Involution refers to the changes that the reproductive organs (particularly the uterus) undergo after birth of the newborn to return to the pre-pregnant size and condition. The process begins after the expulsion of the placenta with uterine muscle contractions. Immediately after birth, the placental site contracts to a size less than half its original diameter. During contractions, the uterine muscles act like living ligatures and compress the blood vessels, which control and reduce the amount of blood loss (Figure 12-1). A unique healing process, called exfoliation, enables the placental site to heal without scarring. In exfoliation, necrotic tissue is sloughed off of the superficial tissues, leaving a smooth surface of endometrial tissue. This unique reparative process ensures that future fertilized ova will implant in an unscarred uterus. Endometrial regeneration is completed within 16 days (Oats & Abraham, 2010), except for the placental site, where regeneration is not complete until 6 weeks postpartum.

Fundal height is measured in centimeters (or fingerbreadths) in relation to the umbilicus (Skill 12-1). It is used to assess the rate of uterine involution. The usual progression of uterine descent into the pelvis is 1 cm (about one fingerbreadth) a day. After delivery (especially when an oxytocin drug is

Skill 12-1

Assessing and Massaging the Uterine Fundus

Purpose

To prevent excessive postpartum bleeding.

Steps

1. Ask the woman to empty her bladder if she has not voided recently. (A full bladder contributes to uterine relaxation and subinvolution.)

2. Have the woman assume supine position with knees slightly flexed (relaxes abdominal muscles).

3. Apply a lower perineal pad, and observe lochia as fundus is palpated.

4. Determine uterine firmness. Cup one hand above the symphysis pubis to support the lower uterine segment; with the other hand, palpate abdomen until top of fundus is located. Determine whether firm (if not, massage lightly until firm).

5. Determine height of fundus. Measure height of top of fundus in fingerbreadths above, below, or at umbilicus.

6. Determine whether fundus is in midline (deviation typically indicates full bladder). Observe for firmness of fundus.

7. If the fundus is not firm, massage the fundus in a circular motion with the flat surface of the fingers of the dominant hand.

8. Document the consistency and location of fundus. Consistency is recorded as “fundus firm with massage” or “fundus boggy.” Record fundal height (e.g., U2 or U2 fingerbreadths below or above umbilicus).

administered after the expulsion of the placenta), the fundus of the uterus is firm and may be approximately at the level of the umbilicus or just below. Breastfeeding enhances involution because sucking stimulates the release of oxytocin from the posterior pituitary gland. The uterus is contracted to the size of a large grapefruit. By 10 days’ postpartum, it should not be abdominally palpable. A full (distended) bladder can push the uterus up and cause it to deviate to one side (usually the right side) and interfere with involution. If blood clots collect within the uterus, contractions stop, and the fundus of the uterus may rise and feel soft or boggy. This atony results in increased bleeding. Massage may be needed. A uterus deviating from the midline usually requires emptying of the bladder in order for involution to continue.

At 6 weeks after delivery, the uterus is approximately pre-pregnant size. Subinvolution is the failure of the uterus to return to the pre-pregnant state and is most commonly caused by retained placental fragments.

Intermittent uterine contractions, which represent relaxation and contraction of the muscle fibers, cause uterine cramping and are called afterpains. Afterpains occur for the first 2 or 3 days’ postpartum. The hormone oxytocin, released by the posterior pituitary gland, strengthens uterine contractions, compressing blood vessels and preventing excessive blood loss. If the mother breastfeeds, infant suckling stimulates oxytocin release. Therefore, the mother often notices the afterpains when she breastfeeds her newborn. Women who have had previous pregnancies often have stronger afterpains because the contraction of the uterine muscles is not sustained because of decreased muscle tone. Nonsteroidal antiinflammatory medications such as ibuprofen are more effective than acetaminophen or propoxyphene in relieving afterpains for most women (Gabbe, Niebyl, & Simpson, 2007). Ibuprofen is safe for nursing mothers (Gabbe, Niebyl, & Simpson, 2007).

Lochia is postpartum vaginal discharge. It contains blood from the placental site, particles of necrotic decidua, and mucus. Lochia normally has a fleshy odor similar to that of menstrual flow. The quantity of lochia rapidly diminishes and becomes moderate and then scant. Lochia is the heaviest during the first 1 or 2 hours after birth. Initial lochia is bright red and commonly called lochia rubra (lasts 1 to 3 days); it may contain small clots. The vaginal flow then pales and becomes pink to brown after approximately 3 days; this is called lochia serosa. Lochia serosa should not contain clots and can last up to 27 days in some women (Gabbe, Niebyl, & Simpson, 2007). Typically, by 10 days’ postpartum, the vaginal discharge often becomes yellow to white and is called lochia alba. Lochia alba may continue, on average, to the sixth week postpartum (Table 12-1).

Estimating the amount of lochial flow by observation is difficult. Many facilities use perineal pads that have cold or warm packs in them. These pads absorb less lochia, which must be considered when estimating the amount of blood loss. If a mother has excessive lochia, a clean pad should be applied and checked within 15 minutes. The number of perineal pads applied during a given period should be counted or the pads weighed to help determine the amount of vaginal discharge. One gram of weight equals 1 mL of blood. In addition, the woman’s fundus should be checked for firmness. Nurses often estimate the amount of lochia in terms of the approximate size of the area soiled in 1 hour (Skill 12-2).

The amount of lochia is less after a cesarean birth. Breastfeeding or the use of oral contraceptives does not affect lochial flow. Lochia is briefly heavier when the mother ambulates because blood that has pooled in her vagina is discharged when she assumes an upright position. The gush of blood can be anxiety provoking to the woman and should not be confused with a postpartum hemorrhage. Excessive lochia rubra early in the postpartum period may suggest bleeding as a result of retained fragments of the placenta or membranes. Recurrence of bleeding in 7 to 10 days after birth suggests bleeding from the placenta site but may be the result of normal sloughing (Gabbe, Niebyl, & Simpson, 2007). After 3 to 4 weeks, late bleeding may also be caused by infection or subinvolution. Continued lochia serosa or alba suggests infection (endometritis) and is often accompanied by fever, pain, or abdominal tenderness and an offensive, foul odor to the lochia. Any abnormal lochia pattern should be documented and reported. Ultrasound is one of the diagnostic methods that can be used to confirm the cause of postpartum bleeding.

Assessment of uterine firmness, location, and position in relation to the midline (see Skill 12-1) is performed at routine intervals. A poorly contracted (soft, boggy) uterus should be massaged until firm to prevent hemorrhage. It is essential not to push down on an uncontracted uterus to avoid inverting it.

The perineum has been stretched and thinned to accommodate the size of the newborn. The pelvic floor muscles are overstretched and weak. The appearance of the perineum varies greatly, depending on the type and extent of the laceration(s) or episiotomy (cut in the perineum). The soft tissues of the perineum are often edematous and bruised.

The nurse puts on clean gloves before assessing the perineum to prevent contact with vaginal blood flow. The perineum is assessed for the type and amount of vaginal discharge, unusual swelling, discoloration, healing of the tissues, and discomfort (Skill 12-3). If an episiotomy was performed, the state of healing is assessed by the REEDA scale, a mnemonic for Redness, Edema, Ecchymosis (bruising), Discharge, and Approximation of the wound. Foul odor accompanied by drainage indicates infection; further examination of the incision and area of warmth and tenderness should be performed. Hemorrhoids, if present, are assessed for size, number, and discomfort. During the assessment, the nurse asks the woman about relief obtained from comfort measures (sitz bath, warm or cold applications, and medications). The nurse should record his or her findings.

Studies have shown a positive response to cold sitz baths (Gabbe, Niebyl, & Simpson, 2007). Occasionally, the cause of perineal pain is prolapsed hemorrhoids. Witch-hazel pads, astringent pads, suppositories, or local anesthetic sprays are helpful. Healing usually takes place within 6 weeks. Daily perineal care is described in Skill 12-4.

tone in the rectus abdominis muscles and the pubococcygeal muscle is restored. The abdominal muscles, including the rectus abdominis muscles, may be separated, and diastasis recti can occur (Figure 12-2). Special exercises can strengthen the abdominal wall. Women need to be advised that with proper diet, exercise, and rest, the abdominal muscle tone is usually regained more rapidly. Good body mechanics and correct posture are important to help relieve low back pain. Kegel exercises help the pubococcygeal muscle (muscle that aids bowel and bladder control) to regain normal function (see Chapter 5).

A generalized decrease in bone mineralization occurs after birth. This bone loss is not affected by calcium intake or exercise but returns to normal within 18 months (Gabbe, Niebyl, & Simpson, 2007).

Venous stasis, particularly during the later part of pregnancy, contributes to the risk of blood clots (thrombosis) forming in the lower extremities. By passively dorsiflexing the woman’s feet, the nurse determines whether there is pain in the calf (a positive Homans’ sign) (Figure 12-3). This may be an early sign of venous thrombosis and should be reported. In addition, the nurse inspects the legs for redness, swelling, and warmth.

Diaphoresis (perspiration) is the elimination of excess fluid through the skin. It is the body’s way of getting rid of excess fluid accumulated during pregnancy. Profuse diaphoresis (excessive sweating) often occurs at night. This adjustment has implications for nursing care. Showers, frequent changes of clothing, and adequate fluid intake are important for the woman’s comfort.

Blood pressure readings should remain stable after birth. A decrease in blood pressure may be related to excessive blood loss. Blood pressure elevation—especially when accompanied by a headache—suggests gestational hypertension and indicates the need for further evaluation (see Chapter 13).