 The postpartal period, or puerperium (from the Latin puer, for “child,” and

parere, for “to bring forth”), refers to the 6-week period after childbirth.
 It is a time of maternal changes that are both retrogressive (involution of

POSTPARTUM the uterus and vagina) and progressive (production of milk for lactation,
restoration of the normal menstrual cycle, and beginning of a parenting
role).
 Assessment During the puerperium, assessment of a woman is
accomplished by health interview, physical examination, and analysis of
laboratory data. It is important to ensure that physical changes, such as
uterine involution, are occurring by evaluating uterine size and consistency
and lochia flow amount.

The Uterus

Because uterine contraction begins

immediately after placental delivery,
the fundus of the uterus
may be palpated through the
PHYSIOLOGICAL CHANGES OF THE POSPARTAL PERIOD abdominal wall, halfway between the
umbilicus and the symphysis pubis,
Reproductive System Changes within a few minutes after birth.
One hour later, it will have risen to
— Involution is the process whereby the reproductive organs return to their
the level of the umbilicus, where it
nonpregnant state. By the time involution is complete (6 weeks), the uterus is
remains for approximately the
completely return to its pre-pregnancy state. next 24 hours. From then on, it decreases
one fingerbreadth per day—on the first
post-partal day, and so forth.
By the ninth or tenth day,
the uterus will no longer be detected
by abdominal palpation.
  Lochia

Uterine flow, consisting of blood, fragments of decidua, white blood cells, mucus, and
some bacteria, is known as lochia. It takes approximately 6 weeks (the entire postpartal
 The Cervix
period). For the first 3 days after birth, a lochia discharge consists almost entirely of
blood, with only small particles of decidua and mucus. Because of its mainly red color, it is Contraction of the cervix toward its prepregnant state begins at once. By the end of 7 days,
termed lochia rubra. As the amount of blood involved in the cast-off tissue decreases the external os has narrowed to the size of a pencil opening; the cervix feels firm and
(about the fourth day) and leukocytes begin to invade the area, as they do with any nongravid again.
healing surface, the flow becomes pink or brownish (lochia
 The Vagina
serosa). On about the 10th day, the amount of the flow decreases and becomes colorless
or white (lochia alba). Lochia alba is present in most women until the third week after After a vaginal birth, the vagina is soft, with few rugae, and its diameter is considerably
birth, although it is not unusual for a lochia flow to last the entire 6 weeks of the greater than normal. The hymen is permanently torn and heals with small, separate tags
puerperium. of tissue. It takes the entire postpartal period for the vagina to involute (by contraction, as
with the uterus) until it gradually returns to its approximate prepregnancy state.
Saturating a perineal pad in less than 1 hour is considered an abnormally heavy flow and
should be reported. Lochia should contain no large clots. Clots may indicate that a portion
of the placenta has been retained and is preventing closure of the maternal uterine blood
sinuses. Lochia should not have an offensive odor. Lochia has the same odor as menstrual
blood. An offensive odor usually indicates that the uterus has become infected.

 The Perineum

Because of the great amount of pressure experienced during birth, the perineum feels Systemic Changes
edematous and tender immediately after birth. . The labia majora and labia minora
 Pregnancy hormones begin to decrease as soon as the placenta is no longer
typically remain atrophic and softened after birth, never returning to their prepregnancy
present. Levels of human chorionic gonadotropin (hCG) and human placental
state.
lactogen (hPL) are almost negligible by 24 hours.
 BREAST
 By week 1, progestin, estrone, and estradiol are all at prepregnancy levels. Estrol
In many women, breast distention becomes marked, and this often is accompanied by a may be elevated for an additional week before it reaches prepregnancy levels.
feeling of heat or pain. The distention is not limited to the milk ducts but occurs in the Follicle-stimulating hormone (FSH) remains low for about 12 days and then begins
surrounding tissue as well, because blood and lymph enter the area to contribute fluid to to rise as a new menstrual cycle is initiated.
the formation of milk. This feeling of tension in the breasts on the third or fourth day after
birth is termed primary engorgement. It fades as the infant begins effective sucking
termed primary engorgement. It fades as the infant begins effective sucking and empties
the breasts of milk.
Urinary System

 During pregnancy, as much as 2000 to 3000 mL excess fluid accumulates in the Urinary System
body. An extensive diuresis begins to take place almost immediately after birth to
To prevent permanent damage to the bladder from overdistention, assess a woman’s
rid the body of this fluid. This easily increases the daily output of a postpartal
abdomen frequently in the immediate postpartal period. On palpation, a full bladder is
woman from a normal level of 1500 mL to as much as 3000 mL/day during the
felt as a hard or firm area just above the symphysis pubis. On percussion (placing one
second to fifth day after birth. This marked increase in urine production causes
finger flat on the woman’s abdomen over the bladder and tapping it with the middle
the bladder to fill rapidly.
finger of the other hand), a full bladder sounds resonant, in contrast to the dull, thudding
 During a vaginal birth, the fetal head exerts a great deal of pressure on the sound of non–fluid-filled tissue.
bladder and urethra as it passes on the bladder’s underside. This pressure may
leave the bladder with a transient loss of tone that, together with the edema
surrounding the urethra, decreases a woman’s ability to sense when she has to
void.

Circulatory System Gastrointestinal System

 The diuresis that is evident between the second and fifth days after birth, as well  Digestion and absorption begin to be active again soon after birth unless a
as the blood loss at birth, acts to reduce the added blood volume a woman woman has had a cesarean birth.
accumulated during pregnancy. This reduction occurs so rapidly, in fact, that the
Almost immediately, the woman feels hungry and thirsty and she can eat without
blood volume returns to its normal prepregnancy level by the first or second
difficulty from nausea or vomiting during this time.
week after birth.
 Hemorrhoids (distended rectal veins) that have been pushed out of the rectum
 The usual blood loss with a vaginal birth is 300 to 500 mL. With a cesarean birth, it
because of the effort of pelvic- stage pushing often are present.
is 500 to 1000 mL. A 4-point decrease in hematocrit (proportion of red blood cells
to circulating plasma) and a 1-g decrease in hemoglobin value occur with each  Bowel sounds are active, but passage of stool through the bowel may be slow
250 mL of blood lost. because of the still-present effect of relaxin on the bowel. Bowel evacuation may
be difficult because of the pain of episiotomy sutures or hemorrhoids.
 Women usually continue to have the same high level of plasma fibrinogen during
the first postpartal weeks as they did during pregnancy. This is a protective
measure against hemorrhage. However, this high level also increases the risk of
thrombus formation.
Integumentary System
 After birth, the stretch marks on a woman’s abdomen (striae gravidarum) still
appear reddened and may be even more prominent than during pregnancy, when
they were tightly stretched.
 Excessive pigment on the face and neck (chloasma) and on the abdomen (linea
nigra) will become barely detectable in 6 weeks’ time.
 If diastasis recti (overstretching and separation of the abdominal musculature) is
present, the area will appear slightly indented. If the separation is large, it will
appear as a bluish area in the abdominal midline. Modified sit- ups help to
strengthen abdominal muscles and return abdominal support to its prepregnant
level
Vital Sign Changes
Pulse
— A woman’s pulse rate during the postpartal period is usually slightly slower than
normal. During pregnancy, the distended uterus obstructed the amount of venous blood
returning to the heart; after birth, to accommodate the increased blood volume
returning to the heart, stroke volume increases. This increased stroke volume reduces the
pulse rate to between 60 and 70 beats per minute.
Vital Sign Changes
Temperature
 A woman may show a slight increase in temperature during the first 24 hours after
birth because of dehydration that occurred during labor. If she receives adequate
fluid during the first 24 hours, this temperature elevation will return to normal.
 Any woman whose oral temperature rises above 100.4° F (38° C), excluding the
first 24-hour period, is considered by criteria of the Joint Commission on Maternal
Welfare to be febrile. In such women, a postpartal infection may be present.
 Occasionally, when a woman’s breasts fill with milk on the third or fourth
postpartum day, her temperature rises for a period of hours because of the
increased vascular activity involved. If the elevation in temperature lasts longer
than a few hours, however, infection is a more likely reason.
Vital Sign Changes
Blood Pressure
 Blood pressure should also be monitored carefully during the postpartal period,
because a decrease in this can indicate bleeding. In contrast, an elevation above
140 mm Hg systolic or 90 mm Hg diastolic may indicate the development of
postpartal pregnancy-induced hypertension, an unusual but serious complication
of the puerperium.
 To evaluate blood pressure, compare a woman’s pressure with her prepregnancy
level if possible, rather than with standard blood pressure ranges.
 Oxytocics, drugs frequently administered during the postpartal period to achieve
uterine contraction, cause contraction of all smooth muscle, including blood
vessels that can increase blood pressure.

Progressive Changes
— Two physiologic changes that occur during the puerperium involve progressive
changes, or the building of new tissue. Because building new tissue requires good
nutrition, caution women against strict dieting that would limit cell-building ability during
the first 6 weeks after childbirth.
Lactation
 Breast milk forms in response to the decrease in estrogen and progesterone levels
that follows delivery of the placenta (which stimulates prolactin production and,
consequently, milk production). When breast milk first begins to form, the milk
ducts become distended.
 The distention of the breast is not limited to the milk ducts but occurs in the
surrounding tissue as well, because blood and lymph enter the area to contribute
fluid to the formation of milk. This feeling of tension in the breasts on the third or
fourth day after birth is termed primary engorgement. It fades as the infant
begins effective sucking and empties the breasts of milk.
Lactation
 The formation of breast milk (lactation) begins in a postpartal woman whether or
not she plans to breastfeed. For the first 2 days after birth, an average woman
notices little change in her breasts from the way they were during pregnancy.
 Since midway through pregnancy, she has been secreting colostrum, a thin,
watery, prelactation secretion. She continues to excrete this fluid the first 2
postpartum days. On the third day, her breasts become full and feel tense or
tender as milk forms within breast ducts.
Return of Menstrual Flow
 With the delivery of the placenta, the production of placental estrogen and
progesterone ends. The resulting decrease in hormone concentrations causes a
rise in production of FSH by the pituitary, which leads, with only a slight delay, to
the return of ovulation. This initiates the return of normal menstrual cycles.
 A woman who is not breastfeeding can expect her menstrual flow to return in 6
to 10 weeks after birth. If she is breastfeeding, a menstrual flow may not return
for 3 or 4 months (lactational amenorrhea) or, in some women, for the entire
lactation period. However, the absence of a menstrual flow does not guarantee
that a woman will not conceive during this time, because she may ovulate well
before menstruation returns
NURSING RESPONSIBILITIES
a. Perineal Care - inspect the perineum. Observe for ecchymosis, hematoma,
erythema, edema, intactness, and presence of drainage or bleeding from any
episiotomy stitches.
b. Provide Pain Relief for Afterpains - Pain from uterine contractions can be
intense, but you can assure a woman that this type of discomfort is normal and
rarely lasts longer than 3 days.
c. Relieve Muscular Aches - Many women feel sore and aching after labor and birth
because of the excessive energy they used for pushing during the pelvic division
of labor. A backrub is effective for relieving an aching back or shoulders.
d. Administer Cold and Hot Therapy - Applying an ice or cold pack to the perineum
during the first 24 hours reduces perineal edema and the possibility of hematoma
formation, thereby reducing pain and promoting healing and comfort. After the
first 24 hours healing increases best if circulation to the area by the use of heat.
Dry heat in the form of a perineal hot pack or moist heat with a sitz bath.
PSYCHOLOGICAL CHNGES
 Postpartal Blues During the postpartal period, as many as 50% of women
experience some feelings of overwhelming sadness (Buultjens & Liamputtong,
2007). They may burst into tears easily or feel let down or irritable. This
temporary feeling after birth has long been known as the “baby blues.”
 This phenomenon may be caused by hormonal changes, particularly the decrease
in estrogen and progesterone that occurs with delivery of the placenta. For some
women, it may be a response to dependence and low self- esteem caused by
exhaustion, being away from home, physical discomfort, and the tension
engendered by assuming a new role, especially if a woman is not receiving
support from her partner.
e. Episiotomy Care - the perineal area heals rapidly, you can assure a woman that
this discomfort is normal and does not usually last longer than 5 or 6 days. Many
physicians and nurse- midwives order a soothing cream or anesthetic spray to be
applied to the suture line to reduce discomfort.
f. Inspect Lochia - Check the Consistency: Lochia should contain no large clots. Clots
may indicate that a portion of the placenta has been retained and is preventing
closure of the maternal uterine blood sinuses. In any event, large clots denote
poor uterine contraction, which needs to be corrected.
Observe the Pattern: Lochia is red for the first 1 to 3 days (lochia rubra), pinkish-brown
from days 4 to 10 (lochia serosa), and then white (lochia alba) for as long as 6 weeks after
birth. The pattern of lochia (rubra to serosa to alba) should not reverse.
PSYCHOLOGICAL CHNGES
 The syndrome is evidenced by tearfulness, feelings of inadequacy, mood lability,
anorexia, and sleep disturbance.
 Anticipatory guidance and individualized support from health care personnel are
important to help the parents understand that this response is normal. You can
assure a woman that sudden crying episodes may occur; otherwise, she may have
difficulty understanding what is happening to her.
 Her support person also needs assurance, or he can think the woman is unhappy
with him or their new baby or is keeping some terrible secret about the baby from
him.
 Phases of the Puerperium
Reva Rubin, a nurse, divided the puerperium into three separate phases (Rubin, 1977).

 Taking-In Phase

A time when the new parents review their pregnancy and the labor and birth, a time of
reflection. During this 2- to 3-day period, a woman is largely passive. This dependence
results partly from her physical discomfort because of afterpains; partly from her
uncertainty in caring for her newborn; and partly from the extreme exhaustion that follows
childbirth.

 Taking-Hold Phase

After a time of passive dependence, a woman begins to initiate action. Now, she
begins to take a strong interest. , it is always best to give a woman brief
demonstrations of baby care and then allow her to care for her child herself—
with watchful guidance.

 Letting-Go Phase

In the third phase, called letting-go, a 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 (or however many
children she had before this birth).