Presentation on theme: "JI Canarie Joy A. Esguerra OB-GYNE UERMMMCI"— Presentation transcript:
1JI Canarie Joy A. Esguerra OB-GYNE UERMMMCI PUERPERIUMJI Canarie Joy A. EsguerraOB-GYNE UERMMMCI
2Outline Definition Clinical and Physiological Aspects Breast Vagina and Vaginal OutletUterine ChangesUrinary Tract ChangesPeritoneum and Abdominal WallBlood and Fluid Changes (Weight Loss)BreastHospital CareCare at Home
3What 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 weeksThe period starting from the delivery of placenta up to the first few weeks after the delivery.Usually 4-6 weeksBy 6 weeks, most of the changes of pregnancy, labor and delivery have resolved and the body has reverted to the non-pregnant state.But of course, maternal adaptations to pregnancy do not necessarily all subside completely by 6 weeks postpartum.
4Puerperium…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.
5CLINICAL and PHYSIOLOGICAL ASPECTS OF THE PUERPERIUM
6I. VAGINA AND VAGINAL OUTLET Vagina gradually diminishes in size but rarely returns to nulliparous dimensionsRugae: reappear by the 3rd weekHymen: represented by several small tags of tissue which scar to form the myrtiform caruncles.Vaginal epithelium: proliferates by 4-6 weeksRugae were not as prominent as beforeVaginal epithelium: coincidental with resumed ovarial estrogen production
7I. VAGINA AND VAGINAL OUTLET Relaxation of vaginal outletd/t extensive laceration or overstretching of perineum during deliveryUterine prolapse, urinary and anal incontinenceDamage to the pelvic floorOperative correction is usually postponed until childbearing was ended
8II. UTERINE CHANGES UTERINE VESSELS CERVIX AND LOWER UTERINE SEGMENT INVOLUTION OF UTERINE CORPUSAFTERPAINSLOCHIAENDOMETRIAL REGENERATIONSUBINVOLUTIONPLACENTAL SITE INVOLUTIONLATE POSTPARTUM HEMORRHAGE
9UTERINE VESSELS Caliber of extrauterine vessels decrease to equal size of prepregnant stateBlood vessels within puerperal uterusobliterated by hyaline changesgradually reabsorbedreplaced by smaller vesselsDuring pregnancy, significant hypertrophy and remodelling of all pelvic vessels happens to comply for the massive increase in uterine blood flow necessary to maintain pregnancy.
10CERVIX AND LOWER UTERINE SEGMENT Cervical opening contracts slowly and for a few days immediately after labor it readily admits 2 fingersEnd of the 1st wk → it had narrowed as the cervix thickens and endocervical canal reforms.External os does not completely ressume its pregravid appearanceRemains somewhat wider and bilateral depression at the site of lacerations becomes permanentDuring labor, the outer cervical margin which corresponds to the external os, is usually lacerated, especially laterally.
11CERVIX AND LOWER UTERINE SEGMENT Markedly thinned-out lower uterine segmentcontracts & retractsUterine isthmus located between the uterine corpus above and the internal cervical os below - over the course of few weeksContracts and retracts but not as forcefully as the uterine corpusDuring the next few weeks, the lower segment is converted from a clearly distinct substructure large enough to accommodate the fetal head, to barely discernible uterine isthmus located between the corpus and the internal os.
12UTERINE INVOLUTION Fundus of contracted uterus immediately after placental expulsion: slightly below umbilicuswithin 2 wks: descended into the true pelviswithin ~ 4 wks: regained previous nonpregnant sizeConsists mostly of myometrium covered by serosa and lined by basal deciduaAnterior and posterior walls, in close apposition, each measures 4 to 5 cm thick
13UTERINE INVOLUTION Weight of uterus immediately postpartum: 1000g1 week later: 500gat the end of 2nd week: 300gsoon thereafter: 100g or less: total number of muscle cells does not decrease→ individual cells decrease markedly in sizeSeparation of the placenta and membrane involves the spongy layer → decidua basalis remains in the uterus
14AFTERPAINS Primiparas: puerperal uterus tends to remain contracted Multiparas: contracts vigorously at interval → afterpainInfant suckles →oxytocin release →Uterine contraction → afterpainOccasionally severe enough to require an analgesic → usually become mild by the 3rd postpartum day
15LOCHIAEarly in the puerperium, sloughing of decidual tissue → vaginal discharge of variable quantitylochia rubra: first few days after delivery blood in lochialochia serosa: after 3 or 4 days becomes progressively pale in colorlochia alba: after 10th day, because of admixture of leukocytes and reduced fluid content, it assumes white or yellowish-white colorMay persist for up to 4 to 6 weeks after delivery
16ENDOMETRIAL REGENERATION the remaining decidua becomes differentiated into 2 layers within 2 or 3 days after deliverysuperficial layer: become necrotic, sloughed in the lochiabasal layer: remains intact, source of new endometriumrapid, except at the placental sitefree surface becomes covered by epithelium within a week or soentire endometrium is restored during the 3rd weekendometritis & salpingitis - not infection but only part of the involutional process
17SUBINVOLUTIONan arrest or retardation of involution, the process by which the puerperal uterus is normally restored to its original sizeAccompanied by prolongation of lochial discharge & irregular or excessive uterine bleeding and sometimes by profuse hemorrhageCauseretention of placental fragments, pelvic infection
18SUBINVOLUTION Bimanual examination Treatment uterus is larger & softer than normal for the particular period of puerperiumTreatmentergonovine or methylergonovine(Methergine)oral antibiotics: usually effective in metritisWager et al: 1/3 of postpartum uterine infection are caused by Chlamydia----- doxycycline or azithromycin
19PLACENTAL SITE INVOLUTION Complete extrusion of placental site takes up to 6 weeksImmediately after delivery, palm size→ 3-4cm in diameter (end of 2nd week, )Placental sitenormally consists of many thrombosed vessels within hours of delivery→ ultimately undergo organization of thrombusPlacental site exfoliationas the consequence of sloughing of infarcted and necrotic superficial tissues followed by a reparative process
20LATE POSTPARTUM HEMORRHAGE Serious uterine hemorrhage occasionally develops 1- 2 weeks after deliveryACOG (2006) defines secondary postpartum hemorrhage as bleeding 24 to 12 weeks after deliveryCauses:abnormal involution of placental site (most often)retention of a portion of the placenta→ usually undergo necrosis with deposition of fibrin→ form a placental polypTreatment:intravenous oxytocin, ergonovine, methylergonovine, prostaglandinscurettage
21II. URINARY TRACT CHANGES dilated renal pelvis & ureters: return to prepregnant state weeks after deliveryPuerperal diuresisphysiological reversal of pregnancy-induced increase in extracellular waterregularly occurs between 2nd and 5th dayPuerperal bladder create optimal condition for development of UTIincreased capacity & relative insensitivity to intravesical fluid pressure→ overdistention, incomplete emptying, excessive residual urinemost women return to normal micturition by 3months postpartumCareful attention to all postpartum women, prompt catheterization for those who cannot void, will prevent most urinary problems
22IV. PERITONEUM AND ABDOMINAL WALL Broad & round ligamentsmuch more lax than nonpregnantrequire considerable time to recover from stretching & looseningAbdominal wallreturn to normal → requires several weeks (aided by exercise)usually resumes its prepregnancy state except for silvery striaeExercises to restore tone
23V. BLOOD AND FLUID CHANGES By 1 week after delivery, blood volume return nearly to nonpregnant levelMarked leukocytosis and thrombocytosis occur during and after laborCardiac output remains elevated for 24 to 48 hours postpartumDue to increased stroke volume from venous returnDeclines to nonpregnant values by 10 days
24WEIGHT LOSS Uterine evacuation & normal blood loss : 5-6 kg Further decrease through diuresis: 2-3 kgFactors of Weight lossweight gain during pregnancyprimiparityearly return to work (outside the home)smokingFactors that do not affect weight lossbreastfeedingagemarital statusReturn to prepregnant weight – 6 months
25BREASTFor 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 hoursRule out other causes of fever esp pelvic infectionTx: breast supports, ice pack, analgesic, pumping of breast or manual expression of milk
27HOSPITAL CARE Attention immediately after labor: BP & PR : should be taken every 15 minutesMonitor amount of vaginal bleedingFundus should be palpated to ensure that it is well contractedif relaxation detected, uterus should be massaged through abdominal wall until it remains contracted
28EARLY AMBULATION Advantages less frequent bladder complications & constipationreduced frequency of puerperal venous thrombosis & pulmonary embolism
29CARE OF THE VULVAShould be instructed to cleanse vulva from anterior to posterior (vulva→anus)Ice bag applied to perineumWarm sitz bathbeginning about 24 hours after deliveryTub bathing after uncomplicated delivery is allowed
30BLADDER FUNCTION Oxytocin: commonly infused after placental delivery sudden withdrawal of antidiuretic effect of oxytocin→ rapid bladder fillingBoth bladder sensation and its capability to empty → diminished by anesthesia, by episiotomy, laceration or hematomascommon complication of the early puerperium→ urinary retention with bladder overdistention
31BLADDER FUNCTIONWoman who has not voided within 4 hours after delivery → indwelling catheter → prevent overdistensionTx of bladder overdistention:indwelling of catheter for at least 24 hoursempty the bladder completelyprevent prompt recurrenceallow recovery of normal bladder tone & sensation
32BLADDER FUNCTIONafter catheter removal, if the woman cannot void after 4hourscatheterize and measure urine volumeIf ≥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.
33BOWEL FUNCTIONearly ambulation and early feeding→ constipation ↓
34SUBSEQUENT DISCOMFORT during the first few days after vaginal deliveryuncomfortable by afterpains, episiotomy & lacerations, breast engorgement→ codeine, aspirin, acetaminophen every 3 hoursEpisiotomy & lacerationsearly application of an ice baglocal analgesic sprayhealed and nearly asymptomatic by the 3rd weeks
35MILD DEPRESSIONSome degree of depression a few days after delivery is fairly commonPostpartum blues = transient depressionCauseThe emotional letdown that follows the excitement and fears The discomforts of the early puerperiumFatigue from loss of sleep during labor and postpartum in most hospital settingsAnxiety over her capabilities for caring for her infant after leaving the hospitalFears that she has become less attractiveSelf-limited & usually remits after 2~3 days
36ABDOMINAL WALL RELAXATION Exercise to restore abdominal wall tone: any time after vaginal delivery: as soon as abdominal soreness diminishes after cesarean delivery
37DIETNo dietary restrictions for women who have been delivered vaginallyMay eat 2 hours after normal vaginal delivery, (if, no Cx)lactating women : should be increased in calories and proteinnon breast feeding : dietary requirement as for a nonpregnant woman
38THROMBOEMBOLIC DISEASE in recent years : decreasedaccdg to Jacobsen and colleagues: pulmonary embolism is most common in the first 6wks post partum
39PELVIC VENOUS THROMBOSIS during the puerperium a thrombus may transiently form in any of the dilated pelvic veinswithout associated thrombophlebitis – not incite clinical signs or symptomsthe massive and fetal pulm. emboli that develop without warning in the puerperium: symptomatic puerperal pelvic thrombosisis most commonly associated with uterine infection
40OBSTETRICAL PARALYSIS 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 pelvisInvolved 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.
41IMMUNIZATION Anti D-immune globulin 300 μg Rubella vaccination : nonimmunized womenwithin 72 hours of the birth of a D-positive infantRubella vaccinationDiphtheria-tetanus toxoid booster infectionMeasles immunization
42TIME OF DISCHARGEIf no complication (at vaginal delivery) hospitalization period ≤ 48 hoursUp to 96 hours for uncomplicated CSGive instructions
44COITUSMedian 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
45RETURN TO MENSTRUATION AND OVULATION If not nursing: usually within 6-8 weeksLactating woman: 2nd~18th mos. postpartumOvulationas early as days(5-6 wks) after deliverydelayed resumption of ovulation with breast feedingbut early ovulation is not precluded by persistent lactation → pregnancy can occur with lactation
46FOLLOW-UP CARE Normal delivery and puerperium : women can resume most activities (bathing, driving, household functions) by the time of dischargeFollow-up examination during 3rd postpartum wk has proven quite satisfactory: identify any abnormalities of later puerperium: initiate contraceptive practice