Maternity - Postpartum, part 1: Assessment of Fundus and Lochia
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.
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