Postpartum Bleeding Assessment

Post Delivery Patient Assessment

• Crucial to know normal vs. abnormal bleeding after delivery

Endometrium Bleeding

• This is the Mucus membrane lining the uterus
• It regenerates and exfoliates after the birth of the placenta
• Changes in lochia, reflect the healing stage of the endometrium

Lochia

• Lochia, a bloody discharge from the uterus contains RBCs, sloughed-off decidual tissue, epithelial cells & bacteria
• Scant lochia is less than 1 inch on pad
• Moderate lochia is less than 4 inches on pad
• Heavy lochia is when the pad is saturated within 1 hour
• Excessively Heavy lochia, the pad is saturated within 15 minutes
• Lochia assessment includes, early identification of bleeding, clots, & signs of infection

Nursing Actions for Lochia

• Assessment should always be done with the uterus
• Look for Lochia color, ranging from red to pink/brown to white
• Assess amount, including: scant, light, moderate, heavy
• Assess for odor, a foul odor indicates infection
• Assess for clots, small clots are normal
• Clots occur when lochia pools in the lower uterine segment, report egg sized clots as they can interfere with uterine involution
• Retained placental tissue can interfere with involution
• Educate after delivery on fundal massage
• Educate mother to check when to come back, pay close attention to changes in color and odor
• Educate on clean practices, lochia is a medium for bacterial growth

Vagina and Perineum Assessment

• Normal: mild edema, minor ecchymosis, approximation of edges should be present
• Mild to moderate pain is expected
• Anesthetics or analgesics may be needed depending on pain severity
• Hygiene is important
• After elimination Clean with peri-bottle and warm water
• Peripads should be changed frequently
• Wash hands prior and after changing pads
• Ice in the first 24-48 hours, side-lying positioning, and warm sitz baths are all comfort measures 24 hours after delivery

Breast Assessment

• Assessing for nipple & skin breakdown is crucial
• Irritation or breakdown is due to poor infant attachment
• Address the mother's concerns as it is the number one reason for breastfeeding cessation
• Medium for bacteria growth exists when the skin is open which can lead to infection
• Frequent feedings or pumping promotes breast decompression
• Warm compresses aid in milk flow
• Use Ice packs after feeding
• Non-breastfeeding mothers can use supportive bra to alleviate Milk leakage, breast pain, & engorgement 1-4 days after delivery
• Breast stimulation should be avoided to prevent swelling, ice packs can allieviate

Cardiac Education

• Ways to reduce orthostatic hypotension includes accompanied ambulation and rising slowly
• Frequent ambulation prevents DVT and blood stasis
• Do not cross legs
• Apply SCD's

Normal Postpartum Changes

• Vaccinations are an immunity measure
• Watch for respiratory distress
• Early urination prevents bladder distention and UTIs
• Early voiding lowers risk for PPH & uterine atony
• Assess for urinary symptoms, CYSTITIS signs are present
• Educate about diaphoresis, wear Cotton clothing due to warmth, and remember warmth, sweating & chills are signs of infection
• Lactation suppresses menses, but ovulation still happens, discuss contraception when returning to intercourse, or in 10 weeks for non-breastfeeders

Breastfeeding teaching and care

• Changes to prepare for lactation
• When the infant starts suckling, prolactin increases, stimulating milk production due to an effect amplified by OXYTOCIN
• Breast fullness is normal
• Primary breast engorgement is an effect of increased vascular and lymphatic system stimulation
• The breasts become larger, firmer, warmer, more tender and throbbing
• Pumping is needed 24-48hrs after delivery if feedings are missed or there's inadequate milk removal

Nursing Actions for Breasts

• Assess for hardness, enlargement, primary engorgement, tenderness, firmness, and warmth
• Also assess for nipple and skin breakdown for irritation or breakdown due to poor infant attachment
• Concerns must be addressed, as it is the number one reason for stopping breastfeeding
• Where the skin is open, bacteria may lead to growth and infection
• WARM compresses, frequent emptying and decompressing the breasts facilitate milk flow
• Ice packs can be used after feeding
• Non-breastfeeding mothers should use supportive bras, avoid breast stimulation to prevent swelling, use ice packs, and watch for mild leakage, breast pain, and engorgement 1-4 days after delivery

Cardiovascular System Changes

• 200-500mL of blood loss occurs during vaginal birth
• Cardiac output increases as blood directed to the uteroplacental unit gets redirected to maternal systems
• Plasma volume decreases causing transient anemia that resolves within eight weeks
• There is a risk for orthostatic hypotension due to decreased vascular resistance in the pelvis, with vascular instability causing postpartum chills
• WBC count rises to 30,000 due to stress of labor and returns within seven days
• There is a high risk of thromboembolism due to clotting factors circulating through the body, increasing risk for pulmonary embolism
• Nursing actions for CV: Assess BP and pulse every 15 minutes for the first hour, then every 30 minutes for the second hour, and then every four hours for the next 22 hours, finally once per shift after the first 24 hours

Other Postpartum Procedures

• Assessing BP and pulse frequently to best monitor volume changes
• Monitor for excessive blood loss, postpartum chills, and orthostatic hypotension
• Hbg and Hct levels can determine a determination of blood content
• Educate on ways to mitigate orthostatic hypotension, such as through frequent ambulation and by rising slowly, and prevention of DVT through leg exercises and wearing SCDs
• Do not cross legs

Education for Mother and Baby

• Teach parenting styles, Intentional learning: engaging in discussions and education during pregnancy
• Unidirectional bonding with bonding behaviors when the parent bonds to the infant through face positioning with face, calling baby by name, verbal engagement fosters communication and Nursing through breastfeeding and holding
• Attachment is bidirectional where the baby reacts to the parent with Eye contact, smiling, cuddling and cries

Mental Health, and Breast Changes

• Postpartum blues have risk factors such as concerns with single mothers, fatigue, and being a multipara
• Blues are also caused by hormonal shifts and fatigue from taking on a new role
• Signs of blues include, mood swings, anxiety, sadness, struggling to sleep or eat, and weeping
• Reassuring the mother that this is normal and stressing support and rest, with a call to assistance if depressive symptoms continue for over four weeks, are nursing actions
• Unlike blues, PPD risk factors are a personal or family history of mental illness, lack of support, childbirth problems, or a poor relationship
• PPD is marked by lack of sleep, appetite issues, uncontrolled crying, anxiety, fear, and guilt with medical and supportive interventions needed

Postpartum Psychosis Risk Factors

• Includes paranoia, delusions, agitation, rapid mood swings, disorganized behavior or thoughts, strange beliefs, also personal or family history of affective disorder
• This can include a history of bipolar, requiring hospitalization and medication

Postpartum Hemorrhage

• Blood loss that's greater than 500mL for a vaginal delivery
• A loss of Blood greater than 1000mL for c-section
• ACOG defines hemorrhage as cumulative blood loss of 1000 mL or greater within 24 hours after birth with accompanying symptoms of hypovolemia
• Treatment involves fluid resuscitation and identifying the cause

PPH and Nursing Management

• Increased pulse, clammy skin, rapid breathing, restlessness, dizziness, light-headedness, hypotension, and low Oxygen saturation are PPH symptoms
• The Placental site is the primary source of blood loss
• Nursing management includes assessing blood loss by weighing and quantifying pads and recognizing shock symptoms.
• Assess saturation, if a pad is soaked in 15 minutes, this signals an emergency
• Check vitals every 15 minutes, monitor the patient, measure input and output, draw labs, insert Foley, massage uterus, and prepare a large bore IV for potential transfusion
• Risks for PPH are pre-existing coagulation problems, uterine atony, High parity, uterine surgery history
• Risks involving labor and birth include precipitous labor and operative vaginal birth/ C-section, polyhydramnios, placental abnormalities, infection or fetal death

PPH Risks and PPH Medication

• Preexisting and prior uterine history and pregnancy factors predispose PPH
• Avoid cephalopelvic disproportion, placenta accreta/previa, unfavorable fetal positions with Oxytocin
• Do not give Methylergonovine (methergine) to patients with hypertension, PEC/eclampsia
• Do not give carboprost to patients with asthma, renal/hepatic or heart disease
• Do not give Misoprostol to patients with hypersensitivity and pregnancy

Infant Feeding

• 85% of newborns are breastfed after birth
• breastfeeding decreases the risk for diseases such as (SUID), asthma, otitis media, NEC, obesity, atopic dermatitis, celiac and CD
• Benefits for the mother includes a reduced risk for blood loss, ovarian and breast cancers, infection, autoimmune disorders and diabetes
• Mothers with active TB, HIV, herpes, galactosemia, illicit drug use or other treatments are not recommended to breastfeed

Benefits and Pros and Cons of Bottle Feeding

• Bottle-feeding advantages include, partner involvement and opportunity for parent absence and separation
• Bottle-feeding disadvantages include, obesity, risk of illness, cost, time, infections due to antibody lack, and intolerance due to formula type and additives
• Babies with allergies can drink hypoallergenic formula
• Kangaroo care stabilizes temperature, oxytocin, milk production, is beneficial to wake feeds and reduces stress

Preterm Babies

• Timeline:
• Extremely Preterm: born 28 weeks or less
• Very Preterm: born between 28 and 31/7 weeks
• Preterm (Traditional): born between 32-33/7 weeks
• Late Preterm: born between 34-36/7 weeks
• Preterm: Risk factors are a mixed bag
• History, Uterine defects race, multiple births family issues
• STIs, drug use, genetics and bleeding

LBW

• Involving assessments, physical, Ballard, respiratory which oxygen and intubation
• Maintain warmth, nutrition, skin to skin
• Feeding preterm newborns is dependent on gestation, requiring BG monitoring
• NTE (neutral thermal environments) is key
• Cold causes respiratory distress

Pre and Post Term

• Post-term: Risk factors are pregnancy, genetics, and previous pregnancy, leading to MAS from hypoxia with a need to administer O2
• Skin, and glucose support are necessary for pre and post term babies

Post Term Labor

• Check records for gestational age, oxygen and vitals.

Stillbirths

• Substance abuse can cause stillborn

Perineal Assessment

• Use REEDA to analyze perineum
• R stands for Redness
• E stands for Edema
• E stands for Ecchymosis
• D stand for Drainage
• A stands for Approximation of edges related to episiotomy or lacerations
• Frequent REEDA assessment identifies potential complications as with swelling, infection or hematoma
• Prevent Stressful cold labor

Wound Infections

• Patients with obesity, diabetes, malnutrition, long labors, multiple births, or infections are at an increasing risk for infections
• Signs and symptoms include drainage, fever and erythema
• Wound culture should be obtained and antibiotics prescribed
• Warm compressions aids to promote blood flow and healing
• Clean and check the wound as well

Hyperbilirubinemia

• Seen when serum bilirubin levels are greater than 5 mg/dL
• Pathological jaundice occurs when the first 24 hours after birth caused by hemolysis, and type incompatibility. O+ mom is more dangerous
• Physiological jaundice results when disorders exacerbate physiological processes that lead to hyperbilirubinemia
• Watch for TSB levels to rise within 24 hours of birth and high levels to exceed 1.5 to 2 mg/dL

Nursing and Medical Actions for Jaundice

• Coombs use to determine hemolytic disease related to Rh or ABO incompatibility, check transcutaneous bilirubin levels
• Draw CBC checks for anemia
• Promote nutrition and excretion by frequent breastfeeding. Watch for skin, lethargy and loose stools
• Medical is to support with transfusion and IVIG
• Ensure that babies feed every 2-3 hours