Postpartum Period: Reproductive System Adaptations

Postpartum Period

• After birth, an interval occurs until the return of reproductive organs to their nonpregnant state
• It is a critical transition period for the woman, newborn, and family, on both a physiological and psychological level
• Puerperium lasts for 6 weeks: this is the period after the delivery of the placenta
• Postpartum includes changes in all aspects of the mother’s life during the first year following the birth
• It also involves the mother and family adjusting to a new family member

Reproductive System Adaptations

• Uterine involution, or the return of the uterus to its pre-pregnancy size, is assisted by oxytocin
• Fundal position should be midline at the level of the umbilicus for the first few hours after delivery: 12 hours postpartum the uterus should be midline
• Fundal Position will decrease 1-2 cm per day (U-1, U-2)
• Uterine tone should be firm
• The uterus returns to its nonpregnant state by 6 weeks
• Hemorrhage is always a concern

Uterus

• Contractions compress intramyometrial blood vessels to achieve hemostasis
• The hormone oxytocin, released by the pituitary gland, strengthens and coordinates uterine contractions
• Lochia refers to postbirth uterine discharge, where color, amount, and odor should be assessed
  • Lochia rubra is a deep red color that consists of blood, decidual, and trophoblastic debris, and typically lasts 3-4 days
  • Serosa is pinkish brown and lasts 3-10 days
  • Alba is white and lasts 10-14 days, but may last 2-6 weeks

Vagina and Perineum

• Requires frequent assessment postpartum
• Assess the perineum for signs of infection such as intactness, pain, edema, erythema, ecchymosis, hematoma, hemorrhoids, and discharge
• Laceration is the tearing of the perineal tissue during birth, and may require repair: REEDA scale
• Episiotomy is an incision in the perineum to enlarge the vaginal outlet and assist with the second stage of labor
  • It can usually heal completely within 4-6 weeks
• Hemorrhoids (anal varicosities) are common and decrease within 6 weeks of childbirth
• Ice and witch hazel can help with discomfort

Nursing Assessments

• Should be completed every 8 hours
• Assess the perineum and teach perineal care to prevent infection
• Promote comfort with ice for the first 24 hours
• Witch hazel pads helps provide moisture and keeps the area clean
• A sitz bath may be ordered after 24 hours
• Teach Kegel exercises to encourage healing and pelvic muscular support

Subinvolution

• This is the failure of the uterus to return to its nonpregnant state
• Requires quick diagnosis and interventions
• Potential causes include:
  • Retained placental fragments
  • Infection
  • Prolonged labor
  • Difficult birth
  • Overdistention of uterine muscles
  • Bladder distention
• Signs and symptoms include a boggy uterus, uterine atony, or heavy lochia
• Interventions include massing the fundus and noting consistency as well as assessing the amount of lochia: weighing pads 1g equals 1 mL of fluid
• Obtain order for Oxytocin to be administered IV as needed
• Retained placental fragments and infection can increase the risk of bleeding

Endocrine System

• Expulsion of placenta results in dramatic decreases of placental-produced hormones
• Estrogen and progesterone levels decrease
• Diuresis and diaphoresis, or increased urine production, occur
• Menstruation usually returns at 7-9 weeks in non-lactating women
• Ovulation and mestruation are usually prolonged in lactating women

Urinary System

• Urinary output increases during the first 12-24 hours due to postpartum diuresis
• Profuse diaphoresis often occurs during the night for the first 2-3 days
• Nursing assessments and actions include:
  • Reviewing the labor and delivery record for risk factors
  • Assessing the client's normal sensation to void, discomfort, or difficulty voiding
  • Assessing the bladder for distention and signs of urinary retention
  • Excessive bleeding may occur because of displacement of the uterus if the bladder is full, so the mother can distract with bubbles and relax as needed
• Epidural can lead to medication side effects like nausea, vomiting, or urinary retention
  • May be asymptomatic or cause retention with overflow

Gastrointestinal System

• Appetite increases in most new mothers after recovery, which is due to decreased progesterone levels
• Constipation and hemorrhoids may occur
• Spontaneous bowel evacuation may not occur for 2-3 days postpartum
• Encourage fluids and food in line with food preferences across cultures

Breasts and Breastfeeding

• Lactating and nonlactating women differ in timing of first ovulation and menstruation
• Lactation is the secretion of milk by the breasts
• Prolactin from the anterior pituitary gland, progesterone and estrogen are key
  • Increased prolactin levels triggers secretion of milk after birth
• Colostrum, thin yellowish fluid, is secreted for 2-3 days and helps maintain blood glucose levels
• Breastmilk production begins 2-3 days postpartum
• Breasts become full when engorgement occurs

Nursing Actions for Breasts

• Assess breasts at least once a shift to check whether the patient is breastfeeding or bottle feeding
  • Breasts should be soft and nontender for the first 2 days
  • Have 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
• Nonbreastfeeding mothers should:
  • Wear a supportive bra
  • Avoid any type of nipple stimulation
  • Use ice packs for 15-20 minutes every 1-2 hours as needed
  • Engorgement should resolve spontaneously, and discomfort decreases within 24-36 hours
• Ovulation can occur as early as 27 days after birth in nonbreastfeeding mothers

Cardiovascular System

• Diaphoresis and diuresis will likely occur
• Average blood loss is around 200-500 mL
• Pregnancy induced hypervolemia allows most women to tolerate blood loss during childbirth
• The hematocrit level should remain stable, and if it decreases it may indicate hemorrhage
• Assess lung sounds
• Check for Homan's sign
• Lung Sounds need to be checked
• Orthostatic hypotension can occur
• A decrease in BP should be assessed for infection or hemorrhage
• An increase in BP along with a headache should be assessed for preeclampsia
• Coagulation factors remain elevated for 2-3 weeks postpartum

Respiratory System

• It returns to its pre-pregnancy stage
• Assess lung sounds

Musculoskeletal System

• Pelvic ligaments and joints relax during pregnancy due to the hormone relaxin
• Growing uterus stretches the abdominal muscles
• Assess for diastasis recti abdominis, or the partial or complete separation of the rectus abdominis muscles
  • Develops late in pregnancy and is identified after delivery
• Relieve muscle soreness after delivery
• Back pain usually resolves a few weeks after birth
• Focus on promoting rest and sleep
• There may be a permanent increase in shoe size

Integumentary System

• Chloasma usually disappears at the end of pregnancy, although it can persist in 30% of women
• Hyperpigmentation of areolae and linea nigra may not regress completely
  • Some women will have permanent darker pigmentation of those areas
• Stretch marks may fade but not disappear

Immune System

• It is mildly suppressed during pregnancy but returns to its prepregnant state
• Common mild temperature elevations occur during the first 24 hours
  • Temperature greater than 38 degrees C (100.4 degrees F) after 24 hours needs further assessment
• Rebound of the immune system can cause flare-ups such as Lupus erythematosus or Multiple sclerosis
• If nonimmune to Rubella, with a titer less than 1:8, order for Rubella vaccine
  • Educate the patient not to get pregnant for a month after vaccination
• Potential vaccinations include: Tdap, hep B, varicella, and influenza
• Rh-negative women with Rh positive infant should receive Rho(D) immune globulin (Rhogam) within 72 hours post delivery

Postpartum Care After Cesarean Section

• Nursing care is the same as a vaginal birth
• Include additional assessments and interventions similar to clients with abdominal surgery:
  • Approximation
  • Edema
• Assist with turn, cough, and deep breaths
• Instruct to splint incision
• Encourage early ambulation as ordered
• Sequential compression devices may be ordered
• Instruct to notify provider if incision separates, redness, drainage, or bleeding
• Avoid any heavy lifting other than newborn
• Pain medication as prescribed

Postpartum Assessment

• Warning signs to assess for include:
  • Fever greater than 100.4 degrees F (38 degrees C)
  • Foul smelling lochia
  • Large clots or bleeding that saturates a pad within one hour
  • Calf pain
  • Swelling or redness in perineum
  • Severe headache or blurred vision
  • Changes in respiratory status
  • Urinary changes
  • Change in mood
• Postpartum depression and “baby blues” are more common today

Supporting Parents of a Child Born with a Disability

• When parents learn that a child may have a birth defect, the experience during pregnancy changes from hopeful to fearful, which creates stress
• Parents who discover birth defects during pregnancy may develop strong coping strategies
• Support should include physicians, geneticists, nurses, pharmacists, nutritionists, social workers, and occupational therapists
• The language should be understandable and avoid using technical terms
• It is vital to congratulate the parents and approach birth with congratulations rather than saying "I'm sorry"

Plan for Discharge

• The length of stay is dependent on:
  • 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

Planning for Discharge

• Care management: Psychosocial needs
• Effect of birth experience and maternal self-image
• Adaptation to parenthood and parent-infant interactions
• A comprehensive assessment and depression screening should occur within 4-6 weeks
• Discharge teaching topics should be reviewed