Psychological and Physiological Changes of
NCM 107- Maternal
Postpartum Period
PSYCHOLOGICAL CHANGES
The postpartum period is a time of transition, during which a couple
gives up concepts such as "childless" or "parents of one" and
moves to not only trying out their new role but also determining
whether they "fir" their new role. Nurses can help couples
acknowledge the extent of the change so that they can gain closure
on their previous life style. Opening channels for communication,
anticipating new needs, and highlighting potential gains that will
occur because of the change are important actions.
BEHAVIORAL ADJUSTMENT: PHASES OF
THE PUERPERIUM
In her classic work on maternal behavior, Reva Rubin, a nurse,
divided the puerperium into three separate phases (Rubin, 1984).
The first of these is the taking-in phase, or the time when the new
parents review their pregnancy and the labor and birth. The
subsequent phases, called the taking-hold and letting-go phases,
are times of renewed action and forward movement. At the time
these phases of the puerperium were identified, women were
hospitalized for 5 to 7 days after child-birth and moved in a paced
manner from one step to the next. Today, with a stay in a
healthcare facility as short as a few hours, women appear to move
through these phases much more quickly and may even
experience two different phases at once.
Taking-In Phase
The taking-in phase is largely a time of reflection. During this 1- to
3-day period, a woman is largely passive. She prefers having a
nurse attend to her needs and make decisions for her rather than
do these things herself. This dependence results partly from her
physical discomfort because of afterpains of hemorrhoids, party
from her uncertainty in caring for her new- born, and partly from the
exhaustion that follows childbirth.
As part of thinking and pondering about her new role, the
woman usually wants to talk about her pregnancy, especially about
her labor and birth. She holds her new child with a sense of wonder
and asks: Is birth really over? Could this child really have been
inside me? She wants to rest to quit and contain her swirling
thoughts. Encouraging her to talk about the birth is an important
way to help her integrate the experience into her total life
experiences.
If the birth experience did not go as planned, such as
surprise cesarean delivery of the infant needing specialaftized care
in neonatal intensive care unit (NICU), encourage the mother to
express her feelings regarding the difference from anticipated birth
plan. Being able to acknowledge and articulate her feelings that her
preconceived birth plan did not occur as intended is a healthy way
to release any negative emotions. Discuss with the mother the
possible medical reasons why the birth was different than
expected. The birth plan often changes to ensure the safety of the
newborn and mother. This will help the mother absorb the new
reality and be able to understand the importance of the need to
make the necessary changes at birth for her own health and the
health of her newborn.
Taking-Hold Phase
After a time of passive dependence, a woman begins to initiate
action (the taking-hold phase). She prefers to get her washcloth
Page 1 of 7
or to make her own decisions. Women who give birth without any
anesthesia may reach this second phase in a matter of hours after
birth.
Taking-hold is a time of initiation of action and greater
independence as evidenced by performing self-care.
During the taking-in period, a woman may have been too
tired to care for her child. Now, she begins to take a stronger
interest in her infant and begins maternal role behaviors. As a rule,
it is usually best to give a woman a brief demonstration of baby
care and then allow her to care for her child herself- with watchful
guidance as she enters this phase.
Although a woman's actions suggest greater
independence during this time, she often still feels insecure about
her ability to care for her new child. She needs praise for the things
she does well, such as supporting the baby's head or beginning
breastfeeding, to give her confidence. This positive reinforcement
begins in the healthcare facility and continues after discharge, at
home and at postpartum and well-baby visits.
Do not rush a woman through the phase of taking-in or
prevent her from taking hold when she reaches this point. For many
young mothers, learning to make decisions about their child's
welfare is one of the most difficult phases of motherhood. It helps
if a woman has practice in making such decisions in a sheltered
setting, such as a hospital, rather than first taking on that level of
responsibility after she is home alone.
First-time mothers may need additional guidance and time during
this phase compared to multigravida moms, but not always, as in
the case of a multigravida mom who is learning to care for twins.
Letting-Go Phase
In this third phase (the letting-go phase), 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). This process requires some
grief work and readjustment of relationships, similar to what
occurred during pregnancy. It is extended and continues during the
child's growing years. A woman who has reached this phase is well
into her new role.
DEVELOPMENT OF PARENTAL ATTACHMENT, BONDING,
AND POSITIVE
FAMILY RELATIONSHIPS.
During pregnancy, almost every woman worries about her ability to
be a "good" mother, and this concern does not evaporate as soon
as the baby is born. Some women are able to recognize a
newborn's needs immediately and to give care with confident
understanding right from the start. More often, however, a woman
enters into a relationship with her newborn tentatively and with
qualms and conflicts that must be addressed before the
relationship can be meaningful. Another factor is the infant's
inherent personality. Some infants are calm and others are easily
excitable. Learning the infant's cues and personality takes time and
patience. This is because parental love is only partly instinctive. A
major portion develops gradually, in stages such as planning the
pregnancy, hearing the pregnancy confirmed, feeling the child
move in utero, birthing, touching the baby, and, finally, giving total
care to the child.
When a woman has successfully linked with her newborn,
it is termed attachment or bonding. Although a woman carried the
child inside her for 9 months, she often approaches her newborn
not as someone she loves but more as she would approach a
stranger. The first time she holds the infant, she may touch only
the blanket. If she unfolds the blanker to examine the baby or count
the fingers or toes, she may use only her fingertips for touch. Skin-
to-skin contact soon after birth facilitates the early attachment and
binding phase. This should ideally occur within the first hour of any
birth, even cesarean deliveries, as soon as the mother and baby
are stable and last until completion of he first breastfeeding.
Gradually, as a woman holds her child more, she begins
to express more warmth, touching the child with the palm of her
hand rather than with her fingertips. She smoothes the baby's hair,
brushes a cheek, plays with toes, and lets the baby's fingers clasp
hers. Soon, she feels comfortable enough to press her cheek
against the baby's or kiss the infant's nose; she has successfully
bonded or become a mother tending to her child. Looking directly
at her newborn's face, with direct eye contact (termed an en face
position), is a sign a woman is beginning effective attachment.
Many fathers can be observed staring at a newborn for long
intervals in this same way.
Often termed engrossment, this action alerts caregivers
to how actively the father, as well as the mother, is beginning
bonding (Fig. 17.2). The length of time parents take to bond with a
child depends on the circumstances of the pregnancy and birth, the
wellness and ability of the child to meet the parents' expectations,
reciprocal actions by the newborn, and the opportunities the
parents have to interact with the child. When pregnancy or
newborn complications lead to separation of the mother from her
newborn, it places the woman at greater risk for developing post
traumatic stress disorder and interferes with the usual process of
bonding (Dale-Hewitt, Slade, Wright, et al., 2012). Guided,
supportive interactions, such as pointing out positive parental
behaviors and infant responses, enhance positive parent-infant
interaction. Helping parents sort out their feelings about being a
mother or father and about their new responsibilities through
anticipatory guidance also strengthens parent-infant bonding.
Facilitating early skin-to-skin bonding between infant and mother
has shown to improve breastfeeding durations and outcomes and
the emotional stability of both infant and mother (Moore et al.,
2016).
Rooming-In
The more time a woman has to spend with her baby, the sooner
she can become better acquainted with her child, feel more
confident in her ability to care for her baby, and more likely form a
sound mother-child relationship (Elliott-Carter & Harper, 2012). In
order to qualify as
"Baby friendly," a hospital must provide "rooming-in, space to keep
the infant with the parents (Smith, Moorem, & Peters, 2012).
Rooming-in occurs when the infant remains in the
woman's room and the mother and child are together 23 out of 24
hours a day. With both complete and partial rooming-in
(Infant spends time in newborn nursery), the father and siblings can
hold the infant when they visit. In many settings, the father can stay
overnight in the mother's room.
Sibling Visitation
Separation from children is often as painful for a mother as it is for
her children. Waiting at home, separated from their mother and
listening only to telephone reports of what a new brother or sister
looks like, can be very difficult for older children. They may picture
the new baby as much older than he or she actually is. "He is eating
well" may produce an image of a child sitting at a table using a fork
and spoon. "He weighs 8 pounds" can be meaningless information.
A chance to visit the hospital and see the new baby and their
mother reduces teachings that their mother cares more about the
new baby than about them. The visit can help to relieve some of
the impact of separation and also help to make the baby a part of
Page 2 of 7
the family (Fig, 17.3). Assess to be certain siblings are free of
contagious diseases such as upper respiratory tract illnesses or
recent exposure to chickenpox before they visit. Then, have them
wash their hands and, if they choose, hold or touch the newborn
with parental assistance.
Encourage the success of a family visit by evaluating if
the mother would like to take her pain medication before the Visit.
If she had a cesarean delivery, protecting her abdomen with
padding can decrease anxiety of the siblings about then condition
of their mother.
You may need to caution a woman thar the opinions of a
new brother or sister expressed by her older children may not be
complimentary: for example, this baby with little hair may not be
their idea of a "pretty baby." If they thought the new baby would be
big enough to play with, they may not agree that he is a "big baby."
MATERNAL CONCERNS AND FEELINGS IN THE
POSTPARTAL PERIOD
Traditionally, it is assumed the bulk of a woman's concerns in the
Postpartal period center on the care of her new infant. As a result,
classes in the postpartal period have traditionally focused on
teaching how to breastfeed and bathe infants. Many women,
however, are not as concerned about infant care as they are about
their adjustment to a new role change.
Typical issues identified by postpartal women that they
would like to hear discussed are breast soreness; regaining their
figure; regulating the demands of a job, housework, their partner,
and their children; coping with emotional tension and sibling
jealousy; and how to combat fatigue.
Abandonment
Many mothers, if given the opportunity, admit to feeling abandoned
and less important after giving birth than they did during pregnancy
or labor. Only hours before, after all, they were the center of
attention, with everyone asking about their health and well-being.
Now, suddenly, the baby is Everyone’s chief interest. Relatives ask
about the baby's health; the gifts are all for the baby. Even a
woman's primary healthcare provider, who has made her feel so
important for the last 9 months, may ask during a visit, “How's that
healthy 8-pound boy?" Comments such as this can make a woman
experience a sensation very close to jealousy. And how can a good
mother be jealous of her own baby?
You can help a woman move past these feelings by
verbalizing the problem: "How things have changed! Everyone's
asking about the baby today and not about you, aren't they?" These
are reassuring words for a woman and help her realize that,
although uncomfortable, the feeling she is experiencing is normal.
When a newborn comes home, a father or partner may express
much the same feelings as he or she feels resentful of the time the
mother spends with the infant. Examination of these competitive
feelings can help a couple realize that parenthood involves some
compromise in favor of the baby's interests. Making infant care a
shared responsibility can help alleviate these feelings and make
both partners feel equally involved in the baby's care. You can help
parents or partners move past this competitive stage by pointing
out positive parenting behaviors, positive self-care behaviors, and
the warm infant response to their behaviors.
Disappointment
Another common feeling parents or partners may experience is
disappointment in the baby. All during pregnancy, they pictured a
chubby-checked, curly-haired, smiling girl or boy. They may have
instead a thinner baby, without any hair, who seems to cry
constantly, or may have a congenital condition. This can make it
difficult to feel positive immediately toward a child who does not
meet their expectations. It can cause parents to remember heir
adolescence, when they felt gangly and unattractive, or to
experience feelings of inadequacy all over again.
You can never change the sex, size, or look of a child, but
in the short time you care for a postpartal family, it is possible for a
key person such as a nurse to tip a scale toward acceptance or at
least help a person involved to take a clearer look at his or her
situation and begin to cope with the new circumstances. As an
example, handle the child warmly, to show you find the infant
satisfactory or even special. Comment on the child's good points,
such as long fingers, lovely eyes, and healthy appetite. Be aware,
however, that, culturally, some groups are fearful for the baby if
these types of comments are made because they could draw evil
influences toward the child.
Postpartal Blues
During the postpartal period, as many as 50% of women
experience some feelings of overwhelming sadness or "baby
blues" (Baselice & Lawson, 2012). They may burst into tears easily
or feel let down and irritable. This phenomenon maybe caused by
hormonal changes, particularly the decrease in estrogen and
progesterone that occurred with delivery of the placenta.
Breastfeeding has been shown to help elevate baby blues and
counteract the effects of the hormonal drop that occurs after
childbirth. 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. In addition to crying, the syndrome is
evidenced by feelings of inadequacy, mood lability, anorexia, and
sleep disturbance.
Anticipatory guidance and individualized support from
healthcare personnel are important to help the parents understand
that this unexpected response is normal. Be certain support
persons also receive assurance of this type, or they can think the
woman is unhappy with them or the new baby or is keeping some
terrible news about the baby secret.
Give the woman a chance to verbalize her feelings and
make as many decisions as she wants to help her gain a sense of
control and move past this strange Postpartal emotion.
Remember, however not all Postpartal women you see crying are
doing so because they have baby blues. Perhaps problems at
home have become overwhelming. A partner may have been laid
off from a job just at this time when they most need money. One of
her parents maybe ill, or her house, may have been damaged by
disaster such as a flood. Encouraging women to talk about their
Postpartal feelings helps to differentiate between problems that
can be handled best with discussion and concerned understanding
and those that should be referred to a social service department or
a community health agency for additional support.
Women are at greater risk (19% to 48%) for moderate to
severe depression after childbirth requiring formal counseling sling,
especially if they are economically stressed or have) comorbid
condition such as diabetes (Fart, Dietz, William,er al., 2011).
Severe psychosis also can occur in women during this time (Heron,
Gilbert, Dolman, et al., 2012). Because these are deeper level
concerns, postpartal depression beyond the scope of "baby blues"
and psychosis are discussed in Chapter 25. If a mother appears to
have a level of depression. That is beyond baby blues and/or has
a history of previous postpartal depression (PPD), closer
observation and referral is indicated immediately.
PHYSIOLOGICAL CHANGES
REPRODUCTIVE SYSTEM CHANGES
Involution – is the process whereby the reproductive organs return
to their nonpregnant state.
Page 3 of 7
A woman is in danger of hemorrhage from the denuded surface of
the uterus until the involution is complete. (Katz, 2012)
The Uterus
The involution of the uterus involves two processes:
• The area where the placenta was implanted is sealed off
to prevent bleeding
• The organ is reduced to its approximate pregestational
size.
How is the sealing of the placenta site 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 halts bleeding.
- And with time, thrombi form within the uterine sinuses
and permanently seal the area.
Note:
The process does not leave a scar within the uterus and does not
compromise future implantation sites
- This is because endometrial tissue undermines the site
and obliterates the organized thrombi, covering and
healing the area completely.
The contraction process also reduces the bulk of the uterus:
• Devoid of the placenta and the membranes.
• The walls of the uterus thicken and contract, gradually
reducing the uterus from a container large enough to hold
a full-term fetus to one the size of a grapefruit.
- Compare it to a rubber band, so after it is
stretched for a few months, it is now regaining its
normal contour, so none of the rubber band is
destroyed, the shape is simply altered.
Note: The postpartum period is not a period of illness, of necrosing
cells being evacuated, but primarily a period of a healthy change.
Weight of the Uterus:
1. Immediately after birth = 1000g
2. End of the first week = 500 g
3. By the time involution is complete (6 weeks) = 50g (similar
to its pre-pregnancy weight.)
Because the uterine contraction begins immediately after placental
delivery, the fundus of the uterus is palpable through the abdominal
wall, halfway between the umbilicus and symphysis pubis, within a
few minutes after birth
After one hour it will rise to the level of the umbilicus and remains
for approximately 24 hours.
From then on it decreases by one fingerbreadth or 1 cm per day.
Example:
First postpartum day, it will be palpable 1 cm below the umbilicus.
By the ninth or tenth day, the uterus will have contracted so much
that it is withdrawn into the pelvis and can no longer be detected
by abdominal palpation.
The uterus of the breastfeeding mother contract even more quickly
because of oxytocin, which is released with breastfeeding,
stimulates uterine contractions.
Note: Breastfeeding alone, however, is not sufficient to protect
against postpartum hemorrhage.
Fundus Type Color Postpartum Composition
- Normally located in the midline of the abdomen. And day
occasionally, can be felt to the right because the bulk of Lochia rubra Red 1-3 Blood,
the sigmoid colon forced it to that side during pregnancy fragments of
and it tends to remain in that position. decidua, and
mucus
When is the best time to assess the fundal height? Lochia Pink 3-10 Blood,
- After a woman has emptied her bladder, because full serosa mucus, and
bladder can keep the uterus from contracting, pushing it invading
upward and increasing the risk if excess bleeding and leukocytes
blood clot formation in the uterus. Lochia alba White 10-14 (may Largely
last 6weeks) mucus;
leukocyte
count high

Cervix

Immediately after birth, a uterine cervix feels soft and malleable to

palpation.

Both internal and external os are open.

Like contractions of the uterus, contraction of the cervix toward its

pre-pregnant 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 process of the cervix does not involve the formation of new
muscle cells unlike for uterine involution. Because of this, the cervix
does not return exactly to its pre-pregnancy state.

The internal os closes as before, but after a vaginal birth, the

What about involution:
- Occur dependably in women who is well nourished and
who ambulates early after birth as gravity may play a role.
- It may be delayed by a condition such as, the birth of
multiple fetuses, hydramnios, exhaustion from prolonged
labor, grand multiparity, or physiological effects of
excessive anesthesia
external os usually remains slightly open and appears slit-like or
stellate (star shaped), whereas previously it was round. Finding this
pattern on a pelvic exam suggest that childbearing has taken place.
Vagina
-after vaginal birth, the vagina feels soft, with a few rugae and its
diameter is considerably greater than normal.

Contraction may be ineffective if there is a retained placenta or The hymen is permanently torn and heals with small, separate tags
membranes. of tissue.

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.
Afterpains
- In some women, contraction of the uterus after birth
causes intermittent cramping termed afterpains.
- This is similar to accompanying a menstrual period.
- Tend to be noticeable by multiparas than primiparas
In afterpains, the uterus must contract more forcefully to regain its
pre-pregnancy size.
These situations are noticed most intensely during breastfeeding;
when the infant’s sucking causes a release of oxytocin, increasing
the strength of the contractions.
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.
The thickening of the walls depends on the renewed estrogen
stimulation from the ovaries.
Because a woman who is breastfeeding may have a delay in
ovulation, so she may continue to have thin-walled or fragile
vaginal cells that cause slight vaginal bleeding during sexual
intercourse until about 6 weeks’ time.
Kegel exercise – is practiced, the strength and tone of the vagina
will crease more rapidly.
Perineum
- It is edematous and tender immediately after birth.

Lochia
- Flow consisting of blood, fragments of decidua, white
blood cells, mucus, and some bacteria.
- A woman can expect to have lochia for 2 to 6 weeks
The labia majora and minora typically remain atrophic and soften
after birth, never returning to their pre-pregnancy state.
Nonpharmacologic measures:
➢ Ice or warm packs or a gentle pillow to sit on

Page 4 of 7
Pharmacologic pain relievers such as acetaminophen or ibuprofen,
and administer according to the prescription.
SYSTEMIC CHANGES
The Hormonal System
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, estrogen, and estradiol are all
at pre-pregnancy levels (estriol may take 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 2,000 to 3,000 ml of excess
fluid accumulates in the body so extensive diaphoresis (excessive
sweating) and diuresis (exxessive urine production begin almost
after birth to rid the body of this fluid. This easily increases the daily
urine output of a postpartal woman from a normal level of 1,500 ml
to as much. As 3,000 ml/day during the second to fifth day after
birth. This marked increase in urine production causes the bladder
to fill rapidly. Reassure the mother that this is normal and she still
needs to continue drinking a healthy amount of fluids daily,
especially if she is breastfeeding.
Because 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 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. A
woman who has had epidural anesthesia can feel no sensation in
the bladder area until the anesthetic has worn off.
To prevent permanent damage to the bladder from over-distention,
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.
Pressure on this area may make a woman feel as if she has to void,
but she is then unable to do so. As the bladder fills, it displaces the
uterus; uterine position and lack of contraction are therefore a
second good gauge of whether a bladder is full or empty (Mulder,
Schoffelmeer, Hakvoort, et al., 2012).
The hydronephrosis or increased size of ureters that occurred
during pregnancy remains present for about 4 weeks after birth.
The increased size of these structures, in conjunction with reduced
bladder sensitivity, increases the possibility of urinary stasis and
urinary tract infection in the postpartal period.
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 re-
duce 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 delivery, it is 500 to 1,000 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. For example, if an average woman enters labor with a
hematocrit of 37%, it will be about 33% on the first postpartal day,
Page 5 of 7
and hemoglobin will fall from 11 to 10 g/dl. If the woman was
anemic during pregnancy, she can expect to continue to be anemic
afterward. As excess fluid is excreted, the hematocrit gradually
rises (because of hemoconcentration), reaching prepregnancy
levels by 6 weeks after birth.
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. There is also an increase in the number of
leukocytes in the blood. The white blood cell count may be as high
as 30,000 cells/mm' (mainly granulocytes) compared to a normal
level of 5,000 to 10,000 cells/mm particularly if labor was long or
difficult. This, too, is part of the body's defense system, a defense
against infection and an aid to healing.
Any varicosities that are present from pregnancy will recede, but
they rarely return to a completely prepregnant appearance.
Although vascular blemishes, such as spider angiomas, fade
slightly, they may not disappear completely either. Bilateral ankle
edema is not uncommon but should not progress above the knees.
This decreases over time as fluid shifts and returns to the
circulatory system.
The Gastrointestinal System
Digestion and absorption begin to be active again soon after
birth unless a woman has had a cesarean delivery. 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 (a
hormone which softens and lengthens the cervix and pubic
symphysis for preparation of the infant's birth during pregnancy) on
the bowel. Bowel evacuation may be difficult because of pain if a
woman has episiotomy sutures or from hemorrhoids. Encouraging
the mother to eat produce and soluble fiber foods, especially fruits,
will help keep her stools naturally soft and ease in her bowel
movements.
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. Typically, in a White woman, these will fade to a pale
white over the next 3 to 6 months; in a Black woman, they may
remain as areas of slightly darker pigment. Excessive pigment on
the face and neck (chloasma) and on the abdomen (linea nigra)
will become barely detectable by 6 weeks’ time. If diastasis recti
(overstretching and separation of the abdominal musculature)
occurred, the area will appear as a slightly indented bluish streak
in the abdominal midline. Modified sit-ups help to strengthen
abdominal muscles and return abdominal support to its
prepregnant level. Diastasis recti, however, may require surgery to
correct (Hickey, Finch, & Khanna, 2011).
RETROGRESSIVE CHANGES IF THE PUERPERIUM
Exhaustion
As soon as birth is completed, a woman experiences total
exhaustion. For the last several months of pregnancy, she probably
experienced some difficulty sleeping. All during labor, she worked
hard with little or no sleep. Now, she has
"sleep hunger," which may make it difficult for her to cope with new
experiences and stressful situations until she has enjoyed a
sustained period of sleep.
Weight Loss
The rapid diuresis and diaphoresis during the second to fifth
days after birth usually result in a weight loss of 5 lb (2 to
4 kg), in addition to the approximately 12 lb (5.8 kg) lost at
birth. Lochia flow causes an additional 2- to 3-Ib (1-kg) loss,
for a total weight loss of about 19 lb. Additional weight loss is
dependent on the amount of pregnancy weight gain and on
whether a woman continues active measures to lose weight (Cahill,
Freeland-Graves, Shah, er al., 2012). It is also influenced by
nutrition, exercise, and breastfeeding.
The weight a woman reaches at G weeks after birth becomes her
baseline postpartal weight unless she continues active measures
to lose the weight. In many women, this baseline is higher than
their prepregnancy weight and one of the reasons that obesity has
become a national health concern (Lipsky, Strawderman, & Olson,
2012).
Balancing a newborn, eating healthy foods, and finding the time to
exercise becomes a challenge to many mothers. Discussing
strategies with her will help to organize
her efforts to find balance, such as helpful babysitters, family
members, and/or her partner to come and give her needed
breaks.
Vital Sign Changes
Vital sign changes in the postpartum period reflect the internal
adjustments that occur as a woman's body returns to its
prepregnant state.
Temperature
Temperature is always taken orally or tympanically (never rectally)
during the puerperium because of the danger of
vaginal contamination and the discomfort involved in rectal
intrusion.
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 takes inadequate fluid during
the first 24 hours, this temperature elevation will return to
normal. Most women are thirsty immediately after birth and
are eager to take in fluid, so drinking a large quantity of fluid
is not a problem unless the woman is nauseated from a birth
analgesic.
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,
and such a high temperature may indicate that a postpartal
infection is present (Johnson, Thakar, & Sultan,
2012).
Occasionally, when a woman's breasts fill with milk on the third or
fourth postpartum day during lactogenesis I, her temperature will
rise for a period of hours because of the increased vascular activity
involved; this process is termed engorgement. If the elevation in
temperature lasts longer than a few hours, however, infection may
be the reason. An infection of the breast during lactation is termed
mastitis. Mothers may or may not feel breast pain or experience
redness of the breast, but they will often have a high temperature
and feel flu-like symptoms such as malaise and fatigue. Mastitis
can interfere with lactation, and sometimes, an infant will refuse to
nurse on the affected side. The women’s medical provider must be
notified to initiate antibiotic treatment (congruent with
breastfeeding). Mothers should be instructed to continue
Page 6 of 7
breastfeeding if the infant will breastfeed from the affected side. If
the infant refuses, instruct the mother to pump her breasts to
maintain Aow (and to avoid clogged ducts) and then offer the
affected breast after 12 to 24 hours. Once the mastitis is treated,
infants often will resume breastfeeding after 12 to 24 hours. Unless
specifically directed otherwise, infants are safe to continue to
breastfeed while a mother is being treated for mastitis; there is no
reason to provide alternative feeding methods or to wean because
of maternal mastitis. Because infection is a major cause of
postpartal mortality and morbidity, nurses have the important role
of being the healthcare providers who may first detect the problem.
Pulse
A woman's pulse rate during the postpartal period is usually
slightly slower than usual. 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/min. As diuresis diminishes the blood vol-
ume and causes blood pressure to fall, the pulse rate increases
accordingly. By the end of the first week, the pulse rate will have
returned to normal. Evaluate pulse rate conscientiously in the
postpartal period because a rapid and thready pulse during this
time could be a sign of hemorrhage.
Blood Pressure
Blood pressure should also be monitored carefully during the
postpartal period because a decrease in this can also indicate
bleeding. In contrast, an elevation above 140 mmg systolic or 90
mmHg diastolic may indicate the development of postpartal
hypertension of pregnancy, an unusual but serious complication of
the puerperium (Chhabra, Tyagi, Bhavani,et al., 2012)
To evaluate blood pressure, compare a woman's pressure
with her prepregnancy level if possible rather than with standard
blood pressure ranges; otherwise, if her blood pressure rose during
pregnancy, a significant postpartal decrease in pressure could be
missed.
Oxytocics, drugs frequently administered during the
postpartal period to achieve uterine contraction, cause
contraction of all smooth muscle, including blood vessels (Karch,
2013).
Consequently, these drugs can increase blood pressure. Always
measure blood pressure before administering one of these agents;
if blood pressure is greater than 140/90 mmHg, withhold the agent
and notify the woman's primary care provider to prevent
hypertension and, possibly, a cerebrovascular accident.
A major complication in women who have lost an appreciable
amount of blood with birth is orthostatic hypotension, or dizziness
that occurs on standing because of the lack of adequate blood
volume to maintain nourishment of brain cells. To test whether a
woman will be susceptible to this, assess her blood pressure and
pulse while she is lying supine. Next, raise the head of the bed fully
upright, wait 2 or 3 minutes, and reassess these values. If the pulse
rare is increased by more than 20 beats/min and blood pressure is
15 to 20 mmHg lower than formerly, the woman might be
susceptible to dizziness and fainting when she ambulates. Inform
the woman's primary care provider of these findings. Advise her to
always sit up slowly and "dangle" on the side of her bed before
attempting to walk. If she notices obvious dizziness on sitting
upright, support her during ambulation to avoid the possibility of a
fall. Caution her not to attempt to walk carrying her newborn until
her cardiovascular status adjusts to her blood loss.
PROGRESSIVE CHANGES OF THE PUERPERIUM feeling of heat or tenderness. During the engorgement phase, the
breast tissue may appear reddened as if an acute inflammatory or
Two physiologic changes that occur during the puerperium infectious process were present and some moms experience
involve progressive changes, or the building of new tissue. increased tenderness or throbbing. This feeling of tension in the
Because this requires good nutrition, caution women against breasts on the third or fourth day after birth is termed primary
strict dieting that would limit cell-building ability during the first 6 engorgèment.
weeks after childbirth (Whitney & Rolfe, 2012).
RETURN OF MENSTRUAL FLOW
Lactation With the delivery of the placenta, the production of placental
The early lactation process, which is driven by hormones estrogen and progesterone ends. The resulting decrease in
from the hypothalamus to the pituitary gland in order to secrete the hormone concentrations cause a rise in production of FSH by the
lactation hormones, is identified by four phases of lactogenesis pituitary, which leads, with only a slight delay, to the
(human milk production). Prolactin hormone is responsible for milk return of ovulation. This initiates the return of normal menstrual
production, and oxytocin is responsible for the let-down reflex arch. cycles. A woman who is not breastfeeding can expect her
A retrained placenta can inhibit this process by causing continual menstrual flow to return in 6 to 10 weeks after birth. If she is
circulation of progesterone, which inhibits prolactin and thus milk breastfeeding, a menstrual flow may not return for 3 or 4 months
production. (lactational amenorrhea) or, in some women, for the entire lactation
period. However, the absence of a menstrual How does not
The lactogenesis I (milk synthesis) process begins around 16 guarantee that a woman will not conceive during this time because
weeks gestation as the glandular luminal cells in the breast begin she may ovulate well, before menstruation returns (Kramer &
secreting colostrum, a thin, watery pre-lactation secretion Kakuma, 2012).
(Wambach & Riordan, 2016).
Reference book:
Lactogenesis Il is triggered at birth by the delivery of the placenta, Silbert-Flagg,J. & Pillitteri, A (2018).Maternal & Child Health
when the progesterone hormone (prolactin is no longer inhibited) Nursing:care of the childbearing and childrearing family, Eighth
and other circulating pregnancy hormones suddenly decrease and Edition (P. 396 - 409).
oxytocin sharply increases as a result of the infant suckling.
Oxytocin helps the uterus to shrink to its prepregnancy size; some
mothers will feel uterine cramps initially when breastfeeding until
the uterus fully involutes. Lactogenesis Il is often when mothers
feel that their "milk has come in" (engorgement) and occurs from
birth to 5 to 10 days postpartum; this is often termed "transitional
milk." Lactogenesis Ill can occur from day 10 until weaning
postpartum, when the "mature milk" supply is now driven by the
circulating lactation hormones oxytocin and progesterone.
Lactogenesis IV occurs after complete weaning and the breasts
involute to their prelactation state. Other hormones are associated
with breastfeeding, such
as endorphins and oxytocin, and may help to mitigate and
reduce the risk of developing postpartum depression (Ahn&
Corwin, 2015).

The formation of breast milk (lactation) begins in a post-

partal woman whether or not she plans to breastfeed (Stuebe,
2012). Early in pregnancy, the increased estrogen level produced
by the placenta stimulated the growth of milk glands; breasts
increased in size because of these larger glands, accumulated
fluid, and some extra adipose tissue. For the first 2 days after birth,
an average woman notices little change in her breasts from the way
they were during pregnancy because, since midway through
pregnancy, she has been secreting colostrum. On the third day
after birth, her breasts become full and feel tense or tender as milk
forms within breast ducts and replaces colostrum. If a mother
reports she experienced little or no changes in her breasts during
pregnancy, alert her provider and call for a
lactation consultation. This may indicate a complication in her
breast anatomy and her ability to secrete enough milk. Generally,
breastfeeding complications are rare and typically initially stem
from a painful latch, a problem chat can be addressed quickly. Most
American women are able to successfully breastfeed their newborn
and even twins or triplets.

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) and an increase in prolactin and oxytocin.
A woman's breasts become fuller, larger, and firmer as blood and
lymph enter the area to contribute fluid to the formation of milk. In
many women, breast distention/engorgement is accompanied by a
Page 7 of 7