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JI Canarie Joy A. Esguerra OB-GYNE UERMMMCI.  Definition  Clinical and Physiological Aspects ◦ Vagina and Vaginal Outlet ◦ Uterine Changes ◦ Urinary.

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Presentation on theme: "JI Canarie Joy A. Esguerra OB-GYNE UERMMMCI.  Definition  Clinical and Physiological Aspects ◦ Vagina and Vaginal Outlet ◦ Uterine Changes ◦ Urinary."— Presentation transcript:

1 JI Canarie Joy A. Esguerra OB-GYNE UERMMMCI

2  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  The period of confinement during and just after birth usually the 6 subsequent weeks during which normal pregnancy involution occurs (Hughes, 1972 in Williams 22 nd Ed)  Usually between 4 to 6 weeks

4  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.

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6  Vagina gradually diminishes in size but rarely returns to nulliparous dimensions  Rugae: reappear by the 3 rd week  Hymen: represented by several small tags of tissue which scar to form the myrtiform caruncles.  Vaginal epithelium: proliferates by 4-6 weeks

7  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  UTERINE VESSELS  CERVIX AND LOWER UTERINE SEGMENT  INVOLUTION OF UTERINE CORPUS  AFTERPAINS  LOCHIA  ENDOMETRIAL REGENERATION  SUBINVOLUTION  PLACENTAL SITE INVOLUTION  LATE POSTPARTUM HEMORRHAGE

9  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

10  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

11  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  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

13  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  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  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  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 3 rd week ◦ endometritis & salpingitis - not infection but only part of the involutional process

17  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

18  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  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

20  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  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

22  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  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

24  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  For 1 st 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

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27  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  Advantages ◦ less frequent bladder complications & constipation ◦ reduced frequency of puerperal venous thrombosis & pulmonary embolism

29  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  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  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

32  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  early ambulation and early feeding → constipation ↓

34  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  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

36  Exercise to restore abdominal wall tone : any time after vaginal delivery : as soon as abdominal soreness diminishes after cesarean delivery

37  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

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

39  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

40  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.

41  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

42  If no complication (at vaginal delivery) hospitalization period ≤ 48 hours  Up to 96 hours for uncomplicated CS  Give instructions

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44  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

45  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  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

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