Nursing Care for the Postpartum Woman

The postpartum period, also known as the puerperium, or the fourth trimester of pregnancy, occurs during the first six weeks after delivery.

During this period, physiological adaptations occur to return the patient’s body to its pre-pregnancy state, including changes to the uterus, perineum, and cardiovascular system.

Following delivery, the uterus begins the process of involution, meaning it returns to pre-pregnancy size and position. As soon as the placenta is delivered, uterine muscle fibers constrict around blood vessels at the placental attachment site and intermittent uterine contractions occur to control bleeding and promote involution.

The fundus, or top of the uterus, is located midway between the umbilicus and the symphysis pubis immediately after the delivery of the placenta.

Then, about 12 hours after delivery, it will rise to the level of the umbilicus. After that, the fundal height continues to descend by about one centimeter, or one fingerbreadth, per day, until it reaches the pelvic cavity by around day ten.

Along with uterine involution, the quantity and characteristics of the lochia, or vaginal discharge after delivery, is monitored.

Lochia should decrease in amount and lighten in color over time. When caring for your postpartum patient, monitor closely for signs of inadequate uterine involution, which can increase the risk of hemorrhage.

Signs to watch for include a soft, or boggy uterus; a fundus that’s above the expected level or deviated away from midline; increasing amounts of lochia, return of a bright red color, or large clots.

If the uterus is boggy, gently massage it until it’s firm; and if it’s not at midline, assist your patient to empty their bladder, since a full bladder can interfere with uterine involution.

If you suspect postpartum hemorrhage, contact the registered nurse immediately. Following a vaginal delivery, the perineum can be swollen and tender, and may have stitches present from repaired lacerations or an episiotomy, where an incision is made to enlarge the vaginal opening.

In some cases, hematomas, bruising, or hemorrhoids can also be present. Monitor your patient’s perineum regularly using the acronym REEDA which stands for Redness; Edema, or swelling, Ecchymosis, or bruising; Discharge; and Approximation, or how closely any incision edges fit together.

During the first 12 to 24 hours after delivery, apply an ice pack to your patient’s perineum to reduce swelling, and replace peri pads and ice packs when soiled to prevent infection.

After 24 hours, transition to the application of warm packs and sitz baths to promote circulation and continued healing.

Remind your patient to keep their perineum clean after voiding and bowel movements by squirting warm water from a peri bottle onto the area from front-to-back, then patting the area dry, and applying a clean peri pad.

Okay, moving on to cardiovascular changes. After delivery, there’s an increase in blood volume and cardiac output as the blood that perfused the uterus and placenta returns to systemic circulation.

This can result in increased urination and diaphoresis as your patient’s body works to excrete excess fluid. Also, orthostatic hypotension, or a drop in blood pressure that occurs when moving from a recumbent position to a sitting or standing position, can occur due to decreased resistance to blood flow in the pelvic blood vessels.

This can result in lightheadedness or syncope, especially the first time your patient ambulates, so be sure to remind your patient to change positions slowly, reinforce the importance of using the call bell when getting up the first few times, and assist them with ambulation, as needed.

Finally, clotting factors that normally increase during pregnancy can increase the risk of blood clots and venous thromboembolism, or VTE, during the postpartum period.

Be sure to observe their lower extremities for signs of thrombus formation, like swelling or redness, and palpate for tenderness and warmth.

Also monitor for signs of pulmonary embolism, such as dyspnea or tachycardia. Take precautions to decrease formation of clots, such as regular ambulation and use of sequential compressive devices for patients who've had a cesarean delivery.

If you suspect a blood clot, report it to the registered nurse. Alright, as a quick recap...The postpartum period, also known as puerperium, or the fourth trimester of pregnancy, refers to the first six weeks after delivery.

During this time, adaptations occur to return the patient’s body to its pre-pregnancy state, including changes to the uterus, perineum, and cardiovascular system.