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POST PARTUM Lecture 8. Puerperium : “to bring forth” 6 wk > childbirth. “4th trimester” - transition for woman/family (pregnancy ends/parenting role begins) I. Physiological Changes of Post Partum Period A. Reproductive System Changes:

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Lecture 8


Puerperium: “to bring forth” 6 wk > childbirth.

  • “4th trimester” - transition for woman/family (pregnancy ends/parenting role begins)
  • I. Physiological Changes of Post Partum Period

A. Reproductive System Changes:

UTERUS: contx’s begin > birth & delivery of placenta

1. placental site seals

2. Entire uterus contracts & reduces gradually for 8-10 days. “INVOLUTION”. Pt. in danger of hemorrhage uterus until involution is complete.

Oxytocin released > uterine contx’s.


Fundus: assess for firmness. Palpate > delivery.

  • Remains @ umbilicus X 24 hrs. Soft aka “boggy” - danger of hemorrhage.

Massage uterus!

Uterus descends one finger breadth every day.

  • Delivery day, uterus @ umbilicus
  • 1st day PP uterus 1 FB ↓ Umbilicus
  • 2nd day PP uterus 2 FB ″ and so forth.
  • Support lower segment of uterus when palpating to prevent uterine eversion.

By day 10, uterus almost back to pre-pregnant size & position in pelvic cavity. [1000 grams→ 50 grams] No longer palpated in abdomen.

  • Full bladder raises fundal height, gives false reading.
  • Natural oxytocin released with breast feeding. ^ contractions . 2FB ↓ umb. on 1st day PP.
  • Breast fdg.offers little protection against hemorr.

Delay in uterine involution: retained placenta/clots -

effective contraction of uterus not possible. Risk of PP Hemorr.

Delay also with:

  • multiparous pt. [grand multip ]
  • exhaustion
  • multi-fetuses.
  • C/S involutes slower; d/t surgery & less initiation of breast feeding > delivery.

After-birth pains = cramping caused by contractions

  • more in multi-parous women than in primips .
  • With Br. Fdg. because of release of oxytocin.


  • Placenta separates from spongy layer of uterus - decidua BASALIS.
  • Inner layer of decidua remains & forms new layer of endometrium . Outer becomes necrotic & sheds.
  • Consists of blood, fragments of decidua, mucus, bacteria.
  • 1st 3 days = rubra =”red” [blood]
  • >3 days = serosa = “pink”
  • 10th day – alba - “white” [up to 3 wks]
  • Total flow lasts about 4-5 wks
  • Should not be bright red; could be PP hemorrhage.


  • Neck; remains slightly opened & contracts > delivery.
  • In 7 days, opening narrow as pencil. Os remains slit-like .


  • Slightly distended after birth. Kegel exercises ^muscle tone and strength. Important for lacerations.


  • Can be edematous/ecchymotic
  • Ice x 24 hrs. then heat [Sitz]
  • Topical anesthetics creams/sprays apply for comfort.
  • Perineal massage relaxes perineum before delivery.

May prevent episiotomy/laceration.

Teach Kegels - tightening & releasing of perineal muscles. Improves circulation & healing of epis/lac.


Complications of Perineum:

  • Hematomas [blood from bleeding vessel]
  • Area of swelling on one side of perineum.
  • If small, absorbs in few days; apply ice & give analgesics.
  • If large bleed, to OR for evacuation & vaginal packing.
  • Common - forceps deliveries
  • Perineal Care - use warm water; wipe from front to back.


  • size of baby, timing of delivery, tension on perineum.
  • Sutured & treated as episiotomies.
  • Analgesics, ice, topical creams, Sitz bath.
  • 1st degree = from base of vagina to base of labia minora.
  • 2nd “ = from base of vagina to mid perineum
  • 3rd = entire perineum to anal sphincter
  • 4th = entire perineum through anal sphincter & some rectal tissue.
  • Nothing into rectum - no rectal temps., suppositories, or enemas with 4th degree to avoid further damage.
  • Colace TID, ^ po fluids to promote BM. Ice X 24 hrs., Sitz baths TID; topicals. KEGELS!

SYSTEMIC CHANGES - Body returns to

pre-pregnant state by 6 wks.

Hormonal System:

  • Pregnancy hormones decrease w. delivery of placenta.
  • HCG & HPL disappear by 24 hrs. FSH rises

12 days - to begin new menstrual cycle. Menses resumes by 4-5 wks. if not Br. Fdg.


The Urinary System:

  • Loss of bladder tone d/t swelling & anesthesia ; urinating difficult. May not feel urge to void.
  • Hydronephrosis [enlargement of ureters] occurs after delivery & to 4 wks. PP. DIURESIS!
  • ↓ bladder sensitivity - ↑ risk for bladder infection - urinary stasis.
  • Avoid bladder damage - assess bladder q 1-2 hrs.til voids qs. Teach voiding q 2 – 3 hours.
  • Palpate abdomen gently, note location of fundus.

When do you suspect full bladder?

  • During preg., 2000-3000 ml. of fluid accumulates in body - Client loses 5- 10 lbs. of water weight in 1st wk.



Circulatory System: Blood volume ^ 30 – 50% in pregnancy.

With diuresis & blood loss @ delivery, blood volume

returns to normal in 1-2 wks.

      • Blood loss for NSVD = 300 cc. & C/S = 500 cc.
  • Non pregnant: HCT=37 - 47% & HGB=12 - 16g/dL
  • Pregnant: HCT=32 -42 % & HGB = 11.5 – 14g/dL
  • HCT drops by 4 pts. & HGB drops by 1 g. for every 250cc. of blood client loses.
  • Patient should not be anemic entering delivery
  • Possible blood transfusion with large blood loss.
  • Average blood volume: pre-pregnant = 4000cc;

pregnant state = 5250cc.


^ Blood volume: provides adequate exchange of nutrients in placenta & compensates for blood loss during delivery.

  • HR remains ^ x 24-48 hrs. PP
  • With diuresis, HCT levels rise [^ hemoconcentration] reach pre-preg level by 6 wks.

Plasma fibrinogen ^^ 50% during pregnancy & remains elevated 6 wks. PP. [^ estrogen levels] WHY?

Can cause ^ thrombus formation.

  • Assess pts. legs/calves for s/s thrombus.
  • Rise in leukocytes; WBC ^ protective measure to prepare for stress of delivery. As high as 20-25,000.

Gastrointestinal System:

  • NSVD: bowels sounds. Eat right away.
  • C/S: bowel sounds hypoactive 1st 8 hrs.
  • Epidural/spinal: po clears after delivery, advance diet if +BS.
  • General anesthesia: usually NPO for ~ 6-8 hrs.
  • Duramorph/astromorph can cause N/V up to 12 hrs.
  • antiemetic meds. [Reglan/Zofran] .
  • BM - difficult/painful d/t lacerations/hemmorhoids.
  • C/S - BM 3rd - 4th day. GI activity slowed d/t surgery.
  • Can go home without BM if + flatus.

Integumentary System: Stretch marks

[striae gravidarum] appear reddened on

abdomen. Fade by 3-6 months;

Pearly white marks may remain in lighter

skinned pts. & darker marks in darker skinned pts.

  • Modified sit-ups strengthen abdomen


Temperature: slightly ^ - dehydration during labor 1st 24 hrs. Returns to normal within 24 hrs.

  • T = 100.4 or > PP infection suspected.
  • Temp. also rises 3rd - 4th day with filling of breast milk
  • Observe for s/s infection - nurse usually 1st to detect ↑ temp. [universal sign of infection 100.4 x 2 readings, on days 2-10 PP]

Pulse: HR ^ slightly x 1st hr.

  • Stroke volume & cardiac output also ^ x 1st hr. then decreases
  • 8-10 wks.,returns to pre-pregnant state.
  • Rapid, thready pulse- sign of PP hemorrhage, infection

Blood Pressure - Monitor carefully.

1st trimester

Heart works faster to handle ^ volume. BP remains same.

2nd trimester

BP drops slightly d/t lowered peripheral resistance in blood

vessels as placenta expands rapidly. Heart beats faster,

more efficiently d/t ^ blood volume.

Pre-pregnant BP 120/80. Pregnant BP 114/65.

3rd trimester

BP back to pre-pregnant value.


BP Complications

↓ BP

[90/60 or less] with dizziness is “Orthostatic hypotension”; could signify hemorrhage.

  • Take BP/pulse lying/sitting/standing. Compare values.
  • Orthostatic: If BP drops 15-20 mmHg and pulse increases 20 bpm or more. Caution for falls.
  • Needs IV fluids. Take VS. Report to MD > order for CBC.

↑ BP

[140/90 or >] could signify PP pre-eclampsia.

  • Notify MD. Could develop into serious complication.
  • Oxytocic meds [Pitocin] > delivery could ^ BP

Other Changes


  • Common
  • Frequent rest periods
  • RN coordinates nursing care & infant feeding times
  • provide maximum rest time.

Weight Loss:

  • Average wt. loss 12 lb. [infant & placenta]
  • 5 lbs. - diuresis & diaphoresis in wk. that follows.
  • Lochial flow - 2-3 lbs.
  • Total = approx. 19-20 lbs. {depends on total wt. gain}
  • At 6 wks. wt. may still be above pre-preg. weight.

Return of Menses: > delivery FSH levels rise causing ovulation

  • No Br. Fdg.- menses resumes ~ 6 wks.
  • Lactation delays menses for several months (6 mos)


Taking-In Phase:

  • time of reflection for client regarding new role
  • may be passive or excited
  • talks at length about birth experience
  • on phone with family/friends recounting birth experience.
  • Usually lasts 1-2 days.
  • Delayed d/t pain r/t vaginal or C/S.

Taking-Hold Phase:

  • woman makes own decisions regarding self & infant care.
  • Usually day 2 - 3. Occur on day 1 esp. if woman is multip.
  • Can occur later, depends on recovery process or cultural beliefs.

Letting Go Phase:

  • Woman gives up fantasy image of baby and accepts

real child.

  • Occurs within few weeks of getting home
  • Needs time to adjust to new experience.


  • Expressing maternal love & attachment toward new baby. Develops gradually.
  • Enface position: close eye contact with infant.
  • Healthy bonding - kissing, touching, counting fingers & toes, cooing, etc.
  • Factors Interfering with Bonding: difficult labor, separation @ birth (NICU)

Other Maternal Feelings of Post Partum Period

  • Abandonment: feelings that occur > birth of child; woman no longer center of attention.
  • Disappointment: infant does not meet expectations of mother/father. Eg. eye color; sex .
  • Post Partum Blues: d/t normal hormonal changes;

Drop in estrogen/progesterone; lasts 1st few days of

PP period. Occurs in 50% of women.


PP Depression: 30% of women exp. this.

      • Therapy & medication may be necessary.
      • Hx of depression & anxiety prior to pregnancy puts mother @ higher risk for developing this.
      • Can manifest itself up to 1 year > birth.
      • Screening tool: Edinburgh PP depression tool
  • Always refer to social worker to assess for degree of depression.
  • Ask: is mother able to take infant home without danger to self or baby?
  • Studies show breast feeding helps reduce symptoms d/t oxytocin “feel good” effect


  •  interest in surroundings
  •  interest in food
  • unable to feel pleasure
  • fatigue
  • health c/o
  • sleep disturbance
  • panic attacks
  • obsessive thinking
  •  hygiene
  •  ability to concentrate
  • odd food cravings
  • irritability
  • rejection of infant

PPD: Teaching

  • relaxation therapy
  • rest & nutrition
  • frequent contact with other adults


The Post Partum Resource Center of New York, Inc.



  • s/s depression
  • s/s manic
  • auditory hallucinations
  • delusions
  • guilt
  • worthlessness

Development of Parental Love & Positive Family Relationships:

  • Rooming In: most hospitals offer this; infant stays in room with mom 24hrs. (partial or complete)
  • Sibling Visitation: encourage siblings to visit to promote family togetherness.


  • Lactation starts regardless if pt. is breastfeeding or not.
  • Entirely up to mother
  • Must feel comfortable doing so.

Advantages to Breast Feeding:

  • Promotes bonding between mother & baby.
  • High nutritional value for infant.
  • Promotes uterine involution thru release of

oxytocin from posterior pituitary.

  • Reduces cost of feeding & preparation time.

Nurse has major role as educator of benefits & methods of

breast feeding.

Ways to teach new moms about lactation:



hands on demo

lactation specialist [in clinical settings]

Offer support

Contraindications to Breast Feeding:

  • Mom receiving meds not appropriate for Br. fdg. [Lithium]
  • Exposure to radioactive compounds [thyroid testing]; pump & dump breast milk x 48 hrs. Flush in toilet.
  • Breast Cancer; HIV

Physiology of Lactation

Body prepares for lactation during pregnancy; stores fat

& nutrients; provide energy, vitamins, minerals in breast milk.

  • Early pregnancy, ↑ estrogen (placenta) stimulates growth of milk glands & size of breasts.
  • Colostrum: middle of pregnancy & day 1-3 PP,
  • Thin, watery pre-lactation secretion. Rich in antibodies; passes to baby in 1-3 days.
  • Breasts begin to get tender; fill up w. milk.

Breast milk by 3rd to 4th day in response to:

  • falling levels of estrogen & progesterone > delivery of placenta.
  • ^ production of prolactin by anterior pituitary
  • Milk ducts become distended & fluid turns bluish-white

Physiology cont.

  • Infant suckling on breast produces more prolactin, which in turn stimulates more milk production.
  • Finally, oxytocin released > delivery of placenta causing mammary glands to send milk to nipples [let down reflex].
  • Progesterone levels drop after delivery which leads to ↑ milk production.

Anatomy of Lactation

Colostrum: protein, sugar, fat, water, minerals, vitamins, maternal antibodies.

  • Provides total nutrition for infant
  • Transitional breast milk by 3 – 4th day.
  • Mature breast milk by 10th day.
  • Each breast - 15-20 lobes of glandular tissue -alveoli.
  • Acinar or alveolar cells of glands form milk.
  • Each alveolus ends in a ductule.
  • Each alveoli produces milk, ejects it into ductules aka let down reflex; milk transported to lactiferous sinus and ejected into infant’s mouth.

Pathway of Droplet of Milk:

  • Milk → mammary ducts → reservoirs behind nipples [lactiferous sinuses] → infant’s mouth

Foremilk: constantly accumulating.

“Let-down reflex” –lets foremilk be available right away.

  • Triggered by sound of baby crying

Hind milk: forms after let-down reflex. Has most calories;

Feed until breast empty.

Breast Milk: Provides complete nutrition for 1st 6 mos of life.

  • > 6 months, iron-fortified cereal.
  • Breast milk easier to digest than formula.
  • Iron in breast milk absorbed better than iron in formula.

Supply & Demand Response - Every time woman breast

feeds, more prolactin produced which then produces ^milk.

  • Time Interval to ↑ milk volume. It takes approx. 30-60 min. to fill up breast after nursing.

Assessment: Antepartum Changes

  • Breasts enlarge [each breast gains ~ 0.5 - 0.9 lb. or more]
  • Glands enlarge
  • Increased blood flow to breasts, causing blood vessels to enlarge & become more visible.
  • Areola [dark circle around nipple] enlarges and darkens
  • Small bumps on areola [Montgomery’s tubercles] enlarge and produce oils to soften nipples and keep them clean.
  • Teach moms no soap on nipples;may ^ irritation.
  • Lanolin; tea bags [wet] [tanic acid] on sore nipples.

Common Problems:

Engorgement : milk enters on 3rd - 4th day; C/S - prior to D/C

  • breasts hard, painful to touch.
  • Warm soaks, hot showers, express milk manually, breast feed q 2-3
  • Pumping produces more milk. Cabbage leaves; diuretic property.
  • nursing bra.
  • tight bra and ice packs x 24-36 hrs– why?
  • Analgesics [Tylenol 650 mg. q 4 - 6 hrs.prn]

Sore/Cracked/Bleeding Nipples

  • Common - from improper positioning or not enough areola in infant’s mouth; may continue to feed; up to mom. Reposition infant. Reattempt nursing.
  • Rest the nipple; apply lanolin ointment prn.
  • Apply tea bag [tanic acid] natural healing property.

Plugged Duct

  • firm nodule under arm; temporarily blocked duct; relieved by infant sucking. Evaluate carefully since may be malignant growth. Warm compresses prn.

Mastitis –

  • “inflammation”; milk duct/gland becomes infected. Poss. antibiotic therapy. Manual expression, continue to breast feed, frequent warm compresses.

Nursing Care : Promote successful breast feeding:

  • Encourage first feeding [L&D, PP; establish pt’s.

desire to breast feed]

  • Emptying of breasts ~ 20 minutes
  • Teach: start on breast where she left off - maintains good supply.
  • Rest, relaxation, ↑ fluids by four 8 oz glasses/day.
  • Not enough fluids, ^ anxiety may lower milk production.
  • Nutritional Counseling: ^ 500 calories/day.

Health Teaching

  • Rooting – sign of hunger
  • Breast feed q 2-3 hrs. for 20-30 minutes
  • Teach “latching”: nipple and part of areola to prevent nipple irritation. Listen for swallowing.
  • Nursing Bra
  • Feeding & Burping [bottle fed infants] upright position
  • Nipple care: no soap; nipple creams -Lansinoh
  • Avoid drugs, alcohol, smoking


Feeding Skills

  • Position upright position- support head and shoulders]
  • Formula [Similac, Enfamil, Isomil; all have iron]
  • milk or soy based
  • Burp

Safety Tips

  • never prop bottle; choking or ear infection.
  • ^ amt. ½-3/4 oz./day; feed q 3 – 4 hrs. x 24 hrs.

Discharge Follow up:

  • Telephone calls & home visits [if needed]
  • Help line; Support groups [La Leche]


Assessment – minimum of twice daily

  • Vital signs
  • Emotional Status
  • Breasts
  • Fundus, lochia, & perineum
  • Voiding & bowel function - flatus, BM
  • Legs [+ Homan’s sign, ankle edema ]
  • S/S complications [PP hemorrhage, infection, ↑ BP ]

Nursing Care


  • Prevent hemorrhage- massage uterus on admission and q 4 for first 8 hrs.
  • Prevent falls – assess when getting out of bed for 1st 8 hrs. Assist when necessary. Check labs for low H&H.

Bowel function (1-3 days to resume).

  • Stool softeners, as ordered [Colace]
  • Encourage ambulation
  • Increase dietary fiber
  • Provide adequate fluid intake

Health teaching & discharge planning

  • Reinforce self care -hand washing, peri care,

Self-breast exam q month; S/S PPD

Comfort Measures

Ice , Sitz Baths, Topical Anesthetics

Analgesia, Kegels for NSVD; modified sit-ups for

NSVD & C/S, Breast Care


Birth Control Plans

Family Planning options [condoms, depo, OC’s, IUD]


Keep 6 week PP appt.

Maternal Warning Signs to Report

  • a) Heavy Vaginal Discharge [poss. hemorrhage]
  • b) Pelvic or perineal pain [traveling clot]
  • c) Fever [temp 100.4 or greater = infection]
  • d) Burning sensation during urination [UTI]
  • e) Swollen area on leg ; painful, red, or hot
  • f) Breast: painful, red, hot area [mastitis]

Infant care

a] Bathing, cord care, circumcision care, diapering

b] Feeding, burping, scheduling feedings [mom can keep chart]

c] Temperature, skin color [dusky], newborn rash, jaundice

d] Stool & voiding [BM’s ; 6 or more voids/day]

e] Back to Sleep [SIDS]

Newborn warning signs:

1. Diarrhea, constipation

2. Colic, repeated vomiting esp. projectile vomiting

3. Fever [temp. 100.0 Rectal or greater]

4. S/S inflammation/ infection @ cord stump [yellow drng.]

5. Bleeding @ circumcision site

6. Rash, jaundice

7. Deviation from normal patterns [long period of sleep >5 hrs.; projectile

vomiting, etc. R/O sepsis; intestinal obstruction]