THE POSTPARTAL PERIOD

General overview: This review of the normal physiological and psychological changes occurring during the post-partal period (birth to 6 weeks after) provides the database necessary for assessing the woman’s progress through involution, planning and implementing care, anticipatory guidance, health teaching, and evaluating the results. Emerging problems are identified by comparing the woman’s status against established standards.

  1. Biological foundations of the postpartal period
    1. Uterine involution-integrated processes by which the uterus returns to nonpregnant size, shape, and consistency.
      1. Assessment:
        1. Contractions (“afterpains”)-shorten muscles, close venous sinuses, restore normal tone.
          1. Frequency, intensity, and discomfort decrease after first 24 hours
          2. More common in multiparas and after birth of a large baby; primiparous uterus remains contracted.
          3. Increased by breastfeeding.
        2. Autolysis-breakdown and excretion of muscle protein (decreasing size of myometrial cells). Lochia-sloughing of decidua and blood.
        3. Formation of new endometrium-4-6 weeks until placental site healed.
        4. Cervix
          1. Immediately following birth-bruised, small tears; admits one hand.
          2. Eighteen hours after birth-becomes shorter, firmer; regains normal shape.
          3. One week postpartum-admits two fingers.
          4. Never returns fully to prepregnant state.
            1. Parous os is wider and not perfectly round.
            2. Lacerations heal as scars radiating out from the os.
        5. Fundal height and consistency
          1. After birth-at umbilicus; size and consistency of firm grapefruit.
          2. Day 1 (first 12 hours)-one finger above umbilicus.
          3. Descends by one finger-breadth daily until day 10.
          4. Day 10-behind symphysis pubis, nonpalpable.
        6. Lochia
          1. Character:
            1. Days 1-3: rubra (red).
            2. Days 3-7: serosa (pink to brown).
            3. Day 10: alba (creamy white).
          2. Amount:
            1. Moderate: 4-8 pads/day (average 6 pads/day).
            2. Following cesarean birth: less lochia-due to manipulation during surgery.
          3. Odor: normal lochia has characteristic “fleshy” odor; foul odor is characteristic of infection.
          4. Clots: normal: a few small clots, most commonly on arising-due to poolinNote: Clots and heavy bleeding are associated with uterine atony, retained placental fragments.
    2. Birth canal
      1. Vagina-never returns fully to prepregnant state.
        1. First few weeks postpartum-thin walled, due to lack of estrogen; few rugae.
        2. Week 3: rugae may reappear.
      2. Pelvic floor
        1. Immediately after birth-infiltrated with blood, stretched, torn.
        2. Month 6: considerable tone regained.
      3. Perineum
        1. Immediately following birth-edematous; may have episiotomy (or repaired lacerations); hemorrhoids.
        2. Healing, incisional line clean; no separation.
        3. Hematoma-blood in connective tissue beneath skin; complains of pain, unrelieved by mild analgesia or heat; perineal distention; painful, tense, fluctuant mass.
    3. Abdominal wall
      1. Overdistention during pregnancy may-rupture of elastic fibers, persistent striae, and diastasis of the rectus muscles.
      2. Usually takes 6-8 weeks to retrogress, depending on previous muscle tone, obesity, and amount of distention during pregnancy.
      3. Strenuous exercises discouraged until 8 weeks postpartum.
    4. Cardiovascular system-characteristic changes:
      1. Immediately after birth-increased cardiac load, due to:
        1. Return of uterine blood flow to general circulation.
        2. Diuresis of excess interstitial fluid.
      2. Volume-returns to prepregnant state (4 L) in about 3 weeks. Major reduction-during first week, due to diuresis and diaphoresis.
      3. Blood values.
        1. High WBC during labor (25,000-30,000/ mm3), drops to normal level in first few days.
        2. Week 1-Hgb, RBC, Het, elevated fibrinogen return to normal.
      4. Blood coagulation
        1. During labor: rapid consumption of clotting factors.
        2. During postpartum: increased consumption of clotting factors. Hypercoagulability maintained during first few days postpartum; predisposes to thrombophlebitis, pulmonary embolism.
      5. Assessment: potential complications-vital signs:
        1. Temperature-elevated in:
          1. Excessive blood loss, dehydration, exhaustion, infection.
          2. Elevation: 100.4°F (38°C) after first day postpartum suggests puerperal infection.
        2. Pulse-physiological bradycardia (50-70) common through second day postpartum; may persist 7-10 days; etiology: unknown. Tachycardia-associated with: excessive blood loss, dehydration, exhaustion, infection.
        3. Blood pressure-generally unchangeElevation-associated with: preeclampsia, essential hypertension.
    5. Urinary tract-characteristic changes:
      1. Output-increased due to: diuresis (12 hours to 5 days postpartum); daily output to 3000 mL.
      2. Urine constituents:
        1. Sugar-primarily lactose, usually not detected by conventional dipstick.
        2. Acetonuria-after prolonged labor; dehydration.
        3. Proteinuria-first 3 days in response to the catalytic process of involution ≤1+.
      3. Dilation of ureters-subsides in first few weeks.
      4. Assessment: potential complications-measure first few voidings, palpate bladder to determine emptying.
        1. Edema, trauma, or anesthesia may-retention with overflow.
        2. Overdistended bladder-common cause of excessive bleeding in immediate postpartum.
    6. Integument (skin)-characteristic changes:
      1. Striae-persist as silvery or brownish lines.
      2. Diastasis recti abdominis-some midline separation may persist.
      3. Diaphoresis-excessive perspiration for first few (approximately 5) days.
      4. Breast changes.
      5. Linea nigra and darkened areola fade.
    7. Legs
      1. Should have no redness, tenderness, local areas of increased skin temperature, or edema.
      2. May have some soreness from birth position.
      3. Homans’ sign should be negative (no calf pain when knee is extended and gentle pressure applied to dorsiflex the foot).
    8. Weight-characteristic changes:
      1. Initial weight loss-fetus, placenta, amniotic fluid, excess tissue fluid.
      2. Weighs more than in prepregnant state (weight maintained in breasts).
      3. Week 6-weight loss is individualized.
    9. Menstruation and ovarian function-first menstrual cycle may be anovulatory.
      1. Nonnursing-ovulation at 4-6 weeks; menstruation at 6-8 weeks.
      2. Nursing-anovulatory period varies (39 days to 6 mo or more); some for duration of lactation; contraceptive value: very unreliable.