Postpartum physiological changes

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The postpartum physiological changes are those expected changes that occur in the woman's body after childbirth, in the postpartum period. These changes mark the beginning of the return of pre-pregnancy physiology and of breastfeeding. Most of the time these postnatal changes are normal and can be managed with medication and comfort measures, but in a few situations complications may develop. [1] Postpartum physiological changes may be different for women delivering by cesarean section. [2] Other postpartum changes, may indicate developing complications such as, postpartum bleeding, engorged breasts, postpartum infections.

Contents

Breasts and lactation

The breasts change during pregnancy to prepare for lactation, and more changes occur immediately after the birth. Progesterone is the hormone that influences the growth of breast tissue before the birth. Afterwards, the endocrine system shifts from producing hormones that prevent lactation to ones that trigger milk production. [3] The first secretions are known as colostrum and are rich in substances that help the newborn adjust to life outside the womb. About two to five days after the birth the breasts begin to produce milk. This sometimes is described as "the milk coming in". [4]

Information can be provided to the mother before the birth to enhance the understanding of breastfeeding and the support that will be available to make it successful. [5] The mother is encouraged to breastfeed and spend time bonding with her infant immediately after the birth.

Sucking causes the pituitary gland to release oxytocin, which contracts the uterus and prevents bleeding. [1] [6] This can be felt by the mother in the breasts. The crying of the infant can also induce the release of oxytocin. Cracked nipples can develop at this time, which can be managed with pharmacological and nonpharmacological treatment. [4]

Uterus

The most drastic change in the uterus is the contraction from an organ weighing one kilogram and a volume of about 10 litres down to a 60 gram organ that only contains 5 ml of fluid. [7] Immediately after delivery, the fundus of the uterus begins to contract. This is to deliver the placenta which can take up to 30 minutes and may involve a feeling of chills. [8] In a normal and healthy response it should feel firm and not boggy. It begins to involute with contractions of the smooth muscle of the uterus. It will contract midline with the umbilicus. It begins its contractions and by twelve hours after the birth it can be felt to be at the level of the umbilicus. [9] The uterus changes in size from one kilogram to 60-80 grams in the space of six weeks. After birth, the fundus contracts downward into the pelvis one centimeter each day. After two weeks the uterus will have contracted and return into the pelvis. [9] The sensation and strength of postpartum uterine contractions can be stronger in women who have previously delivered a child or children. [10]

Cervix, vagina and perineum

The cervix remains soft after birth. The vagina contracts and begins to return to the size before pregnancy. For four to six weeks of the postpartum period the vagina will discharge lochia, a discharge containing blood, mucus, and uterine tissue. [11]

Immunity

During pregnancy the normal inflammatory immune response is shut down in order to allow the acceptance of the embryo to the body. In the postpartum period this needs to be quickly reversed back to normal. This immune reconstitution can result in the symptomatic expression of infections that were present but previously not responded to, especially infections with an autoimmune basis. [12]

Pain control and comfort measures

Education and discussion before the birth can alleviate some of the fear of the unknown and the anxiety when treatments are experienced for the first time. Providing continuous updates on the status of the infant is beneficial.

Perineal pain after childbirth has immediate and long-term negative effects for women and their babies. These effects can interfere with breastfeeding and the care of the infant. [13] The pain from injection sites and possible episiotomy is managed by the frequent assessment of the report of pain from the mother. Pain can come from possible lacerations, incisions, uterine contractions and sore nipples. Appropriate medications are usually administered. [14] Routine episiotomies have not been found to reduce the level of pain after the birth. [15] Comfort is enhanced with changing linens, urination, the cleaning of the perineum and ice packs. Privacy also in implemented to promote comfort. [16]

Hemorrhoid pain can be managed with a variety of methods. Some recommendations for reducing the pain of hemorrhoids include: cleansing with warm water, hemorrhoid creams, increasing fluids, lying on the site and sitz baths. [17]

Medications controlling pain will begin to wear off. This is also true when an epidural or spinal block is given. [5] Uterine contractions are sometimes painful and comfort can be provided by suggesting different positions. Walking around, with assistance, can decrease pain. Since uterine cramping may become more painful during breastfeeding, medications can be given half an hour before nursing. Pain control and comfort can be managed by anticipating the return of sensation and bodily reactions to bruises, tears, incisions and punctured sites.

Management

Immediately after the birth, on going assessments are performed with recommendations from the American Academy of Pediatrics and American College of Obstetricians and Gynecologists. They have identified that vital signs of blood pressure, and pulse, uterine position, and bleeding should be assessed every 15 minutes for the first two hours after birth. [1] [16] The temperature is then measured twice, four hours and eight hours after birth. This is to guard against postpartum infections, previously known as childbed fever or puerpal sepsis, one of the main causes of maternal mortality.

The care during the early postpartum period often continues when the patient returns home. A 2023 systematic review found that blood pressure monitoring at home appears to increase patient satisfaction while reducing hypertension-related hospital admissions. [18]

Nutrition

The caloric needs will change based upon the production of milk for the infant. The caloric requirement for a non-breastfeeding, non-pregnant woman changes from 1,800-2,000 kcal/day to 2,300 to 2500 kcal/day for the breastfeeding woman. Nutritional supplementation is often prescribed and recommended. In some instances women are encouraged to continue to take pre-natal vitamins. Increasing the intake of fluids is discussed. The need for additional levels of minerals is most likely due to lactation. Calcium and iron needs increase postpartum. [19] Calories may need to increase by 333 kcal/day during the first four to six weeks postpartum and then by 400 kcal/day 6 months postpartum. [2]

Other foods or substances are not recommended postpartum if breastfeeding because they may have effects on the baby via breastmilk. Some clinicians discourage the use of caffeine. This could produce fussiness in the baby. Alcohol use is strongly discouraged. Consuming fish is healthy and provides vitamins, minerals and proteins. Consumption of oily fish like haddock, herring, sardines, grouper, and tuna may need to be limited due to pollutants. [20] [21]

Weight loss should be monitored to ensure recovery. Quick weight loss can reduce milk supply. Low carb and high protein diets may not be appropriate. A realistic weight loss goal is one pound per week. [2]

A urinary catheter is usually put in place before the cesarean section to prevent urinary retention. The abdominal incision will be another site for pain and possible infection. Moving out of bed may be delayed. As with any surgical procedure, the risk is higher for the development of blood clots in the legs. In such cases intermittent pneumatic pressure device may be used or much simpler compression stockings could be given. Leg exercise will also be effective in promoting blood circulation in the legs. Higher levels of pain medication may be needed related to abdominal incisions. If the cesarean was not planned, some women will be disappointed and may benefit from encouraging counseling from clinicians. [2]

See also

Related Research Articles

<span class="mw-page-title-main">Childbirth</span> Expulsion of a fetus from the pregnant mothers uterus

Childbirth, also known as labour, parturition and delivery, is the completion of pregnancy where one or more babies exits the internal environment of the mother via vaginal delivery or caesarean section. In 2019, there were about 140.11 million human births globally. In the developed countries, most deliveries occur in hospitals, while in the developing countries most are home births.

<span class="mw-page-title-main">Nipple</span> Part of the breast

The nipple is a raised region of tissue on the surface of the breast from which, in females, milk leaves the breast through the lactiferous ducts to feed an infant. The milk can flow through the nipple passively or it can be ejected by smooth muscle contractions that occur along with the ductal system. Male mammals also have nipples but without the same level of function, and often surrounded by body hair.

<span class="mw-page-title-main">Episiotomy</span> Surgical incision of the perineum and the posterior vaginal wall

Episiotomy, also known as perineotomy, is a surgical incision of the perineum and the posterior vaginal wall generally done by a midwife or obstetrician. This is usually performed during second stage of labor to quickly enlarge the aperture allowing the baby to pass through. The incision, which can be done from the posterior midline of the vulva straight toward the anus or at an angle to the right or left, is performed under local anesthetic, and is sutured after delivery.

<span class="mw-page-title-main">Postpartum period</span> Time period beginning after the birth of a child and extending for about one month

The postpartum period begins after childbirth and is typically considered to last for six weeks. However, there are three distinct but continuous phases of the postnatal period; the acute phase, lasting for six to twelve hours after birth; the subacute phase, lasting six weeks; and the delayed phase, lasting up to six months. During the delayed phase, some changes to the genitourinary system take much longer to resolve and may result in conditions such as urinary incontinence. The World Health Organization (WHO) describes the postnatal period as the most critical and yet the most neglected phase in the lives of mothers and babies; most maternal and newborn deaths occur during this period.

A hysterotomy is an incision made in the uterus. This surgical incision is used in several medical procedures, including during termination of pregnancy in the second trimester and delivering the fetus during caesarean section. It is also used to gain access and perform surgery on a fetus during pregnancy to correct birth defects, and it is an option to achieve resuscitation if cardiac arrest occurs during pregnancy and it is necessary to remove the fetus from the uterus.

<span class="mw-page-title-main">Uterine rupture</span> Medical condition

Uterine rupture is when the muscular wall of the uterus tears during pregnancy or childbirth. Symptoms, while classically including increased pain, vaginal bleeding, or a change in contractions, are not always present. Disability or death of the mother or baby may result.

<span class="mw-page-title-main">Complications of pregnancy</span> Medical condition

Complications of pregnancy are health problems that are related to, or arise during pregnancy. Complications that occur primarily during childbirth are termed obstetric labor complications, and problems that occur primarily after childbirth are termed puerperal disorders. While some complications improve or are fully resolved after pregnancy, some may lead to lasting effects, morbidity, or in the most severe cases, maternal or fetal mortality.

<span class="mw-page-title-main">Uterine atony</span> Loss of tone in the uterine musculature

Uterine atony is the failure of the uterus to contract adequately following delivery. Contraction of the uterine muscles during labor compresses the blood vessels and slows flow, which helps prevent hemorrhage and facilitates coagulation. Therefore, a lack of uterine muscle contraction can lead to an acute hemorrhage, as the vasculature is not being sufficiently compressed. Uterine atony is the most common cause of postpartum hemorrhage, which is an emergency and potential cause of fatality. Across the globe, postpartum hemorrhage is among the top five causes of maternal death. Recognition of the warning signs of uterine atony in the setting of extensive postpartum bleeding should initiate interventions aimed at regaining stable uterine contraction.

<span class="mw-page-title-main">Postpartum bleeding</span> Loss of blood following childbirth

Postpartum bleeding or postpartum hemorrhage (PPH) is often defined as the loss of more than 500 ml or 1,000 ml of blood following childbirth. Some have added the requirement that there also be signs or symptoms of low blood volume for the condition to exist. Signs and symptoms may initially include: an increased heart rate, feeling faint upon standing, and an increased breathing rate. As more blood is lost, the patient may feel cold, blood pressure may drop, and they may become restless or unconscious. The condition can occur up to six weeks following delivery.

<span class="mw-page-title-main">Carbetocin</span> Pabal contains carbetocin used for preventing postpartum bleeding. Potent than oxytocin.

Carbetocin, sold under the brand names Pabal among others, is a medication used to prevent excessive bleeding after childbirth, particularly following Cesarean section. It appears to work as well as oxytocin. Due to it being less economical than other options, use is not recommended by NHS Scotland. It is given by injection into a vein or muscle.

<span class="mw-page-title-main">Vaginal delivery</span> Delivery through the vagina

A vaginal delivery is the birth of offspring in mammals through the vagina. It is the most common method of childbirth worldwide. It is considered the preferred method of delivery, with lower morbidity and mortality than caesarean sections (C-sections).

<span class="mw-page-title-main">Breastfeeding</span> Feeding of babies or young children with milk from a womans breast

Breastfeeding, or nursing, is the process by which human breast milk is fed to a child. Breast milk may be from the breast, or may be pumped and fed to the infant. The World Health Organization (WHO) recommends that breastfeeding begin within the first hour of a baby's life and continue as often and as much as the baby wants. Health organizations, including the WHO, recommend breastfeeding exclusively for six months. This means that no other foods or drinks, other than vitamin D, are typically given. The WHO recommends exclusive breastfeeding for the first 6 months of life, followed by continued breastfeeding with appropriate complementary foods for up to 2 years and beyond. Of the 135 million babies born every year, only 42% are breastfed within the first hour of life, only 38% of mothers practice exclusive breastfeeding during the first six months, and 58% of mothers continue breastfeeding up to the age of two years and beyond.

A postpartum disorder or puerperal disorder is a disease or condition which presents primarily during the days and weeks after childbirth called the postpartum period. The postpartum period can be divided into three distinct stages: the initial or acute phase, 6–12 hours after childbirth; subacute postpartum period, which lasts two to six weeks, and the delayed postpartum period, which can last up to six months. In the subacute postpartum period, 87% to 94% of women report at least one health problem. Long term health problems are reported by 31% of women.

A uterotonic, also known as an oxytocic or ecbolic, is a type of medication used to induce contraction or greater tonicity of the uterus. Uterotonics are used both to induce labor and to reduce postpartum hemorrhage.

Sex after pregnancy is often delayed for several weeks or months, and may be difficult and painful for women. Painful intercourse is the most common sexual activity-related complication after childbirth. Since there are no guidelines on resuming sexual intercourse after childbirth, the postpartum patients are generally advised to resume sex when they feel comfortable to do so. Injury to the perineum or surgical cuts (episiotomy) to the vagina during childbirth can cause sexual dysfunction. Sexual activity in the postpartum period other than sexual intercourse is possible sooner, but some women experience a prolonged loss of sexual desire after giving birth, which may be associated with postnatal depression. Common issues that may last more than a year after birth are greater desire by the man than the woman, and a worsening of the woman's body image.

The following outline is provided as an overview of and topical guide to obstetrics:

<span class="mw-page-title-main">Maternal physiological changes in pregnancy</span>

Maternal physiological changes in pregnancy are the adaptations that take place during pregnancy that enable the accommodation of the developing embryo and fetus. These are normal physiological adaptations that cause changes in behavior, the functioning of the heart, blood vessels, and blood, metabolism including increases in blood sugar levels, kidney function, posture, and breathing. During pregnancy numerous hormones and proteins are secreted that also have a broad range of effects.

<span class="mw-page-title-main">Pain management during childbirth</span>

Pain management during childbirth is the treatment or prevention of pain that a woman may experience during labor and delivery. The amount of pain a woman feels during labor depends partly on the size and position of her baby, the size of her pelvis, her emotions, the strength of the contractions, and her outlook. Tension increases pain during labor. Virtually all women worry about how they will cope with the pain of labor and delivery. Childbirth is different for each woman and predicting the amount of pain experienced during birth and delivery can not be certain.

<span class="mw-page-title-main">Delayed onset of lactation</span>

Delayed onset of lactation (DOL) describes the absence of copious milk secretion (onset of lactation) within the first 72 hours following childbirth. It affects around 20–40% of lactating women, the prevalence differs among distinct populations.

Nipple pain is a common symptom of pain at the nipple that occurs in women during breastfeeding after childbirth. The pain shows the highest intensity during the third to the seventh day postpartum and becomes most severe on the third day postpartum.

References

  1. 1 2 3 Henry 2016, p. 117.
  2. 1 2 3 4 Davidson 2014, p. 168.
  3. ↑ The physiological basis of breastfeeding. World Health Organization. 2009.
  4. 1 2 Henry 2016, p. 120.
  5. 1 2 Davidson 2014, p. 161.
  6. ↑ Davidson 2014, p. 162.
  7. ↑ Lyon 2009.
  8. ↑ "Stages of labor" . Retrieved 30 July 2017.
  9. 1 2 Henry 2016, p. 118.
  10. ↑ Durham 2014, p. 310.
  11. ↑ Henry 2016, p. 119.
  12. ↑ Singh & Perfect 2007, pp. 1192–9.
  13. ↑ Shepherd, Emily; Grivell, Rosalie M. (24 July 2020). "Aspirin (single dose) for perineal pain in the early postpartum period". The Cochrane Database of Systematic Reviews. 2020 (7): CD012129. doi:10.1002/14651858.CD012129.pub3. ISSN   1469-493X. PMC   7388929 . PMID   32702783.
  14. ↑ Henry 2016, p. 122.
  15. ↑ Jiang et al. 2017.
  16. 1 2 Davidson 2014, p. 160.
  17. ↑ Davidson 2014, p. 163.
  18. ↑ Steele, Dale W.; Adam, Gaelen P.; Saldanha, Ian J.; Kanaan, Ghid; Zahradnik, Michael L.; Danilack-Fekete, Valery A.; Stuebe, Alison M.; Peahl, Alex F.; Chen, Kenneth K.; Balk, Ethan M. (2023). "Postpartum Home Blood Pressure Monitoring: A Systematic Review". Obstetrics & Gynecology. 142 (2): 285–295. doi: 10.1097/AOG.0000000000005270 . ISSN   0029-7844. PMID   37311173. S2CID   259155390.
  19. ↑ Davidson 2014, p. 165.
  20. ↑ Davidson 2014, p. 166.
  21. ↑ "Should pregnant and breastfeeding women avoid some types of fish?". nhs.uk. 2018-06-27. Retrieved 2018-08-12.

Bibliography

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