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IMMEDIATE POSTPARTUM ASSESSMENT

(B-U-B-B-L-E-H-E-R)
The postpartum period, or puerperium, refers to the 6-to-8-week period after delivery
during which the mothers body returns to its prepregnant state. Some people refer to this period
as the fourth trimester of pregnancy. Many physiologic and psychological changes occur in the
mother during this time. Nursing care should focus on helping the mother and her family adjust
to these changes and on easing the transition to the parenting role.

Known as the 5th stages labor.


Puerperium covers 1st 6 -8wks wks post partum
Involution return of reproductive organ to its non pregnant state.
Monitoring Vitals Signs:
1. Temperature- slight increase in temp during the 1st 24 hours; 3rd-4th day postpartum temperature
increases for a period of hours.
2. Pulse- PR slightly slower than normal.
3. Blood Pressure- Decrease in Bp indicates bleeding.
Breast3rd day breasts become full/engorged
Breast milk form in response to decrease in estrogen and progesterone levels that follows the
delivery of the placenta (which stimulates prolactin production and consequently, milk
production). When breast milk first begins to form, the milk ducts becomes distended. The nipple
secretion changes from clear colostrum to bluish white, the typical color of breast milk.
The breasts become fuller, larger and firmer. In some women, breast distention becomes marked,
and this often is accompanied by a feeling of heat and throbbing pain. Breast tissue may appear
reddened, stimulating an acute inflammatory or infectious process.
Primary engorgement- feeling of tension on the third and fourth day.
Nursing Management
Relieved when the infant sucks and empties the breast or through the use of a breast pump.- both
actions release oxytocin, contract milk ducts and push milk forward to cause a let-down reflex.
Instruct the mother to use a supportive bra.
Apply warm compress.
Uterus
2 processes of involution: (a.)area where placenta was implanted is sealed off, (b.) organ is
reduced to its approximate pregestational size; 1cm or 1 fingerbreadth/day. After 9-10 days
fundus is no longer palpable.

a well-contracted fundus should feel firm

Uterine Atony relaxed uterus, woman may loss blood rapidly specially if it occurs
during the first hour after birth.

After pains intermittent cramping of the uterus

Common in multiparas, and those who have given birth to large babies
Uterus contracts more forcefully
Intense with breastfeeding (because of oxytocin)
Weight of the uterus:
Right after delivery : 1000 grams
One week after delivery: 500 grams
2 weeks after delivery: 300 grams
6 weeks after delivery: 50-60 grams
Palpation of the fundus:
Place woman supine with small pillow under her head and knees flexed to relaxed
abdominal muscles. Make sure the bed is flat. Palpate the fundus by placing a hand @ the
umbilicus and pressing it downward while the other hand is placed just above the symphysis to
support the lower segment of the uterus. Never palpate the uterus without supporting the lower
segment as this can result to uterine inversion. If on palpation, the uterus feels boggy:
Massage it gently in circular motion, this is the first action to take
Place infant on mothers breast to stimulate uterine contractions by the release
of oxytocin
Administer oxytocin (as ordered) or increase infusion, do not administer ergot
products if BP is above 140/90.
HEIGHT OF THE FUNDUS
Measure the position or height of fundus by using umbilicus as a landmark. Place fingers
on the abdomen of the woman just below the umbilicus and count the number of fingerbreadths
that fit between the top of the fundus and umbilicus.
Immediately after delivery, the fundus is located midway between the umbilicus and
symphysis pubis or slightly higher. After several hours, it rises to the level of the umbilicus. It
then, descends into the pelvic cavity by one cm or one fingerbreadth a day.
Bladder/Urinary System
more nitrogen in the urine;
During vaginal birth, the fetal head exerts a great deal of pressure on the bladder and urethra as it
passes on the bladders underside. This pressure may leave the bladder with a transient loss of
tone that, together with edema on surrounding the urethra, decrease the womans ability to sense
when she has to void.
Hydronephrosis or increased size of ureters that occurred during pregnancy remains present for
about 4 weeks after delivery.
Urine output increases from 1500 ml to 3000 ml per day during the 2nd-5th day due to excess fluid
accumulated in the body during pregnancy.
To prevent permanent damage to the bladder from overdistention, assess the womans abdomen
frequently in the immediate postpartal period. A distended bladder inhibits contraction of the
uterus.
In the postpartal period, urine tends to contain more nitrogen than normal.

Bowel/Gastrointestinal System
Almost immediately, the woman feels hungry and thirsty because of the long period of restricted
fluid during labor and the beginning of diaphoresis. Unless she has aftereffects of anesthesia of
general anesthesia, she can eat without difficulty from nausea or vomiting during this time.
Hemorrhoids (distended rectal veins) that have been pushed out of the rectum due to the effort of
pelvic-stage pushing often are present.
Bowel movement may be delayed due to presence of relaxin in the bowel.
Bowel evacuation may be difficulty due to the pain of episiotomy sutures or hemorrhoids.
Interventions:
Early ambulation and frequent positioning changes.
Increase fiber intake
Increase fluid intake
Lochia
-The seperation of the placenta and membranes occurs in the spongy layer or outer portion of the
decidua basalis
-2nd day after birth, the layer of the deciduas remaining under the placental site and throughout
the uterus differentiates into two distinct layers.
1. Inner layer- attached to the muscular wall of the uterus remains, serving as the
foundation from which a new layer of the endometrium will be formed.
2. Adjacent layer- becomes necrotic and is cast off as a uterine discharge similar to a
menstrual flow.
-Uterine flow, consisting of blood, fragments of deciduas, white blood cells, mucus and
some bacteria
The placental implantation site will take approx. 6 weeks to be cleansed and healed
During the 1st hour while checking the fundus, assess the mothers perineal pad and evaluate
lochia character, amount, color, odor, and presence of any clots.
If a constant trickle of vaginal flow is observed or the woman is soaking through a pad every 60
minutes, she is losing more than average amount of blood. Palpate the uterus, if boggy, gently
massage the uterus, apply an ice pack and refer to the physician.
TYPE OF LOCHIA
Rubra
Serosa
Alba

COLOR
Brown Red
Pink/
White

DURATION
1-3 days
3-10 days
10-14 days

COMPOSITION
Blood fragments, deciduas and mucus
Blood, mucus and invading leukocytes
Largely mucus; WBC count high

Episiotomy
Assess for ecchymosis, hematoma, erythema, edema, intactness, and presence of drainage or
bleeding from any episiotomy stitches.
Episiotomy incission is usually fused by 24 hours after birth.
Hematoma could be present if surface capillaries were broken during the pressure of birth, this
could be noted as a potential complication.
Cervix- immediately after delivery-soft and malleable, internal and external os are open

7th day- external os are narrowed, feel firm and nongravid.


External os will remain slightly open
Vagina- post delivery- soft and with few rugae
Gradually returns to prepregnant state- outlet is slightly more distended than before.
Perineum- portions may show ecchymosis; labia majora and minora remain atrophic and
softened

Homans Sign
Positive Homans sign or pain on standing suggests thrombophlebitis.
Extend the clients leg, and forcibly dorsiflex the foot, pain on the calf or at the popliteal region
indicates a positive Homans sign.
To prevent DVT:
a. Early ambulation
b. Leg exercises- flexion and extension of the legs
c. Do not wear constrictive clothing
Emotional response
Rubins Postpartum phase
Psychological Responses:
a. Taking in phase
dependent phase (1st three days)
passive, cant make decisions, activity is to tell child birth experiences. During this time, the
womans attention is focused on her own needs for sleep, rest and she is dependent on others.
Nursing Care: - proper hygiene
b. Taking hold phase
dependent to independent phase (4 to 7 days). Woman is active, can make decisions, The
concern of the mother at this time is focused on her ability to control body function and her
ability to assume the mothering role. She prefers to do things by herself. As she is not yet
completely recovered, she feels impatient that shes not strong enough to do everything she
wishes to accomplish. Because of the tendency of the woman to overwork herself, fatigue and
exhaustion is common at this stage.
HT:
Begins to take a strong interest for her child
- Give the woman brief demonstration of baby care
- Allow her to care for the child herself with watchful guidance
common post partum blues/ baby blues present 4 5 days 50-80% of mothers overwhelming
feeling of depression characterized by crying, despondence- inability to sleep & lack of appetite.
let woman cry therapeutic.
c. Letting go
interdependent phase 7 days & above.
- redefines new roles may extend until child grows.
Letting-Go the act of ending old ways of thinking or believing
- The woman finally redefines her new role

- Gives up fantasized image of her child and accepts the real one
- Gives up her old role of being childless or the mother of only one or two
- Extended and continues during the childs growing years

Maternal Concerns & Feelings during Postpartum:


ABANDONMENT - Only hours before, they were the center of attention, with everyone asking
about their health and well-being. Now suddenly, the baby is the chief interest. The woman may
feel confused by a sensation very close to jealousy. Father may have much same feelings Shared
responsibility for infant care can help to make both partners feel equally involved in the babys
care and can help alleviate these feelings.
DISAPPOINTMENT - It can be difficult for parents to feel positive immediately about a child
who does not meet their expectations. Handle the child warmly. Comment on the child good
points.
POSTPARTUM BLUES (Baby blues)- 50% of women experience some feelings of
overwhelming sadness. The mother burst into tears easily or may feel let down or be irritable.
Maybe due to hormonal changes (decrease estrogen & progesterone). It maybe a response to
dependence and low self-esteem caused by exhaustion, being away from home, physical
discomfort, and the tension endangered by assuming a new role. A woman needs assurance that
sudden crying episodes are normal. Allow to verbalize feelings

Rest and sleep


- As soon as birth is completed the woman experiences total exhaustion.
Rapid diaphoresis and diuresis during the 2nd to 5th day postpartum will normally result in a
weight loss of an additional 5 lb over the 12 lb that the woman lost at birth.
The woman should rest & sleep as much as needed during the early postpartum period to
overcome fatigue, excitement, anxiety & discomfort associated with long & exhausting labor &
delivery. Sleep and rest promote healing by reducing BMR and allowing O2 & nutrients to be
utilized for tissue growth, healing & regeneration.
Provide pain relief
Promote rest
Promote adequate fluid intake
Instruct the mother to avoid heavy lifting and strenous activity after discharge
The woman may resume light housekeeping on the second week and can go back to normal
activities by 4 to 6 weeks.
Suggested Activity:
Quiz (15 pts)
Enumeration:
1. During assessment you noticed that a 21 year old post partum mother is irritable and
easily bursts into tears. Give 2 interventions for this client.
2. Give 3 interventions to promote bowel movement of a postpartum client.

3. Upon assessment you noted that an immediate status post partum client has 3 fully
soaked pads within 2 hours and the clients uterus is boggy. Give three independent
interventions that you could do in this situation.
4. Enumerate 2 interventions to relieve breast engorgement.
Identification:
1. The postpartum clients delayed bowel movement is due to the presence of ______ in the
bowel.
2. What is the normal color of the clients vaginal discharge 6 days after delivery?
3. How many days does lochia rubra last?
4. This phase occurs 4-7days post partum, wherein the mother is active and can make
decisions.
5. A postpartum mother delivered a live baby boy 2 hours ago, you would expect that her
fundus is at what level?