NORMAL PUERPERIUM

What is puerperium? Period following childbirth Pelvic organs & other body tissues Revert to pre-pregnant state Anatomically & physiologically

Begins as soon as placenta is expelled lasts for appx 6 weeks(42 days) 3 stages Immediate-within 24hrs Early -upto 7 days Remote – upto 6wks

Involution of the Uterus Anatomical consideration At delivery-20 x 12 x 7.5cm and appox. 1000g After involution-reverted to non-preg size of appox. 60g Lower uterine segment isthmus in a few weeks Contour of cervix regained in 6 wks External os never reverts back to nulliparous state

Fibrinoid end arteritis Steroid hormones withdrawn Inc Collagenase & Proteolytic enzymes Autolysis Myometrial cell size reduced Physiological Consideration Muscles: Endometrium: regen starts on day 7 from uterine gland mouths and interglandular stromal cells completed by day 16 except @ placental site Blood Vessels Endophlebitis Thrombosis Fibrinoid end arteritis Hyalinisation

Clinical assessment of Involution of uterus Fundus lies 13.5cm above sypmphysis pubis for the 1st 24hrs following delivery Steady decrease by 0.5'' in nxt 24 hrs Day 14- not palpable- pelvic organ Completed by 6 wks

Involution of other Pelvic structures Vagina 4-8 weeks; Does not revert to original state Broad/round ligaments Long time d/t stretching during parturition Pelvic floor & Fascia Involution of other Pelvic structures

Lochia Lochia Rubra Lochi Serosa Lochia Alba Vaginal discharge for the 1st fortnight during puerperium Odour: offensive fishy smell Colour and composition Lochia Rubra Lochi Serosa Lochia Alba 1-4 days Blood,fetal memb & decidua shreds,lanugo,meconium 5-6 days Leucocytes,Cx mucus,wound exudates,microorganisms 10-15 days Decicual cells,leucocytes,mucus,cholestrin crystals,fatty epithelial cells,microorganisms

Clinical importance Puerperal Sepsis d\t E. Coli Malodorous Infection Lochiometra Scanty/absent Excessive Subinvolution Retained conceptus Causes secondary PPH Red color persist Local genital infection L.Alba beyond 3 wks

Mamogenesis Lactogenesis Galactopoiesis Galactokinesis Changes in breast & lactation Mammary duct-gland growth & development Mamogenesis Initiation Of milk secretion in alveoli Lactogenesis Maintenance of Lactation Galactopoiesis Removal of Milk from Gland Galactokinesis

General Physiological Changes Pulse: Temperature: Urinary Tract: raises but settles down to normal on 2nd day Temperature: Any rise above 0.5C suggestive of infection of genito-urinary tract Urinary Tract: Pronounced Diuresis on 2nd - 3rd day over distension incomplete emptying presence of residual urine high risk of infection GIT: increased thirst constipation Weight Loss: 5-6kg expulsion of fetus placenta, liqour, blood 2kg- during puerperium d\t diuresis Continued upto 6 months of delivery

Blood Values: Menstruation: Ovulation: immediate-reduced blood volume; Normal in 2 weeks rise in cardiac output; Normal in 1 week leuycocyotsis d\t stress Hypercoagulable state for 48 hrs Fibrinolytic activity enhanced in 4 days Menstruation: if not breast feeding- resumes in 6 to 8 wks Ovulation: non-lactating mother- 4 wks lactating mother- 10 weeks Exclusive Breastfeeding- 98% contraception up 6 months

Management of normal Puerperium To restore health of Mother Rest and Early ambulation Emotional support Diet of patients choice Sleep Immunization- anti-D- Gamma globulin Maternal-infant Bonding Postnatal exercise

To take care of the Breasts & promote breast feeding To prevent infection Care of bladder & Vulva Care of episiotomy wound Maintenance of asepsis and proper hygiene Immunization- Rubella vaccine, TT To take care of the Breasts & promote breast feeding To motivate mother for contraception

Treatment of minor ailments After pains Uterus massage Ibuprofen Anti-spasmodic Pain at site of perineum Sitz bath analgesics Treatment of Anaemia Supplementary Iron therapy

Abnormal Puerperium Puerperal fever/ pyrexia Puerperal Sepsis Pelvic pain Fever Foul smelling vaginal discharge Subinvolution

Breast Problems Retracted/cracked nipples Breast engorgement Mastitis Breast abscess Failure of lactation

Urinary Problems Retention Incontinence Infection Venous thrombosis Secondary Hemorrhage Puerperal psychosis Obstetric palsy

THANQ