Section 6.3: Postpartum Care, Postpartum Hemorrhage, and Newborn Assessment

Postpartum Assessment (The Puerperium)

The postpartum period, or puerperium, is the 6-week interval following birth when the maternal body returns to its pre-pregnant state. Nursing assessment is structured and frequent, often utilizing the BUBBLE-HE mnemonic: Breasts, Uterus, Bowel, Bladder, Lochia, Episiotomy/Perineum, Homan's sign/Hemorrhoids, and Emotions.

• Uterine Involution: The rapid reduction in size of the uterus. Immediately after delivery, the fundus should be firm, midline, and at the level of the umbilicus. It descends approximately 1 cm (one fingerbreadth) per day. By day 10-14, it should no longer be palpable abdominally. A boggy (soft) uterus indicates atony and requires immediate intervention.
• Lochia: Postpartum vaginal discharge consisting of blood, tissue, and mucus. It progresses through three stages:
  1. Lochia Rubra: Dark red, lasts 1-3 days. May contain small clots.
  2. Lochia Serosa: Pinkish-brown, lasts from day 4 to 10.
  3. Lochia Alba: Yellowish-white, lasts from day 11 up to 6 weeks. Foul-smelling lochia indicates infection. Reappearance of bright red blood after rubra has ceased suggests delayed postpartum hemorrhage or retained placental fragments.
• Bladder and Bowel: Diuresis begins shortly after birth to eliminate excess fluid volume. A full bladder can displace the uterus and impede involution; nurses must encourage frequent voiding. Bowel movements may be delayed due to decreased muscle tone, fear of pain from episiotomy, or side effects of medications. Stool softeners are often prescribed.
• Psychological Adaptation: Reva Rubin's phases of maternal role attainment describe the psychological transition: "Taking-in" (dependent, focused on self and the birth experience), "Taking-hold" (independent, focused on learning to care for the baby), and "Letting-go" (accepting the new reality and relinquishing the previous childless role). The nurse must also monitor for signs of postpartum blues (transient, mild depressive symptoms), postpartum depression (severe, prolonged symptoms requiring treatment), and postpartum psychosis (a psychiatric emergency involving hallucinations and delusions).

Postpartum Hemorrhage (PPH)

PPH is defined as blood loss exceeding 500 mL after a vaginal birth or 1000 mL after a cesarean section. It is a leading cause of maternal morbidity and mortality. The primary causes are represented by the "4 Ts":

1. Tone (Uterine Atony): The most common cause. The uterus fails to contract effectively. Risk factors include overdistention of the uterus (macrosomia, multiples, polyhydramnios), prolonged labor, and use of oxytocin during labor.
2. Trauma: Lacerations of the birth canal, hematomas, or uterine rupture.
3. Tissue: Retained placental fragments prevent the uterus from contracting fully.
4. Thrombin: Coagulopathies, such as disseminated intravascular coagulation (DIC).

Nursing Management of PPH (Atony): The immediate priority upon identifying a boggy uterus with heavy bleeding is to firmly massage the fundus until it becomes contracted. Concurrently, the nurse should call for help, establish or maintain large-bore IV access, administer prescribed uterotonic medications (e.g., oxytocin, methylergonovine, misoprostol), and ensure the bladder is empty (catheterization may be necessary). Continuous monitoring of vital signs is crucial to detect hypovolemic shock (tachycardia is an early sign, followed by hypotension).

Newborn Assessment

The APGAR Score

The APGAR score is a rapid method to assess the newborn's transition to extrauterine life, performed at 1 minute and 5 minutes after birth. It evaluates five parameters, scoring each 0, 1, or 2 (maximum score 10).

• Appearance (Color): 0 = blue/pale all over, 1 = body pink/extremities blue (acrocyanosis), 2 = completely pink.
• Pulse (Heart Rate): 0 = absent, 1 = < 100 bpm, 2 = > 100 bpm.
• Grimace (Reflex Irritability): 0 = no response to stimulation, 1 = grimace, 2 = cry or active withdrawal.
• Activity (Muscle Tone): 0 = flaccid, 1 = some flexion of extremities, 2 = well flexed, active motion.
• Respiration (Respiratory Effort): 0 = absent, 1 = weak, irregular gasp, 2 = good, strong cry.

A score of 7-10 indicates a vigorous newborn in good condition. A score of 4-6 indicates moderate distress requiring stimulation and oxygen. A score of 0-3 indicates severe distress requiring immediate resuscitation.

Physical Assessment Highlights

• Vital Signs: Normal heart rate (110-160 bpm), respiratory rate (30-60 breaths/min, irregular), axillary temperature (36.5°C - 37.5°C).
• Head: Assess fontanels (anterior should be diamond-shaped and flat; posterior is triangular). Differentiate between caput succedaneum (diffuse edema crossing suture lines, resolves quickly) and cephalohematoma (collection of blood under the periosteum, does not cross suture lines, takes weeks to resolve and increases risk for jaundice).
• Skin: Normal findings include milia (white spots on face), Mongolian spots (bluish pigmentation on back/buttocks), and erythema toxicum (newborn rash).
• Reflexes: Evaluate primitive reflexes such as Moro (startle), rooting, sucking, palmar grasp, and Babinski (fanning of toes is normal in newborns).

Breastfeeding Promotion

Breast milk is the optimal nutrition for infants. Nurses promote exclusive breastfeeding for the first 6 months. Key education points include ensuring proper latch (baby's mouth covers the areola, not just the nipple; audible swallowing), recognizing infant feeding cues, and managing common issues like engorgement (frequent feeding, warm compresses before, cold after) and sore nipples (ensure correct positioning, apply expressed breast milk to nipples). Breastfeeding also benefits the mother by promoting uterine involution and reducing the risk of certain cancers.