postpartum physical assessment by ms. mevelle l. asuncion rn

8/4/2019 Postpartum Physical Assessment by Ms. Mevelle L. Asuncion RN

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MEVELLE L. ASUNCION, RN

Postpartum & Newborn Nursing


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The Postpartum Period

Puerperium: Term 1st 6 weeks after the birth of aninfant

Neonatenewborn from birth to 28 days.

Family adaptation to neonate: Bondingrapidprocess of attachment during 1st 30 to 60 minutesafter birth

Mother, father, siblings, grandparents


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Factors Affecting Family Adaptation Parental fatigue

Previous experience with a newborn Parental expectations of newborn

Knowledge of and confidence in providing fornewborn needs

Temperament of the newborn

Temperament of parents

Age of parents

Available support system Unexpected events


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Postpartum Assessment

VS, amount of lochia, presence of edema, fundalheight and firmness, status of perineum, bladderdistension

1 to 2 hrs after delivery: every 15 minutes

If no problems every 8 hours


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KNOW YOUR PATIENT --- DELIVERY HISTORY/ADMISSION/TRANSITION ASSESSMENT:

Gravida, parity / Time and type of delivery

Anesthesia or medications / Risk factors for PPH

Medical history / Routine medications / Allergies

Infant status / Breast/bottle Rubella immune?

Rh Negative?

Drug/ETOH Abuse


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Body Systems Assessment

Vital signs Level of pain Neurological Pulmonary Cardiovascular Musculoskeletal Gastrointestinal

Genitourinary Integumentary Psychosocial


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Vital Signs

Day 1 Day 2 and after

Heart Rate 50 to 70 bpm Bradycardia ornormal

Respirations Normal Normal

B/P Normal Normal

Temperature 100.4 normal24 hrs.Muscularexertion/dehydration

Normal

If 100.4 suspectinfection


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Postpartum Physical Assessment B - breast

U - uterus

B - bowels B - bladder

L - lochia

E - episiotomy


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General Assessment

Enter the room quietly, speak quietly.

Wash hands and provide for privacy.

Inform patient before turning on lights.

Note LOC, activity level, position, color, general

demeanor.

Take note of the total environment:

Safety/patient considerations

Note equipment and medical devices


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Breast Assessment

Breasts: Soft, engorged, filling, swelling, redness,

tenderness. Nipples: Inverted, everted, cracked, bleeding,

bruised, presence of colostrum or breastmilk.

Colostrumyellowish fluid rich in antibodies and

high in protein. Engorgement occurs by day 3 or 4. Due to

vasoconstriction as milk production begins

Lactation ceases within a week if breastfeeding is

never begun or is stopped.


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Assessing Uterine Fundus

Location in relation to

umbilicus Degree of firmness

Is it at Midline or deviated toone side?

Bladder Full? A boggy uterus may indicate

uterine atony or retainedplacental fragments.

Boggy refers to beinginadequately contracted andhaving a spongy rather thanfirm feeling.


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Massaging the Fundus

Every 15 mins during the 1st hr,

every 30 mins during the next hr,and then, every hr until the patient

is ready for transfer.

Document fundal height.

Evaluate from the umbilicus usingfingerbreadths.

This is recorded as 2 fingers below

the umbilicus (U/2), one finger

above the umbilicus (1/U), and soforth.

The fundus should remain in the

midline. If it deviates from the

middle- distended bladder.


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Uterine Involution

Uterine Involution: return

of the uterus to its pre-pregnancy size andcondition

Uterine fundal descent:uterus size of grapefruit

immediately after birth Fundus half way between

umbilicus and symphysispubis

Fundus rises to the

umbilicus stays for 12hours Descends 1 cm

(fingerbreadth) each dayfor about 10 days


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Uterine Atony

Lack of muscle tone in the cervix.

Uterus feels soft and boggy

After delivery: Postpartum diuresis

The bladder has increased capacity and decreased

muscle tone. This leads to over-distension of the bladder,

incomplete emptying of bladder, retention ofresidual urine and increased risk of UTI and

postpartum hemorrhage.


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Bowels & Bladder

When was the patients last BM?

Is she passing flatus? (gas)

Assess for bowel sounds

Voiding pattern - without difficulty/pain, urine may

be blood tinged from lochia

Nursing interventions: Assist to the bathroom. Usemeasures to encourage voiding (privacy). Encourage

use of peri-bottle with warm water, fluids, fiber,frequent ambulation, stool softeners; teach effectsof pain medication.


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Lochia Assessment

Lochiavaginal discharge after childbirth.

It takes 6 weeks for the vagina to regain its pre-pregnancy contour. Lochia: scant-moderate, rubra, serosa or alba Assessment of lochia includes noting color,

presence and size of clots and foul odor. Day 1- 3 - lochia rubra (blood with small pieces of

decidua and mucus)

Day 4-10 lochia serosa (pink or pinkish brown

serous exudate with cervical mucus, erythrocytesand leukocytes)

Day 11- 21 - lochia alba (yellowish whitedischarge)


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Lochia: Pad Count

1. Scant: 1-inch stain on pad in 1 hour

2. Light/small: 4 inches in 1 hour3. Moderate: 6 inches in 1 hour

4. Heavy/large: Pad saturated in 1 hour

Excessive: Pad saturated in 15 min

Can estimate blood loss by weighing pads: 500 mL = 1 lb. or 454 g


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Episiotomy/Perineal Assessment

Patient in lateral Sims (side lying) position.

Use the acronym REEDA(redness, edema,ecchymosis, discharge, approximation of suture linesedges 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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Episiotomy Pain Relief

Instruct Mother: Tighten her buttocks and perineum before sitting

to prevent pulling on the episiotomy and perinealarea and to release tightening after being seated.

Rest several times a day with feet elevated. Practice Kegel exercise many times a day to

increase circulation to the perineal area and tostrengthen the perineal muscles.


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Assessment of Edema & Homans Sign

Assess legs for presence and degree of edema; may

have dependent edema in feet and legs.

Assess for Homans sign- thromboembolism shouldbe negative

Press down gently on the patients knee (legsextended flat on bed) ask her to flex her foot(dorsiflex)


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Homans Sign


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Thromboembolic Conditions

Thrombophlebitisthe formation of a clot in aninflamed vein.

Risk factors include maternal age over 35, cesareanbirth, prolonged time in stirrups, obesity, smoking,

and history of varicosities or venous thromboses. Prevention: client needs to ambulate early after

delivery.


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Postpartum Cesarean

Incision siteredness swelling, discharge. Intact?

Abdomen soft, distended? Bowel sounds heard all4 quadrants

Flatus?

Lochia is less amount than in normal spontaneousvaginal delivery (NSVD) because uterus is wipedwith sponges during c/section.

If lochia indicates excessive bleeding, combine

palpation and pain management measures.Auscultate breath sounds

Fluid intake and output

Pain?


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RhoGAM

It is given to an Rh- mother within 72 hours afterdelivery of an Rh+ infant or if the Rh is unknown.

The dose must be repeated after each subsequentdelivery. RhoGAM 300 mcg is the standard dose.


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Postpartum Disseminated Intravascular Coagulation

Abnormal stimulation of clotting mechanism.

Normally, the body forms a blood clot in reaction toan injury.

Small blood clots throughout the body, depleting thebody of clotting factors and platelets. Massive

bleeding Causes may include amniotic fluid clots, fetal demise,

abruptio placenta. Eclampsia or Retained placenta

Symptoms: Sometimes severe bleeding and sudden

bruising .


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Postpartum Hemorrhage

Blood loss of more than 500 ml after vaginal birthor 1,000 ml after a cesarean birth. Early hemorrhage Cervical or vaginal tears,

uterine atony, retained placental fragments,lacerations, hematomas.

Late hemorrhage subinvolution, retainedplacental fragments.

Subinvolution: failure of the uterus to return tonormal size.

Management may include CBC, sedimentation rate,type and cross, fluid resuscitation with normalsaline and blood, vaginal examination, diagnosis,and correction of the underlying cause.


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Postpartum Depression

Postpartum depression is a nonpsychotic depressive

episode that begins in the postpartum period due todecreased estrogen level

Symptoms: changes in appetite or weight, sleep, andpsychomotor activity; decreased energy; feeling of

worthlessness or guilt; difficulty thinking,concentrating or making decisions; or recurrentthoughts of death or suicidal ideation, plans, or

attempts.


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Postpartum Psychosis

A very serious type of PPD

illness that can affect newmothers.

Begin 2-3 weeks postdelivery

Fatigue, restlessness,insomnia, crying liableemotions, inability to move,irrationally statementsincoherence confusion andobsessive concerns about theinfants health

Psychiatric emergency


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Nipple soreness is a portal of entry for bacteria -

breast infection (Mastitis).

Maternal after pains: may be due to breastfeedingand multiparity

Always stay with the client when getting out of bedfor the first time hypotension effect and excessbleeding

When assessing fundal height, if you notice any

discrepancies in fundal height have patient voidand then reassess.


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Nursing Diagnosis Related to Breasts andBreastfeeding

Pain r/t improper positioning, engorged breasts

Ineffective breastfeeding r/t maternal discomfort,improper infant positioning

Knowledge deficit r/t normal physiologic changes,breastfeeding

Infection r/t improper breastfeeding techniques,improper breast care


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The Newborn
http://www.solarnavigator.net/animal_kingdom/humans/humans.htm


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Newborns Immediate Needs

Airway

Breathing

Circulation

Warmth


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The Newborn

Neonatal transition: 1st

few hours after birthnewborn stabilizes respiratory and circulatoryfunctions.

When the cord is clamped, placental gas exchange

ceases. These changes stimulate carotid and aortic

chemoreceptors which send impulses to therespiratory center in the medulla.

A brief period of asphyxia stimulates respirations.


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Apgar Score

Assesses the infants cardiopulmonary adaptations

to extrauterine life Provides a quick evaluation on how the heart and

lungs are adapting

5 items to be assessed 1 and 5 minutes after birth.

A S


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Apgar Score Heart rate, respiratory rate, muscle tone, reflex irritability and color Score of 0 2 for each item, then totaled.

Apgar Score 8 or higher no intervention Apgar Score 4 8 gentle rubbing, oxygen Apgar Score 0 4 resuscitation

Points Given 0 1 2

A Activity/muscletone

Limp/flaccid Somemotion/flexion

Active motion/wellflexed

P Pulse Rate Absent 100 bts/min

G Grimace/ReflexIrritability

No Response Grimace Cry, cough,sneeze

A Appearance/Skin Color

Blue, Pale Body pink,extremitiesblue

Pink all over

Absence ofcyanosis

R Respiration Absent Slow weak cry Good Cry


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Prophylactic Care

Vitamin Kto prevent hemorrhagic disorders vitk (clotting process) is synthesized in intestinerequires food for this process. Newborns stomach issterile has no food. aquaMEPHYTON

Hepatitis B vaccination within the first 12 hours Eye prophylaxis (Erythromycin Ointment) to

prevent ophthalmia neonatorum gonorrhea/chlamydia

N b I t l i j ti


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Newborn: Intramuscular injection

aquaMEPHYTON (Vit.K)

1 mg/0.5 ml IM lateral thighVastus lateralis

Vi l Si


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Vital Signs

Temperature - range 36.5 to 37 axillary (97.7-98.6)

Axillary vs Rectal about 0.2 to 0.5 differenceCommon variations

Crying may elevate temperature

Stabilizes in 8 to 10 hours after delivery

Heart rate - range 120 to 160 beats per minute Apical pulse for one minute

Common variations Heart rate range to 100 when sleeping to 180 when crying

Color pink with acrocyanosis

Heart rate may be irregular with crying

Respiration - range 30 to 60 breaths per minute

Blood pressure - not done routinely Ranges between 60-80 mm systolic and 40-45 mm diastolic.


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Reflexes: indicate neurological integrity

Rooting Sucking

Extrusion

Palmar grasp Plantar grasp

Tonic neck

Moro Gallant

Stepping

Babinskis

Crossed extensionreflex

Placing


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Reflexes

Tonic Neck Reflex (FENCING)

EXTENDS arm & leg on the sidethat the face points.

Flexes opposite arm & leg

6-8 wks to 6 months

Moro Reflex Birth to 4-6 months


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Rooting and Sucking Reflexes

Birth to 3-4months Birth to 10 months


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Babinski and Palmer Grasping Reflex

Babinski Reflex is (+)

This is Normal

Birth to after walking

12-18 months age

Birth to 4 months


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Skin

Expected findings Skin reddish in color, smooth and puffy at birth

At 24 - 36 hours of age, skin flaky, dry and pink incolor

Edema around eyes, feet, and genitals

Vernix caceosa Lanugo (baby hair) Turgor good with quick recoil Hair silky and soft with individual strands

l i i


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Common Normal Variations

Acrocyanosis - result of sluggish peripheral

circulation. Mongolian Spots: Patch of purple-black or blue-black

color distributed over coccygeal and sacral regions ofinfants of African-American or Asian descent.

Milia: Tiny white bumps papules (pluggedsebaceous glands) located over nose, cheek,and chin.

Erythema toxicum: Most common newborn rash.

Variable, irregular macular patches. Lasts a fewdays.


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Erythema toxicum, acrocyanosis, milia andmongolian spots

H bili bi i


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Hyperbilirubinemia

Physiologic Jaundice =Appears 24 hours after

birth peaks at 72 hrs. Bilirubin may reach 6 to 10 mg/dl and resolve in 5

to 7 days.

Due to Unconjugated bilirubin circulating in the

blood stream that is deposited in the skin. Immature liver unable to conjugate bilirubin

released by destroyed RBC.

Pathologic Jaundice =Not appear until after 24hrs leads to Kernicterus (deposits of bili in brain).

Bilirubin >20mg/dl

The most common cause is Rh incompatibility.


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The Head and Chest

The Head: Anterior

fontanel diamond shaped 2-3 - 3-4 cms

Posterior fontaneltriangular 0.5 - 1 cm

Fontanels soft, firm and flat head circumference is 33

35 cm

The head is a few

centimeters larger than thechest!!!!

The Chest:circumference is30.5 33 cm


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Anterior and PosteriorFontanelles

Anterior diamond shaped 2-3 -3-4 cms

Posterior triangular 0.5 - 1 cm

Fontanels soft, firm and flat

Molding is shaping offetal head to adapt tothe mothers pelvisduring labor.


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Caput succedaneum

Swelling of the soft tissueof the scalp caused bypressure of the fetal headon a cervix that is not fully

dilated. Swelling is generalized.

may cross suture line anddecreases rapidly in a fewdays after birth. Requiresno treatment

2 3 days disappears


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Cephalohematoma

Collection of bloodbetween the periosteumand skull of newborn.

Does not cross suture

lines Caused by rupturing of

the periosteal bridgingveins due to friction and

pressure during labor. Lasts 3 6 weeks
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Bathing the Newborn

No tub bath until afterthe cord has fallen offand healing iscomplete.

Newborns first bath-the nurse needs towear gloves to prevent

infection.What is wrong with

this nursing action?

G i l A R l i hi I i G h


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Gestational Age Relationship to Intrauterine Growth

Normal range of birth weight for each week of

gestation. Birth weight is classified as follows:

Large for gestational age (LGA): weight falls abovethe 90th percentile for gestational age

Appropriate for gestational age (AGA): weight fallsbetween the 90th and 10th percentile for gestationalage

Small for gestational age (SGA): weight falls belowthe 10th percentile for gestational age

Intrauterine Growth Grid


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Ci i i


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Circumcision

Circumcision is considered an elective procedureAnesthesia should be provided. Parents must give written consent Full term health infantsAftercare: Check hourly for 12 hours Check for bleeding and voiding Before discharge: Newborn goes home within the first 12 hours

after procedure Bleeding should be minimal and infant must void Ensure that parents know how to care for the

circumcision.


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Breastfeeding

Colostrum is rich in immunoglobulins to protectnewborn GI tract from infection; laxative effect.

Breast milk in 2 weeks sufficient nutrients 20kcal/oz (infants nutritional needs)

To support Breastfeeding: Mother needs to

consume extra 500 calories per day. Feeding length: should be long enough to remove

all the foremilk (watery 1st milk from breast highin lactose - skim milk & effective in quenching

thirst) Hindmilk: higher in fat content leads to weight

gain and more satisfying. Breastfeeding time approximately 30 minutes

I fa t F la


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Infant Formula

Formula 7.5 ml to 15 ml at feeding gradually

increase to 90 ml to 120 ml at each feeding in 2weeks.

Formula preparation: mixing must be accurate toprovide the 20 kcal/oz. (newborn nutritional need)

Burping: is needed to expel air swallowed wheninfant sucks.

Should be done about way through feeding forbottle feeders and when changing breasts for

breast feeders.

Respiratory Distress


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p y

2 types: Respiratory Distress Syndrome (RDS) andTransient Tachypnea of the Newborn (TTN)

RDS: preterm infants/surfactant deficiency Hypoxia, respiratory acidosis and metabolic acidosis

Surfactant is produced by alveoli - lung maturity

L/S ratio 2:1 is a test done before birth to determine fetal

lung maturity TTN: AGA, near term infants

Intrauterine or intrapartum asphyxia

Newborn unable to clear airway of lung fluid, mucous or

amniotic fluid aspiration. Expiratory grunting nasal flaring, tachypnea with

respirations as high as 100 to 140 breaths/minute.

Neural Tube Defects


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Neural Tube Defects

3 types:

Spina Bifida Occulta: failure of the vertebralarch to close. Has dimple on the back with a tuft ofhair. No treatment required.

Meningocele: saclike protrusion along the

vertebral column filled with cerebrospinal fluid andmeninges. Surgery required. Myelomeningocele: saclike protrusion along the

vertebral column filled with spinal fluid meninges,nerve roots, and spinal cord = paralysis. Surgicalrepair required.

Sterile saline dressing. hydrocepalus


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Spina bifida occulta meningocele

Spina bifida Occulta myelomeningocele


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Infants of DM mothers (IDM) Complications

Hypoglycemia: maternal glucose declines atbirth. Infant has high level of insulinproduction= decreases infants blood glucosewithin hours after birth.

Respiratory Distress: less mature lungs due

to insulin Hyperbilirubinemia: hepatic immaturity,

increased hematocrit, bruising due to difficultdelivery.

Birth trauma: large size of infant Congenital birth defects: birth defects

Patent Ductus Arteriosus, Ventricular SeptalDefect and more.

postpartum physical assessment by ms. mevelle l. asuncion rn

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