Page 759 - ACCCN's Critical Care Nursing

736 S P E C I A LT Y P R A C T I C E I N C R I T I C A L C A R E

Redundant muscle, fibrous and elastic tissue is disposed Lochia and Perineal Care
of – the phagocytes of the blood stream deal with this – The changes in the appearance of the lochia are described
but the process is usually incomplete and some elastic in three stages: lochia rubra, lochia serosa and lochia
tissue remains. So a uterus that has once been pregnant alba. Lochia rubra consists of blood coming chiefly
200
will never return fully to its pre-pregnant state. The decid- from the placental site, mixed with shreds of the decidua.
ual lining of the uterus is shed in the form of lochia. The Three or four days post delivery, the lochia changes to
new endometrium grows from this basal layer, beginning brownish in colour, and consists of altered blood and
to be formed at the tenth day and completed by 6 weeks serum containing leucocytes and organisms; this is called
postpartum.
lochia serosa. Seven days post delivery the lochia again
The rate of involution is measured by the rate of descent changes, the PV loss is now yellowish in appearance, and
of the uterine fundus (the top of the uterus) in relation consists mainly of cervical mucus, leucocytes and organ-
to either the belly button or the symphysis pubis. Impor- isms; this is called lochia alba. Normal lochia is not
tant markers include: offensive in odour. Offensive lochia coupled with or
without maternal pyrexia may indicate a uterine infec-
l day 1 postnatal, the height of the fundus is usually at tion. High and low vaginal swabs for culture and sensi-
the belly button tivity, and the commencement of antibiotic cover, should
l there is a steady decrease in size of around 1 cm per be initiated. Offensive lochia coupled with a high non-
day involuting (and boggy) uterus may require ultrasound to
l as the uterus reduces, it also recedes and is deeper to exclude retained placental tissue. An infected placental
palpate site may result in a secondary postpartum haemorrhage.
l by postnatal day 7, the fundal height is often only
2–3 cm above the symphysis pubis and by day 10 it is Regular assessment of the PV loss is required in the early
usually not palpable at the symphysis pubis postpartum phase. Generally this includes 1–2 hourly
l the rate of involution is slower in multiparity women, checks if the PV loss is relatively heavy (pad soaked within
if there is an infection present, or retained placental 1–2 hours) for the first day, progressing to 4 hourly checks
tissue/clots. on day 2, with further reductions in observation fre-
quency based on clinical condition. Essentially, you need
A normally contracted uterus is very hard; as you palpate to check the fundus and PV loss regularly enough to
the fundus to locate the top and feel the texture of the detect any excessive blood loss or loss of uterine tone. The
uterus, you can not push your fingertip into the tissue of colour and volume of PV loss is usually documented
the uterus. A so-called boggy uterus is one that is not along with any pad changes.
contracted properly and the fundus does not feel very
hard on palpation. Reasons for a ‘boggy uterus’ include When checking the PV loss, the perineum should also be
uterine atony, retained tissue/membrane/clot or a full examined twice a day, even for women that have had a
bladder that is impeding the uterine nerve stimulus to caesarean birth. A vulval haematoma or varicosities may
contract. The uterus responds well to tactile stimulation, have formed and require attention. For women that have
and the first treatment for a ‘boggy uterus’ is to ‘rub-up’ had a vaginal birth, check the perineum to see if there
the fundus. This involves palpating the top of the uterus was any tear or episiotomy at delivery. If there is a tear
and literally giving it a rub. The uterus will usually or any sutures, make sure to keep the region clean and
respond and you will feel it tighten and become harder. observe for signs of infection or wound dehiscence. Ice
Such an action may result in a small gush of PV loss. On packs applied to the perineum may help with any swell-
some occasions, an uterotonic, a drug that causes the ing and discomfort.
uterus to contract, may be needed to ensure the uterus is
contracting properly. If the uterus does not contract prop- Increased Potential for Deep Vein Thrombosis
erly, then the vessels that fed the placental bed will not All postpartum women have an increased likelihood for
be closed off by the uterine muscle contraction (called DVT. Preeclampsia and obstetric haemorrhage are addi-
the living ligature) and the woman will continue to bleed. tional risk factors, as is an emergency operative procedure
and postpartum immobility. Most postpartum women
admitted to ICU would fulfil the criteria that recommend
Practice tip medical thrombophylaxis. Routine postpartum care
involves examining the legs for signs of DVT and appro-
Uterotonics, drugs that cause the uterus to contract, are priate use of thromboembolic stockings, sequential
usually stored in the refrigerator. For example, syntocinon, compression devices and thrombophylaxis as required
syntometrine.
(see www.rcog.org.uk for more details). 30
BREAST CARE AND BREAST FEEDING
Practice tip A woman’s breasts and nipples should be examined once
a shift to assess their condition and identify signs of
Many midwives document fundal height by fingerwidths in complications, such as mastitis. This examination should
relation to the belly button. For example, two fingerwidths be conducted on all women, regardless of whether she
below the belly button would be notated by 2F ↓ . intends to breastfeed or not. The breasts are usually soft,
although as the milk comes in, they may become