PUERPERIUM
JI Canarie Joy A. EsguerraOB-GYNE UERMMMCI
Definition
Clinical and Physiological Aspects ◦ Vagina and Vaginal Outlet ◦ Uterine Changes◦ Urinary Tract Changes◦ Peritoneum and Abdominal Wall◦ Blood and Fluid Changes (Weight Loss)
Breast
Hospital Care
Care at Home
Outline
The period of confinement during and just after birth usually the 6 subsequent weeks during which normal pregnancy involution occurs (Hughes, 1972 in Williams 22nd Ed)
Usually between 4 to 6 weeks
What Is Puerperium?
By 6 weeks after delivery, most of the changes of pregnancy, labor, and delivery have resolved and the body has reverted to the nonpregnant state.
Puerperium…
CLINICAL and PHYSIOLOGICAL ASPECTS
OF THE PUERPERIUM
Vagina gradually diminishes in size but rarely returns to nulliparous dimensions
Rugae: reappear by the 3rd week
Hymen: represented by several small tags of tissue which scar to form the myrtiform caruncles.
Vaginal epithelium: proliferates by 4-6 weeks
I. VAGINA AND VAGINAL OUTLET
Relaxation of vaginal outlet ◦ d/t extensive laceration or overstretching of
perineum during delivery
Uterine prolapse, urinary and anal incontinence◦ Damage to the pelvic floor ◦ Operative correction is usually postponed until
childbearing was ended
I. VAGINA AND VAGINAL OUTLET
UTERINE VESSELS CERVIX AND LOWER UTERINE SEGMENT INVOLUTION OF UTERINE CORPUS AFTERPAINS LOCHIA ENDOMETRIAL REGENERATION SUBINVOLUTION PLACENTAL SITE INVOLUTION LATE POSTPARTUM HEMORRHAGE
II. UTERINE CHANGES
Caliber of extrauterine vessels◦ decrease to equal size of prepregnant state
Blood vessels within puerperal uterus◦ obliterated by hyaline changes◦ gradually reabsorbed◦ replaced by smaller vessels
UTERINE VESSELS
Cervical opening contracts slowly and for a few days immediately after labor it readily admits 2 fingers
◦ End of the 1st wk → it had narrowed as the cervix thickens and endocervical canal reforms.
External os does not completely ressume its pregravid appearance
◦ Remains somewhat wider and bilateral depression at the site of lacerations becomes permanent
CERVIX AND LOWER UTERINE SEGMENT
Markedly thinned-out lower uterine segment◦ contracts & retracts
Uterine isthmus located between the uterine corpus above and the internal cervical os below - over the course of few weeks
CERVIX AND LOWER UTERINE SEGMENT
Fundus of contracted uterus
◦ immediately after placental expulsion: slightly below umbilicus
◦ within 2 wks: descended into the true pelvis ◦ within ~ 4 wks: regained previous nonpregnant
size
◦ Consists mostly of myometrium covered by serosa and lined by basal decidua
◦ Anterior and posterior walls, in close apposition, each measures 4 to 5 cm thick
UTERINE INVOLUTION
Weight of uterus◦ immediately postpartum: 1000g ◦ 1 week later: 500g ◦ at the end of 2nd week: 300g◦ soon thereafter: 100g or less
: total number of muscle cells does not decrease
→ individual cells decrease markedly in size
Separation of the placenta and membrane involves the spongy layer → decidua basalis remains in the uterus
UTERINE INVOLUTION
Primiparas: puerperal uterus tends to remain contracted
Multiparas: contracts vigorously at interval → afterpain
Infant suckles →oxytocin release →Uterine contraction → afterpain
Occasionally severe enough to require an analgesic → usually become mild by the 3rd postpartum day
AFTERPAINS
Early in the puerperium, sloughing of decidual tissue → vaginal discharge of variable quantity
◦ lochia rubra: first few days after delivery blood in lochia
◦ lochia serosa: after 3 or 4 days becomes progressively pale in color
◦ lochia alba: after 10th day, because of admixture of leukocytes and reduced fluid content, it assumes white or yellowish-white color
May persist for up to 4 to 6 weeks after delivery
LOCHIA
the remaining decidua becomes differentiated into 2 layers within 2 or 3 days after delivery◦ superficial layer: become necrotic, sloughed in the
lochia◦ basal layer: remains intact, source of new
endometrium
rapid, except at the placental site◦ free surface becomes covered by epithelium within a
week or so◦ entire endometrium is restored during the 3rd week◦ endometritis & salpingitis - not infection but only part
of the involutional process
ENDOMETRIAL REGENERATION
an arrest or retardation of involution, the process by which the puerperal uterus is normally restored to its original size
Accompanied by prolongation of lochial discharge & irregular or excessive uterine bleeding and sometimes by profuse hemorrhage
Cause◦ retention of placental fragments, pelvic infection
SUBINVOLUTION
Bimanual examination◦ uterus is larger & softer than normal for the
particular period of puerperium
Treatment◦ ergonovine or methylergonovine(Methergine)◦ oral antibiotics: usually effective in metritis◦ Wager et al: 1/3 of postpartum uterine infection
are caused by Chlamydia----- doxycycline or azithromycin
SUBINVOLUTION
Complete extrusion of placental site takes up to 6 weeks
Immediately after delivery, palm size→ 3-4cm in diameter (end of 2nd week, )
Placental site◦ normally consists of many thrombosed vessels within
hours of delivery
→ ultimately undergo organization of thrombus Placental site exfoliation
◦ as the consequence of sloughing of infarcted and necrotic superficial tissues followed by a reparative process
PLACENTAL SITE INVOLUTION
Serious uterine hemorrhage occasionally develops 1-2 weeks after delivery
ACOG (2006) defines secondary postpartum hemorrhage as bleeding 24 to 12 weeks after delivery
Causes:◦ abnormal involution of placental site (most often)◦ retention of a portion of the placenta
→ usually undergo necrosis with deposition of fibrin
→ form a placental polyp Treatment:
◦ intravenous oxytocin, ergonovine, methylergonovine, prostaglandins
◦ curettage
LATE POSTPARTUM HEMORRHAGE
dilated renal pelvis & ureters: return to prepregnant state 2- 8 weeks after delivery
Puerperal diuresis◦ physiological reversal of pregnancy-induced increase in extracellular
water◦ regularly occurs between 2nd and 5th day
Puerperal bladder create optimal condition for development of UTI◦ increased capacity & relative insensitivity to intravesical fluid pressure
→ overdistention, incomplete emptying, excessive residual urine
most women return to normal micturition by 3months postpartum
Careful attention to all postpartum women, prompt catheterization for those who cannot void, will prevent most urinary problems
II. URINARY TRACT CHANGES
Broad & round ligaments◦ much more lax than nonpregnant◦ require considerable time to recover from
stretching & loosening Abdominal wall
◦ return to normal → requires several weeks (aided by exercise)
◦ usually resumes its prepregnancy state except for silvery striae
◦ Exercises to restore tone
IV. PERITONEUM AND ABDOMINAL WALL
By 1 week after delivery, blood volume return nearly to nonpregnant level
Marked leukocytosis and thrombocytosis occur during and after labor
Cardiac output remains elevated for 24 to 48 hours postpartum◦ Due to increased stroke volume from venous return◦ Declines to nonpregnant values by 10 days
V. BLOOD AND FLUID CHANGES
Uterine evacuation & normal blood loss : 5-6 kg Further decrease through diuresis: 2-3 kg Factors of Weight loss
◦ weight gain during pregnancy◦ primiparity◦ early return to work (outside the home)◦ smoking
Factors that do not affect weight loss◦ breastfeeding◦ age◦ marital status
Return to prepregnant weight – 6 months
WEIGHT LOSS
For 1st 24 hours after the development of the lacteal secretion, it is not unusual for the breasts to become distended, firm and nodular.
Accompanied by transient elevation of temperature ~ less than 4 to 16 hours
Rule out other causes of fever esp pelvic infection
Tx: breast supports, ice pack, analgesic, pumping of breast or manual expression of milk
BREAST
HOSPITAL CARE
Attention immediately after labor:◦ BP & PR : should be taken every 15 minutes
Monitor amount of vaginal bleeding
Fundus should be palpated to ensure that it is well contracted◦ if relaxation detected, uterus should be massaged
through abdominal wall until it remains contracted
HOSPITAL CARE
Advantages◦ less frequent bladder complications &
constipation◦ reduced frequency of puerperal venous
thrombosis & pulmonary embolism
EARLY AMBULATION
Should be instructed to cleanse vulva from anterior to posterior (vulva→anus)
Ice bag applied to perineum
Warm sitz bath◦ beginning about 24 hours after delivery
Tub bathing after uncomplicated delivery is allowed
CARE OF THE VULVA
Oxytocin: commonly infused after placental delivery
◦ sudden withdrawal of antidiuretic effect of oxytocin→ rapid bladder filling
Both bladder sensation and its capability to empty → diminished by anesthesia, by episiotomy, laceration or hematomas
◦ common complication of the early puerperium → urinary retention with bladder overdistention
BLADDER FUNCTION
Woman who has not voided within 4 hours after delivery → indwelling catheter → prevent overdistension
Tx of bladder overdistention:◦ indwelling of catheter for at least 24 hours◦ empty the bladder completely◦ prevent prompt recurrence◦ allow recovery of normal bladder tone & sensation
BLADDER FUNCTION
after catheter removal, if the woman cannot void after 4hours
◦ catheterize and measure urine volume ◦ If ≥200 cc of urine was collected
: catheter should be left in place and the bladder drained for another day.
◦ If ≤200cc of urine was collected
: remove the catheter & recheck the bladder.
BLADDER FUNCTION
early ambulation and early feeding→ constipation ↓
BOWEL FUNCTION
during the first few days after vaginal delivery
uncomfortable by afterpains, episiotomy & lacerations, breast engorgement
→ codeine, aspirin, acetaminophen every 3 hours
Episiotomy & lacerations◦ early application of an ice bag◦ local analgesic spray◦ healed and nearly asymptomatic by the 3rd
weeks
SUBSEQUENT DISCOMFORT
Some degree of depression a few days after delivery is fairly common◦ Postpartum blues = transient depression
Cause◦ The emotional letdown that follows the excitement
and fears The discomforts of the early puerperium◦ Fatigue from loss of sleep during labor and
postpartum in most hospital settings◦ Anxiety over her capabilities for caring for her infant
after leaving the hospital◦ Fears that she has become less attractive
Self-limited & usually remits after 2~3 days
MILD DEPRESSION
Exercise to restore abdominal wall tone: any time after vaginal delivery: as soon as abdominal soreness
diminishes after cesarean delivery
ABDOMINAL WALL RELAXATION
No dietary restrictions for women who have been delivered vaginally
May eat 2 hours after normal vaginal delivery, (if, no Cx)◦ lactating women : should be increased in calories
and protein non breast feeding : dietary requirement as
for a nonpregnant woman
DIET
in recent years : decreased accdg to Jacobsen and colleagues:
pulmonary embolism is most common in the first 6wks post partum
THROMBOEMBOLIC DISEASE
during the puerperium a thrombus may transiently form in any of the dilated pelvic veins
without associated thrombophlebitis – not incite clinical signs or symptoms
the massive and fetal pulm. emboli that develop without warning in the puerperium
: symptomatic puerperal pelvic thrombosis is most commonly associated with uterine infection
PELVIC VENOUS THROMBOSIS
Pressure on branches of lumbosacral plexus during labor: complaints of intense neuralgia or cramplike pains extending down one or both legs as soon as the fetal head begins to descend the pelvis
Involved external popliteal n. femoral n. obturator n, sciatic n.
the gluteal m. are affected. Separation of the symphysis pubis or one of the
sacroiliac synchondroses during labor may be followed by pain and marked interference with locomotion.
OBSTETRICAL PARALYSIS
Anti D-immune globulin 300 μg: nonimmunized women within 72 hours of the birth of a D-positive infant
Rubella vaccination Diphtheria-tetanus toxoid booster infection Measles immunization
IMMUNIZATION
If no complication (at vaginal delivery) hospitalization period ≤ 48 hours
Up to 96 hours for uncomplicated CS Give instructions
TIME OF DISCHARGE
CARE AT HOME
Median interval between delivery and intercourse: 5 weeks (1~12 weeks)
Best rule is one of common sense after 2 weeks, coitus may be resumed based on the pt's desire & comfort
* Breast feeding : cause a prolonged period of suppressed estrogen production with a resulting vaginal atrophy and dryness
COITUS
If not nursing: usually within 6-8 weeks
Lactating woman: 2nd~18th mos. postpartum
Ovulation◦ as early as 36-42 days(5-6 wks) after delivery◦ delayed resumption of ovulation with breast
feeding◦ but early ovulation is not precluded by persistent
lactation → pregnancy can occur with lactation
RETURN TO MENSTRUATION AND OVULATION
Normal delivery and puerperium: women can resume most activities (bathing, driving, household functions) by the time of discharge
Follow-up examination during 3rd postpartum wk has proven quite satisfactory: identify any abnormalities of later puerperium: initiate contraceptive practice
FOLLOW-UP CARE
THANK YOU!!!!