Normal Puerperium (Postpartum)

Normal Puerperium (Postpartum)

• The postpartum period is a crucial transition for the birthing person, the newborn, and the family on both physical and psychological levels.
• The postpartum period typically lasts around 6 weeks.
• Some women may heal in as little as 4 weeks, whereas others may need 10-12 weeks for all structures to recover.
• The postpartum period is sometimes called the "4th trimester".
• The postpartum period involves the restoration of the birthing person to a near pre-pregnant state.
• During the postpartum period significant anatomic, physiologic, and endocrine changes take place.

BUBBLE-LE Assessments

• B: Breasts
• U: Uterus
• B: Bowel
• B: Bladder
• L: Lochia
• E: Episiotomy
• L: Lower Extremities
• E: Emotional Status

Immediate Postpartum Period Assessments

• Vital signs should be assessed every 15 minutes for the first hour, every 30 minutes for the second hour, and then every 4 hours for 24 hours, then once per shift after 24 hours.
• Vital signs should be monitored more frequently for longer if complications arise during the postpartum period.
• Fundus: Assess every 15 minutes for the first hour, every 30 minutes for the second hour, and then every 4 hours for 24 hours, then once per shift after 24 hours.
• After birth, the fundus' position should be even to 1 cm/fingerbreadth above the umbilicus for the first 12 hours, then descend by one fingerbreadth each day.
• Lochia: color and volume monitoring should occur every 15 minutes for the first hour, then every 30 minutes for the second hour, then every hour, then every 4 hours.
• Lochia rubra lasts from day 1-3, serosa day 4-10, and alba day 11-6 weeks PP.
• Urinary: Measure the first void.
• The birthing person may have urethral edema or urine retention.
• Bonding: Encourage interaction through touch and eye contact.

Risk Factors for Postpartum Complications

• Box 16.1 Factors Increasing a Birthing Person's Risk for Postpartum Infection and Hemorrhage
• Risk Factors for Postpartum Infection:
  • Operative procedure (forceps, cesarean birth, vacuum extraction)
  • History of diabetes, including gestational-onset diabetes
  • Prolonged labor (more than 24 hours)
  • Use of indwelling urinary catheter
  • Anemia (hemoglobin <10.5 mg/dL)
  • Multiple vaginal examinations during labor
  • Prolonged rupture of membranes (>24 hours)
  • Manual extraction of placenta
  • Compromised immune system (HIV-positive)
• Risk Factors for Postpartum Hemorrhage:
  • Precipitous labor (less than 3 hours)
  • Uterine atony
  • Placenta previa or abruptio placenta
  • Labor induction or augmentation
  • Operative procedures (vacuum extraction, forceps, cesarean birth)
  • Retained placental fragments
  • Prolonged third stage of labor (more than 30 minutes)
  • Multiparity, more than three births closely spaced
  • Uterine overdistention (large infant, twins, hydramnios)
  • Obesity

The Uterus and Involution

• Involution is the uterus returning to its pre-pregnancy size and condition.
• Involution Involves healing of the placental site, regeneration of the endometrium, and reduction in size.
• Monitor involution by assessing fundal height, and consistency of the uterine fundus in addition to the character/amount of lochia every 4-6 hours postpartum.
• Muscle fibers become shorter, which controls bleeding by compressing and sealing off blood vessels.
• The uterus acts as "the living ligature”.
• Immediately after birth, the fundus should be midline, 2 fingerbreadths below the umbilicus.
• In the next hour, the fundus rises to the level of the umbilicus.
• Following the first hour, the fundus decreases by a fingerbreadth per day.
• By day 10-14 the uterus will no longer be palpable.
• If the uterus is found to be boggy, priority intervention is needed.
• Interventions by nurses, if the uterus is found deviated from the midline, are required.

Lochia

• Lochia flow is a natural process that removes debris and bacteria from the uterus after delivery.
• The amount of lochia may vary at different times.
• Painful uterine contractions after delivery may result in a gush of heavy bleeding with clots which decreases spontaneously.
• Getting up from a sitting or lying position may result in a rush of blood; this is just drainage of collected blood and isn't cause for concern.
• Lochia is sterile for the first 2-3 days, then colonized by bacteria with a typical lochial "bloody/irony" smell, which is normal.
• Characteristics of lochia needing assessment includes color, amount, and odor.
• Lochia should not be excessive in amount, never have an offensive odor, contain large pieces of tissue, or clots larger than a golf ball.
• Types of Lochia progressing includes rubra, serosa, and alba.

Lochia Amount

• Scant lochia: Blood only on tissue when wiped or less than 1-inch on peripad in 1 hour
• Light lochia: Less than 4 inches on peripad within 1 hour
• Moderate lochia: Less than 6 inches on peripad within 1 hour
• Heavy lochia: Peripad saturated within 1 hour

Match the Lochia

• Lochia rubra is dark red and consists mainly of blood, occurring day 1-3 of postpartum.
• Lochia serosa is pinkish to brownish serum with mucus and debris, occurring day 4-10.
• Lochia alba is yellowish brownish and happens after day 10 up to 6 weeks of the postpartum period.

Cervix

• The cervix remains thin and soft, potentially appearing bruised and edematous alongside lacerations.
• Shortening and firming of the cervix occurs in 12-18 hours.
• Cervix dilation to 3-4 cm is observed for 1-2 days after birth.
• The external os does not return to its pre-pregnant appearance, instead permanently appearing as a jagged slit, not a circle.

Vagina

• The vagina may be edematous and bruised, especially if there was a long period pushing or had a tear or episiotomy.
• If the birthing person has concerns, you must monitor for signs of hematoma especially if complaining of pain.
• Decreased tone and absence of rugae is typical.
• The rugae begin to reappear along with the lowering of the vascularity and edema will decrease in 3-4 weeks.
• Full healing of the vagina takes 6 weeks.
• The vagina gradually decreases in size and regains tone, but will never return completely to its pre-pregnancy state.

Perineum and Episiotomy

• The perineum may have episiotomy, lacerations, hematomas or scrapes.
• Check the perineum for hemorrhoids.
• Slight edema and bruising are normal in the perineum, mainly in the first 24-48 hours.
• Muscle tone is reduced for several weeks, Kegels exercises can be suggested to increase blood flow and aid healing/restoration of the pelvic.
• When injuries to the episiotomy and other lacerations occurs, they are recorded in degrees of tissue damage.
• A first-degree laceration includes skin and mucosa; a second-degree extends into the perineal muscles.
• A third degree extends into the anal sphincter complex, and a fourth degree goes completely through the anal sphincter and rectal mucosa.
• Assess the episiotomy and injury for REEDA (redness, edema, ecchymosis, drainage, approximation)
• Early pain treatment involves ice packs, eventually needing dermaplast spray.
• Complete healing is full in 4-6 weeks, but longer if any complications.

Interventions

• Relief of Perineal Discomfort involves: Ice packs (first 24 hours), topical agents, perineal care, and sitz bath (after 24 hours)
• Relief of hemorrhoidal discomfort may include: Sitz baths, topical anesthetic ointments, and witch hazel pads

Endocrine System Changes

• There's a quick decrease in placental hormones including estrogen, progesterone, and human placental lactogen (HPL).
• Oxytocin remains elevated to assist with bonding and uterine involution.
• The interplay of hormones such as estrogen, progesterone, prolactin, and oxytocin occurs during the resumption of ovulation/menstruation.
• Nonlactating patients: ~80% have a return of menstruation within ~10 weeks after birth.
• Lactating patients: return depends on breastfeeding frequency and duration; anywhere from 2 to 18 months or longer.

Breasts

• Allow the mother to assess her own breasts in a self breast exam
• Ask if she feels any nodules, and to be aware that lumps are normal.
• Assessment inquiries should include sore, reddened, blisters, and cracked nipples and if nipples are everted, flat, or inverted.
• Observe for engorgement (swelling as mature milk prepares to come in), which usually occurs in 2-4 days PP with breasts that are firm, warm, and tender to touch.
• Teaching the mother breast care techniques whether breastfeeding or bottle feeding, is required.

Lactating vs Non-Lactating Breasts

• In Lactating breasts, prolactin is responsible for milk production. Oxytocin causes the collecting sinuses of the mammary gland to contract, pushing milk forward through the nipple.
• In non-lactating breasts, engorgement resolves in 24-36 hours due to decreased prolactin levels.
• Breastfeeding Care:
  • Wash the nipples with just water and no soap.
  • Wear a supportive (but not tight) bra.
  • Breastfeeding tips:
    • Must stimulate breasts to maintain milk production.
    • Teach measures to assist infant getting the nipple and areola in the mouth.
    • Teach positions to hold the baby.
    • No timing – on demand (8-12 times per day)
    • Relax to allow for let-down and express colostrum on the nipples & air dry after feeding.
• Breast Milk Stages:
  • Colostrum (first 3-4 days); thick and yellow with maternal antibodies.
  • Transitional Milk
  • Mature Milk: produced by day 10; fore milk, and hind milk.

Suppression of Lactation

• Teach the mother ways to decrease stimulation of the breasts/nipples.
• Wear a tight-fitting bra or binder, not express milk from breasts, take shower with back to warm water, and use cabbage leaves and ice packs.

Systemic Changes

• Postpartum systemic changes include: Cardiovascular, Musculoskeletal, Gastrointestinal, Integumentary, Endocrine, Immune System, and Urinary

Vital Signs, Blood Volume and More

• Temperature: A slight elevation of up to 100.4 degrees may occur related to dehydration/increased basal body metabolism from exertion.
• After 24 hours, temperature should be normal, if not normal, a temperature greater than 100.4 degrees indicates an infection.
• Blood Pressure should remain stable, with hypovolemia possibly showing Postpartum hemorrhage and hypervolemia indicating preeclampsia.
• Pulse: Mild bradycardia of 40 -80 bpm is normal due to an increased stroke volume, lasting ~1wk PP.
• Tachycardia may indicate excessive blood loss.
• Respirations: Should remain stable and within the normal range (16-24), but may be slightly elevated.
• Monitors for 18-24 hours after c-section for respiratory depression from spinal anesthesia.
• Blood Volume: Increases for about 24-48 hours because the blood from the placenta returns to the heart.
• Then, the rest of the fluid volume is removed due to diuresis (increased kidney output) and diaphoresis (sweating), but cardiac output increases.

Blood Values During Pregnancy and Postpartum

• During pregnancy, WBC is elevated slightly to about 12,000, RBC increases slightly, Hemoglobin drops slightly to 10.5-11 (below 10=anemia), and hematocrit lowers slightly to 33-39%.
• If hematocrit drops below 32-35%, there is anemia.
• During the postpartum period, WBC is common with leukocytosis, with values at 20,000-30,000, but RT increased neutrophils. RBC will return to normal.
• Hemoglobin will see a drop of about 1 point from normal blood loss, but more with PPH. Hematocrit decreases in blood volume, and its levels remain normal.

Gastrointestinal Tract

• The GI system quickly returns to normal, bowel tones decrease for days, and decreased peristalsis occurs.
• Constipation is common due to fear of straining and Hemorrhoids from pushing
• Hunger and thirst occur from NPO status prior to delivery

Urinary System

• Difficulty voiding is common.
• Nurses observe for first void, measuring I&O.
• Following a C/S, If there were other complications there may still be a catheter for 12-24hrs PP.
• A palpable bladder is not typical.
• If a palpable bladder, that indicates distention
• A full bladder may distend or displace the uterus resulting in uterine atony
• Diuresis begins within ~12 hours
• Diaphoresis is also normal while the birthing person gets rid of extra fluid.

Musculoskeletal/Integumentary Systems

• Joints stabilize in 6-8 weeks
  • Except feet
• Abdominal Wall
  • Weak for 6-8 weeks
  • Diastasis Recti
• May have activity intolerance, muscle fatigue, and aches and pains, Leg cramps can be very common as well.
• Striae Gravidarum persist over abdomen, thighs, and breasts and Stretch marks are still reddened, but decrease after about 3 months.
• Decrease of hyperpigmentation occurs usually in ~6 weeks, but can remain, but is common in darker skinned individuals.
• Hair loss is common. Estrogen causes more hairs to go into the resting phase, which results in hairs falling out. Should return about 6-12 months.

Thromboembolism, Immune and Rest

• Assess Lower Extremities for Thromboembolism since the birthing person is at higher risk for clots.
• Palpate for signs/symptoms of DVT:
  • (1) reddened area on calf, (2) warm to touch, (3) swollen, will have unilateral.
• Ask about pain during walking.
• If unable to ambulate, encourage early ambulation.
• If not ambulating, especially if post-op, the birthing person will likely use SCDs or Support Stockings.
• Assess for edema as well
• Assess and support Rh Incompatibility
  • Rhogam prevents maternal antibodies from forming if the birthing person is Rh negative.
  • Rhogam must be given within 72 hours of delivery.
• Rubella titer needs assessment
  • Provide Rubella vaccine if the birthing person is non-immune.
  • Avoid pregnancy for 3 months and do not provide if allergy to duck eggs.
• The most common problem for patients is sleep. Allow for times of uninterrupted sleep.
• Walking exercises are safe, and the birthing person can have specific exercises based on their health.

Resuming Activities and Interventions

• Increase activities and ambulation gradually after birth.
• Avoid heavy lifting, activities that involve excessive stair climbing and physically strenuous activity.
• Light housekeeping by the second week is okay and delay work until after their 6-week appointment.
• Promote providing comfort through use of optimal cultural care, comfort with hot and cold applications, topical applications, and analgesics
• Provide care to assist in elimination through promoting voiding. (peribottle or sitz bath) and bowel elimination, through promoting activity, rest and exercise ( such as exercise and ambulation, rest periods, and kegels
• Interventions for safety by check blood pressure, elevate beds before ambulating, let the person sit, help them stand while keeping support and asking how their head feels.
• For feeding: assess mothers needs for nutrition, breastfeeding and bottle-feeding and educations on birth control and sex
• Promote bonding by first being a sensitive time for interaction, bonding is a development of strong affection between and infant and caregiver for time or siblings.

Care Aspects

• Assessment of care aspects include: Maternal, Mother, newborn and their families to adapt to all changes. Rubin says that the mother needs to go thought 3 phases to completely adjust, the 3 phases are: 1. taking-in: this is from day 1 to days 2/3 of having a baby, characterized with the mother depending on others, and needs/focus on herself and past self. Nursing implementations include listen with the most important parts
• Rubin: 2. Taking hold: on days 2/3 where the mother is beginning to show self control, is indepent and requires good interaction but has independence nursing requires praise.
• Rubin: 3: letting go: begins to see the infant more as its own person and refocuses life after that .
• Nurses should begin to assess all these parts to help with the needs and expectatons of mom- baby - families and the nurse should be ready for questions or concerns and educate.

Discharge and Danger Signs

• Discharge teaching includes self care and followup infant care, feeding and information ,medication , nutrition , danger signs
• Recommendation to stay after intercourse the epitostomy is healed or if lochia has decreased
• Danger signs of infection are: Fever greater that 100,4/ 38 is foul smell lochia or and unexplained changes. Large clots of blood may mean an hour is severe like headaches or blind spots, calf pain, or weight gain and rapid heart rate.