Postpartum nursing assessment- BUBBLE-PLEB
B- breast/chest
U-uterus
B-bladder
B-bowels
L-lochia (COCA)
E- episiotomy/laceration/incision (REEDA)
P-pain
L-legs/extremities
E-emotional status
B-bonding/attachment
*REEDA- Redness, Edema, Ecchymosis, Drainage,
Approximation; COCA- Color, Odor, Consistency, Amount
Early discharge criteria for mom and infant- mom recovered
& prepared to care for self & infant, at least 2 successful
feedings >10mins, f/u care
Postpartum Physiologic Changes:
-uterus- involution- return of uterus to pre-preg state;
autolysis of tissue w/o excess hormones of preg; @2-3cm
under umbilicus after delivery, @ or 1cm above at 12hr, then
dec’s 1cm/24h); placental site does not scar; locia (rubra- 13days, bright red; serosa- 10-22days, pinkish brownish; albaup to 6wks, whitish)
-cervix- begins to regenerate 2-3days pp; normal by 1wk
-vagina- muscle tone never completely returns, but back to
normal size 6-10wks
-ovarian fxn & menstruation- return of fxn varies w/
breastfeeding; w/ bf may not ovulate but still need birth
control; nonbf ovulation returns 4-8wks, takes 3-4 cycles
before normal, need birth control
-breasts- colostrums first few days milk; engorgement 3-4
days
-GI- hungry after delivery, have food avail; may take 3-4 days
for b.m.
-VS- temp slightly inc’d, brady 1st wk, BP may be inc’d if there
was pre-eclampsia (continue MgSO4 24-48hr after), dec’d w/
blood loss
-Cardiac- CO inc’d first 48hrs, returns ~3wks; WBC inc’d,
hypercoag; excess fluid dec’d thru urine & sweat w/in 6mos
-muscoloskeletal- ligaments tighten, joints stabilize by 68wks
-integumentary- chloasma (mask) diasappears @ end of
prego; hyperpigmentation of areolae & linea nigra may not
completely regress; stretch marks fade but usually do not
disappear; vascular abnormalities (ie: spider angiomas)
diminish; hair growth slows (may experience hair loss);
profuse diaphoresis
-immune- no significant change; if not immune or equivocal
to rubella, recheck & give immunization if neede\
-Urinary- can take hrs after epidural to be able to feel
fullness; encourage frequent voiding; void before assessing
fundus; w/in 12 hr begin losing excess fluid (profuse
diaphoresis @ night for 2-3days pp); may have proteinuria 12 days pp in ~50%
-Endocrine- estrogen & progesterone significantly dec after
expulsion of placenta reaching lowest 1wk pp breast
engorgement, dieresis of excess fluid; nonlactating women
estrogen begins to inc by 2 wks pp; pituitary & ovarian
hormones remain high in breastfeeding suppress ovulation~
6mos, nonbreastfeeding ovulation as early as 27 days, mean
70-75 days, resume menstruation ~3mos
Subinvolution- failure of uterus to return to nonpregnant
state; 2o infection, retained placental parts, excessive
vigorous massage of uterus
Self care Education- SIDS/safety, pacifier use, when sex is ok
(generally 6wks), contraception, pp blues/depression, f/u
appts
After birth pains- inc’s w/ # of preg & breastfeeding,
Methergine; tx- ibuprofen
Perineal discomfort- stretching, bruising; tx- ice q20min first
24hr, sitz baths after 24hrs
Episiotomy/tears- preicare w/ warm water bottle, pat dry,
wipe front to back
Breast discomfort-non breastfeeding mom- good bra, do not massage, avoid
hot shower/bath
-breastfeeding- early & frequent feedings (q2-3hr; wash
breast daily w/ warm water, avoid soap (dries out); for
cracked nipples break seal before removing baby, proper
latching, air-dry nipples (15-20min after feed), rotate
positions, Lanolin or milk for sore nipples
Nutrition- dec’d peristalsis, need inc fluids & fiber; cont
prenatal vit & possibly need irion; healthy eating; +500cal for
breastfeeding
To assess breasfeeding: LATCH-L (latching on) A (audible
swallowing) T (type of nipple- erect, flat, inverted) C (comfort)
H (help)
Medications- consult w/ provider before taking any OTC or Rx
meds
Post Partum Psychological Disorders
Mood disorders
-postpartum blues- adjustment rx w/ depressed moodoccurs 2-3days pp, disappears 1-2wks, still in touch w/ reality,
able to fxn, crying/lonliness/anxiety/confusion
-pp depression- w/in 6mos of birth, lasts >2wks, interferes w/
ADL’s, anorexia/wt loss/ insomnia/hygiene
neglect/hypochondria/psychomotor agitation/disorientation;
requires intervention (antidepressants, anxiolytics, ECT,
therapy); prior h/o depression inc’s risk
-pp psychosis- break in reality/delusions/panic; inc’d risk of
suicide or harm to baby; psych emergency, may require
hospitalization, tx w/ antipsychotics & mood stabilizers
(lithium)
PP onset panic disorder- 3-5% of pp pts
Adaptation to Parenthood and Parent-Infant Interactions
-taking in- pt focuses on her needs (food, comfort), letting
others care for infant
-taking hold- pt regains control of bodily fxns, active in
her/baby cares, best time to teach
-letting go- loss over separation of baby from body
*adolescents need extra attention
Attachement behaviors- eye contact, maternal gazing, finger
grasping, rooting/seeking, comfort from mom/dad’s voice
-factors affecting- pain, fatigue, knowledge, support system,
expectations of newborn, previous experience, maternal
temperament, infant characteristics, others (c-section,
preterm/ill infant, multiple births)
Postpartum hemorrhage-nursing process
Definition- >1000ml w/ c section, >500ml vag; the most
common & most serious type of excessive obstetric blood
loss
Predisposing factors- previous hemorrhage, previa, MgSO,
clotting disorders, multiple gestations, abruption, uterine
atony (most frequent cause), polyhydramnios, macrosomic
baby, poor uterine tone, rapid/prolonged/precipitous labor,
induction/augmentation, chorioamnionitis, anesthesia, over
massage
Causes- early: retained placental fragments,
tears/lacerations, hematoma, inversion of uterus, DIC (seen
in PIH, HELLP, & stillbirths); late: subinvolution from infection,
retained placental parts, excessive vigorous massage of
uterus
s/s- inc’d lochia, >1pad/hr; boggy uterus (tx fundal massage,
notify PCP if not corrected), u/a to locate fundus (sign of
atony); tachycardia, dec BP
classification- early/acute/primary (w/in first 24hr of
delivery); late/secondary (after 24hr to 6wks)
interventions- may need to cath to empty bladder & monitor
I/O, fundal massage, inc Pitocin, Metergine (do not give if
HTN), Hemabate (not ok for asthmatics); VS & SpO2, O2, labs
(H/H, pt, ptt, fibrinogen), surgery (vessel repair,
hysterectomy)
herbal remedies- witch hazel & lady’s mantle (homeostatic),
blue cohosh & cotton root bark (oxytocic), motherwort &
sheperd’s purse (promotes uterine contraction), alfalfa leaf &
nettle (inc avail of vit K, inc Hgb), red raspberry (homeostatic,
promotes uterine contraction)
Hemorrhagic Shock- perfusion of body organs may become
severely compromised, leading to significant morbidity or
mortality of mom; emergency situation
-s/s- persisten significant bleeding (pad soaked in <15min);
dec BP, pale, cool/clammy, tachycardia, anxiety, air hunger
-interventions- notify PCP, fundal massage for atony, O2 810via mask, I/O, VS, lung sounds, maintain IV site, determine
cause, fluid mngmnt (blood, IV crystalloids 3ml/L loss)
Medications utilized in caring for the patient with
postpartum hemorrhage- Pitocin inc to promote uterine
contractions, Metergine (do not give if HTN), Hemabate (not
ok for asthmatics)
Postpartum (Puerperal) Infections-any inf w/in 28 days of
delivery; strep most common
s/s- temp >38 (100.4) on 2 or more occasions after 24h pp; in
pain, malaise, dysuria, subinvolution, foul odor
-prevention most effective & inexpensive tx; strict aseptic
technique; standard precautions
Endometritis- lining of uterus; *most common pp inf; seen
more in c-sections; s/s- inc’d tenderness; fever (>38), inc HR,
chills, anorexia, Nausea, fatigue,foul smelling profuse lochia;
tx- ABX, encourage fluids, analgesics, fowler’s to promote
drainage
Wound/lacerations- s/s REEDA; tx- ABX, analgesics, sitz bath,
hot/cold
UTI’s- esp w/ freq caths, pelvic exams & w/ epidurals; s/sdysuria, frequency, urgency, lowgrade fever, retention,
hematuria, pyuria, plank pain tx- fluids, hygiene (front to
back), ABX
Mastitis- staph from infants mouth 2o to improper latching,
missed feeding, improper fitting bra; usually 5-6wks pp, s/sunilateral, reddened tender area, flu-like symptoms;
prevention- handwashing, proper breast care & feeding,
good/clean bra; tx-ice pack after feeding, cont feeding (start
on unaffected side), ABX; assess for abscess- if found, no
feeding on this breast, pump & dump until healed (ABX,
drained, heat);
Thromboembolic Disorders-nursing process
Risk factors- pp immobility/inactivity, prolonged
sitting/standing, c section, varicose veins or varicosities, DM,
smoking, multiparity, h/o venous thrombosis, obesity,
mom>35yr
dx- venography, US, CT, MRI; screen w/ Homan’s sign, assess
for hard vessels & pain w/ edema
interventions- *prevention*- early ambulation/ROM, avoid
long sit/stand/immobile, avoid crossing legs, elevate while
sitting, quit smoking, fluids, stockings
-SVT- analgesics (NSAIDS), rest w/ legs elevated, heat
-DVT- @ risk for PE; anticoag (IV heparin 5-7 days, f/b oral
Coumadin up to 3 mo), have protamine sulfate avail (antidote
to heparin), teach s/s of med problems, take as ordered, do
NOT stop abruptly
-PE- assess: dyspnea, cough, pleuritic CP, VS, temp, resp
status/sounds, pain, mental status, neck vein distention
Interventions- semi fowlers w HOB up, O2, con’t heparin,
analgesics
Loss and Grief
Maternal or fetal/neonate death, loss of what was hoped for
(natural birth, girl/boy, etc), perception of loss of control
during birthing (more common in Bradley pts), birth of child
w/ handicap
Plan of care- actualize loss, provide time to grieve, interpret
normal feelings, allow for individual differences, cultural &
spiritual needs, physical comfort, options for parents
(seeing/holding, bathing/dressing, privacy, visitations,
religious rituals/funeral arrangements, special memories,
pictures)
Maternal death- rare; families at risk for developing
complicated bereavement & altered parenting, referral to
social services