Facilitator: Pawin Puapornpong Pueperium care Facilitator: Pawin Puapornpong

Definition After 3rd stage – normal 6 weeks Follow up

Anatomy & Physiology Uterus Size Immediate – Umbilicus or lower, 1 Kg Serosa, Myometrium, Basal decidua 1 week – ½ > SP, 500 g 2 weeks – not palpable, 300 g 4 weeks – normal size

Uterus Decidua Superficial layer -> Lochia Basal layer, endometrial gland – endometrium 10 days Placental site Immediate – palm 2 weeks – 3-4 cm Vessels - thrombosis

Uterus Cervix & Lower segment Vessels Decreased size In myometrium – hyalin change Cervix & Lower segment Lateral tear of external os – parous cervix Lower segment – isthmus

Peritoneum & Abdominal wall Vagina Decreased size Rugae – 3 weeks Hymen – myritiform caruncles Peritoneum & Abdominal wall Loosen ligaments Exercise Remained striae Diastasis recti

KUB system Bladder Overdistension Risk – Prolonged labour, Procedures, Epidural block, Pain Intermittent catheter Renal pelvis Normal size – 2-8 weeks Normal GFR & RPF – 6 weeks CrClearance – 1st week Glycosuria – 2-3 days

Breasts Lobe : separated by septum Nipple : 15-20 lactiferous ducts 10-100 Alveoli Alveolar cells : prolactin => produce milk Myoepithelial cells : oxytocin => contraction

Breasts Areola : smooth muscle Cooper’s ligament : between lobes, skin, pectoral fascia Breast :200 g => 400-600 g during pregnancy => 600-800 g during feeding

Hormone Estrogen : duct growth Progesterone : alveolar growth Prolactin : High during pregnancy but inhibited by estrogen & progesterone (lactogenesis inhibition) precolostrum during 2nd trimester

Postpartum Decreased estrogen & progesterone from placenta Increased prolactin from sucking Oxytocin Sucking => nerve at nipples => hypothalamus => oxytocin => milk let down

Lactogenesis : Initiation of milk secretion 1st : 12 weeks before delivery Breast enlargement 2nd : postpartum Decreased progesterone High prolactin 2-3 days : not depend on feeding 3-4 days : depend on feeding Rapid during 36-96 hours postpartum

Galactopoiesis Galactorrhea Continuation of feeding Supply-dependent response Galactorrhea Postpartum, post breastfeeding For weeks, months, years 30 % high prolactin

Neuroendocrine control of milk secretion and ejection Prolactin reflex Sucking => anterior lobe of pituitary gland => prolactin => alveolar cells => milk High prolactin during sucking 30 minutes => baseline within 3 hours : frequency of feeding Milk for next meal Prolactin night > day Sufficient for at least 2 infants 2 infants => same time Not influenced by other stimulation

Neuroendocrine control of milk secretion and ejection Milk ejection reflex, Oxytocin reflex Posterior lobe of pituitary gland => oxytocin => myoepithelial cells => contraction Influenced by stimulation Pain, stress => inhibition Contracted uterus => after pain during 1st week

Colostrums Protein Immunity : secretary IgA Minerals Vitamins : A, K Less fat and sugar

Colostrums 58-67 calories/100 cc (17 calories/ounce) Yellowish : carotene 1st day : 37 cc/day (7cc/meal) 2nd day : 84 cc/day (14cc/meal) 3rd-4th day : 200-400 cc/day

Colostrums Decreased neonatal sepsis (rate 10%) Secretary IgA 1st day : 11000 mg/day Decrease to 1000 mg/day in 1-2 months Lactoferrin

Component (per 100 cc) Colostrum Mature milk Energy 58-67 70-75 Protein 2.3 0.9 Lactose 5.3 7.3 Fat 2.9 4.2

Immunity in breast milk(mg/24hrs) Day after birth IgG IgM IgA 1 80 120 11000 3 50 40 2000 7 25 10 1000 8-50

Colostrums Fat soluble vitamins Epithelial growth factor : 5 times Vitamin A : 3 times higher Carotene : 10 times Vitamin E : 2-3 times Vitamin K : Supplement to prevent Hemorrhagic disease of the newborn Epithelial growth factor : 5 times Laxative : prevent jaundice

Colostrum : prevent infection Full term milk Colostrum 0-7 days Premature milk Colostrum 3 weeks Colostrum : prevent infection

Breast milk Protective components Nutrients Immunity : Ig, WBC, lactoferrin, lysozyme Maturation : epidermal growth factor, IGF, cytokines, immunomodulator GI & Hormones : Bile salt Stimulated Lipase, enzymes Nutrients Macronutrient : carbohydrate, fat, protein Micronutrient : vitamins, minerals

Strategy Effective suckling Frequency Stimulate oxytocin reflex No stress Supporting environment Healthy mother & infant : nutrition Prevent breast engorgement

ANC, during pregnancy Serology Knowledge Activities HIV : within 12 hours postpartum => breast binding, combined high dose pills (bid, 5 days) Knowledge Benefits Process Working mother Diet Activities Supporting family

Labor room Skin to skin contact First sucking Within 30 minutes Bonding Oxytocin => prevent PPH Decreased breast engorgement

Postpartum Avoid drugs Rooming-in, bedding-in Sucking ½ -1 hour Frequency q 2-3 hours Hand wash Positioning, latch on Pillow Sitting, lying

Hormonal contraceptives Anti-infectives Penicillins, cephalosporins, erythromycin, trimethoprim, acyclovir, mebendazole Analgesics & NSAIDs Paracetamal, codeine, diclofenac, ibuprofen, mefenamic acid Anticonvulsants Diazepam,MgSO4, phenobarbetal, phenytoin, valproic acid Hormonal contraceptives Progestogen-only pills DMPA ?

Thyroid hormones & antithyroid drug Corticosteroids Diuretics Spironolactone Thyroid hormones & antithyroid drug Thyroxine, PTU Corticosteroids Mammoplasty (silicone) no contraindication

Contraindication Amiodarone Antineoplastic agents Bromocriptine Chloramphenicol Gold salts Tetracycline Combined pills

Maternal contraindicaitons Drug addiction HIV Active TB Cytomegalovirus

Cardiovascular system Normal – 2-3 weeks Immediate – increased cardiac output, increased venous return

Respiratory system Increased residual volume Decreased vital capacity, inspiratory capacity 2-3 days – increased pCO2 3 weeks - normal pH

HPO axis Decreased placental hormone Undetectable hPL in 1st day hCG < 1 IU/ml in 2-4 days hCG < 100 mIU/ml in 7 days UPT negative 7 days – latex agglutination 11-16 days - radioimmunoassay

Increased LH – ovulation week 4-8 30% - 90 days Early – day 36 In abortion or ectopic pregnancy – day 14 Delayed ovulation in breastfeeding

Endocrine system Decreased hPL & growth hormone Decreased insulin demand Normal – 6-8 weeks Glucose tolerance test Increased thyroid hormone – decreased TBG Decreased corticosteroid & testosterone – normal in 1st week

After pain (uterine contraction after delivery) Lochia Lochia rubra – 3 days Lochia serosa – 10 days Lochia alba Increased urine – day 2-5 Decreased weight 7-9 kgs, normal in 6 months

Anti-D immune globulin Rubella Discharge 48 hours, C/S 3-5 days Postpartum blues 2-3 days > 10 days – Psychiatrist Anti-D immune globulin Rubella Discharge 48 hours, C/S 3-5 days

Contraception Follow up 4-6 weeks Pap Advice

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