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NUR1 233 (6)
Lecture

Chapter 20.docx

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Department
Nursing
Course
NUR1 233
Professor
Sonia Elizabeth Semenic
Semester
Summer

Description
Chapter 20: Maternal Physiological Changes Uterus  Involution process o Return of the uterus to a nonpregnant state o Begins rdmediately after expulsion of the placenta with contraction of the uterine smooth muscle o End of 3 stage labor: uterus midline 2cm below level of umbilicus – weighs 1000g o 24 hours after birth: same size as it was at 20 weeks gestation o Fundus descends 1-2cm every 24 hours and by 6 postpartum day the fundus halfway between umbilicus and symphysis pubis o Nth palpable after 2 weeks o 6 week postpartum: 50g o After birth and decrease in estrogen/progesterone, autolysis of excess hypertrophied tissue o Additional cells laid down during pregnancy remain and account for slight increase in uterine size after each pregnancy o Subinvolution: uterus doesn’t go back to normal size – cause: fragments of placenta left inside and infection  Contractions o Oxytocin: strengthens and coordinates contractions – compress blood vessels and promote hemostasis o 1-2 hours postpartum: uterine contractions decrease in intensity and become uncoordinated  Afterpains o First time mothers: uterine tone good, fundus generally firm and mild uterine cramping o Subsequent pregnancies: periodic relaxation and vigorous contractions – more in large baby – breastfeeding and oxytocin make it worse  Placental site o After placenta and membranes expelled, vascular constriction and thromboses reduce placental site to an irregular nodular and elevated area o Endometrium: upward growth causes sloughing of necrotic tissue and prevents scar formation characteristic of normal wound healing – enables endometrium to resume usual cycle of changes and permit implantation and placentation in future pregnancies  Regeneration: completed by postpartum day 16 except at placental site  Regeneration at placental site: 6 weeks postpartum  Lochia o Postbirth uterine discharge o Rubra: bright red – small clots – initially heavy o Serosa: pink – old blood, serum, leukocytes, and tissue debris – 22-27 days o Alba: yellow/white – leukocytes, decidua, epithelial cells, mucus, serum, and bacteria – at 10 days for 2-6 weeks o Less lochia after caesarean birth o Flow increases after ambulation and breastfeeding o Pools in vagina when supine o Persistence of lochia rubra early in postpartum: bleeding as result of retained fragments of placenta or membranes o Continued flow of serosa and alba by 3-4 weeks after can suggest endometritis, especially if with fever and pain o Smell like normal menstrual flow Cervix  Soft immediately after birth  2-3 days: shortened, firm, regained form  Cervix up to lower uterine segment remains edematous, thin and fragile for days after birth  Ectocervix: protrudes into vagina – appears bruised and small lacerations  Cervical os: dilated 10cm in labor – closes gradually  External cervical os never regains prepregnant appearance – not shaped like circle – like a slit  Lactation delays production of cervical and other estrogen-influenced mucus and mucosal characteristics Vagina and Perineum  Thinning of vaginal mucosa and absence of rugae  Returns to size by 6-10 weeks postpartum  Rugae: appear within 3 weeks but are never prominent as they are in nulliparous women – permanently flattened  Mucosa remains atrophic in lactating woman until menstruation resumes  Thickening of vaginal mucosa returns with ovarian function  Decreased vaginal lubrication – because of decreased estrogen  Localized dryness and coital discomfort until ovarian function and menstruation resumes  Episiotomies visible only if woman lying on side with upper butt raised – heals same way as surgical incision – healing takes 2-3 weeks  Hemorrhoids: common – internal hemorrhoids may evert while woman pushing during birth – decrease within 6 weeks of birth o Defecation: itching, discomfort, bleeding  Pelvic muscular support o Supportive tissues of pelvic floor that are torn or stretched during childbirth – 6 months to regain tone o Pelvic relaxation: lengthening and weakening of fascial supports of pelvic structures – uterus, bladder, urethra, rectum – can occur in any woman but more a complication of childbirth Abdomen  First 2 weeks: abdominal wall relaxed  Takes 6 weeks to return to prepregnancy state  Regains most elasticity but some straie may remain  Diastasis recti abdominis: abdominal wall muscles separate – large fetus or multiple fetuses Endocrine System  Placental hormones o Decreased in human chorionic somatomammotrpin (human placental lactogen), estrogen, cortisol, and placental enzyme insulinase reverse diabetogenic effects of pregnancy – lower blood sugar initially o Decrease estrogen/progesterone – breast engorgement and diuresis of excess extracellular fluid o Nonlactating: estrogen levels increase by 2 weeks after birth and by postpartum day 17 are higher than in women who are breastfeeding o hCG gone after 14 days  Pituitary hormones and ovarian function o Prolactin and oxytocin increased – suppresses ovulation o Nonlactating: decrease and reach prepregnancy level by 3-4 weeks postpartum  Ovulation: 27 days after – most by 12 weeks o Lactating: resumption of ovulation by 6 months and determined by breastfeeding patterns o First
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