Uterus.

For uterine assessment, position the woman supine

so the height of the uterus is not infl uenced by an elevated
position. Observe her abdomen for contour, to detect distention, and for the appearance of
striae or a diastasis. If a
diastasis is present (a slightly indented, possibly bluish-tinged
groove in the midline of the abdomen), measure the width
and length by fi ngerbreadths.
Palpate the fundus of the uterus by placing one hand on
the base of the uterus, just above the symphysis pubis, and
the other at the umbilicus. Press in and downward with the
hand at the umbilicus until you “bump” against a fi rm globular mass in the abdomen: the uterine
fundus (Fig. 17.5).
Assess consistency (fi rm, soft, or boggy), location (midline),
and height. For the fi rst hour after birth, the height of the
fundus is at the umbilicus or even slightly above it; it then
decreases one fi ngerbreadth in size daily. Measure the distance under the umbilicus in fi
ngerbreadths, such as “2 F↓”
or 2 cm beneath the umbilicus. Although this measurement
seems less scientifi c than a measurement of the height of the
uterus from the pubis, it is a more certain measurement and
demonstrates the gradual decline in size of the uterus.
Never palpate a uterus without supporting the lower segment, because the uterus potentially
could invert (turn inside
out) if not stabilized, resulting in a massive hemorrhage.
Palpation of a fundus should not cause pain as long as the
action is done gently. If the uterus is not fi rm on palpation,
massage it gently with the examining hand; this usually causes
the fundus to contract and immediately become fi rm. Use a
gentle rotating motion, never a hard or forceful touch, so that
you do not cause pain or cause the uterus to expend excess
energy in contracting. If the uterine fundus does not grow
fi rm with massage, extreme atony, possibly retained placenta
fragments, or an excess amount of blood loss may be occurring. Notify the woman’s primary
care provider. Administer
oxytocin as prescribed. In addition, placing the woman’s
infant at her breast will cause endogenous release of oxytocin
and achieve the same effect as oxytocin administration.
If massage appears ineffective, the cause of this may be a
clot present in the cavity of the uterus. This may be expressed from the uterus by gentle
pressure on the fundus, but only
after the uterus has been massaged and is fairly fi rm. As mentioned earlier, if fundal pressure is
applied with the uterus
totally relaxed, fundal pressure could cause inversion of the
uterus, an extremely serious complication that leads to rapid
hemorrhage. Another reason the uterus may not be well contracted is that a rapidly fi lling
bladder is preventing contraction. If contraction remains inadequate, a lower abdominal
ultrasound may be prescribed to help detect an abnormality.
A woman who received no oxytocin after birth to help her
uterus contract is at greater risk for poor uterine contraction
than is a woman who did receive oxytocin and thus needs
frequent uterine assessment (about every 10 to 15 minutes
for the fi rst hour).
Once this fi rst hour has passed, height and consistency can
be assessed less frequently, depending on institutional policy. By
the 9th or 10th day after delivery, the uterus will have become
so small that it is no longer palpable above the symphysis pubis.

Provide Pain Relief for Afterpains. Pain from uterine

contractions is similar to pain from menstrual cramps
and can be intense. It’s usually helpful to assure a
woman that this type of discomfort, although painful,
is normal and rarely lasts longer than 3 days. If necessary, either ibuprofen (such as Motrin),
which has antiinfl ammatory and antiprostaglandin properties, or a common analgesic such as
acetaminophen (such as
Tylenol) is effective for pain relief. As with any abdominal pain, heat to the abdomen should be
avoided,
because it could cause relaxation of the uterus and
subsequent uterine bleeding. Remind the woman
that the total 24-hour dose for acetaminophen is
3,000 mg so she does not take an excessive amount
after returning home (Karch, 2013)

Relieve Muscular Aches. Many women feel so sore

and achy after labor and birth that they describe
feeling as if they have “run for miles.” A backrub
is usually effective for relieving an aching back or
shoulders, but some woman may appreciate a mild
analgesic such as acetaminophen for the pain. Carefully assess a woman who states she has
pain in the
calf of her leg on standing because pain in the calf
on standing (a position that dorsifl exes the foot) is
Homans sign and could indicate that thrombophlebitis is present (see later discussion).
Administer Cold and Hot Therapy.
Applying an ice
or cold pack to the perineum during the fi rst 24 hours
reduces perineal edema and the possibility of hematoma formation, and also reduces pain and
promotes
healing and comfort. Be certain not to place ice or
plastic directly on the woman’s perineum. Use a commercial cold pack, or wrap an ice bag fi rst
in a towel
or disposable pad, to decrease the chance of a thermal burn (risk of injury increases because
the perineum has decreased sensation from edema after birth).
Ice to the perineum after the fi rst 24 hours is no
longer therapeutic because, after this time, healing
increases best if circulation to the area is encouraged
by the use of heat. Dry heat in the form of a perineal
hot pack or moist heat with a sitz bath are both effective ways to increase circulation to the
perineum, provide comfort, reduce edema, and promote healing.
Commercial hot packs grow warm after they are
“cracked” and the chemicals in them combine. Caution
women to use a washcloth or gauze square between
the pack and their skin, to prevent a possible burn.
Promote Perineal Exercises.
Some women fi nd that
carrying out perineal exercises three or four times
a day can greatly relieve perineal edema. The most
effective exercise consists of contracting and relaxing
the muscles of the perineum 5 to 10 times in succession, as if trying to stop voiding (Kegel
exercises).
This aids comfort by improving circulation to the area
and decreasing edema. When repeated frequently,
Kegel exercises can also help a woman regain her
prepregnant muscle tone and help prevent urinary
incontinence (Boyle, Hay-Smith, Cody, et al., 2012).
Give Suture Line Care for Women With an
Episiotomy.
Although relatively small in size,
episiotomy sutures can cause considerable
discomfort, because the perineum is an extremely
sensitive area and the muscles of the perineum
are involved in so many activities such as sitting,
walking, stooping, squatting, bending, urinating,
and defecating.
Because the perineal area heals rapidly, you
can assure a woman that discomfort is normal
and does not usually last longer than 5 or 6 days.
Most primary care providers prescribe a soothing
anesthetic cream or spray to be applied to the
suture line to reduce discomfort. A cortisone-based
cream or warm sitz bath helps to decrease infl ammation and relieve tension in the area.
Because of
their cooling effect, witch hazel–impregnated pads (Tucks) are a mainstay for relief of both
perineal and
hemorrhoidal discomfort.
In addition to local perineum creams or sprays,
many women require an oral analgesic such as hydrocodone for the fi rst 24 hours, then a
milder one such
as acetaminophen for the remainder of the fi rst week.
Caution a woman not to use aspirin for pain relief
during the postpartal period because it interferes with
blood clotting and may increase her risk for hemorrhage from the denuded placental site (Karch,
2013).
If a woman is worried she will experience additional
discomfort when her episiotomy sutures are removed,
you can assure her these sutures will dissolve within
10 days and thus do not need to be removed.