The evidence to support the action of uterine palpation (both method and frequency) remains inadequate. NICE (2014) concluded that as a routine assessment abdominal palpation or measurement of the uterus was unnecessary.
few days. They are often stronger and persist for longer in multiparous women (Blackburn 2013). Women recognize these contractions as ‘after pains’. The rate at which the uterus involutes is considered to be approximately 1 cm per day. Therefore after 6 days, the fundus is usually about halfway between the umbilicus and the symphysis pubis and should be just palpable by the end of 10 days. For many women, the fundus may not be palpable at this time, and is usually no longer palpable after the twelfth postnatal day (Fig. 2.1).
While most textbooks report the changes described here as standard postpartum physiology, Cluett et al (1997) noted several variations in their assessment of 28 women including several days without uterine involution and uteri palpable at 23 days, both without signs of abnormality. It is considered that subinvolution of the uterus is less likely if breastfeeding (due to the increased action of oxytocin on uterine ibres) but more likely if there has been surgery or trauma. Pathological subinvolution usually relates to endometritis (infection within the uterus), often stemming from retained products. This creates the potential risk of a secondary postpartum haemorrhage (PPH).
Changes in the colour and amount of the lochia relect the changes occurring within the endometrium and may
Figure 2.1 The position of the uterus during involution. A, Following delivery.
B, One week following delivery – the fundal height is palpable approximately 5 cm above the symphysis pubis. C, Two weeks following delivery – the fundal height is usually not palpable above the symphysis pubis.
A B C
Umbilicus
Symphysis pubis
A B C
indicative of infection, heavy reddened lochia of haemorrhage.
Palpating after caesarean section
The uterus is often very tender for several days and is slower to involute. While there is less likelihood of retained prod-ucts, there is a risk of endometritis. In the event of needing to palpate the uterus, the hand should be placed gently over the uterus, the action of feeling the tone of the fundus described below is likely to be too painful. Deaths from haemorrhage do occur after caesarean section (Paterson-Brown & Bamber 2014); the midwife should be alert to uterine tone, heavy loss per vaginam and changes in vital signs, especially the pulse rate.
Deviations from the norm
Assessing what the deviation is leads to a plan of care; in almost all instances, the midwife will refer the woman for medical review. Suspected sepsis requires antibiotics promptly, and suspected haemorrhage may require surgery.
Other signs of illness, e.g. raised temperature or pulse rate, would require the review to be undertaken quickly. A minor deviation, e.g. signs of normality except for a slower to involute uterus, may cause the midwife to consider the taking of a lower vaginal swab for culture and sensitivity and to be clear about when uterine involution should be assessed again. The woman should be alert to any symp-toms that should be reported in the meantime.
Verbal assessment
Initially post-delivery, Bick et al (2009) suggest that the following should be considered:
•
Antenatal and delivery records, including antenatal hemoglobin (Hb) and third stage management.•
While palpating the uterus, explanations should be given to the woman as to what is being felt and why. She is then invited to palpate her own uterus.•
Discuss the pattern of her vaginal loss, expected pattern, factors affecting it (e.g. feeding, signs of infection or clots), hygiene and pad changes.•
Visually assess the lochia.At subsequent assessments it is necessary to discuss:
•
Is she feeling well? Are there any signs of pyrexia or pain?•
How much lochial loss is there? Has it changed particularly? What colour is it? Any offensive smell?•
Is there abdominal discomfort? Is it ‘after pains’ or more continuous?However, it also noted that in the presence of other symp-toms (fever, excessive or offensive vaginal lochia, abdomi-nal pain) abdomiabdomi-nal assessment of the uterus is indicated.
If no uterine abnormality is found, other causes for the symptoms should be sought. Davies (2012) found mixed opinions amongst the midwives that she talked to about whether hands-on palpation of the uterus postnatally is necessary. It would seem that if this is not carried out, then other means of assessing normality (see below) should be carefully undertaken. Any deviations from the norm expressed should then lead the midwife to a physical exam-ination. It is clear however, that this will only work if the woman has received guidance on what to realistically expect (and therefore can suggest when there is potentially a deviation from the norm) and if the midwife utilizes good communication skills with open questioning (dis-cussed in detail below).
What is assessed?
•
The midwife should know how the woman is feeling generally. Knight et al (2014) are clear that when presented with an unwell woman, irstly practitioners should ‘think sepsis’, and secondly a full set of vital sign observations should be recorded using a MEOWS chart (p. 66).•
As suggested above, the active ‘descent’ of the uterus back to a pelvic organ forms the largest part of the assessment. It is considered to reduce by 1 cm per day so that at 10 days postnatally it is just palpable above the symphysis pubis. Bick et al (2009) suggest that an initial palpation of the uterus should be undertaken post-delivery to establish a baseline from which the ueterus is seen to involute thereafter.•
The uterus should be positioned centrally within the abdomen. A full bladder can displace the uterus, causing it to deviate to one side. This can interfere with myometrial contraction, predisposing to postpartum haemorrhage. Thus, when the uterus is deviated, the lochia should be assessed to ensure the woman is not haemorrhaging and she should be encouraged to empty her bladder.•
The tone of the uterus should be irm, indicating a well-contracted uterus. If the tone is poor, the uterus will feel soft, again associated with postpartum haemorrhage. A full rectum, retained products of conception or blood clots can cause the uterus to feel bulky.•
The uterus should not feel tender when palpated but should be comfortable. Discomfort could be indicative of infection.•
The lochia should be observed for its amount, colour, and odour. Scant or malodourous lochia may be|
2| Chapter
Principles of abdominal examination: during the postnatal period
SUMMARY
•
It is unnecessary to palpate the uterus routinely postnatally. If a suspected deviation from the norm is revealed on discussion or there are any other clinical signs observed (pyrexia, abdominal pain or offensive lochia) uterine palpation and assessment of lochial loss are then indicated.•
Uterine palpation includes the height, position, tone and comfort of the uterus.•
A deviation from the norm may suggest current or impending haemorrhage or infection. Urgent attention is needed to reduce the morbidity and mortality risks.If the conversation gives the midwife any cause for concern, then the uterus should be palpated.
PROCEDURE: postnatal abdominal palpation of the uterus
•
Conirm that palpation is necessary (see above), gain informed consent.•
Ask the woman to empty her bladder if she has not done so recently.•
Wash and dry hands, apply disposable apron and non-sterile gloves.•
Ask the woman to lie down in a recumbent position with her arms by her side.•
Ensure she is comfortable and privacy is maintained.•
Expose the woman’s abdomen, note any features that may affect the palpation (e.g. obesity, degree of healing for caesarean section wound).•
Using the outer aspect of one hand, gently depress the abdomen to feel for the fundus. If the fundus is not found, remove the hand and reposition higher or lower and gently press down again.•
When the fundus is felt, use the outer aspect of the hand to estimate the height and position of the uterus. Depress slightly further down into the abdomen to feel over the top of the fundus, assess the uterine tone. A well-contracted uterus is often described as feeling like a cricket ball.•
Note whether the woman displays any non-verbal discomfort or expresses any pain on palpation.•
If not already done so, the lochial loss should be assessed by examining the pad. Check when the pad was last changed to obtain an idea of the extent of the loss. This can be done with the woman in the same position or in left lateral; she may prefer to stand up and remove the pad. If the lochial loss is heavy, the uterus should be palpated at the same time as examining the pad to see if on palpation any clots are expelled from the uterus.•
Assist the woman into a covered and comfortable position. Remove gloves and apron, dispose of them correctly, wash and dry hands.•
Discuss the indings with the woman.•
Document the indings and act accordingly, either with a prompt referral or established plan as to when the next reassessment takes place. NICE (2014) indicate that care plans should be individualized and made in consultation with the woman.ROLE AND RESPONSIBILITIES OF THE MIDWIFE These can be summarized as:
•
careful communication, undertaking a physical examination correctly if indicated, in line with standard precaution and infection control protocols•
recognizing deviations from the norm and instigating referral•
education, explanations and support of the woman•
appropriate record keeping.SELF-ASSESSMENT EXERCISES
The answers to the following questions may be found in the text:
1. Describe how involution occurs.
2. Based on what information should the midwife palpate the uterus during the postnatal period?
3. What is being assessed for when palpating the uterus during the postnatal period?
4. The lochia may be examined following abdominal palpation. What information may be gained from this in relation to involution?
5. Describe the action that should be taken if sepsis is suspected.
REFERENCES
Bick, D., MacArthur, C., Winter, H., 2009. Postnatal Care Evidence and Guidelines for Management, second ed. Elsevier, Edinburgh, pp. 1–18.
Blackburn, S.T., 2013. Maternal, Fetal and Neonatal Physiology: A Clinical Perspective, fourth ed. Elsevier, Maryland Heights. (Chapter 11).
Cluett, E.R., Alexander, J., Pickering, R.M., 1997. What is the normal pattern of uterine involution? An investigation of postpartum uterine involution measured by the distance between the symphysis pubis and the uterine fundus using a paper tape measure. Midwifery 13 (1), 9–16.
Davies, L., 2012. Care in the postnatal period part 2. Essentially MIDIRS 3 (1), 36–40.
Gale, E., 2008. Throwing the baby out with the bathwater? MIDIRS Midwifery Digest. 18 (2), 277–281.
Knight, M., Kenyon, S., Brocklehurst, P., et al. on behalf of MBRRACE-UK (Eds.), 2014. Saving Lives, Improving Mothers’ Care – Lessons Learned to Inform Future Maternity Care from the UK and Ireland Conidential Enquiries into Maternal Deaths and Morbidity 2009–12. National Perinatal Epidemiology Unit, Oxford.
NICE (National Institute for Health and Care Excellence), 2014. Postnatal care
CG37. NICE, London. Available online: <www.nice.org.uk> (accessed 5 March 2015).
Paterson-Brown, S., Bamber, J., on behalf of the MBRRACE-UK haemorrhage chapter writing group, 2014.
Prevention and treatment of haemorrhage. In: Knight, M., Kenyon, S., Brocklehurst, P., et al. on behalf of MBRRACE-UK (Eds.), Saving Lives, Improving Mothers’ Care – Lessons Learned to Inform Future Maternity Care from the UK and Ireland Conidential Enquiries into Maternal Deaths and Morbidity 2009–12.
National Perinatal Epidemiology Unit, Oxford, pp. 45–55.
Assessment of maternal and neonatal vital signs:
temperature measurement
Chapter
PROCEDURE: temporal artery
thermometer use 34
Conclusion 35
Taking a baby’s temperature 35
Indications 35
PROCEDURE: taking a baby’s
temperature (axilla site) 36
Roles and responsibilities of the midwife 36
Self-assessment exercises 36
References 37
LEARNING OUTCOMES
Having read this chapter, the reader should be able to:
•
deine normal body temperature for the childbearing woman and baby•
describe the factors that inluence body temperature and the changes relating to childbearing•
discuss the suitable sites for temperaturemeasurement, highlighting their rationale for use, accuracy, normal temperature ranges and the equipment that can be used
•
describe the types of thermometer and how each one is used correctly and safely•
demonstrate taking a baby’s temperature•
discuss the midwife’s role and responsibilities in relation to temperature measurement, identifying when and how it should be undertaken.This chapter considers the means and signiicance of obtain-ing an ‘as accurate as possible’ temperature measurement.
There is discussion about the different sites for temperature assessment, followed by the equipment available.
3
CHAPTER CONTENTS
Learning outcomes 25
Body temperature 26
Normal values 26
Factors inluencing body temperature 26 Temperature changes related to childbirth 27
Pregnancy: maternal 27
Pregnancy: fetal 27
Labour 27
Postnatal period: maternal 27
Postnatal period: baby 27
Temperature assessment 28
Indications 28
Sites for adult temperature recording 29
Choosing a site 29
Oral site 29
Tympanic membrane 30
Axilla site 30
Forehead 31
Sites for paediatric temperature recording 31
Types of thermometer 32
Electronic thermometers 32
PROCEDURE: electronic thermometer
use in oral and axilla sites 32
Tympanic thermometers 33
PROCEDURE: tympanic thermometer use 33 Disposable (chemical dot) thermometers 33 PROCEDURE: disposable thermometer use 34 Temporal artery thermometers 34
Sund-Levander & Grodzinsky 2013). Davie & Amoore (2010) suggest that many clinicians still regard body perature to be 37°C without appreciating that normal tem-peratures are within a range for everyone. The range of normal values for each temperature measurement site is discussed with each site (below). They are taken from Davie
& Amoore (2010).