1. Pain related to engorgement.
      2. Personal identity disturbance related to problems in breastfeeding.
      3. Sleep pattern disturbance related to discomfort or infant care needs.
    2. Nursing care plan/implementation:
      1. Goal: promote successful breastfeeding.
        1. Encourage first feeding within 1 hr after giving birth.
        2. Encourage emptying both breasts at each feeding and before engorgement to stimulate milk production, prevent mastitis.
        3. Encourage rest, relaxation, fluids.
        4. Nutritional counseling.
          1. Additional 500 calories daily - may be supplied by one extra pint of milk, one extra egg, and one extra serving of meat, citrus fruit, and vegetabl
          2. Increase fluid intake to 3000 mL daily.
      2. Goal: prevent or relieve engorgement.
        1. Pain: relieved by warm packs, emptying breasts.
        2. Wear good, supportive br Administer analgesics, as ordered/necessary.
      3. Goal: health teaching.
        1. Instruct, demonstrate rooting reflex and putting infant to breast. Infant must grasp nipple and areola over location of milk sinuses.
        2. Demonstrate burping techniques, what to do if infant chokes; removing infant from breast.
        3. Instruct in basic nipple care.
          1. Teach good hand washing.
          2. Nurse on each breast, making sure areola is in mouth, alternating position of infant.
          3. Alternate “beginning” breast.
          4. Break suction before removing infant from breast.
          5. Air-dry nipples after each feeding and apply lanolin if abrade Note: Creams, lotions, or ointments block secretion of a natural bacteriostatic oil by Montgomery glands—and infant may refuse breast until it is washe Instead: expressed milk may be massaged gently around nipple.
          6. Teach daily hygiene of breasts.
        4. Instruct in care of cracked or fissured nipples.
          1. Encourage and support mothers.
          2. Air-dry nipples after each feeding.
          3. Use nipple shield if nipples extremely sore.
          4. Discontinue nursing for 48 hr; maintain milk supply by expressing milk with pump.

        5. Discuss avoiding use of any drugs except under medical supervision—may affect infant or suppress lactation.
        6. Discuss possibility of sexual stimulation during breastfeeding.
          1. Validate normalcy and acceptability.
          2. Note: During orgasm, milk may squirt from nipples.
        7. Explain that contraceptive value of nursing is unpredictable; time ovulation is inhibited varies widely.
        8. Explain contraindications to breastfeeding:
          1. Active tuberculosis.
          2. Severe chronic maternal diseasr.
          3. Mastitis (temporary interruption may be necessary).
          4. Narcotic addiction, therapeutic drug dependence.
          5. Severe cleft lip or palate in newborn (may pump and give in special bottles).
          6. HIV-positive status; AIDS.
          7. Drug abusers (must be drug-free 3 mo).
    3. Evaluation/outcome criteria:
      1. Woman verbalizes understanding of breastfeeding techniques, nutritional requirements for successful lactation.
      2. Woman successfully demonstrates breastfeeding; infant nurses well.
      3. Woman demonstrates appropriate burping techniques; clears excessive mucus from infant’s mouth without incident.
      4. Woman verbalizes understanding of basic breast care techniques:
        1. Self-examination.
        2. Clear water bat.
        3. Drying nipples after bathing, feeding.
        4. Care of cracked or irritated nipples.
        5. Correct infant positioning for feeding.

Complications During the Postpartal Period

  1. Disorders affecting fluid-gas transport

    1. Postpartum hemorrhage
      1. Definition - loss of 500 mL of blood or more during first 24 postpartal hr in vaginal birth; 1000 mL in cesarean birth.
      2. Pathophysiology - excessive loss of blood secondary to trauma, decreased uterine contractility; results in hypovolemia.
      3. Etiology (in order of frequency):
        1. Uterine atony
          1. Uterine overdistention (multipregnancy, polyhydramnios, fetal macrosomia).
          2. Multiparity.
                1. Prolonged or precipitous labor.
                2. Anesthesia - deep inhalation or regional (particularly saddle block).
                3. Myomata (fibroids).
                4. Oxytocin induction of labor.
                5. Overmassage of uterus in postpartum.
                6. Distended bladder.
              2. Lacerations - cervix, vagina, perineum.
              3. Retained placental fragments - usually delayed postpartum hemorrhag
              4. Hematoma - deep pelvic, vaginal, or episiotomy sit.
            2. Assessment:
              1. Uterus - boggy, flaccid; excessive vaginal bleeding (dark; seepage, large clots) - due to uterine atony, retained placental fragments.
              2. Late signs of shock - air hunger; anxiety/apprehension, tachycardia, tachypnea, hypotension.
              3. Blood values (admission and postpartal) - hemoglobin (Hgb), hematocrit (Het), clotting tim
              4. Estimated blood loss: during labor/birth; in early postpartum.
              5. Pain: vulvar, vaginal, perineal.
              6. Perineum: distended - due to edema; discoloration - due to hematom May complain of rectal pressure.
              7. Lacerations - bright red vaginal bleeding with firm fundus.
            3. Analysis/nursing diagnosis:
              1. Fluid volume deficit related to excessive blood loss secondary to uterine atony, retained placental fragments.
              2. Anxiety/fear related to unexpected complication.
              3. Altered tissue perfusion related to decreased oxygenation secondary to blood loss.
              4. Activity intolerance related to fatigue.
            4. Nursing care plan/implementation:
              1. Medical management:
                1. IV oxytocin infusion; IV or oral ergot preparations (ergonovine [Ergotrate maleate]; methylergonovine [Methergine]; carboprost (Prostin/ M15), an oxytocic; prostaglandin.
                2. Order blood work: clotting time, platelet count, fibrinogen level, Hgb, Het, CB.
                3. Type and crossmatch for blood replacement.
                4. Surgical:
                  1. Repair of lacerations.
                  2. Evacuation, ligation of hematoma.
                  3. Curettage—retained   placental fragments.
              2. Nursing management:
                1. Goal: minimize blood loss.
                  1. Notify physician promptly of abnormal assessment findings.
                  2. Order lab work stat, as directed—to determine blood loss and etiology.
                  3. Fundal massage.
                    1. Administer medications to stimulate uterine ton For ergot products and carboplast, monitor blood pressure (contraindicated in PIH).
                    2. Goal: stabilize status.
                      1. Establish IV line—to enable administration of medications and rapid absorption/action. Administer whole blood (with larger catheter).
                      2. Administer medications, as ordered to control bleeding, combat shock.
                      3. Prepare for surgery, as ordered.
                    3. Goal: prevent infection. Strict aseptic technique.
                    4. Goal: continual monitorin Vital signs, bleeding (do pad count or weigh pads), fundal status.
                    5. Goal: prevent sequelae (Sheehans syndrome).
                    6. Goal: health teaching —after episode: Reinforce appropriate perineal care and handwashing techniques.
            5. Evaluation/outcome criteria:
              1. Maternal vital signs stable.
              2. Bleeding diminished or absent.
              3. Assessment findings within normal limits.
          2. Subinvolution—delayed return of uterus to normal size, shape, position.
            1. Pathophysiology—inability of inflamed uterus (endometritis) to contract effectively —> incomplete uterine involution; failure of contractions to effect closure of vessels in site of placental attachment —> bleeding.
            2. Etiology:
              1. PROM with secondary amnionitis, endometritis.
              2. Retained placental fragments.
              3. Oxytocin stimulation or augmentation of labor of overdistended uterine muscle may interfere with involution.
            3. Assessment:
              1. Uterus: large, boggy; lack of uterine tone; failure to shrink progressively.
              2. Discharge: persistent lochia; painless fresh bleeding, hemorrhagic episodes.
            4. Analysis/nursing diagnosis:
              1. Pain related to tender, inflamed uterus secondary to endometritis.
              2. Anxiety/fear related to change in physical status.
              3. Knowledge deficit related to diagnosis, treatment, prognosis
              4. High risk for injury related to infection.
              5. Fluid volume deficit related to excessive bleeding
            5. Nursing care plan/implementation:
              1. Medical management:
                1. Have woman void or catheterize; massag
                2. Surgical (curettage) —to remove placental fragments.
                3. Antibiotic therapy—to treat intrauterine infection.
                4. Oxytocics—to   stimulate/enhance uterine contractions.
              2. Nursing management:
                1. Explain condition and treatment.
                2. Describe, demonstrate perineal care, pad change, handwashin
                  1. Goal: health teachin
                  2. Goal: emotional support. Encourage verbalization of anxiety regarding recovery, separation from newborn.
                  3. Goal: promote healin
                    1. Encourage rest, compliance with medical/nursing regimen.
                    2. Administer oxytocics, antibiotics, as ordere
            6. Evaluation/outcome criteria:
              1. Verbalizes understanding of condition and treatment.
              2. Complies with medical/nursing regimen. progress.
              3. Demonstrates normal involutional
              4. All assessment findings (vital signs, fundal height, consistency, lochial discharge) within normal limits.
              5. Expresses satisfaction with car
          3. Hypofibrinogenemia
            1. Pathophysiology— decreased clotting factors, fibrinogen; may be accompanied by DI
            2. Etiology:
              1. Missed abortion (retained dead fetus syndrome).
              2. Fetal death, delayed emptying of uterine contents.
              3. Abruptio placentae; Couvelaire uterus.
              4. Amniotic fluid embolism.
              5. Hypertension.
            3. Assessment:
              1. Observe for bleeding from injection sites, epistaxis, purpur
              2. See DIC assessment, p. 459, and Unit
              3. Maternal vital signs, color.
              4. I&O.
              5. Medical evaluation—procedures.
                1. Thrombin clot test—important: size and persistence of clot.
                2. Prothrombin time—prolonge
                3. Bleeding time—prolonge
                4. Platelet count—decrease
                5. Activated partial thromboplastin time—prolonge
                6. Fibrinogen (factor I concentration) —decrease
                7. Fibrin degradation products—present.
            4. Analysis/nursing diagnosis:
              1. Fluid volume deficit related to uncontrolled bleeding secondary to coagulopathy. emergency.
              2. Anxiety/fear related to unexpected critical
              3. Altered tissue perfusion related to decreased oxygenation secondary to blood loss.
            5. Nursing care plan/implementation:
              1. Medical management:
                1. Replace platelets
                2. Replace blood loss
                3. IV heparin—to inhibit conversion of fibrinogen to fibrin.
              2. Nursing management:
                1. Goal: continuous monitorin
                  1. Vital signs.
                  2. I&O hourly.
                  3. Skin: color, emergence of petechia
                  4. Note, measure (as possible), record, and report blood loss.
                2. Goal: control blood loss.
                  1. Establish IV line, administer fluids or blood products as ordere B Position: side-lying—to maintain blood supply to vital organs.
                3. Goal: emotional support.
                  1. Encourage verbalization of anxiety, fear, concerns.
                  2. Explain all procedures.
                  3. Remain with woman continuously.
                  4. Keep woman and family informe
            6. Evaluation/outcome criteria:
              1. Bleeding controlle
              2. Laboratory studies—returning to normal values.
              3. Status stable