NCMA 217: CARE OF THE MOTHER, CHILD, & ADOLESCENT (WELL CLIENT)
MIDTERM REVIEWER
1ST SEMESTER WEEK 7-11
Week 10: POSTPARTUM
STUDY GUIDE
The post-partal 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 pre-pregnancy state.
THE UTERUS
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
entering the 7-cm-wide area left denuded by the placenta
and stops bleeding. With time, thrombi form within the
uterine sinuses and permanently seal the area.
Although the uterus will never completely return to its
pre-pregnancy state, its reduction in size is dramatic.
Immediately after birth, the uterus weighs about 1000 g.
At the end of the first week, it weighs 500 g. By the time
involution is complete (6 weeks), it weighs approximately
50 g, similar to its pre-pregnancy weight.
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.
Uterine involution may be delayed by a condition such
as the birth of multiple fetuses, hydramnios, exhaustion
from prolonged labor or a difficult birth, grand multiparity,
or physiologic effects of excessive analgesia.
2ND YEAR NURSING
Contraction may be difficult if there is retained placenta
or membranes. Involution will occur most dependably in
a woman who is well nourished and who ambulates early
after birth (gravity may play a role).
An estimation of the consistency of the post-partal uterus
is as important as measurement of its height. A well-
contracted fundus feels firm. It can be compared with a
grapefruit in both size and tenseness. Whenever the
fundus feels boggy (soft or flabby), it is not as contracted
as it should be, despite its position in the abdomen.
The first hour after birth is potentially the most dangerous
time for a woman. If her uterus should become relaxed
during this time (uterine atony), she will lose blood very
rapidly, because no permanent thrombi have yet formed
at the placental site.
LOCHIA
Uterine flow, consisting of blood, fragments of decidua,
white blood cells, mucus, and some bacteria, is known
as lochia.
The portion of the uterus where the placenta was not
attached is so fully cleansed by this sloughing process
that it will be in a reproductive state in about 3 weeks’
time. It takes approximately 6 weeks (the entire
postpartal period) for the placental implantation site to be
healed.
• 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
Immediately after birth, a uterine cervix is soft and
malleable. Both the internal and external os are open.
Like contraction of the uterus, 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.
Like the fundus, the cervix does not return exactly to its
pre-pregnancy state. The internal os closes as before,
but after a vaginal birth the external os usually remains
slightly open and appears slit-like or stellate (star
shaped), whereas previously it was round
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
pre-pregnancy state.
Because a woman who is breastfeeding may have
delayed ovulation, she may continue to have thin-walled
or fragile vaginal cells that cause slight vaginal bleeding
during sexual intercourse until about 6 weeks’ time.
Like the cervix, the vaginal outlet remains slightly more
distended than before. If a woman practices Kegel
exercises, the strength and tone of the vagina will
increase more rapidly
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 pre-pregnancy 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 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
pre-pregnancy levels. Estrol may be elevated for an
additional week before it reaches pre-pregnancy levels.
Follicle stimulating hormone (FSH) remains low for about
12 days and then begins to rise as a new menstrual cycle
is initiated.
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.
• 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.
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.
THE 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 pre-
pregnancy 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.
THE 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 pelvic-
stage 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
THE 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 sit-
ups 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.
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.
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 pre-pregnancy 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.
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
PERINEAL CARE – inspect the perineum. Observe for
ecchymosis, hematoma, erythema, edema, intactness,
and presence of drainage or bleeding from any
episiotomy stitches.
PROVIDE PAIN RELIEF FOR AFTER PAINS – 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.
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.
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.
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 nurse-midwives order a soothing cream
or anesthetic spray to be applied to the suture line to
reduce discomfort.
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), pinkishbrown 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 CHANGES
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
self-esteem 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.
• 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 after pains; 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).
NURSING CARE OF A WOMAN AND FAMILY
DURING THE FIRST 24 HOURS AFTER BIRTH
PROVIDE PAIN RELIEF FOR AFTER PAINS.
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.
If necessary, either ibuprofen (such as Motrin), which
has anti-inflammatory properties, or a common
analgesic such as acetaminophen (such as Tylenol) is
effective for pain relief. As with any abdominal pain, heat
to the abdomen should be avoided, because it could
cause relaxation of the uterus and subsequent uterine
bleeding.
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. They describe feeling
as if they have “run for miles.” A woman may need a mild
analgesic such as acetaminophen for the pain.
A backrub is effective for relieving an aching back or
shoulders. Carefully assess a woman who states that
she has pain on standing. Pain in the calf of the leg on
standing (a position that dorsiflexes the foot) is a sign
similar to Homans’ sign suggesting thrombophlebitis
may be present.
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.
Be certain not to place ice or plastic directly on the
woman’s perineum. Wrap an ice bag first in a towel or
disposable pad, to decrease the chance of a thermal
burn (risk of injury increases because the perineum has
decreased sensation from edema after birth).
Commercial cold packs combined with perineal pads
also are available. For a low-cost alternative, a rubber
glove may be partially filled with ice chips, provided latex
allergy is not a concern.
Ice to the perineum after the first 24 hours is no longer
therapeutic. After this time, healing increases best if
circulation to the area is encouraged by the use of heat.
Dry heat in the form of a perineal hot pack or moist heat
with a sitz bath is an effective way to increase circulation
to the perineum, provide comfort, reduce edema, and
promote healing.
PROMOTE PERINEAL EXERCISES
Some women find that carrying out perineal exercises
three or four times a day can greatly relieve perineal
edema. The exercise consists of contracting and relaxing
the muscles of the perineum 5 to 10 times in succession,
as if trying to stop voiding (Kegel exercises).
This aids comfort by improving circulation to the area and
decreasing edema. When repeated frequently, Kegel
exercises also help a woman regain her prepregnant
muscle tone and help prevent urinary incontinence (Hay-
Smith & Dumoulin, 2009).
GIVE EPISIOTOMY CARE
Although relatively small in size, episiotomy sutures can
cause considerable discomfort, because the perineum is
an extremely tender area and the muscles of the
perineum are involved in so many activities such as
sitting, walking, stooping, squatting, bending, urinating,
and defecating. Most women expect labor to be painful.
They usually do not anticipate the pulling pain from
perineal stitches in the postpartal period, discomfort that
interferes with their rest and sleep, with eating, and with
being able to sit and hold their baby comfortably.
Because 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.
ADMINISTER SITZ BATHS
A sitz bath is a portable basin that fits on a toilet seat. A
reservoir filled with water provides a constant supply of
swirling water to the basin. The movement of water
soothes healing tissue, decreases inflammation by
causing vasodilation in the area, and thereby effectively
reduces discomfort and promotes healing.
Sitz baths usually use water that is maintained at 100° to
105° F (38° to 41° C). Be certain that the water in a sitz
bath is not too hot before you help a woman to use it; it
should feel pleasantly warm, not hot.
PROVIDE PERINEAL CARE.
Postpartal women are particularly prone to perineal
infection because lochia, if allowed to dry and harden on
the vulva and perineum, furnishes a rich bed for bacterial
growth, which then can spread to the uterus.
Because the vagina lies in close proximity to the rectum,
there is also always the danger that bacteria will spread
from the rectum to the vagina. Interruption in skin
integrity from an episiotomy also increases the client’s
risk for infection.
Teach a woman to include perineal care as part of her
daily bath or shower and after every voiding or bowel
movement. If the woman is on bed rest during the first
hour after birth, you will need to provide perineal care for
her.
PROMOTE REST IN THE EARLY POSTPARTAL
PERIOD
Few women are prepared for the degree of fatigue they
experience after childbirth. Try to do all procedures
swiftly yet gently, to allow as much time for sleep as
possible.
If a woman has discomfort from hemorrhoids, perineal
stitches, or afterpains, be sure she has pain relief so that
she can rest comfortably or sleep. Urge her not to fall
asleep in a narrow hospital bed with her new infant.
Sharing bed space is controversial even in a large bed
(Horsley et al., 2007).
ASSESS PERIPHERAL CIRCULATION.
To determine whether peripheral circulation is adequate,
assess a woman’s thigh for skin turgor.
• Assess for edema at the ankle and over the tibia
on the lower leg.
• Although this technique is not totally reliable,
assess for thrombophlebitis by dorsiflexing a
woman’s ankle and asking her if she notices
pain in her calf on that motion (Homans’ sign).
• Assess also for redness in the calf area,
because thrombophlebitis can be present even
with a negative Homans’ sign.
Continue to assess for adequate peripheral circulation
once every 8 hours during the woman’s stay in a health
care facility. If you suspect thrombophlebitis, do not
massage the area—doing so could cause an embolus.
Be certain to allow a woman to dangle her legs on the
edge of the bed for a few minutes to prevent dizziness
before she gets up for the first time.
Then, assist her as needed to take the few steps to a
nearby bathroom. Remain with her to be certain that
dizziness does not occur. After this, she may be up on
her own as she wishes. As a rule, women who ambulate
quickly feel stronger and healthier by the end of their first
week and have fewer bowel, bladder, and circulatory
complications than those who do not.
PREVENT/ALLEVIATE BREAST ENGORGEMENT
If a woman is breastfeeding, encouraging her newborn
to suck at the breast is the main treatment for relief of the
tenderness and soreness of primary breast
engorgement. Many women find the application of warm
compresses or standing under a warm shower beneficial
to relieve engorgement discomfort.
Good support from a bra also offers relief because it
prevents unnecessary strain on the supporting muscles
of the breasts, positions the breasts in good alignment,
and diminishes the amount of engorgement caused by
blocked milk ducts. If the woman has not packed a bra in
her suitcase, ask her to arrange to have one brought
from home.
Cold compresses, applied to the breasts three or four
times a day during the period of engorgement, or an oral
analgesic, or both, provide relief. Wearing a snug-fitting
bra and avoiding nipple stimulation may help. Restricting
fluid and pumping milk from the breasts are not effective
measures and are to some degree harmful, so these
actions should be avoided.
PROMOTE BREAST HYGIENE
Breast care during the postpartal period includes
cleanliness and support. These issues are the same
whether or not a woman is breastfeeding. 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.
TEACH METHODS TO PROMOTE UTERINE
INVOLUTION
All during the postpartal period, lying on the abdomen
gives support to abdominal muscles and may aid
involution, because it tips the uterus into its natural
forward position. If this puts too much pressure on sore
breasts, placement of a small pillow under the abdomen
usually solves the problem.
It may be dangerous for a woman to assume a knee–
chest position until at least the third week after birth. In a
knee–chest position, the vagina tends to open. Because
the cervical os remains open to some extent until the
third week, there is a danger that air will enter the vagina
and the open cervix, penetrate the open blood sinuses
inside the uterus, enter the circulatory system, and cause
an air embolism.
BUBBLE-HE
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.
o What is the contour?
o Are the breast full, firm, tender, shiny?
o Are the veins distended?
o Is the skin warm?
o Does the patient complain of sore
nipples?
o 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 the firm 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
cauterization 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 ruba).
• 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.
• 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?

TERMINOLOGIES
PUERPERIUM/Postpartum – 6 weeks period after
giving birth

Engorgement – swell with blood, water, or another fluid

Involution – return of the reproductive organs to their

non-pregnant state.

Lochia – Uterine flow, consisting of blood, fragments of

decidua, white blood cells, mucus

Sitz bath – type of therapy done by sitting in warm,

shallow water