Maternity - Postpartum, part 2: Perineal and Breast Care, Postpartum Immunizations
by Meris Shuwarger BSN, RN, CEN, TCRN November 30, 2021 Updated: June 16, 2022 8 min read
Hi, I'm Meris with Level Up RN. And today, I'm going to be talking to you about postpartum care, specifically perineal care, breast care, and postpartum immunizations that may be administered to a patient prior to discharge. I'm going to be following along using our maternity flashcards. These are available on our website, LevelUpRN.com, if you want to grab a set for yourself. And if you already have your own deck, I would invite you to follow along with me. Okay. Let's get started. So first up, we're talking about perineal care of the postpartum patient. And I've mentioned this in a previous video, but it's important to educate your patients that even if they had a C-section, they are still going to have perineal swelling, pain, and vaginal discharge. And so all of the teaching here will apply to all patients, including patients with C-sections. And it's just going to kind of be plus or minus how much pain they personally are experiencing. So on here, we have a note that says that you can apply ice packs to the perineum. This is going to help with pain, but it can also help to prevent any formation of hematomas. So a collection of blood, which will be very painful as well. Now, when your patients use the restroom, you don't want them to wipe with toilet paper because, again, they're swollen. They are painful. They might have sutures if they needed surgical repair of lacerations. So it's best not to wipe with toilet paper. But instead, we have these spray bottles. They're sometimes called peri bottles. But they're just a water bottle with a little spray nozzle. And so what you would want to educate the patient to do is to fill that bottle up with warm, not hot, but just warm water. And after voiding, they're going to use that bottle to kind of spray down the perineum, the vulva, all of that. That's going to help to remove any urine or feces from the area. And then you would want to just gently pat dry. So we're not wiping. We're just patting dry. This is really going to help to decrease any sort of further irritation. And actually, I know a lot of patients really enjoyed the feeling of that peri bottle because it provides some pain relief as well, especially when everything is so swollen and painful.
Now, another thing that can be done is something called a sitz bath. And this can be done several times a day for 15 to 20 minutes. But the idea here is that-- some places have actual sitz bath setups. Some don't. And you can use just a large emesis basin or something similar. But the idea being just fill it with warm water and have the patient sit in it and place their perineum in it. This, again, is going to help with pain and swelling and just going to feel better for that patient. Then topical anesthetic agents, these are mainly used in patients who had vaginal births. But the example here is benzocaine. There's lots of different brands on the market, but this is a spray that is actually sprayed onto the perineum. And it contains a numbing agent. So that can help with that pain relief as well. And then witch hazel pads can be used to reduce pain and swelling associated with hemorrhoids. And you can actually-- there's lots of tutorials out there. When I did my preceptorship on a postpartum unit, they had what they called padsicles. And they were maxi pads that they had filled with witch hazel and something else that I can't recall. But they kept them in the freezer on the unit. And then they would provide them to the patients. And the patients really loved it. It's frozen. So it's cold. It helps with that swelling. And then it also has the witch hazel for the inflammation. And then,
of course, we want to educate our patients to drink more water, increase their fiber intake, and we may even give them a stool softener per order to help with those first few bowel movements following delivery because they can be pretty painful. So moving on to breast care. We have a couple of things to talk about here. The first is colostrum versus milk. Colostrum is the substance that is first produced, and it's actually produced during pregnancy and then for about the first two to three days after delivery. This is different than milk, and it has tons of antibodies. It's got proteins, fat soluble vitamins. It's really nutrient dense, but there's not a lot of it. Patients sometimes get concerned that they're not producing enough milk, and this is where it would be your job to educate that, "You're right. Actually, this is not milk. This is colostrum. I know it looks like there's very little, but it is all that your baby needs right now." And also, the infant stomach is very small at birth. It gets larger over the next few days, but it is very small, so they are not as hungry as you think they are. And this colostrum is really good for them and gives them a lot of immune boosting benefits. Now, milk is not produced until three to five days following delivery. Which brings us to our next point, breast engorgement. I am going to tell you that I did not have milk until day three when my daughter was born, and I knew that my milk had come in because when I woke up, I was in so much pain. I had breast engorgement because my milk came in while I was sleeping, and she was not feeding. So breast engorgement is very painful, and it can become a problem. It can lead to complications like mastitis, if not dealt with completely. So we would want to encourage our patients to empty their breast completely with each feeding. So this is why we educate patients to feed a newborn on both breasts at each feeding. So we want to empty those breasts. And if we were to find that after feeding they're still full, this may be where we do some manual expression of breast milk or even pump. We do want to be careful because this is kind of that positive feedback mechanism. The more we empty the breast, the more it tells the brain to fill it back up. So there is a little bit of a balance here, and that's one of those things that gets worked out as the baby grows and as breastfeeding becomes more of a constant thing. And also, we would educate our patients to use warm compress on the breasts prior to feeding. This is going to help to open those milk ducts open, get better blood flow to the area and really help us to get everything out with each feeding. Now on the flip side, if we have a patient who does not wish to breastfeed for any reason, we can talk about suppression of lactation. So in this instance, if the patient is trying to suppress or stop breastfeeding lactation, then we would teach them to wear a supportive bra for 72 hours following delivery. So supportive and also kind of tight fitting. We don't want it to be like a nursing bra, but more like a really supportive sports bra, for instance. And then we also want to avoid breast stimulation and warm water on the breast. Again, breast stimulation is going to tell the brain, make more milk and warm compress or warm water is going to also increase that circulation and help make more milk. So we want to avoid that. We have a key point here, and this is something that a lot of students struggle with because it seems fake. But if your patient is trying to suppress lactation, you can apply fresh cold cabbage leaves to the breast, which will actually help
with suppressing lactation. I cannot tell you the exact science behind it, but I can tell you that it is a very real thing. And so I know it sounds weird to be applying cold produce to your patient's breast, but that is actually the appropriate teaching. Okay. Moving on to some more patient teaching about breastfeeding. We want to educate our patients that they've got to wash their hands before breastfeeding because breastfeeding is going to involve touching your own breast, which then is going to go in the mouth of your infant. So be sure to wash your hands. We want to ensure a correct latch, and you can watch my video in the newborn care section for more about that. But that does involve a portion of the areola being in the infant's mouth as well. If your patient has sore or cracked nipples, we can actually teach them to apply breast milk to the nipples after a feeding and allow it to dry. This, again, kind of seems silly and like an old wives tale, but remember that breast milk has white blood cells, emit antibodies, all of that kind of good stuff. And so it can actually help to be sort of prevent infection and to help with that soreness. Now mastitis, which we will talk about in a future video, but we want to educate our patients to report signs of mastitis, and we want our patients to drink a lot of water. That breast milk is mostly water. So you need to stay hydrated by drinking enough water to produce enough milk. Now also, there is a key point on here. We talked about it in the fundal assessment video, but breastfeeding produces oxytocin. Oxytocin causes cramping of the uterus because it causes the uterus to contract back down. Educate your patients that this is normal. This is expected, and this is actually a good thing to help prevent postpartum hemorrhage. Okay. Lastly, we are going to talk about postpartum immunizations. If you think way back to that early pregnancy section of the deck and the videos, we talked about the fact that we test for immunity to several different conditions out there. Things like varicella and rubella. And if your patient is immune, they don't need the vaccination later. However, if they are not, they cannot receive these vaccines in pregnancy because they are live virus vaccines. So we would want to give it to them when they are postpartum. Now, rubella is given to patients without immunity, but it is contraindicated for immunosuppressed or immunocompromised patients, as are all live virus vaccines. And some very important patient teaching is that pregnancy must be avoided for at least 28 days following administration. Remember also that rubella typically comes combined in the measles, mumps and rubella vaccine. So if your patient received the MMR vaccine, that same teaching would apply. They need to avoid pregnancy for 28 days. That is also true for varicella. So the first dose would be given prior to discharge from the hospital. The second dose would be given at the follow-up appointment about six to eight weeks after delivery. But they need to avoid pregnancy for 28 days following that second dose, right? Following either dose. But in order to be fully vaccinated, it would be that second dose.
Tdap. Tdap is given to patients typically around 30 to 32 weeks of pregnancy. However, if the patient did not receive Tdap at that time, we would want them to have it prior to discharge to help protect that infant from contracting pertussis specifically. And then Rhogam. Rhogam, remember is that immune globulin for Rh negative patients to keep them from creating antibodies against Rh positive blood should their infant have RH positive blood. Rogan is given within 72 hours of delivery, but it is only given to patients who have Rh negative blood types. And that would really help to prevent complications in future pregnancies. Okay. I hope this review was helpful. Be sure to stick around because I'm going to ask you some quiz questions to test your knowledge of some key facts I provided you in this video. Okay, let's do some quiz questions to test your knowledge. First up, how long after delivery is it before breast milk is produced? So when does milk come in essentially? Next question. A patient expresses a desire to formula feed and suppress lactation. What interventions might the nurse suggest? So I gave you a few. Think of some. Let me know. Here is a question. Your patient reports having sore nipples. What intervention does the nurse suggest? And lastly, how long should a patient avoid pregnancy following administration of the MMR vaccine? Let me know how you did in the comments. I can't wait to hear. Thanks so much. And happy studying.
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