Ch 18: Maternal Physiologic Changes in the postpartum Flashcards
Uterus
Contractions (After birth)
Lochia rubra
Lochia serosa
Lochia alba
Cervix
Vagina and perineum
Reproductive system and associated structures
one of the first things to adapt to that postpartum body is the uterus
Involution process is the return of the uterus to a non-pregnant state following birth
Uterus
Progresses rapidly
Fundus descends 1 to 2 cm every 24 hours
2 weeks after childbirth the uterus is no longer palpable
two weeks after delivery it is nestled right where it should be
and is now no longer an abdominal organ it’s going to return to it’s not pregnant state
Returns to a nonpregnant state by 6 weeks
Involution process is the return of the uterus to a non-pregnant state following birth
post birth after birth contractions this is the chemical symbol for oxytocin
postpartum hemostasis is achieved by compression of the intramyometrial blood vessels as the uterine muscle contracts - what we’re trying to achieve is that hemostasis of those blood vessels hormone
oxytocin released from that pituitary gland strengthens and coordinates that - we want women to contract
the more babies they have the harder that uterus has got to work in trying to involute so some of these contractions women can report as being just as strong or stronger than labor contractions - actually want something stronger than Ibuprofen for these contractions
Postpartum hemostasis achieved by compression of intramyometrial blood vessels as uterine muscle contracts
Hormone oxytocin, released from pituitary gland, strengthens and coordinates uterine contractions
Contractions (After birth)
different from menstrual blood
This is the discharge that we have after delivery
is actual blood and decidual and trophoblastic debris so you have to kind of look at it as being more debris and not so much blood at the beginning there is a good mixture of blood and so that’s why it has that really purplish red appearance to it this is the kind of discharge you’re going to see in the hospital those first three days sometimes four
Blood and decidual and trophoblastic debris
Duration of 3 to 4 days
Lochia rubra
kind of a mix it’s kind of a pinkish orangish discharge and it consists of Old Blood - orange brown color and serum and white blood cells and just more debris that’s just the uterus cleaning itself out that’s going to take over right about day four and it’s going to persist for upwards of three or more weeks
Old blood, serum, leukocytes, and debris
Duration of 22 to 27 days
Lochia serosa
Leukocytes, decidua, epithelial cells, mucus, serum, and bacteria
Continues 2 to 6 weeks after birth
which is going to continue for about 2 to 6 weeks after birth
whitish yellowish color and it is mostly mucus serum bacteria white blood cells epithelial cells there’s no blood or Old Blood visible
Lochia alba
Is the next to start changing in postpartum
by the time you’re 12 hours postpartum the cervix has already started to progress towards that pre-pregnant state
may actually have a clot that will lodge because that dilation has started to regress soon after delivery
Soft immediately after birth
During the next 12 to 18 hours the cervix shortens, becomes firm, and regains prepregnant form
during the next 12 to 18 hours the cervix will shorten so it’s going to start to be less than it’s going to shorten and kind of thicken up it’s been up and it’s going to start to regain that non or that pre-pregnant form
Cervical os, dilated to 10 cm during labor, closes gradually
Cervix
Postpartum estrogen deprivation responsible for thinness of vaginal mucosa and absence of rugae
Vaginal rugae reappear within 3 weeks
Thickening of vaginal mucosa occurs with return of ovarian function
Dryness and coital discomfort, dyspareunia, may persist until return of ovarian function
Introitus is erythematous and edematous
Episiotomies heal within 2 to 3 weeks (May take longer)
Hemorrhoids (anal varicosities) are common and decrease within 6 weeks of childbirth
Pelvic muscular support
Vagina and perineum
estrogen deprivation that we see especially in a breastfeeding mom is responsible for the thinness of that vaginal mucosa and the absence of the Rouge the actual vaginal Vault that has all this little wrinkles and gets all stretched out during delivery
Postpartum estrogen deprivation responsible for thinness of vaginal mucosa and absence of rugae
women have kind of like a pseudomenopausal state and the few weeks after delivery because estrogen is so low not unlike menopause so women who are choosing to breastfeed will have a prolonged a deprivation of estrogen because we know that estrogen is going to inhibit that way that lactation feedback so estrogen is too high mom’s not going to make any milk so we need estrogen to be low unfortunately that low level of estrogen is also going to cause a lot of dryness and discomfort in the vagina painful intercourse
as ovulation returns so does the hydration of the vaginal mucosa and that reggae and troitus is going to be have erythema and be a little identities
Dryness and coital discomfort, dyspareunia, may persist until return of ovarian function
Have erythema and be a little indentous as that makes sense that their vaginal delivery there will be some trauma to the introitus
Introitus is erythematous and edematous
any lacerations or episiotomies usually heal within just a couple of weeks if they’re extensive care like a third or fourth degree but obviously can take much longer
Episiotomies heal within 2 to 3 weeks (May take longer)
hemorrhoids which are those anal varicosities are very common and pregnancy but typically decrease within those six weeks
Hemorrhoids (anal varicosities) are common and decrease within 6 weeks of childbirth
postpartum pelvic muscular support supportive tissues of pelvic floor that are torn or stretched during childbirth it really kind of depends on the trauma to the pelvic musculature as to how that’s going to heal it can require up to 6 months to regain full tone to the pelvic floor
Supportive tissues of pelvic floor torn or stretched during childbirth
Require up to 6 months to regain tone
Kegel exercises encourage healing
Pelvic muscular support
During first 2 weeks abdominal wall remains relaxed
Woman has still-pregnant appearance
Return to prepregnancy state takes 6 weeks
Depends on previous tone, proper exercise, and amount of adipose tissue
Abdomen
The abdomen so during this first couple of weeks the abdominal wall remains fairly relaxed it’s been stretched out and unless mama has been doing quite a few core exercises while she was pregnant and prior to she could very well still look very pregnant
During first 2 weeks abdominal wall remains relaxed
return to the pre-pregnancy state can take upward 6 weeks and for some women much longer I laugh because some of us take years to look not pregnant depending on the amount of Adipose around our waist and what our core strength was before we ever got pregnant
Return to prepregnancy state takes 6 weeks
Placental hormones
Pit hormones and ovarian func
Endocrine sys
Expulsion of placenta results in dramatic decreases of placental-produced hormones
Decreases in chorionic somatomammotropin (hCS), estrogens, cortisol, and placental enzyme insulinase reverse effects of pregnancy
Estrogen and progesterone levels drop markedly
Placental hormones
Lactating and nonlactating women differ in timing of first ovulation and menstruation
70% of nonbreastfeeding mothers menstruate within first 12 weeks
In breastfeeding women, return of ovulation depends on breastfeeding patterns
In nonlactating women, ovulation occurs as early as 27 days after birth
Pit hormones and ovarian func
lactating and non lactating women differ in timing of the first ovulation and menstruation as we’ve kind of talked about already the non lactating women can very much begin to ovulate within weeks after delivering their baby the lactating moms depending on how often that their exclusive breastfeeding or not can take any given amount of time in order for their ovulation and menstruation to be restored
Lactating and nonlactating women differ in timing of first ovulation and menstruation
70% of non breastfeeding mothers these are our bottle fed are women of who are bottle feeding their babies will have their first period within the first 12 weeks
70% of nonbreastfeeding mothers menstruate within first 12 weeks
after delivery in breastfeeding women return of ovulation is really going to depend on her breastfeeding Pattern ovulation can occur is early as 27 days after birth and a bottle feeding mama and that’s why we tell women upon discharge to make sure that they have decided upon and communicate with their provider as to what kind of contraception that they plan to use because they can very easily show up to their six weeks postpartum checkup and be pregnant again
In nonlactating women, ovulation occurs as early as 27 days after birth
women will third space off just to get it out of the systemic vascular space because we no longer need it - need get rid extra volume
Postpartal diuresis
Urethra and bladder
Urinary sys
Within 12 hours women begin to diurese
Profuse diaphoresis often occurs at night for first 2 to 3 days
often occurs at night not unlike hot flashes tend to do with a premenopausal and menopausal women but for the first couple of days it’s not unheard of for a woman to complain of literally soaking the bed she’s waking up sweating so much that’s just the body’s way of getting rid of that extra fluid
Postpartal diuresis
Excessive bleeding can occur because of displacement of the uterus if bladder is full
Urethra and bladder
Appetite
Bowel evacuation
GI sys
Most new mothers are very hungry after recovery from analgesia, anesthesia, and fatigue
once she kind of finds that homeostasis soon in that early postpartum she’s going to be hungry
plus she doesn’t have the a big growing uterus putting pressure on her stomach for uterus is now where her belly button is so she has a little bit extra room now to where she can fill her belly
Appetite
Spontaneous bowel evacuation may not occur for 2 to 3 days after childbirth
spontaneous bowel movements from the other end actually may not occur for several days after childbirth whereas we used to encourage women or require them to have a bowel movement prior to going home from the hospital that’s not always the case we do like to see your post-op moms of where their passing gas before discharge but having a bowel movement is absolutely not required
Bowel evacuation
Breastfeeding mothers
Nonbreastfeeding mothers
Breasts
Before lactation a yellowish fluid, colostrum, can be expressed from nipples
Breasts become fuller and heavier, estimate when milk comes in (72 to 96 hours after birth)
Before lactation that yellowish fluid the colostrum can be expressed from nipples the breast become Fuller and heavier when the milk comes in they’ll be at their heaviest and that’s anywhere from 72 to 96 hours after birth so the breast that she had pre-pregnancy are going to get larger or any Fuller as she progresses in her pregnancy and then once she delivers in her milk comes in they will become even larger
Breastfeeding mothers
non breastfeeding mothers their milk is still going to come in but if she’s not breastfeeding we’re going to have to do some comfort measures for her in order to resolve the engorgement that will inevitably come - using cabbage leaves and binders and decreasing stimulation to the breast in order to resolve that engorgement will have to sometimes get them pain medicine like ibuprofen really good as far for inflammation
Engorgement resolves spontaneously, and discomfort decreases within 24 to 36 hours
Nonbreastfeeding mothers
Blood volume
CO
CV sys
Changes in blood volume depend on several factors
Blood loss during childbirth
Amount of extravascular water mobilized and excreted
Pregnancy-induced hypervolemia allow most women to tolerate blood loss during child
lots of changes in the blood volume we’re going to lose a little bit of it we are going to push it out to that extra vascular space so we’ll have to mobilize some of that water and pee It Off that hypervolemic state that we did in pregnancy is allowing and helping us compensate for any loss and childbirth
Blood volume
checking to make sure that there is no cardiac decompensation because of this high output
increased stroke volume is caused by the return of blood to the maternal systemic circulation or not perfusing the placenta anymore - we did not lose 1 to 2 L of blood volume that blood volume is still within the intravascular space and so the body is going to start to push it out to the extra vascular and into increase that GFR so she’s peeing it off
Remains increased for 48 hours after birth
Increased stroke volume is caused by the return of blood to the maternal systemic circulation
Stroke volume, end-diastolic volume, and systemic vascular resistance remain elevated for 12 weeks after delivery
Usually resolve by time d/c - remains increased - go time to pregnancy baseline after 48 hrs; see elevations in CV output for upwards 3 months - outcomes hope not to see: weakening of the aorta or any part of the vasculature - can cause issues; can have aneurysms, strokes, etc from increased volume and preexisting conditions
CO
Pregnancy-induced neurologic discomforts abate after birth
Carpal tunnel syndrome is teased by reduced pressure
Postpartum headaches may be caused by gestational hypertension, stress, and leakage of cerebrospinal fluid into extradural space during placement of spinal anesthesia
stress of motherhood and sleepless nights but sometimes it can happen due to any kind of CSF leakage into the extradural space anesthesia from spinal block for a C-section and when it does it will cause just piercing headaches when Mom is sitting straight up only lay her flat and completely resolves if that happens and we know it’s due to a CSF leak many times if a woman can be patient with it it will seal itself up but many times are ending up having to bring her back in and do a blood patch
Neurologic sys
Reversal of pregnancy adaptations
most of the time we have a reversal of this pregnancy adaptation so go back and think about that severe lordosis of the spine and the center of gravity changes oh that’s going to go back cuz you don’t have that heavy load that we’re carrying in front however the joints are going to completely stabilize about 6 weeks after birth
Joints are completely stabilized by 6 to 8 weeks after birth
New mother may notice permanent increase in shoe size
but moms may still see an increase in permanent increase in their shoe size
as joints stabilize from extra pressure on feet the shoe sizes do not go down but persist and wear bigger shoes
MS sys
Vascular abnormalities, spider angiomas, palmar erythema, and epulis regress with rapid decline in estrogens
Spider nevi persist indefinitely for some
Hair growth slows during the postpartum period
Chloasma of pregnancy usually disappears at end of pregnancy
Hyperpigmentation of areolae and linea nigra may not regress completely after childbirth
Integumentary sys
start seeing women with more hair loss and it’s not growing back in it’s not growing in as quickly as it did when she was pregnant
Hair growth slows during the postpartum period
Persists in 30% of women
usually disappears the end of pregnancy but ⅓ women do not
Chloasma of pregnancy usually disappears at end of pregnancy
the areolas do not regress completely after childbirth we need them to be a little bit more hyper pigmented especially at our breastfeeding mamas
Stretch marks on breasts, abdomen, and thighs may fade but not disappear
these stretch marks do tend to fade and they sometimes instead of being so dark purple like that will fade into a silver line sometimes it Disappear Completely
Hyperpigmentation of areolae and linea nigra may not regress completely after childbirth
Which descriptions below are accurate of postbirth discharge, or lochia? (Select all that apply)
A)Should smell like normal menstrual flow unless an infection is present.
B)Will usually increase with ambulation and breastfeeding.
C)The initial lochia present in the first few days after delivery is called rubra.
D)Lochia alba is present by the end of the first day after delivery.
Answer: A, B, C
Lochia alba does not show up for several weeks
B is true is because if up moving around there is increased flow because HR up and if breastfeeding causes uterus to contract - see little increase in flow when breastfeeding
