NURS 3358 - OB Exam 2 Study Guide.
“Postpartum Care And Postpartum Complications”
Nursing Process
• Initial Assessment
o Physical – body Systems and lab work
▪ CBC and lab work can show how much blood she has lost.
o Psychosocial
• Development of Nursing Care Plan – physical and educational needs
• Nursing Diagnoses
o Risk for bleeding / Risk for fluid volume deficit
o Risk for impaired CO / Risk for decreased tissue perfusion
o Risk for infection
o Acute pain
o Knowledge deficit R/T self-care, newborn care, or breastfeeding
o Breastfeeding, ineffective or interrupted
o Alteration in bowel or urinary elimination
o Risk for impaired attachment or impaired parenting
o Disturbed sleep patterns
• Expected Outcomes
o Involution and return to pre-pregnancy state will be accomplished without complications
o Parental roles will be successfully assumed
o New baby will be successfully integrated into family structure
o Successful infant feeding patterns will be established
• Plan of Care
o Orientation to the unit
o Prevention of excessive bleeding
▪ Maintenance of uterine tone
▪ Prevention of bladder distention
o Prevention of infection
o Promotion of comfort, rest, ambulation, and exercise
o Patient teaching:
▪ Self-care
▪ Newborn feeding and care
• Interventions
o Lab work: CBC, Rubella titer
o Medications:
▪ Iron/prenatal vitamins
▪ Analgesics
▪ RhoGAM administration (if Rh negative)
▪ Rubella Titer (if not immune) – 1:8 = immune
▪ Vaccines: Varicella, Tdap
▪ Depo-Provera or other contraceptives
• Evaluation of Outcomes
o Involution successfully initiated and progressing without complication
▪ Uterus returning back to its pre-pregnant state.
o Parents begin to assume new role behaviors and identities
o Beginning integration of newborn into family structure; bonding established
o Infant feeding techniques mastered
o Parents comfortable with infant care
Postpartum Assessment:
• Six B’s: Bleeding, Breasts, Bladder, Bowels, Bottom, Bonding
• BUBBLEHE
o Breasts
o Uterus
o Bladder
o Bowel
o Lochia
o Episiotomy
o High risk clots
o Emotional
Postpartum Period:
,NURS 3358 - OB Exam 2 Study Guide.
• Six-week period following birth in which the mother’s body undergoes anatomic and physiologic changes to reverse pregnancy
changes; body systems return to (nearly) nonpregnant state.
o Begins at the fourth stage of labor (the first 1-2 hours after birth)
o Puerperium – 6-week period in which the mother’s body undergoes anatomic and physiologic changes to reverse pregnancy changes
o Body systems return to (nearly) non-pregnant state
o May or may not include the return of the ovulatory/menstrual cycle
Reproductive System and Associated Structures:
• Uterus
o Involution Process
▪ Involution – the return of the uterus to a non-pregnant state – begins immediately after delivery of placents with contractions
of smooth muscle of uterus
▪ Subinvolution – failure of uterus to return to non-pregnant state
• Most common cause: retained placental fragments and infection
▪ Approximately the size of a grapefruit – varies with parity, size of baby and mother
▪ Autolysis of hypertrophied tissue
▪ Estrogen and progesterone stimulated massive growth of uterus during pregnancy
▪ After birth the decrease in these hormones causes autolysis of hypertrophied tissue
▪ Additional cells laid down during pregnancy remain; hence uterus never truly returns to non-pregnant size and accounts for
slight increase in size with each pregnancy
o Contractions
▪ Uterine contractions compress the intramyometrial blood vessels to stop bleeding at placental site (as opposed to
platelet aggregation and clot formation)
▪ Oxytocin strengthens and coordinates these contractions
▪ Pitocin – IM or IV after expulsion of placent; can be given IU with C/Section
▪ Afterpains – uncomfortable cramping caused by contraction of the uterus; resolves in 3-7 days
• Increased with breastfeeding, multiparity, multiple fetuses, or conditions that causes uterine over-distention
• Also called afterbirth pains
▪ Breastfeeding (nipple stimulation) helps uterus to contract
o Assessment
▪ Fundus – assess firmness and location; should be midline and at or below the umbilicus
▪ Evaluate with bladder empty and woman lying supine with head slightly raised
▪ If displaced to the side or above the umbilicus, indicates full bladder which can cause uterine atony
▪ Descends 1-2 cm per day
• By day 12 it returns as a pelvic organ
• After 2 weeks it is non-palpable
▪ Document:
• Fundal height
• Firm or boggy
o If boggy then massage
• Complaints of afterpains
o Placental Site
▪ Placental site becomes an irregular nodular elevated area due to vascular constriction and thromboses
▪ Upward growth of the endometrium causes sloughing of necrotic tissue and prevents scar formation
• Permits implantation for future pregnancies
▪ Complete by the 16th day postpartum, except at the placental site which is healed by 6 weeks
o Lochia
▪ Vaginal discharge during the puerperium consisting of blood, endometrial tissue and mucus
▪ Color
• Days 1-4: Lochia Rubra – dark red
o Consisting mainly of blood and debris
• Days 4-10 Lochia Serosa – serous, pink/brownish
o Consisting of old blood, serum, leukocytes, and tissue debris
• Starts on day 10-14 and lasting 4-8 weeks’ post-birth: Lochia Alba - thin, yellowish to white discharge
o Consisting of leukocytes, decidua, epithelial cells, mucus, serum, and bacteria
▪ Amount
• Scant, light, moderate, or heavy
• Should not have clots larger than a dime
• Anticipate increased flow the first time the woman ambulates or breastfeeds; may feel a gush – do not confuse with
a hemorrhage
• The amount may increase upon standing after sleeping, due to pooling in the vagina/uterus
• Large or excessive clots indicates possible uterine atony and hemorrhage
• The amount may be less in C/S mothers, but the stages remain the same (rubra serosa alba)
• May feel gush with breastfeeding
,NURS 3358 - OB Exam 2 Study Guide.
• Total amount: 240-270 cc
▪ Normal odor is the same as menstrual flow – call MD if odor becomes foul smelling
▪ DANGER SIGNS:
• Reappearance of bright red blood after rubra has stopped
• Persistence of lochia rubra – possible retained placental fragments or membranes
• Sudden, but brief, increase in bleeding 7-14 days after birth can occur due to sloughing of eschar over placental site
• Notify provider if does not subside within 1-2 hours
• 10%-15% women have normal lochia serosa at 6 week visit
• Continued flow of serosa or alba by 3-4 weeks postpartum can indicate endometritis, especially with fever, pain
or abdominal tenderness
• Not all vaginal bleeding is lochia!! Differentiate between lochia and vaginal, cervical or uterine tear that needs repair
▪ Box 20-1 Lochial and Nonlochial Bleeding
• Lochial:
o Lochia usually trickles from the vaginal opening, with the steady flow increasing as the uterus contracts
o A gush of lochia can appear as the uterus is massaged
o If it is dark in color, it has been pooled in the relaxed vagina
o Amount soon lessens to a trickle of bright red lochia (in the early puerperium)
• Nonlochial:
o If the blood discharge spurts from the vagina, and the uterus is firmly contracted, there can be cervical or vaginal
tears in addition to the normal lochia
o If the amount of bleeding continues to be excessive and bright red, a tear can be the source
▪ Uterus and Lochia Assessment
• Uterine and lochia assessment is ALWAYS assessed together
• Consider parity, size of baby and gestational age, size of mother, length of labor, use of oxytocin, bladder status
• Differentiate between lochial and non-lochial bleeding – is there a tear or laceration?
• Cervix
o Immediately after birth:
▪ Spongy, flabby, bruised, with small lacerations – risk for infection!
▪ Over the next 12-18 hours, it shortens and becomes firmer
o Closes slowly – admits 1 fingertip by 1 week postpartum
o Shape of the cervical os does not return to normal round dimple, but instead changes to a slit
• Vagina
o Edematous and bruised with superficial lacerations
o Not all lacerations sutures
o Rugae is obliterated – vaginal wall with be smooth for 3-4 weeks
▪ Rugae will reappear, although not as prominent as pre-pregnant
o Hypoestrogenic until ovulation and menstruation resume
▪ Estrogen deprivation responsible for the thinnest of the vaginal mucosa and absence of rugae
• Perineum
o Perineal lacerations
▪ 1st degree – skin & superficial tissue
▪ 2nd degree – extends through muscles
▪ 3rd degree – continues through anal sphincter muscle
▪ 4th degree – involves anterior rectal wall
• Nursing interventions:
o Assess site, keep clean, ice packs, analgesics
o Teach pt comfort measures, high fiber diet, stool softeners, increased fluids (3rd/4th degree)
o Episiotomy
o Hemorrhoids
o Hematoma
o Perineal Comfort Measures
• Ovulation and Menstruation
o Non-lactating Mothers:
▪ Period returns as early as 27 days after birth
▪ Mean length of time is 70-75 days
▪ Many women ovulate before the return of menses
▪ Ovulation may occur one month after childbirth
o Lactating Mothers:
▪ Prolactin level remains elevated
▪ Mean length of time until initial ovulation is 6 months
▪ Dependent on the duration of each feeding, the frequency, and the amount of supplemental feedings
▪ Not a reliable method of birth control
• Nursing Interventions for Reproductive System
o Cervical and Vaginal Changes
, NURS 3358 - OB Exam 2 Study Guide.
▪ Assess for s/s of abnormal bleeding
▪ Report abnormal findings
▪ Teach Kegel exercises (pg. 92)
▪ Use of water-soluble lubricant when resuming sexual relations
o Episiotomy
▪ Document if midline or mediolateral (right or left)
▪ Assess episiotomy for REEDA-D
• Redness
• Edema
• Ecchymosis
• Approximation
• Discharge
▪ Assess for tears or lacerations
▪ Teach mother that healing takes about 2 weeks
▪ If perineum is intact – assess for ecchymosis and edema
o Comfort Measures for “Bottom”
▪ Ice packs for the first 24 hours
▪ Analgesia:
• Oral meds and/or topical meds (foam or spray)
▪ Perineal care performed with peri-bottle and water with blot drying from front to back each time woman voids or stools
▪ Positioning:
• Crawl into bed
• Perform Kegel before sitting
• Lie on side
▪ Take stool softener
▪ Tucks – also helps with hemorrhoids
▪ Sitz bath (after first 24 hours)
▪ Hospital gown should be worn at least for the first day
o Pharmacologic Pain Relief
▪ Opioids: Percocet, Meperidine, Morphine
• A PCA pump is often ordered for C/S patients
▪ NSAIDs: Naproxen Sodium
• Toradol or Ketorolac for C/S moms
▪ Topical antiseptic, anesthetic spray or ointment for pain
o Postpartum Sexual Activity
▪ Follow primary HCP orders
▪ Pelvic rest for 6 weeks****
• Can increase risk for intrauterine infection because placental site doesn’t heal for 6 weeks
▪ Abstain until episiotomy has healed, lochial flow has stopped, and there is no vaginal discharge
• If there is a vaginal discharge, they should remain from having sex
▪ Use an additional lubricant (dryness is a result of hormonal deficit)
▪ Contraceptive/family planning should be considered
▪ Body image concerns; breastfeeding; exhaustion
▪ Consider different positions for comfort; encourage creativity! J
Musculoskeletal System
• Abdomen
o Abdominal muscles are relaxed for the first 2 weeks after birth and the return of pre-pregnancy muscle tone takes about 6 weeks
o Diastasis recti abdominis – condition where the abdominal wall muscles separate with large fetus or multifetal pregnancy
▪ Becomes less apparent with time
o The abdomen may still appear pregnant
o Joints stabilize by 6-8 weeks
o Feet may permanently remain a larger shoe size
o Do postpartal exercises
Integumentary System
• Most skin changes during pregnancy resolve following pregnancy
• Melasma (chloasma)-persists in 30% women
• Hyperpigmentation of areola & linea nigra
• Striae gravidarum – lighten, regress in size
• Spider angiomas (nevi) – may persist
• Palmar erythema regresses
• Hair loss; fine hair from pregnancy disappears
• Nails return to prepregnant status
“Postpartum Care And Postpartum Complications”
Nursing Process
• Initial Assessment
o Physical – body Systems and lab work
▪ CBC and lab work can show how much blood she has lost.
o Psychosocial
• Development of Nursing Care Plan – physical and educational needs
• Nursing Diagnoses
o Risk for bleeding / Risk for fluid volume deficit
o Risk for impaired CO / Risk for decreased tissue perfusion
o Risk for infection
o Acute pain
o Knowledge deficit R/T self-care, newborn care, or breastfeeding
o Breastfeeding, ineffective or interrupted
o Alteration in bowel or urinary elimination
o Risk for impaired attachment or impaired parenting
o Disturbed sleep patterns
• Expected Outcomes
o Involution and return to pre-pregnancy state will be accomplished without complications
o Parental roles will be successfully assumed
o New baby will be successfully integrated into family structure
o Successful infant feeding patterns will be established
• Plan of Care
o Orientation to the unit
o Prevention of excessive bleeding
▪ Maintenance of uterine tone
▪ Prevention of bladder distention
o Prevention of infection
o Promotion of comfort, rest, ambulation, and exercise
o Patient teaching:
▪ Self-care
▪ Newborn feeding and care
• Interventions
o Lab work: CBC, Rubella titer
o Medications:
▪ Iron/prenatal vitamins
▪ Analgesics
▪ RhoGAM administration (if Rh negative)
▪ Rubella Titer (if not immune) – 1:8 = immune
▪ Vaccines: Varicella, Tdap
▪ Depo-Provera or other contraceptives
• Evaluation of Outcomes
o Involution successfully initiated and progressing without complication
▪ Uterus returning back to its pre-pregnant state.
o Parents begin to assume new role behaviors and identities
o Beginning integration of newborn into family structure; bonding established
o Infant feeding techniques mastered
o Parents comfortable with infant care
Postpartum Assessment:
• Six B’s: Bleeding, Breasts, Bladder, Bowels, Bottom, Bonding
• BUBBLEHE
o Breasts
o Uterus
o Bladder
o Bowel
o Lochia
o Episiotomy
o High risk clots
o Emotional
Postpartum Period:
,NURS 3358 - OB Exam 2 Study Guide.
• Six-week period following birth in which the mother’s body undergoes anatomic and physiologic changes to reverse pregnancy
changes; body systems return to (nearly) nonpregnant state.
o Begins at the fourth stage of labor (the first 1-2 hours after birth)
o Puerperium – 6-week period in which the mother’s body undergoes anatomic and physiologic changes to reverse pregnancy changes
o Body systems return to (nearly) non-pregnant state
o May or may not include the return of the ovulatory/menstrual cycle
Reproductive System and Associated Structures:
• Uterus
o Involution Process
▪ Involution – the return of the uterus to a non-pregnant state – begins immediately after delivery of placents with contractions
of smooth muscle of uterus
▪ Subinvolution – failure of uterus to return to non-pregnant state
• Most common cause: retained placental fragments and infection
▪ Approximately the size of a grapefruit – varies with parity, size of baby and mother
▪ Autolysis of hypertrophied tissue
▪ Estrogen and progesterone stimulated massive growth of uterus during pregnancy
▪ After birth the decrease in these hormones causes autolysis of hypertrophied tissue
▪ Additional cells laid down during pregnancy remain; hence uterus never truly returns to non-pregnant size and accounts for
slight increase in size with each pregnancy
o Contractions
▪ Uterine contractions compress the intramyometrial blood vessels to stop bleeding at placental site (as opposed to
platelet aggregation and clot formation)
▪ Oxytocin strengthens and coordinates these contractions
▪ Pitocin – IM or IV after expulsion of placent; can be given IU with C/Section
▪ Afterpains – uncomfortable cramping caused by contraction of the uterus; resolves in 3-7 days
• Increased with breastfeeding, multiparity, multiple fetuses, or conditions that causes uterine over-distention
• Also called afterbirth pains
▪ Breastfeeding (nipple stimulation) helps uterus to contract
o Assessment
▪ Fundus – assess firmness and location; should be midline and at or below the umbilicus
▪ Evaluate with bladder empty and woman lying supine with head slightly raised
▪ If displaced to the side or above the umbilicus, indicates full bladder which can cause uterine atony
▪ Descends 1-2 cm per day
• By day 12 it returns as a pelvic organ
• After 2 weeks it is non-palpable
▪ Document:
• Fundal height
• Firm or boggy
o If boggy then massage
• Complaints of afterpains
o Placental Site
▪ Placental site becomes an irregular nodular elevated area due to vascular constriction and thromboses
▪ Upward growth of the endometrium causes sloughing of necrotic tissue and prevents scar formation
• Permits implantation for future pregnancies
▪ Complete by the 16th day postpartum, except at the placental site which is healed by 6 weeks
o Lochia
▪ Vaginal discharge during the puerperium consisting of blood, endometrial tissue and mucus
▪ Color
• Days 1-4: Lochia Rubra – dark red
o Consisting mainly of blood and debris
• Days 4-10 Lochia Serosa – serous, pink/brownish
o Consisting of old blood, serum, leukocytes, and tissue debris
• Starts on day 10-14 and lasting 4-8 weeks’ post-birth: Lochia Alba - thin, yellowish to white discharge
o Consisting of leukocytes, decidua, epithelial cells, mucus, serum, and bacteria
▪ Amount
• Scant, light, moderate, or heavy
• Should not have clots larger than a dime
• Anticipate increased flow the first time the woman ambulates or breastfeeds; may feel a gush – do not confuse with
a hemorrhage
• The amount may increase upon standing after sleeping, due to pooling in the vagina/uterus
• Large or excessive clots indicates possible uterine atony and hemorrhage
• The amount may be less in C/S mothers, but the stages remain the same (rubra serosa alba)
• May feel gush with breastfeeding
,NURS 3358 - OB Exam 2 Study Guide.
• Total amount: 240-270 cc
▪ Normal odor is the same as menstrual flow – call MD if odor becomes foul smelling
▪ DANGER SIGNS:
• Reappearance of bright red blood after rubra has stopped
• Persistence of lochia rubra – possible retained placental fragments or membranes
• Sudden, but brief, increase in bleeding 7-14 days after birth can occur due to sloughing of eschar over placental site
• Notify provider if does not subside within 1-2 hours
• 10%-15% women have normal lochia serosa at 6 week visit
• Continued flow of serosa or alba by 3-4 weeks postpartum can indicate endometritis, especially with fever, pain
or abdominal tenderness
• Not all vaginal bleeding is lochia!! Differentiate between lochia and vaginal, cervical or uterine tear that needs repair
▪ Box 20-1 Lochial and Nonlochial Bleeding
• Lochial:
o Lochia usually trickles from the vaginal opening, with the steady flow increasing as the uterus contracts
o A gush of lochia can appear as the uterus is massaged
o If it is dark in color, it has been pooled in the relaxed vagina
o Amount soon lessens to a trickle of bright red lochia (in the early puerperium)
• Nonlochial:
o If the blood discharge spurts from the vagina, and the uterus is firmly contracted, there can be cervical or vaginal
tears in addition to the normal lochia
o If the amount of bleeding continues to be excessive and bright red, a tear can be the source
▪ Uterus and Lochia Assessment
• Uterine and lochia assessment is ALWAYS assessed together
• Consider parity, size of baby and gestational age, size of mother, length of labor, use of oxytocin, bladder status
• Differentiate between lochial and non-lochial bleeding – is there a tear or laceration?
• Cervix
o Immediately after birth:
▪ Spongy, flabby, bruised, with small lacerations – risk for infection!
▪ Over the next 12-18 hours, it shortens and becomes firmer
o Closes slowly – admits 1 fingertip by 1 week postpartum
o Shape of the cervical os does not return to normal round dimple, but instead changes to a slit
• Vagina
o Edematous and bruised with superficial lacerations
o Not all lacerations sutures
o Rugae is obliterated – vaginal wall with be smooth for 3-4 weeks
▪ Rugae will reappear, although not as prominent as pre-pregnant
o Hypoestrogenic until ovulation and menstruation resume
▪ Estrogen deprivation responsible for the thinnest of the vaginal mucosa and absence of rugae
• Perineum
o Perineal lacerations
▪ 1st degree – skin & superficial tissue
▪ 2nd degree – extends through muscles
▪ 3rd degree – continues through anal sphincter muscle
▪ 4th degree – involves anterior rectal wall
• Nursing interventions:
o Assess site, keep clean, ice packs, analgesics
o Teach pt comfort measures, high fiber diet, stool softeners, increased fluids (3rd/4th degree)
o Episiotomy
o Hemorrhoids
o Hematoma
o Perineal Comfort Measures
• Ovulation and Menstruation
o Non-lactating Mothers:
▪ Period returns as early as 27 days after birth
▪ Mean length of time is 70-75 days
▪ Many women ovulate before the return of menses
▪ Ovulation may occur one month after childbirth
o Lactating Mothers:
▪ Prolactin level remains elevated
▪ Mean length of time until initial ovulation is 6 months
▪ Dependent on the duration of each feeding, the frequency, and the amount of supplemental feedings
▪ Not a reliable method of birth control
• Nursing Interventions for Reproductive System
o Cervical and Vaginal Changes
, NURS 3358 - OB Exam 2 Study Guide.
▪ Assess for s/s of abnormal bleeding
▪ Report abnormal findings
▪ Teach Kegel exercises (pg. 92)
▪ Use of water-soluble lubricant when resuming sexual relations
o Episiotomy
▪ Document if midline or mediolateral (right or left)
▪ Assess episiotomy for REEDA-D
• Redness
• Edema
• Ecchymosis
• Approximation
• Discharge
▪ Assess for tears or lacerations
▪ Teach mother that healing takes about 2 weeks
▪ If perineum is intact – assess for ecchymosis and edema
o Comfort Measures for “Bottom”
▪ Ice packs for the first 24 hours
▪ Analgesia:
• Oral meds and/or topical meds (foam or spray)
▪ Perineal care performed with peri-bottle and water with blot drying from front to back each time woman voids or stools
▪ Positioning:
• Crawl into bed
• Perform Kegel before sitting
• Lie on side
▪ Take stool softener
▪ Tucks – also helps with hemorrhoids
▪ Sitz bath (after first 24 hours)
▪ Hospital gown should be worn at least for the first day
o Pharmacologic Pain Relief
▪ Opioids: Percocet, Meperidine, Morphine
• A PCA pump is often ordered for C/S patients
▪ NSAIDs: Naproxen Sodium
• Toradol or Ketorolac for C/S moms
▪ Topical antiseptic, anesthetic spray or ointment for pain
o Postpartum Sexual Activity
▪ Follow primary HCP orders
▪ Pelvic rest for 6 weeks****
• Can increase risk for intrauterine infection because placental site doesn’t heal for 6 weeks
▪ Abstain until episiotomy has healed, lochial flow has stopped, and there is no vaginal discharge
• If there is a vaginal discharge, they should remain from having sex
▪ Use an additional lubricant (dryness is a result of hormonal deficit)
▪ Contraceptive/family planning should be considered
▪ Body image concerns; breastfeeding; exhaustion
▪ Consider different positions for comfort; encourage creativity! J
Musculoskeletal System
• Abdomen
o Abdominal muscles are relaxed for the first 2 weeks after birth and the return of pre-pregnancy muscle tone takes about 6 weeks
o Diastasis recti abdominis – condition where the abdominal wall muscles separate with large fetus or multifetal pregnancy
▪ Becomes less apparent with time
o The abdomen may still appear pregnant
o Joints stabilize by 6-8 weeks
o Feet may permanently remain a larger shoe size
o Do postpartal exercises
Integumentary System
• Most skin changes during pregnancy resolve following pregnancy
• Melasma (chloasma)-persists in 30% women
• Hyperpigmentation of areola & linea nigra
• Striae gravidarum – lighten, regress in size
• Spider angiomas (nevi) – may persist
• Palmar erythema regresses
• Hair loss; fine hair from pregnancy disappears
• Nails return to prepregnant status
