Obstetrical Nursing / A Text-Book on the Nursing Care of the Expectant Mother, the Woman in Labor, the Young Mother and Her Baby

by Carolyn Conant Van Blarcom

This rapid diminution in the size of the uterus is termed involution and is accomplished by means of a process of self-digestion or autolysis. The protein material in the uterine walls is broken down into simpler components which are absorbed and eventually cast off largely through the urine. This change and absorption of uterine tissues is similar to the resolution that takes place in a consolidated lung in pneumonia.

Since satisfactory involution is necessary to the patient’s future health, its progress should be watched with deep concern and interest, and all possible effort made to promote it; firm consistency of the uterus and a steady descent into the pelvis and normal lochia being the chief evidences of satisfactory involution. There is evidently a close relation between the functions of the breasts and of the uterus during the puerperium, and as a rule involution accordingly progresses more normally in women who nurse their babies than in those who do not.

The so-called “after-pains” are also affected by nursing, being more severe as a rule when the baby is at the breast than at other times. These pains are caused by the alternate contractions and relaxations of the uterine muscles and are more common in multiparæ, than in primiparæ, because the muscles of the former have somewhat less tone than the latter and therefore tend to relax, and then contract, whereas the better muscle tone of the primipara tends to keep the uterus steadily contracted.

These after pains usually subside after the first twenty-four hours, though they may persist for three or four days. They may amount to little more than discomfort, but not infrequently are so severe as to require the administration of sedatives. Persistent after pains may be due to retained clots.

The cervix, vagina and perineum which have become stretched and swollen during labor, gradually regain their tone during the puerperium, and the stretched uterine ligaments become shorter as they recover their tone, finally regaining their former state. Until the ligaments and the pelvic floor and abdominal wall are restored to normal tonicity the uterus is not adequately supported and therefore may be easily displaced.

The lochia consists of the uterine and vaginal secretions and the blood and uterine lining which are cast off during the puerperium. During the first three or four days this discharge is bright red, consisting almost entirely of blood, and is termed the lochia rubra. As the color gradually fades and becomes brownish it is called the lochia serosa. After about the tenth day, if involution is normal, the discharge is whitish or yellowish and is designated as the lochia alba. The total amount of the lochial discharge has been variously estimated at from one to three pints, being more profuse in multiparæ than primiparæ, and in women who do not nurse their babies. Under normal conditions the discharge is profuse at first, gradually diminishing until it entirely disappears by the end of the puerperium. There may be small amounts of blood retained during the first day or two and expelled later as clots, without any serious significance, and there may be a pinkish discharge after the patient gets up for the first time, but if the lochia is persistently blood-tinged it may be taken as an indication that the uterus is not involuting as it should.

The normal characteristic odor is flat and stale. A foul odor, no odor at all or a marked decrease in the amount of the discharge is suggestive of infection.

Loss of Weight. One of the striking changes during the puerperium is the loss in weight, due largely to three factors: the elimination of fluids from the edematous tissues; the decrease in the size of the uterus and the escape of vaginal and uterine secretions, termed the lochia. The smaller amount of food taken during the first few days post-partum also may be a factor.

This loss in weight is extremely variable, fat women naturally losing more than thin women and those who nurse their babies losing more than those who do not.

Dr. Edgar estimates that the loss through the lochia amounts to something over three pounds, and the loss through fluids from the tissues, from nine to ten pounds. According to Dr. Slemons, the loss in fluids equals about 1/10th of the patient’s weight at the beginning of the puerperium, while all agree that the uterus decreases about two pounds in weight. All told, then, the patient may normally lose from twelve to fifteen pounds during the puerperium. This loss may be somewhat controlled, however, by a suitable diet, and under most conditions the patient should return to not less than her pre-pregnant weight by the end of the sixth or eighth week.