Postpartum Physiologic Changes PDF

Chapter 20 Postpartum Physiologic Changes **Postpartum period**: interval between birth and return of reproductive organs to normal nonpregnant state - AKA, puerperium, last 6 wks **[Reproductive systems and associated structures]** - Uterus - Involution: return of uterus to nonpregna...

Chapter 20 Postpartum Physiologic Changes **Postpartum period**: interval between birth and return of reproductive organs to normal nonpregnant state - AKA, puerperium, last 6 wks **[Reproductive systems and associated structures]** - Uterus - Involution: return of uterus to nonpregnant state, begins right after expulsion of placenta with contraction of the uterine smooth muscle - End of 3^rd^ of labor, uterus weighs about 1000g, midline, about 2 cm below the umbilicus - Within 12 hrs, can rise 1 cm above the umbilicus - By 24 hours, the same size as when it was 20 weeks - Fundus descends 1-2 cm q24hr - By 6th day, halfway between the umbilicus and symphysis pubis - After 2 weeks, should not be palpable abdominally - By 1 week, weighs 500g - By 4 weeks, weighs 100g, return to nonpregnant size - After 6 weeks, return to nonpregnant location - Decrease in hormones E, P causes autolysis - self-destruction of excess hypertrophied tissue - Subinvolution: failure of the uterus to return to a nonpregnant state due to ineffective contractions - A common cause is **retained placental fragments and infection** - Contractions - PP hemostasis achieved by compression of uterus contractions - First 1-2 hours, contractions can decrease the intensity and become uncoordinated, risk for PPH - Pitocin is usually given IV, IM to help and breastfeeding can also stimulate oxytocin release - Afterpains (afterbirth pains): periodic relaxation and vigorous contractions in subsequent pregnancies causing uncomfortable cramping, lasts for 3-7 days - Related factor: Uterus overdistended, breastfeeding and Pitocin intensify afterpains d/t stimulate UC - Placental site - Vascular restriction and thromboses reduce placental site - Growth of endometrium sloughs off necrotic tissue - Endometrial regeneration begins at 3^rd^ days, complete by 3^rd^ week - Regeneration of placenta site complete by 6^th^ week - Lochia - May experience for up to 4-6 weeks - First 2 hrs, like a heavy menstrual period - Oxytocic med and c-section may cause less lochia - Lochia increases with ambulation and breastfeeding - Persistence of rubra lochia in PP suggests retained fragments of placenta - Uncommon to experience a sudden, brief, increase in bleeding 7-14 days - Sloughing of eschar over the placental site should subside in 1-2 hr, if not, assess retained placental fragments - Lochia smells like normal menstrual flow - Offensive odors indicate endometritis AEB fever, pain, abd tenderness - Characteristics - Rubra - bright red, 1-3 days - Serosa - pinkish brown, 4-10 days - Alba - whitish-yellow, 10-14 days, last up to 3-6 weeks - **Lochial bleeding** - **Trickles from opening, steady flow is greater as uterus contracts** - **A Gush of lochia can appear as the uterus massaged** - **If it is dark, it has been pooled in a relaxed vagina** - **Amounts lessen to trickle if bright red** - **Nonlochial bleeding** - **If bloody discharge spurts from the vagina, the uterus firmly contracted, and there can be cervical or vaginal tears in addition to normal lochia** - **If the amount of bleeding continues to be excessive and bright red, a tear can be a source** - **Cervix** - Soft immediately after birth, protrudes to the vagina, appears bruised, edematous, small lacerations, risk for infection - 12-18 hr shortens and becomes firmer - 2-3 days shortened, firm, regained form, decreased to 2-3cm dilation - In 1 week it is 1 cm dilation - [External os may not be circular shape anymore] \> jagged slit, "fish mouth" - Ovaries - Can occur as early as 27 days s/p birth in nonlactating women - PP contraception is necessary - Lactating women may suppress ovulation, return ovulation in 6 months - First menstruation heavier than normal, returns normal in 3-4 cycles - Vagina and perineum - Thinness of vaginal mucosa and absence of rugae d/t PP estrogen deprivation - The vagina may [not return completely to the pre-pregnancy state], and rugae reappear in 3 weeks - Decreased vaginal lubrication, dryness more apparent in breastfeeding moms - Water-soluble lubricant during intercourse recommended - Introitus edematous and erythematous, good hygiene in first 2 weeks - Lacerations or episiotomy are visible if lying on the side with the upper buttock raised or in a lithotomy position - May take 4-6 months to heal completely - Hemorrhoids are common and can evert during pushing, decrease in size within 6 weeks and eventually regress - Pelvic muscle support - May require 6 months to regain tone - Kegel exercises help strengthen and healing - Breast - Decrease in hormones may stimulate breast development - Breastfeeding moms - **Colostrum**: early milk, clear yellow fluid first 24hrs - Becomes fuller and heavier as colostrum transitions to mature milk at 72-96 hr (lactogenesis II) - Breast tissue feel nodular or lumpy associated with milk production tends to shift in position - **Engorgement**: increased in blood and lymphatic fluid as milk increase - hard and uncomfortable, mild temperature elevation, difficult latch, temporary if frequent breastfeeding, and lasts only 24-48 hrs - Nonbreastfeeding moms - Breast distention d/t primarily by [temporary congestion of veins and lymphatics] - Engorgement resolves spontaneously and discomfort decreases in 24-36 hours, lactation stops within a few days to 1 week **[Cardiac system]** - Blood volume - Average blood loss for vaginal is 300-500mL - Average blood loss for c-section 500-1000mL - A few days after birth, plasma volume decreases from diuresis - By 3rd-day plasma volume is replenished as extravascular fluid returns to intravascular space - Cardiac output - Increased after birth by 60-80% over prelabor values, and returns prelabor values within 1 hour - 2 weeks after, CO decreased by 30% and gradually decreased back to normal by [6-8 weeks] - VS table 20.2 page 420 - HR increases after birth for an hour - Puerperal bradycardia common, HR decreasing to 40-50 bpm - Transient increase in BP few days - \>140/90 measured on 2 occasions 4 hrs apiary can indicate GHTN and preeclampsia - Respiratory functions rapidly return - A low-grade fever is not uncommon on the first 24hrs - \>38C (100.4F) in first 10 days may indicate infection - Shivering episodes first few min, no treatment is needed - Varicosities - Around legs and anus common during pregnancy - Regress rapidly immediately after birth - Blood components - Hct levels drop moderately 3-4 days, then increase to nonpregnant levels by 8 weeks - WBC may rise to 30,000 - Clotting factors and fibrinogen increased - Hypercoagulability status risk for venous thromboembolism **[Respiratory]** - Decrease in intrabdominal pressure - Rib cage elasticity can take months to return - The costal angle that was increased may not return - A decrease in progesterone may cause partial pressure of PaCO2 to rise **[Endocrine]** - Placental hormones - E&P drops, lowest levels at 1 week - Decrease in estrogen associated with diuresis - HCG disappears fairly quickly but may still be detected for 3-4 weeks - Pituitary hormones - A fall in progesterone triggers a rise in prolactin that stimulates milk production - Those not breastfeeding will decline by 3rd week - Oxytocin triggers milk ejection/let-down reflex - Metabolic changes - [Low blood glucose levels] immediately after birth - Thyroid glands return to normal by 3 months - Risk of transient autoimmune thyroiditis - BMR elevated for 1-2 weeks **[Urinary]** - Renal function - Return by 8 weeks - 6 weeks for pregnancy-induced hypotonia and dilation of ureters and renal pelves to return to normal - Risk of UTI - Renal glycosuria disappears after a week - Urea nitrogen levels increase as autolysis of the involuting uterus occurs - Creatinine returns normal by 6 weeks - Proteinuria returns normal in 6 weeks - Ketonuria can occur with uncomplicated birth or after prolonged labor with dehydration - Fluid loss - Within 12 hours, lose excess tissue fluid - Urine output of 3000mL or more in first 2-3 days - Profuse diaphoresis can occur especially at night for 2-3 days - Weight loss of 2-3kg (5-6.6 lb) - Urethra and bladder - Decrease voiding combined with diuresis can cause bladder distention - Excessive bleeding can occur if the bladder distended bc prevents UC firmly - With adequate emptying, tone is restored in 5-7 days - Some may experience stress incontinence related to pelvic trauma **[GI]** - Most are very hungry after a full recovery - Spontaneous bowel evacuation may not occur till 2-3 days - May be from [slowed peristalsis], prelabor diarrhea, lack of food, dehydration, opioids - 3rd and 4th lacerations at risk of anal incontinence **[Integument]** - Melasma usually disappears - [Hyperpigmentation of areolae] and [Linea nigra] may not regress completely - [Striae gravidarum] may fade but do not disappear completely - Vascular abnormalities like angiomata and palmar erythema may regress in response to hormones decreased - First 3 months may have hair loss - Fingernails return to pre-pregnancy state **[Musculoskeletal]** - First 2 weeks, abd wall relaxed, takes [6 weeks] to return prepregnancy state - Diastasis recti abdominis becomes less apparent - Back pain resolves in a few weeks or months - Joints stabilized by 6-8 weeks - Joints in feet may not stabilize, notice an [increase in shoe size] **[Neuro]** - Ha common in the first week, [bilateral and frontal], still need careful assessment - Can caused by preeclampsia, stress, post epidural HA - Relief of carpal tunnel syndrome from diuresis - Periodic numbness and tingling of fingers disappear - Nasal stuffiness, tinnitus, and laryngeal changes resolve in a few days **[Immune]** - Exact time unclear - The rebound of the immune system can [trigger an exacerbation of autoimmune] conditions like multiple sclerosis or lupus erythematosus **TABLE 20.2 Vital signs after birth... Refer to book....**