Today, we're going to talk about the normal physiologic changes that occur during the
postpartum period.
We're going to talk about how the body makes that transition from a pregnant state
to the new normal state.
We're going to review eight systems and those systems are the
reproductive system, the cardiovascular system, the
hematologic system, the endocrine system, the
renal system, the gastrointestinal system, the
musculoskeletal system, and finally the mind,
yes, we're counting that as a system.
Normally right after delivery of the placenta, the uterus is about two
centimeters above the umbilicus.
So as the uterus sort of begins to contract to push all that extra lochia
out, it actually becomes really big.
So it sits up above the level of the umbilicus.
And then after about 24 hours, it begins the process of involution of
shrinking back down to its nonpregnant state.
So after about 24 hours, the uterus begins the process of
involution where it returns to its nonpregnant state.
It goes from about two centimeters above the umbilicus to about two
centimeters below the umbilicus.
And then from that point forward, the uterus descends about one centimeter a
day. So after about two weeks, when you get to this period,
you shouldn't be able to palpate the uterus anymore.
Subinvolution occurs when the uterus does not decrease as it
should. So let's say the nurse gets to the end of the two-week period and is still
able to palpate the uterus, then that's a sign that something is not as it should
be. Right after delivery, the uterus is very sensitive
to oxytocin and in this case, this explains why sometimes right after delivery to
decrease bleeding, oxytocin will be administered exogenous
or will encourage the parent to breastfeed as a way to initiate the
release of oxytocin.
For multipurpose clients, there's your clients that have delivered more than one
baby, then the uterine contractions are going to get stronger.
So think about a balloon.
And if I blow the same balloon up many, many times, the contractility of that balloon
will be decreased.
It's the same thing with the uterus, but it still has to contract in order to stop
bleeding. So if we have a stretched uterus and it has to contract more,
it's going to be a little more uncomfortable.
Remember that breastfeeding, the actual act of suckling on the breast, releases
oxytocin and so breastfeeding actually may intensify uterine
contractions. Lochia is the blood that comes out
after delivery and it may actually persist up to six weeks postpartum.
On day one through three, that bleeding is bright red and it's known as
lochia rubra. Day four through 10, the characteristics of the
lochia changes just a little bit and it's more of a pinkish color, and that's called
lochia serosa.
Lochia alba is the whitish-yellowish discharged that's typically present
about two weeks postpartum and it can actually continue up to six weeks
postpartum. So let's talk about that cervix, the cervix has actually
been through some real drama, it dilated all the way to 10 centimeters.
The fetus passed through.
We massaged the uterus and pushed lots of clots through.
And so the cervix really isn't looking so great immediately after delivery.
It's bruised, it's open, it's slightly irregular,
and that's pretty normal.
After about two to three days postpartum, however, it retains sort of its round shape.
It still may be dilated a couple of centimeters, but it's starting to look a
little bit better. And by the time we get to the end of one week, then the US
is actually shrunk back down to about one centimeter.
I want you to notice the shape of the eyes.
So a client who's never experienced a vaginal delivery before may have an
opening that looks like a circle.
But if we look at this particular diagram, what we see is that the US is now a
slit like appearance.
And that's one of the ways that we can see that a baby has passed through cervix
previously. Let's talk about the breast next.
So within the breast, colostrum is produced.
Some patients may actually experience production of colostrum earlier in
pregnancy. So it may actually happen that they have some leakage even before the
baby delivers. But definitely after the baby delivers, we expect that colostrum will
be present and it's yellow and thick, kind of sticky, and it may be
present up to 96 hours after birth.
Over time, the more the breasts are stimulated, the breasts will become fuller
and heavier. They may become engorged, which feels like a rock
solid breast, and there may be nodules or irregular areas just from the
production of the milk.
Now that engagement, that rock hard feeling is very uncomfortable and that
production of milk may actually also lead to an increase in maternal temperature.
Let's talk now about the cardiovascular system now, all that extra blood flow that
was required to support the fetus and the patient through pregnancy is
now going to go away.
And plasma volume is going to be reduced by about a thousand milliliters
pretty soon after delivery.
There also may be an elevation in pulse during pregnancy that
decreases about an hour after delivery.
Now, the patient may actually become bradycardic.
So remember, bradycardia means slow heartbeat and the heart rate may get down to
about 40 to 50 beats a minute, which is very unusual.
But it can happen immediately after birth.
Thinking of the changes in the hematologic system, the hematocrit is going to drop the
first three to four days and eventually after about two months, it will
stabilize because of all of the things that are happening during delivery, the white
blood cell count may go up to 25000 and still be considered
normal. However, you always want to double check.
They're not signs of infection.
Now, if you'll remember, pregnancy is a hyper coagulants state, but
coagulation and fibrinogen levels will normalize by about two to three weeks
postpartum. When we think about the endocrine system,
we want to talk about prolactin, so prolactin, pro
Lactaid like pro milk, so prolactin levels are going to
remain elevated as long as the client is breastfeeding.
That's what we need, prolactin to make milk.
If the client is not breastfeeding and decides not to do that, then those levels are
going to normalize by about three weeks postpartum now without
lactation. So without breastfeeding, ovulation may occur in about
45 days.
So in about almost six weeks, someone could conceivably conceive
again. It has happened.
I have delivered some of those patients.
Ovulation may be delayed, however, by as much as six months for someone who is
breastfeeding now, only if the baby is not sleeping through the night.
If we get to a time when the baby is sleeping through the night or more than six
hours, then we cannot use breastfeeding as a way to eliminate
ovulation. Really important to remember that because I've delivered some of those patients
to. Let's talk about the Reno System.
Diaries. This is normal after the first 12 hours postpartum.
So we might find that the client is getting up many, many times to either avoid
or they're sweating profusely.
They've got to get rid of all that extra fluid.
Glomerular filtration rate remains elevated for the first few weeks postpartum,
and then it returns to normal.
The ureters and the renal pelvises that were dilated during pregnancy under the influence
of the progesterone, well, normalize about six to eight weeks postpartum.
Let's think about the guy, System., so right after delivery, we need a lot of energy and
if we have someone who is lactating and breastfeeding their baby, they need to eat,
they need calories, and the body compensates for that with an increased
appetite. So it's normal for patients to want to just really eat a lot.
Plus, when they were in labor, they may not have eaten very much because of all the work
they were doing. And so now they're going to make up for lost time.
Bowel movements may be delayed by two to three days postpartum, and this can often
happen if a client is pushed a really long time, if they didn't eat very much,
because if there's nothing in, well, there's nothing out.
So we want to also think about clients who have had a cesarean birth or maybe a
client who has received a lot of narcotic pain medication because both of those things
can slow peristalsis, which will also affect the return to normal bowel
functioning. Thinking about musculoskeletal changes,
the hormonal influence that made the joints so elastic and made the ligaments
open and soft, which is great for delivery, because we need that flexibility, but they do
need to go back to normal and it takes about six to eight weeks for that to occur.
One thing that maybe isn't so great are the feet sometimes under the influence
of hormones and pregnancy, the feet may grow about a size,
and that doesn't reverse.
So some people may experience enlarged feet that don't go back.
The rectus muscle that separated in order to allow the uterus to expand
may return to normal about six weeks.
The pelvic floor, which also under the influence of progesterone, has relaxed,
hopefully will tighten up in about six weeks.
Now, doing exercises like kegels where we squeeze the pubococcygeus muscle, will
help that occur a little bit faster.
Now, let's talk about the mind and we talk about this psychological adaptation,
baby blues is very normal.
This is experienced by about 80 percent of patients, and they it's described as
transient feelings of anxiousness or overwhelm.
But they should go away by two weeks.
So normal as long as it's contained within that two weeks.
Any feeling of sadness or overwhelm or anxiety that extends
beyond two weeks needs to be assessed for postpartum depression.
And I cannot stress that enough.
Let's talk about the role of attachment and psychological adaptation.
We have three phases taking in, taking hold and
letting go in the taking in phase, the client is oriented
primarily to their own needs.
They may or may not take full care of the baby and they are very dependent on others to
help with that. During taking hold, the patient is going to begin
to look for independence and it's going to start to do things maybe with some help,
but mostly on their own.
And by the time they get to letting go, they're usually at home and they've begun
to integrate the new baby into their daily activities.
So those are the three phases.