Postpartum Period: Reproductive System Adaptations

Postpartum Period Overview:

• The postpartum period is the time between birth and the return of reproductive organs to their non-pregnant state.
• It is a critical transition for the woman, newborn, and family, both physiologically and psychologically.
• Puerperium is the period after delivery of the placenta, lasting about 6 weeks, or 42 days.
• The postpartum period encompasses changes in all aspects of the mother's life that occur during the first year after the birth of the child.
• Additionally, the mother and family adjust to the new family member.

Reproductive System Adaptations

• Uterine involution, or the shrinking of the uterus, is assisted by oxytocin.
• Major concern is hemorrhage.
• The fundus is at the umbilicus level for the first few hours after delivery, usually midline.
• The uterus typically decreases by 1 to 2 cm per day (U-1, U-2).
• Uterine tone should be firm, and the uterus returns to its nonpregnant state around 6 weeks.
• After birth, hemostasis is achieved through compression of intramyometrial blood vessels as uterine muscles contract.
• Oxytocin, released from the pituitary gland, strengthens and coordinates these uterine contractions.
• Lochia: Lochia is the postbirth uterine discharge and includes lochia rubra, serosa, and alba.
• Lochia requires assessment of color, amount, and odor.
• Lochia rubra is deep red, consisting blood, decidual, and trophoblastic debris, and lasts for 3 to 4 days.
• Lochia serosa is pinkish brown, lasting for 3-10 days
• Lochia alba is white lasting for 10-14 days
• Lochia alba can last for 2-6 weeks

Vagina and Perineum Considerations:

• The vagina and perineum require frequent assessment.
• Assess the perineum for signs of infection; intactness; pain, edema, erythema, ecchymosis, hematoma, hemorrhoids, and discharge.
• Tearing of perineal tissue occurs during birth and may require repair.
• Episiotomy involves incision in the perineum to enlarge the vaginal outlet to assist during the second stage of labor.
• Episiotomies may take 4-6 weeks to heal completely.
• Hemorrhoids, or anal varicosities, are common and often decrease within 6 weeks of childbirth
• Witch hazel pads can help provide moisture.
• Nursing assessments should occur at least every 8 hours.
• Perineal care and infection prevention should be taught
• Ice can be used for comfort for the first 24 hours.
• Sitz baths may be used after 24 hours.
• Teach Kegal exercises to encourage healing and pelvic muscle support

Subinvolution:

• Subinvolution is the failure of the uterus to return to its nonpregnant state.
• Requires quick diagnosis and intervention.
• Potential causes may include retained placental fragments, infection, prolonged labor, overdistention of uterine muscles, and bladder distention.
• Signs/symptoms include a boggy uterus, uterine atony, and heavy lochia.
• Interventions include massaging the fundus and noting its consistency, assessing the amount of lochia, and administering Oxytocin IV as ordered.
• Weigh pads where 1 g equals 1 mL of fluid.

Endocrine System after Birth:

• Expulsion of the placenta results in a dramatic decrease of placental-produced hormones.
• Estrogen and progesterone levels decrease.
• There can be diuresis and diaphoresis.
• Menstruation usually returns at 7-9 weeks, but ovulation and menstruation are usually prolonged in lactating women.

Urinary System Changes

• Urinary output increases in the first 12 to 24 hours due to postpartum diuresis.
• Profuse diaphoresis often occurs at night during the first 2-3 days.
• Assess client normal sensation to void, discomfort, or difficulty voiding.
• Assess for bladder distention and signs of urinary retention.
• Excessive bleeding can occur if the bladder is full and causes displacement of the uterus.
• With epidurals, assess for medication side effects like nausea, vomiting, and urinary retention.
• Retention may be asymptomatic with overflow.

Gastrointestinal System Changes:

• Most new mothers are hungry after recovery.
• Appetite changes are due to decreased progesterone levels.
• Constipation and hemorrhoids can occur.
• Spontaneous bowel evacuation may not occur for 2 to 3 days postpartum.
• It is important to encourage fluids and food, with awareness of food preferences across cultures.

Breast Changes

• 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 is increased due to triggers secretion of milk after birth.
• Prolactin, progesterone, and estrogen are involved.
• Secretion of colostrum occurs for 2-3 days, which is a thin, yellowish fluid that helps maintain blood glucose levels for the newborn.
• Breastmilk production begins 2-3 days after birth, and the breasts become full, leading to engorgement.
• Assess breasts at least once each shift to determine whether the patient is breastfeeding or bottle-feeding.
• With breastfeeding, breasts should be soft and non-tender for the first 2 days, and the client should wash with warm water and avoid soap, wearing a supportive bra.
• Encourage early feedings and assisting with positioning and latch as needed.
• Nurses should assess for firmness, redness, tenderness, and cracked nipples.
• With nonbreastfeeding mothers provide a supportive bra to help suppress lactation and to avoid any type of nipple stimulation.
• Ice packs can be used for 15-20 minutes every 1-2 hours as needed.
• Engorgement resolves spontaneously, and discomfort decreases within 24 to 36 hours.
• Ovulation can occur as early as 27 days after birth.

Cardiovascular System Alterations:

• Women experience diaphoresis and diuresis.
• Blood volume and cardiac output need to be monitored.
• Average blood loss is 200-500mL.
• Pregnancy-induced hypervolemia allows most women to tolerate blood loss during childbirth.
• Should remain stable, and an acute decrease may indicate hemorrhage.
• Pregnancy conditions can cause an elevated risk for preeclampsia with blured vision
• Coagulation factors remain elevated for 2 to 3 weeks postpartum.

Other Body Systems:

• The respiratory system returns to its pre-pregnancy state.
• Assess lung sounds postpartum.
• Pelvic ligaments and joints relax during pregnancy due to the hormone relaxin.
• The growing uterus stretches the abdominal muscles during pregnancy; assess for diastasis recti abdominis, which develops late in pregnancy and is identified after delivery.
• Relieve muscle soreness after delivery, and back pain usually resolves a few weeks after birth.
• Women should promote rest and sleep and note there may be a permanent increase in shoe size.
• Chloasma of pregnancy usually disappears at the end of pregnancy, though it persists in 30% of women.
• Hyperpigmentation of areolae and linea nigra may not regress completely after childbirth.
• Some women may have permanent darker pigmentation in those areas.
• Stretch marks on breasts, abdomen, and thighs may fade but not disappear.
• The immune system is mildly suppressed during pregnancy but returns to its prepregnant state.
• Common mild temperature elevations can occur in the first 24 hours.
• If the temperature is greater than 38°C (100.4°F) after 24 hours, further assessment is needed.
• Rebound of the immune system can cause "flare-ups" of some conditions, such as lupus erythematosus and multiple sclerosis.
• If the client is nonimmune, with a titer less than 1:8, order for Rubella vaccine.
• Educate the patient not to get pregnant for 1 month after receiving the Rubella vaccine.
• Potential vaccinations include Tdap (tetanus, diphtheria, and pertussis), hepatitis B, varicella, and influenza
• For Rh-negative women with Rh-positive infants, Rho(D) immune globulin (Rhogam) should be administered within 72 hours post-delivery.

Postpartum Care After Cesarean Birth:

• Nursing care is the same as for vaginal birth.
• Additional assessments and interventions are similar to those for clients with abdominal surgery such as checking for approximation and or edema.
• Assist patients with turning, coughing, and deep breaths.
• Instruct patients to splint the incision.
• Encourage early ambulation as ordered, and use sequential compression devices as ordered.
• Instruct patients to notify their provider if the incision separates, there is redness, drainage, or bleeding. Avoid any heavy lifting other than the newborn.
• Pain medication should be prescribed.

Postpartum Assessment:

• Potential warning signs to assess for during the postpartum period include:
• Fever greater than 100.4°F (38°C).
• Foul-smelling lochia and/or change.
• Large clots or bleeding that saturates a pad within one hour.
• Calf pain.
• Swelling or redness in the perineum.
• Severe headache or blurred vision.
• Changes in respiratory status.
• Urinary changes.
• Change in mood.

Supporting Parents with A Child Born With a Disability

• Parents with a child born with a disability experience changes during pregnancy
• Language used to inform parents needs to be accurate
• After diagnosis, a multidisciplinary approach to care is needed which may inlude Physicians, geneticists, Nurses, Pharmacists, Nutritionists, social workers, occupational therapists

Planning for Discharge:

• This depends on multiple things like
• Physical condition of the mother and newborn
• Mental and emotional status of the mother
• Social support at home
• Educational needs for self-management
• Financial constraints

Care Management:

• Comprehensive assessment and depression screening within 4-6 weeks
• Discharge teaching topics