SHERPATH: NGN – POSTPARTUM

Client is a 27-year-old Gravida 2 Para 2 who delivered a healthy baby boy at 0402. She had an SVD with no complications, an intact placenta, and a QBL of 260 mL. She had epidural anesthesia for the birth. No reported perineal lacerations. No episiotomy. The newborn was skin-to-skin for the first 30 minutes after birth and then breastfed for 15 minutes on the right breast at 0445. Prenatal care began at 6 weeks’ gestation with no complications during the pregnancy.

Medical History 

• SVD 3 years ago (in 2018) of a healthy girl
• Wisdom teeth extraction at age 17 years old
• Childhood exertional asthma

Nurse Handoff Report from Labor and Delivery to Mother/Baby Nurse

0615 

Situation: “Hi, I am in labor and delivery. I am going to be bringing you a postpartum mother in about 15 minutes. I will be bringing the client and her new baby. Her last set of vital signs were taken at 0600 and were: blood pressure 100/64, pulse 100, oral temperature 99.9 °F (37.72 °C), and respiratory rate 16. I will be bringing the client in a bed because she is still numb from her knees to her feet from her epidural and she is unable to ambulate to a wheelchair. Her background is as follows:”

Background: “The client is a 27-year-old Gravida 2 Para 2 who delivered a healthy baby boy at 0402. She had a spontaneous vaginal delivery (SVD), with no lacerations or episiotomy. She is A+, antibody negative, rubella immune, negative group beta strep (GBS), and negative for all sexually transmitted infections (STIs). She received an epidural for anesthesia, and the nurse anesthetist removed an intact epidural catheter at 0530. Her quantitative blood loss (QBL) was 260 mL. She received a total of 2000 mL IV lactated Ringer solution during labor and another 1000 mL IV infusion of oxytocin in lactated Ringer solution after the delivery of the placenta. Her IV was converted to a heparin lock at 0600 in preparation for transfer to the mother/baby unit. The healthcare provider emptied her bladder with a straight catheter after delivery, and a total of 150 mL of concentrated yellow urine was obtained. She drank 100 mL of apple juice and ate a pack of graham crackers at 0500. She was able to breastfeed her baby on the right breast at 0445 for 15 minutes total. Do you have any questions?”

0630

Assessment: Assessment on admission to mother/baby unit: Client is alert and oriented. Vital signs: blood pressure 110/65, pulse 100, oral temperature 99.8 °F (37.66 °C), and respiratory rate 18. Breasts are soft and nontender. Fundus is firm, three fingerbreadths above the umbilicus and deviated to the right. Lochia is heavy, and rubra in color. Bladder is palpable, perineum is intact, bowel sounds are hypoactive in all four quadrants, and the Homan sign is negative. Client can lift her left leg but cannot lift her right leg and reports “numbness in both of her lower legs below the knee,” reports pain at a “2/10,” and describes it as “cramping.”  

Recommendation: Client will be offered a bedpan to void because of the inability to ambulate. Her legs are still feeling “numb” from her epidural, her fundus is three fingerbreadths above the umbilicus and deviated to the right, and she has a palpable bladder during the examination. If the client cannot void via the bedpan, the nurse will refer to the postpartum orders for next steps.

• Laboratory Results
• Flow Sheet
• Orders

• Flow Sheet
• Orders

0600

Vital signs taken in labor and delivery: blood pressure 100/64, pulse 100, oral temperature 99.9 °F (37.72 °C), and respiratory rate 16. Client and her newborn are preparing to transfer to the mother/baby unit via a bed because client still feels numb from her knees to her feet and unable to ambulate.  

0630

Assessment on admission to mother/baby unit: Client is alert and oriented. Vital signs: blood pressure 110/65, pulse 100, oral temperature 99.8 °F (37.66 °C), and respiratory rate 18. Breasts are soft and nontender. Fundus is firm, three fingerbreadths above the umbilicus and deviated to the right. Lochia is heavy and rubra in color. Bladder is palpable, perineum is intact, bowel sounds are hypoactive in all four quadrants, and the Homan sign is negative. Client can lift her left leg but cannot lift her right leg and reports “numbness in both of her lower legs below the knee,” and reports pain at a “2/10” and describes it as “cramping.”

0645

Client is placed in a high Fowler position and offered a bedpan to void. The nurse provides her with privacy and places the call light within reach to call when she finishes.

0650

Client calls the nurse and states that she “cannot pee in the bedpan.”

• Orders

Postpartum Standing Orders 

• Diet as tolerated
• Activity as tolerated
• Catheter: Straight catheter as needed (PRN) x 2 and then call the healthcare provider
• Discontinue intravenous line (IV) when vital signs stable and bleeding is minimal
• Hemoglobin and hematocrit 24 hours after delivery
• Acetaminophen 325 – 650 mg by mouth (PO) every 4-6 hours PRN pain 
• Ibuprofen 400 – 600 milligrams PO every 4 – 6 hours PRN pain
• Docusate 100 mg PO twice daily (BID)

Rationale:

Potential Conditions

The postpartum client has presented to the mother/baby unit 2 hours after an uncomplicated SVD. In her initial postpartum assessment, the nurse notes that the client has a firm fundus that is three fingerbreadths above the umbilicus and deviated to the right. In addition to this finding, the nurse knows from reports that the client has not voided since immediately after delivery, had 3000 mL of IV fluids during delivery and recovery, and is still experiencing numbness because of epidural anesthesia, which often decreases the client’s urge to void. These assessment findings are consistent with a full and overdistended bladder. Although this client has an increase in lochia, her assessment findings are consistent with an overdistended bladder. A postpartum hemorrhage, subinvolution, and retained placenta would be suspected if the fundus were boggy, lochia was large with clots, vital signs were unstable, and the bladder was emptied. This client has normal vital signs.

Actions to take

The nurse should review the postpartum orders, insert a straight catheter until the urine stops flowing, and perform a PVR with the bladder scanner. Because the client is still experiencing residual effects of the epidural anesthesia, it would not be safe to ambulate her at this time. When the client ambulates, it will be important for the nurse to be at the bedside to assist the client and assess lower extremity numbness and/or orthostatic hypotension; however, this client is not ready to be ambulated at this time. The first-line intervention for an extended bladder is to use a straight catheter to empty the bladder. If the client continues to experience high PVRs after straight catheterization or voiding, a Foley catheter may need to be ordered by the healthcare provider. Vigorously massaging the fundus is not an intervention for a distended bladder and a fundus that is firm. This intervention may be used for a fundus that is boggy and when postpartum hemorrhage is suspected.

Parameters to monitor

Additional assessments include: a fundus check before and after the bladder is emptied because an overdistended bladder may cause the fundus to be displaced and not properly contract, which can cause an increase in vaginal bleeding until the bladder is emptied; assessment of the amount of lochia after the bladder is emptied and the fundus has returned to midline, and assessment of lower extremity mobility to determine when it is safe for the client to ambulate to the restroom. The nurse will assess lower (not upper) extremity numbness to determine when it is safe for her to ambulate to the bathroom. It is not necessary to check the client temperature or orthostatic hypotension to address her issue of overdistended bladder.

CASE STUDY
Postpartum – Patient 2
HISTORY & PHYSICAL:
The client is a Gravida 1 Para 1 who delivered a healthy baby girl at 0602. She had a
spontaneous vaginal delivery (SVD) with a third-degree perineal laceration that was repaired
with sutures. She had an epidural for anesthesia. Her placenta was intact, and her quantitative
blood loss was 225 mL. She was transferred via a wheelchair to her postpartum room at 0830
and was ambulatory to her bed.
NURSE’S NOTES:
1755
Nurse call over the call light: “I am in room 325. I got up to go to the bathroom and noticed
that blood was running down my leg, and I felt a gush. When I got into the bathroom, I was
able to pee, and it filled up that bucket in the toilet. I wiped up all the blood on my bottom
with a dry washcloth, and now my bottom is on fire. I also felt a lump and am in excruciating
pain where they stitched me up. I made it back to my bed, but I need my nurse right away to
come look at these stitches and bring me an apple juice.”
1805
Nurse presents to room 325 to attend to client’s needs.
1810
Nurse prepares to do a perineal assessment.
1820
Nurse’s note placed in the flow sheet.
1830
The nurse refers to the postpartum orders to determine plan of care.

FLOW SHEET:
Healthcare Provider’s Perineal Assessment at 1820
Client report: Presented to client’s room at 1805. Client called via call light complaining of
Pain:
Client states pain is a “10/10 only where her stitches are.” Patient winces in pain when
laceration site is touched. Denies any cramping or breast pain.

blood running down her leg, a lump on her perineum, and “excruciating pain” at her perineal
laceration site.
Perineum:
Perineal laceration present from a spontaneous vaginal delivery 12 hours earlier. Laceration
was reported as a “third degree with repair” per the delivery note. Site is pink, moderately
swollen along the suture line, with bruising along the suture line and no apparent discharge,
and the laceration is intact and approximated.
Lochia:
Minimal amount of lochia noted on perineal pad and no pooling of lochia on examination.
Anus:
One large hemorrhoid noted near the anus. Hemorrhoid is purple in color and swollen.
ORDERS: Nursing
-Vital signs every 8 hours. Notify healthcare provider for temperature >100.4, pulse >120, or
BP >160 systolic or <50 diastolic
-Intake and output (I/O): Measure output x 3 voids. If adequate may discontinue I/O
-Diet as tolerated
-Activity as tolerated
-Benzocaine spray and perineal wash bottle at bedside for cleansing and comfort as needed
-Ice pack to perineum as needed for comfort
-Sitz bath 3 times per day as needed for comfort

ORDERS: Laboratory
-Hemoglobin and hematocrit in A.M. of postpartum day 1
-Rho(D) immune globulin workup if Rh-
-Hepatitis B surface antigen if not done prenatally
-Rubella immunity status if not done prenatally
ORDERS: Medications
-Give measles, mumps, rubella (MMR) vaccine (0.5 mL subcutaneous [SQ]) if mother nonimmune or equivocal status
-Give tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) vaccine 0.5 mL
intramuscular (IM) before discharge if previous vaccination >10 years
-Acetaminophen 325-650 milligrams (mg) by mouth (PO) every 4 hours as needed (PRN) mild
pain
Ibuprofen 400-600 mg PO every 4-6 hours PRN mild pain
-Hydrocodone/acetaminophen 5/500 mg 1-2 tablets PO every 4 hours PRN moderate to
severe pain
-Docusate 100 mg PO at bedtime PRN constipation
-Simethicone 80-160 mg PO every 4 hours PRN gas/bloating
-Witch hazel/glycerin pads at bedside to wipe area PRN
-If ineffective use: Hydrocortisone cream at bedside to apply to affected area PRN every 8
hours

The nurse receives notice from the front desk that her client in room 325 needs to see her
right away.
Click to highlight the 3 components of the call light message that require the most attention.
“I am in room 325. I got up to go to the bathroom and noticed that blood was running down
my leg, and I felt a gush. When I got into the bathroom, I was able to pee, and it filled up that
bucket in the toilet. I wiped up all the blood on my bottom with a dry washcloth, and now my
bottom is on fire. I also felt a lump and am in excruciating pain where they stitched me up.

1. I wiped up all the blood on my bottom with a dry washcloth, and now my bottom is on fire.
2. felt a lump
3. excruciating pain where they stitched me up.
   Rationale: done
4. That’s right!
5. Rationale:
6. When a postpartum woman is caring for a perineal laceration, she should use the provided water bottle or a sitz bath with warm water to cleanse the perineum. A dry washcloth could further irritate the friable perineum that is healing from birth. In addition, a lump on the perineum at the site of the stitches could indicate a hematoma and should be further evaluated by the nurse. It is an expected finding for the client who has a perineal laceration (third degree) to have mild to moderate pain at the laceration site; however, “excruciating pain,” when this was not the case before using the restroom, needs to be evaluated by the nurse. It is an expected finding that a 12-hour postpartum woman who has been lying in bed would have pooling of lochia that could run down her leg or “feel a gush” when ambulating. It is a positive sign that this client is voiding and is able to “fill that bucket in the toilet.” This is a good sign that she is not dehydrated. The nurse would prioritize the client’s complaints of pain and lump over getting the apple juice.

The client is a Gravida 1 Para 1 who delivered a healthy baby girl at 0602. She had a spontaneous vaginal delivery (SVD) with a third-degree perineal laceration that was repaired with sutures. She had an epidural for anesthesia. Her placenta was intact, and her quantitative blood loss was 225 mL. She was transferred via a wheelchair to her postpartum room at 0830 and was ambulatory to her bed.

he nurse is following up on the request for assistance from the client.

Which action is an essential component of a perineum assessment? Select all that apply.

Provide the client privacy by asking visitors to step out of the room

Place the client in a frog-legged position

Place the bed in mid-Fowler position

Place the client in a left lateral recumbent position

Place the head of the bed to the lowest position

Put on sterile gloves

Put on clean gloves

Lower the perineal pads and lift the client’s superior buttock

Examine the perineum with a sterile speculum

done

That’s right!

Rationale:

Before examining the client, the nurse should always respect the client’s privacy by asking visitors to step out of the room and explain the procedure. Because a perineal assessment involves inspection of the client’s perineum, the client is typically more cooperative and less anxious if done in private. The perineum is the area between the vagina and the anus; therefore, the left lateral recumbent position provides the most unobstructed view of the perineum and allows for assessment of the perineum, the anus, and any lochia that may be under the mother. The head of the bed should be at its lowest position when using a left lateral recumbent position for maximum patient comfort. A perineal assessment is a clean procedure; therefore, the nurse should implement standard precautions to provide protection from possible contact with bodily fluids. An examination for redness, ecchymosis, edema, discharge, and approximation (REEDA) is the standard assessment technique for any wound. Although the area may be slightly bruised from the birth and the repair of the third-degree laceration, redness, extensive bruising, or discharge may indicate an infection. Edema may indicate the formation of a hematoma. Wound edges (approximation) should be in direct contact for an uncomplicated healing process. Placing the client in a frog-legged and mid-Fowler position would only obstruct the view because the client would be sitting on her perineum. Such a position would not allow for direct visualization of the perineum. A perineal assessment is a clean procedure; therefore, the use of sterile gloves is unnecessary. A perineal assessment by the nurse does not involve the use of a speculum. Only the obstetric provider (obstetrician or midwife) should use a speculum on a client.

The client is a Gravida 1 Para 1 who delivered a healthy baby girl at 0602. She had a spontaneous vaginal delivery (SVD) with a third-degree perineal laceration that was repaired with sutures. She had an epidural for anesthesia. Her placenta was intact, and her quantitative blood loss was 225 mL. She was transferred via a wheelchair to her postpartum room at 0830 and was ambulatory to her bed.

1755

Nurse call over the call light: “I am in room 325. I got up to go to the bathroom and noticed that blood was running down my leg, and I felt a gush. When I got into the bathroom, I was able to pee, and it filled up that bucket in the toilet. I wiped up all the blood on my bottom with a dry washcloth, and now my bottom is on fire. I also felt a lump and am in excruciating pain where they stitched me up. I made it back to my bed, but I need my nurse right away to come look at these stitches and bring me an apple juice.”

1805

Nurse presents to room 325 to attend to client’s needs.

1810

Nurse prepares to do a perineal assessment.

1820

Nurse’s note placed in the flow sheet.

Healthcare Provider’s Perineal Assessment at 1820

Client report: Presented to client’s room at 1805. Client called via call light complaining of blood running down her leg, a lump on her perineum, and “excruciating pain” at her perineal laceration site.

Perineum: Perineal laceration present from a spontaneous vaginal delivery 12 hours earlier. Laceration was reported as a “third degree with repair” per the delivery note. Site is pink, moderately swollen along the suture line, with bruising along the suture line and no apparent discharge, and the laceration is intact and approximated.

Lochia: Minimal amount of lochia noted on perineal pad and no pooling of lochia on examination.

Anus: One large hemorrhoid noted near the anus. Hemorrhoid is purple in color and swollen.

Pain: Client states pain is a “10/10 only where her stitches are.” Patient winces in pain when laceration site is touched. Denies any cramping or breast pain. 

done

That’s right!

Rationale:

The nurse’s perineal assessment revealed a laceration that is in its early stages of healing. Expected assessment findings revealed that the laceration is pink, slightly swollen along the suture lines, bruised along the suture lines, no discharge, and well approximated. One swollen and irritated hemorrhoid was discovered during the examination, and only minimal lochia was noted. Because the client did not follow the recommended instructions for perineal care, she is at risk for a knowledge deficit. 

Although the client reported lochia that was running down her leg, her pain is most likely not due to a postpartum hemorrhage because the perineal assessment revealed that lochia was minimum and was most likely due to pooling, which occurs when a woman is lying down for an extended period of time and then rises to ambulate. According to the delivery summary, the client had a third-degree perineal laceration (a natural tear) and not an episiotomy (a surgical incision) at delivery; therefore, her pain is most likely a result of the perineal laceration because she did not have an episiotomy. Subinvolution is a condition where the uterus does not return to its normal size after birth. This condition can cause an increase in lochia; however, the client’s increase in lochia is most likely caused by pooling and not subinvolution. 

The client reported “filling the bucket” with urine when she went to the restroom. Bladder distention is most likely not causing the client’s pain. The perineal assessment revealed a hemorrhoid, not a rectal fissure (tear) or an open wound; therefore, these options would not be causing the client’s pain.

Although anyone with a wound/perineal laceration is at risk for infection or a wound dehiscence, the client’s laceration is in its early stages of healing and is not showing any signs that it is infected or dehiscing. Perineal lacerations and hemorrhoids are not directly related to the development of postpartum depression.

The client is a Gravida 1 Para 1 who delivered a healthy baby girl at 0602. She had a spontaneous vaginal delivery (SVD) with a third-degree perineal laceration that was repaired with sutures. She had an epidural for anesthesia. Her placenta was intact, and her quantitative blood loss was 225 mL. She was transferred via a wheelchair to her postpartum room at 0830 and was ambulatory to her bed.

1755

Nurse call over the call light: “I am in room 325. I got up to go to the bathroom and noticed that blood was running down my leg, and I felt a gush. When I got into the bathroom, I was able to pee, and it filled up that bucket in the toilet. I wiped up all the blood on my bottom with a dry washcloth, and now my bottom is on fire. I also felt a lump and am in excruciating pain where they stitched me up. I made it back to my bed, but I need my nurse right away to come look at these stitches and bring me an apple juice.”

1805

Nurse presents to room 325 to attend to client’s needs.

1810

Nurse prepares to do a perineal assessment.

1820

Nurse’s note placed in the flow sheet.

1830

The nurse refers to the postpartum orders to determine plan of care.

Healthcare Provider’s Perineal Assessment at 1820

Client report: Presented to client’s room at 1805. Client called via call light complaining of blood running down her leg, a lump on her perineum, and “excruciating pain” at her perineal laceration site.

Perineum: Perineal laceration present from a spontaneous vaginal delivery 12 hours earlier. Laceration was reported as a “third degree with repair” per the delivery note. Site is pink, moderately swollen along the suture line, with bruising along the suture line and no apparent discharge, and the laceration is intact and approximated.

Lochia: Minimal amount of lochia noted on perineal pad and no pooling of lochia on examination.

Anus: One large hemorrhoid noted near the anus. Hemorrhoid is purple in color and swollen.

Pain: Client states pain is a “10/10 only where her stitches are.” Patient winces in pain when laceration site is touched. Denies any cramping or breast pain.

one

That’s right!

Rationale:

The client is experiencing perineal pain as a result of her third-degree perineal laceration and hemorrhoid. The nurse should initiate interventions that address immediate pain and comfort and that promote prevention of further pain and discomfort. Benzocaine spray is a numbing spray that can be applied to a perineal pad to numb the pain at the incision. This spray should not be directly applied to the skin; it can cause burning. A perineal wash bottle should be placed in the client’s bathroom for use when cleansing the perineum after voiding. The client initially used a dry washcloth, which probably irritated the area further, a perineal wash bottle should be filled with warm water and sprayed on the perineum to wash away any lochia or urine. Ice packs (chemical or ice bags) can be placed on the perineum for 20 minutes out of every hour. Ice packs will help numb the perineum, will provide comfort for lacerations and hemorrhoids, will decrease swelling, and are most effective in the first 24 hours postpartum. A sitz bath is a warm, shallow bath that cleanses the perineum. A sitz bath can also provide relief from pain resulting from a perineal laceration or hemorrhoids. Client can take a sitz bath in her bathtub or with a plastic kit that fits over her toilet. The client can use this up to 3 times per day and can take the kit home with her when she is discharged.

Since the client is complaining of pain at a “10/10,” the nurse should consider an oral pain medicine that can make her comfortable. Acetaminophen is typically used for mild pain, headache, and fever, and Ibuprofen is typically used for cramping pain, such as uterine cramping (afterpains). Hydrocodone is an opioid analgesic that can be given PO for moderate to severe pain (often compounded [or combined] with acetaminophen). The nurse has the option of giving 1 or 2 tabs per the orders and may start with one to see whether that relieves the pain before giving 2 tabs. In addition to an oral opioid analgesic, the client should be receiving a stool softener, such as Docusate, to soften her stool and prevent constipation. Women with a perineal laceration and hemorrhoids, and who are taking oral opioids, are at risk for constipation. Often, these women are “afraid” to bear down to have a bowel movement because of the fear of opening their sutures or aggravating the hemorrhoid. Since the nurse is giving the client an oral opioid and because the client has a perineal laceration and a hemorrhoid, it is appropriate to begin Docusate and continue until healed. Finally, any client who has hemorrhoids should have a pack of witch hazel/glycerin pads in the bathroom to use after voiding and when changing perineal pads. These pads contain witch hazel and glycerin and provide extra comfort for those with hemorrhoids. If, after using witch hazel/glycerin pads, the pain from the hemorrhoid worsens, the nurse may consider giving hydrocortisone cream to decrease the swelling of the hemorrhoid, but that should only be used if the witch hazel/glycerin pads are ineffective (per the orders).

Rationale:

Teaching perineal hygiene to women with a laceration, episiotomy, or hemorrhoids is a crucial component of the role of the postpartum nurse. Women should be taught to keep the perineum clean and given options for comfort measures. The client should always wash her hands before and after perineal hygiene. In addition, it is important for the client to be taught to wipe from front to back to prevent cross-contamination of any fecal matter into the perineal area. Wiping back to front can introduce fecal material into the perineal area and cause an infection. Perineal pads should be changed with every void or defecation or at least 4 times a day. Because of the risk for infection, women should not ration perineal pads. The nurse can provide the postpartum woman with perineal pads to take home to give client time to retrieve more from the store if necessary. Washing with soap and water with every perineal pad change is unnecessary if using the perineal wash bottle correctly.

An ice pack is an intervention that can help prevent edema to the perineal laceration or episiotomy in the first 24 hours postpartum. In addition, an ice pack is a nonpharmacological way to provide comfort to the perineum through the healing stages. Most hospitals provide a chemical ice pack that should be discarded after each use and not saved. Ice packs can be used for 20 minutes or until the ice melts; it should then be left off for 10 minutes and then the cycle can be restarted.

A perineal wash bottle should be provided to every postpartum woman regardless of mode of delivery. This bottle should be filled with warm (not cold) tap water (no soap), used while the woman is sitting on the toilet, and sprayed from front to back to avoid cross-contamination. The perineum should be gently blotted to dry the area, not wiped, because this may irritate a perineal laceration or episiotomy.

Rationale:

The nurse should reiterate to the client that the perineum should be cleansed only with soap and water once a day. Using excessive soap can dry out the area and cause further discomfort. Instead, a perineal wash bottle with warm tap water should be used with every void or defecation to keep the perineum clean. Swelling is an expected finding for a client with a perineal laceration or episiotomy for the first couple of days postpartum. If the swelling becomes more pronounced or a unilateral painful lump appears on the laceration, the client should call the healthcare provider. The client should change her perineal pad with every void or defecation or at least 4 times a day. Waiting until the pad is saturated or sitting in old lochia can cause an infection. Foul-smelling discharge and the opening of stitches could indicate an infection of the laceration or a wound dehiscence. The client should call her healthcare provider for either of these findings. Chemical ice packs are safe to use in the perineal area and typically cool to the appropriate temperature. These ice packs can be placed up against the skin but should be used for only 20 minutes out of every hour and discarded after each use. Benzocaine spray is a topical analgesic that can help with numbing the perineum. However, Benzocaine spray can cause friable skin to burn if applied directly to the skin and should be used sparingly by spraying a perineal pad and then applying the pad to the perineum.