Reproductive Issues

FIGURE 27-4 Suggested guidelines for assessment of lochia volume. The pad may also be weighed and compared with the weight of a clean dry pad (1 g of weight equals 1 mL). A, Scant, less than 1 inch (2.5 cm). B, Light, less than 4 inches (10 cm). C, Moderate, less than 6 inches (15 cm). D, Heavy, pad saturated within 1 hour.

(From Lowdermilk DL, Perry SE: Maternity and women’s health care, ed 9, St. Louis, 2007, Mosby.)

in postpartum assessments. Hemorrhoids (varicosities of the rectum) usually disappear quickly after delivery if there is no longstanding history of this problem. Use topical anesthetics to relieve pain if ordered by the physician. Sitz baths also provide relief and should be offered if the physician has ordered them. Suppositories may be ordered for hemorrhoid treatment.

Examine the patient’s legs by stretching and straightening each leg, then using dorsiflexion on the foot. Pain in the calf is a positive Homans’ sign, which indicates inflammation of the blood vessels of the leg and possible thrombophlebitis. Notify the physician promptly. Some facilities have policies that restrict the dorsiflexion of the foot out of concern that it may result in a clot being released. In this case, the lower extremities should be closely examined for warmth and redness. Note that early ambulation is the leading means of prevention of this potential complication.

The postpartum assessment can be organized as a head-to-toe assessment with the eight letters BUBBLE-HE (Box 27-9).

Lactation and breastfeeding.

All new mothers should be encouraged to wear a bra regardless of breast size. The bra should be comfortable and fitted to provide support. Encourage breastfeeding mothers to use bras large enough to accommodate the growth that occurs with lactation. Nonnursing mothers need

Box 27-9 Postpartum Assessment: BUBBLE-HE

• Breast: For assessment of the breast, have the patient lie down and remove her bra. Palpate both breasts for engorgement or nodules. Inspect nipples for pressure, soreness, cracks, or fissures.
• Uterus: The top of the uterus, the fundus, should remain very firm. If it becomes soft, the uterine muscles probably are not contracting properly or the uterus has retained placental fragments. Both conditions predispose the patient to hemorrhage. Gently massage the uterus to help the muscles contract and expel placental fragments.
• Bladder: The new mother may urinate frequently the first few days after giving birth. Be alert for signs and symptoms of infection. Also note any dysuria or urinary retention.
• Bowel: Because of early discharge from the hospital, many women leave without having had a bowel movement. Assess for bowel sounds, encourage activity with rest periods, and encourage adequate fluid intake.
• Lochia: Lochia has a definite fleshy scent, but if it has a fetid odor, it may indicate infection. Assess carefully.
• Episiotomy: Most new mothers have an episiotomy and, in some cases, a laceration. (NOTE: There is a move away from doing an episiotomy on the side—either left or right—and possibly even away from doing episiotomies at all, but midline is the site of choice. For a lateral episiotomy, use the following procedures.) Position the patient on her affected side. Instruct her to flex her top leg at the knee and draw it up toward her waist. Use a flashlight and wear gloves. Stand behind the patient and gently lift her top buttock to expose the perineum. Also assess for hemorrhoids.
• Homans’ sign: For patient assessment, position the legs flat on the bed while she reclines in the supine position. Dorsiflex her foot toward the ankle. Assess both extremities. If she reports calf pain, Homans sign is positive; further assessment is needed because a blood clot in a vessel in the leg is indicated.
• Emotional status: Consider the three phases most new mothers pass through:
  • 1.The first is “taking in,” the time immediately after birth. She sleeps, depends on others for nurturing and food, and relives the events surrounding the birth.
  • 2.Over the next few days, she is “taking hold.” She is preoccupied with the present and concerned about her health and her baby’s condition. She cares for herself and wants to learn to care for her newborn.
  • 3.The next phase, “letting go,” comes later in the postpartum period. She reestablishes relationships with other people.
    • Monitor the patient’s emotional status, noting how she interacts with her family, her level of independence, sleep and rest patterns, mood swings, irritability, or crying.

Modified from Ferguson H: Planning letter-perfect postpartum care. Nursing 17(5);50, 1987.

a bra that provides adequate compression to inhibit lactation without being uncomfortable.

With the bra removed, inspect and palpate the breasts. Observe for erythema, heat, edema, and engorgement.

Engorgement is an uncomfortable fullness of the breasts that occurs when the milk supply initially comes in. It is a result of venous and lymphatic stasis that occurs during lactation. Filling of the breast with milk usually begins in the axillary region, so palpate both the body and the tail of the breast. Engorgement is usually observed about the third day postpartum and resolves in about 48 hours. Because most patients are home by the time engorgement occurs, teach the new mother the symptoms of engorgement and methods of obtaining relief. If the patient is breastfeeding, interventions such as manual expression of milk and application of warm, moist heat are most useful. If the patient is not breastfeeding, compression of the breasts with a firm bra, wrapped ice packs, and analgesics are most often recommended.

Inspect the nipples for inflammation, fissures, or tenderness. The nipples generally do not cause problems for nonlactating mothers; however, if the patient is breastfeeding, the nipples should be kept soft and supple. Most physicians recommend avoiding soap or other chemicals because they dry the skin and may be ingested by the infant. Plain water and air drying may prevent problems. Some physicians recommend allowing the nipples to dry after feeding without removing the milk residue. If additional moisturizer is needed, small amounts of unscented lanolin or a nipple cream may be used to soften and soothe dry, tender nipples. Modifications in the positioning of the baby may be needed if tender or cracked nipples continue to be a problem.

In addition to assessing the breasts, help the breastfeeding mother succeed in establishing lactation. To establish the lactation response, the breast must be adequately stimulated so prolactin can be released by the anterior pituitary. Once the milk supply is established, prolactin production decreases, and oxytocin, released as the baby suckles, primarily maintains the supply of milk.

The mother may feel a tingling or prickling sensation, known as the let-down reflex, when feeding time approaches. If the mother nurses the baby at regular, frequent intervals and empties the breasts, the supply of milk increases in response to the baby’s demands. If the breast is not adequately stimulated, the lactation response may not be established. This can happen when the baby has a weak suck or is not put to breast often enough. If the breast is not emptied adequately, the pressure of the milk in the alveoli can also suppress milk production. Incorrect placement at the breast may also lead to problems. If the baby’s mouth grasps only the nipple and does not apply pressure on the lactiferous glands (mammary glands or Montgomery’s glands, consisting of 20 to 24 glands in the areolae of the nipples), milk is not released and the needed stimulation does not occur. This also may lead to nipple trauma and soreness.