Postpartum examination

postpartum period Is the period beginning immediately after the birth of a child and extending for about six weeks.
The World Health Organization (WHO) describes the postnatal period as the most critical and yet the most neglected phase in the lives of mothers and babies; most deaths occur during the postnatal period
It is the time after birth, a time in which the mother's body, including hormone levels and uterus size, returns to a non-pregnant state.

Postpartum Nursing Physical Assessment
Physical Assessment is necessary to identify individual needs or potential problems
Explain to pt purposes of the examination.
obtain her consent.
Record your findings and report results to the mother.
Avoid exposure to body fluids.
Teach pt as you assess – use every opportunity since there is limited time.

1. EXAMINATION AND CARE OF THE POSTNATAL MOTHER. IYUMVA Aimable BNS Student, CLARKE INTERNATIONAL UNIVERSITY Kampala

2. objectives By the end of this presentation, we expect you to understand the following: What the postpartum period is? Assessment of the postpartum mother. Nursing care of the postpartum mothers. Areas of emphasis during assessment.

3. Postpartum Period Is the period beginning immediately after the birth of a child and extending for about six weeks . The World Health Organization (WHO) describes the postnatal period as the most critical and yet the most neglected phase in the lives of mothers and babies; most deaths occur during the postnatal period It is the time after birth, a time in which the mother's body, including hormone levels and uterus size, returns to a non-pregnant state.

4. Postpartum Nursing Physical Assessment Physical Assessment is necessary to identify individual needs or potential problems Explain to pt purposes of the examination. obtain her consent. Record your findings and report results to the mother. Avoid exposure to body fluids. Teach pt as you assess – use every opportunity since there is limited time.

5. Assessment of the mother First 24 hours after birth All postpartum women should have regular assessment of vaginal bleeding, uterine contraction , fundal height, temperature and heart rate (pulse) routinely during the first 24 hours starting from the first hour after birth. Blood pressure should be measured shortly after birth. If normal, the second blood pressure measurement should be taken within six hours. Urine void should be documented within six hours.

6. Beyond 24 hours after birth At each subsequent postnatal contact, enquiries should continue to be made about general well-being and assessments made regarding the following: micturition and urinary incontinence, bowel function, healing of any perineal wound, headache, fatigue , back pain, perineal pain and perineal hygiene, breast pain, uterine tenderness and lochia . Breastfeeding progress should be assessed at each postnatal contact .

7. At each postnatal contact, women should be asked about their: emotional wellbeing, what family and social support they have and their usual coping strategies for dealing with day-to-day matters. All women and their families/partners should be encouraged to tell their health care professionals about any changes in mood, emotional state and behaviour that are outside of the woman’s normal pattern.

8. At 10–14 days after birth, all women should be asked about resolution of mild, transitory postpartum depression (“maternal blues”). If symptoms have not resolved, the woman’s psychological well-being should continue to be assessed for postnatal depression, and if symptoms persist, evaluated. Women should be observed for any risks, signs and symptoms of domestic abuse. Women should be told whom to contact for advice and management. All women should be asked about resumption of sexual intercourse and possible dyspareunia as part of an assessment of overall well-being two to six weeks after birth. If there are any issues of concern at any postnatal contact, the woman should be managed and/or referred.

9. Maternal history: restored function Ask the mother if since she delivered, she is : now ambulatory / not yet ambulatory has passed her bowels / has not yet passed her bowels has no flatus / is experiencing some flatus has voided her bladder (when) / has not yet voided her bladder Abnormal Findings Bowel: Constipation, diarrhea, epigastric pain, hemorrhoids Bladder: urinary retention, urgency, dysuria , incontinence

10. Postpartum Maternal Physical Assessment Summary- BUBBLE HE B-U-B-B-L-E H-E B: Breasts U: Uterine fundus B: Bladder function B: Bowel function L: Lochia E: Episiotomy (Perineum) H: Homan's sign (legs) E: Emotions

11. Assessment of Breasts inspect for redness & engorgement. Palpate breasts to determine if they are soft or filling, warm, engorged or tender. Teach to promote milk production & let down, and methods to prevent and treat engorgement. Ensure proper bra fit Nipples should be soft, pliable, intact & everted * If mother is NOT breast feeding - DO NOT palpate breasts or assess nipples Abnormal Findings (Breasts) Redness, heat, pain, cracked, and fissured nipples, inverted nipples, palpable mass, painful, bleeding, bruised, blistered, cracked nipples.

12. Abdomen On inspection of the abdomen, Check for presence of visible scars abdomen can: be distended : below / above the umbilicus. move / does not move with respiration, palpation of the abdomen: Ensure privacy and environment where the mother can lie on her back with her head supported. Ensure bladder is empty & lay patient supine with legs flexed. The midwives hands should be clean and warm and help the woman expose the abdomen. The midwife places the lower edge of her/his hand at the umbilical area and gently palpates inwards towards the spine until the uterus fundus is located.

13. Assessment of the uterine fundus . It should be firm, if not, massage prior palpation & assess for any blood discharged during massage. Assess its location and the degree of uterine contraction, any tenderness or pain should be noted Normal findings : normal size and shape, mobile, regular, firm, in the midline, below the umbilicus & non tender.

14. Uterine fundus ….. Abnormal findings: immobile, irregular, soft, tender, deviated away from the midline or above the umbilicus after 24hrs Fundal height is measured in cm above or below the umbilicus Note: * fundus is 2 cm below the level of the umbilicus immediately after birth; fundus descends approximately 1 cm per day; by the 10th day the fundus should no longer be palpated *If fundus is deviated or elevated above level of umbilicus always rule out DISTENDED BLADDER Once the midwife has completed the assessment, she helps to dress and sit up.

15. Postpartum vaginal loss Lochia : is the vaginal loss following birth. As involution progresses, the vaginal loss reflects this, and it changes from fresh blood loss to one that contains stale blood products ( lanugo , vernix, and debris from the unwanted products of conception) Lochia rubra : dark red (red) discharge; occurs the first 3 days. Lochia serosa : pink, serosangineous discharge; lasts 3-10 days Lochia alba : creamy or yellowish discharge (white); occurs after the Tenth day and may last a weeks or two. When lochia subsides, uterus is considered closed; postpartal infection is less likely.

16. Lochia …… On examination, Note the: amount, colour , consistency, odour & presence of clots Note: * the amount is assessed in relation to TIME (scant, light, moderate, heavy). It should be odourless , with no clots & gets less each day. Also assess woman’s pad changing practices & her type of pad. Teach proper wiping & progression of lochia Abnormal Findings ( Lochia ) Heavy, foul odour , bright red bleeding, clots, amount more than a period.

17. Assessment of vaginal blood loss Questions to ask: Is the blood loss more or less? Color and the amount of blood loss(Lighter/ dark) Any concerns about the blood loss? Ask if she has passed any clots and when it occurred. (Clots are associated with prolonged bleeding postpartum) Ask the mother to describe the size of vaginal loss in a sanitary pad, frequency of changing the pad because of saturation level, comparison of clots to familiar items e.g. : 50 shs coin, or a plum.

18. URINARY TRACT Risk for urinary tract infection is increased, if client was catheterized during labor and delivery. May have bruising and swelling caused by trauma around the urinary meatus . Increased bladder capacity, along with decreased sensitivity to pressure leads to urinary retention. Diuresis occurs during the first 2 days after delivery. Bladder distention may displace the uterus, leading to a boggy uterus and increase risk for atony .

19. Assessment of Episiotomy (Perineum)  Inspect with patient in Sims position. Lift buttock to expose perineum & anus If present, assess episiotomy or laceration for REEDA. Should have minimal tenderness with gentle palpation, No hardened areas or hematomas. Assess knowledge, practice, & effectiveness of self peri -care. Educate about suture absorption Advice on what might help perinial pain: use of salts, or savlon in bath water to reduce pain and improve healing. Abnormal Findings (Perineum) Pronounced edema, wound edges not intact, signs of infection, marked discomfort.

20. Assessment of perinial pain Women feel brused around the vagina regardless the trauma in the first few days after birth. In cases of actual perenial injury, a woman will experience pain for several days until healing takes place Long term psychological and physiological trauma is also evident The midwife observes perinial area to ascertain progress of healing from any trauma. Appropriate care immediately after birth or where suturing has taken place can help reducing edema or bruising. Very important Q n : the midwife ask the mother whether she has any discomfort in the perinial area regardless of any record of actual pernial trauma. Clear information and reassurance are helpful where women have a poor understanding of what happened and are anxious or embarrassed about urinary, bowel or sexual functioning in the future If there is no pain in the perinial area, the midwife should not examine. For majority of the women, the perinial wound gradually becomes less painful and should occur 7 to 10 days after birth.

21. Maternal examination: legs *do a homan’s sign test (to detect early DVT) Assess for signs of DVTs, i.e. asymmetric: size, color, or temperature. Asses for signs of superficial thrombophebitis (redness, warmth, tenderness, pain in that limb, darkening of skin over or hardening of vein)

22. Homans’sign or the dorsiflexion sign

23. Maternal examination: affect Assess for: sleep deprivation ability to rest energy level comfort level anxiety level Appetite bonding behaviours support system (family, husband, self supported)

24. Vital signs and general health Pulse rate, respiratory rate, body temperature, any outward odour , skin condition and the woman’s overall color and complexion as you listen to what the mother is saying. If no history of hypertension, BP should return to normal within 24 hours. chest chest should be: clear, with good air entry bilaterally, and no added breath sounds Note the respiratory rate.

25. Post-Natal Care Encourage prescribed medications and supplementation; e.g. iron tablets, vitamin A Introduce exercises (e.g., Kegel /vaginal, abdominal). Remind or give postnatal clinic visit appointment. (6,6,6,6) Encourage and provide family planning counseling. Examine the infant for normal weight gain and performance of pediatric activities like milestones. Answer both mother’s and family’s questions. Counsel Mother about Infant Immunization Schedule and ensure the mother can get access to immunization center. Assess and advise on breastfeeding.

26. Cont…… Monitor and advise the mother on feeding, hygiene and life style. Assess and care for the mother about any infection or disease and manage as soon as possible.

27. EVALUATING BREASTFEEDING How do you know that an infant is getting enough breast milk? Hear infant swallow and make “ka” or “ah” sounds. See smooth nutritive suckling, smooth series of sucking and swallowing with occasional rest periods, not the short, choppy sucks that occur when the baby is falling asleep. Breast gets softer during the feeding Breast-feeding 8-12 times per day; more milk is produced with frequent breast-feeding. Infant has at least 2-6 wet diapers per day for 1st 2 days after birth; 6-8 diapers per day by the 5th day. Infant has at least 3 bowel movements daily during the 1st month and often more. Infant is gaining weight and is satisfied after feedings .

28. Postnatal complications Hemorrhage Pueperial infections Mastitis Subinvolution cystitis and pyelitis Postpartum Depression

29. references http://www.clinicalexam.com/pda/o_obs_postnatal_history_exam.htm Margret Myles textbook for midwifery, 15 th edition…..