The postpartum period, also known as the puerperium, or “the fourth stage of

labor”, starts after delivery of the fetus and the placenta, and it extends through
the first six weeks after birth. During this period, the body gradually returns to
its pre-pregnancy state. There are several complications that can arise during the
postpartum period, and early diagnosis is essential for appropriate management of
these conditions.

Okay, let’s start with some physiology. So, after delivery, the uterus tends to
regress back to its normal size and resume its pre-pregnancy position by the sixth
week, a process known as involution. There are also some physiological changes that
occur during pregnancy that begin to change back to pre-pregnancy levels in the
postpartum period. For example, during pregnancy there is increased blood plasma
volume in relation to red blood cell mass. As a consequence, maternal hemoglobin
and hematocrit are usually relatively low during pregnancy, since the same amount
of red blood cells are circulating in a higher volume of blood. After delivery,
through increased diuresis or urine production, and increased diaphoresis or sweat
production, blood volume returns to normal in about 6 to 12 weeks, and hemoglobin,
and hematocrit levels normalize within 4 to 6 weeks. Likewise, during pregnancy,
plasma fibrinogen and other pro-coagulant factors increase, and they stay elevated
until 4 to 6 weeks following delivery.

Now, there are some complications that can happen during the postpartum period, the
main one being postpartum hemorrhage, meaning excessive blood loss following
delivery. Other common complications include injuries to the genital tract, such as
hematomas and lacerations. Hematomas are localized collections of blood that
commonly affect the vulva, vagina, and perineum. They can cause significant pain
and discomfort, and large hematomas can cause hemodynamic instability and even
hypovolemic shock.

Lacerations, on the other hand, can affect the uterus, cervix, vagina and the
perineum. Perineal lacerations can be classified in 4 degrees. First degree
lacerations are when the tear doesn’t go past the fourchette, which is where the
two labia minora meet posteriorly. Second degree lacerations extend past the
fourchette, but they don’t involve the anal sphincter. Third degree lacerations may
extend as far as the internal anal sphincter. Finally, fourth degree lacerations
reach all the way to the rectal mucosa.

Next up, there are thromboembolic complications, like deep vein thrombosis, which
is when a blood clot develops in one of the major veins, typically those of the
lower leg. This clot can then break off and get lodged in other vessels, which can
cause potentially life-threatening complications like a pulmonary embolism.

Now, infections can also occur during the postpartum period, and typically they
only cause a fever, malaise and possibly tachycardia. However, left untreated, the
infection can progress to potentially life-threatening septic shock or disseminated
intravascular coagulation.

Up next, there are placenta-related complications, like retained placenta, which is

when the placental delivery takes more than 30 minutes; and placenta accreta, which
is a type of retained placenta, where the placenta grows into the uterine wall, and
can’t be removed manually. The main problem with these conditions is that they can
cause severe postpartum hemorrhage which can progress to hypovolemic shock.

Finally, it’s worth mentioning that some hypertensive disorders of pregnancy, like
preeclampsia and eclampsia, can also debut in the postpartum period.

Some common risk factors for developing postpartum complications include extremes
of age, like teenage pregnancy, or age over 35; grand multiparity, meaning 5 or
more previous deliveries; uterine overdistention, like with multiple gestation or
polyhydramnios; preterm delivery and premature rupture of membranes; using certain
medications, like tocolytics or oxytocin; previous uterine surgery, like a previous
cesarean birth; or use of operative procedures during delivery, like cesarean
birth, vacuum extraction and forceps use. Postpartum complications also tend to be
more common in individuals with preexisting health conditions, like diabetes or
heart disease.

Each of these complications has its own clinical manifestations. Clients with
vaginal or vulvar hematomas typically present with deep, severe pain and feelings
of pressure that are not relieved by the usual pain-relief options. There can be
intermittent bleeding, painful or difficult voiding, or emptying their bladder, as
well as discolored, tender swelling over and around the hematoma.

Uterine lacerations typically cause excessive uterine bleeding that continues even
when the fundus contracts firmly; whereas vaginal and perineal lacerations
typically cause bleeding, pain and difficulty voiding.

With thromboembolic complications, most often there is a swollen, red, and painful
lower leg; while a pulmonary embolism can cause dyspnea, cough or hemoptysis.
Infections typically present with fever and tachycardia, and there could be foul
smelling vaginal discharge. Next, the main clinical findings with retained placenta
include excessive bleeding and an inability of the uterus to contract.

The diagnosis of postpartum complications starts with the client’s history and
physical examination. Common lab tests include a CBC, which can show low hemoglobin
and hematocrit in case of hemorrhage; or high WBC count, with an infection.
Inflammatory markers, like CRP and ESR can also be elevated with an infection. A
coagulation panel can also be done to look for abnormalities when suspecting a
thromboembolic event. Imaging studies, like a pelvic ultrasound, can help identify
placental complications; while a CT scan of the chest can help identify or rule out
a pulmonary embolism.

Treating postpartum complications depends on the type of the complication and

addressing the underlying cause. If hemorrhage is severe enough, blood transfusions
might be required. Other options include uterotonic medications, incising and
draining large hematomas; suturing lacerations; or removing the retained placental
fragments from the uterine cavity. More complex surgical procedures, like a
hysterectomy, might be needed when there’s uterine bleeding that can’t be
controlled with other measures. Finally, when an infection is suspected,
antibiotics are typically given and for thromboembolic events, medications like
thrombolytics can be used to dissolve clots.

Alright, let’s look at the care you’ll be providing for a client during the
postpartum period. Your priority goal is to monitor for complications associated
with the postpartum period.

Begin your assessment by monitoring your client’s vital signs in accordance with
your facility’s protocol. Keep in mind that their pulse can be somewhat lower than
normal at first, as their body compensates for the loss of the placenta, as well as
a decrease in intra-abdominal pressure after delivery of the fetus. Blood pressure
can be a little lower due to the normal blood loss that occurs after delivery, or
it may be slightly elevated due to emotional excitement. Be sure to report a heart
rate is more than 100 beats per minute or hypotension, as these may indicate
hemorrhage. In addition, report an elevated blood pressure, such a 140/90 mmHg on 2
or more occasions, as this may indicate preeclampsia. It can be normal for your
client’s temperature to be as high as 100 ° F or 37.8 ° C due to dehydration and
fatigue, but report if their temperature is persistently more than 100.4 ° F or 38
° C, as this could be an indication of infection. Lastly, ask your client about any
pain they are experiencing, and administer the prescribed analgesics, as needed.
Next, use the acronym BUBBLEHE to guide your next assessments. B stands for
breasts, so you’ll want to check both breasts, which are usually soft at this time.
Colostrum can also be present. If your client plans to breastfeed, assist with
positioning their baby at the breast. If you notice potential problems like flat or
retracted nipples, place a referral for a lactation consultant to provide
additional support.

U stands for uterus, which includes an assessment of uterine involution and their
incision if they had a cesarean delivery. Palpate the uterine fundus, which should
be firmly contracted and at midline. If it is soft, gently massage it until it
contracts; and if it is not at midline, assist your client to empty her bladder,
since a full bladder can interfere with uterine involution. Now, remember that the
uterine fundus should be palpated midway between the umbilicus and the symphysis
pubis immediately after birth. Then, as their muscles start to relax, it will rise
up to the level of the umbilicus. After that, the uterus should descend at about 1
cm each day. Findings to report include a soft, boggy uterus that does not remain
firm with massage, or if it does not descend as expected. Lastly, if your client
had a cesarean birth, be sure to check their abdominal incision, which should be
intact with minimal drainage.

B stands for bowel, which means you’ll assess for the return of bowel function,
which typically slows down during the labor process or due to manipulation of the
bowel during a cesarean birth. In addition, your client could be reluctant to have
a bowel movement if they had an episiotomy or a laceration. Apply ice to the
perineum, as needed, and administer the prescribed analgesics. Also assess their
bowel sounds; promote bowel function by encouraging fluids and assisting with
ambulation; and administer the prescribed stool softener.

The next B stands for bladder, which includes monitoring for bladder distention,
and checking the amount and frequency of urination. Be sure to assist your client
to the toilet the first time, since orthostatic hypotension is common due to
hemodynamic changes in the early postpartum period. Also keep in mind that due to
postpartum diuresis, urine output is expected to temporarily increase. So, be sure
to ask them if they are having any difficulty or pain emptying their bladder, and
remember that your client could experience difficulty related to perineal trauma
during delivery, or the effects of anesthesia. Administering pain medications, or
promoting relaxation of the perineal muscles by asking your client to blow bubbles
through a straw can be helpful. Report if the bladder is palpable; if your client
is not able to empty their bladder; or if they frequently void small amounts.
Because a full bladder can interfere with uterine involution and increase the risk
of hemorrhage, anticipate an order for straight catheterization.

L is for lochia, which is the vaginal discharge created as the superficial layer of
the decidua basalis is sloughed off after delivery. Check the color, amount, odor,
and for the presence of clots. Normally, lochia is initially dark red, called
lochia rubra; after 3 to 4 days it starts to become lighter in color, at which time
it’s called lochia serosa; then after about day 10, it takes on a white or
yellowish color, and it’s called lochia alba. The amount of lochia is tracked by
counting the number of perineal pads your client uses, the amount of blood on them,
which can be scant, light, moderate, or heavy; and by their weight. When weighing a
perineal pad, remember that 1 gram equals 1 mL. Assessment findings to report
include a foul odor, which can indicate an infection; or if there are signs of
hemorrhage, including if a pad is saturated in one hour; if the amount of blood
equals 500 mL; or if numerous clots are present. Continue to massage the uterus and
administer the prescribed uterotonic medications.

E is for episiotomy as well as the perineal lacerations. These wounds will have
been repaired in the delivery room, and appear clean, dry, and intact. Think of
REEDA to recall the assessments you’ll need to do if your client had an episiotomy
or laceration. Report the presence of unusual Redness, Edema, Ecchymosis,
Discharge, and if the wound edges are not Approximated, as well as if there’s
excessive pain or tenderness, as these may indicate inflammation and infection.
Apply ice to the perineum for the first 24 hours, offer a sitz bath to reduce pain
and swelling, and administer the prescribed antibiotics, if indicated.

H is for the Homan sign, which is a reminder to check for deep vein thrombosis or
DVT for short, because your client’s coagulability remains elevated during the
postpartum period; and, immobility during labor or cesarean birth can increase the
risk as well. To check that a Homan sign is present, assist your client into a
supine position with their legs straight, grasp their foot, and gentilly dorsiflex
each ankle. Now, the Homan sign may not always indicate a DVT is present, so be
sure to also examine the lower extremities, and report signs of DVT, including
localized redness, heat, edema, tenderness, or a diminished pedal pulse; as well as
a positive Homan sign.

Finally, E stands for emotional status which is focused on promoting parental

confidence in self-care and care of their newborn. Teach your client as you provide
care, encourage them to learn about their newborn, and reinforce successful
parenting behaviors. Also assess the attachment process by observing interactions
with their newborn. Report if you notice emotional lability, disinterest in the
newborn, or if there are risk factors for impaired parenting such a lack of social
support or resources; and be sure to make an urgent referral to your unit’s social
services.

Alright, as a quick recap… During the postpartum period, the body gradually returns
to its pre-pregnancy state. The main complications that can arise during this
period are postpartum hemorrhage; injuries to the genital tract; infections;
thromboembolic complications, and placental complications, like retained placenta
or placenta accreta.

Clinically, with vaginal or vulvar hematomas there’s typically pain, pressure,

painful or difficult voiding, as well as swelling over and around the hematoma.
Uterine lacerations typically cause excessive uterine bleeding that continues even
when the fundus contracts firmly; whereas vaginal and perineal lacerations
typically cause pain and difficulty voiding. Infections typically present with
fever and tachycardia. With deep vein thrombosis, most often there is a swollen,
red, and painful lower leg; while pulmonary embolism can cause dyspnea, cough or
hemoptysis. The main clinical findings with retained placenta include excessive
bleeding and an inability of the uterus to contract.

Diagnosis relies on the history and physical examination, as well as lab work and
sometimes imaging tests, while treatment involves supportive care as well as
addressing the underlying cause. Some surgical procedures, like incising and
draining a hematoma, suturing a laceration, or even a hysterectomy, can also be
used. Other options include antibiotics or thrombolytics, depending on the
complication. Nursing care is mainly focused on assessing complications, which can
be remembered with the BUBBLEHE acronym. This stands for Breasts, Uterus, Bladder,
Bowel, Lochia, Episiotomy, Homan sign and Emotional status.