1. Postpartum Physiology RNSG 2308

2. Learning Objectives
Describe the anatomic and physiologic changes that occur during the postpartum period.
Discuss the characteristics of uterine involution and lochial flow, and describe ways to measure them.
List expected values for vital signs and blood pressure, deviations from normal findings, and probable causes of the deviations

3. Postpartum Physiology
Postpartum period
Interval between the birth of the newborn and the return of the reproductive organs to their nonpregnant state.
Fourth trimester of pregnancy
Also referred to as the puerperium
Last on an average of about 6 weeks

4. Postpartum Physiology
Reproductive System and Associated Structures
Uterus
Involution- the return of the uterus to a nonpregnant state after birth
Fundus descends 1 to 2 cm every 24 hours
Subinvolution- is the failure of the uterus to return to a nonpregnant state
Most common causes are retained placenta fragments and infection

6. Postpartum Physiology
Contractions
Oxytocin- strengthens and coordinates uterine contractions, which compress the blood vessels and thereby promotes hemostasis
Postpartum hemostasis- is achieved primarily by compression of intramyometrial blood vessels as the uterine muscle contracts, rather than platelet aggregation and clot formation
First 1 to 2 postpartum hours, uterine contractions may decrease in intensity and become uncoordinated
Pitocin is usually administered intravenously or intramuscular immediately after the placenta is delivered to maintain a firm uterus
Mothers who plan to breastfeed may be encouraged to put the baby to the breast immediately after birth a s well, because suckling stimulates the release of oxytocin.
Because it is vital that the uterus remain firm and well, contracted, exogenous oxytocin (Pitocin) is usually administered intravenously or intramuscularly immediately after expulsion of the placenta

7. Postpartum Physiology
Afterpains
Intermittent uterine contractions
Maybe intense at times
More common in multiparas
Frequently occurs with breastfeeding
Suckling results in release of oxytocin
Oxytocin causes contractions of the lateral ducts in the breast which cause contractions of the uterine muscles
Afterpains are more noticeable after births in which the uterus was greatly distended ( a large baby, multifetal gestation). Breastfeeding and exogenous oxytocic medication usually cause these afterpains to intensify, because both stimulate uterine contraction.
In first-time mothers, uterine tone is increased, the fundus generally remain firm, and the mother does not perceive uterine cramping

8. 2.While taking sitz baths 3.During breast-feeding
A postpartum client asks the nurse about the occurrence of afterpains. The nurse informs the mother that afterpains will be especially noticeable:
1.When ambulating 
2.While taking sitz baths
 3.During breast-feeding 
4.Once the client arrives home and activities are increased

9. Postpartum Physiology
Lochia
Rubra
Last 3 to 4 days
Consists of blood, mucus, particles of decidua and trophoblastic debris
Bright red
Serosa
After 3 to 4 days
Alba
Consists of leukocytes, decidua, epithelial cells, mucus, serum, and bacteria
After 10 days-up to 6 weeks
Yellow to white
Post chidbirth uterine discharge, commonly called lochia, is initially bright red, changing later to pinkish red or reddish brown. It may contain small clots of blood. Serosa-Last until 10th day
Consist of old blood, serum leukocytes, and tissue debris
Pinkish or brownish in color
The flow of lochia usually increases with ambulation and breastfeeding. Lochia tends to pool in the vagina when the woman is lying in the bed; the woman may then experience gush when she stands.
For the first 2 hours after birth the amount of uterine discharge should be about that of a heavy menstrual period
After that time, the lochia flow should steadily decrease

10. 2.The presence of infection 3.The need for increasing oral fluids
A nurse is assessing the lochia discharge on a 1-day postpartum woman. The nurse notes that the lochia is red and has a fleshy odor. The nurse determines that this assessment finding indicates:
1.A normal finding 
2.The presence of infection 
3.The need for increasing oral fluids
 4.The need for increasing ambulating

11. 1.Increases during ambulation 2.Increases during sleep
A nurse is providing information about lochia flow to a woman who just delivered a newborn. The nurse tells the woman that the amount of lochia flow:
1.Increases during ambulation 
2.Increases during sleep 
3.Is scant immediately following delivery 
4.Increases in amount on the third postpartum day 

12. Postpartum Physiology
Cervix
Remains edematous, thin, and fragile for several days after birth
Ectocervix- portion of the cervix that protrudes into the vagina
May appear bruised
May have some small lacerations
Constitutes an optimal condition for development of an infection
Introduce two fingers into the cervical os for the first 4 to 6 weeks postpartum
Lactation delays the production of cervical and other estrogen-influenced mucus and mucosal characteristics
The cervix is soft immediately after birth
Within 2 to 3 postpartum days, however, it has shortened become firm, and regained its form

13. Postpartum Physiology
Vagina and Perineum
Vagina returns to its prepregnancy size by 6 to 10 weeks after childbirth
Rugae reappears within in 3
Normal estrogen levels and lubrication return by 6 to 10 weeks
Episiotomies heal within 2 to 3 weeks
Hemorrhoids usually decrease in size within 6 weeks
Episiotomy-signs and symptoms of infection include: pain redness, warmth, swelling, or discharge
Hemorrhoids- women often experience associated symptoms such as itching, discomfort, and bright red bleeding with defecation.
Postpartum estrogen deprivation is responsible for the thinness of the vaginal mucosa and the absence of rugae
The greatly distended, smooth-walled vagina gradually returns to its prepregnancy size by 6 to 10 weeks after childbirth
Thickening of the vagina mucosa occurs with the return of ovarian function
Reduced estrogen levels are also responsible for a decreased amount of vaginal lubrication

14. Postpartum Physiology
Endocrine System
Placental hormones
Human placental lactogen (hPL) decreases to undetectable levels in 24 hours
Hcg decreases after birth and remains low until after ovulation
Estrogen and progesterone levels decrease markedly after expulsion of the placenta
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
Estrogen levels in nonlactating women begin to increase by 2 weeks after birth and are higher by postpartum day 17 than in women who breastfeed

15. Endocrine System Pituitary Hormones and Ovarian Function
Elevated serum prolactin levels in breastfeeding women appears to be responsible for suppressing ovulation
Ovulation occurs as early as 27 days after birth in nonlactating women
Menstruation usually resumes by 12 weeks after birth
Mean time of about 70 to 75 days
Mean time to ovulation in women who breastfeed is about 6 months
Women who breastfeed, prolactin levels remain elevated into the sixth week after birth
After birth prolactin levels decline in nonlactating women, reaching the prepregnant range by the third postpartum week
70% of nonbreastfeeding women resume menstruation by 3 months after birth
Women who breastfeed for less than 28 days will ovulate at about the same time as women who do not breastfeed
Lactating women, both the resumption of ovulation and the return of menses are determined in a large part by breastfeeding patterns
First menstrual flow after childbirth is usually heavier than normal
Serum prolactin levels are influenced by the frequency of breastfeeding, the duration of each feeding to which supplementary feedings are used

16. Postpartum Physiology
Abdomen
During the first days after birth, woman’s abdominal muscles protrude and give her a still-pregnant look
6 weeks for the abdominal wall to return almost to it prepregnancy state
Return of muscle tone depends on previous tone, proper exercise, and the amount of adipose tissue
Occasionally with or without overdistention because of a large fetus or multiple fetuses, the abdominal wall muscles separate a condition termed diastasis recti abdominis

17. Abdomen

18. Postpartum Physiology
Urinary System
Diuresis occurs within 12 hours after delivery
Profuse diaphoresis that often occurs, especially at night, for the first 2 to 3 days after childbirth
Fluid loss through perspiration and the increased urinary output accounts for weight loss
Postpartal diuresis, caused by decrease estrogen levels, removal of increased venous pressure in the lower extremities, and the loss of the remaining pregnancy-induced increase in blood volume, is another mechanism by which the body rids itself of excess fluid
Weight of loss of approximately 2.25 kg during the puerperium

19. 1.Diuresis 2.Stress incontinence 3.Urge incontinence 4.Retention
In the immediate postpartum period, the nurse monitors the new mother for which risk related to the urinary system?
1.Diuresis
 2.Stress incontinence
 3.Urge incontinence 
4.Retention

20. Postpartum Physiology
Urethra and Bladder
Trauma to the urethra and bladder may occur during the birth process
Decreased voiding, along with postpartum diuresis, may result in bladder distention
Immediately after birth, excessive bleeding can occur if the bladder becomes distended
Adequate emptying of the bladder, bladder tone is usually restored 5 to 7 days after childbirth
As the infant passes through the pelvis, so that the bladder wall may be hyperemic and edematous, often with small areas of hemorrhage
Birth-induced trauma, increased bladder capacity after childbirth, and the effects of conduction anesthesia, combine to cause a decrease in urge to void.
Pelvic soreness from the forces of labor, vaginal lacerations, or an episiotomy reduces or alters voiding reflux.
Excessive bleeding can occur if the bladder becomes distended because this pushes up and to the side and prevents the uterus from firmly contracting

21. Postpartum Physiology
Gastrointestinal System
Spontaneous bowel evacuation maybe delayed until 2 to 3 days after childbirth
Discomfort may be anticipated due to lacerations, episiotomies, or hemorrhoids and may cause a delay in evacuation
Operational vaginal birth and sphincter lacerations may cause postpartum incontinence
May resolve in 6 months
This can be explained by decreased muscle tone in the intestines during labor and the immediate puerperium, prelabor diarrhea, lack of food and dehydration
Mother of anticipates discomfort
Incontinence is often temporary
Pelvic exercises or Kegel exercises

22. 4.Within 2 weeks postpartum
 A postpartum nurse is providing home care instructions to a woman following delivery of a healthy newborn. The nurse tells the mother that she should expect normal bowel elimination to return:
1.1 day postpartum
 2.3 days postpartum
 3.7 days postpartum 
4.Within 2 weeks postpartum 

23. Postpartum Physiology
Breasts
Breastfeeding Mothers
Colostrum-before lactation begins and is yellowish in color
Breast milk (true)- after lactation begins and is bluish white in color
Breast may feel warm and firm
Tenderness may persist for about 48 hours after the start of lactation.
Nipples are assessed for signs of irritation such as; cracks, blisters, or reddening
Before lactation begins the breast feel soft, and a yellowish fluid, colostrum, can be expressed from the nipple
As lactation is established, a mass (lump) may be felt in the breast
Unlike the lumps associated with fibrocystic breast disease or cancer, which may be consistently palpated in the same location, a filled milk sac shifts position from day to day
After lactation begins breast feels warm and firm

24. 4.Nipples that are level with the skin surface
 A nurse is performing a breast assessment on a client who is preparing to breast-feed her newborn. Which breast finding would the nurse determine to be the most effective for breast-feeding?
1.Erectile nipples
 2.Inverted nipples 
3.Flat nipples
 4.Nipples that are level with the skin surface 

25. Postpartum Physiology
Nonbreastfeeding Mothers
Prolactin levels decrease rapidly
Colostrum is excreted for the first few days after childbirth
On the 3rd or 4th postpartum day, engorgement may occur and the breast become swollen, firm, tender, and warm to touch
Engorgement resolves itself spontaneously, and discomfort usually decreases by 24 to 36 hours
Breast binder or tight bra, ice packs, and analgesics may be used as comfort measures
Breast distention is primarily caused by he temporary congestion of veins, anf lymphatics rather than by an accumulation of milk.
Milk is present but should not be expressed
Axillary breast tissue (the tail of Spence) and any accessory breast or nipple tissue along the milk line also may be involved
Nipple stimulation is avoided
If suckling is never begun (or it is discontinued) lactation ceases within a few days to a week

26. Postpartum Physiology
Blood Volume
Blood volume that increases during pregnancy is eliminated within the first 2 weeks after birth
Blood volume returns to nonpregnant values within 6 months
Normal blood loss for vaginal delivery is 300 to 500 ml
Normal blood loss for a C/Section is 500 to 1000 ml
The changes in blood volume after birth depend on several factors, such as blood loss during childbirth, and the amount of extra vascular water (physiologic edema) mobilized and subsequently excreted
Blood loss results in an immediate but limited decrease in total blood volume
Therefore most of the blood volume increase during pregnancy (1000 to 1500 ml) is eliminated within the first 2 weeks after birth, with return to nonpregnant values by 6 months
Pregnancy-induced hypervolemia (an increased in blood volume of at least 35% more than prepregnancy values ) allows women to tolerate a considerable blood loss during childbirth

27. Postpartum Physiology
Blood Components
Hgb and Hct levels drop moderately for 3 to 4 days
WBC increase to 20,000 to 25,000
Increased neutrophils and eosinophils and decreased lymphocytes ( shifts to the left)
Clotting factors l,ll, V111, lX, decrease to nonpregnant level within a few days
Fibrinogen and thromboplastin remain elevated during the first few days after childbirth
During the first 72 hours after childbirth, a greater loss in plasma volume than in the number of blood cells is found
This results is an increase in the hematocrit and hemoglobin levels by the seventh day after birth
Hypercoagulable state, combined with the vessel damage that occurs during recovery, increases the risk of thromboembolism (blood clots) especially cesarean births

28. Postpartum Physiology
Neuromuscular System
Numbness of thighs, fingers, or hands disappear in several days
Back pain usually resolves in a few weeks or months following birth
Postpartum headaches may be caused by various conditions, including; postpartum onset preeclampsia, stress, and the leakage of cerebrospinal fluid into the extradural space during an insertion of an epidural
Headaches last from 1 to 3 days to several weeks depend on cause and effectiveness of treatment
The elimination of physiologic edema through the diuresis that occurs after childbirth relieves carpal tunnel syndrome by easing the compression of the median nerve
Postpartum headaches may be caused by various conditions, including postpartum-onset preeclampsia, stress, and the leakage of cerebrospinal fluid into the extradural space during placement of the needle into the extradural space during the placement of the needle for an administration of epidural or spinal anesthesia.

29. Varicosities

30. Postpartum Physiology
Musculoskeletal System
Relaxation of the joints and the changes in the mother’s center of gravity in response to the enlarging uterus
Joints are completely stabilized by 6 to 8 weeks after birth
Mother may notice a permanent increase in her shoe size

31. Postpartum Physiology
Integumentary System
Chloasma of pregnancy usually disappears at the end of pregnancy
Hyperpigmentation of the areolae, and linea nigra may not regress completely after childbirth
Spider angiomas (nevi), palmar erythema, and epulis generally regress
Profuse diaphoresis
But may be permanent in some women
Stretch marks on breasts, abdomen, hips, and thighs, may fade but usually do not disappear.
In response to the rapid decline in estrogens after the end of pregnancy
For some women, spider nevi persists indefinitely
Hair growth slows during the postpartum period
Fingernails return to their nonpregnant consistently and strength
Profuse diaphoresis that occurs in the immediate postpartum period is the most noticeable change in the integumentary system

32. Key Points
The rapid decrease in estrogen and progesterone levels after expulsion of the placenta is responsible for triggering many of the anatomic and physiologic changes in the puerperium.
Within 6 weeks after birth, the physiologic changes induced by pregnancy have reverted to their normal state.
Assessing lochia and fundal height is essential to monitor the progress of normal involution and to identify potential problems.

33. Key Points (Cont.)
The uterus involutes rapidly after birth and returns to the true pelvis within 2 weeks.
The return of ovulation and menses is determined in part by whether the woman breastfeeds her infant.
Few alterations in vital signs are seen after birth under normal circumstances

34. Key Points (Cont.)
Hypercoagulability, vessel damage, and immobility predispose the woman to venous thromboembolism.
Marked diuresis, decreased bladder sensitivity, and overdistention of the bladder can lead to problems with urinary elimination.
Pregnancy-induced hypervolemia, combined with several postpartum physiologic changes, allows the woman to tolerate considerable blood loss at birth.

35. Question
Which vital sign deviates from the normal reading as a result of puerperal sepsis?
Temperature
Respirations
Blood pressure (BP)
Pulse
ANS: A
Feedback
A Correct: A diagnosis of puerperal sepsis is suggested if a rise in maternal temperature to 38° C is noted after the first 24 hours after childbirth and recurs or persists for 2 days. Other possible causes are mastitis, endometritis, and urinary tract or other systemic infections.
B Incorrect: Hypoventilation may follow an unusually high spinal block or epidural narcotic after cesarean birth.
C Incorrect: A low or decreasing BP may reflect hypovolemia secondary to hemorrhage. An increased reading may result from excessive use of vasopressor or oxytocic medications.
D Incorrect: A rapid pulse rate or one that is increasing may indicate hypovolemia as a result of hemorrhage.