it weighs 500 g.
By the time involution is complete
WEEK 10: POSTPARTUM
Module
WHAT IS UTILITARIANISM?
UTILITARIANISM 🦖
• 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 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.
PHYSIOLOGICAL CHANGES OF THE POSTPARTAL
PERIOD
REPRODUCTIVE SYSTEM CHANGES
Involution
• is the process whereby the reproductive organs
return to their nonpregnant state. By the time
involution is complete (6 weeks), the uterus is
completely return to its prepregnancy state
The Uterus
• The sealing of the placenta site is accomplished by
rapid contraction of the uterus immediately after
delivery of the placenta. This contraction pinches
the blood vessels entering the 7-cm-wide area left
denuded by the placenta and stops bleeding. With
time, thrombi form within the uterine sinuses and
permanently seal the area.
• Although the uterus will never completely return
to its prepregnancy state, its reduction in size is
dramatic. Immediately after birth, the uterus
weighs about 1000 g. At the end of the first week,
Page 1 of 10 NCMA 217 (Midterms)
(6 weeks), it weighs approximately 50 g, similar to
its prepregnancy weight.
• Because uterine contraction begins immediately
after placental delivery, the fundus of the uterus
may be palpated through the abdominal wall,
halfway between the umbilicus and the
symphysis pubis, within a few minutes after birth.
One hour later, it will have risen to the level of the
umbilicus, where it remains for approximately the
next 24 hours. From then on, it decreases one
fingerbreadth per day—on the first postpartal
day, and so forth. By the ninth or tenth day, the
uterus will no longer be detected by abdominal
palpation
• Uterine involution may be delayed by a condition
such as the birth of multiple fetuses, hydramnios,
exhaustion from prolonged labor or a difficult
birth, grand multiparity, or physiologic effects of
excessive analgesia. Contraction may be difficult
if there is retained placenta or membranes.
Involution will occur most dependably in a
woman who is well nourished and who ambulates
early after birth (gravity may play a role).
• An estimation of the consistency of the postpartal
uterus is as important as measurement of its
height. A well-contracted fundus feels firm. It can
be compared with a grapefruit in both size and
tenseness. Whenever the fundus feels boggy (soft
or flabby), it is not as contracted as it should be,
despite its position in the abdomen.
• The first hour after birth is potentially the most
dangerous time for a woman. If her uterus should
become relaxed during this time (uterine atony),
she will lose blood very rapidly, because no
permanent thrombi have yet formed at the
placental site.
Lochia
• Uterine flow, consisting of blood, fragments of
decidua, white blood cells, mucus, and some
bacteria, is known as lochia.
• The portion of the uterus where the placenta was
not attached is so fully cleansed by this sloughing
process that it will be in a reproductive state in
about 3 weeks’ time. It takes approximately 6
Annotated by: C. Danting
 weeks (the entire postpartal period) for the
placental implantation site to be healed.
• 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 termed lochia rubra. As the
amount of blood involved in the cast-off tissue
decreases (about the fourth day) and leukocytes
begin to invade the area, as they do with any
healing surface, the flow becomes pink or
brownish (lochia 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
birth, although it is not unusual for a lochia flow
to last the entire 6 weeks of the puerperium.
• 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 Cervix
• Immediately after birth, a uterine cervix is soft
and malleable. Both the internal and external os
are open. Like contraction of the uterus,
contraction of the cervix toward its prepregnant
state begins at once.
Page 2 of 10 NCMA 217 (Midterms)
• By the end of 7 days, the external os has
narrowed to the size of a pencil opening; the
cervix feels firm and nongravid again.
• Like the fundus, the cervix does not return exactly
to its prepregnancy state. The internal os closes
as before, but after a
vaginal birth the
external os usually
remains slightly open
and appears slitlike or
stellate (star shaped),
whereas previously it
was round.
The Vagina
• After a vaginal birth, the vagina is soft, with few
rugae, and its diameter is considerably greater
than normal. The hymen is permanently torn and
heals with small, separate tags 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.
• Because a woman who is breastfeeding may have
delayed ovulation, she may continue to have thin-
walled or fragile vaginal cells that cause slight
vaginal bleeding during sexual intercourse until
about 6 weeks’ time.
• Like the cervix, the vaginal outlet remains slightly
more distended than before. If a woman practices
Kegel exercises, the strength and tone of the
vagina will increase more rapidly
The Perineum
• Because of the great amount of pressure
experienced during birth, the perineum feels
edematous and tender immediately after birth. .
The labia majora and labia minora typically
remain atrophic and softened after birth, never
returning to their prepregnancy state.
Breast
• In many women, breast distention becomes
marked, and this often is accompanied by a
feeling of heat or pain. The distention is not
limited to the milk ducts but occurs in the
Annotated by: C. Danting
 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.
SYSTEMIC CHANGES
• Pregnancy hormones begin to decrease as soon
as the placenta is no longer present. Levels of
human chorionic gonadotropin (hCG) and human
placental lactogen (hPL) are almost negligible by
24 hours.
• By week 1, progestin, estrone, and estradiol are
all at prepregnancy levels. Estrol may be elevated
for an additional week before it reaches
prepregnancy levels. Folliclestimulating hormone
(FSH) remains low for about 12 days and then
begins to rise as a new menstrual cycle is
initiated.
THE URINARY SYSTEM
• During pregnancy, as much as 2000 to 3000 mL
excess fluid accumulates in the body. An
extensive diuresis begins to take place almost
immediately after birth to rid the body of this
fluid. This easily increases the daily output of a
postpartal woman from a normal level of 1500 mL
to as much as 3000 mL/day during the second to
fifth day after birth. This marked increase in urine
production causes the bladder to fill rapidly.
• During a vaginal birth, the fetal head exerts a
great deal of pressure on the 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.
• To prevent permanent damage to the bladder
from overdistention, assess a woman’s abdomen
frequently in the immediate postpartal period.
On palpation, a full bladder is felt as a hard or firm
area just above the symphysis pubis. On
percussion (placing one finger flat on the
woman’s abdomen over the bladder and tapping
Page 3 of 10 NCMA 217 (Midterms)
it with the middle finger of the other hand), a full
bladder sounds resonant, in contrast to the dull,
thudding sound of non–fluid-filled tissue.
THE CIRCULATORY SYSTEM
• The diuresis that is evident between the second
and fifth days after birth, as well as the blood loss
at birth, acts to reduce the added blood volume a
woman accumulated during pregnancy. This
reduction occurs so rapidly, in fact, that the blood
volume returns to its normal prepregnancy level
by the first or second week after birth.
• The usual blood loss with a vaginal birth is 300 to
500 mL. With a cesarean birth, it 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
250 mL of blood lost.
• 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.
THE GASTRO INTESTINAL SYSTEM
• Digestion and absorption begin to be active again
soon after birth unless a woman has had a
cesarean birth. Almost immediately, the woman
feels hungry and thirsty and she can eat without
difficulty from nausea or vomiting during this
time.
• Hemorrhoids (distended rectal veins) that have
been pushed out of the rectum because of the
effort of pelvic-stage pushing often are present.
• Bowel sounds are active, but passage of stool
through the bowel may be slow 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.
THE INTEGUMENTARY SYSTEM
• After birth, the stretch marks on a woman’s
abdomen (striae gravidarum) still appear
Annotated by: C. Danting
 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
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.
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.
Page 4 of 10 NCMA 217 (Midterms)
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
• 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.
• 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.
Annotated by: C. Danting
 • 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
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 After pains - 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
Page 5 of 10 NCMA 217 (Midterms)
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.
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), pinkishbrown 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 CHANGES
• 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.
• 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
Annotated by: C. Danting
 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 after pains; 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).
Page 6 of 10 NCMA 217 (Midterms)
NURSING CARE OF A WOMAN AND FAMILY DURING
THE FIRST 24 HOURS AFTER BIRTH
1. Provide pain relief after pains
• 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. If necessary, either ibuprofen (such as
Motrin), which has anti-inflammatory properties,
or a common analgesic such as acetaminophen
(such as Tylenol) is effective for pain relief. As
with any abdominal pain, heat to the abdomen
should be avoided, because it could cause
relaxation of the uterus and subsequent uterine
bleeding.
2. 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.
They describe feeling as if they have “run for
miles.” A woman may need a mild analgesic such
as acetaminophen for the pain. A backrub is
effective for relieving an aching back or
shoulders. Carefully assess a woman who states
that she has pain on standing. Pain in the calf of
the leg on standing (a position that dorsiflexes the
foot) is a sign similar to Homans’ sign suggesting
thrombophlebitis may be present.
3. 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. Be certain not to place ice or plastic
directly on the woman’s perineum. Wrap an ice
bag first in a towel or disposable pad, to decrease
the chance of a thermal burn (risk of injury
increases because the perineum has decreased
sensation from edema after birth). Commercial
cold packs combined with perineal pads also are
available. For a low-cost alternative, a rubber
glove may be partially filled with ice chips,
provided latex allergy is not a concern.
• Ice to the perineum after the first 24 hours is no
longer therapeutic. After this time, healing
Annotated by: C. Danting
 increases best if circulation to the area is
encouraged by the use of heat. Dry heat in the
form of a perineal hot pack or moist heat with a
sitz bath is an effective way to increase circulation
to the perineum, provide comfort, reduce edema,
and promote healing.
4. Promote Perineal Exercises
• Some women find that carrying out perineal
exercises three or four times a day can greatly
relieve perineal edema. The exercise consists of
contracting and relaxing the muscles of the
perineum 5 to 10 times in succession, as if trying
to stop voiding (Kegel exercises). This aids
comfort by improving circulation to the area and
decreasing edema. When repeated frequently,
Kegel exercises also help a woman regain her
prepregnant muscle tone and help prevent
urinary incontinence (Hay-Smith & Dumoulin,
2009).
5. Give Episiotomy care
• Although relatively small in size, episiotomy
sutures can cause considerable discomfort,
because the perineum is an extremely tender
area and the muscles of the perineum are
involved in so many activities such as sitting,
walking, stooping, squatting, bending, urinating,
and defecating. Most women expect labor to be
painful. They usually do not anticipate the pulling
pain from perineal stitches in the postpartal
period, discomfort that interferes with their rest
and sleep, with eating, and with being able to sit
and hold their baby comfortably. Because 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.
6. Administer Sitz Baths
• A sitz bath is a portable basin that fits on a
toilet seat. A reservoir filled with water provides
a constant supply of swirling water to the basin.
The movement of water soothes healing tissue,
decreases inflammation by causing vasodilation
in the area, and thereby effectively reduces
discomfort and promotes healing. Sitz baths
usually use water that is maintained at 100° to
105° F (38° to 41° C). Be certain that the water in
Page 7 of 10 NCMA 217 (Midterms)
a sitz bath is not too hot before you help a woman
to use it; it should feel pleasantly warm, not hot.
7. Provide Perineal Care
• Postpartal women are particularly prone to
perineal infection because lochia, if allowed to
dry and harden on the vulva and perineum,
furnishes a rich bed for bacterial growth, which
then can spread to the uterus. Because the vagina
lies inclose proximity to the rectum, there is also
always the danger that bacteria will spread from
the rectum to the vagina. Interruption in skin
integrity from an episiotomy also increases the
client’s risk for infection. Teach a woman to
include perineal care as part of her daily bath or
shower and after every voiding or bowel
movement. If the woman is on bed rest during the
first hour after birth, you will need to provide
perineal care for her.
8. Promote Rest in the early postpartal period
• Few women are prepared for the degree of
fatigue they experience after childbirth. Try to do
all procedures swiftly yet gently, to allow as much
time for sleep as possible. If a woman has
discomfort from hemorrhoids, perineal stitches,
or afterpains, be sure she has pain relief so that
she can rest comfortably or sleep. Urge her not to
fall asleep in a narrow hospital bed with her new
infant. Sharing bed space is controversial even in
a large bed (Horsley et al., 2007).
9. Assess Peripheral Circulation
• To determine whether peripheral circulation is
adequate, assess a woman’s thigh for skin turgor.
Assess for edema at the ankle and over the tibia
on the lower leg. Although this technique is not
totally reliable, assess for thrombophlebitis by
dorsiflexing a woman’s ankle and asking her if she
notices pain in her calf on that motion (Homans’
sign). Assess also for redness in the calf area,
because thrombophlebitis can be present even
with a negative Homans’ sign. Continue to assess
for adequate peripheral circulation once every 8
hours during the woman’s stay in a health care
facility. If you suspect thrombophlebitis, do not
Annotated by: C. Danting
 massage the area—doing so could cause an
embolus.
• Be certain to allow a woman to dangle her legs on
the edge of the bed for a few minutes to prevent.
Dizziness before she gets up for the first time.
Then, assist her as needed to take the few steps
to a nearby bathroom. Remain with her to be
certain that dizziness does not occur. After this,
she may be up on her own as she wishes. As a
rule, women who ambulate quickly feel stronger
and healthier by the end of their first week and
have fewer bowel, bladder, and circulatory
complications than those who do not
10. Prevent/ Alleviate Breast Engorgement
• If a woman is breastfeeding, encouraging her
newborn to suck at the breast is the main
treatment for relief of the tenderness and
soreness of primary breast engorgement. Many
women find the application of warm compresses
or standing under a warm shower beneficial to
relieve engorgement discomfort. Good support
from a bra also offers relief because it prevents
unnecessary strain on the supporting muscles of
the breasts, positions the breasts in good
alignment, and diminishes the amount of
engorgement caused by blocked milk ducts. If the
woman has not packed a bra in her suitcase, ask
her to arrange to have one brought from home.
• Cold compresses, applied to the breasts three or
four times a day during the period of
engorgement, or an oral analgesic, or both,
provide relief. Wearing a snug-fitting bra and
avoiding nipple stimulation may help. Restricting
fluid and pumping milk from the breasts are not
effective measures and are to some degree
harmful, so these actions should be avoided.
11. Promote Breast hygiene
• Breast care during the postpartal period includes
cleanliness and support. These issues are the
same whether or not a woman is breastfeeding.
Teach a woman to wash her breasts daily with
clear water at the time of her bath or shower and
then dry them with a soft towel. She should avoid
using soap, because it tends to dry and crack the
nipples, possibly leading to fissures and breast
Page 8 of 10 NCMA 217 (Midterms)
abscess. It is not necessary for women to wash
their breasts more often than daily, because
excessive washing means unnecessary
manipulation.
12. Teach Methods to promote uterine Involution
• All during the postpartal period, lying on the
abdomen gives support to abdominal muscles
and may aid involution, because it tips the uterus
into its natural forward position. If this puts too
much pressure on sore breasts, placement of a
small pillow under the abdomen usually solves
the problem. It may be dangerous for a woman to
assume a knee–chest position until at least the
third week after birth. In a knee–chest position,
the vagina tends to open. Because the cervical os
remains open to some extent until the third
week, there is a danger that air will enter the
vagina and the open cervix, penetrate the open
blood sinuses inside the uterus, enter the
circulatory system, and cause an air embolism.
BUBBLE-HE
BUBBLE-HE is an acronym used to denote the
components of the postpartum maternal nursing
assessment. This method enhances the standard physical
assessment process typically performed on hospitalized
patients by the RN, such as those on a Medical-Surgical
floor. For stable patients, vital signs are taken every 15
minutes during the first hour following delivery and then
gradually less frequently. While performing the BUBBLE-
HE, the RN often uses the assessment time to provide for
patient education.
8-POINT POSTPARTUM ASSESSMENT INSTRUCTIONS
1. Breast
a. Gently palpate each breast
b. If you feel nodules in the breast, the ducts may
not have been emptied at last.
c. Stroke downward towards the nipple, then
gently release the milk by manual.
d. If nodules remain, notify the doctor.
e. Take this opportunity to explain the process of
milk production, what to do about engorgement,
how to perform self breast examinations, and
answer any questions she may have about
breastfeeding.
Annotated by: C. Danting
 ▪ What is the contour?
▪ Are the breast full, firm, tender, shiny?
▪ Are the veins distended?
▪ Is the skin warm?
▪ Does the patient complain of sore nipples?
▪ Are breasts so engorged that she requires
pain medication?
2. Uterus
a. Palpate the uterus
b. Have the patient feel her uterus as you explain
the process of involution
c. If uterus is not involution properly, check for
infection, fibroids and lack of tone.
d. Uterus should the firm decrease approximately
one finger breadth below
e. Unsatisfactory involution may result if there are
retained secundines or the bladder not
f. completely empty
3. Bladder
a. Inspect and palpate the bladder simultaneously
while checking the height of the fundus.
b. An order from the physician is necessary
cauterization may be done. An order for culture
and sensitivity test since definitive treatment
may be required.
c. Talk to mother about proper perineal care.
Explain that she should wipe from front to back
after voiding and defecating.
d. Bladder distention should not be present after
recent emptying.
e. When bladder distention does occur, a pouch
over the bladder area is observed, felt upon
palpation; mother usually feels need to urinate.
f. It is imperative that the first three post-partum
voiding be measured and should be at least
150cc. Frequent small voiding with or without
pain and burning may indicate infection or
retention.
4. Bowel Function
a. Question patient daily about bowel movements.
She must not become constipated. If her bowels
have not functioned by the second postpartum
day, the doctor may start her on a mild laxative
b. Encourage patient to drink extra fluids.
c. Have patient select fruits and vegetables from
her menu
Page 9 of 10 NCMA 217 (Midterms)
5. Lochia
a. Assess the amount and type of lochia on pad in
relations to the number of postpartum days.
First 3 days of postpartum, you should find a very
red lochia similar to the menstrual flow (lochia
ruba).
b. During the next few days, it should become
wateryserous (lochia serosa). Onthe tenth day,
it
c. should become thin and colorless (lochia alba).
d. .Inform the mother about what changes she
should expect in the lochia and when it should
cease.
e. Tell the mother when her next menstrual period
will probably begin and when she can resume
sexual relations.
f. Discuss family planning at this time.
g. Notify the doctor if the lochia looks abnormal in
to color or contains clogs other than small ones.
6. Episiotomy
a. Inspect episiotomy thoroughly using flashlight if
necessary, for better visibility.
b. Check rectal area. If hemorrhoids are present,
the doctor may want to start on sitz bath and
local analgesic medication. Reassure patient and
answer questions she may have regarding pain,
cleanliness, and coitus.
c. Check episiotomy for proper wound healing,
infection, inflammation and suture sloughing.
d. Is the surrounding skin warm to touch?
e. Does the patient complain of discomfort? Notify
the doctor if any occurs
7. Homan’s Sign
a. Press down gently on the patient’s knee (legs
extended flat on bed) ask her to flex her foot
b. Pain or tenderness in the calf is a positive
Homan’s sign and indication of
thrombophlebitis. Physician should be notified
immediately.
8. Emotional Status
a. Throughout the physical assessment, notice and
evaluate the mother’s emotional
b. status.
c. Explain to the mother and to her family that she
may cry easily for a while and that her emotions
may shift from high to low. The changes are
normal and are probably caused by the
tremendous hormonal changes occurring in her
Annotated by: C. Danting
 body and by her realization of new
responsibilities that accompany each child’s
birth.
d. Does the patient appear dependent or
independent? Is she elated or despondent?
What does she say about family? Are there other
nonverbal responses?

TERMINOLOGIES

• PUERPERIUM/Postpartum – 6 weeks period after

giving birth
• Engorgement - swell with blood, water, or
another fluid
• Involution - return of the reproductive organs to
their non-pregnant state.
• Lochia - Uterine flow, consisting of blood,
fragments of decidua, white blood cells, mucus
• Sitz bath - type of therapy done by sitting in
warm, shallow water.

Page 10 of 10 NCMA 217 (Midterms) Annotated by: C. Danting