postpartum physiological adaptation
TRANSCRIPT
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