Chapter 20

Maternal Physiologic Changes

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Maternal Physiologic Changes

Postpartum period is interval between birth and return of reproductive organs to their nonpregnant state Referred to as puerperium or fourth stage of pregnancy Traditionally lasts 6 weeks, although this varies among women

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Reproductive System and Associated Structures

Uterus

Involution: return of uterus to nonpregnant state following birth Progresses rapidly

Fundus descends 1 to 2 cm every 24 hours 2 weeks after childbirth uterus lies in true pelvis

Subinvolution: failure of uterus to return to nonpregnant

state

Common causes are retained placental fragments and infection

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Fig. 20-1. Assessment of involution of uterus after childbirth. A, Normal progress, days 1 through 9. B, Size and position of uterus 2 hours after childbirth. C, Two days after childbirth. D, Four days after childbirth.
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Reproductive System and Associated Structurescontd

Uterus

Contractions Hemostasis achieved by compression of

intramyometrial blood vessels as uterine muscle contracts Hormone oxytocin, released from pituitary gland, strengthens and coordinates uterine contractions

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Reproductive System and Associated Structurescontd

Uterus

Afterpains Placental site Lochia: postbirth uterine discharge Lochia rubra

Blood and decidual and trophoblastic debris Duration of 3 to 4 days

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Reproductive System and Associated Structurescontd

Uterus

Lochia: postbirth uterine discharge Lochia serosa

Old blood, serum, leukocytes, and debris Duration of 22 to 27 days

Leukocytes, decidua, epithelial cells, mucus, serum, and bacteria Continues 2 to 6 weeks after birth

Lochia alba

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Reproductive System and Associated Structurescontd

Cervix

Soft immediately after birth Within 2 to 3 postpartum days it has shortened, become firm, and regained form Ectocervix appears bruised and has small lacerationsoptimal conditions to develop infections Cervical os, dilated to 10 cm during labor, closes gradually

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Reproductive System and Associated Structurescontd

Vagina and perineum

Estrogen deprivation responsible for thinness of vaginal mucosa and absence of rugae Vagina gradually returns to prepregnancy size by 6 to 10 weeks after childbirth Thickening of vaginal mucosa occurs with return of ovarian function Dryness and coital discomfort, dyspareunia, may persist until return of ovarian function

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Reproductive System and Associated Structurescontd

Vagina and perineum

Introitus is erythematous and edematous Episiotomies heal within 2 to 3 weeks Hemorrhoids and anal varicosities are common and decrease within 6 weeks of childbirth

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Reproductive System and Associated Structurescontd

Vagina and perineum

Pelvic muscular support Supportive tissues of pelvic floor torn or stretched

during childbirth Require up to 6 months to regain tone Kegel exercises encourage healing

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Abdomen

Abdomen

During first 2 weeks abdominal wall remains relaxed Woman has still-pregnant appearance Return to prepregnancy state takes 6 weeks Depends on previous tone, proper exercise, and amount of adipose tissue

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Endocrine System

Placental hormones

Expulsion of placenta results in dramatic decreases of placental-produced hormones Decreases in chorionic somatomammotropin (hCS), estrogens, cortisol, and placental enzyme insulinase reverse effects of pregnancy Estrogen and progesterone levels drop markedly

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Endocrine Systemcontd

Pituitary hormones and ovarian function

Lactating and nonlactating women differ in timing of first ovulation and menstruation 70% of nonbreastfeeding mothers menstruate within first 12 weeks In breastfeeding women return of ovulation depends on breastfeeding patterns May ovulate before first menstrual cycle

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Urinary System

Urine components Postpartal diuresis

Within 12 hours women begin to diurese Profuse diaphoresis often occurs at night for first 2 to 3 days
Excessive bleeding can occur because of displacement of the uterus if bladder is full

Urethra and bladder

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Gastrointestinal System

Appetite

Most new mothers are very hungry after recovery from analgesia, anesthesia, and fatigue Spontaneous bowel evacuation may not occur for 2 to 3 days after childbirth

Bowel evacuation

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Breasts

Breastfeeding mothers

Before lactation a yellowish fluid, colostrum, can be expressed from nipples Tenderness may persist for 48 hours after start of lactation Engorgement resolves spontaneously, and discomfort decreases within 24 to 36 hours Breast binder or tight bra, ice packs, or mild analgesics may be used to relieve discomfort

Nonbreastfeeding mothers

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Cardiovascular System

Blood volume

Blood volume increase eliminated within first 2 weeks after birth, with return to nonpregnancy values by 6 months after delivery Readjustments in maternal vasculature after childbirth dramatic and rapid

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Cardiovascular Systemcontd

Cardiac output

Remains increased for 48 hours after birth Cardiac output generally returns to normal by 6 weeks after birth Stroke volume, end-diastolic volume, and systemic vascular resistance remain elevated for 12 weeks after delivery

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Cardiovascular Systemcontd

Cardiac output

Vital signs Blood components Hematocrit and hemoglobin White blood cell count Coagulation factors Varicosities Total or nearly total regression of varicosities is
expected after childbirth

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Neurologic System

Pregnancy-induced neurologic discomforts abate after birth Headache requires careful assessment Postpartum headaches may be caused by gestational hypertension, stress, and leakage of cerebrospinal fluid into extradural space during placement of needle for epidural or spinal anesthesia

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Musculoskeletal System

Reversal of pregnancy adaptations

Joints are completely stabilized by 6 to 8 weeks after birth New mother may notice permanent increase in
shoe size

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Integumentary System

Chloasma of pregnancy usually disappears at end of pregnancy Hyperpigmentation of areolae and linea nigra may not regress completely after childbirth

Some women will have permanent darker pigmentation of those areas Stretch marks on breasts, abdomen, and thighs may fade but not disappear

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Integumentary Systemcontd

Vascular abnormalities, spider angiomas, palmar erythema, and epulis regress with rapid decline in estrogens Spider nevi persist indefinitely for some Abundance of fine hair during pregnancy usually disappears after birth

Coarse or bristly hair that appears during pregnancy usually remains

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Immune System

No significant changes in maternal immune system occur during postpartum period Mothers need for rubella vaccination or for Rho (D) immune globulin for prevention of Rh isoimmunization is determined

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Key Points

Uterus involutes rapidly after birth, returning to true pelvis within 2 weeks Rapid decrease in estrogen and progesterone levels after expulsion of placenta responsible for triggering many anatomic and physiologic changes in puerperium

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Key Pointscontd

Assessment of lochia and fundal height is essential to monitor progress of normal involution and identify potential problems Return of ovulation and menses is determined in part by whether woman breastfeeds infant Few alterations in vital signs are seen after birth under normal circumstances

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Key Pointscontd

Hypercoagulability, vessel damage, and immobility predispose the woman to thromboembolism Marked diuresis, decreased bladder sensitivity, and overdistention of the bladder can lead to problems with urinary elimination Pregnancy-induced hypervolemia allows women to tolerate considerable blood loss at birth
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