Postpartum Flashcards
Postpartum Period
• Period of time during which the body adjusts, both physically and psychologically
• Begins immediately after birth and lasts approximately 6 weeks
• Medical follow-up in 6 weeks unless complications
• Usually discharged on 2nd postpartum day
o C/S delivery client usually goes home on 3rd day
• Need follow-up care
o Phone call, home visit, or postpartal class
General Principles for postpartum Assessment
o Before beginning the physical assessment, ask the woman to void
o Ask if the woman needs pain medication before assessment
• Ensuring that the woman is relaxed before starting
• Body fluid precautions
• Start with Heart, Lung and Bowel Sounds!
Vital Signs first 24 hr after delivery
should be obtained when the mother is at rest
1) Blood pressure: Should remain consistent with baseline during pregnancy
2) Pulse: 60-100 bpm
3) Respirations: 12-20 bpm
4) Temperature: 98o -100.4oF
- AFTER the first 24 hours, temp 100.4oF or above indicates infection
BUBBLE-EE” Assessment
Focused postpartum assessment
- ‘B’reasts
- ‘U’terus
- ‘B’owel
- ‘B’ladder
- ‘L’ochia
- ‘E’pisiotomy/Lacerations/Incision/Epidural Site
- ‘E’xtremities (Homan’s/Clonus/Sensation)
- ‘E’motions
‘Breast’
To Assess:
- Palpate the breasts.
- Ask her if they feel firmer than yesterday. If there is a change, then her milk is starting to come in.
- Ask her if there is any pain or tenderness.
- Inspect the breasts observing for any nipple soreness, cracks, or redness.
Findings for Breast
• 1-2 days after delivery:
primary colostrum present, possible tingling sensation, then filling to full, tender; snug bra needed
• 2-4 days average:
breast milk appears, need to be stimulated by nursing, pumping, or manual expression to maintain milk supply
Abdominal Changes
Skin? Muscles ?
Pains? What can help pains?
- loose & flabby but will respond to exercise
- Uterine ligaments will gradually return to their prepregnant state
• Afterpains: result of intermittent uterine contractions
- Mostly felt by multiparous, multiple-gestation, or hydramnios
- Breastfeeding can cause due to release of oxytocin
- Prone positioning with a pillow beneath the abdomen can help
- May at first intensify the discomfort for about 5 minutes, but discomfort then diminishes greatly if not completely
- Positioning, Ambulation, Analgesics assist with pain control
- Striae will take on different colors based on the mother’s skin color
- Diastasis Recti- separation of the rectus abdominus
Uterus
- Uterus decreases in size in a process called involution
* Rapid reduction in size of uterus & return to condition similar to non-pregnant state
Uterus assessment
• Have client void prior to checking fundus
• Remember to hold bottom of uterus with non-dominant hand for support, but do not push it!
• Starting at the umbilicus, use your dominate hand for palpation
• Should descend one centimeter or fingerbreadth per day
1 fingerbreadth above the umbilicus = U+1 (1/U)
At the level of the umbilicus = U
1 fingerbreadth below the umbilicus = U-1 (U/1)
• Check for FIRMNESS of fundus
• Approximately the size of a grapefruit after delivery and just has hard!
Uterus abnormal findings
- If uterus seems larger than normal, attempt to express clots
- If uterus feels soft (“boggy”) at any time, the uterus is not contracting properly leaving the woman at risk for hemorrhage. The nurse should massage the fundus until firm again. Woman may need Oxytocin/Pitocin or Methergine to stimulate uterine contractions for involution. If the bladder is not midline (most often to the right) the woman may have a full bladder
Uterus normal findings
- 1st 6-12 hours after delivery: firm, midline, and possibly above the umbilicus (U+1) (firm is grapefruit)
- 12-24 hours after delivery: firm, midline, and at or near level of umbilicus
- No longer palpable by 10-14 days; back to pre-pregnant size by 6 weeks
Factors that Enhance Involution
- Uncomplicated labor and birth
- Complete expulsion of the placenta or membranes
- Breastfeeding
- Manual removal of the placenta during c/s
- Early ambulation
Factors that SLOW Involution
- Prolonged labor
- Anesthesia
- Difficult birth
- Grand multiparity
- Full bladder
- Incomplete expulsion of placenta or membranes
- Infection
- Overdistention of uterus
Bowel after labor
Eating ?
What can delay bowel movements ?
• Eating & Drinking
- Vaginal deliveries can eat immediately as tolerated
- C/S delivered client
- NPO until bowel sounds heard
- Start with clear liquid diet
- Flatulence relieved by early ambulation/meds - Bowel tends to be sluggish after birth due to lingering effects of progesterone and decreased abdominal muscle tone
- Episiotomy, lacerations, or hemorrhoids may delay elimination
Bowel assessment
How to avoid constipation ?
• Assess bowel sounds
• May not have a bowel movement for 2-3 days after delivery, potentially longer if c/s
• Avoid constipation
o Stool softeners (docusate sodium)
o Ambulation
o Increase fluid intake (2000 mL/day or more)
o Fresh fruits, roughage
Bladder
• ⬆️ bladder capacity
• Swelling and bruising of tissues around the urethra
• ⬇️ in sensitivity to fluid pressure
• ⬇️ in sensation of bladder filling from anesthesia
• Urinary output is greater due to postpartum diuresis
- must eliminate excess fluid
• ⬆️ chance of infection if stasis occurs
• Full bladder increases the risk of uterine atony
Abnormal bladder findings
How long should it take them to void?
Signs of infection ?
• Bladder Distention
- Indicated by a palpable bladder, boggy and/or displaced uterus
- Post c/s will have a urinary catheter in place
- Vaginal delivery must void within 8 hours
- C/S delivery must void within 6-8 hours after catheter removal
• Urinary Tract Infection
- Assess for signs such as odor, incomplete emptying
- Burning MAY exist if episiotomy or laceration
- Frequency is NOT a sign of UTI due to postpartum diuresis
Lochia
Uterine debris in the uterus is discharged through lochia
Lochia assessment
Amount, color, odor, clots
• Amount
-Scant: blood only on tissue when wiped or less than 1-inch stain on peripad
-Light: Less than 4-inch stain on peripad
-Moderate: Less than 6-inch stain on peripad
- Heavy: Saturated peripad within 1 hour
• Need to ask “how long” pad has been on
• C/S client may have less bleeding than vaginal deliveries
• If heavy bleeding suspected, can weigh peripads
• Color
- Lochia rubra: dark red
- Lochia serosa: pinkish to brownish
- Lochia alba: white or yellowish
- Once the lochia has progressed to the next color, it should never regress
• Odor
- Odor is inoffensive, metallic smell
- Foul odor may indicate infection
• Clots
- Few small clots (nickel size or less) are normal as a result of blood pooling in the vagina
- Numerous or large clots are abnormal
Lochia normal findings
- 1-3 days: dark red (lochia rubra)
- 3-10 days: thinner, pink to brown (lochia serosa)
- 3-4 weeks: yellowish, white discharge (lochia alba)
- Abnormal is excessive bleeding in which a pad is saturated in 1-2 hours.
- Clots can be seen at any time
Perineal Changes
How does the vagina look after?
When do periods come back?
- Perineum may be edematous, with bruising
- Lacerations or an episiotomy may be present
- Menstruation generally returns between 7 and 12 weeks (nonbreastfeeding woman)
- Ovulation usually occurs within 70 to 75 days (nonbreastfeeding women)
Episiotomy/incision/epidural site assessment
- Sim’s position
- Lift top buttock to reveal perineum and anus
Assess for REEDA
(Redness, Edema, Ecchymosis, Discharge, Approximation)
- Check for sutures episiotomy & laceration (will dissolve in a few weeks)
- A white line indicates infection
- Presence of Hemorrhoids
- Perineal Hematoma- Severe pain, perineal discoloration and ecchymosis.
Lacerations assessment of the degree of ripping
o 1st : Superficial Tissue
o 2nd : Skin, Mucous Membrane, Muscle
o 3rd : Extends to the anal sphincter, but rectum not ripped
o 4th : Thru rectal mucosa
“Extremities”
To Assess: (Bilaterally)
• Homan’s Sign / Clonus
o Supine position with knee slightly flexed
o Have woman relax the leg
o With non-dominant hand, support the woman’s leg at the calf
o Use dominant hand to manually dorsiflex the woman’s foot
o Ask if any pain in the calf
o Rotate the foot at the ankle and let go to test for clonus
• Assess for Edema, Redness, Tenderness, and Warmth
Homan’s Sign
- Pain in the calf indicates a positive Homan’s sign & potential thrombophlebitis
- Ultrasound used to detect DVT
Clonus
Positive clonus is observed if the foot appears to make a “beating” motion when let go
“Emotions” – Reva Rubin
• 1-2 days: Taking-in:
Immediately after delivery when the mother needs sleep
depends on others for nurturing and food
relives the events of the birth
Nurturing and listening to the mother is most important during this phase.
Reva Rubin 3-10 days: Taking-hold
mother begins to gain control over her bodily functions and becomes preoccupied with the present.
She is concerned about her health, the baby’s condition and her ability to care for baby.
Mother is ready for learning, so this is a most appropriate time for teaching. However, due to hormonal changes, role redefinition, discomfort and fatigue; the mother experiences mood swings, insomnia, irritability, and crying episodes. This period is usually temporary but should be monitored.
Reva Rubin 10 days: Letting-go:
comes much later when the patient re-establishes relationships with other people.
However, age, prior relationships and support factors may influence this phase.
Postpartum blues: a normal time in which mother feels depressed and may cry. It is variable as to time it appears and how long it will last.
Fatigue can look like an attachment problem
- Assess several times throughout hospital stay
- Cluster nursing care
- Encourage and allow for naps
- Nursing interventions for discomfort to promote sleep
Signs of adjustment difficulty
- Excessive continued fatigue
- Marked depression
- Excessive preoccupation with physical status or discomfort
- Evidence of low self-esteem
- Lack of support systems
- Marital problems
- Inability to care for or nurture the newborn
- Current family crisis
Suppression of Lactation in the Nonbreastfeeding Mother
- Tight-fitting sports bra continuously
- Apply ice to breasts 20 min, four times/day
- Avoid breast stimulation
- Back to the shower
- Lactation suppressed in about 5-7 days
Nipple Soreness or cracked
o Mother’s own milk
o Hypoallergenic medical-grade anhydrous lanolin cream
o Peppermint gel
o Protective bra shells
o Consult certified lactation consultant if nipple soreness persists
o Begin nursing on the breast that is less sore
o Analgesics may be taken approximately 1 hour before nursing
Breast Engorgement
What to do to help ?
o Infant should suckle for an average of 15 minutes per feeding and should feed at least 8 to 12 times in 24 hours
o Mother may express milk manually or with a pump
o Warm compresses before nursing
o Cool compresses after nursing
o Well-fitted nursing bra 24 hours a day
Plugged Ducts
What to do to help/ prevent
o Heat and massage
o Warm compresses
o Nurse infant starting on the unaffected breast if plugged breast is tender
▪ Some lactation consultants advocate starting on the affected side because the more vigorous sucking may help dislodge the plug
▪ Breast pump may be effective in unplugging the duct
Plugged Ducts – Prevention
What can it lead too ?
o Frequent nursing
o Variety of positions to ensure complete emptying
o Pressure from purse strap, infant sling, or a car seat belt may cause recurring plugged ducts in the compressed area
o Prevention and prompt correction are important because plugged ducts can lead to mastitis
Alcohol and Medications
o Breastfeeding mothers should not consume alcohol for at least 2 hours before nursing, and alcohol consumption should be limited to occasional use.
o Consume alcohol after breastfeeding rather than before a feeding
o Mothers with alcoholism who consume large quantities of alcohol daily may be advised not to breastfeed
o Consult primary care provider before taking over-the-counter medications, prescription medications, or herbal supplements
Physical peri care
- Peri-bottle with warm water
- Vaginal: no wiping, blot
- Clean front to back
- Change peripads every time go to the bathroom or saturation
Comfort Measures Episiotomy / Laceration
• Ice pack immediately after delivery
- rationale - reduce swelling and numb tissues
- 20 min on, 10 min off for first 2 hours
• Sitz bath
- rationale - increases circulation, relaxes tissue to promote comfort, decreases edema; cool or warm water
- 20 min, 3-4x/day
- Topical anesthetic sprays or ointments (Dermoplast spray, Tucks pads, Witch Hazel)
- Administration of analgesics
- Teach client to “tighten buttocks” before sitting or shifting in bed to avoid direct trauma to perineum
- Rest in lateral side-lying position
- Encourage peri care
- Teach diet high in Vitamin C & protein and adequate fluid intake to enhance wound healing
Special Considerations with C/S
• Needs similar to other surgical pts. in addition to postpartal needs
• May experience anger related to inability to have a vaginal birth
o Guilt related to loss of fantasized birth, feelings of missing out, guilt over something she did wrong
• Physical needs
o Increased risk of pulmonary disease
▪ Encourage deep breathing, activity
o Increased risk of blood clot formation
▪ Early ambulation
o Increased discomfort with abdominal gas
▪ avoid carbonated beverages, straws, ice cold liquids, meds (simethicone) etc.
