Today, we're going to talk about the normal
physiologic changes that occur during the
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
hematologic system, the endocrine system,
renal system, the gastrointestinal system,
musculoskeletal system, and finally the
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
And then after about 24 hours, it begins the
process of involution of
shrinking back down to its nonpregnant
So after about 24 hours, the uterus begins
the process of
involution where it returns to its
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
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
to oxytocin and in this case, this explains
why sometimes right after delivery to
decrease bleeding, oxytocin will be
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
Remember that breastfeeding, the actual act
of suckling on the breast, releases
oxytocin and so breastfeeding actually may
contractions. Lochia is the blood that comes
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 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
And so the cervix really isn't looking so
great immediately after delivery.
It's bruised, it's open, it's slightly
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
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
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
So remember, bradycardia means slow
heartbeat and the heart rate may get down to
about 40 to 50 beats a minute, which is very
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
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
we want to talk about prolactin, so
Lactaid like pro milk, so prolactin levels
are going to
remain elevated as long as the client is
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
So in about almost six weeks, someone could
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
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
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
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
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
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
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
And I cannot stress that enough.
Let's talk about the role of attachment and
We have three phases taking in, taking hold
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
So those are the three phases.