Assessment & Management of

the Postpartal Period

POSTPARTAL PHYSIOLOGY
UNIT VIII
NUR 158

Puerperium

The 4th trimester

The 1st 6 weeks after delivery
Physiological & psychological adjustment

Involution

Involution is the progressive changes in

uterus after delivery.
The uterus begins decreasing in size after
delivery.
Approximately a fingerbreadth / day for 10
days until it returns to pre-pregnant size.

Involution of the Uterus

Involution (contd)

Uterus must be empty & unimpeded to

involute properly
Retained fragments of placenta, etc. delay
involution & cause infection

Involution/Lochia
Involution used to describe rapid reduction in size of

uterus and return to prepregnant state

Exfoliation allows for healing of placenta site and is
important part of involution
Enhanced by uncomplicated labor and birth
complete expulsion of placenta or membranes,
breastfeeding, and early ambulation

Involution/Lochia
Uterus is at level of umbilicus within 6 to 12 hours

after childbirth decreases by one finger-breadth

per day
Uterus rids itself of debris remaining after birth
through discharge called lochia

Assessing the Fundus

Lochia
Discharge from uterus during 1st 3 weeks
after delivery
3 types of lochia:
lochia rubra - dark red for 1st 2-3 days
lochia serosa - pink to brownish, 3-10 days
lochia alba - almost colorless to creamy
white, 10 days to 3 weeks (decreased
RBCs)

Lochia (contd)

Lochia progression - significant sign of

healing. SHOULD decrease each day
Musty odor is normalNOT FOUL
Lochia heavier in A. M. & after breastfeeding
or sitting
Increased lochia can indicate: uterine atony
or cervical lacerations

Assessing Lochia Output

Condition of Cervix After Delivery

Spongy, flabby, formless, bruised

Becomes thicker & firmer
By end of 1st postpartal week still dilated 1
cm.
Shape permanently changed after childbirth
(cervical os from round to elongated)

Condition of Vagina After Delivery

Smooth & swollen with poor tone

Rugae gone - returns by 3 weeks
Labia more loose & flabby after childbearing
Kegal exercises help increase tone (contract
& relax perineum)

Condition of Perineum After Delivery

Edematous & bruised

Episiotomy or lacerations may be present
ICE for first few hours, then heat. Numbs the
area and decreases swelling firstheat
increases circulation to help healing

Sitz Bath Promotes Comfort and Provides

Relief

Peri care: What will you teach?

Promotion of healing
Promotion of comfort
Signs of infection?

Abdomen

Round & broad ligaments stretched

Abdominal wall loose & flabby
Postpartal exercises help to increase tone
Striae remain, but may take on silvery - white
appearance--eventually fade

Abdomen (contd)

Diastasis Recti: separation of abdominal

recti muscles (vertical muscle along the
median line)
Muscles separate d/t enlarging uterus
May occur in women with poor muscle tone

Diastasis Recti

If tone not regained, can cause inadequate

muscle support in future pregnancies
backache, abd. pain, pendulous abdomen

Abdomen (contd)

Assess for diastasis recti by asking woman to

raise head from the bed, while lying flat
will see separation of muscles.
Need to encourage them to try to regain tone
Responds well to exercisecan improve

Breasts

Soft & non-tender

Secretion of colostrum (thicker than milk,
creamy fluid with high protein, fat
soluble vitamins, minerals, & antibodies)
Engorgement in 3-4 days as lactation
established
Breasts larger and firmer

Breasts (contd)
Rapid decrease in estrogen & progesterone
levels
Increase in prolactin & oxytocin
Sucking causes hypothalamus to stimulate
anterior pituitary to release prolactin for
milk production
Sucking causes posterior pituitary to release
oxytocin for milk release (let-down
reflex) & uterine contraction

Breasts (contd)
Wear supportive bra
To stimulate lactation: encourage infant to
suck - warm shower may help let-down
reflex
To suppress lactation: avoid breast
stimulation & use breast binder. Ice
may aid discomfort of engorgement by
decreasing vasocongestion.

Breasts (contd)
Breastfeeding: average amount milk
produced in 24 hours (increases over
time)
1st week: 6 to 10 ounces
1-4 weeks: 20 ounces
after 4 weeks: 30 ounces

Ovulation and Menstruation/Lactation

After delivery, the woman has decreased levels of

Estrogen and Progesterone:

Return of ovulation and menstruation varies for each

postpartal woman

Menstruation returns between 6 and 10 weeks after birth in

nonlactating mother ovulation returns within 6 months

Return of ovulation and menstruation in breastfeeding mother

is prolonged related to length of time breastfeeding continues
and number of feedings per day

Elimination
Intestines sluggish because of lingering effects of

progesterone and decreased muscle tone

Spontaneous bowel movement may not occur for 2 to 3
days after childbirth
Mother may anticipate discomfort because of perineal
tenderness or fear of episiotomy tearing
Mild laxatives / stool softeners (check with physician if
breastfeeding)

G I System (contd)

C Section Patient:
Oral fluids / foods delayed until return of
bowel sounds
Check for abdominal distentiongas
causes pain
anti-flatulents
avoid use of straws, gum

Urinary System
Overdistention of bladder common, due to
increased bladder capacity, swelling,
bruising of tissues around urethra, &
decreased sensation to feel pressure
Increased output (diuresis and diaphoresis for
24 hours)
Full bladder will displace uterus, may cause
urinary retention, & can cause postpartal
hemorrhage

Uterus Becomes Displaced and Deviated to

the Right When the Bladder Is Full

Musculoskeletal System

Early ambulation encouraged to avoid

complications such as thrombophlebitis /
deep vein thrombosis & to promote
involution
Check for Homans sign / edema: extend leg,
flex knee - dorsiflex foot - pain in leg or
foot is positive for Homans sign

Integumentary System

Melanin decreases gradually (decrease in

hyperpigmentation)
Visible vascular changes decrease as estrogen
levels decrease

Cardiovascular System
Transient bradycardia (50 - 70) for 24 to 48
hour after delivery. May persist for first
6 - 10 days.
Blood volume decreasing to pre-pregnant
state.
Blood pressure may be decreased.

Blood Values
White blood cell count often elevated after deliveryleukocytosis --15,000 -20,000
Activation of clotting factors predispose to thrombus

formation risk of thromboembolism lasts 6 weeks

Hemostatic system reaches nonpregnant state in 3 to

4 weeks

Vital Signs
Temp of 100.4 or higher on any 2 of first 10
postpartal days (doesnt have to be
consecutive days) after first 24 hours
can indicate infection.
B/P may decrease, even if has been up
Pulse may be slow (50 to 70 common) due
to decreased vascularity, decreased
cardiac strain, and increased stroke
volume.

Normal Blood Loss

Vaginal delivery
200-500 cc

C-section
500 to 1000 cc

Weight Loss

10 to 12 lbs. @ delivery
5 lb. More with diuresis
Remainder varies with each individual

Chills

Caused by vasomotor changes or neurologic

Should not be accompanied by fever
Offer warm blanket

Afterpains

Related to oxytocin - contractions

Mostly in multiparas
Often with overdistended uterus
Make sure no bogginess exists before
medicate
Rocking may be helpful

The critical
first hour
after
delivery

Check FUNDUS
Check PERINEUM for
visible bleeding
Check frequent V/S
know the s/s of
hemorrhagic shock!!

Hemorrhage is often seen in the

first hour after delivery, so

nursing assessments are frequent
and crucial at this time!

Postpartum Assessment
BUBBLEHE
BREASTS
UTERUS
BOWELS/BLADDER
LOCHIA
EPISIOTOMY/LACERATION/EDEMA
HOMANS SIGN/HEMORRHOIDS
EMOTIONAL

Breasts, Uterus
Breasts

Assess if mother is breast- or bottle-feeding inspect nipples

and palpate for engorgement or tenderness

Uterus

Determine firmness of fundus and ascertain position

Correlate position with approximate descent of 1 cm per day

Bowel, Bladder, Perineum, Extremities

Assess frequency, burning, or urgency palpate for

bladder distention
Bowel: Assess bowel sounds, flatus, and distention
Inspect abdominal incisions for REEDA
Inspect the perineum for REEDA

Bowel, Bladder, Perineum, Extremities

Assess for hemorrhoids
Extremities

Assess for pedal edema, redness, and warmth

Check Homans sign

Assessment for Signs of Subinvolution

Uterus not progressively decreasing in size

& returning to lower pelvis.
Uterus remaining flabby / poorly contracted.
Persistent backache / pelvic pain.
Heavy vaginal bleeding or return to rubra.

Common questions by postpartum mothers

Why do I have a gush of blood the
first time I get up in the morning?
Is it normal to pass blood clots?
Why do I have night sweats?
I am cramping like when I have a
period. Is this After pains
Why is my stomach still large?
Will I lose all this baby weight?