NUR 335 Maternal Health Module 3 Postpartum Period Exam 3
Study Guide Arizona College of Nursing
● The reproductive system changes postpartum
○ BP & pulse should be assessed Q 15 min for 2 hours
○ Temp should be assessed Q 4 hrs for the first 8 hrs, then Q 8 hrs.
■ B - Breasts
● Changes include secretion of colostrum (during pregnancy and 2-3 days after birth, breasts are
soft) and milk (3-5 days after birth breasts become firm).
○ Contains antibodies & some milk.
● Assessment:
○ Assess for colostrum and the presence of milk at the appropriate time.
○ Engorgement (fullness) of the breast is a result of lymphatic circulation, milk production,
and temporary vein congestion.
■ Breasts will appear tight, tender, warm, and full.
■ For non-breastfeeding clients this will resolve on its own
● Do not ever attempt to pump or breastfeed as it will not resolve.
● Wearing supportive bras, breast binders, ice packs, or cabbage leaves can help.
● #1 reason they may not breastfeed is improper latching in the first few days.
■ For breastfeeding clients frequent feedings and pumps can help manage
engorgement.
○ Assess for erythema, tenderness, cracked nipples, and indications of mastitis.
■ Use lanolin or let the milk air dry on the breast to prevent cracked nipples.
○ Determine the client's ability to assist with latching on and ensure that latching is
appropriate to prevent sore nipples.
■ Ineffective feeding can be a result of maternal dehydration, maternal discomfort,
newborn positioning, or difficulty latching.
, ● L: Latch
○ Entire areola and the nipple should be in the infant's mouth.
● A: Audible
○ Audible swallowing
● T: Type
○ Type of nipple - protruding, flat, or inverted
● C: Comfort
○ How does the mom feel?
● H: Hold
○ Cradle
○ Modified Cradle
○ Side Lying (best in cesarean)
○ Football (best in cesarean)
● Interventions:
○ Promote breastfeeding within 1-2 hrs after birth
■ Will also stimulate production of oxytocin to prevent uterine hemorrhage.
○ Educate on latching techniques & breastfeeding positions.
■ Heavy lochia may be normal due to contractions during breastfeeding. ■
U - Uterus
● Involution of the uterus.
○ Contractions will continue and will cause the uterus to return to nonpregnant state and
size.
○ Decreases from 1000g to 60-80g by 6 weeks.
○ It should decrease by 1 fingerbreadth or 1 cm per day
○ At the end of the 3rd stage of labor, the uterus should be palpable at midline (2cm below
the umbilicus)
○ At 2 weeks the uterus should lie within the pelvis and not be palpable.
, ● Fundal height & uterine placement
○ Assess Q 8 hrs postpartum
■ If 3 above after 8 hours we would be concerned about subinvolution.
○ Position the client supine with the knees slightly bent.
○ While palpating observe the lochia flow
○ Place one hand above the pubic symphysis and cup the uterus, place the other hand on
the abdomen to assess fundal placement
○ Document the amount of fingerbreadths or cm above, below or at the umbilicus
■ +2 or 2/U = 2cm above
■ +1 or 1/U = 1cm above
■ 0 = Umbilicus
■ -1 or U/1 = 1cm below
■ -2 or U/2 = 2cm below
○ Determine whether the uterine is midline or displaced (by the bladder).
● Consistency
○ Uterus should be firm.
○ If not firm this is referred to as “boggy”
■ Begin to massage the uterus in a circular motion.
■ If it does not firm up after massaging, continue to massage and notify the
provider.
● Interventions:
○ Administer oxytocics IM or IV to promote contractions and prevent hemorrhage.
■ Oxytocin & Misoprostol
● May cause hypotension
■ Methylergonovine &
Carboprost ● May
cause hypertension
● Cannot be given if the patient has HTN or eclampsia.
○ Encourage breastfeeding (release of oxytocin), and emptying of the bladder (prevents
uterine displacement and atony).
■ B - Bowel
● Forcep, vacuum assisted delivery, and anal spincter lacerations increase the risk of postpartum
incontinence - usually resolves within 6 months.
● Changes include increased appetite, constipation, and hemorrhoids.
● Assessment:
○ Assess hunger (client should have a good appetite).
○ Assess for bowel sounds and return of normal bowel function.
■ Spontaneous bowel movements should return within 2-3 days.
○ Assess for discomfort with defecation due to tenderness, episiotomy, lacerations, or
hemorrhoids.
● Interventions:
○ Early ambulation, increased fluids, and high fiber foods promote bowel function.
○ Administer stool softeners to prevent constipation.
○ Enemas and suppositories are contraindicated in patients with 3rd and 4th degree
lacerations.
○ Flatus is common after cesarean birth.
, ■ Ambulation, rocking in a chair, and avoiding gas-forming foods will help to pass
gas.
■ B - Bladder
● Urinary retention may occur due to loss of bladder elasticity, bladder tone, and/or bladder sensation
from trauma, medications, or anesthesia.
○ A distended bladder can lead to infection, uterine atony, and uterine displacement. ○
Can also lessen postpartum contractions.
● Postpartum diuresis with increased urinary output begins within 12 hrs of delivery.
● Assessment:
○ Assess the ability ro void.
■ Perineal/urethral edema may cause pain and difficulty in voiding in the first 24-48
hrs.
○ More than 3,000 mL/day is normal within the first 2-3 days after birth.
○ Assess for distended bladder
■ Fundal height above umbilicus or baseline level.
■ Fundus displacement
■ Bladder bulging above the symphysis pubis.
■ Excessive lochia
■ Tenderness over the bladder
○ Frequent voiding of less than 150 mL can indicate urinary retention. Or UTI.
● Interventions:
○ Assist the client to void within 6-8 hrs after delivery.
■ If unable to, catheterization may be necessary.
■ Measure the first 2 voidings the client has.
○ Encourage frequent voiding to prevent uterine displacement and atony. ■
L - Lochia
● Post-birth uterine discharge that contains blood, mucus, and uterine tissue.
● Stages of Lochia
○ Lochia Rubra:
■ dark red color, bloody consistency, fleshy odor, may contain clots.
■ Increases during breastfeeding and standing up.
■ Lasts 1-3 days
■ When saturated pad within 2 hours - NORMAL ■
When saturated pad within 15 min - ABNORMAL ○ Lochia
Serosa:
■ Pinkish brown color, and serosanguinous consistency. May contain small clots
and leukocytes.
■ Lasts 4-10 days
○ Lochia Alba:
■ Yellowish white creamy color. Fleshy odor. Consists of mucus and leukocytes.
■ Lasts from 10 days - 8 weeks
● Lochia Amount
○ Scant: less than 2.5cm
○ Light: 2.5 - 10cm
○ Moderate: more than 10cm
○ Heavy: one pad saturated within 2 hrs.
○ Excessive: one pad saturated within 15 min or less - EMERGENCY**
Study Guide Arizona College of Nursing
● The reproductive system changes postpartum
○ BP & pulse should be assessed Q 15 min for 2 hours
○ Temp should be assessed Q 4 hrs for the first 8 hrs, then Q 8 hrs.
■ B - Breasts
● Changes include secretion of colostrum (during pregnancy and 2-3 days after birth, breasts are
soft) and milk (3-5 days after birth breasts become firm).
○ Contains antibodies & some milk.
● Assessment:
○ Assess for colostrum and the presence of milk at the appropriate time.
○ Engorgement (fullness) of the breast is a result of lymphatic circulation, milk production,
and temporary vein congestion.
■ Breasts will appear tight, tender, warm, and full.
■ For non-breastfeeding clients this will resolve on its own
● Do not ever attempt to pump or breastfeed as it will not resolve.
● Wearing supportive bras, breast binders, ice packs, or cabbage leaves can help.
● #1 reason they may not breastfeed is improper latching in the first few days.
■ For breastfeeding clients frequent feedings and pumps can help manage
engorgement.
○ Assess for erythema, tenderness, cracked nipples, and indications of mastitis.
■ Use lanolin or let the milk air dry on the breast to prevent cracked nipples.
○ Determine the client's ability to assist with latching on and ensure that latching is
appropriate to prevent sore nipples.
■ Ineffective feeding can be a result of maternal dehydration, maternal discomfort,
newborn positioning, or difficulty latching.
, ● L: Latch
○ Entire areola and the nipple should be in the infant's mouth.
● A: Audible
○ Audible swallowing
● T: Type
○ Type of nipple - protruding, flat, or inverted
● C: Comfort
○ How does the mom feel?
● H: Hold
○ Cradle
○ Modified Cradle
○ Side Lying (best in cesarean)
○ Football (best in cesarean)
● Interventions:
○ Promote breastfeeding within 1-2 hrs after birth
■ Will also stimulate production of oxytocin to prevent uterine hemorrhage.
○ Educate on latching techniques & breastfeeding positions.
■ Heavy lochia may be normal due to contractions during breastfeeding. ■
U - Uterus
● Involution of the uterus.
○ Contractions will continue and will cause the uterus to return to nonpregnant state and
size.
○ Decreases from 1000g to 60-80g by 6 weeks.
○ It should decrease by 1 fingerbreadth or 1 cm per day
○ At the end of the 3rd stage of labor, the uterus should be palpable at midline (2cm below
the umbilicus)
○ At 2 weeks the uterus should lie within the pelvis and not be palpable.
, ● Fundal height & uterine placement
○ Assess Q 8 hrs postpartum
■ If 3 above after 8 hours we would be concerned about subinvolution.
○ Position the client supine with the knees slightly bent.
○ While palpating observe the lochia flow
○ Place one hand above the pubic symphysis and cup the uterus, place the other hand on
the abdomen to assess fundal placement
○ Document the amount of fingerbreadths or cm above, below or at the umbilicus
■ +2 or 2/U = 2cm above
■ +1 or 1/U = 1cm above
■ 0 = Umbilicus
■ -1 or U/1 = 1cm below
■ -2 or U/2 = 2cm below
○ Determine whether the uterine is midline or displaced (by the bladder).
● Consistency
○ Uterus should be firm.
○ If not firm this is referred to as “boggy”
■ Begin to massage the uterus in a circular motion.
■ If it does not firm up after massaging, continue to massage and notify the
provider.
● Interventions:
○ Administer oxytocics IM or IV to promote contractions and prevent hemorrhage.
■ Oxytocin & Misoprostol
● May cause hypotension
■ Methylergonovine &
Carboprost ● May
cause hypertension
● Cannot be given if the patient has HTN or eclampsia.
○ Encourage breastfeeding (release of oxytocin), and emptying of the bladder (prevents
uterine displacement and atony).
■ B - Bowel
● Forcep, vacuum assisted delivery, and anal spincter lacerations increase the risk of postpartum
incontinence - usually resolves within 6 months.
● Changes include increased appetite, constipation, and hemorrhoids.
● Assessment:
○ Assess hunger (client should have a good appetite).
○ Assess for bowel sounds and return of normal bowel function.
■ Spontaneous bowel movements should return within 2-3 days.
○ Assess for discomfort with defecation due to tenderness, episiotomy, lacerations, or
hemorrhoids.
● Interventions:
○ Early ambulation, increased fluids, and high fiber foods promote bowel function.
○ Administer stool softeners to prevent constipation.
○ Enemas and suppositories are contraindicated in patients with 3rd and 4th degree
lacerations.
○ Flatus is common after cesarean birth.
, ■ Ambulation, rocking in a chair, and avoiding gas-forming foods will help to pass
gas.
■ B - Bladder
● Urinary retention may occur due to loss of bladder elasticity, bladder tone, and/or bladder sensation
from trauma, medications, or anesthesia.
○ A distended bladder can lead to infection, uterine atony, and uterine displacement. ○
Can also lessen postpartum contractions.
● Postpartum diuresis with increased urinary output begins within 12 hrs of delivery.
● Assessment:
○ Assess the ability ro void.
■ Perineal/urethral edema may cause pain and difficulty in voiding in the first 24-48
hrs.
○ More than 3,000 mL/day is normal within the first 2-3 days after birth.
○ Assess for distended bladder
■ Fundal height above umbilicus or baseline level.
■ Fundus displacement
■ Bladder bulging above the symphysis pubis.
■ Excessive lochia
■ Tenderness over the bladder
○ Frequent voiding of less than 150 mL can indicate urinary retention. Or UTI.
● Interventions:
○ Assist the client to void within 6-8 hrs after delivery.
■ If unable to, catheterization may be necessary.
■ Measure the first 2 voidings the client has.
○ Encourage frequent voiding to prevent uterine displacement and atony. ■
L - Lochia
● Post-birth uterine discharge that contains blood, mucus, and uterine tissue.
● Stages of Lochia
○ Lochia Rubra:
■ dark red color, bloody consistency, fleshy odor, may contain clots.
■ Increases during breastfeeding and standing up.
■ Lasts 1-3 days
■ When saturated pad within 2 hours - NORMAL ■
When saturated pad within 15 min - ABNORMAL ○ Lochia
Serosa:
■ Pinkish brown color, and serosanguinous consistency. May contain small clots
and leukocytes.
■ Lasts 4-10 days
○ Lochia Alba:
■ Yellowish white creamy color. Fleshy odor. Consists of mucus and leukocytes.
■ Lasts from 10 days - 8 weeks
● Lochia Amount
○ Scant: less than 2.5cm
○ Light: 2.5 - 10cm
○ Moderate: more than 10cm
○ Heavy: one pad saturated within 2 hrs.
○ Excessive: one pad saturated within 15 min or less - EMERGENCY**
