6 - Postpartum Assessment PDF

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POSTPARTUM Assessment of the fundal position and lochia changes Chapter 18 – pgs. 460-462 The return of the uterus to a nonpregnant state after birth is called involution. This process begins immediately after expulsion of the placenta with contraction of the uterine smooth muscle. Fundal massage – place hand at the lower segment of the uterus right over the pelvic bone, take dominant hand, starts at the umbilicus, and kind of feel down until you feel that top round ledge of the uterus. That’s the part you are going to depress down on to make sure that you have a firm fundus. We have to have a firm fundus. If we don’t, we have bleeding. Fundus The main thing that you want to look for is that the fundus is firm, and that it is going down so the involution processes happening. Usually we start looking for the fundus which is the top of the uterus at the umbilical line, if not lower. If the fundus is higher than the umbilical line. One of the things that you could think of is this the bladder full because the bladder will push the fundus up and out of the way. If the bladder is not full then you still need to start investigating why her involution process has stopped, and it has started going backwards where it's going up higher. Within 12 hours, the fundus can rise to approximately 1 cm above the umbilicus. By 24 hours after birth, the uterus is about the same size as it was at 20 weeks of gestation. Involution progresses rapidly during the next few days. The fundus descends 1 to 2 cm every 24 hours. By the sixth postpartum day, the fundus is normally located halfway between the umbilicus and the symphysis pubis. The uterus should not be palpable abdominally after 2 weeks and should have returned to its nonpregnant location by 6 weeks after birth Uterus Make sure the uterus is soft, it’s not soft and boggy. If it feels like a water balloon, that's soft and boggy, you want it to be firm, like a softball or baseball would be if it happens to be soft and bobby then you want to massage the area   

Need to know where it is – if it is midline, it should be in the center of the women’s abdomen. If it’s into one side , you need to check the bladder Before you do a fundal massage, ask when they last voided. If they haven’t void for the past hr, have them get up and void first and then do the fundal check. At the end of the third stage of labor, the uterus is in the midline, approximately 2 cm below the level of the umbilicus, with the fundus resting on the sacral promontory. At this time, the uterus weighs approximately 1000 g

Lochia Assess for the lochia, what color, and the odor of it is – if there is any clots. Looking at all this while massaging the uterus. You should be seeing lochia coming out from the vagina. 

do we have extreme bleeding? Large saturation of the pad. When you push on the fundus, am I seeing a fountain or just little dribbles. We just want a little dribbles. Do we have clot or purulent?

C-section have very little bleeding while vaginal delivers have more bleeding. For vaginal deliveries, you want to worry if you notice that your pt is soaking more than the size of a parry pad in less than 15 minutes Lochia – postbirth uterine discharge, initially is bright red (lochia rubra) and may contain small clots. For the first 2 hours after birth, the amount of uterine discharge should be about that of a heavy menstrual period. After that time, the lochial flow should steadily decrease. 

Lochia rubra is bright red and consists mainly of blood and decidual and trophoblastic debris.

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POSTPARTUM The flow pales, becoming pink or brown (lochia serosa) after 3 to 4 days. Lochia serosa consists of old blood, serum, leukocytes, and tissue debris. In most women, about 10 to 14 days after birth the drainage becomes yellow to white (lochia alba). Lochia alba consists of leukocytes, decidua, epithelial cells, mucus, serum, and bacteria. Lochia can persist up to 4 to 8 weeks after birth. If the woman receives an oxytocic medication, regardless of the route of administration, the flow of lochia is often scant until the effects of the medication wear off. The amount of lochia is usually less after a cesarean birth because the surgeon suctions the blood and fluids from the uterus or wipes the uterine lining before closing the incision. Flow of lochia usually increases with ambulation and breastfeeding. Lochia tends to pool in the vagina when the woman is lying in bed; the woman then can experience a gush of blood when she stands. This gush should not be confused with hemorrhage. Persistence of lochia rubra in the postpartum period suggests continued bleeding as a result of retained fragments of the placenta or membranes. It is not uncommon for women to experience a sudden, but brief, increase in bleeding 7 to 14 days after birth when sloughing of eschar over the placental site occurs. If this increase in bleeding does not subside within 1 to 2 hours, the woman needs to be evaluated for possible retained placental fragments. About 10% to 15% of women still have normal lochia serosa discharge at their 6-week postpartum examination. However, the continued flow of lochia serosa or lochia alba by 3 to 4 weeks after birth can indicate endometritis, particularly if the woman has fever, pain, or abdominal tenderness. Lochia should smell like normal menstrual flow; an offensive odor usually indicates infection. Not all postpartum vaginal bleeding is lochia; vaginal bleeding after birth can be caused by unrepaired vaginal or cervical lacerations. Postpartum Afterpains o The more babies a person has had, the more pain they will have. o Breastfeeding contracts the uterus, it will cause afterpains o Pharmacological management – Motrin (vaginal delivery) helps with swelling, which will probably have if they deliver vaginally. It will help with the pain. They can get it every 6 hours o Pharmacologic topical agents  Used on the perineum after delivering. It’s topical agents that has medications on it – lidocaine is the most common. It helps numb the pain they have from delivery o Periodic relaxation and vigorous contractions are more common in subsequent pregnancies and can cause uncomfortable cramping called afterpains (afterbirth pains), which typically resolve in 3 to 7 days. Afterpains are more noticeable after births in which the uterus was overdistended (e.g., macrosomic infant, multifetal gestation, polyhydramnios). Breastfeeding and exogenous oxytocic medication usually intensify afterpains because both stimulate uterine contractions Perineum o What assessments  First time that mom gets pregnant, that uterus grows to the size that it needs to be for the baby. And then when the baby's delivered it quickly shrinks back down. The second time a mom gets pregnant. That uterus gets bigger easier than it did the first time, and maybe a little bigger than it did the first time. And then when that baby goes out, that uterus has to work a little bit harder to shrink back down to its original size, but by the time you're having your fourth or fifth baby that uterus is really having to work to make itself get back down to that original size, therefore there's more after pains that they're having the more babies they have  Assess for swelling, hemorrhoids, any hematomas that might be forming in the perineum.  We want to make sure that the patient does not have hemorrhoids, but if they do, we want to make sure that we are helping them keep their stools soft, so they're not having to strain and irritate the hemorrhoids when they do have a bowel movement

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POSTPARTUM Many women do wind up with hemorrhoids after pushing, because we use the same muscles to push, as we do to have a bowel movement so that can often cause enlarged varicose veins also known as hemorrhoids in the rectal area. We want to make sure that mom is increasing her fluids, and we want to offer stool softeners and get them eating more fiber in their diet to help if they do have any hemorrhoid Most episiotomies and laceration repairs are visible only if the woman is lying on her side with her upper buttock raised or if she is placed in the lithotomy position. A good light source is essential for visualization of some repairs. Healing of an episiotomy or laceration is the same as any surgical incision. Signs of infection (pain, redness, warmth, swelling, or discharge) or lack of approximation (separation of the edges of the incision) can occur. Initial healing occurs within 2 to 3 weeks, but 4 to 6 months can be required for the repair to heal completely  Sometimes will have laceration or episiotomy  Make sure you don’t see hematoma – blood vessels will tear during delivery

Meds  Motrin or Tylenol for their pain motor. Motrin also helps with the swelling. If the perineum is swollen, motrin will help with the cramping of the uterus and the swelling of the perineum.  Opioids  Narco or cyconin  We try hard not to give opiods. So, if they've got Tylenol or Motrin ordered and it's not helping with the pain, then we would contact the physician to try and get them something stronger.  Obviously if the patient has had a C section. Then we use stronger medications sometimes for the first 24 hours, you'll see toradol or morphine ordered for your C section mom.  After that we changed them over to PO meds, and that mom might be getting the Norco and Bicoden and eventually transition to Motrin and Tylenol Nonpharmacologic measures  We want to give them ice packs to put on their bottoms so that we can that swelling down and Motrin  Sitz baths, but sitz baths are not used as often as they used to be

POSTPARTUM What’s happening Chapter 18 – ps. g464-465 

V/S changes o V/S – Increased bp may be caused by pain, decrease in bp may indicate dehydration or hypovolemia from bleeding  We also have to remember that this patient had tons of excess blood flowing through their body, and now their body has to start getting rid of that so we may see a fluctuation in vital signs because of that  Mom’s temperature will usually elevate a little when milk comes in but it’s not until 48 to 72 hrs. before that, mom should be below 100.4. we don’t worry about infection unless it’s above 100.4  BP will usually stabilize, and it can lower a little. CO increases between 30 to 50% when they got pregnant. Their CO needs to go back to normal so as they start to diaphoresis and diuresis and get rid of that excess fluid volume, their BP may lower a little bit  There is a transient increase in blood pressure of approximately 5% during the first few days after birth (Isley & Katz, 2017). It can take weeks or months for pulse and blood pressure to return to prepregnancy levels. Increase in blood pressure greater than 140/90 when measured on two or more occasions at least 6 hours apart can indicate preeclampsia.  Respiratory function rapidly returns to nonpregnant levels after birth. After the uterus is emptied, the diaphragm descends, the normal cardiac axis is restored, and the point of maximal impulse and the electrocardiogram are normalized.  Low grade fever is not uncommon during the first 24 hours after birth. However, temperature elevation of 38° C (100.4° F) or higher during the first 10 days postpartum can indicate infection and should be evaluated  As many as 50% of women experience shivering episodes during the first few minutes up to the first hour after birth. The exact cause is unknown, and usually no treatment is needed; if the shivering is related to the effects of anesthesia, pharmacologic treatment may be needed o Orthostatic hypotension – After birth, rapid decrease in intraabdominal pressure resulting in dilation of blood vessels supplying the viscera. Results in engorgement of abdominal blood vessels and rapid fall in BP can cause dizziness & light headed  rapid decrease in the intra abdominal pressure, and that results in dilation of blood vessels that have been supplying the viscera. And this can result in engorgement of abdominal blood vessels, and that rapid fall in that blood pressure, that can cause dizziness and lightheadedness  it goes back to all of that hyperkalemia that was going on with the moms body they had all of this increased blood and fluid that was flowing through their body, and now suddenly after delivery it's all starting to plummet o Pulse – Brady, reflects the large amount of blood that returns to the central circulation after delivery of the placenta.  Mom was producing all of that extra blood to supply blood to that placenta but now that the placenta is gone, the body is still shortly after trying to supply that placenta.  And now that increased blood flow may wind up, giving the mom a little bit of blood produce bradycardia  Pulse rate should stay normal. If pulse rate starts to elevate and BP starts to drop. You need to be concerned about hemorrhage or hypovolemic shock o Tachy with pain, anxiety, fatigue, dehydration, hypovolemia, anemia or infection o Normal respirations

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POSTPARTUM  they might have had a little bit faster respirations because of pressure being put on the diaphragm from the baby but now that all of that pressure is gone and the uterus isn't up so high, one's respiration should return to normal  RR may stay stable. It might be a little less since their diaphragm does not have so much pressure from the baby.  When birth occurs, there is an immediate decrease in intraabdominal pressure, which allows for greater excursion of the diaphragm. With decreased pressure on the diaphragm and reduced pulmonary blood flow, chest wall compliance increases. Rib cage elasticity can take months to return to a prepregnancy state. The costal angle that was increased during pregnancy may not completely return to the prepregnancy level. The decline in progesterone that occurs with loss of the placenta causes PaCO2 levels to rise o Slight increase in temp within first 24 hours or so  You might see in the first 24 to 48, hours a slight increase in temperature  If you see temperature above 100.4, it is an indicator of a sign of infection Assess signs and symptoms Note the patient’s history & meds o Does pt have hx of postpartum hemorrhage since it can happen again? Hypervolemia after birth o Protective mechanism o Hypervolemia is caused immediately after birth because the body is used to the increased production of blood for the placenta and the body has to then work to get this overload out What is the H/H before and after delivery? o Why does this matter?  H/H is the best indicator as to how the blood loss affected the body  Baseline and after delivery  What other lab values should we watch? o WBC – greatest indicator of infection . when pregnant woman deliver, their body is under stress. At the end of pregnancy and right after delivery, their WBC is a little bit higher  Look at the greater picture – do they have a temperature of 101.4 or do they have tachycardia  Normal leukocytosis of pregnancy ranges from 5,000 to 15,000/mm3. During and after labor the white blood cell count may rise to 30,000/mm3. Leukocytosis, coupled with the increase in erythrocyte sedimentation rate that normally occurs, can obscure the diagnosis of acute infection o Hematocrit and hemoglobin  In women with an average blood loss during birth, the hematocrit level drops moderately for 3 to 4 days, then begins to increase, and reaches nonpregnant levels by 8 weeks postpartum. A postpartum hematocrit can be lower than normal if the blood loss was increased or if the hypervolemia of pregnancy was less than normal. o Coagulation Factors  Clotting factors and fibrinogen are normally increased during pregnancy and remain elevated in the immediate puerperium. When combined with vessel damage and immobility, this hypercoagulable state causes an increased risk for venous thromboembolism, especially after a cesarean birth. Fibrinolytic activity also increases during the first few days after birth. Factors I, II, VIII, IX, and X decrease to nonpregnant levels within a few days. Fibrin split products, probably released from the placental site, can be found in maternal blood.

POSTPARTUM Postpartum assessment Cesarean section Chapter 17 – pgs. 451-452 You want to be doing the same assessment as you would be doing that vaginal patient 

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Assessments? o Incision  you need to make sure that the incision is well approximated, you need to be counting your suture or your staples so that you know that they're all there and intact and not missing you want to look for any redness and swelling, any drainage is that hot to the touch  it is well approximated, it is hot and warm to touch, how many sutures or staples are there and if it’s the same amount after reassessing.  Tenderness. Make sure it is staying approximate since C-section can open up o Fundus/lochia  We’re looking at the fundal height. We’re looking if it is foggy, you're still doing a fundal check so pushing on that uterus to see if it's firmer boggy, just because the patient has had a C section does not mean that you do not do a regular fundal assessment  Do the same thing as vaginal delivery o GI  You want to know that their GI system should start to return to normal within about 12 to 24 hours, it will still be slowed after surgery, and the fact that they hadn't had anything to eat or drink, but it should return to normal o GU  Pt probably had a Foley. If they still have the Foley, we need to be monitoring the pt’s output. If the foley is out, we need to be monitoring their output to make sure that they’re able to void after the Foley comes out  If the patient had a Foley, that we're watching for signs and symptoms of infections such as a UTI. o Postpartum diuresis  Remember that when this patient is getting rid of all of this excess Diaphoresis – sweating fluid they should be voiding. They should be getting all of this fluid Diuresis – increase out and you'll see that through diuresis and diaphoresis. The body’s urine output way of compensating Interventions? o We want to get up and moving, a mom who had a C-section has a higher risk of getting a blood clot. We want to make sure that we're keeping this patient's pain under control, so that she can get up and walk and be comfortable doing it. Common Meds? o Toradol is the most common given medication through their IV. After that, they will usually have an order for Norco for PO and Motrin. We recommend alternating those two medications since both are every 6 hours so they can take a Norco or Vicotin then 3 hours later, they can have a Motrin and then 3 hours later. We suggest for them to keep their medications, it is easier to keep pain under control that it is to get out of control pain under control Complications of meds? o We want to make sure that if the mom is on is taking pain medications that she knows how those pain medications are going to affect her. Complications of the meds could be that if we're giving this mom what she could be extremely sleepy

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POSTPARTUM You also want to let the mom know that some medications that she takes may pass through breast milk. And if it makes her sleepy. It can also make the baby sleepy. Don’t leave the pt unattended when giving Nocro. Find out if the pt had the medication before and how it affect their system. We need to make sure that the mom will be able to care for the baby. Do not leave her alone holding the baby in the bed

Safety Alert When holding her baby or breastfeeding, a woman may become drowsy and even fall asleep because of the sedation that occurs with the use of analgesics. It is important that someone be with her during these times to prevent newborn injury.

Postpartum assessment Vaginal Delivery Chapter 18 – pgs. 460-461 

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Fundus/lochia – see above o We also need to be doing our fundal checks, looking at lochia, how much bleeding is there in the pancreas if its nice and firm o Do we have a boggy uterus o Do we need to some type ...