Homans’ Sign

Homans’ sign is often used in the assessment for deep venous thrombosis (DVT) in the leg. To assess for Homans’ sign, the patient’s legs should be extended and relaxed with the knees flexed. The examiner grasps the foot and sharply dorsiflexes it (Fig. 15-4). No pain or discomfort should be present. The other leg is assessed in the same manner. If calf pain is elicited, a positive Homans’ sign is present. The pain occurs from inflammation of the blood vessel and is believed to be associated with the presence of a thrombosis. Pain on dorsiflexion is indicative of DVT in approximately 50% of patients. Thus, a negative Homans’ sign does not rule out DVT. A diagnosis based solely on the evaluation of clinical signs that include pain in the calf, erythema, warmth greater in one calf than the other, and unequal calf circumference has proven to be unreliable. Instead, specific diagnostic procedures (e.g., venography, real-time and color Doppler ultrasound) should be performed when DVT is suspected. (See Chapter 16 for further discussion.)

Emotional Status

The birth of a child is associated with a range of emotional experiences in the new mother. During the early puerperium, it is not unusual for patients to have periods of happiness that are intermingled with sadness, insecurity, and depression. Continued assessment of the woman’s emotional status is an important nursing action that begins immediately after childbirth and continues throughout the hospital stay. The nurse should offer support to the new mother, which may include listening to her share her labor experience or reassuring her about her ability to effectively care for the newborn. The nurse should also provide information regarding the “baby blues,” and emphasize that these feelings are common and temporary (Horowitz & Goodman, 2005).

Now Can You— Discuss essential components of postpartum nursing care?

1. Identify three types of lochia and explain the characteristics and duration of each? 2. Describe nursing interventions to promote healing, enhance comfort, and prevent infection in the patient with an episiotomy? 3. Discuss the nurse’s role in pain assessment of the postpartal patient?

Figure 15-4 Assessing for Homans’ sign.

Maternal Physiological Adaptations and Continued Assessment of the Patient

HEMATOLOGICAL AND METABOLIC SYSTEMS

During the immediate postpartum period, a decrease in blood volume correlates with the blood loss experienced during delivery. During the next few days after childbirth, the maternal plasma volume decreases even further as a result of diuresis. The 500-mL blood loss that typically accompanies a vaginal birth (1000 mL for a cesarean birth) usually results in a 1 gram (2 grams for a cesarean birth) drop in hemoglobin. It is important for the nurse to remember that as the body’s excess fluid is excreted, the hematocrit may rise due to hemoconcentration. However, the hematocrit should have returned to pre-pregnancy levels by 4 to 6 weeks postpartum.

The white blood cell (WBC) count, which increases during labor and in the immediate postpartum period, returns to normal values within 6 days. Levels of plasma fibrinogen tend to remain elevated during the first few postpartal weeks. Although this alteration exerts a protective effect against hemorrhage, it increases the patient’s risk of thrombus formation. Overall, the hematologic system has usually returned to a nonpregnant status by the third to fourth postpartal week.

Circulating levels of estrogen and progesterone decrease dramatically after delivery of the placenta. The decline in these two hormones signals the anterior pituitary gland to produce prolactin in readiness for lactation. In nonlactating (formula feeding) women, prolactin levels return to normal by the third to fourth postpartal week.

After childbirth and expulsion of the placenta, circulating levels of other hormones, including placental lactogen, cortisol, growth hormone, and insulinase, also fall. During the early postpartum period, the decline in the serum levels of these substances reduces the anti-insulin effects that occur during pregnancy. Hence, insulin requirements are reduced for insulin dependent women during this time, sometimes termed a “honeymoon phase.” For many insulin dependent diabetics, glucose levels remain in a normal range (without intervention) during the first few days after childbirth (Chan & Winkle, 2006).

NEUROLOGICAL SYSTEM

Fatigue and discomfort are common complaints after childbirth. The demands of the newborn frequently create altered sleep patterns that contribute to increased maternal fatigue. Anesthesia and analgesia received during labor and birth may cause transient maternal neurological changes such as numbness in the legs or dizziness. When these changes are present, the nursing priority is to safeguard the patient and her infant and prevent injury from falls.

Complaints of headaches require further nursing assessment. Patients who received epidural or spinal anesthesia may experience headaches, especially when they assume an upright position. After spinal or epidural anesthesia, headaches may result from the leakage of cerebrospinal fluid into the extradural space. Labor-induced stress or gestational hypertension may also cause headaches. It is essential that the nurse assess the quality and location of the headache and carefully monitor maternal vital signs. Headaches that are accompanied by double or blurred vision, photophobia, epigastric or abdominal pain, and proteinuria may be signs of a developing or worsening preeclampsia. Report these findings immediately to the primary health care provider. Implement environmental interventions such as reducing the room lighting and noise levels and limiting visitors. The physiological edema of pregnancy is dramatically reversed during postpartum diuresis. Patients who experienced medial nerve compression and carpel tunnel syndrome during pregnancy often obtain relief of symptoms.

RENAL SYSTEM, FLUID, AND ELECTROLYTES

The renal plasma flow, glomerular filtration rate (GFR), plasma creatinine and blood urea nitrogen (BUN) return to pre-pregnant levels by the second to third month after childbirth. Urinary glucose excretion increases in pregnancy by 100-fold over non pregnant values. These values return to nonpregnant levels after the first postpartal week. Pregnancy-associated proteinuria (up to 1_ on a urine dipstick or less than 300 mg in 24 hours) is common during pregnancy and generally returns to pre-pregnancy values by 6 weeks postpartum (Cunningham et al., 2005).

During the postpartum period, there is a rapid, sustained natriuresis (excessively large amount of sodium in the urine) and diuresis as the sodium and water retention of pregnancy is reversed. The physiological reversal is particularly pronounced during the second to fifth puerperal days. In most women, the body’s fluid and electrolyte balance has been restored to a non pregnant homeostatic state by the third postpartal week. After childbirth, a decrease in levels of oxytocin and estrogen naturally occurs and contributes to diuresis. As the serum levels decline, the diuresis becomes more pronounced. Nurses often note a maternal urinary output that reaches 3000 mL excreted in a 24-hour period. For the postpartum patient, a single voiding may contain 500 to 1000 mL of urine.

Now Can You— Describe early postpartal physiological adaptations in the metabolic, neurological, and renal systems?

1. Explain what is meant by the “honeymoon phase” and why this may occur? 2. Identify possible causes and describe appropriate nursing assessments for patients who complain of headache? 3. Discuss physiological adaptations in the renal system and identify one patient teaching need related to these adaptations?

RESPIRATORY SYSTEM

Respiratory alkalosis and compensated metabolic acidosis occur during labor and may persist into the postpartum period. In most situations, however, after delivery of the placenta and the decline in levels of progesterone, the respiratory system quickly returns to a pre-pregnant state. In addition, the immediate decrease in intra-abdominal pressure associated with the birth of the baby allows for increased expansion of the diaphragm and relief from the dyspnea usually associated with pregnancy. By the third postpartal week, the respiratory system has returned to a pre-pregnant state.

INTEGUMENTARY SYSTEM

Changes in the skin during pregnancy and in the postpartum period are related to the major alterations in hormones. Women may experience alterations in pigmentation, connective and cutaneous tissue, hair, nails, secretory glands, and pruritus. Most pregnancy-related skin changes disappear completely during the postpartum period although some, such as striae gravidarum (stretch marks) fade but

may remain permanently.

Ethnocultural Considerations— Pregnancyrelated skin changes in the puerperium

Although abdominal stretch marks (striae gravidarum) appear more pronounced immediately after childbirth, they tend to fade over the following 6 months. In Caucasian women, striae become pale and white in color; in African American women, they will appear as a slightly darker pigment.

CARDIOVASCULAR SYSTEM

During pregnancy, the heart is displaced slightly upward and to the left. As involution of the uterus occurs, the heart returns to its normal position. Dramatic changes in the maternal hemodynamic system result from birth of the baby, expulsion of the placenta, and loss of the amniotic fluid. These abrupt alterations can create cardiovascular instability during the immediate postpartum period. Despite the usual blood loss (500 mL with a vaginal birth; 1000 mL with a cesarean birth), the maternal cardiac output is significantly elevated above prelabor levels for 1 to 2 hours postpartum and remains high for 48 hours postpartum. The cardiac output returns to pre-pregnant levels within 2 to 4 weeks after childbirth.

On average, a 3-kg weight loss occurs during the first postpartal week. Diuresis takes place between the second and fifth day. A major fl uid shift involves the movement of extracellular fluid back into the venous system for excretion through urine and perspiration. If the physiologic diuresis does not occur, there is an increased risk of pulmonary edema. The cardiac output and stroke volume remain elevated for at least 48 hours after childbirth. Within 2 weeks, the cardiac output has decreased by 30% and then reaches pre-pregnant values by 6 to 12 weeks postpartum in most women (Cunningham et al., 2005).

IMMUNE SYSTEM

The WBC count is increased during labor and birth and remains elevated during the early postpartum period, gradually returning to normal values within 4 to 7 days after childbirth. Depending on the patient’s blood type and immune status, administration of RhoGAM (see below) may be indicated. Women who are rubella susceptible during pregnancy should receive the MMR (measles–mumps– rubella) vaccine at the time of hospital discharge; varicella vaccine should also be encouraged (American College of Obstetricians and Gynecologists [ACOG], 2003).

Rho(D) Immune Globulin

Nonsensitized women who are Rho(D)-negative and have given birth to an Rh(D)-positive infant should receive 300 mcg of Rho(D) immune globulin (RhoGAM) within 72 hours after giving birth. RhoGAM should be given whether or not the mother received RhoGAM during the antepartum period. In some situations, depending on the extent of hemorrhage and exchange of maternal–fetal blood, a larger dose of RhoGAM may be indicated.

Rubella Vaccine

Before discharge, the patient needs to be assessed for rubella immunity. If nonimmune (rubella titer less than 1:8, or antibody negative on the enzyme-linked immunosorbent assay [ELISA]), the MMR vaccine should be administered. The nurse should counsel the patient about the need to avoid pregnancy for 1 month after receiving the vaccine (due to the teratogenic effects associated with congenital rubella syndrome) and advise her that she may briefly experience rubella-type symptoms such as lymphadenopathy, arthralgia, and a low-grade fever. The vaccine may be safely given to breastfeeding mothers. A signed consent form must be obtained before administration of the vaccine (ACOG, 2003).

REPRODUCTIVE SYSTEM

The uterus undergoes a rapid reduction in size (involution) and returns to its pre-pregnant state in about 3 weeks. The former site of the placenta heals by the process of exfoliation, which ensures that the placental site heals without leaving a fibrous scar. Formation of scar tissue would limit areas for future implantation and adversely affect the potential for future pregnancies. After a vaginal birth, the vagina often appears edematous or bruised and superficial lacerations may be present. Although swelling is resolved during the healing process, the vagina does not return to its nulliparous size and the labia majora and labia minora remain more flaccid in the multiparous woman (Cunningham et al., 2005).

During the postpartum phase, the return of ovulation and menstruation varies according to the individual. Menstruation usually resumes within 6 to 8 weeks after childbirth in women who are not breastfeeding. Seventy five percent menstruate by the twelfth postpartal week. The first cycle is often anovulatory. The return of ovulation and menstruation is typically prolonged in lactating women. Those who exclusively breastfeed may not ovulate or menstruate for 3 or more months. It is important to educate patients that since ovulation can precede menstruation, breastfeeding is not a reliable method of contraception.

GASTROINTESTINAL SYSTEM

Owing to hormonal effects, gastric motility is decreased during pregnancy. It is further decreased during labor and in the first few postpartal days due to decreased abdominal wall tone. Abdominal discomfort results from gaseous distention related to decreased motility and abdominal muscle relaxation. Constipation, a common nursing diagnosis for the postpartal patient, is associated with abdominal discomfort and decreased hunger. Straining to pass hard stool can cause hemorrhoids and tear episiotomy sutures. Although spontaneous bowel movements usually resume by the second or third day after childbirth, it is important to educate the patient about strategies to prevent constipation. Stool softeners may be necessary. Additional nursing diagnoses for the postpartal patient focus on a variety of other problems such as pain, fatigue, and sleep disturbances, infant feeding difficulties and knowledge deficit (Box 15-2).

Box 15-2 Common Nursing Diagnoses During the Puerperium

• Breastfeeding, ineffective/effective • Risk for constipation • Sleep-pattern disturbed • Fatigue • Pain, acute • Activity intolerance • Skin integrity, risk for impaired • Knowledge, deficient regarding self-care or care of infant • Risk for infection • Family processes parenting impaired • Risk for situational low self-esteem related to body image changes • Risk for urinary retention

MUSCULOSKELETAL SYSTEM

During pregnancy, the pelvic joints and ligaments have increased laxity. The hormones relaxin and progesterone are believed to contribute to the relaxation of the soft tissues (muscles, ligaments, and connective tissue) in the maternal pelvis to create room for the birthing process. In some women, the loosening of the pelvic joints causes pain and functional limitations.

During the first few days after childbirth, the woman may experience muscle fatigue and general body aches from the exertion of labor and delivery of the baby. Muscle fatigue can be exacerbated by the extended lack of nutrition and fluids throughout the course of labor. The maternal expenditure of glucose during parturition (the act of giving birth) can also add to muscle fatigue and may interfere with the patient’s ability to ambulate and initiate postpartum exercises. The nurse needs to assure the patient that the muscular discomforts are temporary and not indicative of a serious medical problem.

During pregnancy, the abdominal walls are stretched to accommodate the growing fetus. The progressive stretching causes a decrease in the muscle tone of the rectus muscles of the abdomen and results in the soft, flabby, and weak muscles experienced after birth. Rectus abdominis diastasis is a conventional term used to define the split between the two rectus abdominis muscles that can occur from pregnancy. Women should be aware that during the early postpartal period, the abdominal wall may not be sufficiently protected to withstand additional stress from increased activities. Nurses should teach them to maintain correct posture when performing activities such as lifting, carrying, and bathing the baby for at least 12 weeks after birth. Performing modified sit-ups during this time is beneficial in helping to strengthen the abdominal muscles.

Now Can You— Describe postpartal physiological adaptations in the respiratory, cardiovascular, and reproductive systems?

1. Explain why pregnancy-related dyspnea is relieved in the early postpartal period?

2. Describe three intra-postpartal events that cause dramatic changes in the maternal hemodynamic system?

3. Identify when ovulation and menstruation usually occur in the postpartal woman and explain specifi c information that should be given to lactating mothers?

Nursing Care Plan Acute Pain/Discomfort in the Postpartal Patient Nursing Diagnosis: Acute Pain related to tissue damage secondary to childbirth Measurable Short-term Goal: The patient will report decreased pain to a level that is acceptable to her. Measurable Long-term Goal: The patient will report minimal or no pain upon discharge from the hospital. NOC Outcomes: Pain Level (2102) Severity of observed or reportedpain Pain Control (1605) Personal actions to controlpain NIC Interventions: Pain Management (1400) Analgesic Administration (2210) Heat/Cold Application (1380) Nursing Interventions: 1. Perform routine, comprehensive pain assessments to include: onset, location, intensity, quality, characteristics, and aggravating and alleviating factors of the discomfort. Note verbal and nonverbal indications of discomfort. RATIONALE: Routine, comprehensive pain assessments enable the nurse to provide interventions in a timely manner to enhance effectiveness of medications and ensures early identification of complications resulting in painful stimuli. 2. Ask the patient to rate her pain on a standard 0 to 10 pain scale before and after interventions and to identify her own acceptable comfort level on the scale. RATIONALE: Use of a consistent pain scale provides objective measurement of the patient’s perception of pain, the effectiveness of interventions, and the acceptable comfort level for the individual. 3. Identify cultural or personal beliefs about the experience of pain and the use of pain interventions, including prescribed medications. RATIONALE: Expression of pain and use of pain relief interventions may vary according to culture and personal beliefs. Patients may prefer a stoic response to pain or fear becoming addicted to narcotics. 4. Provide factual, nonjudgmental information regarding pain interventions that are available to the patient. Encourage use of culturally based comfort measures when appropriate. RATIONALE: Accurate information and respect for the individual’s experience and preferences empowers the patient and reduces psychic discomfort. 5. Offer an ice pack to the perineum if the patient experienced perineal trauma or episiotomy. Apply for 20 minutes followed by removal for 10 minutes. RATIONALE: Cold therapy causes vasoconstriction and reduces edema resulting in decreased pain. Periodic removal avoids thermal injury. 6. Assist the patient with a sitz bath as ordered if the patient experiences perineal discomfort. RATIONALE: Cool water in the sitz bath decreases pain associated with edema while warm water promotes vasodilation and increased circulation to promote healing and provide comfort. 7. Teach the patient to apply topical medications for perineal or hemorrhoid pain as ordered. RATIONALE: Topical anesthetics, such as Dermoplast spray, produce localized pain relief by inhibiting conduction of sensory nerve impulses. Tucks pads contain witch hazel, which has astringent properties to shrink hemorrhoids and reduce perineal edema. 8. Teach the patient about the sources of pain and the effects of prescribed medications and interventions. Encourage her participation in developing a pain management plan. RATIONALE: Information and involvement increases the patient’s perception of control and increases her personal satisfaction with postpartum pain management.