POST PARTUM CARE

The POSTPARTUM is the 6-week period after childbirth:

It is a time of rapid physiological changes within the woman’s body

as it returns to a pre-pregnant state.

Women who enter pregnancy in a healthy state and experience a

low-risk pregnancy and labor and birth are at low risk for
complications during the postpartum period.
THE REPRODUCTIVE SYSTEM:
The reproductive system, which includes the uterus, cervix, vagina, and
perineum, undergoes dramatic changes during the 6 weeks after the
birthing experience. Women are at risk for hemorrhage and infection.

Nursing assessments and interventions are aimed at reducing these risks.

!
“BUBBLE-HE”– acronym used to denote the components of postpartum maternal nursing assessment

B - Breast
U - Uterus
B - Bladder
B - Bowels
L - Lochia’s
E - Episiotomy and perineum

H - Hemorrhoids
E - Emotions
BREAST
During pregnancy, the breasts undergo changes in preparation for lactation.

Around the third postpartum day all women, breastfeeding and non-breastfeeding, experience some
degree of primary breast engorgement.

Primary engorgement, which is an increase in the vascular and lymphatic system of the breasts,
precedes the initiation of milk production.

The woman’s breasts become larger, firm, warm, and tender and the woman may feel a throbbing pain
in the breasts.

Primary engorgement subsides within 24 to 48 hours. Women who breastfeed experience subsequent
breast engorgement related to distention of milk glands that is relieved by having the baby suckle or by
expressing milk.

The primary complication is mastitis, which is an infection of the breast

BREAST
COLOSTRUM, a clear, yellowish fluid, precedes milk production.

It is higher in protein and lower in carbohydrates than breast milk.

It contains immunoglobulins G and A that provides protection for the newborn during
the early weeks of life.
BREAST
CRITICAL COMPONENT:

Mastitis
Mastitis is an inflammation or infection of the breast. The infection may be due to
bacterial entry through cracks in nipples.

Symptoms: Fever, malaise, unilateral breast pain, and tenderness in the

infected area.
Treatment: Antibiotic therapy, analgesia, rest, and hydration.

The woman should continue to breastfeed or pump her breasts as per the physician’s
or midwife’s recommendation.
BREAST
Nursing Actions for the Breastfeeding Woman:

Assess the breasts for engorgement.

Inspect the breasts for signs of engorgement: tenderness, firmness, warmth, and/or
enlargement.

Expected assessment findings:

In the first 24 hours postpartum, the breasts are soft and nontender.
On postpartum day 2, the breasts are slightly firm and nontender.
On postpartum day 3, the breasts are firm, tender, and warm to touch.
Assess the nipples for signs of irritation and nipple tissue breakdown.
Report signs and symptoms of mastitis to the physician or midwife.
BREAST
Patient Education

Apply heat to the breasts to increase circulation and comfort.

Encourage the woman to wear a supportive bra.
Instruct the woman to examine nipples before feedings for signs of irritation.
Instruct the woman to feed her infant or express milk if she is experiencing breast
engorgement.
Document findings and interventions.

Sample charting: The breasts are soft and nontender. There are no signs of
nipple irritation. The patient is wearing a supportive bra.
BREAST
Nursing Actions for the Non-breastfeeding Woman:

Assess the breasts for primary engorgement.

Inspect the breasts for signs of engorgement: Tenderness, firmness, warmth, and/or
enlargement.

Expected assessment findings

During the first 24 hours postpartum, the breasts are soft and nontender.
On postpartum day 2, the breasts are slightly firm and nontender.
On postpartum day 3, the breasts are firm and tender.
BREAST
Patient Education for the Non-breastfeeding Woman:

Instruct the woman to wear a supportive bra 24 hours a day until her breasts become
soft.
Instruct the woman who is experiencing engorgement to:
Apply ice to the breasts.
Do not express milk because this stimulates milk production.
Avoid heat to the breast because this can stimulate milk production.
Take an analgesic for pain.
Inform the woman that breast engorgement will subside within 48 hours.
Document findings and interventions.
Sample charting: Breasts are soft and nontender. The patient is wearing a
supportive bra.
UTERUS
After delivery of the placenta, the uterus begins the process of involution, by which the
uterus returns to a pre-pregnant size, shape, and location; and the placental site heals.

This occurs through uterine contractions and atrophy of the uterine muscle.

Primiparous women usually do not experience discomfort related to uterine

contractions during the postpartum period.

Multiparous women or women who are breastfeeding may experience “afterpains”

during the first few postpartum days (increase of oxytocin) infant suckling.

Uterus needs to be in a contracted - decrease the risk of postpartum hemorrhage -

contracted uterine decreases the amount of blood loss.
UTERUS Before assessment:

Inform the woman that you will be

palpating her uterus.
Nursing Actions: Explain the procedure.
Instruct the woman to void.
Assess the uterus for location, position, and tone of Provide privacy.
Lower the head and foot of the bed so that
the fundus. the woman is in a supine position and flat.
After the third stage of labor, assess the uterus:
Every 15 minutes for the first hour
Every 30 minutes for the second hour
Every 4 hours for the next 22 hours
Every shift after the first 24 hours
More frequently if the assessment findings are not
within normal limits
UTERUS
Support the lower uterine segment by placing one hand just above the symphysis pubis.
Locate the fundus with the other hand using gentle downward pressure.
Determine the tone of the fundus: Firm (contracted) or soft (boggy).

A boggy uterus indicates that the uterus is not contracting and places the woman at risk
for excessive blood loss. If the uterus is boggy the nurse should:

1. Massage the fundus with the palm of the hand.

2. Give oxytocin as per the physician’s or midwife’s orders.
3. Notify the physician or midwife if the uterus does not respond to massage.
UTERUS
Medications:
Antibiotics
Indication - infection
Action: antimicrobial
Common side effects: diarrhea, nausea and vomiting, dizziness, rash, yeast infections
Route and dose: PO or IV
initial dose – IV, followed by oral or as per order
UTERUS
Patient Education:

Teach the woman how to assess the uterus and explain the normal involutional process.
Teach the woman how to massage her uterus if boggy and instruct her to notify the nurse
while in the hospital and health care provider after discharge.
Provide information regarding “afterpains.”
Uterine cramps are caused by the contraction and relaxation of the uterus as it decreases in
size.
Afterpains occur within the first few days and last 36 hours.
UTERUS
Comfort measures:

Empty bladder
Warm blanket to abdomen
Analgesia (ibuprofen is commonly used for postpartum discomfort)
Relaxation techniques
Provide information on the stages of lochia.
Provide information for reducing the risk of infection.
Instruct the patient to change the peripad frequently because lochia is a medium for
bacterial growth.
BLADDER
THE URINARY SYSTEM:

Bladder distention, incomplete emptying bladder, and inability to void are common during
the first few days post-birth.
These are related to a decreased sensation of the urge to void and/or edema around the
urethra.
Diuresis, caused by decreased estrogen and oxytocin levels, occurs within 12 hours post-birth
and aids in the elimination of excess tissue fluids. Primary complications are bladder
distention and cystitis.
BLADDER
CRITICAL COMPONENT:

Cystitis: Bladder inflammation/infection.

Symptoms: Frequency, urgency, pain/burning on urination, and malaise

Treatment: Antibiotic therapy, increased hydration, rest.

BLADDER
Nursing Actions:

Assess for urinary disturbances.

Measure voiding during the first 24 hours post-birth.
If voiding is less than 150 mL, the nurse needs to palpate for bladder distention. This may
indicate incomplete emptying of the bladder and the woman may need to be catheterized.
If unable to void within 12 hours post-birth the woman may need to be catheterized. A Foley
catheter is recommended when inability to void is related to edema.
Assess for frequency, urgency, and burning on urination.
Notify the physician or midwife if the patient reports frequency, urgency and/or burning on
urination.
BOWELS
THE GASTROINTESTINAL SYSTEM:

There is a decrease in gastrointestinal muscle tone and motility post birth with a return to
normal bowel function by the end of the second postpartum week.

Constipation - uncomfortable and infrequent bowel movements

A painful episiotomy site, if you had one performed

Damage to the anal sphincter during birth

BOWELS
Nursing Actions:

Assess bowel sounds at each shift.

Notify the physician or midwife if bowel sounds are faint or absent.
Assess for constipation.
Ask the woman if and when she had a bowel movement.
BOWELS
Patient Education:

Drink lots of fluids (at least eight to 10 glasses of water every day)
Include things like green vegetables, cereals (whole grain), bread, fruits, and bran in your diet
Get plenty of rest
Eat prunes (a natural laxative)
Drink a warm liquid every morning
Use mild laxatives or fiber supplements if other methods do not work
LOCHIA
Lochia is postpartum vaginal discharge. It contains blood from the placental site, particles of
necrotic decidua, and mucus.
Lochia normally has a fleshy odor similar to that of menstrual flow.
The quantity of lochia rapidly diminishes and becomes moderate and then scant.

Lochia is the heaviest during the first 1 or 2 hours after birth.

Initial lochia is bright red and commonly called lochia rubra (lasts 1 to 3 days); it may contain small clots.
The vaginal flow then pales and becomes pink to brown after approximately 3 days; this is called
lochia serosa. Lochia serosa should not contain clots and can last up to 27 days in some womb.
Typically, by 10 days’ postpartum, the vaginal discharge often becomes yellow to white and is called
lochia alba. Lochia alba may continue, on average, to the sixth week postpartum
LOCHIA
Assessment of Lochia

1. Assess lochia for quantity. A guideline to estimate and document the amount of flow on
the menstrual pad in 1 hour is as follows:

a. Scant: less than a 2-inch (5-cm) stain

b. Light: less than a 4-inch (10-cm) stain
c. Moderate: less than a 6-inch (15-cm) stain
d. Large or heavy: larger than a 6-inch stain or one pad saturated within 2 hours
e. Excessive: saturation of a perineal pad within 15 minutes

2. Assess lochia for type and characteristics. In first 3 days, normal lochia has fleshy odor with
small clots with red or reddish brown color. Abnormal lochia has foul odor, large clots, and
saturated pad with bright red color.
LOCHIA
Nursing Actions:

Estimating the amount of lochial flow by observation is difficult. Many facilities use perineal
pads that have cold or warm packs in them.
If a mother has excessive lochia, a clean pad should be applied and checked within 15
minutes.
The number of perineal pads applied during a given period should be counted or the pads
weighed to help determine the amount of vaginal discharge. One gram of weight equals 1
mL of blood.
The woman’s fundus should be checked for firmness.
Nurses often estimate the amount of lochia in terms of the approximate size of the area
soiled in 1 hour.
LOCHIA
Patient Education:

The amount of lochia is less after a cesarean birth.

Breastfeeding or the use of oral contraceptives does not affect lochial flow.
Lochia is briefly heavier when the mother ambulates because blood that has pooled in her
vagina is discharged when she assumes an upright position.
Any abnormal lochia pattern should be documented and reported.
Assessment of uterine firmness, location, and position in relation to the midline is performed
at routine intervals.
A poorly contracted (soft, boggy) uterus should be massaged until firm to prevent
hemorrhage.
It is essential not to push down on an uncontracted uterus to avoid inverting it.
Episiotomy & Perineum
VAGINA AND PERINEUM

The vagina and perineum experience changes related to the birthing process
ranging from mild stretching and minor lacerations to major tears and
episiotomies.
An episiotomy is a cut (incision) made in the tissue between the vaginal opening and the
anus during childbirth
The woman may experience mild to severe pain depending on the degree and
type of vaginal and/or perineal trauma.
The primary complication is infection at the lacerations or episiotomy sites.
The vagina and perineum undergo healing and restoration during the
postpartum period.
Episiotomy & Perineum
Nursing Actions:

Assess the perineum every shift using the acronym REEDA (redness, edema,
ecchymosis, discharge, approximation of edges of episiotomy or laceration).
Explain the procedure.
Provide privacy.
Assist the woman to her side.
Lower the peripad and separate the buttocks to expose the perineum for
assessment.
Encourage the woman to lie on her side to decrease pressure on perineum.
Instruct the woman to wear peripads snugly to prevent rubbing.
Administer analgesia per the physician’s or midwife’s order.
Process of assessing the inflammatory process and tissue healing in the perineal
Episiotomy & Perineum
Patient Education:
To relieve pain or discomfort:
Apply ice packs right after the birth. Using ice packs in the first 24 hours after birth
decreases the swelling and helps with pain
Take warm baths but wait until 24 hours after you have given birth.
Take medicine like ibuprofen to relieve pain.

Use sitz baths(sit in water that covers your vulvar area) a few times a day. Change your pads
every 2 to 4 hours.
Keep the area around the stitches clean and dry. After you urinate or have a bowel
movement, spray warm water over the area and pat dry with a clean towel or baby wipe..
Take stool softeners and drink lots of water. This will prevent constipation.
Do Kegel exercise. Squeeze the muscles that you use to hold in urine for 5 minutes. Do this
10 times a day throughout the day.
Hemorrhoids
Hemorrhoids also known as piles, are veins in or around your anus that have become
swollen.
Many women will experience hemorrhoids for the first time during pregnancy or after giving
birth.
Hemorrhoids are caused by pressure on the veins in your rectum or anus.

Hemorrhoids can be internal, where they form inside the rectum. They can also be external,
located around the anal opening. Symptoms of postpartum hemorrhoids include:
Pain in the anal area
Itchiness in the anal area
Bleeding during bowel movements
Sensitive lumps near the anus
Hemorrhoids
Assess for hemorrhoids:
Instruct the woman to lie on her side, then separate the buttocks to expose the anus.
If hemorrhoids are present:
Instruct the woman to increase fluid intake and increase fiber and roughage in diet to
decrease risk of constipation.
Encourage the woman to avoid sitting for long periods of time by lying on her side.
Instruct the woman to take Sitz baths, which are helpful in promoting circulation and
reducing pain.
Hemorrhoids
Nursing Actions

Provide analgesics, warm sitz baths, or warm compresses to reduce pain and inflammation.
Observe anal area postoperatively for drainage and bleeding.
Administer stool softener or laxative to assist with bowel movements soon after surgery, to
reduce risk of stricture.
Teach anal hygiene and measures to control moisture to prevent itching.

Medication:
Docusate (Colace)
Indication: Prevention of constipation
Action: Promotes incorporation of water into the stool
Common side effects: Mild abdominal cramps
Route and dose: PO; 100 mg twice a day
Hemorrhoids
Patient Education

Teach anal hygiene and measures to control moisture to prevent itching.

Encourage the patient to exercise regularly, follow a high fiber diet, and have an adequate
fluid intake (8 to 10 glasses per day) to avoid straining and constipation, which predisposes to
hemorrhoid formation.
Discourage regular use of laxatives
Emotions
The mother may experience a let-down feeling, which is called postpartal “baby blues.”
This is a form of depression that is usually temporary and may occur in the hospital.

Most new moms experience postpartum "baby blues" after childbirth, which commonly
include mood swings, crying spells, anxiety and difficulty sleeping. Baby blues usually begin
within the first 2 to 3 days after delivery and may last for up to two weeks.
Emotions
Postpartum depression symptoms

Postpartum depression may be mistaken for baby blues at first — but the symptoms are
more intense and last longer.

These may eventually interfere with your ability to care for your baby and handle other daily
tasks. Symptoms usually develop within the first few weeks after giving birth

But they may begin earlier — during pregnancy — or later — up to a year after birth.
Emotions
Patient Education

Assist the woman in planning for her daily activities, such as her nutrition program, exercise,
and sleep.
Recommend support groups to the woman so she can have a system where she can share
her feelings.
Advise the woman to take some time for herself every day so she can have a break from her
regular baby care.
Encourage the woman to keep in touch with her social circle as they can also serve as her
support system.
THE CARDIOVASCULAR SYSTEM:

Women have an average blood loss of 400 to 500 mL related to the vaginal birthing
experience.

Postpartum hemorrhage (PPH) is commonly defined as blood loss exceeding 500 mL

following vaginal birth and 1000 mL following cesarean.

This has a minimal effect on a woman’s system due to pregnancy-induced hypervolemia.

There is an increase in cardiac output during the first few postpartum hours related to blood
that was shunted through the uteroplacental unit returning to the maternal system. Cardiac
output returns to pre-pregnant levels within 48 hours.
White blood cell (WBC) levels may increase to 25,000/mm within a few hours of birth and
returns to normal levels within 7 days.
Nursing Actions:

Assess pulse and blood pressure:

Every 15 minutes for the first hour
Every 30 minutes for the second hour
Every 4 hours for the next 22 hours
Every shift after the first 24 hours

PATIENT EDUCATION:

Instruct the woman on ways to reduce risk of orthostatic hypotension.

Instruct the woman to take temperature if she experiences chills and report
temperature elevations to her physician or midwife.
THE RESPIRATORY SYSTEM:

There is a return of chest wall compliance after the birth of the infant due to reduction of
pressure on the diaphragm. The respiratory system returns to a pre-pregnant state by the
end of the postpartum period.

NURSING ACTIONS:

Assess the respiratory rate:

Every 15 minutes for the first hour
Every 30 minutes for the second hour
Every 4 hours for the next 22 hours
Every shift after the first 24 hours
Expected assessment findings:
Within normal limits
Document findings and intervention.
DISCHARGE TEACHING:

Discharge teaching for the woman and her partner focuses on:

■ Signs of complications that need to be reported to the physician or

midwife:
■ Excessive lochia indicates possible late postpartum hemorrhage.
■ Foul smelling lochia indicates possible infection
■ Increased temperature (100.4°F [38°C] or higher) indicates possible
infection.
■ Pelvic or abdominal tenderness/pain is possible sign of infection
■ Frequency, urgency, or burning on urination indicates possible
cystitis
■ Breast tender, warm, and reddened indicates possible mastitis
■ Health promotion
■ Nutrition and fluids
■ Instruct the woman about nutritional needs for lactating and
nonlactating women.
■ Lactating women should increase their caloric intake by 500 calories
per day and have a fluid intake of approximately 2 liters per day.
■ Explain the food pyramid and how this can assist the woman in
meeting her nutritional needs.
■ Activity and exercise
■ Explain the importance of activity to decrease risk of constipation
and to promote circulation and a sense of well-being.
■ Instruct the woman about appropriate exercises in the postpartum.
■ Rest and comfort
■ Teach the woman the importance of rest in promoting healing and
lactation.
■ Problem solve with the woman ways to increase rest time (e.g., nap
when the baby is napping).
■ Encourage the woman to take pain medication as ordered by the
physician or midwife.
■ Routine health check-ups
■ Stress the importance of following through with follow-up visits to
her physician or midwife.
■ Contraception
■ Assess the couple’s desire for future pregnancies.
■ Assess satisfaction with previous method of contraception.
■ Provide information on various methods of contraception
Thank you!