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The Anatomy and Physiology of the

Postpartum Transition
Transcript of The Anatomy and Physiology of the Postpartum Transition
Uterus and Cervix Perineum Lovely Lochia Cardiovascular System and Coagulation Hormonal
changes Urinary System Gastrointestinal System Weight Changes Temperature Returns to pelvis2 weeks
Complete involution- 6 weeks
Weighs approximately 1,000g (10-20 fold heavier than nonpregnant uterus)
Average diameter of placenta is 18 cm, but the average placental site immediately PP is 9cm
Hemostasis: ischemia, pressure by opposing walls, clotting mechanisms
Cervix is bruised and lacerated
By 1 week the cervix admits one finger
A cervical os reforms with a ____ shape rather than the nulliparous _____ Case Study:
A client calls you one week after the birth of her baby. She had an uncomplicated NSVB with an
intact perinuem. Nursing is going well. She is currently in no pain, just worried. Until this point her
lochia has been decreasing in volume and she reports that it has been similar to a "light
menstrual period". Today she woke up and noticed an increased amount of vaginal bleeding
(bright red) that soaked through a large pad in one hour. She thinks it may be slowing down now.
She wants to know what she should do? What would you tell her? What is the most likely cause of
PPD# 1-3 PPD#7-10 2 Weeks PP
Spiral myometrial fibers occlude uterne vessels Regeneration of edometrial glands Endometrium
(minus placental site) is fully restored
Inflitrate with granulocytes and mononuclear cells Well-demarcated zone between necrotic and
healthy tissue
Decidual necrosis begins Shedding of placental escar
Leukocytes and lymphocytes persist for the first 10 days: antibactrial barrier Rubra!
Decidua and frank blood loss from placental site
Initially sterile, then colonized by vaginal flora
Red color lasts three days Serosa!
Leukocytes, mucous, vaginal epithelial cells, necrotic decidua, bacteria
3-4 weeks brown-pink color
Sweet odor Alba!!!
Mostly serous fluid and leukocytes
Cervical mucous with some microorganisms
Yellow or white color Lochia usually subsides by 6 weeks PP, but 10-15% may have serosa at 6
week exam
Factors that can affect timing of lochia:
Baby size
Mode of delivery
Infection, stress Three phases of wound healing

0-3 days: Inflammation:

Normal reaction to tissue trauma: acts to isolate tissue damage and reduce spread of infection.
Neutrophils and macrophages invade tissue and ingest bacteria and break down nectroctic tissue
7-10 days: Migratory Phase (tissue formation):
Infiltration of wound by mesenchymal cells that form fibroblasts which create a protective scab.
Blood vessels grow into wound. Tissue granulation.
Beyond 10 days: Proliferative phase (tissue reformation phase):
Epithelial cells grow under the scab and scab finally sheds.

6 months PP: Surface depression may be visible, scar becomes paler. Connective tissue becomes
less vascular and stronger Decreased sensation for days to weeks - 2/2 trauma
Incomplete emptying
Stress incontinence in first 10 days PPD#2-5= marked diuresis
Fluid and electrolyte balance is normal at 21 days
Oxytocin is an anti diuretic and falls after delivery- increasing immediate diuresis
Kidneys and renal pelves may remain slightly larger permanently, but mostly return to size within
6 months Immediate loss of 10-13lbs: infant, placenta, amniotic fluid, blood losshappens 1-2 weeks after 2/2 fluid retention By 6wks PP- 28% have returned to prepregnant
weight Breast feeding has little effect on weight loss Most women lose most weight by 6 months
Case Study:
A 24 y/o G1P1001 comes into clinic for a 'problem visit' at 4 weeks PP after a NSVB with a 2nd
degree laceration. She is complaining of vaginal pressure and fullness, especially when she walks
or stands for a long period. She feels like "everything is falling out". She came in for a 2 week
postpartum exam and another midwife told her everything looked normal. She just wants to
make sure everything is okay today. What do you think is going on? Could this be normal? What
phase of wound healing should you expect to see when you evaluate? What type of history and
PE would you want to gather? Do you have any suggestions aout what this woman could do to
alleviate this symptom? Case Study: A 14 year old G1p0101 is in your office for her 6 week PP
exam. She is very worried about a "large booger" coming out of the vagina. She describes it as
looking similar to "what was coming out in labor". She wants to know if this is normal? Can she
have sex now? Case Study:
Jodi is a 30 y/o G3P2103 one week s/p FAVB. She is calling you on the triage line at 11pm
complaining of dysuria and frequency. What types of questions would you ask her? What are your
differential diagnosis? What do you think is going on? Case Study:
Laura is a first-time mother. She had a primary c/s for NRFHTs 3 days ago. The OB/GYN team that
is caring for her plans to d/c her to home tomorrow. You are there as her midwife socially
rounding. She is complaining of profuse sweating at night and chills. She has to get up and
shower so that she can go back to sleep comfortably. Is this normal? Explain what may be
happening. What are your differential diagnosis? Maternal temperature returns to normal by 24
hours PP. There may be some increase in temperature if there is dehydration within the first 24
hours, but this should resolve within 1 day. Case Study:

The RN from the postpartum floor pages you regarding a birth you attended 4 hours ago. The
woman had a 6 hours labor, completely uncomplicated NSVB, intact perineum. She now has a
temperature of 38.0. Could this be a normal postpartum change? What would you do? Relaxed
abdominal tone
Decreased gastric motility (left over from birth)
Pain, fear, soreness
Irregular food intake in labor
Dehydration during labor and PP Increase distention and constipation Gallbladder muscle tone
and contractility is enhanced PP- expulsion of small gallstones First BM is within 2-3 days
Hemorrhoids Anal Fissures Abdominal Wall Striae fade over several months to silvery color
Hyperpigmentation (linea nigra) fade, may remain in women with darker skin
Abdominal wall muscles are flabby
Diastasis recti: separated rectus muscles
Muscle tone
Pregnancy spacing
Diastasis can fill in with fat, peritoneum, fascia
Failure to close diastasis can lead to weak core and back pain Within 72 hours after expulsion of
placenta, progesterone and estrogen levels drop to non-pregnant state
FSH levels are normal within 2 weeks (suppressed during pregnancy)
Luteinizing hormone levels return to normal depending on lactation (suppressed during
Thyroid levels should be normal by 6 weeks PP Case Study: A woman with a hypothyroidism
comes in for a 6-week postpartum visit. Prior to pregnancy her dose of levothyroxine was 25mcg.
Her dose was increased to 50mcg during her pregnancy. She is currently still taking 50mcg as
advised by a CNM upon d/c from hospital. She didn't come in for a 2-week postpartum visit. Has
this patient been on an appropriate dose in the last 6 weeks? Should you keep her on her dose?
What do you recommend? Pregnancy Changes: Case Study:
You are conducting 3-day PP visit for a competitive marathon runner. Many of her friends have
told her that they have returned to competition in a few months postpartum. What are the
considerations for returning to running? Days 1-2: blood loss decreases plasma volume
Day 3: interstitial fluid is mobilized and the plasma
volume is replenished Estrogen leads to:
Formation of new blood vessels
Increased blood flow to tissue
Increased venous distension
Reduced blood viscosity
Reduction in systemic vascular resistance The heart increases in size by about 12% (estrogenstimulated hypertrophy)
Increase in blood volume by 30-50%
Increase in cardiac output from 4.5L to 6L/min Decreased blood pressure Progesterone causes

relaxation of smooth muscle tone Mechanical Changes: Postpartum Changes: causes

hemodilution of hemoglobin and plasma proteins (clotting factors)
Clotting factor then increases Increase risk of thombolitic events:
hemodilution of clotting factors
physiologic peak of clotting factor during labor (gradual decrease for a few weeks PP)
loss of placental and fetal factors that affect clotting Marked increase in cardiac output initially
uteroplacental flow is returned to the venous system
vena cava is not compressed by the uterus Progressive decrease in cardiac output and blood
volume over PP period
Vascular remodeling takes at least a year (hypertrophy, increased cardiac output)