Postpartum Assessment Notes

Postpartum Assessment: ● Determine physiologic needs ○ Vital signs, Assessment and comfort ● Review AP and intrapartum history ○ GBS status,HIV status, HepB status, Blood type ● Need for immunizations ○ If mom hep B + then baby will need HepB and HBIG ○ If mom or rubella nonimmune (titer) mom will need MMR ○ If mom Rh- and baby Rh+, mom needs Rhogam ● Determine educational needs ● Consider religious and cultural factors ● Assess for language barriers ● Intimate partner violence screening Vital Signs ● Temperature should be <100.4, elevated temp in first 24 hours may be related to dehydration, presume infection w/ >100.4 on two occasions 6 hours apart; postpartum shiver or chills common. ● Pulse. : tachycardia may be a sign of infection, hypovolemia, pain/anxiety together with tachycardia may be early signs of shock/impending hemorrhage. May occur proper to drop in BP ● BP ○ ELEVATED BP postpartum is not normal/low or falling BP could be related to orthostatic hypotension or hemorrhage ○ Orthostatic hypotension = risk for falls (fainting) ● Respirations ○ Should be normal ● Pain Cesarean Section Assessment ● Cesarean birth is a major surgery, abdominal distension may cause discomfort, assess for bowel obstruction ○ Early ambulation, increase pro intake, avoid carbonated beverages, avoid straws-may need enemas, stool softeners, antiflatulent meds ● Incision- assess using REEDA (redness, edema, ecchymosis, discharge, and approximation) ● Pulmonary infections may occur related to immobility and use of narcotics ○ TCDB, splint incision, use incentive spirometer every 2 hours Postpartum Focused Assessment ● BUBBLE HEB ○ Breasts ■ Inspect for size, contour, asymmetry and engorgment ■ Note any reddened areas, tenderness, engorgement, warmth, febrile ■ ■ ■ ■ ■ ○ ○ ○ ○ Check nipples for cracks, redness and fissures Note if nipples are flat, inverted, or erect Educate women's on use of supportive bra 24 hours Assess for correct latch on technique if mom is breastfeeding If women is non-lactating then: ● Avoid stimulation ● Ice packs of cabbage leaves ● Mild analgesic for discomfort Uterus ■ Assess with women laying flat and have her void ■ Always support the bottom of the uterus during any assessment of the fundus which prevents uterine prolapse ■ Is it firm or boggy ● If firm and bleeding continues think laceration ■ Midline vs. deviated ■ Vagina- any lacerations or hematoma’s? ■ Intermittent uterine contractions due to involution (after pains) ■ After pains > in multiparous women than in primiparous women ● Interventions for after pain ○ Prone position and place a small pillow under the abdomen ○ Ambulation ○ Medicate with mild analgesic Bladder ■ Monitor output/assess for retention ■ Postpartum diuresis ■ Void within 4 hours after birth ■ Early ambulation ■ Catheterize if unable to void ■ Assess for UTI’s Bowel ■ Anatomy returns to normal location ■ Relaxin depresses bowel motility ■ Diminished intra abdominal pressure ■ Incontinence if sphincter lacerated ■ Spontaneous BM 2nd-3rd post partum ■ 6-8 glasses of water or juice ■ Stool softener ■ Laxative ■ Sitz bath for discomfort ■ Medications for hemorrhoids ■ Note: Auscultate bowel sounds prior to assessing the uterus Lochia ■ Educate mother on the stages of lochia ■ ○ ○ ○ Caution mother that an increase in amount, foul odor or return to rubra lochia is not normal ■ Instruct patient to change peripad frequently ■ Peri care after each void or during to dilute acidic urine and promote comfort if laceration or episiotomy ■ Best practice is to weight the pads to get accurate blood loss ■ Volume ● 1 gram weight=1 mL Episiotomy ■ With episiotomy (or any lacerations) ● Assess using REEDA ● Lacerations: ○ 1st degree: perineal skin and vaginal mucous membrane ○ 2nd degree: includes the fascia and perineal muscles ○ 3rd degree: extends into the rectal sphincter-no suppository ○ 4th degree: Extends through the anterior rectal mucosa exposing the rectal lumen-no suppository ■ Midline ■ Mediolateral ■ Peri Care includes: ● Peri bottles ● Ice packs for first 24 hours ● Sitz baths after 24 hours ● Topical medications ○ Witch hazel pads, dibucaine, dermoplast, epifoam ● Gentle pat dry front to back Homans/Hemorrhoids ■ Hemorrhoids/Homans sign r/o DVT if standard of care current evidence that Homan sign is not always reliable ■ Homan’s sign: With the woman’s knee flexed the nurse dorsiflexes the foot. ■ Pain in the foot or leg is a positive homan’s sign Emotional Adaptation ■ Postpartum blue ● Transient period of depression ● Occurs first few days after delivery ● Mother may experiences tearfulness, anorexia, difficulty sleeping, feeling of letdown ■ Postpartum depression occurs in about 10-20% of all postpartum patients ● Symptoms include: ○ Intense, pervasive sadness ○ Labile mood sings ○ Intense fear, anger, and anxiety ○ ○ Unable to care for self or infant ○ Irritability which may progress to violent outbursts ○ Rejection of infant ○ Obsessive thoughts ■ Postpartum psychosis ■ Hallucinations, delusion, agitation, inability to sleep, bizarre or irrational Bonding ■ Determine mother’s phase of adjustment to parenting ■ Take into account cultural factors with this assessment ■ Describe level of attachment to infant ● Is mother attracted to newborn? ● Is mother inclined to nurture infant? ● Does mother act consistently? ● Is mothering consistently carried out? What is Intimate Partner Violence ● A pattern of coercive control that one individual intermittently exerts over another ○ Power and Control ■ Emotional/Psychological Abuse ■ Verbal Abuse ■ Physical Abuse ■ Sexual Abuse ■ Financial Abuse ■ Spiritual Abuse Violence against Women ● 1 out of 4 in the US and 1 out of 3 in world will be in a abusive relationship in their life ● DV occurs in privileged communities at the same rates as inner-city communities ● Battering is a more common cause of injury for women than automobile accidents, muggings and stranger rapes combined ● ⅓ women who attempt suicide experience violence in the home ● Almost ⅓ of all visits to ER are DV related ● Survivors of DV face high rates of depression, sleep disturbances, anxiety, flashbacks, and other emotional distress Cycle of Violence ● Batterer: Act of Violence ● Batterer: I’m sorry ● Batterer: Moody, nitpicky, etc.