1. Monitoring Postpartum Recovery Jolene K. Bethune, RN, MSN

2. At the completion of this presentation, you will be able to: Perform postpartum checks according to protocol Monitor vital signs and blood pressure Inspect and palpate the breasts Palpate the fundus and bladder Monitor urinary output Monitor bowel activity Monitor lochia Inspect the perineum Monitor extremities for thrombophlebitis Objectives

3. You will need: Hand-washing station. Gloves. Oral glass, electronic or tympanic thermometer. Stethoscope. Doppler ultrasound stethoscope or probe.

4. Conductive jelly. Watch with sweep second hand. Sphygmomanometer with assorted cuffs; or continuous non-invasive blood pressure monitoring device. Maternity pads.

5. Postpartum Check 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

6. Vital Signs and Blood Pressure Wash hands and explain the procedure to the patient To 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.

7. Inspect and Palpate the Breasts Raise the head of the bed Ask the patient lower her gown so that her breasts can be examined Visually inspect and palpate each breast noting: Soft, filling or firm Engorged, reddened, or painful Nipples: erectility, possible cracks and redness

8. Palpate the Fundus 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.

9. Palpate the Fundus 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 tone Fundal 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.

10. Palpate the Bladder During fundal palpation Bladder palpability Bladder distention could displace the uterus Impeding involution Impeding the control of bleeding.

11. Monitor Urinary Output 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?

12. Monitor Bowel Activity Bowel movements: When was her last BM? Normal, diarrhea or constipation? Hemorrhoids: Are there hemorrhoids present? Is there active bleeding Bowel sounds: auscultate all four quadrants: Especially C/S patients; why? Normo-, hyper- or hypoactive?

13. Monitor Lochia 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.

14. 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 hemorrhoids Bruising, hematoma, edema, discharge, approximation Inspect the Perinuem

15. Monitor Extremities for Thrombophlebits Homan’s sign (calf pain from passive dorsiflexion of foot) Redness, tenderness or warmth

16. References Bradshaw, M. J., & Lowenstein, A. J. (2007). Innovative teaching strategies in nursing (4 ed.). Sudbury, MA: Jones and Bartlett Publishers. Mattson, S., & Smith, J. E. (Eds.). (2004). Core curriculum for maternal-newborn nursing (3 ed.). St. Louis, MO: Elsevier-Saunders. McEwen, M., & Wills, E. M. (2007). Theoretical Basis for Nursing (2 ed.). Philadelphia, Pennsylvania: Lippincott Williams & Wilkins. National League for Nursing Accrediting Commission. (2008). 2008 Edition NLNAC Accreditation Manual. New York City. NY: Author. Simpson, K. R., & Creehan, P. A. (2008). Perinatal nursing (3 ed.). Philadelphia, PA: Association of Women’s Health, Obstetric and Neonatal Nurses. Smith, S. F., Duell, D. J., & Martin, B. C. (2000). Clinical nursing skills: basic to advanced skills (5 ed.). Upper Saddle River, NJ: Prentice-Hall, Inc.. Swearingen, P. L., & Howard, C. A. (Eds.). (1996). Photo atlas of nursing procedures (3 ed.). Menlo Park, CA: Addison-Wesley Nursing. Wendt, A., Kenny, L., & Stasko, J. (Eds.). (2008). 2008 Detailed test plan for the NCLEX-PN examination-Item writer/item reviewer/nurse educator version. Chicago, IL: National Council of States Boards of Nursing.