Reproductive health

- T he puerperium * The puerperium, or postpartum period, is the period during which the woman readjusts, physically and psychologically, from pregnancy and birth.

* It begins immediately after birth and continues for approximately 6 weeks or until the body has returned to a near nonpregnant state.

- Reproductive System

- Involution of the Uterus

* The term involution is used to describe the rapid reduction in size of the uterus and its return to a condition similar to its nonpregnant state, although it remains slightly larger than it was before the first pregnancy.

* The weight of the uterus decreases from 1000 g in the immediate postpartal period to 500 g at the end of the first week.

* It reaches 300 g by the end of the second week, finally terminating the involution process with a weight of 100 g or less.

Reproductive health

* The spongy layer of the decidua is cast off as lochia, and the basal layer of the decidua remains in the uterus to become differentiated into two layers within the first 48 to 72 hours after birth.

* The outermost layer becomes necrotic and is sloughed off in the lochia.

* The layer closest to the myometrium contains the fundi of the uterine endometrial glands, and these glands lay the foundation for the new endometrium.

* Except at the placental site, this process is completed in approximately 3 weeks.

* The placental site can take up to 6 weeks to completely heal.

* Exfoliation is one of the most important aspects of involution.

*If the healing of the placental site left a fibrous scar, the area available for further implantation would be limited, as would the number of possible pregnancies.

* With the dramatic decrease in the levels of circulating estrogen and progesterone following placental separation, the uterine cells atrophy, and the hyperplasia of pregnancy begins to reverse.

* The process is one in which the size of the cells decreasesMarkedly.

Reproductive health

* Factors that enhance involution include:1) an uncomplicated labor and birth

2) complete expulsion of the amniotic membranes and the placenta3) breastfeeding

4) manual removal of the placenta during a cesarean birth5) early ambulation.

- Changes in Fundal Position :

* Immediately following the expulsion of the placenta, the uterus contracts firmly to the size of a large grapefruit.

Reproductive health

* The fundus (top portion of the uterus) is situated in the midline of the abdomen, one half to two thirds of the way between the symphysis pubis and the umbilicus.

* Within 6 to 12 hours after birth, the fundus of the uterus rises to the level of the umbilicus because of blood and clots that remain within the uterus and changes in support of the uterus by the ligaments.

* A fundus that is above the umbilicus and boggy (feels soft and spongy rather than firm and well contracted) is associated with excessive uterine bleeding.

* As blood collects and forms clots within the uterus, the fundus rises; firm contractions of the uterine muscle are interrupted, causing a boggy uterus (uterine atony).

* When the fundus is higher than expected and is not in midline (usually deviated to the right), distention of the bladder should be suspected andthe bladder should be emptied immediately.

* If the woman is unable to void, inand- out catheterization of the bladder may be required.

* In the immediate postpartal period many women may not be aware of a full bladder.

* Because the uterine ligaments are still stretched, a full bladder can move the uterus.

* By the end ofthe puerperium these ligaments have regained their non pregnant length and tension.

Reproductive health

* After birth, the top of the fundus remains at the level of the umbilicus for about half a day.

* On the first postpartum day (first day following birth), the top of the fundus is located about 1 cm below the umbilicus.

* The top of the fundus descends approximately one fingerbreadth (width of index, second, or third finger), or 1cm, per day until it descends into the pelvis on the 10th day.

- Lochia* The uterus rids itself of the debris remaining after birth through a discharge called lochia

* which is classified according to its appearance and contents.

1) Lochia rubra

* Named for the Latin word for red, is dark red in color.

*It is present for the first 2 to 3 days postpartal and contains epithelial cells, erythrocytes, leukocytes, bacteria, shreds of the decidua, and,

occasionally, fetal meconium, lanugo, and vernix caseosa.

*Clotting is often the result of pooling of blood in the upper portion of the vagina.

*A few small clots (no larger than a nickel) are common, particularly in the first few days after birth.

* lochia should not contain large (plum sized) clots; if it does, the cause should be investigated without delay.

Reproductive health

2) Lochia serosa

* Is a pinkish color.It follows from about the 3rd to the 10th day.

* Lochia serosa is composed of serous exudate, shreds of degenerating decidua, erythrocytes, leukocytes, cervical mucus, and numerous

microorganisms.

* The red blood cell (RBC) component decreases gradually, and a creamy or yellowish discharge persists for an additionalweek or two.

This final discharge, termed lochia alba

3) lochia alba

* Is composed primarily of leukocytes, decidual cells, epithelial cells, fat, cervical mucus, cholesterol crystals, and bacteria.

* Recent studies examining lochia patterns have found that the lochia rubra phase lasts longer than generally assumed and that it varies

according to breastfeeding practice and parity

* Variation in the duration of lochia discharge is not uncommon; however, the trend should be toward a lighter amount of flow and a

lighter color of discharge.

* When the lochia stops, the cervix is considered closed, and chances of infection ascending from the vagina to the uterus decrease.

Reproductive health

* Any foul smell to the lochia or used perineal pads suggests infection and the need for prompt additional assessment, such as white blood cell

(WBC) count and differential.

* The total volume of lochia is approximately 225 ml.

* Discharge is greater in the morning because of pooling in the vagina and uterus while the mother lies sleeping.

* Multiparous women usually have more lochia than first-time mothers.

* Women who undergo a cesarean birth typically have less lochiathan women who give birth vaginally.

* The type, amount, and consistency of lochia determine the stateof healing of the placental site,

* Persistent discharge of lochia rubra or a return to lochia rubra indicates subinvolution or late postpartum hemorrhage.

* Lacerations should be suspected if the uterus is firm and of expected size and if no clots.

- Cervical Changes

* Following birth, the cervix is spongy, flabby, and formless and may appear bruised.

* The lateral aspects of the external os are frequently lacerated during the birth process.

Reproductive health

* The external os is markedly irregular and closes slowly.

* It admits two fingers for a few days following birth, but by the end of the first week it will admit only a fingertip.

* The shape of the external os is permanently changed by the first childbearing.

* The characteristic dimplelike os of the nullipara changes to the lateral slit (fish-mouth) os of the multipara.

- Vaginal Changes

* Following birth, the vagina appears edematous and gaping and may be bruised.

* Small superficial lacerations may be evident, and the rugae have been obliterated.

* The size of the vagina decreases and rugae begin to return within 3 weeks.

* By 6 weeks, the nonlactating woman’s vagina usually appears normal.

* The lactating woman is in a hypoestrogenic state because of ovarian suppression, and her vaginal mucosa may be pale and without rugae.

* This may lead to dyspareunia (painful intercourse)

* Tone and contractibility of the vaginal opening may be improved by perineal tightening exercises.

Reproductive health

* The labia majora and labia minora are looser in the woman who has borne a child than in the nullipara.

- Perineal Changes

* During the early postpartal period, the soft tissue in and around the perineum may appear edematous with some bruising.

* Ecchymosis occurs, and this may delay healing.

* Initial healing of the episiotomy or laceration occurs in 2 to 3 weeks after the birth, although complete healing may take up to 4 to 6 months.

* Perineal discomfort may be present during this time.

- Recurrence of Ovulation and Menstruation

* Menstruation generally returns in nonbreastfeeding mothers between 6 and 10 weeks after birth; 50% of the first cycles are anovulatory .

* The return of ovulation is directly associated with a rise in the serum progesterone level. * In nonlactating women the average time to first ovulation can occur within 5 to 11 weeks with a mean time of 7 weeks.

* The return of menstruation and ovulation in breastfeeding mothers is usually prolonged and is associated with the length of time the woman breastfeeds and whether formula supplements are used.

Reproductive health

* If a mother breastfeeds for less than 1 month, the return of menstruation and ovulation is similar to the nonbreastfeeding mother.

* In women who exclusively breastfeed, menstruation is usually delayed for at least 3 months.

* Sucking by the infant typically results in alterations in the gonadotropin-releasing hormone (GnRH) production, which is thought to be the cause of amenorrhea

* Although exclusive breastfeeding helps to reduce the risk of pregnancy for the first 6 months after delivery.

* Furthermore, because ovulation precedes menstruation and women often supplement breastfeeding with bottles and pacifiers, breastfeeding is not considered a reliable means of contraception.

- Abdomen

* The uterine ligaments (notably the round and broad ligaments) are stretched and require the length of the puerperium to recover.

* The stretched abdominal wall appears loose and flabby, but it will respond to exercise within 2 to 3 months.

* In the grandmultipara, in the woman whose abdomen is over distended, or in the woman whose muscle tone was poor before pregnancy, the abdomen may fail to regain good tone and will remain flabby.

Reproductive health

* Diastasis recti abdominis, a separation of the rectus abdominis muscles, may occur with pregnancy, especially in women with poor abdominal muscle tone.

* If diastasis occurs, part of the abdominal wall has no muscular support but is formed only by skin, subcutaneous fat, fascia, and peritoneum.

* This may be especially pronounced in women who have undergone a cesarean section.

* If rectus muscle tone is not regained, support may be inadequate during future pregnancies.

* This may result in a pendulous abdomen and increased maternal backache.

- Gastrointestinal System

* Hunger following birth is common, and the mother may enjoy a light meal.

* Frequently, she is quite thirsty and will drink large amounts of fluid. Drinking fluids helps replace fluid lost during labor, in the urine, and through perspiration.

* The bowels tend to be sluggish after birth because of the lingeringeffects of progesterone, decreased abdominal muscle tone, and bowel evacuation associated with the labor and birth.

* Women who have had an episiotomy, lacerations, or hemorrhoids may tend to delay elimination for fear of increasing their pain.

Reproductive health

- Urinary Tract

* The postpartal woman has an increased bladder capacity, swelling and bruising of the tissues around the urethra, decreased sensitivity.

* Women who have had an anesthetic block have inhibited neural functioning of the bladder and are more susceptible to bladder distention, difficulty voiding, and bladder infections.

* In addition, immediate postpartal use of oxytocin to facilitate uterine contractions following expulsion of the placenta has an antidiuretic effect.

* Urinary output increases during the early postpartal period (first 12 to 24 hours) because of puerperal diuresis.

* The kidneys must eliminate an estimated 2000 to 3000 ml of extracellular fluid with a normal pregnancy.

* If stasis exists, chances increase for urinary tract infection because of bacteriuria and the presence of dilated ureters and renal pelves, which persist for about 6 weeks after birth.

* A full bladder may also increase the tendency of the uterus.

* If hematuria occurs in the second or third postpartal week, there may be a bladder infection.

* Acetone may be present in the urine of women with diabetes or of women with prolonged labor and dehydration.

Reproductive health

- Vital Signs

* With the exception of the first 24 hours, the woman should be afebrile.

* A maternal temperature of up to 38°C (100.4°F) may occur up to 24 hours after birth as a result of the exertion and dehydration of labor.

* Orthostatic hypotension, as indicated by feelings of faintness or dizziness immediately after standing up, can develop in the first 48 hours.

* If a woman complains of headache, hypertension must be ruled out before analgesics are administered.

* A pulse rate greater than 100 beats/min may be indicative of hypovolemia, infection, fear, or pain and requires further assessment.

- Blood Values

* Pregnancy-associated activation of coagulation factors may continue for variable amounts of time after birth.

* This condition, in conjunction with trauma, immobility, or sepsis, predisposes the woman to development of thromboembolism.

* Nonpathologic leukocytosis often occurs during labor and in the immediate postpartal period, with WBC counts up to 25,000 to 30,000/mm3

* Hemoglobin and hematocrit levels may be difficult to interpret in the first 2 days after birth because of the changing blood volume.

Reproductive health

* Blood loss averages 200 to 500 ml with a vaginal birth and 1000 ml or more with a cesarean birth.

* Lochia constitutes less than 25% of this blood loss.

* As extracellular fluid is excreted, hemoconcentration occurs, with a concomitant rise in hematocrit.

- Cardiovascular Changes* Maternal hypervolemia typically occurs immediately following birth because the maternal circulation has an increase in blood volume that no longer travels through the placenta.

* Maternal hypervolemia acts to protect the mother from excessive blood loss.

* Cardiac output declines by 30% in the first 2 weeks and reaches normal levels by 6 to 12 weeks.

* Diuresis in the first 2 to 5 days helps to decrease the extracellularfluid and results in a weight loss of 3 kg.

Rulea 4–3 percentage-point drop in hematocrit equals ablood loss of 500 ml.

Reproductive health

- Neurologic Changes and Conditions* Headaches are the most common neurologic symptoms encountered by postpartal women.

* Women with epilepsy are nine times more likely to have a seizure during labor or in the first 24 hours after birth than during pregnancy.

* The postpartum epileptic woman is more likely to be diagnosed with depression, and referral to a therapist or support group should be made.

- Weight Loss

* An initial weight loss of 10 to 12 lb occurs as a result of the birth of infant, placenta, and amniotic fluid.

* Puerperal dieresis accounts for the loss of an additional 5 lb during the early puerperium

* By the sixth to eighth week after birth, many women have returned to approximately prepregnant weight if they gained the average 25 to 30 lb.

* Women often express concern about the slow pace of their postpartal weight loss.

- Postpartum Chill* Frequently the mother experiences intense tremors that resembleshivering from a chill immediately after birth.

Reproductive health

* Several theories have been offered to explain this shivering: the result of sudden release of pressure on the pelvic nerves after birth, a response to a fetus-to-mother transfusion that occurred during placental separation, a reaction to maternal adrenaline production during labor and birth, or a reaction to epidural anesthesia.

* If not followed by fever, this chill is of no clinical concern, but it is uncomfortable for the woman.

- Postpartum Diaphoresis

* The elimination of excess fluid and waste products via the skin during the puerperium greatly increases perspiration.

* Diaphoretic (sweating) episodes frequently occur at night, and thewoman may awaken drenched with perspiration.

* This perspiration is not significant clinically, but the mother should be protected from chilling.

- After pains

* After pains occur more commonly in multiparas than in primiparas and are caused by intermittent uterine contractions.

* The lost tone of the uterus of the multipara results in alternate contraction and relaxation.

Reproductive health

* This phenomenon also occur if the uterus has been markedly distended, as with multiplegestation pregnancies or hydramnios, or if clots or placental fragments were retained.

* These after pains may cause the mother severe discomfort for 2 to 3 days following birth.

* The administration of oxytocic agents (intravenous infusion with Pitocin or oral administration of Methergine) stimulates uterine contraction and increases the discomfort of the after pains.

* A warm water bottle placed against the lowabdomen may reduce the discomfort of after pains.

* In addition, the breastfeeding mother may find it helpful.

- Postpartum Psychologic Adaptations

* The postpartum period is a time of readjustment and adaptation for the entire childbearing family but especially for the mother.

* The woman experiences a variety of responses as she adjusts to a new family member, postpartal discomforts, changes in her body image, and the reality that she is no longer pregnant.

- Taking In and Taking Hold Periods

* Soon after birth during the taking-in period, the woman tends to be passive and somewhat dependent.

Reproductive health

* The new mother follows suggestions, is hesitant about making decisions, and is still rather preoccupied with her needs (Rubin, 1984).

* She may have a great need to talk about her perceptions of her labor and birth.

* This helps her work through the process, sort out the reality from her fantasized experience, and clarify anything that she did not understand, food and sleep are major needs.

* After the taking-in period, which may end by the second day, the new mother may be observed to be ready to resume control of her body, her mothering, and her life in general.

* Rubin (1984) labeled this phase as taking hold.

* If she is breastfeeding, the mother may worry about her technique or the quality of her milk.

* If her baby spits up following feeding, she may view it as a personal failure.

- Postpartum Blues

* The postpartum blues consist of a transient period of depression that occurs during the first few days of puerperium.

* Symptoms may include mood swings, anger, weepiness, anorexia, difficulty sleeping, and a feeling of letdown.

Reproductive health

* This mood change frequently occurs while the woman is still hospitalized

* Changing hormone levels are certainly a factor; an unsupportive environment and insecurity also have been identified as potential causes.

* In addition, fatigue, discomfort, and overstimulation

* The postpartum blues usually resolve naturally within 10 to 14 days, but if they persist or if symptoms worsen, the woman may need evaluation for postpartum depression.

Reproductive health

- Lower Extremities

* Postpartal women are at increased risk for thrombophlebitis, thrombus formation, and inflammation involving a vein

* To assess for thrombophlebitis, the nurse should have the woman stretch her legs out, with the knees slightly flexed and the legs relaxed.

* The nurse then grasps the foot and dorsiflexes it sharply.

* The second leg is assessed in the same way.

* No discomfort or pain should be present.

Reproductive health

* If pain is elicited, the nurse notifies the CNM or physician that the woman has a positive Homans’sign

* The nurse also evaluates the legs for edema by comparing both legs, because usually only one leg is involved.Any areas of redness, tenderness, and increased skin temperature are also noted.

* Early ambulation is an important aspect of preventing thrombophlebitis.