Postpartum

Highlighting the phases of the postpartum period

This chart summarizes the three phases of the postpartum period as identified by Reva Rubin.

Phase	Maternal behavior and tasks
*Taking in* (1 to 2 days after delivery)	Reflective time Assumption of passive role and dependence on others for care Verbalization about labor and birth Sense of wonderment when looking at neonate
*Taking hold* (2 to 7 days after delivery)	Action-oriented time of increasing independence in care Strong interest in caring for neonate; commonly accompanied by feelings of insecurity about ability to care for neonate
*Letting go* (7 days after delivery)	Ability to redefine new role Acceptance of neonate’s real image rather than fantasized image Recognition of neonate as separate from herself Assumption of responsibility for dependent neonate

Palpating the fundus

A full-term pregnancy stretches the ligaments supporting the uterus, placing it at risk for inversion during palpation and massage. To guard against this, place one hand against the patient’s abdo-men at the symphysis pubis level, as shown at right. This steadies the fundus and prevents downward displacement. Then place the other hand at the top of the fundus, cupping it, as shown.

Uterine involution

After delivery, the uterus begins its descent back into the pelvic cavity. It continues to descend about 1 cm/day until it isn’t palpable above the symphysis at about 9 days after delivery.

Assessing lochia flow

Character

Lochia typically is described as lochia rubra, serosa, or alba, depending on the color of the discharge. Lochia should always be present during the first 3 weeks postpartum. The patient who has had a cesarean birth may have a scant amount of lochia; however, lochia is never absent.

Amount

Although it varies, the amount can be compared to that of a menstrual flow. Saturating a perineal pad in less than 1 hour is considered excessive; the doctor should be notified. Expect women who are breast-feeding to have less lochia. Lochia flow also increases with activity—for example, when the patient gets out of bed the first few times (due to pooled lochia being released) or when the patient engages in strenuous exercise, such as lifting a heavy object or walking up stairs (due to an actual increase in amount).

Color

Depending on the postpartum day, lochia typically ranges from red to pinkish brown to creamy white or colorless. A sudden change in the color of lochia—for example, to bright red after having been pink—suggests new bleeding or retained placental fragments.

Odor

Lochia has an odor similar to that of menstrual flow. Foul or offensive odor suggests infection.

Consistency

Lochia should have minimal or small clots, if any. Evidence of large or numerous clots indicates poor uterine contraction, which requires intervention.

Common causes of postpartal hemorrhage

This illustration highlights the common causes of postpartal hemorrhage.

Risks factors for developing postpartal hemorrhage

Cervical or uterine lacerations

Operative birth (episiotomy, forceps application)
Rapid birth

Inadequate blood coagulation

Fetal death
Disseminated intravascular coagulation

Placental problems

Placenta previa
Placenta accreta
Premature separation of the placenta
Retained placental fragments

Uterine distention

Multiple gestation
Hydramnios (excessive amniotic fluid)
Large fetus (> 9 pounds)
Uterine myomas (fibroid tumors)

Uterine incontractability

Deep anesthesia or analgesia
Previous history of postpartum hemorrhage
Secondary maternal illness such as anemia
Endometritis
Prolonged and difficult labor
Labor augmentation or initiation by oxytocin (Pitocin)
Possible chorioamnionitis
High parity
Maternal age > 30
Prolonged use of magnesium sulfate or other tocolytic drugs
Previous uterine surgery

Assessing excessive vaginal bleeding

Use this flowchart to help guide your interventions when you determine that your patient has excessive vaginal bleeding.

Assessing puerperal infection

Localized perineal infection

Pain
Elevated temperature
Edema
Redness, firmness, and tenderness at the site of the wound
Sensation of heat
Burning on urination
Discharge from the wound

Endometritis

Heavy, sometimes foul-smelling lochia
Tender, enlarged uterus
Backache
Severe uterine contractions persisting after childbirth

Parametritis (pelvic cellulitis)

Vaginal tenderness
Abdominal pain and tenderness (pain may become more intense as infection spreads)
Inflammation may remain localized, may lead to abscess formation, or may spread through the blood or lymphatic system

Septic pelvic thrombophlebitis

Caused by widespread inflammation
Severe, repeated chills and dramatic swings in body temp-erature
Lower abdominal or flank pain
Possible palpable tender mass over the affected area, usually developing near the second postpartum week

Peritonitis

Caused by widespread inflammation
Rigid, boardlike abdomen with guarding (commonly the first manifestation)
Elevated body temperature accompanied by tachycardia (heart rate greater than 140 beats/minute), weak pulse, hiccups, nausea, vomiting, and diarrhea
Constant and possibly excruciating abdominal pain

Comparing femoral and pelvic deep vein thrombosis (DVT)

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