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UTERINE SUBINVOLUTION

Uterine subinvolution is a slowing of the process of involution or shrinking


of the uterus.
Subinvolution is a medical condition in which after childbirth, the uterus does not
return to its normal size. Definition When the involution is impaired or retarded it
is called subinvolution.The uterus is the most common organ affected by
subinvolution.As it is the most accessible organ to be measured per abdomen ,the
uterine involution is considered clinically as an index to assess subinvolution.
a. Causes. Endometritis, retained placental fragments, pelvic infection, and
uterine fibroids may cause uterine subinvolution.
b. Signs and Symptoms.
(1) Prolonged lochial flow.
(2) Profuse vaginal bleeding.
(3) Large, flabby uterus.
c. Medical Treatment.
(1) Administration of oxytocic medication to improve uterine muscle tone.
Oxytocic medication includes
(a) Methergine®-a drug of choice since it can be given by mouth.
(b) Pitocin®.
(c) Ergotrate®.
(2) Dilation and curettage (D&C) to remove any placental fragments.
(3) Antimicrobial therapy for endometritis.
d. Nursing Interventions.
(1) Early ambulation postpartum.
(2) Daily evaluation of fundal height to document involution.

6.14 UTERINE SUBINVOLUTION


Uterine subinvolution is a slowing of the process of involution or shrinking of the
uterus.

a. Causes.
Endometritis, retained placental fragments, pelvic infection, and uterine fibroids
may cause uterine subinvolution.

b. Signs and Symptoms.


(1) Prolonged lochial flow.

(2) Profuse vaginal bleeding.


(3) Large, flabby uterus.

c. Medical Treatment.
(1) Administration of oxytocic medication to improve uterine muscle tone.
Oxytocic medication includes

(a) Methergine®-a drug of choice since it can be given by mouth.

(b) Pitocin®.

(c) Ergotrate®.

Brookside Associates Note: Currently, many medical centers would include


misoprostol(Cytotec®) in this list.
(2) Dilation and curettage (D&C) to remove any placental fragments.

(3) Antimicrobial therapy for endometritis.

d. Nursing Interventions.
(1) Early ambulation postpartum.

(2) Daily evaluation of fundal height to document involution

Description

 Subinvolution is delayed return of the enlarged uterus to normal size and


function.
Etiology

 Subinvolution results from retained placental fragments and membranes,


endometritis, or uterine fibroid tumor; treatment depends on the cause .
Pathophysiology

 Uterine atony or placental fragments prevent the uterus from contracting


effectively.
Assessment Findings
Clinical manifestations include:
1. Prolonged lochial discharge
2. Irregular or excessive bleeding
3. Larger than normal uterus
4. Boggy uterus (occasionally)
Nursing Management
1. Prevent excessive blood loss, infection, and other complications.

a. Massage uterus, facilitate voiding, and report blood loss.


b. Monitor blood pressure and pulse rate.
c. Administer prescribed medications. (see Drug Chart )
d. Be prepared for possible D&C.
2. Assist the client and family to deal with physical and emotional stresses of
postpartum complications.

Book laz

Subinvolution of the uterus is a term used when the uterus does not decrease in size
and does not descend into the pelvis. This usually occurs later in the postpartum
period. Before the diagnosis of subinvolution, the uterus and lochia had been
undergoing normal involution.

Risk Factors ■ Fibroids ■ Metritis ■ Retained placental tissue

Assessment Findings ■ The uterus is soft and larger than normal for the days
postpartum. ■ Lochia returns to the rubra stage and can be heavy. ■ Back pain is
present.

Medical Management ■ Ultrasound evaluation to identify intrauterine tissue or


subinvolution of the placental site (ACOG, 2006).

Medical intervention depends on the cause of the subinvolution. ■ A dilation and


curettage (D&C) is performed for retained placental tissue. ■ Methergine PO is
prescribed for fibroids. ■ Antibiotic therapy is initiated for metritis.
Nursing Actions ■ Review prenatal and labor records for risk factors. ■ Monitor
women who are at risk for subinvolution of the uterus more frequently. ■ Patient
education is the primary action, as PPH from subinvolution usually occurs after
discharge. ■ Provide education on involution and signs to report, such as increased
bleeding, clots, or a change in the lochia to bright red bleeding. ■ Provide
education on ways to reduce risk for infection, such as changing peripads
frequently, hand washing, nutrition, adequate fluid intake, and adequate rest. ■
Explain to women who have fibroids that they are at risk for subinvolution.
Provide instruction on the proper use of discharge medication, since these women
are usually dis- charged with an order for Methergine PO

THE REPRODUCTIVE SYSTEM The reproductive system, which includes the


uterus, cervix, vagina, and perineum, undergoes dramatic changes during the 6
weeks after the birthing experience. Women are at risk for hemorrhage and
infection. Nursing assessments and interventions are aimed at reducing these risks.

Uterus

After delivery of the placenta, the uterus begins the process of involution, by which
the uterus returns to a pre-pregnant size, shape, and location; and the placental site
heals. This occurs through uterine contractions, atrophy of the uterine muscle, and
a decrease in the size of uterine cells. Primiparous women usually do not
experience discomfort related to uterine con- tractions during the postpartum
period. Multiparous women or women who are breastfeeding may experience
“afterpains” during the first few postpartum days. Afterpains are moderate to
severe cramp-like pains that are related to the uterus working harder to remain
contracted and/or to the increase of oxytocin that is released in response to infant
suckling. The uterus needs to be in a contracted state during the postpartum period
to decrease the risk of postpartum hemorrhage. The contracted uterine muscle
compresses the open vessels at the placental site and decreases the amount of blood
loss.

Nursing Actions ■ Assess the uterus for location, position, and tone of the fundus.
■ After the third stage of labor, assess the uterus: ■ Every 15 minutes for the first
hour ■ Every 30 minutes for the second hour ■ Every 4 hours for the next 22 hours
■ Every shift after the first 24 hours or as stated in hospital/unit protocols ■ More
frequently if the assessment findings are not within normal limits ■ Rationale:
Frequent assessment of uterine tone and place- ment allows for the identification of
potential complications such as uterine atony (decreased uterine muscle tone) that
may lead to postpartum hemorrhage (James, 2008).The risk for postpartum
hemorrhage is the greatest within the first hour following delivery (James,
2008).Primary (early) postpartum hemorrhage occurs during the first 24 hours after
birth, and secondary (late) postpartum hemorrhage is most prevalent during the
first 6–14 days following birth (James, 2008). See Chapter 14 for more information
about the care of the woman with postpartum hemorrhage. ■ Before assessment: ■
Inform the woman that you will be palpating her uterus. ■ Explain the procedure. ■
Instruct the woman to void. ■ Rationale: An overdistended bladder can result in
uterine displacement and atony (James, 2008).Encouraging the woman to void
prior to uterine assessment will allow for an accurate assessment of uterine
placement and tone. ■ Provide privacy. ■ Lower the head and foot of the bed so
that the woman is in a supine position and flat. ■ Support the lower uterine
segment by placing one hand just above the symphysis pubis (Fig. 12-1). ■
Rationale: During pregnancy there is stretching of the lig- aments that hold the
uterus in place. Fundal pressure could result in uterine inversion (James, 2008).
Supporting the lower uterine segment may prevent uter- ine inversion during
fundal assessment or massage. ■ Locate the fundus with the other hand using
gentle downward pressure. ■ Determine the tone of the fundus: Firm (contracted)
or soft (boggy). ■ A boggy uterus indicates that the uterus is not contracting and
places the woman at risk for excessive blood loss (see Critical Component: Boggy
Uterus). If the uterus is boggy, the nurse should: ■ Massage the fundus with the
palm of the hand. ■ Rationale: Fundal massage stimulates contraction of the uterus
(James, 2008; Katz, 2012). ■ Give oxytocin as per the physician’s or midwife’s
orders. ■ Rationale: Oxytocin promotes contraction of the uterus by stimulating the
smooth muscle of the uterus (Vallerand & Sanoski, 2013). ■ Notify the physician
or midwife if the uterus does not respond to massage. ■ Rationale: Lack of
response to fundal massage and oxy- tocin administration may indicate
complications such as retained placental tissue, or birth trauma. Continued uterine
atony can lead to postpartum hemorrhage and requires assessment and potentially
further treatment by the woman’s health care provider. ■ Measure the distance
between the fundus and umbilicus with your fingers. ■ Each finger breadth equals
1 cm. ■ Determine the position of the uterus. ■ Rationale: A uterus that is shifted
to the side may indicate a distended bladder. A distended bladder interferes with
uterine contractibility, which places the woman at risk for uterine atony and
increases her risk of hemorrhage. ■ If the uterus is deviated, soft, or elevated above
the umbilicus, the immediate action is to explain to the patient need for her to void
and to assist her to the that contains sloughed off necrotic tissue, undergoes
changes that reflect the healing stages of the uterine placental site (Table 12-2).
Uterine contractions constrict the vessels around the placental site and help
decrease the amount of blood loss. A primary complication is metritis, which is an
infection of the endometrial tissue (see Chapter 14).

Nursing Actions ■ Assess lochia each time the uterus is assessed. ■ Rationale:
Frequent assessment of lochia in the early post- partum period allows the nurse to
monitor blood loss and identify if bleeding is excessive. Lower the peripad for
inspection and determine the amount of lochia. ■ The amount of flow is
determined by the amount of lochia on a perineal pad after 1 hour (AWHONN,
2006). ■ Lochia is assessed as scant, light, moderate, or heavy (Fig. 12-3). ■ Scant
is less than 1 inch on the pad. ■ Light is less than 4 inches on the pad. ■ Moderate
is less than 6 inches on the pad. ■ Heavy is when the pad is saturated within 1 hour
(Whitmer, 2011). ■ Assess for clots. ■ Rationale: It is common for lochia to
contain clots, which occur when the lochia has been pooling in the lower uterine
segment. ■ Small clots should be noted in the patient chart. ■ Large clots should be
weighed and findings reported to the physician or midwife. ■ 10 grams equals 10
milliliters of blood loss. ■ Rationale: Large clots can interfere with uterine
contractions. ■ Clots should be examined for the presence of tissue. ■ Retained
placental tissue can interfere with uterine involution and lead to excessive bleeding
(Katz, 2012) (see Critical Component: Excessive Bleeding). ■ Expected
assessment findings CRITICAL COMPONENT Excessive Bleeding ■ Heavy
lochia is a sign of excessive bleeding and/or postpar- tum hemorrhage. ■ Assess
the tone of uterus. ■ If the uterus is boggy, massage. ■ If the uterus is boggy and
displaced to the side, instruct the patient to void and reevaluate. ■ If firm, change
the pad and reevaluate in 15 minutes. ■ In case of continued excessive bleeding,
notify the physician or midwife. ■ Continued heavy bleeding with good fundal
tone may indi- cate the presence of a genitourinary tract laceration or hematoma of
the vulva or vagina (Katz, 2012).

■ Patient education ■ Teach the woman how to assess the uterus and explain the
normal process of involution. ■ Teach the woman how to massage her uterus if
boggy and instruct her to notify the nurse while in the hospital and health care
provider after discharge. ■ Rationale: Secondary hemorrhage often occurs after the
patient has been discharged. To prevent serious complications, women should
understand the normal progression of lochia and uterine involution, and report
abnormal amounts of bleeding.
Provide information regarding “afterpains.” ■ Uterine cramps are caused by the
contraction and relaxation of the uterus as it decreases in size. ■ Afterpains occur
within the first few days and last 36 hours. ■ They occur more commonly with
multiparous women and increase with each additional pregnancy/birth. ■ The
condition may increase when breastfeeding during the first few postpartum days. ■
Comfort measures (see Critical Component: Assessment and Management of Pain
in the Postpartum Period): ■ Empty bladder ■ Rationale: A distended bladder can
increase afterpains. ■ Warm blanket to abdomen ■ Analgesia (ibuprofen is
commonly used for postpartum discomfort) ■ Rationale: Analgesics alter the
perception and response to pain (Vallerand & Sanoski, 2013). ■ Relaxation
techniques ■ Rationale: According to the gate control theory of pain, interventions
such as applying warm compresses and promoting relaxation may inter- fere with
the transmission and sensation of pain. ■ Provide information on the stages of
lochia. ■ Explain that the flow of lochia can increase when getting up in the
morning or after sitting for prolonged periods of time due to vaginal pooling of
lochia, or from excessive physical activity. ■ Instruct the woman to notify the
nurse, physician, or midwife if she experiences: ■ A sudden increase in the amount
of lochia ■ Bright red bleeding after the rubra stage ■ Foul odor ■ Rationale: Foul
smelling lochia could indicate the devel- opment of an infection. An increase in
lochia or threturn of bright red bleeding may be signs of secondary hemorrhage
(James, 2008). ■ Provide information for reducing the risk of infection. ■ Instruct
the patient to change the peripad frequently from the front to back, and to wash
hands before and after changing pads. ■ Rationale: Lochia is a medium for
bacterial growth. Frequent pad changes and hand washing are actions aimed at
preventing infection. ■ Document the stage and amount of lochia and
interventions.

Subinvolution

Subinvolution is the incomplete return of the uterus to its prepregnant size and
shape. With subinvolution, at a 4- or 6-week postpartal visit, the uterus is still
enlarged and soft. Lochial discharge usually is still present. Subinvolution may
result from a small retained placental fragment, a mild endometritis (infection of
the endometrium), or an accom- panying problem such as a uterine myoma that is
interfering with complete contraction.

Therapeutic Management

Oral administration of methylergonovine, 0.2 mg four times daily, is the usual


prescription to improve uterine tone and complete involution. If the uterus feels
tender to palpation, suggesting endometritis is present, an oral antibiotic also will
be prescribed. Being certain women are able to recognize the normal process of
involution and lochia discharge before hos- pital discharge helps women to be able
to identify subinvolu- tion and seek early care if it occurs. A chronic loss of blood
from subinvolution will result in anemia and a lack of energy, conditions that
possibly could interfere with infant bonding or lead to infection.

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