Chapter 12: Postpartum Physiological Assessments and Nursing Care

Assess perineum every shift using REEDA

Redness Edema Ecchymosis Discharge Approximation of edges of episiotomy or laceration

Women who are Rh _____ receive an immunizations at ...

Rh-negative. 28 weeks gestation, and after birth if baby is Rh-positive

Postpartum

The 6 week period of time following childbirth

Endometrium

The mucous membrane lining the interior of the uterus

Involution

The process by which the uterus returns to a pre-pregnant size, shape, and location; and the placental site heals

Should uterus (when doing fundal check) be firm or boggy?

Uterus should be firm. Boggy uterus indicates that the uterus is not contracting and places the woman at risk for excessive blood loss.

Large clots should be ...

Weighed and reported to physician or midwife (10 grams = 10 mL of blood loss) Also be examined for presence of tissue (retained placenta)

Subsequent Breast Engorgement

Women who breast feed experience this which is related to distention of milk glands that is relieved by having the baby suckle or by expressing milk

Women with mastitis should still...

continue to breastfeed or pump her breasts (also apply moist heat to the affected breast before breastfeeding)

Headaches related to epidural or spinal anesthesia tend to be worse when the patient is...

in an upright position and improved when the patient is lying down

The uterus needs to be in a contracted state during the postpartum period to decrease the risk of _________

postpartum hemorrhage

Both nonlactating and lactating women should be advised to _____ when they resume sexual intercourse

use contraception. Ovulation can precede their first menses

Assess lower extremities for _____

venous thrombosis. Increased coagulability associated with pregnancy continues into post-delivery period and most women have limited mobility post birth.

The distance between the fundus and umbilicus (by fingers) postpartum:

- After birth the uterine fundus is midway between the umbilicus and symphysis pubis and is firm and midline - Within 12 hours after birth of the placenta, the fundus is located at the level of the umbilicus or 1 cm above - 24 hours after birth the fundus is located at 1 cm below the umbilicus - The uterus descends 1 cm per day, by day 14 the fundus has descended into the pelvis and is not palpable

Comfort measures for perineum:

- Apply ice first 24 hours - Woman lie on side - Tighten gluteal muscles as she sits and relax when seated - Take warm whirlpool bath starting 24 hours after delievery - Analgesia - Topical anethesetic

Assess for headache

- Assess location and quality - Notify health provider is the headache is associated with signs and symptoms of preeclampsia or if post-epidural/spinal headache is suspected

The urinary system post birth

- Diuresis, caused by decreased estrogen and oxytocin levels, occurs within 12 hours post birth and aids in elimination of excess tissue fluids. - Should void within 6-8 hours, need to be catheterized if she does not void within 12 hours - Voiding less than 150 mL is indicative of urinary retention with overflow

Treatment of breast engorgement for breastfeeding women:

- Frequent feedings to empty the breasts and prevent milk stasis - Warm compresses to the breast and breast massage to facilitate the flow of milk prior to feeding sessions - Express milk by breast pump or manually if the infant is unable to nurse - Ice packs after feedings to reduce inflammation and discomfort - Wear a supportive bra

Excessive bleeding

- Heavy lochia is a sign of excessive bleeding or PPH (postpartum hemorrhage) - Assess tone of uterus - Boggy = massage - Boggy and to side = void - If firm = change pad and reevaluate 15 mins later - If continued heavy bleeding = notify - Continued bleeding w/firm uterus could mean laceration

If woman's temperature is greater than 100.4 F

- Hydrate the woman - Notify physician/midwife

Reduce risk of infection of perneium/laceration by:

- Instruct woman on use of peri-bottle with warm water to rinse perineum after elimination - Change peri-pad frequently - Wash hands

Afterpain Education

- Occur within first few days, can last 36 hours - Increase with each pregnancy/birth (more common with multiparous women) - Comfort measures include: empty bladder, warm blanket to abdomen, analgesia, relaxation

Boggy Uterus

- Sign the uterus is not contracted - Risk of excessive blood loss or hemorrhage increased - Immediate action is to massage fundus with palm of hand in a circular motion until firm (reevaluate within 30 minutes) - If it does not respond follow order for oxytocin and notify physician or midwife

Overview of Postpartum assessment:

- Vital signs, pain, breath sounds - Lab findings (CBC, rubella status, and Rh status) - Breasts - Uterus - Bladder - Bowel - Lochia - Episiotomy, lacerations, perineum, hemorrhoids - Lower extremities - Emotions, bonding with infant, fatigue

Treatment of breast engorgement for non-breastfeeding women

- Wear a supportive bra - Avoid stimulating the breast - Ice packs to breast - Analgesics for pain management - Subsides within 24 hours

If the woman's uterus is boggy, the nurse should intervene in what order:

1. Massage the fundus with palm of the hand 2. Give Oxycontin 3. Notify the physician or midwife if uterus does not respond to massage

Assess the uterus for location, position and tone of the fundus every:

15 minutes - 1st hour 30 minutes - 2nd hour 4 hours - next 22 hours Every shift after first 24 hours

Lochia Rubra

1st stage (Day 1-3) - Expected findings: Bloody with small clots, moderate to scant amount, increased flow on standing or breastfeeding, fleshy odor - Deviations from normal: Large clots, heavy amount (saturate pad within 15 mins), foul odor, placental fragments

Women have an average blood loss of ____ related to the vaginal birthing experience

200 - 500 mL

It is recommended that women wait ____ after birth until the next pregnancy is attempted

24 months

Lochia Serosa

2nd stage (Day 4-10) - Expected findings: Pink or brown color, scant amount, increased flow during physical activity, fleshy odor - Deviations from Normal: Continuation of rubra stage after day 4, heavy amount, foul odor

Hematocrit decreases ____ per 500 mL of blood loss

3-4%

Lochia Alba

3rd Stage Day 10 - Expected Findings: Yellow to white color, scant amount, fleshy odor - Deviations from normal: bright red bleeding, foul odor

Lactating women should increase their caloric intake by ____ per day and have a fluid intake of approximately ____ per day.

500 calories 2 liters

Orthostatic Hypotension

A sudden drop in the blood pressure when the woman stands up, which is due to decreased vascular resistance in the pelvis. (Assist woman when ambulating and assess for excessive blood loss)

Lochia is assessed for:

Amount (scant, moderate, heavy) Color (Rubra, serosa, alba) Clots Time/stage

Primary Engorgement

An increase in the vascular and lymphatic system of the breasts, which precedes the initiation of milk production; the woman's breasts become larger, firm, warm, and tender and woman may feel a throbbing pain the the breasts

Metritis

An infection of the endometrium that usually starts at the placental site and can spread to encompass the entire endometrium

Plugged milk ducts

Are associated with inadequate emptying of the breast, wearing overly tight bras, and/or failure to change the infant into different feeding positions. Palpation of tender breast lumps the size of peas. Treatment: - Frequent feedings - Changing feeding positions - Application of warm compresses to breast or taking warm shower prior to feeding session - Massaging the breasts prior to feeding session

Before performing a fundal check:

Ask the woman to void (can cause uterine displacement and atony) Support the lower uterine segment by placing one hand just about the symphysis pubis (fundal pressure could result in uterine inversion)

Mastitis

Inflammation/infection of the breast (usually occurs 3-4 weeks post-birth) Symptoms: fever, chills, malaise, flu-like symptoms, unilateral breast pain, and redness and tenderness in infected area

Lochia

Bloody discharge from the uterus that contains sloughed off tissue; it undergoes changes that reflect the healing stages of the uterine placental site

Colostrum

Clear, yellowish breast fluid which precedes milk production; it contains proteins, nutrients, and immune globulins; produced prenatally as early as the second trimester and prior to lactation in the first days after birth

Postpartum chills

Episode of shaking and feeling cold that is experienced by most women during the first few hours following birth.

Primary complication related to vagina/perineum

Infection at the lacerations or episiotomy sites

Temperature in postbirth women

It is common to experience mild temperature elevations during the first 24 hours post birth related to muscular exertion, exhaustion, dehydration or hormonal changes.

Afterpains

Moderate to severe cramp-like pains caused by uterine contractions during the first few postpartum days

Weight loss

Most women will experience significant weight loss during the first 2-3 weeks postpartum. The average american woman at the end of 6 months postpartum is approximately 3-4 pounds above her pre-pregnancy weight

Symptoms of DVT

Muscle pain, tenderness, palpation of a hard cordlike vessel, swelling of veins, edema, decreased blood circulation to the affected area