The postpartum period covers a critical transitional time for a woman, her newborn, and

her family on a physical, emotional and social level. In addition to responding to the
mother's and baby's special needs, care should include the prevention, detection and early
treatment of complications and disease and the provision of advice and services on
breastfeeding, birth spacing and contraception, immunisation and maternal nutrition.

Major causes of maternal death worldwide include postpartum haemorrhage, puerperal

infections and pre-eclampsia / eclampsia. Other common complications include urinary
tract problems and infections, perineal pain and infection and psychological problems.

INTRODUCTION — The postpartum period, also known as the puerperium, begins

with the delivery of the baby and placenta. The end of the postpartum period is less
well-defined, but is often considered the six to eight weeks after delivery because the
effects of pregnancy on many systems have resolved by this time and these systems
have largely returned to their prepregnancy state. However, all organ systems do not
return to baseline within this period and the return to baseline is not necessarily
linear over time. In some studies, women are considered postpartum for as long as
12 months after delivery.

CHANGES OF THE SKIN DURING PREGNANCY

Alterations in hormonal balance and mechanical stretching are responsible for several changes in
the integumentary system. The following changes occur during pregnancy:

a. Linea Nigra. This is a dark line that runs from the umbilicus to the symphysis pubis and may
extend as high as the sternum. It is a hormone- induced pigmentation. After delivery, the line
begins to fade, though it may not ever completely disappear.

b. Mask of Pregnancy (Chloasma). This is the brownish hyper pigmentation of the skin over the
face and forehead. It gives a bronze look, especially in dark-complexioned women. It begins
about the 16th week of pregnancy and gradually increases, then it usually fades after delivery.

c. Striae Gravidarum (Stretch Marks). This may be due to the action of the adrenocorticosteroids.
It reflects a separation within underlying connective tissue of the skin. This occurs over areas of
maximal stretch--the abdomen, thighs, and breasts. It will usually fade after delivery although they
never completely disappear.

d. Sweat Glands. Activity of the sweat glands throughout the body usually increases which
causes the woman to perspire more profusely during pregnancy.

5-4. CHANGES OF THE BREASTS

a. In early pregnancy, the breast may feel full or tingle, and increase in size as pregnancy
progresses. The areola of the nipples darken and the diameter increases. The Montgomery's
glands (the sebaceous glands of the areola) enlarge and tend to protrude. The surface vessels of
the breast may become visible due to increased circulation and turns to a bluish tint to the
breasts.

b. By the 16th week (2nd trimester) the breasts begin to produce colostrum. This is the precursor
of breast milk. It is a thin, watery, yellowish secretion that thickens as pregnancy progresses. It is
extremely high in protein.

c. Nursing implication: Inform the pregnant patient to wear a good, supporting bra.

Physiologic Changes During Pregnancy

GENERAL

The changes that occur in the pregnant patient's body are caused by several
factors. Many of these changes are the result of hormonal influence, some are
caused by the growth of the fetus inside the uterus, and some are the result of
the patient's physical adaptation to the changes that are occurring. This lesson is
closely related to anatomy and physiology.

5-2. CHANGES OF THE REPRODUCTIVE SYSTEM DURING PREGNANCY

Figure 5-1. Appproximate height

of the fundus at various weeks
of pregnancy.

Changes in the body during pregnancy are most obvious in the organs of the
reproductive system.
a. Uterus.

(1) Changes in the uterus are phenomenal. By the time the pregnancy has
reached term, the uterus will have increased five times its normal size:

(a) In length from 6.5 to 32 cm.

(b) In depth from 2.5 to 22 cm.

(c) In width from 4 to 24 cm.

(d) In weight from 50 to 1000 grams.

(e) In thickness of the walls from 1 to 0.5 cm.

(2) The capacity of the uterus must expand to normally accommodate a seven-
pound fetus and the placenta, the umbilical cord, 500 ml to 1000 ml of amniotic
fluid, and the fetal membranes.

(3) The abdominal contents are displaced to the sides as the uterus grows in
size, which allows for ample space for the uterus within the abdominal cavity.

(a) Growth of the uterus occurs at a steady, predictable pace.

(b) Measurement of the fundal height during pregnancy is an important factor that
is noted and recorded (see figure 5-1).

(c) Growth that occurs too fast or too slow could be an indication of problems.

(d) The size of the uterus usually reaches its peak at 38 weeks gestation. The
uterus may drop slightly as the fetal head settles into the pelvis, preparing for
delivery. This dropping is referred to as "lightening." This is more noticeable in a
primigravida than a multigravida.

NOTE: Remember a primigravida is a woman pregnant for the first time. A

multigravida is a woman who has been pregnant more than once.

b. Cervix.

(1) The cervix undergoes a marked softening which is referred to as the

Goodell's sign."

(2) A mucus plug, which is known as "operculum" is formed in the cervical canal.
This is the result of enlarged and active mucus glands of the cervix. It serves to
seal the uterus and to protect the fetus and fetal membranes from infection. The
mucus plug is expelled at the end of the pregnancy. This may occur at the onset
of labor or precede labor by a few days. When the mucus is blood-tinged, it is
referred to as a "bloody show."

(3) Additional changes and softening of the cervix occur prior to the beginning of
labor.

c. Vagina. Increased circulation to the vagina early in pregnancy changes the

color from normal light pink to a purple hue which is known as the "Chadwick's
sign."

d. Ovaries.

(1) The follicle-stimulating hormone (FSH) ceases its activity due to the increased
levels of estrogen and progesterone secreted by the ovaries and corpus luteum.
The FSH prevents ovulation and menstruation.

(2) The corpus luteum enlarges during early pregnancy and may even form a
cyst on the ovary. The corpus luteum produces progesterone to help maintain the
lining of the endometrium in early pregnancy. It functions until about the 10th to
12th week of pregnancy when the placenta is capable of producing adequate
amounts of progesterone and estrogen. It slowly decreases in size and function
after the 10th to 12th week.

CHANGES OF THE CIRCULATORY SYSTEM DURING PREGNANCY

a. Blood Volume.

(1) Blood volume increases gradually by 30 to 50 percent (1500 ml to 3 units). This results in
decrease concentration of red blood cells and hemoglobin. This explains why the need for iron is
so important during pregnancy.

(2) By the time pregnancy reaches term, the body has usually compensated for the decrease
resulting in an essentially normal blood count.

Total blood volume during pregnancy is about

5 liters
(3) Blood count is interpreted as anemia by the physician if the hemoglobin falls below 10.5
grams per 100 ml and the hematocrit drops below 30 percent.

(4) Increased blood volume compensates for hypertrophied vascular system of enlarged uterus. It
improves the placental performance. Blood lost during delivery, less than 500 cc is normal (300 to
400 cc is average).

b. Cardiac Output.

(1) Cardiac output increases about 30 percent during the first and second trimester to
accommodate for hypervolemia. This is not a problem for patients with a normal heart. A patient
with a diseased heart is especially at risk for cardiac decompensation 28 to 35 weeks of
pregnancy when the blood volume and cardiac load are at their peak; also, during labor and
immediately after delivery when rapid hemodynamic changes occur.

(2) Change in output is reflected in the heart rate. It usually increases by 10 beats per minute.

(3) Nursing implication. Patients with a diseased heart need to be advised to get plenty of rest
and to report any shortness of breath or unusual symptoms to their physician.

Watch a video showing how to take a blood

pressure

c. Blood Pressure.

(1) Normally, the patient's blood pressure will not rise.

(2) Nursing implications.

(a) The patient's blood pressure should be checked carefully and often since a significant
increase is one of the indicators of toxemia of pregnancy.

(b) When monitoring the blood pressure, be sure it is done under the same circumstances (that
is, patient sitting and left arm).

d. Venous Return.

(1) The lower extremities are often hampered in the last months of pregnancy due to the
expanding uterus restricting physical movement and interfering with the return of blood flow. This
results in swelling of the feet and legs.
(2) Nursing implications.

(a) Advise the patient to rest frequently. This will improve venous return and decrease edema.

(b) Have the patient to elevate her feet and legs while sitting.

(c) Remind the patient not to lie in a supine position since this inhibits return blood flood flow as
the heavy uterus presses on the vessels. This leads to the vena cava syndrome (see figure 5-2)
or supine hypotension. The patient may complain of feeling dizzy, nauseated, or weak.

Prenatal & Postpartum Fitness & YOU MAY ALSO...

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and Postpartum
A Healthful Mission

BeFit-Mom’s mission is to help all women

stay fit and healthy during pregnancy and
beyond. Science now acknowledges these
goals as not only medically sound, but
beneficial for both the mother-to-be and her
developing baby. Data from clinical studies
has shown that fit moms have better
control over weight gain, easier labor,
leaner, healthier babies and they bounce
back faster from pregnancy and childbirth
than do sedentary women. A full discussion
of the value of exercise during pregnancy
can be found on the Benefits of Exercise
during Pregnancy page of this web site.

Knowledge Is Your Ally

Your body will undergo tremendous changes

during your pregnancy and postpartum
periods, changes that may at times cause
concern. Leading obstetrician and
pediatrician Dr. Barry Brazelton stresses
that because the mother’s mental state
influences the health of her baby, it is
crucial for her to a maintain calm, positive
state of mind during pregnancy. Knowing
with reasonable certainty how to manage
these changes—while safely engaging in
activities that enhance the health of you
and your baby—can give you invaluable
peace of mind.

Bodily Systems Impacted during

Pregnancy

During pregnancy, your body produces

special hormones that stimulate physical
changes in virtually every part of your body.
Knowledge about these biomechanical
changes metabolism, cardiovascular and
musculoskeletal system is your best ally in
your quest to have the healthiest pregnancy
possible.

The Cardiovascular System

During pregnancy, the woman’s

cardiovascular system expands to support
the needs of the growing fetus. These
changes include:

• Boosts your blood volume, the amount

of blood circulating through your body,
by 40% to 50%.
• Raises your resting heart rate by about
15 to 20 beats per minute (BPM) by the
third trimester.
• Elevates cardiac output, or amount of
blood pumped per minute.
• Increases stroke volume,—the amount
of oxygenated blood pumped in one
heartbeat.
• Expands tidal volume, or the amount of
air you take in per breath.
• Dilates and relaxes your blood vessels,
thereby decreasing resting blood
pressure, and aiding in circulation.
Metabolism

What Pregnancy Does to Your

Metabolism

• Boosts basal metabolism.

• Raises your core temperature slightly.
• Slightly elevates your insulin levels.
• Elevates your daily caloric needs by 300
calories by second trimester.
• Increases your protein and fluid
requirements.
How Posture and Spine Alignment
Change during Pregnancy
Though subtle, the
postural changes of
pregnancy have
profound effects on
many areas of your
body. As the weight
of your baby grows
and the uterus
expands, the pelvis
tips to
counterbalance the
load. The pubic bone
and tailbone move
backward, thereby
increasing the arch in
your lower back. In
fitness terminology,
this is called an
anterior tilt of the
pelvis or a lordotic
posture.

Because the spine is

a dynamic structure,
alignment changes in
the pelvis have a
ripple effect on the
rest of the spine. The
thorax, or upper
back, increases its
curve, which rounds
the shoulders
forward and
collapses the chest.
In response to the
increased thoracic
curve, the head to
slides forward. Too
much curve in the
upper back vertebrae
is referred to as a
kyphotic posture. So
during pregnancy,
women experience a