# Situation: A 30-year-old woman, gravida 3 para 3, gave birth vaginally to a healthy term newborn at a district hospital. She is breastfeeding, and the nurse on the postpartum ward cares for her during the first days after birth. Two hours after birth, the mother has had skin-to-skin contact with her newborn and has completed the first breastfeed. Her vital signs are stable. The nurse is planning her care for the next several hours. Which objective of early puerperal care should guide the nurse's actions FIRST?

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> subject: Nursing Practice II — Maternal and Child Health Nursing

## 문제

Situation: A 30-year-old woman, gravida 3 para 3, gave birth vaginally to a healthy term newborn at a district hospital. She is breastfeeding, and the nurse on the postpartum ward cares for her during the first days after birth.

Two hours after birth, the mother has had skin-to-skin contact with her newborn and has completed the first breastfeed. Her vital signs are stable. The nurse is planning her care for the next several hours. Which objective of early puerperal care should guide the nurse's actions FIRST?

## 보기

1. Prepare her for discharge by teaching newborn care
2. Detect bleeding promptly through fundus and lochia checks **✔ 정답**
3. Strengthen bonding through rooming-in and feeding on demand
4. Counsel her on birth spacing and family planning methods

**정답: 2**

## 해설

All four are essential objectives of puerperal care, but the first hours after birth carry the highest risk of hemorrhage from poor uterine contraction. Frequent checks of the fundus and lochia come first; bonding has already been started and continues with rooming-in, while teaching and family planning counseling follow once the mother is stable and ready to learn.

## 심화 해설

The immediate postpartum period is a time of rapid physiologic transition, and the priority of nursing care reflects the most life-threatening risk: postpartum hemorrhage (PPH). Uterine atony—failure of the myometrium to contract firmly after placental separation—is the leading cause of early PPH, and the first 2 hours after birth carry the greatest danger because the uterine muscle may relax and allow bleeding from the placental site to go unnoticed.

During pregnancy, the uterine spiral arteries remodel into low-resistance vessels that deliver a large volume of blood to the placental bed. After delivery of the placenta, hemostasis depends almost entirely on mechanical compression of these vessels by sustained myometrial contraction. If the uterus becomes boggy (soft, poorly contracted), the vessels remain open and blood loss can be rapid and concealed. This is why frequent assessment of uterine fundal tone, position, and lochia flow is the first clinical action in early puerperal care. A firm, midline fundus at or below the umbilicus indicates adequate contraction; a displaced or soft fundus suggests bladder distention or atony, both of which require immediate intervention.

The lochia assessment complements the fundal check. In the first hours, lochia rubra is expected—dark red with small clots—but a steady trickle, large clots, or saturation of more than one perineal pad per hour signals excessive bleeding. Key point! Even when vital signs appear stable, significant blood loss can be masked by the physiologic hypervolemia of pregnancy; a young, healthy woman may not show tachycardia or hypotension until she has already lost a substantial volume. Therefore, direct observation of uterine tone and lochia is more sensitive than relying on vital signs alone in the early puerperium.

The educational guideline evidence reinforces that structured postnatal care improves nurse performance in detecting maternal complications [1]. The study emphasizes that the postnatal period carries high morbidity and mortality, and that nurses’ knowledge and systematic assessment directly reduce these risks [1]. Within that framework, the sequence of care is clear: hemorrhage surveillance precedes teaching, bonding facilitation, and family planning counseling. Bonding through skin-to-skin contact and rooming-in has already been initiated and continues naturally, but it does not require the same level of urgent, time-sensitive assessment as bleeding detection. Discharge teaching and contraception counseling are important but are best delivered once the mother is hemodynamically stable and alert enough to retain information.

| Care objective | Timing in early puerperium | Rationale |
| --- | --- | --- |
| Detect bleeding (fundus and lochia checks) | First priority, every 15 minutes for the first hour, then per protocol | Uterine atony is the leading cause of early PPH; bleeding can be concealed |
| Strengthen bonding (rooming-in, feeding on demand) | Ongoing, already initiated | Supports attachment and lactation but is not an immediate life-threat |
| Teach newborn care | After maternal stability is confirmed | Learning requires physical and emotional readiness |
| Counsel on birth spacing and family planning | Before discharge, when mother is stable | Important preventive care but not time-critical in the first hours |

Watch out! A common error is to assume that because the mother completed skin-to-skin contact and the first breastfeed without difficulty, the risk of hemorrhage has passed. Oxytocin released during breastfeeding does promote uterine contraction, but its effect is intermittent and does not replace active surveillance. The fundus must be checked by palpation at regular intervals, not inferred from maternal behavior or apparent comfort.

Key point! When assessing the fundus, always support the lower uterine segment with one hand while palpating the fundus with the other. This prevents uterine inversion and allows accurate evaluation of tone. If the fundus is soft, massage it gently until firm, then reassess lochia flow. If the fundus is displaced upward or to the side, assist the mother to void—a full bladder mechanically prevents effective contraction.

The correct sequence, therefore, is grounded in the pathophysiology of placental site hemostasis and the epidemiology of maternal morbidity. Structured postnatal assessment, as supported by the educational guideline, improves early recognition of complications [1]. Bleeding detection through systematic fundal and lochia evaluation is the objective that must guide the nurse’s actions first, because it addresses the most immediate and preventable threat to maternal life in the early puerperium.References (research sources)

- [1]Effect of Educational Guideline on Nurses Performance Regarding Postnatal Care of Mothers and Neonates.GuidelineSaid SAE, Elbana HM, Salama AM. (2022) · DOI: 10.1177/23779608211070154

## 임상 시나리오

Early Postpartum Hemorrhage SurveillancePrioritize fundus and lochia checks in the first hours
The first 2 hours after birth carry the highest risk of postpartum hemorrhage, most often from uterine atony. Assess fundal tone, position, and height frequently. A firm, midline fundus at or below the umbilicus indicates adequate contraction.

Check lochia rubra for amount, color, and clots. Saturation of more than one perineal pad per hour, large clots, or a steady trickle suggests excessive bleeding even if vital signs appear stable.

CautionA soft, boggy, or displaced fundus suggests atony or bladder distention. Intervene immediately with fundal massage, emptying the bladder, and escalation per protocol. Do not delay because vital signs are still normal.

## 핵심 개념

- **Uterine atony** — Failure of the myometrium to contract firmly after placental separation; the leading cause of early postpartum hemorrhage.
- **Lochia rubra** — Dark red vaginal discharge with small clots expected in the first hours after birth; excessive flow or large clots suggest bleeding.
- **Fundus** — The upper portion of the uterus; assessed postpartum for tone, position, and height to detect atony or bladder distention.
- **Postpartum hemorrhage (PPH)** — Excessive bleeding after birth, most often from uterine atony; the first 2 hours carry the highest risk.
- **Early puerperium** — The first hours to days after birth, when rapid physiologic transition and hemorrhage risk require close monitoring.

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