1. PUERPERIUM

2. DEFINITION  It is the period following childbirth during which the body tissues revert back to the pre-pregnant state both anatomically and physiologically.  Involution  puerpera

3. Contd..  Duration Soon after placenta is delivered up to 6 weeks  Stages Immediate Early remote

4. INVOLUTION OF GENITAL ORGANS  UTERUS Immediate postpartum- uterus firm and retracted 10-12 cm above symphysis pubis, pelvic organ by 2 nd week, becomes normal by the end of 6 weeks. Placenta site contracts  7.5 cm  1.5 cm by 6 weeks  Sub involution

5. Contd..  LUS Flabby/thin  CERVIX 2f for a few days. Tip of 1f by end of 1 week Contour by 6 weeks External os never revert back to nulliparous state.

6. Contd.. Physiological changes occur in Muscles/vessels/ endometrium  Muscles – decrease in the myometrial cell size.( ↓ estrogen/ prog  ↑ proteolytic activity  autolysis)  Blood vessels- arteries constrict by contraction of vessel wall—thrombosis. Neovascularistn —hyaline degeneration.  Endometrium – ET= 2-5mm. regenerates Epithelium-10 th d.entire endo 3 rd week. Placental site -6 th week

7. Involution of other pelvic organs  Vagina 4-8 weeks to involute /delicate mucosa/sub mucous venous congestion/ rugae partially reappear at 3 rd week Hymen- carunculae myrtiformes Broad ligaments/round ligaments/pelvic floor require consider time to recover

8. LOCHIA  LOCHIA - it is the vaginal discharge for the first fortnight during puerperium.  Fishy odour  lochia rubra (1-4),lochia serosa (5- 9)lochia alba (10-15)  Composition- lochia rubra (red) blood,fetal memb,decidua,vernix,lanugo,meconium  Lochia serosa (pink) rbc,more leukocytes, mucus, microbes

9. Contd..  Lochia alba- decidual cells,leukocytes,mucus, cholestrin crystals, fatty and granular epithelia cells and microorganisms.  Amount – in 1 week = 250ml  May be up to 3 weeks  Clinical importance

10. GENERAL PHYSIOLOGIC CHANGES  Pulse  Temperature – should not be above 37.2 C(99)F within first 24 hours. On 3 rd day breast engorgement –slight rise in temp.  Urinary tract – edematous, hyperemic bladder- over distended –uti  Kidney/ ureter normalize in 8 weeks  Diuresis -2 nd /3 rd day

11. Contd..  GIT ↑ thirst /constipation  Weight loss – further loss of 2kg (Diuresis)  Fluid loss – 2l in 1 st week and 1.5l during next 5 weeks.  Changes in abdominal wall Striae gravidarum do not disappear Divarication of recti/ flabby abdominal wall.

12. Contd..  RBC vol /PCV normal by end of 1 st week  Leukocytosis ( up to 30,000)  Platelets decrease immediately but increases in 4-10 days  ↑ fibrinogen levels persists up to 2 weeks  ↑ ESR during puerperium  Hypercoagulable state persists during puerperium

13. CVS CHANGES  Cardiac output peaks after delivery to 80% above pre-labor value and remains elevated for about 48hours post partum  Blood volume reduce by 20% by 5 th day Hormonal changes  hCG,estrogen,progesterone falls to pre-pregnant levels in 1 week time

14. Contd..  Menstruation and ovulation If patient do not breastfeed her baby- menses return by 6 th week following delivery- 40%.by 12 th week in 80% If patient breast feeds her baby then menstruation will be suspended in 70% till breast feeding stopped. In 30% variable starts even before that.

15. Contd…  Ovulation In non-lactating mothers ovulation occurs as early as 4 weeks and in lactating mothers about 10 weeks after delivery. Lactation –natural method of contraception. But not fool proof. So advice contraception.

16. Contd…  Breast feeding  ↑ prolactin  inhibits ovarian response to FSH  less follicular growth  hypo estrogenic state  amenorrhea  ↑ Prolactin  suppress release of LH  no LH surge  anovulation

17. CARE OF NORMAL PUERPERIUM  Early ambulation  After-pains (precipitate/over distended/retained clots)  Temperature( may rise in first 24 hours- any rise above 100C after 24 hours r/o infection)  Diet  Bowel and bladder care  Breast care  Rooming in

18. Contd..  Sleep  Care of perineum/asepsis  Immunisation  Depression  Postpartum exercises  Backache  Maternal palsies  Hospital stay and advice at discharge  Post natal care- after 6 weeks