UNIT 3: Postpartum/Newborn Study Guide (Murray & McKinney, 6th Ed.)
Chapter 17 Postpartum-Physical p. 329-350
1. Describe the three processes of uterine involution and uterine descent.
a. Involution
i. Contraction of muscle fibers
ii. Catabolism: the process of converting cells into simpler compounds
iii. Regeneration of the uterine epithelium
b. Uterine descent
i. Immediately after delivery uterus is softball size and weighs 1000 g. fundus
can be palpated midway btwn symphysis pubis and umbilicus, midline of
abd.
ii. In 12 hours it is level with umbilicus
iii. Descends 1 cm/day. By day 14 it is in the pelvic cavity and can no longer be
palpated.
iv. Descent documented in relation to umbilicus. U-1 or ↓1 fundus is palpable 1
cm below umbilicus.
v. Weight: week 1 decreases to 500 g; 4 wks: 100 g or less
2. Discuss factors the enhance or slow uterine involution.
a. More than one fetus
b. A large fetus
c. Hydramnios
3. Define afterpains and discuss the severity and nursing considerations.
a. Intermittent uterine contrxs.
b. More painful in the multipara since their uterus has been stretched rptdly. Can be
severe if uterus has been overdistended or if retained blood clots remain. Particularly
severe during breast feeding.
c. NC: give analgesics – they won’t harm the baby in small doses and will help with
milk ejection. Lie in prone position with a small pillow/blanket under the abdomen
keeps the uterus contrxd. Afterpains are self-limiting and disappear in time.
4. Be very familiar with the characteristics and amounts of lochia (note table 17-1 – pg.
329).
a. Color
i. Lochia rubra: dark red or brown color (days 1-3)
ii. Lochia serosa: red to pink to brown-tinged (days 3-10)
iii. Lochia alba: white, cream, light yellow (day 10-up to 6 wks)
b. Amount
i. Scant: less than 2.5 cm
ii. Light: less than 10 cm
iii. Moderate: less than 15 cm
iv. Heavy: saturated peripad in 1 hour
v. Excessive: saturated peripad in 15 min
5. Describe post-partal changes in the cervix, vagina and perineum.
a. Cervix: shrinks and the os is now slit-like instead of a circle.
b. Vagina: rugae return by 3-4 weeks, vaginal epithelium returns in 6-10 weeks. It
regains tone and decreases in size, but doesn’t go back to original shape.
1
, c. Perineum: episiotomy will heal fully in 4-6 months. May be edematous and bruised,
but that will subside. Women may experience hemorrhoids.
6. Interpret post-partal vital signs and lab values.
a. WBC: 14-16xxx – can go all the way to 30xxx
b. Hematocrit is low because of excess plasma. Returns to normal as plasma is lost.
c. Plasma fibrinogen and other clotting factors are increased. Fibrinolytic activity is
decreased during pregnancy and shoots back up postpartum.
7. Examine the GI, GU, musculoskeletal, integumentary, neurologic and endocrine system.
a. GI: mom becomes hungry, thirsty, and digestion becomes active again. Constipation
and gas are common. Small, hard stools. First stool usually occurs within 2-3 days.
Normal patterns return in 8-14 days.
b. GU: kidneys fcn normally by 4 weeks. Dilation of renal pelvis/ureters ends in 2-8
weeks. Protein and acetone can be in urine first few days. Bladder has increased
capacity and decreased tone. Urethra, bladder, and urinary meatus tissues may be
edematous. Urinary sensation is diminished. UTIs can occur because of urinary
stasis. Decreased uterine contractility can lead to bloody urine or excessive bleeding.
Stress incontinence may occur.
c. MS: shoulder, neck, arm muscle aches 1-2 days postpartum. Hip/joint pain because
of loss of relaxin makes them stiffen to prepregnancy state. Abd muscle tone is
diminished, will be weak, soft, and flabby. May have diastasis recti (separated abd
musc) that usually goes back to normal by 6 weeks.
d. IT: melisma (mask of pregnancy), linea nigra fade. Spider nevi/palmar erythema
fade. Stretch marks DON’T fade!! Hair loss starts 4-20 wks postpartum, but it comes
back in 4-6 months.
e. NL: body aches/pains common after birth and can cause inability to sleep.
Anesthesia/analgesia can cause lack of feeling in legs and dizziness. Headaches are
common in first week. Extreme headaches should be reported to MD because they
could lead to something worse. Headache with photophobia, blurred vision,
proteinuria, abd pain could be signs of worsening preeclampsia. Pain continues upon
checkout of hosp.
f. EC: estrogen, progesterone, human placental lactogen quickly drop after placenta is
delivered. Prolactin drops if mom is not breastfeeding. Ovulation resumes as soon as
3 wks postpartum, most return 6-8 wks. Menses may return anywhere from 12 wks-
18 mns in breastfeeding moms. 4.5-8.5 lbs are lost during birth, 5-8 lbs from
diuresis, 2-3 lbs from involution/lochia.
8. Be prepared to teach a patient regarding ovulation, menstruation, lactation and weight
loss.
a. Ovulation: can return in 3 wks, use birth control
i. Both ↓ and ↑ return earlier in those who don’t breastfeed, use supplements, or
ween earlier
b. Menstruation: can return 12 wks – 18 mns.
c. Lactation: doesn’t occur until estrogen and progesterone drop. Prolactin stimulates
mild production w/in 2-3 days. Oxytocin necessary for milk ejection.
d. Weight loss: 10-13 lb lost during birth. 5-8 lb lost d/t diuresis. 2-3 lbs from
involution/lochia. Greatest loss in first 3 months, most women with good diets are
back down to prepregnancy weight w/in 1 yr. Provide diet/exercise info to frustrated
moms and inform them of the healthiest weight loss for them and the baby.
2
,9. Assess a patient after a vaginal birth including her potential need for Rhogam and
Rubella.
a. Initial: assess VS, skin color, location/firmness of fundus, amt/color of lochia,
perineum (edema, episiotomy, lacerations, hematoma), presence/degree/location of
pain, IV infusions (type, rate, redness/pain/erythema of site), urinary output
(time/amt of last void, presence of cath, color/characteristic of urine), status of abd
incision/dressing if present, level of feeling and ability to move if regional anesthesia
was administered.
b. Chart: gravida/para, time/type of delivery (c/s, use of vacuum/forceps),
presence/degree of epis./lacerations, anesthesia/meds administered, significant
med/surg hx (diabetes, htn, heart disease), meds given during labor/delivery or
regularly and their uses, food/drug allergies, method of infant feeding, condition of
baby, lab data (prenatal hgb/hct), blood type, Rh factor, hep B surface antigen, rubella
immune status, syphilis screen, group B strep status.
c. Rhogam: if mom is Rh-negative and baby is Rh-positive and mom is not sensitized
to it. Should be admin 72 hrs after birth to prevent maternal antibodies to future
babies.
d. Rubella: if mom is not immune to rubella, must receive shot to prevent her from
acquiring it during future pregnancies. Women should not become pregnant in first
28 days after vaccine.
10. Describe post-partum nursing care after a vaginal and a cesarean birth.
a. Vaginal
i. Ice packs: until the ice melts, wait 10 mins, apply a new one, make sure they
have feeling in peri area to avoid cold burns
ii. Sitz baths: 2-4x/day for women with epis’s/painful hemorrhoids/peri edema,
cold most effective in first 24 hours/warm water after 24 hrs, pat and dry
iii. Peri care: squirting warm water after each void/BM, pat and dry; anesthetic
sprays
iv. Sitting: squeeze buttocks together before sitting and lower slowly to butt.
Prevents stretching of peri area and sharp impact to area. Sitting on 1 side is
helpful
v. Analgesics: take meds for afterpains. Make sure moms don’t receive higher
than 4 g in a 24 hr period.
vi. Bladder elim: as soon as mom is ambulatory, allow plenty of time for new
mom to urinate for the first time. May have to: medicate for pain, run water
in sink/shower, place mom’s hand in warm water, run warm water over the
vulva, provide fluids, have mom blow bubbles into straw, put her in a sitz
bath. May need to cath if unable to void.
vii. Fluids/food: should drink 2500 mls/day, be culturally sensitive to hot/cold
fluid preferences, may need to IV fluids, give healthy food choices and lots
of it, be culturally sensitive
b. Cesarean
i. Pain relief: can be PCA, PCEA (pt controlled epidural analgesia), epidural,
oral analgesics, IM analgesics. WATCH RESPIRATIONS!!!
ii. Abd: assess GI fcn, listen for bowel sds, watch for paralytic ileus, assess
dressing and drainage, assess incision, assess fundus (GENTLE palpation)
iii. I&O: monitor IV, give ice chips and clear fluids, assess urine characteristics
iv. Immobility: TCDB every 2 hrs while awake since she is on bedrest first 8-12
hrs, splint abd, flex knees/move legs frequently, gradually increase mobility,
support while ambulatory
3
, v. Comfort: pillow behind back/btwn knees, excellent physical care
vi. Resume normal activities: cath removed, back on normal diet,
staples/dressing removed
vii. Help find comfortable way to breastfeed the baby
viii. Prevent abd distension: early ambulation, tighten/relax abd musc, avoid
carbonated bevs/straws, pelvic lifts, simethicone, rectal suppositories
11. Review postpartum discharge teaching topics (note table 17-3 pg. 349 for topics).
a. Uterine massage
b. Lochia norms
c. Involution
d. Epis. Care
e. Care of abd incisions
f. Breast care for lactating/nonlactating moms
g. Bowel/urinary fcn
h. Nutrition
i. Rest
j. Exercise
k. Sexual activity/contraception
l. Postpartum danger signs
m. Follow-up care
n. Meds
o. Emotional responses and postpartum depression
p. Infant care/feeding
q. Family adjustment
r. Available resources
Chapter 18 Postpartum-Psychosocial p. 351-367
1. Differentiate the puerperal phases of maternal adaptation described by Rubin.
a. Taking-in: mom is focused mainly on her own need for fluid, food, sleep. Present
passive, dependent behavior and let others make her decisions. Lasts less than a day
to 2 days.
b. Taking-hold: mom becomes more independent of her own care. When she is in
control of herself, she focuses more on the baby. Compares her infant to others.
Might look for advice on mothering and express anxiety about her mothering
abilities. Lasts several days. Called the “teachable, reachable, referable moment.”
c. Letting-go: parents must let go of their old selves and take on their new roles. Must
also give up their idealized expectations of birth. Mom focuses on her rltnshp w/her
partner. May also return to work.
2. Identify the stages of maternal role attainment as described by Mercer.
a. Anticipatory stage: pregnant woman chooses OB or midwife and location for the
birth. May attend childbirth classes. Seeks out maternal role models.
b. Formal stage: birth – 4-6 weeks. Behaviors largely guided by others like health pros,
friends/parents. Parents become acquainted with baby.
c. Informal stage: begins when moms learn appropriate responses to their baby’s
cues/signals. Moms respond to unique needs of their baby and maternal role is
developed.
4
Chapter 17 Postpartum-Physical p. 329-350
1. Describe the three processes of uterine involution and uterine descent.
a. Involution
i. Contraction of muscle fibers
ii. Catabolism: the process of converting cells into simpler compounds
iii. Regeneration of the uterine epithelium
b. Uterine descent
i. Immediately after delivery uterus is softball size and weighs 1000 g. fundus
can be palpated midway btwn symphysis pubis and umbilicus, midline of
abd.
ii. In 12 hours it is level with umbilicus
iii. Descends 1 cm/day. By day 14 it is in the pelvic cavity and can no longer be
palpated.
iv. Descent documented in relation to umbilicus. U-1 or ↓1 fundus is palpable 1
cm below umbilicus.
v. Weight: week 1 decreases to 500 g; 4 wks: 100 g or less
2. Discuss factors the enhance or slow uterine involution.
a. More than one fetus
b. A large fetus
c. Hydramnios
3. Define afterpains and discuss the severity and nursing considerations.
a. Intermittent uterine contrxs.
b. More painful in the multipara since their uterus has been stretched rptdly. Can be
severe if uterus has been overdistended or if retained blood clots remain. Particularly
severe during breast feeding.
c. NC: give analgesics – they won’t harm the baby in small doses and will help with
milk ejection. Lie in prone position with a small pillow/blanket under the abdomen
keeps the uterus contrxd. Afterpains are self-limiting and disappear in time.
4. Be very familiar with the characteristics and amounts of lochia (note table 17-1 – pg.
329).
a. Color
i. Lochia rubra: dark red or brown color (days 1-3)
ii. Lochia serosa: red to pink to brown-tinged (days 3-10)
iii. Lochia alba: white, cream, light yellow (day 10-up to 6 wks)
b. Amount
i. Scant: less than 2.5 cm
ii. Light: less than 10 cm
iii. Moderate: less than 15 cm
iv. Heavy: saturated peripad in 1 hour
v. Excessive: saturated peripad in 15 min
5. Describe post-partal changes in the cervix, vagina and perineum.
a. Cervix: shrinks and the os is now slit-like instead of a circle.
b. Vagina: rugae return by 3-4 weeks, vaginal epithelium returns in 6-10 weeks. It
regains tone and decreases in size, but doesn’t go back to original shape.
1
, c. Perineum: episiotomy will heal fully in 4-6 months. May be edematous and bruised,
but that will subside. Women may experience hemorrhoids.
6. Interpret post-partal vital signs and lab values.
a. WBC: 14-16xxx – can go all the way to 30xxx
b. Hematocrit is low because of excess plasma. Returns to normal as plasma is lost.
c. Plasma fibrinogen and other clotting factors are increased. Fibrinolytic activity is
decreased during pregnancy and shoots back up postpartum.
7. Examine the GI, GU, musculoskeletal, integumentary, neurologic and endocrine system.
a. GI: mom becomes hungry, thirsty, and digestion becomes active again. Constipation
and gas are common. Small, hard stools. First stool usually occurs within 2-3 days.
Normal patterns return in 8-14 days.
b. GU: kidneys fcn normally by 4 weeks. Dilation of renal pelvis/ureters ends in 2-8
weeks. Protein and acetone can be in urine first few days. Bladder has increased
capacity and decreased tone. Urethra, bladder, and urinary meatus tissues may be
edematous. Urinary sensation is diminished. UTIs can occur because of urinary
stasis. Decreased uterine contractility can lead to bloody urine or excessive bleeding.
Stress incontinence may occur.
c. MS: shoulder, neck, arm muscle aches 1-2 days postpartum. Hip/joint pain because
of loss of relaxin makes them stiffen to prepregnancy state. Abd muscle tone is
diminished, will be weak, soft, and flabby. May have diastasis recti (separated abd
musc) that usually goes back to normal by 6 weeks.
d. IT: melisma (mask of pregnancy), linea nigra fade. Spider nevi/palmar erythema
fade. Stretch marks DON’T fade!! Hair loss starts 4-20 wks postpartum, but it comes
back in 4-6 months.
e. NL: body aches/pains common after birth and can cause inability to sleep.
Anesthesia/analgesia can cause lack of feeling in legs and dizziness. Headaches are
common in first week. Extreme headaches should be reported to MD because they
could lead to something worse. Headache with photophobia, blurred vision,
proteinuria, abd pain could be signs of worsening preeclampsia. Pain continues upon
checkout of hosp.
f. EC: estrogen, progesterone, human placental lactogen quickly drop after placenta is
delivered. Prolactin drops if mom is not breastfeeding. Ovulation resumes as soon as
3 wks postpartum, most return 6-8 wks. Menses may return anywhere from 12 wks-
18 mns in breastfeeding moms. 4.5-8.5 lbs are lost during birth, 5-8 lbs from
diuresis, 2-3 lbs from involution/lochia.
8. Be prepared to teach a patient regarding ovulation, menstruation, lactation and weight
loss.
a. Ovulation: can return in 3 wks, use birth control
i. Both ↓ and ↑ return earlier in those who don’t breastfeed, use supplements, or
ween earlier
b. Menstruation: can return 12 wks – 18 mns.
c. Lactation: doesn’t occur until estrogen and progesterone drop. Prolactin stimulates
mild production w/in 2-3 days. Oxytocin necessary for milk ejection.
d. Weight loss: 10-13 lb lost during birth. 5-8 lb lost d/t diuresis. 2-3 lbs from
involution/lochia. Greatest loss in first 3 months, most women with good diets are
back down to prepregnancy weight w/in 1 yr. Provide diet/exercise info to frustrated
moms and inform them of the healthiest weight loss for them and the baby.
2
,9. Assess a patient after a vaginal birth including her potential need for Rhogam and
Rubella.
a. Initial: assess VS, skin color, location/firmness of fundus, amt/color of lochia,
perineum (edema, episiotomy, lacerations, hematoma), presence/degree/location of
pain, IV infusions (type, rate, redness/pain/erythema of site), urinary output
(time/amt of last void, presence of cath, color/characteristic of urine), status of abd
incision/dressing if present, level of feeling and ability to move if regional anesthesia
was administered.
b. Chart: gravida/para, time/type of delivery (c/s, use of vacuum/forceps),
presence/degree of epis./lacerations, anesthesia/meds administered, significant
med/surg hx (diabetes, htn, heart disease), meds given during labor/delivery or
regularly and their uses, food/drug allergies, method of infant feeding, condition of
baby, lab data (prenatal hgb/hct), blood type, Rh factor, hep B surface antigen, rubella
immune status, syphilis screen, group B strep status.
c. Rhogam: if mom is Rh-negative and baby is Rh-positive and mom is not sensitized
to it. Should be admin 72 hrs after birth to prevent maternal antibodies to future
babies.
d. Rubella: if mom is not immune to rubella, must receive shot to prevent her from
acquiring it during future pregnancies. Women should not become pregnant in first
28 days after vaccine.
10. Describe post-partum nursing care after a vaginal and a cesarean birth.
a. Vaginal
i. Ice packs: until the ice melts, wait 10 mins, apply a new one, make sure they
have feeling in peri area to avoid cold burns
ii. Sitz baths: 2-4x/day for women with epis’s/painful hemorrhoids/peri edema,
cold most effective in first 24 hours/warm water after 24 hrs, pat and dry
iii. Peri care: squirting warm water after each void/BM, pat and dry; anesthetic
sprays
iv. Sitting: squeeze buttocks together before sitting and lower slowly to butt.
Prevents stretching of peri area and sharp impact to area. Sitting on 1 side is
helpful
v. Analgesics: take meds for afterpains. Make sure moms don’t receive higher
than 4 g in a 24 hr period.
vi. Bladder elim: as soon as mom is ambulatory, allow plenty of time for new
mom to urinate for the first time. May have to: medicate for pain, run water
in sink/shower, place mom’s hand in warm water, run warm water over the
vulva, provide fluids, have mom blow bubbles into straw, put her in a sitz
bath. May need to cath if unable to void.
vii. Fluids/food: should drink 2500 mls/day, be culturally sensitive to hot/cold
fluid preferences, may need to IV fluids, give healthy food choices and lots
of it, be culturally sensitive
b. Cesarean
i. Pain relief: can be PCA, PCEA (pt controlled epidural analgesia), epidural,
oral analgesics, IM analgesics. WATCH RESPIRATIONS!!!
ii. Abd: assess GI fcn, listen for bowel sds, watch for paralytic ileus, assess
dressing and drainage, assess incision, assess fundus (GENTLE palpation)
iii. I&O: monitor IV, give ice chips and clear fluids, assess urine characteristics
iv. Immobility: TCDB every 2 hrs while awake since she is on bedrest first 8-12
hrs, splint abd, flex knees/move legs frequently, gradually increase mobility,
support while ambulatory
3
, v. Comfort: pillow behind back/btwn knees, excellent physical care
vi. Resume normal activities: cath removed, back on normal diet,
staples/dressing removed
vii. Help find comfortable way to breastfeed the baby
viii. Prevent abd distension: early ambulation, tighten/relax abd musc, avoid
carbonated bevs/straws, pelvic lifts, simethicone, rectal suppositories
11. Review postpartum discharge teaching topics (note table 17-3 pg. 349 for topics).
a. Uterine massage
b. Lochia norms
c. Involution
d. Epis. Care
e. Care of abd incisions
f. Breast care for lactating/nonlactating moms
g. Bowel/urinary fcn
h. Nutrition
i. Rest
j. Exercise
k. Sexual activity/contraception
l. Postpartum danger signs
m. Follow-up care
n. Meds
o. Emotional responses and postpartum depression
p. Infant care/feeding
q. Family adjustment
r. Available resources
Chapter 18 Postpartum-Psychosocial p. 351-367
1. Differentiate the puerperal phases of maternal adaptation described by Rubin.
a. Taking-in: mom is focused mainly on her own need for fluid, food, sleep. Present
passive, dependent behavior and let others make her decisions. Lasts less than a day
to 2 days.
b. Taking-hold: mom becomes more independent of her own care. When she is in
control of herself, she focuses more on the baby. Compares her infant to others.
Might look for advice on mothering and express anxiety about her mothering
abilities. Lasts several days. Called the “teachable, reachable, referable moment.”
c. Letting-go: parents must let go of their old selves and take on their new roles. Must
also give up their idealized expectations of birth. Mom focuses on her rltnshp w/her
partner. May also return to work.
2. Identify the stages of maternal role attainment as described by Mercer.
a. Anticipatory stage: pregnant woman chooses OB or midwife and location for the
birth. May attend childbirth classes. Seeks out maternal role models.
b. Formal stage: birth – 4-6 weeks. Behaviors largely guided by others like health pros,
friends/parents. Parents become acquainted with baby.
c. Informal stage: begins when moms learn appropriate responses to their baby’s
cues/signals. Moms respond to unique needs of their baby and maternal role is
developed.
4
