Assessment: Postpartum Patients (Maternal-Newborn) - CE
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Assessment: Postpartum Patients (Maternal-Newborn) - CE
ALERT
Patients are susceptible to postpartum hemorrhage and infection for several days after giving birth.
Accurately assess normal involution and estimated blood loss because symptoms of shock may not appear until the patient has lost a significant amount of her total blood volume. Preparation and resources to manage maternal hemorrhage in a timely manner can be lifesaving.
Prevent postpartum infections with adequate patient care techniques, hand hygiene, and the appropriate use of antibiotic therapy.
OVERVIEW
The postpartum period begins with the expulsion of the placenta and continues until the maternal reproductive organs have returned to their normal, nonpregnant state. This period varies for each patient as the maternal systems continue to change during the first 6 weeks after birth.undefined#ref1">1 During the postpartum period, the uterus undergoes involution and other maternal reproductive organs return to their nonpregnant state. In addition, the breasts and the cardiovascular, respiratory, endocrine, urinary, gastrointestinal, integumentary, musculoskeletal, neurologic, and immune systems also must go through multiple changes.1
Monitoring during the postpartum period should be dictated by the type of events during delivery, the type of anesthesia or analgesia used, and any complications identified.3 Nursing assessment helps detect problems early in order to initiate interventions in a timely manner and thus prevent serious complications. The nurse incorporates education into assessments, instructing the patient and her support person about what to expect during the postpartum period and what to report to her practitioner once she goes home.2
Along with all the physiologic changes in the postpartum period, the patient and her support person are also undergoing psychosocial changes as they adapt to the newborn. This bonding and integration process is essential to a positive outcome for the postpartum period. The nurse is also responsible for performing psychosocial assessments based on skillful observation and interviewing at regular intervals throughout the inpatient stay.11
Maternal assessments related to the prevention of hemorrhage include vital signs, uterine fundal location and tone, bladder, lochia, and perineal and labial areas.13 The maternal temperature should be assessed at the beginning of the immediate postpartum period and blood pressure, pulse, and respirations should be assessed every 15 minutes for approximately 2 hours after the birth.3,13 Assessment of the uterine fundus and lochia should be performed with each vital sign assessment.13 Ongoing postpartum assessments (Table 1) should be performed at least once per shift, and more frequently if complications are encountered, according to the organization’s practice. Periodic assessments should be completed to detect deviations from normal, determine the level of patient discomfort, ensure patient safety, assess the transition to parenting, and provide appropriate patient and support person education.
All postpartum units should have standardized postpartum hemorrhage medication procedures. Additionally, practitioners should stay up-to-date regarding the use of uterotonic agents. Uterotonic medications such as oxytocin, methylergonovine, misoprostol, and carboprost should be readily available for a postpartum hemorrhage emergency. All postpartum units should be equipped with a cart or kit to be used in a postpartum hemorrhage emergency. A cart would include all instruments needed to treat a postpartum hemorrhage before a hysterectomy is considered.6
PATIENT AND SUPPORT PERSON EDUCATION
Instruct the patient and support person regarding assessments, procedures, and their purposes.
Instruct the patient and support person regarding normal findings as well as signs and symptoms to report to the nurse or practitioner, including:8
Fever
Localized areas of redness, swelling, or pain in either breast
Persistent abdominal tenderness
Feelings of pelvic fullness or pelvic pressure
Persistent perineal pain
Urinary frequency, urgency, or burning
Abnormal change in the character of lochia (foul odor, heavy bleeding, reappearance of bright red lochia, or large clots)
Localized tenderness, redness, swelling, or warmth of the legs
Swelling, redness, drainage from, or separation of, an abdominal incision
Instruct the patient regarding the initiation of self-care measures:
Breasts
Instruct regarding breastfeeding, if indicated.
Instruct a patient who will be breastfeeding to wear a comfortable supportive nursing bra without an underwire.
Instruct a patient who will not be breastfeeding to avoid stimulation of the breasts, including running warm water over them, newborn suckling, or pumping the breasts, and to wear a well-fitted support bra.
Instruct regarding potential complications.
Instruct regarding breast self-examinations.
Uterus
Instruct regarding uterine palpation and massage if needed.
Instruct regarding uterine involution, or the process during which the uterus returns to prepregnancy state.
Perineal care
Instruct to wipe from front to back after voiding or defecating.
Instruct on use of sitz bath or whirlpool, if indicated.
Instruct on care of episiotomy or laceration, if indicated.
Instruct regarding changes in lochia (color, consistency, discharge) and at what intervals to anticipate changes in vaginal discharge.
Instruct regarding when to expect the next menstrual period.
Emotional status
Instruct regarding normalcy of frequent emotional changes.
Instruct regarding signs and symptoms of postpartum depression that should be reported to the practitioner.
Excessive mood swings
Feeling as though she is not a good mother
Having difficulty bonding with her baby
Withdrawal from family and friends
Loss of appetite or eating more than usual
Inability to sleep or sleeping too much
Overwhelming fatigue or loss of energy
Thoughts of harming herself or the baby
Thoughts of suicide
Diminished ability to think clearly, concentrate, or make decisions
Severe anxiety or panic attacks
Reduced interest and pleasure in activities that previously were enjoyable
Confusion
Hallucinations
Instruct regarding normalcy of fatigue and need for frequent rest periods.
Urinary and bowel function
Instruct the patient to increase fluid intake and to consume high-fiber foods to prevent constipation.
Instruct the patient regarding sexual activity.
Resumption of sexual activity
Family planning and contraception
Encourage questions and answer them as they arise.
ASSESSMENT AND PREPARATION
Assessment
Perform hand hygiene before patient contact.
Introduce yourself to the patient.
Verify the correct patient using two identifiers.
Assess maternal vital signs.
Review prenatal, labor, and birth records for risk factors for postpartum hemorrhage and postpartum infection.
Assess blood type and Rh factor and assess rubella, rapid plasma reagin, and Group Beta Streptococcus (GBS) status.
Assess whether the mother plans to breastfeed or bottle-feed the newborn.
Preparation
Ensure that adult resuscitation equipment and other needed supplies, such as a postpartum hemorrhage cart, are readily available.
Receive the hand-off report from the nurse previously caring for the patient.
Verify the patient’s actual admission weight in kilograms.9
Rationale: Actual weight should be verified or measured. Stated, estimated, or historical weight should not be used.
9
PROCEDURE
Perform hand hygiene.
Verify the correct patient using two identifiers.
Explain the procedure to the patient and ensure that she agrees to treatment.
Assess the patient’s temperature at the beginning of the immediate postpartum period and the blood pressure, pulse, and respirations every 15 minutes for approximately 2 hours following the birth, but more frequently and for a longer duration if complications develop.3,13
Assess the patient’s temperature every 4 hours for the first 8 hours after the birth, and at least every 8 hours after that based on her condition.3
Continue to assess vital signs per the organization’s practice.
Perform hand hygiene and don gloves.
Auscultate breath sounds.
Rationale: Crackles in the lungs may indicate fluid overload.
2
Assess the breasts.
Gently palpate each breast. Observe contour, firmness, and skin temperature; assess for presence of nodules.
Inspect breasts for venous engorgement.
Inspect nipples for discharge and observe whether they are intact (i.e., no blisters, cracks, or bleeding).
Assess for breast or nipple tenderness.
Assess the abdomen for bowel sounds.
If the patient had a cesarean delivery, assess the surgical incision for drainage, edema, ecchymosis, redness, heat, dryness, and intact suture line.
Assess the fundus (Table 2) and lochia with each vital sign assessment.13
Monitor vital signs closely if the patient has excessive bleeding.
2
Rationale: Maintaining firm uterine tone is essential to prevent excessive postpartum bleeding.
2
Position the patient in supine or low semi-Fowler position with knees flexed.
While stabilizing the uterus at the symphysis with one hand, cup the other hand over the fundus and press firmly (Figure 1).
Determine whether the fundus is firm, midline, and at or below the umbilicus.
If the fundus is firm, do not massage; it is not necessary.
If the fundus is not firm, massage until firm.
Support the lower uterine segment during fundal massage to help prevent uterine inversion.
Uterine inversion is an obstetric emergency and can be accompanied by hemorrhage and shock.
Evaluate the fundal position in relation to the umbilicus.
Turn the patient to one side, flex the upper leg, and lift the superior buttock to observe for excessive bleeding.8
Rationale: Although the amount of lochia may appear to be small, lochia may flow on the linens under the patient and excessive bleeding may be undetected. The side-lying position will provide an unobstructed view of the perineum.
Observe lochia on perineal pads and under the patient and estimate the amount of bleeding (Figure 2).
Determine the quantified blood loss (QBL), also called cumulative volume of blood loss, using the QBL reported on the patient’s labor and delivery record as the baseline (Box 1).
Immediately assess and intervene with a patient and notify the practitioner if a perineal pad becomes saturated in 1 hour or less with pooling of blood under the patient. This indicates excessive bleeding.
2
While assessing the amount of lochia, assess the perineum for signs of trauma (hematomas, tears, or lacerations).
Rationale: Excessive postpartum blood loss may result from undetected hematomas and lacerations.
2,13
Assess the patient for signs of postpartum hemorrhage.
Vaginal bleeding that is heavy or suddenly gushes, a slow constant flow, or frequent saturation of perineal pads10
QBL of 1000 ml or more, or blood loss between 500 and 999 ml with clinical indications for treatment5,12
Change in mentation (dizzy, light-headed, excessive drowsiness, sleepiness)
Tachycardia, tachypnea, hypotension, or other change in vital signs (late signs)
Change in level of consciousness
Persistent, severe perineal pain or pressure, possibly accompanied by a discolored swollen mass in the vulvar or perineal area
If signs of postpartum hemorrhage are present, initiate obstetric hemorrhage protocol. Call for help and notify additional personnel, including the practitioner and a second labor and delivery nurse.6
Attempt to identify the source of bleeding. Use “the 4 T’s” mnemonic to consider whether the bleeding is related to tone (uterine atony), trauma (lacerations, expanding hematomas, or uterine rupture), tissue (retained placental tissue), and thrombin (coagulation factors).5
If blood is dark red, assess for superficial lacerations.
If blood is bright red, assess for deep lacerations (i.e., lacerations in the cervix).
If blood spurts and clots, assess for uterine atony or partial placental separation.
If blood does not clot, assess for coagulopathies, including idiopathic or immune thrombocytopenic purpura (ITP), von Willebrand disease (vWD), or disseminated intravascular coagulation (DIC).10
Assess the perineum for hemorrhoids, episiotomy repair, and lacerations.
Assist the patient to the lateral position and flex her upper leg.
Gently separate the buttocks.
Assess episiotomy or laceration repairs for intactness, hematoma, edema, bruising, redness, and drainage.
Assess general perineum for intactness, hematoma, edema, bruising, and redness.
Assess rectal area for hemorrhoids.
Assess for bladder distention, ability to void, and patency of indwelling urinary catheter, as indicated.
Rationale: A distended bladder may cause uterine atony and excessive uterine bleeding.
2
If the uterus is boggy or above the umbilicus and laterally shifted, assist the patient to void spontaneously.
If the patient is unable to void spontaneously, consider draining the patient’s bladder using a sterile catheter.2
Remove gloves and perform hand hygiene.
Assess lower extremities for evidence of thrombosis.
Rationale: The normal increase of clotting factors and fibrinogen beginning in pregnancy and continuing in the immediate postpartum period in combination with vessel damage and decreased activity places patients in the postpartum period at increased risk for developing venous thromboembolism.
1
Observe for warmth, redness, calf pain, and an enlarged hardened vein over the site of thrombosis.
If symptoms are present, notify the practitioner.
Rationale: The practitioner is notified because further assessment and testing may be indicated.
Assess the patient's level of pain.
Manage the patient's pain if she has any.
Use pharmacologic interventions for pain management, per the practitioner's orders.
Ensure adequate supervision and monitoring for the mother and her newborn after administration of opioids because they may cause respiratory depression.
Use nonpharmacologic interventions for pain management, per the practitioner's orders.
Ice pack to perineum during the first 24 hours to decrease formation of edema and increase perineal comfort; after 24 hours, ice may be applied for its anesthetic effect.2
Warm sitz baths after the first 24 hours to increase blood flow to the area, decrease local discomfort, and promote healing.2,3
A side-lying position can decrease the discomfort of an episiotomy or lacerations; lying prone can help decrease discomfort associated with uterine contractions (afterpains).2
Other nonpharmacologic interventions may include a cleansing shower, water applied to the site with a squeeze bottle, and if ordered, topical anesthetic sprays or creams.2
Provide warm blankets if the patient reports feeling cold. (The patient may experience tremors during the recovery period that resemble shivering from cold. This is a normal transition in the postpartum period.)
Assess the patient's nutritional and bowel status.
If the patient had a vaginal delivery, a regular diet is appropriate.
If the patient had a cesarean delivery, diet restrictions may apply.8,14
If the patient had regional or general anesthesia, assess her postanesthesia recovery score with each assessment during the recovery period. Obstetric recovery areas should meet the same standard of care that is expected in the traditional postanesthesia care unit (PACU).14
Do not discharge the obstetric patient from the recovery care until she has completely recovered from the effects of anesthesia.
14
Assess IV therapy and the patient's fluid balance.
Assess whether the patient is at high risk for a thromboembolic event and, if so, institute prophylaxis per the organization's practice.
Assess the need for Rho(D) immune globulin.
Rationale: Rho(D) immune globulin is administered to an Rh negative, Coombs-negative mother whose newborn is Rh positive.
2 Injection of Rh immune globulin within 72 hours after birth (even when it has been administered during the antepartum period) appears to prevent alloimmunization, also known as Rh-isoimmunization, in the Rh-negative woman who has had a fetomaternal transfusion of Rh-positive fetal red blood cells (RBCs).
3,4
Assess the need for rubella vaccine.
Rationale: Women who are rubella nonimmune should receive a rubella vaccine before discharge to prevent contracting rubella during future pregnancies because rubella is known to be teratogenic.
Assess the need for the tetanus–diphtheria–acellular pertussis (Tdap) vaccine.
Rationale: The Tdap vaccine is recommended for pregnant patients during each pregnancy in the early part of gestational weeks 27 through 36 and for postpartum patients who have not previously received it.
7 Postpartum administration only provides protection to the mother and takes 2 weeks to provide protection against transmission of pertussis to the newborn.
7 The only time patients should receive the vaccine in the postpartum period is if they have never before received the vaccine. A repeat postpartum vaccination is not recommended.
7
Determine the need for pneumococcal or influenza vaccine, if applicable, to be administered before discharge.
Assess abdominal dressing or incisional status, if applicable.
Assess the patient's knowledge of self-care and newborn care.
Assess the patient's psychosocial needs.
Emotional status
Reaction to the labor and birth
Interactions with the newborn
Interactions with partner and family members
Support system
Self-concept and body image
Rationale: The stressful postpartum period may lead to the onset of various mood disorders such as postpartum baby blues, depression, or psychosis. Women should be screened at least once during the perinatal period for signs of depression and anxiety.
3 Women with signs of depression and anxiety, a history of perinatal mood disorders, or risk factors for perinatal mood disorders must be closely assessed, monitored, and evaluated and appropriate treatment should be facilitated by the practitioner.
3
Perform hand hygiene.
Document the procedure in the patient's record.
MONITORING AND CARE
Complete general assessment as indicated by maternal condition or per the organization's practice.
Assess the patient for postdischarge needs.
Assess patient and support person educational needs.
Implement appropriate interventions related to any abnormal findings.
Notify the practitioner of abnormal findings.
Assess, treat, and reassess pain.
EXPECTED OUTCOMES
Vital signs within normal limits
Fundus firm, at midline, and demonstrating normal involution progression
Lochia color changed and amount decreased, with no foul odor observed
Pain relieved or controlled with pharmacologic and nonpharmacologic interventions
Bladder and bowel function normal
Patient demonstration or verbalization of knowledge regarding perineal self-care
Patient demonstration or verbalization of knowledge regarding care of cesarean incision
Patient free of injury, such as from falls
Patient demonstration or verbalization of knowledge about appropriate breast care based on breastfeeding status
Patient demonstration or verbalization of knowledge about newborn feeding
Patient demonstration of positive bonding and interactions with newborn
Patient demonstration of knowledge about potential complications and when to notify practitioner
Patient demonstration or verbalization of measures to promote appropriate adjustment to parenting
Alden, K.R. (2020). Chapter 20: Postpartum physiologic changes. In D.L. Lowdermilk and others (Eds.), Maternity & women’s health care (12th ed., pp. 417-423). St. Louis: Elsevier.
Alderman, J.T. (2020). Chapter 21: Nursing care of the family during the postpartum period. In D.L. Lowdermilk and others (Eds.), Maternity & women’s health care (12th ed., pp. 424-440). St. Louis: Elsevier.
American Academy of Pediatrics (AAP) Committee on Fetus and Newborn, American College of Obstetricians and Gynecologists (ACOG) Committee on Obstetric Practice, and others. (2017a). Chapter 8: Postpartum care of the mother. In Guidelines for perinatal care (8th ed., pp. 279-300). Elk Grove Village, IL: AAP. (Level VII)
American Academy of Pediatrics (AAP) Committee on Fetus and Newborn, American College of Obstetricians and Gynecologists (ACOG) Committee on Obstetric Practice, and others. (2017b). Chapter 9: Medical and obstetric complications. In Guidelines for perinatal care (8th ed., pp. 301-346). Elk Grove Village, IL: AAP. (Level VII)
American College of Obstetricians and Gynecologists (ACOG) Committee on Practice Bulletins—Obstetrics. (2017, reaffirmed 2019). Practice bulletin no. 183: Postpartum hemorrhage. Obstetrics & Gynecology, 130(4), e168-e186. doi:10.1097/AOG.0000000000002351 (Level VII)
Centers for Disease Control and Prevention (CDC). (2017). Pregnancy and whooping cough: Vaccinating pregnant patients. Retrieved October 9, 2019, from (Level VII)
Drake, E., White, M.S. (2019). Chapter 17: Postpartum adaptations and nursing care. In S.S. Murray and others (Eds.), Foundations of maternal-newborn and women’s health nursing (7th ed., pp. 458-494). St. Louis: Elsevier.
Lanning, R.K. (2020). Chapter 33: Postpartum complications. In D.L. Lowdermilk and others (Eds.), Maternity & women’s health care (12th ed., pp. 721-732). St. Louis: Elsevier.
Letourneau, N.L. (2020). Chapter 22: Transition to parenthood. In D.L. Lowdermilk and others (Eds.), Maternity & women’s health care (12th ed., pp. 441-460). St. Louis: Elsevier.
Main, E.K. and others. (2015). National partnership for maternal safety: Consensus bundle on obstetric hemorrhage. JOGNN: Journal of Obstetric, Gynecologic and Neonatal Nursing, 44(4), 462-470. doi:10.1111/1552-6909.12723 (Level VII)
Scheffer, K.L., DeButy, K. (2019). Chapter 15: Nursing care during labor and birth. In S.S. Murray and others (Eds.), Foundations of maternal-newborn and women’s health nursing (7th ed., pp. 373-425). St. Louis: Elsevier.
Spain, R.O. (2020). Chapter 19: Nursing care of the family during labor and birth. In D.L. Lowdermilk and others (Eds.), Maternity & women’s health care (12th ed., pp. 376-416). St. Louis: Elsevier.
ADDITIONAL READINGS
Behling, D.J., Renaud, M. (2015). Development of an obstetric vital sign alert to improve outcomes in acute care obstetrics. Nursing for Women’s Health, 19(2), 128-141. doi:10.1111/1751-486X.12185
Shields, L.E. and others. (2015). Comprehensive maternal hemorrhage protocols reduce the use of blood products and improve patient safety. American Journal of Obstetrics & Gynecology, 212(3), 272-280. doi:10.1016/j.ajog.2014.07.012
Skupski, D.W. and others. (2017). Improvement in outcomes of major obstetric hemorrhage through systematic change. Obstetrics & Gynecology, 130(4), 770-777. doi:10.1097/AOG.0000000000002207
Elsevier Skills Levels of Evidence
Level I - Systematic review of all relevant randomized controlled trials
Level II - At least one well-designed randomized controlled trial
Level III - Well-designed controlled trials without randomization
Level IV - Well-designed case-controlled or cohort studies
Level V - Descriptive or qualitative studies
Level VI - Single descriptive or qualitative study
Level VII - Authority opinion or expert committee reports
