Other Body Systems

Cardiovascular

Blood volume is reduced to nonpregnant levels by 2 to 4 weeks after delivery. Diuresis (the increased formation and secretion of urine) and diaphoresis (the secretion of sweat, especially when profuse) account for most of the fluid loss. Blood loss during delivery accounts for an additional 300 to 500 mL (600 to 800 mL with cesarean delivery). Cardiac output also declines rapidly. The patient is at risk for thrombus formation as a result of elevation of platelets in the early postpartum period.

Urinary

After childbirth, as a result of trauma, increased bladder capacity, and the effects of conduction anesthesia, women have a decreased urge to void. In addition, pelvic soreness and edema caused by forceps used during labor, vaginal lacerations, or the episiotomy reduce or alter the voiding reflex. Decreased voiding combined with postpartal diuresis may result in bladder distention. Immediately after giving birth, the woman may bleed excessively if the bladder becomes distended because it pushes the uterus up and to the side and prevents the uterus from firmly contracting. Later in the puerperium, overdistention can make the bladder more susceptible to infection and delay the return of normal voiding. With adequate emptying of the bladder, bladder tone is usually restored 5 to 7 days after childbirth, with daily urinary output of up to 3 L common.

Neurologic

Neurologic changes during the puerperium result from a reversal of maternal adaptations to pregnancy or from trauma during labor and childbirth. Pregnancy-induced neurologic discomforts abate after birth. Through diuresis, edema is eliminated, which relieves

Box 27-2 Interventions for Episiotomy, Lacerations, and Hemorrhoids

Cleansing

• Wash hands before and after cleaning perineum and changing pads.
• Explain procedure.
• Wash perineum with mild soap and warm water at least once daily.
• Cleanse from symphysis pubis to anal area.
• Apply peripad from front to back, protecting inner surface of pad from contamination.
• Wrap soiled pad and place in covered waste container.
• Change pad with each void or defecation or at least four times per day.
• Assess amount and character of lochia with each pad change.

Ice Pack

• Apply a covered ice pack to perineum from front to back:
  • During first 2 hours after the birth, to decrease edema formation and increase comfort
  • After the first 2 hours, to provide anesthetic effect

Squeeze Bottle

• Demonstrate for and assist woman; explain rationale.
• Fill bottle with tap water warmed to approximately 100.4° F (38° C; comfortably warm on the wrist).
• Instruct woman to position nozzle between her legs so that squirts of water reach perineum as she sits on toilet.
• Explain that it takes a whole bottle of water to cleanse perineum.
• Remind her to blot dry with toilet paper or clean wipes.
• Remind her to avoid contamination from anal area.
• Apply clean pad.

Sitz Bath

Built-in Type

• Prepare bath by thoroughly scrubbing with cleaning agent and rinsing. Pad with towel before filling.
• Explain procedure.
• Fill one half to one third with water of correct temperature (100.4° to 105° F [38° to 40.6° C]). Some women prefer cool sitz baths; add ice to lower the temperature to a comfortable level.
• Encourage woman to use at least twice a day for 20 minutes.
• Place call bell within easy reach.
• Teach woman to enter bath by tightening gluteal muscles and keeping them tightened and then relaxing them after she is in the bath.
• Place dry towels within reach.
• Ensure privacy.
• Check on woman in 15 minutes; assess pulse as needed.

Disposable Type

• Clamp tubing and fill bag with warm water.
• Raise toilet seat, place bath in bowl with overflow opening directed toward back of toilet.
• Place container above toilet bowl.
• Attach tube into groove at front of bath.
• Loosen tube clamp to regulate rate of flow; fill bath to half full; continue as previously described for built-in sitz bath.

Dry Heat

• Inspect lamp for defects.
• Cover lamp with towels.
• Position lamp 50 cm from perineum; use three times a day for 20-minute periods.
• Provide draping over woman.
• If same lamp is used by several women, clean it carefully between uses.
• Teach woman regarding use of 40-watt bulb at home.

Topical Applications

• Apply anesthetic cream or spray; use sparingly three or four times a day.
• Offer witch hazel pads (Tucks) after voiding or defecating; woman pats perineum dry from front to back, then applies witch hazel pads. Explain rationale.

carpal tunnel syndrome by easing compression of the medial nerve. The periodic numbness and tingling of fingers that affect 5% of pregnant women usually disappear after birth, unless lifting and carrying the baby aggravate the condition.

Headache requires careful assessment. Postpartum headaches may be caused by various conditions, including gestational hypertension, stress, and leakage of cerebrospinal fluid into the extradural space during placement of the needle for epidural or spinal anesthesia. Depending on the cause and the effectiveness of the treatment, the headaches can last from 1 to 3 days to several weeks.

Gastrointestinal

Appetite generally returns to normal immediately after delivery. However, gastric motility may continue to decline, leading to constipation. Normal bowel elimination should resume within 2 or 3 days after delivery. Decreased abdominal tone and tenderness from the episiotomy or hemorrhoids may make the patient reluctant to strain for a bowel movement.

Endocrine

Placental hormone levels rapidly fall after delivery and are soon undetectable or at their nonpregnant values. Estrogen and progesterone levels drop markedly after expulsion of the placenta and reach their lowest levels 1 week into the postpartum period. Decreased estrogen levels are associated with breast engorgement and with the diuresis of excess extracellular fluid that has accumulated during pregnancy. The estrogen levels in nonlactating women begin to rise by 2 weeks after birth and are higher by postpartum day 17 than in women who breastfeed. The anterior pituitary secretes prolactin, but only in response to nipple stimulation. Other 

endocrine glands (thyroid, adrenal, and pancreas) return to prepregnant size and function.

Musculoskeletal

Abdominal muscle tone returns and joint stabilization occurs over a 6- to 8-week period after delivery. The return of muscle tone depends on previous tone, proper exercise, and the amount of adipose tissue. Some pelvic joints may never fully return to their prepregnant position. Patients may feel discomfort in the joints immediately after delivery because of secretion of the hormone relaxin. However, even when all other joints return to their normal pregnant state, those of the parous woman’s feet do not. The new mother may notice a permanent increase in shoe size.

Integumentary

Chloasma of pregnancy usually disappears at the end of pregnancy. Hyperpigmentation of the areola (the area encircling the nipple) and linea nigra (a dark line on the abdomen of a pregnant woman, usually extending from the symphysis pubis midline to the umbilicus) may not disappear completely after childbirth. Some women have permanent darker pigmentation of those areas. Striae gravidarum (stretch marks) on the breasts, the abdomen, and the thighs may fade but usually do not disappear.

Vascular abnormalities such as spider angiomas (nevi), palmar erythema, and epulis generally regress as estrogen rapidly declines after the end of pregnancy. For some women, spider nevi persist indefinitely.

The abundance of fine hair seen during pregnancy usually disappears after birth; however, any coarse or bristly hair that appears during pregnancy usually remains. Fingernails return to their prepregnancy consistency and strength.

Profuse diaphoresis in the immediate postpartum period is the most noticeable change in the integumentary system. This is common, especially at night, during the first week postpartum.

Immune

No significant changes in the maternal immune system occur during the postpartum period. Whether the mother needs a rubella vaccination or Rho(D) immune globulin (RhoGAM) for prevention of Rh isoimmunization should be determined. Pregnant women are routinely screened for immunity to rubella. Women who are not immune are immunized early in the postpartum period. Patients who are Rh negative and who give birth to infants who are Rh positive must receive RhoGAM within 72 hours of delivery.

Transfer From the Recovery Area

After the initial recovery period of 1 to 2 hours, the woman may be transferred to a postpartum room in the same or another nursing unit. In labor, delivery, recovery, postpartum (LDRP) room settings, the nurse who provided care during the recovery period usually continues to care for the woman. In the labor, delivery, recovery (LDR) room or a traditional setting, the woman is transferred to a separate unit where the postpartum nursing staff provide her care. In some settings, the baby remains with the mother wherever she goes. In other facilities, the baby is taken to the nursery for several hours of observation during the mother’s initial recovery period.

The move to another area of the maternity unit requires the nurse to prepare a transfer report. The information to be provided to the nurse accepting the patient must be accurate and concise. Sources of information include the admission record, the birth record, and the recovery record. The postpartum nurse should be advised about the name of the primary care provider; gravidity and parity; age; anesthetic used; medications given; duration of labor and time of rupture of membranes; oxytocin induction or augmentation; type of birth and repair; blood type and Rh status; rubella immunity status; syphilis and hepatitis serology test results; intravenous (IV) infusion of any fluids; physiologic status since birth; description of fundus, lochia, bladder, and perineum; infant’s gender and weight; time of birth; pediatrician; chosen method of feeding; any abnormalities noted; and assessment of initial parent-infant interaction.

Most of this information is also documented for the nursing staff in the newborn nursery. In addition, specific information should be provided on the infant’s Apgar scores, weight, voiding, and feeding since birth. Also, nursing interventions that have been completed (e.g., prophylaxis, vitamin K injection) should be re­corded.