Chapter 020

Mosby items and derived items © 2010, 2006, 2002 by Mosby, Inc., an affiliate of Elsevier Inc.

Chapter 20Chapter 20

Maternal Physiologic ChangesMaternal Physiologic Changes

2Mosby items and derived items © 2010, 2006, 2002 by Mosby, Inc., an affiliate of Elsevier Inc.

Maternal Physiologic ChangesMaternal Physiologic Changes

Postpartum period is interval between birth Postpartum period is interval between birth and return of reproductive organs to their and return of reproductive organs to their nonpregnant statenonpregnant state

Referred to as Referred to as puerperiumpuerperium or or fourth stagefourth stage of of pregnancy pregnancy

Traditionally lasts 6 weeks, although this Traditionally lasts 6 weeks, although this varies among womenvaries among women


Reproductive System and Reproductive System and Associated Structures Associated Structures

UterusUterus Involution: return of uterus to nonpregnant state Involution: return of uterus to nonpregnant state

following birthfollowing birth• Progresses rapidly Progresses rapidly

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

• Subinvolution: failure of uterus to return to nonpregnant Subinvolution: failure of uterus to return to nonpregnant statestate

Common causes are retained placental fragments and Common causes are retained placental fragments and infectioninfection


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.


UterusUterus ContractionsContractions

• Hemostasis achieved by compression of Hemostasis achieved by compression of intramyometrial blood vessels as uterine muscle intramyometrial blood vessels as uterine muscle contractscontracts

• Hormone oxytocin, released from pituitary gland, Hormone oxytocin, released from pituitary gland, strengthens and coordinates uterine contractionsstrengthens and coordinates uterine contractions

Reproductive System and Reproductive System and Associated Structures—cont’d Associated Structures—cont’d


UterusUterus AfterpainsAfterpains Placental sitePlacental site Lochia: postbirth uterine dischargeLochia: postbirth uterine discharge

• Lochia rubraLochia rubra Blood and decidual and trophoblastic debrisBlood and decidual and trophoblastic debris Duration of 3 to 4 days Duration of 3 to 4 days



Reproductive System and Reproductive System and Associated Structures—cont’dAssociated Structures—cont’d

UterusUterus Lochia: postbirth uterine dischargeLochia: postbirth uterine discharge

• Lochia serosaLochia serosa Old blood, serum, leukocytes, and debris Old blood, serum, leukocytes, and debris Duration of 22 to 27 daysDuration of 22 to 27 days

• Lochia albaLochia alba Leukocytes, decidua, epithelial cells, mucus, serum, and Leukocytes, decidua, epithelial cells, mucus, serum, and

bacteriabacteria Continues 2 to 6 weeks after birthContinues 2 to 6 weeks after birth



CervixCervix Soft immediately after birthSoft immediately after birth Within 2 to 3 postpartum days it has shortened, Within 2 to 3 postpartum days it has shortened,

become firm, and regained formbecome firm, and regained form Ectocervix appears bruised and has small Ectocervix appears bruised and has small

lacerations—optimal conditions to develop lacerations—optimal conditions to develop infectionsinfections

Cervical os, dilated to 10 cm during labor, closes Cervical os, dilated to 10 cm during labor, closes gradually gradually



Vagina and perineumVagina and perineum Estrogen deprivation responsible for thinness of Estrogen deprivation responsible for thinness of

vaginal mucosa and absence of rugaevaginal mucosa and absence of rugae Vagina gradually returns to prepregnancy size by Vagina gradually returns to prepregnancy size by

6 to 10 weeks after childbirth 6 to 10 weeks after childbirth Thickening of vaginal mucosa occurs with return of Thickening of vaginal mucosa occurs with return of

ovarian functionovarian function Dryness and coital discomfort, dyspareunia, may Dryness and coital discomfort, dyspareunia, may

persist until return of ovarian function persist until return of ovarian function


Vagina and perineumVagina and perineum Introitus is erythematous and edematousIntroitus is erythematous and edematous Episiotomies heal within 2 to 3 weeksEpisiotomies heal within 2 to 3 weeks Hemorrhoids and anal varicosities are common Hemorrhoids and anal varicosities are common

and decrease within 6 weeks of childbirth and decrease within 6 weeks of childbirth



Vagina and perineumVagina and perineum Pelvic muscular supportPelvic muscular support

• Supportive tissues of pelvic floor torn or stretched Supportive tissues of pelvic floor torn or stretched during childbirthduring childbirth

• Require up to 6 months to regain toneRequire up to 6 months to regain tone

• Kegel exercises encourage healingKegel exercises encourage healing



AbdomenAbdomen

AbdomenAbdomen During first 2 weeks abdominal wall remains During first 2 weeks abdominal wall remains

relaxedrelaxed Woman has still-pregnant appearanceWoman has still-pregnant appearance Return to prepregnancy state takes 6 weeksReturn to prepregnancy state takes 6 weeks Depends on previous tone, proper exercise, and Depends on previous tone, proper exercise, and

amount of adipose tissueamount of adipose tissue


Endocrine System Endocrine System

Placental hormonesPlacental hormones Expulsion of placenta results in dramatic Expulsion of placenta results in dramatic

decreases of placental-produced hormonesdecreases of placental-produced hormones Decreases in chorionic somatomammotropin Decreases in chorionic somatomammotropin

(hCS), estrogens, cortisol, and placental enzyme (hCS), estrogens, cortisol, and placental enzyme insulinase reverse effects of pregnancyinsulinase reverse effects of pregnancy

Estrogen and progesterone levels drop markedly Estrogen and progesterone levels drop markedly


Endocrine System—cont’d Endocrine System—cont’d Pituitary hormones and ovarian functionPituitary hormones and ovarian function

Lactating and nonlactating women differ in timing Lactating and nonlactating women differ in timing of first ovulation and menstruationof first ovulation and menstruation

70% of nonbreastfeeding mothers menstruate 70% of nonbreastfeeding mothers menstruate within first 12 weekswithin first 12 weeks

In breastfeeding women return of ovulation In breastfeeding women return of ovulation depends on breastfeeding patternsdepends on breastfeeding patterns

May ovulate before first menstrual cycleMay ovulate before first menstrual cycle


Urinary SystemUrinary System

Urine componentsUrine components Postpartal diuresisPostpartal diuresis

Within 12 hours women begin to diureseWithin 12 hours women begin to diurese Profuse diaphoresis often occurs at night for first 2 Profuse diaphoresis often occurs at night for first 2

to 3 daysto 3 days Urethra and bladderUrethra and bladder

Excessive bleeding can occur because of Excessive bleeding can occur because of displacement of the uterus if bladder is fulldisplacement of the uterus if bladder is full


Gastrointestinal SystemGastrointestinal System

AppetiteAppetite Most new mothers are very hungry after recovery Most new mothers are very hungry after recovery

from analgesia, anesthesia, and fatigue from analgesia, anesthesia, and fatigue Bowel evacuationBowel evacuation

Spontaneous bowel evacuation may not occur for Spontaneous bowel evacuation may not occur for 2 to 3 days after childbirth 2 to 3 days after childbirth


BreastsBreasts

Breastfeeding mothersBreastfeeding mothers Before lactation a yellowish fluid, colostrum, can Before lactation a yellowish fluid, colostrum, can

be expressed from nipplesbe expressed from nipples Tenderness may persist for 48 hours after start of Tenderness may persist for 48 hours after start of

lactation lactation Nonbreastfeeding mothersNonbreastfeeding mothers

Engorgement resolves spontaneously, and Engorgement resolves spontaneously, and discomfort decreases within 24 to 36 hoursdiscomfort decreases within 24 to 36 hours

Breast binder or tight bra, ice packs, or mild Breast binder or tight bra, ice packs, or mild analgesics may be used to relieve discomfort analgesics may be used to relieve discomfort


Cardiovascular System Cardiovascular System

Blood volumeBlood volume Blood volume increase eliminated within first 2 Blood volume increase eliminated within first 2

weeks after birth, with return to nonpregnancy weeks after birth, with return to nonpregnancy values by 6 months after deliveryvalues by 6 months after delivery

Readjustments in maternal vasculature after Readjustments in maternal vasculature after childbirth dramatic and rapid childbirth dramatic and rapid


Cardiovascular System—cont’d Cardiovascular System—cont’d

Cardiac outputCardiac output Remains increased for 48 hours after birthRemains increased for 48 hours after birth Cardiac output generally returns to normal by 6 Cardiac output generally returns to normal by 6

weeks after birthweeks after birth Stroke volume, end-diastolic volume, and systemic Stroke volume, end-diastolic volume, and systemic

vascular resistance remain elevated for 12 weeks vascular resistance remain elevated for 12 weeks after deliveryafter delivery


Cardiovascular System—cont’d Cardiovascular System—cont’d Cardiac outputCardiac output

Vital signsVital signs Blood componentsBlood components

• Hematocrit and hemoglobinHematocrit and hemoglobin

• White blood cell countWhite blood cell count

• Coagulation factorsCoagulation factors

VaricositiesVaricosities• Total or nearly total regression of varicosities is Total or nearly total regression of varicosities is

expected after childbirthexpected after childbirth


Neurologic SystemNeurologic System

Pregnancy-induced neurologic discomforts Pregnancy-induced neurologic discomforts abate after birthabate after birth

Headache requires careful assessmentHeadache requires careful assessment Postpartum headaches may be caused by Postpartum headaches may be caused by

gestational hypertension, stress, and leakage gestational hypertension, stress, and leakage of cerebrospinal fluid into extradural space of cerebrospinal fluid into extradural space during placement of needle for epidural or during placement of needle for epidural or spinal anesthesiaspinal anesthesia


Musculoskeletal SystemMusculoskeletal System

Reversal of pregnancy adaptationsReversal of pregnancy adaptations Joints are completely stabilized by 6 to 8 Joints are completely stabilized by 6 to 8

weeks after birthweeks after birth• New mother may notice permanent increase in New mother may notice permanent increase in

shoe size shoe size


Integumentary System Integumentary System

Chloasma of pregnancy usually disappears at Chloasma of pregnancy usually disappears at end of pregnancyend of pregnancy

Hyperpigmentation of areolae and linea nigra Hyperpigmentation of areolae and linea nigra may not regress completely after childbirthmay not regress completely after childbirth Some women will have permanent darker Some women will have permanent darker

pigmentation of those areas pigmentation of those areas Stretch marks on breasts, abdomen, and thighs Stretch marks on breasts, abdomen, and thighs

may fade but not disappearmay fade but not disappear


Integumentary System—cont’d Integumentary System—cont’d

Vascular abnormalities, spider angiomas, Vascular abnormalities, spider angiomas, palmar erythema, and epulis regress with palmar erythema, and epulis regress with rapid decline in estrogensrapid decline in estrogens

Spider nevi persist indefinitely for someSpider nevi persist indefinitely for some Abundance of fine hair during pregnancy Abundance of fine hair during pregnancy

usually disappears after birthusually disappears after birth Coarse or bristly hair that appears during Coarse or bristly hair that appears during

pregnancy usually remainspregnancy usually remains


Immune SystemImmune System

No significant changes in maternal immune No significant changes in maternal immune system occur during postpartum period system occur during postpartum period

Mother’s need for rubella vaccination or for Mother’s need for rubella vaccination or for Rho (D) immune globulin for prevention of Rh Rho (D) immune globulin for prevention of Rh isoimmunization is determinedisoimmunization is determined


Key Points Key Points

Uterus involutes rapidly after birth, returning Uterus involutes rapidly after birth, returning to true pelvis within 2 weeksto true pelvis within 2 weeks

Rapid decrease in estrogen and Rapid decrease in estrogen and progesterone levels after expulsion of progesterone levels after expulsion of placenta responsible for triggering many placenta responsible for triggering many anatomic and physiologic changes in anatomic and physiologic changes in puerperiumpuerperium


Key Points—cont’d Key Points—cont’d

Assessment of lochia and fundal height is Assessment of lochia and fundal height is essential to monitor progress of normal essential to monitor progress of normal involution and identify potential problemsinvolution and identify potential problems

Return of ovulation and menses is Return of ovulation and menses is determined in part by whether woman determined in part by whether woman breastfeeds infantbreastfeeds infant

Few alterations in vital signs are seen after Few alterations in vital signs are seen after birth under normal circumstancesbirth under normal circumstances


Key Points—cont’d Key Points—cont’d

Hypercoagulability, vessel damage, and Hypercoagulability, vessel damage, and immobility predispose the woman to immobility predispose the woman to thromboembolismthromboembolism

Marked diuresis, decreased bladder Marked diuresis, decreased bladder sensitivity, and overdistention of the bladder sensitivity, and overdistention of the bladder can lead to problems with urinary eliminationcan lead to problems with urinary elimination

Pregnancy-induced hypervolemia allows Pregnancy-induced hypervolemia allows women to tolerate considerable blood loss at women to tolerate considerable blood loss at birthbirth

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