Name: Laron, Czarina Joy A.

Program/Year/Sec: BSN II – OCTAVIANO

ACTIVITY

Joan is a 26-year-old woman who teaches chemistry at a local university. You enter her room 2 hours
after she gave birth to a 6.5-lb girl and find her just finishing breastfeeding. Her face appears
abnormally pale. You obtain her vital signs and document her pulse as 90 beats/min and her blood
pressure as 90/50 mmHg. When you fold back her bedclothes, you discover her perineal pad is
saturated. The capillary refill in her fingers is sluggish. You suspect she is experiencing one of the
most serious complications of pregnancy: postpartum hemorrhage.

Do postpartum assessment following BUBBLEHE.

Discuss the following conditions that place the postpartum woman at risk.

BUBBBLE-HE ASSESSMENT:
B – Breast
Breast Assessment
 Assessment include evaluating the breast in the postpartum period

 The first step is to determine if the new mamma is breastfeeding or bottle-feeding: This will guide the
assessment along with patient education

Breast Evaluation

 Size  Firmness  Symmetry

 Shape  Redness
 U – Uterus
Uterine Assessment

1. Fundus : firm or boggy- make a “C-shape” with your hand and push up on the lower fundus; if it’s not
stabilized, the uterus can prolapse, or fall into the vagina. Massage of not firm- secure lower uterine
segment. The concern is for hemorrhage; the primary causes are a distended bladder (uterus can’t
contract or uterine atony, or failure to contract fully) and retrained placental fragments (usually a later
cause)
2. Fundal Height : where is it in relation to the umbilicus? “U/U” or “At the U” (1/U = 1 cm above the
umbilicus) - drops one centimeter or finger width. The position drops one centimeter every 24 hours for
10 days postpartum
3. Midline or Deviated to the Left or Right : if deviated, it’s usually a sign of a full bladder
Uterine afterpains of a breastfeeding mom get worse with each pregnancy. The uterus is a muscle and
the more it is stretched, the more force is needed in order to contract.

B – Bladder

Bladder Assessment
 Ask mom when she last voided

 Establish a Voiding Schedule to prevent bladder distension and urinary stasis

 Encourage mom to urinate every time before she feed baby (as they may fall asleep)

Possible Obstacles to Voiding

 Mom may become so engrossed with baby that she forgets to void

 Internal inflammation from labor trauma may impair ability to void

 Mom may hesitate to void from fear of pain, especially if she has an episiotomy or vaginal tearing

 C-section patients may also have issue with voiding following removal of the folly
B – Bowels

Bowels Assessment
 Bowels in shock- just moved into some strange positions.

 Take a stool softener- don’t want ripping or the episiotomy or trauma to the C-section incision

L – Lochia

Lochia Assessment

 Assess the color, odor, and amount

 The lochia color should forward in the progression of lightness, never go backwards

Lochia Color

 Lochia Rubra: bright red, may have small clots, usually lasts 3 days

 Lochia Serosa: pink, serous, other tissues

 Lochia Alba: tissue, whitish

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”

 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 know that business down there is not as usual

E – Episiotomy & Perineum

Episiotomy Assessment
R – Redness
E – Edema
E – Ecchymosis
D – Discharge
A – Approximation

Perineal Assessment
 Pull the labia from front to back
 Check the episiotomy or areas of vaginal tearing
 Look for hematoma formation – a collection of blood in between tissue
 Look for hemorrhoids (developed during pregnancy or during labor from the pushing
process).

H – Homan’s Sign

Assess for Signs of DVT 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 mom underwent a C-section, and it’s easy to see why the
postpartum woman is at such a huge risk for DVT!

E – Emotional Status

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 mamma and baby

 Caregiving of self and baby is an indicator of emotional status

Common Postpartum Assessment Findings

 The Taking in Phase. May be considered as a self-focused, re-lived experience. This is different from the
maladaptive

 Taking Hold Phase. A little bit about the mamma, a little about the baby. The world appears to be
revolved around the baby and mamma as a unit

 Letting-In Phase. Mamma allows other people in

Comparing Blues, Depression, and Psychosis

 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 point where momma can’t care for herself
or the baby

 Postpartum Psychosis. A severe form of depression that warrants immediate intervention. When
mamma harms herself or the neonate or considers doing so. Typically is predicated by depressive episodes

Give the following:

a. Cause
 The cause of postpartal hemorrhage can be remembered easily by using the mnemonic 4T’s

Tone- refers to the failure of the uterine myometrial muscle fibers to contract and retract
 Overdistention -Macrosomnia, hydramnios, multiple pregnancy
 Fatigue- prolonged labor, precipitate labor,oxytocic drugs
 Infection-chorioamnionitis, endomyometritis, septicemia
 Uterine structural abnormality
 Hypoxia due to hypoperfusion or Couvelaire uterus
 Placental site in the lower uterine segment
 Distention with blood before or after placental delivery
 Inhibition of contractions by drugs- anesthetic agents, nitrates, NSAIDS, Mg S04, nifedipine,
beta- symptomimetics

Tissue- Presence of retained placental tissues prevents full uterine contractions resulting in failure to
seal off bleeding vessels Preterm gestation especially in lessthan 24 weeksgestation
 Abnormal adhesions such as accreta, increta and percreta
 Site stop the oozing of blood vessels of the uterus

Trauma- 20% of postpartum hemorrhage is due to trauma anywhere in the genital tract
 Lacerations and episiotomy
 Hematoma
 CS
 Uterine rupture and uterine inversion
  Uterine perforation during forceps application or curettage

Thrombosis – clot formation and fibrin deposition on the placental

 Disorders of the coagulation system and platelets, whether preexistent or acquired can result in
bleeding or aggravate bleeding.
 Acquired disorders - HELLP syndrome, DIC
 Preexistent coagulation disorder thrombocytopenic purpura

b. Therapeutic Management

Healthcare providers treat PPH as an emergency in most cases. Stopping the source of the bleeding as fast
as possible and replacing blood volume are the goals of treating postpartum hemorrhage.

Some of the treatments used are:

 Uterine massage to help the muscles of your uterus contract.

 Medication to stimulate contractions.
 Removing retained placental tissue from your uterus.
 Repairing vaginal, cervical and uterine tears or lacerations.
 Packing your uterus with sterile gauze or tying off the blood vessels.
 Using a catheter or balloon to help put pressure on your uterine walls.
 Uterine artery embolization.
 Blood transfusion.

In rare cases, or when other methods fail, your healthcare provider may perform a laparotomy or
a hysterectomy. A laparotomy is when your surgeon makes an incision in your abdomen to locate the
source of bleeding.

You may be given medications to help induce contractions if uterine atony is the cause of the bleeding.
The most common drugs used are oxytocin, methylergonovine or prostaglandins like carboprost
or misoprostol.
c. Nursing Assessment
 Assess the amount of bleeding.
 Assess maternal vital signs to establish baseline data.
 Assess for signs of shock.
 Assess the condition of the uterus.

Conditions:
1. Postpartum Hemorrhage
Occurs when a woman loses more than 500 mL of blood in a normal delivery and more than
1000mL of blood in a cesarean delivery within 24 hours.
Early Post-partum hemorrhage – occurs during the first 24 hrs after delivery.
Causes of early postpartum hemorrhage
 Uterine Atony – uterus is not well contracted, relaxed or boggy most frequent cause)
 Lacerations of birth canal
 Inversionof the uterus
 Hypofibrinogenemia
 Clotting defect
Late Postpartum Hemorrhage- Occurs from 24 hours after birth to 4 weeks postpartum.
Causes of late postpartal hemorrhage
 Retained Placental Fragments
 Subinvolution of the uterus
 Infection

2. Uterine Atony
 Failure of the uterus to contract continuously after delivery.
 It is the most common cause of Post partal hemorrhage and often occurs following
delivery of the baby and up to 24 hours after the delivery of the placenta.,
 Relaxation of the uterus
 Causes:
 Overdistention : hydramnios, multiple pregnancy, macrosomia
 Complication of labor- Precipitate, prolonged labor
 Uterine relaxing agents: anesthesia, analgesia, terbutaline, magnesium sulfate,
nitroglycerine  Oxytocin given during labor
 High parity and advanced maternal age
 Infection: amnionitis and chorioamnionitis
 Presence of fibroid tumors that interfere with uterine contractions
 Over massage of the uterus that results in very strong uterine contractions and eventual
fatigue
 Retained placental fragments
 Prolonged third stage of labor

3. Lacerations:
Can involve the uterus, cervix, vagina, or vulva. They usually result from precipitous or
uncontrolled delivery or operative delivery of a large infant; however, they may occur after any
delivery. Laceration of blood vessels underneath the vaginal or vulvar epithelium results in
hematomas.

a. Cervical
Are a known cause of postpartum hemorrhage. However, there is little information
about its exact incidence. Hence our goal was to calculate the incidence of cervical
lacerations and determine associated risk factors.

b. Vaginal
Laceration of blood vessels underneath the vaginal or vulvar epithelium results in
hematomas.

c. Perineal
This is a tear in the tissue (skin and muscle) around your vagina and perineum.
The perineal area (also called the perineum) is the space between the vaginal
 opening and your anus. During a typical vaginal delivery, the skin of your vagina
prepares for childbirth by thinning out.

4. Retain Placental Fragments

Are most often clinically manifested as delayed postpartum hemorrhage, or prolonged
postpartum spotting. This is a rare complication of labor, yet can potentially cause severe
morbidity and discomfort. The incidence of the retained placenta has increased during the last
few decades due to a corresponding increase in cesarean deliveries and other risk factors in the
placenta accrete spectrum. Retained placenta can cause postpartum hemorrhage, which can be
fatal.

5. Uterine Inversion
Uterine inversion means the placenta fails to detach from the uterine wall, and pulls the uterus
inside-out as it exits. Treatment options depend on the severity, but could include reinserting the
uterus by hand, abdominal surgery or emergency hysterectomy. Excessive umbilical cord traction
with a fundal attachment of the placenta and fundal pressure in the setting of a relaxed uterus
are the 2 most common proposed etiologies for uterine inversion.

6. Disseminated Intravascular Coagulation

Is a leading cause for maternal mortality across the globe, often secondary to underlying maternal
and/or fetal complications including placental abruption, amniotic fluid embolism, HELLP
syndrome (hemolysis, elevated liver enzymes and low platelets), retained stillbirth and acute fatty
liver of pregnancy.

Symptoms

 Bleeding, from many sites in the body.

 Blood clots.
 Bruising.
 Drop in blood pressure.
 Shortness of breath.
 Confusion, memory loss or change of behavior.
 Fever
7. Subinvolution
Is a rare but severe cause of secondary postpartum haemorrhage (PPH). SPS is characterised by
the abnormal persistence of large, dilated, superficially modified spiral arteries in the absence of
retained products of conception.

Assessment Findings

 Prolonged lochial discharge.

 Irregular or excessive bleeding.
 Larger than normal uterus.
 Boggy uterus (occasionally)

8. Vulvar Hematomas
Are rare events. They result from injury to blood vessels in the absence of laceration or incision
of the surrounding tissue (such as pseudoaneurysm and traumatic arteriovenous fistula. Pain is
the most common symptom of a vulvar hematoma. Patients can describe it as perineal,
abdominal, or buttock pain. The intensity of the pain can be severe enough to interfere with
mobility. There may also be intermittent bleeding.

9. Puerperal Infections
Is a reproductive tract infection occurring within 28 days following childbirth or abortion. It is one
of the major causes of maternal death (ranking second behind postpartum hemorrhage). The
majority of postpartum infections result from physiologic and iatrogenic trauma to the abdominal
wall and reproductive, genital, and urinary tracts that occur during childbirth or abortion, which
allows for the introduction of bacteria into these normally sterile environments.

The puerperal sepsis/pyrexia presents commonly with fever and other symptoms like :
 Pelvic pain
 Foul smelling vaginal discharge
 Delayed reduction of the uterine size.
10. Endometritis
- An infection of the endometrium, the lining of the uterus.
- Bacteria gain access through the vagina and enter the uterus at the time of birth or during the
postpartal period.

Assessment
 Temperature elevation on the third and 4th postpartal day occurs at the same time
during breast filling
 Increase WBC 20,000-30,000cells.mm3 (NORMAL)
 Chills
 Loss of appetite
 General malaise
 Uterus not well contracted and painful to touch
 Strong afterpains
 Lochia is dark brown, foul odor
 If accompanied with high fever - lochia may be scant or absent
 Placental fragments confirmed by UTZ

11. Infection of the Perineum

 Reproductive tract infection developing after delivery
 May spread to the peritoneum (peritonitis) or the circulatory system (septicemia)
Assessment
 Pain
 Fever
 Edema
 Redness
 Firmness
 Tenderness
 Burning on urination
 Wound discharge
  Temperature >100.4 (38C) after 1st 24 hours on any of the first 10 postpartum days.

12. Peritonitis
Complications of the delivery, including prolonged labor, need for operative vaginal delivery,
unplanned cesarean section, and postpartum hemorrhage.

Risk factors for postpartum endometritis include:

 Cesarean delivery (most important risk factor)

 Infections/bacterial colonization present during labor and delivery, including intrapartum
intraamniotic infection (also known as chorioamnionitis), bacterial vaginosis, Group B
streptococcus (GBS), and STIs.

13. Thrombophlebitis:
- Infection of the lining of the vein with formation of thrombi (thrombo for the presence of clots
and phlebitis meaning inflammation of the lining of blood vessels.

a. Femoral Thrombophlebitis
 Infection of the veins of the legs femoral, popliteal vein

b. Septic Pelvic Thrombophlebitis

 is an inflammatory process that, in conjunction with the physiological conditions
of postpartum and proximity with potentially infected tissues (e.g. endometrium,
chorion, amniotic fluid), leads to the formation of a clot blocking the ovarian vein.

14. Pulmonary Embolus

The main cause in most cases of postpartum pulmonary embolism is a blood clot that has formed
in a deep vein, also known as a venous thrombosis, a blood clot. This clot travels through the
bloodstream and becomes trapped in one of the blood vessels in the lungs. Fatal pulmonary
embolism might be caused by ovarian vein thrombosis during cesarean section. Careful and
continuous observation of the patient after delivery and prompt treatment are important.
15. Mastitis
Mastitis is an inflammation of the mammary gland in the breast and is typically due to bacterial
infection. Mastitis may predispose to breast abscess.

16. Urinary System Disorders:

a. Urinary Retention
is a common consequence of bladder dysfunction after vaginal delivery. Patients with covert PUR
are able to void spontaneously but have a postvoid residual bladder volume (PVRV) of ≥150 mL.
Incomplete bladder emptying may predispose to bladder dysfunction at a later stage of life.
Because of physiological changes during pregnancy, the bladder is hypotonic with an increased
post-void residual volume. The occurrence of a perineal neuropathy during delivery may cause a
urinary retention. Risk factors are primiparity, prolonged labour, instrumental delivery and
perineal lacerations.

b. Urinary Tract Infections

Is a common postpartum infection occurring in 2%–4% of all deliveries. Although postpartum UTI
is usually a mild infection, it is associated with discomfort, prolonged hospital stay and
readmission and has been associated with an increased risk of discontinued breast feeding.
Postpartum UTIs are simply urinary tract infections that take place in the days or weeks after
giving birth. Most often, they're the result of having received a catheter, which can introduce
bacteria into the urinary tract that then lead to an infection.

17. Cardiovascular System Disorders:

a. Postpartum Preeclampsia
Is a condition that can happen up to six weeks after your baby is born. This rare condition causes
a person to have high blood pressure and high levels of protein in their urine. This is a serious
condition that can lead to brain damage, stroke and death if not treated. Having uncontrolled
high blood pressure before pregnancy increases your risk of preeclampsia and postpartum
preeclampsia. Diabetes. Having type 1 or type 2 diabetes or gestational diabetes increases your
risk of preeclampsia and postpartum preeclampsia.
18. Reproductive System Disorders:

a. Separation of the Symphysis Pubis

is defined as separation of the pubic symphysis without a fracture after delivery. Although it is an
uncommon peripartum complication, it can lead to various problems such as pain, difficulty in
ambulation, and urinary dysfunction. With a separation or diastasis, the pubic joint dislocates
without a fracture.
The causes of this separation can be due to the:
 pressure and hormonal changes of pregnancy
 trauma from childbirth, falls, motor vehicle accidents
 sports injuries, or horseback riding incidents.

19. Emotional and Psychological Complications of the Puerperium:

a. Postpartum Depression
Is a major maternal health problem affecting 10–15% of women and birthing people after giving
birth. Known risk factors for PPD include a history of depression or anxiety , relationship
dissatisfaction , exposure to domestic violence, lack of social support , stressful life events,
maternal isolation , negative attitudes toward pregnancy , adverse neonatal outcomes such as
preterm birth, small-for-gestational-age, low Apgar score and a major fetal congenital anomaly.
Less clear is whether women who experience postpartum hemorrhage (PPH), a leading cause of
maternal morbidity and mortality globally, are at an increased risk of PPD.

b. Postpartum Psychosis

Is a reversible — but severe — mental health condition that affects people after they give birth.
This condition is rare, but it’s also dangerous. Postpartum psychosis can affect anyone who
recently gave birth. While it usually happens within several days of giving birth, it can happen up
to six weeks after. It can happen to anyone who gives birth, but the odds of having it are higher
for people with certain mental health conditions. While experts don’t know if these conditions
contribute to or cause PPP, they do know that there’s a link (see below under Causes and
Symptoms for more about these conditions).
The two main symptoms of psychosis affect a person’s sense of reality and how they understand
the world around them. They are:

 Hallucinations. A hallucination is when your brain acts as if it’s getting input from your senses
(usually your eyes or ears, but occasionally touch hallucinations can happen, too), but without any
actual input. The things you see or hear feel real, and you can’t tell the difference between a
hallucination and something that’s truly happening.
 Delusions. Delusions are false beliefs that you hold onto very strongly. If you have a delusion, you
hold these beliefs so strongly that you won’t change them even if you have convincing evidence
that what you believe isn’t true. Examples include persecutory delusions (believing someone is
out to get you), control delusions (feeling that someone else is controlling your body) or somatic
delusions (insisting you didn’t have a child or weren’t pregnant).

Other symptoms that are common with postpartum psychosis include:

 Mood changes, such as mania (an increase in activity and mood) and hypomania, or depression
(a decrease in mood).
 Depersonalization (some people describe this as an out-of-body experience).
 Disorganized thinking or behavior.
 Insomnia.
 Irritability or agitation.
 Thoughts of self-harm or harming others (especially their newborn).