POST PARTUM

CARE
 POSTPARTAL ASSESSMENT
ALERT: Assess client for post partal complications.
The puerperium is the period of time spanning the
first 6 weeks after delivery. It is the period of time in
which the body adjust both physically and
psychologically to the process of childbearing.

Physiological Changes
UTERUS
•Uterine involution: process by which the uterus
return to its prepregnant condition.
•Immediately after delivery, top of fundus is several
fingerbreadths above the umbilicus.
•Twelve hours after delivery, fundus is
one fingerbreadth above the
umbilicus.
•Fundus recedes/descends into the
pelvis approximately one finger
breadth per day.
•By day 10, fundus is below the
symphisis pubis and not palpable.
•Afterpains: alternate contractions and
relaxation of the uterine muscle.
•500 grams weight of uterus after birth
Time and Type Normal Discharge Abnormal Discharge

Days 1 - 3 Lochia rubra Blood; small clots, earthy Large clots; saturated
odor perineal pads; foul odor

Days 4 – 10 Lochia serosa Decreased amount; Excessive amount; foul

serosanguineous; pink or smell; continued or reddish
brown color

Days 11 – 21 Lochia alba Creamy, yellowish color; Persistent lochia serosa;

Decreasing amounts return to lochia rubra;
discharge continuing

Amount
 Scant –less than a 2 - inch (5 cm) stain on the peripad (10
ml)
 Small – less than a 4 – inch stain (10 cm) stain (10 to 25 ml)
 Moderate – smaller than a 6 – inch stain (115 cm) stain (25
to 50 ml)
 Large – larger than a 6 – inch stain (50 to 80 ml)
CERVIX
May be stretched and swollen
Small lacerations may be apparent.
External os closes slowly; at the end of the first week
after delivery, the opening is at the fingertip size.

VAGINA
Does not return to its original prepregnant state.
Rugae reappear in 3 weeks.
Labia majora and minora are more flabby.

PERINEUM
May be bruised and tender.
Pelvic floor and ligaments are stretched.
Muscle tone is restored by kegel exercises.
OVULATION AND MENSTRUATION
Non-breast-feeding women.
Menstruation resumes in 6 weeks
Ovulation; 50% may ovulate during the first cycle.

Lactating women
Varies
45% resume menstruation within 12 weeks after delivery.

ABDOMEN
Soft and flabby
Possible separation of the abdominal wall; diastasis recti.
Muscle tone can be restored within 2 to 3 months with
exercise.
BREAST
1. Anterior pituitary releases prolactin, which stimulates
secretion of milk.
2. Engorgement may occur approximately 36-48 hours after
delivery.
3. Colostrum (thin, yellowish fluid) is released.
Contains antibodies(immunoglobulin A is 90% of the
immunoglobulin present) along with more protein, fat-
soluble vitamins (E,A,K) and more minerals such as
sodium and zinc.
• Colostrum has a laxative effect o the newborn; promotes
expulsion of bilirubin-laden meconium.
• Also encourages the colonization of the intestines with
Lactobacillus bifidus, which are bacteria that inhibit the
growth of pathogenic bacteria, fungi, and parasites.
GASTROINTESTINAL SYSTEM
1. Immediately after delivery, hunger is common.
2. Gastrointestinal tract is sluggish and hypoactive because
of decrease muscle tone and peristalsis.
3. Constipation may be a problem.

URINARY TRACT
1. Risk for urinary tract infection is increased, if client was
catheterized during labor and delivery.
2. May have bruising and swelling caused by trauma around
the urinary meatus.
3. Increased bladder capacity, along with decreased
sensitivity to pressure leads to urinary retention.
4. Diuresis occurs during the first 2 days after delivery.
5. Bladder distention may displace the uterus, leading to a
boggy uterus and increase risk for atony.
VITAL SIGNS
1. Temperature maybe slightly elevated after a long labor;
should return to normal within 24 hours.
2. Blood pressure maybe slightly decreased after delivery;
however it should remain stable.
3. Pulse rate slows after delivery; puerperal bradycardia rate
is 50-70 beats per minute; usually returns to normal after
10 days.
BLOOD VALUES
1. Leukocytosis is present; WBC count of 20-30,000/min
2. Hemoglobin and hematocrit values and red blood cell
count return to normal within 2-6 weeks.
3. Pregnancy induced increase in coagulation factors during
the first week after delivery leads to increased risk of
development of thrombophlebitis and thromboembolism.
WEIGHT LOSS

1.Initial 10-12 lb loss is from the weight of

the infant, placenta, and amniotic fluid.
2.Diuresis leads to an additional 5 lb
weight loss.
6-8 weeks after delivery; return to
normal prepregnant weight if an
average if an average of 25-30 lbs. was
gained.
ATTACHMENT: PSYCHOLOGICAL
RESPONSE
Phases:
Taking-in phase
1. First few days after delivery.
2. Characterized by passiveness and dependency.
3. Mother is preoccupied with her own needs; food attention, and
physical comforts and care.
4. Talkative

Taking-hold phase
1. Occurs about 2-3 days after delivery; characterized by
increase in physical well being.
2. Emphasis on the present; woman takes hold of the task of
mothering; requires reassurance.
3. Very receptive to teaching.
. Letting –go (Independent)
Characteristics
Usually evident by fifth or sixth weeks
Show pattern of life style that includes new
baby but still focuses on entire family as unit
Reestablishment of husband –wife
Mother may still fell tired and overwhelmed
by responsibility and conflicting demands on
her time and energies
Psychosocial Changes
A. Adoption to Parenthood
Motor skills – new parents must learn new physical skill to care
for the infants (e.g. feeding holding, burping, changing
diapers, skin care)
Attachment skills
a. Bonding
-The development of a caring relationship with the baby, which
includes:
- Claiming- identifying the way in which the baby looks or acts
like members of the family
- Identification – establishing the baby’s unique nature
(assigning the baby his/her own name)
- Attachment – is facilitated by positive feedback between
baby and caregivers
b. Sensual Response
*Touch – important communication with the baby
Eye to eye contact – forms a trusting
relationship
Voice – baby respond to higher pitched voice that
parent use in talking to the baby
Odor – baby quickly identify their own mothers
breast milk and scent.
POSTPARTUM NURSING CARE
Nursing alert!!! Perform postpartum assessment and
instruct client on postpartum care.

Goal: To initiate routine postpartum assessment

1. General observations of mood, activity level, and
feeling of wellness; routine vital sign assessment.
2. Inspection of breast; Check for beginning
engorgement and presence of cracks in nipples, any
pain or tenderness, progress of breast feeding.
3. Check uterine fundus; determine height of fundus in
relation to umbilicus; should feel firm and globular.
4. Assess for bladder distention, especially during the
first 24-48 hours after delivery.
5. Perineal area: REEDA
-observe episiotomy site : evaluate healing
status of episiotomy, apply anesthetic
sprays or ointments to reduce pain
-Determine whether hemorrhoids are present,
and if so provide relief measures.
6. Lochia: record the color, odor, and amount of
discharge
7. Lower extremities: assess for
thrombophlebitis (+ Homan’s sign)
8. Abdomen and perineum: Initiate
strengthening exercises for both
abdominal wall and perineum. (e.g. kegels)
Goal: To provide comfort and relief of pain.

Episiotomy: ice packs for first few hours, followed by peri light,
hot sitz baths.
Perineal care: use of “peri bottles” to squirt warm water over
perineum (front to back) to prevent contaminations and
avoid use of toilet tissue.
Afterpains; use of analgesics (preferably 1 hour before
feeding, especially for breastfeeding mothers.)
hemorroidal pain.
Sitzs baths, analgesic, rectal suppositories,
Encourage lying on side and avoidance of prolonged sitting.
Stool softener or laxatives may be indicated; client usually has a
normal bowel movement usually by second or third day
postpartum.
Breast engorgement;
well fitting bra should be worn to provide support.
P-AIN
V-ITAL SIGNS
B- REASTS
U-TERUS
B-LADDER
B-OWELS
L-OCHIA
E-PISIOTOMY AND PERINEUM ( REEDA: redness,
edema, ecchymosis,discharge,
approximation
H-oman’s signs
E-motional stations
Goal: To promote maternal-infant attachment and facilitate
integration of the newborn into the family unit.
1. Use infant’s name when talking about him or
her.
2. Serve as a role model; be cautious not to
appear too expert in handling the infant
because it may lead to feelings of
discouragement in the mother.
3. Assist parents in problem solving and meeting
their infants needs. Explain ways to
distinguish different types of cries- those
related to hunger, illness, or discomfort.
4. Encourage parents to provide as much of the
care to the infant as possible while in the
hospital.
5. Accept parents emotions and encourage
expression of feelings.
6. Help parents understand sibling behavior to
plan for the arrival of the new family member.
Physiology of Breastmilk
Production
Goal: To establish successful infant feeding patterns.
Non-lactating mother
-Provide supportive bra
-Explain proper position for feeding.
-Formulas; ready to feed in disposable bottles, often
with disposable nipples.
Lactating mothers
1. Avoid the use of nipple creams, ointments or any topical
preparations.
2. Teach mother to avoid using sunlamps or hair dryer to dry
nipples.
3. Application of expressed breast milk to nipples after each
feeding has a bacteriostatic effect and may protection to
damaged skin.
4. Asses breast for engorgement, nipple inversion, cracking,
inflammation, or pain.
Types of feeding positions
• Cradle position, side lying, football or clutch position, and
modified clutch positions.
Teach mother to:
1. Bring infant to level of the breast; don’t lean over.
2. Turn infant completely on side with arms embracing the
breast on either side
3. Bring infant in as close as possible with legs wrapped
around the mothers waist and the tip of the nose touching
the breast.
4. Bring infants lips to nipple; when infant opens mouth to the
widest point, draw the infant the rest of the way on to the
nipple for him to latch on.
5. Break the suction by placing a clean finger in the side of the
infants mouth before removing the infant from the breast.
6. Infant should be put to breast 8-12 times per day.
EVALUATING BREASTFEEDING
1. How do you know that an infant is getting enough breast
milk?
2. Hear infant swallow and make “ka” or “ah” sounds.
3. See smooth nutritive suckling, smooth series of sucking and
swallowing with occasional rest periods, not the short, choppy
sucks that occur when the baby is falling asleep.
4. Breast gets softer during the feeding
5. Breast-feeding 8-12 times per day; more milk is produced
with frequent breast-feeding.
6. Infant has at least 2-6 wet diapers per day for 1st 2 days after
birth; 6-8 diapers per day by the 5th day.
7. Infant has at least 3 bowel movements daily during the 1st
month and often more.
8. Infant is gaining weight and is satisfied after feedings.
THE TEN STEPS TO SUCCESSFUL BREASTFEEDING: ( outline by
UNICEF / WHO )
1. Maintain a breastfeeding policy that is routinely that is communicated to all
health care staff.
2. Train all health care staff in skills necessary to implement this policy.
3. Inform all the 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 infants no food or drinks other than breastmilk, unless medically
indicated.
7. Practice “rooming in”—allow mothers and infants to remain together 24 hours
a day.
8. Encouraged unrestricted breastfeeding.
9. Give no pacifiers or artificial nipples to breastfeeding infants.
10. Foster the establishment of breastfeeding support groups and refer mothers to
them on discharge from the hospital or clinic.
COMPLICATIONS OF THE PUERPERIUM
HEMORRHAGE
Assessment;
Risk factors:
1. Precipitous labor
2. dystocia
3. premature separation of placenta
4. forceps delivery
5. multiple pregnancy
6. large fetus
7. polyhydramnios
Causes:
1. Uterine atony
2. Lacerations
3. Retained placental tissue
                 
Clinical manifestations:
1. Early postpartal hemorrhage; blood loss greater than 500ml
24 hours after delivery.
2. Late postpartal hemorrhage; blood loss greater than 500ml
after the first 24 hours.
3. Symptoms of shock; weak, rapid pulse; low blood pressure;
pallor; restlessness; etc.
Treatment:
Medical:
1. Uterine atony: oxytoxic medications, bimanual compression
of the uterus.
2. Fluid and blood replacement.
Surgical:
1. Lacerations; suturing the bleeding edges
2. Retained placenta; dilatation and curettage to remove
retained placenta.
3. Hysterectomy for uncontrolled bleeding.
NURSING INTERVENTIONS
Goal: To control and correct the cause of the hemorrhage
1. Uterine atony
2. Massage uterus to stimulate contractions.
3. Administer oxytocin
Lacerations:
1. Inspect perineal area
2. Hematoma formation
3. Vulvar hematoma may appear as a discoloration of the
perineal area
4. Any complaint of pain in the perineal area should prompt
careful inspection.
5. Retained placenta:
6. Inspect placenta at the time of delivery for intactness.
7. Never force the expulsion of the placenta.
Goal: To maintain adequate circulating blood
volume to prevent shock and anemia.

Type and crossmatch blood for women at high

risk for development of postpartum hemorrhage.
Anticipate replacement of IV fluids and blood.
Check hematocrit and hemoglobin levels.
Treat for shock
Monitor vital signs and amount of lochia.
Goal: To prevent postpartal infection.
Maintain aseptic technique
Administer prophylactic antibiotics.
Monitor vital signs.
 PUERPERAL INFECTION
Puerperal infection is also called childbirth fever.
Assessment
Predisposing factor:
Antepartal infection
Premature rupture of the membranes
Prolonged labor
Laceration
Anemia: postpartal hemorrhage
Poor aseptic technique.
Clinical manifestations:
1. Temp elevation from 38oC, if taken at least 4 times daily on any 2 of
the first 10 postpartum days with the exemption of the first 24 hours.
2. Symptoms vary according to system involved.
3. Area of involvement is characterized by five cardinal symptoms of
inflammation ( redness, pain, edema, and loss of functions)
4. Tachycardia, chills, and abdominal tenderness are common.
5. Headache, malaise, deep pelvic pain.
6. Profuse, foul smelling lochia
Area involved:
Uterus is most often affected: endometritis.
May have localized infection of the perineum, vulva, and vagina.
Local infection may extend via the lymphatics into the pelvic organ resulting in:
thrombophlebitis
salpingitis
oophoritis
peritonitis
septicemia
Urinary system
a. pyelitis
b.Cystitis
Treatment:
Antibiotics
Antipyretics
Diatary; high protein, high calorie, high vitamin diet.
Encourage intake of 3000-4000 ml of fluids per day.
Nursing interventions:
Goal: To prevent puerperal infection.
1. Maintain meticulous aseptic technique during labor
and delivery.
2. Assess and treat antepartal infection.
3. Detect anemia: check hematocrit during prenatal
visits.
4. Avoid prolonged labor.
Goal: To promote mother’s resistance to infection.
1. Administer antibiotic, antipyretic,
2. Encourage good nutrition
3. Isolate client from other maternity clients
4. Use semi-fowlers position to promote free drainage of
lochia and prevent upward extension of infection into
pelvis.
MASTITIS
Mastitis is the invasion of the breast tissue by pathogenic
organisms.
Assessment:
Predisposing factors:
-Fissured nipples
-Erosion of the areola
-Mastitis is most frequently caused by
staphylococci, which are transmitted from
the nasopharynx of the nursing infant.
Clinical manifestations:
1. Occurs most often between the first and fourth weeks of
the postpartal period.
2. Chills and tachycardia.
3. Red, swollen, painful breast
4. Fever
Treatment:
Antibiotics
Antipyretics
Analgesics
Nursing Interventions:
Goal: To prevent the complication of mastitis.
1. Teach mother to care for breast and nipples.
2. Explain importance of wearing bra that provides adequate
support.
Goal: To promote comfort and maintain lactation.
1. Frequent breast-feeding, starting on the affected side.
2. Breast massage before and during each feeding to
thoroughly drain any blockages ( a breast pump may be
used if the infant is unable to do this.)
3. Encourage good nutrition and adequate rest.
4. Application of moist heat; increased intake of fluids and
vitamin C.
5. Administer antibiotics, as ordered.
THROMBOPHLEBITIS
General Information:
1. Formation of a thrombus when the vein wall is inflamed.
2. May seen in the legs or pelvis.
3. May result from injury, infection, or the normal increase in
circulating clotting factors in the pregnant and newly
delivered woman.
Assessment findings:
1. Pain/discomfort in the area of thrombus (legs, pelvis,
abdomen)
2. If in the leg, pain, edema, redness over affected area.
3. Elevated body temperature and chills.
4. Peripheral pulses may be decreased.
5. If in a deep vein, legs may be cool and pale
Nursing Interventions:
1. Maintain bed rest with legs elevated on pillow.
2. Never raise knee gatch on bed.
3. Apply moist heat as ordered.
4. Administer analgesics as ordered.
5. Provide bed cradle to keep sheets off leg.
6. Administer anticoagulant therapy as ordered.
(usually heparin), and observe for signs of
bleeding.
7. Apply elastic support hose if ordered, with daily
inspection of legs with hose removed.
8. Teach client not to massage legs.
9. Allow client to express fears and reactions to
conditions.
SUBINVOLUTION
General Information:
-Failure of the uterus to revert to prepregnant state through
gradual reduction in size and placement.
-May be caused by infection, retained placental
fragments, or tumors in the uterus.
Assessment findings:
1. Uterus remains enlarged.
2. Fundus higher in the abdomen than anticipated.
3. Lochia does not progress from rubra to serosa to alba.
4. If caused by infection, possible leucorrhea and backache.
Nursing Intervention:
1. Teach client to recognize unusual bleeding patterns
2. Teach client the usual pattern of uterine involution.
3. Instruct client to report abnormal bleeding to physician.
4. Administer oxytoxic medications if ordered.
CYSTITIS AND PYELITIS
Cystitis and pyelitis occur as a result of trauma to the bladder
mucosa, the temporary loss of the bladder tone, and an
increased bladder capacity. All three lead to distention and
incomplete emptying of urine, predisposing the postpartum
client cystitis and pyelitis.
Postpartum Depression
1. Mother experience a “let down” feeling after
giving birth
2. Doubts about ability to cope effectively with
the demands of childbearing
3. This depression is mild and transient
beginning 2-3 days after delivery and
resolving within 1-2 weeks
4. Mild depression may lead to POSTPARTUM PSYCHOSIS,
a pathologic condition
Assessment
1. Assess maternal and paternal physical and emotional status
2. Determine what parents know about infant care
3. Evaluate impact of parents cultural background
4. Assess readiness for parenthood, emotional maturity, pregnancy
planned or unplanned, financial status, jobs
5. Assess physical conditions of mother prior to pregnancy during labor
and delivery and puerperium
6. Assess physical condition of infant at birth (e.g. prematurely,
congenital defects)
7. Assess opportunities for early parent – infant, interaction
8. Evaluate parental knowledge of normal growth and development
Nursing Diagnoses
• Knowledge deficit
• Self-care deficit
• Alteration in Family process
• Potential alteration in Parenting
• Disturbance in self-concept, Role Performance
Planning and Implementation
1. Provide time for parents to be alone with baby in crucial early time
after delivery
2. Identify learning needs of parents
3. Plan teaching to include both parents where possible
4. Help parents realize that fatigue is normal at this time
5. Help parents identify and strengthen their own coping mechanism
6. Help parents identify resource available to them
7. Promote positive self-esteem on part of parents as they learn new
roles
8. Provide initiatory guidance after discharge
9. Prepare for discharge, reinforce physicians instructions about
activities, rest, diet, drugs, exercise, resumption of sexual intercourse,
return to postpartum examinations
Evaluation
1. Mother demonstration increasing levels of competence in carrying out
tasks of newborn care
2. Mother appears relaxed and secure in her interaction with infant
3. Couple plan time together
4. Mother does not appear unduly depressed or anxious
 Postpartum Psychosis
A more serious and rare condition is postpartum
psychosis. It affects about 1 in 1,000 women who
give birth and occurs within the first month after
labor and delivery. It may include hallucinations,
such as hearing voices or seeing things, or feelings of
paranoia. A woman can have irrational ideas about her
baby — such as that the baby is possessed or that
she has to hurt herself or her child. This condition can
be extremely serious and disabling, and new mothers
who are experiencing these symptoms need medical
attention right away.
Women who have other psychiatric
illnesses, such as bipolar disorder or
schizoaffective disorder, may be at
greater risk of developing
postpartum psychosis. Postpartum
psychosis requires immediate
medical attention and, often, a brief
hospitalization. If you or someone
you know is experiencing symptoms,
don't delay getting medical
attention.