The postpartum family: Maternal

assessment

NSG3111
Week 1 – Jan 10, 2022

Original version by: Professor Wendy Peterson RN, PhD, PNC(C)

Updated: January 2022
Learning outcomes
1. Describe maternal anatomical and physiological changes
that occur during the postpartum period.
2. Describe the normal process of uterine involution and signs
of potential complications.
3. List expected values for vital signs and blood pressure,
deviations from normal findings, and probable causes of the
deviations.
4. Describe components of a systematic maternal postpartum
assessment & recognize deviations from normal.
5. Summarize nursing interventions to care for postpartum
mothers and to prevent complications Describe content of
discharge teaching.
6. Describe the nurse’s role in referrals to community
resources.
Terminology

• The ‘postpartum period’ is the interval

between birth and return of reproductive
organs to their non-pregnant state.

• May also be referred to as puerperium or

fourth trimester of pregnancy.

• Traditionally lasts 6 weeks, although this

varies among women.
 Postpartum nursing
care is a balancing act….

Assessment, monitoring &

support of mother’s
physiological and emotional adaptation

Assessment, monitoring &

support of infant’s
health

Fostering
family relationships
and adaptation
Some context
Some context (cont’d)
Principles of Family-Centered
Maternity & Newborn Care

(Source: Public Health Agency of Canada- Chapter 1)

 Postpartum assessment: Maternal vital signs
(Perry text, p. 568 – table 22.2 & p. 562 – table 21.1))

• Temperature in 1st 24 hrs can be high (< 38 C), should

normalize after.

• Pulse is elevated for ~ first hour (60-100), then begins to

decrease to non-pregnant rate

• Respiratory rate (16-24) decreases to pre-birth rate

• Blood pressure should be “normal” (check prenatal records to

see pattern).

~Watch for orthostatic hypotension when she stands~

Postpartum Assessment: BUBBLLEE
B - breasts
U - uterus
B - bladder
B - bowel
L – lochia
L - legs
E – episiotomy/laceration or caesarean
incision
E – emotional status

See Perry text, 2017 page 566

 Postpartum assessment
BUBBLLEE
Breasts
Breastfeeding mothers
➢ Soft (days 1-2); filling (days 2-3); full, soften with
breastfeeding (days 3-5)
➢ Nipples – skin intact, no soreness
➢ Colostrum, a yellowish fluid, can be expressed

Non-breastfeeding mothers (Perry 2017 p. 576)

➢ Suppression of lactation
➢ Reduce discomfort from engorgement
➢ For first 72 hours – Wear a well-fitted support bra or breast
binder, ice packs, fresh cabbage leaves, or mild analgesics
may be used to relieve discomfort.
Postpartum assessment BUBBLLEE
Uterus
Pregnant uterus:
Non-pregnant uterus:

Height of fundus by weeks of normal gestation with a single fetus.

 Postpartum assessment
BUBBLLEE
Uterus
• Involution:
– Is the process of the uterus returning to non-
pregnant state
– Stable size by 6-7 weeks postpartum
– Role of hormones ( estrogen, progesterone;
oxytocin)
– Endometrial regeneration
• Decidua lochia is almost complete after 3 weeks
• Except at placental site - regeneration by 6-7
weeks
 U - uterus

• Involution (continued):
– Enhanced by effective uterine contractions
that compress blood vessels
• “Afterpains”
that are felt more intensely by multiparas
and during breastfeeding
 U - uterus
• Assessment of uterine involution by palpating
the fundus.

– Technique
– Normal findings

See Figure 22-3, page 572, Perry et al., 2017

 2 hours after birth

2 days after birth 4 days after birth

Fig. 20-1. Assessment of involution of uterus after childbirth. A: Normal progress, days 1
through 9. B : Size and position of uterus 2 hours after childbirth. C: Two days after
childbirth. D: Four days after childbirth.
 U - uterus
• Assessment of uterine involution by palpating
the fundus:
– At end of third stage, ~ 2 cm below umbilicus
– Within 12 hours, rises to the level of umbilicus
to 1 cm above
– First day following birth (first postpartum day):
fundus at 1cm below umbilicus
– Descends 1-2 cm daily
- By 6th day: halfway btwn umbilicus & symphysis
pubis
– Not palpable by 2 weeks
Olds’ Maternal-Newborn Nursing &
Women’s Health Across the Lifespan, 8/e
Michele Davidson, Marcia London, and Patricia Ladewig

Copyright ©2008 by Pearson Education, Inc.

Upper Saddle River, New Jersey 07458
All rights reserved.
 U - uterus
• Subinvolution is the failure of the uterus to
return to a non-pregnant state.

• Factors that slow involution

– Full bladder
– Prolonged or difficult labour
– Incomplete expulsion of placenta or
membranes
– Infection
– Grand multiparity
– Overdistension of uterus
– Anesthesia
 U - uterus
• Assessment findings that require intervention:
– “Boggy” fundus (soft & spongy, not firm)
– Fundus higher than expected
– Fundus deviated from midline

• Intervention
– Assist woman to empty bladder
– Assess lochia
– Gentle fundal massage
– If no improvement report to
MD/RM.
 U - uterus
Postpartum Hemorrhage (PPH)

• Early PPH: (during first 24 hrs)

~ 5% of births (Knight et al., 2009)
• Uterine atony (relaxation of the uterus)
But may also be caused by…
• Lacerations
• Retained placental tissue
• Other

• Late PPH (24 hrs to 6 weeks PP)

– Due to subinvolution
– Retained placental tissue
 Postpartum assessment
BUBBLLEE
Bladder

• Urination
– Bladder tone and sensation diminished due to
birth trauma
– Diuresis begins within first 12hrs & can be
profuse x 3 days

• Assessment
– Look for frequency of voiding / if had catheter
watch S&S UTI.
– Mother should be taught how to prevent urinary
incontinence - Kegel exercises = pelvic
muscle exercises
(see Perry text, 2017 p. 72, patient teaching box)
 Postpartum assessment
BUBBLLEE

Bowels
• Bowel sounds +
• Bowel movements (by 2-3 days)

Assess for causes of decreased bowel activity:

– Fear of pain, tearing sutures
– Hemorrhoids
– Dehydration
– Immobility
 Postpartum assessment
BUBBLLEE
Lochia
Lochia: post-birth uterine discharge
~ 240-400ml in total
Assess colour, amount / odour? clots?

1. Lochia rubra
– Bright red flow
– Blood and decidual and trophoblastic debris
– May contain small clots
– Duration of 3 to 4 days
 Postpartum assessment
BUBBLLEE
Lochia (cont’d)
2. Lochia serosa
• Pink or brown
• Old blood, serum, leukocytes, and tissue debris
• Until day 10 (for most women)

3. Lochia alba
• Yellow to white
• By about 10 days in most women
• Leukocytes, decidua, epithelial cells, mucus,
serum, and bacteria
• May continue 4 to 8 weeks after birth
Assessment: Amount of lochia

Scant Light Moderate Heavy > 15 cm

< 5cm 10 cm 15 cm Saturated in 2 hrs.
(see Perry et al., 2017, p. 571, Figure 22-1)
 Postpartum assessment
BUBBLLEE

Lochial bleeding
• Uterine atony
• Retained placental fragments

Non-lochial bleeding
• Unrepaired cervical or vaginal tears

Perry text 2017, p. 557-558; Box 21-1

 Postpartum assessment
BUBBLLEE

Legs
Some ankle edema normal first few days PP

Assess for signs indicating thrombophlebitis:

• < 1% of births
• Encourage ambulation
• Assess legs for edema, redness, tenderness,
pain
 Postpartum assessment
BUBBLLEE
Episiotomy / laceration / cesarean incision
– REEDA

Episiotomies & lacerations

– Edema reaches maximum by 24 hours postpartum
then subsides.
– Edema can cause urinary difficulty the first day.
– Edges should be well approximated.
– To encourage healing & decrease pain:
• Ice packs in first 24 hours
• Perineal hygiene
• Sitz baths Perry text, 2017 p. 569-570
 Postpartum assessment
BUBBLLEE
E = Emotional status
- Able to care for self
- Postpartum blues – sad, tearful (starts ~ day 3)

- Impact of birth experience

- Able to sleep
- Interested / involved in infant care
- Adaptation to parenthood
- Family structure & functioning
- Cultural safety
BUBBLLEE – ongoing assessments
Nursing interventions

• Prevention of infection • Promotion of exercise

• Prevention of excessive • Promotion of nutrition
bleeding • Promotion of normal
• Maintenance of uterine bladder & bowel function
tone • Promotion of breastfeeding
• Prevention of bladder / suppression of lactation
distension • Health promotion for
• Promotion of comfort planning future
• Promotion of rest pregnancies
• Promotion of ambulation

See Perry 2017 - Chapter 22 pages 568-577

Example care plan
Nursing Expected Interventions
diagnosis outcome
Risk for Firm fundus • Monitor colour, amount of lochia (weigh pads prn)
bleeding related Moderate • Monitor I/O, assess bladder fullness, encourage
to uterine atony lochia voiding
No evidence • Monitor VS
of hemorrhage • Monitor and palpate fundus. If fundus is boggy,
apply gentle massage and assess tone response
• Explain involution and teach pt to assess and
massage fundus prn
• Administer uterotonic agents per orders and
evaluate effectiveness
• Administer fluids, blood, blood products as
ordered.
Risk for No signs of Teach perineal care: (see box 22-2, p. 570)
infection related infection • wipe front to back
to postpartum (REEDA) • use of peri-bottle
(or interruption • use of sitz bath
in skin integrity Afebrile • frequent pad changes
- laceration / • frequent hand washing.
episiotomy)
Example care plan
Nursing Expected Interventions
diagnosis outcome
Risk for Voids • Assist woman to bathroom / to use bedpan
impaired urinary spontaneously • Teach strategies to encourage voiding
elimination within 6-8 • Use peri-bottle to pour water over perineum
related to hours of birth • Sound of running water
childbirth • Analgesics prn
Adequate • Catheterize prn per orders
emptying of • Teach kegel exercises
bladder (150
ml each void)

No signs of
UTI
Potential for Parents will • Teach re: importance of rest
sleep state 3 • Initiate discussion about strategies to promote rest
disturbances strategies for • Identify support persons
related to new promoting rest • Normalize accepting offers of assistance
parenthood… • Sleep when newborn sleeps
• Relaxation & comfort measures prn
 Post-op Cesarean Care
Additional considerations:
– Cough & deep breathing exercises
– Gradual ambulation
– Pain relief
– Rest
– Assess for signs of infection
• Skin surrounding incision: REEDA (Redness, -
Edema, Ecchymosis, Drainage, Approximation).
• Fever
– Full healing takes 4-6 weeks
 Rh Isoimmunization
• “Rh disease”
• A concern if
– Mom is Rh - (protein absent on RBC)
– Infant is Rh +
– AND occurrence of fetomaternal
hemorrhage
• Cause of erythroblastosis fetalis in subsequent
Rh + infants.
• Preventable by administration of Anti-D Ig
– Routinely given when indicated since 1968.
See Perry et al. (2017) text p. 577 – Rh Isoimmunization
 Figure 20–10 Rh alloimmunization sequence. A, Rh-positive father and Rh-negative mother. B, Pregnancy with Rh-
positive fetus. Some Rh-positive blood enters the mother’s blood. C, As the placenta separates, the mother is further
exposed to the Rh-positive blood. D, The mother is sensitized to the Rh-positive blood; anti-Rh-positive antibodies
(triangles) are formed. E, In subsequent pregnancies with an Rh-positive fetus, Rh-positive red blood cells are attacked
by the anti-Rh-positive maternal antibodies, causing hemolysis of red blood cells in the fetus.

Olds’ Maternal-Newborn Nursing & Copyright ©2008 by Pearson Education, Inc.

Women’s Health Across the Lifespan, 8/e Upper Saddle River, New Jersey 07458
Michele Davidson, Marcia London, and Patricia Ladewig All rights reserved.
 Prevention of Rh Alloimmunization
SOGC Guidelines*
• Anti-D Ig given routinely to nonsensitized Rh- women
antenatally if fetal blood type is unknown or known to be
Rh+

• Anti-D Ig should be given to nonsensitized Rh- women who

have delivered an Rh + infant.

• IM or IV given within 72 hrs of delivery (up to 28 days

postpartum)

• Verbal or written consent required (a blood product).

*Fung et al. (2003). Prevention of Rh Alloimmunization. JOGC,

25(9):765-773.
Discharge teaching
Newborn care
Maternal self-care
Signs of complications (See Table 22-2, p. 568)
• Red sore breasts / mastitis
• Passing many blood clots
• Foul smelling vaginal odor
• Pain when voiding
• Incisional changes
• Painful swollen lower legs
• Postpartum depression
• Infant concerns
Prescribed medications
Visitors
Sexual activity & contraception
Follow-up care
Community resources
(Perry text pp. 580-581)
 Discharge teaching: contraception

Return of ovulation & menses

– Non-Breastfeeding Mothers
• Average 7-9 weeks
– Breast Feeding Mothers (> 6 times per day)
• Average 6 months
~15% resume by 6 weeks
~45% resume by 4-6 months
~40% resume when weaning is complete
Depends on frequency of feedings & if exclusive
Discharge teaching: contraception
Ovulation can occur BEFORE menstrual cycle is re-
established.
Discuss contraception
• Many birth control pills affect lactation
– Breastfeeding mothers can take the pill after
lactation is well established (after 6 weeks)
– Non breastfeeding mothers can take the pill
at 3-4 weeks
- Depo-provera IM
• No adverse effects
 Follow-up postpartum care in the
community
• Usually remain with/return to prenatal care
provider
• May require a postpartum care provider
• Appointments for baby at: ~q week x 3 & 6 wks.
• Appointments for mom at: (1 week) & 6 weeks

Ottawa Public Health – HBHC program

• ‘At risk’ moms receive phone call from PHN
• Home visits by PHN when requested by
mom/referred/indicated by PHN assessment
Healthy Babies Healthy Children Program (HBHC)
https://www.ottawapublichealth.ca/en/public-health-services/healthy-
babies--healthy-children--hbhc-.aspx

A Public health nurse or a family visitor

may continue to visit you to:
• Support you when your baby comes home
• Help you connect with community resources
• Provide ongoing guidance on parenting, feeding and
caring for your child
• For more information call:
Ottawa Public Health Information Line (OPHIL): 613-
580-6744
 Other resources/services for new parents

• Ottawa Public Health

– Healthy Babies Healthy Children & many other
programs/services (self referrals)
• Breastfeeding drop-ins/lactation consultants
• Baby Express (Well baby) drop-in groups
• Community Health & Resource Centres
• Walk -in clinics
• Monarch Clinic (for TOH families)
https://www.monarchcentre.ca
• Montfort Postnatal Care at Home Program
https://hopitalmontfort.com/en/postnatal-homecare
Ottawa Public Health website
http://www.parentinginottawa.ca/en/index.aspx
 Some key terms & concepts to know

• Fundus • Kegel exercises

• Atony • Rh alloimmunization
• Boggy uterus • Postpartum hemorrhage
• Involution • Endometritis
• Subinvolution • Mastitis
• Afterpains • Family assessment &
• Lochia rubra interventions
• Lochia serosa • Family-centered care
• Lochia alba • Culturally appropriate
care
 References
de Montigny, F. & Lacharité, C. (2004). Fathers’ perceptions of the
immediate postpartal period. JOGNN, 33(3),328-339.
Martell, L. (2005). Family Nursing with Childbearing Families In SM
Harmon Hanson, V Gedaly-Duff & J. Rowe Kaakinen (Eds), Family
Health Care Nursing (3rd ed.) (pp. 267-289). Philadelphia: FA Davis
(on reserve)
Mercer, R.T. (2006). Nursing support of the process of becoming a
mother. JOGNN, 35, pp. 649-651
Olds et al. (2008). Maternal-Newborn Nursing & Women’s Health Care (8th
ed.)
Perry,SE, Hockenberry, MJ, Lowdermilk, D, Wilson, D., Keenan-Lindsay, L,
& Sams, CA (2017). Maternal Child Nursing Care in Canada (2nd ed.).
Elsevier: Toronto.
Public Health Agency of Canada [PHAC] (2008). Canadian perinatal health
report: 2008 edition.
PPPESO (2007a). Perinatal Nursing Procedure: Nursing care during fourth
stage of labour. Available at:
http://www.cmnrp.ca/en/cmnrp/Perinatal_Nursing_Procedures_p736.ht
ml
PPPESO (2007b). Perinatal Nursing Procedure: Postpartum hemhorrage.
Available at:
http://www.cmnrp.ca/en/cmnrp/Perinatal_Nursing_Procedures_p736.ht
ml