Dr. Areefa Al Bahri
Ch. 6
The post natal care
Postpartum care begins immediately after childbirth. During
this time, the nurse assists the new mother in learning
how to care for herself and her baby. This 6-week period
of time, also known as the puerperium,
Early Maternal Assessment
VITAL SIGNS
During the postpartum period, vital signs can alert the nurse to the presence of
hemorrhage or infection and should be monitored according to
hospital policy. vital signs are typically monitored every 15 minutes during the first
hour after childbirth, then every 30 minutes during the second hour, once during the
third hour, and then every 8 hours until discharge or until they are stable.
Temperature
During the first 24 hours postpartum, some women experience an increase in body
temperature up to (38°C). High temperature at this time may be indicative of
infection.
Pulse
Heart rates of 50 to 70 beats per minute (bradycardia) commonly occur during the
first 6 to 10 days of the postpartum period. During pregnancy, the weight of the
gravid uterus causes a decreased flow of venous blood to
the heart. The elevated stroke volume leads to a decreased heart rate. Postpartal
tachycardia may result from a complication, prolonged labor, blood loss,
temperature elevation, or infection.
Blood Pressure
Decreased blood pressure may result from the physiological
changes associated with the decrease in intrapelvic pressure, or it
may be indicative of uterine hemorrhage. An increase in the
systolic blood pressure of 30 mm Hg or 5 mm Hg in the diastolic
blood pressure, especially when associated with headaches or
visual changes, may be a sign of gestational hypertension.
Orthostatic hypotension may occur when the patient moves from
a supine to a sitting position.
Respirations
The respiratory rate normal range of 12 to 20 respirations per
minute. elevated respirations may occur due to pain, fear,
excitement, exertion, or excessive blood loss. Tachypnea,
abnormal lung sounds, shortness of breath, chest pain, anxiety, or
restlessness are abnormal findings that must be reported
immediately. These signs and symptoms may be indicative of
pulmonary edema or emboli.
FUNDUS, LOCHIA, PERINEUM
Within a few minutes after birth, the firmly contracted uterine
fundus should be palpable through the abdominal wall halfway
between the umbilicus and the symphysis pubis. Approximately 1
hour later, the fundus should have risen to the level of the umbilicus,
where it remains for the following 24 hours.
[Uterine assessment crucial during the first hour postpartum]
Because the first post-partal hour represents the most dangerous time
for the patient, it is essential that the nurse conduct frequent uterine
assessments during this time. Relaxation of the uterus (a tony)
results in rapid, life threatening blood loss because no permanent
thrombi have yet formed at the placental site.
The fundus then descends one fingerbreadth (1 cm) per day in
size. The fundus, lochia (puerperal discharge of blood, mucus,
and tissue), and perineum need to be assessed every 15 minutes
during the immediate postpartum period. To facilitate the perineal
assessment, the nurse assists the patient into a Sim’s (side-lying)
position with her back facing the nurse.
Use of the acronym REEDA guides the nurse to assess for
Redness, Edema, Ecchymosis, Drainage or discharge, and
Approximation of the episiotomy if present .The episiotomy
and/or laceration repairs should appear intact with the tissue
edges closely approximated.
Postpartum Assessment Guide to Facilitate Nursing Care
THE BUBBLE-HE MNEMONIC
To assist with the postpartum assessment, the mnemonic
BUBBLE-HE is commonly used to guide nursing practice.
BUBBLE-HE reminds the nurse to assess the breasts, uterus,
bladder, bowel, lochia, and episiotomy. Assessment of maternal
pain, Homans’ sign, the patient’s emotional status and initiation of
infant bonding are other important components to be included in
the postpartum evaluation (Table below).
Uterus
Involution is a term that describes the process whereby the
uterus returns to the non-pregnant state. The uterus undergoes a
dramatic reduction. Immediately after expulsion of the
placenta, the uterus rapidly contracts to prevent hemorrhage.
The uterus weighs approximately 1000 g in the immediate postpartal period and by the end of the first week, its weight has
diminished to 500 g. Uterine size and weight continue to
decrease and on average, the uterus weighs 300 g by the end of
the second week
Subinvolution is the failure of the uterus to return to the nonpregnant state. Uterine involution may be inhibited by multiple
births, hydramnios, prolonged labor or difficult birth, infection,
grand multiparity, or excessive maternal analgesia.
In addition, a full bladder or retained placental tissue may
prevent the uterus from sustaining the contractions needed to
prevent hemorrhage or to facilitate involution.
FUNDUS: The uterine fundus can be palpated midline, midway
between the umbilicus and symphysis pubis. Within an hour, the
uterus settles in the midline at the level of the umbilicus. Over the
course of days, the uterus descends into the pelvis at a rate of
about 1 cm/day (one fingerbreadth) (Fig below). After 10 days, the
uterus has descended into the pelvis and is no longer palpable.
The fundus is assessed for consistency (firm, soft, or boggy),
location (should be midline), and height (measured in finger
breadths).
Afterpains (afterbirth pains) are intermittent uterine contractions
that occur during the process of involution describe as a discomfort
similar to menstrual cramps.
The primiparous woman typically has mild afterpains, if she
notices them at all, because her uterus is able to maintain a
contracted state. Multiparas and patients with uterine overdistention
(e.g., large baby, multifetal gestation, hydramnios) are more likely
to experience afterpains, due to the continuous pattern of uterine
relaxation and vigorous contractions.
Breastfeeding and the administration of exogenous
oxytocin usually produce pronounced afterpains because
both cause powerful uterine contractions. Afterbirth pain
is often severe for 2 to 3 days after childbirth.
Nursing interventions
assisting the patient into a prone position
a small pillow placed under her abdomen
 initiating sitz baths (for warmth)
encouraging ambulation
and administrating mild analgesics.
Lochia
Lochia is composed of erythrocytes; epithelial cells; blood; and
fragments of decidua, mucus, and bacteria (Cunningham et al.,
2005).
lochia consists
1) lochia rubra (it a characteristic red color).
2) lochia serosa (3 to 4 days, the lochia becomes the pinkish
brownish.
3) Lochia alba (after approximately 10 to 14 days, the uterine.
discharge has a reduced fluid content and is largely composed
of leukocytes. This combination produces a white or yellowwhite thick discharge known as lochia alba.
also contains decidual cells, mucus, bacteria, and epithelial
cells. It is present until about the third week after childbirth but
may persist for 6 weeks.
Homans’ Sign
Homans’ sign is often used in the assessment for deep venous
thrombosis (DVT) in the leg. To assess for Homans’ sign, the
patient’s legs should be extended and relaxed with the knees
flexed. The examiner grasps the foot and sharply dorsiflexes it .
No pain or discomfort should be present. The other leg is
assessed in the same manner. If calf pain is elicited, a positive
Homans’ sign is present. The pain occurs from inflammation of
the blood vessel and is believed to be associated with the
presence of a thrombosis. Pain on dorsiflexion is indicative of
DVT in approximately 50% of patients. Thus, a negative
Homans’ sign does not rule out DVT. Instead, specific diagnostic
procedures (e.g., venography, real-time and color Doppler
ultrasound) should be performed when DVT is suspected.
Maternal Physiological Adaptations
Assessment of the Patient
and
Continued
Hematological And Metabolic Systems
The 500-mL blood loss that typically accompanies a vaginal birth
(1000 mL for a cesarean birth)
It is important for the nurse to remember that as the body’s excess
fluid is excreted, the hematocrit may rise due to hemoconcentration. However, the hematocrit should have returned to
pre-pregnancy levels by 4 to 6 weeks postpartum. The white blood
cell (WBC) count, which increases during labor and in the
immediate postpartum period, returns to normal values within 6
days. Levels of plasma fibrinogen tend to remain elevated during
the first few postpartal weeks, it increases the patient’s risk of
thrombus formation. Overall, the hematologic system has usually
returned to a nonpregnant status by the 3 –4 postpartal week.
NEUROLOGICAL SYSTEM (Common Sign)
Fatigue and discomfort are common complaints after childbirth.
altered sleep patterns that contribute to increased maternal
fatigue.
 during labor and birth may cause transient maternal neurological
changes such as numbness in the legs or dizziness.
When these changes are present, the nursing priority is to
safeguard the patient and her infant and prevent injury from falls.
 Complaints of headaches require further nursing assessment.
 Patients who received epidural or spinal anesthesia may
experience headaches, especially when they assume an upright
position.
After spinal or epidural anesthesia, headaches may result from
the leakage of cerebrospinal fluid into the extradural space.
RESYSTEM, FLUID, AND ELECTROLYTES
The renal plasma flow, glomerular filtration rate (GFR), plasma
creatinine and blood urea nitrogen (BUN) return to prepregnant levels by the second to third month after childbirth.
Pregnancy-associated proteinuria (up to 1 on a urine dipstick or
less than 300 mg in 24 hours) is common during pregnancy and
generally returns to pre-pregnancy values by 6 weeks
postpartum (Cunningham et al., 2005).
During the postpartum period, there is a rapid, sustained
natriuresis (excessively large amount of sodium in the urine)
and diuresis as the sodium and water retention of pregnancy is
reversed.
IMMUNE SYSTEM
The WBC count is increased during labor and birth and remains
elevated during the early postpartum period, gradually returning
to normal values within 4 to 7 days after childbirth.
Women who are rubella susceptible during pregnancy should
receive the MMR (measles–mumps– rubella) vaccine at the time
of hospital discharge; varicella vaccine should also be encouraged
(American College of Obstetricians and Gynecologists [ACOG],
2003).
CARDIOVASCULAR SYSTEM
Despite the usual blood loss (500 mL with a vaginal birth;
1000 mL with a cesarean birth), the maternal cardiac output is
significantly elevated above pre labor levels for 1 to 2 hours
postpartum and remains high for 48 hours postpartum.
The cardiac output returns to pre-pregnant levels within 2 to 4
weeks after childbirth.
GASTROINTESTINAL SYSTEM
Abdominal discomfort results from gaseous distention related to
decreased motility and abdominal muscle relaxation. Constipation,
a common nursing diagnosis for the pos-tpartal patient, is
associated with abdominal discomfort and decreased hunger.
Straining to pass hard stool can cause hemorrhoids and tear
episiotomy sutures. Although spontaneous bowel movements
usually resume by the second or third day after childbirth, it is
important to educate the patient about strategies to prevent
constipation. Stool softeners may be necessary. Additional nursing
diagnoses for the postpartal patient focus on a variety of other
problems such as pain, fatigue, and sleep disturbances, infant
feeding difficulties and knowledge deficit.
MUSCULOSKELETAL SYSTEM
During the first few days after childbirth, the woman may
experience muscle fatigue and general body aches from the
exertion of labor and delivery of the baby. The progressive
stretching causes a decrease in the muscle tone of the rectus
muscles of the abdomen and results in the soft, flabby, and weak
muscles experienced after birth.
Women should be aware that during the early postpartal period,
the abdominal wall may not be sufficiently protected to withstand
additional stress from increased activities. Nurses should teach
them to maintain correct posture when performing activities such
as lifting, carrying, and bathing the baby for at least 12 weeks
after birth.
Postpartum Psychosis
Postpartum psychosis develops in approximately one or two
women for every 1000 births and is unlikely to manifest itself
during the early postpartum period.
Symptoms
include
delusions;
hallucinations;
agitation;
inability to sleep; and bizarre, irrational behavior. Before
hospital discharge, patients with a history of mood disorders or
depression should be referred to appropriate resources for
community support and follow-up. (See Chapter 16 for further
discussion.) (notice this will be discuss by st. presentation)