post partum changes

expected blood loss during labor

• vaginal vs c/s

• tolerated/fine bc?

• if more?

vagnial: less than 500

c/s: less than 1000

Tolerated due to pregnancy-induced hypervolemia

if more: post partum hemorrhage

• QBL: Quantitative Blood Loss

involution

• what is it/def

• what happens/causes

• what do we want

• how do we assess/what to measure

process of the uterus returning to its nonpregnant state, beginning immediately after the placenta is expelled.

happens with contraction of uterine muscle

fundal height changes

FIRM FUNDUS

involution process/fundal height changes

midline fundus

Immediately after birth: ~2 cm below umbilicus.

Within 12 hours: ~1 cm above umbilicus.

By 24 hours: umbilicus.

Descends 1–2 cm every 24 hours.

Day 6: Located halfway between umbilicus and symphysis pubis.

By 2 weeks: No longer palpable abdominally.

By 6 weeks: Returns to nonpregnant position

Subinvolution

• define

• common causes

• what to do

Failure of the uterus to return to nonpregnant state.

Common causes: retained placental fragments and infection.

massage the fundus; empty bladder

placental site

Shrinks to 4–5 cm after expulsion

No scar forms due to sloughing of necrotic tissue

lochia

• types/days

Lochia rubra (Days 1–3):

• Dark red, blood, tissue debris

Lochia serosa (Days 4–10):

• Pink/brown, serum + leukocytes

Lochia alba (After day 10):

• Yellow/white, mostly leukocytes

Factors Affecting Amount 5

Oxytocics → ↓ lochia temporarily

C-section → less lochia (uterus is suctioned/cleaned)

Increases with:

1. Ambulation

2. Breastfeeding

3. Position change (e.g., standing up → pooled lochia gush)

lochia vs bleeding 3each

Lochial bleeding: Trickles, may gush with massage; normal if uterus is contracting.

Nonlochial bleeding: Spurts, bright red, with firm uterus → suggests tear/laceration.

cervical pp changes 3/4

Soft, bruised, edematous, possible lacerations

↑ infection risk

starts to shorten and firm up over time

• fully by day 2-3

ovaries pp changes 3

ovulation is delayed in lactating mothers

Prolactin suppresses ovulation

First menses: Often heavier than normal

Vagina

• 3

thin mucosa, no rugae,

Rugae return: ~3 weeks, but flattened

↓ lubrication = localized dryness and Dyspareunia (painful sex) common → use water-based lubricant

Introitus & Perineum 2

Erythema & edema after birth (esp. with laceration/episiotomy)

Check for signs of infection or dehiscence

Pelvic muscular support

birth can change support structures

Kegel exercises help restore muscle tone and promote healing.

breast feeding mothers: milks

Day 1: Colostrum (clear yellow fluid)

Day 3–4: Milk comes in (lactogenesis II) → breasts fuller, warm, tender

engorgement breast feeding

• what is it and how to help

breasts become swollen, hard, and tender due to an oversupply of milk, which can make it difficult for the baby to latch and for milk to flow properly

• relieved by frequent breastfeeding

Nonbreastfeeding Mothers

• prolactin

• engorgement

• discomfort

• lactation

Prolactin ↓ rapidly

engorgement

• Caused by venous & lymphatic congestion (not milk buildup)

• Milk is present but should not be expressed

Discomfort resolves in 24–36 hrs

Lactation stops in a few days to 1 week

endocrine changes: placental hormones

4

↓ Estrogen, progesterone, hCG, prolactin, cortisol, insulin

• hCG: Detectable for 3–4 weeks

reverses diabetogenic effects of pregnancy = lower BSL

Type 1 diabetics need less insulin postpartum

pituitary hormones

low progesterone = inc prolactin

• breastfeeding

• milk PROduction

Oxytocin

• Released with suckling

• Triggers milk let-down reflex

metabolic rate

increases for 1-2 weeks, then returns to normal

ovulation/breastfeedin

Nonbreastfeeding

• as early as 27 days

breastfeeding

• prolactin suppresses ovulation

• LAM: Lactational Amenorrhea Method

fluid loss

• when does it start 1

• moa/what hormone 1

• s/s or cms 3

Begins within 12 hrs

Estrogen ↓ → diuresis

Urine output: ≥3000 mL/day (first 2–3 days)

Diaphoresis (night sweats) common

Weight loss: ~2–3 kg (5–6.6 lb) in early days

Bladder & Voiding

• what changes occur 2

• what causes the change? 3

• can result in

• returning to normal?

stress inc and dec urge to void due to:

dec urge to void due to:

• Trauma, anesthesia, swelling, lacerations

can result in bladder distention

bladder tone returns 5-7 days

bladder dist can cause

• early 2

• later 2

Early → pushes uterus up/side → ↑ bleeding

Later → UTI risk, delayed voiding

notes

• pp diuresis is d/t

• urinary retention is d/t

  • can result in

tissue fluid accumulation + blood volume

dec tone, anesthesia, vag birth

uterine displacement

gi system 3

appetite/advanced diet: can they eat? yes!

• assess bowel sounds/gas, esp in c/s

constipation

anal inc

constipation

• how long

• causes 3/4

No bowel movement: Common for 2–3 days postpartum

• ↓ Peristalsis (from labor, meds, dehydration, etc.)

• Opioids, decreased muscle tone

• reluctance/ Fear of pain (episiotomy, lacerations, hemorrhoids)

Anal Incontinence

• what type is common

• linked to 3

more common: Gas (flatus) incontinence > stool

linked to:

• Pelvic floor

• nerve injury

• 3rd–4th degree lacerations

cv changes groups

cardiac output

vs

blood components

Varicosities

hemorrhoids

c/o

c/o: initial increase in c/o, returns to prelabor levels (within 1 hour) and pre-pregnancy levels (6-8 weeks)

vs

temp: slight fever (38c/100.4) bc of dehydrating effect for first 24 hrs

hr: elevated, then decreases

• Puerperal bradycardia

Respirations

• unchanged or slight inc

BP

• slight inc, returns to normal

• orthostatic hypotension in 48 h

blood components

dec hgb/hct

wbc inc

clotting factors inc

Varicosities/hemorrhoids

Leg, anal (hemorrhoids), and vulvar varices are common in pregnancy

Regress rapidly after birth

Near-total resolution is expected during the postpartum period

other systems

• int 7/8

Melasma ("mask of pregnancy"): Fades postpartum, may persist or return with pregnancy/oral contraceptives

Areolae & linea nigra: May remain darker permanently

Striae gravidarum (stretch marks): Fade but don’t disappear

Spider angiomas & palmar erythema: Usually regress (↓ estrogen)

Hair loss: Common up to 3 months postpartum

Fine hair disappears; coarse hair often stays

Nails: Return to prepregnancy strength/consistency

musculoskeletal

• abd tissue

Relaxed for first 2 weeks

Returns close to prepregnancy state by 6 weeks

• AVOID ABD EXERCISES DURING THIS TIME

Diastasis recti abdominis:

• Muscle separation (esp. with large/multiple babies)

• Usually resolves without surgery

musc

• joint and posture

Back pain usually resolves in weeks to months

Joints stabilize by 6–8 weeks

Foot joints may not return to prepregnancy state → permanent increase in shoe size

NEURO

Headaches

Carpal tunnel syndrome improves with postpartum diuresis

• Numbness/tingling often resolves unless aggravated by lifting

Nasal stuffiness

Tinnitus

Laryngeal changes

in HA, assess for

Postpartum preeclampsia

Stress

Spinal/epidural CSF leak