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Pueperium care

Pueperium care. Facilitator: Pawin Puapornpong. Definition. After 3 rd stage – normal 6 weeks Follow up. Anatomy & Physiology. Uterus Size Immediate – Umbilicus or lower, 1 Kg Serosa, Myometrium, Basal decidua 1 week – ½ > SP, 500 g 2 weeks – not palpable, 300 g 4 weeks – normal size.

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Pueperium care

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  1. Pueperium care Facilitator: Pawin Puapornpong

  2. Definition • After 3rd stage – normal • 6 weeks • Follow up

  3. Anatomy & Physiology • Uterus • Size • Immediate – Umbilicus or lower, 1 Kg • Serosa, Myometrium, Basal decidua • 1 week – ½ > SP, 500 g • 2 weeks – not palpable, 300 g • 4 weeks – normal size

  4. Uterus • Decidua • Superficial layer -> Lochia • Basal layer, endometrial gland – endometrium 10 days • Placental site • Immediate – palm • 2 weeks – 3-4 cm • Vessels - thrombosis

  5. Uterus • Vessels • Decreased size • In myometrium – hyalin change • Cervix & Lower segment • Decreased size • Lateral tear of external os – parous cervix • Lower segment – isthmus

  6. Vagina • Decreased size • Rugae – 3 weeks • Hymen – myritiform caruncles • Peritoneum & Abdominal wall • Loosen ligaments • Exercise • Remained striae • Diastasis recti

  7. KUB system • Bladder • Overdistension • Risk – Prolonged labour, Procedures, Epidural block, Pain • Intermittent catheter • Renal pelvis • Normal size – 2-8 weeks • Normal GFR & RPF – 6 weeks • CrClearance – 1st week • Glycosuria – 2-3 days

  8. Breasts • Lobe : separated by septum • Nipple : 15-20 lactiferous ducts • 10-100 Alveoli • Alveolar cells : prolactin => produce milk • Myoepithelial cells : oxytocin => contraction

  9. Breasts • Areola : smooth muscle • Cooper’s ligament : between lobes, skin, pectoral fascia • Breast :200 g => 400-600 g during pregnancy => 600-800 g during feeding

  10. Hormone • Estrogen : duct growth • Progesterone : alveolar growth • Prolactin : • High during pregnancy but inhibited by estrogen & progesterone (lactogenesis inhibition) • precolostrum during 2nd trimester

  11. Postpartum • Decreased estrogen & progesterone from placenta • Increased prolactin from sucking • Oxytocin • Sucking => nerve at nipples => hypothalamus => oxytocin => milk let down

  12. Lactogenesis : Initiation of milk secretion • 1st : 12 weeks before delivery • Breast enlargement • 2nd : postpartum • Decreased progesterone • High prolactin • 2-3 days : not depend on feeding • 3-4 days : depend on feeding • Rapid during 36-96 hours postpartum

  13. Galactopoiesis • Continuation of feeding • Supply-dependent response • Galactorrhea • Postpartum, post breastfeeding • For weeks, months, years • 30 % high prolactin

  14. Neuroendocrine control of milk secretion andejection • Prolactin reflex • Sucking => anterior lobe of pituitary gland => prolactin =>alveolar cells => milk • High prolactin during sucking 30 minutes => baseline within 3 hours : frequency of feeding • Milk for next meal • Prolactin night > day • Sufficient for at least 2 infants • 2 infants => same time • Not influenced by other stimulation

  15. Neuroendocrine control of milk secretion and ejection • Milk ejection reflex, Oxytocin reflex • Posterior lobe of pituitary gland => oxytocin => myoepithelial cells => contraction • Influenced by stimulation • Pain, stress => inhibition • Contracted uterus => after pain during 1st week

  16. Colostrums • Protein • Immunity : secretary IgA • Minerals • Vitamins : A, K • Less fat and sugar

  17. Colostrums • 58-67 calories/100 cc (17 calories/ounce) • Yellowish : carotene • 1st day : 37 cc/day (7cc/meal) • 2nd day : 84 cc/day (14cc/meal) • 3rd-4th day : 200-400 cc/day

  18. Colostrums • Decreased neonatal sepsis (rate 10%) • Secretary IgA • 1st day : 11000 mg/day • Decrease to 1000 mg/day in 1-2 months • Lactoferrin

  19. Immunity in breast milk(mg/24hrs)

  20. Colostrums • Fat soluble vitamins • Vitamin A : 3 times higher • Carotene : 10 times • Vitamin E : 2-3 times • Vitamin K : Supplement to prevent Hemorrhagic disease of the newborn • Epithelial growth factor : 5 times • Laxative : prevent jaundice

  21. Full term milk • Colostrum 0-7 days • Premature milk • Colostrum 3 weeks • Colostrum : prevent infection

  22. Breast milk • Protective components • Immunity : Ig, WBC, lactoferrin, lysozyme • Maturation : epidermal growth factor, IGF, cytokines, immunomodulator • GI & Hormones : Bile salt Stimulated Lipase, enzymes • Nutrients • Macronutrient : carbohydrate, fat, protein • Micronutrient : vitamins, minerals

  23. Strategy • Effective suckling • Frequency • Stimulate oxytocin reflex • No stress • Supporting environment • Healthy mother & infant : nutrition • Prevent breast engorgement

  24. ANC, during pregnancy • Serology • HIV : within 12 hours postpartum => breast binding, combined high dose pills (bid, 5 days) • Knowledge • Benefits • Process • Working mother • Diet • Activities • Supporting family

  25. Labor room • Skin to skin contact • Within 30 minutes • First sucking • Bonding • Oxytocin => prevent PPH • Decreased breast engorgement

  26. Postpartum • Avoid drugs • Rooming-in, bedding-in • Sucking ½ -1 hour • Frequency q 2-3 hours • Hand wash • Positioning, latch on • Pillow • Sitting, lying

  27. Anti-infectives • Penicillins, cephalosporins, erythromycin, trimethoprim, acyclovir, mebendazole • Analgesics & NSAIDs • Paracetamal, codeine, diclofenac, ibuprofen, mefenamic acid • Anticonvulsants • Diazepam,MgSO4, phenobarbetal, phenytoin, valproic acid • Hormonal contraceptives • Progestogen-only pills • DMPA ?

  28. Diuretics • Spironolactone • Thyroid hormones & antithyroid drug • Thyroxine, PTU • Corticosteroids • Mammoplasty (silicone) • no contraindication

  29. Contraindication • Amiodarone • Antineoplastic agents • Bromocriptine • Chloramphenicol • Gold salts • Tetracycline • Combined pills

  30. Maternal contraindicaitons • Drug addiction • HIV • Active TB • Cytomegalovirus

  31. Cardiovascular system • Normal – 2-3 weeks • Immediate – increased cardiac output, increased venous return

  32. Respiratory system • Increased residual volume • Decreased vital capacity, inspiratory capacity • 2-3 days – increased pCO2 • 3 weeks - normal pH

  33. HPO axis • Decreased placental hormone • Undetectable hPL in 1st day • hCG < 1 IU/ml in 2-4 days • hCG < 100 mIU/ml in 7 days • UPT negative • 7 days – latex agglutination • 11-16 days - radioimmunoassay

  34. Increased LH – ovulation week 4-8 • 10-15 % - week 6 • 30% - 90 days • Early – day 36 • In abortion or ectopic pregnancy – day 14 • Delayed ovulation in breastfeeding

  35. Endocrine system • Decreased hPL & growth hormone • Decreased insulin demand • Normal – 6-8 weeks • Glucose tolerance test • Increased thyroid hormone – decreased TBG • Decreased corticosteroid & testosterone – normal in 1st week

  36. After pain (uterine contraction after delivery) • Lochia • Lochia rubra – 3 days • Lochia serosa – 10 days • Lochia alba • Increased urine – day 2-5 • Decreased weight 7-9 kgs, normal in 6 months

  37. Postpartum blues • 2-3 days • > 10 days – Psychiatrist • Anti-D immune globulin • Rubella • Discharge 48 hours, C/S 3-5 days

  38. Contraception • Follow up 4-6 weeks • Pap • Advice

  39. อ่านเพิ่มเติมได้จากหนังสือรอบรู้เรื่องการเลี้ยงลูกด้วยนมแม่อ่านเพิ่มเติมได้จากหนังสือรอบรู้เรื่องการเลี้ยงลูกด้วยนมแม่ Thank you

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