Assessment of postnatal women

Assessment of postnatal women

1. Assessment of postnatal women Neethu s s First year MSc nursing

2. definition PUERPERIUM Puerperium is the period following childbirth during which the body tissues, especially the pelvic organs revert back approximately to the prepregnant state both anatomically and physiologically.

3. Involution is the process whereby the genital organs revert back approximately to the state as they were before pregnancy. The women is termed as puerpera . DURATION: Puerperium begins as soon as the placenta is expelled and lasts for approximately 6 weeks when the uterus becomes regressed almost to the nonpregnant size.

4. The period is arbitrarily divided into 1.immediate - within 24 hour 2.early – up to 7 days 3.remote – up to 6 weeks

5. NURSING ASSESSMENT PHYSIOLOGICAL POSTPARTUM ASSESSMENT FOCUSES ON: The involution processes of the reproductive organs Biophysical changes of other body systems The initiation or suppression of lactation

6. Psychosocial assessment focuses on: The mother's emotional state and response to the birth experience Interactions with the newborn Newborn feeding Adjustment to the caretaking role and to new family relationships Progress in learning self-care incorporation of the newborn into the family

7. Schedule of postpartum physiologic assessments A REA ASSESSED F REQUENCY Temperature   1 st hour after delivery: once 2 nd – 8 th hour: twice 9 th – 24 th hour : every 4 h 24 th hour to discharge: every 8 h Pulse, respiration and blood pressure 1 st hour after delivery: every 15 min 2 nd – 3 rd hour: every 30 min 4 th – 24 th hour: every 4 h 24 th hour to discharge: every 8 h Fundus, lochia, bladder 1 st hour after delivery: every 15 min 2 nd – 3 rd hour: every 30 min 4 th – 24 th hour: every 4 h 24 th hour to discharge: every 8 h Perineum 1 st hour after delivery: once 2 nd – 24 th hour: every 4 h 24 th hour to discharge: every 8 h Breasts, legs 1 st – 8 th hour: once at end of 8 th h 9 th – 24 th hour : every 4 h 24 th hour to discharge: every 8 h Bowel elimination 9 th hour to discharge: daily stool

8. Early postpartum period a chart review; interval history, including physical, psychological, and emotional changes since the birth physical examination, including observation of family interactions management plans that focus on treatments for symptoms and conditions of the puerperium, follow-up visit plans, and health education .  

9. CLINICAL ASSESSMENT OF PARENT'S INTERACTION WITH NEWBORN Uses gentle touch with newborn   Positions infant for face-to-face interaction   Directs gaze toward newborn when interacting   Makes visual contact   Displays range of facial expressions   Verbalizes to newborn    Makes positive, affirming, loving comments to the newborn; avoids making disparaging comments   Modulates interaction in response to newborn's cues   Elicits verbalizations and behaviors from the newborn and responds contingently   Responds to newborn's distress  

10. Physical examination The examination during the early postpartum period is focused on the physiologic changes that occur after birth. It is important to ensure privacy is maintained according to the woman's wishes. A comfortable location for the exam should be used, and pillows for support may be helpful. Because the woman may have an expected level of discomfort during the exam, a gentle touch should be used and permission requested before examining any part of her body. Physical assessments during the early puerperium include the heart, lungs, breasts, abdomen, perineum and anus, and lower extremities. The midwife may provide teaching about the physiologic changes of the puerperium during the examination.

11. Heart And Lungs The examination of the heart and lungs during the early puerperium is performed in the same manner as when the woman is not pregnant or postpartum

12. Breasts ASSESS Size , shape, fullness Consistency –Soft - Filling (increasing firmness or slightly enlarged) - Engorged (enlarged, hard, reddened, shiny) Colour Symmetry Tenderness Express colostrum Primary and secondary areola Soft swelling in axilla indicate accessory mammary tissue

13. ABDOMEN Examination of abdomen begins with uterus Assess INVOLUTION OF UTERUS by noting fundal height. Take measurement at a fixed time every day. Following delivery, the fundus lies about 13.5 cm   (51/2") above the symphysis pubis. During the first 24 hours, the level remains constant Thereafter, there is  a steady decrease in height by 1.25 cm (0.5”) in 24 hours By the end of 2 nd week the uterus becomes a pelvic organ. The rate of involution thereafter slows down until by 6 weeks, the uterus becomes almost normal in size. While palpating the consistency of fundus should be a round, smooth shape. A soft or boggy fundus indicates atony or subinvoluion . The bladder should be empty for accurate fundal assessment; a full bladder displaces the uterus and rises the height of the fundus .

14. Bladder The woman is encouraged to void as soon as following delivery to avoid bladder distention. Even with full bladder, the newly postpartum women may not experience an urge to void. This decreased perception  of bladder fullness is due to increased bladder  capacity resulting from reduced intra-abdominal pressure, edema of the trigone area at the base Of the bladder resulting from trauma, and impaired transmission of afferent neural impulses due to regional anesthesia. The bladder may fill rapidly after delivery if the woman received intravenous fluids during labor and because of increased physiologic urinary output in the early postpartum period.   The nurse assesses the condition of the bladder by abdominal palpation, percussion, and observation. The contour of the abdomen, height and consistency of the fundus, and characteristics of the suprapubic area are assessed. 

15. lo chia The character and amount of lochia indirectly indicate the progress of endometrial healing. In normal healing processes. The amount of lochia gradually diminishes with typical color changes that reflect decreasing blood components in the  lochial  flow. The quantity of lochia varies with individuals and is generally more profuse in multiparas. The amount of lochia may increase on early ambulation because of vaginal pooling and increased   uterine contractions .

16. TYPES OF LOCHIA Lochia rubra – first 1 to 3 days – red in colour Lochia serosa – 4 to 10 days – serous and pink Lochia alba – 10 days to 3 weeks –yellowish white in colour

17. Lochia is dark red (lochia rubra) in the first 1-3 days after delivery and is usually moderate in amount. Scant: less than 2.5 cm on menstrual pad in 1 hour Light: less than 10 cm on menstrual pad in 1 hour Moderate: less than 15 cm on menstrual pad in 1 hour Heavy: saturated menstrual pad in 1 hour Excessive: menstrual pad saturated in 15 minutes

18. Lochia smells similar to normal menstrual flow and should not have a foul or disagreeable odor. Heavy, persistent, and malodorous lochia rubra, especially if accompanied by fever, indicates a potential infection or retained placental fragments. If lochia serosa or alba continues beyond the normal time ranges and is accompanied by brownish malodorous discharge, fever, and abdominal pain, the woman may have endometritis.  

19. Lacerations may be: First degree: through skin and structures that are superficial to muscles Second degree: extends through perineal muscles Third degree: continues through anal sphincter muscle Fourth degree: extends through the anterior rectal mucosa, exposing the rectal lumen

20. Lower extrimities Assess for Size Shape Colour Edema Symmetry Varicosities Temperature and swelling Thrombophlebitis-unilateral swelling, redness, heat and calf muscle tenderness Homan’s sign-presence of calf pain with active dorsiflexion Femoral vein thrombosis-pain and tenderness in the distal thigh and popliteal region Lower extrimities pulses

21. Laboratory tests To assess for anemia, a complete blood count, hematocrit, or hemoglobin is done 24—48 hours after delivery. Blood values change postpartum due to many physiologic adaptations as the woman returns to a nonpregnant state. With an average blood loss of 400—500 mL, a drop of 1 g in hemoglobin level or 3% in hematocrit value is within the expected range. Larger decreases in these values result from heavy bleeding at delivery, hemorrhage, or antenatal anemia. During the first 10 days postpartum, the white blood count may increase to 20,000/mm 3  before returning to normal values (Bond, 1993). Because the cellular components of this leukocytosis are similar to those during an infection, this increase may conceal an infectious process unless the white blood count is higher than physiologic levels.  

22. ASSESSMENT OF POSTPARTUM RISK FACTORS Assess for risk factors of postpartum complications: Multipara Multiple pregnancy Hydramnios A large newborn Prolonged labour Lacerations of cervix, vagina or perineum High risk pregnancies a

23. Psychosocial assessment- family dynamics Assessment of emotional, behavioural, and social factors in the postpartum periods allows the nurse to identify the mother’s and family’s needs for support, teaching, and anticipatory guidance; their response to the childbearing experience and postpartum care; and factors affecting the assumption of new parenting responsibilities. The nurse also assesses the mother’s knowledge and abilities related to self- care, new born care, and health maintenance and feelings about herself and her body image .

24. Psychologic changes Role change is an important psychological change for the mother The mother must relinquish other roles and take on the role of mother New mothers typically progress through a series of developmental stages. The rate of progression through these stages is unique to each mother. Dependent and taking-in phase of mother Increase in dependent behaviour ; wants care for herself Asks many questions and talk a great deal about delivery experience Might be the only phase observed by nurse during hospitalization because of the trend toward a shortened inpatient stay for obstetric patients without complications

25. Dependent-independent or “taking-hold” phase of mother Begins to focus on needs of infant Relinquishes pregnant role Takes on maternal role Is interested in learning to care for infant Experiences a period of high fatigue and increased demands by infant Might experience baby blues at 3 to 4 days postpartum during this phase Is typically in this phase 4 to 5 weeks

26. Interdependent, or letting- go phase of mother Lets go of perception of infant as extension of herself, and views infant as separate Refocuses on relationship with partner Might return to work and relinquish part of child care to other caretakers

27. 2.Attachment Attachment is an emotional tie between two people that endures over time and involves close proximity and contact with each other Attachment is described by health care professionals as the interactive behaviours between infants and their caregivers in their large surroundings The mother infant bond is the basis on which all subsequent attachments are formed and plays a major role in the infants developing sense of self Maternal attachment to the infant begins in utero due to fetal movements and maternal fantasies about the infant

28. 3.Baby blues Baby blues or postpartum blues are described as a mild, transient mood disturbance that frequently begins on the third postpartum day and can last up to 10 days. Symptoms lasting longer than 10 days should be evaluated by health care providers Approximately 50% to 75% of women experience baby blues during postpartum The onset of postpartum blues coincides with the normal physiologic drop in estrogen and progesterone, and this, along with fatigue, may be a possible cause of this emotional change.

29. Also assess 1.reaction to child birth process - review of birth experience - self evaluation 2.Adaptation to parenting and care taking -adaptive and mal adaptive behaviour of both parents 3.cultural variations

30. Kristin P. Tully PhD ,  Alison M. Stuebe  MD, MSc  and  Sarah B. Verbiest  DrPH, MSW, MPH American Journal of Obstetrics and Gynecology , 2017-07-01, Volume 217, Issue 1, Pages 37-41, Copyright © 2017 Elsevier Inc. An online national survey of 1072 postpartum women found that women struggled with a variety of new health problems in the first 2 months after birth related to adjusting to the demands of motherhood.  These problems are extraordinarily common, affecting up to half of the 4 million US women who give birth each year, but treatment is uneven, and health care is often fragmented. 

31. Early intervention to protect the mother-infant relationship following postnatal depression: study protocol for a randomised controlled trial Jeannette Milgrom  &  Charlene Holt   Trials   volume 15 , Article number: 385 (2014)  Cite this article 6111  Accesses 19  Citations 1  Altmetric Metricsdetails At least 13% of mothers experience depression in the first postnatal year, with accompanying feelings of despair and a range of debilitating symptoms. Serious sequelae include disturbances in the mother-infant relationship and poor long-term cognitive and behavioural outcomes for the child. Surprisingly, treatment of maternal symptoms of postnatal depression does not improve the mother-infant relationship for a majority of women. Targeted interventions to improve the mother-infant relationship following postnatal depression are scarce and, of those that exist, the majority are not evaluated in randomised controlled trials. This study aims to evaluate a brief targeted mother-infant intervention, to follow cognitive behavioural therapy treatment of postnatal depression, which has the potential to improve developmental outcomes of children of depressed mother

32. To encourage use of skin-to-skin contact with all healthy term infants during the first two hours of life and throughout their mothers’ postpartum hospitalization, an easy, rapid newborn assessment tool, the “RAPP”, has been developed to enhance labor and delivery and mother-baby nurses’ ability to swiftly and accurately assess newborn physiologic condition. The “RAPP” assessment (respiratory activity, perfusion, and position) tool is being proposed as a way to swiftly evaluate infants’ physiologic condition and position. Position of the infant is a key factor in minimizing risk of Sudden Unexpected Postnatal Collapse (SUPC). SUPC is an emerging complication of skin-to-skin contact and breastfeeding in the first hours and days post-birth. The “RAPP” assessment parameters and flow sheet are discussed, risk factors for SUPC are enumerated, and a checklist to prevent SUPC is presented so skin-to-skin contact can be safely provided. Infant  assessment  and reduction of sudden unexpected  postnatal  collapse risk during skin-to-skin contact SM Ludington-Hoe, K Morgan - Newborn and Infant Nursing Reviews, 2014 - Elsevier

33. Infant Sleep During the First Postnatal Day: An Opportunity for Assessment of Vulnerability Kimberly A. Freudigman  and Evelyn B. Thoman Methods.  The sleep of 36 healthy newborns was recorded continuously throughout the first two postnatal days, starting immediately after birth, using an automated Motility Monitoring System. The Motility Monitoring System consists of a pressure-sensitive mattress pad connected to an amplifier and a small 24-hour analog recorder. A single channel of analog signals produced by the newborn's respiration and motility is continuously recorded onto a 60-minute cassette tape. The signals are digitized and scored, in 30-second epochs, for Active Sleep, Quiet Sleep, Active-Quiet Transition, Sleep-Wake Transition, and Wake. In addition to the percent of time spent in each state, the Mean Bout Length of Active Sleep, Mean Bout Length of Quiet Sleep, Mean Sleep Period, Longest Sleep Period, and Arousals in Quiet Sleep were also measured Results.  On postnatal day 1, four measures were significantly related to 6-month Bayley mental scores: Mean Sleep Period, Longest Sleep Period, Sleep-Wake Transition, and Arousals in Quiet Sleep; and two measures were significantly related to Bayley motor scores: Mean Sleep Period and Sleep-Wake Transition. On postnatal day 2, none of the measures were related to mental scores, while two measures were related to the motor scores: Quiet Sleep and Mean Bout Length of Quiet Sleep. Conclusions.  The results suggest that the newborn's sleep characteristics during the first postnatal day provide uniquely sensitive indices of later neurobehavioral function