Normal Postpartum Physiological Changes

Normal Postpartum Changes

• Puerperium lasts 6-12 weeks after placenta delivery.
• Most physiological changes revert to pre-pregnancy conditions within 6 weeks, although cardiovascular and pelvic changes may take months or years.

Reproductive System: Uterus

• Involution is the process where the uterus reverts to its pre-pregnancy size.
• The uterus rapidly descends back into the pelvis within 2 weeks, with normal size achieved by 6 weeks.
• Granulocytes and mononuclear cells rapidly respond to the placental attachment site for repair.
• Endometrium is fully restored by postpartum day 16, not including the placenta site.
• Contractions/afterpains assist with involution, more severe in multiparous women, most intense in first 12 hours.
• Lochia is postpartum bleeding expelling placenta remnants and uterine lining.
• Lochia rubra is immediate red, heavy bleeding lasting 3-4 days.
• Lochia serosa is pinkish/brown discharge, possibly malodorous, lasting up to 27 days.
• Lochia alba is white/yellow discharge which is until complete uterine healing (5-6 weeks).
• Heavy bleeding may occur between days 7-14 related to sloughing.
• Evaluate for retained placenta tissue should heavy bleeding last more than a few hours.
• The inner lining of the uterus heals by day 16 PP, excluding the placental site.

Reproductive System: Cervix

• Cervix slowly returns to its pre-pregnancy size after delivery.
• By week 1 postpartum, edema and bleeding are minimal and it is about 1cm dilated.
• After vaginal delivery, the cervical os appears as a transverse slit, rather than a circular shape.

Reproductive System: Vagina & Perineum

• The vagina stretches to accommodate the fetus during childbirth.
• The vagina gradually returns to its normal size over weeks.
• Vaginal tone and tightness may not return to pre-pregnancy state.
• The perineum is the area between the vagina and anus.
• Lacerations or episiotomies can occur during vaginal delivery.
• Healing of lacerations that can cause discomfort can take several weeks.

Laceration Grading

• First-degree lacerations involve only the vaginal mucosa and epithelial layer and may not require repair.
• Second-degree lacerations extend into the perineal body but not to the external anal sphincter and require suturing.
• Third-degree lacerations involve the perineal body, extend to the external anal sphincter muscles, and are further classified as 3A (less than 50% of the sphincter muscle), 3B (more than 50%), and 3C (involving the whole muscle and internal anal sphincter).
• Healing may take weeks for third-degree, with a risk of infection/bowel control issues.
• Fourth-degree lacerations: the most severe, extending through vaginal/perineal skin, sphincter complex, and anal epithelium, requiring complex surgical repair.
• Fourth degree carries a higher risk of complications and specialized postpartum care.

Urinary System

• Immediately after birth, bladder mucosa and urethra are edematous due to labor and delivery.
• Regional analgesia can temporarily affect bladder performance.

Renal System

• Increased pregnancy-related kidney function gradually returns to normal.
• Glomerular Filtration Rate increased by 50% return to normal by PP week 8.
• Renal plasma flow increased by 25% during pregnancy normalizes within 24 months.
• Diuresis occurs immediately after delivery to excrete fluids retained during pregnancy.
• Average net fluid loss is 2L in the first week and an additional 1.5L within the first 6 weeks.
• Weight loss noted can be 10-13 lbs in the first week and continue for 6 months.
• Bladder function may be temporarily less sensitive due to Relaxin.
• Difficulty fully emptying the bladder post-delivery, particularly with epidural or perineal trauma.
• Urinary retention may occur, requiring temporary catheterization.
• Operative deliveries may cause bladder damage or prolonged catheterization.

Cardiovascular System

• Cardiovascular and hemodynamic systems respond to blood loss, fluid shifts, and repair after delivery.
• Cardiac output decreases by about 28% within the first 2 weeks postpartum, returning slow and gradually in 12 months.
• Total blood volume decreases from 5-6L to the volume of a non-pregnant body of 4L within 3 weeks postpartum.
• Expansion during pregnancy protects against blood loss during delivery.
• Blood pressure generally decreases postpartum but may slightly increase in the first 5 days.
• Blood pressure stabilizes in several weeks, and its important to monitor for return to normal.

Blood Coagulation

• There are rapid changes in coagulation and fibrinolytic systems post-delivery.
• Fibrinogen decreases during labor, reaching a low on day 1, returns to pre-labor levels by days 3-5, and decreases to normal by weeks 3-4 PP.
• VIII (8) and plasminogen follow a similar pattern.
• Increased clotting factor concentrations compensate for rapid changes after delivery.
• Higher risk for a thromboembolic event exists.

Respiratory System

• It has rapid changes with abdominal/thoracic capacity increase following delivery.
• Respiratory rate may temporarily increase as the body adjusts to fluid removal.
• Oxygen consumption remains elevated due to anemia, lactation, and psychological factors.
• Normal diaphragm position returns after delivery.
• Symptoms of shortness of breath improve as thoracic cavity expands.
• Progesterone decreases ventilation rate, causing increased PCO2 in the 1st week PP.
• pH and base excess increase until normal by 3 weeks PP.

Endocrine System Changes

• HPL, HCG, estradiol, and progesterone rapidly decrease post placenta delivery.
• FSH and LH remain low postpartum and are relative to breastfeeding status.
• Ovulatory function resumes by 6 weeks PP in non-breastfeeding women.
• Menstrual cycle returns within 6-8 weeks for non-breastfeeding women.
• Hormonal changes contribute to symptoms like mood changes and vaginal dryness.
• Oxytocin plays a key role in milk production and uterine contractions and helps uterus contract to pre-pregnancy size and milk ejection.
• Prolactin stimulates milk production and is released in response to breastfeeding.
• Prolactin is elevated during pregnancy and proportional to breast feeding after birth, with levels rising substantially during the PP period.
• Thyroid volume increases by 30% in pregnancy and returns to normal by 12 weeks PP.
• Thyroxine & triiodothyronine are also elevated, but normal by 4 weeks PP.
• Evaluating is appropriate at 6 weeks PP for dosage adjustments
• A higher risk of PP thyroiditis exists for women with thyroid disorders and DM, can evolve into permanent hypothyroidism.

Postpartum Assessment

• Post partum; PP may be called the "fourth trimester."
• ACOG supports continued care and follow-up from delivery until 12 weeks PP.

Breastfeeding & Lactogenesis

• Assessment should ensure both health of mother & NB.
• Shape and size: breasts increase with fullness from milk, asymmetry should be noted
• Skin: check for redness, bruising or infection, stretch marks are common and should not be concerning.
• Engorgement: breasts tight/shiny when overly full.
• Nipple condition: cracking, soreness, inverted nipples, signs of infection (redness, swelling, or discharge).
• Milk Flow: Assess milk flow/effectiveness of pumping/nursing.
• Engorgement may interfere with pumping/nursing.
• Palpation for lumps: Engorged areas are detected with palpation which determines hardness/swelling and blocked ducts. A firm/painful mass indicates abscess that requires tx, unusual lump should be assessed d/t breast cancer

Breast Health Education

• Proper breast care: education on breasts during PP; BF techniques/hygiene.
• Signs of complications: education on mastitis/blocked ducts.
• Emotional support of body image and BF challenged should be provided.
• Assess feelings about physical/emotional challenged with BF and her changing body.

Postpartum Visits Schedule

• Two Weeks PP
  • Check incision and s/s of infection
  • Mental health assessment, breastfeeding, contraception
  • Ensure that hospital vaccines were given
• Six Weeks PP
  • Assess healing of uterus, perineum, vag, abd
  • Assess discomfort: pelvic, urinary, breasts
  • Assess breastfeeding, mental health, contraception, resuming sexual activity/exercise
  • Discuss birth spacing
• PRN Visits
  • Any other visit for high risk pt w/ chronic health disease, complications w/ delivery
• Assessments
  • Weight and BP in each visit
  • Check CBC with possible anemia
  • Exam breasts & nipples
  • Vaginal Inspection (vagina estrogen)
  • Cervical exam, perenial repair assessment and bimanual exam of uterus

Postpartum Vaccine Recommendations

• Rhogam: Given after abortion/delivery of Rh- mom with Rh+ newborn
• Rubella: Vaccine is indicated; live attenuated rubella virus should be given w/in 72 hours of delivery if a non-immune and avoid for 1M.
• Tdap: Recommended in the 3rd trimester of EACH pregnancy regardless of last tdap.
• Influenza: Encouraged as high-risk, begins flu season in september, and can be taken while pregnant.
• Hep B: Take action if declines during PP, can be started in PP period if declines during pregnancy.

Postpartum Vaccinations Cautions

• Give vaccines in separate sites, verify rubella immunity after three months.
• Obtain Tdap for mother after if have concerns, can be given to pt without a history of Rubella.
• Two hours wait time is recommended after before breastfeeding because there would be a chance for allergy to pass through breastmilk.
• Rubella test after 3 months to obtain rubella immunity.

Nutrition, Sleep, and Emotional state

• Increase Protein intake with Veggies, fruits and water to help regain some electrolytes and good nutrients. Recommend daily multivitamin. BF moms need 500kcal more.
• Emotional Rest, or naps in the day. Can be stressful with NB so emotional state matters.
• Activity after recovery is good, light cardio for the first few weeks.
• Can resume sexual activity once is comfortable & bleeding is minimal
• Postpartum blues exist up to 10 days postpartum

Pharmacology

- Physiologic Changes During the Postpartum Period = There are rapid physiologic changes which influence pharmacology; ex: involution of the uterus, lactogenesis and multiple endocrine changes

 - Considerations Prior to Prescribing Drugs in the Postpartum Period = Changes are: They rarely require modifications in dosing or choice of drugs; Treatment of PP symptoms should be minimized SE; carefully assessed drug in breastmilk.

- Immunobiologics (vaccines & immunoglobulins) = Used based on mom's status status, potential for exposure and imminent international travel such as rubella, RhoGAM, Tdap

- Vitamin Supplementation = Helpful and can start postpartum, recommended if has restricted diets and health conditions = Continue as lactating women