Postpartum Adaptations

Postpartum Adaptations

Involution of the Uterus

  • Definition: Involution refers to the process through which the uterus reduces in size after childbirth, returning to its pre-pregnant state.

  • Key Mechanism: Uterine contractions facilitate this rapid reduction in size.

  • Importance of Exfoliation: This process involves sloughing off of tissue, crucial for preventing scarring and allowing for future pregnancies.

Factors That Affect Involution

  • Slow Involution:

    • Prolonged labor

    • Anesthesia

    • Difficult birth

    • Grandmultiparity (having many previous pregnancies)

    • Full bladder

    • Retained placenta or membranes

    • Infection

    • Overstretching of the uterus

  • Speeding Involution:

    • Uncomplicated labor and birth

    • Early ambulation (walking soon after delivery)

    • Complete expulsion of membranes and placenta

    • Breastfeeding

    • Manual removal of placenta during cesarean birth

Lactation

  • Breastmilk: Considered the best source of nutrition for nearly all newborns.

  • Timing: Should be encouraged as soon as possible after delivery.

  • Colostrum:

    • Definition: Thick, creamy early milk characterized as being rich in vitamins, minerals, and proteins.

    • Contains immunoglobulins and antioxidants beneficial for newborn health.

  • Mature Milk: Typically arrives around the third day post-delivery.

  • Review Teaching: Emphasize proper positioning, latch, and feeding patterns with mothers.

Lochia

  • Definition: Lochia refers to the discharge of debris remaining in the uterus following childbirth, which exits through the vagina.

  • Odor: Normally has a musty, stale scent that is not offensive.

  • Importance: Assessing the amount and color of lochia is critical for postpartum recovery.

  • Types of Lochia:

    • Lochia Rubra:

    • Color: Dark red.

    • Duration: Lasts for 2-3 days post-delivery.

    • Lochia Serosa:

    • Color: Pinkish.

    • Duration: Lasts from approximately day 3 to day 10 postpartum.

    • Lochia Alba:

    • Color: Creamy white/yellow.

    • Duration: Persists for an additional 1-2 weeks after lochia serosa.

Perineal Changes

  • Common Symptoms: Bruising and edema in the perineum are typical following vaginal delivery.

  • Management: Ice packs and sitz baths can alleviate discomfort.

  • Healing Time:

    • Healing from a laceration or episiotomy can take several weeks, with complete healing taking up to 4-6 months.

  • Kegel Exercises:

    • Help improve the tone of the pubococcygeus muscle.

    • Provides support for the uterus and bladder, potentially preventing problems such as stress incontinence or uterine prolapse.

Return of Ovulation and Menses

  • Breastfeeding Mothers:

    • Ovulation and menses may be delayed for 3 months to 3 years.

    • Note: Breastfeeding is not a reliable method of contraception; patients should be informed.

  • Non-Breastfeeding Mothers:

    • Ovulation and menses can return as soon as 7 to 12 weeks post-delivery.

    • The return of ovulation correlates with a rise in serum progesterone.

Gastrointestinal System

  • Common Symptoms Post-delivery: Hunger and thirst are prevalent.

  • Digestive Issues: Digestion can be slow due to various reasons, leading to constipation.

  • Management: Encouragement of plenty of fluids, fiber-rich foods, and early ambulation.

  • Stool Softeners: May be ordered, especially for patients with an episiotomy or laceration repair.

  • Cesarean Patients: Initially restricted to a clear liquid diet until bowel sounds return.

Urinary Tract

  • Risks: Postpartum women are at risk for bladder over-distension and incomplete emptying, potentially leading to urinary tract infections (UTIs).

  • Contributing Factors:

    • Increased bladder capacity.

    • Bruising and swelling at the urethra following delivery.

    • Decreased sensation when the bladder is full.

    • Puerperal diuresis, resulting in 2000-3000 mL of excess fluid during the first 24 hours postpartum.

Vital Signs

  • Temperature: May rise to 38 degrees Celsius within 24 hours after delivery due to exertion and dehydration.

    • An additional rise may occur with breast engorgement when milk comes in.

    • Persistent elevations outside these parameters require attention.

  • Blood Pressure: May slightly rise post-delivery and then return to pre-pregnancy levels over several days.

    • Monitor for orthostatic hypotension.

  • Pulse: A lower pulse rate of 50-70 bpm is normal.

    • Rates over 100 bpm may indicate issues such as hypovolemia, pain, fear, or infection.

Normal Complete Blood Count (CBC) Results for Adults

  • Red Blood Cell Count:

    • Male: 4.32-5.72 ext{ trillion cells/L} (equivalent to 4.32-5.72 ext{ million cells/mcL})

    • Female: 3.90-5.03 ext{ trillion cells/L} (equivalent to 3.90-5.03 ext{ million cells/mcL})

  • Hemoglobin:

    • Male: 13.5-17.5 ext{ grams/dL} (equivalent to 135-175 ext{ grams/L})

    • Female: 12.0-15.5 ext{ grams/dL} (equivalent to 120-155 ext{ grams/L})

  • Hematocrit:

    • Male: 38.8-50.0 ext{ percent}

    • Female: 34.9-44.5 ext{ percent}

  • White Blood Cell Count:

    • 3.5-10.5 ext{ billion cells/L} (or 3,500 ext{ to } 10,500 ext{ cells/mcL})

  • Platelet Count:

    • 150-450 ext{ billion/L} (or 150,000 ext{ to } 450,000 ext{ cells/mcL})

Postpartum Blood Values

  • WBC Count: May be elevated during labor and postpartum, reaching up to 30,000 cells/mcL without pathology if no signs of infection present.

  • Hemoglobin (Hgb) and Hematocrit (Hct): Change rapidly after delivery. Due to blood and fluid loss, blood becomes hypercoagulable in the postpartum period.

  • Indicators of Abnormal Blood Loss:

    • Hct dropping below pre-delivery levels raises suspicion of abnormal blood loss:

    • More than 500 ext{ mL} for vaginal delivery

    • More than 1000 ext{ mL} for cesarean delivery.

Cardiovascular Changes

  • Importance of Maternal Hypervolemia: This condition acts to protect the mother from excessive blood loss during delivery.

  • Potential Complication: Failure to diurese (excessive fluid loss through urination) postpartum can lead to pulmonary edema, which may cause cardiac problems.

Common Discomforts

  • Afterpains:

    • More pronounced in multipara than primipara.

    • Caused by uterine contractions.

    • Severity is enhanced by breastfeeding due to the release of natural oxytocin.

  • Other Symptoms:

    • Diaphoresis (sweating)

    • Chills (if not followed by fever, these are considered normal), and the nurse may provide supportive measures for these symptoms.

Cultural Considerations

  • Assess Cultural Practices: Inquire if the patient’s culture has specific beliefs regarding postpartum care.

  • Respect Practices: Accommodate these beliefs as much as possible in the healthcare setting.

  • Examples: May involve special meals, bathing customs, and privacy needs.

  • Family Role: Extended family may play a significant role during the postpartum period.

Immunizations

  • Vaccines recommended include:

    • Tdap (tetanus, diphtheria, pertussis)

    • MMR II (measles, mumps, rubella - live virus)

    • Varivax (varicella virus - live)

    • Flu Vaccine

    • Rho(D) immune globulin (RhoGAM)

  • Timing of Administration: Within 72 hours after childbirth.

  • Advantage of Live Virus Vaccines: Administering these soon after childbirth is beneficial because the woman is not pregnant and typically does not want to conceive again soon.

Postpartum Assessment

Getting Started

  • Meet & Greet:

    • Introduce yourself as you enter the patient's room, check her ID and allergies, and explain the exam's purpose to assess postpartum adaptation.

    • Wear gloves for any part of the exam involving bodily fluids.

  • Next Steps:

    • Start with vital signs, listen to breath and heart sounds, check IV sites (if present).

    • Establish rapport and ask for permission to proceed with the exam while providing privacy and exposing only the necessary body parts.

    • Sample Documentation:

    • “AOx4, cooperative. VS stable. Lungs clear to auscultation, apical pulse regular, no murmurs. IV patent in L forearm, no redness, swelling, heat, or pain at insertion site.”

Assessment Framework: BUBBLE HE

  • B: Breasts

  • U: Uterus

  • B: Bladder

  • B: Bowel

  • L: Lochia

  • E: Episiotomy/Perineum

  • H: Hemorrhoids/Homan’s Sign

  • E: Emotional Status

Breasts Assessment

  • Questions: Ask if the patient is breastfeeding or bottle-feeding to customize education.

  • Inspection: Look for reddened areas, engorgement, and nipple condition (fissures, cracks, or inversion).

  • Palpation: Lightly palpate for breast softness, firmness (related to engorgement), warmth, or tenderness.

  • Sample Documentation:

    • “Breasts soft, no evidence of nipple tenderness or cracking; nipples everted. Plans to breastfeed; teaching provided.”

Breasts Teaching for Mothers

  • Breastfeeding Mothers:

    • Use a supportive bra.

    • Maintain dry nipples and monitor for fissures or cracks.

    • Be attentive to reddened or tender spots on the breast.

    • Provide additional teaching during breastfeeding attempts as needed.

  • Non-Breastfeeding Mothers:

    • Recommend supportive bras.

    • Advise against breast stimulation.

    • Apply cold packs or cold, raw cabbage leaves inside the bra for discomfort relief.

Uterus Assessment

  • Palpation: Determine the position of the fundus relative to the umbilicus.

  • Assessment Questions:

    • Is the fundus firm or boggy?

    • Is the fundus midline?

  • Inspections for Cesarean patients: Use REEDA mnemonic to inspect the abdominal incision:

    • R: Redness

    • E: Edema

    • E: Ecchymosis (bruising)

    • D: Drainage

    • A: Approximation (of wound edges)

  • Sample Documentation:

    • “Fundus firm, midline, U-2. Horizontal skin incision in the lower abdomen well approximated, with no redness, swelling, bruising, or drainage. Reports current pain at 2 on a 0-10 scale, tolerated palpation easily.”

Uterus Teaching for Mothers

  • Educate on Fundal Position:

    • Discuss how to determine firmness.

    • Provide instructions on how to massage the fundus.

Bladder Assessment

  • Frequent Monitoring: Assess bladder for distension due to postpartum diuresis.

  • Symptoms to Assess:

    • Frequency of urination

    • Burning sensation

    • Urgency of voiding

    • A boggy or displaced uterus can be an indicator of bladder distension.

  • Intervention: Catheterization may be needed if distension is present, and the patient is unable to void.

  • Sample Documentation:

    • “Bladder not distended; patient reports voiding twice in the past 3 hours without discomfort.”

Bladder Teaching for Mothers

  • Encouragement for Eliminations:

    • Out of bed.

    • Pouring warm water over the perineum.

    • Running water in the sink to mimic the sound of urine flow.

    • Encourage relaxation and breathing.

    • Promote frequent voiding and increase fluid intake.

Bowel Assessment

  • Bowel Movement Timeline: Typically returns within 2-3 days postpartum.

  • Concerns: Constipation can increase pressure on sutures and cause discomfort.

  • Sample Documentation:

    • “Bowel sounds hypoactive, abdomen rounded but not distended. Patient confirms she has passed gas but no stool since delivery.”

Bowel Teaching for Mothers

  • Re-establish Normal Patterns: Encourage ambulation, fluid intake, and high fiber foods such as fresh fruits and vegetables.

  • Stool Softeners: May be recommended for ease of bowel movements.

  • Reassurance: Patients should feel confident and not afraid regarding bowel activity.

Lochia Assessment

  • Characteristics to Assess: Evaluate for changes in color, amount, odor, and presence of clots.

  • Types of Lochia to Identify: Lochia Rubra, Lochia Serosa, and Lochia Alba.

  • Signs of Concern:

    • Clots and heavy bleeding might signify uterine relaxation, retained placental fragments, or cervical lacerations.

  • Sample Documentation:

    • “Scant lochia rubra on pad, with no unusual odor noted, no clots expelled during fundal massage.”

Lochia Teaching for Mothers

  • Patient Education: Inform mothers about the normal changes in color and characteristics.

  • Effects of Position Changes: Discuss how position changes may affect lochia flow.

  • Hygienic Measures: Counsel on the importance of cleanliness and monitoring lochia.

  • Cesarean Mothers: Acknowledge that they may experience less bleeding.

Episiotomy/Perineum Assessment

  • REEDA Mnemonic for Inspection:

    • R: Redness

    • E: Edema

    • E: Ecchymosis (bruising)

    • D: Discharge

    • A: Approximation (of wound edges)

  • Sample Documentation:

    • “Perineum intact.”

Episiotomy/Perineum Teaching for Mothers

  • Discuss Care: Explain the type of episiotomy or laceration sustained.

  • Self-Care:

    • Sutures typically dissolve on their own.

    • Use ice packs, sitz baths, and a peri bottle after voiding and BM.

    • Encourage Kegel exercises.

    • Discuss topical sprays or foam for pain management.

Hemorrhoids Assessment

  • Perineal Inspection: Inspect for hemorrhoids, noting size, number, and tenderness.

  • Management: Discuss pain management and the implications of hemorrhoids in the future.

  • Sample Documentation:

    • “One pea-sized hemorrhoid noted, non-tender.”

Emotional Status Assessment

  • Fatigue Evaluation: Assess how much rest the patient is getting.

  • Emotional Appropriateness: Evaluate if the patient's emotions are suitable for the postpartum situation.

  • Supportive Measures: Appropriate nursing interventions are needed for discomforts such as afterpains and episiotomy pain.

  • Sample Documentation:

    • “Patient reports sleeping well last night between midnight and 3 am feedings, was able to sleep another 3 hours until the assessment. Family members providing support with the newborn. Fresh linens and a clean gown provided. Patient up and showering now.”

Emotional Status Teaching for Mothers

  • Support Advice: Promote adequate rest and a gradual increase in activity level.

  • Nutrition Advocacy: Stress the importance of good nutrition and asking for help before feeling overwhelmed.

References

  • Complete blood count (CBC). (n.d.). In Mayo Clinic’s Tests & Procedures. Retrieved from https://www.mayoclinic.org/tests-procedures/complete-blood-count/about/pac-20384919

  • Davidson, M. R., London, M. & Ladewig, P. A. (2020). Olds’ maternal-newborn nursing & women’s health across the lifespan (11th ed.). Boston: Pearson.