Chapter 20: Postpartum Adaptations Flashcards
Postpartum period or puerperium
First 6 weeks after the birth
Retrogressive changes
Occur in the body systems during pregnancy and are reversed as the body returns to a non pregnant state
These account for many postpartum physiologic changes
Progressive changes
Less likely to occur than retrogressive but do occur
Ex: initiation of lactation
Involution
Changes of the reproductive system (esp. the uterus) after childbirth so the mother returns to their nonpregnant size and condition
Entails 3 processes: contraction of muscle fibers, catabolism (converting cells into simpler compounds), and regeneration of the uterine epithelium.
When does involution occur
Immediately after driver of the placenta, when uterine muscle fibers contract firmly around maternal blood vessels at the area where the placenta was attached. This contraction controls bleeding from the area left denuded when the placenta separates
The uterus becomes smaller as the muscle fibers (which have been stretched for many months) contract and gradually regain their former contour and size
How is the enlarged uterine muscle cells affected?
By catabolic changes in protein cytoplasm that cause a reduction in individual cell size.
The products of the catabolic changes are absorbed by the bloodstream and excreted in the urine as nitrogenous waste
When does regeneration of the uterine epithelial lining occur?
Soon after childbirth. The outer portion of the endometrial layer is expelled with the placenta
Within 2-3 days, the remaining decidua (endometrium during pregnancy) separates in 2 layers
What are the 2 layers of the decidua?
The first layer is superficial and is shed in lochia
The basal layer remains to provide the source of new endometrium
Regeneration of the endometrium (except at the site of placental attachment) occurs by day 16 after birth
What occurs with the placental site?
It is about 8-10 cm (3-4 inches) in diameter and heals by process of exfoliation (scaling off dead tissue)
A new endometrium is generated from glands and tissue that remain in the lower layer of the decidua after separation from the placenta
This process leaves the uterine lining free of scar tissue which may interfere with implantation of future pregnancies
Healing the placenta takes about 6 weeks
Descent of the uterine fundus (top of the uterus above the openings of the Fallopian tubes)
Helps determine the involution process. Immediately after birth, the uterus is about 1000g (2.2 lbs) and the fundus can be palpated between the symphysis pubis and the umbilicus. Within 12 hours, the fundus rises to the level of the umbilicus. The fundus descends by about 1 finger/ 1cm per day. By the 14th day, it’s in the pelvic cavity and cannot be palpated abdominally.
Descent is documented in relation to the umbilicus. Ex: U - 1 or (down arrow) 1 means the fundus is palpable 1cm below the umbilicus. Within 1 week, the uterus weighs 500g (1 lb) and at 4 weeks, it weighs 100g (3.5oz) or less
Other findings of descent of the uterine fundus
The fundus may be slightly higher in multiparas or women who had an overdistended uterus
When involution doesn’t occur properly, sub involution may occur which can lead to postpartum hemorrhage
Etiology of after pains (intermittent contractions)
This discomfort is more acute for multiparas due to repeated stretching of muscle fibers which leads to loss of muscle tone that causes alternate contraction and relaxation of the uterus. The uterus of a primipara tends to remain contracted- she may still experience severe after pains if the uterus has become over-distended by multifetal pregnancy, a large infant, hydramnios, or if retained blood clots are present. Oxytocin released from the posterior pituitary during breastfeeding may cause strong contractions of the uterine muscles. After pains usually decrease to mild discomfort by the 3rd day after birth.
Nursing interventions for after pains (intermittent contractions)
Analgesics are frequently used for short-term pain relief without harm to the infant
Lying in prone position with a small pillow or folded blanket under the abdomen helps keep the uterus contracted and provides relief
These pains are self-limited and decrease rapidly after 48 hours
Benefits of pain relief (usually outweigh the small effects of the med on the infant)
Comfort and relaxation/ pain relief
Milk-ejection reflex/ letdown reflex
The release of milk from the alveoli into the ducts
Lochia: color changes
First 3 days after childbirth: lochia consists of blood with small particles of decidua and mucus. Reddish/brown color is referred to as lochia rubra.
Amount of blood decreases by day 4 and changes from red to pink or brown-tinged known as lochia serosa composed of serous exudate, erythrocytes, leukocytes, and cervical mucous.
By day 11, erythrocytes decrease and is now known as lochia alba which consists of leukocytes, decidual cells, epithelial cells, fat, cervical mucous, and bacteria. This is present usually until the 3rd week but can last to the 6th week
Lochia: amount
Scant: less than a 2.5 cm (1”) stain on the perineal pad
Light: 2.5-10 cm (1-4”) stain
Moderate: 10-15 cm (4-6”) stain
Heavy: saturated perineal pad
Excessive: saturated peripad in 15 minutes
Understand that what appears to be a light flow may be a moderate flow of the peripad has been in use less than an hour
Women who have cesarean births will go through the same lochia phases as the women who have vaginal births, but the amount will be less.
Lochia is often heavier when getting out of bed because blood that has pooled in the vagina gravitates to flow freely when standing
Days 1-3: lochia rubra
Normal discharge: bloody, small clots, fleshy, earthy odor, red or red/brown
Abnormal discharge: large clots, saturated perineal pads, foul odor
Days 4-10: lochia serosa
Normal discharge: decreased amount, serosanguineous, pink or brown-tinged
Abnormal discharge: excessive amount, foul smell, continued or recurrent reddish color
Days 11-21: lochia alba (may last until 6th week postpartum)
Normal discharge: further decreased amounts, white, cream, or light yellow
Abnormal discharge: persistent lochia serosa, return to lochia rubra, foul odor, discharge continuing
The cervix after childbirth
Immediately after childbirth, the cervix is formless, flabby, and open wide; small tears or lacerations may be present; often edematous
Healing occurs rapidly and by the end of the 1st week, the cervix feels firm, and the external os is dilated 1 cm. The shape of this os is permanently changed: remains slightly open and appears slit-like rather than round, as in the nulliparous woman
The internal os closes as before pregnancy
The vagina after childbirth
Vaginal walls appear edematous, and multiple small lacerations may be present, few vaginal rugae (folds) are present. The hymen is permanently torn and heals with small, irregular tags of tissue visible at the vaginal introitus
Rugae are regained by 3-4 weeks. It takes 6-10 weeks for the vagina to complete involution and regain size and contour it had before pregnancy. It doesn’t regain entire nulliparous size
Vaginal mucosa becomes atrophic and don’t regain thickness until estrogen production by the ovaries is reestablished
Because ovarian function & estrogen production is not well established during lactation, breastfeeding mothers are likely to experience vaginal dryness and possibly dyspareunia (discomfort during intercourse)
The perineum after childbirth
Muscles of pelvic floor stretch significantly during second stage of labor due to fetal head. May be edematous and bruised after childbirth. Some women have a episiotomy (surgical incisions of perineal area) to enlarge opening for birth. Healing of this site begins in 2-3 weeks but complete healing can take 4-6 months
Lacerations of the perineum may occur during delivery. Lacerations and episiotomies are classified according to the tissue involved.
Lacerations of the birth canal: perineum
Classified in degrees to describe the amount of tissue involved. Also may be used to describe the extent of midline episiotomies.
First-degree: involves superficial vaginal mucosa or perineal skin
Second-degree: involves the vaginal mucosa, perineal skin, and deeper tissues, which may include fascia and muscles of the perineum
Third-degree: same as second-degree but involves the anal sphincter
Fourth-degree: extends through the anal sphincter into the rectal mucosa
Lacerations of the birth canal: Periurethral area
A laceration in the area of the urethra may cause women difficulty urinating after birth. Am I dwelling catheter may be necessary for a day or two.
Lacerations of the birth canal: vaginal wall
A laceration involving the mucosa of the vaginal wall
Lacerations of the birth canal: cervix
Tears in the cervix may be a source of significant bleeding after birth
Discomfort
Episiotomies are relatively small; however, the perineal muscles are involved in many activities (e.g., walking, sitting, stooping, squatting, bending, urinating, and defecating)
An incision here can cause great discomfort
Many pregnant women are affected by hemorrhoids (distended rectal veins) which are pushed out of the rectum during the second stage of labor
Nursing considerations
Hemorrhoids, perineal trauma, episiotomy, or lacerations can make physical activity or bowel elimination difficult postpartum.
Relief of this discomfort includes teaching self-care measures such as applying ice, performing perineal care, use of topical anesthetics, and taking ordered analgesics
CV changes
Hypervolemia occurs: 45% increase in blood volume occurs at term allowing the female to tolerate substantial blood loss during birth without falling ill
Average of 500 mL of blood loss occurs with vaginal delivery
Average of 1000 mL of blood loss occurs with cesarean births
CV changes: cardiac output
There is a transient increase in maternal CO after childbirth cause by 1.) an increase flow of blood back to the ❤️ when blood from the urethroplacental unit returns to central circulation, 2.) decrease pressure from the uterus on the vessels, 3.) mobilization of excess extra cellular fluid into the vascular compartment
CO returns to prelabor values within an hour after delivery
Gradually, CO decreased and returns to prepregnancy levels by 6-12 weeks after birth
CV changes: plasma volume
The body rids excess plasma volume needed for delivery by diuresis and diaphoresis
Diuresis (increased excretion of urine)
Facilitated by a decline in the adrenal hormone aldosterone, which increases during pregnancy to counteract the salt-wasting effect of progesterone
As aldosterone production decreases, sodium retention declines and fluid excretion accelerates
A decrease in oxytocin (which promotes reabsorption of fluid) contributes to diuresis
Urinary output of 3000 mL/day is common esp. on days 2-5 during postpartum
Diaphoresis (profuse perspiration/sweating)
Rids the body of excess fluids
Can be uncomfortable and unsettling
Explanations of the cause and provision of comfort measures, such as showers and dry clothing
CV changes: blood values
Leukocytosis occurs with the WBC count increasing to up to 30,000/mm3 during labor and immediately postpartum. WBCs fall to normal by day 6 after birth
The hematocrit is low when plasma increases and diluted the concentration of blood cells and other substances carried by the plasma. As excess fluid is excreted, the dilution is gradually reduced. Hematocrit returns to normal within 4-6 weeks postpartum unless excessive blood loss occurs
CV changes: coagulation
During pregnancy, plasma fibrinogen and other coagulation factors increase. Result: mother’s body has greater ability to form clots to prevent excessive bleeding.
Fibrinolytic activity (ability to break down clots) is decreased during pregnancy. Fibrinolysis increases shortly after delivery and continues for several days, increasing the risk for thrombus formation
It takes 4-6 weeks before hemostasis returns to normal and thrombophlebitis risks declines however is still prevalent. Those who have varicose veins, Hx of thrombophlebitis, or cesarean births are at higher risk.
Lower extremities should be monitored. Pneumatic compression devices should be applied before cesarean delivery for those not already receiving anticoagulants
GI changes
Soon after childbirth, the digestive system reactivates and hunger occurs due to expended energy from labor
Excessive thrust occurs due to decreased intake and early diaphoresis
Constipation is common postpartum due to bowel tone and intestinal motility, which were diminished during pregnancy from progesterone, remain sluggish for several days. Abdominal musclulature is relaxed. Decreased food and fluids may result in small, hard stools. Perineal trauma, episiotomy, and hemorrhoids interfere with effective bowel elimination. Some women anticipate pain with defecation and avoid this.
Temporary constipation isn’t harmful but may cause full feeling and flatulence. Stool softeners and laxatives are used to prevent or treat this. The first stool usually occurs within 2-3 days postpartum. Normal bowel patterns usually resume by 8-14 days postpartum
Urinary system changes
Trauma to the perineal area often results in sensitivity to fluid pressure and many have no sensation of needing to void even when the bladder is distended.
Postpartum, the mother is at risk for overdistention of the bladder, incomplete emptying, and retention of residual urine. Those who have received regional anesthesia are at risk for distinction and difficult voiding until feeling returns.
Retention and overdistention may cause UTI (occurs when urinary stasis allows for bacteria to accumulate) and increased postpartum bleeding (due to uterine ligament-stretched during pregnancy- allows the uterus to be displaced upward and laterally due to the full bladder; result: decreased uterine muscle contraction or uterine atony- a primary cause of excessive bleeding)
Stress incontinence may begin and improves within 3 months after birth. Pelvic floor exercises and time for healing helps. Some women may have continued problems.
Dilation of the ureters and kidney pelvis improves by the end of the first week. Usually regain normal state 2-8 weeks postpartum. Protein and acetone may be present in urine for first few weeks postpartum. Acetone suggests dehydration (may occur from exertion of labor) and mild proteinuria is usually the result of the catabolic processes involved in uterine involution
Musculoskeletal system changes: muscles and joints
In the first 1-2 days postpartum, muscle fatigue and aches are common esp. in the shoulders, neck, and arms due to effort of labor. Warmth and gentle massage increase circulation to the area and provide comfort/relaxation
First few days: level of relaxin hormone gradually subside, ligaments and cartilage of the pelvis begin returning to prepregnancy positions which can cause hip or joint pain that interferes with ambulation/exercise. Teach that this is temporary. Correct posture and good body mechanics are important to prevent low back pain and injury to joints
Musculoskeletal system changes: abdominal wall
Abdominal wall stretches and muscle tone is diminished during pregnancy. Immediately after childbirth, abdominal muscles remain weak, soft, and flabby
Longitudinal muscles of the abdomen may separate (diastasis recti) during pregnancy which may be minimal or severe. The mother may benefit from gentle exercises to strengthen the abdominal wall and usually resolved within 6 weeks
Exercise for diastasis recti: laying down, the woman inhaled and supports the abdominal wall firmly with hands; exhaling, the woman raises her head while pulling the abdominal muscles together
Integumentary system changes
Many skin changes are due to an increase in hormones. After birth, hormone levels decline and the skin reverts to prepregnancy state. EX: estrogen, progesterone, and melanocyte-stimulating hormone (caused hyperpigmentation during pregnancy) decrease rapidly after childbirth and pigmentation begins to recede which is noticeable when melasma (mask of pregnancy) and linea nigra fade and disappear.
Striae gravidarum (stretch marks) from connective tissues being stretched, gradually fade to silvery lines but do not disappear. Loss of hair is a normal response due to hormonal changes and begins at 4-20 weeks postpartum and is regrown in 4-6 months for 2/3s or women and by 15 months for the rest
Neurological system changes
Discomfort, fatigue, and inability to sleep postpartum may be seen with after pains, episiotomies, lacerations, incisions, muscle aches, and breast engorgement (swelling from increased blood flow, edema, and presence of milk)
Anesthesia or analgesia may result in lack of feeling in the legs and dizziness. Prevent injuries r/t falling.
HAs require careful assessment. Bilateral and frontal are common in 1st week postpartum and may be a result of F&E changes. Spinal HAs after spinal anesthesia may occur and may be more severe with woman in upright- relieved with supine position. They should be reported to HCW (usually anesthesiologist). HA, proteinuria, blurry vision, photophobia, and abd pain may indicate development or worsening of preeclampsia
Pain continues after being discharged and some report that pain interferes with self care and ability to care for infant
Endocrine system changes
Rapid decline occurs in placental hormones (e.g., estrogen, progesterone, and human placental lactogen) after expulsion of the placenta
Human chorionic gonadotropin is present for 3-4 weeks
If mom is not breastfeeding, prolactin (pituitary hormone that stimulates milk secretion) returns to nonpregnant levels in 14 days
Endocrine system changes: Resumption of ovulation and menstruation
The first few cycles for lactating and non-lactating women are often anovulatory, ovulation may occur before the first menses. For some, ovulation resumes as early as 3 weeks postpartum. Contraceptives are important for sexual activity for lactating and non-lactating women.
~40-45% of non-nursing moms resume menstruation 6-8 weeks postpartum, 75% by 12 weeks, and all within 6 months. Menses while lactating may resume as early as 8 weeks or as late as 18 months. Frequent breastfeeding with no supplements is more likely to delay menses. Yet, menses and ovulation are increasingly likely after the infant is 6 months old
Endocrine system changes: lactation
During pregnancy, estrogen and progesterone prepare the breasts for lactation. Prolactin also rises. Lactation is inhibited by high level of estrogen and progesterone. After expulsion of the placenta, estrogen and progesterone decline rapidly, and prolactin initiates milk production within 2-3 days postpartum. Once milk is established, it continues due to frequent removal of milk from the breast.
Oxytocin is necessary for milk ejection, or “letdown”. Oxytocin causes milk to be expressed from the alveoli into the lactiferous ducts during suckling
Endocrine system changes: weight loss
~5.5 kg (12lbs) is lost during birth from the weight of the fetus, placenta, amniotic fluid, and blood loss. An additional 4 kg (9lbs) are lost over the first 2 weeks postpartum and another 2.5 kg (5.5lbs) are lost by 6 months postpartum. Adipose tissue gained during pregnancy to meet energy requirements for labor and breastfeeding isn’t loss right away and the usual rate of loss is slow. Younger women with lower prepregnancy weight and lower parity lose weight sooner and faster.
Many women don’t lose all the weight gained and retain an average of 1kg (2.2lbs) per pregnancy. Often get frustrated because of this- provide info about diet and exercise to produce acceptable weight loss but doesn’t deplete energy or impair moms health
Postpartum assessments
Provide essential, cost-effective postpartum care
Most women stay in the birth facility for 48 hours after vaginal birth and 96 hours after cesarean birth. Some may choose to go home earlier.
Postpartum assessments: clinical pathways
Also known as critical pathways, care maps, care paths, or multidisciplinary action plans
Guide necessary care while reducing the length of stay. Identify expected outcomes and establish time frame for specific assessments and interventions to prepare the mother and infant for discharge.
It is a guideline and documentation tool
Postpartum assessments: initial assessments
The nurse faces a high risk of contact with body fluids (colostrum, breast milk, lochia from mother, urine, stool, and blood from child). Follow CDC guidelines for standard blood and body fluid precautions.
Postpartum assessments begin during 4th stage of labor (1st 1-2 hours after delivery). Mom is examined to determine if she’s physically stable. VSs, skin color, location and firmness of fundus, amount and color of lochia, perineum (edema, episiotomy, lacerations, hematoma), presence/degree/location of pain, IV infusion (type of fluid, rate, type and amount of added meds, patency of IV line, redness/pain/edema of site, urine output (time and amount of last void or catheter, color and character of urine, status of abd incision and dressing if present, level of feeling and ability to move if regional anesthesia is present
Postpartum assessments: chart review
Review the chart after assessments suggest mom is stable. Obtain PT info and if there’s factors that increase risk for complications postpartum. Relevant info: gravida/para, time and type of delivery (use of vacuum extractor, forceps), presence and degree of episiotomy or lacerations, anesthesia or meds administered, significant medical and surgical history (e.g., diabetes, HTN, or ❤️ disease, meds given during labor and delivery or routinely taken and reasons for their use, food and drug allergies, chosen method of infant feeding, condition of the baby.
Examine labs esp. the prenatal hemoglobin and hematocrit levels, blood type and Rh factors, hepatitis B surface antigen, rubella immune status, syphilis screen, and group B streptococcus status
Need for Rh 0 (D) immune globulin
Prenatal and neonatal records are checked to determine if this should be administered. It may be necessary if the mother is Rh negative and the newborn is positive and the mother is not already sensitized.
To prevent the development of maternal antibodies that would affect subsequent pregnancies, this should be administered within 72 hours after childbirth
Need for vaccines: rubella
A prenatal rubella antibody screen is performed on each pregnant women to determine if she is immune. If not, rubella vaccine is recommended after birth to prevent her from acquiring rubella with subsequent pregnancies which can cause serious anomalies. There is a theoretical risk of fetal defects because the vaccine contains a live virus; however, there is no evidence of damage when the vaccine is inadvertently given to pregnant women. Therefore, women are advised not to become pregnant for at least 28 days after receiving the vaccine. Women need to sign a statement that they accept the vaccine and understand the risks if she were to become pregnant too soon after. If statement isn’t required, document that risks have been explained and the woman has verbalized understanding.
Need for vaccines: pertussis vaccine
Outbreaks have had serious effects in infants and young children. Although most adults have been vaccinated as children, effectiveness fades with time. Full protection doesn’t occur until entire series is completed.
CDC recommends that adults in contact with infants and young children get a booster dose.
The vaccine may be offered to women before hospital discharge after childbirth.
Rubella vaccine drug guide info
Class: attenuated live virus vaccine
Action: produces a modified rubella (German measles) infection that’s not communicable, causing the formation of antibodies against the rubella virus
Indications: administered at least 1 month before pregnancy or after birth or abortion to women whose antibody screen shows they’re not immune to rubella. It prevents rubella infection and possible severe congenital defects in the fetus during a subsequent pregnancy.
Dose and route: 0.5 mL subcutaneously
Absorption: well absorbed
Contraindications and precautions: women who are immunosuppressive, pregnant, or sensitive to the vaccine components or have a mod-severe illness. The attenuated virus may appear in breast milk and some infants may develop a rash but this is not a contraindication for lactating women. Can be given near the time of Rh 0 (D). Should be tested for immune status 6-8 weeks to be sure they are immune.
Side effects: transient stinging at site, fever, lymphadenopathy, arthralgia, and transient arthritis are most common
NRSG implications: vials should be refrigerated. Reconstitute only with diluent supplies with vial. Used immediately after reconstituted or discard 8 hours after. Protect from light. Check with HCP before giving near admin time of Rh 0 (D). Birth of infants with congenital rubella syndrome has not been documented when the vaccine has been given inadvertently during pregnancy- yet women are advised to avoid pregnancy for at least 4 weeks after vaccination
Two most common complications of the puerperium
Hemorrhage and infection
Postpartum risk factor: hemorrhage
Grand multiparity (5+)
Overdistention of the uterus (large baby, twins, hydramnios)
Rapid or prolonged labor
Retained placenta
Placenta previa or previous placenta accreta or abruptio placentae
Drugs (tocolytics, magnesium sulfate, general anesthesia, prolonged use of oxytocin)
Operative procedures (cesarean birth, vacuum extraction, forceps)
Uterine fibroids
History of postpartum hemorrhage
Preeclampsia
Coagulation defects
Postpartum risk factor: infection
Operative procedures (cesarean birth, vacuum extraction, forceps)
Multiple vertical exams
Prolonged labor
Prolonged rupture of membranes
Manual extraction of placenta or retained fragments
Diabetes
Catheterization
Bacterial colonization of lower genital tract
Focused assessments after vaginal birth
Per facility protocol, assessments may be required every 15 minutes for the first hour, every half hour for the next hour, every 4 hours for the first 24 hours, and every 8 hours thereafter.
Focused assessments per vaginal birth generally includes VSs, fundus, lochia, perineum, bladder elimination, breasts, and lower extremities
Focused assessments after vaginal birth: Vital Signs
Blood pressure
Varies with position and arm used
Measure on the same arm and in the same position each time
Compare postpartum to predelivery period so deviations from what is normal
An increase from baseline may be caused by anxiety or pain
140/90+ may indicate preeclampsia
A decrease may indicate dehydration or hypovolemia resulting from excessive bleeding
Focused assessments after vaginal birth: Vital Signs
Orthostatic hypotension
After delivery, a rapid decrease in intraabdominal pressure results in dilation of blood vessels supplying the viscera. Resulting engorgement of these vessels contributes to a rapid fall in BP of 15-20 when moving from a recumbent to a sitting position. This causes feeling of dizziness or lightheaded ness or possible faint upon standing.
Risk for injury applies to this.
This may indicate hypovolemia
Assess for hemorrhage (location and firmness of the fundus, amount of lochia, pulse rate for tachycardia) if the BP is significantly less than the prenatal baseline BP
Focused assessments after vaginal birth: Vital Signs
Pulse
Bradycardia (40-50 bpm): the lower pulse may reflect the large amount of blood returns to the central circulation after placental delivery. Increase in central circulation results in increased stroke volume and allows a slower heart rate to provide adequate maternal circulation.
Tachycardia may indicate pain, excitement, fatigue, dehydration, hypovolemia, anemia, or infection. Assess BP, location and firmness of uterus, amount of lochia, estimated blood loss from delivery, hemoglobin and hematocrit. Objective of additional assessments: to rule out excessive bleeding and to intervene if hemorrhage is suspected
Focused assessments after vaginal birth: Vital Signs
Respirations
A normal rate of 12-20 should be maintained.
Especially important to assess in mothers with cesarean birth, smokers (history), a history of frequent or recent upper respiratory infections or asthma, and for those receiving magnesium sulfate
Focused assessments after vaginal birth: Vital Signs
Temperature
A temp of up to 38 C (100.4 F) is common first 24 hours after birth and may be cause by dehydration or normal postpartum leukocytosis
If elevated temperature lasts longer than 24 hours or exceeds 38 C (100.4 F) or the mom shows other signs of infection, report to the physician or nurse midwife
Focused assessments after vaginal birth: Vital Signs
Pain
The fifth vital sign
Determine location, type, and severity on a pain scale (COLDSPA)
Be alert to signs off after pain, perineal discomfort, and breast tenderness
Nonspecific signs of discomfort: inability to relax or sleep, change in VSs, restlessness, irritability, and facial grimaces
Encourage moms to take prescribed meds as needed and evaluate the effectiveness of pain-relief measures
Focused assessments after vaginal birth: the fundus
Assess for consistency and location. It should be firmly contracted and at or near the level of the umbilicus
Bladder may be distended if uterus is above expected level or shifted- usually to the right- from the middle of abdomen (midline position). Recheck after bladder is emptied.
If difficult to locate or is soft or “boggy”, stimulate uterine muscle to contract by massaging the uterus. Not necessary if the uterus is firmly contracted. Use nondominant hand to support and anchor the lower uterine segment if necessary to massage an uncontracted uterus.
The uterus can contract only if it’s free of intrauterine clots. Massage the fundus until firmly contracted. Supporting the lower uterine segment prevents inversion of the uterus (turning inside out) when applying form pressure downward toward the vagina to express collected clots. Observe the perineum for number and size of expelled clots.
If lochia is excessive or clots present, weigh to estimate amount.
Drugs are sometimes needed to maintain contraction of the uterus and prevent postpartum hemorrhage. The most common is oxytocin (Pitocin).
Observations of the uterine fundus and nursing actions:
nL find: fundus firmly contracted
Abnormal find: fundus is soft, “boggy”, uncontracted, or difficult to locate
Action: support lower uterine segment. Massage until firm
Observations of the uterine fundus and nursing actions:
nL find: fundus remains contracted when massage is discontinued
Abnormal find: fundus becomes soft and uncontracted when massage is stopped
Action: continue to support lower uterine segment. Massage fundus until firm, then apply pressure to express clots that may be accumulating in uterus. Notify health care provider and begin oxytocin administration, as prescribed, to maintain a firm fundus
Observations of the uterine fundus and nursing actions:
nL finds: fundus located at level of umbilicus and midline
Abnormal find: fundus above umbilicus and/or displaced from midline
Action: assess bladder elimination. Assist mother in urinating or catheterization, if necessary. Recheck the position and consistency of fundus after bladder is empty.
