage for the development of mastitis, which can be treated with moist heat, massage, fluids, rest, proper positioning of the infant during nursing, nursing or manual expression of milk, and analgesics. - Mastitis does not contaminate the breast milk, and the baby should continue to nurse from both breasts. If nursing from the affected breast is too painful, use of a breast pump or manual expression of milk may be needed to prevent engorgement and facilitate continued milk production. b. Endometritis - It is an inflammation of the endometrium, the mucous membrane lining the uterus. It is usually caused by a bacterial infection. Symptoms of this infection include fever, abdominal pain, and foulsmelling vaginal discharge. Physical examination of the patient reveals a tender uterus. Endometritis is treated with a course of antibiotics and other care, including bed rest, acetaminophen for pain and fever relief, and increased fluid intake. Severe cases may require hospitalization. - Endometritis is an ascending polymicrobial infection. The causative agents usually are normal vaginal flora or enteric bacteria. Endometritis is the primary cause of postpartum infection. Endometritis occurring on postpartum day 1 or 2 most frequently is caused by group A Streptococcus. If the infection develops on day 3 or 4, the causative organism frequently is enteric bacteria, most commonly E coli, or anaerobic bacteria. Endometritis that develops more than 7 days after delivery most frequently is caused by Chlamydia trachomatis. Endometritis following cesarean section most frequently is caused by anaerobic gram-negative bacilli, specifically Bacteroides species.

Known risk factors for endometritis include cesarean section, young age, low socioeconomic status, prolonged labor, prolonged rupture of membranes, multiple vaginal exams, placement of an intrauterine catheter, preexisting infection or colonization of the lower genital tract, twin delivery, and manual removal of the placenta. Symptoms: fever, chills, lower abdominal pain, foul smelling lochia, increased vaginal bleeding, anorexia, and malaise. Endometritis is an infection of the uterus characterized by uterine subinvolution, infection, abdominal cramps, and purulent, foulsmelling lochia. It is caused by the bacteria normally present in the uterus and cervix, such as E. coli and group B streptococcus. Manual removal of the placenta, multiple vaginal examinations during labor, C-sections, premature rupture of members, and internal fetal and/or uterine monitoring predispose clients to developing endometritis. 3. Post Partum Pain During the postpartum period, it is very important that healthcare providers continually assess a client for pain, taking into account the client's acceptable pain levels. They should look for pain in all areas of the body, including the head, chest, breast, back, limbs, abdomen, uterus, perineum, and extremities. Positioning during labor may cause muscular discomfort, and headaches can indicate gestational hypertension. Clients should also be assessed for emotional pain and treated accordingly. Mild analgesics or narcotics may be prescribed. Providers can also teach nonpharmacologic methods of pain relief to the client and her family. Some of these methods include the application of hot or cold packs, massage, progressive relaxation, and meditation.

a. Headache b. Involution c. Bladder Elimination 4. Vaginal Discharge (Lochias) The color and amount of vaginal discharge (lochia) is assessed by frequently removing the perineal pad and checking the flow of lochia after delivery. An excessive amount could be a sign of a

complication such as clot formation or a retained portion of the placenta. The vaginal discharge is red for one to three days following delivery and is called lochia rubra. Between days two and 10, the discharge changes to a pink or brownish color and is called lochia serosa. The last phase occurs when the vaginal discharge turns white. This vaginal discharge is referred to as lochia alba and may occur from 10-14 days postpartum. The spotting can continue for another six weeks. It is common in mothers who breastfeed their babies. A constant trickling of blood or the soaking through of a perineal pad in an hour or less is not normal and should be further evaluated. 5. Vital Signs -During the postpartum period, clients may exhibit a slight temperature elevation due to dehydration following delivery or as a result of breast milk coming in around day 3 or 4. Immediately after delivery, the blood pressure should remain the same as during delivery. An increase in blood pressure could indicate gestational hypertension (previously referred to as pregnancyinduced hypertension), while a decrease could indicate shock or orthostatic hypotension. Slight bradycardia is normal immediately after delivery; however, tachycardia could indicate hemorrhage or infection and should be monitored carefully. Respirations are usually within the normal range for an adult. 6. Blood pressure

7. Episiotomy An episiotomy is a surgical incision made along the perineum - the area of skin and muscle between the vagina and rectum - to aid in the safe delivery of your child or to simply speed delivery. Indications

There is a serious risk to the mother of second or third degree tearing In cases where a natural delivery is adversely affected, but a Caesarean section is not indicated 'Natural' tearing will cause an increased risk of maternal disease being vertically transmitted The baby is very large When perineal muscles are excessively rigid

When instrumental delivery is indicated When a woman has undergone FGM (female genital mutilation), indicating the need for an anterior and or mediolateral episiotomy Prolonged late decelerations or fetal bradycardia during active pushing The baby's shoulders are stuck (shoulder dystocia), or a bony association (Note that the episiotomy does not directly resolve this problem, but it is indicated to allow the operator more room to perform maneuvers to free shoulders from the pelvis)

There are four main types of episiotomy: Medio-lateral: The incision is made downward and outward from midpoint of fourchette either to right or left. It is directed diagonally in straight line which runs about 2.5 cm away from the anus (midpoint between anus and ischial tuberosity). Median: The incision commences from center of the fourchette and extends on posterios side along midline for 2.5 cm. Lateral: The incision starts from about 1 cm away from the center of fourchette and extends laterally. Drawback include chance of injury to Bartholin's duct. Thus some practiotioners have totally condemned it. 'J' shaped: The incision begins in the center of the fourchette and is directed posteriorly along midline for about 1.5 cm and then directed downwards and outwards along 5 or 7 o'clock position to avoid the anal sphincter. This is also not done widely.

8. Laceration A laceration is an injury that results in an irregular break in the skin, more commonly referred to as a cut, but defined as a torn and ragged wound. There are five general types of lacerations: Split laceration: This type of wound is caused when part of the body is crushed between two objects. While not as serious and a crush injury, a split laceration is caused in the same manner, with the striking object making a blunt impact and causing the skin and tissues to tear from compression. Split lacerations most commonly show up on the face, head, hands and legs.

Over-stretching: This would is typically caused by a single, angular force that strikes the skin and either pushes or pulls the skin, causing it to stretch and break. An example of an over-stretching wound would be a gunshot. As a bullet pierces the skin at an angle and continues underneath, it will lodge beneath the skin and cause compression and expansion that will tear the skin beyond the initial point of impact. Grinding compression: When an object strikes the skin with a blunt impact at either an angle or with a sweeping motion, the resulting laceration is a grinding compression. In the same manner that a potato is peeled, a persons skin is essentially peeled back when this type of laceration occurs. As the object strikes the skin, the tissue is crushed beneath the epidermis and the top layer of skin peels away. Cut laceration: The most common type of laceration, a cut occurs when any type of blade (knife, ax, scissors, etc.) comes into contact with the skin, causing a break of the skin and possibly the underlying tissue. Tearing: Just as the name implies, this type of laceration occurs when the skin is broken by an object and the break is ripped due to pressure pushing the wound in two different directions, essentially causing the skin to tear like a piece of paper.

9. Relief of Perinial Pain or Discomfort Perinial Pain is a soreness around the vaginal opening, the rectum, and the site of an episiotomy or a vaginal tear. The degree of pain and discomfort from incisions, lacerations, and uterine cramping (afterbirth pains) is assessed by hospital staff. The woman may also complain of muscle pain after a prolonged labor. If the level of pain warrants it, analgesic medications are given, usually orally. Women who have undergone cesarean births may have more pain than women who have given birth vaginally, and may need injectable analgesics. If a woman complains of pain in her calf, she should be evaluated for thrombophlebitis. Also, if a woman complains of a headache, her blood pressure should be checked to rule out the presence of pregnancy-induced hypertension. A woman who received epidural anesthesia during delivery may develop a "spinal headache." A spinal headache is due to the loss of cerebrospinal fluid from the subarachnoid space that

may occur during the administration of the spinal anesthesia. Spinal headaches should be treated by the anesthesiologist or nurse-anesthetist. Treatment for this type of headache typically includes keeping the patient flat in bed, encouraging increased fluid intake, and administering pain medication. What You Can Do About Perinial Pain:

Let yourself heal. That means, hands off! If you're constantly "testing" how the site's healing by touching it, it's going to take longer to get better. Ice can ease the swelling. Try chilled witch hazel pads, a surgical glove filled with crushed ice, or a maxi-pad with a cold pack. Heat can also soothe some of the discomfort. A warm sitz bath for 20 minutes, three times a day, or warm compresses are a good place to start. Heat lamp exposure is another one to try, but do this only after getting a physician's advice. Kegel exercises stimulate circulation and help you heal faster. They're great for muscle tone, too. Do them as soon as you can after delivery even if you can't feel yourself doing it (you probably won't right away). Your practitioner may recommend an anesthetic to numb the area. They come in all forms, from sprays to ointments to pads. Avoid activities that could cause strain. Sleep on your side, and try not to stand or sit for long periods of time, which can up perineal pain. Doughnut-shaped pillows that are marketed for hemorrhoid sufferers could give you some comfort while you sit. (If you had hemorrhoids during pregnancy and are still recovering, you can kill two pains with one pillow.) If difficult bowel movements are a problem (the problem being you're dreading the pain of passing them), drink lots of fluids. You can also try eating more fiber, which will give you less strain, more gain. Or ask your practitioner about a stool softener or mild laxative for constipation during pregnancy.

10. Breast Enlargement, Crack Nipples, Inverted Nipples Breast engorgement is characterized by low-grade fever and the absence of systemic symptoms. It is usually bilateral; the breasts feel warm to the touch and appear shiny. Pain from breast engorgement can be minimized for the breastfeeding mother by mild analgesics, the application of warm packs, and frequent nursing. For the mother who is not breastfeeding, this pain can be

minimized by mild analgesics and the application of cold packs. A nursing mother may find that the use of a lanolin-based preparation or a nipple shield (although controversial) provides relief for sore or cracked nipples. Changing positions for the nursing baby also can help in reducing irritation and minimizing stress on sore spots. A plugged duct can also cause breast pain. Breast pain caused by a plugged duct is distinguished from breast engorgement by the fact that it is usually confined to one breast and the breast is not warm to the touch. This pain may be relieved by heat packs, gentle massage of the breast toward the nipple, and changing positions for nursing the baby.

11. Post Partum Depression Postpartum depression is a more serious condition that affects between 8 - 20% of women after pregnancy, especially the first 4 weeks. It is necessary to seek medical attention to treat postpartum depression. A pregnant woman may have a higher chance of postpartum depression if:

Are under age 20 Currently abuse alcohol, take illegal substances, or smoke (these are also serious medical health risks for the baby) Did not plan the pregnancy or do not want the pregnancy Had a mood or anxiety disorder prior to pregnancy, including depression with a previous pregnancy Had something stressful happened to you during the pregnancy, including illness, death or illness of a loved one, a difficult or emergency delivery, premature delivery, or illness or abnormality in the baby Have a close family member who has had depression or anxiety Have a poor relationship with your husband, boyfriend, or significant other or are unmarried Have financial problems (low income, poor housing) Have little support from family, friends, and a significant other Previously attempted suicide Received poor support from your parents in childhood

Signs and Symptoms of Postpartum Depression

Lack of interest in the baby

Negative feelings towards the baby Worrying about hurting the baby Lack of concern for yourself Loss of pleasure Lack of energy and motivation Feelings of worthless and guilt Changes in appetite or weight Sleeping more or less than usual Recurrent thoughts of death or suicide a. Post partal Blues
-A state of sadness or an emotional effect of childbirth

experienced by mothers, consisting mainly of transient feelings of sadness for a period of about 72 hours b. Post Partal Psychosis -Also known as puerperal psychosis. It is a term that covers a group of mental illnesses with the sudden onset of psychotic symptoms following childbirth. It is characterized by loss of contact with reality. Symptoms of postpartum psychosis can include:

Delusions or strange beliefs Hallucinations (seeing or hearing things that arent there) Feeling very irritated Hyperactivity Decreased need for or inability to sleep Paranoia and suspiciousness Rapid mood swings Difficulty communicating at times Suicidal thoughts or actions Bizarre behavior Thoughts of harming or killing the baby

Postpartum depression is usually treated with counseling and medication. Nurses can support these clients in the healing process at follow-up appointments and during home visits. Driscoll (2006) recommends that nurses help clients and their families understand postpartum depression and assist them in exploring the spiritual aspects of their suffering as an aid in the healing process. Additionally, nurses

should encourage these clients to get adequate nutrition, rest, relaxation, and exercise.