POSTPARTAL CHANGES

Puerperium (Postnatal Period)

Puerperium (Postnatal Period)

Refers to the 6 weeks period after childbirth

“PUER”

Latin word - means “child”

“PARERE”

Latin word - means “to bring forth”

Involution (Retrogressive Changes)

• Process of the uterus returning to its pre-pregnancy size and condition after childbirth.

• Reproductive system changes and other systemic changes

Progressive Changes

• Refers to the gradual adaptations and modifications of the uterus and body during and after pregnancy, including hormonal and anatomical adjustments.

• Production of milk for lactation, restoration of normal menstrual cycle and beginning of parenting role

CERVIX (REPRODUCTIVE SYSTEM CHANGES)

1. Soft and malleable to palpation 

2. Both Internal os external os are open 

3. Contraction of the cervix towards prepregnant state begins

4. End of 7 days external os narrowed to size of a pencil opening.

   • involves formation of new muscle cells

   • Internal os closed as before, after vaginal birth external os remain slightly open and appears slit - like or stellate (star shaped) 

PERINEUM (REPRODUCTIVE SYSTEM CHANGES)

1. Edematous and tender 

2. Ecchymosis patches from ruptured capillaries 

3. Labia majora and minora remain atrophic and soften

PERINEUM (NURSING RESPONSIBILITIES)

1. Perineal Care

2. Observe for abnormalities

3. Presence of Hemorrhoids

4. Apply cold pack during first 24 hrs (reduces perineal edema & hematoma)

5. Perineal hot pack or moist heat (increase circulation)

6. Episiotomy Care (Soothing cream, Acetaminophen/Ibuprofen)

7. Kegel Exercises (improve circulation, lessen edema, prevent urinary incontinence)

8. Relieve Muscular Aches (Backrub)

VAGINA (REPRODUCTIVE SYSTEM CHANGES)

1. Vagina is soft with few rugae and its diameter is greater than normal 

2. Hymen is permanently torn and heals with small, separate tags of tissue 

3. Thickening of the vaginal walls appears

   • whole puerperium to involute

UTERUS (REPRODUCTIVE SYSTEM CHANGES)

Involution of the uterus involves two process:

1. The area where the placenta was implanted is sealed off by rapid contraction to prevent bleeding

2. The organ is reduced to its approximate pregestational size

• the uterus of a breastfeeding mother may contract more quickly because of the released of oxytocin which stimulates uterine contraction

PALPATION OF FUNDUS - Few minutes after birth

fundus is palpable, halfway between umbilicus and symphysis pubis

PALPATION OF FUNDUS - One hour later

at the level of umbilicus and remains for 24 hrs.

PALPATION OF FUNDUS - First day Postpartum

decreases by one fingerbreadth per day (1 cm.) a day in size 

PALPATION OF FUNDUS - Day 9-10

no longer palpable

UTERUS WEIGHT - After birth

about 1,000 grams

UTERUS WEIGHT - End of First Week

weighs 500 grams 

UTERUS WEIGHT - Complete Involution

50 grams (Prepregnancy Weight)

Causes for Delayed Involution

1. Multiple fetuses 

2. Hydramnios 

3. Exhaustion from prolonged labor 

4. Grand multiparity 

5. Physiologic effect of analgesia 

6. Retained placenta or membrane

Uterine Atony

• failure of the uterus to contract adequately following delivery

• The first hour after birth is potentially the most dangerous time for a woman.

  • If the uterus is relaxed during this time patient will lose blood very rapidly, because no permanent thrombi have yet formed at the placental site

Involution will occur most dependably

1. Well-nourished

2. Ambulates early after delivery

Advantages of Ambulation

1. Decreased incidence of thrombophlebitis 

2. Better uterine drainage and enhanced uterine involution

3. Preventing urinary retention and constipation 

4. Less respiratory complications (Pneumonia and Pulmonary embolism)

5. Early regain of maternal strength 

6. Improved well-being and self-esteem 

7. Greater confidence in providing baby care 

8. Shorter hospitalization days (If hospitalized)

Pulmonary Embolism

a blockage (blood clot) in one of the pulmonary arteries in the lungs

UTERUS (NURSING RESPONSIBILITIES)

1. Pain Relief (Acetaminophen/ Iburprofen)

LOCHIA (REPRODUCTIVE SYSTEM CHANGES)

vaginal discharge of a postpartum mother, consists of shreds of decidua, erythrocytes (RBC) leucocytes, epithelial cells, and bacteria

Reasons for Lochial Evaluation

1. To detect the normality of vaginal discharge and rule out postpartum hemorrhage 

2. To evaluate the state of uterine involution 

3. To detect the presence of puerperal sepsis

Lochia Rubra

• red color

• 1 - 3 days

• Blood, small particles of decidua and mucus

Lochia Serosa

• pink or brownish

• 3 - 10 days 

• Blood, mucus, and invading leukocytes

Lochia Alba

• white with streaks of brownish mucus 

• 10 - 14 days until 3 – 6 wks.

• Largely mucus, leukocytes count high

COLOR (EVALUATION OF LOCHIA)

• red, pinkish brown, whitish with or without clots

• Reddish color – more than two wks. (involution problems, placental retention)

ODOR (EVALUATION OF LOCHIA)

• Normal: fleshy, musky, non-offensive, non-foul odor

• Abnormal: malodorous or foul odor

HEAVY/LARGE AMOUNT (EVALUATION OF LOCHIA)

one perineal pad saturated in 15-30 mins.

MODERATE AMOUNT (EVALUATION OF LOCHIA)

Perineal pad blood stain less than 15 cm (6 inch) 

LIGHT/SMALL AMOUNT (EVALUATION OF LOCHIA)

Perineal pad blood stain less than 10 cm. (4 inch) 

SCANT AMOUNT (EVALUATION OF LOCHIA)

Perineal pad blood stain less than 2.5 cm. (1 inch)

LACTATION

• Breast milk forms in response to the decrease in Estrogen and Progesterone levels that follows delivery of the placenta , which stimulates Prolactin production and, consequently, milk production

• When breast milk first begins to form, the milk ducts become distended

Primary Engorgement

feeling of tension in the breasts and fades on the 3 rd or 4th day after birth as the infant begins effective sucking and empties the breasts of milk

1. Breast Distension

2. Heat/Throbbing Pain

3. Reddened Breast

RETURN OF MENSTRUAL FLOW

• increase production of FSH, leads to return of ovulation 

Lactational Amenorrhea (Breastfeeding Mothers)

• menstrual flow may not return for 3-4 months or for the entire lactation period

  • Absence of a menstrual flow does not guarantee that a woman will not conceive during this time, because she may ovulate well before menstruation returns

Not Breastfeeding

flow return in 6-10 weeks after birth

Hormonal System Changes

1. HCG and HPL decreased by 24 hrs.

2. FSH remains low for 12 days then begins to rise to initiate new menstrual cycle 

3. Wk.1 – Progestin, estrone and estradiol are all at pre pregnancy Level

Urinary System Changes

• During pregnancy, as much as 2000 to 3000 mL excess fluid accumulates in the body.

• An extensive diuresis begins to take place almost immediately after birth to rid the body of this fluid

• Increases the daily output of a postpartal woman

Diuresis

• from a normal level of 1500 mL to as much as 3000 mL/day during the 2nd to 5th day afterbirth

• Increase in urine production causes bladder to fill rapidly

Hydronephrosis

• increase in size of ureters present for about 4 wks. Postpartum

Causes for Hydronephrosis

1. Pressure on the bladder and urethra due to fetal head exertion.

2. Transient loss of bladder tone

3. Edema surrounding the urethra decreases the ability to sense when to void 

4. Epidural anesthesia – can feel no sensation in the bladder area until anesthetic has worn off

Circulatory System

• blood volume return to its normal level 1-2 wks. after birth

• A 4-point decrease in hematocrit (proportion of red blood cells to circulating plasma) 

• 1-g decrease in hemoglobin value occur with each 250 mL of blood loss.

Blood Loss after Vaginal Delivery

300-500 ml

Blood Loss after Cesarean Delivery

500-1000 ml

Gastrointestinal System Changes

1. Digestion and absorption begins to be active after birth 

2. Bowel sounds are active, but passage of stool may be slow because of the still-present effect of relaxin on the bowel. 

3. Bowel evacuation may be difficult because of the pain of episiotomy sutures or hemorrhoids

Integumentary System Changes

1. Striae gravidarum - after birth stretch marks still appear reddened will fade to a pale white over the next 3-6 mons. 

2. Melasma (Chloasma) – excessive pigmentation from the face and neck is barely detectable by 6 wks. time 

3. Linea nigra – barely detectable by 6 wks.

4. Diastasis Recti

Diastasis Recti

• partial or complete separation of the rectus abdominis, which meet at the midline of your stomach

• overstretching and separation of the abdominal musculature - the area will appear slightly indented.

• If the separation is large, it will appear as a bluish area in the abdominal midline.

Temperature (Vital Signs)

• first 24 hrs. – slightly increase due to dehydration 

• 3 - 4 th day after birth – slightly increase due to breast fill with milk

• Any woman whose oral temperature rises above 100.4° F (38° C), excluding the first 24-hour period, is considered to be febrile. 

• In such women, a postpartal infection may be present.

Pulse (Vital Signs)

• slightly slower than normal 

• End of first week – pulse return to normal 

• Rapid, thready pulse – sign of hemorrhage

Decrease Blood Pressure (Vital Signs)

• Indicates bleeding

• Complications

1. Acute blood loss 

2. Orthostatic hypotension

3. Dizziness

Increase Blood Pressure

• 140/90 mmhg

• Indication

1. Pregnancy induced hypertension 

2. Oxytocin drugs

PSYCHOLOGICAL CHANGES

Behavioral Adjustment

Phases of Puerperium

Reva Rubin, 1977

1. Taking-in Phase

2. Taking-hold Phase

3. Letting-go phase

TAKING-IN Phase

• 1-3 days period

• time of dependence

• The woman is passive 

• Time of reflection 

• Sense of wonder 

• Wants to talk about her pregnancy (Labor and birth)

TAKING-HOLD Phase

• begins to initiate action and make her own decisions

• Takes interest to infant, begins maternal roles

• Often feels insecure about ability of care

LETTING-GO

• redefines her new role

• Gives up fantasized image of her child and accept the real one 

• Gives up her old role of being childless or the mother of only one or two 

• Readjustment of relationships, extended and continues during the child’s growing years.

Abandonment

a feeling of abandonment and less important after giving birth.

Disappointment

common feelings parents may experience disappointment in the baby

Postpartal Blues

• overwhelming sadness 1-10 days after birth

• burst into tears easily or feel let down or irritabl

• Baby Blues

BUBBLE-HE

1. Breast

2. Uterus

3. Bladder

4. Bowel

5. Lochia

6. Episiotomy

7. Homan’s Sign

8. Emotional Status

REEDA

• For Episiotomy Inspection

  1. Redness

  2. Edema

  3. Ecchymosis

  4. Discharge

  5. Approximation of Skin

Homan’s Sign

• Press down gently on the patient’s knee (legs extended flat on bed) ask her to flex her foot 

• Pain or tenderness in the calf is a positive sign and indication of thrombophlebitis.