Jolene K. Bethune, RN, MSN
Jun 25, 2015
Jolene K. Bethune, RN, MSN
At the completion of this presentation, you will be able to:Perform postpartum checks according to protocolMonitor vital signs and blood pressureInspect and palpate the breastsPalpate the fundus and bladderMonitor urinary outputMonitor bowel activityMonitor lochiaInspect the perineumMonitor extremities for thrombophlebitis
Hand-washing station.Gloves.Oral glass, electronic or tympanic thermometer.Stethoscope.Doppler ultrasound stethoscope or probe.
Conductive jelly.Watch with sweep second hand.Sphygmomanometer with assorted cuffs; or continuous
non-invasive blood pressure monitoring device.Maternity pads.
Frequency of postpartum checks according to protocol:First hour: every 15 minutes
Second hour: every 30 minutes
First 24 hours: every four hours
After 24 hours: every 8 hours
Wash hands and explain the procedure to the patientTo make sure the client is as comfortable as possible,
make sure the patient has voided.Take vital signs and make sure they are within normal
limits when compared to the baseline. Take vital signs before hands-on procedures; the
discomfort of palpating the fundus could reflect in an elevated blood pressure or pulse.
Raise the head of the bedAsk the patient lower her gown so that her breasts can be
examinedVisually inspect and palpate each breast noting:Soft, filling or firmEngorged, reddened, or painfulNipples: erectility, possible cracks and redness
The fundus should be palpated until the 10th day postpartum.
Since patients are usually discharged sooner, patients should be instructed in self-examination so that she can be alert to sudden changes in the uterus.
Lower the head of the bed so that the abdomen will be relaxed.
Position the ring finger directly over the umbilicus so that the small finger is the closest to the client’s head.
Using the ring finger as a fulcrum, roll the hand back and forth gently and note the fundus in relationship to the umbilicus. Note:
Fundal consistency and toneFundal position – in relationship to
the midline. Displacement to the left or right could be caused by a distended bladder.
Fundal height – measured in finger breadths from the umbilicus.
During fundal palpation
Bladder palpability
Bladder distention could displace the uterus
Impeding involutionImpeding the control of bleeding.
Voiding pattern and amounts voided:Is it at least 30ml/hr?Distention:Is a distended bladder displacing the
uterus?Pain:Is voiding painful, burning or
itching?S/S of what?
Bowel movements:When was her last BM?Normal, diarrhea or constipation?Hemorrhoids:Are there hemorrhoids present?Is there active bleedingBowel sounds: auscultate all four quadrants:Especially C/S patients; why?Normo-, hyper- or hypoactive?
Detach the peripad from the front to the back to minimize the risk of contaminating the vagina with rectal discharge. Note:
Type and amount – rubra (dark and red); serosa (serous or brown)
Four to eight saturated pads per 24 hours is normal.
Presence of odor – could indicate infection
Presents of clots – could indicate retained placental tissue or inadequate uterine contraction.
Instruct the client to assume a side-lying (Sims) position.
If a laceration or episiotomy repair is present, instruct the client to flex the top leg to minimize the strain on the repair.
Gently separate the buttocks and inspect the perineum for:
Episiotomy, lacerations and hemorrhoidsBruising, hematoma, edema, discharge,
approximation
Homan’s sign (calf pain from passive dorsiflexion of foot)
Redness, tenderness or warmth
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