so this is a typical pattern for monitoring for Mom postpartum remember that even if the mom is completely normal and healthy um you still have to watch for infections bleeding and um thrombotic issues um if they were to happen to have hemorrhoids ice is always helpful tux pads witch hazel pads um tea Parry pads but you don't want them to use a donut now on their peranan you may see some redness or swelling um you don't want them to have any kind of foul smell and discharge or bleeding more than um where they'll have to change more than one pad an hour no large clots or anything like that sometimes they will have like an otomy or laceration they will sometimes get a hematoma or bruising now they may be swollen and bruised postpartum just you know from delivery and if they have to have an otomy where the doctor cuts um their bottom so that the baby can come out easier that can take four to six months to completely heal um a midline is going to be straight down towards their butt or medialateral is going to be um laterally and down toward the right or the left of their bottom and then lacerations and otomies are classified according to the tissue that's involved so they're classified through a first degree through a fourth degree then periurethral um stuff like that it's just breaks down into different things this is is a very painful area to have to have an incision it's going to affect how they walk how they sit how they squat Bend even go to the bathroom sits baths um have heat to promote the blood flow and the healing to that area ice packs are more for um swelling and discomfort peric care um they'll rinse with warm tap water after each time they go to the bathroom and then you want to make sure that you have them pat dry they can take like um moin or Tylenol sometimes the doctors will prescribe them like a percocet or um Laura tab to take every so often um they'll also use those witch hazel pads and like a topical anesthetic like um I don't know I can't remember the word for it right now and then with that surgical incision um again could just be that midline or that medial lateral dermoplast is the topical anesthetic that I was thinking of a slight temperature um is normal for 24 hours just because that's the body's response to birth um the body has went through a lot um any anything over 100.4 that's persisting over 24 hours is not normal their pulse may be lower posttop it may be tacky if they're in pain if they're dehydrated anemic infection um a big one here is blood loss you really want to make sure you're monitoring their pulse especially for blood loss um just try to keep a good eye on it especially if it varies um much from their normal and then their blood pressure um should start going back to those first trimester levels so watch for um orthostatic hypotension and then respirations should be stable um always osculate um on those C-section patients anybody that smokes especially if they're on magnesium if they have any kind of history with respiratory issues they um they tnic short of breath um if they have chest pain or anxiety or they become Restless think of um PE when you're doing a postpartum assessment um you want to make sure that you're paying attention to the breasts making sure that they're symmetrical looking for any redness temperatures um any cracks on the mom's nipples are bleeding just from poor latch and that's a good educational moment um are their breasts firm usually that's a sign or symptom that the milk's starting to come in um you especially want to take a look at their uterus um you'll have them empty their bladder first um usually they'll lay back and you'll assess the location of the fundus um is it firm is it boggy you want to use two hands um one to support the base and one to massage the fundus um it should go down about one finger width per day and then the bladder you want to make sure you're checking to see if it's distended making sure that they're um actually able to empty their bladder if they're not that will affect their bleeding um bow sounds they're usually A little sluggish at first um check their belly if to see if it's distended make sure you're off for in full St um stool softeners and encourage them to drink lots of fluids um one for um breast milk the more fluid you drink the more breast milk that you usually end up with and two the more fluids that they drink the easier it's going to be on them to have a bowel movement you'll look at that low the amount color if it has a bad odor the num number of Parry pads that they're going to be using um scant is usually 1 to 2 in um light or small is about 4 in on a Parry pad moderates 4 to six and then large or heavy um is saturated is one pad in an hour okay so anytime we're doing teaching for these moms we tell them if you're having to change your pad more than once an hour make sure that you're telling a nurse or the doctor or whoever um call out for help especially if you're discharged and you go home and that bleeding starts um make sure you come back to the emergency room so that's important to know you want to look at their otomy or their panum makeing sure that those sutures are intact is there any bruising swelling hematomas hemorrhoids and you can offer to get them ice pack or to do a sits bath um a lot of people really like doing both of those and then you want to look at their extremities and always check their home ins signs assess for dvts um make sure that they have sensory functions and feelings in their legs um always encourage early ambulation and the those scds if they're at high risk for DVT so emotional status how they're bonded with the baby are they able to do eye contact are they happy are they touching the baby or holding him or her that's something you're going to want to look at and then with lacerations that first degree is usually superficial um that vaginal mucosa or paranal skin is all that's torn second degree is that vaginal mucosa paranal skin and deeper tissues like the fascia and the muscle third degree is a second degree but it extends into that anal sphincter and a fourth degree goes through the anal sphincter and into that rectal mucosa par urethal is in the area where the urethra is and they may need a catheter if it's too bad until it heals the um vaginal wall is just the mucosa of the vaginal wall and then cervix is going to include the cervix but with um cervical tears they're going to have significant bleeding because the cervix are very very vascular this is um a list of things to assess when regarding emotional status how they're interacting with their family are they able to do things on their own um did they have any energy to do anything or they only wanting to lay in the bed and not even try to do very much are they Mak an eye contact with the baby are they comfortable with the baby um their sleep and rest patterns you want to make sure that you're paying attention specifically to um are they having mood swing are they irritable are they having um crying episodes where they'll just start crying for no reason for a long periods of time um those are all very important to pay attention to when it comes to um postpartum depression especially bonding is the rapid initial attraction felt by parents um for their new baby usually this occurs within the first 30 to 60 minutes after they're born um usually it occurs um One Direction the baby's quiet um alert and seems to you know just be taking it all in um we need to usually back off during all that and allow them to bond with their baby as much as possible so attachment occurs between the infant and the parents and the parents are going to provide food they're going to provide warmth they're going to be able to give the baby security um the mom's going to accept the responsibility for the baby in the best case [Music] scenario um she's going to be able to put the babies needs before her own she's going to have satisfaction out of all this and grow in her identity as a mom um the baby will then you know continue to be thriving um mom gives and gets something back from this experience she forms this attachment to the baby and the baby's going to form an attachment to her so this is going to move in two directions there are three stages of attachment one um is proximity where the parents are remaining close to the baby um reacy um is when infants behaviors elicit a um parental response and then commitment is the parents place the infants welfare at their utmost important so touch is another process at first you see the mom's gazing on at the baby and then once she gets to hold the baby um she holds it at an inace position so that she can see the baby and the baby can see her next um she usually will start touching the baby but only with her fingertips you know just to be gentle um eventually she'll go ahead and start to use more of her hand the palm of her hand then her entire hand and arms to hold the baby close to her and then she'll start to identify familiar features that baby has that she claims um she'll start to claim the baby as her own like um the baby you will have my dad's nose or her dad's eyes um things of that nature now verbally parents progress from calling the baby it to using the baby's name again this is when they're claiming the baby this is where that Ericson's trust versus mistrust starts it begins right through here so if this doesn't happen it can affect the baby for the rest of its life so um read the positive and negative attachment behaviors in your book the rest of these slides talk more about teaching for those postpartum patients so after pains um after delivery they're still going to have those intermittent contractions it's going to feel like menstrual cramps or Worse these are going to be more pronounced with the more babies they have because the repeat stretching leads to loss of that muscle tone so those contractions um postpartum is going to be a little worse same for multifetal pregnancies um if they're having twins or triplets if the babies are large for gestational age or if they have polyhydramnios um most severe during breastfeeding because um breastfeeding helps to release oxytocin from the posterior pituitary to stimulate that milk let down and that's going to stimulate contraction so they will complain of more pain and um cramping during breastfeeding analgesics are given for comfort and that's going to allow mom to breastfeed more comfortably um usually it will start to decrease after the first two days now with pain they might actually be hesitant to take any medicines because they don't want any medicines that are going to go to their baby or that's going to hurt their baby and that's completely normal so you want to ask the mom if she needs pain medicine um they you know can take analgesics um Tylenol moin a Le they can even take like Tylenol 3 peret or Lura tab stuff like that is safe for the baby um applying those ice packs for any kind of ASO constriction and pain control for the first 24 hours are beneficial you can put ice in gloves or in a washcloth or paper towel um remove you know in 10 minutes and apply a new one so ambulating early if possible to prevent that um any kind of clots is recommended you can give Lovenox um if it's ordered and use those scds when you're doing per care squirting that warm tap water over the perineum with a warm or with a Parry bottle after they void or have a bowel movement um is always B beneficial you want to make sure that you're telling them you know always wipe from front to back never back to front and pat dry especially if there are stitches involved that dermaplast after the peric care helps um it's that local anesthetic and then you can apply the pad um tuck and stuff like that's used for hemorrhoids usually I'll have my patients lay those tux pads um in a line on their pad and just push that up onto their bottom and not only is it cool um for them to to have that on there it's a cooling feeling um it'll help with hemorrhoids and just like healing so please make sure that you read through the information about infant safety I cannot imagine anything worse than a baby being stolen from a hospital that would be absolutely absolutely absolutely terrible um you really don't want that to happen um at all but much less under your care so be very diligent about um checking those baby bands we do have matching baby bands for moms dads and babies um there's a number on there you'll check those numbers you'll check the name you'll tell the parents you know this is the bands that we use this is why we use them this is the way it works um please don't give the baby to anybody who comes in the room asking for it who doesn't have um an ID badge on and in the labor and delivery unit at Princeton hospital they have um colorcoded scrubs so I always will tell them you know if they don't have these Navy scrubs on for one you know they're not up here um the lab will never come in and ask to take your baby to the nursery please if you're confused um ask to see their badge it won't hurt anybody's feelings so it is mandatory now for some or for all hospitals to use some sort of security measures so those ID bracelets that you'll check every single time you take the baby to the mom or they come and get the baby from the nursery or whoever they have to have a band to do that special photo name tags for staff um Footprints are done in the delivery room before the infant leaves the parents site that's not practiced at um Princeton we just do those bands before the baby ever leaves the room they're transported only in a crib wherever they go they're never allowed to be carried in the hallway under any circumstances and then we do have a security band system that we use and it kind of looks like a little home confinement bracelet and we put those on the baby's ankles um until they go to be discharged and then we'll discontinue those and anytime they get too close to the window or the doors it will um set off alarm on the whole unit you want to make sure that you're providing a balanced diet with plenty of fluids about 2500 MLS a day Mom can count on losing about 10 to 13 lbs during delivery and another 5 to 8 lbs in the first week most women have a steady loss over the first 3 to six months but do usually retain a little weight with each pregnancy um supply and demand system so is um for breastfeeding so the more that the baby nurses the more the mom will produce so nipple stimulation will stimulate oxytocin and prolactin to release the milk they usually are soft and non- tender the first few days um until that milk really comes in they usually will start to be more engorged and their breasts will be more firm that third day postpartum um and it may actually take up until 5 days from infrequent feedings and incomplete emptying of the breasts so frequent nursing is the best cure if the mom is breastfeeding and then um if the mom's not breastfeeding I mean even if she is there's some other things that they can do for Comfort um especially on they're really really engorged that's very painful so warm showers or compresses cold or ice packs cabbage leaf compresses um ever wonder why they keep cabbage in the fridge on postpartum um that right there is why those cabbage leaf compresses ineds if they're hurting too bad they can take moin or something like that don't use soap on the breasts if Mom's nursing because you don't want the baby um putting their mouth on that um for sure if they're not breastfeeding you want to do a tight tight tight tight supportive bra about 24 hours a day usually we recommend a sports bra ice for about 15 to 20 minutes every other hour cold showers cool showers um turn away from the water you don't want to let warm water if you're taking a warm shower run over the breasts and you don't want to do any kind of breast stimulation so usually after Mom delivers we will try to get them out of the bed and moving around um at that 2hour Mark if not beforehand um so you want to make sure you're checking their blood pressure first you don't want to get them up if their blood pressure is too high or too low you can Elevate the head of the bed for a few minutes before you get them out of the bed you know just to make sure that they're not going to get dizzy or laded um they can sit on the side of the bed for a few minutes but their feet on the floor again make sure they're not going to get too dizzy or too laded you know just sit there compose themselves before they try to go anywhere um further then you can have help have them stand up now usually the first time they get out of the bed you want to have two people in case they do go to pass out cuz it's common you'll kind of stand there hold the arms or be readily available walk beside of her towards the bathroom and provide any kind of support if she needs it cuz again that dizziness stringing in the ears that feeling that they're going to pass out or passing out it's very common when they get out of the bed the first time um after delivery so continuously you're saying you know how do you feel can you see everything okay do you have any ringing in your ears do you feel dizzy do you feel nauseous um you know just talk to them to the bathroom and be cautious if you notice they were talking and now they're not just you know pay attention in a assess the situation make sure that you are close enough to help if those things do start to happen because once they come they usually pass out fairly quickly so when you're preparing mom for discharge that discharge criteria is going to include the mom had a no fever um FAL signs are good bleeding amounts okay and the color's good um that fundus is going to be firm and that urine output is adequate their hemoglobin and hematica are in those normal ranges or hasn't had a significant drop from their normal their um blood type and Rh status if they have to have Rog gam you know they'll get that before they go home you'll assess their wounds make sure those are healing properly that the mom's able to ambulate without any kind of assistance self and infant care teaching is done and understood um the baby's going to be eating very well um and you want to make sure they do have a support system available at home now during their pregnancy their labs are done so they will be given the rebell vaccine if they um are non-immune on those labs when they come back now they can refuse them um but you want to make sure you're telling them you to avoid being pregnant for 28 days if you're getting that rebell vaccine and of course like anything else you're going to make sure you have a consent even if they're not immune you have to have a consent before you do any of this so rogam is given within 72 hours of delivery to those Rh negative moms that are are eligible so the first dose is usually given at 28 weeks and then again after delivery and this is given I am and again consent is required heaps often given prior to discharge to prevent pusis if not um given within the last two years so you'll just have to evaluate that and again you have to have consent for that as well if your patient has any history of te um seizures they cannot have a Dap vaccine