Revised 2009

C. POSTPARTUM CARE

Puerperium / Postpartum period

– refers to the six (6) weeks period after delivery of the baby
– time of maternal changes that are both
o retrogressive (involution of uterus and vagina) and
o progressive (production of milk for lactation, restoration of normal menstrual
cycle, and beginning parenting role)
*Involution – return of the reproductive organs to their prepregnant state (6 weeks)

Postpartum Care & Assessment mnemonic: “BUBBLE-HE”

� Breasts
� Uterus
� Bladder
� Bowels
� Lochia
� Episiotomy
� Homan's Sign
� Emotional Status

A. IMMEDIATE NURSING CARE

1. Vital Signs
� Assess q 15 min x 4; then q 30 min x2; then q 4 hrs first 24 hrs (if stable) then q8hrs
� BP should be WNL for patient
� Pulse - 50-90 beats/min;
� Temp – 98 to100.4° F (36.6- 38° C) OK 1st 24 hrs due to dehydration during labor
� Resp 16-24/min

*Implication:
• Increase in body temperature during the first 24 hours postpartum is not
necessarily a sign of postpartum infection. Any mother whose temperature
reaches 38 degrees celcuis in any two consecutive 24 hours period during
the first 10 postpartum days may suggest infection.
• Bradycardia (heart rate of 50 – 70 beats per minute) is common for (24-48
hours) and persist 6 – 8 days postpartum. Returns to non pregnant rate by 3
months postpartum.
2. Breast
• Lactation – formation of breast milk (BM); begins in a postpartal woman
whether or not she plans to breast-feed.
*BM forms in response to decrease in estrogen and progesterone levels that follows
delivery of the placenta (which stimulates prolactin production)
• Prolactin – hormone for production of breast milk
• Oxytocin – hormone for excretion/ejection of milk
• Colostrum is present at the time of delivery; breastmilk is produced by the
third and fourth postpartum day; yellow sticky fluid; more protein, less sugar, less fat
than mature milk
• Engorgement – the feeling of tension (heat or throbbing pain) in the
breast as breast distention becomes marked (fuller, larger, firmer); occurs on the third or
fourth day.
*Due to expanding veins and pressure of new breast milk contained within them
*There may be a slight elevation of body temperature during this time.
• Congestion subsides in 1 or 2 days.
• In breast, prolactin stimulates alveolar cells to produce milk. Sucking of
the newborn triggers a release of oxytocin and contractility of the myoepithelial cells,
which stimulate milk flow; this is known as the let down reflex. The average amount of
milk produced in 24 hours increases with time.
First week – 6 to 10 oz
1 to 4 weeks – 20 oz
after 4 weeks – 30 oz

1
 Mature milk:
*Foremilk – watery milk coming from full breast (low in fat, high in carbohydrates)
*Hindmilk - creamy milk coming from a nearly empty breast

*Amount of supply depend on how often the mother nurse or pumps (the more the mother
nurses, the more milk is produced
*For those who choose not to breastfeed, lactation can be suppressed through:
> use of well-fitting bra
> avoid any type of nipple stimulation or heat to the breasts (such as warm/hot showers)
> may use ice packs or cold cabbage leaves to ease breast discomfort until milk
production ceases (it generally takes 5 – 7 days)
> mild analgesics as prescribed

2. Uterus/Fundus
• after delivery of the newborn, involution of the uterus must
occur; 2 main processes:
a. area where placenta was implanted is sealed off to prevent bleeding
b. uterus reduced to its pregestational size (grapefruit)
*firm, midline, reduced in its size
*soft & boggy, displaced (hemorrhage risk)

• Few minutes after birth, fundus halfway between umbilicus and

symphysis pubis
• One hour later, rise to the level f umbilicus & it remains for the
next 24 hours
• First postpartal day (Day 1) – one fingerbreadth below umbilicus
• Day 2 - 2 fingerbreath below and so forth until day 10, it can no
longer be palpated because it is already behind the symphysis pubis
• At 10 to 14 postpartum days, the uterus cannot be palpated
abdominally.

*SUBINVOLUTED UTERUS is a uterus larger than normal and vaginal bleeding with
clots. Since blood clots are good media for bacteria, it is, therefore, a sign of puerperal
sepsis.
- To encourage the return of the uterus to its usual anteflexed position, PRONE and
KNEE CHEST POSITIONS are advised.
- Assess full bladder; uterus becoming uncontracted or feels soft & displaced to the
right; encourage woman to void.
- Fundal massage; ice pack over hypogastrium, IV oxytocin, nipple stimulation
(breastfeeding)

*AFTERPAINS/AFTERBIRTHPAINS – strong unterine contractions felt more particularly

by multis, those who delivered larger babies or twins and those who breastfeed. It is
normal and rarely last for more than 3 days

• Menstruation
*IF NOT breastfeeding, return in 6 – 8 weeks after birth
*IF breastfeeding, in 3 – 4 months (lactational amenorrhea) or entire lactation period
- though does not guarantee that woman will not conceive because she may
ovulate well before menstruation returns

3. Bladder Elimination
• There is marked diuresis to eliminate excess fluid (as much as 2,000 to 3,000 ml
accumulates in the body during pregnancy)
*Urine output from 1,500ml/day to as much as 3,000ml/day 2nd to 5th day after birth

• Some newly delivered mothers may complain of frequent urination in small amounts:
explain that this is due to urinary retention with overflow. Others on the other hand, may

2
 have difficulty voiding because of abdominal pressure or trauma to the trigone of the
bladder.
• Assess hypogastric area for overdistention of bladder:
o Palpation: hard or firm just above symphysis pubis
o Percussion: resonant

• Voiding may be initiated by:

o Pouring warm and cool water alternately over the vulva
o Encourage the client to go to the comfort room
o Let her listen to the sound of running water
o If these measures fail, catheterization, done gently and aseptically, is the last
resort on doctor’s order. (If there is resistance to the catheter when it reaches the
internal sphincter, ask patient to breathe through the mouth while rotating the
catheter before moving it inward again.)

4. Bowel Elimination:
• Full diet (unless under GA)
• Constipation: delayed bowel evacuation postpartally may be due to;
o Decreased muscle tone
o Lack of food + enema during labor
o Dehydration
o Fear of pain from perineal tenderness due to episiotomy, lacerations or
hemorrhoids

5. Lochial discharge (during the 1st 3 weeks after delivery) – uterine discharge consisting of
blood, deciduas, WBC, mucus and some bacteria.
* It should approximate menstrual flow. It increases with activity and decreases with
breastfeeding.
Types of lochia:
i. LOCHIA RUBRA
• Dark red in color within first 2 to 3 days
• Contains epithelial cells, erythrocytes, leukocytes and deciduas and has a
characteristic human odor.
ii. LOCHIA SEROSA
• Pink to brownish discharge
• 3 to 10 days after delivery
• It is a serosanguineous discharge containing erythrocytes, leukocytes, cervical
mucus and microorganisms.
• It has a strong odor
iii. LOCHIA ALBA
• Almost colorless to creamy yellowish discharge occurring from 10 days to 3
weeks after delivery. It contains leukocytes, deciduas, epithelial cells, fat, cervical
mucus, cholesterol crystals and bacteria. It’s odorless.

6. Episiotomy/Perineum
*The perineum appears edematous and bruised after delivery caused by episiotomy (if
performed) and some degree of laceration.

*Assess s/s of infection and inflammation

“REEDA” (redness, edema, ecchymosis, discharge, approximation of sutures”
*Assess for lacerations:
1. first degree – lacerations extend through the skin and superficial layers of the
perineum
2. second degree – through perineal muscles
3. third degree – through anal sphincters
4. fourth degree – through anterior rectal wall and can be damaging to the perineum

Prevention of lacerations:
> massage
> warm compress

3
 > manual support (Ritgen’s maneuver)
> birthing in a lateral position

To relieve pain:
• Sim’s position – minimizes strain on the suture line
• Perineal heat lamp or warm sitz baths twice a day – vasodilation increases blood
supply and, therefore, promotes healing
• Apply ice or cold therapy to the episiotomy or laceration immediately after
delivery to decrease edema and provide anesthesia; thereafter, apply moist or
dry heat therapy to promote comfort and healing.
• Application of topical analgesics or administration of mild oral analgesics as
ordered.

7. Homan’s sign/Legs
� Assess s/s of DVT:
redness, warmth, tenderness, Homan’s sign (pain upon dorsiflexion of foot)
*It is also important to note that a DVT may be present despite a negative Homan’s sign
� Early ambulation
� Avoid crossing of legs, constrictive clothings/undergarments

8. Emotions; Psychological adaptation (Reva Rubin)

• ESSENTIAL CONCEPTS
a. The postpartum period represents a time to emotional
stress for the new mother, made even more difficult by the tremendous physiologic
changes that occur.
b. Factors influencing successful transition to parenthood
during the postpartum period include:
• Response and support of family and friends
• Relationship of the birthing experience to expectations and aspirations
• Previous childbearing and childrearing experiences
• Cultural influences
c. Rubin (1997) describes this period as occurring in three
stages – TAKING-IN, TAKING-HOLD and LETTING-GO.

• TAKING-IN PERIOD
o Occurring 1 to 2 days after delivery, the new mother typically is
passive and dependent.
o Energies are focused on bodily concerns.
o She may review her labor and delivery frequently.
o Uninterrupted sleep is important if the mother is to avoid the
effects of sleep deprivation, which include fatigue, irritability and
interference with normal restorative processes
o Additional nourishment may be needed because the mother’s
appetite unusually increased; poor appetite may be a clue that the
restorative process is not progressing normally.
o Encourage her to talk about the birth will help her integrate it into
her life experiences.

• TAKING-HOLD PERIOD

o During this period extending from 2 to 4 days after delivery, the

mother becomes concerned with her ability to parent successfully
and accepts increasing responsibilities for her newborn
o Woman begins to initiate action; she prefers to get her own wash
cloth and make her own decisions.
o The mother focuses on regaining control over her bodily functions-
bowel and bladder function, strength and endurance.
o The mother strives to master newborn care skills (eg. Holding,
breastfeeding or bottle feeding, bathing and diapering). She may
be sensitive to feelings of inadequacy and may tend to perceive

4
 nurses’ suggestions as overt or covert criticism. The nurse should
take this into account when providing instructions and emotional
support.

• LETTING-GO PERIOD
o This period generally occurs after the new mother returns home. It
involves a time of family reorganization.
o The mother assumes responsibility for newborn care; she must
adapt to demands of the newborn’s dependency and to her
decreased autonomy, independence, and (typically) social
interaction.
o She gives up the fantasized image of her child and accepts real
one

*Attachment refers to the emotional connection between a patient and her infant.

Behaviors indicating a positive attachment include:

• Touching
• Holding
• Kissing
• Cuddling
• Talking and singing
• Choosing the "en face" position
• Expressing pride in the infant

Mal-attachment behaviors vary, but can include:

• Refusing to look at the infant

• Refusing to touch or hold the infant
• Refusing to name the infant
• Negative comments about the infant
• Refusing to respond or responding negatively to infant cues (eg, crying, smiling)

*POSTPARTUM BLUES – “baby blues” (normal part of postpartum experience but only for a
few days)
> tearfulness, irritability, sometimes insomnia
> causes: hormonal fluctuations, physical exhaustion, maternal role adjustment
1. reassure that this is normal
2. anticipatory guidance and individualized
support from health care personnel are important to help the parents understand.
3. keeping lines of communication open
4. allow her to make as many decision as
possible can help give her sense of control over her life.
5. allow her to verbalize her feelings and
concerns

POSTPARTUM DEPRESSION
• a serious and debilitating depression, occurring within first 9 months after delivery, often
within the initial weeks or months
• sadness, crying, insomnia, decreased appetite, withdrawal, and sometimes suicidal
ideation or the desire to harm the infant
• somatic symptoms: headaches, diarrhea, constipation, severe anxiety, feeling as though
they are jumping out of their skin, and/or just not feeling like themselves

MANAGEMENT:
1. Assessment tools: Edinburgh Postnatal Depression Scale (EPDS) and the Postpartum
Depression Screening Scale (PDSS)
2. Refer to Dr.: counseling and medication

5
3. Help patient and family to understand this condition and assist to explore spiritual aspect of
care
4. Instruct on adequate nutrition, rest, relaxation, exercise

Additional physiologic adaptations after delivery:

1. Cardiovascular system

• The 30-50 % increase in total cardiac volume during pregnancy will be

reabsorbed into the general circulation within 5 to 10 minutes after placental delivery.
Thus, the first 5-10 minutes after placental delivery is crucial to gravidocardiacs because
the weak heart may not be able to handle such workload.
• Usual blood loss with vaginal birth is 300-500 ml; with cesarean birth, it is
500- 1000 ml
• Blood volume decrease to non-pregnant levels by fourth week after
delivery.
• Hematocrit rises by the third to seventh postpartum day.
• WBC increases to 20,000 – 30,000/mm3.
The WBC count, therefore cannot be used as an indicator or signs of postpartum infection,
part of body`s defense system against infection and an aid to healing.
• There is extensive activation of the clotting factors, which encourages
thromboembolization. This is the reason why:
a.c.1 Ambulation is done early 4-8 hours after normal vaginal delivery.
When ambulating the newly-delivered patient for the first time, the nurse should hold on to the
patient’s arm.
• Massage is contraindicated
• All blood values are back to prenatal levels by the 3rd or 4th week
postpartum

2. Reproductive system
VAGINA
: is smooth and swollen, with poor tone after delivery. Rugae reappear by 3 to 4
postpartum weeks. Diameter is greater than normal. Hymen is permanently torn. The estrogen
index returns in 6 to 10 weeks.

: Vaginal dryness and painful intercourse, known as dyspareunia, may be noted during
the postpartum period due to decreased estrogen levels

3. Integumentary system
• mask of pregnancy (chloasma) usually disappears, while stretch marks
(striae gravidarum) and linea nigra fade, but generally do not disappear

4. Endocrine system
• Estrogen and progesterone level decrease as soon as the placenta is no
longer present.
• HPL and HCG are almost negligible by 24 hours.
• FSH remains low for about 12 days and begins to rise as new menstrual
cycle is initiated. Menstruation returns in approximately 6 to 8 weeks; ovulation can
return within 4 weeks.

5. Musculoskeletal system
• Relaxin is the hormone responsible for the relaxation of the pelvic
ligaments and joints during pregnancy. After delivery, relaxin levels subside and the
pelvic ligaments and joints return to their pre-pregnant state. However, the joints of the
feet remain altered and many patients notice a permanent increase in shoe size
• Abdominal wall is weakened and the muscle tone of the abdomen is
diminished after pregnancy. Some patients have a separation between the abdominal
wall muscles, called diastasis recti. This separation can often be corrected with certain
abdominal exercises performed during the postpartum period

6
6. Urinary changes

• Extensive diuresis begins to take place almost immediately after birth to

rid the body of fluid
• This easily increases the daily output a postpartal woman from a 1500 ml
to as much as 3000 ml/day during the 2nd to 5th day after birth.
• Urine tends to contain more nitrogen than normal ( due to breakdown of
protein in a portion of uterine muscle activity during labor and in line muscles that occur
during involution
• Urinary retention as a result of decreased bladder tone and emptying can
lead to urinary tract infections (UTIs).
PATIENT TEACHING

Self-care guidelines to the mother

• Instruct the client on sitting properly to relieve pain (e.g.
squeeze the buttocks together and contract pelvic floor muscles before sitting).
• Instruct to wear perineal pads loosely and to lie in sim’s
position.
• Demonstrate how to clean the perineum after each voiding
and defecation (wiping from front to back, washing the hands, and applying a perineal pad
from front to back.
• Teach the importance of adequate fluid intake, exercise,
proper diet and a regular defecation time.
• Instruct to avoid garters or constricting clothing that can
impair circulation.
• Encourage client to shower as soon as she can ambulate
and to take tub baths, if desired, after 2 weeks. Recommended daily shower to promote
comfort and a sense of well-being.
• Provide adequate dietary fiber and fluids to promote bowel
movements; if necessary, administer stool softeners, laxatives, suppositories or enemas.
• Demonstrate newborn care and safety measures.
• Recommended exercises:
a. Kegal and abdominal breathing on postpartum day
one (PPD1)
b. Chin-to-chest ON PPD2 to tighten and firm up
abdominal muscles
c. Knee-to-abdomen when perineum has healed, to
strengthen abdominal and gluteal muscles.
• Sexual activity – maybe resumed by the 3rd or 4th week
postpartum if bleeding has stopped and episiorrhaphy has healed ( usually 1st week after
delivery. Lochia has turned to alba. Decreased physiologic reactions to sexual stimulation
are expected for the first 3 months postpartum because of hormonal changes and
emotional factors.

Implication: She should be protected against a subsequent pregnancy by observing a

method of contraception, except the PILLS)

• Postpartum check-up – four to six weeks after birth

woman should return to her physician for an examination ( visit is important to ensure that
involution is complete and reproductive planning id desired may be discussed further.

BREASTFEEDING
• Feed newborn per demand (breastfeeding or
bottlefeeding) or at least every two hours and intervals should not exceed 5 hours.

• If breastfeeding:
> from birth to at least 2 years and should continue as long as the mother & child wish
> exclusive breastfeeding until 6 months of age (when solids are gradually introduced)
> correct latching on (to prevent nipple sores & allow baby to get enough milk):

7
 - large part of the breast and areola need to enter the baby's mouth
- nipple should be at the back of the baby's throat, with the baby's tongue lying flat in its
mouth
> 10 - 20 minutes each breast
> cradling position

• Storage of expressed breast milk

> hard-sided containers with airtight seals

Place of storage Temperature Maximum storage time

In a room 25°C Six to eight hours
Insulated thermal bag with ice packs Up to 24 hours
In a refrigerator 4°C Up to five days
Freezer compartment inside a refrigerator -15°C Two weeks
A combined refrigerator and freezer with separate doors -18°C Three to six months
Chest or upright manual defrost deep freezer -20°C Six to twelve months

* Oral contraceptives are contraindicated in lactating mothers because they contain estrogen
and progesterone derivatives, thereby decreasing milk supply.

Breast care:
• Wash breast daily at bath or shower time
• Soap or alcohol should never be used on the breast as they tend to
dry and crack the nipples and cause sore nipples.
• Wash hands before and after every feeding
• Insert clean OS squares or piece of cloth in the brassiere to absorb
moisture when there is considerable breast discharges.
• Engorgement management:
- Nurse often (not going more than 3 hours without nursing and not skipping
night feedings)
- well-fitted bra
- warm compress/shower
- chilled cabbage leaves (placed on breast with nipple exposed)
- Acetaminophen or ibuprofen for pain
- pumping or manually expressing breast milk

*Marmet technique (Manual expression of milk)

1. Position the thumb (above the nipple) and first two fingers (below the nipple) about 1” to 1–1/2” from the nipple,
though not necessarily at the outer edges of the areola. Use this measurement as a guide,
since breasts and areolas vary in size from one woman to another. Be sure the hand forms
the letter “C” and the finger pads are at 6 and 12 o’clock in line with the nipple. Note the
fingers are positioned so that the milk reservoirs lie beneath them.

• Avoid cupping the breast

2. Push straight into the chest wall

• Avoid spreading the fingers apart.

• For large breasts, first lift and then push into the chest wall

3. Roll thumb and fingers forward at the same time. This rolling motion compresses and empties milk reservoirs
without injuring sensitive breast tissue.

8
Note the position of thumb and fingernails during the finish roll as shown in the illustration.

4. Repeat rhythmically to completely drain reservoirs.

• Position, push, roll...
• Position, push, roll...

5. Rotate the thumb and fingers to milk other reservoirs, using both hands on each breast.

Avoid These Motions

1. Do not squeeze the breast, as this can cause bruising.

2. Sliding hands over the breast may cause painful skin burns.

3. Avoid pulling the nipple which may result in tissue damage.

*If mother bottle-feeds the baby, a type of formula should be selected, the one the infant can
tolerate without excessive regurgitation or constipation.
• Measure amount of formula ingested at each feeding.
• Formula preparation, sterilization and bottle-feeding techniques