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Postnatal Mother Examination - BUBBLE-HE

Postnatal Assessment through BUBBLE-HE

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Postnatal Mother Examination - BUBBLE-HE

  1. 1. Postnatal Assessment By-Isha Thapa Magar Nursing Instructor B.Sc 3th Year
  2. 2. History Taking Postnatal Mother Examination
  3. 3. Postnatal Mother Examination
  4. 4. Objective • To observe the general condition of the mother. • To find out postnatal problem and manage. • To provide necessary health teaching to mother and family. • To improve mental and physical health of mother.
  5. 5. Equipments • Thermometer tray • BP instrument • Measuring tape • Clean glove • Kidney tray
  6. 6. • Clean swabs and gauze piece • Weighing scale • Bed pan for mother unable to move • Screen • Torch
  7. 7. Procedure Procedure
  8. 8. A. Getting Ready • Prepare the necessary equipment. • Greet the women respectfully and with kindness. • Explain mother about the procedure
  9. 9. • Ask the mother to empty her bladder. • Maintain Privacy. • Wash hands.
  10. 10. B. Physical Examination
  11. 11. 1.Assessment of General well being
  12. 12. Gait and Movement - Normal walk without a limp - Gait and movements are steady and moderately paced. Behavior &Facial expression - Alert, responsive, cooperative, calm
  13. 13. General cleanliness, noting visible dirt and odor. Check skin noting lesions and bruises - Normally , skin free from lesions and bruises. Check conjunctiva – If conjunctiva appears white or very pale see anemia for additional information
  14. 14. 2. Vital sign Measurement
  15. 15. 2. Vital Signs measurement: Temperature - Temperature during the first 24 hours postpartum is within the normal range. - If fever, up to 100.4◦F (38◦C)→ indicate dehydration
  16. 16. - Temperature should be normal after 24 hours with replacement of fluids - A temperature above100.4◦F (38◦C) at any time or an abnormal temperature after first 24 hours → indicate infection
  17. 17. Pulse - Puerperal bradycardia (40 to 80 beats per minute) → normal during the first week after birth - Orthostatic hypotension - Tachycardia → indicate anxiety, excitement, fatigue, pain, excessive blood loss, infection, cardiac problems.
  18. 18. Blood pressure • Immediately after childbirth, the blood pressure should remain the same as during labor. • An increase in blood pressure →indicate gestational hypertension
  19. 19. A decrease in blood pressure → indicate shock, orthostatic hypotension, dehydration, a side effect of epidural anesthesia. Blood pressure vary based on the woman's position, so assess blood pressure in the same position every time.
  20. 20. Respirations - Normal respiratory rate of 12 to 20 breaths per minute should be maintained. - No important to assess breath sounds → if the mother has had a normal vaginal delivery, is ambulatory, and is without signs of respiratory distress.
  21. 21. • Breath sound always should be auscultated if the birth was cesarean or the mother is receiving magnesium sulfate, is a smoker, or has a history of frequent or recent upper respiratory tract infections, or asthma. -Important for auscultation of breath sound →if birth was cesarean, mother is receiving magnesium sulfate, is a smoker, or has a history of frequent or recent upper respiratory tract infections, or asthma.
  22. 22. Pain • Pain is fifth vital sign • Ask the woman about the type of pain and its location and severity using a numeric scale from 0 to 10 points
  23. 23. Components of postnatal examination “BUBBLE-HE” •BreastB •UterusU •BladderB
  24. 24. •Homan’s signH •Emotional StatusE •BowelB •LochiaL •EpisiotomyE
  25. 25. 3. Breast examination
  26. 26. Inspection Inspect breasts for; - Size, asymmetry - Contour - Erythema - Engorgement - Note any abnormalities. Inspect nipples for; - Cracks - Redness - Lesions - Sores, rashes - Fissures or bleeding - Erect, flat or inverted
  27. 27. • One breast is slightly larger than other. • If breastfeeding, breasts look lumpy or irregular than usual. • Veins larger and darker, more visible beneath the skin. • Regular with no dimpling, no visible lumps, skin is smooth with no puckering, no redness, no lesion sores or rashes. • Tenderness and lumpiness in both breasts during the menstrual cycle. • Areolas larger and darker. Normal Breast
  28. 28. • Changes in colour of breast or nipple, wrinkling, dimpling, thickening, puckering. • A nipple sink into breast. • A red, scaly rash or sore on breast &nipple. Abnormal findings
  29. 29. Punker /Dimpling Inverted nipple Dripping Nipple Cracked Nipples
  30. 30. Breast Lump
  31. 31. Contd………
  32. 32. Palpate • If breastfeeding, breast feel lumpy or irregular depending on emptying of milk ducts/lobes. • No discharge, pus coming from nipple, no cracks, fissures, or other lesions , no inverted nipples. • A clear or milky discharge called galactorrhea present when nipple is squeezed. Normal Finding
  33. 33. Galactorrhea
  34. 34. • Redness, warmth, painful lump or on entire breast →indicate abscess or mastitis. • A bloody discharge or milk discharge occur without stimulation Abnormal Finding
  35. 35. 4. Abdominal Examination
  36. 36. Inspection Inspect the shape, size, movement of abdomen with respiration, scarred gravid, linea nigra, caesarean section, old and new incision on the abdomen. Caesarean section incision sites →healing process, discharge, redness and signs of infections.
  37. 37. Linea nigra
  38. 38. Scarred gravida
  39. 39. Palpate Fundus 2.Place mother in a supine position with her knees slightly flexed. 1. Palpate fundus for consistency and location. It should be firmly contracted and at or near the level of the umbilicus.
  40. 40. 4. Place non-dominant hand above mother’s symphysis pubis. This supports and anchors the lower uterine segment during palpation or massage of the fundus. 3. Put on clean gloves and lower the perineal pads to observe lochia as the fundus is palpated.
  41. 41. 6. Palpate gently at umbilicus until the fundus is located. Determine the firmness and location of the fundus. This should be firmly contracted, in the midline and approximately at the level of the umbilicus. 5.Use flat part of fingers (not the finger tips) for palpation. Palpation may be painful, for the mother who had a cesarean birth.
  42. 42. 8.The location of fundus should be rechecked after emptying bladder. If fundus is difficult to locate or is soft or boggy, keep non dominant hand above symphysis pubis and massage fundus with dominant hand until fundus is firm. 7.If uterus is above the expected level or shifted from the middle of the abdomen (usually to the right), the bladder may be distended.
  43. 43. - Removing clots allows the uterus to contract properly. A firm fundus and pressure over the lower uterine segment help prevent uterine inversion. 9.After boggy fundus is massaged until it is firm, press firmly to expel clots. Do not attempt to expel clots before the fundus is firm. Keep one hand pressed just above the symphysis (over the lower uterine segment) throughout. - Removing clots allows the uterus to contract properly. - A firm fundus and pressure over the lower uterine segment help prevent uterine inversion.
  44. 44. 11. Document the consistency and location of the fundus. 10.Measure fundus height in centimeters or use fingers breaths. Generally fundal height decreases about 1cm per day for first 9-10 days post-partum
  45. 45. - Consistency is recorded as "fundus firm", "firm with massage", or "boggy". - Fundus height is recorded in finger breaths or centimeters above or below the umbilicus. For example, "fundus firm, midline, ↓1'' (one finger breath or 1 cm below the umbilicus). - "fundus firm with light massage, U+2 (two finger breaths or 2 cm above the umbilicus), displaced to right".
  46. 46. 5. Bladder examination - Ask to pass urine frequently the first few days. - Normal if bladder is not palpable. - Women is able to urinate when the urge is felt.
  47. 47. - Monitor clients for signs of UTI, including fever, urinary frequency and/ or urgency, difficult or painful urination. - Infrequent or insufficient voiding (less than 200 ml) discomfort, burning urgency, or foul smelling urine suggest infection
  48. 48. 6. Bowel examination Inspect the woman's abdomen for distention, auscultation for bowel sounds in all four quadrants prior to palpating the uterine fundus, and palpate for tenderness. Ask the patient about daily bowel movement or has passed gas since giving birth.
  49. 49. She must no become constipated. Explain that she should wipe from front to back after voiding or defecating. Normal assessment findings are active bowel sounds, passing gas, and a non-distended abdomen.
  50. 50. 7. Lochia Examination Check and note colour, order and amount of lochia. To assess amount - ask her how many perineal pads she has used in the past 1 to 2 hours and - how much drainage was on each pad. (pad completely, or was only half of pad covered with drainage) - Ask about color of drainage, odor, and presence of any clots. Lochia increases with maternal activity and breastfeeding which is normal.
  51. 51. Lochia Type & Color Lochia Rubra. • Bright red, have small clots • Usually lasts first 3 days Lochia Serosa • Pink, contain more serum, leucocytes and bacteria • Discharge usually during 4th to 7th day. Lochia alba • White in colour, creamy brown. • Contains leucocytes, cervical mucus, serous exudates, granular epithelial cells, cholesterol crystal, debris from healing tissue. • Usually discharge upto 10-15 days. If lochia is foul smelling, lochia rubra persists for 2 weeks or more need more additional assessment.
  52. 52. Lochia Odor Lochia should have" no foul odor". A truly foul odor may be a sign of infection.
  53. 53. Lochia Amount • 5cm saturation of pad in one hour =10 ml.Scant • 10 cm saturation of pad within 1 hour =10 to 25mlLight The average amount of discharge for the first 5-6 days is estimated to be 250 ml.
  54. 54. • Moderate; 15cm saturation with in 1 hour =25 to 50 ml. Moderate • Heavy; pad is completely saturated within 1 hour = 50 to 80 ml. Heavy • Postpartum hemorrhage is clinically defined as a pad saturated within 15-30 minutes. PPH
  55. 55. Amount of lochia
  56. 56. During examination, the quantity, colour, odor and consistency of lochia are significant. a. Persistence of red lochia → indicates secondary postpartum hemorrhage. b. Brown profuse lochia with bulky uterus → sub-involution of the uterus c. Excessive lochia → retained product of conception.
  57. 57. d. Scanty lochia → indicate poor drainage. e. When associated with pyrexia they are due to localized uterine infection.
  58. 58. 8. Episiotomy and perineum examination Examine episiotomy and perineum area through REEDA Assessment R-Redness E-Edema E-Ecchymosis D-Discharge A- Approximation
  59. 59. • Redness → infection or hematoma. • Ecchymosis (excessive bruising) → vaginal trauma and requires additional evaluation. • Discharge→ should follow the expected lochia pattern. • Approximation→ episiotomy lines should be well approximated.
  60. 60. Episiotomy line
  61. 61. Perineum • Pull the labia from front to back. • Check the episiotomy or areas of vaginal tearing. • Look for hematoma formation, hemorrhoids, vaginitis, perineal tearing.
  62. 62. Vulvar hematoma
  63. 63. 9. Homan’s sign Complain of pain in calf of the leg upon dorsi- flexion of foot with leg extended is diagnostic of Deep Vein Thrombosis (DVT) of the area. A positive Homan's sign is indicative of DVT.
  64. 64. Homan’s sign
  65. 65. 10. Emotional status After delivery the woman may progress through Rubin’s stages of taking in, taking hold & letting go phases. • May Begin with a refreshing sleep after delivery. • During first 24 to 48 hours after giving birth, mother exhibits passive, dependent behavior. • New mothers spend time touching baby commonly identifying specific features in newborn such as " he has my nose" or his fingers are long like his father's. 1. Taking In Phase
  66. 66. • Starts on 2nd to 3rd day postpartum and may last several weeks. • Woman begins to initiate action and to function more independently but still show dependent behaviors. • Woman may require more explanation and reassurance that she is functioning well, especially in caring for her infant. • As the woman meets success in caring for the newborn, her concern extends to other family members and their activities. 2.Taking hold phase
  67. 67. • It begins near end of 1st weeks. • Mother reestablishes relationships with couple and other people. • She assumes responsibility and care for newborn independently. 3. Letting go phase
  68. 68. 11. Health Teaching Health teaching should be given as per need identification of mother.
  69. 69.   