Postpartum comfort measures

Question 1

Assessment of incision

Answer 1

R-redness
E-edema
E-ecchymosis
D-drainage
A- approximation of edges

Question 2

Episiotomy

Answer 2

incision through the area between the vaginal opening and the anus (perineum)

Question 3

Normal finding for episiotomy

Answer 3

The nurse would expect to see well approximated edges

Question 4

Care for episiotomy

Answer 4

Perineal bruising: An ice pack can be placed on the mother’s perineum to reduce bruising and edema for 12 hours followed by a warm pack after the first 12 to 24 hours after delivery (Leifer 67 q. 20)

Question 5

Patient Teaching for Episiotomy

Answer 5

Clients who have had episiotomies often avoid sitting normally. Nurses should encourage them to take medications as needed, to contract their buttocks before sitting, and to sit normally rather than trying to favor one buttock over the other.

Hemmorrhoids: Wipe from the front to the back

Question 6

First degree episiotomy

Answer 6

First degree — superficial vaginal mucosa or perineal skin

Question 7

Second degree episiotomy

Answer 7

involves vaginal mucosa, perineal skin, and deeper tissues of the perineum

Question 8

Third degree episiotomy

Answer 8

same as second degree, plus involves anal sphincter

Question 9

Fourth degree episiotomy

Answer 9

extends through the anal sphincter into the rectal mucosa

Question 10

Episiotomy

Answer 10

controlled surgical enlargement of the vaginal opening during birth

Question 11

Lacerations

Answer 11

uncontrolled tear of the tissues that results in a jagged wound

Women who have experienced a third or fourth degree lacerations are not given anything via the rectum. This includes enemas and suppositories

Question 12

What are comfort promoting measures?

Answer 12

a - Apply ice packs to the pt’s perineum for the first 24-48 hrs to reduce edema and provide anesthetic effect
b - encourage sitz baths at the temperature of 38-40 C (100-104 F) or cooler at least twice a day
c - administer analgesia, such as non-opioids (acetaminophen [Tylenol]), NSAIDs (ibuprofen [Advil]), and opioids (codeine, hydrocodone), as prescribed for pain and discomfort
d - opioid analgesia may be administered via a PCA (pt controlled analgesia) pump after c-section. Continuous epidural infusions may also be used for pain control after c-section.
e - apply topical anesthetics (Americaine spray or Dermoplast) to the pt’s perineal area as needed or witch hazel compresses (Tuck’s Pads) to the rectal area for hemorrhoids

Question 13

Maternal Warning Signs to Report

Answer 13

a) Heavy Vaginal Discharge [poss. hemorrhage]
b) Pelvic or perineal pain [traveling clot]
c) Fever [temp 100.4 or greater = infection]
d) Burning sensation during urination [UTI]
e) Swollen area on leg ; painful, red, or hot
f) Breast: painful, red, hot area [mastitis]