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

2. Outline Definition Clinical and Physiological Aspects Breast
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
The period starting from the delivery of placenta up to the first few weeks after the delivery.
Usually 4-6 weeks
By 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.

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 myrtiform caruncles.
Vaginal epithelium: proliferates by 4-6 weeks
Rugae were not as prominent as before
Vaginal epithelium: coincidental with resumed ovarial estrogen production

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 extrauterine vessels
decrease to equal size of prepregnant state
Blood vessels within puerperal uterus
obliterated by hyaline changes
gradually reabsorbed
replaced by smaller vessels
During pregnancy, significant hypertrophy and remodelling of all pelvic vessels happens to comply for the massive increase in uterine blood flow necessary to maintain pregnancy.

10. CERVIX AND LOWER UTERINE SEGMENT
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
During labor, the outer cervical margin which corresponds to the external os, is usually lacerated, especially laterally.

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
Contracts and retracts but not as forcefully as the uterine corpus
During 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.

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 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. 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 lochial discharge & irregular or excessive uterine bleeding and sometimes by profuse hemorrhage
Cause
retention of placental fragments, pelvic infection

18. SUBINVOLUTION Bimanual examination Treatment
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 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. 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 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. 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 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. 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
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. 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 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. ABDOMINAL WALL RELAXATION
Exercise to restore abdominal wall tone
: any time after vaginal delivery
: as soon as abdominal soreness diminishes after cesarean delivery

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 nonpregnant woman

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 fetal pulm. 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 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. IMMUNIZATION Anti D-immune globulin 300 μg Rubella vaccination
: nonimmunized women
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 estrogen production 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 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 wk has proven quite satisfactory
: identify any abnormalities of later puerperium
: initiate contraceptive practice

47. THANK YOU!!!!