1. Facilitator: Pawin Puapornpong
Pueperium care
Facilitator: Pawin Puapornpong

2. Definition
After 3rd stage – normal
6 weeks
Follow up

3. 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

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

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

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

7. 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

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

9. Breasts Areola : smooth muscle
Cooper’s ligament : between lobes, skin, pectoral fascia
Breast :200 g => g during pregnancy => g during feeding

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

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

13. 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 hours postpartum

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

15. 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

16. 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

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

18. 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 : cc/day

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

20. 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

21. 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

22. 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

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

24. 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

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

26. 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

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

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

29. 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 ?

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

31. Contraindication Amiodarone Antineoplastic agents Bromocriptine
Chloramphenicol
Gold salts
Tetracycline
Combined pills

32. Maternal contraindicaitons
Drug addiction
HIV
Active TB
Cytomegalovirus

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

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

35. 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

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

37. 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

38. 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

39. 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

40. Contraception
Follow up 4-6 weeks
Pap
Advice

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