Chapter 17 Postpartum Physiological Adaptations

What are the physiological changes that a postpartum patient goes through?

• uterine involution (uterus returns back to normal)

• lochia flow

• cervical involution

• decrease in vaginal distention

• alteration in ovarian function & menstruation

• cardiovascular, urinary tract, breast & GI tract changes

What are the greatest risks during the postpartum period for the patient?

• hemorrhage

• shock

• infection (especially through the cervix)

What’s important to remember about oxytocin and its purpose?

• oxytocin, a hormone released from the pituitary gland, coordinates and strengthens uterine contractions.

• breastfeeding stimulates the release of oxytocin from the pituitary gland.

What hormones are decreased and what happens after they are decreased in postpartum patients?

• Estrogen is decreased: diminishes vaginal lubrication causing local dryness and intercourse discomfort until the ovarian function returns

• Placental enzyme insulinase is decreased: reverses Gestational Diabetes

• HCG levels disappear from blood quickly

In lactating clients, why do blood lactic levels remain elevated and how long is postpartum ovulation suppressed?

1. the infants suck is believed to affect prolactin levels

2. length of time to the first postpartum ovulation is approximately 6 months

What occurs in non-lactating clients?

• reaches pre pregnant level by 3 weeks postpartum

• ovulation occurs 7-9 weeks after birth

• menses resumes by 12 weeks postpartum

What’s included in a focused physical assessments? (BUBBLE)

• B: Breasts

• U: Uterus (fundal height, uterine placement, and consistency)

• B: Bowel and GI function

• B: Bladder function

• L: Lochia (color, odor, consistency, and amount [COCA])

• E: Epiosotomy (edema, ecchymosis [bruising], approximation)

• Vital signs (pain assessment)

• teaching needs

How rapidly does the uterus decrease in size?

approximately 1,000 g at the end of the third stage of labor to 60-80 g at 6 weeks postpartum with the fundal height steadily descending into the pelvis approximately one fingerbreadth (1 cm) per day

How often should the fundus descend?

• every 24 hours, approximately 1-2 cm

• should be halfway between the symphysis pubis and the umbilicus by 6 days postpartum

• after 2 weeeks, uterus should lie within the true pelvis and should not be palpable

What should be assessed at least every 8 hours after the recovery period has ended?

• fundal height

• uterine placement

• uterine consistency

What could be the cause of the fundus not being midline and what should be done to fix it?

• full bladder

• have patient empty the bladder

When assessing the fundus, the nurse notices that it is boggy. What nursing intervention should be done to help firm it?

Lightly massage the fundus in a circular motion

How does the nurse document the position and location of the uterus?

• by the number of fingerbreadths (cm)

• if above the umbilicus, document as +1, U+1, 1/U

• if below the umbilicus, document as -1, U-1, U/1

• if at the umbilicus, document as U/U

What is the purpose of oxytocics?

to promote uterine contractions and to prevent hemorrhage

Which oxytocics are most commonly used?

• oxytocin

• methylergonovine

• carboprost

• misoprostol (prostaglandin)

What side effect can oxytocin and misoprostol have on a postpartum patient?

can cause hypotension

What side effects can methylergonovine, ergonovine, and carbopost have on a postpartum patient and what's important to remember?

• can cause hypertension

• do not give to preeclampsia, severe preeclampsia, or eclampsia patients

What is the least invasive method of promoting uterine contractions and preventing hemorrhage?

encourage emptying of the bladder to prevent uterine displacement and atony (lack of normal muscle tone)

What is lochia?

post-birth uterine discharge that contains blood, mucus, and uterine tissue

What are the three stages of lochia?

1. Lochia Rubra

2. Lochia Serosa

3. Lochia Alba

What is seen with lochia rubra?

• Dark red color (ruby red rubra), bloody consistency, fleshy odor

• can contain small clots

• lasts 1-3 days after birth

What is seen with Lochia Serosa?

• pinkish brown color and serosanguineous (watery) consistency

• can contain small clots and leukocytes

• lasts approximately day 4 tp day 10 after birth

What is seen with Lochia Alba?

• yellowish white (alba) creamy color, fleshy odor

• can consist of mucus and leukocytes

• lasts approximately day 10 up to 6 weeks postpartum

What is considered excessive blood loss when assessing lochia amount?

one pad saturated in 15 minutes or less or pooling of blood under buttocks

How often should the lochia be assessed?

• at least every 15 minutes for first hour of bleeding

• every 1 hour for next 4 hours

• then every 4-8 hours

What’s a normal finding after massaging the uterus or ambulating?

a gush of lochia with the expression of clots and dark blood that has pooled in the vagina but should soon decrease back to a trickle of bright red lochia.

What are manifestations of abnormal lochia?

• blood clots larger than 50 cent coin

• numerous large clots and excessive blood loss (hemorrhage)

• foul odor (infection)

• persistent heavy lochia rubra beyond day 2 (placental fragments)

What client education should be given to a patient in regards to perineal care?

• change pads frequently (every 2-3 hours)

• perform hand hygiene after peri care & changing of pads

• do not use tampons due to increased risk of infection

What physical changes occur to the cervix postpartum?

• 2-3 days after, it shortens, regains its form, and becomes firm with cervical outlet gradually closing

• external outlet of cervix will no longer have round-dimple shape and will have a slit-like appearance

What physical changes occur to the vagina postpartum?

• muscle tone is never restored completely

• breastfeeding increases the incidence of vaginal dryness and atrophy

What physical changes occur to the perineum?

hematomas or hemorrhoids can be present (evaluate)

When does healing normally occurs for the cervix, vagina, and perineum?

initial healing occurs in 2-3 weeks and complete occurs within 4-6 months

What comfort measures can be done for perineal tenderness, lacerations, and episiotomy?

• apply ice/cold packs to the perineum for the first 24 hours to reduce edema and provide anesthetic effect (do not apply directly)

• heat therapy (hot packs), moist heat, and sits baths can be used to increase circulation and promote healing and comfort

• encourage the sitz baths at a hot or cool temperature for at least 20 minutes for at least twice a day

• apply topical anesthetic (benzocaine spray) to the clients perineal area as needed or witch hazel compresses or hemorrhoidal creams to the rectal area for hemorrhoids

What client education should be given in regards to perineal care?

wash both hands thoroughly before and after voiding

What are the physical changes of the breasts?

• secretion of colostrum which occurs during pregnancy & 2-3 days immediately after birth

• milk is produced about 72-96 hours after the birth

What education should be made about colostrum?

colostrum (early milk) transitions to mature milk about 72-96 hours after birth (milk coming in)

What is engorgement and what does it look like?

• engorgement (fullness) of the breast tissue is a result of lymphatic circulation, milk production, and temporary vein congestion

• breast will aparea tight, tender, warm, and full

What should the nurse inform the client about breast engorgement?

• non breastfeeding client: this will resolve on its own; support bras, ice pack, birth control, or cabbage leaves can be applied to help resolve

• breastfeeding clients: breast care and frequent feedings will help prevent or manage engorgements

What should the nurse observe for/assess of the breast?

• erythema (redness)

• breast tenderness

• cracked nipples

• indications of mastitis (infection of milk duct with flu-like symptoms)

What patient-centered care should be done for breastfeeding patients?

• promote early breastfeeding within the first 1-2 hrs after birth

• encourage early demand feeding (feeding only when baby is hungry) for client who chooses to breastfeed

  • this will stimulate production of natural oxytocin and help prevent uterine hemorrhage