Postpartum Adaptations

Involution

Gradual return of uterus to its size and condition prepregnancy by contracting uterus, shrinking enlarged myometrial cells, and regenerating uterine lining

How should the fundus be by day 10?

Descended into pelvis, not palpable

When should the uterus return to prepregnancy size?

Around 6 weeks

What factors help with involution?

Normal delivery, breastfeeding, early ambulation, complete delivery of placenta/membranes

What factors delay involution?

Prolonged labor, retained placenta, infection, full bladder, uterine-relaxing meds/anesthesia

Subinvolution

Delayed/inadequate return of the uterus to its normal size → remains larger/softer/boggy

Why is it bad when uterine can’t contract or stay firm postpartum?

Blood vessels will remain open → postpartum hemorrhage

Lochia

Normal vaginal discharge after birth containing blood tissue and uterine lining (4-8 weeks)

Normal Lochia Odor

Fleshy/musty

Lochia normal staging

Rubra → serosa → alba, becomes lighter and decreases in amount

Lochia rubra

Deep bright red with blood, mucus, and tissues during Days 1-4

Lochia serosa

Pinkish brown with leukocytes, tissue, RBCs and serous fluids during Days 3-10

Lochia alba

White/cream/light-brown with mostly leukocytes and tissue during Days 10 and onward (3-6 weeks)

When should lochia be evaluated?

Bright-red bleeding that reappears after lochia rubra ended

Afterpains

Painful uterine contractions that occur as uterus involutes

Who tends to have stronger afterpains?

Multiparous patients and breastfeeding

How are afterpains treated?

With mild analgesics (ibuprofen or acetaminophen)

How is the cervix like immediately after birth?

Soft, edematous, bruised, and partially dilated but returns gradually by about 6 weeks

How does the cervical os change after birth?

Changes from original round shape to slit-like/jagged opening permanently

How is the vagina like after birth?

Initially edematous, relaxed, thin with fewer rugae, then tissues thicken and rugae return as estrogen returns

Why does dyspareunia occur after birth?

Vaginal dryness and tissue changes makes intercourse painful, but improves when estrogen returns to prepregnancy levels

How is the perineum like after birth?

Edematous, bruised, hemorrhoids, lacerations/episiotomy, and weak muscle tone takes months to heal

What does excessive pelvic floor stretching do?

Urinary/fecal incontinence, sexual dysfunction, pelvic organ prolapse

What happens to blood volume and cardiac output postpartum?

Levels return by about 4 weeks postpartum

How does hematocrit levels stay stable or slightly increase postpartum?

Plasma volume decreases significantly more than RBCs from diuresis, reversing hemodilution

What other findings should be assessed when infection is suspected?

Fever, uterine tenderness, foul-smelling lochia, etc.

What happens to pulse rate after birth?

Decreases after birth due to decreasing CO and SV volumes with mild bradycardia (1-2 weeks)

Why can tachycardia postpartum be concerning?

Can indicate hemorrhaging, hypovolemia, dehydration, or infection

What postpartum finding indicates preeclampsia?

Elevated BP + headache

What BP postpartum finding may indicate hemorrhaging?

Decreased BP accompanied by other signs of blood loss

When is the mother in a hypercoagulable state?

During pregnancy and early postpartum (2-3 weeks)

Why is there a decreased sensation to void postpartum?

Regional anesthesia, oxytocin (Pitocin), or swelling or trauma around perineum affects voiding

What does a full bladder/urinary retention do?

Displaces the uterus and contributes to uterine atony, increasing bleeding postpoartum

What factors can interfere with postpartum voiding?

Birth trauma (laceration, swelling, bruising, prolonged delivery, C/S), anesthesia, catherization → decreased bladder sensation/tone → urinary retention

How does the body eliminates extra fluid accumulated during pregnancy?

Excessive diuresis starts within 12 hours after birth and significant during first 2 weeks

How much urine does postpartum output reach?

3000mL/day

How is bowel function like after birth?

Decreased bowel tone and peristalsis from analgesics, low fiber, decreased abd pressure → constipation

Complications of constipation

Causes straining leading to pain around episiotomy/lacerations, worsens hemorrhoids, pressure on pelvic floor

What happens to feet after birth?

All joints return to prepregnant state except feet, sometimes leading to permanent increase in shoe size

Why is postpartum sweating common?

Diaphoresis helps eliminate excess fluid retained during pregnancy (first week, normal)

How is the integumentary system like after birth?

Skin hyperpigmentation returns to normal, temporary hair loss, increased sweating

How is the endocrine system like after birth?

Rapid decrease in estrogen and progesterone, FSH and LH low but rises 2 weeks postpartum

What is prolactin’s role postpartum?

Produces breast milk and remains elevated with breastfeeding to maintain production

What is oxytocin’s role postpartum?

Causes milk let-down/ejection and strengthens uterine contractions (afterpains)

When does mature breast milk begin?

Around 4-5 days postpartum

How does infant sucking promote breastfeeding?

Nipple stimulation increases prolactin for milk production and oxytocin for ejection

Breast engorgement

Breasts become hard, swollen, tender, and uncomfortable when milk production increases, increasing blood and lymph supply 2-3 days postpartum

How to relieve breast engorgement when breastfeeding?

Frequent breastfeeding/pumping to empty breasts and prevent milk buildup, warmth before feeds, cold between feeds, anti-inflammatory meds

When can ovulation occur postpartum?

Before first menstrual period, meaning pregnancy can occur before menstruation returns

When may menstruation return in nonbreastfeeding patients?

Around 7-9 weeks postpartum, first cycle can be anovoluntary

How does breastfeeding affect return of menstruation?

Frequent breastfeeding delays menstruation from prolactin (↓GnRH, FSH, LH), may return about 2-18 months

When is lactational amenorrhea method (LAM) effective as temporary contraception?

No menstrual period returning AND exclusively breastfeeding, AND infant is under 6 months

What happens when there’s no breastfeeding?

No nipple stimulation → milk production decreases/subsides few days later (engorgement + discomfort still there but subsides in 2-3 days)

What is Rubin’s Taking-in phase?

First 24-48 hours after birth → client is dependent on others to meet basic needs (food, fluid, rest) and shares experience

What is Rubin’s Taking-hold phase?

Around days 2-3 → parent more independent and often takes responsibility for self-care and newborn care

Why is Taking-hold phase a good time for teaching?

Parent is becoming more independent and ready to learn newborn care and self-care skills

What is Rubin’s Letting-go phase?

Parent adjusts to new parental role, accepts real newborn instead of fantasy infant, incorporates baby into daily life and develops confidence

How to relieve breast engorgement if not breastfeeding?

Tight supportive bra, ice, don’t stimulate nipple or let water hit nipple in shower