Medicine

THE PHYSIOLOGY OF THE POSTNATAL PERIOD

The physiology of the postnatal period

 

Once a woman becomes a mother, everything changes—her body, her obligations, her priorities. Not only does she need to heal physically, but she’s responsible for another human being. It’s easy for her to put her needs aside in the interest of the baby’s.

 

The first month after giving birth is a time to recuperate and adjust. The pelvic floor has been stretched significantly during birth and may even have been cut or torn to facilitate delivery. The cervix has to close back down from dilating to 10 centimeters (4 inches) and then stretching to let the baby pass through. The uterus shrinks a lot in the first few days, but it will take at least a month to return to its postpartum size, and the internal organs have to settle back into position after being crowded for so long. If the mother had a Caesarean section, the pelvic floor will be intact, but she has had a major abdominal surgery that will take several months to heal.

 

Perhaps one of the most surprising (and possibly disappointing) aspects of the postnatal period for a new mother is that she still looks about four to five months pregnant. The baby and the afterbirth add up to only about 15 to 20 pounds of weight lost immediately. In the first week or two after giving birth, she still has a lot of extra fluids in her system that are slowly being flushed out or reabsorbed. Her abdominals and the skin over the belly are loose after being stretched out for nine months.

 

These first few weeks can also be hugely emotional as she learns to take care of her new baby and adjust to her role as a mother. This intense responsibility, combined with hormones that are still present in the system (and will remain for months if she is breast-feeding), can lead to mood swings and even depression.

Easing Back into Practice

 

Doctors and midwives recommend that a new mom wait for at least six weeks (eight weeks, if she’s had a C-section) before restarting exercising. She may have exercised regularly during pregnancy, but she doesn’t have the same body she had then—or ever before. (Even if this pregnancy wasn’t her first, her body and recovery needs won’t necessarily be the same after each birth.)

 

The abdominals are the muscles most affected by pregnancy, and so they’re an obvious set to focus on. The shoulders and neck are another area that can be very sore in the postpartum period.  Simply carrying a newborn around will strain the upper back, because the tendency is to hunch over the baby instead of standing up straight.

 

By the end of the first eight weeks of motherhood, the postpartum mother should be ready to resume her regular practice, but remind her to listen to what her body is ready to do.

 

The Importance of Rest

 

This time is exciting, exhausting, thrilling, and scary. A new mother will be flooded with conflicting emotions while simultaneously trying to manage all the physical demands of parenthood. Taking time for complete relaxation at the end of class is a good way for her to recuperate and calm her mind. It may be the only time in the day she gets to focus on her own needs.

Baby the Mother

 

Some points to consider for postnatal mother:

 

Encouraging patience. It took nine months and one birth to get to this place, so a new mother should give herself another nine months to get back to “normal.” If she tries to rush the healing process, she could actually prolong it by aggravating any strained muscles, tears, or incisions. She needs to listen to what her body is ready to do. Focus on the center. A postpartum mother’s torso is the area that needs the most attention. She needs to work on her abdominals and lower back by starting with gentle stretches and gradually moving into strength-building poses, as well as lots of chest and shoulder openers to ease soreness in the upper body.

 

Turning the focus on her. The early months of a baby’s life are its most helpless. She will be spending so much time caring for and worrying about this little person that she will neglect her own health and needs. Therefore she her to relax and focus on herself while practicing, so she will be refreshed and ready to parent again after class.

 

Postpartum Care

 

COURSE OBJECTIVE:  The purpose of this course is to provide a review of postpartum physiology, psychology, assessment, normal adaptation, complications, and teaching the postpartum client.

 

LEARNING OBJECTIVES

Upon completion of this course, you will be able to:

Describe the normal physiologic and psychological adaptations to the postpartum period.

Explain how to perform a postpartum nursing assessment.

Identify the teaching topics that are relevant to postpartum clients.

Discuss nursing care for the postpartum client.

Summarize the treatment of maternal complications seen during the postpartum period.

List the symptoms that postpartum clients should report to their healthcare providers after discharge.

 

The postpartum period covers the time period from birth until approximately 6 weeks after delivery. This is a time of healing and rejuvenation as the mother’s body returns to pre-pregnancy states. Nurses need to be aware of the normal physiologic and psychological changes that take place in clients’ bodies and minds in order to provide comprehensive care during this period. In addition to client and family teaching, one of the most significant responsibilities of the postpartum nurse is to recognize potential medical complications after delivery.

 

NORMAL POSTPARTUM ADAPTATIONS: PHYSIOLOGIC

Reproductive System

 

UTERUS

 

Immediately after delivering, clients experience massive shifting as the body returns to its pre-pregnant state. This process, known as involution, begins immediately after the delivery of the placenta. The uterus, with the assistance of the uterine muscles, contracts the blood vessels at the site of placental attachment to control bleeding.

 

A process known as exfoliation also occurs at this time. Exfoliation is the sloughing off of dead tissue at the site where the placenta attached to the uterine wall. Exfoliation leaves the site smooth and without scar tissue to allow for the implantation of fertilized ova in subsequent pregnancies.

 

The uterus continues to contract after delivery, and its size decreases rapidly as estrogen and progesterone levels diminish. Immediately after delivery, the upper portion of the uterus, known as the fundus, is midline and palpable halfway between the symphysis pubis and the umbilicus. By approximately 1 hour post delivery, the fundus is firm and at the level of the umbilicus. The fundus continues to descend into the pelvis at the rate of approximately 1 cm (finger-breadth) per day and should be nonpalpable by 10 days postpartum. Uterine involution can be impeded by anything that would cause distention of the uterus, including an unusually large (macrosomic) infant, multiple pregnancies, multiple births, or excessive amniotic fluid.

 

Afterpains, or intermittent uterine contractions, are a normal occurrence during the postpartum period. Afterpains are caused by the release of the hormone oxytocin and the subsequent relaxation and contraction of the uterine muscles. Afterpains can be quite intense for postpartum clients and are particularly painful for clients who have given birth previously (multiparous). Afterpains are caused by the loss of uterine muscle tone following numerous pregnancies. Clients may also experience afterpains while breastfeeding as a result of nipple stimulation and the subsequent release of oxytocin. Afterpains generally last for a few days and can be alleviated by relaxation techniques and, if necessary, analgesics.

 

After delivery, the endometrial surface of the uterus is shed via the vagina. The shedding endometrium is known as lochia. Lochia occurs in three successive stages that include lochia rubra, lochia serosa, and lochia alba. Lochia rubra is bright red and is noted on postpartum days 1 to 3. Lochia serosa is pink to brown in color and occurs after day 3. By 10 days postpartum, lochia is yellow to white in color and is referred to as lochia alba.

 

CERVIX

 

As with all other reproductive organs and structures, the cervix also changes as the body returns to a pre-pregnancy state. After delivery, the cervix is edematous and may appear bruised. The external os resembles a slit as compared to the circular, dimpled opening prior to the first pregnancy. The internal os closes almost completely within 2 weeks of delivery.

 

VAGINA

 

The vaginal walls are smooth after delivery and the vaginal folds, known as rugae, do not return until approximately 4 weeks postpartum. The vagina itself will never return to the pre-pregnant size but will decrease in size and return to a near pre-pregnancy state as the postpartum period progresses. The vagina usually appears edematous and may have small lacerations incurred during the delivery. Vaginal dryness and painful intercourse, known as dyspareunia, may be noted during the postpartum period due to decreased estrogen levels. Mucous production should return with ovulation, and clients are frequently encouraged to use water-based lubricants (e.g., K-Y Jelly) with intercourse to ease discomfort.

 

 PERINEUM

 

This area between the posterior portion of the labia majora and the anus stretches and thins during birth to accommodate the delivering infant. Lacerations of the perineum may occur during delivery, or an episiotomy (surgical incision) may be performed in this area to accommodate the infant during delivery.

 

Lacerations of the perineum are identified as first-, second-, third-, or fourth-degree. First-degree lacerations extend through the skin and superficial layers of the perineum. Second-degree lacerations extend through the perineal muscles, while third-degree lacerations extend through the anal sphincter muscles. Fourth-degree lacerations extend through the anterior rectal wall and can be damaging to the perineum.

 

In the 2005 National Hospital Discharge Summary, DeFrances, Cullen and Kozak (2007) indicated that repair of obstetric lacerations rose from 11% in 1980 to 45% in 2005. Ideally, the perineum should be protected from trauma during labor and birth. Hastings-Tolsma and colleagues (2007) postulate that factors "protective against perineal trauma (i.e., lacerations) included massage, warm compress use, manual support, and birthing in the lateral position."

 

Regardless of the presence of lacerations or an episiotomy, the perineum is generally edematous and often bruised immediately following delivery. The muscle tone of this area is weakened as a result of delivery and never completely returns to the state it was prior to the first pregnancy.

 

EPISIOTOMY

 

An episiotomy to aid in the delivery of the infant should be performed only when necessary. There is much debate regarding the maternal benefits of episiotomies, and researchers continue to denounce its usage, except under extenuating circumstances. “An episiotomy was performed during a majority of vaginal deliveries in 1980 (64 percent), but by 2005, it was performed during less than one of every five vaginal deliveries (19 percent)” (DeFrances, Cullen & Kozak, 2007).

 

BREASTS

 

After delivery there is a significant decrease in estrogen and progesterone levels. Before milk production begins, the breasts secrete colostrum, a thin, yellowish fluid that helps maintain the blood glucose level in the breastfeeding infant. Nipple stimulation by the infant causes the release of the hormone oxytocin from the posterior pituitary gland, which triggers the release of the hormone prolactin from the anterior pituitary. Prolactin initiates milk production, and the breasts become full (engorged), as well as warm and tender, between postpartum days 3 and 4. Clients often refer to this as having their milk “come in.” There may be a slight elevation in body temperature during this time.

 

Clients who choose not to breastfeed will also experience their milk “coming in”; however, lactation can be suppressed through the use of a well-fitted bra. Non-breastfeeding clients should also avoid any type of nipple stimulation or heat to the breasts, such as warm or hot showers in which the water is allowed to run continuously over the breasts. These clients can use ice packs or cool cabbage leaves to ease breast discomfort until milk production ceases. It generally takes 5 to 7 days for the breasts to stop producing milk. Healthcare providers may consider prescribing mild analgesics if a client has significant discomfort.

Endocrine System

 

With the sharp decrease of estrogen and progesterone levels following delivery of the placenta, lactation begins and menstruation returns. Estrogen is a prolactin-inhibiting hormone. When clients choose to bottle-feed, prolactin levels diminish and estrogen levels begin to rise. Menstruation returns in approximately 6 to 8 weeks for these clients. However, ovulation can return within 4 weeks.

 

When clients breastfeed, prolactin levels increase as breastfeeding continues. Therefore, menstruation does not return until 12 weeks or later. Because ovulation can return prior to menses, it is important for healthcare providers to discuss family planning with clients during the early postpartum period in order to prevent undesired pregnancies.

 

Cardiovascular System

 

As the body prepares the pregnant body for blood loss at birth, there is an increase in circulating blood volume during pregnancy. Clients may lose up to 500 mL of blood during a vaginal delivery and between 800 and 1000 mL of blood during a cesarean (C-section) delivery. However, due to the increase in circulating blood volume that occurs during pregnancy, blood loss at delivery can easily be managed by the postpartum client who does not have cardiovascular or clotting problems.

 

At delivery, there are fluid changes within the body to accommodate postpartum blood loss and to prevent hypovolemia. “These changes include (1) elimination of the placenta, which diverts 500 to 750 mL of blood flow into the maternal systemic circulation; (2) rapid reduction of the size of the uterus, which puts more blood in the systemic circulation; (3) increase of blood flow to the vena cava from elimination of compression by the gravid uterus; and (4) mobilization of body fluids accumulated during pregnancy” (Leifer, 2005).

 

The postpartum body removes excess fluid accumulated during pregnancy by diuresis. Clients may excrete up to 3000 mL of fluid per day during the postpartum period. In addition, clients frequently experience excessive perspiration (diaphoresis), which also releases accumulated fluid during the postpartum period. Clients should be educated about increased urination and perspiration during this period.

 

During the early postpartum period there is a loss of plasma blood volume that is greater than that of red blood cells. Thus, there is a temporary rise in hemoglobin and hematocrit levels by the seventh postpartum day (Crum, cited in Lowdermilk & Perry, 2006). It is difficult to measure hemoglobin and hematocrit levels accurately at this time. However, these levels do eventually return to normal.

 

Due to the inflammation, pain, and the stress of birth, neutrophils, a type of white blood cell, are increased and are responsible for a marked increase in the white blood cell count during the postpartum period (McKinney et al., 2005). As a result of this normal increase in the white blood cell count, it is important for healthcare providers to monitor clients closely for indications of infection during the postpartum period.

 

Fibrinogen is a protein that, along with other clotting factors, is responsible for the clotting of blood. In addition to the increase in circulating blood volume during pregnancy, plasma fibrinogen levels increase and remain increased for several days after delivery. Postpartum clients have an increased risk of developing blood clots. Therefore, early ambulation is imperative.

 

Respiratory System

 

During pregnancy, the diaphragm is slightly elevated as the fetus nears term. This, along with other respiratory changes, causes thoracic versus abdominal breathing in the third trimester (McKinney et al., 2005). After delivery, the diaphragm descends and postpartum clients’ respirations normally return to the pre-pregnant state.

Gastrointestinal System

 

Clients are generally hungry and thirsty after delivery due to the amount of energy expended during labor. Food and fluid intake is usually restricted during labor, and many clients may not have eaten for a number of hours prior to delivery. The diaphoresis that occurs during the postpartum period may also lead to increased thirst. It is important for nurses to provide nourishment and hydration upon delivery.

 

Many clients experience constipation from the lack of fluid and food intake during labor. Furthermore, bowel tone is sluggish as a result of elevated progesterone levels. Often clients are hesitant to have a bowel movement in the postpartum period due to pain in the perineal area resulting from an episiotomy, lacerations, or hemorrhoids. Some clients are also fearful that they will rip their stitches should they have a bowel movement. Healthcare providers may prescribe stool softeners and/or laxatives to treat constipation and provide perineal comfort during defecation.

 

Urinary System

 

The bladder, urethra, and urinary meatus are edematous after delivery as a result of the fetal head passing through the birth canal. Bladder tone is diminished, and many clients are unable to feel the need to void, despite the rapid diuresis that occurs following delivery. In this situation, the bladder can become distended and displace the uterus upward and to the side, which prevents the uterine muscles from contracting properly and can lead to a postpartum hemorrhage. Therefore, healthcare providers must carefully monitor bladder distention, the firmness of the fundus, and bleeding during the postpartum period.

 

Urinary retention as a result of decreased bladder tone and emptying can lead to urinary tract infections (UTIs). It is imperative that nurses monitor postpartum clients for signs of urinary tract infection, including tenderness over the costovertebral angle, fever, urinary frequency and/or urgency, and difficult or painful urination.

 

According to Varney and colleagues (2004), 40% of postpartum clients have protein in their urine that can be noted up to the second postpartum day. Proteinuria during this time is considered benign unless there are signs of a urinary tract infection or preeclampsia.

 

Musculoskeletal System

 

As with all other body systems, the musculoskeletal system undergoes changes during the postpartum period. Relaxin is the hormone responsible for the relaxation of the pelvic ligaments and joints during pregnancy. After delivery, relaxin levels subside and the pelvic ligaments and joints return to their pre-pregnant state. However, the joints of the feet remain altered and many clients notice a permanent increase in shoe size (Crum, cited in Lowdermilk & Perry, 2006).

 

The abdominal wall is weakened and the muscle tone of the abdomen is diminished after pregnancy. Some clients have a separation between the abdominal wall muscles, called diastasis recti. This separation can often be corrected with certain abdominal exercises performed during the postpartum period. Clients should be instructed to begin abdominal exercises anytime following a vaginal delivery and after abdominal tenderness resolves following a cesarean section (Cunningham et al., 2005). Clients should also be instructed to avoid overexertion during the first few weeks after delivery.

 

Integumentary System

 

Melanocyte-stimulating hormone (MSH) is responsible for the hyperpigmentation that occurs during pregnancy. MSH levels rapidly decrease after delivery, and the skin changes that occurred as a result of pregnancy revert to the pre-pregnant state or are permanently altered. More specifically, the mask of pregnancy (chloasma) usually disappears, while stretch marks (striae gravidarum) and linea nigra fade but generally do not go away. Hair loss may occur during the postpartum period but usually resolves without the need for intervention. As previously mentioned, diaphoresis is common during the postpartum period, and clients should be informed that they may need to change clothes and bed linens more frequently than usual.

 

Immune System

 

There are few changes in the immune system during the postpartum period. However, it is important for Rh-negative clients to receive Rh immune globulin within 72 hours of delivery to prevent maternal antibody production in response to the Rh-positive antigen received from infants during pregnancy or birth.

 

The rubella vaccine should also be administered to postpartum clients who tested nonimmune or had a rubella titer less than 1:10 prior to delivery. Clients should be informed that the vaccination is given to prevent fetal anomalies in subsequent pregnancies. Additionally, the rubella vaccine is a live virus and is contraindicated during pregnancy. Therefore, all female clients should be instructed to avoid becoming pregnant for the 4 weeks following the administration of the vaccine (CDC, 2008).

 

NORMAL POSTPARTUM ADAPTATION: PSYCHOLOGICAL

 

The postpartum period is a time of immense change for the new mother and her family. Roles and expectations often shift as families adjust to their newest addition and clients learn to “become mothers” (Mercer, 2004).

 

Attachment

 

Bonding, sometimes referred to as attachment, between clients and their infant is affected by a multitude of factors, including socioeconomic status, family history, role models, support systems, cultural factors, and birth experiences. Nurses are encouraged to consider these variables when assessing the attachment process between mothers and infants. It is also important to note that clients begin to show attachment behaviors not only in the postpartum period but also during pregnancy. Therefore, healthcare providers have multiple opportunities to assess how pregnant clients will likely bond with their infants after delivery. Various tools, such as the Postpartum Bonding Questionnaire, can be helpful in assessing bonding (see below).

 

In maternal-newborn healthcare, attachment refers to the emotional connection between a mother and her infant. This attachment is reciprocal; both the mother and the infant exhibit attachment behaviors. The infant responds to the mother by cooing, grasping, smiling, and crying. However, these behaviors are nondiscriminatory before approximately 8 weeks. Nurses can assess for attachment behaviors by observing the interactions between mothers and their infants. Behaviors exhibited by mothers that indicate positive attachment include:

·        Touching

·        Holding

·        Kissing

·        Cuddling

·        Talking and singing

·        Choosing the “en face” position

·        Expressing pride in the infant

 

Postpartum assessment of attachment should begin immediately after delivery and continue throughout the infant’s first year of life. Most clients positively attach to their newborn infants. However, there are some who do not form attachments appropriately. Mal-attachment behaviors vary, but can include:

·        Refusing to look at the infant

·        Refusing to touch or hold the infant

·        Refusing to name the infant

·        Negative comments about the infant

·        Refusing to respond or responding negatively to infant cues (eg, crying, smiling)

 

It is important to note that during the early postpartum period many factors can affect attachment, including anesthesia after a cesarean section, pain, or a traumatic birthing experience. Healthcare providers should to consider these factors when assessing attachment. If mal-attachment is noted, providers should immediately report the observation and continue to monitor both the mother and infant

 

POSTPARTUM ASSESSMENT AND PATIENT EDUCATION

 

Primary responsibilities of nurses in postpartum settings are to assess postpartum clients, provide care and teaching, and, if necessary, report any significant findings. Postpartum nurses are essentially detectives searching for findings that might lead to negative outcomes for clients if left unattended. Thus, it is imperative for nurses to distinguish between normal and abnormal findings and to have a clear understanding of the nursing care necessary to promote clients’ health and well-being.

 

Many nurses find it useful to use the acronym BUBBLE-LE to remember the necessary components of the postpartum assessment and teaching topics. These include: breasts, uterus, bowel function, bladder, lochia, episiotomy/perineum, lower extremities, and emotions.

 

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