Editing Maternal and Newborn Nursing (section)

== Postpartum Care ==

=== Systematic assessment: BUBBLE-HE ===

'''B'''reasts, '''U'''terus, '''B'''ladder, '''B'''owel, '''L'''ochia, '''E'''pisiotomy or perineum, '''H'''oman sign and lower extremities or VTE risk, '''E'''motional status. Many facilities add pain and Rh or rubella status.

* '''Uterus''': the fundus should be '''firm, midline, and at or near the umbilicus''' within a few hours of birth, then descend about 1 fingerbreadth (1 cm) per day, becoming nonpalpable by roughly 10 to 14 days. '''A boggy fundus is massaged first.''' A fundus that is '''high and deviated to the right''' almost always means a '''full bladder''', which prevents contraction and causes bleeding; have the patient void, then reassess. Afterpains are stronger in multiparas, with breastfeeding, and with an overdistended uterus.
* '''Lochia''': '''rubra''' (dark red, days 1 to 3), '''serosa''' (pinkish-brown, days 4 to 10), '''alba''' (creamy white or yellow, day 11 through about 4 to 6 weeks). Small clots can be normal early. '''Abnormal: saturating a perimeter pad in 1 hour or less, a foul odor, large clots, bright red bleeding that returns after progressing to serosa, or lochia that is heavier when the fundus is firm''' (suggesting a laceration rather than atony). Always check underneath the patient; blood pools under the buttocks.
* '''Breasts''': assess for engorgement, nipple integrity, and mastitis (usually unilateral, localized redness, warmth, tenderness, fever, and flu-like symptoms). '''Mastitis is treated with antibiotics and continued emptying of the breast; the patient keeps breastfeeding or pumping.'''
* '''Bladder''': postpartum diuresis is normal and large. Watch for urinary retention with overflow (frequent small voids) especially after an epidural. Aim for voiding within about 6 to 8 hours of birth.
* '''Bowel''': constipation is very common. Fluids, fiber, ambulation, and a stool softener; a third- or fourth-degree laceration is a contraindication to suppositories and enemas.
* '''Perineum''': assess with the '''REEDA''' framework - '''R'''edness, '''E'''dema, '''E'''cchymosis, '''D'''ischarge, '''A'''pproximation. Ice for the first 24 hours, then sitz baths, peri-bottle rinsing front to back, topical anesthetics, and a donut cushion as needed. A '''hematoma''' presents as severe unrelieved perineal or rectal pain with a bulging bluish discolored area, and it can hide significant blood loss.
* '''Extremities''': assess for unilateral calf swelling, warmth, redness, and pain. Homan sign is unreliable and is no longer recommended as a diagnostic maneuver, but it appears in older material. Early ambulation and prophylaxis reduce VTE risk, which is elevated for weeks after birth.

=== Normal postpartum physiology ===

* '''Bradycardia of 50 to 70 beats per minute in the first days is normal''' from increased stroke volume and mobilized blood volume. '''Tachycardia is the abnormal finding''' and suggests hemorrhage, pain, infection, or anxiety.
* Temperature up to 100.4 degrees F (38 degrees C) in the first 24 hours may reflect dehydration and normal exertion. '''A temperature of 100.4 degrees F or higher on two occasions after the first 24 hours suggests puerperal infection.'''
* Profuse '''diuresis and diaphoresis''' occur in the first days as the extra plasma volume is excreted.
* A '''chill and shaking''' right after birth is common and benign if the patient is afebrile.
* Hemoglobin and hematocrit are unreliable in the first 24 hours because of fluid shifts.

=== Postpartum hemorrhage ===

Commonly defined as cumulative blood loss of 1,000 mL or more, or blood loss with signs or symptoms of hypovolemia, within 24 hours of birth regardless of route. Older thresholds of 500 mL after vaginal and 1,000 mL after cesarean birth still appear in test material. '''Early (primary)''' hemorrhage occurs within 24 hours; '''late (secondary)''' occurs from 24 hours to 12 weeks and is most often from retained placental fragments or subinvolution.

'''The four T's''': '''T'''one (uterine atony, the cause in roughly 70 to 80 percent), '''T'''rauma (lacerations, hematoma, uterine inversion or rupture), '''T'''issue (retained placenta), '''T'''hrombin (coagulopathy, including DIC).

'''Nursing sequence for a boggy uterus with heavy bleeding''': '''massage the fundus first''' (an independent nursing action that often works), '''have the patient empty the bladder or catheterize''', then anticipate '''uterotonics''', large-bore IV access, isotonic fluids, oxygen, type and crossmatch, quantitative blood loss measurement, and provider notification. Reassess after every intervention.

'''Uterotonics and their key contraindications''' (a very high-yield set):
* '''Oxytocin (Pitocin)''' - first line; watch blood pressure and, with prolonged high-dose use, water intoxication.
* '''Methylergonovine (Methergine)''' - '''contraindicated in hypertension and preeclampsia'''; check the blood pressure before every dose.
* '''Carboprost tromethamine (Hemabate)''' - '''contraindicated in asthma'''; commonly causes diarrhea, nausea, and fever.
* '''Misoprostol (Cytotec)''' - can be given by several routes; causes fever and shivering.
* '''Tranexamic acid''' is used as an adjunct within 3 hours of birth.

Classic early signs of hypovolemia in a healthy young obstetric patient are '''tachycardia, narrowing pulse pressure, restlessness or anxiety, and cool clammy skin'''; a falling blood pressure is a late sign.

=== Psychosocial and discharge issues ===

* '''Postpartum blues''': tearfulness, mood lability, and fatigue affecting a majority of patients, beginning within days and resolving by about 2 weeks. Care is reassurance, rest, and support.
* '''Postpartum depression''': persists beyond 2 weeks or begins later within the first year, with impaired function, anhedonia, guilt, and possible thoughts of harming self or the infant. Screening with a validated tool such as the Edinburgh Postnatal Depression Scale is standard. Treatment is effective; the nurse screens, refers, and follows up rather than reassuring the patient that it will pass.
* '''Postpartum psychosis''': a '''psychiatric emergency''' with hallucinations, delusions (often about the infant), disorganized thinking, and elevated risk of infanticide and suicide. It requires immediate evaluation and usually hospitalization, and the infant must not be left alone with the parent.
* '''Rubella-nonimmune patients''' receive MMR before discharge, with teaching to avoid pregnancy for 28 days. '''Rh-negative patients with an Rh-positive newborn''' receive Rho(D) immune globulin within 72 hours.
* Teach the patient to report fever, foul-smelling lochia, bleeding that soaks a pad in an hour, severe headache or visual changes (preeclampsia can present or worsen ''after'' birth, including up to 6 weeks postpartum), chest pain or dyspnea, unilateral leg pain and swelling, and thoughts of harming self or baby.
* Ovulation can return before the first menses, so contraception counseling happens before discharge. Estrogen-containing contraception is generally avoided in the early postpartum period because of VTE risk and is timed with lactation and risk factors in mind.