The postpartum period lasts 6 weeks after childbirth. During this time, the body undergoes both retrogressive and progressive changes. Psychologically, most women experience the taking-in, taking-hold, and letting-go phases as they adjust to their new role as parents. Nursing care focuses on assessment and support of the physiological changes like uterine involution and lactation. Pain management, nutrition, and ensuring adequate rest are also priorities in the postpartum period.

1. THE POSTPARTAL FAMILY
Maybelle B. Animas

2. Postpartal Period
• Puerperium- “puer”- child, “parere” –to bring
forth
• 6-weeks period after childbirth
• Retrogressive- involution of the uterus
and vagina
• Progressive- production of milk for lactation,
restoration of the normal menstrual cycle,
and beginning of a parenting role

3. Psychological Changes of the
Postpartal Period

4. PHASES OF PUERPERIUM
Taking-In Phase
• 2- to 3-day period, a woman is largely
passive
• woman usually wants to talk about her
pregnancy, especially about her labor
and birth
• ***Main nursing is to listen and help the mother interpret
events of the delivery to make them more meaningful and
clarify and misconceptions

5. PHASES OF PUERPERIUM
Taking-Hold Phase
– Occurs during day 1 - 3 following delivery.
– Marked by a period of being dependent and passive
behavior.
– Mother’s primary needs are her own -- food
and sleep
– Mother is talkative about her labor and delivery
experience
***It is the best time for teaching!

6. PHASES OF PUERPERIUM
Letting-Go Phase
• woman finally redefines her new role
• She gives up the fantasized image of her
child and accepts the real one; she gives
up her old role of being childless or the
mother of only one or two

7. Development of Parental Love and
Positive Family Relationship
1. En Face position -- eye-to-eye contact
2. Explore with finger-tips
3. Hand and Palmar contact
4. Whole arms --enfolds whole baby
close to body

8. DPLPFR
• Claiming or Bonding
The Claiming Process
Includes the identification
Of the baby’s specific
Features, relating them
To other family members
“Those long toes are
just like his Dad’s”

9. Rooming-In
• Infant stays in the room rather than in the
nursery.
• She can become better acquainted with
her child and begin to feel more confident
in her ability to care

10. Postpartal Blues
• 50% of women experience some feeling of
overwhelming sadness for which they
cannot account
• Hormonal changes- dec progesterone and
estrogen
• Response to dependence and low self
esteem caused by exhaustion, being away
from home, physical discomfort and
tension

11. Postpartal Blues
• Fearfulness, feeling of inadequacy, mood
lability, anorexia and sleep disturbance
• Assurance and support

13. Physiologic Changes of the Postpartal
Period
• Involution
– Reproductive organs
return to their normal
state

14. Physiologic Changes of the Postpartal
Period
• Uterus
• 2 process
1.The area where the placenta is sealed off
– Accomplished by rapid contraction of the uterus after
the delivery of the placenta
– Muscle fibers become shorter controlling the bleeding
by compressing and sealing off blood vessels

15. 2. The organ is reduced to its pregestational size
through
– Autolytic process
• Few cells of the uterine wall are broken down
into their protein component which is then
absorbed in the blood stream and excreted in
the urine.
– Contraction
- Immediately after birth – 1000g
- At the end of 1st wk- 500g
- 6wks – 50g

16. Physiologic Changes of the Postpartal
Period
- After placental delivery
the uterus may be
palpated through the
abdominal wall halfway
bet the umbilicus and
the symphysis pubis
- 1hr after- level of
umbilicus
- Decrease 1 fingerbreath
per day

17. Assessment of the Uterus
• Placement and Size (location)
• Tone
• Lochia

18. Nursing Care of Uterine Changes
• Assessment of the
Uterus
– Placement and size -- should
be level with the umbilicus
after delivery. The uterus
then should decrease 1 FB /
day. Should also be midline
and the size of a grapefruit

19. Nursing Care of Uterine Changes
• Tone -- should be firm.
Assess by supporting
lower portion with one
hand and palpate
fundus with other.
• If found boggy, then
massage. Do not
overmassage.

20. Lochia
TYPE COLOR DURATION COMPOSITI
ON
Lochia Rubra Red 1-3 days Blood,
fragments of
decidua,
mucus
Lochia Pink 3-10 days Blood,
Serosa mucus and
leukocytes
Lochia Alba White 10-14 days Largely
mucus

21. Characteristics of Lochia
• Should not be excessive in amount
• Should not have an offensive odor
• Should not contain large pieces of tissue
or blood clots
• Should not be absent during the first 3
weeks
• Should proceed from rubra -- serosa --
alba

22. Physiologic Changes of the
Postpartal Period
• Cervix
– After birth- soft and
malleable, internal and
external os is open
– Pre-pregnant appearance
is a dimpled area in the
center -- post-pregnancy
appears as a jagged slit.

23. Physiologic Changes of the
Postpartal Period
• Vagina
– May be edematous and bruised.
– Rugae begin to appear when ovarian function
returns.
– May teach the mom to do Kegels exercises

24. Perineum
• May have tears, lacerations, or an episiotomy
• Assessment Procedure:
– Turn patient to side-lying / sims position
– Gently spread buttocks apart inspect with
penlight
Assessment:
– Episiotomy/lacerations/edema/hemorrhoids
– Assess for complications/hematoma
Interventions:
– Hygiene/ Peri-bottle filled with warm water
– Wipe front to back; change pads frequently/snug fit
– Sitz bath 3-4 x day

25. Breasts
• Teach to assess her own breasts -- similar
to doing a self-breast exam (SBE)
• Assessment:
– Breasts- nodules, lumps
– Nipples - assess for eversion, flat, inverted, cracking,
bleeding, pain, blisters
• Individualize teaching for breasts for
breastfeeding and non-breastfeeding
moms

26. Process of Lactation
• Sucking of infant stimulates
the nerves beneath skin of
the areola to transmit
messages to the
hypothalamus
• Hypothalamus sends
messages to the pituitary
gland

27. Process of Lactation
– Anterior pituitary -- stimulates
Prolactin to be released which is
the ultimate stimulation for milk
production
– Posterior pituitary -- releases
Oxytocin which stimulates the
contraction of the cells around
the alveoli in the mammary
glands. This causes milk to be
propelled through the duct
system to the infant. This is the
“LET-DOWN” reflex. Felt as a
tingling sensation

28. Breastfeeding Care
• No soap on the nipples, wash in water wear
supportive bra
• Breastfeeding tips:
– Most important is the “latch-on” Teach measures to
assist with the infant getting the nipple and areola in
the mouth
– Teach different positions to hold the baby
– No timing
– Relax to allow for “let-down”

29. Suppression of Lactation
• Key: teach measures to decrease
stimulation of the breasts
– Tight-fitting bra or binder
– Do not express milk from the breasts
– Take shower with back to the warm water
– Ice packs

30. Elimination Changes
Urinary System
• Assess and measure first two voidings post-
delivery.
• Important to attempt to void every 3 - 4 hours.
If unable to void– catheterize based on
assessment
• Diuresis is common -- loss of fluid of pregnancy
• Mild proteinuria is normal.

31. Elimination Changes
Urinary System
• Patient Teaching:
– increase fluids, fiber, and activity
– stool softeners, anesthetic sprays, Tucks
– **Do NOT give an enema or suppository to
a person who has a 3rd or 4th degree
laceration.

32. Regulatory Changes
• Most common problem is Sleep
deprivation -- the excitement and
exhilaration following the birth may make
it difficult to sleep.
• Exercise – Should be individualized per
patient. Use caution until involution is
complete.

33. Postpartum Pain
– Perineal pain – result of trauma during delivery-
episiotomy/lacerations/hemorrhoids.
Interventions: Comfort measures: sitz, Tucks,
sprays / Foams, oral analgesics.
– Afterbirth pain -- more common in multigravidas
and breastfeeding moms. Interventions; Treat
with mild analgesics (NSAIDS, Acetomenophen)
heating pad, lie on abdomen, discontinue use of
oxytocins, Norco for severe pain

34. Postpartum Pain
– Breast engorgement -- warm or cold packs, cabbage
leaves, increase feedings if breastfeeding, decrease
stimulation if not breastfeeding. Breast binder.
– Gas distention -- no ice chips or cold liquids, provide
warm / hot fluids, increase walking, rocking chair,
Simethicone.

35. Integumentary Changes
• Skin -- pigment changes will begin to
disappear; diaphoresis is normal
• Striae - May have stretch marks over
abdomen and legs
• diastasis recti- Can occur with
overdistention of the uterus, caution with
exercise

36. Integumentary Changes
• Episiotomy/lacerations – Important to
treat as any other incision and maintain
cleanliness
• C/S Incision – Maintain pressure dressing
for 24 hours and then open to air, closure
with staples/ steri strips/dermabond.
Document and assess approximation, and
signs of infection

37. Oxygenation Alterations
Cardiovascular System Changes
• Plasma volume – body rids itself of excess by:
– Diuresis – urinary output of 3000 cc / day is
common
– Diaphoresis
• Blood Volume
– Increase for about 24-48 hours after delivery
– Increase in blood flow back to the heart when blood
from the placenta unit returns to central circulation
– Extravascular interstitial fluid is moved into the
vascular system / intravascular
– Leads to increased cardiac output mainly RT increase
stroke volume.

38. Oxygenation
• Vital Signs
– Temperature -- may see a SLIGHT ~100. rise in temperature
because of dehydration and exertion of labor in first 24 hrs
– Pulse -- Bradycardia is common for 6 - 8 days postpartally.
RT vagal response to increased sympathetic nervous system
stimulation during labor and increase in stroke volume.
– Respirations –begin to fall to normal pre-birth range.
– B/P -- should remain steady. Not elevated or decreased

39. Oxygenation – Lab Assessment
Pregnancy Post Partum
WBC – elevated slightly to about 12,000 WBC – leukocytosis is common with
values of 20,000 – 30,000 RT increassed
neutrophils
RBC – increase slightly to about 10 milion. RBC – return to normal
Hemoglobin – stays about normal at ~ 12 Hgb. – normal to see a drop of about 1
g. Below 10 g = anemia gram
Hemotocrit – lowers 33-39% RT Hct – normal to see a drop of about 4
hemodilution. If drops below 32- 35% = points and then a rise RT > loss of plasma
anemia than RBC death

40. • Assess for Thromboembolism
– During pregnancy, plasma fibrinogen
(coagulation) increases to prepare for delivery
and prevention of excess blood loss
– Plasminogen (lysis of clots) does not rise
– Hypercoagulable state and the woman is at a
greater risk for thrombus formation.
– Assess for homan’s sign?

41. – Assess for Hemorrhage -- related to uterine
atony
• Normal for loss of up to 500 cc during vaginal
delivery and 1000 cc in cesarean delivery.
• Assessment of lochia: should be scant to small with
no large clots.
• Assessment of fundus: tone, location
• If excess bleeding and decreased tone may
administer Methergine. Assess B/P prior to giving--
hold the dose if elevated >140 / 90. Other drugs to
contract uterus

42. Nutritional Alterations
• Most moms are hungry and eager to eat. Progress
slowly to avoid nausea and vomiting.
• Diet should include:
– High in Protein, vitamin C, and fiber
– Increase in fluids
• Lactating moms need about 500 extra calories for
milk production
• Prenatal vitamins and iron supplements are often
continued in the postpartum period.

43. “ Because the more a
mother is cared for,
the more easily she
can care for her
baby.”
- Shivam Rachana