Postpartum Assessment PDF

Abdominal examination during the post – natal period (Fundal / lochia checking) A head to toe assessment must be completed for the postpartum patient who has unique needs. To assist with the postpartum assessment BUBBLE-HE is commonly used to guide nursing practice....

Abdominal examination during the post – natal period (Fundal / lochia checking) A head to toe assessment must be completed for the postpartum patient who has unique needs. To assist with the postpartum assessment BUBBLE-HE is commonly used to guide nursing practice. Assessment include Post – natal Abdominal Examination Definition: Abdominal palpation during the immediate postpartum period to assess the uterine involution and discharge and prevent complications from a relaxed fundus after delivery.  Objectives: To evaluate the involution process. To prevent the uterus from becoming boggy and soft. To determine the position and consistency of the uterus. To prevent hemorrhage and shock. Descent of the uterine fundus: The uterus should be firm, well contracted and in the midline.  Size of the uterus: Immediately after labor the level of the fundal height should be at or below the level of the umbilicus. The level of the fundus descends gradually at a rate of about I finger breadth every day. So, by the end of 1st week the fundus is midway between umbilicus and symphsis pubis. By the 2nd week the fundus is just behind the symphysis pubis, and thereafter, it becomes a pelvic organ. Post Partum Uterine Massage: keep the non-dominant hand above the symphysis pubis and massage the fundus with dominant hand until the fundus is firm. N.B; The uterus becomes displaced and deviated to the right when the bladder is full. Document the consistency and location of the fundus:- Consistency is recorded as― fundus firm ―― firm with massage ― ― boggy ― Fundus height is recorded in fingerbreadth above or bellow the umbilicus ( i.e.,fundus firm , U-2 )( fundus firm with light massage , U+2 ) Lochia: It is the uterine discharge coming through the vagina during the first 3—4 weeks of the postpartum. It is alkaline in reaction; the amount is rather more than the menstrual flow, with fleshy odor. It contains blood, fibrin, leucocytes, (lead decidual tissue, vaginal epithelial cells, peptone, cholesterol, and numerous nonpathogenic bacteria.  Types of Lochia: There are three types: Lochia Rubra: presence of a the discharge is red in color due to the high amount of blood, shreds of the decidua, large amount of chorion, amniotic fluid lanugo hair, vernix caseosa, and meconium may also be present. This discharge lasts from the 1st postpartum day to the 4th day’ (and sometimes to 7th day). Lochia serosa: A pink yellow discharge containing less blood and more serum, and extends for another 3 to 4 days. Lochia Alba: a creamy or white colored discharge containing leucocytes and mucus. It remains for the 10 days postpartum.   Lochial amount assessment: (1) (2) (3) (4) 1-Scant amount 1- to 2- inch stain 10 ml loss 2-Light or small amount approximately 4- inch stain 10-25 ml loss 3-Moderate amount 4- to 6- inch stain 25-50 ml loss 4-Heavy or large amount Saturated pad within 1 hours after changing it Technique for assessing involution Nursing action Rational 1-Introduce yourself and explain the -To reduce anxiety and elicit cooperation. procedure. 2-Ask the mother to empty her bladder (if -A distended bladder displaces the uterus. she had not voided recently) 3-keep privacy. 4-wash hands. -To decrease the spread of microorganisms. 5-Place the mother in a supine position -This relaxes the abdominal muscles and with her knee slightly flexed. Ensure she is permits accurate location of the fundus. comfortable. 6-Expose the woman's abdomen 7-Done clean gloves, and lower the -Gloves are recommended any time there is perineal pads to observe lochia as the possibility of coming into contact with body fundus is palpated. fluids. 8-Place the non-dominant hand above the -This supports and anchors the lower uterine symphysis pubis segment during palpation or massage of the fundus. 9-Gently palpate the fundus using the flat -The larger surface provides more comfort. part of the fingers of the dominant hand. 10-Begin palpation at the umbilicus and palpate gently until the fundus is located. -Measure by finger breadth how far the fundus from the umbilicus. 11-Determine its size, position (at the -The fundus should be firm in midline and middle or displaced to either sides) and approximately at the level of the umbilicus. consistency (normally contracted and firm or boggy and soft require massage) 12-The fundus is difficult to locate or is -The non-dominant hand anchors the lower soft or boggy, keep the non-dominant hand segment of the uterus and prevents trauma above the symphysis pubis and massage while the uterus is massaged. the fundus with dominant hand until the fundus is firm. -The uterus contracts in response to tactile stimulation; contraction is essential to control excessive bleeding. 13-Put new perineal pad after performing -To promote comfort. perineal care. 14-Recover the abdomen, assisting the woman to a comfortable position. 15-Discuss the findings with the woman. 16-Document the consistency and location -This promotes accurate communication and of the fundus. identifies deviation from the expected so that -Consistency is recorded as "fundus firm", potential problems can be identified early. "firm with massage "or boggy. -A fundal height is recorded in fingerbreadth above or below the umbilicus. *i.e., "fundus firm, U-2" (two fingerbreadth below umbilicus). *Another example "fundus firm with light massage ,U+ 2" (two fingerbreadth above umbilicus)  Nursing action Rational ROUTINE EPISIOTOMY CARE 1-Prepare the necessary equipment (gloves, mackintosh, bedpan, kidney basin, warm water with antiseptic solution, gauze, towels, and light source) and take it to bed side table. 2-Greet the woman respectfully and explain the - To gain cooperation, helps minimize procedure to her and obtain her consent for the anxiety during procedure. procedure. 3- Protect the woman from air drafts and keep her privacy throughout the procedure. PERINEUM ASSESSMENT 1- Ask woman to turn on side and flex upper - Provides full exposure of perineum. leg, lower perineal pad, and lift up upper buttock; if necessary, use flashlight to inspect perineum. 2- Assess the episiotomy and suture during - To prevent spread of infection. the procedure for the healing process and the presence of hematoma or infection according to REEDA. Redness: - indicate inflammatory response if accompanied by pain or tenderness it indicates localized infection. Edema and tenderness:-indicates localized infection. Ecchymosis:-indicates soft tissue damage. Discharge: - indicate localized infection. Approximation of the edges: - it assesses the healing process. - Note also the number and size of hemorrhoids if present. EPISIOTOMY CARE STEPS 1. Wash and dry hands then use examination -Gloves are recommended any time there is gloves. possibility of coming into contact with body fluids. 2. Ask the woman to lie on the dorsal - Provides easy access to perineum. recumbent position with her knees slightly bent and legs opened. 3. Place large mackintosh and a bedpan under - To protect the bed linen. the mother’s hips. 4. Remove and dispose the soiled perineal pad - To observe vaginal discharge or lochia, according to procedure. condition of vulva and episiotomy. 5. Encourage the woman to void before the - Provides for the woman’s comfort. procedure to avoid discomfort during the procedure. 6. Do perineal care according to the procedure. 7. Wipe the episiotomy site with antiseptic - To prevent ascending infection. solution (betadine) and gauze. -Use gentle pressure technique and avoid fraction to episiotomy stitches. -Start webbing from inside of the vagina to its outside then from the outside vaginal opening suture down to rectum direction. 8. Instruct the woman to turn on the side and -To promote comfort. remove the bed pan. - Dry woman’s buttocks and thighs. 9- Ask the woman to have the original position and cover the perineum correctly with sterile perineal pad from up to down without touching its surface. -Discuss the findings with the woman. POST PROCEDURE TASKS 1. Remove used equipment from bedside to the cleaning area. 2. Remove gloves by turning them inside out - To prevent cross infection. and dispose them correctly. 3. Help the woman to readjust her clothes and to have any comfortable position. 4. Wash hands thoroughly and dry it. -To remove any microorganism. 5. Record finding accurately in the woman’s fill 6. Give health education as needed. Other Nursing Interventions For perineal area Relief of Perineal Discomfort Ice packs for 24 hours, then warm sitz bath Topical agents - Epifoam Perineal care – warm water, gently wipe dry front to back