OB Ch. 12: Postpartum Physiological Assessments & Nursing Care
Postpartum Nursing The postpartum period, the 6-week period after childbirth, is a time of rapid
Care physiological changes as the woman’s body returns to a prepregnant state.
Overview of the Postpartum Assessment:
e Vital signs, pain, breath and heart sounds
Laboratory findings, such as CBC, rubella status, and Rh status
Vaccination status, including tetanus, diphtheria, and acellular pertussis (Tdap);
influenza; pneumococcal; and COVID-19 vaccine
Breasts
Uterus
Bladder
Bowel
Lochia
Episiotomy, lacerations, perineum, hemorrhoids
Lower extremities
Emotions, bonding with infant, fatigue, psychosocial factors
Breast size, shape, &
mlmlfilmlwlclw’
engorgement
Uterus: firm or boggy?
Bladder: tender or
distended?
Bowel movement?
Lochia: amount, odor
color, clots
Episiotomy location,
stiches, edema, & redness
Homan’s Sign- positive?
Student Nurse Learning Card #5
www.iStudentNurse.com
Emotional status & bonding
1
[}
| ol copyright ©2013 istudentNurse, LLC
Uterus — Maternal Assessment
ivoion
e Involution — takes place 6- 8 weeks postdelivery of the placenta
o This occurs through uterine contractions, atrophy of the uterine muscle, and
a decrease in the size of uterine cells.
=T (OPidk e Afterpains — moderate to severe cramp-like pains related to the uterus
DELEALI
working to remain contracted or the increase of oxytocin released in response
to infant suckling (affects multiparous women or women breastfeeding)
Site 0F e
o The intensity of afterpains will typically decrease after the third postpartum
day.
051t B
“ o Treatment: ibuprofen (1st priority action), then provide warm blanket
Assess the uterus (fundus) for location, position, and tone of the fundus after the 3rd
™ W nin-
stage of labor — Tell pt that you’re palpating her fundus/uterus to evaluate for normal
ReaNONE Si0e
involution and bleeding
After the 3rd stage of labor, assess the uterus:
e Every 15 minutes for the first hour
e Every 30 minutes for the second hour
e Every 4 hours for the next 22 hours
o Every shift after the first 24 hours or as stated in hospital or unit protocols
, @ "BUBBLES"
MASTITIS
May be sore after breastfeeding Infection & inflammation of breast tissue
Breastfeed every 2-3 hours * Continue breastfeeding
(15-20 minutes each breast) * Warm compress
0 REASTS * Hydration
Position newborn "tummy to mummy"
Latch should be completely * Rest
around the areola * Analgesics
* Wash hands!
UTERINE ATONY:
| RISCFACTORS NN SYMPTOMS INTERVENTIONS
Retained placenta Enlarged Fundal massage
Chorioamnionitis (infection) Soft Assist to void or use
Uterine fatigue Boggy a straight catheter
Not midline
Full bladder Poorly contracted uterus
O~ W o
HEMORRHOIDS
Constipation is common after birth.
Increasmg FLUIDS & FIBER may help! * May see blood in the stool
* Should begin to shrink following birth
Fluids, Fruits & Fiber
FiII up the toilet! :
INTERVENTIONS:
* Tucks/witch hazel * Ice pack
* Squeeze bottle * Sitz bath
Postpartum urinary retention is common
LADDER (\Vj In-and-out catheterization may be needed
O
Bladder distention can cause a displaced & boggy uterus!
"Really fore " fter"
\“;_',
- TYPE | | TIMING | DESCRIPTION HEMORRHAGE
AR » Soaking pad in < 1 hour
skubra Really Birth-% days rlgs;zlrl Ciaortsre ' . t(;lots Iar.girlin size
ocin (]| I\ s an a nicke
‘
e
pinkish/brown; [ INFECTION
erosa ore 4-10 days !
less or no clotting » Foul odor
N * Green/yellow
whitish/yellow; purulent discharge
\ Iba fter 10-20 days little to no blood « Fever (> 100.4°F)
or blood clots
Postpartum depression (PPD) is common for women following childbirth
MOTIONAL As the nurse ask about feelings of...
Crying,
STATUS depression * hopelessness * self-harm
QW
irritable, sleep
harm to the newborn dlsturbances
anxiety, feelmgs
of guilt
ECTION A Promote proper wound healing
(-section incisions/ | {‘ REPORT to the health care provider:
Episiotomy pain - inflammation - surrounding skin is warm to touch
© 2023 NurselnTheMaking LL(. Sharing and distributing this copyrighted material without permission is illegal. 109
Prepared exclusively for Truc Phan () Order: 2-34763
, Reproductive system: o Frequent assessment of uterine tone and placement helps identify
complications such as uterine atony (decreased uterine muscle tone)
Uterus that may cause postpartum hemorrhage (PPH).
o The risk for postpartum hemorrhage is the greatest within the first hour
a. The weight of the uterus decreases from
following delivery.
approximately 2 Ib (900 g) to 2 oz
Remove pt’s peripads to evaluate lochia (weigh) at the same time the fundus
(57 g) in 6 weeks.
is palpated.
b. The endometrium regenerates.
Give oxytocin per provider’s orders — Oxytocin promotes contraction of the
c. The fundus steadily descends into the uterus by stimulating its smooth muscle, which prevents and controls
pelvis. postpartum hemorrhage
d. Fundal height decreases about Notify provider if the uterus does not respond to massage and oxytocin
1 cm/day (Fig. 25-1). o Lack of response to fundal massage and oxytocin administration may
e. By 10 days postpartum, the uterus indicate complications such as retained placental tissue or birth trauma
cannot be palpated abdominally. Determine the position of the uterus: A uterus that is shifted to the side may
f. A flaccid fundus indicates uterine atony, jndicate a distended bladder
and it should be massaged until firm; a o Adistended bladder interferes with uterine contractibility, which places the
tender fundus indicates an infection. woman at risk for uterine atony and increases her risk of hemorrhage
g. Afterpains decrease in frequency after |f the uterus is displaced (deviated, soft, or elevated above the umbilicus), this
the first few days. means bladder is full - THE PT NEEDS TO VOID to empty the bladder
o 6-12 hours post delivery, the fundus should be level at U or 1 above
umbilicus (width of finger — 1cm)
e Provide information regarding afterpains, uterine cramps caused by the
contraction, and relaxation of the uterus as it decreases in size.
o Afterpains occur within the first few days and typically decrease 3 days after
delivery — They occur more commonly with multiparous women and
increase with each additional pregnancy & occur in breastfeeding women
o Encourage her to void frequently, as a distended bladder can increase
‘afterpains.
o ( Apply a warm blanket to the abdomen (relaxation techniques and warm
compresses can interfere with the transmission and sensation of pain).
o Analgesics such as ibuprofen and acetaminophen are effective in relieving
uterine cramping.
Fundal massaae {"‘ " m\,ss.\ ‘“0“ W
s the fundus firm or boggy?
o If fundus is boggy — MASSAGE (requires 2 hands)
o Massage until firm -
Uterine Atony (Boggy Uterus) Sm
Uterine atony is the most common cause of postpartum hemorrhage.
e A boggy uterus is a sign that the uterus is not contracted.
e Risk of excessive blood loss or hemorrhage is increased.
¢ Immediate nursing action: massage the fundus with the palm of your hand in
a circular motion until firm and reevaluate within 5 to 10 minutes.
o If the uterus does not respond to massage, follow the standing order for
oxytocin and notify the physician or midwife.
Oxytocin (Pitocin) Administration
e Oxytocin stimulates the upper segment of the myometrium to contract rhythmically,
which constricts spiral arteries and decreases blood flow through the uterus.
e Oxytocin is an effective first-line treatment for postpartum hemorrhage.
Oxytocin Given as a Component of Active Management of Third Stage of Labor
e Increase IV oxytocin rate, 500 mL/hour of 10 to 40 units/500 to 1,000 mL solution.
e Indication: Reduction of blood loss.
e Action: Stimulates uterine smooth muscle to produce uterine contraction.
e Adverse reactions with IV use: coma, seizures, hypertension, hypotension,
and water intoxication.
Admin: Administer via IV infusion using an IV infusion pump, or via IM route if the
patient does not have IV access (10 units of oxytocin IM)
, Reproductive System: [¢] Rationale: Lochia is a medium for bacterial growth. Frequent pad
changes and hand washing are actions aimed at preventing infection.
Endometrium (the
mucous membrane that TABLE 12-2 Stages and Characteristics of Lochia
lines the uterus) STAGE TIME FRAME EXPECTED FINDINGS DEVIATIONS FROM NORMAL
Lochia rubra Days 1-3 Bloody with small clots Large clots
Moderate to scant amount Heavy amount; saturates pad within 1 hour
Increased flow on standing or (sign of possible hemorrhage), excessively
breastfeeding heavy, saturates a pad in 15 minutes
Fleshy odor Foul odor (sign of infection)
Placental fragments
Lochia serosa Days 4-10 Pink or brown color Continuation of rubra stage after day 4
Scant amount Heavy amount; saturates pad within 1 hour
Increased flow during physical (sign of possible hemorrhage), excessively
activity heavy; saturates pad within 15 minutes
Fleshy odor Foul odor (sign of infection)
Lochia alba Day 10 Yellow to white in color Bright red bleeding, saturates pad within 1
Scant amount hour (sign of possible late postpartum
Fleshy odor )
Foul odor (sign of infection)
Comparison of heavy,
*
= =
moderate, light & | °
N /
scant lochia on pads Scant: <2.5-cm (1-inch) stain
***always weigh***
~
Lo y
Light: 2.5- to 10-cm (1- to 4-inch) stain
. o
Moderate: 10- to 15-cm (4- to 6-inch) stain
Heavy: Saturated in 1 hour .
|
Reproductive System: Vagina & Perineum
e The vagina & perineum experience changes related to the birthing process that may
Vagina & Perineum include edema, mild stretching, minor lacerations, major tears, or episiotomy.
e The perineum is assessed when the fundus and lochia are checked in the
postdelivery period. After that, the perineum is assessed every shift using the
acronym REEDA (redness, edema, ecchymosis, discharge, approximation of edges
of episiotomy or laceration).
R.EE.L
Ecchymosis
Discharge
d
Approximation
I =
Student Nurse Learning Card #6
www.iStudentNurse.com
e
L | copyright ©2013 istudentiurse, LLC
Postpartum Nursing The postpartum period, the 6-week period after childbirth, is a time of rapid
Care physiological changes as the woman’s body returns to a prepregnant state.
Overview of the Postpartum Assessment:
e Vital signs, pain, breath and heart sounds
Laboratory findings, such as CBC, rubella status, and Rh status
Vaccination status, including tetanus, diphtheria, and acellular pertussis (Tdap);
influenza; pneumococcal; and COVID-19 vaccine
Breasts
Uterus
Bladder
Bowel
Lochia
Episiotomy, lacerations, perineum, hemorrhoids
Lower extremities
Emotions, bonding with infant, fatigue, psychosocial factors
Breast size, shape, &
mlmlfilmlwlclw’
engorgement
Uterus: firm or boggy?
Bladder: tender or
distended?
Bowel movement?
Lochia: amount, odor
color, clots
Episiotomy location,
stiches, edema, & redness
Homan’s Sign- positive?
Student Nurse Learning Card #5
www.iStudentNurse.com
Emotional status & bonding
1
[}
| ol copyright ©2013 istudentNurse, LLC
Uterus — Maternal Assessment
ivoion
e Involution — takes place 6- 8 weeks postdelivery of the placenta
o This occurs through uterine contractions, atrophy of the uterine muscle, and
a decrease in the size of uterine cells.
=T (OPidk e Afterpains — moderate to severe cramp-like pains related to the uterus
DELEALI
working to remain contracted or the increase of oxytocin released in response
to infant suckling (affects multiparous women or women breastfeeding)
Site 0F e
o The intensity of afterpains will typically decrease after the third postpartum
day.
051t B
“ o Treatment: ibuprofen (1st priority action), then provide warm blanket
Assess the uterus (fundus) for location, position, and tone of the fundus after the 3rd
™ W nin-
stage of labor — Tell pt that you’re palpating her fundus/uterus to evaluate for normal
ReaNONE Si0e
involution and bleeding
After the 3rd stage of labor, assess the uterus:
e Every 15 minutes for the first hour
e Every 30 minutes for the second hour
e Every 4 hours for the next 22 hours
o Every shift after the first 24 hours or as stated in hospital or unit protocols
, @ "BUBBLES"
MASTITIS
May be sore after breastfeeding Infection & inflammation of breast tissue
Breastfeed every 2-3 hours * Continue breastfeeding
(15-20 minutes each breast) * Warm compress
0 REASTS * Hydration
Position newborn "tummy to mummy"
Latch should be completely * Rest
around the areola * Analgesics
* Wash hands!
UTERINE ATONY:
| RISCFACTORS NN SYMPTOMS INTERVENTIONS
Retained placenta Enlarged Fundal massage
Chorioamnionitis (infection) Soft Assist to void or use
Uterine fatigue Boggy a straight catheter
Not midline
Full bladder Poorly contracted uterus
O~ W o
HEMORRHOIDS
Constipation is common after birth.
Increasmg FLUIDS & FIBER may help! * May see blood in the stool
* Should begin to shrink following birth
Fluids, Fruits & Fiber
FiII up the toilet! :
INTERVENTIONS:
* Tucks/witch hazel * Ice pack
* Squeeze bottle * Sitz bath
Postpartum urinary retention is common
LADDER (\Vj In-and-out catheterization may be needed
O
Bladder distention can cause a displaced & boggy uterus!
"Really fore " fter"
\“;_',
- TYPE | | TIMING | DESCRIPTION HEMORRHAGE
AR » Soaking pad in < 1 hour
skubra Really Birth-% days rlgs;zlrl Ciaortsre ' . t(;lots Iar.girlin size
ocin (]| I\ s an a nicke
‘
e
pinkish/brown; [ INFECTION
erosa ore 4-10 days !
less or no clotting » Foul odor
N * Green/yellow
whitish/yellow; purulent discharge
\ Iba fter 10-20 days little to no blood « Fever (> 100.4°F)
or blood clots
Postpartum depression (PPD) is common for women following childbirth
MOTIONAL As the nurse ask about feelings of...
Crying,
STATUS depression * hopelessness * self-harm
QW
irritable, sleep
harm to the newborn dlsturbances
anxiety, feelmgs
of guilt
ECTION A Promote proper wound healing
(-section incisions/ | {‘ REPORT to the health care provider:
Episiotomy pain - inflammation - surrounding skin is warm to touch
© 2023 NurselnTheMaking LL(. Sharing and distributing this copyrighted material without permission is illegal. 109
Prepared exclusively for Truc Phan () Order: 2-34763
, Reproductive system: o Frequent assessment of uterine tone and placement helps identify
complications such as uterine atony (decreased uterine muscle tone)
Uterus that may cause postpartum hemorrhage (PPH).
o The risk for postpartum hemorrhage is the greatest within the first hour
a. The weight of the uterus decreases from
following delivery.
approximately 2 Ib (900 g) to 2 oz
Remove pt’s peripads to evaluate lochia (weigh) at the same time the fundus
(57 g) in 6 weeks.
is palpated.
b. The endometrium regenerates.
Give oxytocin per provider’s orders — Oxytocin promotes contraction of the
c. The fundus steadily descends into the uterus by stimulating its smooth muscle, which prevents and controls
pelvis. postpartum hemorrhage
d. Fundal height decreases about Notify provider if the uterus does not respond to massage and oxytocin
1 cm/day (Fig. 25-1). o Lack of response to fundal massage and oxytocin administration may
e. By 10 days postpartum, the uterus indicate complications such as retained placental tissue or birth trauma
cannot be palpated abdominally. Determine the position of the uterus: A uterus that is shifted to the side may
f. A flaccid fundus indicates uterine atony, jndicate a distended bladder
and it should be massaged until firm; a o Adistended bladder interferes with uterine contractibility, which places the
tender fundus indicates an infection. woman at risk for uterine atony and increases her risk of hemorrhage
g. Afterpains decrease in frequency after |f the uterus is displaced (deviated, soft, or elevated above the umbilicus), this
the first few days. means bladder is full - THE PT NEEDS TO VOID to empty the bladder
o 6-12 hours post delivery, the fundus should be level at U or 1 above
umbilicus (width of finger — 1cm)
e Provide information regarding afterpains, uterine cramps caused by the
contraction, and relaxation of the uterus as it decreases in size.
o Afterpains occur within the first few days and typically decrease 3 days after
delivery — They occur more commonly with multiparous women and
increase with each additional pregnancy & occur in breastfeeding women
o Encourage her to void frequently, as a distended bladder can increase
‘afterpains.
o ( Apply a warm blanket to the abdomen (relaxation techniques and warm
compresses can interfere with the transmission and sensation of pain).
o Analgesics such as ibuprofen and acetaminophen are effective in relieving
uterine cramping.
Fundal massaae {"‘ " m\,ss.\ ‘“0“ W
s the fundus firm or boggy?
o If fundus is boggy — MASSAGE (requires 2 hands)
o Massage until firm -
Uterine Atony (Boggy Uterus) Sm
Uterine atony is the most common cause of postpartum hemorrhage.
e A boggy uterus is a sign that the uterus is not contracted.
e Risk of excessive blood loss or hemorrhage is increased.
¢ Immediate nursing action: massage the fundus with the palm of your hand in
a circular motion until firm and reevaluate within 5 to 10 minutes.
o If the uterus does not respond to massage, follow the standing order for
oxytocin and notify the physician or midwife.
Oxytocin (Pitocin) Administration
e Oxytocin stimulates the upper segment of the myometrium to contract rhythmically,
which constricts spiral arteries and decreases blood flow through the uterus.
e Oxytocin is an effective first-line treatment for postpartum hemorrhage.
Oxytocin Given as a Component of Active Management of Third Stage of Labor
e Increase IV oxytocin rate, 500 mL/hour of 10 to 40 units/500 to 1,000 mL solution.
e Indication: Reduction of blood loss.
e Action: Stimulates uterine smooth muscle to produce uterine contraction.
e Adverse reactions with IV use: coma, seizures, hypertension, hypotension,
and water intoxication.
Admin: Administer via IV infusion using an IV infusion pump, or via IM route if the
patient does not have IV access (10 units of oxytocin IM)
, Reproductive System: [¢] Rationale: Lochia is a medium for bacterial growth. Frequent pad
changes and hand washing are actions aimed at preventing infection.
Endometrium (the
mucous membrane that TABLE 12-2 Stages and Characteristics of Lochia
lines the uterus) STAGE TIME FRAME EXPECTED FINDINGS DEVIATIONS FROM NORMAL
Lochia rubra Days 1-3 Bloody with small clots Large clots
Moderate to scant amount Heavy amount; saturates pad within 1 hour
Increased flow on standing or (sign of possible hemorrhage), excessively
breastfeeding heavy, saturates a pad in 15 minutes
Fleshy odor Foul odor (sign of infection)
Placental fragments
Lochia serosa Days 4-10 Pink or brown color Continuation of rubra stage after day 4
Scant amount Heavy amount; saturates pad within 1 hour
Increased flow during physical (sign of possible hemorrhage), excessively
activity heavy; saturates pad within 15 minutes
Fleshy odor Foul odor (sign of infection)
Lochia alba Day 10 Yellow to white in color Bright red bleeding, saturates pad within 1
Scant amount hour (sign of possible late postpartum
Fleshy odor )
Foul odor (sign of infection)
Comparison of heavy,
*
= =
moderate, light & | °
N /
scant lochia on pads Scant: <2.5-cm (1-inch) stain
***always weigh***
~
Lo y
Light: 2.5- to 10-cm (1- to 4-inch) stain
. o
Moderate: 10- to 15-cm (4- to 6-inch) stain
Heavy: Saturated in 1 hour .
|
Reproductive System: Vagina & Perineum
e The vagina & perineum experience changes related to the birthing process that may
Vagina & Perineum include edema, mild stretching, minor lacerations, major tears, or episiotomy.
e The perineum is assessed when the fundus and lochia are checked in the
postdelivery period. After that, the perineum is assessed every shift using the
acronym REEDA (redness, edema, ecchymosis, discharge, approximation of edges
of episiotomy or laceration).
R.EE.L
Ecchymosis
Discharge
d
Approximation
I =
Student Nurse Learning Card #6
www.iStudentNurse.com
e
L | copyright ©2013 istudentiurse, LLC
