Normal Puerperium



§         It is the period of recovery that occurs from childbirth and extends for 6 weeks after delivery


§          It is a period of INVOLUTION -- process by which the reproductive organs return to their normal size or pre-pregnant state and functions.


Mother’s Responses to Birth

§         The responses of the mother to the birth of her infant are influenced by many factors such as:

–   Her parents own birth  --  parenting and nurturing

–   Cultural background -- only by understanding and respecting the values and beliefs of each woman can the nurse plan and meet the patient’s needs

–   Readiness for parenthood -- emotional maturity,  pregnancy planned or unplanned,  financial status,  job status

–   Freedom from discomfort --  physical condition

–   Health of her newborn --  physical condition, prematurity, congenital defects

–   Opportunities for parent- infant interactions


Postpartum Phases by Rubin

§         Taking - in

–   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


***Main nursing is to listen and help the mother interpret events of the delivery to make them more meaningful and clarify and misconceptions


§         Taking - Hold

–   Occurs during day 3 to about 2 weeks postpartum

–   Ready to deal with the present

–   More in control .  Begins to take hold of the task of “mothering”


***It is the best time for teaching!  The nurse should

           tailor teaching to individual Learning Styles: 

Demonstrations; Group Classes; Videotapes


§         Letting Go Phase

–  occurs after about 2 weeks

–  Mother may feel a deep loss over the separation of the baby from part of her body and may grieve over this loss. 

–  Common for Postpartum Blues to occur during this time


Reproductive System Changes

 The Uterus

Involution of Uterus occurs by:

1.   Contraction of the Uterus

2.  Autolysis / Catabolism –

     -- Release of a proteolytic enzyme into the endometrium

         and myometrium.  This breaks down the protein

         material in the hypertrophied cells causing the uterine

         muscle cells to decrease in size

3.  Regeneration of the Endometrium

–  the placenta site heals in about 6 weeks with the other part healing in 3 weeks.

–   Heals by exfoliation rather than by forming scar tissue. 

     Critical Thinking

§         Why does the uterus heal by exfoliation and not by primary intention?

§         Answer:  so there is no scar tissue               


Assessment and 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

     -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. 

         causes relaxation and more bleeding.



§         Assess Type

–    Rubra -- 1 - 3 days; dark red; consists mainly of blood

–    Serosa -- 3 - 10 days; pinkish serum with tissue and debris

–    Alba -- 10 - 14 days;  creamy yellowish, brownish

§         Assess Amount

Ask -- When did you last change your pad?

§         Assess Odor

–    Fleshy, not foul smelling Lochia


Characteristics of Lochia

1.     Should not be excessive in amount

2.     Should never have an offensive odor

3.     Should not contain large pieces of tissue

4.     Should not be absent during the first 3 weeks

5.     Should proceed from rubra -- serosa – alba



§         Remains soft and flabby,  appears bruised and may have some lacerations

§         No longer does the external os have the pre-pregnant appearance --  now appears as a jagged slit not a circle.



§         May be edematous and bruised. 

§         Rugae begin to appear when ovarian function returns. 

§         May teach the mom to do Kegels exercises to increase the blood flow to the area and aid in healing


§         May have tears, laceratioins, or an episiotomy

§         Assessment Procedure:

–    Turn patient to side-lying / sims position

–    Gently spread buttocks apart and with penlight inspect

§         Assess:

o         the episiotomy the same as with any incision. 

o        Assess for hematoma

§         Teach hygiene measures to aid in healing

–    Use Peri-bottle each time to the bathroom

–    Wipe front to back; Change pads frequently

–    Use Tucks and Spray

–    Sitz bath


Match the Lochia:

1. Lochia rubra               a.  Pinkish serum with mucus and

                                          debris usually occurs on day 3 - 10.

2.  Lochia serosa            b.  Creamy yellowish brownish.

                                           Occurs after day 10

3. Lochia alba.                C. Dark Red and consists mainly of

                                           blood.  Occurs day 1 - 3.


Fill in the Blank:

§         Lochia should never be ______________ in amount.

§         Lochia should never have an ______________odor.

§         Lochia should not contain ________  _______ of tissue.

§         Lochia should not be _____ during the first ____ weeks.

§         Lochia should proceed from _____ to ____ to ________.


Short Answers:

The nurse is going to assess the uterus.  The 3 main assessments include:





The normal height of a first day postpartum woman is ______.   It

      should decrease  ___fingerbreadth per ___.

The tone should be __________.  If found boggy, the nurse would ___________ the uterus.



§         Allow the mother to assess her own breasts -- similar to doing a self-breast exam

o        ask if feels any nodules, lumps

o        ask if nipples are sore, reddened, blisters, cracks

§         Assess nipples for everted, flat, inverted

§         Teach to care for breasts according to whether they are breastfeeding or bottle feeding.

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

–    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

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”

–    express colostrum on the nipples after feeding

–    remember drops of colostrum are the same as ounces of milk -- if wetting 6 - 10 diapers / day, then must be getting enough to eat


Suppression of Lactation

§         Key is to teach the mother measures to decrease stimulation of the breasts

–  Wear a tight-fitting bra or binder

–  Do not express milk from the breasts

–  Take shower with back to the warm water

–  Ice packs

Fill in the Blank

§         The Anterior pituitary stimulates the release of _______ which is responsible for ______    ___________.


§         The posterior pituitary gland releases ___________ which  is responsible for the ______-________  reflex.

§         Short Answers

§         What are four important interventions to teach a mom who is bottle feeding to decrease stimulation of the breasts.





 Urinary System

§         Assess voiding carefully.  Make sure the patient is emptying her bladder.  Must void every 3 - 4 hours.  If unable to void-- catheterize

§         Diuresis is common -- loss of fluid of pregnancy

§         Mild Proteinuria – release of proteolytic material

§         Most common problem is urinary retention RT:

–    loss of elasticity and diminished bladder tone

–    loss of sensation from trauma, drugs, anesthesia

–    urethra edematous

§         Teach to do sitz baths, peri - lite, Tucks to decrease swelling

Critical Thinking

§         A primigravida delivered 2 hours ago.  The client states she would like to go to the bathroom.  What should the nurse do?

§         The client is unable to void.  What should the nurse do next?


Gastrointestinal System

§         Most common problem is constipation RT:

–    decrease muscle tone and intraabdominal pressure

–    prelabor diarrhea and decrease peristalsis

–    pre- delivery enema

–    dehydration

–    perineal tenderness, hemorrhoids and episiotomy

–     FEAR

§         Teach:

–    increase fluids, fiber, and activity

–    Stool softeners, anesthetic sprays, Tucks

–    **Do NOT give an enema or suppository to a person who has a 4th degree laceration.


Rest and Sleep

§         Most common problem is Sleep -- the excitement and exhilaration experienced by birth my make it difficult to sleep.  They are tired and need rest.  Allow for times of uninterrupted sleep.

§         Exercises -- have the patient to ask her own doctor for specific exercises.  Usually walking is safe.  May eventually do postpartum exercises.  Just need to allow the body to return to its pre-pregnant state before straining it.


§         Pain

–    Perineal pain -- caused from trauma during delivery, episiotomy, hemorrhoids.  Provide comfort measures such as:  sitz baths,  Tucks,  Sprays / Foams,  oral analgesics.

–    Afterbirth pain -- more common in multigravidas and breastfeeding moms.  Treat with * mild analgesics (NSAIDS, Acetamenaphen),heating pad, lie on abdomen,  discontinue use of oxytocins,

–    Breast engorgement -- warm or cold packs,  increase feedings,  decrease stimulation.  Bind breasts.

–    Gas distention -- no ice,  increase warm / hot fluids, increase walking, rocking chair, antiflatus drugs.

§         Skin -- pigment changes will begin to disappear;  diaphorsis is normal;  may have diastasis recti


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. 

§         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


Critical Thinking

The client’s vital signs are: 

    T.100.8,  P- 56, R – 16,  B/P – 110/65.

  How would the nurse interpret these findings?    What interventions are indicated?

Blood Work

During Pregnancy:

WBC – elevated slightly to about 12,000

RBC – increase slightly to about 10 milion. 

Hemoglobin – stays about normal at ~ 12 g.  Below 10 g = anemia

Hemotocrit – lowers  33-39% RT hemodilution.  If drops below 32- 35% = anemia    


Normal Post Partum Results:

WBC – leukocytosis is common with values of 20,000 – 30,000 RT increassed neutrophils

RBC – return to normal

Hgb. – normal to see a drop of about 1 gram

Hct – normal to see a drop of about 4 points and then a rise RT > loss of plasma than RBC death


Decision Making

§         During your shift assessment of the post partum mom’s peri pad,  you found it saturated with lochia rubra.


§          What would be your nursing interventions now?



§         Most moms are hungry and eager to eat.  Start off slowly to avoid nausea and vomiting.

§         Diet should include:

–    High in Protein, vitamin C, and fiber

–    Increase in fluids 

§         Lactating moms need about 700 extra calories for milk production

§         Prenatal vitamins and iron supplements are often continued in the postpartum period.


§         Bond that endures over time.  Contact should occur as early as possible and as frequently as possible.

§         Allow time for attachment to occur with all members of the family

Attachment Process

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


The Claiming Process

-  Includes the identification of the baby’s specific features, relating them to other family members