Module IV Postpartum

University of San Agustin
General Luna St., Iloilo City 5000, Philippines

www.usa.edu.ph
COLLEGE OF HEALTH AND ALLIED MEDICAL PROFESSIONS
NCM 107: Care of the Mother, Child and Adolescent (Well – Clients)
MODULE IV: POSTPARTUM PERIOD
Module Overview:
Dear Learners:
Welcome to NCM 107 Module 4, I look forward to virtually meeting and working with
you all and helping you prepare for this course. I am very optimistic that with your
cooperation, you will have a better grasp of our subject matter and integrate it in your
nursing practice.
We will have a synchronous (real-time/online) and asynchronous (not real-time/offline)

learning activities in accordance with flexible learning strategies. You can communicate
your concerns through messenger or email whichever is convenient.
This module is designed for nursing students to have an overview of the physiologic
and psychological care of the postpartum woman and her family.
Module Outcomes:
At the end of the module the learner should be able to:

1. Describe the psychological and physiologic changes that occur in a postpartum
woman.
2. Use critical thinking to analyze ways that postpartum nursing care can be more
family centered.
3. Integrate knowledge of the physiologic and psychological changes of the
postpartal period with the nursing process to achieve quality maternal and child
health nursing care.
Module Content:
• Postpartum psychological changes

• Postpartum physiologic changes
A Legacy of Excellent Education in Virtus et Scientia

Email: [email protected] | Cel. No.: 0939-278-90-80
www.usa.edu.ph
PUERPERIUM
Is the six-weeks period starting from child birth, during which the reproductive organs
undergo physical and physiologic changes.
POSTPARTUM PSYCHOLOGICAL CHANGES

RUBIN’S POSTPARTUM PHASE
Taking-In Phase
• First 2 to 3 days postpartum
• Woman’s attention is focused on her own needs for sleep, rest, and she is
dependent on others.
Taking-hold Phase/ Transition Phase

• 3rd day to 2 weeks postpartum
• The concern of the mother at this time is focused on her ability to control body
function and her ability to assume the mothering role.
• She prefers to do things for herself. Because of the tendency of the woman to
overwork herself, fatigue and exhaustion is common at this stage.
Letting-go Phase
• The mother, at this point, realizes that the infant is a separate individual and not
a part of herself.
• As the mother realizes the individuality of the baby, she gives up fantasies’ about
the child.
• The mother also undergoes role transition, she gives up her role as a childless
woman and adjust herself and lifestyle to meet the needs of he child.
ROOMING-IN
The infant stay with the mother’s room rather than the central nursery.
2 types:
• Complete – mother and child re together 24 hours a day
• Partial – infant remains in the woman’s room for most of the time but is taken
to a small nursery besides the woman’s room and returned to the central nursery.
PHYSIOLOGIC CHANGES POSTPARTUM
Cardiovascular System
• The 40% increase in blood volume during pregnancy enters

the maternal circulation within 5 to 10 minutes after placental
delivery, making this period very critical to gravidocardiacs
because their damaged heart may not be able to handle this drastic
change in cardiac workload.
• Blood volume returns to nonpregnant levels one week after

delivery.

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Other noticeable Changes:

• Cardiac output decreases by 30% within 2 weeks after delivery.
• Physiologic bradycardia during the first 24-48 hours (50 bpm). This returns to
normal about 3 months postpartum.
• Orthostatic hypotension during the first 48 hours after delivery.
• Increased leukocyte sedimentation rate.
• Leukocytosis of 20,000 to 30,000 (normal is 5,000 to 10,000) during the first 12
days characterized by increased neutrophils and eosinophils and decreased
lymphocytes.
Integumentary System
• Chloasma, palmar erythema, linea nigra and other skin changes during
pregnancy gradually disappear during the postpartum period.
• Striae gravidarum do not disappear and assumes a silvery white appearance.
• Hyperpigmentation of the areola may not disappear completely.
Gastrointestinal System
Many woman are hungry after delivery because of foods and fluids restriction during
labor, diaphoresis and the strenuous labor they just went through.
Bowel movement may be delayed for days after delivery resulting in constipation. This is
caused by:
• Decreased muscle tone during labor and puerperium.
• Lack of food during labor
• Dehydration
• Perineal pain caused by episiotomy, hemorrhage, laceration
UTERINE INVOLUTION
• The sudden withdrawal of estrogen and progesterone after delivery result in
atrophy of myometrial cells and eventually, a decrease in uterine weight.
• The uterus does not return to its original
prepregnant condition, uterine size is
slightly increased after each pregnancy.
• Breastfeeding promote involution
because stimulation of the nipple when
the infant suckles results in the release of
Oxytocin. Oxytocin stimulates uterine
contraction.
• The endometrium heals in 3 weeks.
• Weight of the uterus:
✓ After delivery : 1000 g
✓ One week after: 500 g
✓ Two weeks after : 300 g
✓ Six weeks after delivery : 50 to 60 g

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FUNDUS
Should be frequently assessed for firmness, position and height. A full bladder displaces
the uterus upwards and to the sides.
Palpation of the fundus:

• Place the woman in supine position with
small pillow under her head and knees
flexed to relaxed the abdominal muscles.
• Make sure the bed is flat.
• Palpate the fundus by placing a hand at
the umbilicus and pressing it downward,
while the other hand is placed just above
the symphysis to support the lower
segment of the uterus.
• Never palpate the uterus without
supporting the lower segment as this can
result to uterine inversion.
If uterus feels soft and boggy:

• Massage it gently in circular motion (this is the first action to take by the release
of Oxytocin.)
• Place infant on mother’s breast to stimulate uterine contractions by the release of
Oxytocin.
• Administration oxytocics (as ordered) or increase infusion, do not administer
ergot products if BP is above 140/90 mmHg.
Height of fundus:
• Immediately after delivery, the fundus is located midway between the umbilicus
and symphysis pubis or slightly higher.
• After several hours, it rises to the level of the umbilicus. It then, descends into the
pelvic cavity by 1 cm or 1 fingerbreath a day.
• Postpartum day 1 – 1 cm or 1 fingerbreath below umbilicus
• Postpartum day 2 – 2 cm or 2 fingerbreath below umbilicus
• Postpartum day 10 – cannot be palpated anymore, uterus is a pelvic organ again.
LOCHIA
• Is the uterine discharge following delivery consisting of blood, mucus, epithelial
cells, leukocytes and bacteria.
• Lochia is never absent regardless of the method of delivery. However less lochia
is expected in woman who delivered by CS, ambulate early and those who
breastfeed their babies.
Pattern of Lochial Flow

• Lochia rubra – from delivery up to 3rd day. Bright red in color, fleshy odor,
may contain small clots.
• Lochia serosa – from 4th to 10th day, pinkish to brownish in color
• Lochia alba – from 10th day until 2 to 6 weeks postpartum, cream to yellowish
in color.

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Amount of lochial flow:

• Should be like menstrual flow.
• When checking the amount of lochial discharge, do not forget to check under the
buttocks of the woman.
• Normal for lochial flow to increase during ambulation and breastfeeding.
Estimated amount of blood loss:

✓ 1 inch stain after an hour – scant
amount
✓ 2-4 inches stain after one hour – light
amount
✓ 4-6 inches stain after one hour –
moderate amount
✓ Fully saturated after one hour – heavy
amount
Presence of clots:
• In the first few days after delivery, it is normal for lochia to contain small clots
but never large ones.
• Large clots indicate retained placental fragments
Smell:
• Smells like menstrual discharge. A foul-smelling lochia is a sign of infection.
Color:
• Pattern is from rubra to serosa. Should not reverse.
• Return to bright red bleeding after 3 weeks or reversal of pattern from alba or
serosa to rubra are abnormal signs.
SIGNS OF ABNORMAL LOCHIA
SIGNS POSSIBLE CAUSE

Foul smell Infection
Large clots Retained fragments
Excessive amount with Laceration of birth canal
contracted uterus
Returned to rubra after Retained fragments, infection. A reddish color
serosa alba in lochia that persists for more than 2 weeks is
indicative of retained fragments
Persistent bleeding after 6 Subinvolution of the uterus, infection
weeks
BLADDER:
• The bladder and urethra are traumatized by the pressure exerted by the fetal
head as it passes through the birth canal.
• Trauma to bladder results in loss of bladder tone, edema and hyperemia.
• Loss of bladder tone leads to increased bladder capacity and decreased sensation
to void, which predisposes to infection.
• Generally, bladder tone is regained after 1 week and normal kidney function after
1 month.

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DIURESIS (excessive urination)

Begins 12 hours after delivery and extends up to the 5th day as the body gets rid of
extracellular fluid accumulated during pregnancy.
Signs of full bladder:

• Suprapubic swelling that produce a resonant sound upon percussion.
• High fundus because a full bladder displaces the uterus upwards.
• Increase lochia because displacement of the uterus interfere with effective uterine
contraction.
Effects of bladder distention:

• Hemorrhage – displacement of the uterus leads to uterine relaxation.
• Infection – stasis of urine promotes bacterial growth.
• Increase discomfort to the woman
• Atony of the bladder wall – if bladder distention is allowed to continue for a long
period of time, it can damage the bladder and cause atony of the bladder wall.
VAGINA:
o The vagina right after delivery is smooth and swollen
passage.
o After 3 to 4 weeks, rugae reappears, but not as
numerous as before pregnancy.
o Returns to its prepregnant condition after 6 to 8
weeks but does not regain to it’s original virginal state.
PERINEUM:
The perineum is observed for signs of infection

(edema, redness, purulent discharge, gaping at
suture line) and trauma.
Perineal care:
• Flush with warm water after each voiding and defection from front to back.
• Ice packs are applied first 24 hours after delivery to prevent edema by promoting
vasoconstriction and lessen discomfort by providing anesthesia effect.
• Sitz bath (application of heat to the perineum) is done after the first 24 hours
following delivery to promote circulation by vasodilation.
Perineal Lamp (peri-light)

• Place woman in dorsal recumbent position, drape thighs and place lamp in
between the legs.
• The lamp should be positioned at least 12 inches away from the perineum.
• Used for 20 minutes 3 times a day.

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MENSTRUATION AND OVULATION
• Non-lactating woman usually menstruates by 6 to 10 weeks and ovulates by 10

weeks after delivery.
• Menstruation may come as early as 6 weeks and as late as 18 months.
• If the woman breastfeeds for 6 months, ovulation usually begins after 28 weeks.
AMBULATION
• Mothers who had spontaneous delivery are allowed to ambulate 4 to 8 hours after
childbirth.
• Patients who receive anesthesia are allowed to get out of bed after 8 hours when
they are fully awake, and reflexes have returned.
• Carefully assess a woman who states she has intense warmth or pain in the calf of
her leg on standing position (Homans sign) because it could indicate that
thrombophlebitis is present.
Advantages of early ambulation:

• Prevents constipation
• Prevent thrombophlebitis
• Prevent urinary problems
• Promote rapid recovery and return of woman’s strength
• Hasten drainage of lochia
• Improves GI and urinary function
RESUMPTION OF SEX
Sexual intercourse can be resumed 3 to 4 weeks after vaginal delivery if bleeding has
stopped and healing is completed, and if does not cause discomfort to the woman.
Low estrogen during the first 3 months after delivery reduce the sexual response of a
woman who has just given birth.
There is also reduced vaginal lubrication which causes painful intercourse.
CLINIC VISITS
The mother is instructed to come back to the hospital or her obstetrician 4 to 6 weeks
after delivery for examination and follow-up care.

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Activity 1:
20 item online test c/o NEO LMS
Activity 2:
Readings to Share: Look for a research abstract in relation to postpartum. Write
your reaction and reference.
Rubric:
CRITERIA POINTS
1 4 7 10
Organization Does not respond Minimally responds Adequately responds Clearly and
well to assignment. to the assignment to the assignment. It effectively responds
It is aimless and and sometimes has a compelling and to assignment. It has
disorganized discussion is out of logical flow of ideas. compelling and
the topic logical flow of ideas
Analysis Lack of critical or Some critical Proficient critical Exceptional critical

analytical thought comments given to comments and comments and
in comments and issue and effects, analysis of issue, analysis of issue,
little to no insight more details, insight, interpretations and interpretations,
used. and critical thought impact using many impact, effect, using
needed details and evidence details, insight,
and some insight evidence from essay
and comprehensive
thought.
Communication Poor delivery and delivery and timing Proficient delivery and Exceptional delivery
timing of of information needs timing of information, and timing of
information, to be smoother (too proficient discussion information,
discussion needs to much reading), more started and exceptional
be more controlled active interaction maintained discussion initiated
and dynamic and discussion and maintained to
further student
learning
Reference No Reference Reference not Reference in APA Reference in APA
(APA Format) following APA format but all format and all
format necessary components necessary
are not included or no components are
hanging indent included
Timeliness Assignment Assignment Assignment submitted Assignment
submitted 3 days or submitted 1 - 2 days a few hours after the submitted before or
more after the due after the due date. due date. on the due date.
date.
/50
Activity 3:
Group Activity: Create an infographic that could be used to prepare new parents
for the emotional and physiologic changes occurring after childbirth.
Rubric:
CRITERIA
1 2 3
Layout Not balanced, cluttered, Balanced, uncluttered, Creatively enhances
insufficient space adequate space information
Graphics/ Text Graphics do not enhance Graphics enhance text All graphics are engaging.
size text. Some text is clear and Text is clear and readable; All text is clear and readable, a
readable; frequent changes changes in size and color; few changes in size and color;
in size and color and do not enhance understanding enhance understanding
enhance understanding
Writings Poorly written and Adequately written and Well written and organized,
organized, unclear, hard to organized, clear, reasonably clear, easy to follow
follow easy to follow
Quality of Information/description is Information/description Information/description is
information unclear, incomplete and not mostly could be a little more clear; complete and concise
concise concise
Timeliness Assignment submitted 3 days Assignment submitted 1 - 2 Assignment submitted before
or more after the due date. days after the due date. or on the due date.
/15

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References
Salustiano, R.P. (2009). Dr. RPS Maternal & Newborn Care. A Comprehensive Review
Guide and Source Book for Teaching and Learning. C&E Publishing, Inc.,
Quezon City
Pilliterri, A & Silberrt-Flagg, J. (2018). Maternal & Child Health Nursing: Care of the
Childbearing & Childrearing Family 8th edition. Wolters Kluwer
Wald, L.A. (2009). Nursing Board Exam Review Notes, Volume 2, CENE Maria
Loreto J. Evangelista-Sia, Outline in Obstetrics, 2004 edition
https://nursekey.com/12-postpartum-assessment-and-nursing-care/
https://childrenswi.org/medical-care/fetal-concerns-center/conditions/pregnancy-
complications/postpartum-hemorrhage
https://www.babycenter.com/pregnancy/your-body/perineal-tears_1451354


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University of San Agustin

General Luna St., Iloilo City 5000, Philippines

COLLEGE OF HEALTH AND ALLIED MEDICAL PROFESSIONS