NCLEX-RN: Maternal–Newborn Nursing

Maternal–Newborn Nursing: POSTPARTUM PERIOD

Focus topic: Maternal–Newborn Nursing

Maternal–Newborn Nursing: Physiology of the Puerperium

Focus topic: Maternal–Newborn Nursing

Definition: The puerperium is the period of 4 to 6 weeks following delivery in which the reproductive organs revert from a pregnant to a nonpregnant state.

Maternal–Newborn Nursing: Reproductive Organs

Focus topic: Maternal–Newborn Nursing

Uterus
A. Involution: rapid diminution in the size of the uterus as it returns to a nonpregnant state due primarily to a decrease in size of myometrial cells.
B. Lochia: discharge from the uterus that consists of blood from vessels of the placental site and debris from the decidua.
C. Placental site: blood vessels of the placenta become thrombosed or compressed.

Cervix And Vagina
A. Cervix: remains soft and flabby the first few days, and the internal os closes.
B. Vagina: usually smooth walled after delivery. Rugae begin to appear when ovarian function returns and estrogen is produced.

Ovarian Function And Menstruation
A. Ovarian function depends on the rapidity in which the pituitary function is restored.
B. Menstruation usually returns in 4 to 6 weeks in a nonlactating mother.

Urinary Tract
A. May be edematous and contain areas of submucosal hemorrhage due to trauma.
B. May have urine retention due to loss of elasticity and tone and loss of sensation from trauma, drugs, anesthesia, loss of privacy.
C. Diuresis: mechanism by which excess body fluid is excreted after delivery. Usually begins within the first 12 hours after delivery.
D. Kidney function returns to normal.

Breasts
A. Proliferation of glandular tissue during pregnancy caused by hormonal stimulation.
B. Usually continue to secrete colostrum the first 2 to 3 days postpartum (PP); enhances immunity and nutrition of infant. Breast milk (bluish-white, thin) usually produced by third day.
C. Anterior pituitary: stimulates secretion of prolactin after the placental hormones that inhibited the pituitary are no longer present → stimulate alveolar (acini) cells → milk.
D. In 3 to 4 days, breasts become firm, distended, tender, and warm (engorged), indicating production of milk.
E. Breastfeeding woman: apply warm compress, suckle. Nonbreastfeeding woman: apply cold compress, don’t express milk.
F. Milk usually produced with stimulus of sucking infant.
G. Posterior pituitary: discharges oxytocin, alveoli contract, and milk flows in response to sucking “let down reflex.”

Blood
A. White blood cells increase (25,000–30,000/mm3) during labor and early postpartum period and then return to normal in a few days.
B. Decrease in hemoglobin and red blood cells, and hematocrit usually returns to normal in 1 week.
C. Elevated fibrinogen levels usually return to normal within 1 week.

Gastrointestinal Tract
A. Constipation due to stretching, soreness, lack of food, and loss of privacy.
B. Postpartum clients are usually ravenously hungry.

Assessment
A. Check vital signs every 8 hours and prn: decreased blood pressure, increased pulse, or temperature over 100.4°F (38°F) indicates abnormality; use pain scale to evaluate comfort.
B. Observe fundus for consistency and level; massage fundus lightly with fingers if it is relaxed. Immediately after delivery, fundus is 2 cm below umbilicus, 12 hours later it is 1 cm above umbilicus. Fundus gradually descends into pelvic cavity, and by ninth postpartum day should no longer be palpable (1 cm or 1 finger-breadth qd).
C. Evaluate lochia for amount, color, consistency, and odor. Watch for hemorrhage. Assess color rubra (red, 1–3 days PP), serosa (pink to brownish; 3–7 days PP), alba (creamy white, 10 days PP).
D. Check perineum for redness, discoloration, or swelling.
E. Check episiotomy for healing and drainage.
F. Check breasts for engorgement or redness; cracking or inverted nipples.
G. Assess emotional status of new mother for depression or withdrawal.
H. Assess for problems with flatus, elimination, hemorrhoids, and bladder or bowel retention.
I. Observe status of mother–infant relationship.

J. Assess mother–infant feeding quality (see Breastfeeding).
K. Assess for thrombophlebitis.
L. Assess blood values (e.g., Rh, hemoglobin, hematocrit, WBCs).

Implementation
A. Nursing interventions for first critical hour after birth.
B. Routine postpartum continues after first hour.
C. May administer drug to inhibit lactation if it has not been given immediately postpartum (rarely, if ever, used today).
D. Administer RhoGAM as ordered within 72 hours postpartum to Rh-negative client who has delivered an Rh-positive fetus (direct Coombs’-negative) and who is not sensitized.
E. Maintain I&O until client is voiding a sufficient quantity without difficulty.

  • Usually the first three voids are measured.
  • If client fails to void sufficient quantity within 12–24 hours, she is usually catheterized.

F. Teach client perineal care and give perineal care until client is able to do so.
G. Encourage ambulation as soon as ordered and as client is able to tolerate it; give assistance the first time.
H. Encourage verbalization of client’s feelings about labor, delivery, and baby.
I. Give warm sitz baths as ordered.
J. Remind client to return for postpartum checkup.
K. Instruct that sexual relations may be resumed as soon as healing takes place and bleeding stops and client feels comfortable with it.
L. Discuss contraception if client so desires.
M. Provide opportunities to enhance mother–infant relationship, rooming-in, early contact, successful feedings, etc.

Maternal–Newborn Nursing: Emotional Aspects of Postpartum Care

Focus topic: Maternal–Newborn Nursing

Maternal–Newborn Nursing: Parenting

Focus topic: Maternal–Newborn Nursing

Postpartum Phases as Outlined by Rubin
A. Taking-in phase: first 2–3 days.

  • Mother’s primary needs are her own: sleep, food.
  • Mother is usually quite talkative: focus on labor and delivery experience.
  • Important for nurse to listen and help mother interpret events to make them more meaningful.

B. Taking-hold phase: third postpartum day to 2 weeks varies with each individual.

  • Emphasis on present mother is impatient and wants to reorganize self.
  • More in control. Begins to take hold of task of “mothering.”
  • Important time for teaching without making mother feel inadequate success at this time is important in future mother–child relationship.

C. Letting-go phase.

  • Mother may feel a deep loss over the separation of the baby from part of her body and may grieve over this loss.
  • Mother may be caught in a dependent independent role wanting to feel safe and secure yet wanting to make decisions. Teenage mother needs special consideration because of the conflicts taking place within her as part of adolescence.
  • Mother may in turn feel resentful and guilty about the baby causing so much work.
  • May have difficulty adjusting to mothering role.
  • May feel conflict between the roles of mother and wife.
  • May feel upset and depressed at times postpartum blues. If depression continues, client requires referral for therapy depression may lead to suicide.
  • May be concerned about other children.
  • Important for nurse to encourage vocalization of these feelings and give positive reassurance for task well done.

Assessment
A. Assess maternal and paternal physical and emotional status.
B. Determine what parents know about infant care.
C. Assess parents’ own birth parenting and nurturing.
D. Evaluate impact of parents’ cultural background.
E. Assess readiness for parenthood: emotional maturity, pregnancy planned or unplanned, financial status, job status.
F. Assess physical conditions of mother prior to pregnancy, during labor and delivery, and during puerperium.
G. Assess physical conditions of infant at birth, prematurity, congenital defects, etc. (parents may feel guilty, angry, cheated, and so forth).
H. Check for parental career plans.
I. Assess opportunities for early parental–infant interaction.
J. Evaluate parental knowledge of normal growth and development.

Implementation
A. Promote optimum parent–infant interactions during the early postpartum period (crucial time in parent–infant bonding).

  • Allow periods of time for both mother and father to be alone with infant.
  • Allow parents to hold infant in delivery and recovery rooms, and provide rooming-in and privacy.

B. Based upon assessment of parents, plan nursing care. Be sure to begin at same level as parents.
C. Be alert to parental cues but be careful not to label.
D. Support mother in infant care activities and use these opportunities to promote her self-esteem.
E. Provide a role model for parents.
F. Plan nursing care to reduce maternal fatigue and anxiety so that time with her infant is pleasurable.
G. Explain to parents that it is normal at this time to feel fatigued, tense, insecure, and sometimes depressed.
H. Anticipatory guidance regarding baby blues, maternal depression, and maternal psychosis.
I. Counsel mother on home care plan.

  • Rest periods to avoid overfatigue.
  • Time spent away from baby: to be alone, to be with significant other or husband, to be with other children, and to resume contact with people.
  • Time for father and baby together.
  • Enlist support from husband or significant other to listen and validate emotional distress new mothers may experience.
  • Encourage to seek professional help if symptoms of depression are prolonged or severe.

Maternal–Newborn Nursing: Breastfeeding

Focus topic: Maternal–Newborn Nursing

Assessment
A. Review intrapartum medications and possible effects on initial breastfeeding.
B. Assess degree of physical comfort prior to nursing.
C. Assess breasts and nipples for factors that may decrease successful breastfeeding experience (flat or inverted nipples, scarring from breast surgery, significantly asymmetrical breasts, lack of normal pregnancy breast changes, discomfort, engorgement).
D. Observe entire infant feeding and assess infant’s position at breast, latch, suck, and transfer of milk; confirm correct infant position (nose, cheeks, and chin are touching mother’s breast).
E. Assess parent’s knowledge base: infant feeding cues, maternal response to cues, infant cues of satiety, importance of feeding, proper techniques, breast care, infant weight gain, maternal nutrition, personal plans, resources for support, coping with return to work while breastfeeding.
F. Assess nutritional and hydration status: increased maternal needs for protein, vitamins, iron, and fluids during lactation.
G. Evaluate emotional responses toward nursing: satisfaction, relaxation, mastery.
H. Evaluate LATCH (latch on, audible swallow, type of nipple, comfort, help).

Implementation
A. Complete hand hygiene.
B. Provide skin-to-skin contact between mother and child immediately after birth, unless contraindicated.
C. Assist mother with breastfeeding as soon as possible after birth, once mother is comfortable and infant demonstrates feeding cues, usually within the first hour.
D. Assist mother to a comfortable position (sitting or side-lying), using pillows for support to enhance relaxation and proper positioning.
E. Guide baby to breast; stimulate rooting reflex, if necessary; place as much of areola in baby’s mouth as possible.
F. Release suction by inserting a finger into side of baby’s mouth. The breast will become sore if baby is pulled from it.
G. Burp baby after each breast.
H. Encourage mothers to feed infants at least q 3 hrs or at least 8 times in 24 hours.
I. When possible, avoid use of pacifier and supplemental water or formula until infant is able to latch on and is successfully breastfed.
J. Teach mother and significant other importance of obtaining adequate rest, breast massage, correct latching, engorgement/nipple soreness, breastfeeding patterns, breastfeeding positions, determining adequate intake.
K. Promote comfort by carefully managing/preventing sore nipples (proper positioning; express colostrum or breast milk on nipple and areola at end of q feeding hind milk; moist compresses) and breast engorgement (feed on demand, use warm compresses; breast massage and manual expression prior to nursing; warm shower between feedings; observe for signs of mastitis; wear well-fitting, supportive bra). Nutrition counseling: additional 500 calories in well-balanced diet. Drink 3000 mL fluid qd.
L. Uterine cramping may occur the first few days after delivery while nursing, due to oxytocin stimulation, which also causes uterus to contract.

M. Counsel mothers to avoid:

  • Medications or drugs contraindicated unless necessary to client’s life—drugs pass to infant through breast milk.
  • Some foods, such as cabbage or onions, may alter the taste of the milk or cause gas in infant.
  • Birth control pills are often avoided as milk production may be decreased and the medication is passed to infant in the milk.

N. Explain contraindications to breastfeeding:

  • Active tuberculosis.
  • Severe chronic maternal disease.
  • Narcotic addiction drug abusers must be drug-free for 3 months.
  • Severe cleft lip or palate in newborn.
  • HIV-positive status; AIDS.

Maternal–Newborn Nursing: Complications of the Puerperium

Focus topic: Maternal–Newborn Nursing

Assessment
A. Observe for postdelivery hemorrhage (leading cause of maternal death in the world).
B. Check for uterine atony.
C. Assess for lacerations of birth canal.
D. Assess for postdelivery infection (puerperal sepsis).
E. Evaluate for postpartum alterations in mental state (e.g., depression, psychosis).
F. Assess for mastitis.
G. Check for presence of embolism.

Implementation
A. Postpartum hemorrhage: Identify degree of hemorrhage and implement measures to contain it.
B. Endometritis: Treat inflammation and prevent further complications.
C. Urinary tract infection: Identify presence of infection and initiate treatment.
D. Mastitis: Administer antibiotics, support mother during exacerbation, and perform palliative measures.
E. Subinvolution: Identify condition and initiate treatment.

Maternal–Newborn Nursing: Postpartum Hemorrhage

Focus topic: Maternal–Newborn Nursing

Definition: A condition that occurs when 500 mL or more of blood is lost during or 24 hours after vaginal birth; 1000 mL in cesarean birth.

Characteristics
A. Uterine atony (lack of muscle tone in uterus) is the primary cause of early postpartum hemorrhage. Causes for uterine atony include:

  • Prolonged or precipitous labor.
  • Overdistention: multiple pregnancies, polyhydramnios.
  • Sluggish muscle.
  • PIH.
  • Presence of fibroid tumors.
  • Deep inhalation anesthesia—may inhibit uterine activity.
  • Pitocin induction of labor.
  • Distended bladder.

B. Lacerations of the reproductive tract is a second cause of early postpartum hemorrhage.

  • Lacerations of the cervix or of the high vaginal walls.
  • Oozing from blood vessels.

C. Retained placental tissue or incomplete separation of the placenta is the most frequent cause of late postpartum hemorrhage.

D. Hematomas.
E. Early postpartum hemorrhage occurs in the first 24 hours after birth. Late postpartum hemorrhage occurs 24 hours to 6 weeks after delivery.
F. Placenta accreta is the abnormal adherence of placenta due to penetration of placental trophoblast into myometrium.

  • May be partial or complete.
  • Removal of placenta by hand or hysterectomy if bleeding persists.

Assessment
A. Observe for uterine atony.

  • Boggy, relaxed uterus.
  • Dark bleeding.
  • passage of clots.

B. Check any lacerations.

  • Firm fundus.
  • Oozing of bright red blood.

C. Check for retained placental tissue.

  • Boggy, relaxed uterus.
  • Dark bleeding.

D. Evaluate for signs and symptoms of shock.

  • Air hunger: difficulty in breathing.
  • Restlessness.
  • Weak, rapid pulse.
  • Rapid respirations.
  • Decrease in blood pressure.

E. Evaluate lab values (compare admission and postpartal)—hemoglobin, hematocrit, clotting time, platelets.

Implementation
A. Remain with client.
B. Monitor vital signs every 15 minutes or prn until stable.
C. Administer intravenous fluids, blood, volume expanders, or Pitocin as ordered.

D. Palpate fundus every 15 minutes or prn while bleeding continues; then every 2 to 4 hours.
E. Gently massage fundus until firm. Be careful not to overmassage.
F. Administer Pitocin or other uterine stimulants (Methergine [methylergonovine], Ergotrate [ergonovine], Hemabate [carboprost], or Prostin [prostaglandin]) as ordered for boggy uterus.
G. Have physician notified.
H. Weigh pads and linen.
I. Provide warmth for client.
J. Measure I&O.
K. Explain carefully to client and family to help allay anxiety.
L. Observe for blood reactions and check for clotting defect, monitor lab values (clotting time, platelets, fibrinogen, Hgb, Hct, CBC), and observe for signs of clotting defect.
M. Return client to delivery room or to surgery for removal of placental tissue or repair of laceration.

Maternal–Newborn Nursing: Postdelivery Infection

Focus topic: Maternal–Newborn Nursing

Definition: An infection in the uterus within 28 days as a consequence of abortion or labor and delivery.

Characteristics
A. Cause.

  • Organisms that were introduced during labor and delivery.
  • Bacteria normally present in vaginal tract.

B. Predisposing factors.

  • Cesarean birth is major risk.
  • Weakened resistance due to prolonged labor and dehydration.
  • Traumatic delivery.
  • Excessive vaginal examinations during labor.
  • Premature rupture of membranes.
  • Excessive blood loss.
  • Poor health status; anemia.
  • Intrauterine manipulation.
  • Retained placental fragments.
Maternal–Newborn Nursing

Assessment
A. Assess for elevated temperature of 100.4°F (38.0°C) for 2 or more consecutive days, not counting first 24 hours.
B. Assess any discomfort in the abdomen and perineum.
C. Evaluate burning on urination and character of urine.
D. Check for foul-smelling lochia or discharge.
E. Assess for pelvic pain.
F. Assess for chills.
G. Check for rapid pulse and assess other vital signs.
H. Evaluate malaise, anorexia.
I. Assess boggy, relaxed, and/or tender uterus.

Implementation
A. Administer IV fluids or blood as ordered.
B. Encourage fluid intake: 3000 to 4000 mL if not contraindicated.
C. Administer medications: broad-spectrum IV antibiotics and analgesics as ordered.
D. Offer warm sitz bath for relief of symptoms.
E. Monitor laboratory studies: blood and urine.
F. Provide high-calorie nutritious diet.
G. Place client in Fowler’s or semi-Fowler’s position as ordered. Position of client promotes drainage.
H. Provide emotional support to mother, who is usually in isolation and unable to see baby.

Maternal–Newborn Nursing: Deep Vein Thrombosis (Thrombophlebitis)

Focus topic: Maternal–Newborn Nursing

Definition: A vascular occlusion of vessels of the pelvis or lower extremities. Results from infection, circulatory stasis, and increased postdelivery coagulability of blood.

Assessment
A. Assess for discomfort in abdomen and pelvis.
B. Assess for femoral symptoms—usually do not appear until the second week or later.

  • Edema and pain in affected leg.
  • Chills and low-grade fever.
  • Changes in color and temperature.
  • Area may feel firm and hard.

C. Assess Homan’s sign (now not considered reliable).
D. Use Doppler flow studies.

Implementation
A. Provide specific care for extremity.

  • Maintain bed rest; keep bed clothes off leg.
  • Apply warm compresses, as ordered, for 15 to 20 minutes.
  • Elevate affected leg.
  • Apply bed cradle.
  • Never massage leg and teach client not to do so.
  • Apply antiembolic stocking, and teach client its proper use.

B. Encourage fluids.
C. Provide diversion.
D. Administer medications as ordered.
E. Teach client to administer heparin.
F. Teach client to watch for signs of excessive bleeding.
G. Allow client to express fears and concerns.
H. Watch for signs of pulmonary embolism.

Maternal–Newborn Nursing: Urinary Tract Infection

Focus topic: Maternal–Newborn Nursing

Definition: Postdelivery urinary tract infections are usually caused by the coliform bacteria and generally occur soon after vaginal delivery.

Characteristics
A. Edema and hyperemia of bladder due to stretching and trauma in labor and delivery.
B. Temporary loss of bladder tone; pressure and injury may result in bladder being less sensitive to fullness.
C. Overdistention and residual urine or inability to void may occur.
D. Trauma to urethra may cause difficulty in voiding.

Assessment
A. Monitor bladder frequently during recovery period to institute preventive measures.

  • Assess for suprapubic or perineal discomfort.
  • Check for frequent urination, burning, dysuria.

B. Check for hematuria.
C. Assess for elevated temperature.
D. Assess for pyelitis—pain in flank.
E. Perform urine cultures and chemical tests to determine presence and number of bacteria.

  • Evaluate microscopic examination for detailed identification of the organism (especially important in chronic infections).
  • Note that a colony count of over 100,000/mL is the most important lab finding and designates infection.

Implementation
A. Observe postpartum client closely for full bladder or residual urine.

  • Palpate bladder for distention.
  • Palpate fundus: Full bladder displaces fundus upward and to the sides.

B. Institute measures to help client void.
C. Insert catheter, as ordered, using sterile technique.
D. Encourage fluids to 3000 mL per day.
E. Administer drugs as ordered. Most common are Bactrim (trimethoprim sulfamethoxazole), Cipro (ciprofloxacin), Levaquin (levofloxacin), and Macrodantin (nitro furadantoin.) May give systemic antibiotics.
F. Obtain urine specimens for microscopic examination.
G. Provide emotional support to client: Allow her to express feelings about her illness and the baby.

Maternal–Newborn Nursing: Mastitis

Focus topic: Maternal–Newborn Nursing

Definition: An infection in breast tissue usually caused by the Staphylococcus organism. It occurs in about 1% of women who have recently delivered.

Characteristics
A. Infected hands of client or attendants.
B. Bacteria normally present in lactiferous glands.
C. Fissure in nipples.
D. Bruising of breast tissue.
E. Stasis of milk or overdistention may injure tissue, but does not cause infection in itself.
F. Infected baby.

Assessment
A. Assess for chills.
B. Assess for elevated temperature: 103°F (39.5°C) or above.
C. Check for elevated pulse rate.
D. Evaluate breast lobe which may appear hard, red, painful, and evidence localized tenderness.

Implementation
A. Provide support for breast. Make sure client wears snug-fitting, supportive brassiere.
B. Administer antibiotics as ordered (may be based on culture of breast milk).
C. Bed rest for first few days.
D. Increased fluid intake (2000 to 3000 mL).
E. Apply ice or heat to breast.
F. Teach client to empty breast every 4 hours if nursing is to be discontinued.
G. Wash hands before touching client’s breast.
H. Teach client careful hand washing and care of the breast.

Maternal–Newborn Nursing: Subinvolution

Focus topic: Maternal–Newborn Nursing

Definition: Failure of the uterus to revert to normal postpartum state, caused by retained placental tissue or fetal membranes, endometritis, or uterine tumors.

Assessment
A. Assess for enlarged, boggy, and tender uterus.
B. Assess for profuse red lochia or hemorrhage.
C. Check for pelvic discomfort and backache.

Implementation
A. Monitor oxytocic meds given: Methergine (0.2 mg three to four times a day for 3 days) to cause contractions.
B. Administer antibiotics to prevent infection as ordered.
C. Assist physician in manual replacement of malposition.
D. Explain condition and treatment to client.

Maternal–Newborn Nursing: Postpartum Depression

Focus topic: Maternal–Newborn Nursing

Definition: Intense and prolonged feelings of sadness, crying, fear, irritability, severe anxiety, panic attacks, or spontaneous crying.

Characteristics
A. Lasts longer than postpartum blues, which usually lasts several weeks.
B. Occurs in about 8–26%; greatest risk around fourth week postpartum or just prior to initiation of menses, and upon weaning.
C. Not associated with depression during pregnancy.
D. Woman often cannot continue normal parenting tasks, which can increase guilt feelings.
E. Usually requires medical intervention and medication.
F. Symptoms of psychosis (paranoia, hallucinations) require psychiatric interventions.

Assessment
A. Assess for risk factors: primiparity, ambivalence toward pregnancy, history of postpartum depression (PPD) or psychiatric illness, stressful life events, lack of supportive relationships, personal expectations, and perceptions of self.
B. Observe for signs of depression.

  • Note severity and duration.
  • Ask appropriate questions, which show sensitivity to the negative feelings and thoughts that may occur.

C. May utilize PPD checklists or screening scales.

Implementation
A. Anticipatory guidance: realistic information regarding possible negative feelings and reactions that often occur, detrimental effect of the perfect mother or perfect newborn expectations.
B. Encourage family to seek early and/or continue interventions.

  • Call if notice symptoms.
  • Take medication (depending on symptoms— tranquilizers, mood elevators, phenothiazines).
  • Obtain emotional support (encourage verbalization, support positive self-image, participate in support groups).

C. Implement follow-up interventions to ensure safety (self or newborn).
D. Discuss possible strategies for mother and family to prevent PPD.

  • Don’t be ashamed of having emotional problems after the baby is born—about 15% have this problem. Be open and share knowledge about PPD with close friends and family.
  • Adhere to good health habits: well-balanced diet/hydration, exercise regularly, 7–8 hours of sleep.
  • Have realistic expectations—don’t try to be a “supermom.”

FURTHER READING/STUDY:

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