Normal Postpartum

Mathematical Application in Newborn Assessment

• A newborn weighing $3.631\,kg$ at birth converts to approximately $8.005\,lb$ ($3.631\,kg \times 2.20462\,lb/kg = 8.004975\,lb$).

Overview of the Postpartum Period

• The postpartum period, also known as the "puerperium" or the "fourth trimester of pregnancy," begins immediately after the birth of the infant and typically lasts for $6\,weeks$.

• This period is defined as the interval between birth and the return of the reproductive organs to their nonpregnant state.

• It involves significant physical and psychological changes as the woman transitions back to a pre-pregnant state and the family adjusts to new dynamics.

• By the end of this $6\,week$ period, most physiologic changes that occurred during pregnancy have reverted to their pre-pregnant state.

Physiologic Adaptations and Uterine Involution

• Involution is the process by which the uterus returns to its nonpregnant size and position.

• This process involves the autolysis of excess hypertrophied tissue.

• Indicators of progression include fundal height and the characteristics of lochia.

• The uterus involutes rapidly, returning to the true pelvis by approximately $2\,weeks$ after birth.

• Subinvolution refers to the failure of the uterus to return to a nonpregnant state, often due to retained placental fragments or infection.

• The placental site heals through a process that prevents scarring, allowing for future pregnancies.

• Uterine contractions are necessary after birth to compress intramyometrial blood vessels and prevent hemorrhage.

• Afterpains (postpartum contractions) are periodic relaxation and vigorous contractions that may be more noticeable in multiparous women or those with overdistended uteri.

Systematic Postpartum Assessment: BUBBLE-HE

• Breasts: Assess for engorgement, pain, presence of milk or colostrum, nipple inversion, cracking, or bleeding.

• Uterus: Assess the location, position of the fundus, and firmness.

  • The fundus should be firm, midline, and roughly the size of a grapefruit immediately after delivery.

  • Shortly after birth, it rises to the level of the umbilicus and then descends approximately $1\,cm$ per day.

  • Uterine atony (relaxation of uterine muscle tone) is a primary risk for hemorrhage.

• Bowel: Assess for the last bowel movement, bowel sounds, appetite, and any medications that might affect elimination.

• Bladder: Monitor for difficulty urinating, measure urine output especially after a Foley catheter is discontinued, and check for bladder distension.

  • Bladder distension can displace the uterus upward and to the side, preventing effective contraction.

• Lochia: assess the type, amount, odor, and presence of clots.

• Episiotomy/Laceration: Evaluate the perineum using the REEDA Scale:

  • Redness

  • Edema

  • Ecchymosis (bruising)

  • Drainage

  • Approximation (how well the edges of the wound are closed)

• Homan’s / Hemorrhoids: Check calves for edema, redness, and pain (Homan's sign is an assessment for deep vein thrombosis). Inspect for hemorrhoids or hematomas on the perineum.

• Emotions: Assess for nutrition, fatigue, pain level, adaptation to motherhood, and body image issues.

Lochia Characteristics and Assessment

• Lochia is the vaginal discharge that occurs after birth as the uterine lining sheds. It is categorized by its appearance and timing:

  • Lochia Rubra (Days 1–3): Bright or dark red; contains blood from the placental site, trophoblastic tissue debris, vernix, lanugo, and meconium.

  • Lochia Serosa (Days 4–10): Pinkish-brown or pink; contains blood, wound exudate, RBCs, WBCs, trophoblastic tissue debris, cervical mucus, and microorganisms.

  • Lochia Alba (Day 10–14, up to 3–6 weeks): Whitish-yellow or cream-colored; contains WBCs and trophoblastic tissue debris.

• Amount of Lochia (Saturation on Perineal Pad):

  • Scant: $< 2.5\,cm$

  • Light: $< 10\,cm$

  • Moderate: $> 10\,cm$

  • Heavy: Pad saturated within $1\,hour$.

  • Excessive: Pad saturated within $15\,minutes$.

Perineal and Tissue Integrity

• Lacerations of the perineum are classified in degrees based on severity.

• An episiotomy is a surgical incision made to the perineum during birth.

• Interventions:

  • Apply ice or cold packs for the first $24\,hours$ to reduce swelling and provide comfort (e.g., Cardinal Health Perineal Cold Pack).

  • After the first $24\,hours$, heat/sitz baths may be used.

  • Topical creams or anesthetic sprays may be used for comfort.

  • The perineum must be inspected for signs of infection or the development of hematomas.

Breastfeeding and Hormonal Regulation

• Immediate skin-to-skin contact and early breastfeeding attempts are encouraged.

• Hormonal Changes:

  • The rapid decrease in estrogen and progesterone after the placenta is expelled triggers physiologic changes and allows prolactin levels to increase.

  • Prolactin: Secreted by the pituitary gland; responsible for milk production. Levels rise when the infant suckles.

  • Oxytocin: Triggers the milk ejection reflex ("letdown") and causes tiny muscles around the alveoli to squeeze milk into the ducts. It also causes uterine contractions.

• Milk Stages:

  • Colostrum: Creamy, yellowish fluid produced the first few days; high in protein, vitamins, minerals, and antibodies.

  • Transitional Milk: Appears after $2-3\,days$.

  • Mature Milk: Established by day $5$.

• Milk Composition During Feeding:

  • Foremilk: The milk at the start of a feeding; thinner, bluish/watery, high in lactose, and very hydrating.

  • Hindmilk: The milk that comes later in the feeding; thicker, creamier, white or yellow, and higher in fat and calories.

• Low estrogen levels during the postpartum period can lead to vaginal dryness and tenderness.

Postpartum Elimination and Vital Signs

• Bladder: The mother is at risk for urinary retention. Marked postpartum diuresis typically occurs within $12-24\,hours$.

• Vital Signs: Typically remain stable. However, a rapid/increasing heart rate and low/decreasing blood pressure can indicate hypovolemia secondary to hemorrhage.

• Coagulation: Hypercoagulability, combined with vessel damage and immobility, increases the risk of venous thromboembolism.

Cesarean Section Considerations

• The current Cesarean Section (C/S) rate in the U.S. is approximately $33\%$.

• Additional Risks and Assessments:

  • Increased risk of infection (wound, UTI, pulmonary).

  • Increased use of narcotics or sedatives for pain management.

  • Decreased mobility, necessitating assessments for respiratory function and DVT.

Maternal and Paternal Psychosocial Adaptation

• Maternal Pregnancy Adaptation:

  • 1st Trimester: Disbelief and ambivalence.

  • 2nd Trimester: Quickening (fetal movement) helps viewing fetus as separate.

  • 3rd Trimester: Anxiety regarding birth; "nesting" behaviors.

• Maternal Postpartum Adaptation: Assessment involves monitoring behaviors that facilitate or impair mother/baby bonding, mood swings, or insecurity in the maternal role.

• Paternal Adaptation:

  • Pregnancy: May feel left out or resent the attention the partner receives; decides which behaviors to model from their own father.

  • After Birth: Development of bond and transition into the fatherhood role.

• Sibling Adaptation: Reaction depends on age; siblings may feel threatened by the new baby, making preparation essential.

Interventions and Pharmacological Management

• Analgesics: Pain management for afterpains and perineal trauma.

• Antibiotics: Ampicillin, cefazolin, gentamycin.

• Antidepressants: Sertraline.

• Narcotic Agonists: Oxycodone.

• NSAIDS: Ibuprofen, ketorolac.

• Stool Softeners: Docusate (to aid elimination and prevent straining).

• Uterotonics: Medications used to induce uterine contractions and prevent hemorrhage, including oxytocin, misoprostol, methergine, and carboprost.

• Vaccines: TDAP, flu, rubella, varicella.

• Vitamins and Iron: To support recovery and combat anemia.

Discharge Criteria and Teaching

• Mother: Teaching includes signs of complications, area support groups, mother-baby unit contact information, follow-up with the OB provider, and medication instructions.

• Infant: Teaching covers feeding (breast or bottle), basic infant care, umbilical cord care, immunizations, safety, car seat use, and follow-up with a pediatrician.