postpartum physiological adaptation

Postpartum Physiology

Ching-Yu Cheng, PhD, RN

School of Nursing

Email: chingyutmu@tmu.edu.tw

Objectives

• After the class, students can understand

– Physiological changes on various body

system

– Care for postpartum mothers

Reproductive System

• Uterus

– Uterine involution to prepregnant condition

• Hypoplasia/autolysis of uterine cells

Reproductive System

• Uterus

– Factors enhance involution

• Breastfeeding

• Uncomplicated L&D

• Complete expulsion of products of conception

• Early ambulation

Reproductive System

• Uterus

– Factors inhibit involution

• Anesthesia

• Retained placenta

• Over distention of the uterus

• Prolonged/difficult labor

• Multiparity

• Infection

Reproductive System

• Uterus

– Position

• Right after delivery

• Within 12 hours

• By 24 hours

• Descends about 1 to 2cm/day

Reproductive System

• Uterus

– Contraction

• Oxytocin released from the posterior pituitary gland

coordinates uterine contraction

– Afterpain

Reproductive System

• Uterus

– Lochia

• Lochia rubra

– Blood, decidual and trophoblastic debris

– Red color for about 3 to 4 days

Reproductive System

• Uterus

– Lochia

• Lochia serosa

– Old blood, serum, leukocytes, tissue debris

– Brown or pink color for about 22 to 27 days (?)

Reproductive System

• Uterus

– Lochia

• Lochia alba

– Leukocytes, decidua, epithelial cells, mucus, serum,

bacteria

– Yellow or white for about 10 to 14 days

Reproductive System

• Uterus

– Lochia

• Gush of blood when stand up from lying position

Lochial bleeding Nonlochial bleeding

Lochia usually trickles from the

vaginal opening. The steady flow

is greater as the uterus contracts

If the bloody discharge spurts

from the vagina, there may be

cervical or vaginal tears in

addition to the normal lochia

A gush of lochia may result as

the uterus in massaged. If it is

dark in color, it has been pooled

in the relaxed vagina, and the

amount soon lessens to a trickle

of bright red lochia (in the early

postpartum)

It the amount of bleeding

continues to be excessive and

bright red, a tear may be the

source.

From textbook

Lochial and Nonlochial Bleeding

Reproductive System

• Uterus

– Endometrial regeneration

• Endometrium is restored during the third week

• subinvolution

Reproductive System

• Uterus

– Cervix

• Shortened, become firm within 2 to 3 days

• External os shaped like “fish mouth”

Reproductive System

• Vagina and perineum

– Rugae reappear within 3 weeks, most rugae

are permanently flattened

– Mucosa remains atrophic till menstruation

resumes

Reproductive System

• Vagina and perineum

– Localized dryness and dyspareunia are

caused by estrogen deficiency, especially in

breastfeeding mom

– Episiotomy

– Hemorrhoid

Reproductive System

• Pelvic muscular support

– Torn or stretched supportive tissues may

need 6 months to regain tone

Other Systems

• Urinary system

– Diuresis occurs between 2nd and 5th days

– Increased bladder capacity and insensitivity to

intravesical fluid pressure may result in

bladder distention

Other Systems

• Peritoneum and abdomen

– Require considerable time to recover

Other Systems

• Bowel

– May not have bowel movement within 2 to 3

days

Other Systems

• Blood and fluid

– Leukocyte may increase, relative

lymphopenia and absolute eosinopenia may

occur

– Hb and Ht increase because of reduction in

plasma volume

Other Systems

• Cardiac output

– Increased blood return to system increases

stroke volume and cardia output for 48 hours

and returns normal by 6 weeks

Other Systems

• Endocrine System

– Placental hormones

• Immediate hopyglycemic state is caused by

decreased human chorionic somatomammotropin,

estrogens, cortisol, placental enzyme

Other Systems

• Endocrine System

– Placental hormones

• Levels of estrogen and progesterone decrease in 1

week

• Human chorionic gonadotropin disappears in 14

days

Other Systems

• Endocrine System

– Pituitary hormones

• Elevated prolactin suppresses ovulation

• Ovary does not respond to FSH stimulation in

lactating mom

Other Systems

• Breast

– Nodularity (nodule tends to shift in position) is

associated with milk production

– Brest fever should not persist longer than 4 to

16 hours

Anatomy of Breast

Ramsay, D.T., Kent, J.C., Hartmann, R.A., & Hartmann, P.E. (2005). Anatomy of the lactating human breast redefined with

ultrasound imaging. J Anat, 206, 525–534.

Other Systems

• Breast

– Milk

• Colostrum contains antibodies and IgA, more

minerals and protein (globulin) but less sugar and

fat, secrets for about 5 days

Other Systems

• Breast

– Milk

• Milk is isotonic with plasma, lactose, major proteins

(α-lactalbumin, β-lactoglobulin, casein), amino

acids

Other Systems

• Shivering

– Sudden release of pressure on pelvic nerves,

response to fetus-to-mother transfusion,

reaction to maternal adrenaline production or

epidural anesthesia

Postpartum Experience

• What physical conditions new mothers may

experience?

Decrease in memory 178 (52.0)

Interrupted sleep 177 (51.8)

Backache 146 (42.7)

Retained body weight 136 (39.8)

Physical exhaustion 135 (39.5)

Lack of sexual desire 115 (33.6)

Sleep disturbance 106 (31.0)

Postpartum Experience

• What physical conditions new mothers may

experience?

Frequent headaches 99 (28.9)

Hemorrhoids 69 (20.2)

Sore nipples/breast tenderness 52 (15.2)

Eating disorder/GI upsets 50 (14.6)

Painful intercourse 42 (12.3)

Bowel problems 37 (10.8)

Care

• Concerns of New Mothers

– Fear for inadequacy

– Loss of marital intimacy

– Isolation

– Constant responsibility of caring for the baby

and others

Care

• Needs of New Mothers– Information

• baby care

• Breastfeeding

• Signs of problems

• Self-care

• Sexual life

• Contraception

• Nutrition

Care

• Needs of New Mothers– Support from healthcare providers and family

– Healthcare for complications

– Time

Care

• Needs of New Mothers– Help with domestic tasks

– Maternity leave

– Social reintegration

– Protected from abuse/violence

Care

• WHO

– Medical assessment of postpartum

complications

– Mother-infant attachment

– Breastfeeding

– Family visiting during hospitalization

– Community and partner support

– Family planning

Care

• Prevention of infection

– Wound care

– Perineal care

Care

• Prevention of excessive bleeding

– Assessment of vitals, lochia, uterus

– Fundal massage

Care

• Prevention of thrombus

– Assessment of Homan’s sign

– Ambulation

Care

• Comfort promotion

– Ice pack

– Dry heat

– Sitz bath

– Topical applications

Care

• Resume bladder and bowel functions

Care

• Postpartum exercise

– Abdominal breathing

– Reach for the knees

– Double/single knee roll

– Leg roll

Care

• Postpartum exercise

– Supine/sitted pelvic tilt

– Buttocks lift

– Arm raise

– Leg extension

– Shoulder roll

– Side lying leg lift

Care

• Lactation support

– Breastfeeding mom 2, 3

– Nonbreastfeeding mom

Recommendations for hormonal contraception if

used by breast feeding women

• Progestin-only oral contraceptives

prescribed or dispensed at discharge from

the hospital to be started 2-3 weeks

postpartum, for example, the first Sunday

after the newborn is 2 weeks of age

Cite William’s Obstetrics, ACOG, 2000

Recommendations for hormonal contraception if

used by breast feeding women

• Depot medroxyprogesterone acetate

initiated at 6 weeks postpartum

Cite William’s Obstetrics, ACOG, 2000

Recommendations for hormonal contraception if

used by breast feeding women

• Hormonal implants inserted at 6 weeks

postpartum

Cite William’s Obstetrics, ACOG, 2000

Recommendations for hormonal contraception if

used by breast feeding women

• Combined estrogen-progestin

contraceptives, if prescribed, should not

be started before 6 weeks postpartum,

and only when lactation is well established

and the infant's nutritional status well

monitored.

Cite William’s Obstetrics, ACOG, 2000

Meds and Breastfeeding

• Absolutely contraindicated – Chemotherapeutic or cytotoxic agents

– All drugs used recreationally (including

alcohol and nicotine)

– Radioactive nuclear medicine tracers

– Lithium carbonate

– Chloramphenicol

Meds and Breastfeeding

• Absolutely contraindicated – Chloramphenicol

– Phenylbutazone

– Atropine

– Thiouracil

– Iodides

– Ergotamine and derivatives

– Mercurials

Meds and Breastfeeding

• Lactation-suppressing– Levodopa

– Anticholinergics

– Bromocriptine

– Trazodone

– Large-dose estradiol birth control pills

Care

• Discharge plan

– Signs of complications

– Sexual activities

• Usually resume after 6 weeks

– Contraception

– Medication

– Mother and baby checkups

Cultural Care

• African-Caribbean

– 2 weeks

– No shower

– Breastfeeding

– Older women (family) support

– Starchy vegetables (potatoes, yams, rice,

plantains), fish, spices

Cultural Care

• South Asia

– Pakistan, Bangladesh, Sri Lanka: 6 weeks

• Support by older women of family

• Go parents’ home for postnatal seclusion

• Rest, sleep, and warmth

• Good food

• Discard colostrum

• Wash baby before handling after childbirth

Postnatal Care

• India

– Stay indoor to avoid evil spirit

– Limited visitors (widow, people in mourning,

women lost children)

– Stayed with newborn

– Less nutritious foods for female baby

Postnatal Care

• Hispanic

– Support from partner, cared by mother/

grandmother

– Foods

– Restrict full bathing or hair washing

– Secluded in house to keep from cold evil wind

(Mayan Indian)

Postnatal Care

• Korean

– Cared for by own mother (less by mother-in-

law)

– Foods

• Pumpkin soup (for urination), seaweed (miyok-guk,

every meal for making blood), enchovy, liver, bone

soup…

• No cold food (based on temperature), pepper and

salt (prevent milk production), caffeine

Postnatal Care

• Korean

– Activity

• Wear long sleeves (avoid cold wind)

• No heavy lifts, no shower

Postnatal Care

• Chinese

– Food

– Activity

Summary

• Postpartum care includes prevention of

infection, prevention of excessive bleeding,

prevention of thrombus, promotion of

comforts, resume bladder and bowel

function, ambulation/exercise, and

lactation support.

• Cultural differences in postpartum care

should be notified.

Summary page

– Physiological changes on various body

system

– Care for postpartum mothers