Chapter 17: Postpartum Physiologic Adaptations Flashcards
Involution
The rapid reduction in the size of the uterus and return to pre-pregnant state.
Exfoliation
Scaling off of dead tissue
How does the placental site heal?
Exfoliation of the post delivery decidua allows healing of the placenta site.
Is an important part of involution.
When does involution begin?
Begins immediately after delivery of the placenta when the uterine muscle fibers contract firmly around maternal blood vessels at the area where the placenta was attached.
Why is contraction of uterine muscle fibers important in involution?
- Controls bleeding from the area left denuded when placenta separated.
- As muscle fibers contract, the uterus decreases in size and gradually regains it’s former contour and size.
Uterine Involution depends on what three processes?
- Contraction of muscle fibers
- Catabolism
- Regeneration of uterine epithelium
Uterine Involution: Catabolism
The enlarged muscle cells ofthe uterus undergo catabolic changes in the protein cytoplasm -> leading to reduction in individual cell size.
What happens to the products of catabolism during involution?
It goes through the blood stream to be excreted in urine as nitrogenous waste.
What happens during regeneration of the uterine epithelium?
- Outer portion of the endometrial layer is expelled with the placenta.
- Within 2-3 days, the remaining decidua separates into two layers.
- The first layer is superficial and is shed in the lochia.
- The basal layer containing the residual endometrial glands remains intact to provide the source of new endometrium.
When does regeneration of the endometrium occur?**
Regeneration of the endometrium, except at the site of placental attachment, occurs by 16 days after birth.
How long does it take for healing at the placental site to occur?**
Occurs slowly and requires approximately 6 weeks.
How is the placental site regenerated?
New endometrium is generated at the site from the sides and from glands and tissue that remain in the lower layer of the decidua after separation of placenta.
Where is the location of the uterus within 6-12 hours after childbirth?
At the level of the umbilicus
How much should the uterus decline each day?
One finger breadth per day or 1 cm
After birth, the uterus needs to remain
Firm and midline
What can cause the uterus to rise and become boggy?
If blood collects and forms clot within the uterus (uterine atony)
How can the uterus rid itself of remaining debris after birth?
Through discharge called lochia.
What factor can determine whether involution is progressing normally?
Location of the uterine fundus determines if involution is progressing normally.
Characteristics of the uterus immediately after delivery
- About the size of a large grapefruit or softball
- Weighs approximately 1000 g (2.2 lbs)
When does the fundus of the uterus descend into the pelvic cavity?
By the 14th. Not able to palpate at this point.
What can slow the process of uterine involution?
Normally slower when the uterus was distended during pregnancy with more than one fetus, a large fetus or hydramnios.
When the process of involution does not occur properly, what can happen?
Subinvolution can occur.
Subinvolution can cause
Postpartum hemorrhage.
How is descent document?
- Is document in relation to the umbilicus.
- For example, U-1 indicates that the fundus is palpable about 1 cm below the umbilicus.
Within one week, what should the weight decreases to about
500 g (1 lb)
At 6 weeks, the uterus weighs
60-80 g (2-3 oz), which is roughly prepregnancy weight (uterus of multipara may be slightly heavier)
Lochia Rubra
- Reddish or red-brown vaginal discharge that occurs immediately after childbirth.
- Composed mostly of blood. Also contains mucus.
Lochia serosa
- Pink or brown-tinged vaginal discharge that follows lochia rubra and precedes lochia alba.
- Composed largely of serous exudate, cervical mucus, blood and leukocytes.
Lochia alba
- White, cream colored or light yellow vaginal discharge that follows lochia serosa.
- Occurs when the amount of blood is decreased and the number of leukocytes is increased.
- Also contains cervical mucus and fat.
When does the amount of blood decrease?
By the fourth day when leukocytes begin to invade the area, as they do any healing surface.
When is lochia alba present?
Present in most women until the third week after childbirth but may persist until the end of the 6th week.
What is the normal total amount of lochia?
250 mL
How is lochia documented?
Use terms such as scant, light, moderate, heavy, excessive.
Lochia: Scant Amount
Less than 2.5 cm (1 inch) stain on the peripad
Lochia: Light Amount
2.5-10 cm (1-4”) stain
Lochia: Moderate Amount
10-15 cm (4-6”) stain
Lochia: Heavy Amount
Saturated peripad in 1 hour
Lochia: Excessive Amount
Saturated peripad in 15 minutes
Lochia flow after c-section
Is less because some of the endometrial lining is removed during surgery.
When is lochia flow heavier?
- Immediately after delivery.
- When mother first gets out of bed or after sleeping (d/t gravity which allows blood that pooled in the vagina during hours of rest to flow freely when she stands)
Why do some women have a sudden, short episode of bleeding at 7-14 days after birth?
Occurs when the eschar over the placental site sloughs.
Bleeding that lasts longer than ___________ should be reported to the HCP.
2 hours
Postpartum Afterpains
Intermittent uterine contractions.
Postpartum Afterpains are worse in what women?
Multiparas d/t repeated stretching of muscle fibers which leads to loss of muscle tone and ends with repeated contraction and relaxation of the uterus.
What can cause severe afterpains in a primipara?
-If her uterus has been overdistended by multifetal pregnancy, a large infant, hydramnios or if retained blood clots are present.
Afterpains are particularly severe during
Breastfeeding.
This causes the release of oxytocin from the posterior pituitary to stimulate the milk-ejection reflex and stimulates strong contraction of uterine muscles.
What can be used to lessen the discomfort of afterpains?
- Ibuprofen (given with food to decrease nausea/irritation)
- Percocet
- Toradol
What is contradicted with the administration of Toradol?
Motrin/ibuprofen!
Promotion of Perineal Comfort and Healing includes
· Ice packs
· Topical agents
· Perineal care
Relief of hemorrhoids discomfort may include:
· Sitz baths
· Topical anesthetic ointments/sprays
· Rectal suppositories* or ointment (steroids for edema)
· Witch hazel pads (Tucks)
What are the benefits of pain relief such as comfort and relaxation?
It facilities the milk-ejection reflex.
What position do mothers find keeps the uterus contracted and provides relief?
Lying in prone position with a small pillow or folded blanket under the abdomen.
Hypervolemia during pregnancy
Allows the woman to tolerate substantial blood loss during pregnancy without ill affect.
About how much blood is lost during vaginal and cesarean deliveries?
Vaginal delivery: Up to 500 mL
C-Section: Up to 1000 mL
Postpartum: Maternal Cardiac Output
Despite blood loss, a transient increase in maternal cardiac output occurs after childbirth.