Postpartum Period and Uterine Involution

Postpartum Adaptations

• This is a critical transition period for the woman, newborn, and family, both physiologically and psychologically.
• Puerperium refers to the period after delivery of the placenta, lasting for 6 weeks.

Reproductive System Adaptations: Uterus

• Uterus returns to its normal size over approximately 6 weeks due to involution, a retrogressive process involving:
  • Contraction of muscle fibers
  • Catabolism
  • Regeneration of uterine epithelium
• Subinvolution, where the uterus fails to return to its previous healthy state, indicates a potential underlying issue.
• Factors facilitating involution:
  • Complete expulsion of amniotic membranes and placenta
  • Complication-free labor and delivery (L&D)
  • Breastfeeding
  • Early ambulation
• Factors inhibiting involution:
  • Prolonged labor and delivery
  • Incomplete expulsion of amniotic membranes and placenta
  • Uterine infection
  • Overdistension of uterine muscles
  • Full bladder
  • Anesthesia relaxing uterine muscles
  • Close childbirth spacing
• Overdistension can result from polyhydramnios (excess amniotic fluid) seen in women with gestational diabetes, or with twins
• After giving birth, patients are at high risk of falls due to orthostatic hypotension, so ambulation should be assisted
• Close childbirth spacing, or having babies too quickly in succession without allowing the body to recover, inhibits involution
• Before discharge, ensure the uterus is contracted and has returned to its pre-pregnancy state to prevent hemorrhage.
• The uterus should be located below the belly button.

Lochia

• Lochia is the vaginal discharge after birth resulting from involution.
• A foul odor may indicate infection.
• C-sections typically result in less bleeding because uterine debris is manually removed.
• Lochia is typically present for at least 3 weeks postpartum but can persist for up to 6 weeks.

Three Stages of Lochia

• Lochia Rubra:
  • Occurs 3-4 days after birth
  • A deep-red mixture of mucus, tissue debris, and blood that transitions to a paler, more serous consistency.
• Lochia Serosa:
  • Occurs 3 -20 days postpartum
  • Pinkish brown in color
  • Contains leukocytes, decidua tissue, RBCs, and serous fluid.
• Lochia Alba:
  • Occurs 10-14 days postpartum and can last 3-6 weeks
  • Creamy white or light brown discharge
  • Consists of leukocytes, decidual tissue, and reduced fluid content.
• Danger Signs:
  • Clots
  • Bright red bleeding after lochia rubra has stopped, indicating potential postpartum hemorrhage.

Other Postpartum Changes

• Afterpains facilitate uterine involution.
• The cervix closes by 6 weeks, resulting in a jagged, slit-like opening.
• The vagina gradually thickens with the return of rugae in approximately 3 weeks.
• Ovarian function returns, and estrogen production resumes.
• The perineum is typically edematous and bruised.
• Complete healing after episiotomy or laceration may take 4-6 months without complications.

Cardiac System

• Blood volume decreases but cardiac output remains high for the first few days, then decreases.
• Pulse rate decreases to 40-60 bpm during the first two weeks, followed by a blood pressure decrease in the first 2 days, then an increase to pre-pregnancy values.
• Hemoglobin levels drop, but hematocrit levels remain relatively stable.
• Coagulation factors increase as a response to the trauma of birth, highlighting the importance of ambulation to prevent clot formation.
• Red blood cell production resumes.
• Increased pulse with a drop in blood pressure could indicate shock and warrants checking vital signs (VS).

Urinary System

• Glomerular filtration rate (GFR) and renal plasma flow increase and return to normal by 6 weeks postpartum.
• Voiding sensation may be affected by:
  • Medications, such as anesthetic blocks and oxytocin.
  • Perineal lacerations.
  • Generalized swelling and bruising of the perineum and tissues surrounding the urinary meatus.
  • Hematomas.
  • Decreased bladder tone due to regional anesthesia.
• Other changes include diuresis (profuse sweating) and urinary retention, which can cause subinvolution.

Postpartum Diuresis

• The causes are:
  • Large amounts of intravenous fluids administered during labor
  • Declining antidiuretic effects of oxytocin
  • Buildup and retention of extra fluids during pregnancy
  • Decreased production of aldosterone, which decreases sodium retention and increases urine production

GI System

• Normal function typically returns within a month postpartum.
• Ambulation supports involution and promotes mother-baby care, which can prevent clots and/or deep vein thrombosis (DVT).
• Decreased peristalsis occurs.
  • Constipation is common due to fear of straining the perineum.
  • Hunger and thirst are common due to NPO status during labor and delivery.
  • Increase fluid intake and follow a better diet overall.

Musculoskeletal System

• Joints return to the pre-pregnant state, except for the feet, commonly experiencing edema.
• Fatigue and activity intolerance persists for weeks after birth.
• Diastasis recti: Loss of muscle tone with separation of the rectus abdominis muscle.

Integumentary System

• Pigmentation fades.
• Hair loss may occur in the first 3 months until estrogen levels normalize, but is usually temporary.
• Stretch marks fade to silvery lines.
• Diaphoresis, or profuse sweating, is common for about a week postpartum.

Respiratory System

• Respiratory rate typically remains within the normal range.
• The diaphragm returns to its usual position.
• Relief from shortness of breath (SOB) and rib aching after delivery.

Endocrine System

• Placental hormones decline rapidly.
  • Estrogen and progesterone levels drop quickly.
  • Prolactin levels remain elevated for breastfeeding mothers, but decline within 2 weeks if you are not breastfeeding
• The first menstrual cycle is typically anovulatory.
• Nonlactating mothers resume their cycle in 7-9 weeks postpartum.

Lactation

• Lactation refers to the secretion of milk by the breasts resulting from the interaction of progesterone, estrogen, prolactin, and oxytocin.
• Milk "comes in" 4 to 5 days after childbirth.
• The "breast crawl" process assists with early breastfeeding.

Engorgement

• Engorgement, or swelling of the breast tissue, typically presents with the breasts being swollen, hard, and tender to the touch.
  • If breastfeeding:
    • Frequent emptying, warm showers and compresses before feeding increases vasodilation in the alveoli to better facilitate emptying
    • Cold compresses between feedings can vasoconstrict to reduce soreness.
    • The breast must typically be stimulated by a nursing infant, breast pump, or manual expression of milk in order to maintain milk supply
• Breastfeeding individuals should avoid tight supportive bars, and use ice for 15–20 minutes every other hour to avoid breast stimulation

Ovulation & Return of Menstruation

• The interplay of estrogen, progesterone, prolactin, and oxytocin impacts timing.
  • Nonlactating women will return to menstruation 7-9 weeks after birth.
  • Lactating women: Return is dependent on the frequency and duration of breastfeeding and may range from 2 to 18 months.

Self-Care Measures

• Afterpains, caused by prostaglandins in the uterus, are often stronger during breastfeeding because oxytocin release strengthens the contractions. Mild analgesics, such as Motrin, can reduce this discomfort.
• Perineal muscle tone can be maintained or restored with Kegel exercises to avoid urinary incontinence later in life.
• Replenish body fluids and consume fiber to combat constipation.
• If rectus muscle tone is not regained through exercise, support may not be adequate during future pregnancies.

Maternal Psychological Adaptations

• Attachment is the formation of a relationship between parent and newborn via physical and emotional interactions.
• Early and sustained contact between newborns and parents is vital, such as kangaroo care (skin-to-skin).
• Nurses play a crucial role in assisting this process.
• Influencing factors include environmental circumstances, newborn health, and quality of nursing care.

Phases of Maternal Adaptation to Parenthood (Reva Rubin)

• Taking-in phase:
  • Immediate time after birth when the client needs sleep seeks dependency on others and relives events of birth (lasts 1-2 days).
• Taking-hold phase:
  • Dependent and independent maternal behavior (starts 2-3 days, lasts several weeks).
• Letting-go phase:
  • Woman reestablishes relationships with others and accepts reality, gaining a new sense of self as a mother (occurs later in the postpartum period).

Engrossment: Partner Psychological Adaptation

• Visual awareness of the newborn.
• Tactile awareness of the newborn.
• Perception of the newborn as perfect.
• Strong attraction to the newborn.
• Awareness of distinct features of the newborn.
• Extreme elation.
• Increased sense of self-esteem.

Three-Stage Role Development Process

• Expectations:
  • Preconceptions about life with a newborn - can be eye-opening and dramatic.
• Reality:
  • Occurs when expectations don’t align with reality.
• Transition to Mastery:
  • Partner makes a conscious decision to take control and be central to the newborn's life, regardless of preparedness.

Nursing Management During the Postpartum Period: Typical Assessments

• The frequency of postpartum assessments:
  • Every 15 minutes during the first hour.
  • Every 30 minutes during the second hour.
  • Every 4 hours during the first 24 hours.
  • Every 8 hours after 24 hour
• Vital Signs Assessment:
  • Temperature: Slight elevation during the first 24 hours is normal, followed by a return to normal.
  • Pulse: 40 to 80 bpm, or puerperal bradycardia.
  • Respirations: 16 to 20 breaths per minute.
  • Blood Pressure: Should remain within the usual range.
  • Pain: Goal between 0 and 2 on pain scale.
• Assessing the patient helps ensure that there is no hemorrhage and that natural involution is happening.

Factors Increasing Risks for Postpartum Complications

• Postpartum infection:
  • Operative Procedures (forceps, cesarean birth, vacuum extraction)
  • History of diabetes, including GDM
  • 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 (more than 24 hours)
  • Manual extraction of the placenta
  • Immunocompromised system (HIV-positive)
• Postpartum Infections:
  • Ppl who are diabetic should be watched closely for signs of infection at higher risk.
• 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 overdistension (large infant, twins, hydramnios)
  • Obesity
• Term Definitions:
• Precipitous labor » stressful on reproductive organs (uterus contracting down pushing baby out can cause internal damage as its being forced out)
• Uterine atony » soft/boggy uterus that cannot contract
• Placenta previa >> when the placenta is attachment to an area off the uterus that is right on top of the cervix
• Abruptio placenta » when the placenta becomes detached

Postpartum Danger Signs

• Fever > 100.4°F (38°C)
• Foul-smelling lochia or an unexpected change in color or amount.
• Large blood clots or bleeding that saturates a peripad in an hour.
• Severe headaches or blurred vision that do not go away
• Visual changes such as blurred vision or spots
• Calf pain with dorsiflexion of the foot.
• Sudden weight gain.
• Feeling faint, dizzy, or weak.
• Rapid heart rate.
• Swelling, redness, or discharge at the episiotomy, epidural, or abdominal sites.
• Dysuria, burning, or incomplete emptying of the bladder.
• Shortness of breath or difficulty breathing without exertion.
• Depression or extreme mood swings.
• Do a fundal check if the first peri pad is fully saturated bloody ahhh to see where the fundus is (with either be boggy (stuck chunk of placenta) or displaced due to a full bladder)
• Calf pain with dorsiflexion of the foot warrants immediately calling the Health Care Provider
• Sudden weight gain may indicate edema, CHF, or preeclampsia
• Shortness of breath (SOB) or difficulty is also indicative of pulmonary embolism

Physical Assessment Postpartum Period

• Perform a Physical Assessment: "BUBBLE-EE";
  • Breasts (size, contour, engorgement)
  • Uterus (height of fundus, firmness, should be below the belly button)
  • Bladder (voiding, bladder emptying)
  • Bowels (bowel sounds, distention) (no food until bowel sounds are heard in all quadrants espc for c-sec's)
  • Lochia (amt, color, odor)
  • Episiotomy and perineum (lacerations, hematoma)
  • Extremities
  • Emotional status (no bonding or mother's response to baby's crying raises a red flag)
• Breasts:
  • Check the nipples for cracks, redness, or bleeding.
  • Palpate the breasts lightly doc findings on if they are soft, filling, or engorged &
  • Use gentle, light touch to avoid breast stimulation since it could exacerbate engorgement
  • Nursing Interventions:
    • In breastfeeding women, encourage frequent feedings at least every 2-3 hrs
    • Encourage bottle feeding women to use ice packs, wear supportive bra 24 hrs a day, and that they take mild analgesics(acetaminophen)to avoid stimulation to breasts that might foster milk prod (ex: warm showers or pumping massaging the breasts)
• Uterus:
  • Determine the degrees of uterine involution (can cause it is being turned inside out » causing one bleed to death)
• Always use two handed approach to stabilize & prevent uterine inversion for a fundal massage
  • Fundus should be midline & should feel firm
  • 1 to 2 hrs after birth, the fundus it is typically between the umbilicus and symphysis pubis
  • 6 to 12 hrs after birth the fundus lies at, at the lvl of the umbilicus
  • Fundus progresses downward @ a rate of one fingerbreadth (1cm) per day after childbirth (U-1).
• Bladder:
  • Assess the bladder for distention (hemorrhage) and adequate empting)
  • Palpate the area over the symphysis
  • NURSE has to be the one there when the pt first ambulates from delivering
  • A full bladder tends to displace the uterus up and to the right
• Bowels:
  • Inspect abdomen for distention, auscultate for bowel sounds in all 4 quadrant's and palpate for tenderness
  • Bowel sounds should be present in all 4 quad's » ask woman if she has had a bowel movement/has since giving birth
  • Constipation » common + stool softener is routinely given
• Lochia:
  • Should be excellent medium for bacterial growth
  • Is examined at various levels:
    • Scant (typically seen w c-sec's) » 1-2 inch
    • Light/small >> approx 4 inch
    • Moderate (typically seen espc on the 1st day) → 4-6 inch
    • Large/heavy (pt is being monitored) » pad is saturated within 1 hr
• Episiotomy and perineum:
  • Assess episiotomy & any lacerations
  • Assess perineum for...:
    • Hemorrhoids & their conditions
    • Hematomas (complaining of pressure/bluish plum like mass filled w fluid) (apply ice pack + call HCP)
• Majority of healing takes place within first 2 wks but can take 4 to 6 months for the episiotomy to heal completely
• Classifications of Lacerations:
  • First degree >> involves only skin & superficial structures above muscle
  • Second degree » extends through perineal muscles (needs to be repaired)
  • Third degree » extends through the anal sphincter muscle
  • Fourth degree » continues through anterior rectal wall
• If Epidural:
  • A white line along the length of the episiotomy is a sign of infection, as is swelling or discharge (could be lack of O2 to the site)
  • Severe, pain, perineal discoloration, & ecchymosis indicate a perineal hematoma
  • Assess wound site + side effects of medications such as itching, N&V, or urinary retention
  • Visual inspection of the epidural site + accurate documentation of intake + output is essential
  • If the woman is experiencing hypercoagulability then note that (during pregnancy) (protects the mother against excessive blood loss during childbirth & placental separation).

Factors Predisposing Women to Thromboembolic Disorders During Pregnancy

• Stasis
• Altered coagulation (state of pregnancy).
• Localized vascular damage (may occur during the birthing process).

Risk Factors for PE

• Anemia, DM, smoking, obesity, PIH, HTN, severe varicose veins, Pregnancy, OCs, C/S, severe infection, hx thromboembolic disease multiparity, Bed rest/immobility >4 days, or the individual is of the AMA
• Report lower extremity tightness/aching when ambulating that is relieved w rest & elevation of the leg
  • DVT >> unilateral
  • Edema → bilateral
• Women with an increased risk should wear anti embolic stockings/sequential compression devices. Emotional Status
• Examine individuals interactions with family and infant, their LvL of independency, an their contact with the infant (assessing posture, comfort eye contact. One should be keenly watching for their levels of sleep, rest patterns, and energy, all the possible mood swings that may occur.
• Bonding:
  • Is the close emotional attraction to a newborn by the parents that develops the first 30-60 min from birth
  • Typically unidirectional from parent to infant

Maternal Nutrition for Breastfeeding

• Breastfeeding woman need a higher nutritional diet from when they were pregnant the diet. Factors that influence quantity and quality of breastmilk ~Calories: +500 cal/day ~Protein: >20 g/day ~Daily calcium 400 mg Increase the fluid by 2-3 quarts (milk/water)
• Teaching Topics for Post-partum period:
• Pain and discomfort
• Immunizations
• Follow through, especially when it comes to follow up.
• If any labor is to occur be sure it is approved by the OBGYN

Thromboembolic Conditions

Postpartum Infections

• Have a higher occurrence is Caesarean section and NSVD

• Fever 100.04 Fahrenheit after the first 24 hours

• therapeutic Management

  • Broad-spectrum antibiotics(metritis)
  • Wound care
  • Fluid-antibitoics
  • Breast emptying

• Factors influencing infection: Premature raptures. Caesarean sections. Instrument and increase chance of having bacteria

• Assessments: What risk factors is the patient experiencing

"REEDA Assessment": Examines the presence of redness, echymosis, Edima and Approximation. Always perform this when assessing postpartum

Explore the postpartum period, uterine involution, and potential complications. Understand the key processes involved in the uterus returning to its pre-pregnant size. Learn about catabolism and regeneration of the uterine epithelium.