The puerperium

Christiana p. Calagui-damaso, m.d. Ob-gyn

period of time encompassing the first few weeks following birth between 4 and 6 weeks

Anatomical, Physiological, and Clinical Aspects

Vagina and Vaginal Outlet

Rugae - begin to reappear by the third week but are not as prominent as before Myrtiform caruncles Vaginal epithelium - begins to proliferate by 4 to 6 weeks
usually coincidental with resumed ovarian estrogen production

Uterus
Vessels
their caliber diminishes to approximately the size of the prepregnant state within the puerperal uterus, larger blood vessels become obliterated by hyaline changes, gradually resorbed, and replaced by smaller ones

Cervix and Lower Uterine Segment

end of the first week
cervical opening narrows, the cervix thickens, and the endocervical canal reforms external os does not completely resume its pregravid appearance

next few weeks

lower segment is converted from a clearly distinct substructure large enough to accommodate the fetal head, to a barely discernible uterine isthmus located between the corpus and internal os

Uterine Involution
1000 g weight of the uterus immediately postpartum 2 days after delivery, the uterus begins to involute
1 week - 500 g 2 weeks, 300 g and has descended into the true pelvis 4 weeks - it regains its previous nonpregnant size of 100 g or less

cells decrease markedly in sizefrom 500-800 m by 5 to 10 m at term to 50-90 m by 2.5-5 m postpartum decidua basalis is not sloughed

Lochia - consists of erythrocytes, shredded decidua, epithelial cells, and bacteria

lochia rubra - first few days after delivery; red lochia serosa - 3 or 4 days; progressively pale in color lochia alba - 10th day; admixture of leukocytes and reduced fluid content; white or yellowishwhite color

Endometrial Regeneration
superficial layer - becomes necrotic and is sloughed in the lochia basal layer adjacent to the myometrium - remains intact and is the source of new endometrium endometrium arises from proliferation of the endometrial glandular remnants and the stroma of the interglandular connective tissue

Subinvolution

arrest or a retardation of involution accompanied by prolongation of lochial discharge and irregular or excessive uterine bleeding, which sometimes may be profuse both retention of placental fragments and pelvic infection may cause subinvolution bimanual examination
uterus is larger and softer than would be expected.

Ergonovine or methylergonovine (Methergine), 0.2 mg every 3 to 4 hours for 24 to 48 hours

Chlamydia trachomatis - azithromycin or doxycycline

Late Postpartum Hemorrhage

secondary postpartum hemorrhage - bleeding 24 hours to 12 weeks after delivery
result of abnormal involution of the placental site occasionally is caused by retention of a placental fragment

Treatment
oxytocin, ergonovine, methylergonovine, or a prostaglandin analog Antimicrobials gentle suction curettage curettage

Urinary Tract
overdistension, incomplete emptying, and excessive residual urine dilated ureters and renal pelves return to their prepregnant state - 2 to 8 weeks after delivery

Incontinence
Urinary incontinence in the first few days postpartum is uncommon

Peritoneum and Abdominal Wall

broad and round ligaments require considerable time to recover from the stretching and loosening that occur during pregnancy

Blood and Fluid Changes

Marked leukocytosis and thrombocytosis may occur during and after labor white blood cell count - 30,000/uL Relative lymphopenia and an absolute eosinopenia 1 week after delivery - blood volume has nearly returned to its nonpregnant

Cardiac output
usually remains elevated for 24 to 48 hours postpartum declines to nonpregnant values by 10 days

Weight Loss
5 to 6 kg loss - due to uterine evacuation and normal blood loss 2 to 3 kg loss - diuresis

2 L - decrease in sodium space during the first week postpartum

Breasts and Lactation

Colostrum

deep lemon-yellow liquid can be expressed from the nipples by the second postpartum day contains more minerals and amino acids has more protein, (globulin), less sugar and fat contains antibodies, and its content of immunoglobulin A (IgA) secretion persists for approximately 5 days, with gradual conversion to mature milk during the ensuing 4 weeks.

Human milk
suspension of fat and protein in a carbohydratemineral solution. nursing mother produces 600 mL of milk daily

isotonic with plasma, and lactose accounts for half of the osmotic pressure.

Essential amino acids - derived from blood nonessential amino acids - derived in part from blood or synthesized in the mammary gland.

milk proteins -lactalbumin, -lactoglobulin, and casein

All vitamins except K are found in human milk

Vitamin D content is low22 IU/mL

T and B lymphocytes
contains factors that act as biological signals for promoting cellular growth and differentiation

Whey - milk serum which contain large amounts of interleukin-6

associated closely with local IgA production by the breast.

Prolactin - actively secreted into breast milk Epidermal growth factor (EGF)
it may be absorbed to promote growth and maturation of newborn intestinal mucosa

Endocrinology of Lactation
Progesterone, estrogen, and placental lactogen, as well as prolactin, cortisol, and insulin
stimulate the growth and development of the milk-secretion

Decrease in the level of estrogen and progesterone during delivery

This decrease removes the inhibitory influence of progesterone on -lactalbumin production by the rough endoplasmic reticulum

Lactation prolactin secretion is increased by the repeated stimulus of suckling

Stimulus from the breast triggers the release of dopamine (prolactin-inhibiting factor) from the hypothalamus, and this in turn transiently induces increased prolactin secretion

Oxytocin secreted by the neurohypophysis

stimulates milk expression from a lactating breast by causing contraction of myoepithelial cells in the alveoli and small milk ducts Milk ejection or letting down - reflex initiated especially by suckling, which stimulates the neurohypophysis to liberate oxytocin

Immunological Consequences Of Human Mulk

1) Secretory IgG - predominant immunoglobulin in colostrum and milk
Contains antibodies against Escherichia coli, and breast-fed infants are less prone to enteric infections than bottle-fed infants

2) protection against rotavirus infections 3) reduces the risk of atopic dermatitis and wheezing illnesses in early childhood

Breast Engorgement/Pain Milk fever - 37.8 to 39 degrees Celsius Contraception

Contraindications to BF

women who take street drugs or do not control their alcohol use

have an infant with galactosemia

have human immunodeficiency virus (HIV) infection have active, untreated tuberculosis take certain medications undergoing treatment for breast cancer

Mastitis - Parenchymatous infection of the mammary glands

Staphylococcus aureus Dicloxacillin, 500 mg orally four times daily Erythromycin is given to women who are penicillin sensitive

Breast Abscess
when defervescence does not follow within 48 to 72 hours of mastitis treatment, or when a mass is palpable surgical drainage

Care of the Mother during the Puerperium

Hospital Care
For the first hour after delivery, blood pressure and pulse should be taken every 15 minutes, or more frequently if indicated

Early Ambulation Perineal Care

Bladder Function Depression Abdominal wall relaxation Diet

Neuromuscular and Joint Problems

Pressure on branches of the lumbosacral nerve plexus during labor may be manifest by complaints of intense neuralgia or cramplike pains extending down one or both legs as soon as the head descends into the pelvis

Pelvic or hip muscles and tendons can be stretched, torn, or separated during even normal labor Separation of the symphysis pubis or one of the sacroiliac synchondroses during labor may be followed by pain and marked interference with locomotion Time of Discharge

Home Care

Coitus Late maternal morbidity Postpartum Care follow up

Thank you!!