postpartum physical assessment by ms. mevelle l. asuncion rn
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MEVELLE L. ASUNCION, RN
Postpartum & Newborn Nursing
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The Postpartum Period
Puerperium: Term 1st 6 weeks after the birth of aninfant
Neonatenewborn from birth to 28 days.
Family adaptation to neonate: Bondingrapidprocess of attachment during 1st 30 to 60 minutesafter birth
Mother, father, siblings, grandparents
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Factors Affecting Family Adaptation Parental fatigue
Previous experience with a newborn Parental expectations of newborn
Knowledge of and confidence in providing fornewborn needs
Temperament of the newborn
Temperament of parents
Age of parents
Available support system Unexpected events
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Postpartum Assessment
VS, amount of lochia, presence of edema, fundalheight and firmness, status of perineum, bladderdistension
1 to 2 hrs after delivery: every 15 minutes
If no problems every 8 hours
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KNOW YOUR PATIENT --- DELIVERY HISTORY/ADMISSION/TRANSITION ASSESSMENT:
Gravida, parity / Time and type of delivery
Anesthesia or medications / Risk factors for PPH
Medical history / Routine medications / Allergies
Infant status / Breast/bottle Rubella immune?
Rh Negative?
Drug/ETOH Abuse
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Body Systems Assessment
Vital signs Level of pain Neurological Pulmonary Cardiovascular Musculoskeletal Gastrointestinal
Genitourinary Integumentary Psychosocial
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Vital Signs
Day 1 Day 2 and after
Heart Rate 50 to 70 bpm Bradycardia ornormal
Respirations Normal Normal
B/P Normal Normal
Temperature 100.4 normal24 hrs.Muscularexertion/dehydration
Normal
If 100.4 suspectinfection
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Postpartum Physical Assessment B - breast
U - uterus
B - bowels B - bladder
L - lochia
E - episiotomy
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General Assessment
Enter the room quietly, speak quietly.
Wash hands and provide for privacy.
Inform patient before turning on lights.
Note LOC, activity level, position, color, general
demeanor.
Take note of the total environment:
Safety/patient considerations
Note equipment and medical devices
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Breast Assessment
Breasts: Soft, engorged, filling, swelling, redness,
tenderness. Nipples: Inverted, everted, cracked, bleeding,
bruised, presence of colostrum or breastmilk.
Colostrumyellowish fluid rich in antibodies and
high in protein. Engorgement occurs by day 3 or 4. Due to
vasoconstriction as milk production begins
Lactation ceases within a week if breastfeeding is
never begun or is stopped.
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Assessing Uterine Fundus
Location in relation to
umbilicus Degree of firmness
Is it at Midline or deviated toone side?
Bladder Full? A boggy uterus may indicate
uterine atony or retainedplacental fragments.
Boggy refers to beinginadequately contracted andhaving a spongy rather thanfirm feeling.
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Massaging the Fundus
Every 15 mins during the 1st hr,
every 30 mins during the next hr,and then, every hr until the patient
is ready for transfer.
Document fundal height.
Evaluate from the umbilicus usingfingerbreadths.
This is recorded as 2 fingers below
the umbilicus (U/2), one finger
above the umbilicus (1/U), and soforth.
The fundus should remain in the
midline. If it deviates from the
middle- distended bladder.
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Uterine Involution
Uterine Involution: return
of the uterus to its pre-pregnancy size andcondition
Uterine fundal descent:uterus size of grapefruit
immediately after birth Fundus half way between
umbilicus and symphysispubis
Fundus rises to the
umbilicus stays for 12hours Descends 1 cm
(fingerbreadth) each dayfor about 10 days
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Uterine Atony
Lack of muscle tone in the cervix.
Uterus feels soft and boggy
After delivery: Postpartum diuresis
The bladder has increased capacity and decreased
muscle tone. This leads to over-distension of the bladder,
incomplete emptying of bladder, retention ofresidual urine and increased risk of UTI and
postpartum hemorrhage.
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Bowels & Bladder
When was the patients last BM?
Is she passing flatus? (gas)
Assess for bowel sounds
Voiding pattern - without difficulty/pain, urine may
be blood tinged from lochia
Nursing interventions: Assist to the bathroom. Usemeasures to encourage voiding (privacy). Encourage
use of peri-bottle with warm water, fluids, fiber,frequent ambulation, stool softeners; teach effectsof pain medication.
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Lochia Assessment
Lochiavaginal discharge after childbirth.
It takes 6 weeks for the vagina to regain its pre-pregnancy contour. Lochia: scant-moderate, rubra, serosa or alba Assessment of lochia includes noting color,
presence and size of clots and foul odor. Day 1- 3 - lochia rubra (blood with small pieces of
decidua and mucus)
Day 4-10 lochia serosa (pink or pinkish brown
serous exudate with cervical mucus, erythrocytesand leukocytes)
Day 11- 21 - lochia alba (yellowish whitedischarge)
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Lochia: Pad Count
1. Scant: 1-inch stain on pad in 1 hour
2. Light/small: 4 inches in 1 hour3. Moderate: 6 inches in 1 hour
4. Heavy/large: Pad saturated in 1 hour
Excessive: Pad saturated in 15 min
Can estimate blood loss by weighing pads: 500 mL = 1 lb. or 454 g
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Episiotomy/Perineal Assessment
Patient in lateral Sims (side lying) position.
Use the acronym REEDA(redness, edema,ecchymosis, discharge, approximation of suture linesedges of episiotomy) to guide assessment.
Even if there is no episiotomy, the perineum should
still be assessed. Unusual perineal discomfort may be a symptom of
impending infection or hematoma.Hemorrhoids ?
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Episiotomy Pain Relief
Instruct Mother: Tighten her buttocks and perineum before sitting
to prevent pulling on the episiotomy and perinealarea and to release tightening after being seated.
Rest several times a day with feet elevated. Practice Kegel exercise many times a day to
increase circulation to the perineal area and tostrengthen the perineal muscles.
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Assessment of Edema & Homans Sign
Assess legs for presence and degree of edema; may
have dependent edema in feet and legs.
Assess for Homans sign- thromboembolism shouldbe negative
Press down gently on the patients knee (legsextended flat on bed) ask her to flex her foot(dorsiflex)
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Homans Sign
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Thromboembolic Conditions
Thrombophlebitisthe formation of a clot in aninflamed vein.
Risk factors include maternal age over 35, cesareanbirth, prolonged time in stirrups, obesity, smoking,
and history of varicosities or venous thromboses. Prevention: client needs to ambulate early after
delivery.
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Postpartum Cesarean
Incision siteredness swelling, discharge. Intact?
Abdomen soft, distended? Bowel sounds heard all4 quadrants
Flatus?
Lochia is less amount than in normal spontaneousvaginal delivery (NSVD) because uterus is wipedwith sponges during c/section.
If lochia indicates excessive bleeding, combine
palpation and pain management measures.Auscultate breath sounds
Fluid intake and output
Pain?
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RhoGAM
It is given to an Rh- mother within 72 hours afterdelivery of an Rh+ infant or if the Rh is unknown.
The dose must be repeated after each subsequentdelivery. RhoGAM 300 mcg is the standard dose.
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Postpartum Disseminated Intravascular Coagulation
Abnormal stimulation of clotting mechanism.
Normally, the body forms a blood clot in reaction toan injury.
Small blood clots throughout the body, depleting thebody of clotting factors and platelets. Massive
bleeding Causes may include amniotic fluid clots, fetal demise,
abruptio placenta. Eclampsia or Retained placenta
Symptoms: Sometimes severe bleeding and sudden
bruising .
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Postpartum Hemorrhage
Blood loss of more than 500 ml after vaginal birthor 1,000 ml after a cesarean birth. Early hemorrhage Cervical or vaginal tears,
uterine atony, retained placental fragments,lacerations, hematomas.
Late hemorrhage subinvolution, retainedplacental fragments.
Subinvolution: failure of the uterus to return tonormal size.
Management may include CBC, sedimentation rate,type and cross, fluid resuscitation with normalsaline and blood, vaginal examination, diagnosis,and correction of the underlying cause.
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Postpartum Depression
Postpartum depression is a nonpsychotic depressive
episode that begins in the postpartum period due todecreased estrogen level
Symptoms: changes in appetite or weight, sleep, andpsychomotor activity; decreased energy; feeling of
worthlessness or guilt; difficulty thinking,concentrating or making decisions; or recurrentthoughts of death or suicidal ideation, plans, or
attempts.
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Postpartum Psychosis
A very serious type of PPD
illness that can affect newmothers.
Begin 2-3 weeks postdelivery
Fatigue, restlessness,insomnia, crying liableemotions, inability to move,irrationally statementsincoherence confusion andobsessive concerns about theinfants health
Psychiatric emergency
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Nipple soreness is a portal of entry for bacteria -
breast infection (Mastitis).
Maternal after pains: may be due to breastfeedingand multiparity
Always stay with the client when getting out of bedfor the first time hypotension effect and excessbleeding
When assessing fundal height, if you notice any
discrepancies in fundal height have patient voidand then reassess.
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Nursing Diagnosis Related to Breasts andBreastfeeding
Pain r/t improper positioning, engorged breasts
Ineffective breastfeeding r/t maternal discomfort,improper infant positioning
Knowledge deficit r/t normal physiologic changes,breastfeeding
Infection r/t improper breastfeeding techniques,improper breast care
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The Newborn
http://www.solarnavigator.net/animal_kingdom/humans/humans.htm -
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Newborns Immediate Needs
Airway
Breathing
Circulation
Warmth
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The Newborn
Neonatal transition: 1st
few hours after birthnewborn stabilizes respiratory and circulatoryfunctions.
When the cord is clamped, placental gas exchange
ceases. These changes stimulate carotid and aortic
chemoreceptors which send impulses to therespiratory center in the medulla.
A brief period of asphyxia stimulates respirations.
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Apgar Score
Assesses the infants cardiopulmonary adaptations
to extrauterine life Provides a quick evaluation on how the heart and
lungs are adapting
5 items to be assessed 1 and 5 minutes after birth.
A S
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Apgar Score Heart rate, respiratory rate, muscle tone, reflex irritability and color Score of 0 2 for each item, then totaled.
Apgar Score 8 or higher no intervention Apgar Score 4 8 gentle rubbing, oxygen Apgar Score 0 4 resuscitation
Points Given 0 1 2
A Activity/muscletone
Limp/flaccid Somemotion/flexion
Active motion/wellflexed
P Pulse Rate Absent 100 bts/min
G Grimace/ReflexIrritability
No Response Grimace Cry, cough,sneeze
A Appearance/Skin Color
Blue, Pale Body pink,extremitiesblue
Pink all over
Absence ofcyanosis
R Respiration Absent Slow weak cry Good Cry
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Prophylactic Care
Vitamin Kto prevent hemorrhagic disorders vitk (clotting process) is synthesized in intestinerequires food for this process. Newborns stomach issterile has no food. aquaMEPHYTON
Hepatitis B vaccination within the first 12 hours Eye prophylaxis (Erythromycin Ointment) to
prevent ophthalmia neonatorum gonorrhea/chlamydia
N b I t l i j ti
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Newborn: Intramuscular injection
aquaMEPHYTON (Vit.K)
1 mg/0.5 ml IM lateral thighVastus lateralis
Vi l Si
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Vital Signs
Temperature - range 36.5 to 37 axillary (97.7-98.6)
Axillary vs Rectal about 0.2 to 0.5 differenceCommon variations
Crying may elevate temperature
Stabilizes in 8 to 10 hours after delivery
Heart rate - range 120 to 160 beats per minute Apical pulse for one minute
Common variations Heart rate range to 100 when sleeping to 180 when crying
Color pink with acrocyanosis
Heart rate may be irregular with crying
Respiration - range 30 to 60 breaths per minute
Blood pressure - not done routinely Ranges between 60-80 mm systolic and 40-45 mm diastolic.
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Reflexes: indicate neurological integrity
Rooting Sucking
Extrusion
Palmar grasp Plantar grasp
Tonic neck
Moro Gallant
Stepping
Babinskis
Crossed extensionreflex
Placing
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Reflexes
Tonic Neck Reflex (FENCING)
EXTENDS arm & leg on the sidethat the face points.
Flexes opposite arm & leg
6-8 wks to 6 months
Moro Reflex Birth to 4-6 months
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Rooting and Sucking Reflexes
Birth to 3-4months Birth to 10 months
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Babinski and Palmer Grasping Reflex
Babinski Reflex is (+)
This is Normal
Birth to after walking
12-18 months age
Birth to 4 months
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Skin
Expected findings Skin reddish in color, smooth and puffy at birth
At 24 - 36 hours of age, skin flaky, dry and pink incolor
Edema around eyes, feet, and genitals
Vernix caceosa Lanugo (baby hair) Turgor good with quick recoil Hair silky and soft with individual strands
l i i
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Common Normal Variations
Acrocyanosis - result of sluggish peripheral
circulation. Mongolian Spots: Patch of purple-black or blue-black
color distributed over coccygeal and sacral regions ofinfants of African-American or Asian descent.
Milia: Tiny white bumps papules (pluggedsebaceous glands) located over nose, cheek,and chin.
Erythema toxicum: Most common newborn rash.
Variable, irregular macular patches. Lasts a fewdays.
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Erythema toxicum, acrocyanosis, milia andmongolian spots
H bili bi i
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Hyperbilirubinemia
Physiologic Jaundice =Appears 24 hours after
birth peaks at 72 hrs. Bilirubin may reach 6 to 10 mg/dl and resolve in 5
to 7 days.
Due to Unconjugated bilirubin circulating in the
blood stream that is deposited in the skin. Immature liver unable to conjugate bilirubin
released by destroyed RBC.
Pathologic Jaundice =Not appear until after 24hrs leads to Kernicterus (deposits of bili in brain).
Bilirubin >20mg/dl
The most common cause is Rh incompatibility.
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The Head and Chest
The Head: Anterior
fontanel diamond shaped 2-3 - 3-4 cms
Posterior fontaneltriangular 0.5 - 1 cm
Fontanels soft, firm and flat head circumference is 33
35 cm
The head is a few
centimeters larger than thechest!!!!
The Chest:circumference is30.5 33 cm
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Anterior and PosteriorFontanelles
Anterior diamond shaped 2-3 -3-4 cms
Posterior triangular 0.5 - 1 cm
Fontanels soft, firm and flat
Molding is shaping offetal head to adapt tothe mothers pelvisduring labor.
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Caput succedaneum
Swelling of the soft tissueof the scalp caused bypressure of the fetal headon a cervix that is not fully
dilated. Swelling is generalized.
may cross suture line anddecreases rapidly in a fewdays after birth. Requiresno treatment
2 3 days disappears
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Cephalohematoma
Collection of bloodbetween the periosteumand skull of newborn.
Does not cross suture
lines Caused by rupturing of
the periosteal bridgingveins due to friction and
pressure during labor. Lasts 3 6 weeks
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Bathing the Newborn
No tub bath until afterthe cord has fallen offand healing iscomplete.
Newborns first bath-the nurse needs towear gloves to prevent
infection.What is wrong with
this nursing action?
G i l A R l i hi I i G h
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Gestational Age Relationship to Intrauterine Growth
Normal range of birth weight for each week of
gestation. Birth weight is classified as follows:
Large for gestational age (LGA): weight falls abovethe 90th percentile for gestational age
Appropriate for gestational age (AGA): weight fallsbetween the 90th and 10th percentile for gestationalage
Small for gestational age (SGA): weight falls belowthe 10th percentile for gestational age
Intrauterine Growth Grid
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Ci i i
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Circumcision
Circumcision is considered an elective procedureAnesthesia should be provided. Parents must give written consent Full term health infantsAftercare: Check hourly for 12 hours Check for bleeding and voiding Before discharge: Newborn goes home within the first 12 hours
after procedure Bleeding should be minimal and infant must void Ensure that parents know how to care for the
circumcision.
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Breastfeeding
Colostrum is rich in immunoglobulins to protectnewborn GI tract from infection; laxative effect.
Breast milk in 2 weeks sufficient nutrients 20kcal/oz (infants nutritional needs)
To support Breastfeeding: Mother needs to
consume extra 500 calories per day. Feeding length: should be long enough to remove
all the foremilk (watery 1st milk from breast highin lactose - skim milk & effective in quenching
thirst) Hindmilk: higher in fat content leads to weight
gain and more satisfying. Breastfeeding time approximately 30 minutes
I fa t F la
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Infant Formula
Formula 7.5 ml to 15 ml at feeding gradually
increase to 90 ml to 120 ml at each feeding in 2weeks.
Formula preparation: mixing must be accurate toprovide the 20 kcal/oz. (newborn nutritional need)
Burping: is needed to expel air swallowed wheninfant sucks.
Should be done about way through feeding forbottle feeders and when changing breasts for
breast feeders.
Respiratory Distress
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p y
2 types: Respiratory Distress Syndrome (RDS) andTransient Tachypnea of the Newborn (TTN)
RDS: preterm infants/surfactant deficiency Hypoxia, respiratory acidosis and metabolic acidosis
Surfactant is produced by alveoli - lung maturity
L/S ratio 2:1 is a test done before birth to determine fetal
lung maturity TTN: AGA, near term infants
Intrauterine or intrapartum asphyxia
Newborn unable to clear airway of lung fluid, mucous or
amniotic fluid aspiration. Expiratory grunting nasal flaring, tachypnea with
respirations as high as 100 to 140 breaths/minute.
Neural Tube Defects
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Neural Tube Defects
3 types:
Spina Bifida Occulta: failure of the vertebralarch to close. Has dimple on the back with a tuft ofhair. No treatment required.
Meningocele: saclike protrusion along the
vertebral column filled with cerebrospinal fluid andmeninges. Surgery required. Myelomeningocele: saclike protrusion along the
vertebral column filled with spinal fluid meninges,nerve roots, and spinal cord = paralysis. Surgicalrepair required.
Sterile saline dressing. hydrocepalus
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Spina bifida occulta meningocele
Spina bifida Occulta myelomeningocele
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Infants of DM mothers (IDM) Complications
Hypoglycemia: maternal glucose declines atbirth. Infant has high level of insulinproduction= decreases infants blood glucosewithin hours after birth.
Respiratory Distress: less mature lungs due
to insulin Hyperbilirubinemia: hepatic immaturity,
increased hematocrit, bruising due to difficultdelivery.
Birth trauma: large size of infant Congenital birth defects: birth defects
Patent Ductus Arteriosus, Ventricular SeptalDefect and more.