- Postpartum definition: period of time immediately after delivery through 6 weeks
- The time that the maternal body is returning to the prepregnant state
- Involution – shrinking of an organ when inactive (uterus, cervix)
- Changes include:
- Uterine and cervical involution
- Presence of lochia
- Vaginal changes
- Resuming of menstrual cycle
- Breast changes
- Urinary changes
- GI changes
- Estrogen and progesterone levels plummet → ↑ prolactin levels and therefore milk production
- Colostrum is secreted for first 3-4 days
- Milk typically comes in on day 5-6
- Mothers not breastfeeding will still have milk come in
- No nipple stimulation
- Wear tight bra
- Milk production typically stops after 5-7 days
- Mild pain meds may be needed to ease engorgement
- Uterine changes
- Rapid shrinking / involution
- Patients who are breastfeeding will experience more rapid shrinking due to oxytocin release
- “Afterpains” are the pains after birth from uterine contractions
- Due to the release of oxytocin
- Breastfeeders will have more afterpains
- Fundal height decreases approximately 1 cm each day and should be midline
- Rapid shrinking / involution
- Bowel (GI changes)
- Hemorrhoids and constipation are common
- Administer stool softeners as ordered
- Excessive output / diuresis the first 12 hrs post delivery due to fluid shifts
- Encourage regular emptying of the bladder to prevent urinary retention and displacement of uterus
- Note whether urinary retention occurs as it can be common due to any trauma, meds, anesthesia, etc.
- Because fetus has occupied the uterus for 9 months, the lining has not shed as it normally does with each menstrual cycle. The lining is no longer needed and must be shed.
- Postpartum mothers will experience vaginal bleeding for up to 6 weeks as the uterine lining is shed.
- Lochia is shed in 3 stages:
- Rubra – bloody
- Serosa – brownish pink
- Alba – milky white
- Most accurate way to determine amount of lochia = weigh pad before and after use
- Heavy amount of lochia = saturating a pad in 1 hour
- Excessive amount of lochia = saturating a pad in 15 minutes
- 1 g = 1 mL
- Return to normal cycle depends if mother is breastfeeding or not
- Breastfeeding moms might have amenorrhea until they stop breastfeeding or could return sooner
- Breastfeeding moms may have amenorrhea but may still ovulation.
- Education is important! Some may rationalize that if they do not have their normal monthly bleeding that they cannot get pregnant again – not true!
- Non-breastfeeding moms will return in 1-2 months
- Episiotomy and/or Vagina
- Decreased tone: Will likely never return to pre-pregnancy state
- Assess perineum for tears
- Monitor infection signs
- Pain medication→ afterpains
- Ice packs→ vaginal swelling
- Tucks pads→ Hemorrhoids
- Stool softeners→ hemorrhoids
- Nipple care→ breastfeeding
- Hormone Regulation
- Patient Education
- Fundal height
- Involuting, fundus moving lower
- Assessed for bleeding
- It is a progression
- Should not go from red to brown and back to red
- How much is too much?
- Soaking a pad an hour
- Breastfeeding amenorrhea→ still can ovulate
- Breast care
- Nipple care
- Non-breastfeeding→ tight bra, no stimulation, no pumping, cabbage leaves, keep warm water on back
- Attempt to urinate every couple of hours
- Empty bladder → decreases urinary risk
- Decrease infection risk
- We don’t want to retain
- Take stool softeners
- For breast milk production
- Help with constipation
In this lesson I will explain postpartum physiological maternal changes and your role in providing care for this patient and the changes.
Let’s first look at what time frame we are talking about and some terms.. Postpartum is the time immediately after delivery through 6 weeks after. During this time the maternal body is returning to the prepregnant state. During this time a lot of changes occur during pregnancy so some women have a very hard time during this time frame because they expect everything to be back to normal immediately. It took 9 months for their body to get to this state and they just did something super amazing so it’s going to take some time and more changes to get back to that pre-pregnancy state. During this time the biggest change that is occurring is involution. Involution is when the uterus shrinks back down to pre-pregnancy state and the cervix goes back to its normal state as well. There are so many changes that are going to occur so let’s look at that.
So first I wanted to show you this mnemonic for your postpartum assessment. Something known as BUBBLE. It is Breasts, uterus, bowel, bladder, lochia, episiotomy, extremities, and emotions. So that last E stands for 3 things. Some people teach on just one but you need to understand all 3. So this is just a general order top to bottom of what you are looking at. You have at this point learned your basic head to toe assessment that you do on a regular med surg patient bit this is added for our postpartum patients so they will get their head to toe assessment with this included in it. Now that you have this tucked in your brain let’s look at our assessment in more detail.
So let’s break down the mnemonic a little more. What is going on with the breasts? The breasts are going to produce colostrum for the first few days and you can refer to the breastfeeding lesson for more on that. The second that placenta is removed the hormones drop signally the body to kick into action. The hormones estrogen and progesterone are no longer needed since the baby is born so they take a big plummet. This will stimulate the hormone prolactin and milk will now begin to be produced. So milk does not just come in for someone that is breastfeeding. The body is meant to make milk so it is going to come in regardless of whether they breastfeed or not. The breasts will get engorged with milk on day 3-5 . For this postpartum patient the uterus is going to undergo big changes. It was stretched so big to house a baby so now it is going to rapidly shrink., which is involution. A patient that chooses to breastfeed is going to have a more rapid shrinking of the uterus because natural oxytocin is released during breastfeeding and that causes contractions of the uterus, which is what shrinks it back down. So just a little added benefit of breastfeeding! Because this uterus is shrinking down the fundus is going to be decreasing in height and moving down. Right after delivery the fundus will be around the umbilicus and then it should decrease about 1 cm each day and be midline. Onto our bowel piece of assessment. The GI system is also going to undergo some changes as well. These changes that might occur are hemorrhoids from pushing in labor and possible constipation that is worsened because of pain medications. So next our bladder and urinary system. The urinary system is going to have excessive output because diuresis is occurring. The body has been retaining fluid and has excess blood volume so now the body is trying to get rid of all that excess. You want to ensure your patient is voiding enough and fully emptying that bladder. A full bladder can push on the uterus and make it mad and bleed more and also retaining urine can cause a UTI. The patient will have lochia. This is just a fancy word for bleeding and is the uterine lining being shed. This bleeding can last up to 6 weeks but most likely will be less. For women that are breastfeeding the bleeding will stop sooner because all the contracting of the uterus getting it back down to prepregnancy faster so bleeding is less, another great benefit! Postpartum mothers will experience vaginal bleeding for about 2 weeks up to 6 weeks as the uterine lining is shed. Lochia is a progression and is described as either rubra which is bright red, serosa, which is a brownish color, and alba which is white. Now the progression is important to remember. A patient should be progressing in this fashion and not moving backwards. If they get to alba and go back to rubra it is a sign that there is a problem. So a big question that many of the women want to know is when menstruation will occur again. This is going to depend on somethings. If the mom is breastfeeding she might not get a cycle until she stops breastfeeding. Those hormones can keep her from having a complete cycle. Non-breastfeeding moms will usually have their cycle return in 1-2 months. Our last piece is the episiotomy and vaginal area. For the vagina there will be decreased tone. This will likely never return to pre-pregnancy state. You know she has just pushed out a baby and stretched that skin and perineum so the tone is lost. On our assessment there will be swelling and some bruising of the vagina. If there is an episiotomy or a tear we want to assess that to ensure it is healing properly.
Now what is our management going to look like for this patient? Therapeutic management will be pain medication to help with these after pains and cramping as the uterus involutes. Ice packs to the vagina for swelling. Tucks pads that have witch hazel are awesome to help with hemorrhoids and then stool softeners just to ease the pain of going after delivery. This is a big fear for patients so talking to them about taking stool softeners and drinking water to ease and make it better can be encouraging. Most patients are literally terrified but say it wasn’t as bad as they thought so I always tell my patients that because it eases their fear. For our breastfeeding patients we want to help with nipple care so some lanolin or Jack Newman’s ointment to the nipples to ease that and help ensure the infant has a good latch so nipple damage doesn’t occur.
Education is going to involve several different things. We want to explain what we are doing when we push on her abdomen and assess the fundal height. We are ensuring the uterus is tight and Involuting properly. The uterus is moving lower into the pelvis and it also helps us assess for bleeding. We need to educate on the lochia. It is a progression and should be red to brown, to white. It should not go from red to brown and back to red. Even if the patient has had bleeding that has slowed or stopped and restarts again is a red flag. This is a sign of a problem or that the patient is doing too much. While she is at the hospital it will really on be red to pink so this education is important for her to know what to watch for at home. She needs to know how much is too much? Soaking a pad an hour is too much and should be reported. We need to educate on contraception. The patient cannot get pregnant again. She needs to understand her options for birth control and that lactation is not a good form of birth control. Women will have breastfeeding amenorrhea so they are not bleeding and having a cycle but they can still ovulate and get pregnant. Breast care education will be on nipple care so making sure the baby has a good latch and applying lanolin ointment as needed. Non breastfeeders are still going to make milk so they need to wear a tight bra for support. There should be no stimulation, no pumping, because breast milk production is supply and demand. If they have any stimulating to their breasts then more milk will be made. So it is important to avoid that and avoid warm water to the breasts because that will also cause milk to drop in. Cabbage leaves can be suggested to help dry up the milk. It is an old wives tale that works!
Even more education pieces! We need to ensure we educate the patient to attempt to urinate every couple of hours. A full bladder pushes on the uterus and can make it bleed more. We also need to ensure she empties her bladder so that she doesn’t retain urine and get a UTI. If she is having any trouble with emptying her bladder then she needs to let us know. This could be from trauma at delivery but we want to ensure she is able to empty her bladder. We can educate on the importance of taking stool softeners to help with hemorrhoids and ease discomforts. Hydration is also important for adequate breast milk production and to help with constipation.
Hormone Regulation and patient education are our nursing concepts for this patient because hormones are regulating all of these changes and there is so much patient education that goes into this.
Alright so that was a lot of information. Let’s look at the main key points to remember. This postpartum time frame is the time frame when the body is getting back to its pre pregnancy state. It is getting back to normal. Remember it takes a while for the body to get to the pregnancy state and patients sometimes think they are going to have a baby and it will instantly all be back to normal but that is just not the case. The postpartum time is 6 weeks. and now it is going to take a while to get through the changes and get like this and a lot of changes happen so now it is going to take a while for the body to get through all of the postpartum changes. So 6 weeks is the time to get back to prepregnancy. And involution is the term for the uterus shrinking back to the prepregnancy state and into the pelvis and is one of the main things we are assessing for in the postpartum period. And of course the BUBBLE mnemonic. Breasts, uterus, bowel, bladder, lochia, episiotomy, extremities and sometimes emotions are included.
Make sure you check out the resources attached to this lesson and review all the education we give for these patients as well as the BUBBLE assessment. Now, go out and be your best selves today. And, as always, happy nursing.