1. Care of the Mother During the
Postpartum Period

2. Nursing Care of the Mother
• Mother means;
- Postpartum women
- Puerperial women
- After childbirth women
• The puerperium is the period beginning after
delivery and ending when the woman’s body
has returned as closely as possible to its
prepregnant state.
• The period lasts approximately 6 weeks.

3. Physiologic Changes of the
puerperium
1. Uterine changes
a. The fundus is usually midline and about at
the level of the woman’s umbilicus after
delivery.
Within 12 hours of delivery, the fundus may
be 1cm above the umbilicus.
After this, the level of the fundus descends
about 1 finger breadth (or 1 cm) each
day, until by the 10th day, it has descended
into the pelvic cavity and can no longer be
palpated.

4. Level of fundus height

5. Lochia
b. After delivery, lochia, a vaginal discharge
consisting of fatty epithelial cells, shreds of
membrane, decidua, and blood, is red color
(lochia rubra) for about 2 or 3 days.
It then progresses to a paler or more
brownish color (lochia serosa), followed by a
whitish or yellowish color (lochia alba) in the
7th to 10th day.
Lochia usually ceases by 3 weeks, and the
placental site is completely healed by the 6th
week

6. Vagina
2. The vaginal walls, uterine ligaments, and
muscles of the pelvic floor and abdominal
wall regain most of their tone during the
puerperium.

7. Urination
3. Postpartum diuresis occurs between the
2nd and 5th postpartum days, as
extracellular water accumulated during
pregnancy begins to be excreted. Diuresis
may also occur shortly after delivery
if urinary output was obstructed because
of the pressure of the presenting part(less
sensitive of bladder)

8. 4. Breasts
a. With loss of the placenta, circulating levels of estrogen and
progesterone decrease while levels of prolactin
increase, thus initiating lactation in the postpartum woman.
b. Colostrum, a yellowish fluid containing more minerals and
protein and immunologic component(IgA) but less sugar and
fat than mature breast milk and having a laxative effect on the
infant, is secreted for the first 2 days postpartum.
c. Mature milk secretion is usually present by the third
postpartum day but may be present earlier if a woman breastfeeds immediately after delivery.
d. Breast engorgement with milk, venous and lymphatic
stasis, and swollen, tense, and tender breast tissue may
occur between days 3 and 5 postpartum.

9. Breast milk production

10. Breast engorgement

11. Emotional and Behavioral Status
1. After delivery the woman may progress through Rubin’s
stages of “taking in” and “taking hold.”
a. Taking in phase
(1) May Begin with a refreshing sleep after delivery.
(2) Woman exhibits passive, dependent behavior.
b. Taking hold phase
(1) Woman begins to initiate action and to function more
independently.
(2) Woman may require more explanation and reassurance
that she is functioning well, especially in caring for her infant.
(3) As the woman meets success in caring for the
newborn, her concern extends to other family members and
their activities.

12. Postpartum blue/depression
2. Many women may experience temporary
mood swings during this period because of
the discomfort, fatigue, and exhaustion after
labor and delivery and because of hormonal
changes after delivery(decrease of
Estrogen).
3. Some mothers may experience “postpartum
blues” at about the third postpartum day and
exhibit irritability, poor
appetite, insomnia, tearfulness, or crying.
This is a temporary situation. Severe or
prolonged depression is usually a sign of a
more serious condition

13. Contributing factors of postpartum
blue/depression
Difficult of Coping with:
a. The physical changes and discomforts of the
puerperum, including a need to regain their
prepregnancy figure.
b. Changing family relationships and meeting the
needs of family members, including the infant.
c. Fatigue emotional stress, feelings of isolation, and
being “tied down.”
d. A lack of time for personal needs and interests.

14. NURSING ASSESSMENT
Immediate Postpartum Assessment
• The first 1 hour after delivery of the
placenta (fourth stage of labor) is a critical
period; post partum hemorrhage is most
likely to occur at this time.

15. Subsequent Postpartum
Assessment
1. Check firmness of the fundus at regular
intervals.
2. Inspect the perineum regularly for frank
bleeding.
a. Note color, amount, and odor of the lochia.
b. Count the number of perineal pads that are
saturated in each 8 hour period.
3. Assess vital signs at least twice daily and
more frequently if indicated.

16. • Palpating the uterine fundus
• Firm or “ *Boggy”
– not palpable by 10 days PP
• “afterpains”
• Multiparas, multiple births, breastfeeding
=>

17. Amount of bleeding

18. Subsequent Postpartum
Assessment
4. Assess for bowel and bladder elimination.
5. Assess for breast engorgement and
condition of nipples if breast-feeding.
6. Assess perineal incisions(episiotomy
wound) for signs of infection and healing.
7. Inspect legs for signs of thromboembolism,
and assess Homan’s sign.
8. Evaluate interaction and care skills of
mother and family with infant.

19. Common site of thrombophlebitis

20. Homan’s sign

21. NURSING MANAGEMENT
•
Nursing Diagnoses
A. Risk for Fluid Volume Deficit related to blood loss and effects from
anesthesia
B. Altered Urinary Elimination related to birth trauma
C. Colonic Constipation related to physiologic changes from birth
D. Risk for Infection related to birth process
E. Fatigue related to labor
F. Pain related to perineal discomfort from birth trauma, hemorrhoids, and
physiologic changes from birth
G. Altered Health Maintenance related to lack of knowledge of postpartum
care
H. Altered Health Maintenance related to lack of knowledge of newborn care
I. Ineffective Breastfeeding related to lack of knowledge and inexperience

22. Nursing Interventions
A.
Monitoring for Hypotension and Bleeding
1. Monitor vital signs every 4 hours during the first 24 hours, then
every 8 to 12 hours. Observe for the following:
a. Decreased respiratory rate below 14 to 16 breaths per minute
may occur.normal
b. Increased respiratory rate greater than 24 breaths per minute
may be due to increased blood loss, pulmonary edema, or a
pulmonary embolus.
c. Increased pulse rate greater than 100 beats per minute may
be present with increased blood loss, fever, or pain.
d. Decrease in blood pressure 15 to 20 mm Hg below baseline
pressures may indicate decreased fluid volume or increased
blood loss.

23. A. Monitoring for Hypotension and Bleeding
2. Assess the woman for light-headedness and
dizziness when sitting upright or before
ambulating.
3. Assess vaginal discharge for amount and
presence of clots.
4. Evaluate lower extremity sensory and motor
function before ambulation if the woman had
regional anesthesia.
5. Encourage food and drink as tolerated.
6. Maintain intravenous line as indicated.
7. Monitor postpartum hemoglobin and hematocrit.

24. B. Encouraging Bladder Emptying
1. Observe for the woman’s first void within 6 to
8 hours after delivery.
2. Palpate the abdomen for bladder distention if
the woman is unable to void or complains of
fullness after voiding.
a. Uterine displacement from the midline
suggests bladder distention
3. Instruct the woman to void every several
hours and after meals to keep her bladder
empty.

25. C. Promoting Proper Bowel
Function
1. Teach the woman that bowel activity is sluggish
because of decreased abdominal muscle
tone, anesthetic effects, effects of
progesterone, decreased solid food intake during
labor, and prelabor enema.
2. Inform the woman that pain from
hemorrhoids, lacerations, and episiotomies may cause
her to delay her first bowel movement.
3. Review the woman’s dietary intake with her.
4. Encourage daily adequate amounts of fresh
fruit, vegetable, fiber, and at least eight glasses of
water.
5. Encourage frequent ambulation.
6. Administer stool softener as indicated.

26. D. Preventing Infection
1. Observe for elevated temperature above
38℃.
2. Evaluate episiotomy/perineum for redness,
ecchymosis, edema, discharge (color,
amount, odor) and approximation of the skin.
3. Assess for pain, burning, and frequency on
urination.
4. Administer antibiotics as ordered.

27. Inspection of perineum

28. E. Reducing Fatigue
1. Provide a quiet and minimally disturbed
environment.
2. Organize nursing care to keep
interruptions to a minimum.
3. Encourage the woman to minimize
visitors and phone calls.
4. Encourage the woman sleep while the
baby is sleeping.

29. F. Minimizing Pain
1. Instruct the woman to apply ice packs to the
perineal area for the first 24 hours for perineal
trauma or edema.
2. Initiate the use of sitz baths for perineal
discomfort after the first 24 hours
a. Use three times a day for 15 to 20 minutes
3. Instruct the woman to contract her buttocks before
sitting to reduce perineal discomfort.
4. Assist the woman in the use of positioning
cushions and pillows while sitting or lying.
5. Administer pain medication as indicated.

30. F. Minimizing Pain
8. Check the breasts for signs of engorgement
(swollen, tender, tense, shiny breast tissue).
a. If breasts are engorged and the woman is breast-feeding:
(1) Allow warm-to-hot wet towel to over the breasts and massage to
improve comfort.
(2) Express some milk manually or by breast pump to improve
comport and make nipple more available for infant feeding.
(3) Feeding the infant.
(4) A mild analgesic may be used to enhance comfort.
b. If breasts are engorged and the mother is bottle-feeding:
(1) Teach the woman to wear a supportive bra night and day.
(2) Teach the woman to avoid handling her breasts, because this
stimulates more milk production.
(3) Suggest ice bags to the breasts to provide comport.
(4) Moderately strong analgesics maybe needed to provide comfort.

31. G. Promoting Postpartum Health
Maintenance
1. Teach the woman to perform perineal care-warm water over
the perineum after each voiding and bowel movement
routinely several times a day to promote
comfort, cleanliness, and healing.
2. Promote sitz baths for the same purpose.
3. Teach the woman to apply perineal pads by touching the
outside only, thus keeping clean the portion that will touch her
perineum.
4. Assess the condition of the woman’s breasts and nipples.
Inspect nipples for reddening, erosions, or fissures.
Reddened areas may be improved with A & D ointment, a
lanolin cream, and air drying for 15 minutes several times a
day.

32. G. Promoting Postpartum Health
Maintenance
5. Teach the woman to wash her breasts
with warm water and No soap, which
prevents the removal of the protective skin
oils(lanolin).
6. Teach the woman to wear a bra that
provides good support night and day.
7. Instruct the breast-feeding woman to add
between 500 and 750 additional calories
daily for milk production.

33. G. Promoting Postpartum Health
Maintenance
8. Instruct the woman in postpartum exercises for the immediate
and later postpartum period.
a. Immediate postpartum exercises can be performed in bed.
(1) Toe Stretch (tightens calf muscles)- While lying on your
back, keep your legs straight and point your toes away from
you, then pull your legs toward you and point your toes toward
your chest. Repeat 10 times.
(2) Pelvic floor exercise (tightens perineal muscles)-Contract
your buttocks for a count of 5 and relax. Contract your
buttocks and press thighs together for a count of 7 and relax.
Contract buttocks, press thighs together, and draw in anus for
a count of 10 and relax.
b. Exercises for the later postpartum period can be done after
the first postpartum visit.

34. postpartum exercises
(1) Bicycle (tightens thighs, stomach, waist)-Lie on your back on the
floor, arms at sides, palms down. Begin rotating legs as if you were
riding a bicycle, bringing the knees all the way in toward the chest
and stretching the legs out as long and straight as possible.
Breathe deeply and evenly. Do the exercises at a moderate speed
and do not tire yourself.
(2) (2) Buttocks exercise (tightens buttocks)-Lie on your stomach and
keep your legs straight. Raise your left leg in the air, then repeat
with your right legs (feel the contraction in your buttocks). Keep
your hips on the floor. Repeat 10 times.
(3) Twist (tightens waist)-Stand with legs wide apart. Hold your arms at
your sides, shoulder level, palms down. Twist your body from side to
front and back again. Feel the twist in your waist.

35. Postpartum exercise

37. H. Promoting Health Maintenance
of the Newborn
1. Encourage the parents to participate in daily care of
the infant.
2. Advise the parents to attend parenting and baby care
classes offered during their stay at the birth facility
mother’s class
3. Teach the parents to bathe and diaper the infant,
perform circumcision care, and initiate either breast
feeding.
4. Foster bonding by encouraging skin-to-skin contact
with the infant, eye contact, and talking to and
touching the infant.

38. I. Promoting Breast-Feeding
1. Assist the woman and infant in the breast-feeding process.
a. Have the mother wash her hands before feeding to help prevent
infection.
b. Encourage the mother to assume a comfortable position, such as
sitting upright, tailor sitting, lying on her side.
c. Have the woman hold the baby so that he or she is facing the
mother.
Common positions for holding the baby are
- the “cradle hold,” with the baby’s head and body supported against
the mother’s arm with buttocks resting in her hand;
- the “football hold,” in which the baby’s legs are supported under the
mother’s arm while the head is at the breast resting in the mother’s
hand;
-lying on the side with the baby lying on his/her side facing the
mother.

39. cradle hold

40. “football hold

41. facing the mother.

43. I. Promoting Breast-Feeding
d. Teach the woman to bring the baby close to her, to prevent
back, shoulder, and arm strain.
e. Have the woman cup the breast in her hand in a “C” position with bottom of
the breast in the palm of her hand the thumb on top.
f. Have the woman place her nipple against the baby’s mouth, and when the
mouth opens, guide the nipple and the areola into the mouth.
g. Encourage the woman to alternate the breast she begins feeding with at
each feeding to ensure emptying of both breasts and stimulation for
maintaining milk supply.
h. Have the mother breast-feed frequently and on demand (every 2 to 4 hours)
to help maintain the milk supply.
i. Have the mother air dry her nipples for about 15 to 20 minutes after feeding
to help prevent nipple trauma.
j. Have the mother burp the infant at the end or midway through the feeding to
help release the air in the stomach and make the infant less fretful.

47. I. Promoting Breast-Feeding
2. Alert the mother that uterine cramping may
occur, especially in multiparous women, due to the
release of oxytocin, which can be worse in women
with lessened uterine tone.
3. Teach the mother to provide for adequate rest and to
avoid tension, fatigue, and a stressful
environment, which can inhibit the letdown reflex and
make breast milk less available at feeding.
4. Advise the woman to avoid taking medications and
drugs, because many substances pass into the breast
milk and may affect milk production or the infant.

48. Evaluation
A. Vital signs within normal limits; decreasing color and amount
of lochia
B. Voids freely and without discomfort
C. Lack of constipation; eats high-fiber foods and uses stool
softeners
D. Afebrile, no abnormal redness of perineum, no purulent
discharge or foul odor of lochia
E. Verbalizes feeling rested
F. Verbalizes decreased pain
H. Demonstrates confidence in performing infant care; shows
signs of maternal-child bonding
I. Demonstrates successful breast-feeding; breasts and nipples
infant and without redness or cracks