6.2a Postpartum Physiological Changes

Question 1

Postpartum Physiology

Answer 1

• 6-8 weeks for organs to return to normal function.
• Post partum shivers usually start within 30 minutes and last from 2 minutes to an hour
• Uterus contracts immediately after delivery and then the muscles shrink.
• Within 24 hours after delivery uterus shrinks down and fundus should be at the umbilicus
• After 1 week the fundus should be felt halfway between umbilicus and symphysis pubis
• After 6-8 weeks the fundus should be normal
• Breast feeding causes quicker reduction in size of uterus due to oxytocin
• ## Oxytocin’s primary purpose is to contract ducts of breasts to help release milk.

Question 2

Postpartum Physiology

Answer 2

• Decidua Basalis has 2 layers, superficial layer sheds and deeper layer regenerates a new endometrium
• Lochia Rubra (red) is the shedding of the decidua superficial layer. (2-3 days)
• Lochia Serosa (watery) - 2-3 weeks
• Lochia Alba (Yellow/White)

Question 3

Post Partum Physiology

Answer 3

Cervix Contracts
- After a week cervix will be less than 1 cm dilated. It will never return back to the same shape as before birth. Looks like a large horizontal split

Question 4

Post Partum Physiology

Answer 4

• Safe to resume sex 3-4 weeks postpartum
• Ovulation returns 6-8 weeks in women who don’t breastfeed.
• Ovulation doesn’t return for up to 6 months for women who do breastfeed
• Prolactin inhibits sex hormones and ovulation

Question 5

Uterus

Answer 5

Involution - Return to nonpregnant state after birth. Begins with contractions after expulsion of fetus

• After birth - fundus 2cm below umbilicus
• 12 hours - fundus rises 1cm above umbilicus
• 24 hours - Uterus same size as 20 weeks of gestation
• Fundus descents 1-2 cm every 24 hours
• Day 6 fundus is halfway between umbilicus and symphysis pubis
• 2 weeks fundus is not palpable
• 6 weeks fundus is returned to normal

Question 6

Uterus

Answer 6

• Estrogen and progesterone stimulate the growth of uterus during pregnancy
• After birth, decrease in hormones causes autolysis (self destruction of tissue)

Subinvolution - Failure of uterus to return to pre-pregnant stage due to ineffective uterine contractions.

• Commonly caused by placental fragments and infection

Question 7

Lochia Bleeding

Answer 7

• Trickles from vaginal opening
• Greater flow when uterus contracts
• Gush appears following massage

Question 8

Cervix

Answer 8

• Soft immediately after birth
• After birth it protrudes into vagina, appears bruised, edematous, and may have lacerations (bad for infection)
• 2-3 days cervix shortens and regains its form
• Never goes back to original shape. Becomes a “fish mouth”

Question 9

Ovaries

Answer 9

• Ovulation returns in as early as 27 days (average 7-9 weeks) in non-lactating patients
• Ovulation returns in 6 months for patients who breastfeed
• Prolactin suppresses ovulation
• Because of uncertainty of when ovulation will return, contraceptive education in post-partum is necessary

Question 10

Vagina/Perineum

Answer 10

• Estrogen deprivation causes vagina mucosa to be thin and absence of rugae (ridges)
• Rugae re-appears in 3 weeks but never as prominent
• Estrogen deficiency causes decrease vaginal lubrication
• Breastfeeding mothers experience vaginal dryness

Dyspareunia - Localized vaginal dryness and discomfort

• Lasts until menstruation resumes
• Water soluble lubricant during sex is recommended

Question 11

Episiotomy/Lacerations

Answer 11

• Initial healing in 2-3 weeks

- 4-6 months to fully repair

Question 12

Hemorrhoids

Answer 12

• Anal varicosities which are common
• Develop during pregnancy
  SYMPTOMS
• Itching/Discomfort
• Bright red bleeding with defecation
• Decrease in size after 6 weeks of birth

Question 13

Kegel Exercises

Answer 13

• Help strengthen perineal muscles and encourage healing after birth

Question 14

Painful Cramps in Uterus

Answer 14

• After pains
• Breastfeeding causes release of oxytocin which cause contractions leading to after pains
• Happens first few days of postpartum

Question 15

Uterus

Answer 15

• Fundus becomes not palpable within 2 weeks of childbirth

Question 16

Lochia

Answer 16

• Should only last up to 6 weeks

Question 17

Protruding Abdomen

Answer 17

• Can cause women to look pregnant still after birth
• Should return to normal after 6 weeks
• Encourage exercise and sensible weight loss to return tone

Question 18

Frequent Urination After Birth

Answer 18

• Diuresis (extra urine) and diaphoresis are normal ways for body to rid fluid retained during pregnancy.

Question 19

Large Breasts After Pregnancy

Answer 19

• Due to lactation
• Occurs with drop in estrogen/progesterone after expulsion of placenta
• Because milk is not removed, the process will stop and the milk gets reabsorbed into circulatory system.
  INTERVENTIONS
• Wear snug bra
• Avoid warmth on breasts
• Icepack/analgesics can be used for pain

Question 20

Prolactin

Answer 20

• Inhibits estrogen and vaginal lubrication
• Breastfeeding may lead to dry vagina
• Use of water-based lubricants during sex is recommended

Question 21

VS After Birth Temperature

Answer 21

• First 2 hours temp can rise to 100.4 due to dehydration
• Patient should return to normal after 24 hours
• Sepsis watch is placed if temperature remains 100.4+ after 24 hours or persists for 2 days

Question 22

VS After Birth Pulse

Answer 22

• Remains elevated for first hour after birth
• Bradycardia is common
• Increasing HR can be due to hypovolemia or hemorrhage
• Returns to normal after 48 hours

Question 23

Blood Pressure

Answer 23

• Increases over the first few days after birth (5%)
• Returns to normal after a few weeks to months
• Orthostatic hypotension can develop in first 48 hours
• Low blood pressure can indicate hypovolemia and hemorrhage
• Elevated BP over 140/90 on 2 occasions can indicate gestational hypertension or preeclampsia

Question 24

Respirations

Answer 24

• Normal, stays normal right after birth

Question 25

After-Pains

Answer 25

Most common in - Multiparity - Macrosomia - Multifetal Pregnancy - Breastfeeding - Administration of oxytocin

Question 26

Colostrum

Answer 26

- Early milk (clear yellow fluid) - Mature milk occurs 72-96 hours after birth (lactogenesis 2) - Engorgement (hard, uncomfortable, elevated temperature) breasts are temporary and last 24-48 hours

Question 27

Non-Breastfeeding Mothers

Answer 27

- Prolactin levels drop rapidly - Engorgement occurs on 3-4 days - Lactation ceases in a few days to a week