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

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

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.

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.

CLINICAL and PHYSIOLOGICAL ASPECTS OF THE PUERPERIUM

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

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

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

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.

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.

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.

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

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

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

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

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

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

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

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

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

II. URINARY TRACT CHANGES 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

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

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

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

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

HOSPITAL CARE

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

EARLY AMBULATION Advantages less frequent bladder complications & constipation reduced frequency of puerperal venous thrombosis & pulmonary embolism

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

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

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

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.

BOWEL FUNCTION early ambulation and early feeding → constipation ↓

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

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

ABDOMINAL WALL RELAXATION Exercise to restore abdominal wall tone : any time after vaginal delivery : as soon as abdominal soreness diminishes after cesarean delivery

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

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

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

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.

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

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

CARE AT HOME

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

RETURN TO MENSTRUATION AND OVULATION 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

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

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