POSTPARTAL CARE

POSTPARTUM CARE NCM 107

Post partum care refers to the medical and nursing care given
THE PUERPERIUM
to a woman during the puerperium, which is the 6-week period
after delivery, beginning with termination of labor and ending
with the return of the reproductive organs to the non-pregnant
state.
This period constitutes a physical and psychological
adjustment to the process of childbearing and is sometimes
referred to as the 4th trimester of pregnancy.
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).
BREASTFEEDING POLICY
1. Have a written breastfeeding policy that is routinely communicated to all health
care staff.
2. Train all health care staff in the skills necessary to implement this policy.
3. Inform all pregnant women about the benefits and management of
breastfeeding.
4. Help mothers initiate breastfeeding within one hour of birth.
5. Show mothers how to breastfeed and how to maintain lactation, even if they are
separated from their infants.
6. Give newborn infants no food or drink other than breast-milk, unless medically
indicated.
7. Practice “rooming in”—allow mothers and infants to remain together 24 hours a
day.
8. Encourage breastfeeding on demand.
9. Give no pacifiers or artificial nipples to breastfeeding infants.
10. Foster the establishment of breastfeeding support groups and refer mothers to
PHASES OF THE
PUERPERIUM
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 after-pains or
hemorrhoids, partly from her uncertainty in caring for her
newborn, and partly from the exhaustion that follows childbirth.
The woman usually wants to talk about her pregnancy,
especially about her labor and birth. Encouraging her to talk
about the birth is an important way to help her integrate the
experience into her total life experiences.
TAKING-HOLD PHASE

After a time of passive dependence, a woman begins to initiate

action (the taking-hold phase). 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.
 LETTING-GO PHASE
In this third 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.
PHYSIOLOGIC CHANGES OF THE
POSTPARTUM PERIOD
REPRODUCTIVE SYSTEM
CHANGES
Involution is the process whereby the
reproductive organs return to their non pregnant
state.
 REPRODUCTIVE SYSTEM
CHANGES: THE UTERUS
Involution of the uterus involves two processes.
1.The area where the placenta was implanted is sealed off to prevent bleeding. 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 halts bleeding. With time, thrombi form within the
uterine sinuses and permanently seal the area. Eventually, endometrial tissue undermines the
site and obliterates the organized thrombi, covering and healing the area so completely the
process leaves no scar tissue within the uterus so does not compromise future implantation
sites.
2.The organ is reduced to its approximate pre-gestational size. The same contraction process
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, a phenomenon that can be compared
with a rubber band that has been stretched for many months and now is regaining its normal
contour. None of the rubber band is destroyed; the shape is simply altered. For this reason,
the postpartum period, like pregnancy, is not a period of illness, of necrosing cells being
evacuated, but primarily a period of healthy change.
THE UTERUS:
Immediately after birth, the uterus weighs about 1,000 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 is palpable through the abdominal wall, halfway
between the umbilicus and the symphysis pubis, within a few minutes after
birth. One hour later, it will rise to the level of the umbilicus, where it
remains for approximately the next 24 hours. From then on, it decreases by
one fingerbreadth, or 1 cm, per day; for example, on the first post-partum
day, it will be palpable 1 cm below the umbilicus.
 In the average woman, 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.
Involution will occur most dependably in a woman who is well nourished and who
ambulates early after birth as gravity may play a role. Involution may be delayed by a
condition such as the birth of multiple fetuses, hydramnios, exhaustion from prolonged
labor, grand multiparity, or physiologic effects of excessive analgesia. Contraction may
be ineffective if there is retained placenta or membranes.
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.
In some women, contraction of the uterus after birth causes intermittent cramping
termed afterpains, similar to that accompanying a menstrual period. Afterpains tend to
be noticed most by multiparas than by primiparas and by women who have given birth
to large babies or multiple births. In these situations, the uterus must contract more
forcefully to regain its pre-pregnancy size. These sensations are noticed most intensely
with breastfeeding, when the infant’s sucking causes a release of oxytocin from the
posterior pituitary, increasing the strength of the contractions.
 LOCHIA
The separation of the placenta and membranes occurs in the spongy layer or outer
portion of the decidua basalis of the uterus. By the second day after birth, the layer of
decidua remaining under the placental site (an area 7 cm wide) and throughout the uterus
differentiates into two distinct layers. The inner layer attached to the muscular wall of
the uterus remains, serving as the foundation from which a new layer of endometrium
will be formed. The layer adjacent to the uterine cavity becomes necrotic and is cast off
as a vaginal discharge similar to a menstrual flow. This flow, consisting of blood,
fragments of decidua, white blood cells, mucus, and some bacteria, is termed Lochia.
 EVALUATING
Amount
LOCHIA FLOW
: Lochia amount varies greatly from
woman to woman. Mothers who breastfeed tend to
have less lochial discharge than those who do not
because the natural release of the hormone oxytocin
during breastfeeding strengthens uterine contractions.
Lochial flow increases on exertion, especially the
first few times a woman is out of bed but decreases
again with rest. Saturating a perineal pad in less than
1 hour is considered an abnormally heavy flow and
should be reported. Don’t use tampons to halt the
flow or this could lead to infection.
Consistency: Lochia should contain no
exceedingly large clots as these may indicate 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.
Pattern: Lochia is red for the first 1 to 3 days (lochia rubra), pinkish-brown 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 as this suggests a placental
fragment has been retained or uterine contraction is decreasing and new bleeding is
beginning.

Odor: Lochia should not have an offensive odor as this suggests the uterus has become
infected. Immediate intervention is needed to halt postpartal infection.

Absence: Lochia should never be absent during the first 1 to 3 weeks as absence of
lochia, like presence of an offensive odor, may indicate postpartal infection. Lochia may be
scant in amount after cesarean delivery, but it is never altogether absent.
THE CERVIX
Immediately after birth, a uterine cervix feels soft and malleable to palpation. 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.
In contrast to the process of uterine involution, in which the changes consist primarily of
old cells being returned to their former position by contraction, the process in the cervix
does involve the formation of new muscle cells. Because of this, the cervix does not return
exactly to its prepregnancy 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. Finding this pattern on pelvic examination suggests that
childbearing has taken place.
 THE VAGINA
After a vaginal birth, the vagina feels 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 postpartum period for the vagina to involute (by
contraction, as with the uterus) until it gradually returns to its
approximate pre-pregnancy state. Thickening of the walls appears
to depend on renewed estrogen stimulation from the ovaries.
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. 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 is edematous and tender immediately after
birth.
Ecchymosis patches from ruptured capillaries may show on the
surface.
The labia majora and labia minora typically remain atrophic and
softened after birth, never returning to their pre-pregnancy state.
Mothers may experience various levels of tenderness in the
perineum area.
 Suggesting nonpharmacologic comfort measures such as ice or
warm packs or a gentle pillow or doughnut pad to sit on will be
much appreciated by the mother.
SYSTEMIC CHANGES
POST PARTUM
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 (excess urine production)
begin almost immediately after birth to rid the body of this
fluid. This easily increases the daily urine output of a
postpartum 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.
 THE CIRCULATORY
SYSTEM
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, and hemoglobin will fall from 11 to 10g/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/mm3
(mainly granulocytes) compared to a normal level of 5,000 to 10,000
cells/mm3, 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.
 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.
 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 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 pre-pregnant level. Diastasis recti, however,
may require surgery to correct.
PROGRESSIVE CHANGES OF
THE PUERPERIUM
1. Lactation
Lactogenesis (human milk production)
Prolactin hormone is responsible for milk production, and oxytocin is responsible for
the let-down reflex arch.
The lactogenesis I (milk synthesis) process begins around 16 weeks gestation as the
glandular luminal cells in the breast begin secreting colostrum, a thin, watery prelactation
secretion.
Lactogenesis II is triggered at birth by the delivery of the placenta, when the
progesterone hormone (prolactin is no longer inhibited) and other circulating pregnancy
hormones suddenly decrease and oxytocin sharply increases as a result of the infant
Suckling. Lactogenesis II 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 III 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.
PROGRESSIVE CHANGES OF
THE PUERPERIUM
2. 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 (lactation 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 CARE OF A WOMAN AND FAMILY
DURING THE FIRST 24 HOURS AFTER BIRTH
Skin-to-skin cuddling with the newborn should be encouraged as well as offering the newborn the breast to try to suckle.
Provide Pain Relief for afterpains.
Relieve Muscular Aches.
Administer Cold and Hot Therapy to the perineum.
Promote Perineal Exercises.
Give Suture Line Care for Women With An Episiotomy.
Provide Perineal Care.
Promote Perineal Self-Care.
Promote Rest in the Early Postpartal Period.
Promote Adequate Fluid Intake.
Promote Urinary Elimination.
Prevent constipation
Prevent Development of Hemorrhoids.
Assess Peripheral Circulation.
Promote Breast Hygiene.
POST PARTUM DISCHARGE
INSTRUCTIONS
 Work
 All women should avoid heavy work (lifting or straining) for at least the
first 3 weeks after birth. Women differ in their concept of heavy
work, so it is a good idea to explore what a woman considers heavy
work. If she plans to do too much, you can perhaps help her to
modify her plans. It is usually advised that a woman not return to an
outside job for at least 3 weeks (or better, 6 weeks), not only for her
own health but also for enjoyment of the early weeks with her
newborn.
 Rest
 A woman should plan at least one rest period each day while her baby
sleeps and try to get a good night’s sleep. If she has other family
members dependent on her, explore the possibility of having a
neighbor, another family member, or a person from a community
health agency relieve her so she can rest.
 Exercise
 A woman should limit the number of stairs she climbs to one flight/day
for the first week at home. This limitation may involve some
planning on her part, especially if her washing machine is in the
basement or if she must go up and down stairs to check on her baby.
Help her plan for a place for the baby to sleep downstairs to alleviate
the second concern. She should continue with muscle-strengthening
exercises, such as abdominal crunches.
 Hygiene
 A woman may take either tub baths or showers. She should
continue to apply any perineal cream or ointment. Remind her to
cleanse her perineum from front to back after voiding to prevent
fecal contamination. Any perineal stitches will be absorbed within
10 days.
 Coitus
 Coitus is safe as soon as a woman’s lochia has turned to alba and, if
present, an episiotomy is healed (usually the first week after birth).
Vaginal cells may not be as thick as formerly because pre-pregnancy
hormone balance has not yet completely returned to supply
lubrication. Use of a contraceptive foam or lubricating jelly will aid
comfort. Be certain she knows safer sex precautions.
 Contraception
 If desired, a woman should begin a contraception measure with the
initiation of coitus. If she wants an intrauterine device, this may be
fitted immediately after birth or at her first postpartum checkup.

 Combination oral contraceptives are begun about 2–3 weeks after

birth due to clotting factor risks and interference with milk
production for women who are breastfeeding (progestin-only oral
contraceptives can be started earlier). A diaphragm must be refitted at
a 6-week checkup. Until she returns for this checkup, an over-the-counter
spermicidal jelly and condoms can provide protection.
Follow-up
 A woman should notify her primary care provider if she notices an
increase, not a decrease, in lochial discharge, or if lochia serosa or
lochia alba becomes lochia rubra; if lochia has a foul odor; if she has
a temperature greater than 101°F; or if symptoms of sadness last
longer than 2 weeks.
 A woman should schedule a 4- to 6-week
checkup so she can be assured involution is complete and
immunization if not previously immunized against the virus
associated with cervical cancer (human papillomavirus) can be
administered and so reproductive life planning (if desired) can be
discussed.