Comprehensive Postpartum Physiology & Disorders Study Notes

Postpartum Physiological Adaptations – Overview

• "Fourth stage of labor" = recovery period beginning with placental delivery and encompassing the first 2 hr PP

  • Nurse priorities: comfort, frequent assessments, hemorrhage prevention, initiation of bonding

• Interval from birth ➔ complete return of reproductive organs to non-pregnant state (\approx 6) wk (may vary)

• Greatest maternal risks during this time: hemorrhage, hypovolemic shock, infection

• Oxytocin (endogenous from pituitary or exogenous meds)

  • Coordinates & strengthens uterine contractions → limits bleeding

  • Breast-feeding stimulates natural release → afterpains

Systematic Assessment Mnemonic – BUBBLE-HE (+ VS & Teaching)

• B – Breasts

• U – Uterus (fundal height, placement, consistency)

• B – Bowel/GI

• B – Bladder function

• L – Lochia (COCA)

• E – Episiotomy/laceration (edema, ecchymosis, approximation)

• H – Homan’s sign / lower-leg assessment for VTE (Note: Homan's sign is often considered unreliable, but lower leg assessment for VTE is crucial)

• E – Emotional status & bonding

• Plus: Vital signs (inc. pain) & individualized teaching needs

  • BP & pulse: q 15 min × first 2 hr (Critical assessment frequency)

  • Temp: q 4 hr × first 8 hr, then (\ge) q 8 hr

Uterine Involution

• Weight declines from (\approx 1{,}000) g (immediately PP) ➔ (60–80) g by 6 wk

• Fundal position (midline unless bladder distended): Crucial for assessing uterine tone and potential hemorrhage

  • Birth: fundus (\approx 2) cm below umbilicus

  • 1 hr PP: at umbilicus

  • 12 hr PP: +1 cm above U

  • Descends 1–2 cm (( \approx) one fingerbreadth) q 24 hr

  • 6 d: midway between U & symphysis pubis

  • (\approx 14) d: within true pelvis – non-palpable

• Afterpains = intermittent cramping from myometrial contractions (intensified with breast-feeding, multiparity, and uterine over-distention)

• Firm, well-contracted uterus = primary defense against hemorrhage (Most critical point for hemorrhage prevention)

Lochia – Post-Birth Uterine Discharge

• Amount initially similar to heavy menses first 2 hr; should steadily diminish

• Stages:

  • Lochia rubra: dark-red, fleshy odor, small clots; birth ➔ day (\le 3) (Should be dark red, not bright red after the initial hours)

  • Lochia serosa: pink-brown, serosanguineous; day (4–10)

  • Lochia alba: yellow-white, mucus & leukocytes; day 10 ➔ up to 6 wk

• Quantifying pad saturation (Crucial for blood loss estimation):

  • Scant < 2.5 cm

  • Light (2.5–10) cm

  • Moderate\ > 10 cm

  • Heavy = one pad (\le 2) hr

  • Excessive = one pad (\le 15) min or pooling beneath buttocks

• Normal assessment frequency:

  • q 15 min × 1 hr → q 1 hr × 4 → q (4–8) hr as policy (Standard of care assessment timing)

• Abnormal findings & possible causes:

  • Bright-red spurting: cervical/vaginal tear

  • Large clots/excessive loss: hemorrhage

  • Foul odor: infection (endometritis)

  • Persistent rubra > 3 d: retained placental fragments

  • Prolonged serosa/alba with pain/fever: endometritis

Cervical, Vaginal, & Perineal Changes

• Cervix

  • Soft, edematous, bruised immediately PP; small lacerations common

  • Shortens & firms; external os closes within (2–3) d – becomes slit-like

• Vagina

  • Initially distended; rugae reappear, mucosa thickens by week 3

  • Breast-feeding ((\downarrow) estrogen) ➔ dryness & atrophy

• Perineum

  • Erythema, edema, possible laceration/episiotomy, hemorrhoids, hematomas

  • Comfort measures:

  • Ice packs first 24 hr, then warm sitz baths 20 min (\times 2)/day

  • Analgesics: acetaminophen, ibuprofen, opioid combos

  • Topicals: benzocaine spray, witch-hazel pads, hemorrhoid creams

  • Stool softeners; encourage high-fiber diet & fluids

  • Peri-bottle cleansing after voiding; pat dry front-to-back; change pads frequently; nothing per vagina until cleared (Crucial hygiene and restrictions)

Hormonal / Ovarian Function

• Placenta delivery ➔ sharp fall in estrogen, progesterone, placental enzyme insulinase

  • ((\downarrow) Estrogen: breast engorgement, diaphoresis, diuresis, (\downarrow) lubrication)

  • (\downarrow) Progesterone: (\uparrow) muscle tone

• Prolactin

  • Lactating: remains elevated, suppressing ovulation; 1st ovulation (\approx 6) wk (range (6) wk–months) depending on BF pattern

  • Non-lactating: drops to baseline by 3 wk; ovulation (7–9) wk; menses by (\le 12) wk

Breast & Lactation Care

• Colostrum present during pregnancy & first (2–3) d PP (Important for infant nutrition)

• Mature milk “comes in” (72–96) hr PP ➔ engorgement (tense, warm, tender) (Expected timeline)

• Early initiation: within (1–2) hr post-birth; feed on demand (Key practice for successful breastfeeding)

• Positions: football, cradle, cross-cradle, side-lying (Be familiar with these)

• Assess latch; cracked nipples/erythema may signify poor latch or mastitis (Key assessment and potential complications)

• Non-lactating education: supportive bra, avoid nipple stimulation, ice packs/cabbage leaves PRN (Crucial teaching for non-lactating mothers)

Cardiovascular Adaptations & Vital Signs

• Normal EBL: (Important to know baseline for identifying hemorrhage)

  • Vaginal (300–500) mL ((\approx 10\%) blood volume)

  • Cesarean (500–1{,}000) mL ((\approx 15–30\%))

• Protective mechanisms against hypovolemic shock

  • Pregnancy-expanded plasma volume

  • Autotransfusion from uterine contraction & placenta removal

  • Mobilization of extracellular fluid (diuresis/diaphoresis (1–5) d)

  • Typical weight loss (\approx 19) lb ((8.6) kg) in first 5 d

• Blood values

  • H&H (\downarrow) transiently, normalize by 8 wk

  • Physiologic leukocytosis: WBC (20{,}000–25{,}000\text{/mm}^3) (up to (30{,}000)) common (Important to recognize as a normal PP finding, not infection)

  • Coagulation factors & fibrinogen (\uparrow) ➔ hypercoagulable (VTE risk) (Key risk factor for VTE)

• VS patterns

  • BP stable; (\downarrow) may signal hemorrhage, (\uparrow) may reflect gestational HTN (Key abnormal findings to report)

  • Orthostatic hypotension due to splanchnic engorgement (Common finding, risk for falls)

  • Pulse, SV, CO (\uparrow) first hr; baseline by (6–8) wk

  • Temp (\le 100.4)°F ((38)°C) first (24) h = dehydration; persisting elevation suggests infection (Key abnormal findings)

  • Interventions: hydrate, early ambulation, anti-embolism stockings (Key nursing interventions to prevent complications)

Gastrointestinal System

• (\uparrow) Appetite soon after recovery; provide nourishing meals & fluids

• Constipation factors: (\downarrow) muscle tone, opioids, fear of pain; BM usually by day (2–3) (Key factors and expected timeframe)

• Hemorrhoids common; inspect rectum for varicosities

• (3°/4°) perineal lacerations → NO enemas/suppositories (Crucial contraindication due to risk of damaging repair)

• Cesarean: flatus common; encourage ambulation & antiflatulents

Urinary System / Bladder Function

• Post-partal diuresis: begins within 12 h; output may exceed (3{,}000) mL/day first (2–3) d (Expected physiological change)

• Risk for retention: birth trauma, edema, anesthesia, oxytocin diuresis (Key causes)

  • Signs: fundus above baseline or deviated, bladder palpable, excessive lochia, voids < 150 mL (Crucial assessment findings)

  • Consequences: UTI, atony, hemorrhage (Serious complications of retention)

• Nursing care: assist to void within (6–8) h, measure first several voids, catheterize PRN (Key nursing interventions)

Musculoskeletal Adaptations

• Joints restabilize by (6–8) wk; feet may remain (\uparrow) size permanently

• Abdominal wall: diastasis recti resolves (\approx 6) wk (longer if severe) (Understanding of body changes)

• Pelvic floor (pubococcygeus) regains tone; teach Kegel exercises (Important teaching for recovery)

• Post-cesarean: delay abdominal exercises (4–6) wk (Crucial teaching)

• Emphasize good posture & body mechanics; prevent falls (hypotension, fatigue)

Immune Considerations & Vaccinations

• Rubella

  • Non-immune (titer < (1\text{:}8)) ➔ MMR before discharge; avoid pregnancy (\ge 4) wk (Critical intervention and teaching)

• Rh Iso-immunization

  • Rh-neg mother + Rh-pos neonate ➔ Rho(D) immune globulin (\le 72) h PP; observe 20 min for reaction (Critical intervention and monitoring)

• Varicella

  • No immunity ➔ first dose before discharge; avoid pregnancy (\ge 1) mo; second dose (4–8) wk later (Key intervention and teaching)

• Tdap

  • Give if not up-to-date; recommended for all close caregivers; compatible with BF

Psychosocial Adaptation

• Hormonal shifts + role transition → mood lability

• Assess for bonding behaviors (eye contact, touch, verbalization) (Important assessment)

• Screen for postpartum blues vs. depression

  • Blues: transitory, peaks day (3–5), resolves by 2 wk (Key differentiating factor)

  • Concerning signs: poor appetite, sleep disturbance, social withdrawal, persistent sadness (Red flags requiring intervention)

• Encourage skin-to-skin, rooming-in, verbalization of feelings; document & refer PRN

Postpartum Disorders – Venous Thromboembolism Spectrum

Deep-Vein Thrombosis (DVT)

• Patho: thrombus with inflammatory response (thrombophlebitis) usually in femoral, saphenous, or popliteal veins

• Incidence (\approx 1) in (1{,}500) pregnancies; highest first 3 wk PP (Important timeframe)

• Risk factors: cesarean ((\times 2)), operative delivery, immobility, obesity, multiparity, age >(35), smoking, varicosities, prior VTE, thrombophilias (All crucial for identification)

• Subjective/Objective findings: unilateral leg pain, tenderness, warmth, edema, palpable hardened vein, +Homan’s (not reliable) (Key assessment findings)

• Diagnostics: Doppler ultrasound (first-line), MRI; CT contraindicated in pregnancy

Prevention & Education

• SCDs until ambulatory; active/passive ROM if bedrest >(8) h; early ambulation; fitted TED hose (Crucial nursing interventions)

• Avoid prolonged standing/sitting & leg crossing; elevate legs when seated; hydrate (Key patient education)

Management

• Elevate affected leg above heart; bedrest with position changes; warm compresses; measure circumference (Key interventions)

• Analgesia (NSAIDs); DO NOT massage (Crucial contraindication: Do Not Massage)

• Thigh-high stockings once ambulating

Anticoagulation

• Heparin (IV) initial therapy; adjust dose per aPTT (1.5–2.5\times) control ((30–40) s); antidote = protamine sulfate (Key drug, monitoring, antidote)

• Warfarin (PO) for long-term; monitor PT ((10–13) s) & INR (goal per provider); antidote = vitamin K; teratogenic—use progestin-only or barrier contraception; avoid OTCs with ASA/NSAIDs, alcohol; electric razor, soft toothbrush (Key drug, monitoring, antidote, and crucial patient teaching points)

• General precautions: no leg massage, avoid prolonged immobility, report bleeding signs

Pulmonary Embolus (PE)

• Dislodged clot (often from DVT) ➔ pulmonary artery occlusion → ventilation–perfusion mismatch; life-threatening (mortality up to (25\%)) (Crucial understanding of patho and severity)

• Diagnostics: Spiral CT chest (first-line), V/Q scan, MRI, pulmonary angiogram; emergent management may proceed on clinical suspicion

Nursing Care & Therapy

• Semi-Fowler with HOB (\uparrow); O₂ mask; same anticoagulation regimen as DVT (Key interventions for PE)

• Thrombolytics (alteplase, streptokinase) may be ordered – monitor for bleeding (Key drugs and monitoring)

Coagulopathies

Idiopathic Thrombocytopenic Purpura (ITP)

• Autoimmune platelet destruction (antiplatelet antibodies) → thrombocytopenia → PP hemorrhage risk (Pathophysiology and key risk)

Disseminated Intravascular Coagulation (DIC)

• Simultaneous widespread clotting & bleeding → organ ischemia & hemorrhage (Core pathophysiology)

• Secondary to OB complications: placental abruption (most common), amniotic fluid embolism, massive hemorrhage, severe preeclampsia/HELLP, hydatidiform mole, IUFD retained (\ge 6) wk, sepsis, cardiopulmonary arrest (Key causes to recognize)

Assessment Findings

• Oozing from surgical/puncture sites, petechiae, ecchymoses, hematuria, GI bleed, tachycardia, hypotension, diaphoresis (Crucial assessment findings)

Laboratory Profile

• Platelets (\downarrow); Fibrinogen (\downarrow) (norm (200–400) mg/dL)

• PT prolonged (>(12.5) s); aPTT prolonged; fibrin-split products & D-dimer (\uparrow) (Key lab values indicative of DIC)

Interventions

• Continuous VS & hemodynamic monitoring; measure output

• Identify & correct underlying cause (The most critical intervention)

• Volume resuscitation: crystalloids, blood products (platelets, FFP, cryoprecipitate)

• Oxygen therapy; protect from injury; possible splenectomy (ITP) or hysterectomy (uncontrolled DIC) (Comprehensive management strategies)

Pain & Comfort Management – General Principles

• Assess type, location, intensity routinely; medicate per orders (ibuprofen, acetaminophen, oxycodone, etc.)

• Reassess efficacy; teach non-pharmacologic methods (position change, imagery, heat/cold, relaxation) (Complete pain management process)

Key Patient Education Highlights

• Lochia norms & warning signs; perineal hygiene; when to call provider

• Breast-feeding technique, engorgement relief, signs of mastitis

• Uterine involution expectations & fundal self-palpation if instructed

• Return of fertility & contraception options (esp. with anticoagulants)

• Nutrition (extra (450–500) kcal/day if BF), hydration, gradual exercise program, lifting restrictions post-cesarean

• Immunization schedule & pregnancy avoidance windows

• Mood changes; support systems; resources for PPD

• VTE prevention, medication adherence, follow-up labs