- The postpartum period is the period of time immediately following delivery to approximately 6 weeks after birth.
- The nurse must thoroughly assess both mom and newborn during the postpartum period.
- The nurse must also thoroughly educate mom (and dad and/or support system)
- Head to toe assessment
- Utilize BUBBLE mnemonic
- B – breasts
- U – uterus
- Fundus (patient should empty bladder prior to fundal assessment as this can affect results)
- Last bowel movement
- Passing gas?
- Last bowel movement
- Signs of UTI
- Is she fully emptying
- Any odor?
- Incisions (c/s) and laceration or episiotomy repairs
- Assess for blood clots
- Assess, observe and promote bonding with newborn
- Assess emotional status
- Nipple ointment
- Supportive bra
- U- uterus
- Stool softeners
- UTI treatment if needed
- Slow bleeding if too heavy
- Manage blood clot if present
- Promote bonding
- Infection control
- Assess and educate about feeding (breast or bottle)
- Demonstrate and have patient participate in bathing newborn
- Educate that intercourse should be avoided until cleared by physician at 6 weeks
- Once intercourse has been resumed, educate on importance of contraception as women can still get pregnant while breastfeeding even if no menstrual bleeding has resumed
- Promote compliance with outpatient follow up visit in 4-6 weeks
- Educate on when to notify MD after discharge
- Signs of infection
- Signs of postpartum depression
- Increasing lochia
In this lesson I will explain postpartum interventions and when each are used.
When the patient has delivered she now enters the postpartum period. This lasts until about 6 weeks post delivery. This patient needs frequent assessment. We will assess pain. Our 5th vital sign, right? She just had a baby and that hurts no matter how it came out so let’s assess it and fix it if there is pain. So medications like ibuprofen and oxycodone. Then you will be assessing her from head to toe. A regular head to toe assessment like you do on your med-surg patients. In addition to the head to toe assessment we will add some extra assessment pieces to this because she has had a baby so this makes her a little more unique then our regular med-surg patient. For this we will utilize the BUBBLE mnemonic. This mnemonic is breasts, uterus, bowel, bladder, lochia, and the e is episiotomy, extremities, and emotions. Some instructions only pick one of these but I think all three are super important and should be included in the mnemonic because they should all be included in the assessment.
Ok so now you will be assessing your patient and doing the BUBBLE assessment. This is breasts, uterus, bowel, bladder, lochia, episiotomy, extremities, and emotions. For more information and details on this refers to the postpartum physiological changes. Now let’s talk about what could be found as a problem with each of these and how we will intervene.
Now we have assessed our patient and need to know the interventions we will do for what we have found. So let’s say our patient is breastfeeding and has some nipple damage. We can use lanolin or Jack Newmans nipple ointment. We want to tell her to wear a supportive bra to help ease discomforts as the milk comes in. Remember even a bottle feeding mom will have her milk come in. Now you move down to assess the uterus and it is boggy. Our first intervention will be to massage the fundus and try to get it to firm up. So you literally make a fist and rub the fundus in a circular motion. It should firm up. On assessment you also noted that your patient’s uterus was above the umbilicus. We want to have her void, make sure her bladder isn’t full and pushing that uterus up which could also cause it to bleed. During your assessment your patient told you she is constipated and hasn’t had a bowel movement. You also noted she had hemorrhoids on your assessment. So we can offer tucks pads which have witch hazel to ease the hemorrhoids and then make sure she is drinking plenty of water and taking a stool softener for her constipation. If it is really bad a laxative could be given. Your patient is also telling you that it burns when she voids. Usually these patients have a catheter at some point during labor so they are more at risk for a UTI. So for this patient we would want to have her urine sent to the lab for a urinalysis and culture and the patient on antibiotics if it is a UTI. Now some patients that deliver vaginally are going to complain of burning because they could have a urethral tear but they still need to be checked for a UTI. While you were massaging her boggy uterus you noted there to be a soaked pad. When you asked how long ago she changed the pad she told you 15 minutes ago when she used the bathroom. Well that is a problem! We don’t want a patient to soak a pad in under an hour, it is just too much bleeding. So for this patient we are massaging a boggy uterus which would hopefully fix the problem but if not we are putting a fresh pad so we can assess for additional bleeding and might need to give medications. These medications would include oxytocin or pitocin being our main drug to contract the uterus. Methylergonovine and carboprost tromethamine are some other hemorrhage medications that could be used. Refer to the postpartum hemorrhage lesson for more information on that. Not only does your patient have all of this going on but you also note a foul odor in her lochia. This could be a sign of infection and that would need to be assessed and address with antibiotics. Ok we are now at the last bit of assessment and I know you are hoping nothing else could be wrong, but her vagina is so swollen and there is bruising around her episiotomy, one leg is red and more swollen than the other and the patient doesn’t want to hold her baby because she is scared. The patient shows signs of a blood clot so interventions that can be done to prevent this would be compression hose, which will specifically be done on all c-section patients. Her vagina will be bruised and swollen but we can intervene with ice packs to help reduce pain and swelling. She is not bonding well so we want to encourage that. Ways you can help promote bonding are to talk to her about her baby and involve her in the care.
We will provide education on feeding. So bottle feeding will occur every 3-4 hours and this mother will still make breast milk. So both mother’s will need to wear a supportive bra. A bottle feeding mother will want to prevent any stimulation to the breasts so this also includes hand expression and pumping. It is supply and demand so if stimulation occurs or milk is leaked out then the body will make more. Also the warm shower water should be kept on the back if possible because it can stimulate the milk to drop in. She can also use cabbage leave to dry up the milk. Motrin is helpful for both breast and bottle feeders to help with the engorgement pain. A breastfeeding mother will need to ensure she has a good latch to prevent nipple damage. Refer to the lesson on breastfeeding. If we can include the parents in the infant’s care it will help promote bonding. So educate on things like giving a bath, diaper changes, and holding and have them do these things to promote bonding. Contraception education is important because this patient probably doesn’t want to get pregnant again quite yet. She needs to know that she should have nothing in the vagina for 6 weeks or when she gets cleared by her physician. So this means no intercourse. Sometimes this education needs to be given more so to the significant other then to the mother. We always direct this education with the father in the room so they hear it too. Contraception should be used even if a patient is breastfeeding and having no period because the patient can still get pregnant. Patient’s need to understand that lactation amenorrhea does not mean it is safe to use no precautions. She needs to know when to follow up. Usually around the 6 week point unless there is something unusual with her case. The patient must know when to notify the doctor after discharge. So this would be any signs of infection like a temperature. Signs of postpartum depression should be reported. So everyone is going to experience some type of blues after delivery because of those hormones again,. They cry at everything and that is ok, but if that lasts longer than 10 days they should let their doctor know. A big piece of education needs to be on lochia. If there is an increase in lochia or the progression of color moves back to red then she needs to notify the doctor.
Our concepts are infection control because we are watching for this and intervening, comfort because the patient has just had a baby and is getting pain medication and ice packs, and safety because our priority is to keep the patient safe and intervene however possible.
Our interventions will depend on what is needed. So breast care education will be an intervention, uterine massage if the uterus is boggy or bleeding, stool softeners for constipation, tucks pads for hemorrhoid care, ice packs for the perineal swelling, compression hose to prevent blood clots, and any intervention we can do to promote care and bonding.
Make sure you check out the resources attached to this lesson and review what to watch for any how you would intervene.
Now, go out and be your best selves today. And, as always, happy nursing.