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PUERPERIUM

Chapter 30, Williams Obstetrics, 23rd Edition

PUERPERIUM

Period of time
encompassing the
first few weeks
(between 4 to 6
weeks) after birth
May be a time o
intense anxiety for
many women

ANATOMICAL, PHYSIOLOGICAL AND CLINICAL


ASPECTS OF PUERPERIUM
VAGINA AND VAGINAL OUTLET
Early Puerperium: Vagina and its outlet form a
capacious, smooth-walled passage that gradually
diminishes in size but rarely returns to nulliparous
dimensions.
3rd week : ruggae begin to reappear
Myrtiform caruncles scarred small tags of tissue in
the hymen
4th to 6th week : vaginal epithelium begins to
proliferate (coincidental with ovarian estrogen
production)

ANATOMICAL, PHYSIOLOGICAL AND CLINICAL


ASPECTS OF PUERPERIUM
UTERINE VESSELS
During pregnancy:
Massively increased uterine blood flow
Significant hypertrophy and remodelling of all pelvic vessels
After delivery
caliber of extrauterine vessels decreases to equal, or at least
closely approximates, that of the prepregnant state.
larger blood vessels are obliterated by hyaline changes,
gradually resorbed, and replaced by smaller ones.
Minor vestiges of the larger vessels, however, may persist
for years.

ANATOMICAL, PHYSIOLOGICAL AND CLINICAL


ASPECTS OF PUERPERIUM
CERVIX
external os is usually lacerated, especially laterally
cervical opening contracts slowly, and for a few days
immediately after labor readily admits two fingers.
End of 1st week: Cervix narrows, thickens, and a
canal reforms
external os does not completely resume its pregravid
appearance
It remains wider and bilateral depressions at the site
of laceration PAROUS CERVIX

ANATOMICAL, PHYSIOLOGICAL AND CLINICAL


ASPECTS OF PUERPERIUM
UTERINE INVOLUTION
after placental expulsion, the fundus of the
contracted uterus is slightly below the umbilicus
Anterior and posterior walls, in close apposition,
each measures 4 to 5 cm thick
ischemic organ (vessels are compressed by the
contracted myometrium) -puerperal uterus
reddish-purple hyperemic organ pregnant
2 days after delivery-uterus begins to involute
2 weeks after delivery-uterus descended into the
cavity of the true pelvis

ANATOMICAL, PHYSIOLOGICAL AND CLINICAL


ASPECTS OF PUERPERIUM
UTERINE INVOLUTION
4 weeks after delivery-uterus regains its previous
nonpregnant size
Immediately postpartum, the uterus weighs
approximately 1000 g
1 week later it weighs about 500 g
2 weeks later it weighs about 300 g, and soon
thereafter to 100 g or less
total number of muscle cells does not decrease,
but instead, the individual cells decrease markedly
in size.

CROSS
SECTIONS
OF UTERI
MADE AT
THE LEVEL
OF THE
INVOLUTING
PLACENTAL
SITE AT
VARYING
TIMES
AFTER
DELIVERY

ANATOMICAL, PHYSIOLOGICAL AND CLINICAL


ASPECTS OF PUERPERIUM

Sonographic Findings:

It takes up to 5 weeks for the uterine cavity to


regress to its nonpregnant state of a potential
space
By Doppler studies, there is continuously
increasing uterine artery vascular resistance
during the first 5 postpartum days

ANATOMICAL, PHYSIOLOGICAL AND CLINICAL


ASPECTS OF PUERPERIUM
AFTER PAINS
Similar but milder that the pain of labor contractions
primiparas, the puerperal uterus tends to remain
tonically contracted
multiparas, the uterus often contracts vigorously at
intervals, and gives rise to afterpains
more pronounced as parity increases
worsen when the infant suckles
decrease in intensity and become mild by the third day

ANATOMICAL, PHYSIOLOGICAL AND CLINICAL


ASPECTS OF PUERPERIUM
LOCHIA
sloughing of decidual tissue results in a vaginal
discharge of variable quantity
consists of erythrocytes, shredded decidua, epithelial
cells, and bacteria
LOCHIA RUBRA- first few days after delivery, there is
blood sufficient to color it red
LOCHIA SEROSA- After 3 or 4 days, lochia becomes
progressively pale in color
LOCHIA ALBA- After about the 10th day, because of an
admixture of leukocytes and reduced fluid content,
lochia assumes a white or yellowish-white color

ANATOMICAL, PHYSIOLOGICAL AND CLINICAL


ASPECTS OF PUERPERIUM
ENDOMETRIAL REGENERATION
2 or 3 days after delivery, the remaining decidua
becomes differentiated into two layers
1. superficial layer- becomes necrotic, and it is
sloughed in the lochia
2. basal layer- adjacent to the myometrium, remains
intact and is the source of new endometrium
The endometrium arises from proliferation of the
endometrial glandular remnants and the stroma of
the interglandurlar connective tissue

ANATOMICAL, PHYSIOLOGICAL AND CLINICAL


ASPECTS OF PUERPERIUM

Endometrial regeneration is rapid, except at the


placental site
Full restoration of the endometrium is obtained
16th day onward

HISTOLOGIC ENDOMETRITIS part of normal


reparative process
ACUTE SALPINGITIS seen in almost half of
postpartum women between 5 and 15 days

ANATOMICAL, PHYSIOLOGICAL AND CLINICAL


ASPECTS OF PUERPERIUM

SUBINVOLUTION
an arrest or retardation of involution
prolongation of lochial discharge
irregular or excessive uterine bleeding
uterus is larger and softer than would be
expected
due to retention of placental fragments and
pelvic infection

ANATOMICAL, PHYSIOLOGICAL AND CLINICAL


ASPECTS OF PUERPERIUM

Management of Subinvolution

Ergonovine or methylergonovine, 0.2 mg every 3


to 4 hours for 24 to 48 hours
Antibiotic therapy for bacterial metritis

Chlamydia trachomatis

cause of almost third of late postpartum uterine


infection;
treated with Azithromycin or Doxycycline

ANATOMICAL, PHYSIOLOGICAL AND CLINICAL


ASPECTS OF PUERPERIUM
PLACENTAL SITE INVOLUTION- a process of
exfoliation, consequence of sloughing of infarcted and
necrotic superficial tissues followed by a reparative
process.
placental site is about the size of the palm of the hand,
rapidly decreases thereafter
end of the second week, it is 3 to 4 cm in diameter.
Complete extrusion of the placental site takes up to 6
weeks
when it is defective, late-onset puerperal hemorrhage
may ensue

LATE POSTPARTUM HEMORRHAGE

develops 1 to 2 weeks into the puerperium


result of abnormal involution of the placental site,
retention of a portion of the placenta
initial treatment may be best directed to medical
control of the bleeding with intravenous oxytocin,
ergonovine, methylergonovine, or prostaglandins
curettage is carried out only if appreciable
bleeding persists or recurs after medical
management

URINARY TRACT CHANGES

diuresis that occurs postpartum (2nd-5th day) is a


physiological reversal of increase in extracellular water in
normal pregnancy
puerperal bladder has an increased capacity and a
relative insensitivity to intravesical fluid pressure
paralyzing effect of analgesics, especially epidural and
spinal blocks are contributory
Overdistention, incomplete emptying, and excessive
residual urine are common
dilated ureters and renal pelves return to their prepregnant
state over the course of 2 to 8 weeks after delivery
dilated renal pelves and ureters, and traumatized bladder
create an optimal condition for the development of UTI

INCONTINENCE

3% to 26% of women report daily episodes of


incontinence in the 3 to 6 months after delivery
Can be due to Impaired muscle function in or
around the urethra as a result of vaginal delivery
correlated with obstetrical factors such as length of
second-stage labor, infant head circumference,
birthweight, and episiotomy
women whose deliveries had all been vaginal had
a 70-percent higher risk of incontinence than
women whose deliveries had all been by cesarean

PERITONEUM AND ABDOMINAL WALL

abdominal wall remains soft and flaccid due to


rupture of elastic fibers in the skin and the
prolonged distention caused by the pregnant
uterus
several weeks are required for these structures to
return to normal
DIASTASIS RECTI- marked separation of the
rectus muscles ,midline abdominal wall is formed
only by peritoneum, attenuated fascia,
subcutaneous fat, and skin

BLOOD AND FLUID CHANGES

marked leukocytosis and thrombocytosis


occur during and after labor
relative lymphopenia and an absolute
eosinopenia
during the first few postpartum days,
hemoglobin concentration and hematocrit
fluctuate moderately
1 week after delivery, the blood volume has
returned nearly to its nonpregnant level

WEIGHT LOSS

loss of about 5 to 6 kg due to uterine


evacuation and normal blood loss
loss of about 2 to 3 kg through diuresis

MAMMARY GLANDS

composed of 15 to 25 lobes
arranged radially and are separated from one
another by varying amounts of fat
lobe consists of several lobules, which are
made up of large numbers of alveoli, every
alveolus is provided with a small duct
alveolar secretory epithelium synthesizes the
various milk constituents

BREASTFEEDING
COLOSTRUM- deep lemon-yellow-colored liquid,
expressed from the nipples by the 2nd postpartum day,
contains more minerals and protein, much of which is
globulin, but less sugar and fat
secretion persists for about 5 days, with gradual
conversion to mature milk during the ensuing 4 weeks
content of immunoglobulin A (IgA) may offer protection
for the newborn against enteric pathogens
host resistance factors that are found in colostrum and
milk:

complement, macrophages, lymphocytes,


lactoperoxidase, and lysozymes

lactoferrin,

HUMAN MILK

a suspension of fat and protein in a carbohydrate-mineral


solution

Whey is milk serum and has been shown to contain large


amounts of interleukin-6 (IL-6)
positive correlation between its concentration and the
number of mononuclear cells in human milk

nursing mother easily makes 600 mL of milk per day

IL-6 was associated closely with local IgA production by the breast

Prolactin and Epidermal growth factor


All vitamins except K are found in human milk
Vitamin K administration to the infant soon after delivery is
required to prevent hemorrhagic disease of the newborn

ENDOCRINOLOGY OF LACTATION
Progesterone ,estrogen, and placental lactogen, prolactin, cortisol,
and insulin: stimulate the growth and development of the milksecreting apparatus of the mammary gland
Decrease estrogen and progesterone
Removes the inhibitory influence of progesterone on the production of
alpha lactalbumin by the rough endoplasmic reticulum
increased alpha lactalbumin stimulate lactose synthase
increase milk lactose
neurohypophysis secretes oxytocin in pulsatile fashion
stimulates milk expression from a lactating breast by causing
contraction of myoepithelial cells in the alveoli and small milk ducts

IMMUNOLOGICAL CONSEQUENCES OF
BREASTFEEDING
predominant immunoglobulin in milk is secretory IgA
SECRETORY
IgA is secreted across mucous
membranes and has important antimicrobial functions
breast-fed infants are less prone to enteric infections
than bottle-fed infants
human milk also provides protection against rotavirus
infections,Escherichia coli infections
contains both T and B lymphocyte
milk T lymphocytes are almost exclusively composed
of cells that exhibit specific membrane antigens

NURSING
Ideal for neonates
Provides species and age specific nutrients
Promotes cellular growth & differentiation
Decreases incidence of infections
Protective against: SIDS, IDDM, IBD,
Lymphoma, Allergy, Chronic Digestive disease
Enhances Cognitive development

LACTATION INHIBITION

Milk leakage, engorgement, and breast pain


peak at 3 to 5 days postpartum
Ice packs and oral analgesics for 12 to 24
hours may be required to relieve
Bromocriptine ,a commonly used drug for
lactation inhibition, had been associated with
strokes, myocardial infarctions, seizures, and
psychiatric disturbances.

CONTRACEPTION FOR BREASTFEEDING


WOMEN
Recommendations for Hormonal Contraception if Used
by Breast Feeding Women
Progestin-only oral contraceptives prescribed or
dispensed at discharge from the hospital to be started 2
3 weeks postpartumfor example, the first Sunday after
the newborn is 2 weeks of age.
Depot medroxyprogesterone acetate initiated at 6
weeks postpartum.a
Hormonal implants inserted at 6 weeks postpartum.
Combined estrogenprogestin contraceptives, if
prescribed, should not be started before 6 weeks
postpartum, and only when lactation is well established
and the infant's nutritional status well monitored

CONTRAINDICATIONS TO BREASTFEEDING
in women who take street drugs or do not control their alcohol use

have an infant with galactosemia

have human immunodeficiency virus (HIV) infection

have active, untreated tuberculosis

take certain medications

undergoing treatment for breast cancer

*although hepatitis B virus is excreted in milk, breast feeding is not

contraindicated if hepatitis B immune globulin is given to infants of seropositive


mothers.

* Maternal hepatitis C infection is also not a contraindication to breast feeding


* Women with active herpes simplex virus may suckle their infants if there are no
breast lesions and if particular care is directed to hand washing before nursing.

NIPPLE CARE

cleanliness and attention to fissures


cleaning of the areola with water and mild
soap is helpful before and after nursing
When the nipples are irritated, use a nipple
shield for 24 hours or longer

Drugs That Have Been Associated with Significant Effects on Some Nursing Infants

Drugs That Have Been Associated with Significant


Effects on Some Nursing Infants
*cytotoxic drugs may interfere with the cellular
metabolism of the infant and potentially cause immune
suppression or neutropenia, affect growth, or, at
least theoretically, increase the risk of cancer
1.cyclophosphamide
2.cyclosporine
3.doxurubicin
4.methotrexate
* Radioactive isotopes of copper, gallium, indium, iodine,
sodium, and technetium rapidly appear in breast milk.
This ranges from 15 hours up to 2 weeks, depending
on the isotope used.

BREAST FEVER
breasts become distended, firm, and nodular
a transient elevation of temperature (ranged
from 37.8 to 39)
Treatment: supporting the breasts with a binder
or brassiere, applying an ice bag, an analgesic,
pumping of the breast or manual expression of
milk

MASTITIS

infection of the mammary glands during the puerperium and


lactation or antepartum
unilateral, and marked engorgement usually precedes the
inflammation.
first sign of inflammation is chills or actual rigor, soon followed
by fever and tachycardia.
About 10 % of women with mastitis develop an abscess

ETIOLOGY: Staphylococcus aureus 40 %; coagulase-negative


staphylococci and viridans streptococci

Immediate source of organisms almost always the infant's nose


and throat

TREATMENT: MASTITIS
clinicians recommend that milk be expressed from the
affected breast onto a swab and cultured
initiate antimicrobial therapy:
staphylococcal infections are usually sensitive to
penicillin or a cephalosporin

Dicloxacillin 500 mg orally four times daily, may be started


empirically
Erythromycin is given to women who are penicillin sensitive
Vancomycin is effective against MRSA

treatment should be continued for 10 to 14 days


If the infected breast is too tender to allow suckling, gently
pumping until nursing can be resumed is recommended.

BREAST ABSCESS
development is either from failure of defervescence within 48
to 72 hours or development of a palpable mass
TREATMENT: Traditional therapy is surgical drainage less
invasive alternative is ultrasonographic-guided needle
aspiration using local anesthesia
GALACTOCOELE
result of the clogging of a duct by inspissated secretion,milk
may accumulate in one or more lobes of the breast
excess may form a fluctuant mass that may give rise to
pressure symptoms
resolve spontaneously or require aspiration

SUPERNUMERARY BREAST
so small as to be mistaken for pigmented moles, or when without
a nipple, for a lipoma
situated in pairs on either side of the midline of the thoracic or
abdominal walls, usually below the main breasts; also found in
the axillae, and more rarely on other portions of the body, such
as the shoulder, flank, groin, or thigh
no obstetrical significance

ABNORMALITIES OF NIPPLES
Inverted- draw the nipple out, using traction with fingers.
Normal size and shape- may become fissured lesions
provide a convenient portal of entry for pyogenic bacteria effort
should be made to heal such fissures

ABNORMALITIES WITH SECRETION

complete lack of mammary secretion


(agalactia)
mammary secretion is excessive
(polygalactia).

CARE OF THE MOTHER DURING


PUERPERIUM
HOSPITAL CARE
first hour after delivery, blood pressure and pulse
should be taken every 15 minutes, or more frequently if
indicated

amount of vaginal bleeding is monitored


significant hemorrhage is greatest immediately
postpartum
fundus should be palpated to ensure that it is well
contracted
If relaxation is detected, the uterus should be massaged
through the abdominal wall until it remains contracted.

EARLY AMBULATION
1.

2.

3.

Women are out of bed within a few hours


after delivery
Advantages of early ambulation include less
frequent bladder complications and
constipation
Reduced the frequency of puerperal venous
thrombosis and pulmonary embolism

CARE OF THE VULVA

cleanse the vulva from anterior to posterior


(vulva toward anus)
ice bag applied to the perineum may help
reduce edema and discomfort during the first
several hours after episiotomy repair.
Beginning about 24 hours after delivery, moist
heat as provided with warm sitz baths can be
used to reduce local discomfort. Tub bathing
after uncomplicated delivery is allowed

BLADDER FUNCTION
Oxytocin, in doses that have an antidiuretic effect, as a
consequence of infused fluid and the sudden withdrawal of
the antidiuretic effect of oxytocin, rapid bladder filling is
common

bladder sensation and capability to empty spontaneously


may be diminished by anesthesia, especially conduction
analgesia, as well as by episiotomy, lacerations, or
hematomas
it usually is best to leave the catheter in place for at least 24
hours, whenever the bladder becomes overdistended
If the woman cannot void after 4 hours, she should be
catheterized and urine volume measured

BLADDER FUNCTION

If the woman cannot void after 4 hours, she


should be catheterized and urine volume
measured.
If there is more than 200 mL of urine, it is
apparent that the bladder is not functioning
appropriately. The catheter should be left in place
and the bladder drained for another day. If less
than 200 mL of urine is obtained, the catheter can
be removed and the bladder rechecked
subsequently as described.

SUBSEQUENT DISCOMFORT

uncomfortable for a variety of reasons,


including afterpains, episiotomy and
lacerations, breast engorgement, and at times,
postspinal puncture headache
Early application of an ice bag may minimize
swelling and discomfort
severe pain warrants careful examination
episiotomy incision normally is firmly healed
and nearly asymptomatic by the third week

DEPRESSION
postpartum blues- degree of depressed mood a few days
after delivery

The emotional letdown that follows the excitement and fears


that most women experience during pregnancy and delivery.
The discomforts of the early puerperium.
Fatigue from loss of sleep during labor and postpartum.

Anxiety over her capabilities for caring for her infant after
leaving the hospital.
Fears that she has become less attractive

*effective treatment need be nothing more than anticipation,


recognition, and reassurance
*mild disorder is self-limited and usually remits after 2 to 3 days,
although it sometimes persists for up to 10 days

ABDOMINAL WALL RELAXATION

Exercises to restore abdominal wall tone may


be started any time after vaginal delivery and
as soon as abdominal soreness diminishes
after cesarean delivery

DIET

NO dietary restrictions for women who have been


delivered vaginally

if there are no complications likely to necessitate an


anesthetic, the woman should be allowed to eat if she
desires

The diet of lactating women, compared with that


consumed during pregnancy, should be increased in
calories and protein, as recommended by the Food
and Nutrition Board of the National Research
Council

If the mother does not breast feed, dietary requirements


are the same as for a nonpregnant woman

THROMBOEMBOLIC DISEASE
Half of thromboembolic events associated with
pregnancy develop in the puerperium,

Pressure on branches of the lumbosacral nerve plexus


during labor may be manifest by complaints of intense
neuralgia or cramplike pains extending down one or
both legs as soon as the head begins to descend into
the pelvis
If the nerve is injured, pain continues after delivery and
may be accompanied by variable degrees of sensory
loss or muscle paralysis supplied by the damaged
nerve

OBSTETRICAL NEUROPATHIES
If the nerve is injured, pain continues after delivery and
may be accompanied by variable degrees of sensory
loss or muscle paralysis supplied by the damaged nerve

Lateral femoral cutaneous neuropathies were the most


common

Nulliparity and prolonged second-stage of labor were


independent risk factors for nerve injury.
Separation of the symphysis pubis or one of the
sacroiliac synchondroses during labor may be followed
by pain and marked interference with locomotion

PELVIC JOINT SEPARATION


1 in 600 to 1 in 30,000 deliveries
the onset of pain is acute at delivery
Treatment: lateral decubitus position and an appropriately
fitted pelvic binder

surgery may be necessary when symphyseal separation is


more than 4 cm Recurrence is more than 50 percent in
subsequent pregnancy, cesarean delivery be considered.

IMMUNIZATION
D-negative woman who is not isoimmunized and whose
infant is D-positive is given 300
microgram of anti-D immune globulin shortly after delivery

TIME OF DISCHARGE
Following vaginal delivery, if there are no complications,
hospitalization is seldom warranted for more than 48 hours.
Receive instructions regarding:

normal physiological changes of the puerperium, including lochia


patterns, weight loss from diuresis, and when to expect milk letdown
what to do if she becomes febrile, has excessive vaginal bleeding,
or develops leg pain, swelling, or tenderness,any shortness of
breath or chest pain warrants immediate concern

EARLY DISCHARGE
The norms are hospital stays of up to 48 hours following
uncomplicated vaginal delivery and up to 96 hours following
uncomplicated cesarean delivery.
American
Academy of Pediatrics, American Academy of
Obstetricians and Gynecologists, 2002

CONTRACEPTION
effort should be made to provide family planning
education
If a woman is not breastfeeding, menses usually
return within 6 to 8 weeks
Ovulation is much less frequent in women who
breast feed compared with those who do not
lactating women, the first period may occur as
early as the second or as late as the 18th month
after delivery

CONTRACEPTION
Clearly, there is delayed resumption of ovulation with
breast feeding, although as already emphasized, early
ovulation is not precluded by persistent lactation.
Other findings included the following:
1.Resumption of ovulation was frequently marked by
return of normal menstrual bleeding
2.Breast feeding episodes lasting 15 minutes seven
times each day delayed resumption of ovulation.
3. Ovulation can occur without bleeding.
4.Bleeding can be anovulatory.
5.The risk of pregnancy in breast feeding women was
approximately 4 percent per year.

HOME CARE
COITUS - no definite time after delivery when coitus should be
resumed
The median interval between delivery and intercourse was 5
weeks range was 1 to 12 weeks
reasons cited for not resuming intercourse included perineal pain,
bleeding, and fatigue
-coitus may be resumed based on the patient's desire and comfort
B. INFANT FOLLOW UP
importance of subsequent neonatal and well-baby care should be
stressed and an emphasis placed on infant immunizations.
Any neonate discharged early should be term, normal, and have
stable vital signs.
Initial hepatitis B vaccine should be administered, and all
screening tests required by law should be performed

Puerperal Morbidity in Percent Reported by


Women After Hospital Discharge
By 8 weeks Post
partum
59

2 to 18 months Postpartum
54

Breast Problems

36

20

Anemia

25

Backache

24

20

Hemorrhoids

23

15

Headache

22

15

Tearfullness/depression

21

17

Constipation

20

Stitches breaking down

16

Vaginal discharge

15

Others

2-7

1-8

At least 1 of the above

87

76

Morbidity
Tiredness

FOLLOW UP CARE
Postnatally, most societies did not restrict maternal
work activity, and about half expected a return to full
duties within 2 weeks

only half of women regained their usual level of energy


by 6 weeks postpartum

Women who delivered vaginally were twice as likely to


have normal energy levels at this time compared with
those with a cesarean delivery.

Ideally, the care and nurturing of the neonate should be


provided by the mother with ample help from the father.