Subinvolution of the Uterus

Nursing Knowledge

Subinvolution of the Uterus

Subinvolution of the uterus refers to a condition where the uterus does not shrink to its pre-pregnancy size in the expected timeframe after childbirth. Often caused by retained placental tissue or infections, this can lead to heavy bleeding and increased risk of infection. Nurses need to know how to perform fundal checks and educate clients on what to look out for in the postpartum period.
Last updated: May 2, 2024

Table of contents

What is subinvolution? 

Subinvolution is a condition in which the uterus remains enlarged postpartum. 

This can lead to prolonged or excessive bleeding and higher risk of infection. 

Uterine atony vs subinvolution – what is the difference? 

Subinvolution of the uterus refers to the size of the uterus not returning to its pre-pregnancy state quickly enough after birth. It is therefore observed over an extended period of time after birth until the uterine recovery can be classified as being delayed. 

Uterine atony, on the other hand, is noted directly after birth if the uterus fails to contract effectively postpartum and bleeding is occurring. It is the most common cause of postpartum hemorrhage

Signs and symptoms of subinvolution 

Clinical features of subinvolution are heavy, prolonged bleeding, a boggy uterus, and the irregular descent of the uterus.

Subinvolution can be diagnosed by physical assessment of the height of the uterus. 

On the day of delivery, the fundus should be at the umbilicus. Each postpartum day after, the umbilicus should be approximately 1 fingerbreadth lower.

Additional signs could show up, such as: 

  • Uterine tenderness (related to infection) 
  • Abnormal lochia (more than expected, or foul odor if infection is present)

Causes and risk factors for subinvolution

Retained placental fragments are one of the most common causes of subinvolution of the uterus. Other causes include postpartum infections (chorioamnionitis, endometritis), excessive stretching of the uterus during pregnancy, previous surgeries, and uterine submucosal fibroids. 

Review of uterine subinvolution defintion, risk factors, clinical features, diagnosis, nursing care and client education

Nursing assessment and care 

Assessing clients after birth, preventive measures and nursing care for uterine subinvolution include: 

  • Closely monitor the uterus and bleeding. 
  • Notify the provider of any abnormal findings. 
  • Encourage the client to breastfeed, if possible. 
  • Encourage urination. 
  • Give medications as ordered (may include medications that encourage the uterus to contract).
  • If other measures fail, dilation and curettage (D&C) may be required. 

In dilation and curettage, the cervix is dilated to allow access for surgical instruments into the uterus and the uterine lining is scraped off with a curette. The goal is to remove any remaining fetal tissue or polyps to prevent infection. The procedure is usually done under general or local anesthesia and may lead to cramping and bleeding for a few days after. 

Common client questions around subinvolution and the uterus after birth

How long does it take for the uterus to shrink after birth? 

Six weeks is a good rule of thumb for how long the uterus takes after birth to return to its pre-pregnancy size. Of course, this can vary individually, but generally, by two weeks postpartum the uterus is no longer palpable abdominally. 

Why do nurses massage the uterus after birth? 

Fundal massage stimulates the uterus to contract more effectively after birth. This is necessary to prevent excessive bleeding/hemorrhage. The massage also is a way for nurses to assess the tone of the uterus, to monitor for uterine atony and take countermeasures early enough. 

How long does postpartum cramping last? 

How long clients experience cramping after delivery can vary individually, but can typically be expected for a few days to a week with decreasing intensity over time. Cramping may be more noticeable during breastfeeding, since the release of oxytocin promotes uterine contractions. 

Other client education measures

  • Explain to your clients why daily fundal checks are performed. 
  • Educate the client on the relationship between newborn suckling and uterine involution. 
  • Make sure clients know when to contact providers (abnormal bleeding or odor).


Subinvolution of the Uterus

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