Psychology of puerperium
Most women are happy during Puerperium. Some may be anxious, apprehensive and sensitive. These groups of women cry easily and find the task of caring for the baby too cumbersome. The midwife needs to be understanding in her dealings with the mother. Mothers are always appreciative of the midwife’s advice, kind approach, assurance, and assistance.
Puerperium is a period of excitement, the mother is eager to share her experiences with partner, family and friends.
Physiology of puerperium
These are the changes that take place after delivery. This is characterized by endocrine activity. Oxytocin acts upon the uterine muscle and breast tissue. In the 3rd stage the action brings about the separation of the placenta and prevents hemorrhage (by the action of living ligature) and initiation of lactation. Other changes include the lochia which undergo sequential changes as involution progresses. The main changes occur in the uterine and decidua but the ligament also return to their former state prior to pregnancy. The stretched vagina, pelvic floor and perineum regain their tone but, in some instances a degree of laxity persists. There is a dramatic reduction in the level of estrogen and progesterone reaches basal level by the 7th day if she breastfeeds, otherwise the oestradiol begins to rise 14 – 21 days after birth indicating a resumption of ovarian follicle development and later ovulation
Return of the uterus to its pre-gravid state. The reduction in the size of the uterus is brought about by the process known as Autolysis and Ischaemia i.e. self digestion of the uterine muscle fibres by proteolytic enzymes and self destruction. The end results are removed by the phagocytic action of polymorphs and macrophages in the blood and lymphatic system which invades the collagen fibres between the myometrial cells and remove the fat from the area. This process is further assisted by the contraction and retraction of the uterine muscles under the influence of oxytocin resulting in the compression of blood vessels and reducing uterine blood flow causing the release of more lochia and after pain during breast feeding. Involution reduces the size of the uterus by about 1.6 in. (about a finger breath) a day.
Progressive changes in the uterus after delivery
The remains of the spongy layer of the decidua are shed. At the end of the 8th week, the placenta site is healed and a new endometrium is regenerated. After about 4 or more weeks menstruation may commence, by the 12th day of Puerperium the uterus has shrunk behind the symphysis pubis.
This is the term given to the discharges from the uterus during the Puerperium. They are alkaline in reaction and organism flourish more in it than in the acid vaginal secretion. The amount varies in
women and more in quantity than menstrual flow. The odor is heavy and unpleasant but not offensive, similar to menstrual flow. Lochia undergo changes as involution progresses. The volume is described as heavy, moderate and scanty
· Lochia rubra (red): 1 – 4 days of Puerperium. For t he first 3 days the lochia consist mainly of blood, shred of decidua and fragments of chorion, amniotic fluid, laguno vernix caseosa and meconium.
· Lochia serosa (pink): 5 – 9 days. The discharge is paler and brownish in color. It contains less blood and more serum. Also contains leucocytes and organism , no clots
· Lochia Alba (white) 10 –15 days: the discharge is c reamy greenish in color and contains leucocytes, organisms, cervical mucus and debris from healing process in the uterus and vagina. Slight blood discoloration may be seen for a further 2—3 weeks. A persistent red lochia is a warning s ign of retained product of conception and likelihood of puerperal hemorrhage and this should be reported without delay.
Kidneys: renal action is increased in early part of Puerperiummore urine is passed because of reduction of blood volume (red cell mass) from its raised pregnancy levels and excretion of waste products of autolysis.
Bladder in the first few days micturation may be difficult partlybecause of reflex suppression of the destrusor activity and sphincters spasm from irritation of the levator ani muscle during delivery or odema of the urethra. During the first 1 or 2 days marked diuresis occurs due to falling progestrone and alteration of cell metabolism to the non-pregnant state.
During pregnancy circulatory volumeincreases by 50%,this places exact strain on the heart. The cardiac output immediately after delivery increases for about 48 hrs returing to pre-gravid level in 4 weeks. Fluid loss result from diaphoresis (profuse perspiration) and diuresis (urinary output) during labor and childbirth is approximately 2.2kg. Up to 500mls of blood may be lost in normal delivery. Amniotic fluid is another source during birth. The cardiovascular system has to quickly adjust itself to these changes. It also results in improvement in varicosities. There is relief of pressure on the vena cava placed on it by the gravid uterus.
Blood changes : in the last 4 weeks of pregnancy there is a significant rise in the levels of fibrous plasmogen factors II,VII,VIII &X. A few days a rapid fall in fibrogen plasminogen factor VIII level occurs while there is a rise in circulating fibrinogen degradation products, probably due to the lysis of fibrin deposits in placenta bed. By the 2nd week of Puerperium the coagulability of the blood is altered and increases risk of thrombosis is present. The normal non-pregnant red cell levels are reached about the 40th day.
The stretching muscles and lossof tone of abdominal muscles during pregnancy results in flabby appearances of the abdomen immediately after delivery. This normally responds to exercise and involution and gradual tightening of pelvic muscles and ligaments. This is however faster and better with primiparae than multiparae.
Nervous systems: this is normally unaffected except for theeffects of drugs during labor
Integumentary: striae gravidarum become lighter and silvery;gradual disappearance of linea nigra, chloasma gravidarum and nipple hyperpigmentation. With exercise and good diet circulation, muscle tone, skin elasticity and healing improves.
Respiratory:after child birth many women are able to breatheeasily. Shortness of breath at anytime after child birth requires further assessment to rule out underlying pathophiology ; Post – Partum Hemorrhage (PPH) .
Gastrointestinal system:some women experience constipation inpuerperium which may be attributed to relaxation of abdominal wall and loss of intra-abdominal pressure. The presence of hemorrhoids or an episiotomy may cause some discomfort during bowel movement.
Breasts: the female breast undergoes changes during pregnancy inpreparation for lactation and breast feeding. Colostrums supply the neonate with good nourishment. It contains more protein and salts (NaCl, Zinc) but less fat & Carbohydrate. The breast milk is secreted in the last month to 3 days postpartum when breast milk appears. It is rich in antibodies, acts as laxative aiding massage of mechonium. Lactation begins 48-72hrs after child birth, but not fully established until about 10 days after birth.