Nursing Challenges in Postpartum Care

Challenges of Providing Care

Care during the postpartum period can present some challenges to the nurse caring for both the mother and infant. There is a large amount of information and care to be provided in a short amount of time, therefore, care needs to be thoughtfully planned. The nurse along with coordinating care of multiple health care professionals such as, the pediatrician, obstetrician, and lactation consultant (if needed) is responsible for coordinating timing of assessments, screenings, vaccines, diagnostics tests, and any additional procedures such as circumcisions. The nurse is also responsible for ensuring the patient receives and understands education on how to care for herself and her infant once they are home. Along with coordinating and educating, the nurse's focus of care is the woman's physiologic recovery, her psychologic well-being, and her ability to care for herself and her new baby (Wong et al., 2006). An additional challenge placed upon the postpartum nurse is being aware of all possible complications in the postpartum period, being able to assess for and recognized signs and symptoms along with educating the patient to recognize these signs and symptoms and when to contact a health care professional. We have provided some guides for educating and assessing the postpartum patient.

Nursing Plans and Interventions:

Maintain bed rest for 2 hours after delivery

Obtain blood pressure, pulse, respirations, and temperature as ordered

Offer fluids when alert and able to swallow

Promote ambulation in first 6 hours after delivery --watch for syncope

Determine need for rubella vaccine and RhoGAM

Assess fundus --should be firm, midline and at or below the umbilicus

• Massage fundus firmly if it is soft or boggy, ensuring stabilization
• Suspect full bladder if fundus is deviated from midline (usually to the right)
• Keep bladder empty and catheterize only if necessary
• Place warm blanket over abdomen

Assess lochia --should progress from red to pinkish/brownish to white-yellow discharge, should not soak more than one pad/hour and clots should be no greater than 2-3 cm.

• Suspect hemorrhage if blood loss is >500 cc in 1st 24 hours
• Lochia rubra is red tinged with shreds of tissue and deciduas (2-3 days)
• Lochia serosa is a pale pinkish to brownish discharge (up to 10 days)
• Lochia alba is a thicker, white-yellowish discharge which contains leukocytes and cells (up to 4 weeks)

Assess perineum --should be intact, clean, and slightly edematous

• Suspect hematomas if discoloration is present or increased pain
• Change pads and cleanse perineum as needed and with every voiding and defecation
• Witch hazel and ice packs may be applied for comfort
• Ice packs are applied to reduce pain and swelling

Observe, document and assess episiotomy site

• Clean with warm water and iodine solution if prescribed
• Reinforce hygiene by avoiding anal area
• Use stool softeners as prescribed
• 1st degree tear only involves epidermis
• 2nd degree tear involves dermis, muscle, and fascia
• 3rd degree tear extends into the rectal mucosa

Support parent emotional needs and bonding

• Provide skin to skin contact within first 15 minutes after delivery
• Provide dark environment for newborn to open eyes
• Encourage parents to participate in giving babies their first bath
• Have newborn room-in same room
• Praise and reinforce all positive parenting behaviors
• Eye prophylaxis can be withheld for 24 hours

Provide mother with information and benefits of breast feeding

• Show correct position of ear, shoulder, and hip alignment
• Show how baby can latch and to switch breast every 10 minutes
• Discuss low cost immunologic advantages of breastfeeding
• Explain that continued breast stimulation will produce more milk
• Explain that breast size does not correlate with milk production
• Encourage mom to rest and increase calorie intake by 500 calories
• Educate mom on risks of smoking, drug use (recreational and OTC), caffeine use etc. when breastfeeding

When to notify primary care provider

• If there is heavy vaginal bleeding with clots (>500 cc blood loss)
• If temperature is 100.4 or higher
• If breast become red, painful, and warm
• If pain occurs upon urination
• If tenderness or pain in felt in legs

Discharge topics

• Continue good hygiene techniques
• Get plenty of rest with good diet (sleep when baby is sleeping)
• Warn about sibling rivalry --especially in toddlers
• Discuss different methods of birth control (oral contraceptives, IUD's, condoms, etc.)
• Educate on when to resume intercourse (usually 4-6 weeks, after discharge has ceased)
• Discuss signs and symptoms of postpartum depression and who to contact if suspected

Reference:

Mosby Elsevier. (2009). Evolve Reach Comprehensive Review for the NCLEX-RN Examination, 2nd Edition. Mosby Inc.

Wong, D.L., Perry, S.E., Hockenberry, M.J., Lowdermilk, D.L., & Wilson, D. (2006). Maternal child nursing care (3rd ed). St. Louis, MO; Mosby Elsevier

Submitted by : Stephanie Pickard and Jenn Goldenstein