Postpartum Maternal Physical Assessment Summary.docx

Postpartum Maternal Physical Assessment Summary- BUBBLE HE                  

Breasts: inspect: size, symmetry, shape of breast and nipples taking note of erection, flatness, redness, bruising, open wounds, presence of mastitis and colostrum palpate: fullness, soft or engorged, firmness and lumps pain assessment Uterus (Fundus): palpate: firmness/bogginess, location of the fundus in relation to the abdomen, determine the location of the fundus in relation to the belly button to determine amount of fundal involution inspect incision site check policy: in some organizations, they may not assess fundal involution by palpation due to fear of dehiscence Bladder: void amount (~30ml/hr) assess for distention, incontinence, urinary retention, urinary infection especially if the patient had a foley catheter Bowel: last bowel movement/flatus assess for distention, abdominal pain Lochia: amount, color, odour assess for postpartum hemorrhage Episiotomy level of laceration number of stitches, redness, edema, bruisin, discharge, approximation of wound edges assess perineal area Homan’s Sign-for DVT assess for pain with dorsiflexion check policy: this is sometimes not done in organizations Emotional State: assess for signs and symptoms of postpartum depression and infant-maternal bonding

Postpartum physical adaptations � Uterus continued � Changes in Fundal Position � Immed after placenta expelled:

� Uterus contracts to compress blood vessels � Size of large grapefruit

� Fundus in midline, about half way to 2/3 way between umbilicus and symphysis pubis � Rises to level of navel about 6-12 hours after delivery changes in ligaments � Fundus above umbilicus and soft and spongy (boggy) associated with excess bleeding � If high and displaced to side (usually right), prob secondary to full bladder � Empty bladder and reassess Postpartum physical adaptations � Uterus continued � Uterus remains at level of umbilicus about ½ day after birth � On first day following birth – top of fundus about 1cm below umbilicus

Postpartum physical adaptations � Lochia � Debris eliminated in discharge called lochia, is classified according to appearance � Lochia rubra: � Dark red, first 2-3 days after delivery � Clotting result of pooling in vagina, nickel size clots otherwise ok

� Fundus descends about 1 fingerbreadth or 1 cm daily � Descends into pelvis on 10th day, can no longer be palpated � Returns to pre-preg size and location by 5-6 wks � If descends slower, called subinvolution � Lochia serosa: � Pinkish to brownish � 3-10 days pp � Lochia alba: � Yellowish-whitish � Duration varies

Postpartum physical adaptations � Lochia � When lochia stops, cervix is closed, less chance of uterine infection � Total lochia blood loss volume is 225 mL � Volume decreases gradually, may increase with nursing, exertion � Normal odor slightly musty, non-offensive � Foul odor to lochia suggests infection

� Assessment of lochia necessary � Type, amt of lochia corresponds to involution & healing of placental site � Failure of lochia to progress and decrease in amount = subinvolution or PP hemorrhage � If continuous bright red seep with firm uterus right after birth, must consider possibility of laceration

Postpartum physical adaptations � Cervical Changes � Spongy and flabby, formless after birth � Reforms with in few hours & closes slowly, by end of first week will only admit fingertip � Shape permanently changed � Vaginal Changes

� May be edematous and bruised, no rugae � Size decreases and rugae returns in 3-4 wks, normal by 6 wks � Can improve tone with Kegel’s exercises � If nursing may be dry, pale

Postpartum physical adaptations � Perineal Changes � Appears swollen and bruised � If episiotomy or laceration, should be well approx � Should be healed by 2-3 weeks after delivery with complete healing by 4-6 months � May have some discomfort during this time � Recurrence of Ovulation and Menstruation

� Generally 6-10 wks after birth if not nursing � If nursing, return is prolonged � Depends on length of breastfeeding and supplements � Not reliable form of contraception

Postpartum physical adaptations � Abdomen � Appears loose and flabby � Responds to exercise with in 2-3 months � If abdomen over distended or poor muscle tone pre-preg, may not regain tone, remains flabby � Diastasis recti abdominis � Is separation of abdominis muscles � Often occurs with preg, especially if poor abd tone

� Abdominal wall has no muscle support � Improvement depends on cond of mom, type and amt of exercise, number of pregnancies and spacing � May result in pendulous abd � Striae � Results from rupture of elastic fibers of skin � Fade to silvery white if Caucasian � If dark skin, they stay darker than surrounding skin

Postpartum physical adaptations � Gastrointestinal system � Hunger, thirst immediately after birth common � Bowels tend to be sluggish � d/t progesterone, decreased abdominal tone

� If episiotomy – scared will hurt or tear sutures with BM � Nursing interventions may help prevent, relieve � If C/S, clear liq till bowel sounds, then solid food

Postpartum physical adaptations � Urinary system � At risk for over distention, incomplete emptying with residual urine d/t � Increased bladder capacity � Swelling and bruising of tissues around urethra � Decreased sensation of full bladder (anesthetic block) Postpartum physical adaptations � Vital signs

� Output first 12-24 hrs pp (PP diuresis) � Eliminate 2000-3000 mL preg fluid, more if PIH � Fills bladder quickly, watch closely for distention � Risk of UTI high � Full bladder will also uterine relaxation, bleeding

� Should be afebrile after 24 hrs

� May have temp up to 100.4 F (38 C) for 24 hrs d/t dehydration � May also have elevation of 100 to 102 F (37.8-39 C) when milk comes in � BP may spike immediately after delivery � Should have normal BP within few days � Orthostatic hypotension common first couple days Postpartum physical adaptations � Blood values � Values return to normal by 6-8 wk after delivery � Increased coagulation factors continue for variable time, increases risk for blood clot � Blood loss averages � H & H difficult to determine in first 2 days pp d/t changing blood volume (diuresis) Postpartum physical adaptations � Cardiovascular changes � Blood volume increases because no longer has blood circulating to placenta � Works to protect mother against excess blood loss � Diuresis decreases extracellular fluid � If fails to happen, can lead to pulmonary edema esp in mother with preeclampsia or existing cardiac problems Postpartum physical adaptations � Afterpains � Are intermittent contrx of uterus � More common in multips, retained placenta or with overdistention of uterus � Oxytocin & breastfeeding increases afterpains

� Decrease = hemorrhage versus normal? � Increase = preeclampsia, excess oxytocin use? � Decreased pulse common for first 6-10 days PP � Pulse > 100 related to hemorrhage, fear, pain, infection

� 200-500 cc with vag del � 700-1000cc with C/S � Rule of thumb – 2 point drop in Hct = 500 mL blood lost � WBC increases in labor & early pp to 25,00030,000 � Platelets return to normal by 6 weeks � Weight loss � 10-12 # immediately after birth (infant, placenta, amniotic fluid) � Diuresis additional 5# first wk � By 6-7 wks return to pre-preg wt if gained normal amt

� Can use mild analgesic 1 hour before nursing � May be very uncomfortable for 2-3 days � Usually gone in 5 minutes

Postpartal Nursing Physical Assessment � Physical Assessment – see guide pg 1001-1004 � Explain to pt purposes � Record and report results

� Avoid exposure to body fluids � Teach pt as assess – use q opportunity since limited time

Post Partum Nursing Assessment � Assessment necessary to identify individual needs or potential problems � See page 1053-1055 for complete assessment guide � Also see table on page 1052 about postpartal high risk factors and their implications � Term BUBBLEHE can help remember components � breast, uterus, bladder, bowel, lochia, episiotomy, Homan’s/hemorrhoids, emotional

� Principles in assessment of pp woman � Provide explanation of assessment to client � Perform procedures gently to avoid unnecessary discomfort � Record and report results � Take appropriate precautions to prevent exposure to body fluids � Provides excellent opportunity for client teaching about physical changes of pp and common concerns

Post Partum Nursing Assessment � Vital signs � Alterations in VS can indicate complications already discussed � Lung auscultation

� Lungs should be clear � Women treated for PTL, PIH @ risk for pulmonary edema

Post Partum Nursing Assessment � Breasts � Assess fit and support of bra � Helps maintain shape by limiting stretching of ligaments and connective tissue � Bra for nursing mother � Non-elastic straps � Be one size larger than normal � Have cups that fold down for nursing

� Breast assessment � Inspect for redness, engorgement � Palpate for warmth, firmness of filling or engorgement, tenderness � In nursing women: � Assess nipples for cracks, bleeding, soreness, fissures, inversion

Post Partum Nursing Assessment � Abdomen and Fundus – pg 1057 -1058 � Pt should void prior to checking fundus � Uterus positioned better � More comfortable to client � Position pt on back with legs flexed � Assess relationship of fundus to umbilicus, midline � Assess firmness of uterus

� Massage prn if not firm � Assess any blood discharged during massage � Assess gently, uterus slightly tender � Excessive pain with palpation clue to infection � If cesarean � Palpate fundus gently � Assess incision (REEDA, patency of staples)

Post Partum Nursing Assessment � If uterine atony (boggy): � Question patient about her bleeding, passage of clots � Re-eval bladder

� Babe to breast if nursing � Assess maternal BP, pulse � Notify MD since may need oxytocic med

Post Partum Nursing Assessment � Lochia – pg 1059 � Assess for character, amt, odor, clots � Should never be more than moderate amt with non-offensive odor: � Partially saturate 4-8 pads, 6 average/day � Women with C/S bleed less first day than vag del

Post Partum Nursing Assessment � Perineum – pg 1061-1062 � Inspect with pt in Sims position � Lift buttock to expose perineum, anus � If present, assess episiotomy or laceration for REEDA � Should have minimal tenderness with gentle palpation

Post Partum Nursing Assessment � Lower Extremities � PP woman at increased risk of thrombophlebitis, thrombus formation; most likely site is legs � To screen, use Homan’s sign (not diagnostic) � Nurse grasps foot and dorsiflexes sharply � Should have no calf pain � If positive for pain notify MD

� Also assess woman’s pad changing practices, her type of pad � Assess chux pad � If pt reports heavy bleeding, change pad, reassess in 1 hr � If need accurate assessment, can weigh pad; 1g = 1cc � Teach proper wiping, progression of lochia � No hardened areas or hematomas � Also assess hemorrhoids: size, pain � Evaluate effectiveness of any comfort measures performed � Educate about suture absorption

� Check for edema, redness, tenderness, warmth of leg � Prevention best � Early ambulation � Passive ROM for cesarean client till sensation returns � Teach � Signs and symptoms to watch after discharge

� Self care for prevention – ambulate, leg exercises in bed, avoid crossing legs and pressure behind

knees

Post Partum Nursing Assessment � Elimination � Urinary � Should void within 4 hours, then q 4-6 hours � Monitor bladder carefully first few hrs (diuresis) � Watch for distention � Misplaced or boggy uterus, palpable bladder signs

� Check to see if empty first few times � Use techniques to encourage void � If can’t void after 8 hours or voiding small (2000mL/day) � Fresh fruits and veggies

Post Partum Nursing Assessment � Rest status � Requires energy to make adjustments to motherhood and infant � Fatigue often significant problem � Evaluate amount of rest mother is getting

� Determine cause of not sleeping, use appropriate interventions � Encourage daily rest period � Arrange activities in hospital

Post Partum Nursing Assessment � Nutritional status � Non-nursing � Decrease calories by 300/day � Return to pre-preg nutritional requirements � If nursing � Increases calories by 200 over preg level or 500 over pre-preg level Postpartal Psychologic Adaptations � PP time of adjustment and adaptation to new baby, pp discomfort, change in body, loss of pregnancy � 2 periods of adjustment: � Taking in period � First couple days, tends to be passive, dependent Postpartal Psychologic Adaptations

� Refer to dietician if vegetarian, food allergies, lactose intolerance or have specific food needs related to culture/religion � Advise iron supplements, prenatal vitamins for 3 months esp if nursing

� Hesitates to make decisions, follows suggestions � Preoccupied with her needs � Must assimilate experience � Talks about labor, sorts out reality � Sleep, eat is major focus

� Periods of adjustment � Taking hold period � By 2nd – 3rd day ready to resume control of body, mothering and her life � Needs reassurance needed she’s doing well as mother � This theory 40 years old, slightly outdated as women more independent today � Adjust more rapidly in shorter time periods than these