POSTPARTUM ASSESSMENT��Mrs MANAL SAMI

Scenario

Abeer 20 years old, G1P1 in first day postpartum vaginal delivery, V/S checked was found T38c, BP 120/70, RR 16, Pulse 70 b/min. uterine involution checked Fundus is on umbilicus level, in midline, and Firmly contracted. Lochia Rubra present in moderate amount, Mediolateral episiotomy was found intact no signs of infection. Abeer looks Fatigue, sad, and complaining of moderate abdominal cramp when she started to do breast feeding.

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Postpartum glossary

• Postpartum period: interval between the birth of the newborn and the return of the reproductive organs to their normal non-pregnant state(6 weeks).
• Involution :return of the uterus to non-pregnant state after birth
• Sub involution: failure of the uterus to return to non-pregnant state.

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• Uterine atony: relaxation of the uterus in the postpartum period.
• Boggy uterus: a term used to describe the uterine fundus when it is not firmly contracted after the birth of baby early in the postpartum period.
• Postnatal hemorrhage: loss of blood greater than 500 ml following vaginal birth this classified as early or immediate if it occurs within the first 24 hours.

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• Lochia :vaginal discharge, consisting of blood, fragments of deciduas, white blood cells, mucus following birth.
• Lochia rubra: vaginal discharge consisting almost entirely of blood with only small particles of deciduas, occurring from days 1-3 of the postpartum period.
• Lochia serosa: pinkish brown vaginal discharge consist of old blood serum leukocytes and tissue debris that follows lochia rubra until about the tenth day after birth.
• Lochia alba: thin, yellowish to white vaginal discharge that follows lochia serosa consist of leukocytes deciduas, epithelial cells and mucus usually continues for 10 to 14 days but may last to 6 weeks postpartum.

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• After pain: intermittent cramping due to uterine contraction during involution in the postpartum period.
• Engorgement: breast distention or vascular congestion. the process of swelling of the breast tissue brought about by an increase in blood and lymph supply to the breast, which precedes true lactation it last about 48 hrs and usually reach a peak between the third and fifth postpartum day.

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• Mastitis: infection in the beast, usually confined to milk duct, characterized by influenza-like symptoms and redness and tenderness in the affected breast..

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TAKE NOTE

• Comprehensive nursing assessment begins within an hour after the woman gives birth and continues through discharge.
• Nurses need a firm grasp of normal findings so that they can recognize abnormal findings and intervene appropriately.

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Postpartum Physical Adaptations �

• Uterine Involution
• Fundal position changes: “Boggy”
• Lochia: Rubra, Serosa, Alba
• Cervical changes
• Vaginal changes
• Perineal changes
• Recurrence of ovulation and menustration

• Lactation
• Gastrointestinal System
• Urinary tract
• Vital signs
• Weight loss
• Postpartum chill
• Postpartal diaphoresis
• Afterpains or Afterbirth pains

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�NORMAL POSTPARTUM ADAPTATIONS: PHYSIOLOGIC�

• UTERUS:

Uterine Involution: The rapid reduction in size of the uterus after delivery of placenta and it’s return to a condition similar to its pre-pregnancy state.

The uterus with the assistance of the uterine muscles, contracts the blood vessels at the site of placental attachment to control bleeding.

• The uterus continues to contract after delivery, and its size decreases rapidly as estrogen and progesterone levels diminish

The fundus continues to descend into the pelvis at the rate of approximately 1 cm (finger-breadth) per day and should be non palpable by 10 days postpartum

• Afterpains, or intermittent uterine contractions, are a normal occurrence during the postpartum period. Afterpains are caused by the release of the hormone oxytocin and the subsequent relaxation and contraction of the uterine muscles

• After pains
• Uterine contractions as uterus involutes
• Relief of after pains
• Positioning (prone position)
• Analgesia administered an hour before breastfeeding
• Encourage early ambulation - monitor for dizziness and weakness

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• After delivery, the endometrial surface of the uterus is shed via the vagina. The shedding endometrium is known as lochia. Lochia occurs in three successive stages that include lochia rubra, lochia serosa, and lochia alba.

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Lochia: Rubra, Serosa, Alba

• Rubra: dark red in color, present the first 2-3 days postpartum, should not contain clots, a few small clots are considered normal.
• Serosa: pinkish to brownish in color, from the 3rd to the 10th day post delivery.
• Alba: creamy or yellowish in color, persists until 6weeks

• PERINEUM

This area between the posterior portion of the labia majora and the anus stretches and thins during birth to accommodate the delivering infant. Lacerations of the perineum may occur during delivery, or an episiotomy (surgical incision) may be performed in this area to accommodate the infant during delivery.

• BREASTS

After delivery there is a significant decrease in estrogen and progesterone levels. Before milk production begins, the breasts secrete colostrum, a thin, yellowish fluid that helps maintain the blood glucose level in the breastfeeding infant. Nipple stimulation by the infant causes the release of the hormone oxytocin from the posterior pituitary gland, which triggers the release of the hormone prolactin from the anterior pituitary. Prolactin initiates milk production, and the breasts become full (engorged), as well as warm and tender, between postpartum days 3 and 4.

Gastrointestinal System

• After delivery the client feel hungry
• May have a regular diet
• Bowels tend to be sluggish
• Cesarean birth clients may receive clear liquids and progress to a regular diet
• Stool softeners may be used

• Urinary System

The bladder, urethra, and urinary meatus are edematous after delivery as a result of the fetal head passing through the birth canal. Bladder tone is diminished, and many clients are unable to feel the need to void, despite the rapid diuresis(puereperal diuresis) that occurs following delivery to eliminate 2000-3000ml of extracellular fluids

• Vital signs

• Temperature elevations should last for only 24 hours – should not be greater than 38c
• Bradycardia rates of 50 to 70 beats per minute occur during first 6 to 10 days due to decreased blood volume
• Assess for BP within normal limits :may experience transiet rise in BP
• Notify MD for tachycardia, hypotension, hypertension
• Respirations stable

• Blood Values

• White blood cell count often elevated after delivery
• Leukocytosis
• Elevated WBC to 30,000/mm3
• Physiologic Anemia
• Blood loss – 200 – 500 Vaginal delivery
• Blood loss 700 – 1000 ml C/S
• RBC should return to normal w/in 2 - 6 weeks
• Hgb – 12 – 16, Hct – 37% - 47%
• Activation of clotting factors (PT, PTT, INR) predispose to thrombus formation - hemostatic system reaches non-pregnant state in 3 to 4 weeks
• Risk of thromboembolism lasts 6 weeks

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Postpartum Chill and Postpartal Diaphoresis

• Most clients experience a shaking chill or tremor after delivery. Warm blankets usually relieve this tremor or chill.
• Chills and fever late in the postpartum period may indicate sepsis.
• Diaphoretic episodes may occur at night, a normal occurrence as the body rids itself of waste products.

Nursing assessment during post partum period

Post partum assessment typically is performed as follows:

1. During the first hour: every 15 minutes
2. During the second hour: every 30 minutes
3. During the first 24 hours: every 4 hours
4. After 24 hours: every 8 hours

Post partum assessment

����TAKE A NOTE

Immediately after birth your assessment must be prioterized for uterus & lochia to assess bleeding

BREAST ASSESSMENT

• Inspect the breast for size, contour, asymmetry, engorgement, or erythema.
• Check the nipples for cracks, redness, fissures, or bleeding, and note whether they are erect, flat, or inverted?? ( Flat or inverted nipples can make breastfeeding challenging for both mother and infant.
• Palpate the breasts lightly to ascertain if they are soft, filling, or engorged.
• Palpate the breasts for any nodules, masses, or areas of warmth, which may indicate a plugged duct that may progress to mastitis if not treated promptly.
• First day or two after delivery, the breast should be soft and non tender.

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• Assess for presence of colostrum: a clear , yellow fluid, expressed from breasts in first 72hrs after birth. it is Rich in antibodies, which provide protection from many disease, and high in protein.

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FUNDAL ASSESSMENT

• Location in relation to umbilicus
• Degree of firmness
• Midline or deviated to one side

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ASSESSING THE UTERINE FUNDUS

• The uterus is best evaluated with the patient in a supine position and with an empty bladder.
• The nurse should support the lower uterine segment just above the symphysis pubis with the non-dominant hand and palpate the uterine fundus for degree of involution.
• Fundal descent is measured in relationship to the umbilicus in fingerbreadths or centimeters.

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FIGURE 23–6 Measurement of descent of fundus for the woman with vaginal birth. The fundus is located two finger-breadths below the umbilicus. Always support the bottom of the uterus during any assessment of the fundus.

UTERINE INVOLUTION

• At the end of third stage of labor, the uterus in midline, about 2 cm below the level of umbilicus.
• Within 12 hrs fundus maybe approximately 1 cm above the umbilicus, or at umbilicus level.
• The fundus descends about 1-2 cm every 24 hrs.
• Factors that enhance involution include an uncomplicated labor and birth, complete expulsion of the placenta or membranes, breast feeding and early ambulation.

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BLADDER ASSESSMENT

• Voiding pattern, complete emptying, pain burning on urination
• Record first three voids with the amount and times voided
• A full bladder displaces the uterus upwards and laterally and prevents contraction of the uterus = UTERINE ATONY =  > risk of postpartum hemorrhage.

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Bowel

• Spontaneous bowel movements may not occur for 2 – 3 days after giving birth because of a decrease in muscle tone in the intestine during labor and the immediate puerperium, pre labor diarrhea, lack of food, or dehydration.
• Inspect the woman’s abdomen for distention, auscultate for bowel sounds in the four quadrants, and palpate for tenderness.

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LOCHIA ASSESSMENT

• Assessment of lochia includes noting color, presence of clots and foul odor.
• Day 1- 3 lochia rubra                              
• Day 4-10 lochia serosa                                
• Day 11 -14or 6 weeks, lochia alba
• If soaking 1 or > pads /hour, assess uterus, notify health care provider

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PERINEAL ASSESSMENT

• Assessment of the episiotomy/perineum should occur with the woman in lateral Sims (side lying) position.�Use the acronym REEDA (redness, edema, ecchymosis, discharge, approximation of edges of episiotomy) to guide assessment.
• Even if there is no episiotomy, the perineum should still be assessed.
• Unusual perineal discomfort may be a symptom of impending infection or hematoma.�Hemorrhoids.

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• R = redness (erythema)
• E = edema
• E = ecchymosis
• D = drainage, discharge
• A = approximation

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Extremities

• Assess for pedal edema, redness, and warmth
• Check Homan's sign – dorsiflex foot with knee slightly bent
• - encourage client to early Ambulate to prevent D.V.T

Normal Post partum psychological �changes�

Rubin’s Phase

• Taking in phase: First 3- days
• Mother focuses on her own primary needs, such as sleep and food.
• The woman is largely passive ,dependence results partly from her physical discomforts.
• The woman usually wants to talk about her pregnancy, especially her labor and birth.

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4. It is important for the nurse to listen and help the mother interpret the events of delivery to make them more meaningful.

5. This phase is not an optimum time to teach the mother a bout baby care.

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Taking hold phase: days 4-10

• The woman is more in control of independence
• The woman begins to assume the tasks of mothering.
• This phase is an optimum time to teach the mother a bout baby care.
• Although a woman actions suggest strong independence during this time ,she often still feels insecure about her ability to care for her new child.

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Letting-Go phase

• The woman finally re defines her new role. She gives up the fantasized image of her child and accepts the real one.
• A woman who has reached this phase is well into her new role.

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• Maternal role attainment: process by which a woman learns mothering behaviors. (anticipatory, formal, informal, and personal)

Postpartum blues

• Transit period of depression during the first few days of postpartum( moodswing, anger, anorexia& difficulty sleeping)
• Considered normal reaction to new motherhood and causes few problems ,
• Causes: Exact cause still unknown, but suggested causes may be: hormonal changes cause mood swings (sudden fall in blood progesterone), changes in life style , new responsibilities (motherhood).
• Incidence increase by: stress, fatigue , anxiety from family tension or inability to cope with baby demands.

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Postpartum blues

*Women are emotionally labile ,often crying easily and for no apparent reason. This lability seems to peak around the fifth day and subside by the tenth day.

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* If worsen the woman may need evaluation for postpartum depression

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POSTPARTUM CESAREAN

In addition to the usual postpartum evaluation, postcesaren mother must be assessed like any other postoperative client.

• Pain Relief: Assessment of pain level and the effectiveness of pain medication is an important part of nursing care for postcesaren clients.
• Respiration mothers receive narcotics for postoperative pain relief must be assessed frequently because narcotics depress the respiratory center.

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• The chances of pulmonary infection are increased because of immobility after the use of narcotics and sedatives and because of altered immune response in postoperative clients. Therefore, the woman is encouraged to cough and deep breath every 2 to 4 hours while awake until she is ambulating frequently.

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• Abdomen :Nurses assess gastrointestinal function by auscultating for bowel sounds until normal peristalsis is noted in all abdominal quadrants .
• Nurses must be assess for abdominal distention, absent or decreased bowel sounds, and failure to pass flatus or stool.
• Observe the incision, which should be approximated , and use the acronym REEDA to assess for signs of infection.

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• Intake and output
• Legs: leg exercise encouraged every 2 hrs until the woman is ambulating.

The woman should be encouraged to flex her legs and to move her feet and legs frequently to improve peripheral circulation and prevent thrombi.

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Discharge post partum mother�

• Provide good education for mother that include:
• Self hygiene
• Need for rest and exercise
• Breast feeding and the type of diet that need to her and her baby

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• cont
• Care of the baby sleep and hygiene:
• Baby cord stump
• Baby stool& skin
• Immunization and when it must taken

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Danger sign postpartum

• Inform mother when to return immediately:
• Fever
• Vomiting
• Fainting
• Abdominal pain
• Change in the character of the lochia foul smell, return to bright red bleeding, excessive amount, passage of large clots.
• Pain at the site of a laceration, episiotomy, or abdominal incision.

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7. Evidence of thrombophlibitis, such as calf pain, tenderness, redness.

8. Evidence of wound infection including redness, swelling, severe or worsening pain , or foul smelling discharge.

9. Evidence of mastitis, such as breast tenderness, swelling, reddened areas, malaise.

10. Evidence of urinary tract infection, such as urgency, frequency burning on urination.

11. Sever headache

12. Mood changes

13. Problem with sleeping.

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Nursing Diagnosis:

• Pain related to uterine cramping (after pains) or perineal sutures.

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• Risk for infection (uterine) related to lochia and episiotomy.

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• Disturbed sleep pattern related to exhaustion from and excitement of childbirth.

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• Imbalanced nutrition, less than body requirements, related to lack of knowledge about postpartum needs.

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• Risk for deficient fluid volume related to uterine atony and hemorrhage.

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• Health Seeking Behaviors: information about infant care related to an expressed desire to improve parenting skills.

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• Ineffective Health Maintenance related to insufficient knowledge of self care, signs of complications, and preventive measures.

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• Impaired urinary elimination related to perineal trauma

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• Fatigue related to multiple role demands.

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