Psychological Postpartum Assessment (Nursing)

by Jacquelyn McMillian-Bohler, PhD, CNM

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      Slides Psychological Changes Nursing.pdf
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      Slides Psychological Changes Psychological Postpartum Assessment Nursing.pdf
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      Reference List Maternity Nursing Care of the Childbearing Family.pdf
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    00:01 So let's talk about emotions.

    00:03 This is one of the areas in the postpartum period that up until recently, we just weren't asking enough questions.

    00:09 So we absolutely want to look for signs of depression.

    00:12 And this is, I just can't stress enough how important this is.

    00:17 Because what we have found is that when we don't take care of the patient's emotional status, that can have long term effects for them, it can have long term effects for the child and for everyone else that they're around.

    00:30 So it's very important that we begin the assessment here, it doesn't end with the hospital.

    00:35 But we definitely need to make sure that we start.

    00:38 So if a client has had a history of depression, or they've been treated for depression, during their antepartum period, then we definitely know their increased risk for postpartum depression.

    00:49 And one of the biggest things we can do to help prevent depression is to make sure that the client is getting enough rest.

    00:56 Oh I know, rest and new baby don't exactly go together.

    01:00 But there are ways that we can help promote that.

    01:04 Now, baby blues is just that feeling of maybe overwhelm, anxiety that's very typical and it may last up until 2 weeks postpartum.

    01:13 Think about all the hormones that are floating around in the system that are trying to find their way back to a normal level.

    01:18 And that might cause some teary moments.

    01:21 And being a little tired may make you teary and things hurting sometimes may make you feel not so great.

    01:28 That's normal, about 80% of clients can expect that they will have that as a symptom.

    01:34 But they need to understand that if it progresses longer than 2 weeks, that's not baby blues, and they need to come in and they need to talk to someone.

    01:42 So we can not only promote rest, but also support.

    01:46 So while we're in there with the client, who's coming to visit? Who's there? Who can they identify to give them a break when they need it? Or let them sleep and watch the baby so they can do something else.

    01:57 This is so so so important.

    02:01 We have a scale called Edinburg depression scale.

    02:03 And I'm going to talk a little bit more about that a little bit later in this slide deck.

    02:07 But I want to make sure that you think about this because we don't do enough of assessment with this scale.

    02:14 Thinking about bonding.

    02:16 So this is our final end of our pneumonic.

    02:18 We want to see how the client is interacting with the infant.

    02:22 Are they together? Where is the infant? Every time the nurse comes in the room, is the baby on the other side? Is someone else holding the baby? Does the client seem not very interested in the newborn? That is a sign that something may not be going as it should be.

    02:37 If they're not interested in taking care of the baby, if they're not interested in changing the diaper or knowing that the feeding is going okay, then again, there may be an issue.

    02:48 Now I want to put this in context.

    02:49 If this is baby number 8, this may be the only break that the patient gets.

    02:54 And their desire to maybe have some time away from the baby might be completely understandable.

    02:59 But definitely check in on this.

    03:02 And you want to make sure that maybe the parents are proud of the baby like this should be a wonderful thing or they're making fun of the baby or not talking about the baby in a way that exudes sort of positivity, that could also be a sign that the bonding has been impaired.

    03:17 Now Reva Rubin performed this experiment many, many years ago, believe it or not, I learned about this when I was in nursing school, I don't even want to tell you how many years ago, but this is about attachment.

    03:30 And there are 3 phases of attachment.

    03:32 They're called taking in, taking hold and letting go.

    03:37 So in the taking in phase, this usually happens for about the first 24 hours up to day 2.

    03:44 And in this particular phase, then the client is really dependent.

    03:49 So they may need help, they may be preoccupied with the labor and how it went.

    03:54 And so they are really focused on themselves and maybe need some extra help with changing diaper or getting the baby to breast or any of those things.

    04:03 After we move past day 2, the phase of taking hold comes in.

    04:08 And the interest about taking care of the infant should pop in.

    04:11 And they should be eager to learn about what they need to do to make sure the baby is safe and happy.

    04:16 They're still reliant on a little bit of support from everybody else, but they're not as focused on themselves.

    04:23 The final phase of attachment is letting go.

    04:26 Now, this letting go phase means that they've really integrated this baby into their whole life.

    04:31 So they're thinking about, "Oh, I'm going to take the baby to the store, I'm going to be with the baby while I'm doing my daily tasks", and they've just sort of gone back to their new normal.

    04:42 Now, letting go with someone who's had 2 or 3 babies before may happen really soon.

    04:48 But if you find that this particular stage is delayed, and this is something you might want to talk to the support and the family about because usually they're going to notice if we find that the client is still very dependent and we're 2 weeks out, something is going on with attachment and we need to assess that a little bit further.

    05:05 So this is Reva Rubin and her stages of attachment.

    05:09 So let's go back through that pneumonic, so that you remember BUBBLE DEB.

    05:14 B for breast, U for uterus, B for bladder, B for bowel, L for lochia, E for episiotomy and that includes cesarean incision, D for DVT, E for emotion, and the last B for bonding.

    05:28 Now, there's some other things that we need to do during the postpartum period.

    05:33 So maybe you'll remember that back when we discuss antepartum.

    05:36 We talked about RhoGAM.

    05:38 And RhoGAM being an injection, and that's given for clients who are Rh-negative.

    05:43 In cases where they may have a fetus that's Rh-positive, and we want to decrease the possibility of sensitization.

    05:49 So this issue is going to come back up again, after the baby is delivered.

    05:53 So if the client is Rh-negative and the infant is Rh-negative, then we don't have to give any RhoGAM, okay? But if the client is Rh-negative, and the fetus is Rh-positive, then there is a possibility of sensitization and so we will need to give RhoGAM within 72 hours, okay.

    06:13 So the good thing is, is that now that the baby is outside, we can actually get a blood type for the fetus, or now the baby, and we'll know.

    06:23 Vaccinations.

    06:24 So again, thinking about the antepartum period, rubella injections were contraindicated, because we can transmit the rubella it's a live vaccine, and that can be transmitted to the fetus.

    06:36 While once the baby's out, then it's safe for the mother or the patient to receive rubella.

    06:42 So if they are rubella nonimmune, this may be an opportunity to correct that.

    06:47 Also, if we're in the middle of flu season, if the client has not already gotten the flu shot, now would be a wonderful time to do so.

    06:56 What other things do we need to think about during the postpartum period? Well, comfort, because again, there's a lot of reasons why the patient might not be comfortable after all those things that have happened.

    07:06 So we can offer some suggestions.

    07:09 If the client is feeling contractions, then remember, the uterus has to stay firm in order to diminish the possibility of a uterine hemorrhage, right.

    07:19 So if we do that, then thinking about how hard the uterus has to contract to stay firm, it's going to be pretty uncomfortable.

    07:26 And the more babies you have, the more outstretched the uterus is going to be, and the stronger those contractions are going to be.

    07:34 So if that happens, and this is a complaint that the client has, we can use non-steroidal anti-inflammatories to help with that.

    07:42 Other things that are non-pharmacological for clients who really don't want that would be things like a heating pad or lying prone.

    07:50 So applying pressure to the abdomen sometimes will alleviate some of that discomfort.

    07:55 If you think about it that the uterus is sort of flopping, it's going to contract more.

    07:58 So if we keep it tight, then it will contract less and then we'll have less pain.

    08:04 If the client has experienced any lacerations at all, so whether they be vaginal, whether they've had an episiotomy, or they have a uterine incision, they may have some discomfort.

    08:15 If the lacerations are in the vaginal area, we can use an ice pack for the first 24 hours.

    08:20 Only 20 minutes though, if we keep the ice pack on longer than 20 minutes, we can necrose the skin tissue so we don't want to do that.

    08:28 So ice the first 24 hours, we can use a sitz bath where they sit in warm or cool water to help alleviate some of that discomfort.

    08:37 Or there may be a topical anesthetic spray or foam that might be prescribed that they can use to help alleviate some of that discomfort.

    08:46 Remember those hemorrhoids we were looking at or looking for.

    08:49 We want to see if they're there because they can be very uncomfortable.

    08:53 Again, ice packs work wonders.

    08:55 We can do sitz baths for that as well, tucks pad and they have witch hazel sort of on a nice big round pad that we can use.

    09:03 We can use gel.

    09:05 There are other sort of topical applications that can be used to help alleviate discomfort from hemorrhoids.

    09:11 If we have sore nipples.

    09:13 Often sore nipples are an indication of poor latch.

    09:16 So one of the things you can do as the nurse is to really check and make sure that the latch while the baby is breastfeeding is actually secure that we're not getting a lot of smacking.

    09:26 So yes, smacking when you eat indicates that something is good.

    09:30 However, smacking when you're breastfeeding indicates that the latch is not good and that will lead to things like bruising and blistering and things like that.

    09:39 So if that occurs, then we can do things like check the latch, we can call the lactation consultant for help with latch.

    09:49 We can also place things like ice or believe it or not teabags.

    09:55 If the breasts are engorged, so let's say the milk is starting to come in.

    09:59 Check this out.

    10:00 Cabbage leaves, right? There is something in cabbage leaves that help with breast engorgement.

    10:05 Really strange, but it works.

    10:08 And one of the best advice that I can give clients when they go home is to take the cabbage and separate the leaves, put it in the freezer, and then you can go to the store, like with cabbage leaves on and they're the perfect shape and they help with engorgement.

    10:21 It's awesome.

    10:23 Okay.

    10:24 If the client is tired, which absolutely makes sense, then we want to encourage them to rest when the baby's resting and ask for help.

    10:33 If someone says, "Is there something I can do?" The answer is always yes.

    10:37 Always yes.

    10:38 Always yes.

    10:40 So I told you we would talk about the Edinburgh depression scale.

    10:44 So now we're going to talk about it.

    10:45 So the Edinburgh depression scale is a series of 10 questions.

    10:49 And the client will answer these questions.

    10:51 Hopefully they did it during the antepartum period.

    10:54 But definitely during the postpartum period.

    10:57 If they have a score that is greater than 10, that is an indication that they may be experiencing postpartum depression, not just blues, but postpartum depression.

    11:06 Question number 10 asked specifically about self harm.

    11:10 If they answered that question in the affirmative, it doesn't matter what else the scale says, then we know that we're going to refer them for care.

    11:17 So this is the Edinburgh depression scale.

    11:21 Before the client leaves the hospital, we have some teaching that we need to do.

    11:25 They need to know what might happen when they go home.

    11:28 And when they might need to call their provider because something serious is going on.

    11:33 If they have a fever that's over 38°C or 100.4°F, then we need to know because there may be an infection brewing.

    11:41 If they have extreme engorgement in the breast so that they are uncomfortable, especially if it's unilateral so 1 breast more engorge than the other, along with pain or redness may indicate mastitis.

    11:53 So we definitely want to hear from them if they're experiencing that.

    11:56 Any pelvic or abdominal pain, especially that's not relieved by our normal medications, because that may be indicative of an infection or it may be indicative of a hematoma that's brewing in the pelvic area.

    12:09 Abnormal lochia.

    12:10 So thinking about the stages, the alba, the rubra, the serosa.

    12:15 Are those occurring in the correct order? We have to talk to the client and let them know what to expect.

    12:20 So if something is off there, they can call.

    12:22 It may indicate again, an infection or hemorrhage.

    12:26 If they're soaking more than a pad an hour, so if you have a maxi pad, and you use it, and you find that you're needing to change that sooner than an hour, because it's saturated, that's too much lochia and we need to know.

    12:39 If the clots are larger than a golf ball, especially if it's not after a period of lying down for a really long time, then we need to know that's too much bleeding.

    12:49 Vaginal odor might indicate an infection.

    12:52 So a fleshy sort of odor is pretty typical, but something that really wrinkles, your nose that smells foul, that's a problem and we need to know about that.

    13:01 If they have urinary frequency, urgency, burning that may be indicative of a urinary tract infection.

    13:08 So we need to hear about that.

    13:11 If they've not had any bowel movement, 2-3 days postpartum, especially if they had a cesarean delivery we want to know about that.

    13:18 But even if they had a vaginal delivery, they may be severely constipated and that's not what we want.

    13:23 So we need to hear from them if they experience that.

    13:27 Calf tenderness might indicate a DVT so if they're feeling that, tell them to give us a call.

    13:33 If they have a depressed mood after 14 days, again, sign of emotional challenges, sign of postpartum depression.

    13:40 We need to know.

    About the Lecture

    The lecture Psychological Postpartum Assessment (Nursing) by Jacquelyn McMillian-Bohler, PhD, CNM is from the course Physiological and Psychological Changes and Assessments (Nursing).

    Included Quiz Questions

    1. Rest
    2. Therapy
    3. Socialization
    4. Antidepressants
    1. The grandmother is holding the baby every time the nurse checks in.
    2. The mother is complaining the baby has no hair.
    3. The mother is breastfeeding the baby.
    4. The mother is taking and sending pictures of the baby.
    5. The mother is inquiring of the nurse about how to care for the baby.
    1. The mother is eager to learn how to breastfeed.
    2. The mother is dependent on others to care for the baby.
    3. The mother is preoccupied with herself and her recovery from labor.
    4. The parents take the baby for a walk in the stroller.
    1. The mother is Rh-negative, and the infant is Rh-positive.
    2. The mother is Rh-positive, and the infant is Rh-negative.
    3. The mother is Rh-positive, and the infant is Rh-positive.
    4. The mother is Rh-negative, and the infant is Rh-negative.
    1. To alleviate postpartum contractions, encourage prone positioning.
    2. To alleviate sore nipples, encourage rotation of the feeding position.
    3. To alleviate hemorrhoids, ensure constipation is controlled.
    4. To alleviate perineal lacerations, ice the area continuously for 24 hours.
    5. To alleviate breast engorgement, place kale leaves on the breasts.
    1. A fever of 101 degrees F
    2. Bilateral breast tenderness
    3. Lochia that turns from pinkish-brown to white
    4. Soaking 1 pad every 3 hours
    1. "I feel like jumping off a bridge."
    2. "I just don't have the energy to care for my baby."
    3. "My husband and I argue constantly."
    4. "I just don't feel like I am an adequate mother."

    Author of lecture Psychological Postpartum Assessment (Nursing)

     Jacquelyn McMillian-Bohler, PhD, CNM

    Jacquelyn McMillian-Bohler, PhD, CNM

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