PUERPERIUM

1. PUERPERIUM JI Canarie Joy A. Esguerra OB-GYNE UERMMMCI

2. Outline • 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

3. What Is Puerperium? • 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

4. 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.

5. CLINICAL and PHYSIOLOGICAL ASPECTS OF THE PUERPERIUM

6. I. VAGINA AND VAGINAL OUTLET • 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 myrtiformcaruncles. • Vaginal epithelium: proliferates by 4-6 weeks

7. 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

8. II. UTERINE CHANGES • UTERINE VESSELS • CERVIX AND LOWER UTERINE SEGMENT • INVOLUTION OF UTERINE CORPUS • AFTERPAINS • LOCHIA • ENDOMETRIAL REGENERATION • SUBINVOLUTION • PLACENTAL SITE INVOLUTION • LATE POSTPARTUM HEMORRHAGE

9. UTERINE VESSELS • Caliber of extrauterinevessels • decrease to equal size of prepregnant state • Blood vessels within puerperal uterus • obliterated by hyaline changes • gradually reabsorbed • replaced by smaller vessels

10. CERVIX AND LOWER UTERINE SEGMENT • Cervical opening contracts slowly and for a few days immediately after laborit 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

11. 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

12. UTERINE INVOLUTION • Fundus of contracted uterus • immediately after placental expulsion: slightly below umbilicus • within 2 wks: descended into the true pelvis • within ~ 4 wks: regained previous nonpregnantsize • 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

13. 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

14. AFTERPAINS • 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

15. LOCHIA • 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

16. ENDOMETRIAL REGENERATION • 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

17. SUBINVOLUTION • an arrest or retardation of involution, the process by which the puerperal uterus is normally restored to its original size • Accompanied by prolongation of lochialdischarge & irregular or excessive uterine bleeding and sometimes by profuse hemorrhage • Cause • retention of placental fragments, pelvic infection

18. 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

19. PLACENTAL SITE INVOLUTION • 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 thrombosedvessels 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

20. LATE POSTPARTUM HEMORRHAGE • 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

21. II. URINARY TRACT CHANGES • 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 intravesicalfluid 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

22. IV. PERITONEUM AND ABDOMINAL WALL • 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

23. V. BLOOD AND FLUID CHANGES • By 1 week after delivery, blood volume return nearly to nonpregnant level • Marked leukocytosisand 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

24. WEIGHT LOSS • 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

25. BREAST • 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

26. HOSPITAL CARE

27. 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

28. EARLY AMBULATION • Advantages • less frequent bladder complications & constipation • reduced frequency of puerperal venous thrombosis & pulmonary embolism

29. CARE OF THE VULVA • 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

30. BLADDER FUNCTION • 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

31. BLADDER FUNCTION • Woman who has not voided within 4 hours after delivery → indwelling catheter → prevent overdistension • Txof bladder overdistention: • indwelling of catheter for at least 24 hours • empty the bladder completely • prevent prompt recurrence • allow recovery of normal bladder tone & sensation

32. 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.

33. BOWEL FUNCTION • early ambulation and early feeding → constipation ↓

34. SUBSEQUENT DISCOMFORT • 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

35. MILD DEPRESSION • 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 laborand 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

36. ABDOMINAL WALL RELAXATION • Exercise to restore abdominal wall tone : any time after vaginal delivery : as soon as abdominal soreness diminishes after cesareandelivery

37. DIET • 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 nonpregnantwoman

38. THROMBOEMBOLIC DISEASE • in recent years : decreased • accdg to Jacobsen and colleagues: pulmonary embolism is most common in the first 6wks post partum

39. PELVIC VENOUS THROMBOSIS • 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 fetalpulm. emboli that develop without warning in the puerperium : symptomatic puerperal pelvic thrombosis is most commonly associated with uterine infection

40. OBSTETRICAL PARALYSIS • Pressure on branches of lumbosacral plexus during labor : complaints of intense neuralgia or cramplikepains extending down one or both legs as soon as the fetalhead 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 synchondrosesduring labor may be followed by pain and marked interference with locomotion.

41. IMMUNIZATION • Anti D-immune globulin 300 μg : nonimmunizedwomen within 72 hours of the birth of a D-positive infant • Rubella vaccination • Diphtheria-tetanus toxoid booster infection • Measles immunization

42. TIME OF DISCHARGE • If no complication (at vaginal delivery) hospitalization period ≤ 48 hours • Up to 96 hours for uncomplicated CS • Give instructions

43. CARE AT HOME

44. COITUS • 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 estrogenproduction with a resulting vaginal atrophy and dryness

45. RETURN TO MENSTRUATION AND OVULATION • 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

46. FOLLOW-UP CARE • Normal delivery and puerperium : women can resume most activities (bathing, driving, household functions) by the time of discharge • Follow-up examination during 3rd postpartum wkhas proven quite satisfactory : identify any abnormalities of later puerperium : initiate contraceptive practice

47. THANK YOU!!!!