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Maternal Newborn Nursing

20.1 Physiologic Changes During the Postpartum Period

Maternal Newborn Nursing20.1 Physiologic Changes During the Postpartum Period

Learning Objectives

By the end of this section, you will be able to:

  • Differentiate the basic physiologic changes that occur in the postpartum period as the person transitions from pregnant back to a prepregnant state
  • Describe the elements of the postpartum assessment with the most common concerns
  • Summarize the impact of cultural influences on postpartum recovery

The physiologic changes that occur in the postpartum period affect every system in the body. Rapid shifts in fluid and levels of estrogen and progesterone occur during the immediate postpartum period. Slower physiologic changes that restore the body to the prepregnant state, such as the tightening of the ligaments, occur throughout the 6 weeks of the postpartum period. This period of physiologic change is influenced by previous births, family traditions, and cultural influences as well as comorbidities and perinatal complications.

Postpartum Physiologic Adaptation

The body makes changes during the 40 weeks of pregnancy that return to the prepregnant state after birth. During the first few days after birth, large changes occur in the cardiovascular, reproductive, neurologic, gastrointestinal, and musculoskeletal systems. Subtle changes continue in those systems throughout the postpartum period. The nurse caring for the postpartum person provides anticipatory guidance on these changes.

Vital Signs

During the immediate postpartum period, the person’s temperature can be slightly elevated due to dehydration and the work of labor. A temperature above 100.4º F (38º C) is not expected, and it is important for the nurse to review the patient’s labor and birth record for risks for infection. The nurse will note the pertinent patient data when the nurse contacts the health-care provider and include the patient data along with the increased temperature in the SBAR (situation, background, assessment, and recommendation) communication tool.

A slight increase in blood pressure (BP) in the immediate postpartum period is normal. Blood pressures around 130/80 mm Hg can be due to postdelivery pain, anxiety, or cesarean birth (Parker et al., 2023). Blood pressures greater than 140/90 mm Hg can indicate postpartum preeclampsia, gestational hypertension, or chronic hypertension. The nurse assesses the postpartum person to gather data supporting the most probable cause of the rise in BP, then contacts the health-care provider to report possible postpartum preeclampsia or an unexpected high level of pain. A slight decrease in BP can also be normal due to dehydration and expected blood loss. Hypotension, a BP below 90/60 mm Hg, can occur after a postpartum hemorrhage. Hypotension combined with tachycardia, dizziness, and weakness is reported to the health-care provider by the nurse to determine if fluid replacement is indicated.

The patient’s respiratory rate can be slightly increased because of the work of labor or pain, but is lower than that of pregnancy (Kanakaiah, 2023). The nurse can place a pulse oximeter to determine oxygenation status and can supplement with oxygen as needed. The pulse can be increased due to pain, recovery from birth, and preexisting anemia. The pulse can also be elevated from dehydration and blood loss (Varrias et al., 2022). The person who has experienced a postpartum hemorrhage will have an elevated pulse due to the body compensating for hypovolemia. The nurse can provide an intravenous (IV) fluid bolus to help with dehydration and hypovolemia.

Postpartum Fluid Shift

During pregnancy, many people experience edema. After birth, extracellular fluid from edema is pulled back into the venous system and excreted through increased urine output and diaphoresis, which is the process of excessive sweating to rid the body of excess fluid, stimulated by the levels of estrogen and progesterone decreasing from the higher levels of pregnancy (Martin et al., 2022). Postpartum diaphoresis continues during lactation. The nurse educates the postpartum person on the cause of the sweating, clothing modifications to ease discomfort, and hygiene practices to cope with the diaphoresis.

The intravascular fluid supporting the enlarged uterus also accounts for a portion of the increased urination in the postpartum person. Involution and decreasing levels of estrogen and progesterone produce the increase in fluid into the postpartum person’s vascular system. The average amount of postpartum fluid loss is 2 liters, with the majority over the first 5 to 7 days after giving birth (Martin et al., 2022). The nurse informs the postpartum person that antepartum swelling should subside over the next several days and that they will be urinating often. The edema may take more than a week to resolve after birth if the postpartum person received IV fluids during the labor and birth process. It is also important for the postpartum person to understand that to prevent a urinary tract infection the person must not postpone urination.

Blood loss occurs during birth and postpartum, causing a decrease in intravascular fluid. Normal blood loss during birth can be as low as 150 mL and up to 1,000 mL for a vaginal or cesarean birth (American College of Obstetricians and Gynecologists [ACOG], 2017; Association of Women’s Health Obstetrics and Neonatal Nursing [AWHONN], 2021). The placenta also retains 75 to 400 mL of blood after delivery, depending on the weight of the infant (Martin et al., 2022).

Cardiovascular Instability

Cardiac output increases significantly in the immediate postpartum period. The decrease in the size of the uterus immediately after birth and the birth of the placenta increase the amount of intracellular fluid, contributing to the rise in cardiac output. Edema and extracellular fluid reabsorb into the vascular system, further contributing to the increase in cardiac output. This increase in intravascular fluid and cardiac output makes the heart work harder, and any preexisting cardiac disease can worsen. (More information on these and other complications are discussed in Chapter 21 Postpartum Complications.)

Urinary System

As discussed previously, the shift in fluids increases urine output in the postpartum period. Because of this increase in urinary output, overdistention and decreased sensation of the bladder without complete emptying can occur (Martin et al., 2022). Postpartum persons can have difficulty in emptying their bladder in the immediate postpartum period due to the normal physiologic accommodations needed to allow for a vaginal birth. Vaginal births, with or without genital tract trauma, can lead to swelling around the urethra, causing urinary retention. Laceration or episiotomy repair can also cause swelling and pain upon urination. Urinary retention can be caused by epidural or spinal anesthesia, which results in a decreased urge to urinate while in use, and it can take time for feeling to return.

An overdistended bladder interferes with uterine contractions, causing the uterus to become boggy (or soft). The distended bladder can also displace the uterus to the left or right side instead of midline in the abdomen (Figure 20.2), causing the uterus to lose tone and increasing the risk for postpartum hemorrhage. The nurse encourages the person to attempt to empty their bladder often, either on a bed pan or with assistance to the restroom. If the postpartum person cannot empty the bladder, the nurse follows the postpartum orders for urinary catheterization.

Image of (left) full bladder pushing up against uterus and pubic bone and (right) Foley catheter being inserted into empty bladder through urethra.
Figure 20.2 Change in Uterine Placement A full bladder displaces the uterus farther up into the abdomen. (credit: modification of work from Anatomy and Physiology, 2e. attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)

Clinical Judgment Measurement Model

Postpartum Assessment

The nurse is called to the room by the postpartum person, who states they are bleeding a lot. The nurse begins the assessment of the postpartum person’s vaginal bleeding.

  1. The nurse assesses the uterus to ensure it is firm and midline.
  2. The uterus is firm and deviated to the right.
  3. Uterine deviation can be caused by a full bladder. Palpate the bladder.
  4. Bladder distention is noted.
  5. The nurse assists the postpartum person in emptying their bladder (bedpan, bathroom, catheter).
  6. The nurse reassesses the uterus for tone and location.
  7. The uterus is firm, midline, and at the umbilicus.
  8. The nurse assesses the vaginal bleeding (lochia) and notes it has slowed to normal.

Clinical judgment used by the nurse in this patient scenario:

The nurse assesses the postpartum person for possible causes of the increased vaginal bleeding. The nurse is aware that bladder distention is a common reason. Palpation of the bladder is a necessary assessment.

Breast Changes and Lactation

The growth of the breasts during pregnancy may cause striae (stretch marks) and loss of elasticity of the skin. Superficial veins occurring during pregnancy will fade in those who do not breast-feed but will continue to be seen in breast-feeding persons, especially during engorgement. Darkening of the areola during pregnancy will fade over the first 6 weeks postpartum (Martin et al., 2022). The nurse encourages the postpartum person to wear a supportive bra.


The physiologic process of developing the means to secrete milk is called lactogenesis (Lawrence & Lawrence, 2022). The first stage of lactogenesis (secretory differentiation) occurs during pregnancy and results in the growth of the mammary lobes, ducts, and alveoli within the breast (Figure 20.3). A balance of hormones during pregnancy prevents the secretion of milk once the first stage is complete at around 22 weeks of pregnancy. After the birth of the newborn and placenta, progesterone levels drop significantly, and the second stage of lactogenesis (secretory activation) begins (Lawrence & Lawrence, 2022). As progesterone levels decrease, prolactin levels rise, stimulating milk production. The lobes, ducts, and alveoli within the lactating breast (Figure 20.3) increase in size. Stimulation of the nipples by the newborn increases secretion of oxytocin, causing the milk to let down and secrete out of the breast for the newborn to ingest.

Images of breast at three times: (a) nonpregnant breast, (b) pregnant breast, and (c) lactating breast.
Figure 20.3 Changes in the Breast The drawings illustrate the changes in the ductal system, lobes, and alveoli of the breast from nonpregnant (a) to pregnant (b) to lactating (c) due to the hormonal changes of lactogenesis. (credit: modification of work from Anatomy and Physiology, 2e. attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)

Initiating Breast-Feeding

Immediately after birth if the newborn and postpartum person are stable, the newborn should be placed skin-to-skin on the birthing person’s chest. The World Health Organization (2023) recommends breast-feeding within the first hour of birth. Having the newborn on the chest allows the newborn to learn the smell of the postpartum person and milk and encourages breast-feeding. Colostrum, present in the breasts at the time of birth, is a nutrient-dense first milk, thick and whitish-yellow with little volume, containing antibodies to build the infant’s immune system. The nurse teaches the postpartum person the importance of colostrum for the newborn’s immune system and digestion.

Real RN Stories

Nurse: Alexis, RN, postpartum nurse
Years in practice: 8
Clinical setting: Medical City McKinney
Facility location: McKinney, Texas

I enjoy teaching patients about breast-feeding. I was caring for a patient who was concerned that her baby was not getting enough milk because when she pumped, she only got a tiny amount. She was only 18-hours postpartum. I explained the difference between colostrum and traditional milk. She insisted that her baby could not be satisfied with such a little amount.

We had sweetened condensed milk in the staff refrigerator. I got a teaspoon of the thick, sweet milk and a teaspoon of skim milk. I asked the patient to drink the skim milk, then the sweetened condescended milk. When she tasted the sweet milk, I asked if she could drink an entire glass of that milk. She said that she could not, that it was too sweet. I explained that colostrum was similar. The baby did not need as much because it was concentrated and the perfect amount.

After our “experiment,” she laughed and thanked me for explaining that to her. She said it made so much more sense to her. It was great to see her feel good about the colostrum she was feeding to her baby.

At approximately postpartum day 2 or 3, milk changes from colostrum to traditional milk that is thinner with more volume than colostrum. The nurse explains that some lactating persons will have an increase in temperature and feel feverish as their milk comes in. The painful sensation of filling of the breasts characterized by hard breasts that ache and are hot to the touch is called engorgement. The nurse explains hand expression of milk (Figure 20.4) and offers cold packs to help ease engorgement. Milk production works through supply and demand. As the newborn empties the breasts, prolactin stimulates the breasts to produce more milk. The newborn will set somewhat of a schedule to feed every 2 to 3 hours.

Photo of steps for hand expressing breast milk: 1. Positioning, 2. Pressing, 3. Compressing, and 4. Release and repeat.
Figure 20.4 Patient Education: Hand Expressing Breast Milk The nurse educates the breast-feeding person and provides educational material on hand expression. (credit: “Steps for expressing milk by hand” by Centers for Disease Control and Prevention/Division of Nutrition, Physical Activity, and Obesity, National Center for Chronic Disease Prevention and Health Promotion, Public Domain)

Milk released during a breast-feeding session has different nutritional content. Milk high in water and protein and low in fat, called foremilk, is released at the beginning of a breast-feeding session; hindmilk, a milk high in fat and calories, is released later in the breast-feeding session (Pu et al., 2023). The nurse educates the breast-feeding person on the importance of both types of milk and encourages complete emptying of one breast prior to changing the infant to the other breast during a feeding.

For postpartum persons not desiring to breast-feed, their breasts should be bound with a tight, supportive, and well-fitting bra to avoid filling of the breasts with milk. The nurse can provide a cold compress or encourage the person to use cold cabbage leaves to reduce the production of milk. The nurse encourages the person to face away from warm water in the shower, as this stimulates letdown. Letdown is a reflex caused by the release of oxytocin that contracts the alveoli, ejecting milk from the breast. Letdown can be caused by heat, hearing a baby cry, thinking of the infant, and while the infant is feeding. Ice packs or frozen peas in an unopened bag and a mild analgesic can be recommended to ease any breast discomfort in the postpartum person who is not breast-feeding.

Very few conditions are contraindications to breast-feeding. However, a person who is human immunodeficiency virus (HIV) positive or has AIDS is advised by their provider to not breast-feed if living in the United States. In low-income countries where water is unclean or inaccessible, breast-feeding is encouraged even in those who are HIV positive. Other contraindications include infants with a rare genetic disorder called galactosemia and the postpartum person with T-cell lymphotropic virus type I or II or active herpes lesion or who uses illicit drugs. Persons with active tuberculosis or varicella can pump and feed the infant breast milk (Centers for Disease Control and Prevention [CDC], 2023).

Reproductive System

The reproductive system undergoes the most changes during pregnancy and the postpartum period. After birth, the cervix and uterus must begin the process of changing back to the prepregnant state. The perineum and vagina begin the healing process from the birth. The nurse explains that the uterus takes several weeks to return to the prepregnancy state. The nurse also explains that the perineum and vagina will heal and that any stitches used to repair lacerations or the episiotomy will dissolve with time.

Uterus and Lochia

During the first 24 to 48 hours, the uterus involutes, or shrinks, to the approximate level of the umbilicus. The uterus shrinks approximately 1 cm per day and is within the confines of the pelvis by day 10, as illustrated in Figure 20.5. Involution is aided by postpartum uterine contractions. These contractions stop the blood flow from the spiral arteries, which are attempting to perfuse the placenta even after delivery. Without contractions, the risk of postpartum hemorrhage increases. If the nurse notices the fundus is not firm, the nurse should massage the uterus, assess the lochia, and administer oxytocin (Pitocin) according to postpartum orders. Complete involution of the uterus to the prepregnant size occurs over approximately 6 weeks.

Image of the fundal height on an abdomen from the 1st day postpartum (higher on the abdomen) to the 10th day postpartum (lower on the abdomen).
Figure 20.5 Involution of the Uterus The fundus is at the umbilicus after birth, then involutes 1 cm per day during the first 10 days postpartum. (attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)

The placental site takes 6 weeks to heal as well. The placental site heals by sloughing off old tissue, and the endometrium generates new tissue. The old tissue is sloughed off as part of the lochia. Placental fragments or membranes that are not sloughed off are retained and can cause infection or subinvolution of the uterus. The nurse teaches the person to call the health-care provider for increased bleeding, foul-smelling discharge, or expulsion of pieces of membranes or placenta.

The vaginal bleeding that occurs during the postpartum period is called lochia. When it is bright to dark red and consists of blood, cervical discharge, and uterine lining, it is considered lochia rubra. It occurs during the first 1 to 4 postpartum days and originates from the placental site. Lochia is measured based on the amount of peripad saturation. Lochia that saturates a peripad in less than 1 hour is considered excessive and requires immediate assessment of the uterus to determine if the cause is bladder distention or uterine atony. The nurse also assesses the blood pressure and pulse for signs of hypovolemia. The health-care provider will be provided a report by the nurse. Figure 18.7 illustrates the measurement of lochia by peripad saturation. The quantitative blood loss of lochia is accurately measured by weighing each peripad used by the patient. A gram of weight is considered equal to 1 mL of blood loss.

As the placental site heals, the lochia changes to pinkish-brown, or lochia serosa, which lasts 4 to 10 days. This lochia consists of white blood cells, cervical mucus, and discharge from the healing placental site. The final postpartum discharge, lochia alba, is yellow-white and consists of white blood cells, epithelial cells, and mucus. It occurs from approximately day 10 to 28. The nurse explains the stages of lochia progression to the postpartum person, including the expected amount and appearance of the lochia. These are summarized in (Figure 20.6).

Chart of coloring of lochia discharge from days 1-3 (bright red), days 4-10 (pale pink), and days 10-28 (yellowish).
Figure 20.6 The Stages of Lochia Lochia discharge of blood and fluids changes in color and quantity during the postpartum period, which can range from 10 to 28 days. (attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)

Uterine cramping during the immediate postpartum period and up to 12 hours after birth is strong and rhythmic. The cramping continues for 2 to 3 days, is a part of the uterine involution process, and is usually more painful in multiparous persons. These cramps are more noticeable during nursing because oxytocin is released with milk letdown, and oxytocin causes rhythmic uterine contractions perceived as cramping or pain. The nurse educates the patient on the cause of the cramping and offers the prescribed analgesic such as nonsteroidal anti-inflammatory drugs (NSAIDs) to decrease cramping pain (ACOG, 2022). The nurse also encourages the person to lie on their side with a pillow splinting the fundus or a warm compress or heating pad to relieve pain.

Cervical Changes

The cervix is bruised and floppy after a vaginal birth (or a cesarean birth performed after cervical changes have occurred) and remains slightly dilated. It returns to its prepregnant state gradually and is less than 1 cm dilated after a week. The cervical os permanently changes shape after the first vaginal birth or after a cesarean birth where cervical dilation occurred, going from a round pinhole to a transverse slit (see Figure 11.3). The cervix of a person after an elective or planned cesarean birth must also go through a recovery period back to prepregnant status. Even though the cervix is not dilated like the vaginal birth cervix, the cervical canal must return to a long, closed, recollagenized state without the influence of excessive estrogen.

Vagina and Perineum

The vagina is enlarged and often swollen after a vaginal birth, possibly with lacerations present. The nurse reassures the person that the vagina will heal and revert to its prepregnant size. Lacerations or episiotomy sites are repaired using absorbable sutures and take 2 to 3 weeks to heal. The nurse provides prescribed comfort measures to decrease perineal pain. These include ice packs to the perineum for the first 24 hours, sitz baths after 24 hours, and topical analgesics (ACOG, 2022).

The pelvic floor muscles have decreased tone due to stretching to accommodate the fetus during the birth process. The decrease in tone increases the incidence in postpartum stress incontinence. Kegel exercises, sometimes called pelvic floor muscle exercises or therapy, are exercises performed to strengthen the pelvic floor and are important to the postpartum person’s recovery. To perform a Kegel, the patient should be instructed to squeeze the muscles of the pelvic floor in an upward motion, contracting the muscles around the urethra, vagina, and rectum. The contraction should feel like trying to stop the flow of urine.

Because the pelvic floor is stretched from the weight of the pregnant uterus or the birth process, many postpartum persons suffer from pelvic floor relaxation and can experience urinary incontinence. Kegel exercises throughout pregnancy and postpartum will strengthen the pelvic floor muscles. The nurse can teach the postpartum person how to perform a Kegel and recommend starting with 10 Kegels three times per day. For the person with urinary incontinence, suggest working up to 30 Kegel exercises one to three times every day for 3 months (Yount et al., 2021). Sometimes Kegel exercises may be insufficient, and pelvic floor therapy may be needed.

Musculoskeletal and Integumentary Changes

During pregnancy, the muscles in the midline of the abdomen can stretch to a point of separation, a condition known as diastasis recti abdominis (Figure 20.7). If diastasis occurs, part of the abdominal wall has no muscular support. Birthing persons who have a history of multiple gestation, polyhydramnios, macrosomia, short intervals between pregnancies, and are multiparous are at greater risk for diastasis due to the overdistention of the abdomen (Martin et al., 2022). Persons experiencing a cesarean birth are also at increased risk because of the rectus abdominis muscles being manually separated to access the uterus. If the healing of the diastasis is not complete by 6 weeks postpartum (the diastasis is less than 2 cm in width), the patient should consult their health-care provider or a physical therapist (Chen et al., 2023). Persons giving birth by cesarean will have a longer recovery due to inability to exercise until the incision has healed and pain has resolved. The nurse educates the person that the incision will take approximately 6 weeks to heal and encourages them to roll to their side while getting out of bed to avoid using the abdominal muscles.

Image of (a) normal abdominal muscles with little distance between muscles and (b) diastasis recti abdominis muscles which are separated down the middle.
Figure 20.7 Diastasis Recti Abdominis During pregnancy, the muscles in the midline of the abdomen (a) can stretch to a point of separation (b), a condition known as diastasis recti abdominis. (modification of work from Anatomy and Physiology 2e. attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)

Relaxation and softening of the pelvic bones, muscles, and ligaments occur during pregnancy due to increased estrogen, progesterone, and placental relaxin, a hormone produced in the ovaries and placenta (Stolarczyk et al., 2021). Relaxin allows the pelvic bones to separate, increasing the diameters of the pelvis to accommodate birth of the newborn. These hormones also cause lordosis (curving in of the spine), separation of the symphysis pubis, and alterations in center of gravity. These changes cause feelings of pelvic instability and pain. After delivery of the placenta, relaxin gradually decreases, and the pelvic bones return to their prepregnant state in approximately 5 months (Stolarczyk et al., 2021).

The abdominal skin also stretches under the influence of pregnancy hormones. Stretching of the skin can cause striae, also known as stretch marks. Striae can occur on the abdomen, hips, breasts, legs, or anywhere the skin has stretched during pregnancy. Figure 20.8 shows an example of striae on the pregnant abdomen. Striae in light-skinned persons are pink-purple during pregnancy and fade to a silver color. People with darker skin have striae that are darker during pregnancy and fade over time. Striae are not preventable and do not completely disappear from the skin but become much less visible over time.

Photo of pregnant abdomen with dark line on the skin running down the middle.
Figure 20.8 Striae on the Abdomen Striae can be seen on the pregnant abdomen as a result of the skin stretching. (credit: “Woman in Black and White Zebra Print Bikini Top” by directorvinny studios/Pexels, CC0)

Gastrointestinal System

Nausea and vomiting can occur during labor and postpartum. As the gastrointestinal (GI) system awakes from the birth process or anesthesia, some persons experience nausea and vomiting. The nurse can encourage small, bland meals or administer antiemetics according to the postpartum orders to calm the nausea and vomiting. Constipation can also occur (Martin et al., 2022). This can be due to dehydration, poor diet, decreased mobility, hormonal shifts, or medication, such as opiates for pain control. Fear of pain or tearing stitches after a vaginal birth can prevent a person from attempting to have a bowel movement. Hemorrhoids occur during pregnancy and labor. Pain from hemorrhoids can also cause fear of defecation, increasing the risk for constipation. The nurse explains the importance of attempting to have a bowel movement so that the person does not become constipated and encourages ambulation to promote defecation. Increased ambulation and stool softeners may also be recommended.

After a cesarean birth, the GI system is slowed due to anesthesia. These persons must wait for bowel motility to return before having a bowel movement. The nurse explains that passing flatus is a sign that the bowels are moving. Increased water intake, early ambulation, and a prescribed stool softener can help with constipation. Routine bowel movements return in 2 to 3 days after birth.

Weight Loss

Weight loss of approximately 10 to 15 pounds occurs immediately after the delivery of the infant, placenta, and amniotic fluid. Depending on the amount of edema during pregnancy and labor, some persons lose more than 5 pounds in extracellular fluid over the first few postpartum days. The nurse reassures the postpartum person that returning to prepregnant weight is gradual and different for every person. The nurse educates the postpartum person to eat fruits and vegetables for vitamins and fiber; whole grains for energy; lean proteins to rebuild muscle and tissue after labor and birth; dairy for calcium; and a small amount of healthy fats for breast milk. According to the U.S. Department of Agriculture (USDA, 2020), the breast-feeding person should eat 330 extra calories per day the first 6 months of breast-feeding (500 extra calories for milk production minus 170 calories per day for weight loss), then 400 extra calories after 6 months postpartum (assuming weight is back to the prepregnant level). The nurse can use the MyPlate recommendations for nutrition education (Figure 20.9).

Image of USDA MyPlate meal recommendations for Fruits, Vegetables, Grains, Protein, and Dairy servings displayed on a plate.
Figure 20.9 MyPlate Recommendations The USDA has recommended using this food guide to educate persons on nutrition. This guide is acceptable for postpartum and breast-feeding people. (credit: “Start simple with MyPlate” by U.S. Department of Agriculture/MyPlate U.S. Department of Agriculture, Public Domain)

Neurologic Changes

Neurologic changes can occur in the postpartum period for several reasons. Spinal or epidural anesthesia is one cause. When the epidural or spinal needle is inserted, if the dura is punctured, the puncture causes cerebrospinal fluid to leak, and the postpartum person can develop a spinal headache. The nurse recognizes a spinal headache as a severe headache that worsens when the person sits up. The anesthesia provider will be consulted to address this problem. Headaches can also be a neurologic sign of preeclampsia, dehydration, fatigue, and loss of sleep. The nurse will assess the characteristics of the headache of the postpartum person to differentiate the most likely cause(s) of the headache. The nurse will also assess the deep tendon reflexes of the postpartum person because persons with preeclampsia could continue to have brisk reflexes for several days and still be at risk for an eclamptic seizure for up to 6 weeks after birth. See Chapter 21 Postpartum Complications for further discussion.

Lab Values

During labor, the white blood cell (WBC) count can elevate up to 20,000 to 30,000 and remain elevated for several days due to the stress of labor. The WBC count returns to prepregnant values after 1 week (Moldenhauer, 2022). If the person did not hemorrhage, the hemoglobin and hematocrit usually remain in the prepregnant range; however, levels can fluctuate and can be less than the prepregnant range. Plasma fibrinogen is elevated for 1 week to help with clotting; however, this elevation can cause a risk for deep vein thrombosis (DVT). Erythrocyte sedimentation rate also remains elevated for 1 week. The nurse monitors postpartum lab results for signs of anemia and infection, especially in people with a history of postpartum hemorrhage or chorioamnionitis. For persons with a low hemoglobin and hematocrit, the nurse educates on foods high in iron and encourages prescribed supplemental iron. The nurse contacts the health-care provider with an elevated WBC count and assessment findings suggestive of infection. Table 20.1 compares lab values during pregnancy and the postpartum period.

Lab Prepregnanta Antepartuma Postpartuma (24 hours)
Hemoglobin (g/dL) 12–16 9.5–15 8–13.7
Hematocrit (g/dL) 35–44 28–41 24.5–40.8
WBC (×109/L) 4–10 6–16 7–-21
Platelets (×109/L) 150–400 145–400 67–251 (average 160)
Fibrinogen (g/L) 1.5–4.0 2.38–5.9 2.5
Ferritin (ng/mL) 10–150 16–-24 32–50b

aMorton, 2021

bEmegoakor et al., 2015

Table 20.1 Lab Values Pre-Pregnancy, Antepartum, and Postpartum

Postpartum Physical and Emotional Assessment

Postpartum assessment begins after the birth of the placenta and continues until the patient’s discharge home. The nurse will remain with the postpartum person and newborn during the initial recovery period. The newborn should remain skin-to-skin with the postpartum person during this time if both are stable. The nurse assesses vital signs, the uterus and lochia, level of pain, and attachment and bonding during the immediate postpartum period. Breast-feeding can be initiated during this time, and the nurse can help the person to obtain a good latch. Postpartum assessment is continued for the time the person is in the birthing facility; however, assessment findings will change slightly from the immediate postpartum to the next 48 hours.

The postpartum assessment can be summarized using the acronym BUBBLE-EE explained in Table 20.2. The nurse will perform the postpartum assessment in a systematic manner and observe for progression in healing or signs of complications (Khidhir & Ahmed, 2022). The assessment begins at the breasts, assessing both the breast-feeding and non–breast-feeding person for signs of filling, infection, or nipple cracking. The uterus is assessed for firmness and location. The amount and character of lochia are noted. The nurse assesses the bladder and assists the person to the restroom or bedpan if needed. Bowel sounds are auscultated. The nurse discusses the passing of flatus as a good sign, especially for persons having a cesarean birth. The nurse assesses the perineum and notes any hematomas, hemorrhoids, or signs of infection. Extremities are assessed to detect DVTs, reflexes, and overall edema. The nurse also assesses the emotional status of the person, noting signs of baby blues, depression, anxiety, and bonding. Postpartum education can be included while performing the assessment.

Category Areas of Assessment
B: Breasts Feeding method
If breast-feeding: frequency and duration, LATCH scorea
U: Uterus Fundus: firm or boggy
Fundal height: in relation to the umbilicus
Midline or deviated
If cesarean birth: incision
B: Bladder Last void
B: Bowels Last bowel movement
Bowel sounds
L: Lochia Color
E: Episiotomy and perineum Redness
E: Extremities Reflexes
Signs of DVT in extremities
E: Emotional Status Postpartum blues
Postpartum depression (PPD)
Postpartum psychosis
Screening tool for PPD
Support system

aA breast-feeding charting system and documentation tool that assigns a score, of 0, 1, or 2 to five key components of breast-feeding.

Table 20.2 Postpartum Assessment: BUBBLE-EE

Breast Assessment Including Lactation

The nurse assesses the breasts for general appearance, noting any dimpling, redness, or changes in skin color or texture. They assess for filling of milk by noting firmness of the breasts. When breasts are filling, the nurse will note a slight firmness. Engorgement can occur when milk fills the breasts and makes the breasts very full, firm, and painful. Engorgement is expected at 3 to 5 days postpartum. The nurse encourages nursing every 2 to 4 hours to help with engorgement. The nurse assesses nipples for signs of inversion, trauma, or blisters. The nurse also observes a session of breast-feeding to assess latch (Figure 20.10). The nurse can utilize the LATCH score to assess the breast-feeding session and observe for progress or signs of breast-feeding difficulties (see 24.1 Basic Newborn Care). A lactation consultant or counselor can provide additional assistance.

Image of steps to a good latch for breastfeeding, which include: tickling baby’s lips, aiming nipple at baby’s top lip, and leaning baby onto the breast.
Figure 20.10 Steps to a Good Latch The nurse can provide a visual aid to help the breast-feeding person create a good latch. (credit: “Steps to a Good Latch” by U.S. Department of Agriculture/USDA WIC Breastfeeding Support, Public Domain)

Uterine/Fundal Assessment

The nurse assesses the uterus for firmness and position after either a vaginal or cesarean birth. The fundus should be firm, slightly above or below the umbilicus after birth, and midline. The uterus involutes approximately 1 cm daily. If the fundus is boggy, the nurse massages the fundus and teaches the postpartum person how to massage it. If the fundus is deviated to one side, a full bladder is usually the cause (Martin et al., 2022). If a cesarean birth occurred, the nurse assesses the abdominal dressing to ensure it is clean and dry. When uncovered, the nurse assesses the incision for approximation, heat, redness, and discharge. The nurse premedicates the postsurgical person with a pain reliever prior to assessment of the uterus and incision if possible.

Bladder Assessment

Postpartum diuresis will cause an increase in urine output. The nurse assesses the bladder for fullness and retention. A full bladder can also cause the uterus to be boggy, rise above the umbilicus, and be deviated to one side (Martin et al., 2022). The nurse can measure the amount of urine with each void to ensure emptying of the bladder and can assess the bladder for residual urine using a bladder scanner per facility policy. If the person is unable to void, the nurse can encourage the person to use a peri-bottle or attempt to void while taking a shower, as the warm water sometimes helps relax the muscles, allowing urination. The peri-bottle is a plastic bottle with a spray spout that the patient fills with warm water to help cleanse the perineum (Figure 20.11). If the bladder is palpable and the person cannot void, the nurse can insert a catheter per the health-care provider’s order.

Photo of a peri-bottle.
Figure 20.11 Peri-Bottle The peri-bottle is used during the postpartum period to cleanse the perineum. (attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)

Bowel Assessment

The nurse will determine if the postpartum person has passed flatus or had a bowel movement. The nurse also assesses the abdomen for bowel sounds and firmness. Hypoactive bowel sounds and abdominal guarding can be normal for the person who had a cesarean birth (Elsevier, 2024). The abdomen should be soft and easy to palpate, not taut. The nurse will palpate and percuss the abdomen for signs of bloating. The nurse will encourage fiber, ambulation, and increased fluid intake. Prescribed stool softeners can be administered.

Lochia Assessment

The nurse assesses lochia for color, amount, and odor. Lochia rubra is present for the first 3 days and should not fill a pad in less than an hour. The nurse teaches the person that small clots (size of a quarter) are normal; however, larger clots (larger than a golf ball) should be evaluated (Elsevier, 2024). They also teach the person that a foul odor could be a sign of uterine infection and to contact the health-care provider.

Episiotomy and Perineal Assessment

The nurse assesses the perineum and the anus. The nurse positions the postpartum person in the lateral position and lifts the buttock to assess for stitches and wound healing. The REEDA (redness, edema, ecchymosis, discharge, and approximation) assessment is documented as shown in (Table 20.3). Hemorrhoids and hematomas should be noted. The nurse will also inquire about pain at the perineum or during a bowel movement.

  0 1 2 3
R: Redness None < 0.25 cm of incision bilaterally < 0.5 cm of incision bilaterally > 0.5 cm of incision bilaterally
E: Edema None < 1 cm from incision 1–2 cm from incision > 2 cm from incision
E: Ecchymosis None < 0.25 cm bilaterally or < 0.5 cm unilaterally 0.25–1 cm bilaterally or 0.5–2 cm unilaterally >1 cm bilaterally or > 2 cm unilaterally
D: Discharge None Serous Serosanguineous Bloody or purulent
A: Approximation Closed < 3 mm separation of wound edges Separation of skin and subcutaneous fat Separation of skin, subcutaneous fat, and fascia
Table 20.3 REEDA Episiotomy Healing Assessment (Ernawati et al., 2020)

Extremities Assessment

The nurse assesses the lower extremities for edema, reflexes, and signs of deep vein thrombosis (DVT). The level of edema varies in the postpartum person based on the amount of edema present during the pregnancy, the amount of IV fluids administered during the labor and birth process, and the presence of preeclampsia (Martin et al., 2022). Deep tendon reflexes are expected to be normal; when brisk, they require further evaluation for preeclampsia. Postpartum persons are at increased risk for DVT due to a hypercoagulable state, increased production of clotting factors, decreased fibrinolysis, obesity, or traumatic birth along with decreased movement after birth. The nurse assesses all extremities for signs of a DVT, such as single-extremity edema with a painful area of redness and warmth. A DVT can dislodge and cause a pulmonary embolism; therefore, the postpartum person is assessed for shortness of breath and diminished breath sounds. The nurse teaches the postpartum person to call if shortness of breath or chest pain occurs.

Nurses should encourage early ambulation to decrease edema and prevent DVT occurrences for the postpartum person after either vaginal or cesarean birth. If ambulation is restricted, especially in the first 12 hours after a cesarean birth, application of sequential compression devices and administration of prescribed anticoagulants (enoxaparin [Lovenox], heparin, aspirin) will be performed by the nurse.

Emotional Assessment

The postpartum period is a time of change. This time of transition for the body and mind can be stressful for the postpartum person and their support person. The person is encouraged to talk about their perceptions and feelings surrounding their birth. Family presence and support are evaluated.

A postpartum depression screening tool helps identify persons with positive postpartum depression so that referrals can be made prior to discharge from the birthing facility. The most common postpartum depression screening tool is the Edinburgh Postnatal Depression Scale (EPDS). The EPDS is usually performed during pregnancy, during the initial birthing facility stay, at the postpartum follow-up visits with the health-care provider, and at the newborn’s health-care visit (Levis et al., 2020). The nurse educates the person and family on the difference between postpartum blues and postpartum depression and instructs them on signs of when to call the health-care provider.

Low moods that are common during the first 2 weeks of the postpartum period are called postpartum blues, or baby blues. These moods resolve by themselves without treatment or medication. Postpartum blues are attributed to the massive change in hormones after birth. Symptoms can include fatigue, crying, irritability, anxiety, insomnia, and sadness (ACOG, 2021a). The nurse educates the postpartum patient on the importance of contacting the health-care provider to be assessed for postpartum depression if symptoms worsen or last longer than 2 weeks.

Postpartum depression (PPD) is When the symptoms include feelings of extreme stress, detachment from the newborn, anxiety, and feelings of being overwhelmed, the postpartum person is diagnosed with postpartum depression (PPD). These feelings last longer than 2 weeks and are more severe than postpartum blues.

Postpartum depression can affect maternal-newborn attachment, leading to avoidance of the newborn, negative feelings toward the newborn, and inability to be a caretaker (ACOG, 2021a). Postpartum persons who lack attachment behaviors exhibit little eye contact, avoid holding the newborn, and do not find joy in their new role. The nurse supports the postpartum person and explains the importance of receiving help for their feelings. A consult with social worker services is initiated, and the health-care provider is notified. The person will follow up with the health-care provider to monitor for worsening symptoms of PPD after being discharged.

Parent-Infant Attachment

Parent-infant attachment is the relationship that develops between the newborn and the parent in which the infant gains security and the parent takes on the caregiver role (Trombetta et al., 2021). The nurse assesses this attachment by observing the interaction between the postpartum person and their newborn. Parent-infant attachment will be further explored in 20.3 Nursing Care During the Postpartum Period.

Abnormal Findings

The nurse evaluates the postpartum person for abnormal findings. Some findings can necessitate an immediate intervention, while other findings can be monitored. Table 20.4 describes the most common abnormal postpartum assessment findings and suggested nursing interventions.

Physical Assessment Normal Findings Abnormal Findings Nursing Interventions
Vital signs
  • afebrile
  • BP ≤120/80
  • pulse <100
  • respirations <22
  • temp ≥100.4º F (38º C)
  • BP >140/90
  • pulse >100
  • labored breathing, shortness of breath
  • respirations >24
  • assess for dehydration and signs of infection
  • assess for signs of preeclampsia
  • assess for hemorrhage
  • assess for signs of pulmonary embolus
  • notify health-care provider for fever, preeclampsia signs, excessive bleeding, shortness of breath, or signs of embolus
  • nipple everted
  • colostrum expressed
  • filling
  • firm with milk
  • inverted nipples
  • red, hot area on breast
  • nipple trauma
  • bloody discharge
  • engorgement
  • assess for infection
  • encourage hydration
  • contact lactation consultant
  • apply nipple cream
  • encourage hand expression for engorgement
  • can apply cool compress for engorgement
  • can use nipple shield
Uterine/Fundal assessment
  • firm
  • at the umbilicus
  • midline
  • boggy
  • elevated >2 fingerbreadths above the umbilicus
  • deviated to one side or the other
  • massage fundus
  • assess lochia amount
  • assess bladder for fullness
  • empty bladder if necessary
  • notify health-care provider if bogginess continues
  • nonpalpable
  • able to void without difficulty
  • palpable
  • urinary retention
  • deviated uterus
  • elevated uterus
  • assist to bathroom
  • provide bedpan
  • empty bladder with catheter per health-care provider order
  • normoactive bowel sounds
  • passing flatus
  • absent bowel sounds
  • no flatus
  • administer stool softener
  • encourage ambulation
  • encourage hydration
  • lochia rubra
  • soaking a pad after 1 hour
  • bright red bleeding
  • soaking a pad in <1 hour
  • large clots
  • foul smell
  • assess fundus; if boggy, massage
  • assess for bleeding from laceration or episiotomy if fundus is firm
  • assess for tenderness or pain with fundal massage
  • notify health-care provider if lochia is heavy and bright red
  • slight edema
  • bruising
  • stitches intact
  • mild to moderate laceration/episiotomy pain
  • rectal hemorrhoids
  • redness
  • edema
  • ecchymosis
  • discharge
  • not approximated
  • hematoma
  • severe laceration/
    episiotomy pain
  • rectal hemorrhoids red, hot, painful
  • apply ice pack for 24 hours
  • encourage sitz baths
  • apply local anesthetic spray or foam
  • assess for infection
  • administer stool softener
  • apply witch hazel to hemorrhoids
  • notify health-care provider for hematoma or nonapproximated edges of laceration
  • able to walk without pain in legs
  • extremities slightly edematous
  • pain when flexing
  • hot, red area
  • pitting edema
  • notify health-care provider
  • happy
  • tired
  • slightly overwhelmed
  • holding the baby en face
  • exploring the baby
  • talking to the baby
  • cuddles
  • manic
  • crying uncontrollably
  • sad about the birth
  • not holding the baby
  • leaving the baby in the bassinet
  • not talking to the baby
  • making negative comments about the baby
  • encourage rest and limitation of visitors
  • provide privacy for sleep
  • educate on postpartum blues and depression
  • evaluate support system
  • evaluate history of depression or anxiety
  • administer postpartum depression screen (EPDS)
  • notify health-care provider for concerns with depression
  • demonstrate behaviors that increase bonding
  • point out positive attributes of the baby
  • encourage postpartum person to explore and talk to the baby
  • notify health-care provider if concerned about bonding
Table 20.4 Normal Postpartum Assessment, Abnormal Findings, and Nursing Interventions

Cultural Influence on Postpartum Recovery

The nurse must be aware of cultural differences that affect postpartum care and recovery. The nurse honors the postpartum person’s traditions and asks about dietary restrictions, important practices, and alterations in the plan of care to aid in their recovery. The nurse can encourage family members to bring in traditional foods. Some cultures encourage the postpartum person to rest and stay in bed for extended periods, while in other cultures the person is responsible for the household very soon after birth (Finlayson et al., 2020). In certain cultures, the extended family plays a large role in caring for the infant and postpartum person. Breast-feeding practices may differ, such as avoiding colostrum and supplementing with formula until the transition milk is present. By supporting cultural preferences, the nurse creates an accepting environment for the postpartum person to thrive and transition into their new parental role.

People of different cultures, races, and socioeconomic status have differing postpartum outcomes. Some of these outcomes are based on discrimination and stigma. For example, people of color have higher rates of postpartum depression than White people (Beck, 2023). Nurses should be diligent in assessing for postpartum depression in Black persons and offering resources for mental health providers. Members of the LGBTQIA+ community have less access to mental health care; higher rates of abuse, postpartum depression, and substance use; and experience a lack of social support (Griggs et al., 2021). Nurses can discuss resources for support groups and encourage persons to reach out to friends and family when feeling stressed. Approximately 31 percent of postpartum teen parents will become pregnant again in 2 years (Roque et al., 2022). Nurses can encourage teens to discuss birth control methods with the health-care provider. Persons experiencing homelessness have difficulty accessing health care in the postpartum period, and some fear being reported to Child Protective Services (McGeough et al., 2020). The nurse can provide emotional support and initiate a social services consult to aid these persons in finding and securing postpartum care. Finally, exclusive breast-feeding at 3 months postpartum is practiced at lower rates than at birth (Garrett et al., 2018). The nurse can educate the postpartum person on the importance of breast-feeding for 12 months and discuss barriers to breast-feeding.

Cultural Context

Birthing in a Different Environment

A first-generation immigrant can have a difficult journey during the postpartum and new parenting period. They may be in the United States without their family or with very few family members. They may not be accustomed to the health-care system in the United States. The nurse can inquire about traditions in their country of origin.

A person from Mexico may request tummy binding, also known as faja. This tradition is believed to help support the uterus and abdomen. In Turkey, a special herbal bath is prepared and believed to promote healing. In some Native American cultures, a “Blessing Way” ceremony is conducted to honor the postpartum person during the new parent journey. Providing support and resources for patients allows them to honor their traditions.


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