Physiological Postpartum Assessment (Nursing)

by Jacquelyn McMillian-Bohler, PhD, CNM

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      Slides Psychological Changes Nursing.pdf
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    00:01 Now we're going to make the next part of this a little bit easier.

    00:04 We have a mnemonic to help us remember what we do and what we need to check in the postpartum period.

    00:11 The mnemonic is called BUBBLE DEB.

    00:14 Now, you may have heard some other iterations.

    00:16 And as we've gotten more evidence about the things we need to do, we've made some changes.

    00:21 The newest mnemonic is bubble deb.

    00:23 So here we go.

    00:24 B stands for breast.

    00:26 U stands for uterus.

    00:28 The next B stands for bladder.

    00:30 There's another B but this time it stands for bowel.

    00:34 L stands for lochia.

    00:36 E stands for episiotomy.

    00:38 It can also stand for lacerations that may hurt that happen as a result of surgery so a cesarean.

    00:45 D stands for deep vein thrombosis.

    00:48 The next E stands for emotion, and the final B, wow, there's a lot of B's in this mnemonic stands for bonding.

    00:55 So bubble deb is what we remember when we're trying to perform our postpartum assessment.

    01:01 So let's break down each of those elements.

    01:04 So the first B stands for breast.

    01:07 So the examiner really should use the back of the hand to examine the breast and the examiner is feeling for things like temperature and fullness, we don't want to use the front of our hand because that can be a little bit more intimate.

    01:18 So we'll use the back of our hand to make that assessment.

    01:22 We want to see if colostrum is present.

    01:24 And that'll look sort of golden yellow or if there's mature milk that's present, it'll be thinner and have a grayish appearance.

    01:32 So we want to see if that's coming in.

    01:34 We want to observe the nipple for any sign of trauma, so bruising or blistering.

    01:40 We want to look for signs of inverted nipples because this can complicate breastfeeding.

    01:45 We'll talk about this a little bit more in a later presentation that's all about feeding the infant.

    01:51 If the client is not breastfeeding, because everybody does not make the choice, and for some clients, breastfeeding is actually contraindicated.

    01:59 We want to make sure that the client is wearing some type of supportive bra, we used to bind the breast with actual ace wrap.

    02:06 And we found that that really was not helpful through lots of research studies.

    02:10 So at this point, what's recommended is a nice supportive bra.

    02:14 And in the shower, making sure that we don't turn our front to the shower so that there's lots of warm water.

    02:20 Because guess what warm water does to milk? It makes it come in.

    02:25 And if you've decided not to breastfeed than having milk come in is exactly the opposite of what you want to do.

    02:31 So everyone needs a supportive bra.

    02:33 But clients who are not breastfeeding definitely want to make sure that they don't turn face forward into the shower.

    02:39 So back to the shower.

    02:42 Next, we want to assess the uterus.

    02:44 So the best way to position the client for this exam is to try to lie them flat.

    02:50 So if you sit up a little bit, it makes it really hard to assess the uterus, so a flat position is actually much better.

    02:58 You also want to make sure the client has gone to the restroom and empty the bladder, because it's very uncomfortable to have someone massaging your uterus, which just pushed a baby out and your bladder is full, that's very uncomfortable.

    03:11 So empty the bladder first.

    03:14 The next thing you want to do is to palpate the top of the fundus.

    03:18 Okay, the very top and compare that to the umbilicus.

    03:22 And what we're doing is seeing how large the uterus is, and we measure it in finger breadths.

    03:28 So how many fingers from the fundus.

    03:33 When we do this assessment, we want to make sure to guard the lower uterine segment.

    03:37 And I say this because remember all of those ligatures, everything in there is all soft, it's not very taut.

    03:45 So there's a very good possibility if we vigorously massage the uterus, we could actually push it all the way out.

    03:52 So if we guard and we feel the lower uterine segment at the same time we're massaging the fundus then we can feel the uterus if we're pushing too much.

    04:00 So guarding is really important.

    04:02 The uterus should feel burn, again, like the tennis ball we talked about earlier.

    04:08 It should also be in the midline.

    04:10 So if the uterus is leaning to one side or the other, sometimes that's a sign that the bladders full or there may be a hematoma located somewhere in the pelvic cavity.

    04:20 Really important to check that out.

    04:23 The next B stands for bowel.

    04:26 Now, if you had a patient who's delivered by a cesarean, it's really important that before you do any of that uterine check that you actually listened for the bowels.

    04:35 Remember, when you learn how to do your head to toe assessment, we always listen to the bowel before we do the abdominal assessment so that we don't throw off our exam.

    04:44 So if you need to assess the bowel and listen and auscultate for bowel sounds in the case of a cesarean birth, you're actually going to do bowel before you check the uterus, okay? So we want to listen to bowel sounds.

    04:57 If we've had a cesarean delivery, make sure you realize that it might be a couple of days before those bowel sounds come back.

    05:05 Ask the client if they've been passing flatus.

    05:08 So flatus is another word for, well you know, passing gas.

    05:12 So ask them about that.

    05:13 You don't have to hear it, see it or anything else, you can ask them and take their word for it, that would be just fine.

    05:20 You also want to look for hemorrhoids, especially for a client and go back to the labor record.

    05:25 If they pushed for a really long time and second stage, maybe they push for a really long time and still ended up with a cesarean delivery.

    05:32 Those clients you are especially want to check for hemorrhoid because those are very painful and if we missed them, they can become infected so take a look at those.

    05:43 You also want to provide anticipatory guidance.

    05:46 When we use the word anticipatory guidance, what we mean is letting somebody know something's going to happen before it occurs, so they won't be surprised.

    05:54 Constipation is not one of those good surprises.

    05:57 But it definitely happens, especially for clients who are breastfeeding, so let them know.

    06:02 And if I can put the picture together to help it make sense.

    06:04 Imagine that you've just pushed out a baby, and you might have hemorrhoids from pushing.

    06:11 And the last thing you want to think about as being constipated and how that could irritate everything, but they need to know.

    06:18 It also may help encourage increasing fluids and increasing fiber inactivity to make sure that the constipation is minimal.

    06:26 The next B stands for bladder.

    06:28 We've already talked a little bit about the bladder, and the importance of keeping the bladder small and enlarged bladder can actually exacerbate uterine apnea.

    06:39 And what that will do is lead to a postpartum hemorrhage.

    06:42 So hopefully, if we palpate the bladder, we find that we actually don't feel it at all, that's ideal.

    06:48 The other thing is that if the bladder is enlarged, it may indicate that we have urinary retention, and that may be an issue as well.

    06:57 So we want to encourage the client to empty their bladder at least every two hours, even if they don't feel like it to avoid both of those things.

    07:05 There may be some decreased sensitivity in the bladder.

    07:07 And if you think about all the things that have been going on in the pelvis, that completely makes sense.

    07:13 So when we assess for urinary retention, then we may ask the client to go to the restroom and attempt to empty the bladder and see if we can feel it, that may be how we assess.

    07:23 If the uterus is deviated.

    07:25 Remember, one of the most common reasons is that the bladder is full.

    07:29 So if you find that the uterus is tilted, and the fundus is not midline, then the next thing you do is check and make sure that the client has emptied their bladder.

    07:40 Lochia, again, is the bleeding.

    07:42 And we want to assess for the amount of bleeding after we have massage the uterus.

    07:47 Because often when we do a little massage of the uterus, we'll push out more clots or more lochia and we want to get a really accurate assessment of what it looks like, especially if the client has been lying down for a long time because the lochia may pull in the uterus.

    08:02 And so when they get up, it may come out.

    08:04 So we definitely want to massage first and see what's there.

    08:08 We want to ask the client when is the last time they change their pad, because maybe you see a large amount of lochia on the pad.

    08:15 And maybe they haven't changed their pad for three or four hours.

    08:18 That's a lot different than seeing a saturated maxi pad and the client says, "Oh, I just changed it a couple minutes ago." Very different picture so ask that question.

    08:28 Clots should be smaller than the size of a golf ball, which is "Oh, about like this." So passing a few clots here and there, not particularly unusual right after delivery.

    08:38 And also again, if the clients been lying flat for a long time, they're waking up in the morning or after a nap, they may be more likely to pass clots.

    08:47 So it's always good to get the context of what's been going on before you worry about what you're seeing.

    08:53 If the client has had a cesarean delivery, one of the things that's done at the very end of the delivery is that the provider will scoop out the lining of the uterus, so they essentially clean a lot of lochia that might be there.

    09:07 So you may find that clients who've had a cesarean birth have a lot less lochia.

    09:11 And that's pretty normal.

    09:14 Now the lochia is going to change in characteristics over time, and it's important that the nurse knows what to expect when.

    09:21 So lochia rubra is the lochia we typically see in the hospital.

    09:25 And that duration is up to about three to four days postpartum.

    09:29 It's usually dark red, and it looks a lot like menstrual blood.

    09:34 The next stage of the lochia is called lochia serosa and it's sort of a pinkish color.

    09:40 And it's from day 4 to about day 10 postpartum.

    09:44 And the final stage is lochia alba, and alba means white.

    09:48 And so it's sort of a milky whitey yellow sort of discharge, and it's usually present day 10 through about day 28.

    09:56 Now, it's not only important that the client transitions through each of these stages.

    10:01 But it's also important to understand that if a client gets all the way today, maybe 14 or 15 and they see lochia alba, and then all of a sudden, they go back to lochia rubra, that's a sign of a complication.

    10:14 So this is why we have to know when we should see what color.

    10:18 Now, the next E stands for episiotomy.

    10:22 And so an episiotomy doesn't happen as often as it used to.

    10:27 So we use this term to blanketly refer to any kind of laceration.

    10:31 So tears that may occur from delivery or maybe an incision from a cesarean birth, those are all going to be under E.

    10:39 So what are we looking for with any kind of laceration? We're looking for Reeda.

    10:44 Reeda is not a person.

    10:46 Reeda stands for redness, ecchymosis, edema, and approximation.

    10:51 So we want to look for normal healing.

    10:54 So make sure again, that you look for the delivery record and see if there were other lacerations or repairs that were done during delivery to make sure that they are healing okay.

    11:05 We want to check for comfort because sometimes if the laceration is hurting more than it should be, it's a sign of infection or a sign that it's not repaired correctly, or something like that so always check the record and make sure.

    11:19 If we're looking at a cesarean incision, we want to make sure that the bandage if it's not been removed yet, doesn't have a lot of exudate or bleeding.

    11:28 And if you see it, really good practice is to take your pen and make a line around where the bleeding is so that the next time you come back, you'll notice if there's more, okay? So don't necessarily take the bandage off unless it's ordered to do that, because they're antibacterials on it or maybe it's applying pressure to the incision.

    11:47 But when it's ordered to remove, then we're going to look for reeda there as well.

    11:51 Now let's talk about the D.

    11:53 The D stands for deep vein thrombosis.

    11:56 In the old days, this used to be homans, and I'll talk about why we don't do that anymore.

    12:01 But D, deep vein thrombosis.

    12:03 So when we think about this graphic, what we can see is normal healthy blood flow, we've got lots of space, we've got our blood cells floating around and everything's happy.

    12:12 If we develop a thrombus, then we actually can sort of impede blood flow.

    12:17 And so once we do that, we might find that there's swelling or warmth.

    12:22 What can happen is we can have what's called an embolus where that clot, actually, or that thrombus breaks off and it can make its way into the pulmonary system.

    12:30 And that's where we might have a pulmonary embolus or we could develop a stroke so DVT's are really serious.

    12:37 And we think about the fact that there's been a lot of blood movement, when we think about the fact that the client is hypercoagulable.

    12:44 Just because of pregnancy, DVT's are a real risk that we're concerned about.

    12:49 So how do we assess what we don't do is do Homan's sign.

    12:53 So homan's sign is where we dorsiflex the foot and we ask about signs of pain.

    12:59 The reason we don't do that anymore is because if there's a thrombus present, and we're manipulating the leg, we can actually break the thrombus off and cause exactly what we're trying to detect.

    13:09 So we no longer recommend Homan's sign.

    13:13 But we gently palpate the leg and the calf, we look for any signs of redness or swelling, maybe a difference between one leg versus the other.

    13:23 We're looking for warmth or anything that might indicate some abnormality.

    13:27 Now remember, one of the things that can make your legs feel sore and uncomfortable is holding it in a really awkward position for a really long time.

    13:36 Hopefully this is making you think of holding your leg in a really long time in a really weird position maybe in labor.

    13:41 So go back to the delay delivery record and talk to the client about what they were doing during labor because sometimes I found that the pain they're describing has more to do with some weird position they were in rather than a DVT.

    About the Lecture

    The lecture Physiological Postpartum Assessment (Nursing) by Jacquelyn McMillian-Bohler, PhD, CNM is from the course Physiological and Psychological Changes and Assessments (Nursing).

    Included Quiz Questions

    1. Shower with your back to the water.
    2. Breastfeeding is the best way to nourish your baby.
    3. Try to wear a bra as little as possible.
    4. Stimulate the breasts to reduce engorgement.
    1. Count the number of finger breadths from the fundus to the umbilicus.
    2. Assess and confirm that the uterus feels firm.
    3. Before the assessment, ensure the client has emptied their bladder.
    4. Before the assessment, place the client in the semi-Fowlers position.
    5. Use both hands to massage the upper segment of the uterus.
    1. Provide anticipatory guidance about constipation
    2. Ask the client if they are passing flatus
    3. Assess for hemorrhoids
    4. Palpate the fundus and then listen to bowel sounds
    5. Post cesarean, confirm overactive bowel sounds
    1. A saturated pad after changing it 15 minutes ago
    2. A saturated pad after changing it 4 hours ago
    3. Clots the size of golf balls
    4. Large amount of lochia after the client stands up
    1. Lochia turns from white to red 10 days postpartum.
    2. Lochia is continuously red for days 1–3 postpartum.
    3. Lochia turns from pink-brown to yellow-white 10 days postpartum.
    4. Lochia turns from red to pink or brown 4 days postpartum.
    1. Gently palpate the leg and ask about pain.
    2. Look for unilateral redness, warmth, or swelling.
    3. Read the labor record to confirm the position the client was in.
    4. Massage the calf and ask about pain.
    5. Dorsiflex the client's ankle and ask about pain.
    1. Uterine hemorrhage
    2. Large uterine blood clots
    3. Bladder infection
    4. Bladder trauma

    Author of lecture Physiological Postpartum Assessment (Nursing)

     Jacquelyn McMillian-Bohler, PhD, CNM

    Jacquelyn McMillian-Bohler, PhD, CNM

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