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INTRODUCTORY PAGE CONTENT PAGE CASE STUDY- 35YRS OLD, MRS AMY LEE NORMAL VAGINAL DELIVERY EPISIOTOMY SUBCUTICULAR SUTURES COMPLICATION POST NATAL UNIT AIMS OF POSTNATAL CARE POST DELIVERY ASSESSMENT ALL ABOUT BREASTFEEDING POTENTIAL COMPLICATIONS HOME CARE CARE OF EPISIOTOMY WOUND MAINTAINING HEALTHY BODY & MIND CONTINUITY OF EFFECTIVE BREASTFEEDING CARE OF NEWBORN
Mrs. Amy Lee 35 years Deliver full-term male infant Normal vaginal delivery Had an episiotomy repaired with subcuticular sutures. Estimated blood loss was 200mls. She and her baby have just been transferred to your postnatal ward. Informs that she wants
Shahila
refers to the intentional incision of the vaginal opening to hasten delivery or to avoid or decrease potential tearing. is the most common procedure performed in modern day obstetrics reported benefits included preservation of the integrity of the pelvic floor and prevention of uterine prolapse and other vaginal trauma
Evidence of maternal or fetal distress (i.e. no time to allow perineum to stretch). The baby is premature or in breech position, and his/her head could be damaged by a tight perineum. The baby is too large to be delivered without causing extensive tearing. The delivery is being assisted by forceps or a vacuum extractor The mother is too tired or unable to push Existing trauma to the perineum Twin or multiple deliveries
Subcuticular sutures
Subcuticular suture is a method of skin closure involving placement of stitches in the subcuticular tissues parallel with the line of the wound.
Subcuticular suturing
Subcuticular suturing is a very useful and neat way of closing the skin. The suture runs continuously just under the cutis of the skin where the strength is. The epidermis, where regeneration of skin cells occurs, is not damaged by subcuticular sutures. This avoids the cross hatching scars of full thickness skin stitches.
Provide consistency of advice and support for recovery from pregnancy and the birth
Nursing Care
Directed by a knowledge of the stages of the puerperium Monitoring safety Intensive discharge planning Repetitive anticipatory guidance Increasing self care and self confidence Increasing independence with baby care Closing knowledge deficits Group Classes Nurses lead group classes on postpartum units Baby care Breastfeeding Group classes are not a substitute for individualized care planning
Postpartum Check
Vital signs Fundus Bladder Bowel Lochia Perineum
Ashima
Vital Signs
Blood pressure Blood pressure is altered slightly but will either decrease if high and increase if low Temperature During first 24 hours may increase to 38 degree as a result off dehydrating of labor. After 24 hours , the women should be afebrile . Pulse Remains elevated for the first hour or so after birth . it then begins to decrease at an unknown rate. By 8 to 10 weeks after childbirth , the pulse has returned to a non-pregnant rate Respiration The respiration rate should decrease to with the
Raise the head of the bed Ask the patient lower her gown so that her breasts can be examined Visually inspect and palpate each breast noting: Soft, filling or firm Engorged, reddened, or painful Nipples: Inverted , cracked, bleeding, bruised, presence of colostrum or breastmilk.
FIGURE 232
The uterus becomes displaced and dev iated to the right when the bladder is f ull.
2007 by Pearson Education, Inc. Pearson Prentice Hall Upper Saddle River, New Jersey 07458
Maternal & Child Nursing Care, 2/e By London / Ladewig / Ball / Bindler
Monitor Lochia
Detach the peripad from the front to the back to minimize the risk of contaminating the vagina with rectal discharge. Note: Type rubra (dark and red) 1-3 days -serosa (serous or brown)3-10 days -alba (white) 10-14 days Amount Estimate of Drainage Number of Pads Presence of odor could indicate
Episiotomy/Perineum
Instruct the client to assume a side-lying (Sims) position. Gently separate the buttocks & inspect the perineum for: Episiotomy, lacerations and hemorrhoids Bruising, hematoma, edema, discharge Intact Suture Line Signs of Infection
Emotional Status
Can have Mood Swings post delivery Observing Bonding Behavior & Ability to give Infant Care Willingness to cooperate
Clinical Assessment
Mrs Amy Lee
Vital Signs
Temperature: 37.3 (Normal) HR: 99 (Normal) RR: 19 (Normal) BP: 110/65 mmhg
UTERUS: Well contracted, midline at umbilicus LOCHIA: Normal ,moderate amount of lochia, nil presence
of odor & clots
EPISIOTOMY: Sutures intact, Slight edematous BLADDER: Not distended,Catherized in LWD (350mls Clear
Urine) BOWEL: Nil, bowel sounds present THROMBOPHLEBITIS: Nil seen POST EPIDURAL: Sensations present, ambulate
Breast Milk
Has a unique smell which enhances bonding between mum & baby and a taste that varies with mums diet (unlike formula milk). Contain easily absorbable fat such as omega fatty acids, which enhance babys brain & eye development. Meet the energy needs of the baby compared to formula milk. Is more digestible& easily absorbed. Contain antibodies It is always fresh and at just
Yan xing
Colostrum or Early Milk is produced in the late stage of pregnancy till 4 days after delivery and is rich in antibodies. Transitional Milk is produced from day 4 10 is lower in protein in comparison to Colostrum. Mature milk is produced from approximately ten days after delivery up until the termination of the breastfeeding.
Benefits of Breastfeeding
BABY Creates a special bond between mum & baby. Helps in Gastrointestinal development & function Helps in cognitive & immune system development Reduced risk of infections eg otitis media, Lower respiratory tract infection, Diarrheal MUMMY
Early suckling helps womb contract , reducing blood loss after childbirth. Aids involution of the uterus. Long term breastfeeding helps in loss of the excess weight acquired during pregnancy. It lower the risks
Wang ke
Cradle hold
Cross-cradle Hold
Lying Down
Football
is not usually the best position for the first days of nursing
Infants head is supported in the elbow, the back and buttock is supported by the arm and lifted to the breast
The other hand is placed beneath the breast in a Ushaped to guide the baby's mouth to your breast
Mother holds the baby crosswise in the crook of the arm opposite the breast the infant is to be fed
Babys body is supported with the forearm and the head is supported with
The mother lies on her side propping up her head and shoulder with pillows.
Ashima
Babys mouth is open wide enough to take in nipple and most of areola
Open wide
Babys upper and lower lips flare out to form a good seal on the breast Babys chin is touching the breast and the nose is slightly away from the breast The areola is drawn into your babys mouth Babys check is round You may feel the initial tug on the nipple when baby suckles but you should not have nipple pain or discomfort You can observe your babys sucking rhythm to ensure good milk transfer. Suck > swallow > Breathe (pause) rhythm.
Nurhakim
HEMORRHAGE
Most common cause of excessive bleeding during childbearing cycle. Loss of blood of more than 500 ml following uncomplicated vaginal birth First 24 hour is the most critical time. Early pp Hemorrhage -1st 24hour caused by uterine atony & laceration. Later pp Hemorrhage -from 24hour to 6weeks caused by retained placenta fragments& hematomas & subinvolution of uterus.
Common Causes
A. B. C. D. E. primigravida birth retained placenta uterine atony uterine rupture lacerations of the cervix
Risk Factors
Prolonged 3rd stage of labor Fibroids, placenta previa Previous PPH Overdistended uterus
HEMATOMAS
Vulvar hematoma is a localized collection of blood in the connective tissue beneath the skin covering the external genitalia or vaginal mucosa. It generally forms as a result of injury to the perineal blood vessels during the delivery process.
Medical Treatment.
This is consists of analgesics given for discomfort, opening the hematoma so blood clots can be evacuated and the bleeders can be ligated, and packing for pressure.
Nursing Interventions.
Apply ice to area of hematoma. Observe for evidence of enlarged hematoma.
Wang Ke
Infections
Uterus & Vagina open after vaginal delivery provide easy access to microorganism Therefore it increases the risks of : Reproductive System Infections Peurperal Infection Bacterial Infections of the Genital Tracts Sites other than genital tracts include : Mastitis UTI
MASTITIS
is inflammation of the breast tissue, usually unilateral after the milk flow is established. caused by streptococcal or staphylococcal invasion of the breast tissue through cracks or fissures around the nipple. may be obtained from the infant's nose or throat. The infant probably acquired it while in the nursery. Signs and Symptoms Erythema over the infected breast. Marked breast engorgement. Acute breast pain, tenderness. Fever and chills. Ancillary lymph gland enlargement
Medical Treatment
Antibiotic therapy and analgesic therapy. Periodic cultures of breast milk. Intravenous fluids. Possible I&D, if abscesses. Discontinued breast-feeding for a short time depending on antibiotic used and closeness of abscess site to nipple. Nursing Care
Apply ice or heat to painful, swollen breast depending on the stage of infection. Ice should be avoided if the mother plans to resume or continue breast-feeding. Encourage increased fluids. Inform mother to wear a support bra. Have the mother pump her breast until nursing resumes. Pumping the breast should be avoided if the mother plans to bottle-feed.
Yan Xing
Depression
Psychological problems
Having a baby can be both exhilarating and exhausting. It can bring much joy, but it can also challenge you in ways you never expected. Soon after giving birth, many women feel weepy and moody. You may be blessed with a beautiful baby
Postpartum Blues
Complicates 50% of deliveries Mild, transient, selflimited disorder. Mode swings, with change in appetite and sleep. Onset at 3rd or 4th day postdelivery. Often resolves within few
Why?
After pregnancy, hormonal changes in a woman's body may trigger symptoms of depression. During pregnancy, the amount of two female hormones, estrogen and progesterone, in a woman's body increases greatly. In the first 24 hours after childbirth, the amount of these hormones rapidly drops back down to their normal nonpregnant levels. Researchers think the fast change in hormone levels may lead to depression, just as smaller changes in hormones can affect a woman's moods before she gets her menstrual period.
Symptoms:
Sadness, anxiety, irritability
Uncontrollable tearfulness Wide mood swings
Decreased concentration
Insomnia constant worry about minor problems
Primary Treatment:
Supportive care and reassurance about the condition
G U I D A N C E
HOMECARE
G U I D A N C E
Shahila
Avoid touching the open wound. Cleaning the area at least twice a day, with local dilute antiseptic solution like Chlorhexidine or Dettol Remember, always wash from front to back, never the other are to prevent infection. While youway, urinating, squirt lukewarm water with a peri-bottle. Take a warm sitz bath. Walking can be good exercise to increase blood flow and speed healing. Purchase a donut-shaped pillow to sit on after you give birth as is allows you to sit
Kegel exercises are very beneficial for strengthening the weakened muscles in this area .
Oral medications such as pain killer tablets (paraceptamol, ibuprofen, etc. ) should only be taken as advised by your doctor.
Most doctor use stitches, which dissolve on their own and / or fall off after a few days. Ask your doctor if you need to come back to show the stitches.
Ashima
A Healthy Mind
Getting organised
Planning to have additional support in the first few months can make the transition to motherhood less stressful. Try not to make major life changes like moving house or changing jobs late in pregnancy or in the first few months after you have your baby.
Getting support
Develop a support system of friends, family and/or health professionals, including parent groups, that give you the opportunity to share stories and experiences and meet new people who are in a similar situation.
Staying healthy
Try to eat healthy meals, exercise regularly and avoid drugs and alcohol. Having a good night's sleep is also important for maintaining good health, but can be almost impossible with a new baby. Taking every available opportunity to nap can not only help you stay physically fit, but also mentally healthy. Do this when the baby is Taking when partners, asleep ortime out family members and friends are able to time for Organise your routine so you get some look after the baby. yourself. Arrange for a . It can also be helpful to try to get the baby into look childcare service, friends or family members to a good sleeping pattern as after the children early as possible. occasionally.
Nurhakim
A HEALTHY BODY
Healthy Diet
Increase of Fluid Intake
Drinking sufficient amount of water, is the first rule of breastfeeding diet, therefore it is advised to drink lots of water. Keep a glass of water with you while feeding baby. Juices, milk are the recommended fluids.
Eat in Variety
Thinking from the baby's nutrition point of view, experiment with your food to get adequate diet. Have lots
Body Relaxations
Post Natal Massage
After giving birth the body craves nurturing touch to assist with the integration of this amazing transition into motherhood. Massage will ease away any aches and pains, melt away tension and tiredness. The stress from childbirth and time spent caring for your newborn is taxing on our body. Therefore post-natal massage not only gives nurturing and emotional support to help mothers gain back their lost energy, it also brings body back to its pre-pregnancy condition by retaining muscles and connective tissue.
Naturopathy
Herbs can be gentle and effective in supporting both mother and baby after birth. It is not always possible to have the time to recover fully from the physical stress of childbirth so herbs can aid in a rapid recovery. Some mothers may need help with sleep patterns, adequate lactation, emotional support or later on, a normal menstrual cycle . Herbs can be useful for babies with common ailments such as colic, skin rashes or poor sleep patterns.
Continuity of Breastfeeding
Shahila
Nursing
Let baby nurse as long as he wants Do not watch the clock, watch the infant Generally, 10-30 minutes, longer or shorter ok Active nursing from first breast Stimulate infant if sleepy When done, burp, check diaper and offer 2 nd He may or may not take 2nd Alternate the starting breast each feeding
Weight loss less than seven percent of birth weight. Three or more bowel movements per day after day one. Seedy, yellow bowel movements by day five. At least six wet diapers per day by day four. Satisfied baby. Audible swallowing. No weight loss after day three ; gaining weight by day five. Back to birth weight by day 10.
Engorgement
Wang ke
Occurs 2-5 days after delivery Lasts 24-48 hours Swelling of the breast by increase blood & lymph fluid as milk comes in
Prevention of Engorgement
Nurse frequently Correct latch Skin to skin contact No supplements Pump only for comfort Engorgement care plan
Yan Xing
Date all bottles and bags. Store in properly working refrigerator or freezer. Do NOT store milk in the door of the refrigerator. If a refrigerator or freezer is not available, store milk in a cooler packed with ice or an ice gel pack until you get home. Use the milk with the oldest date first.
Ashima
I'm hungry. Most newborns eat every few hours round-the-clock. Some babies become frantic when hunger strikes. I need to burp. During and after each feeding, take time to burp your baby. I'm wet. For some babies, a wet or soiled diaper is a sure way to trigger tears. I'm tired. Tired babies are often fussy .Newborns often sleep up to 16 hours a day. I'd rather be bundled. Some babies feel most secure in a swaddle wrap. I want to move. Sometimes a rocking session or walk through the house is enough to soothe a crying baby. I want to suck on something. Sucking is a natural reflex. For many babies, it's a comforting, soothing activity.
2. Ensuring warmth
Wrap in soft dry clean cloth, cover head with cap Keep the room warm; if room not warm cover baby with a blanket or use skinto-skin Keep room warm for baby During the day, dress or wrap baby At night, let baby sleep with mother
3. Cord care
Wash hands before and after cord care Keep the cord stump clean & dry Fold diaper below stump If the stump is soiled, wash with alcohol swabs or clean water and soap Cord stump usually dries and fall within 7 to 10 days Ask mother to visit health facility, if umbilicus is red or draining pus / blood or adjoining skin is red.
4. Hygiene
Wipe the face, neck, underarms DAILY Wipe the buttocks when soiled Give bath when necessary: Use lukewarm water for bathing Dry the baby thoroughly , dress & cover after bath Wash hands after disposing soiled items DO NOT put anything in babys eyes or ears
Not feeding well Less active than before Fast breathing (>60/ min) Moderate or severe chest in-drawing Grunting Convulsions
Floppy or stiff Temperature >37.50C or <35.50C Umbilicus draining pus or umbilical redness extending to skin. >10 skin pustules Bleeding from umbilical Stump
Assessment Of Jaundice
Jaundice is common in the first week of life and may be missed in dark skinned babies Blanch the tip of the nose or hold baby up and gently tip forward and backward to get the eyes to open. Teach mother to do the same at home in the first week and report to hospital if significant jaundice is observed.
Follow up visit
Assessment of growth & development Ensure immunization Early diagnosis and management of illness
Health education
Exclusive breastfeeding for 6 months Complementary feeds after 6 months
Spacing of family
Ensure immunization
Age
At birth 1 month 3 months 4 months 5 months 5-6 months
Vaccine
BCG Hepatitis B 1st dose Hepatitis B -2nd dose DPT/DT 1st dose Oral Sabin -2nd dose DPT/DT 2nd dose Oral Sabin 2nd dose DPT/DT 3rd dose Oral Sabin -3rd dose Hepatitis B 3rd dose
1-2 Years
18 months 6-7 years (Primary 1) 10-11 years (Primary 5)
MMR- Primary dose(1st dose) DTPT/DT 1st booster Oral Sabin 1st booster Oral Sabin 2nd booster MMR Booster(2nd dose)
DT-containing vaccine- 2nd booster
rd
Frader, D. and Cooper, M. (Eds.). (2009). Myles textbook for midwives (15th ed). Edinburgh: Churchill Livingstone. Murray, S.S. & Mckinney, E.S (2010). Foundation of maternal newborn nursing (5th ed). St. Louis : Elsevier Saunders. Chao, V.T.T.(1993) . Breastfeeding. The Journal of Singapore Paediatric Society 35 ( 1 & 2), 77-91 Lowdermilk, D. L. & Perry, S.E.(Eds.).(2012). Maternity & Womens Health Care (10th ed) St. Louis Mosby Towie , M. A. (2009). Maternal-newborn nursing care. New Jersey: Prentice Hall From http://www.youtube.com/watch?v=pHLgva3PLuk . http://www.nlm.nih.gov/medlineplus/ency/article/002920.htm (assessed on 20 December 2011) http://www.babycenter.com.sg/baby/health/immunisationchart/ (assessed on 20 December 2011) http://www.drugs.com/cg/episiotomy.html (assessed on 20 December 2011) http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0004481/ (27 December 2011)