Postpartum care

Postpartum nursing is fundus, flow, and feelings: massage what is soft, empty what is displacing, and know when sadness needs more than reassurance.

Assessment: fundus and lochia

After birth the uterus must clamp down on open vessels at the placental site. A firm, midline fundus means that muscle is contracting. Soft (boggy) muscle leaves those vessels open — atony is the leading cause of early postpartum hemorrhage. A full bladder pushes the uterus up and often to the right, so the fundus can feel firm but high or displaced; emptying the bladder lets it drop midline again and contract effectively.

Lochia is expected shedding: rubra (red) first, then serosa (pink-brown), then alba (yellow-white). The trap is treating any red discharge as hemorrhage, or dismissing saturating pads and egg-sized clots as “normal flow.” Heavy bright rubra that soaks pads quickly, large clots, or a fundus that will not firm with massage is the hemorrhage pathway — massage, call for help, uterotonics as ordered — not a wait-and-see pad count. Foul odor with fever points to endometritis; escalate, do not chalk it up to afterpains.

• Check fundus and lochia with every assessment in the early postpartum period.
• Support perineum care, ice as ordered, and early ambulation for VTE prevention.

The distractor that looks busy is starting uterotonics before massaging a boggy fundus, or massaging a firm but displaced fundus without emptying the bladder. Soft needs tone; displaced needs void, then recheck.

Complications and immunizations

Pregnancy and the puerperium are hypercoagulable, and venous stasis climbs with immobility and cesarean recovery. Unilateral calf pain, warmth, or swelling is not “normal postpartum ache” — it is a VTE screen. Chest pain or dyspnea with that picture moves to pulmonary embolism urgency. Early ambulation and the teaching cues in the list below are prevention and recognition, not optional discharge fluff.

1. Teach VTE warning signs: unilateral calf pain, warmth, swelling, chest pain/dyspnea.
2. Give rubella vaccine if nonimmune and consented; teach pregnancy delay interval.
3. RhoGAM when Rh-negative mother / Rh-positive infant indications are met (see maternity meds chapter for timing detail).

Rubella (often as MMR) postpartum is for the nonimmune client who consents. It is a live vaccine, so teach reliable contraception for the interval your protocol uses (commonly about 1–3 months) — the distractor is sending her home with the shot and no pregnancy-delay teaching. RhoGAM prevents sensitization when an Rh-negative mother delivers an Rh-positive infant (and in other sensitizing events). Timing and dose detail live in Maternity and newborn medications; the postpartum rule here is: confirm blood types and give when indicated before discharge, not “she can get it at the six-week visit.”

Bonding, feeding, mood

Attachment and feeding problems show up as indifference, rough handling, or skipped eye contact — and as breast pain that tempts people to stop milk removal. Mastitis is infection or inflammation of breast tissue, often when milk sits. Continuing to breastfeed or pump on the affected side empties the duct and is usually part of treatment with rest, fluids, warm compresses, and antibiotics if ordered. The distractor that feels protective — “stop feeding that side so it can heal” — worsens engorgement and prolongs the infection.

Baby blues are common in the first days to about two weeks: tearfulness, mood swings, still able to care for the infant, and symptoms that lift with sleep help and support. Postpartum depression lasts, deepens, or blocks function — persistent hopelessness, inability to care for self or baby, or thoughts of harm. That is referral and safety assessment, not “give it another week of cheerleading.” Psychosis cues (hallucinations, severe disorganization, harm ideation) are an emergency pathway.

Rooming-in, skin-to-skin, and praising responsive care build the feedback loop of bonding. Poor attachment cues need support and a safety look — not a lecture that shames the parent into performing eye contact for the nurse.

Priority map