Postpartum Period: Physiological Changes

• The postpartum period, also known as the puerperium, typically lasts for six weeks after childbirth

Physiological Changes in the Postpartum Period

• Involution is the process where the uterus returns to its pre-pregnant size, shape, and location, and the placental site heals
• Uterine contractions, breastfeeding, and uterine massage facilitate involution
• Lochia is the vaginal discharge after birth, consisting of blood, tissue, and mucus; it progresses from lochia rubra (red) to lochia serosa (pinkish-brown) to lochia alba (yellowish-white)
• Afterpains, or postpartum uterine contractions, are more common in multiparas and breastfeeding mothers
• Cervical changes include a gradual closing, but the external os never returns to its pre-pregnant, nulliparous shape
• Vaginal dryness and discomfort are common initially, with gradual restoration of vaginal tone
• Ovulation can occur as early as 27 days after birth in non-lactating women; breastfeeding delays ovulation
• Blood volume and cardiac output decline after birth; diuresis helps reduce extracellular fluid
• White blood cell count increases during labor and immediate postpartum, returning to normal within a week
• Hemoglobin and hematocrit levels can fluctuate; a significant drop may indicate hemorrhage
• Coagulation factors remain elevated, increasing the risk of thromboembolism
• Gastrointestinal motility decreases, leading to constipation; stool softeners may be needed
• Urinary retention can occur due to decreased bladder tone and effects of anesthesia
• Weight loss occurs due to blood loss, diuresis, and decreased fluid volume
• Hormonal changes include a rapid decrease in estrogen and progesterone; prolactin levels increase with breastfeeding
• Skin changes, such as melasma and linea nigra, gradually fade
• Postpartum chill is common immediately after birth due to hormonal and metabolic changes
• Postpartum diaphoresis, or profuse sweating, helps eliminate excess fluid

Psychological Adaptations

• Maternal role attainment is the process where a woman learns and integrates the mothering role
• Rubin's phases of maternal adaptation include the taking-in phase, taking-hold phase, and letting-go phase
• The taking-in phase is characterized by the mother's focus on her own needs and recounting her labor experience
• The taking-hold phase involves the mother becoming more independent and interested in caring for her baby
• The letting-go phase is when the mother adjusts to her new role and separates herself from the fantasy of her ideal birth experience
• Becoming a mother involves commitment, attachment to the infant, and preparation for role changes
• Factors influencing maternal role attainment include infant temperament, partner support, and cultural practices
• Postpartum blues are common, characterized by mild depression, tearfulness, and anxiety, typically resolving within a few weeks
• Postpartum depression is a more severe mood disorder requiring professional treatment

Nursing Assessment in the Postpartum Period

• BUBBLE-HE is a common mnemonic for postpartum assessment: Breasts, Uterus, Bowel, Bladder, Lochia, Episiotomy/Laceration, Homan's sign/Extremities, Emotional status
• Assess breasts for engorgement, tenderness, and nipple condition
• Palpate the uterus for fundal height, location, and firmness; massage if boggy
• Assess bowel sounds and bowel movements; inquire about flatus
• Evaluate bladder function and urinary output; assess for distention
• Assess lochia for amount, color, odor, and presence of clots
• Inspect the perineum for episiotomy or laceration healing, edema, and hematoma
• Assess lower extremities for signs of thrombophlebitis, such as warmth, redness, and pain and edema
• Evaluate the mother's emotional status, coping mechanisms, and support system

Nursing Interventions in the Postpartum Period

• Promote comfort with pain management techniques, such as ice packs, sitz baths, and analgesics
• Encourage early ambulation to prevent complications like thrombophlebitis
• Provide education on postpartum self-care, including hygiene, nutrition, and rest
• Encourage breastfeeding or formula feeding based on the mother's choice
• Administer medications as prescribed, such as pain relievers, stool softeners, and Rh immune globulin
• Monitor for complications, such as hemorrhage, infection, and thromboembolism
• Provide emotional support and encouragement to the mother and her family
• Facilitate bonding between the mother and her baby
• Teach infant care skills, such as bathing, diapering, and feeding
• Provide information on postpartum depression and resources for help
• Ensure appropriate follow-up care and referrals as needed
• Promote adequate nutrition and hydration
• Encourage rest and sleep to aid recovery

Postpartum Complications

• Postpartum hemorrhage is defined as blood loss greater than 500 mL after vaginal birth or 1000 mL after cesarean birth
• Causes of postpartum hemorrhage include uterine atony, retained placental fragments, lacerations, and coagulation disorders
• Uterine atony is the most common cause of postpartum hemorrhage, characterized by a boggy uterus that does not contract effectively
• Management of postpartum hemorrhage includes uterine massage, medications (oxytocin, misoprostol, methylergonovine, carboprost), and possibly blood transfusion or surgery
• Postpartum infection can include endometritis, wound infections, mastitis, and urinary tract infections
• Risk factors for postpartum infection include cesarean birth, prolonged labor, and compromised immune system
• Signs and symptoms of postpartum infection include fever, chills, abdominal pain, and foul-smelling lochia
• Treatment of postpartum infection includes antibiotics, wound care, and supportive measures
• Thromboembolic disorders, such as deep vein thrombosis and pulmonary embolism, are more common in the postpartum period
• Risk factors for thromboembolic disorders include hypercoagulability, venous stasis, and vessel injury
• Signs and symptoms of thromboembolic disorders include leg pain, swelling, shortness of breath, and chest pain
• Treatment of thromboembolic disorders includes anticoagulants and supportive measures
• Postpartum depression is a mood disorder that can occur after childbirth, characterized by persistent sadness, anxiety, and fatigue
• Risk factors for postpartum depression include previous history of depression, lack of social support, and stressful life events
• Treatment of postpartum depression includes therapy, medication, and support groups
• Postpartum psychosis is a rare but severe mental illness characterized by hallucinations, delusions, and disorganized thinking
• Treatment of postpartum psychosis requires immediate psychiatric intervention and hospitalization

Newborn Assessment

• Initial newborn assessment includes vital signs, gestational age assessment, and physical examination
• Apgar score is assessed at 1 and 5 minutes after birth to evaluate the newborn's overall condition
• Normal newborn vital signs include heart rate (110-160 bpm), respiratory rate (30-60 breaths per minute), and temperature (36.5-37.5°C)
• Gestational age assessment estimates the newborn's maturity based on physical and neurological characteristics
• Physical examination includes assessment of skin, head, eyes, ears, nose, mouth, chest, abdomen, and extremities
• Common newborn reflexes include Moro, rooting, sucking, and grasping reflexes

Newborn Care

• Maintaining a clear airway is a primary nursing intervention
• Thermoregulation is essential to prevent cold stress; methods include drying the newborn, using a radiant warmer, and skin-to-skin contact
• Vitamin K is administered to prevent bleeding
• Eye prophylaxis is administered to prevent ophthalmia neonatorum
• Newborn feeding can be breastfeeding or formula feeding; education on techniques and frequency is essential
• Cord care involves keeping the umbilical cord clean and dry
• Circumcision care involves monitoring for bleeding and infection
• Newborn screening tests are performed to detect metabolic and genetic disorders
• Hepatitis B vaccine is typically administered before discharge
• Education on newborn care, safety, and follow-up appointments is provided to parents

Common Newborn Problems

• Jaundice is a common condition caused by elevated bilirubin levels; treatment includes phototherapy
• Hypoglycemia is low blood sugar; treatment includes feeding or IV glucose
• Respiratory distress syndrome is a common problem in premature infants; treatment includes oxygen and respiratory support
• Infections can occur in newborns; prevention includes handwashing and early treatment
• Congenital anomalies may be present at birth; management depends on the specific anomaly

Discharge Teaching

• Provide instructions on postpartum self-care, newborn care, and feeding
• Discuss potential complications and when to seek medical attention
• Ensure follow-up appointments are scheduled for both mother and newborn
• Provide information on support groups and resources for new parents
• Review safe sleep practices to prevent sudden infant death syndrome (SIDS)
• Discuss contraception and family planning options
• Emphasize the importance of nutrition, rest, and emotional well-being for the mother