Gladys C.

Yares, RN RM
Antenatal/Prenatal Care
• It refers to the health care given to a woman
and her family during pregnancy
• the systematic examination and advices given to the
pregnant women at regular and periodic intervals
based on the individual needs starting from the
beginning of pregnancy till delivery.
• To ensure a health and uncomplicated pregnancy and
the delivery of a healthy infant through regular check up
• To identify and treat high risk conditions such as HPN,
bleeding disorders during pregnancy and diabetes.
• To individualize client care for her preparation for labor,
delivery, and puerperium.
• To screen and identify risk factors or disease that may
affect the mother or the infant’s health and life
• To reinforce healthy habits to the woman and her family
PRIMARY GOAL: to provide maximum health to
expectant mothers and their babies
• Antenatal care must follow a definite plan.
• Antenatal care must be problem oriented.
• Identify risk factors from the previous obstetric history.
• Possible complications and risk factors that may occur at a
particular gestational age must be looked for at these visits.
• The fetal condition must be repeatedly assessed.
• Healthcare education must be provided.
• All information relating to the pregnancy must be entered in a
patient-held Maternity Case Record. This antenatal record
can also serve as a referral letter if a patient is referred to the
next level of care and therefore serves as a link between the
different levels of care as well as the antenatal clinic and
labour ward.
Confirm that the patient is pregnant before
beginning antenatal care.
The general information of an
antenatal record
• Establish a baseline of present health
• Determine the gestational age of the fetus
• Monitor fetal development and maternal well being
• Identify women at risk for complications
• Minimize the risk of possible complications by
anticipating and preventing problems before
they occur
• Provide time for education about pregnancy,
lactation, and newborn care
• Equipment and Materials Needed
• Examination Table • BP apparatus
• Draping sheet • Kidney tray
• Screen or curtain • Paper bag
• Urine testing articles • Torch/Goose
& bottle for specimen Lamp
• Temperature tray • Stethoscope
• Weighing scale • Tape measure
• Environment : Clean, Well-ventilated, &
Properly Lighted
• Detailed Health History
• Physical Examination
• Breast and Pelvic Examination
REGISTRATION: Once pregnancy is confirmed,
pregnant women should be registered.
❑Biographic / Identification Data – first information
gathered during prenatal visit
✓ Age
✓ Marital Status
✓ Education
✓ Nature of Occupation
✓ Family Composition
✓ Socio-cultural background
✓ Economic background
❑Surgical History
✓ Hx of any operation
✓ Injury or accidents
✓ Hx of blood transfusion. etc

❑ Menstrual History
✓ Menarche
✓ Length % regularity of menses
✓ Duration of Normal Period
✓ Amount of Flow
✓ Dysmenorrhea & other discomforts during
periods and action taken
❑ Contraceptive History
✓ Actual feelings about contraception
✓ Current method used
✓ Length of used & problems and issues encountered
complications
✓ Complaints R/T the method
❑ Sexual History
✓ Age at first coitus
✓ Number of Partners
✓ STD exposure
✓ Current problems s.a erectile dysfunction
✓ Libido –sexual desire
✓ Orgasmic fxn
✓ Dyspareunia – painful sexual intercourse
✓ Vaginismus – vaginal tightness, causing discomfort, pain,
penetration problems or inability to have sexual intercourse
✓ History of sexual abuse
❑ Medical History
✓ Presence of DM, HPN or Cardiac disease
❑ Family Health History
✓ both maternal and paternal history of breech delivery
✓ twin delivery
✓ hypertension
✓ heart disease
✓ Diabetes
✓ congenital malformation
Antenatal assessment starts with
determination of risk factors.
Better knowledge about risk factors =
better preparation to care for the
client.
❑ Obstetric History
✓ TPAL
❖ T – number of full term infants born after 37 weeks
❖ P - number of preterm infants born born before 37 weeks
❖ A - :number of spontaneous miscarriages or therapeutic abortions
❖ L - Number of living children

✓ GP
❖ G – (Gravida) number of pregnancies irrespective of
gestational age. This would include abortion, molar, ectopic,
preterm and term pregnancy. Multiple pregnancies are counted
as one pregnancy
❖ P – (Para) number of pregnancies that reached period of
viability. The fetus weighed more than 500 grams at birth or
has gestational age of 20 weeks or more
❑ Obstetric History
✓ Primigravida - Woman who is pregnant for the first time
✓ Primipara - Woman who has given birth to one child past age of
viability
✓ Multigravida - Woman who has been pregnant previously
✓ Multipara - Woman who has carried two or more pregnancies
to viability
✓ Nullipara - Woman who has never been and is not currently
pregnant
❑ Present Illness
✓ Pain – dysmenorrhea, dyspareunia, pelvic pressure,
acute/chronic pelvic pain, vulvar pain or pruritus

TYPES OF DYSMENORRHEA
❖ Primary Dysmenorrhea – cramping pain in the lower
abdomen occurring during the onset of menstruation in
the absence of identifiable disease or disorder
❖ Secondary Dysmenorrhea – dysmenorrhea is attributed
to an underlying disease.
❑ Present Illness
✓ Bleeding

CLINICAL TYPES OF UTERINE BLEEDING

❖ Menorrhagia: Excessive & / or prolonged menstruation, at regular
intervals
❖ Metrorrhagia: Uterine bleeding occurring at completely irregular but
frequent intervals, the amount being variable.
❖ Menometrorrhagia: Excessive & / or prolonged bleeding at irregular
intervals.
❖ Polymenorrhoea: Frequent <21 d menstruation, at regular intervals
❖ Intermenstual bleeding: Bleeding of variable amounts occurring
between regular menstrual periods.
❖ Hypomenorrhoea: Scanty menstruation
❖ Oligomenorrhea: Infrequent menstruation >35 d
❖ Amenorrhea: Absence of menses for > 6 months.
.

❑ Prenatal Physical Examination

❑ Present Illness
✓ Abnormal Discharge

❖ Leukorrhea: vaginal discharge common during pregnancy as well as

other times during a woman’s reproductive years. It is thick and sticky
vaginal discharge that is white, yellow or green in color
❖ Nipple discharge – physiologically, color may range from white to
yellow to green and/or bluish gray. The most common type of
discharge is milky white. Uncommon discharge is bloody or watery
(serous) with red, pink or dark brown in color.

✓ Bowel Symptoms
✓ Urinary Symptoms
❑ Present Illness
✓ Menstruation
❖ Menarche
❖ Interval of cycles
❖ Flow (duration and amount)
❖ Date of Last Menstrual Period (LMP)
❖ Date of Preceding LMP
❖ Premenstrual tension
❖ Irritability
❖ Anxiety
❑ Diagnostics
✓ Urine — Albumin and sugar every visit (Refer Skill Bag Technique)
✓ Blood — Hb testing on every visit, once a month to exclude
anaemia.
Normal Value

Reference:
• Abbassi-Ghanavati M, Greer LG, Cunningham FG. Pregnancy and laboratory studies: a
reference table for clinicians. Obstet Gynecol. 2009 Dec;114(6):1326-31.
✓ Blood Group
✓ VDRL (Venereal Disease Research Laboratory) Test for
syphilis done on the first visit
✓ HIV test for high risk groups
✓ Ultrasound- To be done if indicated (If sending for an
ultrasound make sure bladder is full)
✓ TORCH Test – To rule out the following infections (in selected
cases)
T : Toxoplasmosis
O : Other Viral infections
R : Rubella
C : Cytomegalovirus
H : Herpesvirus
❑ Prenatal PE
✓ Weight and height taking (assess nutritional status)
✓ BP taking (assess possible HPN)
✓ Exam of the eyes, palms (pallor may indicate anemia)
✓ Exam of the Abdomen ( determine fetal position and
presentation)
✓ Exam of the FHT and FH (baseline data)
✓ Exam of the hands, face and lower extremities ( edema)
✓ Exam for breast and neck (goiter)
✓ History Taking – Compute for AOG, EDC/EDD (Naegele’s
Rule),
✓ Iron Supplementation
✓ Oral/Dental Exam
✓ Patient /Client Education
• Make the woman stand against the
wall and measure the height.
• The average Filipino woman is
149.60cm (4 feet 10.89 inches) tall.
• Height indicates the pelvic size.
• provides information about the
progressive growth of pregnancy
• taken by measuring the distance
between the upper border of
symphysis pubis and the uppermost
curved level of the fundus (in cm)
12 weeks — Uterus is just about the symphysis pubis
18 weeks — Uterus half way between the symphysis pubis &
umbilicus
20 weeks — above the half way but 2.5 cms below the umbilicus
24 weeks — fundus will be present at the upper margin of the
umbilicus about 20 cms from the symphysis pubis or 3 finger
breadth above 20 weeks.
28 weeks — fundus is 1/3rd from the umbilicus to the xiphisternum
or 30 cms from the symphysis pubis approximately.
32 weeks — 2/3rd distance from the umbilicus and xiphisternum, 6
finger above the umbilicus
36 weeks — 3/3rd distance, which means at the level of
xiphisternum approximately 35 cms or 13-14 inches
40 weeks — mostly lightening takes place and uterus descends
down to the level of 32 wks.
Sometimes fundal height does not
correspond with period of gestation and the
reasons could be:
i) Multiple pregnancy
ii) Polyhydramnios
iii) Fetal macrosomias
iv) Big baby
v) Wrong dates
If the fundal height is less than the period of
gestation then it could be due to:
❖Abnormal fetal presentation
❖Growth retarded fetus
❖Congenital malformations
❖Oligohydramnios
❖IUD (Intrauterine Death)
❖Wrong dates
• Abdominal circumference is measured using
tape measure.
• Normal increase of 1 inch or 2.5 cms. per
week after 30 weeks.
• Measurement in inches is same as the wks of
gestation after 32 wks in an average built
woman. For example, the abdominal girth in a
32 weeks pregnant mother may
be 32 or 31 inches.
• Weight checking should be done at
each visit. Obesity can lead to risk of
gestational diabetes. Average weight of
a Filipino woman in the age group of
25-30 yrs is 46 kgs.
• During pregnancy the weight increase
in the:
❑First trimester — 1 kg.
❑Second trimester and Third trimester
— 5 kg. (2 kgs. a month)
• Total weight gain during pregnancy is
approximately 11 kgs.
• The total weight gain during pregnancy indicates
the birth weight of the child
• A higher than normal increase in weight indicates
early manifestation of toxemia.
• Stationary weight for some period of pregnancy
suggests intrauterine growth retardation or
intrauterine death.
• Poor weight gain also indicates fetal abnormality.
Underweight 28-40 lbs

Normal weight 25-35 lbs

Overweight 15-25 lbs
Obese ~ 15 lbs

Twins 35-45 lbs

Triplets 50 lbs

1 pound = about 0.45 kilograms

Breast 0.5 kg 1-1.5 lbs
Blood 1-2 kg 3-4.5 lbs
Extra water 1.5-3 kg 4-6 lbs
Uterus 1-1.5 kg 2.5-3.0 lbs
Placenta/
1.5- 2.5 kg 3.5-5.5 lbs
amniotic fluid
Baby 2.5-3.5 kg 7-8 lbs
Fat stores 1.5-3 kg 4-6.5 lbs
Total 11- 15 kg 25-35 lbs

33
• Low weight gain in second or third trimester increases risk of
intrauterine growth retardation

• Low weight gain in third trimester increases risk of preterm delivery

• Higher weight gains and greater postpartum weight retention is

common if mother is still growing (teenager)
• Blood pressure should be recorded during
each visit. Any reading above 140/90
should be reported.
• Temperature, pulse, respiration to be
recorded in each visit
❖ Hair and Scalp — healthy or infection
❖ Eyes
— Observe the color of the conjunctiva – yellow,
pink or normal.
— Sclera – normal, yellow tinge suggest anemia
— Infection, discharge
❖ Mouth
— Hygiene
— Gums and teeth — healthy, cavities, infection
❖ Ear, Nose and Throat -— Healthy, enlargement or
infection.
❖ Breast changes—Normal changes during
pregnancy
· 3-4 wks — Pricking and tingling
sensation
· 6 wks — Enlarged, tense, painful
· 8 wks — Bluish surface, veins
visible
· 8-12 wks— Montgomery glands
become prominent on the
areola
· 16 wks — Colostrum can be expressed
❖ Abdomen — Palpate for liver or spleen enlargement or any
other abnormality
❖ Skin — Observe for any scar or infection
❖ Extremities —
Upper: Check hands, color of nails-pink or pale, shape
of nails
Lower : Any pain, tenderness, varicose veins,
presence of edema
❖ Back and Spine:
— Observe the back and spine for any deformity
— Observe the symmetry of the rhomboids of
Michaelis which is a diamond shaped area formed
anteriorly by the fifth lumbar vertebra laterally by the
dimples, of the superior iliac spine and posteriorly by
the gluteal cleft.
• PHYSICAL EXAM
❑ Collect all required articles
❑ Keep room ready — adequate light
— Privacy
— Warm or as per season
❑ Prepare the mother explain the procedure
— ensure that the bladder is empty
— give a comfortable and relaxed
position
❑ Stand on the right side of the woman or
the examination table
• PHYSICAL EXAM
❑ Collect relevant history which includes identification data,
socio-economic data, cultural, medical, surgical, family and
personal history
❑ Collect information about previous pregnancies and the
present one and record in the performa or the card
❑ Drape the mother and provide enough privacy by curtain or
screen
❑ Do a thorough physical examination from head to toe and
record the findings
❑ Bowel and bladder habits
❑ Any complaints related to pregnancy or minor ailments
❑ Explain and assist in routine investigation like urine, stool
or blood.
1. Proper nutrition
2. Having enough rest and sleep
3. Prenatal exercises
4. Stop smoking and alcohol beverages
5. Self-medicating
6. Wearing comfortable clothing
✓ The rule estimates the Expected Date of Delivery (EDD) from
the first day of the woman's Last Menstrual Period (LMP) by
adding a year, subtracting three months and adding seven
days to that date.
Procedure:
a. Get the LMP
b. Subtract LMP from the total number of days of
the month
c. Add to the total number of succeeding
month before latest consultation date
d. Get the latest consultation date
e. Add all the answers to get AOG in days
f. Divide the result by 7 to get
AOG in weeks
Computation:
June 30-20 = 10 LMP =June 20, 2020
July 31
August 31
September 8
80

80/7 = 11 weeks and 3 days or

11 3/7 weeks AOG
 FUNDIC HT X 7/8=AOG in WK

Fundic Ht X 7 = AOG in weeks

8
Ex.
FH 24 X 7 =21 wks
8

Note: FH is taken from symphysis pubis to the fundus

• Determines
the AOG by
the relative
position of
the uterus in
the
abdominal
cavity
3 mos –above symphysis pubis½ from umbilicus
4 mos – ¾ from umbilicus
5 mos – level of umbilicus
6 mos – ¼ from umbilicus to xyphoid process
7 mos – ½ from umbilicus to xyphoid process
8 mos – ¾ from umbilicus to xyphoid process
9 mos – just at the xyphoid process
10 mos – level of 8th mos
Formula: 1st ½ of preg , square @ month
2nd ½ of preg, x @ month by 5
3mos x 3 = 9cm
4 mos x 4 = 16 cm 1st ½ of preg
5 x 5 = 25 cm
6 x 5 = 30 cm
7 x 5 = 35 cm 2nd ½ of preg
8 x 5 = 40 cm
9 x 5 = 45 cm
10 x 5 = 50 cm
(applicable only in Vertex presentation):
FORMULA:
If engaged (vertex is below Ischial Spines)
EFW= Fundal height (cm) – 11
(constant) X 155
If not yet engaged (vertex above Ischial Spine)
EFW= Fundal height (cm) – 12
(constant) X 155
E.g., A baby who is already engaged and FH is
32cm
EFW= 32 cm – 11 X 155 = 3255 gms
 POSTPARTAL(Postpartum)
PERIOD/ PUERPERIUM
❑ the period beginning after delivery and
ending when the woman’s body has
returned as closely as possible to its
prepregnant state
❑ lasts approximately 6 weeks.
❑ “the most critical and yet the most neglected
phase in the lives of mothers and babies;
most deaths occur during the postnatal
period” (WHO)
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.
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.
 Subjective Objective Psychosocial
• Pain • Vital signs – Cultural factors
• Other c/o • Breasts – Maternal
(Patient • Abdomen and adjustment
mood, uterus - Family Adjustment
bonding with • Bladder – Emotional recovery
baby/skin to • Bowel from birth
skin, support • Lochia • PTSD
into • Perineum • Depression
motherhood) • Legs • PP Psychosis
 Postpartum VS
• Vital Signs-every 4 hours for the first 24 hours and then
BID
• Temp- up to 100.4 is considered NORMAL!
• Temp may be slightly elevated due to blood loss or
dehydration
• If the temp is above 100.4, this warrants further
assessment
• Pulse: generally bradycardia- 50-70 bpm. Pulse returns to
normal in 1 week due to a reduction in blood volume
.
 Postpartum VS

• A rapid pulse indicates hemorrhage, infection or anxiety

• BP remains stable or slightly lower due to blood/ fluid
loss
• Respirations: slower and less labored due to absence of
uterine pressure on diaphragm
.
 The 5th Vital Sign
Pain is thought to be the 5th vital sign and we need to
assess for its presence with every set of VS as well as
prn.
 The 5th Vital Sign- PAIN
Subjective/Objective Assessments:
• Pain should be characterized by
‒Position
‒Degree
‒Radiating
‒Associated symptoms
‒What makes it better? Worse?
Afterpains
• decrease in frequency after the first few days, and
usually are associated with:
‒Breastfeeding
‒Multiparity
 BUBBLE HE - an acronym used to denote the components
of the postpartum maternal nursing assessment.
 B: Breast
 U: Uterus
 B: Bladder
 B: Bowels
 L: Lochia
 E: Episiotomy and perineum

 H: Homan’s
 E: motional Status
 BREAST ASSESSMENT:
• 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 snugly-fitted bra
• Nipples should be soft, pliable, intact & everted
 BREAST ASSESSMENT:
Abnormal Findings
Redness, heat, pain, cracked, and fissured
nipples, inverted nipples, palpable mass,
painful, bleeding, bruised, blistered, cracked
nipples.
 It
is an infection of the breast surrounding the
ducts that’s characterized by fullness, pain,
warmth, and hardness of the breast.

-Cause of Infection: associated with

stagnant milk in the ducts
-S &Sx: fever, breasts appear red and
warm to touch and possibly hardened
-Tx: antibiotics and the patient is usually
encouraged to continue breastfeeding.
 Positioning: Hold the baby chest to chest or tummy to
tummy in some way, grab under the breasts and push
down and out (taking the milk ducts and pushing it
forward, make a C-Hold around the areola (pull back,
down, and forward while bringing forward).
 Get a nice big drop of colostrum on the nipple
 Tickle the lip with nipple, shove as much breast as
possible into the mouth once it’s open
 5 to 15 minutes firstto prevent soreness
 Start with the breasts that was left from
 Try to feed every 2 hours
 Ready-to-feed: most expensive but convenient
 Concentrate: do not ever add more water or
concentrate it Powder: follow directions perlabel
 Throw the bottle contents out after the feeding- do not
save for next feeding
 Start off small by only preparing 2 ounces at a time
 No need to warm formulaup.
• What to assess/what to expect
– Height
• Where is the top of the fundus located in
relationship to the umbilicus (below, at the level of
or above)
• The fundus is measured in fingerbreadths above
or below the umbilicus
• Documentation of findings
– If the fundus is 1 fingerbreadth above the
umbilicus it is documented as 1/u meaning
1 fingerbreadth above the umbilicus
– If the fundus is 2 fingerbreadths below the
umbilicus it is documented as u/2 meaning
2 fingerbreadths below umbilicus
– If the fundus is at the level of the umbilicus
then it is documented as u/u meaning the
fundus is at the level of the umbilicus
• What to assess/what to expect
 Firmness
 Palpate the fundus, what does it feel like?
 The fundus should be firm and hard ☺
 If fundus is found to be soft and mushy (boggy), or gets
firmer or harder when massaged interventions are indicated
 Centeredness
 Where is the fundus located?
 The fundus should be located midline to the umbilicus
 If the fundus is to the left or right of umbilicus pt. will need to
void then be reassessed for placement
 Afterpains
 Cramping caused by involution of the uterus
 Increased with greater number of pregnancies
 Breastfeeding also increases afterpains
• What to teach
✓Encourage pts. to empty bladder every
two hours to aide involution and decrease
bladder distention
✓Encourage pts. to breastfeed (causes the
release of oxytocin) helps the uterus
contract to promote involution
✓Encourage pts. to massage own uterus
UTERINE ASSESSMENT:
FUNDUS: firm or boggy
- make a “C-shape” with your hand and push up on
the lower 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

It is always a PRIORITY after delivery to maintain

a well-contracted uterus to prevent bleeding
(hemorrhage)
• Normal findings: normal size and shape, mobile, regular, firm, in
the midline, below the umbilicus & non tender.
• 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
 NURSING CONSIDERATION: A boggy fundus may
be a sign of uterine atony, which places the patient at
risk for developing a postpartum hemorrhage and
other complications.
 Also, fundal location that lies out of range with
anticipated location according to postpartumstatus
may be anotherindication.
 BLADDER ASSESSMENT:
1. Accompany mother and record first 2 voidings. (More if
voiding less than 150cc each time)
2. Palpate for distention above the symphysis pubis
3. If patient has not voided in 6-8 hours post-delivery
--straight cath per Doctor’s order
--notify Doctor for any voiding difficulties
4. Be alert for signs and symptoms of UTI:
--infrequent voiding
--painful urination (dysuria)
--burning
--frequency
--urinary retention
--foul-smelling urine
 BLADDER ASSESSMENT:

5. Postpartum voiding difficulties related:

--fatigue
--perineal swelling
--long, difficult Labor and Delivery eg.use of
Forceps, Vacuum Extractor
1. Assess for presence of bowel sounds every shift;
palpate abdomen for distension
2. Administer daily stool softeners per doctor’s
order
3. Avoid use of enemas and or suppositories for
clients with 3rd or 4th degree laceration. If needed,
use with caution.
4. First BM usually occurs on or after 2nd PP day.
5. Best for client to have BM before discharge but
may not happen.
6. Often sent home with stool softeners &
encouraged to eat fiber & exercise.
❑ 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.
❑ Instruct client to notify nurse if she passes clots.
Note size and number.
❑ Call Doctor for any excessive bleeding
❑ Peri-Care:
-- Instruct client wash with warm water and rinse
stitches area after each voiding or BM
--Wipe from front to back, patting gently
--Change peripads after each voiding
--Encourage use of sitz bath 24 hrs postpartum per
Doctor’s order for 20 min bid-tid especially if client
had 3rd or 4th degree laceration
❑ Also assess woman’s pad changing practices & her
type of pad.
• Teach proper wiping & progression of lochia
 LOCHIA COLOR
 LOCHIA RUBRA: Bright red, may have smallclots,
usually lasts 3 days
 LOCHIA SEROSA: Pink, serous, othertissues
 LOCHIA ALBA: Tissue, whitish
 LOCHIA AMOUNT:

  Scant = 2.5 centimeters saturation

 Light = < 10 centimeters saturation
 Moderate =• > 10 centimeters saturation.
 Heavy = pad is completely saturated within 2 hours
 Postpartum hemorrhage is clinically defined as apad
saturated within 15-30 minutes
 The pad is saturated within 15 minutes to be
considered a hemorrhage situation. In the real world, a
pad that becomes saturated within 30 minutes is a
cause for additionalevaluation.
 Scant saturation in the immediate postpartum period
can be just as concerning as excessive lochia
production. Clots: up to cherry sized are okay, peach or
plum sized is not. Clots are the most common in the
morning following the first void due to the saggy
texture of the vagina, which releases the lochia build-
up from the night.
 LOCHIA ODOR

 Lochia should have “no odor” or “no foul odor”

 Real world: virtually all lochia has an unpleasant or at
least a neutral odor associated with it and moms may
be quick to describe it as “foul”.
 It’s important for the nurse to assess the odor to
eliminate subjective patient description of the scent
 A truly foul odor or a change in odor may be a sign of
infection
Abnormal Findings
- Heavy
- foul odour
- bright red bleeding
- Clots amount more than a period.
 ASSESSMENT

• Assess using REEDA every shift

--R=redness
--E-edema
--E=ecchymosis
--D=discharge
--A=approximation
• Position in lateral Sims position with upper knee bent.
Gently lift the buttocks to view perineum. Flashlight
may be helpful.
• Apply ice bags if ordered, for 6 - 8 hours post delivery
to minimize swelling
 ASSESSMENT

• Assess for presence of hemorrhoids-- Teach client to

apply medication as ordered.
• Most women deliver with an episiotomy
--Midline
--R or L mediolateral
--3rd degree extension-- laceration extends
to the rectum
--4th degree extension-- laceration extends
through the rectum
 Nursing Intervention


❑ Always help the client get up and
ambulate the first two times after
birth to assess for mobility, reduce
the risk of falling and prevent trauma
to the perineum and C-section
incision
 HEMATOMA CARE :
 Start with cold to stop the bleeding, once it
stops, begin warm
Continue to monitor
If it get worse, that active area of bleeding is
non- healing and it will need to be opened
and the active area is discovered and
cauterized
May not appear so much of an out-pouching as
much as a disfigurement.
 HEMORRHOIDS:
 Vasculature that forms a pouch
Color can match the skin of the rectal area and
may look more like a blood blister when irritated
Severe hemorrhoids appear as grape
clusters Dermaplast spray
Patient may not be aware, may only known
that business down there is not as usual
 NURSING INTERVENTION:
 Sitz Bath: a rotating fluid that moves the
water. May fit over the commode or one can
be performed with no special equipment
using the bathtub other than a bathing
ring. Turn tub on and allow drain to open
and use a ring for circulating water. It’s very
shallow and only bathes the perinealarea.
❖ Assess for Signs of DVT (Deep Vein
Thrombosis) by the Homan’s Sign
A positive Homan’s sign is indicative of DVT,
although it’s not the most reliable indicator.
All of the characteristic changes to maternal
clotting factors are higher than any other point
as the body prepares for labor.
Combine this with being in bed, especially if
client underwent a C-section, and it’s easy to
see why the postpartum woman is at such a
huge risk for DVT.
❑ Assess daily for redness, nodular or warm
areas, discolorations, or leg varicosities and
notify Doctor.
❑ Assess Homan’s Sign every shift
❑ Assess peripheral pulses and for presence
of and amount of edema
❑ Women are more prone to thrombophlebitis
post-partum related to hypercoagulability of
the blood caused by:
--pregnancy( hormonal changes)
--anemia
--pelvic infection
Most commonly performed with the woman in a
supine position while laying in bed
The calf is flexed at a 90° angle
The nurse manipulates the foot in a
dorsiflexion movement
If pain is felt in the calf, the Homan’s Sign is said to
be positive.
•  A sudden and unexplainable pain, usually
in the back of the leg or calf
• Tachycardia and shortness of breath or
dyspnea (from decreased oxygenation
status)
• Edema, redness, and warmth localized
over the area of the DVT (from the vascular
buildup around the clot)
 Dangle at the side of the bed within 6 hours
Stand up within 8 hours
Encourage ambulation at first and
independent walking when ready
 Pulmonary embolism (PE) occurs when a clot
breaks way from the leg area and travels to the
lungs.
A PE is a medical emergency!
Emotional Status and Bonding Patterns
Fluctuations in estrogen levels are blamed for the
emotional roller-coaster that many moms
experience after birth.
High levels of stress, increased responsibility,
and sleep deprivation exacerbate this
Bonding refers to the interactions between the
mother and baby
Care giving of self and baby is an indicator of
emotional status
3 Normal Phases
1. “Taking In” --immediately after delivery till up to 2d PP
--need rest and sleep
--self-focus
--relives events of Labor and Delivery
2. “Taking Hold”-preoccupied with the present
--usually encompasses days 2 - 5 postpartum
--interested in self-care
--optimal time for teaching
--focus on caring for baby
3. “Letting Go”--reestablishes relationships with others with
outward focus
 POSTPARTUM BLUES: Usually occurs within 2-3
weeks. Mamma may be sensitive, such as crying
during a commercial, mamma may view it as
humorous in hindsight.
 POSTPARTUM DEPRESSION (PPD): When the
blues moves to the pointwhere momma can’t care for
herself or the baby.
 POSTPARTUM PSYCHOSIS: A severe form of
depression that warrants immediateintervention.
When mamma harms herself or the neonate or
considers doing so. Typically is predicated by
depressive episodes.
•  The patient should fill out a form to assess emotional
risks. The form will ask if the patient has a history of
PPD or depression not associated with pregnancy.
•  There’s always a social worker available in the event
that the patient is acting strangely. The nurse may need
to fill out a document such as a Risk Assessment Form