Assessment of the Newly Delivered Mother
As you complete Part 2 of this module, you will learn:
Components and expected findings of the physical assessment of a newly delivered mother
Variations from normal findings during the early postpartum period and familiarity with common interventions
Nursing interventions that promote parent–infant attachment
Techniques to assist the mother with the initiation of breastfeeding in the immediate postpartum period
Necessary interventions for women with recovery complicated by surgery, anesthesia, infection, or pregnancy-related hypertension
Ongoing needs of the newly delivered mother during postpartum hospitalization
General guidelines for discharge of mother and infant
When you have completed this module, you should be able to recall the meaning of the following terms. You should also be able to use the terms when consulting with other health professionals. The terms are defined in this module or in the glossary at the end of this book.
Part 1 Immediate Postpartum Assessment of the Mother
Immediately following the delivery of the placenta until maternal stabilization is a time of complex physiologic and psychosocial changes for the new mother. It is imperative that the nurse caring for the newly delivered woman has knowledge of the prenatal history as well as the intrapartum course.
What are the components of the physical assessment of a newly delivered mother?
The nurse must be well versed in postpartum assessment and be able to identify subtle changes that could indicate a woman’s deteriorating condition. Components of care should be standardized regardless of whether the recovery is done in a post-anesthesia care unit (PACU), a labor and delivery room or a postpartum room. According to the 2010 recommendations from the Association of Women’s Health, Obstetric, and Neonatal Nurses (AWHONN), the nurse caring for the woman should not have any other patient or infant care responsibilities until an initial assessment is completed and documented, the repair of the episiotomy or perineal lacerations is complete and the woman is hemodynamically stable.1
The care provided should be family centered, which incorporates the needs of the woman and newborn as well as the family. The family consists of the woman and whoever she identifies as her family—this group of people is encouraged to take part in the care of both the woman and the newborn. Healthcare providers should listen to and honor the choices and perspectives of the family as a whole. The family’s beliefs, values, and cultural backgrounds are then incorporated into the woman’s plan of care. Findings of assessments and explanations of interventions should continue to be explained to the woman and family throughout the postpartum period.2,3,4,5
Assessments during the immediate postpartum period start from the delivery of the placenta and continue for at least 2 hours or until stable. Assessments should be orderly and ongoing so that timely identification can be made of any abnormal changes in the woman’s clinical condition. Note the overall appearance of the woman, including skin color, motor activity, facial expression, speech, mood, state of awareness, and interactions with others. Any variation from normal assessment parameters requires reassessment, communication, and early intervention as indicated to prevent potentially serious consequences.2,3,4,5
NOTE: Assessments are done every 15 minutes in the first 2 hours.4
Women undergo significant cardiovascular changes during the immediate postpartum period. Average blood loss for a vaginal birth is 400 to 500 mL. If the mother has additional blood loss, vital signs may change to reflect the mother’s compensation to maintain cardiac output and tissue perfusion. In addition, blood flow that had been circulating in the uteroplacental vasculature is shunted back into the maternal system, increasing cardiac output.2,3,5
Systolic blood pressure between 90 and 140 mm Hg.
Diastolic blood pressure between 60 and 90 mm Hg.
Heart rate between 60 and 100 beats per minute.
Respirations between 16 and 24 breaths per minute.
Temperature between 97°F and 100.4°F.
NOTE: Tracking trends in vital signs are helpful when determining the cause of abnormal values.
If blood pressure is elevated, assess the woman for pain and provide pain relief as indicated. Excessive pain may cause a temporary elevation in blood pressure. If blood pressure remains elevated after reassessment, notify the provider as elevated blood pressure in the postpartum period can be a sign of gestational hypertension or preeclampsia.
If a decrease in blood pressure (hypotension) is noted, immediately assess the amount of lochia and watch for signs of shock such as rapid pulse (tachycardia), confusion, clammy skin, rapid breathing (tachypnea), decreased pulse pressure (30 mm Hg or less), weak peripheral pulses, anxiety, or lightheadedness. If hypotension is reassessed, notify the provider to come to the bedside and call for additional assistance if blood pressure does not stabilize rapidly and is accompanied by excessive flow of lochia or signs of shock. The risk of orthostatic hypotension is increased in the postpartum period due to decreased vascular resistance in the pelvis. To prevent falls, assist the woman to the side of the bed in a sitting position prior to ambulation, and support her with the first ambulation.2,3,5
Changes in intravascular volume may lead to tachycardia.
Hypovolemia signs and symptoms: initial blood pressure increases followed by dropping blood pressure values, increased respiratory rate, narrowed pulse pressure (less than 30 mm Hg), weak peripheral pulses, dry mucous membranes, and decreased urine output.
Hypervolemia signs and symptoms: increased blood pressure, increased respiratory rate, decreased pulse oximetry values, wide pulse pressure (greater than 70 mm Hg), bounding peripheral pulses, jugular venous distention, adventitious breath sounds, S3 heart sounds.
Following birth, chest wall compliance improves with a decrease in upward pressure on the diaphragm. An elevated respiratory rate may indicate changes in intravascular volume. Other signs of respiratory compromise should be assessed. A decrease in respiratory rate may be caused by anesthetic and/or analgesic medication administration.
NOTE: If BP, HR, or RR is abnormal, reassess every 5 to 15 minutes until normal and notify the provider. With continued abnormal vital sign parameters, the provider should come to the bedside and evaluate the woman to determine the cause and develop an interprofessional plan of care.
Take a temperature upon initiation of recovery and repeat in 1 hour, if normal, repeat at the end of recovery, if abnormal retake in 30 minutes. Remember that epidural anesthesia, hormone changes, muscle exertion, and some medications can cause an increase in temperature, but should remain below 100.4°F.
Abnormal values must be evaluated to determine cause. Dehydration after a lengthy labor with inadequate fluid intake is a common cause of early postpartum fever. Women who have had epidural anesthesia may have fever unrelated to infection. Notify the provider and the newborn’s pediatric provider if maternal temperature is higher than 100.4°F.
During pregnancy, the breasts undergo changes to prepare for lactation. Assessment should include the following2,3,5,6:
Inspection of the breasts for redness and the nipples for cracks, fissures, or blisters. Nipples may be erect, flat, or inverted. Flat nipples that cannot be made to protrude when gently squeezed just behind the nipple can cause difficulty with the infant latching onto the breast. An inverted nipple inverts further when this pinch test is attempted. A manual or electric breast pump can be used immediately before nursing to attempt to make the nipples easier for the infant to grasp.
Palpation of the breasts for engorgement.
Breasts should palpate soft and nontender in the first 24 hours.
Postpartum day 2, the breasts are slightly firm and nontender as primary engorgement begins.
Postpartum day 3, the breasts are firm and tender. If breastfeeding, the breasts may be warm to touch.
See Figure 17.1.
The woman’s decision on whether to breast or bottle feed determines breast care during the postpartum period. If the woman chooses to bottle feed, instruct on the following2,3,5,6:
Wear a supportive bra 24 hours a day until the breasts become soft again.
Ice packs can be applied to the breasts to reduce breast milk formation and discomfort.
Do not manually express milk because this can stimulate milk production.
Avoid heat to the breasts.
Mild analgesic medications may be taken to ease discomfort.
Breast engorgement usually decreases within 48 hours.
Involution is the process of the uterus returning to its prepregnant state. Uterine tone should be assessed at least as frequently as vital signs, every 15 minutes in the first 2 hours.4 Amount of blood loss should be assessed on an ongoing basis during this time. Uterine atony is the most common cause of postpartum hemorrhage, which remains a major cause of maternal morbidity and mortality.7,8,9
Evaluate the uterus by noting the fundal height, position, and tone. In order to do this, place one hand just above the symphysis pubis to “cup” the lower portion of the uterus. With the other hand palpate the abdomen starting above the umbilicus to locate the fundus. The fundal height is measured in relation to the umbilicus and is calculated in centimeters above or below the umbilicus. The tone should be firm. If the uterus is boggy (soft), massage until firm.2,3,5,6
In the immediate postpartum period, the fundus should be:
directly midline, not deviated to either side of the umbilicus;
firm to the touch; and
approximately 2 cm below the umbilicus.
Over the next 12 hours, the fundus will rise to approximately 1 cm above the umbilicus before it starts to descend at a rate of approximately 1 to 2 cm every 24 hours. Figure 17.2 indicates expected fundal height measurements during the postpartum period.2,3,5,6
A fundus that is higher than 2 cm above the umbilicus may indicate a distended bladder or a uterus that is filled with blood. After delivery of a large infant, the fundal height can be slightly elevated, and this may be a normal finding. Assist the woman to empty her bladder. Catheterize only if the woman is unable to void and the bladder is distended. Once the bladder is empty, reevaluate the fundal height. Massage the fundus in an attempt to expel any retained blood clots. Report increased fundal height that does not respond to intervention. A boggy uterus may indicate uterine atony, retained placental fragments, or clots. Boggy means the uterus feels spongy as it is not adequately contracted. The boggy uterus should firm up with massage by cupping one hand just above the symphysis pubis to stabilize the uterus and the other hand midline on the abdomen near the umbilicus and begin massaging the area. Moderate massage usually stimulates the relaxed uterus to contract. Massage only until firm. While massaging the uterus, continue to observe the perineum for the amount of bleeding and/or size of expelled clots. If uterine massage does not result in a firm uterus, notify the provider.2,3,5,6
Often, a uterotonic agent will be ordered to maintain a firmly contracted uterus. Some clinical situations that can predispose a newly delivered woman to uterine atony are prolonged labor, oxytocin induction of labor, magnesium sulfate therapy, large infant or multiple gestation, chorioamnionitis, or cesarean birth under general anesthesia.6 For further discussion of postpartum hemorrhage, refer to Module 16 on Obstetric Emergencies.
During the postpartum period, there is a decrease in gastrointestinal muscle tone and motility. Normal bowel function should return by the end of the second postpartum week. In addition to these changes, decreased activity, hydration, diet, perineal pain, and narcotic medications increase the risk of constipation. Note the date of her last bowel movement. This will be helpful information for continued postpartum care. Auscultate the woman’s bowel sounds in all four quadrants. The postpartum woman should be able to pass flatus. Notify the provider if bowel sounds are absent.2,3,5,6
Bladder distention, incomplete emptying, urine retention, and/or the inability to void may occur during the first few days postpartum. Within 12 hours of birth, changes in hormone levels (decreased estrogen and oxytocin) occur resulting in diuresis. Measure and record urine output in the first 24 hours post birth. A bladder scan can also be used at this time to assess for post void residual.2,3,5,6
Gently palpate the lower abdominal area just above the symphysis pubis for bladder fullness or tenderness. The bladder should not be palpable or tender. The sensation of needing to void may be decreased as a result of pressure on the bladder during labor and birth or because of continued effects of neuraxial anesthesia.2,3,5,6
The bladder may become distended from intravenous fluids administered during labor or from the diuresis that normally occurs postpartum. A distended bladder can interfere with uterine contractility and lead to uterine atony and excessive vaginal bleeding. Attempt to have the woman void either into a bed pan or assist with ambulation to the bathroom. Many women are able to void without the sensation of a full bladder. If the woman is unable to void or the bladder scan shows more than 150 mL remains in the bladder, a sterile in-and-out catheterization may be indicated. Avoid allowing the bladder to become over distended, which can lead to loss of muscle tone and continued difficulty with voiding. Burning with urination should be reported to the provider.2,3,5,6
With adequate lighting and exposure, evaluate for edema and signs of hematoma (a discolored or bruised and edematous area). Provide privacy, and placing the woman in a side-lying position to separate the buttocks to expose the perineum for assessment.2,3,5,6
Provide thorough perineal care to assist with visualization. The perineum should be pink, without signs of excessive bruising or findings of considerable edema. Inspection of an episiotomy or laceration repair should reveal approximated tissues with mild edema. An ice pack to the perineum during the first 24 hours may be used to improve comfort and decrease/prevent edema. Sitz baths may be ordered after 24 hours to promote circulation, healing, and comfort. Nonsteroidal anti-inflammatory medications may be ordered by the provider to reduce the inflammatory response and promote healing. Analgesics may be required to meet the woman’s pain goals.2,3,5,6
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