Postpartum Assessment Flashcards
What does BUBBLE TEA stand for?
B → Breast Assessment
U → Uterus Assessment
B → Bladder Assessment
B → Bowel Function Assessment
L → Lochia (Postpartum Vaginal Discharge)
E → Episiotomy
T → Thromboembolism Check
E & A → Emotional Adaptation
List the expected findings of breasts during the postpartum assessment (5)
- Soft
- Non-tender
- Intact skin on nipples
- Nipples everted
- Absence of lumps or swelling
When is milk produced?
typically produced by days 3-5, before that, colostrum
*keep this in mind during postpartum assessment of breasts**
What are potential problems found during postpartum assessment of breasts? (3)
- cracked nipples
- inverted nipples
- engorgement
what causes cracked nipples postpartum?
improper latch
how does inverted nipples present? what might be needed?
nipples retract into skin and it is very hard for babies to latch
may require nipple shield
how does engorgement present?
the breasts are red, swollen, warm and very painful
palpation will reveal tenderness
What is the purpose of the uterine postpartum assessment?
the uterus must contract to stop postpartum bleeding
How is the fundal check performed? What should it feel like?
One hand supports symphysis pubis, the other palpates the fundus
It should feel like a firm melon
a firm fundus controls what?
bleeding
Where should the fundus be on the day of delivery? How much does it shrink after the day of delivery? When should it no longer be palpable?
at the level of the umbilicus
It shrinks ~1 cm (or fingerbreadth) per day after delivery
By day 10, it should no longer be palpable.
What does it mean if the fundus is not going down a finger per day?
subinvolution is occurring and there is a risk for hemorrhage/bleeding
What is an abnormal finding during the uterine postpartum assessment?
boggy uterus → soft, non-contracted uterus
How can the bladder cause a boggy uterus?
a full bladder can displace the uterus upward and to the right, making it boggy, and increases the risk for hemorrhage
Post-delivery, the bladder can lose ___
tone
There is increased diuresis after delivery. What does this mean?
there is an excessive amount of urine production by the kidneys
What urinary infection are postpartum women at risk for?
Urinary tract infections
What interventions should the nurse make during the bladder assessment? (3)
- ask her when she last voided
- encourage her to empty bladder
- if ineffective, perform a straight catherization
how can the nurse encourage the postpartum woman to empty her bladder? (3)
- use running water
- pour warm water on perineum
- encourage forward leaning to help void
What makes the postpartum woman at risk for urinary retention? (3)
- Bladder → tone decreased
- Periurethral trauma (tearing downward)
- Pitocin can cause urinary retention
Regarding bowel function post-delivery, there is decreased peristalsis due to what?
elevated progesterone
What meds can constipate the bowel? (3)
- continuance of prenatal vitamins postpartum
- iron
- opioid pain meds
Why are C-section patients especially at risk for constipation postpartum?
due to surgery and anesthesia slowing down bowel function
*It is not uncommon for mom to have absent bowel sounds after surgery and anesthesia as they slow peristalsis
How is postpartum constipation managed? (4)
Fluids
Ambulation
Fiber
Stool softeners & laxatives as prescribed
List and describe the stages of lochia
Rubra → bright red discharge in the first 1-2 days
Serosa → pink/ brownish discharge (like end of your period)
Alba → white or creamy discharge at the end
List the amount classifications of lochia (4)
Scant → only when wiping or <1 inch stain
Small → <4 inches
Moderate → <6 inches
Heavy → saturated pad within 1 hour
When is lochia a concern?
Soaking pad <1 hour = alert
Soaking pad in 15 mins or passing egg-sized clot = likely hemorrhage.
If the uterus is firm but bleeding continues, what should you suspect?
suspect cervical tear or unrepaired laceration
What is the mnemonic for episiotomy?
REEDA:
R → Redness
E → Edema
E → Ecchymosis
D → Drainage
A → Approximation
same mnemonic applies for c-section incision
Why are postpartum women at risk for DVT?
Pregnancy is a hypercoagulable state
What DVT assessment is outdated and no longer used?
Homan’s sign
List signs of DVT to look out for during postpartum assessment (4)
- calf pain (esp unilateral)
- swelling
- redness
- palpable cord-like knot
The process of developing a new identity as a mother takes how long?
3-10 months
What should the nurse do when assessing emotional adaptation in the postpartum mother? (3)
- It is common for mothers to feel inadequate at first, so encourage support systems (family/community/online)
- look for signs of bonding: holding, eye contact
- screen for PPD if indicated
What is the estimated blood loss for a vaginal delivery?
200-500 mL
What is the estimated blood loss for c-section?
500-1000 mL
what happens to cardiac output after delivery?
it remains elevated for 24-48 hrs after delivery
How frequent should vital signs be monitored after delivery?
every 15 mins for 1-2 hours, and then per protocol
what is expected of blood pressure after delivery?
it should return to baseline
what is expected of heart rate after delivery?
it is decreased due to fluid shift; 50-70 bpm is common
what is expected of respiratory rate after delivery?
it is decreased
what is expected of temperature after delivery?
should remain below 100.3°F
What are postpartum chills?
Common shaking after delivery due to fluid shift; normal but requires reassurance.
what causes post-epidural spinal headache? how can we assess it?
CSF may leak out causing a headache
if mom lays down and is fine and then sits up and has excruciating pain this is probably a spinal headache
Why is oxytocin (IV or IM) administered immediately after delivery?
to help the uterus contract and reduce bleeding
What is usually indicated if Hgb is <7?
transfusion
What should the nurse teach the pt to decrease their risk of complications due to bleeding?
- fundal massage
- progression of lochia
- void every 2-3 hrs
how often should women change pads?
every 2-3 hrs
