The nurse is caring for a postpartum patient. one day after delivery the nurse assesses the lochia

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Postpartum Nursing Assessment

Post-baby Assess-man

The postpartum nursing assessment is an important aspect of care in order to identify early signs of complications in the woman who has just given birth. Following pregnancy, the woman is at risk for infection, hemorrhage, and the development of a Deep Vein Thrombosis (DVT). The nurse can remember the key points of a postpartum assessment by learning the acronym BUBBLE-LE, which stands for breasts, uterus, bladder, bowels, episiotomy, lower extremities, and emotions.

9 KEY FACTS

BUBBLE-LE is an acronym to remember the key points for postpartum nursing assessment.

The first form of breast milk produced is colostrum, which contains high levels of bioactive compounds like immunoglobulins and growth factors. As the milk matures, usually within 72-96 hours, the breasts may become heavier and fuller and feel nodular and firm. The breasts should be assessed for signs of infection (mastitis) such as pain, redness, and warmth.

The uterus must remain firm and contracting in order to prevent postpartum hemorrhage. If the uterus feels boggy, it should be massaged. If the uterus becomes deviated to one side, it may indicate bladder distention.

Postpartum, the woman may experience difficulty voiding resulting in a distended bladder. If the bladder becomes distended, the woman is at a higher risk for hemorrhage because the distended bladder applies pressure on the uterus.

It may take 2 or 3 days for the woman to have a bowel movement due to pain, lack of food, dehydration, and soreness from lacerations or hemorrhoids. A stool softener may be given to the woman in order to aid in easier passage of the bowel movement.

The lochia should be assessed for color, amount, and odor. Too much lochia may indicate hemorrhage so it is important to know how the lochia is expected to look. In addition, foul smelling lochia may indicate infection. Lochia is usually bright red and contains small clots after birth. Normal shedding of blood and decidua is referred to as lochia rubra (red/red-brown) and lasts for the first few days following delivery. Between day 3-4 the lochia becomes more pink/brown color and contains serum, leukocytes, tissue debris and old blood and is called lochia serosa. Around 10 days post birth, the lochia becomes yellow/white and contains mainly leukocytes. This is referred to as Lochia Alba. Lochia will last 4-8 weeks postpartum.

If the woman had an episiotomy, the nurse should assess for redness, edema, ecchymosis, discharge, and approximation.

The lower extremities must be assessed for deep vein thrombosis. This can be done easily by looking for redness, warmth and edema. DVT could lead to pulmonary embolism which presents with tachycardia and shortness of breath. There is controversy on the usefulness and accuracy of checking for Homan’s sign (dorsiflexion of the foot while knee is flexed - positive sign is pain in the calf muscle indicating a thrombus). The mother is at risk for developing a DVT due to increased clotting factors from birth and lying in bed.

Hormone fluctuations, as well as the birth experience, can cause the mother to experience many new and strong emotions. The nurse should assess how the mother is feeling to determine whether the mom may be experiencing the postpartum blues. E can also include providing “education” to the mother dependent on her needs.

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General activities

The more you are up and out of bed, the faster your recovery will be. You may gradually resume your normal activities as soon as you wish, beginning with mild exercise, like walking. The benefits of exercise include improved muscle tone, quicker healing and a more positive attitude. Fresh air and sunshine are refreshing for both you and your baby.

Avoid heavy lifting, strenuous exercise and excessive stair climbing. Refer to your doctor’s specific activity restrictions given to you when you leave the hospital. A good rule to follow is that you should not lift anything heavier than your baby in the car seat.

It is common for postpartum women to have swelling, especially in their legs and feet. This is the body’s way of getting rid of some of the excess fluid accumulated in pregnancy. It can take up to two weeks for the swelling to resolve. Elevate your feet when sitting or lying down and make sure you drink a lot of fluids to help your body get rid of the excess fluid. Call your doctor if one leg is much more swollen than the other, if you have pain in your leg when walking or if there is a red hot area in one leg.

Start Kegel exercises immediately after delivery. This movement is similar to stopping the flow of urine. Squeeze for three seconds and release. Begin with 10 repetitions twice a day, gradually building up to 100 repetitions twice a day. This will help with healing as well as minimize bladder leakage (stress incontinence).

Try to get as much rest as you can. Plan to get at least one nap a day as you will be up frequently during the night with the baby. A good time to nap is when the baby sleeps. Lack of sleep can affect your mood and can increase anxiety. Allow friends and relatives to help with housework, cooking and other chores.  

Shower as often as you like, but avoid tub baths or swimming until after your postpartum checkup. There should be nothing placed in the vagina until after your postpartum checkup. This means no tampons, douching or intercourse (sex). Make your follow-up appointment for about six weeks after delivery.

Driving should be avoided for one to two weeks, or until the operation of an automobile will not be painful or cause undue exertion. Do not drive if you are taking narcotics for pain relief. Refer to the discharge instructions from your physician or call your doctor’s office.

Nutrition

Good nutrition and adequate fluids are necessary for tissue repair, healing, breastfeeding and general health. Refrain from any weight-reducing diets until after your postpartum checkup. Most women lose eight to 10 pounds just from delivery. It takes almost a full year to return to your pre-pregnancy weight. If you are breastfeeding, continue to take your prenatal vitamins. Eat a well-balanced diet that is high in protein (meat, fish, legumes), fiber (fruits, vegetables, whole grains), calcium (milk, yogurt, cheese, green leafy vegetables) and fluids. If you have a family history of food allergies or are concerned about food allergies for your baby while breastfeeding, consult your physician for guidance.

Bowel care

Concern about the ability to have a bowel movement is common after having a baby. Often mothers fear tearing their stitches or experiencing pain. Bowel function should return to normal three to four days after delivery. A diet high in fiber and fluids can help avoid constipation. Walking promotes bowel movements, passing gas and increased general circulation. Raising your feet onto a stool during a bowel movement can help decrease straining. For constipation, take an over-the-counter stool softener (Colace, Metamucil) or add prunes, prune juice or bran to your diet. If you have additional questions, please contact your doctor’s office.

Uterine changes/bleeding/perineal care

Your uterus should feel firm after delivery. You will feel contractions (afterbirth pains) after delivery as your uterus works to get back to a non-pregnant size. These pains tend to get more intense with each delivery. Breastfeeding mothers may experience more cramping during and after feeding, especially in the early weeks. These contractions are temporary. Use relaxation/breathing techniques and the pain medications prescribed by your doctor to lessen discomfort.

Continue to use the peri-bottle to clean your perineum, rinsing front to back with warm water until the bleeding stops. Use your sitz-bath as directed; this will help dissolve any stitches and aid in healing the perineum.

The first few days after delivery, your bleeding (also called lochia) is bright red; it changes to dark red, then brown, much like a normal period. This bleeding usually lasts two to four weeks. You may have light bleeding or continue to spot for up to six weeks. In the first days home, you may notice an increase in bleeding or darkening in bleeding due to increased activity; this may be a sign that you need more rest. You may also notice that you pass some blood clots, especially if you have been sitting or lying down for long periods of time. This is normal. If you are passing frequent clots or clots larger than an egg, please contact your health care provider.

If you are breastfeeding, your first period may not start until after you wean your baby. If you are not breastfeeding, your first period will probably start four to six weeks after delivery and may be unusually heavy. Remember, even if you are breastfeeding, ovulation and fertility can return at any time, so it is important to use contraception. Make sure you discuss your options with your doctor/midwife before resuming sexual relations. To allow for mom’s complete recovery, it is recommended that children be spaced at least 18 months apart.

Breast care

Wear a well-fitting bra. Nurse the baby as frequently as possible. Make sure your baby is latched properly to avoid sore or cracked nipples. You can express a small amount of breast milk on your nipples after feeding and let it air dry. Refer to the information included in this booklet for assistance with breastfeeding.

If your breasts become engorged (very full/firm and tender), use ice packs for 15 to 20 minutes at a time. Lie flat while applying ice, if possible. You may also use over-the-counter pain relievers. Engorgement usually resolves in two to three days. If you are still experiencing significant discomfort, please contact your doctor’s office for an appointment. You may want to contact a lactation consultant or the La Leche League for additional support and information.

If you have a fever higher than 100.4°F; a lump; or red, sore or hot area in the breast that does not go away after nursing, contact your doctor.

Psychological adjustment

Families go through many changes when a new baby is born. All family members are adjusting. Mothers experience a wide range of emotions. Mild feelings of sadness, depression and anxiety are common and are due to hormonal changes, lack of sleep and the demanding job of caring for a newborn. These are frequently referred to as the “baby blues.” These feelings are usually temporary and self-limiting.

Postpartum depression is less common and more serious. It is characterized by feelings of depression, anxiety, worry, hopelessness and lack of self-worth. It may also include thoughts of hurting yourself or the baby. Postpartum depression requires treatment by a therapist and often medication. Please contact your doctor/midwife if you or your family has any concerns about your mental health. Neither of these conditions reflects your feelings for your baby, your partner or your abilities as a mother. You cannot control these feelings, but they can be helped. There are medications that are safe to take while breastfeeding.

Postpartum Support International: www.postpartum.net, 1-800-944-4PPD

Other ways you and your family can adjust to a new baby are:

• Rest/sleep when the baby sleeps.
• Eat a well-balanced diet. Now is not the time for dieting or junk food.
• Be flexible. It takes time to get to know your baby.
• Let others help you. Accept offers to bring dinner, go to the market or do other necessary chores.
• Spend special time with your other children and your partner. A new baby is an adjustment for them as well.
• If you have other young children, put together a box/basket of age-appropriate special snacks, toys and activities that only comes out when you are feeding the baby. Make sure to include a book so you can all read together while the baby is being fed.
• Talk to other parents who are going through some of the same experiences.

When to call the doctor

• Frequent urgency or burning upon urination
• Temperature of 100.4°F or above
• Unrelieved pain in your back, side or incision
• Bloody or pus-like drainage from your incision
• No bowel movement for four days or longer
• Bleeding stays heavy despite rest
• Saturating a pad an hour
• Passing many clots or passing clots larger than an egg (some clots are normal if you have been sitting or lying down for long periods of time)
• Foul-smelling bleeding
• Severe headache that is not relieved by a snack, nap and acetaminophen or visual disturbances like blurred vision or tunnel vision
• Social withdrawal or persistent baby blues/depression
• Hot, firm, red area in the breast
• If one leg is much more swollen than the other; you have pain in your leg when walking; or there is a red, hot area, especially in the back of your leg

« Taking Baby Home

What type of lochia will the nurse assess initially after delivery?

When assessing lochia what signs would indicate infection?

When assessing a woman's lochia on the fifth postpartum day what the nurse expect to find?

What would you include in your initial postpartum assessment following delivery?