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Post-maternity Body Changes
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MiguelOliveirada Silva andJoaquimSilvaNeves
1
Take-Home Points
• Pregnancy induces maternal anatomical and
physiological body changes. Puerperium is
the time following term or post-term delivery.
• Pregnancy, labour, and delivery can signicantly change maternal body and body image:
weight gain, abdominum striae, body fat
redistribution, breast and abdominal augmentation, hair growth, skin changes (striae gravi-
darum and pigmentation with cloasma/
melasma, capillary telangectasia), vaginal and
bladder prolapse (cystocele), hemorrhoids,
and edema are among the most common and
obvious body change examples.
• Maternal body changes are frequently a serious subject of concern and sometimes even
dissatisfaction and fear for women. This is an
issue for women and future parents that health
professionals should comprehensively
approach within routine antenatal and prenatal
care.
• Concerns and fears are related not only to
maternal and fetal outcomes but also some-
M. O. da Silva (*)
Obsterics and Gynaecology, Pre-Natal Consultation,
Hospital Santa Maria, Lisbon, Portugal
e-mail: mos@fm.ul.pt
J. S. Neves
Obsterics and Gynaecology, Gynecology and Family
Planning Consultation, Hospital Santa Maria,
Lisbon, Portugal
e-mail: nevesj@netcabo.pt
times specially to body image, self- esteem,
and self-image changes.
• Self-identication body changes are not only
due to personal, media and societal ideals (e.g.
feminist theories about the so-called ‘tirany of
the reproduction’), myths and misconceptions. The partner anxiety and misinformation
is also one additional reason to approach and
overcome such issues, including the partner as
an essential dialogue element.
• A considerable number of women believe that
their maternal body changes often have a negative inuence on their future image and sexuality, considerably decreasing their sexual
performance and capacity in general, as well
as their partner erotic attraction, with less ability to give and receive shared pleasure.
• Some women consider and deeply regret that
their body will never become the same after
their pregnancy and childbirth.
• Cosmetic female surgery after childbirth is a
serious and increasing ongoing individual and
societal concern that deserves a comprehensive approach by health professionals and
public policies.
1.1 Introduction
All these facts, concerns, anxieties, and misconceptions allow us to consider the necessity of all
maternal health professionals (nutritionists
© Springer Nature Switzerland AG 2023
M. Gomes-Ferreira, J. Olivas-Menayo (eds.), Post-maternity Body Changes,
https://doi.org/10.1007/978-3-030-43840-1_1
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M. O. da Silva and J. S. Neves
included) to cooperate in order to help mothers to
achieve their desirable body aspect and image.
This is not necessarily the same exact body aspect
existing before pregnancy, being sometimes
essential to cope with natural and permanent
body changes. Sometimes, the mediatic and
trendy ‘thin post-pregnancy ideal’ cannot always
be achieved and lived as an obsessive goal. This
is a must for most mothers and couples.
Maternal health professional team has a
unique role dealing with both maternal body
changes prevention and recovery. Midwifes, general practitioners, obstetricians, nutritionists,
social workers should work together and cooperate in order to achieve such goals.
However, some previous basic and evidencebased facts and principles should never be denied
or avoided.
Every informed and empowered future pregnant, every partner, and citizen should a priori be
educated, learned, and know about the general
facts:
1. Maternal adaptations during pregnancy are
physiological phenomena;
2. Pregnancy is not a time to lose weight, neither
for calories restriction diets;
3. Exercise during pregnancy has no contraindi-
cations; it shall be provided and performed
according to appropriated indications and
surveillance;
4. The older the mother is, the more difcult and
time consuming it can be for postpartum
recovery and/or achievement of the desired
body goal;
5. Many women become obese with such a con-
dition after pregnancy;
6. Maternal and childhood obesity can be a con-
sequence of excessive weight gain during
pregnancy;
7. Post-partum is the right time for those women
to exercise in order to achieve their physical
goals. Additional interventions may be needed
to assist women in returning to pre-pregnancy
tness;
8. Some maternal body changes cannot fre-
quently be avoided neither predicted and have
not (yet?) full successful treatment (such is
the case of abdominal, legs, and breast striae
gravidarum); and
9. Sexuality (also during pregnancy and after) is
not limited or restricted to genitalia contacts.
Body change concerns and sexual phantasies
and inhibitions must straightly be approached by
maternal health team during pre-conception and
antenatal care, with women and their partner.
Misconception and misinformation can be so
devastating that sometimes doctors and women
consider a priori a preventive cesarean section ‘at
request’ (with no maternal neither fetal indication), in order to prevent future sexual dysfunction due to a bladder or vaginal descent or a too
much large vaginal introitus.
Such an attitude– as a rule– is bad maternal
medicine and bad ethics. It is not at all evidence
based, no studies supports such a measure, which
is a preconception or, worse, sometimes an
unethical and articially induced business.
After delivery, the routine practice and trend
now supports and encourages so early as possible
ambulation and discharge.
1
Numerous well-controlled studies conrm the
many advantages of early ambulation and early
discharge.
Even so, it is mandatory to be very cautious
when comparing different data, routines, and
practices among different post-partum health
realities.
Many variables shall be considered and not
biased, including responsibility level in different
maternal health players, namely, eventual specialized and trained midwifes puerperium home
access.
Immediate post-maternity is the time when
genital and urinary tract involutions can occur,
reduce size from the vagina, rugae reappearance,
perineum lacerations or stretching (leading to
vaginal outlet relaxation), damage on pelvic oor
1
It is interesting to compare, even among the European
Member States, how different are the routine discharge
timings from maternity after a normal vaginal delivery
with no maternal and fetal complications—it ranges from
several hours to several days.
Of course, the existence of home personal post maternal
care availability has to be considered.
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(predisposing for organ prolapse), changes in
mammary glands (nipples cleanliness; skin ssures; painful and negative inuence on milk production; cracks and risk for bacterial invasion),
breast feeding, after pains, lochia, home return,
menstruation cycle activation, and ovulation.
Abdominal wall can be acid and soft, with
atonic muscles including rectus abdominis
separation.
Exercise can be practiced soon (a few days,
progressively) after a normal delivery.
The follow-up with comprehensive team takes
care of breasts and nipples, adequate diet, bowel,
and bladder functions.
It should as well prevent, diagnose, and treat
any mild maternal depression or ‘postpartum
blue’.
Return to menstruation and ovulation can
occur by the third week after delivery in women
not breastfeeding and taking a dopamine inhibitor (e.g. bromocriptine).
In such cases, it is advisable to start hormonal
contraceptive 15days after delivery, not forgetting that sexual activity and sexual intercourse
return cannot be surely predictable, which
changes according to different people and different cultures.
1.2 Conclusion
Most of post maternity body changes are partly a
consequence of previous life style, before and
during pregnancy. Not all body changes can be
avoided or predicted, due to body maternal adaptations to pregnancy. In any case, it is mandatory
that the whole maternal health team– since pregnancy is planned or has started– has a proactive
and comprehensive approach with woman.
Excessive weight gain and obesity have to be prevented, self-esteem, sexuality, intimacy, and
body image concerns are part of a global maternal health care and dialogue. Post-maternity evaluation of body changes and sexual life should
also be an integrative part of a modern and global
women’s health approach.
Bibliography
The puerperium. In: Williams obstetrics, coordinated
by Cunningham FG, Leveno KJ, Bloom SL, et al.
NewYork: McGraw Hill Education; 2018. p.652–65.
Edmonds DK.Puerperium and lactation. In: Dewhurst’s
textbook of obstetrics and gynaecology, coordinated
by Edmonds DK.Oxford: Wiley; 2012. p.365.
Coyne SM, Liechty T, Collier KM, et al. The effect of
media on body image in pregnant and postpartum
women. Health Commun. 2018;33(7):793–9.
Lovering ME, et al. Exploring the tripartite inuence
model of body dissatisfaction in postpartum women.
Body Image. 2018;24:44–54.
Mento C, et al. BMI at early puerperium: body image,
eating attitudes and mood states. J Obstet Gynaecol.
2017;37–4:428–34.
Nash M. Making “postmodern” mothers—preg-
nant embodiment, baby bumps and body image.
Houndmills: Palgrave Macmillan; 2012.
Bergmeier H, etal. Maternal body dissatisfaction in preg-
nancy, postpartum and early parenting. An overlooked
factor implicated in maternal and childhood obesity
risk. Appetite. 2020;144:104525.
Lee Megan F, et al. Striving for the thin ideal post-
pregnancy: a cross-sectional study of intuitive eating in postpartum women. J Reprod Infant Psychol.
2019;38:127. https://doi.org/10.1080/02646838.2019.
1607968.
Part II
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Pregnancy, Birth and Postpartum
Physiological andHormonal
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Changes During Pregnancy
TatianaCostas andMónicaGomes-Ferreira
2
Take-Home Points
• Understanding pregnancy as a dynamic and
physiological process in the woman’s body.
• Mostly, the physiological changes are due to
the inux of fetal-placental hormones.
• All the physiological changes are for the sake
of developing and nurturing the fetus.
• Although other changes may be “adverse
effects” of this process, thankfully most of
them are resolved on their own.
2.1 Introduction
The pregnant woman’s body is a place of
dynamic change for the sake of the developing
fetus. There are anatomical, physiological, and
biochemical alterations in the woman’s body
even before fertilization continuing throughout
pregnancy and puerperium.
Most of these adaptations occur due to the
inuence of hormonal changes and the creation
of new organs such as the placenta. Mother, fetus,
T. Costas (*)
Obstetrics and Gynaecology, Complejo Hospitalario
Universitario de Salamanca, Salamanca, Spain
e-mail: tcostas@saludcastillayleon.es
M. Gomes-Ferreira
Department Obstetrics and Gynecology,
MS Medical Institutes, Lisbon, Portugal
e-mail: info@drmonicagomesferreira.com
and placenta interrelate to cover the new metabolic and spatial needs of the new life.
These adaptations are physiological during pregnancy but could be interpreted as pathological in a
non-pregnant woman. For this reason, it is important to establish a difference between physiological
changes during pregnancy and diseases prior to gestation. That is our objective as obstetricians.
Pregnancy is not an illness. The daily life of an
expecting woman could be similar to her previous state in absence of medical or gynecological
complications. Many of her activities may be
adapted with better, comfortable positions or a
reduction of her working week. Maintaining her
daily life with normality (with adaptations) as far
as possible is important for her good physical,
mental, and social well-being [1].
2.2 Physiological Maternity
Changes
The fetal-placental unit (from the 13th week
onwards, before this function is developed by the
corpus luteum) secretes hormones and proteins
(estrogen, progesterone, human chorionic gonadotropin [β-HCG] and human placental lactogen
[HPL]) that are going to manage the function and
the changes in almost all the body systems. Also,
the corpus luteum produces other hormones such
as relaxin, which seems to play a role in renal
hemodynamics.
© Springer Nature Switzerland AG 2023
M. Gomes-Ferreira, J. Olivas-Menayo (eds.), Post-maternity Body Changes,
https://doi.org/10.1007/978-3-030-43840-1_2
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Although hormonal secretion is the main factor at play, part of the adaptations corresponds to
anatomical changes due to the uterine enlargement and the new arrangement of the organs in
the pelvic, abdominal, and thoracic spaces [1].
2.2.1 Reproductive Tract
The most dramatic changes occur in the reproductive tract, mainly in the uterus:
2.2.1.1 Uterus
During pregnancy, the uterus is transformed into
a relatively thin-walled muscular organ with
enough capacity to accommodate the fetus, placenta, and amniotic uid. In the non-pregnant
woman, this organ weighs 70 g and is almost
solid (except for a cavity of 10mL or less). At
the end of pregnancy, the content averages
5L. The uterus has achieved a capacity that is
500–1000 times greater than in its non-pregnant
state and it weighs nearly 1100 g [1]. This
enlargement is due to myocyte hypertrophy,
accumulation of brous tissue and an increase in
elastic tissue, which explains why the uterus
walls are thin.
The main stimulation in this process comes
from estrogen and, to a lesser extent, from
mechanical distension in the rst weeks (Fig.2.1).
The role changes from the 12th week onward.
Also, at the 12th week, the uterus has become too
large for the pelvis and it starts to displace adjacent organs [1].
While the uterus is growing, it is necessary for
the uterine blood ow to increase accordingly.
For that reason, estrogen causes vasodilation that
increases uterine ow. Furthermore, uterine vessels irrigate the placenta and this rise in ow is
essential for the function of the placenta.
2.2.1.2 Cervix
The cervix is formed by collagen-rich connective
tissue (mostly), smooth muscle, and cervical
glands. Estrogen increases vascularization,
edema, and hypertrophy and hyperplasia of the
cervical gland [2].
This enlargement is necessary to maintain the
pregnancy, as well as dilation and repair in the
postpartum period.
In addition, the proliferation of columnar
endocervical glands gives the cervix a red and
bloody look with a friable surface (Arias Stella
reaction) (Fig.2.2). These cells produce a greater
amount of mucus. This mucus, with the action of
progesterone, creates an immunological and antiinfective barrier due to the cytokines and immunoglobulins it contains [3].
The friable surface of the cervix during pregnancy produces slight bleeding with minimal
Fig. 2.1 Extrauterine pregnancy in week 8in the right
fallopian tube (letter A). Despite gestation taking place
outside the uterus, it is growing according to gestational
age due to hormonal mechanisms
Fig. 2.2 Cervix eversion of a woman in week 13 viewed
through speculum. The friable surface with the cervical
glands can be observe (arrowhead)
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trauma that may scare a pregnant woman. For
this reason, this condition should be explained to
them.
In the same way, a cytology or Pap test is
advisable before pregnancy due to the fragility of
the tissue at this stage, which has the same look
as atypical glandular cells.
2.2.1.3 Ovaries andFallopian Tubes
Due to hormonal mechanisms, the maturation of
new follicles is suspended. The corpus luteum
that maintains pregnancy until the sixth or seventh week and produces progesterone disappears
at that moment. For that reason, ovarian surgical
interventions before these weeks could result in
abortion.
Fallopian tubes suffer slight hypertrophy during pregnancy, but they are not involved in a general increase in size [1].
2.2.1.4 Vagina, Perineum
With the same mechanism as the cervix, the tissue of the vagina suffers an increase in its vascularity and hyperemia. This results in a violet color
called “Chadwick sign” (Fig.2.3).
In order to prepare the vagina for the partum
where the mucosa tissue grows, connective tissue
is reduced, and smooth muscle cells could
increase. Also, there is a growth in papillary epi-
Fig. 2.3 Vagina and vulva through speculum (woman in
week 13). The “Chadwick sign” should be identied in
the right side of the image (left labium minus of the
patient, under the arrowhead)
thelium in order to maximize cervical secretions
and the production of lactic acid by Lactobacillus
acidophilus, so as to maintain an acidic pH.This
factor strengthens vulvovaginal infections [1].
A summary of the entire reproductive tract can
be seen in Table2.1.
2.2.2 Breasts
Breasts must be understood as dynamic organs,
and during pregnancy and breastfeeding, they are
going to suffer the most dramatic alterations.
They are inactive during most of a woman’s life,
and they have an aesthetic function. During pregnancy, some changes are needed in order to activate the function of the gland: breastfeeding.
These changes can be attributed to various
hormones such as estrogens, progesterone, and
prolactin. Vascularization, skin, tissue composition, and pigmentation changes are examples of
the multiple adaptations to which breasts are
going to be subjected. These changes may resolve
spontaneously, or they could require surgical
procedures.
2.2.2.1 Basic Physiology
Breasts are an ectodermal derivative (specialized
skin). They are exocrine glands that are able to
secrete milk thanks to a differentiation process.
Hormones and protein factors such as prolactin,
aldosterone (responsible for duct differentiation),
and placental lactogen are involved in the fetal
breast development, and progesterone and estrogens also participate.
During pregnancy, the breasts have to be prepared for their function: breastfeeding.
Nowadays, the inherent mechanism involved is
still a mystery.
It is known that the increased levels of estrogens, progesterone, and placental lactogen
induced by pregnancy (due to the corpus luteum
and placenta) are involved in breast changes due
to their mammotropic effects.
During the rst weeks of pregnancy, there is
simply growth of ducts and lobules. In the third
trimester, due to an increase in the level of hormones, the breast undergoes remarkable
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Table 2.1
during pregnancy
System
Reproductive
tract
↑E: increase of estrogen levels
↑P: increase of progesterone levels
Summary of mechanisms, changes, functions of the changes, and main problems in the reproductive tract
Uterus
Cervix
Ovaries
Fallopian
tubes
Vagina and
perineum
Hormonal
mechanism
↑E, ↑P
↑E, ↑P
↑E, ↑P
↑E, ↑P
↑E, ↑P
Physiological
changes Function Main problems
Increased
enlargement
Increased
vascularization
Increased
vascularization
Edema
Hypertrophy
Hyperplasia
Lack of
maturation of
follicles
Corpus luteum
Hypertrophy of
musculature
Increased
vascularization
Edema
Hypertrophy
Hyperplasia
changes: it grows further, with proliferation of
the duct epithelium and creation of new lobules,
and the lumen of the ducts dilates due to an accumulation of secretions. The involution of fatty
and connective tissue to allow this enlargement
is mediated by progesterone. The rst colostrum
is formed. Also, the nipple–areola complex
grows.
After childbirth, the levels of estrogens, progesterone, and placental lactogen decrease dramatically and, for that reason, prolactin can carry
out its function: lactogenesis. During pregnancy,
levels of prolactin are similar to those of the
puerperium stage, but the other hormones were
previously inhibiting it.
At the end of breastfeeding, the spacing of
baby breastfeeding intake stops the stimulation
of prolactin and breasts gradually come back to
normal.
In menopause, the hormonal decrease also
causes changes in the mammary tissue, which
involutes and loses rmness. However, there are
other anatomical factors, such as changes in the
Embracing gestation
Placental nutrition
Pregnancy maintenance
Immunological and
anti-infection barrier
Pregnancy maintenance
the pregnancy until
week 6 or 7
None? –
Preparing birth canal Infections
Displacement of
adjacent organs
Slight bleeding
Avoid surgical
interventions in the
rst trimester
connective tissue or in ligaments, which also
have an inuence on this process [1].
This topic will be widely covered in Chap. 14:
Mammary Tissue Changes during Pregnancy and
Breast Feeding.
2.2.3 Cardiovascular System
The rst system that changes in the maternal
body is the cardiovascular system. It needs to
adapt to the necessary requirements in nurture
and oxygenation that the fetus demands.
Moreover, these demands are constantly changing and increasing, and the cardiovascular function becomes more difcult due to the weight and
the position of the uterus and the fetus.
2.2.3.1 Cardiac Output
The most important event is the increase in cardiac output. In the non-pregnant woman, the cardiac output accounts for 30% of the global output.
During pregnancy, it reaches 50%.
Modifications of cardiac ouput during pregnancy
Cardiac output (%)
Gestational weeks
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Half of these changes take place in the rst
8weeks of pregnancy. At the end of pregnancy,
output decreases due to the obstruction of the
inferior vena cava. At the moment of childbirth,
during contractions, the cardiac output can rise
up to more than 40% [4].
The increase in cardiac output takes place
through two mechanisms: the rst of them is an
increase in the systolic volume and the second
one is an increase in cardiac frequency; both of
them are mediated by hormones.
An increase in the systolic volume is the prevalent mechanism in the rst months. It is mediated by the rise in the blood volume (see
hematological system) and the decrease of
peripheral resistance due to progesterone and
other vasodilators.
When the heart cannot improve the cardiac
output with an increase in volume anymore, the
cardiac frequency rises—also mediated by hormones—by 10beats/min [4] (Fig.2.4).
2.2.3.2 Blood Pressure
The blood pressure in pregnant women is signicantly lower than in non-pregnant women in the
rst weeks [1]. It reaches its minimum in weeks
24–32, and from that moment on, it rises gradually. At childbirth, blood pressure could increase
by 10mmHg, mostly due to pain [4].
It is important to highlight illnesses during
pregnancy related to blood pressure, such a preeclampsia, where a vascular endothelial dysfunction creates a hypertensive state.
2.2.3.3 Uterine Blood Flow
The uterus receives around 2% of the cardiac output in the non-pregnant woman and in the rst
trimester during gestation. At the end of the pregnancy, the uterus receives more than 20% of all
the cardiac output [4]. This could be due to the
increase of the total cardiac output and also to the
distribution of the output itself. Structures such
as the musculoskeletal tissue receive less input
than in a non-pregnant state.
2.2.3.4 Anatomical Changes
Owing to the enlargement of the uterus, the
abdominal viscera are displaced. This modies
the diaphragm, which is elevated. For that reason,
the heart changes to a more horizontal position
and it is displaced upward and to the left, while it
rotates laterally. This can be observed with
X-rays (slight changes) and in an ECG, which
shows a slight deviation of the axis.
Also, due to the increase in the systolic volume, the heart is enlarged, and ventricles are
remodeled without hypertrophy of the myocytes
[1, 5].
Uterine enlargement causes a compression of
inferior cava vein (aorta does not suffer compression due to it has muscle war). This compression
reduces the vein lumen and it causes a venous
stasis in lower limbs. Edema, typically at the end
of the day, should appear (it is caused also by
hormones). Lifestyle and position recommendations may be enough to allow complications.
Fig. 2.4 Modications
of cardiac output during
pregnancy and its
mechanism
systolic
volume
30
0816 24 32 40 childbirth
cardiac
frequency
50
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Inferior cava vein compression is also related
with sickness and dizziness due to the reduction
of cardiac output. Liberation of cava vein from
uterus compression with left lateral decubitus
position should improve this condition.
2.2.3.5 Repercussion ofCardiovascular
Changes
Pregnancy is considered a hyperdynamic state. In
this state, it is normal to nd a split S2 during
inspiration. In addition, a slight systolic murmur
(never diastolic) may be heard.
2.2.4 Respiratory System
Since the moment of fertilization, the need for
oxygen increases. Changes in the respiratory system have two components: rst of all, an increase
in oxygen uptake, together with anatomical
changes due to uterine enlargement.
Most mechanisms are mediated by
progesterone.
2.2.4.1 Anatomical Changes
The diaphragm rises 4cm at the end of pregnancy
due to visceral displacement. As a way of compensation, the subcostal angle increases, and also
the diameters of the chest walls. With this mechanism, the pregnant woman does not lose respiratory capacity (Fig.2.5).
2.2.4.2 Functional Adaptation
The anatomical changes induce physiological
changes. These changes usually deteriorate the
respiratory function slightly, and it may be compensated physiologically.
Due to diaphragm elevation, residual volume decreases from 1000 to 800 mL in the
pregnant woman. Also, with the same mechanism, the expiratory reserve mechanism
decreases from 700 to 550 mL. Both of them
Fig. 2.5 Anatomical changes in the diaphragm. Left:
non-pregnant woman. Right: pregnant woman. It should
be observed that the diaphragm rises more than 4 cm.
Change in
diaphragm position
Also, the anteroposterior and transverse diameters of the
thoracic cavity increase
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