Postpartum Changes

Postpartal period (Puerperium) – refers to the 6 weeks period after childbirth

• Latin word “puer” - means “child”

• parere – “to bring forth”
• Fourth trimester of pregnancy
• Physiological and Psychological Changes of Postpartum Period’

Physiological Changes of the Postpartal Period 2 Changes:

1. Involution (Retrogressive) – return of the uterus and vagina to their non-pregnant state
• 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.

Systemic Changes

a. Hormonal System
b. Urinary System
c. Circulatory System
d. Gastrointestinal System
e. Integumentary System

Reproductive System

a. Cervix
o Soft and malleable to palpation
o Both Internal os external os are open
o Contraction of the cervix towards prepregnant state begins
o End of 7 days external so narrowed to size of a pencil opening.
• involves formation of new muscle cells and because of this cervix does not return to its pre
pregnancy state
• Internal so closes as before, after vaginal birth external os remain slightly open and appears slit -
like or stellate (star shaped)
b. Perineum
• great amount of pressure experienced during birth
o Edematous and tender
o Ecchymosis patches from ruptured capillaries
o Labia majora and minora remain atrophic and soften
 Nursing Responsibilities:

o Perineal Care - inspect the perineum.

o Observe for ecchymosis, hematoma, erythema, edema, intactness, and presence of
drainage or bleeding from any episiotomy stitches.
o Assess rectal area for the presence of hemorrhoids
o 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
o 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 to increase circulation
to the perineum
o Episiotomy Care - the perineal area heals rapidly; discomfort is normal and does not usually
last longer than 5 or 6 days.
• Soothing cream or anesthetic spray to be applied to the suture line to reduce discomfort.
• Promote Perineal exercises (Kegel exercises)
▫ 3-4 x /day can improve circulation and decrease perineal edema
▫ Regain prepregnant muscle tone and help prevent urinary incontinence
o Relieve Muscular Aches

Nursing Responsibilities:

▫ Sore and aching after labor and birth due to excessive energy used for pushing during
the pelvic division of labor.
▫ Backrub is effective for relieving an aching back or shoulders
c. Vagina
o Vagina is soft with few rugae and its diameter is greater than normal
o Hymen is permanently torn and heals with small, separate tags of tissue
o Thickening of the vaginal walls appears
• (It takes the entire postpartal period for the vagina to involute)
d. Uterus

Involution of the uterus involves two processes:

o The area where the placenta was implanted is sealed off by rapid contraction to prevent
bleeding
o The organ is reduced to its approximate pregestational size
• The sealing of the placenta site is accomplished by rapid contraction of the uterus immediately
after delivery of the placenta.
• This contraction pinches the blood vessels and left denuded by the placenta and stops bleeding.
With time, thrombi form within the uterine sinuses and permanently seal the area.
• Fundus is palpable, halfway between umbilicus and symphysis pubis few mins. after birth
• One hr. later – at the level of umbilicus and remains for 24 hrs.
• First day postpartum – decreases by one fingerbreadth per day (1 cm.) a day in size
• Day 9-10 no longer palpable
• Immediately after birth uterus weighs about 1,000 grams
• End of the first week, it weighs 500 grams
 • Involution is complete (6 weeks) - it weighs approximately 50 grams (prepregnancy weight)

Delayed Involution Causes:

▪ Multiple fetuses
▪ Hydramnios
▪ Exhaustion from prolonged labor
▪ Grand multiparity
▪ Physiologic effect of analgesia
▪ Retained placenta or membrane
• the uterus of a breastfeeding mother may contract more quickly because of the released of
oxytocin which stimulates uterine contraction
• a well-contracted fundus is firm and can be compared with a grapefruit in both size and
tenseness

Uterine atony - is failure of the uterus to contract adequately following delivery

• The first hour after birth is potentially the most dangerous time for a woman.
• If the uterus is relaxed during this time patient will lose blood very rapidly, because no
permanent thrombi have yet formed at the placental site.

Assessment:

▪ Assess vital signs every 15 mins for the first hour

▪ Observe the amount and characteristics of lochia
▪ Palpate the fundus (size, consistency, and position (Fundal height)

Involution will occur most dependably:

▪ Well-nourished
▪ Ambulates early after delivery

Advantages:

▪ Decreased incidence of thrombophlebitis

▪ Better uterine drainage and enhanced uterine involution
▪ Preventing urinary retention and constipation
▪ Less respiratory complications (Pneumonia and Pulmonary embolism)
▪ Early regain of maternal strength
▪ Improved well-being and self-esteem
▪ Greater confidence in providing baby care
▪ Shorter hospitalization days (If hospitalized)

Pulmonary embolism - is a blockage in one of the pulmonary arteries in the lungs

Nursing Responsibilities:

• Provide pain relief for uterine cramping (After pains)

 • Pain from uterine contractions can be intense, this type of discomfort is normal and rarely lasts
longer than 3 days.

• Ibuprofen - an anti-inflammatory and anti prostaglandin properties

• Analgesic (Acetaminophen) effective for pain relief
• Avoid: Heat to abdomen

Lochia – is the vaginal discharge of a postpartum mother, consists of shreds of decidua, erythrocytes
(RBC) leucocytes, epithelial cells, and bacteria

Types of Lochia:

• Lochia rubra- red color, 1 - 3 days (Blood, small particles of decidua and mucus)
• Lochia serosa- – pink or brownish, 3 - 10 days (Blood, mucus, and invading leukocytes)
• Lochia alba- – white with streaks of brownish mucus, 10 - 14 days until 3 – 6 wks. (Largely
mucus, leukocytes count high)

Reasons for Lochial evaluation:

• To detect the normality of vaginal discharge and rule out postpartum hemorrhage
• To evaluate the state of uterine involution
• To detect the presence of puerperal sepsis
• Lochia Rubra – Systemic Changes

Evaluate the Lochia:

• Color: red, pinkish brown, whitish with or without clots. Reddish color – more than two wks.
• Odor: Normal: fleshy, musky, non-offensive, non-foul odor Abnormal: malodorous or foul odor

Indications:

• Retention of small portions of the placenta

• Imperfect involution of the uterus

Amount – depending on how much the perineal pad is stained within one hour period

• Heavy/large: one perineal pad saturated in 15-30 mins.

• Moderate: Perineal pad blood stain less than 15 cm (6 inches)
• Light/small: Perineal pad blood stain less than 10 cm. (4 inches)
• Scant: Perineal pad blood stain less than 2.5 cm. (1 inch)

Nursing Responsibilities:

Inspect Lochia – color, odor, amount

o Check the consistency - lochia should contain no large clots

o Clots may indicate that a portion of the placenta has been retained and is preventing closure
of the maternal uterine blood sinuses.
• Large clots denote poor uterine contraction, which needs to be corrected
 2. Progressive – production of milk for lactation, restoration of normal menstrual cycle and
beginning of parenting role.
• Progressive Changes or the building of new tissue requires good nutrition
• caution women against strict dieting that would limit cell building ability during the first 6 weeks
after childbirth
• First 2 days after birth, an average woman notices little change in her breasts from the way they
were during pregnancy.

Lactation – the formation of breast milk begins in a postpartal woman whether or not she plans to
breastfeed

▪ Since midway through pregnancy, she has been secreting colostrum

▪ Colostrum – is a thin, watery, yellow fluid composed of protein, sugar, fat, mineral, water,
vitamins, and antibodies
• 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

Primary engorgement - feeling of tension in the breasts and fades on the third or fourth day after birth
as the infant begins effective sucking and empties the breasts of milk

Engorgement – feeling of tension in the breast 3 rd or 4th day after birth.

Signs:

• Breast distention
• Feeling of heat or throbbing pain
• Breast tissue appear reddened

Prevent / Relieve Breast Engorgement

• Empty the breasts of milk by having the infant suck more often or at least continue to suck as
much as before
• Mild analgesic for pain relief
• Good breast support from a Firm-fitting bra
• Warm packs applied to both breasts or standing under a warm shower for a few minutes before
feeding
• Massage to begin milk flow
• Use of breast pump to completely empty the breast after the baby has nursed
Promote Breast Hygiene
Breast care during the postpartum period includes cleanliness and support.
• Teach a woman to wash her breasts daily with clear water at the time of her bath or shower and
then dry them with a soft towel.
• She should avoid using soap, because it tends to dry and crack the nipples, possibly leading to
fissures and breast abscess.
• It is not necessary for women to wash their breasts more often than daily, because excessive
washing means unnecessary manipulation.

Return of Menstrual flow

• Delivery of the placenta, production of placental estrogen and progesterone ends.
• Decrease in hormone causes a rise in production of FSH which leads to a slight delay, to the
return of ovulation. This initiates the return of normal menstrual cycles
• increase production of FSH, leads to return of ovulation
• Breastfeeding mothers menstrual flow may not return for 3-4 months or for the entire lactation
period (Lactational Amenorrhea)
• 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

Not breastfeeding – flow return in 6-10 weeks after birth

Systemic Changes

Hormonal System – hormones begins to decrease as the placenta no longer present

• HCG and HPL decreased are negligible by 24 hrs.
• FSH remains low for 12 days then begins to rise to initiate new menstrual cycle
• Wk.1 – Progestin, estrone and estradiol are all at prepregnancy level

The 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.
• Increases the daily output of a postpartal woman

Diuresis - from a normal level of 1500 mL to as much as 3000 mL/day during the 2nd to 5th day after
birth, increase in urine production causes the bladder to fill rapidly

Hydronephrosis – increase in size of ureters present for about 4 wks. postpartum Side effects: Urinary
stasis and UTI
Causes:
• Pressure on the bladder and urethra due to fetal head exertion.
• Transient loss of bladder tone
• Edema surrounding the urethra decreases the ability to sense when to void
• Epidural anesthesia – can feel no sensation in the bladder area until anesthetic has worn off

Management of Full bladder

To prevent permanent damage to the bladder from overdistention:
• Assess the client abdomen frequently
▪ Palpation – hard or firm area just above the symphysis pubis
▪ Percussion – full bladder sounds resonant\

Circulatory System
• Blood loss at birth, acts to reduce the added blood volume a woman accumulated during
pregnancy.
• This reduction occurs so rapidly, that the blood volume returns to its normal prepregnancy level
by the 1st or 2nd week after birth
• blood volume return to its normal level 1-2 wks. after birth

Blood loss after delivery:

▪ Vaginal birth – 300-500 ml.
▪ Caesarean birth – 500 – 1000 ml
▪ A 4-point decrease in hematocrit (proportion of red blood cells to circulating plasma)
▪ 1-g decrease in hemoglobin value occur with each 250 mL of blood loss.

Gastrointestinal System
• Digestion and absorption begins to be active after birth
• Bowel sounds are active, but passage of stool 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
• Striae gravidarum
▪ After birth, the stretch marks on a woman’s abdomen (striae gravidarum) still appear
reddened
▪ will fade to a pale white over the next 3-6 months
• Melasma (Chloasma) – excessive pigmentation from the face and neck is barely detectable by 6
wks. time “Mask of Pregnancy”
• Linea nigra – barely detectable by 6 wks.

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.
Diastasis recti is - the partial or complete separation of the rectus abdominis, which meet at the midline
of your stomach
Management;
• Modified sit-ups help to strengthen abdominal muscles and return abdominal support to its
prepregnant level
• May require surgery to correct

Vital Signs
• Temperature
▪ first 24 hrs. – slightly increase due to dehydration
▪ 3 - 4 th day after birth – slightly increase due to breast fill with milk
▪ Any woman whose oral temperature rises above 100.4° F (38° C), excluding the first 24-hour
period, is considered to be febrile.
▪ In such women, a postpartal infection may be present.

• Pulse - slightly slower than normal

▪ End of first week – pulse return to normal
▪ Rapid, thready pulse – sign of hemorrhage

• Blood pressure – should be monitored

Decrease BP – indicates bleeding

Complications:
▪ Acute blood loss
▪ Orthostatic hypotension
▪ Dizziness

Increase BP – (140/90 mmhg)

Indication:
▪ Pregnancy induced hypertension
▪ Oxytocin drug

Psychological Changes of Postpartum Period

Behavioral Adjustment

Phases of Puerperium
Taking-in- Phase- in Phase – 1-3 days period, time of dependence
▪ The woman is passive
▪ Time of reflection
▪ Sense of wonder
▪ Wants to talk about her pregnancy (Labor and birth)
 Cause:
▪ Physical discomfort (afterpains, hemorrhoids)
▪ Uncertainty in caring for her newborn
▪ Exhaustion that follows childbirth
Nursing Responsibilities:
▪ Encourage her to talk about the birth.
▪ Ensure bonding but there must be enough rest period

Taking - hold phase

• begins to initiate action and make her own decisions.
▪ Begins to take a stronger interest for her infant and begins maternal role behaviors
▪ Often feels insecure about the ability to care for her new child

Nursing Responsibilities:
▪ Give a brief demonstration of baby care.
▪ Allow her to care for her child with watchful guidance
▪ Praise for the things she does well to give her confidence.

Letting- go phase- – redefines her new role

• Gives up fantasized image of her child and accept the real one
• Gives up her old role of being childless or the mother of only one or two
• Readjustment of relationships, extended and continues during the child’s growing years.

Maternal concerns and feelings in the Postpartal Period

• Abandonment – it is a feeling of abandonment and less important after giving birth.
• Disappointment – common feelings parents may experience disappointment in the baby
• Postpartal Blues – feelings of overwhelming sadness
▪ During the postpartal period, as many as 50% of women experience some feelings of
overwhelming sadness
▪ 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.
Postpartal Blues – feeling of sadness 1-10 days after childbirth
Causes:
• Hormonal changes (decrease estrogen and progesterone)
• Physical discomfort
• Disappointment in some aspect of her newborn
• Not receiving support from her parents
• Response to dependence and low self-esteem
Symptoms:
• Tearfulness
• Feelings of inadequacy
• Mood lability
• Anorexia, and sleep disturbance.
Anticipatory guidance and individualized support from health care personnel
Give the woman a chance to verbalize her feelings and make as many decisions as she wants to help
gain a sense of control and move past postpartal emotion

BUBBLE-HE
is a acronym used to denote the components of the postpartum maternal nursing assessment

This method enhances the standard physical assessment process typically performed on hospitalized
patients by the RN, such as those on a Medical-Surgical floor

For stable patients,

• Vital signs are taken every 15 minutes during the first hour following delivery and then gradually
less frequently.
• While performing the BUBBLE-HE, the RN often uses the assessment time to provide for patient
education

8 - POINT POSTPARTUM ASSESSMENT INSTRUCTIONS

Breast
• Gently palpate each breast
• If you feel nodules in the breast, the ducts may not have been emptied at last.
• Stroke downward towards the nipple, then gently release the milk by manual.
• If nodules remain, notify the doctor
• Take this opportunity to explain the process of milk production, what to do about engorgement,
how to perform self-breast examinations, and answer any questions she may have about
breastfeeding.

❑ What is the contour?

❑ Is the breast full, firm, tender, shiny?
❑ Are the veins distended? Is the skin warm?
❑ Does the patient complain of sore nipples?
❑ Are breasts so engorged that she requires pain medication?

Uterus
• Palpate the uterus
• Have the patient feel her uterus as you explain the process of involution
• If uterus is not involution properly, check for infection, fibroids and lack of tone.
• Uterus should be firm and decrease approximately one finger breadth below
• Unsatisfactory involution may result if there are retained secundines or the bladder not
completely empty
Bladder
• Inspect and palpate the bladder simultaneously while checking the height of the fundus.
• An order from the physician is necessary catheterization may be done. An order for culture and
sensitivity test since definitive treatment may be required
• Talk to mother about proper perineal care. Explain that she should wipe from front to back after
voiding and defecating
• Bladder distention should not be present after recent emptying.
• When bladder distention does occur, a pouch over the bladder area is observed, felt upon
palpation; mother usually feels need to urinate
• It is imperative that the first three post-partum voiding be measured and should be at least
150cc. Frequent small voiding with or without pain and burning may indicate infection or
retention.

Bowel Function
• Question patient daily about bowel movements. She must not become constipated. If her
bowels have not functioned by the second postpartum day, the doctor may start her on a mild
laxative
• Encourage patient to drink extra fluids.
• Have patient select fruits and vegetables from her menu

Lochia
• Assess the amount and type of lochia on pad in relations to the number of postpartum days.
First 3 days of postpartum, you should find a very red lochia similar to the menstrual flow (lochia
rubra).
• During the next few days, it should become watery serous (lochia serosa). On the tenth day, it
should become thin and colorless (lochia alba).
• Inform the mother about what changes she should expect in the lochia and when it should
cease.
• Tell the mother when her next menstrual period will probably begin and when she can resume
sexual relations.
• Discuss family planning at this time.
• Notify the doctor if the lochia looks abnormal in to color or contains clogs other than small ones.

Episiotomy
• Inspect episiotomy thoroughly using flashlight if necessary, for better visibility. (REEDA)
• Check rectal area. If hemorrhoids are present, the doctor may want to start on sitz bath and
local analgesic medication. Reassure patient and answer questions she may have regarding pain,
cleanliness, and coitus.
• Check episiotomy for proper wound healing, infection, inflammation and suture sloughing.
• Is the surrounding skin warm to touch?
• Does the patient complain of discomfort? Notify the doctor if any occurs
Homan’s Sign
• Press down gently on the patient’s knee (legs extended flat on bed) ask her to flex her foot
• Pain or tenderness in the calf is a positive Homan’s sign and indication of thrombophlebitis.
• Physician should be notified immediately.

Emotional Status
• Throughout the physical assessment, notice and evaluate the mother’s emotional status.
• Explain to the mother and to her family that she may cry easily for a while and that her
emotions may shift from high to low
• The changes are normal and are probably caused by the tremendous hormonal changes
occurring in her body and by her realization of new responsibilities that accompany each child’s
birth
• Does the patient appear dependent or independent? Is she elated or despondent? What does
she say about family? Are there other nonverbal responses?