Postpartum Care Fundamentals (2) Flashcards
Postpartum Assessment
BUBBLLEE
Breasts Uterine fundus Bladder Bowel movements Lochia Legs Episiotomy/lacerations/incisions Emotional status
Postpartum BP Normal Range
• BP: at pregnancy baseline, orthostatic hypotension
- Women BP tends to run lower than men, need to look at antenatal chart to see what it was during pregnancy, depends on many factors
- Major factor post epidural is change in BP
- Orthostatic hypotension, initial change in position after birth; be with the client first time they stand up and make sure they are stable
Postpartum HR Normal Range
• HR: 60-100bmp (10-15 increase over baseline)
- Due to cardiovascular demands of pregnancy and physic shifting of diaphragm pushing up as uterus grows and forward rotation to the heart; normal for it to be faster than their non-pregnant baseline
Postpartum RR Normal Range
• RR: 12-20 breaths/min (or slightly increased 16-24)
- Breathe faster to meet needs of body
- In postpartum it quickly goes back; with variations
Postpartum T Normal Range
• T: 36.5 – 37.5 (ax/tymp)
- With epidurals can run high due to foreign body, should come down in a few hours
Role of Contractions
• Importance of postpartum hemostasis
- Contractions cause the uterus to compress and minimize bleeding
• “afterpains” and the role of oxytocin
- Oxytocin causes the uterus to contract, after delivery is it still present and can cause afterpains
- Reduces risk of PPH
• Primip versus multip
- After multiple children uterus stretches a bit more, has to work harder to return back to normal size
- Can result in stronger/more afterpains
• Breastfeeding
- Sucking stimulates the release of prolactin and oxytocin for milk drop
- Can cause contractions while breastfeeding, good sign
Uterine Involution
• Under influence of oxytocin
- The uterus returns to its pre-pregnancy state, or attempting to
- A normal, healthy, expected process
• Descends approximately 1-2cm every 24hrs
- Measures by finger breaths
• Involution vs subinvolution
- Subinvolution is when the uterus is not involuting at the rate or way it normally needs to
- Due to infection of uterus postpartum or parts of the placenta left behind in the uterus unknowingly
- Biological tissue can cause PPH or fever
Fundus Exam: two-handed technique
- Best practice
- Client is laid down on a flat surface
- Non-dominant hand in on the symphysis pubis (pubic bine) and supporting the lower segment of the uterus as we’re applying pressure at the top to assess where the top of the uterus (fundus) is
- If not support can cause the uterus to invert
- Also need to be looking to see what’s coming out of the vagina
- Will be uncomfortable for the client; especially for fundal massage in order to get the uterus to contract
BUBBLLEE: Breasts
- Inspect for size, symmetry, and shape
- Palpate for degree of fullness (soft/filling/engorged) firmness, tenderness, lumps, pain
- assess even for clients who are formula feeding
- Inspect nipples for shape (erect/flat/inverted), redness, bruising, blisters, discomfort, fissures
BUBBLLEE: Uterine fundus
- Palpate for consistency (firm/boggy)
- Palpate for location (midline/deviated to left or right)
- Palpate for height of fundal involution (in relation to umbilicus)
BUBBLLEE: Bladder
- Assess amount voided, fullness after void, burning/pain with voiding
- Assess for distension; physical signs of a full bladder
BUBBLLEE: Bowel
- Assess for last bowel movement (BM)
- If no BM assess for abdominal distension/discomfort
- Assess for passage of flatus (listen to bowel sounds in all 4 quadrants if not passing flatus)
BUBBLLEE: Lochia
- Assess amount (scant/small/moderate/heavy)
- Assess colour (rubra/serosa/alba)
- Foul odour?
BUBBLLEE: Legs
- Peripheral edema
- Venous thromboembolism (red, tender, unilateral leg pain, localized edema)
BUBBLLEE: Episiotomy/laceration/ C/S incision
Assess for:
- Redness
- Edema
- Ecchymosis (bruising)
- Discharge/Discomfort
- Approximation
- Assess hemorrhoids (number, size, discomfort)
- Assess perineum for edema
BUBBLLEE: Emotional status
- Assess coping (happy/sad/overwhelmed/level of fatigue/risks factors for PPD)
- Assess bonding/attachment behaviours
- Puerperal phases: taking in/taking hold/letting go
Fundal Assessment
• Height (in relation to umbilicus - bellybutton)
- @u or u/u (at the umbilicus)
- 1/u vs u/1 (over or under umbilicus by number of cm)
• Location (midline or deviated?)
- If deviate usually tips to the right side, may be due to the urinary bladder being full/somewhat full; can also make a firm uterus become boggy
• Consistency (firm or boggy?)
- ff (fundus firm) or ffirm
- boggy uterus is also a flaccid uterus
Lochia Colour Assessment
• Rubra (red)
- Blood, small clots, tissue debris
- Hours (heavy), 3-4 days postpartum
• Serosa (pink-brown)
- Old blood, serum, leukocytes, tissue debris
- 22-27 days postpartum
• Alba (yellow-white)
- Serum, leukocytes, mucus, epithelial cells
- 2-6 weeks postpartum
Lochia Flow Assessment
- Amount: scant/small/mod/heavy and variations
- Clots
- Odour
- Lochia vs non-lochia flow
Degrees of Lacerations
• 1st degree
- Most superficial type
- Extends through the skin but doesn’t go through muscles
- May or may not need stitches
• 2nd degree
- Goes through the perineal muscle
• 3rd degree
- Laceration continues thorough the perineal muscle and reaches the anus
• 4th degree
- Right through to the anus
- Can takes weeks of recovery; lots of fibre, laxatives
Episiotomy
- No longer a routine assessment
- Usually midline or medio-lateral (RML)
- Dissolvable sutures
Perineum Assessment
- Assessed REEDA
- Hemorrhoids
- Ice therapy, peri bottle, sitz bath
- Padsicle; first 24 hours, 20mins on/40 min off, catches blood and soothes
- Sitz bath for post 24hr for ongoing warm moist therapy to help with suture healing sensation
- Have to keep perineal area clean and dry
REEDA Assessment
- Redness
- Ecchymosis – bruising
- Edema – usually more if pushing for longer
- Discharge/discomfort – pus is sign of infection
- Approximation – are the edges remaining together
Assessment Post C/S; what’s different in BUBBLLEE
• Vital signs
- More frequently; post-surgery
- Breasts – same
- Uterine fundus – careful
- While the epidural is wearing off so no pain
- Don’t want to disturb the stitches, have to be gentle and carful
- If off epidural, time fundal assessment when pain medication is at peak effect (usually 1hr post administration)
• Bladder – foley catheter
- Stays in place usually 12hr postpartum
- Once removed, keep eye and teach client (maybe measure volume)
• Bowel – gas pains
- Abdominal pain rom gas pain; especially if not moving around enough
- Try to get patients to get up and move around ASAP
• Lochia – often slightly less
- Because at time of C/S when placenta is removed, the surgeon might mechanically remove from walls instead of waiting to be sloughed off
• Legs – increased risk for venous clots
- Get up and moving ASAP to reduce risk
- Pain – incisional and other locations
- Incision – dressing, REEDA
- Perineum still needs to be assessed
- Dressing comes off within 24 hours
- Staples have to be removed; staples dissolve
- Once can see incision line, then we do REEDA
• Emotional status
- Same
Nursing Interventions after C/S
• Additional assessments – lung sounds, bowel sounds
- Post anesthetic
- Everything is manipulated, needs tome to be reoriented
- Peristalsis stops but will resume shortly after; if absent in all 4 quadrant is reportable
- Directly ask if they’re passed gas/how many times
- IV therapy
- Bladder
- Assess how much they’re urinating
- Have to ensure they can empty their own bladder; if they can’t may need catheter
• Blood work as ordered
• Activity
- Gradual; ambulating ASAP; don’t lift anything heavier than the baby
• Diet
- Ice chips; quickly progress to full diet
- Bowel sounds have to return before they can have solid food
• Feeding baby
- Can’t use normal position; side lying positions to prevent pain on incision line
• Discharge teaching – lifting, reportable symptoms
Postpartum Hemorrhage (PPH) Definition
• Old definition of >500ml Vaginal; >1000mL C/S no longer used
- Tend to overestimate blood loss
- Eyeballing is not accurate
• Blood loss causing hemodynamic instability (symptomatic)
- Shock symptoms, etc.
- Life threatening with little warning
- Early recognition and prompt management critical
Causes of PPH
• Many causes:
- Uterine atony (#1) – boggy uterus
- Genital tract laceration
- Retained placenta
Early PPH vs Late PPH
- Early; from birth to first 24hr; uterine atony is primary cause
- Late: post 24hr to 6weeks postpartum; not until uterus is complete involuted is the risk gone
- General late is post 24hr to 2weeks; due to infection and/or placental fragments remaining in uterus
Risk Factors of PPH - the four T’s
- Tone
- Tissue
- Trauma
- Clotting
• Anything that can decrease uterine tone is a risk factor for PPH (multifetal, not first birth, super-fast birth (precipitous labour), placenta separating prematurely or during expulsion, pre-existing clotting issues, or those that develop clotting issues during labour)
PPH Nursing Interventions
- Fundal massage – first thing always
- Frequent vital signs
- Urinary bladder status
- Circulatory support: IV fluids (start or increase), O2 and uterotonics (1st line: oxytocin)
- Call for help, stay with client
- Assist with medical interventions as needed
PPH Medical Interventions
• Uterotonics escalation • Blood transfusion • Bimanual uterine compression (short term) • Surgical - Intrauterine balloon tamponade - Uterine artery embolization - Hysterectomy
Perinatal Mood Disorder (PMD)
• Postpartum is time of increase risk for onset of mood disorders
- Can be antenatal and postpartum
- Increased especially if pre-existing
3 types
• Postpartum “blues”
• Postpartum depression (no psychosis)
• Postpartum depression (psychosis)
Postpartum Blues
- Incidence - 50-80%
- Duration - Peaks by day 5; subsides by day 10; transient, mild, time limited
- Symptoms - Labile emotions, fatigue, sadness, anger, insomnia, no functional impairment
- Interventions - reassurance, health teaching connection with supports and community resources
Postpartum Depression (No psychosis)
- Incidence - 10-15%
- Duration - weeks to 1 year
- Symptoms - insomnia/hypersomnia, fatigue, appetite changes, worthlessness, guilt, irritability, decreased concentration, inability to cope, despondency, crying, intense irrational fears
- Interventions - Non-directive counselling, interpersonal psychotherapy, CBT, peer support, medication
Postpartum Depression (Psychosis)
- Incidence - 1-2 per 1000 births
- Duration - 208 weeks
- Symptoms - Depression, delusions, thoughts of harm to self or infant, agitated, overactive, disorganized behaviour, inability to care for infant
- Interventions - Prompt assessment and hospitalization, medication, psychotherapy
PP Depression Risk Factors
Strong risk factors
- Prenatal depression and/or anxiety
- Personal/family history of depression
Moderate risk factors
- Stressful life events
- Intimate partner violence
- Lack of social support
Weak risk factors
- Single parent
- Stress of child care
- Low socioeconomic status
- Unwanted/unplanned pregnancy
Role of Nursing in PMD
• Screening - Must be a good active listener and demonstrate caring • Health promotion/education/prevention • Anticipatory guidance • Safety assessment • Support, reassurance - Facilitate mobilization of support - Referrals
Risk factors that have no effect on PPD
- Ethnicity
- Level of education
- Parity
- Gender of child (for Western society)
Temp Normal Findings after childbirth
- During first 24hr temp may increase to 38 degrees as a result of dehydrating effects of labour
- After 24hr the woman should be afebrile
Causes of high temperature postpartum
- Puerperal sepsis
- Mastitis
- Endometritis
- Urinary tract infection
- Other systemic infections
Pulse findings postpartum
- Pulse, along with stroke volume and cardiac output, remains elevated for the first hour or so after childbirth
- It then begins to decrease at un unknown rate to a non-pregnant state
Causes of not normal pulse postpartum
- A rapid pulse rate or one that in increasing may indicate hypovolemia as a result of PPH or increased temperature
Respiration findings postpartum
- The respiratory rate should rapidly decrease to within the woman’s normal pre-birth range
- 12-20 breathes/min
Causes of abnormal resp. rates postpartum
- Hypoventilation (bradypena) may occur after an unusually high subarachnoid (spinal) block or epidural narcotic after C/S
BP postpartum findings
- BP is altered slightly, if at all
- Orthostatic hypotension, as indicated by feelings of faintness or dizziness immediately after standing up, can develop in the first 48hrs as a result of the splanchnic engorgement that may occur after birth
Causes of abnormal BP findings postpartum
- A low of decreasing BP may indicate hypovolemia secondary to PPH (but is a late sign)
- An increased BP may result from excessive use of vasopressor or oxytocic medications
- Due to gestational hypertension persisting its important to assess BP often in first PP period
Normal findings in breast assessment
- Days 1-2: soft
- Days 2-3: filling
- Days 3-5: full, soften when breastfeeding (milk is “in”)
- Nipples skin intact, no soreness reported
Abnormal findings in breast assessment
- Firmness, heat, pain can mean engorgement
- Redness of breast tissue, heat, pain, fever, body aches can mean mastitis
- Nipples red, bruising, cracks, fissures, abrasions, blisters are usually associated with latching problems
Normal findings in fundus assessment
- Firm
- Midline
- First 25Hr at level of umbilicus; involutes 1-2cm/day
Abnormal findings in fundus assessment
- Soft
- Boggy
- Higher then expected
- All due to uterine atony
Normal findings in bladder assessment
- Able to void spontaneously by 8hrs
- No distension
- Able to empty completely
- No dysuria
Abnormal findings of bladder assessment
- Over distended bladder possible causing uterine atony and excessive lochia
Normal findings of bowel assessment
- Bowel movement 2-3days after birth
- Abdomen soft, active bowel sounds in all 4 quadrants (for C/S)
Abnormal findings of bowel assessment
- No BM by day 3-4; constipation
- Diarrhea
Normal findings for lochia assessment
- Days 1-3: rubra
- Days 4-10: serosa
- After day 10: alba
- Amount: scant to moderate
- Few clots
- Fleshy odour
Abnormal findings in lochia assessment
- Large amount of lochia; uterine atony, vaginal or cervical laceration
- Foul odour: infection
Normal findings in legs assessment
- Peripheral edema possibly present
Abnormal findings in legs assessment
- Redness, tenderness pain can indicate VTE
Normal findings for perineum/incision assessment
- Minimal edema
- Laceration or episiotomy; approximated
- C/S; incision dressing clean and dry, soft and pink
Abnormal findings for perineum/incision assessment
- Pronounced edema, bruising, hematoma
- Redness, warmth, drainage, all can indicate infection
- Abdominal incision; redness, edema, warmth and drainage all indicate infection
Normal findings for rectal assessment
- No hemmorrhoids
- If present, soft and pink
Abnormal findings for rectal assessment
- Discoloured hemmorrhoidal tissue
- Severe pain
- Thrombosed hemmorrhoid
Normal findings for emotional status assessment
- Able to care for self and infant
- Able to sleep
- Excited, happy, interested in infant care
- Sad and tearful on day 3-14; postpartum blues
Abnormal findings for emotional status assessment
- Lethargy; extreme fatigue, difficulty sleeping; PPD
- Sad, tearful, disinterested in infant care; PMD
Signs of potential psychosocial complications
- Unable/unwilling to discuss labour and birth experience
- Refers to self as ugly and useless
- Excessively preoccupied with self (body image)
- Markedly depressed
- Lacks social support
- Partner or other family members react negatively to baby
- Refuses to interact with or care for baby
- Expresses disappointment over baby’s sex
- Sees baby as messy or unattractive
- Baby reminds mother of family member or friend she doesn’t like
- Has difficulty sleeping
- Experiences loss of appetite
4 T’s: Tone (Uterine Atony)
- Over-distended uterus; large fetus, multiple fetuses, hydramnios, distension with clots
- Anaesthesia and analgesia; conduction anaesthesia
- Previous history of uterine atony
- High parity
- Prolonged labour; oxytocin-induced labour
- Magnesium sulphate administration during labour or postpartum period
4 T’s: Trauma
- Lacerations of the birth canal
- Trauma during labour and birth; forceps, vacuum, C/S
- Ruptured uterus
- Inversion of the uterus
- Manual removal of a retained plasma
4 T’s: Tissue
- Retained placental fragments
- Placenta accreta, increta, percreta
- Placental abruption
- Placenta previa
4 T’s: Thrombin
- Coagulation disorders
What to do if symptoms of preterm labour occur
- Empty your bladder
- Drink 2-3 glasses of water or juice
- Lie down on side for 1hr
- Palpate your contractions
- If symptoms continue, call HCP or go to hospital
- If symptoms go away, resume light activity but not what you were doing when the symptoms began
- If they return, call HCP or go to hospital
If any of the following symptoms occur, call HCP or go to hospital immediately:
- Uterine contraction every 10mins of less for 1hr or more
- Vaginal bleeding
- Fluid leaking from the vagina
What to do during a post-term pergnancy
- Perform daily fetal movement counts
- Assess for signs of labour
- Call your HCP if membranes rupture of if you perceive a decrease or no fetal movement
- Keep appointments for fetal assessment tests of cervical checks
- Go to hospital soon after labour begins
