Normal Puerperium

Normal Puerperium

Puerperium is the period following childbirth during which the body tissues especially the pelvic organs, revert approximately to the pre-pregnant state both anatomically and physiologically.

Anatomic and physiologic changes

·  Uterus involution

·  Regeneration of endometrium

·  Reduced bladder sensitivity to over distention

·  Increased coagulability

·  Fall in plasma volume

Uterine Involution

·  In pregnancy, uterus increases 11 times in size and weight.

·  Rapid involution – immediately following delivery it reduces from 1000gm to 100gm at the end of 6 weeks.

·  Reversal of hypertrophy due to withdrawal of sex hormone causes increases collagenase, proteolytic enzyme causes autolysis of intracellular protein.

·  Decrease uterine volume due to increase myometrial force and intrauterine pressure 150 mmHg.

·  After pains 2 – 3 days more in multiparous and more during lactation due to increase in oxytocin.

·  Uterine cavity- sterile, bactericidal effects of granulation tissues.

Lochia

Lochia is the vaginal discharge after giving birth.

Rubra– last for 3 days, contains fresh blood and necrotic tissue.

Serosa – last for 4-9 days, contains liquefied blood, leucocytes, serous, palour and reddish brown in colour.

Alba – last for 10-15 days ,contains leucocytes, mucus decidual cells, yellowish white in colour.

Cervix

·  1ST week – closes to 1 cm.

·  External os – transverse slit.

·  Complete healing 6 – 12 weeks.

Vagina

·  Smooth, swollen and poor tone after delivery.

·  3 weeks – rugae first appear.

·  6 – 10 weeks – epithelium restored to normal.

·  Lower vagina – suffers superficial laceration.

Pelvic Floor

Normal by 6 weeks except varying degree of musculoskeletal laceration.

Urinary Tract

·  Immediate postpartum – bladder mucosabecomes edematous

·  Over distension – incomplete emptying and presence of , residual urine are common urinary problem in puerperium

·  1 – 2 days – mild proteinuria in 50 % of women

·  By 8 weeks – renal plasma flow reduces to normal, glomerular filteration returns to normal.

·  Creatinine clearance becomes normal by 1st week.

Fluids And Electrolytes

·  Weight loss - immediately after delivery – 5.5 kg – fetus, placenta, amniotic fluid 4 kg – excretion of fluids and electrolytes.

·  Fluid loss – 2 liltres during 1st week. – 1.5 litres – next 5 weeks.

Electrolytes

·  Total exchangeable sodium decreased but body water loss exceeds sodium loss.

·  Decreased plasma progesterone causes decreased aldosterone antagonism and increased sodium.

·  Tissue involution – cellular breakdown, increases potassium level.

Cardio Vascular Changes

1. Blood coagulation:

Rapid and dramatic changes in the coagulation and fibrinolytic system after delivery.

·  Extensive activation of clotting factors together with immunity.

ii.  Blood volume: During delivery and soon after 1/5 of the volume is reduced due to

·  Blood loss in normal delivery – 400 ml and in caesarean section – 1000 ml

·  Obliteration of loss – resistance uteroplacental circulation

·  Maternal vascular bed decreases 10 – 15 %

iii.  Hematopoiesis:

·  Leukocytosis – 25000/mm³ during labour and puerperium.

·  Bone marrow hyperactivity present

·  Iron decreases,becomes normal by 2nd week.

Respiratory Changes

·  Residual volume increase.

·  Vital capacity and inspiratory capacity decrease.

·  Post partum decreased progesterone and decreased respiration increase PCO2.

Menstruation

·  Non-lactating: starts at about 12 weeks.

·  Lactating: starts after 6 months

·  1st cycle: anovulatory or inadequate

Lactation

·  Prolactin is an obligatory hormone which increases as pregnancy advances.

·  Prolactin induced secretory activity is placental sex steroid.

·  After delivery decreased sex steroid of lactation.

·  Milk ejection by myoepithelial cells contraction. Milk propelled along with the ducts into lactiferous sinus beneath the areola.

·  Neurohormonal reflex: afferent pathway to hypothalamus are stimulated by suckling through 4th and 6thintercostals nerve. Oxytocin is released by stimulation of auditory and visual efferent limb.

·  Maintenance: suckling and emptying of duct and alveoli.

Complications Of Puerperium

·  Genital tract infection

·  Urinary tract infection

·  Wound infection

·  Mastitis

·  Thromboembolism

·  Incontinence/ urinary retention

·  Anal sphincter dysfunction

·  Episiotomy wound gaping

Postnatal Care

Mother:

·  Rest and sleep: Adequate rest and sleep are vital for maternal health, lactation and baby care.

·  Diet: A balanced diet contains high protein, carbohydrate, fats, minerals and vitamins. Additional calories are required for lactation. (500 calories/day)

·  Ambulation: Ambulation should be encouraged as soon as possible, 6 hours after normal delivery and 24 hours after a caesarean delivery. This helps preventing thrombo-embolism complications, improve venous return and muscle tone.

·  Bladder: The postnatal mother usually passes urine within 6 hours. In case of any difficulties, she should be encouraged to do so, by ambulation, plenty of oral fluids, opening the water tap while she is trying to pass urine, pour hot and cold water over vulva.

·  Bowel: Constipation is common due to painful perineum. Plenty of fluids, green leafy vegetables and roughage in diet will help.

·  Hygiene: Bed sheet, linen and clothing should be clean and changed as when required. This will prevent infection. Bath, body sponging, cleaning at the breast and nipple and toileting of the perineum should be done.

·  Exercise: pelvic floor and abdominal exercise to restore muscle tone