Hi, I'm Meris with Level Up RN. And in this video,
I'm going to be starting off our postpartum care by talking about assessing a patient's fundus and
lochia. I'm going to be following along using our maternity flashcards. These are available on our
website, leveluprn.com if you want to grab a set for yourself, and if you already have your own
deck, I would invite you to follow along with me. All right. Let's get started. So, first up,
we're going to be talking about assessing a patient's fundus. I think it's helpful to
know what a fundus is before we get started. So the fundus is the topmost portion of the
uterus, and that is the part that you can actually palpate from the outside to assess it, see how it
feels, and see where it is. So you'll see that, on this card here, we have a bunch of bold, red text,
which means that we think it's pretty important for your nursing practice. One of the things
that we have on here is that you need to assess the fundal height, and we'll talk about that in
a minute. But what you're going to be doing is feeling where it is in relation to the rest of
the patient's abdomen. So is it at the level of the umbilicus? Is it above it? Is it below it?
We need to know where it is and specifically, we want to see how it's trending, if it's going
down, if it's coming up, what's going on with it. Then we have on here in bold red that, if the
fundus is displaced laterally, that this means that the patient needs to empty their bladder.
If you remember anatomy, the bladder is anterior to the uterus, so as it fills up with urine, it's
going to prevent that uterus from being midline. It's going to kind of push it off to the side. And
this is important because, if the uterus is not able to come back down normally and sort of what
we call involute, if it's not able to get to where it needs to go because of an over-full bladder,
we're now at risk for postpartum hemorrhage, and that's really scary. So if you are assessing
the fundus and you note that the fundus deviated to the left or to the right, then the first thing
you would want to do is have the patient empty their bladder. If your patient has an epidural or
a spinal, they may have some difficulty urinating, and this is pretty normal. We've put everything
to sleep in the body to take away pain, so we can have difficulty getting those nerves
to kind of wake back up. So if the patient is not able to urinate, we're not going to jump straight
to just catheterizing them to remove that urine because of the risk of infection. So, instead,
we want to try noninvasive measures first.
We can do things like turning on the tap water
to have that running water sound maybe give an effect of relaxing the bladder. We can also
pour water over the patient's vulva and perineum. This can help to relax and stimulate those
nerves to help the patient empty their bladder. Now, obviously, if this is unsuccessful, we
are going to end up having to catheterize the patient to remove that urine, but we always
want to start with the least invasive measures first before moving on to invasive ones. Now,
when we feel the fundus, it can either be firm, right, and that's what we like - we like a nice
firm fundus - or it can be what we call boggy. A boggy fundus is kind of a mushy, squishy fundus,
and that is not good because that says to us that things are not contracting the way they should be
and, again, risk for postpartum hemorrhage. We're very concerned about hemorrhage immediately after
the baby is born and in those first few days.
So if we find that the fundus is boggy, the
primary nursing action is going to be to massage the fundus, and that's going to be done using
the side of the hand. Usually, the other hand, the non-dominant hand, is going to kind of put
some pressure suprapubic to hold that uterus in place and then massage that fundus until it firms
up. That's going to help it to expel any clots and to kind of contract down some more. Now,
another thing you'll see on this card is that, occasionally - and actually, this is very common
practice in many facilities - oxytocin is given to patients who are postpartum. If they had
C-sections, if they were induced, if it was completely spontaneous labor, oxytocin is given
because it helps to contract that uterus down and to decrease the risk for postpartum
hemorrhage. So a nursing action would be to administer oxytocin as ordered. And then we would
also want to encourage our patient to breastfeed if that is the path that they have chosen
because breastfeeding, nipple stimulation, increases oxytocin production, which then is going
to cramp down-- I mean, it hurts. It's crampy, but it is going to help to contract that uterus
back down, so natural oxytocin can work as well.
Now, when we talk about assessing the position
of the fundus, you'll see here not too much information but some pretty important information
on this card. 12 hours after delivery, the fundus of the uterus should be firm - we always like
firm - midline, meaning in the middle of the body, not deviated to one side or the other, and
approximately at the level of the umbilicus, so at the level of the belly button.
Now, you will see that this position can change over time. It can then come up about a centimeter
before it then begins to re-descend. Then it says the fundus descends about one centimeter each
day, so that's very helpful to remember. If I'm two days postpartum, the fundus is probably
two centimeters below the umbilicus. And then, at day six, the fundus is halfway between the
umbilicus and the symphysis pubis. So we have made our descent pretty far down. And then, two
weeks postpartum, the uterus should not be palpable anymore. So those are kind of important
things. When you work in a postpartum unit, you will hear-- the terms used to describe the
location of the fundus will be things like UU or U-minus-1 or U-plus-1, which means at the level of
the umbilicus minus 1 centimeter, so down, or plus 1 centimeter up. And typically, this is measured
also in finger breadths because this is about 1 centimeter. So if you hear that on a unit if
you're doing clinicals, that is what that means.
So, now, let's move on to talking about lochia,
and lochia is essentially just the discharge that comes out of the vagina after delivery. So it
doesn't matter if your patient had a C-section or vaginal delivery; lochia will still be
passed vaginally. And I think that that was something that surprised me in particular when
I had my first child, was I had a C-section, and I knew I was going to have bleeding and
things like that, but I was surprised at how much still came out of me and how much
kind of vaginal pain and pressure I had given that I was never in labor. I had a scheduled
C-section, so a good patient teaching there, especially if this is their first baby. Now,
we do have a nice chart here to show you the different kinds of lochia and what they
mean. So lochia rubra; I think of ruby red, right? So this is going to be a dark red color,
and this typically is for one to four days after delivery. That's kind of what we expect to see.
Now, lochia serosa, so this is a pinkish brown. It's that kind of serous fluid, right? It's going
to have not such a bloody color, but more of a pink tinge to it, and this is going to be from
about four to nine days following delivery.
After that, though, we have lochia alba, and
alba means white. So this is kind of a creamy, white-color discharge. This happens for about
10 to 14 days following delivery. However, it is possible for it to happen up to a few months.
So that is normal, and that is a good thing to educate your patients to. I know that I, for
one, was very surprised how long I had this vaginal bleeding and discharge after the birth
of my children. I thought it was going to be just three to five days and we would be done with
it. It's not. It persists for a lot longer. Now, any time we have malodorous lochia,
meaning foul-smelling, that is a big red flag for infection, and we will talk in a future
video about one complication called endometriosis that that is a big red flag for. Also, don't
forget that, when we have that lochia rubra, we expect it to last for just a few days. If
it's lasting for more than a week after delivery, that is another thing to report to the provider
because that is too much of that type of lochia.
Now, the other thing; whenever we assess a fluid
that comes out of the body, we assess the color, the odor, the consistency, and the amount. So
we've just talked about color. We talked about odor some. And now, let's talk about the amount.
We have on here another chart for you that gives you the descriptions of the amounts. But on
here, you can have scant, light, moderate, large, or heavy, and excessive. So the one that
I want to call your attention to here is going to be scant, is less than five centimeters
or less than two inches of a stain on a pad. That's what scant means. It means very little.
Versus when we talk about excessive bleeding, excessive bleeding is never normal, and this is
marked by saturation of a pad within 15 minutes. And we are talking about those big pads, the
big postpartum-- I mean, they basically look like diapers, right? They're huge. We're talking
about soaking, saturating this pad in 15 minutes.
When you're assessing the amount in the
lochia, it's very tempting to just kind of pull the patient's briefs down and look at
what is right there in the front of the pad. However, if your patient is laying in bed,
remember that they are subject to gravity and that the lochia is going to pool behind them. It
can pool behind the buttocks. So when you are assessing it, yes, you can pull it down and
look from the front to see what's in there, but then I would also suggest rolling your
patient to check behind them or having them lift their hips so that you can see what is on the
pad in the posterior side of the patient as well because it would be really scary if you
saw scant bleeding on the front of the pad but they're bleeding much heavier and it's just
going backwards. That would be something that you had missed, and it's really important to know
exactly how much is coming out of a patient.
Now, we do have a cool chicken on here. Our
hint here is that 2.5 centimeters is the size of 25 cents, so 2.5, 25. That helps you to
understand what length 2.5 centimeters is. So if I have 2 quarters' worth of length of lochia,
that is still scant because it is 5 centimeters. So definitely review this chart if you have
more questions about the amount of lochia. But very important to help us understand
what is going on with our patients in the postpartum period and help us catch any sort of
complications such as hemorrhage or infection. All right. I hope that review was helpful.
I'm going to give you some quiz questions to help you test your knowledge
of some key facts I provided you, so let's do that now. Okay, so we've got a
bunch of quiz questions this time because this is a lot of really important information.
So the first one is, when assessing the fundus, the nurse notes that it is deviated to
the right. What should the nurse do? What's the priority action here for a
fundus that is deviated to the right? Next question, if the nurse finds that the
patient's fundus is boggy, what is her priority action? So what is the first thing you should do
if you find that your patients fundus is boggy? Moving right along, when caring for
a patient who is 12 hours postpartum, where does the nurse expect to feel the fundus?
So where should it be? Next question. When is lochia alba expected to begin? When does lochia
alba start? Okay, and last one. The nurse notes a nine-centimeter stain of lochia on the patient's
pad. How should this be documented? How should that be documented? Now, I didn't actually
give you the answer to this one in the video, but I want to see if you can use your nursing
knowledge and your nursing judgment to think of what you believe a nine-centimeter stain
of lochia should be documented as. All right. Let me know how you did in the comments. I can't
wait to hear. Thanks so much, and happy studying. I invite you to subscribe to our channel
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