1. Maternal and Child Health Nursing
Postpartum
MATERNAL and CHILD HEALTH NURSING
POSTPARTUM
Lecturer: Mark Fredderick R. Abejo RN, MAN
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I. PHYSIOLOGICAL MATERNAL CHANGES
A. LOCHIA – discharge from the uterus during the first 3 weeks after delivery.
Increasing Lochia as the day passes by may indicate Heparin Intoxication.
LOCHIAL CHANGES
LOCHIA RUBRA
• Dark red discharge occurring in the first 2-3 days.
• Contains epithelial cells, erythrocytes and decidua.
• Characteristic human odor.
LOCHIA SEROSA
• Pinkish to brownish discharge occurring 3-10 days after delivery.
• Serosanguineous discharge containing decidua, erythrocytes, leukocytes, cervical mucus and
microorganisms.
• Has a strong odor.
LOCHIA ALBA
• Almost colorless to creamy yellowish discharge occurring from 10 days to 3 weeks after delivery.
• Contains leukocytes, decidua,epithelial cells, fat, cervical mucus, cholesterol crystals, and bacteria.
• Has no odor.
B. UTERUS
• Process of involution takes 4-6 weeks to complete.
• Weight decreases from 2 lbs to 2 oz.
• Fundus steadily descends into true pelvis; Fundal height decreases about 1 fingerbreadth (1 cm)/day; by
10-14 days postpartum, cannot be palpated abdominally.
MCHN Abejo

2. Maternal and Child Health Nursing
Postpartum
C. Uterine Involution
1. Description
a. The rapid decrease in the size of the uterus as it returns to the nonpregnant state
b. Clients who breastfeed may experience a more rapid involution
2. Assessment
a. Weight of the uterus decreases from 2 pounds
to 2 ounces in 6 week
b. Endometrium regenerates
c. Fundus steadily descends into the pelvis
d. Fundal height decreases about 1 fingerbreadth (1 cm) per day
E. By 10 days postpartum, uterus cannot be palpated abdominally
NOTE: Deviation of the fundus to the right or left and location of the fundus above the umbilical are signs that the
bladder is distended
NOTE: Height of the Umbilicus on the First Postpartum Day
The height is usually SLIGHTLY below the umbilicus about 24 hours after delivery. The top of the umbilicus is
normally MIDWAY between the umbilicus and the symphysis pubis.
D. Breasts
1. Breasts continue to secrete colostrum
2. A decrease in estrogen and progesterone levels after delivery stimulates increased prolactin levels, which
promote breast milk production.
3. Breasts become distended with milk on the third day
4. Engorgement occurs in 48 to 72 hours in non breast feeding mothers.
NOTE:
Bradycardia is a normal physiologic change for 6-10 days postpartum
E. Gastrointestinal tract
1. Women are usually very hungry after delivery
2. Constipation can occur
3. Hemorrhoids are common
II. POSTPARTUM NURSING INTERVENTIONS
Monitor Vital Signs
NOTE: Maternal temperature during the first 24 hours following delivery may rise to 100. 4` F (38`C) as a
result of dehydration. The nurse can reassure the new mother that these symptoms are normal.
Postpartum Exercise
Supine Position with the knee’s flexed, and then inhale deeply while allowing the abdomen to expand and
exhale while contracting the abdominal muscles. The purpose of this exercise is to strengthen the
abdominal muscles. Examples are reaching for the knees; push ups and sits ups on the first postpartum
day.
Assess height, consistency, and location of the fundus
Monitor color, amount, and odor of lochia
Assess lochia and color volume
Give RhoGAM to mother if ordered. RhoGAM promotes lysis of fetal Rh (+) RBCs.
Administer RhoGam as prescribed within 72 hours postpartum to the Rh-negative client who has given
birth to an Rh-positive neonate.
Rhogam (D) immune globulin is given by intramuscular injection
Check episiotomy and perineum for signs of infection.
Promote successful feeding.
Non-nursing woman- tight bra for 72 hours, ice packs, minimizes breast stimulation.
Nursing woman- success depends on infant sucking and maternal production of milk.
“Postpartum Blues” (3-7 days) – Normal occurrence of “roller coaster” emotions
MCHN Abejo

3. Maternal and Child Health Nursing
Postpartum
Sexual activities- abstain from intercourse until episiotomy is healed and lochia ceased
around 3-4 weeks. Remind that Assess height, consistency, and location of the fundus breastfeeding
does not give adequate protection.
Assess breasts for engorgement
Monitor episiotomy for healing ( assess dehiscence & evisceration)
Assess incisions or dressings of cesarean birth client ( prone to infection)
Monitor bowel status ( prone to constipation)
Monitor I &0
Encourage frequent voiding (prevent urinary retention which will predispose the mother to uterus
displacement & infection)
Encourage ambulation ( to prevent thromboplebitis & paralytic ileus
Assess bonding with the newborn infant ( to prevent failure to thrive)
NOTE:
A positive bonding experience is indicated when the mother turns her face toward the baby to initiate eye-to-eye
contact. Observation of new mothers has shown that a fairly regular pattern of maternal behaviors is exhibited at
first contact with the newborn. The mother follows a progression of touching activities from fingertip exploration
toward palmar contact to enfolding the infant with the whole hand and arm. The mother also increase the time
spent in the en face position. The mother arranges herself or the newborn so that her face and eyes are in the same
plane as in her infant.
III. POSTPARTUM DISCOMFORTS
A. Perineal discomfort
Apply ice packs to the perineum during the first 24 hours to reduce swelling after the first 24 hours, apply
warmth by sitz baths
B. Episiotomy
1. Instruct the client to administer perineal care after each voiding
2. Encourage the use of an analgesic spray as prescribed
3. Administer analgesics as prescribed if comfort measures are unsuccessful
C. Breast discomfort
PREVENTION:
The BEST PREVENTION TECHNIQUE IS TO EMPTY THE BREST REGULARLY AND FREQUENTLY
WITH FEEDINGS. The 2nd is EXPRESSING A LITTLE MILK BEFORE NURSING, MASSAGING THE BREASTS
GENTLY OR TAKING A WARM SHOWER BEFORE FEEDING MAY HELP TO IMPROVE MILK FLOW. Placing
as much of the areola as possible into the neonate’s mouth is one method. Other methods include changing position
with each nursing so that different areas of the nipples receive the greatest stress from nursing and avoiding breast
engorgement, which make I difficult for the neonate to grasp. In addition, nursing more frequently, so that a
ravenous neonate is not sucking vigorously at the beginning of the feedings, AND FEEDING ON DEMAND to
prevent over hunger is helpful. AIRDRYING THE NIPPLES AND EXPOSING THEM TO THE LIGHT HAVE ALSO
BEEN RECOMMENDED. Warm Tea bags, which contain tannic acid also, will sooth soreness. WEARING A
SUPPORTIVE BRASSIERE DOES NOT PREVENT BREAST ENGORGEMENT. APPLYING ICE and LANOLIN
DOES NOT RELIEVE BREAST ENGORGEMENT.
MCHN Abejo

4. Maternal and Child Health Nursing
Postpartum
INTERVENTION:
Measures that help relieve nipple soreness in a breast-feeding client include lubricating the nipples with a
few drops of expressed milk before feedings, applying ice compresses just before feedings, letting the nipples air dry
after feedings, and avoiding the use of soap on the nipples.
NOTE: Specific nursing care for breast Engorgement
1. Breastfeed frequently
2. Apply warm packs before feeding
3. Apply ice packs between feedings
NOTE: Specific Nursing Care for Cracked nipples
1. Expose nipples to air for 10 to 20 minutes after feeding
2. Rotate the position of the baby for each feeding
3. Be sure that the baby is latched on to the areola, not just the nipple
NOTE: Do not use soap on the breasts, as it tends to remove natural oils, which increases the chance of cracked
nipples
IV. POST PARTUM COMPLICATIONS
A. HEMORRHAGE
CAUSES SIGNS OF HEMORRHAGE MANAGEMENT
The #1 cause of POSTPARTUM Boggy uterus (does not Fluid replacement
HEMORRHAGE IS RETAINED respond to massage) Emergency lay
PLACENTAL FRAGMENTS. Oxygen
Uterine atony and vaginal & A boggy uterus would be Vital signs
cervical tears are associated with palpable above the umbilicus and Perineal pad count
early postpartum hemorrhage would be soft and poorly Psychological support
contracted.
The #2 cause is OVER- Abnormal clots unusual Massaging the lower abdomen
DISTENTION OF THE UTERUS pelvic discomfort or headache after delivery is done to maintain
from more than (10) pounds, Excessive or bright-red a firm uterus, which will aid in
OTHERS ARE: 4000 gms, bleeding the clumping down of blood
neonate, excessive oxytocin use, Signs of shock vessels in the uterus, thereby
Polyhydramnios and Placental preventing any further bleeding.
Disorders. Early Hemorrhage starts on the
first 24 hours, or more than 500 “BOGGY UTERUS
ml of blood on the first 24 hrs in Uterine atony means that the
You should assess for uterine a Normal spontaneous delivery.. uterus is not firm or it is not
atony after a c-section delivery. contracting. The nurse should
This is more common after a c- gently massage the uterus which
section than after a vaginal will contract the uterus and make
delivery. it firm. Clients who are
predisposed are usually
MULTIPLE GESTATION,
POLYHYDRAMNIOS,
PROLONGED LABOR and LGA
(LARGE GESTATIONAL AGE
fetus.
B. THROMBOPLEBITIS
Inflammation of the vein caused by a clot
The positive Homan’s sign indicate is possibility of thrombophlebitis or a deep venous thrombosis that is
present in the lower extremities.
When assessing for Homan’s sign ask the patient to stretch her kegs out with the knee slightly flexed while
dorsiflex the foot. A positive sign is present when pain is felt at the back of the knee or calf. It is normal for a
patient on magnesium sulfate to feel tired because it acts as a central nervous depressant and often makes the
patient drowsy.
MCHN Abejo

5. Maternal and Child Health Nursing
Postpartum
MANIFESTATION MANAGEMENT CURATIVE
Edematous extremities Preventive Immobilize extremity
Fever with chills Analgesics
Pain and redness in affected Anticoagulant
area Thrombolytics
Positive Homan’s sign
C. INFECTION
PREDISPOSING FACTORS MANIFESTATION MANAGEMENT
Rupture of membranes over Fever Antibiotics
24 hours before delivery Chills Oxytocin
Retained placental Poor appetite Analgesics
fragments General body malaise Maintain hygiene
Internal fetal monitoring Abdominal pain Semi-fowlers positions
Vaginal infection Foul-smelling lochia Vital signs
Early ambulations
Puerperial infection is an Assess lochia
infection of the genital tract.
Bright red blood is a normal
Early signs and symptoms of
puerperial infection include lochial finding in the first 24
chills, fever, and flu-like
symptoms. It can occur up to one hours after delivery. Lochia
month after delivery.
should never contain large clots,
tissue fragments, or membranes.
A foul odor may signal infection,
as may absence of lochia.
D. MASTITIS
MCHN Abejo

6. Maternal and Child Health Nursing
Postpartum
ASSESSMENT MANAGEMENT
Elevated temperature, chills,  Instruct the mother in good hand washing and breast
general aching, malaise and hygiene techniques
localized pain  Apply heat or cold to site as prescribed
Engorgement, hardness and
 Maintain lactation in breastfeeding mothers
reddening of the breasts
Nipple soreness and fissures  Encourage manual expression of breast milk or use
Inflammation of the breast as a of breast pump every 4 hours
result of infection  Encourage mother to support, breasts by wearing a
Primarily seen in breastfeeding supportive bra
mothers 2 to 3 weeks after  Administer analgesics & antibiotics as prescribed
delivery but may occur at any
time during lactation
E. Postpartum Mood Disorders
MOOD DISORDERS ASSESSMENT
Postpartum Blues Onset: 1-10 days postpartum lasting 2 weeks or less
Fatigue
Weeping anxiety
Mood instability
Postpartum Depression Onset: 3-5 days lasting more than 2 weeks
Confusion
Normal processes during Fatigue
postpartum include the withdrawal Agitation
of progesterone and estrogen and Feeling of hopelessness and shame “let down feeling”
lead to the psychological response Alterations in mood “roller coaster emotions”
known as "the blues." Appetite and sleep disturbance
Postpartum depression is a
psychiatric problem that occurs According to Rubin, dependence and passivity are typical during the taking-
later in postpartum and is in period, which may last up to 3 days after delivery. A client experiencing
characterized by more severe postpartum depression demonstrates anxiety, confusion, or other signs and
symptoms of inadequacy. symptoms consistently. Maternal role attainment occurs over 3 to 10 months.
Because the client's behavior is Attachment also is an ongoing process that occurs gradually.
normal, notifying her physician and
conducting a home assessment
aren't necessary.
Onset: 3-5 days postpartum
Postpartum Psychosis Symptoms of depression plus delusions
Auditory hallucinations
Hyperactivity
POSTPARTUM WARNING S/S TO REPORT TO THE PHYSICIAN
 Increased bleeding, clots or passage of tissue.
 Bright red vaginal bleeding anytime after birth.
 Pain greater than expected.
 Temperature elevation to 100.4º F.
 Feeling of full bladder accompanied by inability to void.
 Enlarging hematoma.
 Feeling restless accompanied by pallor; cool, clammy skin; rapid HR; dizziness; and visual disturbance.
 Pain, redness, and warmth accompanied by a firm area in the calf.
 Difficulty breathing, rapid heart rate, chest pain, cough, feeling of apprehension, pale, cold, or blue skin
color
MCHN Abejo

7. Maternal and Child Health Nursing
Postpartum
V. Psychological Adaptation
Psychological Adaptation
Taking-in Phase Postpartum blues: overwhelming sadness
Taking-hold Phase Postpartum depression
Letting-Go Postpartum Psychoses
Rubin's Postpartum Phases of Regeneration (POSTPARTUM PSYCHOSOCIAL ADAPTATION)
“TAKING IN” PHASE (DEPENDENT) First 3 Days
During this time, food and sleep are a major focus for the client. In addition, she works through the birth
experience to sort out reality from fantasy and to clarify any misunderstandings. This phase lasts 1 to 3 days after
birth. The primary concern is to meet her own needs.
• Takes place 1-2 days postpartum
• Mother is passive and dependent; concerned with own needs.
• Verbalizes about the delivery experience.
• Sleep/food important.
• Mother focuses on her own primary needs, such as sleep and food
Important for the nurse to listen and to help the mother interpret the events of delivery to make them more
meaningful
Not an optimum time to teach the mother about baby care
“TAKING HOLD” PHASE (DEPENDENT/INDEPENDENT)
The client is concerned regarding her need to resume control of all facets of her life in a competent manner. At this
time, she is ready to learn self-care and infant care skills.
• 3-10 days postpartum
• Mother strives for independence and begins to reassert herself.
• Mood swings occur. May cry for no reason.
• Maximal stage of learning readiness.
• Mother requires reassurance that she can perform tasks of motherhood.
•
Begins to assume the tasks of mothering
• An optimum time to teach the mother about baby care.
“LETTING GO” PHASE (INTERDEPENCE)
• 10 to 6 weeks postpartum
• Realistic regarding role transition.
• Shows pattern of life-style that includes the new baby but still focuses on entire family as a unit.
• Accepts baby as separate person.
Mother may feel deep loss over separation of the baby from part of the body and may grieve over the loss
Mother may be caught in a dependent/independent role, wanting to feel safe and secure yet wanting to
make decisions
Teenage mothers need special consideration because of the conflict taking place within them as part of
adolescence
MCHN Abejo