1. Chapter 18 Maternal Physiologic Changes All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.

2.  Postpartum period is the interval between birth and return of reproductive organs to their nonpregnant state  Referred to as puerperium or fourth stage of pregnancy  Traditionally lasts 6 weeks, although this varies among women Maternal Physiologic Changes 2 All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.

3.  Uterus  Involution process is the return of the uterus to a nonpregnant state following birth Progresses rapidly  Fundus descends 1 to 2 cm every 24 hours  2 weeks after childbirth the uterus is no longer palpable  Returns to a nonpregnant state by 6 weeks Subinvolution is the failure of uterus to return to nonpregnant state Reproductive System and Associated Structures 3 All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.

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5.  Uterus  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 Reproductive System and Associated Structures (Cont.) 5 All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.

6.  Uterus  Afterpains  Placental site  Lochia: postbirth uterine discharge Lochia rubra  Blood and decidual and trophoblastic debris  Duration of 3 to 4 days Reproductive System and Associated Structures (Cont.) 6 All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.

7.  Uterus  Lochia: postbirth uterine discharge Lochia serosa  Old blood, serum, leukocytes, and debris  Duration of 22 to 27 days Lochia alba  Leukocytes, decidua, epithelial cells, mucus, serum, and bacteria  Continues 2 to 6 weeks after birth Reproductive System and Associated Structures (Cont.) 7 All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.

8.  Cervix  Soft immediately after birth  During the next 12 to 18 hours the cervix shortens, becomes firm, and regains prepregnant form  External os regains its prepregnancy appearance  Cervical os, dilated to 10 cm during labor, closes gradually Reproductive System and Associated Structures (Cont.) 8 All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.

9.  Vagina and perineum  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 Reproductive System and Associated Structures (Cont.) 9 All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.

10.  Vagina and perineum  Introitus is erythematous and edematous  Episiotomies heal within 2 to 3 weeks May take 4 to 6 weeks to heal completely  Hemorrhoids (anal varicosities) are common and decrease within 6 weeks of childbirth Reproductive System and Associated Structures (Cont.) 10 All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.

11.  Vagina and perineum  Pelvic muscular support Supportive tissues of pelvic floor torn or stretched during childbirth Require up to 6 months to regain tone Kegel exercises encourage healing Reproductive System and Associated Structures (Cont.) 11 All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.

12.  Abdomen  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 12 All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.

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14.  Placental hormones  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 Endocrine System 14 All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.

15.  Pituitary hormones and ovarian function  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 Endocrine System (Cont.) 15 All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.

16.  Urine components  Postpartal diuresis  Within 12 hours women begin to diurese  Profuse diaphoresis often occurs at night for first 2 to 3 days  Urethra and bladder  Excessive bleeding can occur because of displacement of the uterus if bladder is full Urinary System 16 All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.

17.  Appetite  Most new mothers are very hungry after recovery from analgesia, anesthesia, and fatigue  Bowel evacuation  Spontaneous bowel evacuation may not occur for 2 to 3 days after childbirth Gastrointestinal System 17 All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.

18.  Breastfeeding mothers  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)  Nonbreastfeeding mothers  Engorgement resolves spontaneously, and discomfort decreases within 24 to 36 hours Breasts 18 All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.

19.  Blood volume  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 Cardiovascular System 19 All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.

20.  Cardiac output  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 Cardiovascular System (Cont.) 20 All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.

21.  Cardiac output  Vital signs  Blood components Hematocrit and hemoglobin White blood cell count Coagulation factors  Varicosities Total or nearly total regression of varicosities is expected after childbirth Cardiovascular System (Cont.) 21 All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.

22.  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 Neurologic System 22 All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.

23.  Reversal of pregnancy adaptations  Joints are completely stabilized by 6 to 8 weeks after birth New mother may notice permanent increase in shoe size Musculoskeletal System 23 All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.

24.  Chloasma of pregnancy usually disappears at end of pregnancy  Persists in 30% of women  Hyperpigmentation of areolae and linea nigra may not regress completely after childbirth  Some women will have permanent darker pigmentation of those areas  Stretch marks on breasts, abdomen, and thighs may fade but not disappear Integumentary System 24 All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.

25.  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  Some women experience significant hair loss Integumentary System (Cont.) 25 All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.

26.  Mildly suppressed during pregnancy, the immune system returns to its prepregnant state  Rebound of the immune system can cause “flare-ups” of some conditions  Lupus erythematosus  Multiple sclerosis Immune System 26 All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.

27.  To provide optimum care for the postpartum woman, the nurse understands that the most common causes of subinvolution are:  postpartum hemorrhage and infection.  multiple gestation and postpartum hemorrhage.  uterine tetany and overproduction of oxytocin.  retained placental fragments and infection. Question 27 All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.