NCM 107 MATERNITY RLE ABNORMAL FINDINGS

NURSING CARE OF WOMAN DURING THE - Redness, warmth, painful lump or on entire breast indicate
FIRST 24 HOURS AFTER BIRTH abscess or mastitis.
- A bloody discharge or milk discharge occur without
POSTPARTAL PERIOD (PUERPERIUM) stimulation
- The postpartum (or postnatal) period begins immediately
after childbirth as the mother's body, including hormone 2. ABDOMEN EXAMINATION
levels and uterus size, returns to a non-pregnant state. Inspection
- inspect the
- The terms puerperium, puerperal period, or immediate o shape, size, movement of abdomen with
postpartum period are commonly used to refer to the first six respiration, scarred gravid, linea nigra, caesarean
weeks following childbirth. section, old and new incision on the abdomen.
o Caesarean process, section discharge, incision
COMPONENTS OF POSTNATAL EXAMINATION redness sites and healing signs of infections
“BUBBLE HE” - Scarred gravida- striae
B-breast - Linea nigra- dark line that develops on your stomach during
U- uterus pregnancy
B- bladder
B-bowel Palpation
L- lochia - Palpate Fundus
E- episiotomy o Palpate funds for consistency and location.
H- homan’s sign o It should be firmly contracted and at or near the
E- emotional status level of the umbilicus.
- Place mother in a supine position with her knees slightly
POSTPARTUM ASSESSMENT flexed
1. BREAST EXAMINATION - Put on clean gloves and lower perineal pads to observe
lochia as the fundus is palpated.
- Place non-dominant hand above mother's symphysis pubis.
This supports and anchors the lower uterine segment during
palpation or massage of the fundus.
- If uterus is above the expected level or shifted from the
middle of the abdomen (usually to the right), the bladder
Inspection
may be distended.
- Inspect breasts for. - The location of funds should be rechecked after emptying
o Size, asymmetry bladder.
o Contour - If fundus is difficult to locate or is soft or boggy, keep non
o Erythema dominant hand above symphysis pubis and massage funds
o Engorgement with dominant hand until fundus is firm
o Note any abnormalities.
- Inspect nipples for.
o Cracks
o Redness
o Lesions
o Sores, rashes
o Fissures or bleeding
- After boggy fundus is massaged until it is firm, press firmly
o Erect, flat or inverted
to expel clots.
o Do not attempt to expel clots before the fundus is
NORMAL BREAST
firm.
- One breast is slightly larger than other
o Keep one hand pressed just above the
- If breastfeeding, breasts look lumpy or irregular than usual.
symphysis (over the lower uterine segment)
- Veins larger and darker, more visible beneath the skin.
throughout.
- Regular with no dimpling, no visible lumps, skin is smooth
o Removing clots allows the uterus to contract
with no puckering, no redness. No lesion sores or rashes.
properly
- Tenderness and lumpiness in both breasts during the
o A firm fundus and pressure over the lower uterine
menstrual cycle.
segment help
- Areolas larger and darker.
- Measure fundus height in centimeters or use fingers
breaths.
 o Generally fundal height decreases about 1cm per Lochia Type and Color
day for first 9-10 days post-partum 1. Lochia Rubra
- Document the consistency and location of the fundus o Bright red,
o have small clots
- Consistency is recorded as "fundus firm", "firm with o Usually, last first 3 days
massage", or "boggy"
o Fundus height is recorded in finger breaths or 2. Lochia Serosa
centimeters above or below the umbilicus. o Pink
- For example, "fundus firm, midline, L1" (one finger breath or o contain more serum, leukocytes, and bacteria
1 cm below the umbilicus) o Discharge usually during 4th to 7th day.
- "Fundus firm with light massage, U+2 (two finger breaths or
2 cm above the umbilicus), displaced to right" 3. Lochia alba
o White in color, creamy brown.
o Contains leucocytes, cervical mucus, serous
exudates, granular epithelial cells, cholesterol
crystal, debris from healing tissue.
o Usually discharge
o Up to 10-15 days.

- If lochia is foul smelling, lochia rubra persists for 2 weeks or

more need more additional assessment.

Lochia amount
3. BLADDER EXAMINATION - The average amount of discharge for the first 5-6 days is
- Ask to pass urine frequently the first few days. estimated to be 250 ml.
- Normal if bladder is not palpable. - Scant
- Women is able to urinate when the urge is felt. o 5cm saturation of pad in one hour =10 ml.
- Monitor clients for signs of UTI, including fever, urinary - Light
frequency and/or urgency, difficult or painful urination. o 10 cm saturation of pad within 1 hour =10 to 25ml
- Infrequent or insufficient voiding (less than 200 ml)
discomfort, burning urgency, or foul-smelling urine suggest - Moderate
infection o Moderate; 15cm saturation with in 1 hour =25 to
50 ml.
4. BOWEL EXAMINATION - Heavy
- Inspect the o Heavy; pad is completely saturated within 1 hour
o woman's abdomen for distention, auscultation for =50 to 80 ml.
bowel sounds in all four quadrants prior to - PPH
palpating the uterine fundus and palpate for o Postpartum hemorrhage is clinically defined as a
tenderness. pad saturated within 15-30 minutes.
o Ask the patient about daily or has passed gas
since giving birth. During examination, the quantity, color, odor and consistency of
o She must no become constipated. lochia are significant.
o Explain that she should wipe from front to back
after voiding or defecating. A. Persistence of red lochia
o Normal sounds, assessment findings passing o Indicates secondary postpartum hemorrhage.
gas, and are an active bowel non-distended
abdomen B. Brown profuse lochia with bulky uterus
o sub-involution of the uterus
5. LOCHIA EXAMINATION
- Check and note color, order, and amount of lochia C. Excessive lochia
- To assess amount ask her how many perineal pads she has o retained product of conception.
used in the past 1 to 2 hours and how much drainage was
on each pad. (Pad completely, or was only half of pad D. Scanty lochia
covered with drainage) o indicate poor drainage.
- Ask about color of drainage, odor, and presence any clots.
- Lochia increases with maternal activity and breastfeeding E. When associated with pyrexia
which is normal. o they are due to localized uterine infection.
6. EPISIOTOMY AND PERINEUM EXAMINATION 9. EMOTIONAL STATUS
- Examine episiotomy and perineum area through REEDA - After delivery the woman may progress through Rubin's
- Assessment stages of taking in, taking hold & letting go phases.
o R-Redness
o E-Edema 1. Taking in Phase
o E-Ecchymosis o May Begin with a refreshing sleep after delivery.
o D-Discharge o During first 24 to 48 hours after giving birth,
o A-Approximation mother exhibits passive, dependent behavior.
o New mothers spend time touching baby
Redness commonly identifying specific features in
- infection or hematoma. newborn such as " he has my nose" or his fingers
Ecchymosis (excessive bruising) are long like his father's.
- vaginal trauma and requires additional evaluation.
Discharge 2. Taking hold Phase
- should follow the expected lochia pattern. o Starts on 2nd to 3rd day postpartum and may last
Approximation several weeks.
- episiotomy lines should be well approximated. o Woman begins to initiate action and to function
more independently but still show dependent
behaviors.
o Woman may require more explanation and
reassurance that she is functioning well,
especially in caring for her infant.
o As the woman meets success in caring for the
newborn, her concern extends to other family
members and their activities.

3. Letting go Phase
o It begins near end of 1st weeks.
7. PERINEUM o Mother reestablishes relationships with couple
- Pull the labia from front to back. and other people.
- Check the episiotomy or areas of vaginal tearing. o She assumes responsibility and care for newborn
- Look for hematoma formation, hemorrhoids, vaginitis, independently.
perineal tearing.
HEALTH TEACHING
- Health teaching should be given as per need identification of
mother.

PERILIGHT EXPOSURE
- ls the application of dry heat to the perennial area to provide
comfort
- it increases blood circulation and hasten healing

IMPORTANCE OF PERLIGHT EXPOSURE

- Relief pain and muscular spasm
8. HOMAN'S SIGN - Provides comfort by relief of pain
- Complain of pain in calf of the leg upon dorsi-flexion of foot - It relaxes muscle and capillaries making pain less tolerable
with leg extended is diagnostic of - Increases blood circulation
- Deep Vein Thrombosis (DVT) of the area. a positive - Hasten wound healing following episiotomy repair
Homan's sign is indicative of DVT. - Reduces soreness and swelling
- Homans ‘sign or the dorsiflexion sign

- (Deep vein thrombosis) INDICATIONS

- Passive - Those who have undergone rectal or perennial surgery
- Supine - Postpartum women who undergone episiotomy
- Dorsiflex the foot and squeeze the calf - Patient having vaginal inflammation and bladder spasm
- (+): 1 pain at the posterior leg or calf thrombophlebitis - Patient with painful or local irritation from hemorrhoids
PROVIDE PAIN RELIEF FOR AFTERPAINS
- Pain from uterine contractions can be intense, but you can
assure a woman that this type of discomfort is normal and
rarely lasts longer than 3 days.
- If necessary, either ibuprofen (such as Motrin), which has
anti-inflammatory properties, or a common analgesic such
as acetaminophen (such as Tylenol) is effective for pain
relief.
- As with any abdominal pain, heat to the abdomen should be
avoided, because it could cause relaxation of the uterus and
subsequent uterine bleeding.
RELIEVE MUSCULAR ACHES
- Many women feel sore and aching after labor and birth
because of the excessive energy they used for pushing
during the pelvic division of labor.
- They describe feeling as if they have "run for miles." A
woman may need a mild analgesic such as acetaminophen
for the pain.
- A backrub is effective for relieving an aching back or
shoulders.
- Carefully assess a woman who states that she has pain on
standing.
- Pain in the calf of the leg on standing (a position that
dorsiflexes the foot) is a sign similar to Homans' sign
suggesting thrombophlebitis may be present
ADMINISTER COLD AND HOT THERAPY
- Applying an ice or cold pack to the perineum during the first
24 hours reduces perineal edema and the possibility of
hematoma formation, thereby reducing pain and promoting
healing and comfort.
- Be certain not to place ice or plastic directly on the woman's
perineum.
- Wrap an ice bag first in a towel or disposable pad, to
decrease the chance of a thermal burn (risk of injury
increases because the perineum has decreased sensation
from edema after birth)
- Ice to the perineum after the first 24 hours is no longer
therapeutic.
- After this time, healing increases best if circulation to the
area is encouraged by the use of heat.
- Dry heat in the form of a perineal hot pack or moist heat with
a sitz bath is an effective way to increase circulation to the
perineum, provide comfort, reduce edema, and promote
healing
PROMOTE PERINEAL EXERCISES
- Some women find that carrying out perineal exercises three-
or four-times a day can greatly relieve perineal edema.
- The exercise consists of contracting and relaxing the
muscles of the perineum 5 to 10 times in succession, as if
trying to stop voiding (Kegel exercises).
- This aids comfort by improving circulation to the area and
decreasing edema.
- When repeated frequently, Kegel exercises also help a
woman regain her prepregnant muscle tone and help
prevent urinary incontinence
GIVE EPISIOTOMY CARE
- Although relatively small in size, episiotomy sutures can
cause considerable discomfort, because the perineum is an
extremely tender area and the muscles of the perineum are
involved in so many activities such as sitting, walking,
stooping, squatting, bending, urinating, and defecating.
- Because the perineal area heals rapidly, you can assure a
woman that this discomfort is normal and does not usually
last longer than 5 or 6 days. Explain that these sutures are
made of an absorbable material so will not need to be
removed. Sutures usually dissolve within 10 days.
ADMINISTER SITZ BATHS
- A sitz bath is a portable basin that fits on a toilet seat.
- A reservoir filled with water provides a constant supply of
swirling water to the basin.
- The movement of water soothes healing tissue, decreases
inflammation by causing vasodilation in the area, and
thereby effectively reduces discomfort and promotes healing
- Sitz baths usually use water that is maintained at 100° to
105° F (38° to 41° C). Be certain that the water in a sitz
bath is not too hot before you help a woman to use it; it
should feel pleasantly warm, not hot.
- The woman may not be sensitive to the temperature herself,
because healing surfaces are not good indicators of
temperature.
- This caution applies particularly to a woman who is using an
analgesic cream or spray on her perineum or who has a
great deal of generalized perineal edema. Both situations
make her prone to burns from scalding water unless you act
to protect her.
- Women should use a sitz bath three to four times a day for a
maximum of 20 minutes each time.
- Because of the soothing effect of the warm water and the
sitting position, alert a woman that she may feel extremely
tired and unsteady on her feet after using a sitz bath and
may need help in getting back to bed.
SITZ BATH
- Purpose:
o To aid healing of the perineum through
application of moist heat
- Procedure
1. Wash your hands; identify client and explain
procedure.
o Principle: Handwashing prevents the spread of
infection; identification ensures that procedure is
performed on correct client, thereby promoting
safety; explanation assists in alleviating any
anxiety.
2. Assess client's condition; ascertain whether
client is able to ambulate as necessary
o Principle: A sitz bath can make a woman feel
lightheaded, increasing her risk of injury. Fatigue
and exhaustion may interfere with client's ability
to ambulate or tolerate procedure, also
increasing her risk for injury.
3. Assemble equipment, including sitz bath, clean
towel, perineal pad.
o Principle: Organization of equipment increases
efficiency of the procedure
4. Place sitz bath on toilet seat. Fill collecting bag
with warm water at a temperature of 100° F to
105° F (38° C to 41° C). Hang the bag overhead
so a steady stream of water will flow from the
bag, through the tubing, and into the basin
o Principle: Using correct temperature of water
(pleasantly warm) eliminates risk of thermal
injury. Adequate flow of warm water increases
circulation to the perineum, thereby reducing
inflammation and aiding healing.
8. Assist client with ambulating back to room
o Principle: Client may become fatigued from the
procedure or lightheaded from the warm water,
increasing her risk of falling
9. Evaluate client's tolerance and response to
procedure; ask client to report how she feels.
Institute health teaching, such as continuing sitz
baths when at home.
o Principle: Evaluation assists with determining
effectiveness of procedure and making any
changes. Health teaching helps to promote
continuity of care after discharge.
10. Record completion of procedure, condition of
perineum, and client's condition and response.
o Principle: Documentation provides additional
means for evaluation of care and client
outcomes.

5. Assist client with ambulating to bathroom; help

with removal of perineal pad from front to back.
Assist client to sit in basin.

o Principle: Assisting ambulation minimizes risk of

injury. Removing pad from front to back
minimizes risk of infection transmission. Proper
placement ensures effectiveness of treatment.

6. Instruct client to use clamp on tubing to regulate

water flow; use robe or blankets to prevent
chilling and provide for privacy. Have call bell
within reach

o Principle: Continuous swirling water aids in

reducing edema and promoting comfort. Privacy
enhances self-esteem. Quick, easy access to call
bell allows for prompt intervention should
problems arise

7. After 20 minutes, assist client with drying

perineum and applying clean pad (holding pad
by the bottom side or ends)

o Principle: After 20 minutes, heat is no longer

therapeutic because vasoconstriction occurs.
Proper handling of pad prevents contamination
and possible risk of infection.