NUR 315 Exam 3 - Postpartum Maternal Physiologic Adaptation

Uterus postpartum changes

Involution

• Decreasing size and weight

• Muscle contraction, catabolism, and regeneration

• Separation of decidua

  • The thick layer of modified mucous membrane which lines the uterus during pregnancy and is shed with the afterbirth

Fundal height

• Decrease corresponds with # days postpartum

Afterpains

• Pain associated with contractions after birth

Fundal height

Lochia patterns

Short time frame of bleeding 7-14 days after birth (associated with sloughing at the placental attachment site)

• Lochia rubra (days 1-3)

• Lochia serosa (days 3-10)

• Lochia alba (days 10-42)

Lochia rubra

Days 1-3

Bloody, small clots, dark red or red-brown

Lochia serosa

Days 3-10

Serosanguinous, pink or brown tinged

Lochia alba

Days 10-42

Serous, white to light yellow

Measuring lochia

• Consider

  • Time since last pad change and any position change

• Quantified blood loss (QBL)

  • Weigh pad with lochia

  • Weigh clean pad

  • Subtract the difference

• Estimated blood loss (EBL)

  • Scant

  • Light

  • Moderate

  • Heavy

  • Excessive (saturated in 15 min)

Calculating blood loss

• Remember 1 gram is assumed to equal to 1 mL of blood

• Assume one dry peripad = 30 grams

• Assume one dry chucks pad = 100 grams

Cervix postpartum changes

• Dilated, edematous, and bruised after birth

• Small lacerations may be present

• Returns to 1 cm by 1 week postpartum

• Internal os shaped slit-like rather than round

Vagina postpartum changes

• Vaginal walls

  • Edematous with small lacerations

  • Tone and rugae slowly improve starting about week 3

• Cervical mucus

  • Less production until estrogen levels re-establish

• More likely to experience dyspareunia (painful intercourse)

Perineum postpartum changes

• Edematous and bruised

• Episiotomy begins healing about wk 2-3; complete 4-6 mo

• Labor may create or worsen hemorrhoids

• Pain with positional changes or bowel movements

Ovulation and mensturation postpartum changes

• First few bleeds may be anovulatory

• Ovulation may begin before 1st menses

• Nonlactating: resumes in about 6 to 10 weeks

• Lactating: resumes in 10 weeks to 6 months, but may be shorter or longer duration

Breasts postpartum changes

• Placental brith triggers increase in breastmilk production

• Oxytocin = breastmilk let-down

• Areola darker as a visual cue to infant

Breastmilk phase 1

Colostrum

• First milk following delivery

• Production starts by week 16 of pregnancy

• AKA liquid gold, thick, yellowish-white fluid

• High in protein and IgA

• Lower in carbs and fat than breastmilk

• Assists in infant digestive system bacteria growth

Breastmilk phase 2

Transitional milk

• Starts 2-5 days after delivery until 2 weeks

• Sometimes bluish-white in color

• Often associated with initial symptoms of breasts feeling warmer and fuller (AKA Engorgement)

Breastmilk phase 3

Mature milk

• Starts 10-15 days after birth

• Should allow infant to empty one breast before changing to other side to ensure proper mix of nutrients at each feeding.

• Demand vs. supply dependent

Breast care general recommendations

• If non-breastfeeding...

  • Wear form-fitting bra (but not super tight)

  • Do not express milk unless necessary for comfort

• If breastfeeding...

  • Breastfeed, pump, or hand express q 2-3 hr approx. 15 minutes/session

  • No special cleansers or ointments needed, but can use lanolin for chapping

• Engorgement

  • Feed as appropriate to empty regularly

  • Use cool packs; cabbage leaves; supportive bra

• Consult early and often with clinical expert if questions or concerns!

Postpartum cardiovascular changes

Blood volume

• Immediate loss of ~1000 mL during delivery 

• Rebound increase of 900–1200 mL over days due to fluid redistribution

• Normal plasma volume restored by 6–8 weeks postpartum

Cardiac output

• Elevated during pregnancy

• Returns to baseline by ~6 weeks postpartum 

• Heart rate & blood pressure

  • Heart rate normalizes within 6 weeks

  • Blood pressure typically returns to pre-pregnancy levels early in the puerperium 

Hormonal influence

• Fluctuations in estrogen and progesterone affect vascular tone and fluid balance 

Thrombosis risk

• Increased coagulation factors (I, II, VII, VIII, IX, X) during pregnancy

• Risk of thromboembolism heightened postpartum, especially with trauma or immobility

• Cardiac output at pre-pregnancy levels within 6-12 wk via diuresis and diaphoresis

Postpartum hematologic changes

WBC

• Leukocytosis up to 30,000 can be normal during labor/immediate postpartum

• Temp up to 38 degree (100.4) for first 24 hr

• Baseline WBC's by day 6

RBC and clotting

• Vary widely depending on compensatory mechanisms, normal physiology, and blood loss during delivery

• Baseline Hct and clotting factors by 4-6 wk

Postpartum gastrointestinal changes

• Increased hunger d/t energy expenditure

• Increased thirst

  • From exertion

  • Breastfeeding

  • Fluid loss

• Constipation

  • Progesterone levels decrease gradually

  • Recent decreased food and fluid intake

  • Discomfort → ineffective bowel movements

  • Iron intake

• Normal bowel pattern

  • Return by 8 to 14 days postpartum

Postpartum urinary changes

• Urinary retention initially

  • Urethra edematous, traumatized

  • R/t diuresis and decreased sensation

  • May displace uterus from midline

• Baseline kidney function within 4 weeks

• Increased bladder capacity and decreased tone

  • Stress incontinence

  • Takes several weeks to months to resolve

Postpartum musculoskeletal changes

Muscles

• Fatigue and aches from labor exertion

Decrease in relaxin

• Ligaments and cartilage return to pre-pregnancy position

Abdominal muscles

• Weaker

• Softer

• May separate longitudinally

Postpartum integumentary changes

• Chloasma and linea nigra gradually fade and disappear

• Striae gravidarum fade but do not disappear

• Increased hair loss due to increased hair growth during pregnancy

Postpartum neurologic changes

Anesthetics or analgesics

• Cause temporary lack of feeling in extremities or dizziness

Headaches may occur...reasons vary

• Normal fluid-electrolyte changes?

• Pre-eclampsia?

• Stroke?

• Post-dural puncture headache?

Postpartum endocrine changes

• Decrease in estrogen, progesterone, and human placental lactogen

• Prolactin

  • Supersedes and triggers more breastmilk production

  • Returns to pre-pregnancy level in non-breastfeeding parents

  • Helps regulate the menstrual cycle

Postpartum vaccines

• MMR or varicella if mother's titers were non-immune prenatally

• Influenza if in season and not given during pregnancy

• Rhogam within 72 hours after birth for Rh- mother if baby is confirmed as Rh +