Postpartum Adaptations and Complications

Module 6: Postpartum Adaptations and Complications

Chapter 20: Postpartum Adaptations

Puerperium

• The first 6 weeks postpartum are known as the puerperium.

• Changes during this time are both retrogressive and progressive.

  • Retrogressive Changes:

  • Reversal of pregnancy-associated changes.

  • The body returns to a non-pregnant state.

  • Progressive Changes:

  • New changes/processes occur, notably the initiation of lactation.

Reproductive System Changes

• Involution of the Uterus:

  • Begins immediately postpartum after the delivery of the placenta.

  • Uterine muscle fibers contract tightly around maternal blood vessels where the placenta was attached.

  • Three processes involved in involution:

  • Contraction of Muscle Fibers

  • Catabolism

  • Regeneration of Uterine Epithelium

  • Physically, the fundus is located halfway between the symphysis pubis (SP) and umbilicus within 12 hours postpartum.

  • Descends approximately 1 cm per day, and by the 14th day postpartum, the fundus is no longer palpable on abdominal examination.

  • Physical Exam Findings:

  • Document fundal height in either FB or CM in relation to the umbilicus.

  • Subinvolution:

  • Describes when the process of involution does not occur properly.

Afterpains

• Definition: Uterine contractions experienced in the first few days postpartum.

• More acute for multiparous women or those with uterine overdistention.

• Symptoms:

  • Oxytocin is the hormone responsible for the "let down".

  • Nursing with a good latch can increase afterpains.

• Nursing Considerations:

  • Treat with as-needed pain medication; this improves the milk ejection reflex.

  • Reassure the patient that afterpains are self-limited and typically decrease after 48 hours.

Lochia

• Changes in Lochia Color:

  1. Lochia Rubra (first 3 days postpartum): Mostly blood with small particles of decidua and trophoblastic debris; reddish or red-brown color.

  2. Lochia Serosa (starts day 4 postpartum): Composed of serous exudate, erythrocytes, leukocytes, and tissue debris; pink or brown-tinged.

  3. Lochia Alba (from about day 11 PP to 4-8 weeks PP): Decreased erythrocyte content; contains leukocytes, decidual cells, epithelial cells, serum, cervical mucus, and bacteria; appears white, cream, or light yellow.

• Amount of Lochia:

  • Scant: Less than a 2.5-cm (1-inch) stain on the perineal pad.

  • Light: Less than a 10-cm (4-inch) stain.

  • Moderate: Less than a 15-cm (6-inch) stain.

  • Heavy: Saturated perineal pad in 1 hour.

  • Excessive: Saturated peripad in 15 minutes.

  • Measured over 1 hour.

Characteristics of Lochia (TABLE 20.1)

• Time and Type of Lochia:

  • Days 1-3: Lochia Rubra (normal discharge - bloody; small clots; fleshy odor)

  • Abnormal: Large clots; saturated perineal pads; foul odor.

  • Days 4-10: Lochia Serosa (normal discharge - decreased amount; serosanguineous; pink or brown)

  • Abnormal: Excessive amount; foul smell; return to reddish color.

  • Days 11-21: Lochia Alba (may last until the 6th week postpartum)

  • Normal: Further decreased amounts; white, cream, or light yellow.

  • Abnormal: Persistent lochia serosa; return to lochia rubra; foul odor.

Lacerations of the Birth Canal (BOX 20)

• Perineal Lacerations: Classified by degrees to describe the tissue involved.

  • First Degree: Superficial vaginal mucosa or perineal skin.

  • Second Degree: Vaginal mucosa, perineal skin, and deeper tissues, including fascia and pelvic muscles.

  • Third Degree: Involves anal sphincter.

  • Fourth Degree: Extends through anal sphincter into the rectal mucosa.

• Periurethral Area:

  • Lacerations may cause difficulty urinating, requiring an indwelling catheter for a day or two.

• Cervical Lacerations: May lead to significant bleeding postpartum.

Nursing Considerations for Lacerations:

• Pain Management: Use topical anesthetics and apply ice.

• Self-Care/Hygiene: Teach proper hygiene and positioning techniques.

Cardiovascular System Changes

• Blood volume increases by 40-50% during pregnancy, allowing women to tolerate blood loss associated with delivery:

  • Up to 500 mL for vaginal delivery.

  • Up to 1,000 mL for cesarean section.

• Average Blood Loss:

  • Increased cardiac return leads to increased cardiac output despite decreased blood volume.

• Cardiac Output: Returns to prepregnancy levels within 6-8 weeks postpartum.

  • Patients must wear Sequential Compression Devices (SCDs) if undergoing cesarean.

• Marked Leukocytosis and Coagulation Changes:

  • White blood cell count decreases to normal within 4-7 days postpartum.

  • Hematocrit (H&H) values may be difficult to interpret due to plasma volume changes.

  • The body rids excess plasma volume via:

  • Diuresis (urine output up to 3,000 mL/day)

  • Diaphoresis (sweating)

• Risk Factors for Clotting: Varicose veins, history of clots, thrombophilias, cesarean sections, hemorrhage, infection.

Visceral Organ Changes

• Gastrointestinal System:

  • Increased need for food and fluids soon after delivery to combat constipation.

• Urinary System Changes:

  • NPO/clear liquids are typically ordered in labor.

  • Factors contributing to constipation:

  1. Continued slow motility from pregnancy.

  2. NPO status during labor.

  3. Perineal trauma.

  4. Hemorrhoids.

  • Symptoms: abdominal fullness, flatulence, pain with bowel movements.

  • Treatment: Stool softeners, laxatives, increased fluids, fiber intake, and ambulation.

  • Increased risks of urinary issues and complications such as infections due to incomplete emptying and overdistention.

• Musculoskeletal System Changes:

  • Fatigue and aches from labor.

  • Decreasing relaxin levels result in the return of pelvic ligaments and cartilage to prepregnancy state, potentially causing pain.

  • Abdominal Wall: Diastasis recti may occur, typically resolves within 8 weeks postpartum.

Integumentary System Changes

• Hyperpigmentation often resolves.

• Striae Gravidarum: Fade to silvery lines but do not disappear and are a normal response to hormonal changes.

• Hair Loss: Commonly seen as telogen effluvium.

Neurological System Changes

• Post-anesthesia/analegesia changes include headaches (bilateral and frontal) or spinal headaches that may present with associated symptoms of dizziness or numbness.

• Positioning can influence headaches:

  • Worse when upright, may resolve when lying flat.

  • Keep a record of any headaches that accompany blurred vision, significant proteinuria, photophobia, or abdominal pain as they may signal preeclampsia.

Endocrine System Changes

• Formula feeding typically leads to the return of the menstrual cycle around 6-9 weeks postpartum.

• Breastfeeding may lead to lactational amenorrhea, where the cycle returns after about 6 months postpartum.

• Prolactin initiates milk production within 2-3 days postpartum, and oxytocin promotes milk letdown.

• Postpartum weight loss can average 10-13 pounds during birth, with the remainder gradually lost over 6 weeks to 6 months.

Postpartum Assessment

• Initial Assessment Includes:

  • Vital signs

  • Skin color

  • Assessment of fundus (location, firmness)

  • Amount and color of lochia

  • Evaluation of perineum for edema, episiotomy, lacerations, hematoma

  • Presence, degree, and location of pain.

• Additional assessments may include:

  • IV infusion status (type, rate, patency)

  • Urinary output (last void, presence of a catheter)

  • Status of abdominal incision and dressing if present.

Nursing Education

• Educate about symptoms requiring medical attention after discharge:

  • Fever

  • Local redness, swelling or pain in breasts

  • Persistent abdominal tenderness

  • Persistent perineal pain

  • Changes in lochia (increased amount, resumed brightness, foul odor)

  • Localized tenderness, redness, edema, or warmth of legs

  • Changes in incision status (redness or separation)

Criteria for Discharge

• Mother experiences no complications and has a normal exam.

• Labs are stable, and Rhogam given if needed.

• Patient received all necessary discharge education.

Postpartum Risk Factors for Complications

• Most common complications include hemorrhage and infection.

• Risk Factors for Hemorrhage:

  • Grand multiparity (five or more)

  • Overdistention of the uterus

  • Rapid or prolonged labor

  • Retained placenta

  • Previous aberrant placentation issues

  • Drugs influencing labor

  • History of postpartum hemorrhage

• Risk Factors for Infection:

  • Operative procedures

  • Multiple cervical examinations

  • Retained placental fragments

  • Poor nutritional status, diabetes, or catheterization.

Nursing Assessments for Postpartum Hemorrhage

• Frequent evaluations are crucial.

• Document any abnormal signs and symptoms, including fundal softness and lochia output.

Thrombosis and Infection Risks

• Various risk factors associated with thromboembolic disorders, including venous stasis, obesity, and previous history of thrombosis.

• Common S/S: warmth, redness, tenderness.

Conclusion

• A comprehensive understanding of postpartum adaptations and potential complications is critical for effective nursing care and patient education during the postpartum period.

References

• Refer to either textbooks or clinical guidelines for further reading and application.