Chapter 12
Postpartum Assessment
and Nursing Care
Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.
1
Immediate Postpartum
Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.
2
Objectives





Define key terms listed.
Describe the postpartum period.
Explain the involution of the uterus and
describe changes in the fundal position.
Explain the cause of afterpains.
Distinguish among the characteristics of
lochia rubra, lochia serosa, and lochia alba.
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3
Objectives (cont.)




Explain how to assess the postpartum
woman’s perineum.
Describe two ways in which the fluid
accumulated during pregnancy is eliminated
during the postpartum period.
Explain the importance of monitoring the vital
signs during the first 24 hours postpartum.
List three factors that influence urinary
retention after delivery.
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4
Postpartum Period


Also called puerperium
Six-week interval from childbirth to the return
of the uterus and other organs to a
prepregnant state

Immediate postpartum: first 24 hours
 Early postpartum: first week
 Late postpartum: second to sixth weeks
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5
Goals of Postpartum Care



Assist and support the woman’s recovery to
the prepregnant state and identify deviations
from the norm
Educate the mother about her own self-care
and newborn feeding and care
Promote bonding between newborn and
family
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6
Dangers in Immediate
Postpartum

Hemorrhage


Hypovolemic shock
Infection


Uterine cavity easily accessible to microorganisms
from exterior
Placental attachment site is like an open wound
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7
Clinical Pathway
in Postpartum Period





Nursing assessments
Teaching
Medical and nursing interventions
Discharge
Follow-up care for woman
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8
Physiologic Changes in the
Reproductive System
and Nursing Interventions
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9
Involution of the Uterus




Begins after expulsion of placenta
Placental site contracts to a size less than
half of its original size immediately after birth
Contractions cause uterine muscles to act like
“living ligatures” and compress blood vessels
Caused by sudden withdrawal of estrogen
and progesterone
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10
Involution of the Uterus (cont.)

Release of proteolytic enzymes into
endometrium


Causes protein material within endometrial cells to
break down into substances that are excreted in
the urine
Number of muscle cells does not change,
only their size
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11
Exfoliation

Unique healing process that allows healing of
placental site without scarring




Necrotic tissue is sloughed off
Reparative process ensures future fertilized ova
will implant in an unscarred uterus
Endometrial regeneration is complete within
16 days postpartum
Placental regeneration is complete at 6
weeks postpartum
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12
Uterus



Immediately after birth weighs about 1000 g
(2.2 lbs)
Decreases to 500 g (1.1 lb) during first week
postpartum
By second week postpartum, weighs around
340 g (12 oz)
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13
Factors That Can Slow
Involution







Prolonged labor
Incomplete expulsion of placenta and
membranes
Anesthesia
Previous labors
Distended (full) bladder
Blood clots
Boggy uterus
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14
Factors That Can Enhance
Involution



Uncomplicated labor and birth
Breastfeeding
Early, frequent ambulation
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15
Cervix




After birth it is soft
By 18 hours postpartum, has regained its
usual form
Gradually closes around 2 weeks postpartum
Never regains original appearance

After pregnancy, os looks like a slit instead of a
circle or dot
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16
Descent of Uterine Fundus



Usual progression of uterine descent into
pelvis at about 1 cm/day
Immediately after delivery, fundus typically at
umbilicus or just below it
By 10 days postpartum, uterus should not be
abdominally palpable
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17
Subinvolution of the Uterus


Failure of the uterus to return to the
prepregnant state
Most common cause is retained placental
fragments
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18
Afterpains



Intermittent uterine contractions
Occur for the first 2 to 3 days postpartum
Hormone oxytocin




Strengthens uterine contractions
Compresses blood vessels
Infant suckling can cause afterpains
Ibuprofen can be given
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19
Lochia


Postpartum vaginal discharge
Contains




Blood from placental site
Particles of necrotic decidua
Mucus
Normally fleshy odor similar to menstrual flow
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20
Lochia Rubra




Heaviest during first 1 to 2 hours after
delivery
Initially bright red (lochia rubra)
Lasts 1 to 3 days
May contain small clots
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21
Lochia Serosa



Vaginal flow pales
Becomes pink to brown after about 3 days
Should not contain clots and can last up to 27
days in some women
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22
Lochia Alba


Typically by 10 days postpartum, vaginal
discharge becomes yellow to white
May continue on average to the 6th week
postpartum
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23
Estimating Lochial Flow




Count number of pads
being changed per hour
Pads can be weighed
(1 g = 1 mL blood)
Check fundal firmness
Document per facility
protocol
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24
Lochial Flow



Teach mother that she may see an increase
in lochia on rising due to pooling of fluids
within the vagina
Excessive lochia rubra early in postpartum
may suggest bleeding due to retained
placental fragments
Recurrence of bleeding in 7 to 10 days
suggests bleeding from placenta site but
could also be normal sloughing
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25
Lochial Flow (cont.)



After 3 to 4 weeks, late bleeding may be
caused by infection or subinvolution
Continued lochia serosa or alba suggests
infection (endometritis) and may also indicate
fever, pain, or abdominal tenderness
Lochia will have an offensive odor if infection
is present
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26
Vagina


Appears edematous and bruised
By week 3, resumes prepregnant appearance


Rugae begin to reappear
By week 6, has almost regained prepregnant
form

May notice dryness, which usually disappears
when ovulation and menstruation return
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27
Perineum


Often edematous and bruised from delivery
Assess for type and amount of vaginal
discharge, unusual swelling, discoloration,
healing of tissues, discomfort
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28
Assessing Episiotomy Site

REEDA scale






Redness
Edema
Ecchymosis (bruising)
Discharge
Approximation of wound
Healing overall takes around 6 weeks
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29
Changes in the
Musculoskeletal System
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30
Muscles and Joints

Relaxin hormone decreases


Ligaments and cartilage of pelvis begin to return to
prepregnant state
Progesterone hormone decreases


Muscle tone improves
Woman can develop diastasis recti
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31
Lower Extremities

Homans’ sign



May occur due to
venous stasis
If present, may be
early sign of venous
thrombosis
Report immediately
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32
Changes in the
Cardiovascular System


Women lose at least 200 to 500 mL of blood
during vaginal delivery
Twice as much during cesarean birth
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33
Rapid Changes in Blood Volume


Prevent hypovolemia
Changes include




Elimination of placenta
Rapid reduction of size of uterus
Increase of blood flow to vena cava
Mobilization of body fluids accumulated during
pregnancy
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34
Excess Fluid

Disposed of two ways


Diuresis (increased excretion of urine)
• Woman may have urinary output as high as 3000 mL/day
Diaphoresis (profuse perspiration)
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35
Blood Values


First 72 hours, greater loss of plasma volume
than RBCs
Temporary rise in hematocrit and hemoglobin


Normal levels return in 2 to 4 weeks postpartum
Leukocytosis (WBC can be as high as
15,000/mm3 or higher) without infection

Normal levels return within 10 days postpartum
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36
Blood Coagulation


Increased during pregnancy
Fibrinogen levels return to normal within 2
weeks postpartum




Increases risk of thrombosis formation
Risk can be decreased by early and frequent
ambulation
Dyspnea and tachypnea hallmark signs of
pulmonary embolus
Varicose veins diminish
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37
Orthostatic Hypotension




Pelvic blood flow resistance decreases after
delivery
Woman’s blood pressure falls
May complain of lightheadedness or
dizziness or may even faint (pass out)
Instruct woman to rise slowly to prevent this
from occurring
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38
Postpartum Diaphoresis



Elimination of excess fluid through the skin
Body’s way of getting rid of excess fluid
accumulated during pregnancy
Profuse diaphoresis occurs most often at
night
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39
Vital Signs
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40
Temperature

First 24 hours after delivery, temperature may
rise to 38° C (100.4° F)




Result of dehydration and exertion of labor
Thereafter temperature should be in normal range
If temperature still elevated, infection may
have developed and should be reported
Breast engorgement can cause a short-term
elevation in temperature
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41
Pulse

In first 6 to 8 days


Decreases to a rate of 50 to 60 beats/minute
Elevated rate may indicate undue blood loss,
infection, pain, anxiety, or cardiac disease
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42
Blood Pressure



Should remain stable after birth
Decrease may indicate blood loss
Elevation with a headache may indicate
gestational hypertension that still needs to
resolve in the postpartum period
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43
Changes in the Urinary System





Loss of muscle tone in the bladder
During labor and delivery, urethra, bladder,
and surrounding tissue may become
edematous or traumatized
Urination can be impeded by anesthetic
agents
Urinary output in the early postpartum period
can be significantly high
Close observation of I&O is essential
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44
Urine Composition




Mild proteinuria as result of uterine cell
breakdown
May test positive for acetone or ketones
Lactosuria may occur in breastfeeding
women
Normal status returns about 4 weeks
postpartum
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45
Audience Response System
Question 1
Glomerular filtration rate can remain high in the
postpartum phase for up to:
A. 2 weeks
B. 4 weeks
C. 6 weeks
D. 8 weeks
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46
Physiological Changes
Postpartum
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47
Objectives



Discuss three factors that contribute to
postpartum constipation.
List two significant events that occur as a
result of changes in the endocrine system.
Explain the factors involved in the woman’s
weight loss after birth.
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48
Objectives (cont.)


Interpret Rubin’s taking-in and taking-hold
phases.
Explain the psychological alteration called
postpartum blues.
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49
Changes in the GI System

May have constipation postpartum due to






Decreased peristalsis
Stretched abdominal muscles
Limited food or fluid intake
Soreness and swelling of perineum or hemorrhoids
Fear of pain
Woman should have a bowel movement within 3
days postpartum
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50
Fluid and Nutrition
in Postpartum Period

Eat three balanced meals a day


Maintain adequate calcium and phosphorus intake
If breastfeeding, high fluid and high fiber
intake to reduce risk of constipation

Increase calories by 500 per day if breastfeeding
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51
Changes in the Nervous System


Carpal tunnel syndrome may be lessened
due to diuresis that occurs in postpartum
period
Headaches may continue for a while in
women who experienced gestational
hypertension

Should be investigated
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52
Changes in the
Integumentary System

Melanocyte-stimulating hormone (which
causes hyperpigmentation) decreases rapidly
after delivery




Chloasma (mask of pregnancy) and linea nigra fade
Spider nevi and palmar erythema due to
increased estrogen levels disappear
Striae gravidarum (stretch marks) gradually
fade, but do not totally disappear
Hair growth slows; may experience some hair
loss
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53
Changes in the Endocrine
System


Estrogen and progesterone levels decrease
after expulsion of placenta
Prepregnant levels



If bottle-feeding, returns in about 3 weeks
If breastfeeding, normal levels take longer
First menses is usually anovulatory, but birth
control should still be used
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54
Prolactin and Oxytocin

Prolactin promotes milk production and
ejection


Oxytocin triggers milk ejection when infant
sucks on nipple


Stimulates alveolar cells of breast
Also stimulates uterine contractions
Day 3 postpartum, breast engorgement can
occur
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55
Breast Engorgement




Primarily caused by temporary congestion of
veins and lymphatics, not milk accumulation
Spontaneously resolves within 24 to 36 hours
Supportive bra should be worn for 72 hours;
ice packs and mild analgesics may be used
Milk production ceases within a few days to a
week
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56
Resumption of
Ovulation and Menstruation

Nonlactating woman



Lactating woman



Ovulation may return within 1 month
Menstruation usually resumes within 3 months
Ovulation may return within 1 month
Menstruation usually resumes within 6 months
Menstruation may be heavy initially
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57
Weight Loss

Immediately after delivery weight decreases
by 4.5 to 5.4 kg (10 to 12 lbs)



Accounts for loss of fetus, placenta, and amniotic
fluid
Additional loss of 2.3 kg (5 lbs) due to
diuresis and diaphoresis
2.3 to 3.2 kg (5 to 7 lbs) of fat stored during
pregnancy for lactation

Takes about 6 months to use if breastfeeding
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58
Psychological Changes
and Nursing Interventions

Mood swings common



Related to rapid decline of estrogen and
progesterone
Maternal role and personal insecurity may also
contribute
Maternal adaptation takes place in phases
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59
Taking-In Phase




Begins immediately after birth and lasts up to
2 days postpartum
Passive, dependent behavior
Focuses on her own needs and health of
newborn
Repeatedly reviews labor and delivery
experience
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60
Taking-Hold Phase



Ready to assert independence
Initiates independent care of her newborn
Often becomes exhausted in new role and
verbalizes anxiety about it
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61
Letting-Go Phase


Assumes position in home and new maternal
role
Demands may lead to mild depression
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62
Attainment of Maternal Role

Learns mothering behaviors



Becomes comfortable with identity as mother
Bond between newborn and mother forms
Occurs in four stages




Anticipatory
Formal
Informal
Personal
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63
Interference with
Maternal Role Attainment




Woman’s maturity level
Minimum exposure of mother to baby in days
after birth
Lack of support system
Ill health
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64
Postpartum Blues



70% of women experience this
Generally starts a few days after birth and
lasts around 10 days
Characterized by




Tearfulness
Insomnia
Lack of appetite
Feeling of being disappointed
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Teaching the Postpartum Woman




Relaxation techniques
Increasing confidence in self-care and
newborn care
Promote communication between woman and
partner
Postpartum support group referral that may
be in community
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66
Audience Response System
Question 2
Ovulation and menstruation typically resumes:
A. Nonlactating woman
B. Lactating woman
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67
Care Management After Delivery
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Objectives



Demonstrate three ways to prepare the
sibling for the new family member.
Present two ways to encourage parentnewborn attachment.
Explain why early ambulation is encouraged.
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Objectives (cont.)


Review the importance of Kegel (perineal
tightening) exercises.
Describe five danger signs that the woman
should report after discharge from the
hospital.
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Care Management After Delivery

Nursing assessment per facility protocol



For mother, includes vital signs, fundal location
and consistency, amount of bleeding
Infant may be put to breast
Infant is assessed on arrival in the newborn
nursery
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Care Plan




Begins by using every contact with mother to
fulfill teaching and learning goals
Assist mother and family in learning about
self-care and care of newborn
Family and siblings can visit
Mother encouraged to ask questions
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Cultural Considerations


Rituals, taboos, and traditions need to be
respected
Birth control practices vary and must be
considered when discussing family planning
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Postpartum Check: BUBBLE-HE








Breasts
Uterus
Bladder
Bowel
Lochia
Episiotomy (perineum)
Homans’ sign
Emotions (psyche)
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Ambulation



Early and often
Reduces risk of thrombus formation and
infection
Advise woman to ask nurse for assistance
when she is first getting out of bed

May experience orthostatic hypotension
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Postpartum Chill

Uncontrollable, usually after birth





Cause is unknown
May be related to nervous response or to
vasomotor changes
If chill is without fever, there is no clinical
significance (i.e., infection)
Cover woman with warm blankets
Reassure woman that this is a normal
response
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Promoting Comfort




Episiotomy
Hemorrhoids
Afterpains
Breast engorgement
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Nursing Interventions


Application of cold or heat to the perineum
Sitz bath—provides comfort, promotes
healing, reduces incidence of infection


Should not last longer than 20 minutes
Topical anesthetic application

Wait to apply peripad for 1 to 2 minutes to prevent
medication from being absorbed into pad
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78
Family Adjustment
and Development of Attachment
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Partner Bonding




Partner should be included in all teaching
sessions involving newborn care and feeding
Bonding begins prenatally when father or
partner feels fetus move or hears the
heartbeat
Engrossment is shown by holding, studying,
and touching infant
Adjustment and transition occur when partner
is able to increase interaction with newborn
and understands that time will be set aside
for partner interaction
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Sibling Adjustment



Depends on age and development
Younger siblings may consider newborn as
competition
May see behaviors such as




Regression
Jealousy
Frustration
Special time should be set aside for parents
to give to older siblings
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Grandparent Involvement




Level of involvement depends on proximity
Parenting practices change from one
generation to next
May bring conflict in child-rearing between
parents and grandparents
Attending grandparenting classes is
encouraged
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Promoting Parent-Newborn
Bonding

Bonding and attachment processes produce
affectionate and emotional commitment
between two individuals



Touch
Voice pitch (a high pitch causes infant to become
more alert and turn toward voice)
Progresses over time
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Early Discharge Planning
and Health Promotion


Greatest need is education
Mother must know



How to prevent infection
Danger signs to report for herself and her newborn
Nurse provides education on how to care for
newborn and then observes parents to see if
additional education is needed
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Discharge Teaching

Can be provided through




Video/DVD
Pamphlets
Return demonstrations
Consultants, such as La Leche League for
breastfeeding
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Resumption of Normal Activity



Increase activities gradually and avoid fatigue
Most can resume all activities within 4 to 5
weeks postpartum
Cultural factors also determine when normal
activities can be resumed
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Resumption of Sexual
Intercourse



Can be safely resumed when lochia has
ceased, episiotomy has healed, and woman
feels ready
Usually takes 2 to 6 weeks
First intercourse may be uncomfortable


Partly attributed to vaginal dryness and diminished
vaginal lubrication
Breastfeeding woman may have milk spurts
during orgasm due to release of oxytocin
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Postpartum Fatigue



Overwhelming sustained sense of exhaustion
and decreased capacity for physical and
mental work
May persist for more than a year after
delivery
Early postpartum fatigue may be due to labor,
hormone changes, wound healing,
establishment of breast milk
Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.
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Postpartum Fatigue (cont.)

Factors contributing to continued fatigue




Continuing sleep difficulties
Child care responsibilities
Lack of assistance
Nurse should provide anticipatory guidance to
woman and her partner on how to lessen
some of these factors
Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.
89
Family Planning



Provide couple with options (see Chapter 19)
Stress that ovulation often resumes before
first menses, and pregnancy can occur
Oral contraceptives can be started 2 to 3
weeks after delivery if not breastfeeding


Progestin-only for birth control
Enhances quality and duration of lactation
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90
Postpartum Exercises

Hormonal effects on connective tissue are not
reversed until ~6 weeks postpartum


Risk of injury still present until after this time frame
With normal, uneventful delivery, on first or
second day, woman can

Deep breathe
 Perform abdominal exercises, Kegel exercises,
pelvic tilts
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Kegel Exercises


Strengthen and tone muscles of pelvic floor
May help




Decrease stress incontinence
Speed recovery
Increase sexual response
Advised to do throughout life
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Pelvic Tilt

Assists with postural alignment and relieves
strain on lower back
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Rubella Vaccine


Woman with a serum titer of 1:10 or less is
given rubella vaccine in the postpartum
period
Stress with woman that she is not to become
pregnant for at least 3 months after the
vaccine has been given

Can cause birth defects
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RHo(D) Immune Globulin
(RhoGAM)


Given to women who are Rh negative and
meet specific criteria
Should receive within 72 hours after delivery
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Signs of a Distended Bladder

Discuss the signs of a distended bladder in a
postpartum woman:



Fundus: ____________
Bladder: ____________
Voiding: ____________
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Review Key Points
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