CARE OF WOMEN AND FAMILIES DURING POSTPARTUM C.
Diuresis: Mechanism by which excess body fluid is excreted after
POSTPARTUM PERIOD
 The post partum period covers the time period from birth until
approximately six to eight weeks after delivery.
 This is a time of healing and rejuvenation as the mother’s body
returns to pre-pregnancy states.
 Healthcare professionals need to be aware of the normal
physiologic and psychological changes that take place in women’s
bodies and minds after delivery in order to provide
comprehensive care during this period.
 In addition to patient and family teaching, one of the most
significant responsibilities of the postpartum nurse is to recognize
potential medical complications after delivery.
UTERUS
A. Involution: rapid diminution in the size of the uterus as it returns
to a non-pregnant state due primarily to a decrease in size of
myometrial cells.
B. Lochia: discharge from the uterus that consists of blood from
vessels of the placental site and debris from the decidua.
C. Placental site: blood vessels of the placenta become thrombosed
or compressed.
LOCHIA
Lochia is the vaginal discharge after giving birth, containing blood,
mucus, and uterine tissue. Lochia discharge typically continues for four
to six weeks after childbirth, a time known as the postpartum period
or puerperium.
 Lochia rubra occurs in the first 1-3 days after childbirth. It is
reddish in color. Hence the term “rubra.” It is made up of mainly
blood, bits of fetal membranes, decidua, meconium and cervical
discharge.
 Lochia serosa is the term for lochia that has thinned and turned
brownish or pink in color within 3-7 days. It contains serous
exudate, erythrocytes, leukocytes, cervical mucus and
microorganisms.
 Lochia alba is a colorless or whitish, turbid fluid which drains from
the vagina for 10-14 days.
AFTERPAINS
Afterpains are caused by the release of the hormone oxytocin and the
subsequent relaxation and contraction of the uterine muscles. Women
may also experience afterpains while breastfeeding as a result of
nipple stimulation and the subsequent release of oxytocin.
Afterpains are usually resolved by the end of the first postpartum week
and can be alleviated by the relaxation techniques and, if necessary,
analgesics, including short-acting nonsteroidal and anti-inflammatory
drugs (NSAIDs).
CERVIX AND VAGINA
A. Cervix: remains soft and flabby the first few days, and the internal
os closes.
B. Vagina: usually smooth walled after delivery. Rugae begin to
appear when ovarian function returns and estrogen is produced.
OVARIAN FUNCTION AND MENSTRUATION
A. Ovarian function depends on the rapidity in which the pituitary
function is restored.
B. Menstruation usually returns in 4-6 weeks in a non-lactating
mother.
URINARY TRACT
A. May be edematous and contain areas of submucosal hemorrhage
due to trauma.
B. May have urine retention due to loss of elasticity and tone and
loss of sensation from trauma, drugs, anesthesia, loss of privacy.
delivery. Usually begins within the first 12 hours after delivery.
D. Kidney function returns to normal.
BREASTS
A. Proliferation of glandular tissue during pregnancy caused by
hormonal stimulation.
B. Usually continue to secrete colostrum the first two to three days
postpartum (PP); enhances immunity and nutrition of infant.
Breast milk (bluish-white, thin) usually produced by third day.
C. Anterior pituitary: stimulates secretion of prolactin after the
placental hormones that inhibited the pituitary are no longer
present  stimulate alveolar (acini) cells  milk.
D. In 3 to 4 days, breasts become firm, distended, tender, and warm
(engorged), indicating production of milk.
E. Breastfeeding woman: apply warm compress, suckle. Non-
breastfeeding woman: apply cold compress, don’t express milk.
F. Milk usually produced with stimulus of sucking infant.
G. Posterior pituitary: discharges oxytocin, alveoli contract, and milk
flows in response to sucking “let down reflex.”
BLOOD
A. White blood cells increase (25,000 – 30, 000/mm3) during labor
and early postpartum period and then return to normal in a few
days.
B. Decrease in hemoglobin and red blood cells, and hematocrit
usually returns to normal in 1 week.
C. Elevated fibrinogen levels usually return to normal within 1 week.
GASTROINTESTINAL TRACT
A. Constipation due to stretching, soreness, lack of food, and loss of
privacy.
B. Postpartum clients are usually ravenously hungry.
ASSESSMENT
A. Check vital signs every 8 hours and prn: decreased blood
pressure, increased pulse, or temperature over 100.4°F (38°C)
indicates abnormality; use pain scale to evaluate comfort.
B. Observe fundus for consistency and level; massage fundus lightly
with fingers if it is relaxed.
 Immediately after delivery, fundus is 2 cm below umbilicus
 12 hours later it is 1 cm above umbilicus.
 Fundus gradually descends into pelvic cavity, and by ninth
postpartum day should no longer be palpable (1cm or 1
fingerbreadth qd).
C. Evaluate lochia for amount, color, consistency, and odor. Watch
for hemorrhage. Assess color rubra (red, 1-3 days PP), serosa
(pink to brownish, 3-7 days PP), alba (creamy white, 10 days PP).
D. Check perineum for redness, discoloration, or swelling.
E. Check episiotomy for redness, discoloration, or swelling.
F. Check breasts for engorgement or redness; cracking or inverted
nipples.
G. Assess emotional status of new mother for depression or
withdrawal.
H. Assess for problems with flatus, elimination, hemorrhoids, and
bladder or bowel retention.
I. Observe status of mother-infant relationship.
J. Assess mother-infant feeding quality (see breastfeeding).
K. Assess for thrombophlebitis.
L. Assess blood volume (e.g. Rh, hemoglobin, hematocrit, WBCs)
IMPLEMENTATION
A. Nursing interventions for first critical hour after birth.
B. Routine postpartum continues after first hour.
C. Administer RhoGAM as ordered within 72 hours postpartum to
Rh- negative client who has delivered an Rh- positive fetus (direct
Coombs’ -negative) and who is not sensitized.
D. Maintain I & O until client is voiding a sufficient quantity without
difficulty.
 Usually the first voids are measured.
 If client fails to void sufficient quantity within 12-24 hours,
she is usually catheterized.
E.
F. Teach client perineal care and give perineal care until client is able
to do so.
G. Encourage ambulation as soon as ordered and as client is able to
tolerate it; give assistance the first time.
H. Encourage verbalization of client’s feelings about labor, delivery,
and baby.
I. Give warm sitz bath as soon as ordered.
J. Remind client to return for postpartum check-up.
K. Instruct the seual relations may be resumed as soon as healing
takes place and bleeding stops and client feels comfortable with
it.
L. Discuss contraception if client so desires.
M. Provide opportunities to enhance mother-infant relationship,
rooming-in, early contract, successful feedings, etc.
POSTPARTUM PLACES AS OUTLINED BY RUBIN
TAKING-IN PHASE
 First 2-3 days.
 Mother’s primary needs are her own: sleep, food
 Mother is usually quite talkative: focus on labor and delivery
experience.
 Important for nurse to listen and help mother interpret events to
make them more meaningful.
TAKING-HOLD PHASE
 Third postpartum day to 2 weeks varies with each individual.
 Emphasis on present mother is impatient and wants to recognize
self.
 More in control. Begins to take hold of take hold of task of
“mothering.”
 Important time for teaching without making mother feel
inadequate success at this time is important in future mother-
child relationship.
LETTING-GO PHASE
 Mother may feel a deep loss over the separation of the baby from
part of her body and may grieve over this loss.
 Mother may be caught in a dependent-independent role wanting
to feel safe and secure yet wanting to make decisions. Teenage
mother needs special consideration because of the conflicts
taking place within her as part of adolescence.
 Mother may in turn feel resentful and guilty about the baby
causing so much work.
 May have difficulty adjusting to mothering role.
 May feel conflict between the roles of mother and wife.
 May feel upset and depressed at times postpartum blues. If
depression continues, client requires referral for therapy
depression may lead to suicide.
 May be concerned about other children.
 Important for nurse to encourage vocalization of these feelings
and give positive reassurance for task until done.
ASSESSMENT
A. Assess maternal and paternal physical and emotional status.
B. Determine what parents know about infant care.
C. Assess parents’ own birth parenting and nurturing.
D. Evaluate impact of parents’ cultural background.
E. Assess readiness for parenthood: emotional maturity, pregnancy
planned or planned, financial status, job status.
F. Assess physical conditions of mother prior to pregnancy during
labor and delivery, and during puerperium.
G. Assess physical conditions of infant at birth, prematurity,
congenital defects, etc. (parents may feel guilty, angry, cheated,
and so forth).
H. Check for parental career plans.
I. Assess opportunities for early parental-infant interaction.
J. Evaluate parental knowledge of normal growth and
development.
IMPLEMENTATION
A. Promote optimum parent-infant interactions during the early
postpartum period (crucial time in parent-infant bonding).
Allow period of time for both mother and father to be along with
infant.
Allow parents to hold infant in delivery and recovery rooms, and
provide rooming-in and privacy.
B. Based upon assessment of parents, plan nursing care. BE sure to
begin at the same level as parents.
C. Be alert to parental cues but be careful not to label.
D. Support mother in infant care activities and use these
opportunities to promote her self-esteem.
E. Provide a role model for parents.
F. Plan nursing care to reduce maternal fatigue and anxiety so that
time with her infant is pleasurable.
G. Explain to parents that it is normal at this time to feel fatigued,
tense, insecure, and sometimes depressed.
H. Anticipatory guidance regarding baby blues, maternal depression
and maternal psychosis.
I. Counsel mother on home care plan.
 Rest periods to avoid over fatigue.
 Time spent away from baby: to be alone, to be with
significant other or husband, to be with other children, and
to resume contact with people.
 Time for father and baby together.
 Enlist support from husband or significant other to listen and
validate emotional distress new mothers may experience.
 Encourage to seek professional help if symptoms or
depression are prolonged or severe.
BREASTFEEDING
ASSESSMENT
A. Review intrapartum medications and possible effects on initial
breastfeeding.
B. Assess degree of physical comfort prior to nursing.
C. Assess breasts and nipples for factors that may decrease
successful breastfeeding experience (flat or inverted nipples,
scarring from breast surgery, significantly asymmetrical breasts,
lack of normal pregnancy breast changes, discomfort,
engorgement).
D. Observe entire infant feeding and assess infant’s position at
breast, latch, suck, and transfer of milk; confirm correct infant
position (nose, cheeks, and chin are touching mother’s breast).
E. Assess parent’s knowledge base: infant feeding care, maternal
response to cues, infant care of satiety, importance of feeding,
proper techniques, breast care, infant weight gain, maternal
nutrition, personal plans, resources for support, coping with
return to work while breastfeeding.
F. Assess nutrition and hydration status: increased maternal needs
for protein, vitamins, iron, ad fluids during lactation.
G. Evaluate emotional responses toward nursing: satisfaction,
relaxation, mastery.
H. Evaluate LATCH (latch on, audible swallow, type of nipple,
comfort help).
IMPLEMENTATION
A. Complete hand hygiene.
B. Provide skin-to-skin contact between mother and child
immediately after birth, unless contraindicated.
C. Assist mother with breastfeeding as soon as possible after birth,
once mother is comfortable ad infant demonstrated feeding care,
usually within the first hour.
D. Assist mother to a comfortable position (sitting or side lying),
using pillows for support to enhance relaxation and proper
positioning.
E. Guide baby to breast; stimulate rooting, if necessary; place as
much of areola in baby’s mouth as possible.
F. Release suction by inserting a finger into side of baby’s mouth.
The breast will become sore if baby is pulled from it.
G. Burp baby after each breast.
H. Encourage mothers to feed infants at least q 3 hours or at least 8
times in 24 hours.
I. When possible, avoid use of pacifier and supplemental water or
formula until infant is able to latch on and is successfully
breastfed.
J. Teach mother and significant other importance of obtaining
adequate rest, breast massage, correct latching,
engorgement/nipple soreness, breastfeeding patterns,
breastfeeding positions, determining adequate intake.
K. Promote comfort by carefully managing/preventing sore nipples
(proper positioning; express colostrum or breast milk in nipple
and areola at end of q feeding hind milk; moist compresses) and
breast engorgement (feed on demand, use warm compresses;
breast massage and manual expression prior to nursing; warm
shower when feedings observe for signs of mastitis; wear well-
fitting, supportive bra).
Nutrition counseling: Additional 500 calories in well-balanced diet.
Drink 3000 ml fluid qd.
L. Uterine cramping may occur the first few days after delivery while
nursing, due to oxytocin stimulation, which also causes uterus to
contract.
M. Counsel mothers to avoid:
 Medications or drugs contraindicated unless necessary to
client’s life – drugs pass to infant through breast milk.
 Some food, such as cabbage or onions, may alter the taste
of the milk or cause gas in infant.
 Birth control pills are often avoided as milk production may
be decreased and the medications is passed to infant in the
milk.
N. Explain contraindications to breastfeeding:
 Active tuberculosis.
 Severe chronic maternal disease.
 Narcotic addiction drug abusers must be drug-free for
months.
 Severe cleft lip or palate in newborn.
 HIV-positive status; AIDS.