Chapter 17. The Puerperium

1. Chapter 17. The Puerperium OBGY R1변정미`

2. Definition • Period of confinement during and just after birth   • includes 6 subsequent weeks postpartum during which normal pregnancy involution occurs Chapter. 17 Puerperium

3. Clinical and Physiological Aspects of the Puerperium • Uterine Changes • Urinary Tract Changes • Relaxation of the Vaginal Outlet and Prolapse of the Uterus • Peritoneum and Abdominal Wall • Blood and Fluid Changes Chapter. 17 Puerperium

4. Chapter. 17 Puerperium Mammary Glandes • Breast Anatomy • Breast Feeding

5. Care of the Mother during the Puerperium • Hospital Care • Care at Home Chapter. 17 Puerperium

6. Chapter. 17 Puerperium Uterine Changes Changes in the uterine vessels • Caliber of extrauterine vessels : decrease to equal size of prepregnant state after delivery •   Blood vessels within puerperal uterus       :  obliterated by hyaline change replaced by smaller vessels

7. Chapter. 17 Puerperium Uterine Changes Changes in the Cervix & Lower Uterine Segment • Cervical opening contracts slowly and for a few days immediately after labor ( ≒ 2fingers )  :  by the end of the 1st wk → it has narrowed • As the opening narrows the cervix thickens and a canal reforms. • Bilateral depression at the site of lacerations remain as permanent changes that characterize the parous cervix

8. Chapter. 17 Puerperium Uterine Changes Changes in the Cervix & Lower Uterine Segment • Markedly thinned-out lower uterine segment     : contracts & retracts    → uterine isthmus located between the uterine corpus above and the internal cervical os below - over the course of few weeks

9. Chapter. 17 Puerperium Uterine Changes Involution of uterine corpus • Fundus of contracted uterus    : slightly below umbilicus immediately after placental expulsion - within 2 wks : descend into a cavity of true pelvis            - within about 4 wks : regain previous nonpregnant size

10. Chapter. 17 Puerperium Uterine Changes Involution of uterine corpus • Weight of uterus       : immediately postpartum, 1000g         - 1 week later : 500g          - at the end of 2nd week : 300g,  - soon thereafter 100g or less       : total number of muscle cells does not decrease → individual cells decrease markedly in size •  Separation of the placenta and membrane involves the spongy layer →decidua basalis remains in the uterus

11. Chapter. 17 Puerperium Uterine Changes Afterpains  • Primiparas: puerperal uterus tends to remain tonically contracted • Multiparas : contracts vigorously at interval → afterpain • Infant suckles →oxytocin release →Ut. contraction → afterpain • Occasionally severe enough to require an analgesic    : usually become mild by the 3rd postpartum day

12. Chapter. 17 Puerperium Uterine Changes Lochia    Early in the puerperium, sloughing of decidual tissue  → vaginal discharge of variable quantity • lochia rubra : first few days after delivery blood in lochia • lochia serosa : after 3 or 4 days becomes progressively pale in color • lochia alba    : after 10th day white or yellowish-white color, • lasted for approximately 2weeks after delivery

13. Chapter. 17 Puerperium Uterine Changes Endometrial regeneration the remain decidua becomes differentiated into 2 layers within 2 or 3 days after delivery    • superficial layer : become necrotic, sloughed in the lochia • basal layer  : remains intact, source of new endometrium

14. Chapter. 17 Puerperium Uterine Changes Endometrial regeneration • Endometrial regeneration is rapid, except at the placental site      - free surface becomes covered by epithelium within a week or so  - entire endometrium is restored during the 3rd week - endometritis & salpingitis : not infection but only part of the involutional       process 

15. Chapter. 17 Puerperium Uterine Changes Subinvolution  • an arrest or retardation of involution , the process by which the puerperal uterus is normally restored to its original proportions • Cause    : retention of placental fragments, pelvic infection • Accompanied by prolongation of lochial discharge & irregular or excessive uterine bleeding and sometimes by profuse hemorrhage

16. Chapter. 17 Puerperium Uterine Changes Subinvolution  • Bimanual examination    : uterus is larger & softer than normal for the particular period of puerperium • Treatment   : ergonovine or methylergonovine(Methergine)      oral antibiotics : usually effective in metritis

17. Chapter. 17 Puerperium Uterine Changes Placental site involution   : Complete extrusion of placental site takes up to 6 weeks • Immediately after delivery, palm size    → 3-4cm in diameter (end of 2nd week, ) • Placental site   : normally consists of many thrombosed vessels within hours of delivery → ultimately undergo organization of thrombus • Placental site exfoliation : as the consequence of sloughing of infarcted and necrotic superficial tissues followed by a reparative process - Anderson and Davis (1968)-

18. Chapter. 17 Puerperium Uterine Changes Late postpartum hemorrhage Serious uterine hemorrhage occasionally develops 1-2 weeks after delivery • Cause abnormal involution of placental site (most often) retention of a portion of the placenta           → usually undergo necrosis with deposition of fibrin           → form a placental polyp • Treatment intravenous oxytocin, ergonovine, methylergonovine, prostaglandins curettage

19. Chapter. 17 Puerperium Urinary Tract Change • dilated renal pelvis & ureters       : return to prepregnant state 2-8 weeks after delivery  • Puerperal diuresis      physiological reversal of pregnancy-induced increase in extracellular water       : regularly occurs between 2nd and 5th day • Puerperal bladder create optimal condition for development of UTI : increased capacity & relative insensitivity to intravesical fluid pressure       → overdistention, incomplete emptying, excessive residual urine  

20. Chapter. 17 Puerperium Urinary Tract Change • most women returned to normal micturition by 3months postpartum • Careful attention to all postpartum women, with prompt catheterization for those who cannot void, will prevent most urinary problems

21. Chapter. 17 Puerperium Relaxation of the vaginal outlet and prolapse of the Uterus • Vagina and vaginal outlet gradually diminishes in size but rarely returns to nulliparous dimensions • Rugae : reappear by the 3rd week • hymen: represented by several small tags of tissue, which during cicatrization are converted into the myrtiform caruncles • Relaxation of vaginal outlet     ← extensive laceration or overstretching of perineum during delivery • Changes in pelvic supports during parturition       : predispose to uterine prolapse & urinary stress incontinence          → operative correction is usually postponed until childbearing is ended

22. Chapter. 17 Puerperium Peritoneum and Abdominal wall • Broad & round ligaments      : much more lax than nonpregnant      : require considerable time to recover from stretching & loosening • Abdominal wall     : return to normal → requires several weeks (aided by exercise)     : usually resumes its prepregnancy state except for silvery striae

23. Chapter. 17 Puerperium Blood and Fluid Changes • leukocytosis and thrombocytosis occur during and after labor     : by 1 week after delivery, blood volume return nearly to nonpregnant level •  Cardiac output remains elevated for at least 48 hours postpartum       (due to increased stroke volume from venous return)

24. Chapter. 17 Puerperium Weight loss • Uterine evacuation & normal blood loss : 5-6 kg • Further decrease through diuresis        : 2-3 kg   • factors of Weight loss • weight gain during pregnancy • primiparity • early return to work (outside the home) • smoking • not affect weight loss • breastfeeding • age • marital status

25. Chapter. 17 Puerperium Breast anatomy • A ducts • B lobules • C dilated section of duct to hold milk • D nipple • E fat • F pectoralis major muscle • G chest wall/rib cageEnlargement: • A normal duct cells • B basement membrane • C lumen (center of duct)

26. Chapter. 17 Puerperium Breast Feeding Lactation • Colostrum the deep lemon-yellow colored liquid secreted initially by the breasts        - expressed from the nipples by the second postpartum day        - contains more minerals and protein - globulin less sugar and fat        - Abs esp. IgA               - persists for about 5days - gradual conversion to mature milk during the ensue 4weeks • Milk   - 600mL/day     - major proteins -including α-lactalbumin, β-lactoglobulin and casein  - interleukin -6, epidermal growth factor 

27. Chapter. 17 Puerperium Breast Feeding Endocrinology of lactation  • Progesterone, estrogen, placental lactogen, prolactin, cortisol, insulin       : appear to act in concert to stimulate the growth & development of           milk-secreting apparatus of mammary glands • Prolactin is essential for lactation       Although plasma prolactin falls after delivery, suckling triggers a rise • Milk ejection or letting down reflex       : initiated especially by suckling       → stimulates neurohypophysis to liberate oxytocin       → contraction of myoepithelial cells in the alveoli & small milk ducts       → milk expression from lactating breast     

28. Chapter. 17 Puerperium Breast Feeding Immunological Consequences of Breast Feeding • Predominant immunoglobulin in milk is secretory IgA       : contains secretory IgA antibodies against E. coli → breast-fed infants are less prone to enteric infections • Contains both T & B lymphocytes Nursing • Even though the milk supply at first appears insufficient, it become adequate if suckling is continued • Nursing accelerates uterine involution : repeated stimulation of nipples release oxytocin → contracts uterine muscle 

29. Chapter. 17 Puerperium Breast Feeding Lactation Inhibition • Milk leakages, engorgement, & breast pain peak at 3 to 5 days postpartum    → support with well-fitting brassiere or breast binder, ice packs oral analgesics   • Inhibitors Bromocriptine bromocriptine has been associated with strokes, myocardial infarction, seizures, and psychiatric disturbances in puerperal women 

30. Chapter. 17 Puerperium Breast Feeding Contraception • Not needed in the first 3 weeks postpartum • Progestin only contraceptives      : mini-pills, depot medroxyprogesterone, levonorgestrel implant      : do not affect the quality & increase the volume of milk very slightly          → contraceptives of choice for breast feeding women • Estrogen-progestin contraceptives     : reduce the quantity & quality of breast milk : puerperal women have predisposition to venous thrombosis           → increased by combination contraceptive pills               ⇒ low dose pills are preferred if used in lactating women   

31. Chapter. 17 Puerperium Breast Feeding Contraindications • take street drugs • do not control alcohol use • have an infant with galactosemia • have HIV infection • have active, untreated tuberculosis • take certain medications • are undergoing breast cancer treatment         (ACOG, 2000) • Cytomegalovirus and hepatitis B virus are excreted in milk • Women with active herpes simplex virus

32. Chapter. 17 Puerperium Breast Feeding Drugs secreted in milk   Most drugs given to the mother are secreted in breast milk        : but amount of drug ingested by the infant is typically small Care of the breasts and nipples Dried milk is likely accumulate & irritate the nipples   → cleaning of areola with water & mild soap is helpful before and after nursing

33. Chapter. 17 Puerperium Breast Feeding Breast fever • For the first 24 hours after development of lacteal secretion, : breasts to become distended, firm, & nodular        ← exaggeration of normal venous & lymphatic engorgement of the breast             (not the result of overdistention of lacteal system with milk) • Puerperal fever from breast engorgement is common           : 37.8~39℃, seldom persists for longer than 4~16 hours           : other causes (especially infection) of fever must be excluded • Treatment           : binder or brassiere, ice bag, analgesics, pumping or manual expression     

34. Chapter. 17 Puerperium Breast Feeding Mastitis • Parenchymatous infection of mammary glands • seldom appear before the end of the 1st week postpartum not until the 3rd or 4th week. • unilateral, breast becomes hard, reddened and painful  • Signs : chills (1st), rigor, fever, tachycardia • Etiology Staphylococcus aureus (most common)  ※ breast abscess : caused by group B streptococcus - almost always from nursing infant's nose & throat   → the organism enters the breast through the nipple at the site of a fissure or abrasion      

35. Chapter. 17 Puerperium Breast Feeding • Treatment • swab and cultured  • antimicrovial therapy        : penicillin or cephalosporin       : MRSA →vancomycin       - continued for about 7-10days • Continue breast feeding      : early Tx & continued lactation is successful in avoiding abscess formation Breast abscess • surgical drainage (essential) & general anesthesia

36. Chapter. 17 Puerperium Hospital Care Attention immediately after labor • for the first hour after delivery    - BP & PR : should be taken every 15 minutes • monitor amount of vaginal bleeding • Fundus should be palpated to ensure that it is well contracted if relaxation detected, uterus should be massaged through abdominal wall until it remains contracted

37. Chapter. 17 Puerperium Hospital Care Early ambulation • Advantages less frequent bladder complications & constipation reduced frequency of puerperal venous thrombosis & pulmonary embolism Care of the Vulva • Should be instructed to cleanse vulva from anterior to posterior (vulva→anus) • Ice bag applied to perineum • Warm sitz bath : beginning about 24 hours after delivery • Tub bathing after uncomplicated delivery is allowed

38. Chapter. 17 Puerperium Hospital Care Bladder function • Oxytocin : commonly infused after placental delivery sudden withdrawal of antidiuretic effect of oxytocin      → rapid bladder filling • both bldder sensation and its capability to empty      → diminished by anesthesia (esp. conduction analgesia), by episiotomy, laceration or hematomas → Urinary retention with bladder overdistention          : common complication of the early puerperium • woman who has not voided within 4 hours after delivery       → indwelling catheter → prevent overdistension        

39. Chapter. 17 Puerperium Hospital Care • Tx of bladder overdistention indwelling of catheter for at least 24 hours • empty the bladder completely • prevent prompt recurrence • allow recovery of normal bladder tone & sensation  • after catheter remove, if the woman cannot void after 4hours     → should be catheterized and urine vol. measured • ≥200 cc of urine        : catheter should be left in place and the bladder drained for another day • ≤200cc of urine : remove the catheter & recheck the bladder.

40. Chapter. 17 Puerperium Hospital Care Bowel function early ambulation and early feeding    → constipation ↓ Subsequent discomfort • during the first few days after vaginal delivery uncomfortable by afterpains, episiotomy & lacerations, breast engorgement    → codeine, aspirin, acetaminophen • Episiotomy & lacerations     - early application of an ice bag     - local analgesic spray      - healed and nearly asymptomatic by the 3rd weeks

41. Chapter. 17 Puerperium Hospital Care Mild depression • Some degree of depression a few days after delivery is fairly common : Postpartum blues (= transient depression) • Cause • 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 in most hospital settings • Anxiety over her capabilities for caring for her infant after leaving the hospital • Fears that she has become less attractive • self-limited & usually remits after 2~3 days

42. Chapter. 17 Puerperium Hospital Care Abdominal wall relaxation Exercise to restore abdominal wall tone       : any time after vaginal delivery, as soon as abdominal soreness diminishes after cesarean delivery Diet No dietary restrictions for women who have been delivered vaginally    2 hours after normal vaginal delivery, (if, no Cx) • lactating women : should be increased in calories and protein • not breast feeding : dietary requirement as for a nonpregnant woman

43. Chapter. 17 Puerperium Hospital Care Immunizations • Anti D-immune globulin 300 μg : nonimmunized women    - within 72 hours of the birth of a D-positive infant • Rubella vaccination   • Diphtheria-tetanus toxoid booster infection • Measles immunization Time of discharge       if, no complication (at vaginal delivery)           hospitalization period ≤ 48 hours 

44. Chapter. 17 Puerperium Care at Home Coitus • Median interval between delivery and intercourse : 5 weeks (1~12 weeks) • Best rule is one of common sense after 2 weeks, coitus may be resumed based on the pt's desire & comfort * breast feeding : cause a prolonged period of suppressed estrogen production with a resulting vaginal atrophy and dryness

45. Chapter. 17 Puerperium Care at Home Return of menstruation and ovulation  • If not nursing : usually return within 6-8 weeks • Lactating woman            : first period may occur 2nd~18th months after delivery  • Ovulation - as early as 36-42 days(5-6 wks) after delivery       - delayed resumption of ovulation with breast feeding            but early ovulation is not precluded by persistent lactation             → pregnancy can occur with lactation   

46. Care at Home Chapter. 17 Puerperium Follow-up care • Normal delivery and puerperium : women can resume most activities (bathing, driving, household functions) by the time of discharge • Follow-up examination during 3rd postpartum wk has proven quite satisfactory     - identify any abnormalities of later puerperium    - initiate contraceptive practice

47. Chapter. 17 Puerperium Care at Home Thromboembolic disease in recent year : decreased identified during the antepartum period Pelvic venous thrombosis • during the puerperium a thrombus may transiently form in any of the dilated pelvic veins • without associated thrombophlebitis – not incite clinical signs or symptoms • The massive and fetal pulm. emboli that develop without warning in the puerperium : symptomatic puerperal pelvic thrombosis is most commonly associated with uterine infection    

48. Chapter. 17 Puerperium Care at Home Obstetrical paralysis  • Pressure on branches of lumbosacral plexus during labor      : complaints of intense neuralgia or cramplike pains extending down one or both legs as soon as the fetal head begins to descend the pelvis           • Involved external popliteal n. femoral n. obturator n, sciatic n. • the gluteal m. are affected. • Separation of the symphysis pubis or one of the sacroiliac synchondroses during labor may be followed by pain and marked interference with locomotion.

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