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PUERPERIUM DR.PRIYA SAXENA
DEFINITION:Puerperium is the period following childbirth during which the body tissues, especially the pelvic organs revert back approximately to the prepregnant state both anatomically and physiologically. • DURATION:Puerperium begins as soon as the placenta is expelled and lasts for approximately 6 weeks when the uterus becomes regressed almost to the nonpregnant size. The period is arbitrarily divided into — • immediate – within 24 hours • early – up to 7 days and • remote – up to 6 weeks.
ANATOMICAL AND PHYSIOLOGICAL CHANGES • Changes in the uterus during puerperium: • Uterus • Involution • After third stage: At the level of umbilicus,weighs 1000g • After 1 week: midway between umbilicus and pubic symphysis,weighs 500g • After 2 weeks: within the pelvis, weighs 300g • After 6 weeks:prepergnantsize,weighs 100g
CLINICAL ASSESSMENT OF INVOLUTION: • The rate of involution of the uterus can be assessed clinically by noting the height of the fundus of the uterus in relation to the symphysis pubis. • The measurement should be taken carefully at a fixed time every day, preferably by the same observer. • Bladder must be emptied beforehand and preferably the bowel too, as the full bladder and the loaded bowel may raise the level of the fundus of the uterus. • The uterus is to be centralized and with a measuring tape, the fundal height is measured above the symphysis pubis. Following delivery, the fundus lies about 13.5 cm(5 1/2") above the symphysis pubis.
During the first 24 hours, the level remains constant; thereafter, there is a steady decrease in height by 1.25 cm (0.5") in 24 hours, so that by the end of 2nd week the uterus becomes a pelvic organ. The rate of involution thereafter slows down until by 6 weeks, the uterus becomes almost normal in size.
Lower segment: contracts and becomes isthmus • Cervix: • Contracts and thickens • External os becomes a transverse slit • Endometrium: • Superficial decidua sloughs • New endometrium from basal layer of decidua(starts by 10th day and entire endometrium is restored by 3 weeks except at the placental site where it takes 6 weeks. • Leukocytic infiltration initially, plasma cells appear later.
The involution may be affected adversely and is called subinvolution. Sometimes, the involution may be continued in women who are lactating so that the uterus may be smaller in size — superinvolution. The uterus, however, returns to normal size if the lactation is withheld.
Vagina: • Decrease in vascularity • Reappearance of rugae after 3rdweek,vagina regains its tone but never to the virginal state. • Complete involution of cervix and vagina takes place at 4-8 weeks.Involution of cervix and vagina is never complete like patulous os,lax vaginal mucosa and few healed lacerations. • Vulva: Partial/complete regression • Relaxation/enlargement of introitus • Pelvic floor: Relaxation of pelvic muscles/ligaments/fascia
Ovarian function: • Return of ovulation • Nonlactating:4 weeks • Lactating:10 weeks • Return of menstruation: • Nonlactating:8-12 weeks • Lactating: Depends on duration and frequency of breastfeeding. • The physiological basis of anovulation and amenorrhea is due to elevated levels of serum prolactin associated with suckling. • In lactating mothers the mechanism of amenorrhea and anovulation are depicted schematically below.
Women who is exclusively breastfeeding, the contraceptive protection is about 98% up to 6 months of postpartum. Thus, lactation provides a natural method of contraception. • However, ovulation may precede the first menstrual period in about one-third and it is possible for the patient to become pregnant before she menstruates following her confinement. • Nonlactating mother should use contraceptive measures in 3rd postpartum week and the lactating mother in 3rd postpartum month.
LOCHIA: It is the vaginal discharge for the first fortnight during puerperium. The discharge originates from the uterine body, cervix and vagina. • Odor and reaction: It has got a peculiar offensive fishy smell. Its reaction is alkaline, tending to become acid toward the end. • Color: Depending upon the variation of the color of the discharge, it is named as: • lochiarubra(red) :1–4 days, consists of blood, shreds of fetal membranes and decidua, vernixcaseosa,lanugo and meconium. • lochiaserosa(5–9 days) — the color is yellowish or pink or pale brownish,consists of less RBC but more leukocytes, wound exudate, mucus from the cervixand microorganisms (anaerobic streptococci and staphylococci). The presence of bacteria is not pathognomonic unless associated with clinical signs of sepsis.
(3) Lochia alba(pale white) — 10–15 days,contains plenty of decidual cells, leukocytes, mucus, cholesterin crystals, fatty and granular epithelial cells and microorganisms. • Amount:The average amount of discharge for the first 5–6 days is estimated to be 250 mL. • Normal duration:The normal duration may extend up to 3 weeks. The red lochia may persist for longer duration especially in women who get up from the bed for the first time in later period. The discharge may be scanty, especially following premature labors or may be excessive in twin delivery or hydramnios.
Clinical importance: The character of the lochial discharge gives useful information about the abnormal puerperal state. The vulval pads are to be inspected daily to get information of: • Odor: If malodorous—indicates infection. Retained plug or cotton piece inside the vagina should be kept in mind. • Amount: Scanty or absent — signifies infection or lochiometra. If excessive — indicates infection. • Color: Persistence of red color beyond the normal limit signifies subinvolution or retained bits of conceptus. • Duration: Duration of the lochia alba beyond 3 weeks suggests local genital lesion.
GENERAL PHYSIOLOGICAL CHANGES • Pulse: • For a few hours after normal delivery, the pulse rate is likely to be raised, which settles down to normal during the second day. However, the pulse rate often rises with after-pain or excitement. • Temperature: • The temperature should not be above 37.2°C (99°F) within the first 24 hours. • There may be slight reactionary rise following delivery by 0.5°F but comes down to normal within 12 hours. • On the 3rd day, there may be slight rise of temperature due to breast engorgement which should not last for more than 24 hours. However,genitourinary tract infection should be excluded if there is rise of temperature.
Abdominal wall: • Flabby and the muscles are lax in the immediate postnatal period (as the result of ruptured elastic fibres in the skin and prolonged distension caused by the pregnant uterus). The muscles regain their tone over a period of time and can be aided by exercises. • Divarication of recti • Striaegravidarum during pregnancy is permanent. • Abdominal wall and its ligaments require 6 week to retain their formal state.
Urinary tract: • Renal plasma flow • Glomerular filtration rate • Dilatation of renal pelvis and ureter Return to normal by 6-8 weeks
Postnatal urinary retension and stasis due to: • Increased bladder capacity • Reduced bladder sensation • Edema of bladder base • Submucosal hemorrhage • Epidural analgesia and Reflex urethral spasm due to pain at the episiotomy/perineal tear can worsen these symptoms • Stress urinary incontinence: can occur following prolonged labor or instrumental delivery due to stretching and damage to the pelvic muscles and fascia. It commonly improves over the next few weeks but may persist long term.
Hematological changes: • Leukocytes: • Increase immediately after delivery(increase upto 30,000/cumm, predominant increase in granulocytes) • Decrease soon after • Hemoglobin: • Fluctuates • Rises after 1 week
Increase in blood coagulability: • Thrombocytosis • Increased platelet adhesiveness • Increase in fibrinogen • Persistence of increase in other coagulation factors • Increased 10-20 times in first 2 weeks, hence the risk of venous thromboembolism is greatly increased in puerperium especially in the first 10 days. • Balance between procoagulation and anticoagulation is restored in 6-8 weeks. • However some studies shows that coagulation factors remain elevated for upto 8-12 weeks postpartum.
Cardiovascular changes: • Fall in cardiac output • Decrease in blood volume • Fall in heart rate Occurs within a week • Peripheral resistance increases • Blood pressure returns to normal • Third heart sound and functional systolic murmurs disappear
Thyroid function: • Postpartum thyroiditis in 10% of women. Etiology is autoimmune and it is largely asymptomatic • Gastrointestinal tract: • Constipation common due to slight intestinal paresis • Loss of fluid in the lochia,urine(diuresis) and sweating cause increased thirst in early puerperium
Respiratory changes: • Diaphragm comes down due to decrease in uterine size • The resting oxygen consumption remains high in first 1-2 weeks of puerperium • Bone loss: • Temporary generalized bone loss and returns to normal after 12-18 months. However it is important to ensure adequate dietary calcium intake and calcium supplements during this period. • Fluid loss: • About 2L fluid is lost within the first week and 1.5L in the next 5 weeks after delivery through loss of extracellular fluid.
LACTATION AND BREASTFEEDING The current recommendation is exclusive breastfeeding for first 6 months. 4 phases of lactation: • Mammogenesis(breast preparation for lactation) • Lactogenesis (production of milk) • Galactokinesis (milk discharge) • Galactopoiesis
Mammogenesis (breast preparation for lactation): • Significant ductal and alveolar growth by various steroid hormones. • Milk production does not start due to its inhibition by high concentration of progesterone and estrogen from placenta. • Lactogenesis(production of milk): • Prolactin secreted by anterior pituitary as a response to suckling. • Acts on milk secreting cells of alveoli stimulating milk synthesis. It is called prolactin reflex.
Galactokinesis(milk discharge): • During suckling a conditioned reflex called milk ejection or milk let down reflex is set up. • It is mediated by hormone oxytocin. • Oxytocin secreted in short bursts in response to hearing the baby’s cry before feeding. • Oxytocin binds to specific receptors on the myoepithelial cells causing their contraction to expel milk into ducts. • Galactopoiesis: • For successful and effective lactation, suckling is essential and prolactin is single most important galactopoietic hormone.
COLOSTRUM • The colostrum is a thin serous fluid secreted from breast by 24 to 48 hours till 2 weeks following delivery. • COMPOSITION OF THE COLOSTRUM: • It is deep yellow serous fluid, alkaline in reaction. • It has got a higher specific gravity; a high protein, vitamin A, sodium and chloride content but has got lower carbohydrate, fat and potassium than the breast milk. • Colostrum and milk contains immunologic components such as immunoglobulin A (IgA), complements, macrophages, lymphocytes, lactoferrin and other enzymes (lactoperoxidase).
Microscopically: • It contains fat globules, colostrum corpuscles and acinar epithelial cells. • The colostrum corpuscles are large polynuclear leukocytes, oval or round in shape containing numerous fat globules. • Advantages: • The antibodies (IgA, IgG, IgM) and humoral factors (lactoferrin) provides immunogical defense to the new born. • (2) It has laxative action on the baby because of large fat globules.
MILK PRODUCTION: • A healthy mother will produce about 500–800 mL of milk a day to feed her infant. • This requires about 700 Kcal/day for the mother, which must be made up from diet or from her body store. • For this purpose a store of about 5 kg of fat during pregnancy is essential to make up any nutritional deficit during lactation.
STIMULATION OF LACTATION: • Mother is motivated as regard the benefits of breastfeeding since the early pregnancy. • No prelacteal feeds (honey, water) are given to the infant. • Following delivery important steps are: (i) to put the baby to the breast at 2–3 hours interval from the 1st day, (ii) plenty of fluids to drink and (iii) to avoid breast engorgement. • Early (½ – 1 hour) and exclusive breastfeeding in correct position is encouraged.
INADEQUATE MILK PRODUCTION (Lactation failure): • It may be due to infrequent suckling or due to endogenous suppression of prolactin (ergot preparation, pyridoxin, diuretics or retained placental bits). Pain, anxiety and insecurity may be the hidden reasons. • Unrestricted feeding at short interval (2–3 hours) is helpful. • DRUGS TO IMPROVE MILK PRODUCTION (Galactogogues): • Metoclopramide (10 mg thrice daily) increases milk volume (60–100%) by increasing prolactin levels. • Sulpiride (dopamine antagonist),domperidone has also been found effective by increasing prolactin levels. • Intranasal oxytocin contracts myoepithelial cells and causes milk let down.
Lactation suppression: • It may be needed for women who cannot breastfeed for personal or medical reasons. • Lactation is suppressed when the baby is born dead or dies in the neonatal period or if breastfeeding is contraindicated. • Methods commonly used are: • to stop breastfeeding, • to avoid pumping or milk expression, • to wear breast support, • ice packs to prevent engorgement, • analgesics (aspirin) to relieve pain and • a tight compression bandage is applied for 2–3 days. • The natural inhibition of prolactin secretion will result in breast involution.
Medical methods of suppression with estrogen, androgen or bromocriptine is not advised. • The side effects of bromocriptine are: hypotension, rebound secretion, seizures, myocardial infarction and puerperal stroke. • Breast milk for premature infant is beneficial by many ways (psychological, nutritional and immunological). • Metabolic disturbances like azotemia, hyperaminoacidemia and metabolic acidosis are less with breast milk compared to formula. It gives immunological protection to the premature infant. • There are methods for collection (manual expression or electric pumps), and milk preservation.
MANAGEMENT OF NORMAL PUERPERIUM • The principles in management are: (1) To restore the health of the mother. (2) To prevent infection. (3) To take care of the breasts, including promotion of breastfeeding. (4) To motivate the mother for contraception.
SUBSEQUENT CARE AFTER DELIVERY • MOTHER: • Ambulation: within a few hours after a vaginal delivery and after 6 hours following a cesarean section to facilitate bowel movement and reduce the risk of venous thrombosis and embolism. • Care of the bladder: • The patient is encouraged to pass urine following delivery as soon as convenient. • At times, the patient fails to pass urine and the causes are — (1) unaccustomed position and (2) reflex pain from the perineal injuries. This is common after a difficult labor or a forceps delivery.
If the patient still fails to pass urine, catheterization should be done. • Catheterization is also indicated in case of incomplete emptying of the bladder evidenced by the presence of residual urine of more than 60 mL. Continuous drainage is kept until the bladder tone is regained. • The underlying principle of the bladder care is to ensure adequate drainage of urine so that infection and cystitis are avoided. • Care of the bowel: • The problem of constipation is much less because of early ambulation and liberalization of the dietary intake. • A diet containing sufficient roughage and fluids is enough to move the bowel. • If necessary, mild laxative such as isabgol husk two teaspoons may be given at bed time.
Care of the breast: • Nipples should be cleaned before and after each feed. • Breast support with a well fitting brassiere must be encouraged. • Retracted nipples are common and must be attended to in the antenatal period. Drawing out the nipples using fingers or the reverse end of a syringe may be necessary. • In case of cracked nipples, local application of breast milk or lanolin and using a nipple shield are recommended.
Care of the perineum: • Perineal hygiene is important. • Moist heat, ice packs, sitz bath, and rectal or oral analgesics may be required for painful episiotomy or lacerations. • Lochia must be checked for abnormal foul odor. • Diet and supplements: • A well balanced diet (30 cal/kg ideal body weight) with extra 500 kcal for lactation is recommended. • Iron supplementation should be continued for 3 months and calcium supplements as long as breastfeeding continues.
NEONATE: • Breastfeeding: • should begin within an hour of delivery. • Rooming in and skin to skin contact are essential. • Nulliparous women must be given instructions regarding proper positioning of the mother and infant and the technique of breastfeeding. • Immunization: • The mother must be counseled regarding the importance of immunization and a written/printed schedule should be given to her. • Rh negative mothers who are not isoimmunized should be given anti-D immunoglobulin.
7 B’S OF PUERPERAL MANAGEMENT: • Bladder • Bowel • Bleeding/lochia • Bottom(perineum) • Breasts • Birth controls • Blues
POST NATAL CHECKUP • History: • Vaginal bleeding/discharge • Breastfeeding • General Examination: • Blood pressure • Pallor • Breast Examination: • Engorgement • Cracked nipple • Abdominal Examination: • Involution of uterus
Local and pelvic examination: • Episiotomy/laceration • Lochia • Uterine size • Investigations: • Oral GTT if gestational diabetic • Advice: • Contraception • Resumption of sexual activity: about 4-6 weeks after delivery or whenever the mother is comfortable. Decreased libido, postpartum blues and occasionally postpartum depression is noticed. Dyspareunia due to episiotomy or perineal laceration and vaginal dryness due to estrogen deficiency are also common.
Postnatal exercises • Weight reduction
ADVICE AT DISCHARGE: • Personal hygiene; douche,tampons to be avoided. • Iron and calcium supplements are prescribed for 3 to 6 months. • Care of baby (including immunization) • Resumption of sexual intercourse • Contraception • Postnatal exercises: can be started 4-6 weeks after a vaginal delivery and 6-8 weeks after a cesarean section.
