Breast

Breast tissue increases in size as breast milk forms. To assess breasts, ask a patient to remove their bra
and cover their breasts with a towel or folded sheet to protect modesty. Ask them to raise their hands
and tuck them under their head because this stretches and thins breast tissue. Inspect and then
palpate for breast size, shape, and color. Breast tissue should feel soft on palpation on the first and
second postpartal day. On the third day, it should begin to feel firm and warm (described as filling). On
the third or fourth day, breasts appear large and reddened, with taut, shiny skin (engorgement) and, on
palpation, feel hard and tense and painful. Because, normally, engorgement causes the entire breast to
feel warm or appear reddened, if only one portion of a breast appears this way, inflammation or,
possibly, infection of glands or milk ducts (mastitis) is suggested.

Uterus

Involution of the uterus involves 2 process. First the area where the placenta was implanted is sealed off
to prevent bleeding. Second, the organ is reduced to its approximate progestational site. Eventually,
endometrial tissue undermines the site and obliterates the organized thrombi, covering and healing the
area so completely that the process leaves no scar tissue within the uterus and therefore does not
compromise future implantation.

Bladder

During pregnancy, as much as 2,000 to 3,000 mL of excess fluid accumulates in the body so that
extensive diaphoresis (excessive sweating) and diuresis (excess urine production) begin almost
immediately after birth to rid the body of this fluid. This easily increases the daily urine output of a post-
partal patient from a normal level of 1,500 mL to as much as 3,000 mL per day during the second to the
fifth day after birth. This marked increase in urine production causes the bladder to fill rapidly

Bowel

Digestion and absorption begin to be active again soon after birth unless a patient has had a cesarean
delivery. Almost immediately, the patient feels hungry and thirsty and 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 (a hormone
which, during pregnancy, softens and lengthens the cervix and pubic symphysis for preparation of the
infant's birth) on the bowel

Lochia

The separation of the placenta and membranes occurs in the spongy layer or outer portion of the
decidua basalis of the uterus. By the second day after birth, the layer of decidua remaining under the
placental site (an area 7 cm wide) and throughout the uterus differentiates into two distinct layers.
The inner layer attached to the muscular wall of the uterus remains, serving as the foundation from
which a new layer of endometrium will be formed. The layer adjacent to the uterine cavity becomes
necrotic and is cast off as a vaginal discharge similar to a menstrual flow. This flow, consisting of
blood, fragments of decidua, white blood cells, mucus, and some bacteria, is termed lochia.

EPISIOTOMY

Because of the great amount of pressure experienced during birth, the perineum is edematous and
tender immediately after birth. Ecchymosis patches from ruptured capillaries may show on the surface.
The labia majora and labia minora typically remain atrophic and softened after birth, never returning to
their prepregnancy state. Patients may experience various levels of tenderness in the perineum area.

HOMAN’S SIGNS

During the immediate postpartal period, therefore, repetition of a complete examination is not usually
necessary. However, crucial assessments examining particular aspects of health, such as an estimation
of nutrition and fluid state, energy level, presence or absence of pain, breast health, fundal height and
consistency, lochia amount and character, perineal integrity, and circulatory adequacy, are required.

EMOTIONAL STATUS

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, estrogen, and estradiol are all at prepregnancy levels (estriol may take an additional
week before it reaches prepregnancy levels). Follicle-stimulating hormone (FSH) remains low for about
12 days and then begins to rise as a new menstrual cycle is initiated.