Postpartum Period: Reproductive System Adaptations

Postpartum Period

• Postpartum period is the interval between birth and the return of reproductive organs to their nonpregnant state.
• This period represents a critical transition for the woman, newborn, and family, both physiologically and psychologically.
• Puerperium refers to the 6-week period after the delivery of the placenta.
• The postpartum period involves changes in all aspects of a mother's life during the first year after the child's birth.
• During this time, the mother and family adjust to the new family member.

Reproductive System Adaptations

• Hemorrhage is a major concern.
• Uterine involution, or the return of the uterus to its pre-pregnancy size, is assisted by oxytocin.
• The fundus is at the level of the umbilicus in the midline for the first few hours. Approximately 12 hours postpartum, the uterus will be midline.
• The fundal position, tone, and location should be assessed.
• The uterus decreases 1 to 2 cm per day (U-1, U-2).
• The tone of the uterus should be firm.
• The uterus returns to a nonpregnant state by 6 weeks.
• After birth hemostasis is achieved by compression of intramyometrial blood vessels as uterine muscle contracts.
• The hormone oxytocin, released from the pituitary gland, strengthens and coordinates these uterine contractions.
• Lochia refers to the postbirth uterine discharge, assess for color, amount and odor.
• Lochia rubra is deep red and consists of blood, decidual, and trophoblastic debris, and lasts for 3 to 4 days.
• Lochia serosa is pinkish brown and lasts for 3-10 days.
• Lochia alba is white, occurs 10-14 days, and may last for 2-6 weeks in some women.
• Frequent assessment of the vagina and perineum is required.
• Assess the perineum for signs of infection, including: intactness, pain, edema, erythema, ecchymosis, hematoma, hemorrhoids, and discharge.
• Tearing of the perineal tissue during birth, known as laceration, may require repair using the REEDA scale.
• An episiotomy is an incision in the perineum to enlarge the vaginal outlet and assist with the second stage of labor, that may take 4-6 weeks to heal completely.
• Hemorrhoids, which are anal varicosities, are common and usually decrease within 6 weeks of childbirth.
• Witch hazel can help hemorrhoids.
• Nursing assessments and actions should occur at least every 8 hours.
• Teach perineal care to prevent infection.
• Ice is a comfort measure for the first 24 hours.
• There may be an order for a sitz bath after 24 hours.
• Kegel exercises encourage healing and provide pelvic muscular support.
• Subinvolution is the failure of the uterus to return to its nonpregnant state.
• Subinvolution requires quick diagnosis and interventions.
• Potential causes of subinvolution include retained placental fragments, infection, prolonged labor, difficult birth, overdistention of uterine muscles, and bladder distention.
• Signs and symptoms of subinvolution include a boggy uterus, uterine atony, and heavy lochia, increased risk for bleeding.
• Interventions include massaging the fundus and noting consistency, assessing the amount of lochia, and weighing pads (1g equals 1 mL of fluid).
• Obtain an order for oxytocin to be administered intravenously.

Endocrine System

• Expulsion of the placenta results in dramatic decreases of placental-produced hormones.
• Estrogen and progesterone levels decrease.
• Diuresis and diaphoresis, increased in urine production, occur.
• Menstruation usually returns at 7-9 weeks postpartum.
• Ovulation and menstruation are usually prolonged in lactating women.
• Nursing actions are required.
• Patient education is important.

Urinary System

• Urinary output increases in the first 12 to 24 hours due to postpartum diuresis.
• Profuse diaphoresis often occurs at night for the first 2-3 days.
• Review the labor and delivery record for risk factors.
• Assess the client's normal sensation to void, discomfort, or difficulty voiding.
• Assess for bladder distention and signs of urinary retention.
• Excessive bleeding can occur due to displacement of the uterus if the bladder is full.
• An epidural can lead to urinary retention.
• Assess for side effects of epidural medication: nausea, vomiting, and urinary retention.
• Epidural effects may be asymptomatic-retention with overflow.

Gastrointestinal System

• Most new mothers are hungry after recovery.
• Constipation and hemorrhoids are common due to decreased progesterone levels.
• Spontaneous bowel evacuation may not occur for 2 to 3 days postpartum.
• Fluids and food should be encouraged.
• Food preferences vary across cultures.
• Nursing assessment and actions are important.

Breasts

• Lactating and nonlactating women differ in the timing of their first ovulation and menstruation.
• Lactation is the secretion of milk by the breasts.
• Prolactin from the anterior pituitary gland triggers the secretion of milk after birth.
• Prolactin, progesterone, and estrogen are key hormones in lactation.
• Secretion of colostrum, a thin, yellowish fluid that helps maintain blood glucose levels, occurs for 2-3 days.
• Breastmilk production begins 2-3 days after birth.
• Breasts become full, and engorgement occurs.
• Assess breasts at least once a shift to determine feeding method of breast or bottle.
• Breasts should be soft and nontender for the first 2 days.
• Clients should wash with warm water and avoid soap.
• Encourage early feedings.
• Assist with positioning and latch as needed.
• Assess for firmness, redness, tenderness, and cracked nipples.
• Nonbreastfeeding mothers should wear a supportive bra to help suppress lactation.
• Nipple stimulation should be avoided.
• 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

• Diaphoresis and diuresis occur.
• Blood volume and cardiac output are important to monitor lung sounds.
• The average blood loss is 200-500 ml.
• Pregnancy-induced hypervolemia allows most women to tolerate blood loss during childbirth.
• The hematocrit level should remain stable.
• A marked decrease may indicate hemorrhage.
• Assess/monitor the pulse rate and blood pressure.
• Assess for orthostatic hypotension.
• Decreases in BP should be assessed for infection or hemorrhage.
• Increased BP with headache should be assessed for preeclampsia with the potential of blurred vision.
• Coagulation factors remain elevated for 2 to 3 weeks postpartum.
• Nursing actions are required.

Respiratory System

• Returns to the 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.
• The growing uterus stretches the abdominal muscles during pregnancy.
• Assess for diastasis recti abdominis, occurs late in pregnancy and are identified after delivery.
• Muscle soreness should be relieved after delivery.
• Back pain usually resolves within a few weeks after birth.
• Rest and sleep should be promoted.
• There may be a permanent increase in shoe size.

Integumentary System

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

Immune System

• Mildly suppressed during pregnancy, the immune system returns to a prepregnant state.
• Common mild temperature elevations occur in the first 24 hours.
• A temperature greater than 38°C (100.4°F) 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.
• If nonimmune to Rubella with a titer less than 1:8, an order for the Rubella vaccine is needed.
• The patient should be educated 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.
• Rh-negative women with an Rh-positive infant need Rho(D) immune globulin (Rhogam) within 72 hours post-delivery.

Postpartum Care After Cesarean Section

• Nursing care is the same as vaginal birth, with additional assessments and interventions similar to clients with abdominal surgery.
• Look for approximation and/or edema.
• Assist the patient when turning and assist with deep breaths.
• Sequential compression devices may be needed.
• Instruct the patient to notify the provider if the incision separates, or experiences redness, drainage, or bleeding.
• Heavy lifting, other than the newborn, should be avoided.
• Pain medication is prescribed as needed.

Postpartum Assessment Warning Signs

• Fever greater than 100.4 F (38C)
• Foul-smelling lochia and/or change
• Passing large clots, or bleeding that saturates a pad within one hour
• Calf pain
• Swelling or redness in the perineum
• Severe headache or blurred vision indicates preeclampsia.
• Changes in respiratory status
• Urinary changes
• Change in mood, depression and "baby blues" is common.

Supporting Parents Who Have a Child Born With a Disability

• When parents learn that a child may have a birth defect, their experience during pregnancy changes from hopeful expectation to fear, which creates stress.
• 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, comprising physicians, geneticists, nurses, pharmacists, nutritionists, social workers, and occupational therapists.
• The language used to inform parents of their baby's diagnosis should be understandable, avoid using technical terms and ambiguous statements.
• It is important for nurses to remember the importance of congratulating the parents of their child and never approach the birth of a child by stating, "I'm sorry."

Planning for Discharge

• Length of stay is dependent upon the physical condition of the mother and newborn, mental and emotional status of the mother, social support at home, educational needs for self-management, and financial constraints.
• Care management includes attention to psychosocial needs, the effect of the birth experience as well as maternal self-image, adaptation to parenthood, and parent-infant interactions.
• Comprehensive assessment and depression screening should occur within 4 to 6 weeks.
• Many women do not have postpartum follow-up.
• The nurse will provide discharge teaching on a variety of topics.

Summary

• Physical and hormonal changes occur during the postpartum period.
• The postpartum period requires consistent and astute nursing assessment skills.
• Postoperative nursing care is important for women with cesarean births.
• Assess for warning signs that may occur during the postpartum period.
• Identify behaviors that enhance or inhibit the attachment process.
• Describe the critical elements of discharge teaching.
• Identify factors that influence women, partners, and families in their role transitions to parents.
• Identify the behaviors that enhance or inhibit the bonding and attachment process.
• Develop an awareness of cultural values and diversity in caring for the postpartum woman and her family.