Detty - Puerperium - Nov 2008

8/18/2019 Detty - Puerperium - Nov 2008

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Detty NurdiatiDetty Nurdiati

Dept of Obstetric & GynecologyDept of Obstetric & Gynecology

Fac of Medicine, Gadjah Mada UniversityFac of Medicine, Gadjah Mada University

YogyaartaYogyaarta


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Period of confinement during and just after birth

includes 6 subsequent weeks postpartum duringwhich normal pregnancy involution occurs

The period of adjustment after delivery when theanatomic and physiologic changes of pregnancy are

reversed and the body returnd to the normalnonpregnant state.


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Immediate PuerperiumThe first 2 hours after parturition

!cute postanesthetic or post"delivery complications may

occur

#arly Puerperium#$tends until the first week postpartum

%emote PuerperiumThe period of time required for involution of the genitaorgans and returns od menses& usually by 6 weks innonlactating women and the return od normalcardiovascular and physiological function.


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'. (terine )hanges

2. (rinary Tract )hanges

*. %ela$ation of the +aginal ,utlet andProlapse of the (terus

. Peritoneum and !bdominal -all

. /lood and 0luid )hanges

6. -eight 1oss


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!hanges in the uterine vessels

In pregnancy arteries 3 veins within theuterus& especially to the placental site&enlarge and grow remarkably

!fter delivery the caliber of e$trauterinevessels decreases to equal of prepregnantstate


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!hanges in the !ervi" & #o$er Uterine %egent

)ervical opening contracts slowly0or a few days immediately after labor it readily admits 2 fingers

/y end of the 'st week& it has narrowed the cervi$ thickenss and thecanal reforms

!t the completion of involutionThe e$ternal os does not resume its prepregnant appearance completely/ilateral depression at the site of lacerations remain as permanent

changes that characteri4e the parous cervi$


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!hanges in the !ervi" & #o$er Uterine %egent

5arkedly thinned"out lower uterine segment contracts 3retracts

The lower segment is converted from a clearly evidentstructure into a barely discernible uterine isthmus located

between the uterine corpus above and the internal cervical os below " over the course of few weeks


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'nvolution of uterine corpus

Immediately after placental e$pulsion0undus of contracted uterus is slightly below umbilicus

!fter the first 2 days the uterus begins to shrink

-ithin 2 wksdescend into a cavity of true pelvis

-ithin about wksregain previous nonpregnant si4e


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'nvolution of uterine corpus

-eight of uterus

immediately postpartum 'g

' week later gat the end of 2nd week *g

soon thereafter 'g or less

Total number of muscle cells does not decrease7 individual cells decrease markedly in si4e

8eparation of the placenta and membrane involves the spongylayer

7 decidua basalis remains in the uterus


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(fterpains

Primiparas puerperal uterus tends to remain tonicallycontracted

5ultiparas contracts vigorously at interval 7 afterpain

Infant suckles 7 o$ytocin release 7 (terine contraction

7 afterpain

,ccasionally severe enough to require an analgesic(sually become mild by the *rd postpartum day


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#ochia#arly in the puerperium& sloughing of decidual tissue 7 vaginaldischarge of variable quantity)onsists of erythrocytes& shred of decidua& epithelial cells and

bacteria lochia rubra first few days after delivery

red"colored lochia& blood in lochialochia serosa after * or days

becomes progressively pale in color

lochia alba after 'th day white or yellowish"white color&

1ochia persists for up to weeks& and may stop and resume upto 6 days after delivery


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)ndoetrial regeneration

the remain decidua becomes differentiated into 2 layers within 2or * days after delivery

superficial layer become necrotic& sloughed in the lochia

basal layer remains intact& source of new endometrium


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)ndoetrial regeneration

#ndometrium arises from proliferation o the endometrial

glandular remnants and the stroma of the interglandularconnective tissue.

#ndometrial regeneration is rapid& e$cept at the placental site" free surface becomes covered by epithelium within

a week or so

" entire endometrium is restored during the *rd week


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%ubinvolution

an arrest or retardation of involution & the process bywhich the puerperal uterus is normally restored to its

original proportions

)ause retention of placental fragments& pelvic infection

!ccompanied by prolongation of lochial discharge 3irregular or e$cessive uterine bleeding and sometimes by

profuse hemorrhage


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%ubinvolution

/imanual e$amination

uterus is larger 3 softer than normalfor the particular period of puerperium

Treatment ergonovine or methylergonovine95ethergine:

oral antibiotics usually effective in metritis


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*lacental site involution)omplete e$trusion of placental site takes up to 6 weeks

Immediately after delivery palm si4e

7 *"cm in diameter by end of 2nd week

Placental site normally consists of many thrombosed vessels within hours ofdelivery 7 ultimately undergo organi4ation of thrombus


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#ate postpartu heorrhage 8erious uterine hemorrhage occasionally develops '"2 weeks after

delivery

)auseabnormal involution of placental site 9most often:retention of a portion of the placenta

7 usually undergo necrosis with deposition of fibrin7 form a placental polyp

Treatment

intravenous o$ytocin& ergonovine& methylergonovine& prostaglandinscurettage


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*uerperal diuresis

physiological reversal of pregnancy"induced increase ine$tracellular water

regularly occurs between 2nd and th day

*uerperal bladder

increased capacity 3 relative insensitivity to intravesical fluid pressureoverdistention& incomplete emptying& e$cessive residual urine

residual urine& bacteriuria in traumatic bladder& coupled with thedilated renal pelves and ureters create optimal condition for (TI


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Impaired muscle function in or around the urethra during

vaginal delivery the pathophysiology underlying puerperal incontinence

5ost women returned to normal micturition by * months postpartum

)areful attention to all postpartum women& with promptcatheteri4ation for those who cannot void& will preventmost urinary problems


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+agina and vaginal outlet gradually diminishes in si4e but rarelyreturns to nulliparous dimensions

%ugae reappear by the *rd week

;ymen represented by several small tags of tissue& which duringcicatri4ation are converted into the myrtiform caruncles

%ela$ation of vaginal outlet < e$tensive laceration oroverstretching of perineum during delivery

)hanges in pelvic supports during parturition predispose to uterine prolapse 3 urinary stress incontinence


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/road 3 round ligaments much more la$ than nonpregnant require considerable time to recover from stretching

3 loosening

!bdominal wall return to normal 7 requires several weeks9aided by e$ercise:

usually resumes its prepregnancy state e$cept for silverystriae


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/y ' week after delivery the blood volume has returned nearlyto its nonpregnant level

1eukocytosis and thrombocytosis occur during and after labor ;emoglobin and hematocrit fluctuate moderately

)ardiac output remains elevated for at least = hours

postpartum& due to increased stroke volume from venousreturn


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(terine evacuation 3 normal blood loss "6 kg0urther decrease through diuresis 2"* kg

factors of weight loss

weight gain during pregnancy primiparity

early return to work 9outside the home:

smoking

not affect weight loss breastfeeding

age

marital status


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+reast (natoy

+reast Feeding


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( ducts + lobules ! dilated section of duct to hold milk D nipple ) fat F pectoralis major muscle G chest wall>rib cage

)nlargeent

( normal duct cells + basement membrane ! lumen 9center of duct:


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#actation)olostrum

the deep lemon"yellow colored liquid secreted initially by the breasts " e$pressed from the nipples by the second postpartum day" contains more minerals and protein " globulin

less sugar and fat

" !bs esp. Ig!" persists for about days" gradual conversion to mature milk during the ensue weeks

5ilk" 6m1>day" major proteins "including ?"lactalbumin& @"lactoglobulin

and casein" interleukin "6& epidermal growth factor


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)ndocrinology of lactationProgesterone& estrogen& placental lactogen& prolactin& cortisol&insulin appear to act in concert to stimulate the growth 3development of milk"secreting apparatus of mammary glands

*rolactin is essential for lactation!lthough plasma prolactin falls after delivery& suckling triggers arise

Mil ejection or letting do$n refle" initiated especially by suckling

7 stimulates neurohypophysis to liberate o$ytocin7 contraction of myoepithelial cells in alveoli 3 small milk ducts7 milk e$pression from lactating breast


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'unological !onse-uences of +reast Feeding

Predominant immunoglobulin in milk is secretory Ig! contains secretory Ig! antibodies against #. coli

7 breast"fed infants are less prone to enteric infections

)ontains both T 3 / lymphocytes

Nursing

#ven though the milk supply at first appears insufficient& it becomeadequate if suckling is continued

Aursing accelerates uterine involution repeated stimulation of nipples release o$ytocin7 contracts uterine muscle


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./01 hours postpartu

/lood lossPain/lood pressure

!dvice>warning signs

2/. days postpartu

/reast care

Temperature1ochia8ign of infection5ood


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. $ees postpartu

%ecovery!nemia

)ontraception problems

. onths postpartu

Beneral health)ontraception)ontinuing morbidity


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(ttention iediately after labor

for the first hour after delivery" /P 3 P% should be taken every ' minutes

monitor amount of vaginal bleeding0undus should be palpated to ensure that it is well contracted

if rela$ation detected& uterus should be massaged through abdominal wall until it remains contracted

3he first $ee postpartu

! healthy mother and newborn need not be in a hospitalThe length of hospital stay postpartum

+aginal delivery 2"= hours)aesarean birth C2"D6 hours


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Maternal (ssessentBeneral well"being& micturition& possible complaints

!bdomen fundal height& distended bladder

Perineum& vaginal hemorrhage& lochia& haemorrhoids

1egs thrombophlebitis& sign of thrombosis

Temperature suspec infection& EF *= ) is abnormal& especially duringthe first days after delivery

!ssessment and help with breastfeeding to prevent problems


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Maternal (dvice5aternal and newborn physical& psychosocial and culturo"environmentalneeds& including nutrition and breastfeeding

Information regarding warning signs of problems and where to seek help)ounseling to women and men on se$ual issues related to the postpartum

period& infertility regulation and provision of contraceptives& 1!5

+oluntary counseling and testing of ;I+>!IG8 if necessary

Immuni4ation of the newborn>infant and the women


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!djustment to parenthood )hanges in mood or behavior Aeed for information about child care 8e$ual relationship -eight change )ontraception 0ollow"up of any complication that arose in pregnancy or

during childbirth

Detty - Puerperium - Nov 2008

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