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.