The postpartum period, also known as the puerperium and the fourth trimester, refers to the time after birth when the physiologic changes related to pregnancy return to the nonpregnant state (Berens, 2022).
Definition
The postpartum period starts following the expulsion of the placenta until the complete physiological recovery of various organ systems. The postpartum period divides into three arbitrary phases: acute phase (the first 24 hours after delivery of the placenta), early phase (up to seven days), and late phase (up to six weeks to six months.
Postpartum Period Changes
Vital signs
There is generalized physical fatigue immediately after delivery. The pulse rate may be elevated a few hours after childbirth due to excitement or pain. The blood pressure may be elevated due to pain but is generally in the normal range. The temperature is slightly elevated up to 37.2℃ (99℉) along with increased shivering, sweating, or diaphoresis in the first 24 hours and normalizes within 12 hours. The temperature rise may have been caused by the systemic absorption of metabolites accumulated due to muscle contractions. The respiratory rate also begins to fall back to the pre-pregnancy level within two to three days. There is a weight loss of five to six kg due to the expulsion of products of gestation and accompanying blood loss (Chauhan & Tadi, 2021).
Reproductive
Involution is the term given to the process of reproductive organs returning to their prepregnant state. Immediately postpartum, the uterine fundus is palpable at or near the level of the maternal umbilicus. The endometrial lining rapidly regenerates, so that by the seventh day endometrial glands are already evident. Immediately after delivery, a large amount of red blood flows from the uterus until the contraction phase occurs. Therefore, the volume of vaginal discharge rapidly decreases. The cervix also begins to rapidly revert to a nonpregnant state, but it never returns to the nulliparous state. The vagina also regresses but it does not completely return to its prepregnant size. The swollen and engorged vulva rapidly resolves within one to two weeks (Kansky & Isaacs, 2021).
Breasts
The changes to the breasts that prepare the body for breastfeeding occur throughout pregnancy. After delivery of the placenta, there is a rapid decline in progesterone and subsequent swelling, or engorgement, of the breasts in the postpartum period. The colostrum is the liquid that is initially released by the breast during the first two to four days after delivery. Over the first seven days, the milk matures and contains all the necessary nutrients in the neonatal period (Kansky & Isaacs, 2021).
Endocrine
If the client is not breastfeeding, then the menstrual function returns by the sixth to eighth week postpartum in most cases. Elevated serum prolactin levels inhibit the ovarian response to the follicular stimulating hormone, suppress the release of luteinizing hormone, and suppress the secretion of gonadotropins. This approach offers a natural method of contraception to the lactating female. In lactating females, menstruation usually reappears in four to five months and can be as late as 24 months.
Renal
The bladder wall may become edematous, and hyperemic, and the bladder might be overdistended without the urge to pass urine. The retention of urine in the first few days after labor may be due to the laxity of the abdominal musculature, tone of pelvic floor muscles, atony of the bladder, compression of urethra by edema or hematoma, reflex inhibition of micturition due to genitourinary trauma. The dilated ureters and renal pelvis usually return to the pre-pregnant state within four to eight weeks.
Hematologic
The hematocrit may initially drop due to blood loss associated with delivery but starts to rise again as plasma volume decreases due to diuresis and hemoconcentration. The hematocrit values return to normal in three to five days postpartum as plasma volume starts to increase. The discrepancy in hemoglobin values in the postpartum phase indicates that it takes at least four to six months to restore the pregnancy-induced dip in hemoglobin to non-pregnant states The white blood cell count returns to pre-pregnant values within four weeks. The gestational thrombocytopenia resolves in four to ten days after delivery as platelet count increases in response to platelet consumption during delivery.
Cardiovascular
In the immediate postpartum period, following delivery, there is an increase in preload from the relief of the inferior vena cava obstruction, leading to an increase in stroke volume and heart rate leading to a 60 to 80% rise in cardiac output, which rapidly declines to pre-labor values in one to two hours following delivery and to pre-pregnancy values in two weeks postpartum. Systemic vascular resistance decreases by 35 to 40% during pregnancy and increases to pre-pregnant levels two weeks postpartum. There is also a decrease in systemic blood pressure by five to ten mm Hg during pregnancy. Diastolic blood pressure decreases more than systolic blood pressure. The systemic blood pressures start to rise during the third trimester and return to prepregnant values at 16 weeks postpartum.
Gastrointestinal
The client may develop flatulence or constipation due to intestinal ileus (induced by pain or the presence of placental hormone relaxin in the circulation), loss of body fluids, laxity of the abdominal wall, and hemorrhoids. Postpartum constipation is due to the progesterone-induced decrease in gastrointestinal transit time. After delivery, the levels of progesterone and gastrin drop within 24 hours, and the acid reflux and associated symptoms resolve in the next three to four days.
Nursing Diagnosis for Postpartum
Nursing Diagnosis
Risk for Impaired Parent/Infant Attachment
Assessment
Lack of support from significant others / ineffective or no role model / anxiety associated with the parental role / unrealistic expectations / presence of stressors, such as financial or employment
Problem
Unmet family needs
Decreased sense of trust
Family role disruption
Depression
Inability to provide a protective environment
Nursing Diagnosis
Risk for Deficient Fluid Volume
Assessment
Vaginal hemorrhage / dry skin or mucous membranes / decreased skin turgor / tachycardia / fever / hypotension / increased urine output / weakness / changes in mental state / hemoconcentration / altered electrolyte balance
Problem
Dehydration
Hypovolemic or hemorrhagic shock
Electrolyte imbalances
Cardiac dysrhythmias
Nursing Diagnosis
Acute Pain
Assessment
Reports of pain / self-focusing / grimacing / distraction / guarding behaviors / increased blood pressure / tachycardia / tachypnea / altered muscle tone
Problem
Fear or anxiety
Decreased tolerance of activities
Isolation or depression
Impaired role performance
Impaired attachment to the infant
Nursing Diagnosis
Impaired Urinary Elimination
Assessment
Urinary frequency, urgency, or hesitancy / dysuria / incontinence / urinary retention / bladder fullness / suprapubic discomfort
Problem
Decreased self-esteem
Irritation of the urinary tract and urethra
Loss of bladder tone
Fluid shifts
Nursing Diagnosis
Constipation
Assessment
Bowel urgency / inappropriate toileting behaviors / incontinence / hard, impacted stools
Problem
Inability to locate the bathroom or recognize need
Lost of neurological functioning and muscle tone
Nutritional imbalance
Trauma to the rectal tissue
Nursing Diagnosis
Disturbed Sleep Pattern
Assessment
Verbal reports of difficulty in falling asleep / not feeling well-rested / interrupted sleep / frequent yawning / irritability / dark circles under the eyes
Problem
Discomfort
Weakness
Decreased ability to function
Impaired parental role
Decreased sense of well-being
Nursing Diagnosis
Health-seeking behaviors
Assessment
Expressed desire to participate in newborn care / expressed concern over the newborn / stated unfamiliarity with resources / observed desired to seek a higher level of wellness
Problem
Situational or maturational occurrence precipitating concern about the newborn
Limited mobility
Physical exertion
Pain of lacerations or episiotomy
Nursing Diagnosis
Fear/Anxiety
Assessment
Identification of stimulus believed to be a threat / fatigue / anorexia / dry mouth palpitations / apprehension / increased tension / excitement / jitteriness
Problem
Unfamiliarity with newborn care
Impaired parenting role
Impaired attachment to infant
Chronic/acute disease process
Language barriers
References
- Berens, P. (2022). Overview of the postpartum period: Normal physiology and routine maternal care. UpToDate. https://www.uptodate.com/contents/overview-of-the-postpartum-period-normal-physiology-and-routine-maternal-care#:~:text=The%20postpartum%20period%2C%20also%20known,return%20to%20the%20nonpregnant%20state.
- Chauhan, G., & Tadi, P. (2021, November 21). Physiology, Postpartum Changes – StatPearls. NCBI. Retrieved November 26, 2022, from https://www.ncbi.nlm.nih.gov/books/NBK555904/
- Kansky, C., & Isaacs, C. (2021, December 22). Normal and Abnormal Puerperium: Overview, Routine Postpartum Care, Hemorrhage. Medscape Reference. Retrieved November 26, 2022, from https://emedicine.medscape.com/article/260187-overview
