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Flashcards in Postpartum A&P Deck (20):
1

What is the cause of uterine involution?

Myometrial cell autolysis - cells decrease in size, not in number

2

On postpartum day 7, where is the uterus?

Still palpable right above/ at the symphysis pubis

3

A few days postpartum, how much has the uterus involuted?

~50%, still retroverted and palpable

4

What is the typical color/amount/course of bleeding for a postpartum patient?

Lochia
- rubra: 3 days
- serosa: 7-10 days
- eschar bleeding (from scab at placental site) may occur at 7-14 days for just a few hours
- alba: up to 4 weeks

5

What happens to the cervix postpartum?

- after birth: “reconstitution” — repair of extracellular matrix, restoration of epithelial barrier
- end of wk 1: endocervical canal returns, dilation of os 1 cm (looks like a slit in parous people)
- cervical endothelium: remodels, can help to facilitate regression of CIN

6

What happens to the vagina postpartum?

3-4 weeks: vaginal rugae returns
6-10 weeks: vaginal epithelium healed

- Hymenal ring tags are present
- Labia minora no longer hide introitus
- Vaginal tone may not be same as pre-pregnancy

7

What are the 3 phases of healing of the perineum?

1. hemostasis & inflammation
2. granulation & proliferation
3. remodeling

8

Your patient gave birth last night and you are seeing her during postpartum rounds this morning. She is concerned about swelling, itchiness, and burning in her perineum. What is the most likely cause?

Hemostasis & inflammation phase of healing.

Duration: right after injury to a few days
- adherence of platelets, formation of platelet plug at site of injury
- fibrinogen moves to plug --> thrombin helps it to break into fibrin --> fibrin holds injured site together

@6-8hrs: inflammation --> swelling, itching, burning
- short-term: polymorphonuclear neutrophils help to clean the damage from bacteria and debris
- longer term: monocytes → become macrophages → use phagocytosis to get rid of debris. Stimulate growth factors.

9

At 1 month postpartum, your patient calls because she is concerned that her perineum has a red, "pebbled" appearance and wonders if she has an infection. What phase of healing is most likely occurring at this time, and what advice can you give her?

Granulation & proliferation phase

@ 5-7 weeks: early fibroblasts create framework (collagen and extracellular matrix) for granulation tissue
@ 4-5 weeks: blood vessels form to perfuse the granulation tissue, new epithelium is built from tissue nearby. Granulation tissue fills up the space of the wound.

Advice:
- practice good hygiene
- be gentle with drying
- reabsorption of sutures can take 6 weeks

10

At your patient's 6 week postpartum appt, she asks you about whether or not her perineum has fully healed because she is scared to have intercourse again. What phase of healing is most likely occurring at this time, and what anticipatory guidance can you give her?

Remodeling phase

- can take years
- tissue resembles that before labor and delivery
- scar tissue forms from collagen: thickness and lack of flexibility can cause dyspareunia, scar may be numb
- may be vulnerable to future lacerations

Anticipatory guidance:
- Kegels/ pelvic floor exercises
- wait until she's ready to resume sexual activity
- vaginal lubrication, esp if she is lactating
- alternative positions for intercourse

Physiology:
- collagen that was part of the granulation and proliferation process remodels
- regression of proliferation stage blood vessels
- myofibroblasts cause wound to contract
- scar tissue forms from collagen

11

What cardiovascular changes occur to a parturient immediately or soon after giving birth?

Immediate:
- auto-transfusion of 10-15% of blood volume s/t removal of placenta & shifting of extracellular fluid (ECF) into intravascular system
- !! pts w/ HTN, PEC, cardiac dz: at increased risk for pulmonary edema or cardiac failure in 1st 24-48 hrs

Within 48 hrs:
- cardiac output (CO) increases s/t increased flow of blood back to heart from loss of uteroplacental circulation, decreased pressure from gravid uterus, and shift of ECF
- CO gradually returns to normal by 6-12 weeks postpartum
- !! pts w/ some CVD: increased risk for pulmonary edema, cardiac failure, and other cardiac abnormalities postpartum

Within 2 wks:
- plasma volume slowly returns to non-pregnant values
- natural diuresis and diaphoresis in initial postpartum period, especially days 2-5

12

During postpartum rounds, your patient asks if it is normal for her to be so constipated on day 3. What are the causes of constipation postpartum? When will normal GI and bowel patterns return?

Decreased peristalsis in early puerperium:
- progesterone levels drop, which helps to increase motility, but it takes some time
- bowel and abdominal wall tone is decreased, which also delays peristalsis

Other causes of constipation:
- Fear
- Perineal pain
- Narcotics in labor
- c/s
- dehydration
- restriction of food/fluids during labor
- iron supplements
- decreased activity

Normal GI & bowel patterns typically return around 1-2 wks

13

Your patient on postpartum day 2 appears short of breath while talking to you after coming out of the bathroom. What is your next best action?

a. Reassure her that this is normal. It takes 48-72 hours for pregnancy-related dyspnea to resolve.
b. Assess/ evaluate her SOB, any other s/s, and proceed from there.
c. Report her symptoms to the attending OB.

b. Dyspnea r/t pregnancy usually resolves rapidly after birth. SOB and/or chest pain in the postpartum period should be evaluated immediately, especially b/c of the increased risk of thromboembolic events postpartum.

14

Which is potentially concerning-- a pt who develops proteinuria in the first few days or in the first 2-3 weeks postpartum?

What should you do in each scenario?

New-onset proteinuria in first 2-3 weeks postpartum. Evaluate for PEC.

In first few days postpartum, mild proteinuria may develop. May be r/t normal postpartum changes. Depending on full clinical picture, consider further evaluation.

15

What differences might you see on your patient's urinalysis right after delivery?

- protein (from uterine involution) and ketones (from dehydration) may be in urine right after delivery
- UTI risk increases w/ urinary retention and decreased bladder tone and urinary sensation

16

What are the 3 main reasons for postpartum urine retention?

- decreased bladder tone
- decreased urinary sensation
- increased diuresis

17

Which hormones are involved with lactogenesis 1?

placental lactogen, progesterone, estrogen, and prolactin

18

What hormonal changes normally occur with lactogenesis 2?

- plasma progesterone levels drop w/ placenta expulsion
- prolactin secreted from anterior pituitary and increases in plasma --> milk secreted by alveolar cells
- oxytocin release from posterior pituitary → myoepithelial cells contract → milk ejected from alveoli and lobules → milk flows into lactiferous ducts and becomes available to baby

19

What are the different roles of oxytocin during lactogenesis 2?

- Calming to parent and child, helps to decrease anxiety
- Stabilizes BP
- Keeps cortisol levels low
- Helps to establish trust, facial recognition
- ejection of milk

20

What is the usual recurrence of ovulation and menses in breastfeeding vs. non-breastfeeding women?

- breastfeeding: depends on duration/amount/frequency... can be up to 36 months
- non-lactating: up to 12 weeks per PP module; 4-6 weeks postpartum per Jamille's AP lecture