NURSING CARE OF POSTPARTAL FAMILY LOCHIA

INVOLUTION → lochia present for 2 – 6 wks

→ occurs in the spongy layer or outer part of the
→ process whereby the reproductive organs
decidua basalis
return to their nonpregnant state
→ consists of blood, fragments of decidua, wbc,
→ in danger for hemorrhage from the denuded
mucus, and some bacteria
surface of the uterus until involution is
→ check every 15 mins for the 1st hr also fundus
complete
→ check perineal pad
UTERUS → evaluate lochia
• consistency
→ area where the placenta is planted is sealed
• amount
off to prevent bleeding
• absence
→ organ is reduced to its approximate
• pattern
pregestational size
• odor
→ after birth: 1000g
→ first cycle is unovulatory
→ end of 1st week: 500 g
→ non-lactating: menses return in 4 to 6 wks
→ 6 wks/ end of involution: 50 g (like
prepregnancy wt) → Lactating: menses less predictable, resume
in 12 - 24 weeks
→ uterine contraction begins after placental
delivery TYPE COLOR PPD COMPOSITION
→ fundus is palpable through the abdominal Lochia Red 1-3 Blood,
wall, halfway between the umbilicus and Rubra days fragments of
symphysis pubis, within few minutes after decidua, mucus
birth Lochia Pink/brown 3-10 Blood, mucus,
→ after 1 hr, it will rise to the level of umbilicus Serosa days invading
and remain for the next 24 hrs leukocyte
→ then decreases by 1 fingerbreadth or 1 cm Lochia white 10-14 Largely mucus,
Alba days high amnt of
per day
(may leukocyte
→ fundus is in the midline of abdomen; can be last until
felt to the right because of the bulk of the 6 wks)
sigmoid colon
→ involution occurs most dependably when
• well-nourished SIGNS OF ABNORMAL LOCHIA
• ambulated early Signs Possible Cause
→ involution is delayed with: Foul smell Infection
• multiple birth Large clots Retained fragments;
• hydramnios (too much amniotic fluid) poor uterine
• exhaustion from prolonged labor contractions
• grand multiparity Excessive amnt Lacerations of birth
• physiologic effects of excessive canal
Return to rubra after Retained fragment;
analgesia
serosa or alba infection
→ contraction is ineffective if there is retained
Persistent bleeding Subinvolution of the
placenta or membranes uterus, infection
→ well-contracted fundus feels firm like a
grapefruit
→ if fundus is boggy (soft or flabby), it is not BLOOD CLOTS
contracted
→ good media for bacteria
→ first hour of birth is dangerous
→ sign of puerperal asepsis
→ uterus should not be relaxed (uterine atony)
because she will lose blood rapidly CERVIX

AFTERPAINS → soft and malleable to palpation after birth

→ Intermittent cramping like a menstrual period
→ Strong uterine contractions are mostly felt by:
• Multiparas
• Those who delivered large babies
• Those who delivered twins
• Those who breastfeed (infant’s
sucking causes a release of oxytocin)
SUBINVOLUTED UTERUS
→ internal and external os are open
→ end of 7 days, external os has narrowed to
the size of a pencil opening; cervix feels firm
and non-gravid again
→ does not involve formation of new muscle
cells thus does not return exactly to its
prepregnancy state
→ shape of external os changed by delivery
from round to slit-like or stellate opening

→ not decreasing in size VAGINA

→ uterus is larger than normal → feels soft w/ few rugae after birth
→ has vaginal bleeding w/ clots → diameter is greater than normal
 → hymen is permanently torn; heals w/ small,
separate tags of tissue
→ takes entire postpartal period to involute
→ Thickening of the walls appears to depend on
renewed estrogen stimulation from the
ovaries
→ woman who is breastfeeding and in whom
ovulation is delayed may continue to have
thin-walled or fragile vaginal cells that cause
slight vaginal bleeding during sexual
intercourse
→ edematous after delivery
→ may have small lacerations
→ vaginal outlet will remain slightly more
distended than before
→ Kegel’s exercise: increase strength and tone
of vagina
SEXUAL ACTIVITY
→ 3rd or 4th week postpartum
→ if bleeding has stopped and episiorraphy has
healed
→ Decrease physiologic reactions to sexual
stimulation
→ expected for the first 3 months postpartum
because of hormonal changes and emotional
factors
PERINEUM
→ Edematous and tender after birth
→ may show ecchymosis from the rupture of
surface capillaries
→ labia majora and labia minora: remain
atrophic and softened, never returning to
their prepregnant state
→ Pain in perineal region may be relieved by:
• Sim’s position: minimizes strain on
the suture line
• Perineal heat lamp or warm sitz
baths BID: vasodilation increases
blood supply and promotes healing
• Application of topical analgesics or
administration of mild oral analgesics
as ordered
SYSTEMIC CHANGES
HORMONAL SYSTEM
→ Level of HCG (Human Chorionic
Gonadotrophin) and human placental
lactogen (HPL): almost negligible by 24
hours
→ By week 1, progestin, estrone, and estradiol
are at pre-pregnancy levels
→ FSH (Follicle-stimulating hormone) remains
low for about 12 days, and then begins to rise
to initiate a new menstrual cycle
URINARY SYSTEM
→ 2000 – 3000 ml is excreted via diaphoresis
(excessive sweating) and diuresis
(excessive urine production)
→ 1500 ml: normal urine production for
postpartum mother
→ Decrease sense of voiding bcs of anesthesia
and the pressure on the bladder and urethra
as the fetal head moves out
→ Urine retention: due to loss of elasticity tone
and loss of sensation from trauma, drugs,
anesthesia, and loss of pregnancy
→ Full bladder is firm or hard just above the
symphysis pubis when palpated
→ Full bladder has resonant sound when
percussion
→ hydronephrosis or increased size of ureters
occurs during pregnancy remains present for
about 4 weeks postpartum
→ Urine tends to contain more nitrogen than
normal
→ Lactosuria: may be seen in nursing mothers
→ Slight proteinuria: during first 1 - 2 days after
involution
→ Management
• pouring warm and cold water
alternately over the vulva
• encouraging the client to go to the
comfort room
• let her listen to the sound of running
water
• if these measures fail,
catheterization, done gently and
aseptically, is the last resort on
doctor’s order
CIRCULATORY SYSTEM
→ diuresis is evident on 2nd to 5th day after birth
→ blood vol return to its prepregnancy state
after first or second week of birth
→ 300 to 500 ml: blood loss w/ vaginal birth
→ 500 to 1000 ml: cesarian birth
→ Hemoglobin will fall from 11g to 10g/dl
→ Plasma Fibrinogen: protective measure
against hemorrhage but increases risk for
thrombus formation
→ WBC count may be as high as 30,000
cells/mm3 total (normal: 5000 to 10000
cells/mm3)
GASTROINTESTINAL SYSTEM
→ Feels hungry and thirsty
→ Hemorrhoids: distended rectal veins are
often present bcs of pushing
→ Active bowel sound
→ Slow passage of stool due to relaxin
→ Relaxin: hormone which softens and
lengthens the cervix and pubid symphysis
→ Difficult bowel evacuation due to pain of
episiotomy sutures or hemorrhoids
→ encourage to eat soluble fibers
ABDOMINAL WALL/ INTEGUMENTARY
SYSTEM
→ May need six weeks to reestablish good
muscle tone (modified sit-ups)
→ stretch marks (striae gravidarum) appear
reddened and may be even more prominent
than during pregnancy
→ stretch marks gradually disappears or fade to
silvery appearance
→ Chloasma: excessive pigment on the face
→ Linea Nigra: barely detectable line on
abdomen
 → Diastasis Recti: overstretching and
separation of abdominal musculature;
appears slightly indented bluish streak in the
abdominal midline
→ Both the abdominal wall and the ligaments
that support the uterus require the full 6
weeks of the puerperium to return to their
former state
RETURN OF MENSTRUAL FLOW
HOMAN’S SIGN
→ Test for deep vein thrombosis
→ Must be negative
→ Venous thrombosis in the legs
→ Thrombophlebitis: painful calf area
NURSING CARE DURING FIRST 24 HOURS
WEIGHT LOSS
→ Rapid diuresis and diaphoresis= -5 lb
→ Loss at birth= -12 lb
→ Lochia flow= -2 to -3 lb
→ Total loss= 19 lb
→ Wt woman reached at 6 weeks after birth will
become her baseline
VITAL SIGNS: internal adjustments
TEMPERATURE
→ taken orally or tympanically; never rectally
→ increase in 1st 24 hrs due to dehydration in
labor
→ rise of about 38 degrees Celsius is
considered as febrile, and suspected as
having infection
→ On the 3rd-4th day postpartum, the breasts fill
with milk (engorgement) and the temperature
rises
→ Mastitis: infection of breast during lactation
→ Apply cold compression for engorged breast
PULSE
→ Bradycardia is common for 6 to 8 days
postpartum
→ After birth, stroke volume increases to
accommodate the increased blood volume
returning to the heart.
→ increased stroke volume reduces the pulse
rate between 60-70bpm
→ rapid and thready pulse could be sign of
hemorrhage
RESPIRATORY RATE
→ no changes
BLOOD PRESSURE
→ decrease indicates internal bleeding
→ increase indicates postpartum induced
hypertension
→ reading above 140mmHg systolic or
90mmHg diastolic may indicate the
development of postpartal pregnancy-
induced hypertension
→ orthostatic hypotension: dizziness that
occurs on standing
LACTATION
→ prolactin hormone is responsible for milk
production
→ oxytocin is responsible for the let-down reflex
arch
→ Colostrum: thin, watery prelactation
secretion
→ breast milk forms due to decrease of
estrogen and progesterone levels and
increase in prolactin and estrogen
→ non-breastfeeding: return after 6 to 10 wks
→ breastfeeding: may not return for 3 to 4 mos.
Or the entire lactation period (lactation
amenorrhea)
→ Reassure a woman that sudden crying
episodes are normal
→ Encourage to verbalize her feelings
→ Allow her to make as many decisions as
possible
→ Provide Pain Relief for Afterpains:
• Analgesics is effective for relief
• Heat to the abdomen should be
avoided
→ Relieve Muscular Aches through back rub
→ Give Episiotomy care
• Apply soothing cream or anesthetic
spray
• Sitz bath
→ Promote perineal exercises
• Kegel’s exercise: Improves
circulation and decreases edema;
Heps regain prepregnant muscle
tone and form
→ Administer Cold and Hot therapy
• Apply an ice or cold pack to the
perineum during the first 24 hours
• After 24 hours sitz bath or perineal
hot pack is effective
→ Administer sitz bath
• Use water that is maintained at at
38C to 41C
• Use 3 to 4 times a day for a maximum
of 20 minutes each time
→ Provide Pain Management
→ Provide Perineal Care
• Teach a woman to include perineal
care as part of daily bath
→ Promote Perineal Self-Care
→ Promote rest in the early and throughout the
puerperium
→ Promote adequate Fluid intake
• Encourage to drink at least 3 to 4, 8
oz of glasses of fluid each day
→ Promote Urinary Elimination
→ Prevent constipation
→ Prevent development of Hemorrhoids
→ Assess peripheral circulation
• Assess for skin turgor
• Assess for edema at the ankle
• Homan’s sign
→ Promote Breast Hygiene: Breast care
→ Teach Methods to promote uterine involution
→ Lie on the abdomen
→ dangerous to assume a knee chest position
until at least the 3rd week after birth