PUERPERIUM
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
Contd.. Duration Soon after placenta is delivered up to 6 weeks Stages Immediate Early remote
INVOLUTION OF GENITAL ORGANS UTERUS Immediate postpartum- uterus firm and retracted 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
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.
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
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
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
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
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
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.
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
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
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.
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.
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
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
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