Postpartum Maternal Physical Assessment Summary- BUBBLE HE

Breasts:
inspect: size, symmetry, shape of breast and nipples taking note of erection, flatness, redness, bruising, open wounds, presence of
mastitis and colostrum
palpate: fullness, soft or engorged, firmness and lumps
pain assessment
Uterus (Fundus):
palpate: firmness/bogginess, location of the fundus in relation to the abdomen, determine the location of the fundus in relation to
the belly button to determine amount of fundal involution
inspect incision site
check policy: in some organizations, they may not assess fundal involution by palpation due to fear of dehiscence
Bladder:
void amount (~30ml/hr)
assess for distention, incontinence, urinary retention, urinary infection especially if the patient had a foley catheter
Bowel:
last bowel movement/flatus
assess for distention, abdominal pain
Lochia:
amount, color, odour
assess for postpartum hemorrhage
Episiotomy
level of laceration
number of stitches, redness, edema, bruisin, discharge, approximation of wound edges
assess perineal area
Homans Sign-for DVT
assess for pain with dorsiflexion
check policy: this is sometimes not done in organizations
Emotional State:
assess for signs and symptoms of postpartum depression and infant-maternal bonding
Postpartum physical adaptations
Uterus continued
Changes in Fundal Position
Immed after placenta expelled:
Uterus contracts to compress blood vessels
Size of large grapefruit

Fundus in midline, about half way to 2/3 way between umbilicus and symphysis pubis
Rises to level of navel about 6-12 hours after delivery changes in ligaments
Fundus above umbilicus and soft and spongy (boggy) associated with excess bleeding
If high and displaced to side (usually right), prob secondary to full bladder
Empty bladder and reassess

Postpartum physical adaptations
Uterus continued
Uterus remains at level of umbilicus about day
after birth
On first day following birth top of fundus about
1cm below umbilicus
Fundus descends about 1 fingerbreadth or 1 cm
daily
Descends into pelvis on 10
th
day, can no longer be
palpated
Returns to pre-preg size and location by 5-6 wks
If descends slower, called subinvolution

Postpartum physical adaptations
Lochia
Debris eliminated in discharge called lochia, is
classified according to appearance
Lochia rubra:
Dark red, first 2-3 days after delivery
Clotting result of pooling in vagina, nickel size
clots otherwise ok
Lochia serosa:
Pinkish to brownish
3-10 days pp
Lochia alba:
Yellowish-whitish
Duration varies

Postpartum physical adaptations
Lochia
When lochia stops, cervix is closed, less chance
of uterine infection
Total lochia blood loss volume is 225 mL
Volume decreases gradually, may increase with
nursing, exertion
Normal odor slightly musty, non-offensive
Foul odor to lochia suggests infection
Assessment of lochia necessary
Type, amt of lochia corresponds to involution &
healing of placental site
Failure of lochia to progress and decrease in
amount = subinvolution or PP hemorrhage
If continuous bright red seep with firm uterus
right after birth, must consider possibility of
laceration

Postpartum physical adaptations
Cervical Changes
Spongy and flabby, formless after birth
Reforms with in few hours & closes slowly, by
end of first week will only admit fingertip
Shape permanently changed
Vaginal Changes
May be edematous and bruised, no rugae
Size decreases and rugae returns in 3-4 wks,
normal by 6 wks
Can improve tone with Kegels exercises
If nursing may be dry, pale

Postpartum physical adaptations
Perineal Changes
Appears swollen and bruised
If episiotomy or laceration, should be well approx
Should be healed by 2-3 weeks after delivery
with complete healing by 4-6 months
May have some discomfort during this time
Recurrence of Ovulation and Menstruation
Generally 6-10 wks after birth if not nursing
If nursing, return is prolonged
Depends on length of breastfeeding and
supplements
Not reliable form of contraception

Postpartum physical adaptations
Abdomen
Appears loose and flabby
Responds to exercise with in 2-3 months
If abdomen over distended or poor muscle tone
pre-preg, may not regain tone, remains flabby
Diastasis recti abdominis
Is separation of abdominis muscles
Often occurs with preg, especially if poor abd
tone
Abdominal wall has no muscle support
Improvement depends on cond of mom, type and
amt of exercise, number of pregnancies and spacing
May result in pendulous abd
Striae
Results from rupture of elastic fibers of skin
Fade to silvery white if Caucasian
If dark skin, they stay darker than surrounding
skin

Postpartum physical adaptations
Gastrointestinal system
Hunger, thirst immediately after birth common
Bowels tend to be sluggish
d/t progesterone, decreased abdominal tone
If episiotomy scared will hurt or tear sutures
with BM
Nursing interventions may help prevent, relieve
If C/S, clear liq till bowel sounds, then solid food

Postpartum physical adaptations
Urinary system
At risk for over distention, incomplete emptying
with residual urine d/t
Increased bladder capacity
Swelling and bruising of tissues around urethra
Decreased sensation of full bladder (anesthetic
block)
Output first 12-24 hrs pp (PP diuresis)
Eliminate 2000-3000 mL preg fluid, more if PIH
Fills bladder quickly, watch closely for distention
Risk of UTI high
Full bladder will also uterine relaxation, bleeding

Postpartum physical adaptations
Vital signs Should be afebrile after 24 hrs
May have temp up to 100.4 F (38 C) for 24 hrs d/t
dehydration
May also have elevation of 100 to 102 F (37.8-39
C) when milk comes in
BP may spike immediately after delivery
Should have normal BP within few days
Orthostatic hypotension common first couple days
Decrease = hemorrhage versus normal?
Increase = preeclampsia, excess oxytocin use?
Decreased pulse common for first 6-10 days PP
Pulse > 100 related to hemorrhage, fear, pain,
infection

Postpartum physical adaptations
Blood values
Values return to normal by 6-8 wk after delivery
Increased coagulation factors continue for
variable time, increases risk for blood clot
Blood loss averages
H & H difficult to determine in first 2 days pp d/t
changing blood volume (diuresis)
200-500 cc with vag del
700-1000cc with C/S
Rule of thumb 2 point drop in Hct = 500 mL
blood lost
WBC increases in labor & early pp to 25,000-
30,000
Platelets return to normal by 6 weeks

Postpartum physical adaptations
Cardiovascular changes
Blood volume increases because no longer has
blood circulating to placenta
Works to protect mother against excess blood loss
Diuresis decreases extracellular fluid
If fails to happen, can lead to pulmonary edema
esp in mother with preeclampsia or existing cardiac
problems
Weight loss
10-12 # immediately after birth (infant, placenta,
amniotic fluid)
Diuresis additional 5# first wk
By 6-7 wks return to pre-preg wt if gained normal
amt

Postpartum physical adaptations
Afterpains
Are intermittent contrx of uterus
More common in multips, retained placenta or
with overdistention of uterus
Oxytocin & breastfeeding increases afterpains
Can use mild analgesic 1 hour before nursing
May be very uncomfortable for 2-3 days
Usually gone in 5 minutes

Postpartal Nursing Physical Assessment
Physical Assessment see guide pg 1001-1004
Explain to pt purposes
Record and report results
Avoid exposure to body fluids
Teach pt as assess use q opportunity since
limited time

Post Partum Nursing Assessment
Assessment necessary to identify individual needs
or potential problems
See page 1053-1055 for complete assessment
guide
Also see table on page 1052 about postpartal high
risk factors and their implications
Term BUBBLEHE can help remember
components
breast, uterus, bladder, bowel, lochia, episiotomy,
Homans/hemorrhoids, emotional
Principles in assessment of pp woman
Provide explanation of assessment to client
Perform procedures gently to avoid unnecessary
discomfort
Record and report results
Take appropriate precautions to prevent exposure
to body fluids
Provides excellent opportunity for client teaching
about physical changes of pp and common concerns

Post Partum Nursing Assessment
Vital signs
Alterations in VS can indicate complications
already discussed
Lung auscultation
Lungs should be clear
Women treated for PTL, PIH @ risk for
pulmonary edema

Post Partum Nursing Assessment
Breasts
Assess fit and support of bra
Helps maintain shape by limiting stretching of
ligaments and connective tissue
Bra for nursing mother
Non-elastic straps
Be one size larger than normal
Have cups that fold down for nursing
Breast assessment
Inspect for redness, engorgement
Palpate for warmth, firmness of filling or
engorgement, tenderness
In nursing women:
Assess nipples for cracks, bleeding, soreness,
fissures, inversion

Post Partum Nursing Assessment
Abdomen and Fundus pg 1057 -1058
Pt should void prior to checking fundus
Uterus positioned better
More comfortable to client
Position pt on back with legs flexed
Assess relationship of fundus to umbilicus,
midline
Assess firmness of uterus
Massage prn if not firm
Assess any blood discharged during massage
Assess gently, uterus slightly tender
Excessive pain with palpation clue to infection
If cesarean
Palpate fundus gently
Assess incision (REEDA, patency of staples)

Post Partum Nursing Assessment
If uterine atony (boggy):
Question patient about her bleeding, passage of
clots
Re-eval bladder
Babe to breast if nursing
Assess maternal BP, pulse
Notify MD since may need oxytocic med

Post Partum Nursing Assessment
Lochia pg 1059
Assess for character, amt, odor, clots
Should never be more than moderate amt with
non-offensive odor:
Partially saturate 4-8 pads, 6 average/day
Women with C/S bleed less first day than vag del
Also assess womans pad changing practices, her
type of pad
Assess chux pad
If pt reports heavy bleeding, change pad, reassess
in 1 hr
If need accurate assessment, can weigh pad; 1g =
1cc
Teach proper wiping, progression of lochia

Post Partum Nursing Assessment
Perineum pg 1061-1062
Inspect with pt in Sims position
Lift buttock to expose perineum, anus
If present, assess episiotomy or laceration for
REEDA
Should have minimal tenderness with gentle
palpation
No hardened areas or hematomas
Also assess hemorrhoids: size, pain
Evaluate effectiveness of any comfort measures
performed
Educate about suture absorption


Post Partum Nursing Assessment
Lower Extremities
PP woman at increased risk of thrombophlebitis,
thrombus formation; most likely site is legs
To screen, use Homans sign (not diagnostic)
Nurse grasps foot and dorsiflexes sharply
Should have no calf pain
If positive for pain notify MD
Check for edema, redness, tenderness, warmth of
leg
Prevention best
Early ambulation
Passive ROM for cesarean client till sensation
returns
Teach
Signs and symptoms to watch after discharge
Self care for prevention ambulate, leg exercises
in bed, avoid crossing legs and pressure behind
knees

Post Partum Nursing Assessment
Elimination
Urinary
Should void within 4 hours, then q 4-6 hours
Monitor bladder carefully first few hrs (diuresis)
Watch for distention
Misplaced or boggy uterus, palpable bladder signs
Check to see if empty first few times
Use techniques to encourage void
If cant void after 8 hours or voiding small (<100
mL) amounts frequently, then cath
Evaluate for fluid intake, ask if bladder feels
empty, UTI symptoms

Post Partum Nursing Assessment
Elimination
Bowels
Ask about concerns
Evaluate whether having stools since delivery
Constipation causes pressure on sutures, increases
discomfort
To avoid constipation:
Stool softeners
Encourage ambulation
Force fluids (>2000mL/day)
Fresh fruits and veggies

Post Partum Nursing Assessment
Rest status
Requires energy to make adjustments to
motherhood and infant
Fatigue often significant problem
Evaluate amount of rest mother is getting
Determine cause of not sleeping, use appropriate
interventions
Encourage daily rest period
Arrange activities in hospital

Post Partum Nursing Assessment
Nutritional status
Non-nursing
Decrease calories by 300/day
Return to pre-preg nutritional requirements
If nursing
Increases calories by 200 over preg level or 500
over pre-preg level
Refer to dietician if vegetarian, food allergies,
lactose intolerance or have specific food needs
related to culture/religion
Advise iron supplements, prenatal vitamins for 3
months esp if nursing

Postpartal Psychologic Adaptations
PP time of adjustment and adaptation to new
baby, pp discomfort, change in body, loss of
pregnancy
2 periods of adjustment:
Taking in period
First couple days, tends to be passive, dependent
Hesitates to make decisions, follows suggestions
Preoccupied with her needs
Must assimilate experience
Talks about labor, sorts out reality
Sleep, eat is major focus
Postpartal Psychologic Adaptations

Periods of adjustment
Taking hold period
By 2
nd
3
rd
day ready to resume control of body, mothering and her life
Needs reassurance needed shes doing well as mother
This theory 40 years old, slightly outdated as women more independent today
Adjust more rapidly in shorter time periods than these