NLE Antepartum, Intrapartum & Postpartum Care — Normal Postpartum CareCheat Sheet
A printable cheat sheet for Normal Postpartum Care, built for NLE reviewers who want one go-to reference in the final stretch. Covers formulas, key definitions, common question types, and the Professional Regulation Commission (PRC) — Board of Nursing-specific twists you will see on NLE day.
Exam context
For the Philippine Nurse Licensure Examination (PNLE), Professional Regulation Commission (PRC) — Board of Nursing tests Antepartum, Intrapartum & Postpartum Care under a "Core" label, with Normal Postpartum Care in the 4th slot across 4 chapters. NLE candidates must clear the 75% weighted average with no sub-test below 60% cut on the 2026 paper, which draws about 50 Antepartum, Intrapartum & Postpartum Care questions. Date to watch: Bi-annual.
Normal Postpartum Care - Cheat Sheet
Your last-minute revision companion for Normal Postpartum Care. This rapid-fire reference covers physiologic changes, BUBBLE-HE assessment, PPH prevention, breastfeeding essentials, and psychological adaptation. Focus on what the PRC Board tests most: uterine involution timelines, lochia progression, hemorrhage management, and postpartum complications.
Sections
Formulas
Formula
Fundal descent = ~1 cm (1 fingerbreadth) per day
Meaning
Starting from umbilicus (immediately postpartum) → pelvic cavity by day 10–14
Watch Out
A BOGGY (soft) uterus, NOT height, is the first sign of atony and hemorrhage—massage FIRST before checking height
When To Use
Assess fundal height relative to umbilicus at every postpartum check
Formula
Lochia progression: Rubra (1–3 d) → Serosa (4–10 d) → Alba (10 d–6 wk)
Meaning
Red blood/decidua → pinkish-brown → white/yellowish discharge over time
Watch Out
Return to BRIGHT RED or pad soaked in <1 hour = hemorrhage; foul odor = infection (endometritis)
When To Use
Every lochia assessment; report if progression deviates or reverses
Common Values
Value
At the umbilicus (2 fingerbreadths below xiphoid)
Symbol
Day 1
Quantity
Fundal position immediately postpartum
Value
~1 cm (1 fingerbreadth/day)
Symbol
Involution rate
Quantity
Daily fundal descent
Value
Day 10–14 (back in pelvis)
Symbol
Normal involution complete
Quantity
Fundal palpability ends by
Value
Days 1–3 postpartum
Symbol
Red stage
Quantity
Lochia rubra duration
Value
Days 4–10 postpartum
Symbol
Pinkish-brown stage
Quantity
Lochia serosa duration
Value
Days 10 to ~6 weeks postpartum
Symbol
White/yellowish stage
Quantity
Lochia alba duration
Section Title
Uterine Involution & Lochia
Important Facts
- Fundus should be FIRM (tetanically contracted) and MIDLINE immediately after delivery.
- A BOGGY uterus = earliest sign of atony; massage the fundus and lower uterine segment immediately.
- High, RIGHT-DEVIATED uterus = full bladder distending; empty bladder urgently (prevents hemorrhage).
- Lochia should smell fleshy/musty like menses; foul odor suggests endometritis.
- Immediate lochia volume loss ~5–6 kg (baby, placenta, amniotic fluid, maternal blood); then gradual weight loss.
- Increased lochia on standing (blood pools in vagina when supine) and during breastfeeding (oxytocin) is normal.
- Clotting cascade remains hypercoagulable postpartum → DVT/PE risk increases for 6 weeks.
Key Definitions
Term
Involution
Example
Fundus at umbilicus day 1 → not palpable by day 10–14 = normal involution
Definition
Return of uterus to non-pregnant size (prepregnancy weight ~70 g); completed by ~6 weeks postpartum.
Term
Lochia rubra
Example
Heavy flow first 24–48 h; pad change q 1–2 h normal if firm fundus
Definition
First 1–3 days postpartum: red, contains blood, decidua, fetal membranes.
Term
Lochia serosa
Example
Transition from heavy red bleeding to lighter, brownish flow
Definition
Days 4–10: pinkish-brown, serous exudate with fewer RBCs; fleshy odor normal.
Term
Lochia alba
Example
By week 3–4 may see mainly yellowish discharge; should be nearly absent by 6 weeks
Definition
Days 10 to ~6 weeks: white/yellowish, mainly WBCs, endothelial cells, bacteria; minimal bleeding.
Term
Afterpains (afterpains)
Example
Primiparas: mild; multiparas: severe enough for analgesia; peaks days 2–3
Definition
Cramping from uterine contractions, more intense in multiparas and with breastfeeding (oxytocin release).
Term
Uterine atony
Example
Boggy, soft uterus that doesn't firm with massage = life-threatening hemorrhage risk
Definition
Loss of uterine muscle tone/contractility; leads to excessive bleeding (first cause of PPH).
Diagrams To Know
- Timeline of lochia color/character changes (rubra → serosa → alba)
- Fundal descent graph: day 1 (umbilicus) to day 10–14 (not palpable)
Common Values
Value
2–4 pads/day in early postpartum; increases with activity/breastfeeding
Symbol
Baseline
Quantity
Normal postpartum lochia pads per day (breastfeeding)
Value
Within 6–8 hours postpartum
Symbol
Catheterize if not by 8 h
Quantity
First void target
Value
0–5 (mild healing is normal)
Symbol
Healing score
Quantity
Normal REEDA score
Section Title
BUBBLE-HE Postpartum Assessment Framework
Important Facts
- B—Breasts: soft day 1–2 → filling day 3–4 → ENGORGED day 3–5 if breastfeeding continues. Assess for cracks, soreness, firmness.
- U—Uterus: FIRM, MIDLINE, height (relative to umbilicus). Boggy = massage immediately; deviated right = full bladder.
- B—Bladder: assess distension; encourage void within 6–8 hours. Full bladder prevents uterine contraction → hemorrhage.
- B—Bowel: check bowel sounds; constipation common (fear, decreased tone). Use fluids, fiber, stool softeners, ambulation.
- L—Lochia: color (rubra/serosa/alba), amount (number of pads saturated/h), odor (fleshy vs. foul), clots (normal <walnut size).
- E—Episiotomy/perineal: REEDA scoring (0–15 total); ice packs first 24 h, then warm sitz baths; assess approximation.
- H—Homans'/legs: unilateral calf pain, warmth, swelling = DVT sign (though Homans' sign unreliable); assess entire leg.
- E—Emotional: mood (tearfulness normal day 3–5 vs. persistent depression); attachment/bonding behaviors; support system.
Key Definitions
Term
BUBBLE-HE
Example
Perform head-to-toe at each postpartum check (q 1 h first 4 h, then q 4 h, then daily if uncomplicated)
Definition
Systematic postpartum assessment: Breasts, Uterus, Bladder, Bowel, Lochia, Episiotomy (REEDA), Homans'/legs, Emotional/bonding.
Term
REEDA (perineal assessment)
Example
0 = none, 1 = mild, 2 = moderate, 3 = severe per criterion; total score guides intervention
Definition
Redness, Edema, Ecchymosis, Discharge, Approximation—score each 0–3 to quantify perineal healing.
Diagrams To Know
- BUBBLE-HE checklist with normal vs. abnormal findings for each component
- REEDA scoring grid (0–3 for each: redness, edema, ecchymosis, discharge, approximation)
Formulas
Formula
PPH definition: >500 mL (vaginal) or >1,000 mL (cesarean) blood loss OR hemodynamic instability
Meaning
Vaginal = 500+ mL; Cesarean = 1,000+ mL; any amount causing maternal compromise = PPH
Watch Out
Hemodynamic changes (tachycardia, hypotension, pallor) may lag; measure blood loss early and often
When To Use
Classify hemorrhage severity; guide triage and intervention urgency
Formula
4 Ts of PPH causes: Tone (atony 70%), Trauma (lacerations), Tissue (retained placenta/fragments), Thrombin (coagulopathy)
Meaning
Tone = uterine atony (most common); Trauma = vaginal/cervical tears; Tissue = retained products; Thrombin = DIC/bleeding disorders
Watch Out
Atony is #1 cause; massage fundus FIRST. If bleeding persists after massage, suspect trauma/tissue/coagulation disorder.
When To Use
Systematic approach to diagnose PPH cause and direct treatment
Common Values
Value
300–400 mL (vaginal), 600–1,000 mL (cesarean)
Symbol
Expected loss
Quantity
Normal immediate postpartum blood loss
Value
>500 mL
Symbol
Abnormal
Quantity
PPH threshold (vaginal)
Value
>1,000 mL
Symbol
Abnormal
Quantity
PPH threshold (cesarean)
Value
10 units
Symbol
Standard
Quantity
Oxytocin IM dose
Value
0.2 mg IM/PO
Symbol
Standard
Quantity
Methylergometrine dose
Value
250 micrograms IM
Symbol
Standard
Quantity
Carboprost dose
Section Title
Postpartum Hemorrhage (PPH) Prevention & Management
Important Facts
- FIRST action for boggy uterus = massage fundus and support lower segment (do NOT express clots from atonic uterus).
- SECOND = check/empty bladder (full bladder prevents uterine contraction).
- THIRD = give oxytocic per order and increase IV fluids; notify physician for continued bleeding.
- Oxytocin: 10 units IM or diluted IV per protocol; first-line, no major contraindications.
- Methylergometrine (Methergine): 0.2 mg IM/PO; CONTRAINDICATED in hypertension/pre-eclampsia (causes vasoconstriction)—CHECK BP FIRST.
- Carboprost (prostaglandin): 250 micrograms IM; CAUTION in asthma (bronchospasm), may cause fever/diarrhea.
- Misoprostol: 600–800 mcg per protocol; alternative where injectables unavailable.
- Monitor vital signs, lochia, fundal tone every 15 min in first 2 h postpartum; weigh pads for accurate blood loss estimate.
- Anticipate possible transfer to OR for manual removal of retained products, uterine artery ligation, or hysterectomy if massive bleed.
- Document blood loss, vital signs, oxytocic given, time given, and maternal response for medicolegal protection (RA 9173).
Key Definitions
Term
Postpartum hemorrhage (PPH)
Example
Mother soaking 2+ pads/hour on day 1–2, or pad soaked in <1 hour after lochia lightening, or tachycardia/hypotension
Definition
Excessive bleeding after delivery: >500 mL vaginal, >1,000 mL cesarean, or blood loss causing hemodynamic compromise; leading cause of maternal death.
Term
Uterine atony
Example
Boggy, soft uterus on palpation; firm with massage but re-softens; requires ongoing intervention
Definition
Loss of uterine contractility; accounts for ~70% of PPH; managed by massage, oxytocics, bladder emptying.
Diagrams To Know
- Algorithm: boggy uterus → assess response to massage → bladder assessment → oxytocic administration → escalation to physician/OR
- 4 Ts of PPH: causes and initial management for each
Formulas
Formula
Lactation physiology: Prolactin (production) + Oxytocin (let-down/ejection) = milk delivery
Meaning
Prolactin stimulated by suckling → milk synthesis; oxytocin stimulated by suckling/touch → milk ejection and uterine contraction (afterpains)
Watch Out
Inadequate/infrequent feeding → lower prolactin → low supply. Stress/inadequate latch blocks let-down (oxytocin inhibited).
When To Use
Explain how milk is made and why breastfeeding causes cramping; educate on demand-driven supply
Formula
Exclusive breastfeeding: First 6 months NO other foods/formula; continued with complementary foods to 2 years (WHO/DOH/RA 10028)
Meaning
First 6 mo = breast milk only; 6–24 mo = breast milk + appropriate complementary foods
Watch Out
Formula marketing (Milk Code EO 51) restricts advertising; counter misinformation and provide education on colostrum/breast milk benefits
When To Use
Counsel on national breastfeeding policy (RA 10028) and support for exclusive breastfeeding
Common Values
Value
Within 1 hour of delivery
Symbol
DOH guideline
Quantity
First breastfeeding time (Unang Yakap)
Value
First 6 months
Symbol
WHO/DOH/RA 10028
Quantity
Exclusive breastfeeding duration
Value
Until 2 years
Symbol
WHO recommendation
Quantity
Continued breastfeeding with complementary foods
Value
8–12 times/24 hours
Symbol
On-demand
Quantity
Normal feeding frequency
Value
6+ wet diapers/day
Symbol
Hydration marker
Quantity
Adequate infant urine output
Value
Day 3–5 postpartum
Symbol
#1milk comes in
Quantity
Colostrum transition to transitional milk
Value
Day 3–5 postpartum
Symbol
Highest discomfort
Quantity
Peak engorgement day
Section Title
Breastfeeding Essentials (RA 10028, Milk Code EO 51, Unang Yakap)
Important Facts
- Unang Yakap: breastfeeding initiated within FIRST HOUR postpartum (DOH policy; skin-to-skin contact).
- Colostrum: rich in IgA (immunity), protein, laxative effect (clears meconium); must not be discarded.
- Demand-driven supply: frequent, effective feeding MAINTAINS and INCREASES milk supply; inadequate stimulation → low supply.
- Feeding frequency: 8–12 times/24 hours; on-demand; 6+ wet diapers/day and appropriate weight gain indicate adequate intake.
- Good latch: baby's mouth wide, taking full areola, chin to breast, audible swallowing, NO pain. Poor latch → sore/cracked nipples.
- Engorgement relief: frequent feeding, warm compress BEFORE feeding (improves let-down), cold compress AFTER (reduces edema).
- For NON-breastfeeding mother: supportive bra, avoid stimulation, apply ice/cabbage leaves to suppress lactation.
- Mastitis management: CONTINUE breastfeeding (or pump to drain affected breast), antibiotics, rest, warm compresses, fluids.
- Milk is SAFE even if mother has mastitis or is on most antibiotics (check drug references for exceptions).
- Postpartum contraception: progestin-only methods (minipill) safe for breastfeeding; hormonal estrogen suppresses milk.
- LAM (Lactational Amenorrhea Method): if exclusively breastfeeding + amenorrheic + <6 mo, ~99% effective, but ovulation may precede first menses.
- RA 10028 (Expanded Breastfeeding Promotion Act) and Milk Code (EO 51): regulate formula marketing; support exclusive breastfeeding.
Key Definitions
Term
Colostrum
Example
Days 1–3: baby receives colostrum; feeds frequently to stimulate supply and clear meconium
Definition
First milk (first 1–5 days): thick, yellowish, rich in IgA antibodies, protein, and laxative; transitions to transitional milk then mature milk.
Term
Let-down (milk ejection) reflex
Example
Mother feels tingling in breast, milk flows; baby swallows more; cramping occurs simultaneously
Definition
Oxytocin-mediated milk expulsion from alveoli; triggered by suckling, infant cry, thought of baby, or touch; causes simultaneous uterine contraction (afterpains).
Term
Engorgement
Example
Primiparas: peak day 3–4; managed by: feed q 2–3 h, warm compress before feeding, cold compress after
Definition
Painful, hard, swollen breasts (day 3–5) from milk accumulation and tissue edema; relieved by frequent feeding and cold compresses.
Term
Mastitis
Example
Mother presents with fever, chills, hard lump in breast; milk is safe for baby; continue feeding or pump to drain
Definition
Breast inflammation/infection: warm, red, tender, wedge-shaped area with fever/flu-like symptoms; usually unilateral; managed by continued breastfeeding, rest, fluids, warm compresses, antibiotics.
Term
Latch
Example
Wide mouth, chin to breast, audible swallowing = good latch; lip blanching, cracks, pain = poor latch
Definition
Correct positioning of infant mouth on areola (not just nipple) for effective milk transfer and to prevent nipple trauma.
Diagrams To Know
- Latch assessment checklist: mouth position, chin contact, areola coverage, audible swallowing
- Mastitis vs. engorgement vs. normal breast: differences in onset, distribution, systemicRx
Common Values
Value
Day 3–5 postpartum
Symbol
#1affected day
Quantity
Peak postpartum blues onset
Value
Within ~2 weeks
Symbol
Spontaneous
Quantity
Postpartum blues resolution
Value
Day 2–3 postpartum
Symbol
Best teaching window
Quantity
Taking-hold phase onset
Value
Days 2–14 postpartum
Symbol
EMERGENCY timing
Quantity
Postpartum psychosis onset
Section Title
Psychological Adaptation & Maternal-Infant Bonding
Important Facts
- Attachment behaviors: eye contact (en face), fingertip touch → palm contact → enfolding, calling baby by name, responding to cues, verbalizing positive feelings.
- Poor bonding red flags: avoidance of eye contact, minimal touching, calling baby 'it' or by non-name, no response to cues, negative/critical comments; DOCUMENT and refer.
- Postpartum blues (baby blues): normal, transient; peak day 3–5 (when milk 'comes in,' hormones plummet); mother still functional; reassure it will pass.
- Postpartum depression: onset often delayed (weeks 2–6 or even months); mother unable to function; anhedonia, guilt, intrusive thoughts; REQUIRES TREATMENT.
- Postpartum psychosis: onset rapid (days 2–14); bizarre behavior, delusions (baby is evil/dead), command hallucinations; LIFE-THREATENING; psychiatric emergency.
- Risk factors for postpartum mood disorders: history of depression/anxiety, trauma, lack of support, difficult labor, complications, sleep deprivation.
- Screen for depression at every visit (e.g., Edinburgh Postnatal Depression Scale, PHQ-9); lower threshold to refer in Filipino/collectivist contexts where shame/stigma may delay disclosure.
- Maternal mental health is integral to infant safety and breastfeeding success; depression affects bonding, feeding, and child development outcomes.
- Cultural sensitivity: in Philippines, family involvement (lola, ate, partner) varies; use appropriate support systems; respect traditional practices (hilot, pampalusog).
- Safety planning: if mother expresses suicidal/homicidal ideation or thoughts of harming baby, CALL PSYCHIATRY, ensure supervision, remove access to means.
Key Definitions
Term
Rubin's taking-in phase
Example
Day 1–2: mother sleeps, eats, talks about labor; provider gives care, teaching postponed; needs nurturing and listening
Definition
First 1–2 days: mother is passive, dependent, focused on her own needs (rest, food); relives birth experience; limited infant care interest.
Term
Rubin's taking-hold phase
Example
By day 2–3: mother asks for diaper change demonstration, asks about feeding cues, wants to bathe baby; high motivation to learn
Definition
Days 2–10: mother becomes independent, eager to learn infant care; BEST TIME FOR TEACHING; asks many questions; anxious about competence.
Term
Rubin's letting-go phase
Example
Weeks 2–4: mother integrates motherhood into identity; less fantasy about baby; realistic expectations; routine established
Definition
Gradual adaptation to motherhood role; mourning loss of old identity; realistic acceptance of infant and self.
Term
Postpartum blues
Example
Mother cries during assessments, feels overwhelmed but can describe why, improves with company and validation; resolved by day 14
Definition
Mild, transient tearfulness, mood swings, anxiety; peaks day 3–5; resolves in ~2 weeks; affects 50–80% of mothers; needs REASSURANCE and SUPPORT, NOT medication.
Term
Postpartum depression
Example
Mother unable to get out of bed, not interested in baby, suicidal ideation; REFER to psychiatry; do not delay
Definition
More severe, persistent depression (>2 weeks) interfering with ADLs, infant care, sleep; requires REFERRAL and TREATMENT (antidepressants, counseling).
Term
Postpartum psychosis
Example
Mother believes infant is possessed, hears voices commanding harm, confused; CALL PSYCHIATRY immediately; ensure constant supervision
Definition
RARE, EMERGENCY: delusions, hallucinations, disorientation, risk to self/infant; requires URGENT psychiatric admission and infant safety precautions.
Diagrams To Know
- Rubin's 3 phases timeline: taking-in (1–2 d) → taking-hold (2–10 d) → letting-go (weeks 2+)
- Postpartum mood spectrum: normal/blues → depression → psychosis (severity/urgency increase)
Common Values
Value
20,000–25,000/mm³
Symbol
Not infection unless other signs
Quantity
Normal postpartum leukocytosis ceiling
Value
50–70 bpm
Symbol
Physiologic
Quantity
Normal postpartum bradycardia range
Value
~5–6 kg
Symbol
Baby + placenta + fluids
Quantity
Immediate postpartum weight loss
Value
Within 6–8 hours postpartum
Symbol
Baseline
Quantity
Target first void time
Section Title
Systemic Physiologic Changes Postpartum
Important Facts
- Cardiovascular: transient bradycardia (50–70 bpm) may be normal postpartum; however, tachycardia + hypotension = hemorrhage until proven otherwise.
- Immediate weight loss: ~5–6 kg (baby + placenta + amniotic fluid + maternal blood loss); gradual loss thereafter (breastfeeding accelerates loss).
- Constipation: very common postpartum; causes include fear of pain, perineal/abdominal trauma, decreased GI tone, dehydration, and opioid use.
- Management of constipation: hydration (2–3 L/day), dietary fiber, stool softeners (docusate), ambulation, and reassurance about incision/perineal safety.
- Urinary retention: risk factors include epidural anesthesia, catheterization during labor, perineal trauma; assess void within 6–8 hours; catheterize if unable to void.
- Overdistension of bladder: prevents uterine contraction → increases PPH risk; empty bladder early and often (q 2–4 h first 24 h).
- Endocrine: sharp drop in estrogen/progesterone after placental delivery; prolactin rises if breastfeeding; TSH may transiently rise (postpartum thyroiditis risk).
- Menses/ovulation return: delayed in breastfeeding mothers (LAM: exclusively breastfeeding, amenorrheic, <6 mo ≈ 99% effective contraceptive).
- IMPORTANT: Ovulation can precede first postpartum menses → contraception should NOT be delayed even if amenorrheic.
- Rh-negative mothers: confirm anti-D immunoglobulin (RhoGAM) given within 72 hours if infant is Rh-positive or Coombs-positive.
Key Definitions
Term
Diuresis and diaphoresis
Example
Mother voids large quantities, sweats through gown/linens first 24–48 h; normal process; maintain hydration and fresh linens
Definition
Increased urination and sweating in first postpartum days as body sheds pregnancy fluid overload and normalizes volume.
Term
Postpartum leukocytosis
Example
WBC 22,000 on day 2 postpartum + low-grade fever = do not assume infection; assess source; normal labs don't rule out infection either
Definition
WBC count up to ~20,000–25,000/mm³ is NORMAL postpartum; do NOT automatically attribute to infection.
Term
Hypercoagulability (postpartum hypercoagulable state)
Example
Immobility + hypercoagulability + endothelial injury = major DVT/PE risk; early ambulation, compression stockings, hydration reduce risk
Definition
Increased clotting factors and decreased fibrinolysis persist for ~6 weeks postpartum; increases DVT/PE risk.
Term
Lochia alba vs. infection
Example
Yellowish lochia day 14 = normal; purulent, foul lochia with fever + lower abdominal pain = endometritis; TREAT with antibiotics
Definition
Lochia alba (white/yellowish, day 10+) is normal; distinguish from foul-smelling, purulent lochia (endometritis) by odor and associated symptoms (fever, pain).
Diagrams To Know
- Postpartum volume shifts and fluid management (diuresis/diaphoresis timeline)
- Normal vs. abnormal vital sign changes postpartum
Formulas
Formula
REEDA scoring: R (Redness 0–3) + E (Edema 0–3) + E (Ecchymosis 0–3) + D (Discharge 0–3) + A (Approximation 0–3) = Total 0–15
Meaning
0 = none/no edema/well-approximated; 1 = mild; 2 = moderate; 3 = severe; higher score = slower healing/more intervention needed
Watch Out
Score does NOT predict wound infection alone; also assess for purulent discharge, dehiscence, fever, foul odor
When To Use
Serial REEDA scores track perineal healing; baseline day 1, then q 1–2 d; scores should improve
Common Values
Value
0–15 (0 = perfect, 15 = worst)
Symbol
Higher = slower healing
Quantity
REEDA score range
Value
15–20 minutes
Symbol
First 24 h
Quantity
Ice pack application duration
Value
15–20 minutes
Symbol
After 24 h
Quantity
Sitz bath duration
Value
1–2 weeks (REEDA 0)
Symbol
With good care
Quantity
Expected episiotomy healing time
Section Title
Perineal Care & Episiotomy Healing (REEDA)
Important Facts
- First 24 hours: ICE PACKS to perineum q 1–2 h for 15–20 min (reduces edema, pain, ecchymosis); keep perineum clean/dry.
- After 24 hours: WARM SITZ BATHS q 2–3 h for 15–20 min (promotes healing, pain relief, cleansing); especially after void/defecation.
- Perineal hygiene: FRONT-TO-BACK wiping/cleansing ALWAYS (prevent fecal contamination of wound); change pads q 2–4 h or after void/defecation.
- Analgesia: acetaminophen, NSAIDs (ibuprofen), or topical anesthetics (lidocaine spray); severe pain → assess for hematoma or infection.
- Activity: sitting on donut cushion may help if severe perineal pain; KEGEL exercises (pelvic floor) start day 2–3 for tone recovery.
- Constipation prevention critical: hard stool can tear healing episiotomy; stool softeners, fluids, fiber, ambulation prevent straining.
- Signs of episiotomy infection: increasing pain after day 3, purulent discharge, fever, gaping wound edges, foul odor; ASSESS and TREAT.
- Delayed healing: maternal age >35, malnutrition, anemia, diabetes, poor hygiene, infection; assess and address modifiable factors.
- Dyspareunia: some pain with intercourse weeks 1–3 normal; if persistent >1 month, assess for incomplete healing, scar tissue, infection.
Key Definitions
Term
Episiotomy
Example
Routine episiotomy NOT recommended (RA 9173 supports evidence-based practice); selective use if indicated (instrumental delivery, fetal distress)
Definition
Planned perineal incision to facilitate delivery; can be mediolateral or midline (mediolateral has lower 3rd-degree tear risk but more pain).
Term
Perineal trauma
Example
2° tear (most common with vaginal delivery) requires sutures; healing 1–2 weeks with good perineal care
Definition
1°, 2°, 3°, or 4° tear: 1° = skin/mucosa; 2° = involves perineal muscles; 3° = involves anal sphincter; 4° = through rectal mucosa.
Term
REEDA score components
Example
Day 1: R=1 (mild), E=2 (moderate), E=1 (mild), D=0 (none), A=0 (well approximated) = Total 4
Definition
Redness = hyperemia; Edema = swelling; Ecchymosis = bruising; Discharge = serous/sanguineous/purulent; Approximation = edges touching/gaping.
Diagrams To Know
- REEDA scoring sheet with visual examples of each grade (0–3) for redness, edema, ecchymosis
- Perineal trauma degrees (1°–4°) anatomical diagram
Common Values
Value
≥38°C (100.4°F)
Symbol
Report immediately
Quantity
Fever threshold for postpartum infection
Value
≥1 pad soaked per hour
Symbol
Danger sign
Quantity
Heavy bleeding threshold
Value
6 weeks postpartum
Symbol
Routine follow-up
Quantity
Postpartum check timing
Value
4–6 weeks postpartum
Symbol
After bleeding stopped + pain resolved
Quantity
Expected resumption of intercourse
Section Title
Discharge Teaching & Danger Signs
Important Facts
- HEAVY BLEEDING: saturating 1 pad in <1 hour, large clots (>walnut), bright red after lochia had lightened, passing clots = CALL provider; possible retained products/PPH.
- FOUL LOCHIA: musty/fleshy odor normal; purulent, foul odor + fever/pain = endometritis; TREAT with antibiotics (phone provider).
- FEVER ≥38°C: postpartum infection risk (endometritis, mastitis, UTI, wound); check source (lochia odor, breast exam, urinalysis); report to provider.
- CALF PAIN/SWELLING (unilateral): DVT until proven otherwise; IMMOBILIZE leg, CALL provider; do NOT massage; anticipate imaging (doppler ultrasound).
- CHEST PAIN/SHORTNESS OF BREATH: PE risk (hypercoagulable state); URGENT evaluation; do NOT wait; call ambulance if severe.
- SEVERE HEADACHE/VISION CHANGES: late pre-eclampsia can occur postpartum; check BP; if BP elevated + headache/vision = urgent evaluation.
- HOT/RED/PAINFUL BREAST + FEVER: mastitis; CONTINUE breastfeeding (drainage), warm compresses, antibiotics; milk is safe for baby.
- DEPRESSION/SUICIDAL THOUGHTS: screen at every visit; reassure about postpartum blues vs. depression timeline; LOW THRESHOLD to refer to mental health.
- Activity: return to work/full activity gradual; pelvic rest until bleeding minimal (to prevent ascending infection); safe to resume intercourse once bleeding stopped and pain resolved (usually ~4–6 weeks).
- Follow-up: postpartum check at 6 weeks (assess healing, lochia, mood, infant feeding); sooner if problems; newborn check-ups and immunization.
- Contraception: discuss options before discharge; progestin-only methods/non-hormonal if breastfeeding (estrogen suppresses milk); LAM if exclusive breastfeeding; NO delay.
- Rh-negative: confirm anti-D immunoglobulin given within 72 hours if infant Rh-positive or Coombs-positive; prevents alloimmunization.
Key Definitions
Term
Postpartum danger signs (to report immediately)
Example
Mother calls: 'I'm soaking through a pad in 30 minutes since this morning + I feel dizzy' = possible PPH; URGENT evaluation
Definition
Heavy bleeding (>1 pad/h), foul-smelling lochia, fever ≥38°C, calf pain/swelling, chest pain/SOB, severe headache/vision changes, hot/red/painful breast, depression/suicidal thoughts.
Term
Lactational Amenorrhea Method (LAM)
Example
Mother exclusively breastfeeding, no period, day 90 postpartum = LAM effective; BUT if she introduces 1 bottle formula or first menses returns = need backup method
Definition
Natural contraceptive if mother is fully breastfeeding (no formula/solids), amenorrheic, and <6 months postpartum (~99% effective); NOT reliable once any deviation occurs.
Diagrams To Know
- Postpartum danger signs checklist with phone-provider triggers
- Postpartum activity/exercise progression timeline
Must Remember
- **FUNDAL DESCENT**: Starts at umbilicus (day 1) → descends ~1 cm/day → not palpable by day 10–14. BOGGY uterus (NOT height) = atony = hemorrhage risk #1; massage FIRST.
- **4 Ts OF PPH**: Tone (70%), Trauma, Tissue, Thrombin. Atony = massage fundus + empty bladder + oxytocics. If bleeding persists, suspect trauma/retained products/coagulopathy.
- **LOCHIA PROGRESSION**: Rubra (1–3 d, red) → Serosa (4–10 d, pinkish) → Alba (10 d–6 wk, white). Foul odor/return to bright red/pad soaked <1 h = danger sign; report immediately.
- **METHYLERGOMETRINE CONTRAINDICATION**: CHECK BP BEFORE GIVING Methergine; CONTRAINDICATED in hypertension/pre-eclampsia (vasoconstriction); causes strongest uterine contraction; use oxytocin instead if BP elevated.
- **EXCLUSIVE BREASTFEEDING**: 6 months (RA 10028, WHO, DOH); Unang Yakap within 1 hour; colostrum rich in IgA; demand-driven supply; 8–12 feeds/24 h; 6+ wet diapers/day = adequate.
- **MASTITIS MANAGEMENT**: CONTINUE breastfeeding (drain the breast), NOT stop; milk is safe for baby; add antibiotics, rest, warm compresses; do not stop feeding because of infection.
- **RUBIN'S TAKING-HOLD PHASE (Days 2–10)**: BEST TIME TO TEACH; mother eager to learn, anxious about competence, asks questions. TAKING-IN (day 1–2) = passive, needs rest/listening; NOT teaching time.
- **POSTPARTUM BLUES vs. DEPRESSION**: Blues = day 3–5, ~2 wk, tearfulness, functional = REASSURE ONLY. Depression = >2 wk, anhedonia, interferes with function = REFER to psychiatry. Psychosis = EMERGENCY (delusions, risk to baby).
- **BUBBLE-HE ASSESSMENT**: Breasts, Uterus (firm/midline), Bladder (void q 6–8 h), Bowel, Lochia, Episiotomy (REEDA), Homans'/legs (DVT), Emotional (bonding/mood). Perform at every postpartum check.
- **RH-NEGATIVE MOTHERS**: Confirm anti-D immunoglobulin (RhoGAM) given WITHIN 72 HOURS if infant Rh-positive or Coombs-positive; prevents alloimmunization; document date/time/lot number.
Last Minute Tips
- **FUNDAL BOGGY = MASSAGE FIRST**: Do NOT check height, do NOT express clots, do NOT wait. Massage fundus + lower segment immediately; then assess bladder. This is the single most important emergency action in postpartum care.
- **METHERGINE = CHECK BP FIRST**: Before giving any dose, CHECK BP. If elevated, use oxytocin instead. This drug causes vasoconstriction and is contraindicated in hypertension/pre-eclampsia—one of the TOP exam tricks.
- **LOCHIA FOUL = INFECTION UNTIL PROVEN OTHERWISE**: A foul-smelling lochia (not musty) + fever + lower abdominal pain = endometritis; TREAT with antibiotics. Do not wait or assume it is normal.
- **POSTPARTUM BLUES = REASSURE, NOT MEDICATE**: Day 3–5 tearfulness + overwhelm + STILL FUNCTIONAL = blues (normal in 50–80% of mothers). Do NOT give antidepressants for blues; give support. Distinguish from depression (>2 wk, can't function).
- **MASTITIS = KEEP BREASTFEEDING**: The most common mistake is telling mothers to stop breastfeeding when they have mastitis. CONTINUE feeding (or pump), add antibiotics, warm compresses. Milk is safe; stopping drains cause abscess.
Comparison Tables
Rows
Values
- 1–3 d
- Bright red
- RBCs, fibrin, decidua, fetal membranes
- Fleshy/musty (normal menses-like)
- 2–4 pads (heavier)
Property
Lochia Rubra
Values
- 4–10 d
- Pinkish-brown
- Fewer RBCs, serous exudate, WBCs
- Fleshy/musty (normal)
- 1–3 pads (moderate)
Property
Lochia Serosa
Values
- 10 d–~6 wk
- White/yellowish
- WBCs, endothelial cells, bacteria, mucus
- Fleshy/musty or absent
- Scant (<1 pad/day by wk 3–4)
Property
Lochia Alba
Values
- Any stage (often days 2–5)
- May remain red or dark
- Purulent, tissue debris
- FOUL (putrid, not musty)
- Variable; may continue heavy
Property
ABNORMAL: Endometritis
Columns
- Stage
- Days
- Color
- Composition
- Odor
- Expected Pads/Day
Table Title
Lochia Progression: Color, Composition, Odor, Timeline
Rows
Values
- Day 3–5 (peaks with hormone crash)
- Weeks 2–6 (often delayed)
- Days 2–14 (rapid, abrupt)
Property
Onset
Values
- ~2 weeks (self-limited)
- >2 weeks (persistent); months if untreated
- EMERGENCY; days to weeks if untreated
Property
Duration
Values
- Mild mood swings, tearfulness
- Moderate to severe; interferes with ADLs
- SEVERE; delusions, hallucinations, psychomotor changes
Property
Severity
Values
- Tearfulness, overwhelm, but still functional
- Anhedonia, guilt, fatigue, sleep disturbance, intrusive thoughts
- Bizarre behavior, disorientation, command hallucinations, risk to self/infant
Property
Symptom pattern
Values
- 50–80% of mothers (NORMAL)
- ~10–15% of mothers
- <1% (RARE but EMERGENCY)
Property
Incidence
Values
- REASSURANCE, support, company, validation (NO medication)
- REFER to psychiatry; antidepressants + counseling
- URGENT psychiatric admission; ensure infant safety; 1:1 supervision
Property
Management
Values
- Normalize, teach about hormone changes, encourage rest/support
- Screen at each visit (Edinburgh scale); low threshold to refer; do not delay
- CALL psychiatry immediately; do not leave mother/infant alone; remove means
Property
Nursing action
Columns
- Feature
- Baby Blues
- Postpartum Depression
- Postpartum Psychosis
Table Title
Postpartum Mood Disorders: Comparison of Blues vs. Depression vs. Psychosis
Rows
Values
- 10 units
- IM or diluted IV per protocol
- 2–3 min (IM), <1 min (IV); 15–60 min duration
- None major; caution if hypotension, cardiac disease
- Hypotension (rapid IV), water intoxication (if massively diluted)
- FIRST-LINE; dilute IV dose to prevent hypotension; watch for afterpains
Property
Oxytocin (Pitocin)
Values
- 0.2 mg
- IM or PO
- 6–7 min; 3 h+ duration (LONG)
- **HYPERTENSION/PRE-ECLAMPSIA** (vasoconstriction danger); cardiac disease
- Vasoconstriction, hypertension, headache, chest pain, coronary spasm
- CHECK BP BEFORE GIVING; caution use in migraine; never give if BP elevated; causes strongest uterine contraction
Property
Methylergometrine (Methergine)
Values
- 250 micrograms
- IM
- 8–10 min; ~3 h duration
- ASTHMA/COPD (bronchospasm risk); caution in liver/renal disease
- Bronchospasm, diarrhea, fever, chills, nausea, vomiting, transient BP changes
- Caution in asthma; inform patient of fever/diarrhea (expected); rarely used 1st-line but valuable for refractory atony
Property
Carboprost (Hemabate, PGF2α)
Values
- 600–800 mcg
- Oral, sublingual, or rectal per protocol
- Variable (slow); 3+ h duration
- None absolute; caution in diarrhea-prone patients
- Diarrhea (common), fever, chills, nausea, abdominal cramping
- Alternative where injectables unavailable (resource-limited settings); longer onset but acceptable; GI side effects
Property
Misoprostol
Columns
- Drug
- Dose (usual)
- Route
- Onset/Duration
- KEY Contraindications
- Side Effects
- Nursing Notes
Table Title
Uterotonic Medications: Indications, Doses, Contraindications
Rows
Values
- Mild/good healing
- Normal postpartum perineal healing
- Continue ice (24 h), then warm sitz baths; routine perineal care; assess day 3–5
Property
0–5
Values
- Moderate healing
- Edema, some ecchymosis; slower but still normal progress
- Intensify cold/warm compresses; pain management; frequent sitz baths; assess for signs of infection
Property
6–10
Values
- Slow/complicated healing
- Significant edema, ecchymosis, discharge, or gaping
- Assess for hematoma, infection, or wound dehiscence; may need 2° repair; refer to provider; close follow-up
Property
11–15
Values
- Deteriorating wound
- Possible infection or breakdown
- ASSESS for infection signs (fever, foul odor, purulent discharge, increasing pain); culture if purulent; treatment (antibiotics) may be needed
Property
Increasing score between visits
Columns
- Total REEDA Score
- Interpretation
- Wound Status
- Intervention/Timing
Table Title
REEDA Score Interpretation: Healing Progress Markers
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