Postpartum Period and Reproductive System Changes

Postpartum Period

• The postpartum period is the interval between birth and the return of reproductive organs to their nonpregnant state.
• It is a critical transition period for the woman, newborn, and family, both physiologically and psychologically.
• Puerperium lasts for 6 weeks after the delivery of the placenta.
• Postpartum period involves changes in all aspects of the mother's life during the first year after childbirth.
• It involves the mother and family adjusting to the new family member.

Reproductive System Adaptations

• Uterine involution is assisted by oxytocin.
• Hemorrhage is a major concern.
• The fundus should be at the level of the umbilicus a few hours after delivery.
• The fundus will be midline.
• The fundus decreases 1 to 2 cm per day (U-1, U-2).
• Uterine tone should be firm.
• The uterus returns to a nonpregnant state by 6 weeks.
• After birth, hemostasis is achieved via compression of intramyometrial blood vessels as uterine muscle contracts.
• Oxytocin, released from the pituitary gland, strengthens and coordinates uterine contractions.
• Lochia is postbirth uterine discharge and should be assessed for color, amount, and odor.
  • Lochia rubra (deep red) consists of blood, decidual, and trophoblastic debris and lasts for 3 to 4 days.
  • Serosa (pinkish brown) lasts for 3-10 days.
  • Alba (white) lasts for 10-14 days, but may last 2-6 weeks.
• Frequent assessment of the vagina and perineum is required.
  • Assess the perineum for signs of infection: intactness, pain, edema, erythema, ecchymosis, hematoma, hemorrhoids, and discharge.
• Laceration is the tearing of perineal tissue during birth that may require repair using the REEDA scale.
• Episiotomy involves an incision in the perineum to enlarge the vaginal outlet and assist with the second stage of labor.
  • It may take 4-6 weeks to heal completely.
• Hemorrhoids (anal varicosities) are common and decrease within 6 weeks of childbirth.
  • Ice and witch hazel can help.
• Nursing assessments and actions should occur at least every 8 hours.
  • Assess the perineum and teach perineal care for infection prevention.
  • Promote comfort with ice for the first 24 hours.
  • Witch hazel pads help provide moisture and keep the area clean.
  • A sitz bath may be ordered after 24 hours.
  • Teach Kegel exercises to encourage healing and pelvic muscular support.
• Subinvolution is failure of the uterus to return to its nonpregnant state.
  • It requires quick diagnosis and interventions.
  • Potential causes: retained placental fragments, infection, prolonged labor and/or difficult birth, overdistention of uterine muscles, and bladder distention.
  • Signs/symptoms: uterus boggy, uterine atony, and lochia heavy.
  • Interventions: massage the fundus, note consistency, and assess the amount of lochia (weighing pads where 1g equals 1 mL of fluid).
  • Obtain Oxytocin to be administered IV.

Endocrine System

• Expulsion of the placenta results in a dramatic decrease in placental-produced hormones.
  • Estrogen and Progesterone levels decrease
  • Diuresis and diaphoresis occur, with an increase in urine production.
• Menstruation usually returns at 7-9 weeks.
• Ovulation and menstruation are usually prolonged in lactating women.
• Nursing actions and patient education are important.

Urinary System

• Urinary output increases the first 12 to 24 hours due to postpartum diuresis.
• Profuse diaphoresis often occurs at night for the first 2-3 days.
• Nursing interventions include:
  • Reviewing labor and delivery records for risk factors.
  • Assessing client sensation to void, discomfort, or difficulty voiding.
  • Assessing bladder distention and signs of urinary retention.
  • Excessive bleeding can occur with bladder distention
• An epidural can cause nausea, vomiting, and urinary retention.
  • Retention with overflow may be asymptomatic.

Gastrointestinal System

• Most new mothers are hungry after recovery.
  • This is due to decreased progesterone levels.
• Constipation and hemorrhoids are common.
  • Spontaneous bowel evacuation may not occur for 2 to 3 days postpartum.
• Encourage fluids and food, considering food preferences across cultures.
• Nursing assessment and actions.

Breasts and Breastfeeding

• Lactating and nonlactating women differ in the timing of first ovulation and menstruation.
• Lactation is the secretion of milk by the breasts.
• Prolactin from the anterior pituitary gland increases levels and triggers secretion of milk after birth.
• Prolactin, progesterone and estrogen are all involved.
• Secretion of colostrum occurs for 2-3 days, providing a thin, yellowish fluid that helps maintain blood glucose levels.
• Breastmilk production begins 2-3 days after birth.
• Breasts become full and engorgement occurs.
• Nursing actions include:
  • Assessing breasts at least once a shift whether breast or bottle feeding.
  • Breasts should be soft and nontender for the first 2 days.
  • Have the client wash with warm water and avoid soap.
  • Wear a supportive bra.
  • Encourage early feedings.
  • Assist with positioning and latch as needed.
  • Assess for firmness, redness, tenderness, and cracked nipples.
• For nonbreastfeeding mothers:
  • Wear a supportive bra to help suppress lactation
  • Avoid any type of nipple stimulation
  • Use an ice pack for 15-20 minutes every 1-2 hours as needed.
  • Engorgement resolves spontaneously, and discomfort decreases within 24 to 36 hours.
  • Ovulation occurs as early as 27 days after birth.

Cardiovascular System

• Diaphoresis and diuresis occur with Homan's sign.
• Average blood loss is 200-500 ml.
• Pregnancy-induced hypervolemia allows most women to tolerate blood loss during childbirth.
• Hematocrit level should remain stable and an acute decrease may indicate hemorrhage.
• Pulse rate and blood pressure:
  • Orthostatic hypotension is possible.
  • Decrease in BP assess for infection, hemorrhage
  • Increase in BP with headache assess for preeclampsia
• Coagulation factors remain elevated for 2 to 3 weeks postpartum.
• Nursing actions are required.

Respiratory System

• The respiratory system returns to its pre-pregnancy state.
• Assess lung sounds postpartum.
• Nursing actions are required.

Musculoskeletal System

• Pelvic ligaments and joints relax during pregnancy due to the hormone relaxin.
• During pregnancy, the growing uterus stretches the abdominal muscles.
  • Assess for diastasis recti abdominis, which develops late in pregnancy and is identified after delivery.
• Relieve muscle soreness after delivery.
• Back pain usually resolves a few weeks after birth.
• Promote rest and sleep.
• There may be a permanent increase in shoe size.

Integumentary System

• Chloasma of pregnancy usually disappears at the end of pregnancy.
  • But it persists in 30% of women.
• Hyperpigmentation of areolae and linea nigra may not regress completely after childbirth.
  • Some women will have permanent darker pigmentation of those areas.
• Stretch marks on breasts, abdomen, and thighs may fade, but not disappear.

Immune System

• It is mildly suppressed during pregnancy, but the immune system returns to its prepregnant state.
• Common mild temperature elevations occur in the first 24 hours.
  • Temperatures greater than 38 C (100.4F) after 24 hours requires further assessment.
• Rebound of the immune system can cause “flare-ups” of some conditions, such as Lupus erythematosus and Multiple sclerosis.
• For Rubella: if nonimmune, with a titer less than 1:8, order for the Rubella vaccine.
  • Educate the patient not to get pregnant for 1 month.
• Potential vaccinations: Tdap(Tetanus, diphtheria, and pertussis), hep B, varicella and influenza.
• For Rh-negative women with an Rh-positive infant:
  • Administer Rho(D) immune globulin (Rhogam) within 72 hours post-delivery.

Postpartum Care After Cesarean Section

• The nursing care is the same as for a vaginal birth.
• Include additional assessments and interventions similar to a client with abdominal surgery.
  • Assist with turning and coughing with deep breaths
  • Look for approximation
  • Instruct the patient to splint the incision.
  • Encourage early ambulation, as ordered.
  • Sequential compression devices may be ordered.
  • Instruct the patient to notify the provider if the incision separates, is red, has drainage, or bleeding.
  • Avoid any heavy lifting other than the newborn.
  • Administer pain medication as prescribed.

Postpartum Assessment

• Warning signs to assess include:
  • Fever >100.4 F (38C)
  • Foul smelling lochia and/or change
  • Large clots, or bleeding that saturates a pad within one hour
  • Calf pain
  • Swelling or redness in perineum
  • Severe headache or blurred vision
  • Change in respiratory status
  • Urinary changes
  • Change in mood

Supporting Parents Who Have a Child Born With a Disability

• When parents learn that a child may have a birth defect, the experience during pregnancy changes from hopeful anticipation to fear, creating stress for the parents.
• Parents who discover birth defects during pregnancy can develop more effective coping strategies than parents who discover the diagnosis months later.
• After diagnosis, a multidisciplinary approach to care is needed. Including, physicians, geneticists, nurses, pharmacists, nutritionists, social workers, and occupational therapists.

Plan for Discharge

• The length of stay is dependent upon:
  • Physical condition
  • Mental and emotional status
  • Social support
  • Educational needs
  • Financial constraints
• Care management: Psychosocial needs.
  • Effect of birth experience & maternal self image
  • Adaptation to parenthood and parent-infant interactions
  • Comprehensive assessment for depression screening within 4 to 6 weeks.
• Many women do not have postpartum follow-up.
• Discharge teaching topics are essential.