POSTPARTUM
 The postpartal period, or puerperium (from the Latin
puer, for “child,” and parere, for “to bring forth”),
refers to the 6-week period after childbirth.
 It is a time of maternal changes that are both
retrogressive (involution of the uterus and vagina) and
progressive (production of milk for lactation,
restoration of the normal menstrual cycle, and
beginning of a parenting role).
 Assessment During the puerperium, assessment of a
woman is accomplished by health interview, physical
examination, and analysis of laboratory data. It is
important to ensure that physical changes, such as
uterine involution, are occurring by evaluating uterine
size and consistency and lochia flow amount.
PHYSIOLOGICAL CHANGES OF THE
POSPARTAL PERIOD
Reproductive System Changes
 Involution is the process whereby the reproductive
organs return to their nonpregnant state. By the time
involution is complete (6 weeks), the uterus is
completely return to its prepregnancy state.
The Uterus
Because uterine contraction
begins immediately after placental
delivery, the fundus of the uterus
may be palpated through the
abdominal wall, halfway between
the umbilicus and the symphysis
pubis, within a few minutes after
birth. One hour later, it will have
risen to the level of the umbilicus,
where it remains for
approximately the next 24 hours.
From then on, it decreases one
fingerbreadth per day—on the first
postpartal day, and so forth. By
the ninth or tenth day, the uterus
will no longer be detected by
abdominal palpation.
 Lochia
Uterine flow, consisting of blood, fragments of decidua, white blood cells,
mucus, and some bacteria, is known as lochia. It takes approximately 6
weeks (the entire postpartal period). For the first 3 days after birth, a
lochia discharge consists almost entirely of blood, with only small particles
of decidua and mucus. Because of its mainly red color, it is termed lochia
rubra. As the amount of blood involved in the cast-off tissue decreases
(about the fourth day) and leukocytes begin to invade the area, as they do
with any healing surface, the flow becomes pink or brownish (lochia
serosa). On about the 10th day, the amount of the flow decreases and
becomes colorless or white (lochia alba). Lochia alba is present in most
women until the third week after birth, although it is not unusual for a
lochia flow to last the entire 6 weeks of the puerperium.
Saturating a perineal pad in less than 1 hour is considered an abnormally
heavy flow and should be reported. Lochia should contain no large clots.
Clots may indicate that a portion of the placenta has been retained and is
preventing closure of the maternal uterine blood sinuses. Lochia should
not have an offensive odor. Lochia has the same odor as menstrual blood.
An offensive odor usually indicates that the uterus has become infected.
 The Cervix
Contraction of the cervix toward its prepregnant state
begins at once. By the end of 7 days, the external os has
narrowed to the size of a pencil opening; the cervix feels
firm and nongravid again.
 The Vagina
After a vaginal birth, the vagina is soft, with few rugae,
and its diameter is considerably greater than normal. The
hymen is permanently torn and heals with small,
separate tags of tissue. It takes the entire postpartal
period for the vagina to involute (by contraction, as with
the uterus) until it gradually returns to its approximate
prepregnancy state.
 The Perineum
Because of the great amount of pressure experienced during birth,
the perineum feels edematous and tender immediately after birth. .
The labia majora and labia minora typically remain atrophic and
softened after birth, never returning to their prepregnancy state.
 BREAST
In many women, breast distention becomes marked, and this often
is accompanied by a feeling of heat or pain. The distention is not
limited to the milk ducts but occurs in the surrounding tissue as
well, because blood and lymph enter the area to contribute fluid to
the formation of milk. This feeling of tension in the breasts on the
third or fourth day after birth is termed primary engorgement. It
fades as the infant begins effective sucking termed primary
engorgement. It fades as the infant begins effective sucking and
empties the breasts of milk.
Systemic Changes
 Pregnancy hormones begin to decrease as soon as
the placenta is no longer present. Levels of human
chorionic gonadotropin (hCG) and human placental
lactogen (hPL) are almost negligible by 24 hours.
 By week 1, progestin, estrone, and estradiol are all at
prepregnancy levels. Estrol may be elevated for an
additional week before it reaches prepregnancy
levels. Follicle-stimulating hormone (FSH) remains
low for about 12 days and then begins to rise as a
new menstrual cycle is initiated.
Urinary System
 During pregnancy, as much as 2000 to 3000 mL excess
fluid accumulates in the body. An extensive diuresis
begins to take place almost immediately after birth to rid
the body of this fluid. This easily increases the daily
output of a postpartal woman from a normal level of
1500 mL to as much as 3000 mL/day during the second
to fifth day after birth. This marked increase in urine
production causes the bladder to fill rapidly.
 During a vaginal birth, the fetal head exerts a great deal
of pressure on the bladder and urethra as it passes on the
bladder’s underside. This pressure may leave the bladder
with a transient loss of tone that, together with the
edema surrounding the urethra, decreases a woman’s
ability to sense when she has to void.
Urinary System
 To prevent permanent damage to the bladder from
overdistention, assess a woman’s abdomen
frequently in the immediate postpartal period. On
palpation, a full bladder is felt as a hard or firm area
just above the symphysis pubis. On percussion
(placing one finger flat on the woman’s abdomen
over the bladder and tapping it with the middle
finger of the other hand), a full bladder sounds
resonant, in contrast to the dull, thudding sound of
non–fluid-filled tissue.
Circulatory System
 The diuresis that is evident between the second and fifth days
after birth, as well as the blood loss at birth, acts to reduce the
added blood volume a woman accumulated during pregnancy.
This reduction occurs so rapidly, in fact, that the blood
volume returns to its normal prepregnancy level by the first or
second week after birth.
 The usual blood loss with a vaginal birth is 300 to 500 mL.
With a cesarean birth, it is 500 to 1000 mL. A 4-point
decrease in hematocrit (proportion of red blood cells to
circulating plasma) and a 1-g decrease in hemoglobin value
occur with each 250 mL of blood lost.
 Women usually continue to have the same high level of
plasma fibrinogen during the first postpartal weeks as they
did during pregnancy. This is a protective measure against
hemorrhage. However, this high level also increases the risk of
thrombus formation.
Gastrointestinal System
 Digestion and absorption begin to be active again soon
after birth unless a woman has had a cesarean birth.
Almost immediately, the woman feels hungry and thirsty
and she can eat without difficulty from nausea or
vomiting during this time.
 Hemorrhoids (distended rectal veins) that have been
pushed out of the rectum because of the effort of pelvicstage pushing often are present.
 Bowel sounds are active, but passage of stool through the
bowel may be slow because of the still-present effect of
relaxin on the bowel. Bowel evacuation may be difficult
because of the pain of episiotomy sutures or
hemorrhoids.
Integumentary System
 After birth, the stretch marks on a woman’s abdomen
(striae gravidarum) still appear reddened and may be
even more prominent than during pregnancy, when they
were tightly stretched.
 Excessive pigment on the face and neck (chloasma) and
on the abdomen (linea nigra) will become barely
detectable in 6 weeks’ time.
 If diastasis recti (overstretching and separation of the
abdominal musculature) is present, the area will appear
slightly indented. If the separation is large, it will appear
as a bluish area in the abdominal midline. Modified situps help to strengthen abdominal muscles and return
abdominal support to its prepregnant level
Vital Sign Changes
Temperature
 A woman may show a slight increase in temperature during
the first 24 hours after birth because of dehydration that
occurred during labor. If she receives adequate fluid during
the first 24 hours, this temperature elevation will return to
normal.
 Any woman whose oral temperature rises above 100.4° F (38°
C), excluding the first 24-hour period, is considered by criteria
of the Joint Commission on Maternal Welfare to be febrile. In
such women, a postpartal infection may be present.
 Occasionally, when a woman’s breasts fill with milk on the
third or fourth postpartum day, her temperature rises for a
period of hours because of the increased vascular activity
involved. If the elevation in temperature lasts longer than a
few hours, however, infection is a more likely reason.
Vital Sign Changes
Pulse
 A woman’s pulse rate during the postpartal period is
usually slightly slower than normal. During
pregnancy, the distended uterus obstructed the
amount of venous blood returning to the heart; after
birth, to accommodate the increased blood volume
returning to the heart, stroke volume increases. This
increased stroke volume reduces the pulse rate to
between 60 and 70 beats per minute.
Vital Sign Changes
Blood Pressure
 Blood pressure should also be monitored carefully during the
postpartal period, because a decrease in this can indicate
bleeding. In contrast, an elevation above 140 mm Hg systolic
or 90 mm Hg diastolic may indicate the development of
postpartal pregnancy-induced hypertension, an unusual but
serious complication of the puerperium.
 To evaluate blood pressure, compare a woman’s pressure with
her prepregnancy level if possible, rather than with standard
blood pressure ranges.
 Oxytocics, drugs frequently administered during the
postpartal period to achieve uterine contraction, cause
contraction of all smooth muscle, including blood vessels that
can increase blood pressure.
Progressive Changes
 Two physiologic changes that occur during the
puerperium involve progressive changes, or the
building of new tissue. Because building new tissue
requires good nutrition, caution women against
strict dieting that would limit cell-building ability
during the first 6 weeks after childbirth.
Lactation
 The formation of breast milk (lactation) begins in a
postpartal woman whether or not she plans to
breastfeed. For the first 2 days after birth, an average
woman notices little change in her breasts from the
way they were during pregnancy.
 Since midway through pregnancy, she has been
secreting colostrum, a thin, watery, prelactation
secretion. She continues to excrete this fluid the first
2 postpartum days. On the third day, her breasts
become full and feel tense or tender as milk forms
within breast ducts.
Lactation
 Breast milk forms in response to the decrease in estrogen
and progesterone levels that follows delivery of the
placenta (which stimulates prolactin production and,
consequently, milk production). When breast milk first
begins to form, the milk ducts become distended.
 The distention of the breast is not limited to the milk
ducts but occurs in the surrounding tissue as well,
because blood and lymph enter the area to contribute
fluid to the formation of milk. This feeling of tension in
the breasts on the third or fourth day after birth is
termed primary engorgement. It fades as the infant
begins effective sucking and empties the breasts of milk.
Return of Menstrual Flow
 With the delivery of the placenta, the production of
placental estrogen and progesterone ends. The resulting
decrease in hormone concentrations causes a rise in
production of FSH by the pituitary, which leads, with
only a slight delay, to the return of ovulation. This
initiates the return of normal menstrual cycles.
 A woman who is not breastfeeding can expect her
menstrual flow to return in 6 to 10 weeks after birth. If
she is breastfeeding, a menstrual flow may not return for
3 or 4 months (lactational amenorrhea) or, in some
women, for the entire lactation period. However, the
absence of a menstrual flow does not guarantee that a
woman will not conceive during this time, because she
may ovulate well before menstruation returns
NURSING RESPONSIBILITIES
a.
Perineal Care - inspect the perineum. Observe for
ecchymosis, hematoma, erythema, edema, intactness, and presence
of drainage or bleeding from any episiotomy stitches.
b.
Provide Pain Relief for Afterpains - Pain from uterine
contractions can be intense, but you can assure a woman that this
type of discomfort is normal and rarely lasts longer than 3 days.
c.
Relieve Muscular Aches - Many women feel sore and
aching after labor and birth because of the excessive energy they
used for pushing during the pelvic division of labor. A backrub is
effective for relieving an aching back or shoulders.
d.
Administer Cold and Hot Therapy - Applying an ice or
cold pack to the perineum during the first 24 hours reduces perineal
edema and the possibility of hematoma formation, thereby reducing
pain and promoting healing and comfort. After the first 24 hours
healing increases best if circulation to the area by the use of heat.
Dry heat in the form of a perineal hot pack or moist heat with a sitz
bath.
e.
Episiotomy Care - the perineal area heals rapidly, you
can assure a woman that this discomfort is normal and does not
usually last longer than 5 or 6 days. Many physicians and nursemidwives order a soothing cream or anesthetic spray to be applied
to the suture line to reduce discomfort.
f.
Inspect Lochia - Check the Consistency: Lochia should
contain no large clots. Clots may indicate that a portion of the
placenta has been retained and is preventing closure of the
maternal uterine blood sinuses. In any event, large clots denote
poor uterine contraction, which needs to be corrected.
Observe the Pattern: Lochia is red for the first 1 to 3 days (lochia
rubra), pinkish-brown from days 4 to 10 (lochia serosa), and then
white (lochia alba) for as long as 6 weeks after birth. The pattern of
lochia (rubra to serosa to alba) should not reverse.
PSYCHOLOGICAL CHNGES
 Postpartal Blues During the postpartal period, as many
as 50% of women experience some feelings of
overwhelming sadness (Buultjens & Liamputtong, 2007).
They may burst into tears easily or feel let down or
irritable. This temporary feeling after birth has long been
known as the “baby blues.”
 This phenomenon may be caused by hormonal changes,
particularly the decrease in estrogen and progesterone
that occurs with delivery of the placenta. For some
women, it may be a response to dependence and low selfesteem caused by exhaustion, being away from home,
physical discomfort, and the tension engendered by
assuming a new role, especially if a woman is not
receiving support from her partner.
PSYCHOLOGICAL CHNGES
 The syndrome is evidenced by tearfulness, feelings of
inadequacy, mood lability, anorexia, and sleep
disturbance.
 Anticipatory guidance and individualized support from
health care personnel are important to help the parents
understand that this response is normal. You can assure
a woman that sudden crying episodes may occur;
otherwise, she may have difficulty understanding what is
happening to her.
 Her support person also needs assurance, or he can think
the woman is unhappy with him or their new baby or is
keeping some terrible secret about the baby from him.
Phases of the Puerperium
Reva Rubin, a nurse, divided the puerperium into three separate phases
(Rubin, 1977).
 Taking-In Phase
A time when the new parents review their pregnancy and the labor and birth, a
time of reflection. During this 2- to 3-day period, a woman is largely passive.
This dependence results partly from her physical discomfort because of
afterpains; partly from her uncertainty in caring for her newborn; and partly
from the extreme exhaustion that follows childbirth.
 Taking-Hold Phase
After a time of passive dependence, a woman begins to initiate action. Now, she
begins to take a strong interest. , it is always best to give a woman brief
demonstrations of baby care and then allow her to care for her child herself—
with watchful guidance.
 Letting-Go Phase
In the third phase, called letting-go, a woman finally redefines her new role.
She gives up the fantasized image of her child and accepts the real one; she
gives up her old role of being childless or the mother of only one or two (or
however many children she had before this birth).