Puerperium

Suhaima Tahir 271Narmeen Hassan 168

Ahsan Farid 281

Puerperium

• Refers to first 6 weeks after delivery.• Physiological changes that took place during

pregnancy are reversed.• Body goes back to pre-pregnant state

REPRODUCTIVE SYSTEM CHANGES

• INVOLUTION: Process whereby the reproductive organs return to their non-pregnant state

• Changes in the uterus, cervix, vagina and perineum.

Uterus• In terms of weight:

-Immediately after birth: 1000g-End of first week: 500 g-End of second week: 300g -After 6 weeks (involution has completed): 50 g (prepregnant

state)

• In terms of size:- First 24 hours, fundus palpated at the level of the umbilicus. - decreases 1 fingerbreadth per day

-9th– 10th day: uterus have already receded under the pubic bone and is no longer palpable

Causes of delayed involution

• Fibroids• Uterine infection• Retention of placental products• Broad ligament hematoma

• First hour postpartum is potentially the most dangerous time for the woman

• Uterine atony can occur-Uterus becomes relaxed-Patient will bleed very rapidly

• After pains-Intermittent cramping after childbirth-Due to contraction of the uterus-Increase with breastfeeding

Lochia

• Lochia: vaginal discharge due to sloughing of decidual tissue, mainly from the placenta site

• Lochia rubra: – red in color – first 3-4 days

• Lochia serosa: – pink→serous– after 3-4 days,– last for about 10 days

• Lochia alba: – yellowish→white– 2weeks

• Persistent red lochia- due to delayed involution

-Infection (offensive, pyrexia and tender uterus)

-Retained piece of placental tissue

Cervix

• 2-3 days later : admits two fingers• end of the first week : outline and internal os

are closed. It usually admits only one finger.• 2nd week: internal os should be closed,

external os can remain open (parouscervix)• 4 weeks: the cervix is completely recovery

URINARY SYSTEM

Difficult voiding due to• Transient loss of bladder tone• No sensation of having to void

Over distended bladder can cause non-contraction of uterus

Bowel function

• Constipation is common complaindue to -dehydration during labour

-interruption in normal diet-fear of evacuation due to pain from a

sutured perineum, prolapsed hemorrhoids or anal fissures.• Large hard bolus will disrupt repaired anal

sphincter and cause anal incontinence• You keep patient on laxatives

Symphysis pubis diastasis

• Separation of symphysis pubis• Associated with forceps delivery, rapid second

stage of labour and severe abduction of thighs during delivery

• Signs: Symphyseal pain aggravated by weight bearing and walking, waddling gait, pubic tenderness and palpable interpubic gap

• Treatment: bed rest, anti-inflammatory drugs, physiotherapy and a pelvic corset for support.

Vital Signs Changes

Temperature• Slight increase of temperature during the first

24 hours of peurperium due to dehydration during labor is normal.

• Temperature above 100.4F (38C) after 24 hours is abnormal and may be a sign of postpartum infection

Pulse• Slightly slower than normal

-Due to increase stroke volume

• By end of first week, the pulse rate has returned to normal

• Rapid and thready pulse during the postpartum period is a possible sign of hemorrhage

Blood Pressure• Reading above 140 mmHg systolic or 90mmHg

diastolic may indicate post partal PIH

• Oxytocin administration can also cause increase blood pressure

Counseling

• Routine care of the baby: feeding, diapering etc.

• Breastfeeding• Contraception

Non breast feeding mothers

• Breast engorgement and pain.• Prevention:-tight undergarments for support-fluid restriction-Dopamine receptor stimulants: Bromocriptine.(Associated with hypertension and stroke)

Post-Partum Hemorrhage

• Excessive blood loss during or after the third stage of labor.

• The average blood loss is 500 mL at vaginal delivery and 1000 mL at cesarean delivery.

• Primary postpartum hemorrhage occurs within the first 24 hours after delivery.

• Secondary postpartum hemorrhage occurs after 24 hours up to 6 weeks postpartum.

Causes of Primary PPH

• uterine atony• retained products of conception• uterine rupture• uterine inversion• placenta accreta• lower genital tract lacerations, coagulopathy,

and hematoma.

Causes of secondary PPH

• retained products of conception• Infection• sub involution of placental site• coagulopathy.

Puerperal PyrexiaTemperature of 38°C or higher on any two of the first 10 days post partum.Common risk factors

Prolonged rupture of membrane causing ascending infectionFrequent use of urinary cathetersProlonged labour, with increased interventions and VE Assisted births Vaginal lacerationsPost partum hemorrhageCaesarean section

Most important cause: Puerperal sepsis

Thromboembolism

• Puerperium is a hypercoagulable state• Prone to develop DVT• Can be a cause of pyrexia• Embolism can be life threatening

Infections

• Endometritis • UTI’s (Urinary Tract Infections)• Mastitis• Wound infections

Infections (Predisposing factors)

• cesarean delivery• Instrumental delivery• prolonged labor• prolonged rupture of membranes• multiple vaginal examinations• placement of an intrauterine catheter• bladder catheterization

Mastitis (Predisposing factor)

• Milk stasis and cracked nipples, which contribute to the influx of skin flora

• Primiparity• incomplete emptying of the breast• improper nursing technique

Psychiatric Problems

• Postpartum blues -transient disorder-lasts hours to weeks-characterized by bouts of crying and sadness.

• Postpartum-depression (PPD)- lasts for weeks to months. -signs and symptoms do not differ from depression in other

settings. • Postpartum psychosis

-occurs in the first postpartum year-refers to a group of severe and varied disorders that elicit

psychotic symptoms.