Maternity · Postpartum
Postpartum Care & Postpartum Hemorrhage
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On this page
- 1. Overview: Normal Postpartum Physiology
- 2. Postpartum Assessment — BUBBLE-HE
- 3. Postpartum Hemorrhage (PPH)
- 4. Priority Nursing Interventions for PPH
- 5. Medications
- 6. Other Postpartum Complications
- 7. Rh and Rubella After Birth
- 8. Patient Education
- 9. Memory Aids
- 10. NCLEX-Style Practice Questions
- References
Prepared for Pass the Shift (owner: Kristina, RN). Always follow your facility’s protocols, provider orders, and current references.
1. Overview: Normal Postpartum Physiology
The postpartum period (“fourth trimester”) runs about 6 weeks, but serious complications can occur up to a year after birth.
- : the uterus shrinks back. Right after birth the fundus is firm, midline, near the umbilicus; it rises to about the umbilicus in the first 12–24 h, then descends ~1 cm (one fingerbreadth) per day and is usually not palpable abdominally by ~2 weeks
- : rubra (red, days 1–3) → serosa (pink-brown, ~days 4–10) → alba (yellow-white, up to ~6 weeks). It should never go backward to red after it lightens, have large clots, or smell foul
- Cardiovascular: diuresis and diaphoresis remove extra fluid in the first days. Expect a temporary rise in WBC
- Clotting risk stays high for weeks (VTE)
- Bladder may be hard to empty (trauma, epidural) — a full bladder pushes the uterus up and to the side and causes bleeding
2. Postpartum Assessment — BUBBLE-HE
| Letter | Assess | Normal / concern |
|---|---|---|
| Breasts | Soft → filling → firm; nipples | Engorgement; cracked nipples; red, hot, wedge-shaped area + fever = |
| Uterus | Fundal height, firmness, position (support the lower uterus with one hand while palpating) | Firm, midline. Boggy = atony. Deviated to the right and high = full bladder |
| Bladder | Voiding amount, distension | Void within ~6 h; small frequent voids = retention |
| Bowel | Flatus, BM, hemorrhoids | Stool softeners as ordered |
| Lochia | Color, amount (pad count/weight), clots, odor | Scant–moderate is normal. Soaking 1 pad in ≤ 1 h or clots larger than an egg = report |
| Episiotomy/incision | REEDA: Redness, Edema, Ecchymosis, Discharge, Approximation | Severe perineal pain/pressure → |
| Homans → now legs | Unilateral swelling, warmth, calf pain | DVT. (Homans sign is no longer considered reliable) |
| Emotions | Bonding, mood, sleep, support | Baby blues vs. depression/psychosis |
Plus vital signs, pain, and Rh/rubella status.
3. Postpartum Hemorrhage (PPH)
Definition (ACOG): cumulative blood loss ≥ 1,000 mL or blood loss with signs of hypovolemia within 24 h of birth, regardless of route. Blood loss > 500 mL after a vaginal birth is abnormal and deserves close attention. Quantify blood loss (QBL) by weighing pads and drapes (1 g ≈ 1 mL) — visual estimates underestimate.
Primary (early): within 24 h. Secondary (late): 24 h to 12 weeks (retained tissue, subinvolution, infection).
Causes — the 4 Ts
| T | Cause | Clues |
|---|---|---|
| Tone (~70%) | Boggy, enlarged uterus; steady bleeding. Risks: overdistended uterus (twins, macrosomia, polyhydramnios), long or very fast labor, oxytocin exposure, magnesium, chorioamnionitis, high parity, full bladder | |
| Trauma | Lacerations, hematoma, uterine rupture or inversion | Firm uterus but bright red continuous bleeding = laceration. Severe pain/pressure = hematoma |
| Tissue | Retained placenta/fragments, placenta accreta spectrum | Incomplete placenta on inspection; late bleeding |
| Thrombin | Coagulopathy (DIC from abruption, HELLP, AFE, sepsis; inherited disorders) | Oozing from IV sites, gums; won’t clot |
Signs: pregnant/postpartum patients compensate well — tachycardia and restlessness come before hypotension. Late signs: low BP, pallor, cool clammy skin, low urine output, altered mental status. The shock index (HR ÷ SBP) > ~0.9–1.0 suggests significant loss.
4. Priority Nursing Interventions for PPH
- Fundal massage first for a boggy uterus (support the lower uterine segment)
- Call for help / activate the hemorrhage protocol; stay with the client
- Empty the bladder (straight cath if unable to void)
- Give uterotonics as ordered (table below)
- Two large-bore IVs; warmed fluids; labs (CBC, type and crossmatch, fibrinogen, coagulation); prepare blood products (massive transfusion protocol)
- Oxygen, monitor VS, SpO₂, level of consciousness, and urine output (Foley)
- QBL — weigh everything
- Prepare for procedures: bimanual compression (provider), intrauterine balloon tamponade, repair of lacerations, removal of tissue, embolization, surgery/hysterectomy
- Keep the client warm; support the family; document times and totals
5. Medications
| Drug | Use / action | Key nursing points |
|---|---|---|
| First-line uterotonic; also routine after birth | IV infusion or IM. Don’t give undiluted IV push (hypotension). Watch for water intoxication with prolonged high doses | |
| Methylergonovine | Sustained uterine contraction | Contraindicated with hypertension/preeclampsia (vasoconstrictor). Check BP before giving. IM; refrigerate |
| Carboprost (15-methyl PGF2α) | Prostaglandin uterotonic | Contraindicated in asthma (bronchospasm). Diarrhea, fever, vomiting. IM |
| Misoprostol | Prostaglandin E1 | Rectal/sublingual/oral; fever, shivering |
| Tranexamic acid (TXA) | Antifibrinolytic; reduces bleeding deaths in PPH | Given IV ideally within 3 h of birth per order |
6. Other Postpartum Complications
- Infection (endometritis, wound infection, UTI, mastitis): fever ≥ 100.4 °F (38 °C) after the first 24 h, uterine tenderness, foul lochia, wound redness/drainage. Mastitis: keep breastfeeding or pumping on the affected side; antibiotics as ordered
- : early ambulation, SCDs, anticoagulants per risk. PE → sudden dyspnea, chest pain, tachycardia — emergency
- Postpartum preeclampsia can appear up to 6 weeks after birth (headache, vision changes, BP ≥ 140/90)
- Mood disorders:
- Baby blues: tearful, moody, first ~2 weeks, resolves on its own; reassurance and rest
- : symptoms ≥ 2 weeks that interfere with function; screen (e.g., EPDS); therapy, medications (SSRIs; zuranolone is approved for PPD)
- Postpartum psychosis: hallucinations, delusions, confusion, usually within the first weeks — psychiatric emergency; safety of client and baby is the priority
7. Rh and Rubella After Birth
- Rh immune globulin within 72 h if the client is Rh-negative (not sensitized) and the newborn is Rh-positive. It’s given to the parent, IM — never to the baby
- MMR for rubella-nonimmune clients before discharge; teach to avoid pregnancy for 4 weeks (live vaccine). It is compatible with breastfeeding. Timing with Rh immune globulin may affect vaccine response; follow protocol
8. Patient Education
- Fundus massage and expected lochia pattern; soaking a pad in an hour, clots bigger than an egg, foul odor, or fever → call
- Perineal care: peri-bottle front to back, ice packs first 24 h then sitz baths, change pads often
- Breastfeeding support; engorgement relief (frequent feeding; if not breastfeeding: supportive bra, cold packs, avoid stimulation)
- Pain control; stool softener; fluids and fiber
- Activity: rest, no heavy lifting after cesarean, splint the incision when coughing
- Contraception and birth spacing; resume sex per provider (often ~6 weeks)
- CDC/AIM urgent maternal warning signs for the year after birth: severe headache, vision changes, chest pain, trouble breathing, leg swelling, thoughts of self-harm
- Postpartum visit within 3 weeks and comprehensive visit by 12 weeks (ACOG)
9. Memory Aids
- BUBBLE-HE for the head-to-toe postpartum check
- 4 Ts: Tone, Trauma, Tissue, Thrombin — “Tone is #1”
- Boggy → massage; firm but bleeding → trauma
- Methergine = “Methe-raises BP” → no hypertension. Carboprost: “Carbo-lungs” → no asthma
- “Fundus off to the right? Void it tonight.” (full bladder)
- Lochia “Ruby, Sarah, Alba” — red → pink → white, never backward
10. NCLEX-Style Practice Questions
1. One hour after a vaginal birth, the nurse finds a soft fundus 2 cm above the umbilicus and heavy bleeding. What is the first action?
A. Notify the provider
B. Massage the fundus while supporting the lower uterus
C. Start a second IV line
D. Give methylergonovine
Answer: B. A boggy uterus with heavy bleeding points to uterine atony. Fundal massage is the immediate nursing action, followed by calling for help, emptying the bladder, and giving uterotonics as ordered.
2. A postpartum client with preeclampsia has continued bleeding despite oxytocin. Which medication order should the nurse question?
A. Carboprost IM
B. Misoprostol rectally
C. Methylergonovine IM
D. Tranexamic acid IV
Answer: C. Methylergonovine causes vasoconstriction and can trigger a hypertensive crisis, so it is contraindicated with hypertension and preeclampsia.
3. A client’s fundus is firm and midline, but she has a steady trickle of bright red blood. What is the most likely cause?
A. Uterine atony
B. Cervical or vaginal laceration
C. Full bladder
D. Normal lochia rubra
Answer: B. A firm uterus rules out atony; continuous bright red bleeding suggests trauma such as a laceration. A full bladder (C) causes a displaced, often boggy uterus.
4. On postpartum day 1, the fundus is 2 cm above the umbilicus and deviated to the right. What should the nurse do?
A. Massage the fundus vigorously for 5 minutes
B. Help the client to the bathroom to void
C. Notify the provider of possible retained placenta
D. Document an expected finding
Answer: B. A high, right-deviated fundus is classic for a distended bladder, which keeps the uterus from contracting and raises bleeding risk. Emptying the bladder comes first; reassess the fundus afterward.
5. Which postpartum findings should the nurse report right away? Select all that apply.
A. Heart rate rising from 78 to 118 with restlessness
B. Lochia rubra on day 2
C. Saturating a pad in 45 minutes
D. Temperature 100.2 °F (37.9 °C) at 12 hours after birth
E. A client who hears voices telling her the baby is evil
Answer: A, C, E. Tachycardia with restlessness is an early sign of hemorrhage; saturating a pad in < 1 h is excessive bleeding; hallucinations about the infant indicate postpartum psychosis, an emergency. Lochia rubra on day 2 (B) is normal, and a mild temperature in the first 24 h (D) is often from dehydration — encourage fluids and recheck.
References
American College of Obstetricians and Gynecologists. (2017, reaffirmed). Postpartum hemorrhage (Practice Bulletin No. 183). Obstetrics & Gynecology, 130(4), e168–e186. https://doi.org/10.1097/AOG.0000000000002351
Centers for Disease Control and Prevention. (2024). Urgent maternal warning signs and symptoms. HEAR HER Campaign. https://www.cdc.gov/hearher/maternal-warning-signs/index.html
Lopez-Gonzalez, D. M., & Mikes, B. A. (2026). Postpartum care of the new mother. In StatPearls. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK565875/
National Council of State Boards of Nursing. (2026). 2026 NCLEX-RN test plan. https://www.nclex.com/test-plans.page
Wormer, K. C., Jamil, R. T., & Bryant, S. B. (2024). Postpartum hemorrhage. In StatPearls. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK499988/