Maternal Assessment Flashcards
Postpartum period
interval between birth and return of reproductive organs to their nonpregnant state
lasts 6 weeks
Involution process
return of uterus to true pelvis after birth
Progresses rapidly
Fundus descends 1 to 2 cm every 24 hours
2 weeks after childbirth uterus lies in true pelvis
sub involution
failure of uterus to return to non-pregnant state
Common causes are retained placental fragments and infection.
Uterus
Contractions
Hemostasis achieved by compression of blood vessels as uterine muscle contracts (as opposed to platelet aggregation or clot formation).
Hormone oxytocin, released from pituitary gland, strengthens and coordinates uterine contractions. Breast feeding also.
After pains
Placental site (vascular constriction & thrombosis reduce the placental site)
Lochia
post birth uterine discharge
Rubra
- Bright red flow
- Blood and decidual debris (mucosal lining of uterus)
- Duration of 3 to 4 days
Serosa (pink/brown)
- blood, serum, leukocytes, and debris
- Median duration of 22 to 27 days
Alba (yellow/white)
- Leukocytes, decidua, epithelial cells, mucus, serum, and bacteria
- Continues 4 to 8 weeks after birth
Cervix
Soft immediately after birth
Within 2 to 3 postpartum days, cervix is 2 to 3 cm, and by 1 week, it is about 1 cm.
Ectocervix (portion that protrudes into vagina) appears bruised and has small lacerations—optimal conditions to develop infections
Vagina and perineum
Estrogen deprivation: responsible for thinness of vaginal mucosa and absence of rugae (muscular folds on internal wall of vagina)
Vagina gradually decreases in size and regains tone (never completely returns to pre-pregnancy state)
Thickening of vaginal mucosa occurs with return of ovarian function.
Dryness and coital discomfort (dyspareunia) may persist until return of ovarian function
Episiotomies heal within about 2 weeks
Hemorrhoids (anal varicosities) are common and decrease within 6 weeks of childbirth
Pelvic muscular support
Breastfeeding
Colostrum – early milk (yellowish fluid can be expressed from nipples)
Tenderness may persist for 48 hours after start of lactation.
Non breastfeeding mothers
Engorgement resolves in 24 – 36 hours after milk comes in
Breast binder /tight bra, ice packs, fresh cabbage leaves, or mild analgesics may be used to relieve discomfort.
Lactation ceases within a few days to 1 week
Average blood loss for vaginal birth
up to 500 mL
Average blood loss for c-section
500-1000 mL
Respiratory system
Immediate decrease in intra-abdominal pressure at birth causing an increase in chest wall compliance
Decreased pressure on diaphragm
Rib cage elasticity can take months to return to normal state
PaCO2 levels rise with loss of placenta
Placental hormones
Expulsion of placenta = decreased estrogen and progesterone levels
decreases in HCS which becomes normal again with maternal circulation (AKA human placental lactogen), estrogen, cortisol, insulinase
What do the placental hormones do?
reversal of the diabetogenic effects of pregnancy leading to significant lower blood sugar levels
Postpartum headaches
may be due to postpartum-onset pre-eclampsia, stress, and leakage of cerebrospinal fluid into the extradural space during placement of the needle for administration of epidural or spinal anaesthesia.
When to do a postpartum assessment for SVD
every 15 minutes for one hour after birth
at 2 hours post delivery
once per shift
as required
When to do a postpartum assessment for c-section
every 15 minutes for one hour, at 2 hours post delivery
every 4 hours for the first 24 hours, then once a shift
as required
Post partum head to toe
VS, sedation scale
BUPPLE LEP
Skin to skin with baby
support, family functioning and family planning
concerns and past history
VS
T 36.7-37.9
HR 55-100
RR 12-24
BP 90-140/50-90
(manual BP. pulse one min, oral temp)
Sedation scale
Fully awake and oriented
Drowsy
Eyes closed but rousable to command
Eyes closed but rousable to mild physical stimulation (earlobe tug)
Eyes closed but unrousable to mild physical stimulation
BUBBLE LEP
B- Breasts
U- Uterus
B- Bladder
B- Bowel
L- Lochia
E- Episiotomy/ Perineum
L- Legs and feet
E– Emotional coping and mental health
P- Pain
Breasts and newborn feedings
Ask permission
Normal: soft, filling from day 3-5
Intact skin on nipples and areola; not sore, nipples may be flat or inverted , but protrude with baby’s feeding attempts
Able to express small amount of colostrum
Support non- breastfeeding mom
BF/ bottle feeding well
Hand expression
A: One hand is placed on breast with
thumb above and fingers below.
Press back toward chest.
B: Gently compress the breast while rolling
thumb and fingers forward. Maintain steady,
light pressure.
C: Relax. Rotate hand to all sections of breast.
Fundal assessment
Firm, midline, at or below umbilicus
Void before palpate
Woman supine , knees flexed, support uterus
above symphysis except with C-section
No S & S of infection
Incision healing, dressing dry & intact
Bladder
Void comfortably 2/3 times a shift
Able to empty bladder
No feelings of pressure or fullness
Dysuria following catheter removal
Postpartum diuresis and diaphoresis
Catheter drainage 30 ml/hour post C- section
Keep in mind factors such as episiotomy, tears
Peri-bottle, hydration
Bowels
May or may not have bowel movement ( 3 x a day or once in 3 days)
Use stool softeners when needed
Post C-Section: bowel sound present
: may eat and drink post section when hungry or thirsty
: minimal abdominal distension
: flatus passed
Teaching with lochia
Absence of Loonie size or bigger clots and any trickling No saturation of pad in one hour
No foul smelling
Increased flow when Bf/ambulating
Overall 4-8 weeks, generally lessens & follows expected progressions
Episiotomy/perineum/extremities
Discomfort ( less than 4/10 pain scale)
Tears/ Episiotomy stitched, well approximated
No swelling, bruising, hematoma, discharge
Analgesics, comfort measures ( teabags. Ice packs, sitz baths, peri-care, stool softeners)
No s & s of infection
Edema lower extremities
Pedal pulses present
No signs of DVT
Emotional/mental status
Explore response to delivery experience
- C/S, Birth Trauma
Assess PPD, emotional status, mood variations
Feels supported
Feels able to care for self and infant
- confidence & competence
Excited; interested or involved in infant care
Able to sleep
Accepts assistance in care and willingness to learn
Pain
Location: Where is the pain?
Quality: What does the pain feel like?
Onset: When did your pain start?
Intensity: On a scale of 0 to 10 (with 0=no pain and 10=worst pain possible) where would your pain be? (Pain Scale is used on Postpartum Clinical Care Path)
What makes the pain better?
What makes the pain worse?
What is a primary concern that we are watching for in a postpartum assessment?
PPH
Signs of PPH
VS out of range
Uterus is boggy
Lochia is steady trickle or gush (saturated pad less than one hour)
Pain indicates retained tissue
Interventions with PPH
Retake VS and watch sedation
Massage
Observe flow during fundal massage
- Check under buttocks for pooling
- Weigh pads or clots
Compare against previous pain assessments
Supports and family assessment
Maternal support system
Family function, interaction, and positive coping
No signs of intimate partner violence, family abuse
Family understanding of family planning and resumption of intercourse.
Safe home environment
Healthy lifestyle ( free of second hand smoke, drug free, alcohol use)
Healthy eating and fluid intake
Activity /rest/ambulation
Concerns and past history
Communicable diseases
RH (compatibility)
Blood group
Gestational diabetes
Hypertension
Birth history
Baseline vitals
GTPAL
Discharge Criteria
Postpartum Pathway (BC Postpartum Clinical Path)
Must have all maternal & infant criteria as normal or plan in place for variances
Must have completed all discharge education
Maternal benefits of breastfeeding
enhanced uterine involution, faster completion of lochia flow
enhanced metabolism - mobilization of fat stores, easier pp weight loss
enhanced satisfaction/ well-being as mother,
> bonding with infant
decreased risk of CA of breasts, ovarian CA
Decreased risk of Hypertension, hypercholesterolemia & CVD
decreased risk post- menopausal osteoporosis, & Rheumatoid arthritis
Infant benefits of breastfeeding
BREAST MILK IS UNIQUELY DESIGNED FOR THE NUTRITIONAL NEEDS OF EACH SPECIFIC BABY
AS BABY GROWS.
enhanced bonding through regular physical contact of feeding episodes
immune system benefits,
Reduced Risk of many common ‘childhood diseases’
Infants who are not fed human breastmilk have greater incidence of…
Lymphoma/ Leukemias
Type 2 diabetes
Allergies
Necrotizing entercololitis
Inflammatory bowel diseases
Crohn’s disease
Ulcerative colitis
Celiac disease
Rheumatoid Arthritis
Asthma
SIDS
GI & Urinary Tract Infection
Otitis Media
Chronic reflux
Family and environment benefits of breastfeeding
Decreased cost
Decreased time (after first few weeks)
Always ready, right there, right temperature
Less likely to become pregnant soon after birth
Contentedness of infant -makes for more relaxed home atmosphere
No exposure to BPA (now out of bottles but concern with plastic lined cans).
Less waste
LATCH acronym
L - latch (moms and babys position, babys mouth as wide as a yawn, mouth to nipple, mom knows feeling of good latch, nose to nipple)
A - Audible swallow (once transition milk, swallowing should increase, allow for rest periods, what do cheeks look like?)
T - type of nipple (Everted - spontaneous, flat - no protrusion with cold, arousal or starting BF, inverted - often the breast pump or baby can draw nipple out)
C - comfort (should not hurt, investigate any pain)
H - hold (use of pillows, “c” hold of breast)
Pituitary hormones and ovarian function
Prolactin Levels are highest levels during 1st month in women who breastfeed & remain elevated in women who breastfeed
What are prolactin levels influenced by?
frequency of breastfeeding, duration of each feed and supplementary feeds, strength of infant suck
this can affect the time women get their period again
Assessments that you are pregnant
Added urine components (ketonuria, BUN, proteinuria etc.)
Fluid loss
Excessive bleeding
Appetite (hungry because of fatigue)
Spontaneous BM
Abd wall muscles separate
Joints stabilize
Change in center of gravity
A new mother may notice permanent increase in shoe size
Immune system suppressed in pregnancy
