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!!!!