The Puerperium (suite de couche normale).

Plan:

Definition.

Objectives:-Monitor physiological changes of

the puerperium.

-Diagnose and treat postpartum omplications.

-Discuss breast feeding.

-Provide emotional support.

-Disacuss family planning and contraception.

-Postpartum consultation.

Physiological Changes.• Involution of the Genital and Urinary tracts.

I- Uterus, Uterine height 30-35cm, 1-1.5kgs, involutes by 1-2cm dailly,

10-14 days becomes a pelvic organ.

By 4 weeks non gravid size(50-70gms).

3wks <100gms, 2wks 300gms, 1wk 500gms.

Uterine involution occurs by reduction in the size of individual

cells(autolysis).

Lower segment disappears(junction between cervix and body of uterus).

Dr. Nana

Physiological Changes(1).

Cervix regresses, internal OS is closed, infra vaginal1.5-2cm,by a

week, external OS remains dehiscent.

Ectropion, endocervical mucosa may remain visible for a long

period.

• Regeneration of the Endometrium.

Separation of placenta / membranes involves only spongy layer.

2-3 days later basal portion differentiates into superficial layer,

becomes necrotic and basal layer, regenerates the new

endometrium. Dr. Nana

Physiological Changes(2).• Involution of the Placenta site.

At delivery, size of a palm, 2 weeks 3-4cm in diameter, complete

extrusion <6 weeks.

Involution of endometrium and placenta site can be summarised into

four stages:

1. Regression delivery to day five.

2. Scarring of placenta site day five to 25 without hormonal stimulation.

3. Proliferation of endometrium day 25-45 influenced by oestrogens.

Dr:Nana

Physiological Changes(3).4 Resumption of menses triggered by ovulation by 40th day.

Sometimes ovulation doesnot occur,bleeding is withdrawal in

origin, ovulation usually occurs by the 60th day.

• Vagina,vaginal outlet.

Sperficial erosion scar quickly, some degree of colpocele

occurs at delivery , regresses quick, myrtiforme caruncles

may be seen, intriotus closes with time, perineum regains ist

tonicity but must be reinforced with appropriate gymnastics.

Dr.Nana

Physiological Changes(4).

• Abdomen. Rupture of elastic fibers, diastases of the rectus

abdominus muscle.

• A slow regression of other changes, biliary and urinary

tracts(cholecystography and IVP interpretation difficult).

• Relative insensitivity to intravesical pressure, Retention.

• Biochemistry: several modifications progressively regress to

normal, tolerance to glucose or carbohydrates, changes in lipid

levels( HDL,LDL,Cholesterol,trigycerldes), clotting factors,

antithrobine III. DrNana

Physiological Changes(5).

• Hormonolgy:

1. Oestrgens decrease at delivery, increases from the 25th day

inflenced by FSH.

2. Progesterone decreases within 10 days of delivery, appears only

after the 1st ovulation.

3. LHrh is low until the 25th day, LH peak occurs at about the 40th

day.

4. FSH increases from the 25th day.

Dr.Nana

Breast Feeding.• Colostrum ( 2nd half of pregnancy-delivery).

1. It contains more amino-acids (cystine, arginine, histidine),

minerals.

2. It contains less sugars (lactose) and fats (linoloeic acid).

3. Rich in immunoglobulins-secretory IgA.

4. Other host resistance factors in milk and colostrum include: IgA,

components of complements, macrophages, lymphocytes,

lactoferrin, lactoperoxidase, lysozymes

5. Colostrum has a laxative action. Dr.Nana

Breast Feeding(1).

• Breast Milk (2-5days).

1. Volume increases, maximum by the 3rd month. Volume varies

between 500-750ml /day by 3 months.

2. Volume inceased in twin delivery.

3. Hypogalactia or low milk secretion is rare.

4. It may be of 1ary or 2ary origin, primary rare and is due to

hypothalamo-pituitary disorder.

Dr.Nana

Breast Feeding(2).

5-Secondary is common: maternal fatigue, emotional breakdown,

change of lifestyle. Reversible with emotional support, frequent

breast feeding, complete emptying of breast at each feed,

bedrest, increase fluid intake and galactogil.

6-Breast milk is isotonic to water, contains proteins, fats and water.

7-All vitamins are found in breast milk but for vitamin K.

8-Breast milk has several advantages over artificial milk.

Dr.Nana

Breast Feeding(3).

• Complications of Breast Feeding.

1. Nipple cracks/ lacerations: occur in 1:4 breast feeding

mothers, occurs within 2 weeks of delivery.

Risk factors: clear skin women, synthetic breast wears, prolonged

breast feeding and poor breast feeding techniques.

Treatment,expose to air or sunlight, use topical lotions containing

vitamin A and E, 1% aqueous eosin etc.

Dr.Nana

Breast Feeding(4).

2-Engorgement: 1st week, 15% of breast feeding mothers

affected.

Risk factors, poor feeding (SFD, sickchild), nipple cracks, pains,

maternal anxiety, weaning etc. Breast distended, hard

tender with low-grade fever.

Treatment: massage, topical ointment, continue breast feeding.

May complicate with breast lymphangitis or abscess.

Dr.Nana

Breast Feeding(5).

3-Lymphangitis: 5%, Risk factors:nipple cracks, engorgement.

Germs skin flora, swollen warm tender breast , fever 39-40 `C.

Treatment, humid dressing, ATBs, Anti-inflammatory, bedrest.

4-Galactophoritis: complicates lymphangitis/ engorgement.

Hard painful nodule in the breast, fever and axilla nodes.

Budin sign positive. Treament: ATBs, Anti-inflammatory,

stop breast feeding but empty breast.

Dr.Nana

Breast Feeding(6).

5- Breast Abscess: 1%, complicates a poorly treated

lymphangitis or galactophoritis. Pain, fever 39- 40 ` C,

fatique, insomnia.

Treament: Drainage, ATBs, stop breast feeding, empty breast.

Contra-indications to breast feeding: Active TB infection,

congestive heart failure, viral hepatitis, HIV, some drugs.

Dr. Nana

Clinical Aspects of the puerperium.• Useful parameters: BP, pulse, temperature,duiresis.

• Day 1: 0-2hrs Immediate postpartum

2-24hrs Early postpartum.

>24hrs- 6weeks Late postpartum.

• Other Days: complete examination.

• After birth pains, Lochia rubra 1-3 days, lochia serosa 4-7 days,

lochia alba >7days,

• Lochia contains epithelial cells, RBCs, shreds of decidua, bacteria.

Dr.Nana

Clinical Aspects of the Puerperium(1).

• Duiresis increase (day 2-5).

• Leucocytosis (labour, delivery and immediate postpartum).

• Weight loss ( content ofuterus, uterine involution, duiresis).

• Check for depression ( Transient depression or postpartum

blues).

Dr.nana

Clinical Aspects of the puerperium(2).

Risk factors:-Emotional breakdown that follows the excitement

and fear of pregnancy and delivery.

-Discomfort of the early puerperium.

-Fatique from loss of sleep at labour /postpartum.

-Fear of becoming less attractive and anxiety.

Dr.Nana

Clinical Aspects of the Puerperium(3).

• Preventive Measures – Haemorrhage

-Immunisation, Rh –ve, ATT, vaccination of baby.

-Deep vein thrombosis.

-Personal hygiene, vulva, breast, exercise.

-Supplementation(Fe).

-Mentruation and ovulation, 6-8weeks without breast feeding,

majority between 2-18 months, 8% after one month, 61% at a

year, 25% become pregnant by one year. Intermittent bleeding.

Dr.Nana

Pathologic Puerperium.• Several complications occur within 2 weeks of delivery: Infections,

thrombo-embolism, haemorrhage, anaemia, postpartum hypertension

and /or psychosis.

• Risk factors for infection in the puerperium:

-Anaemia, UTI in pregnancy.

-PROM >24hrs.

-Prolonged labour.

-Intrapartum fever.

-Obstetric manoeuvres.Intrumental deliveries, manual delivery of placenta,

uterine revision. Dr.Nana

Pathologic Puerperium(1).• Risk factors for Thrombo-embolism:

-Age >35 years.

-C/S.

-P/H thrombo-embolic disease.

-Varices.

-Cardiopathies.

-Prolonged hospitalisation.

-Postpartum haemorrhage.

-Postpartum BTL. Dr.Nana

Postpartum Consultation.

• Objectives:Verify

- Regression of physiologic changes.

- Involution of the uterus/ genital tract.

- Persistence of pathologies developed during pregnancy.

- Counsel for sexual life and family planning.

NB: Late complication of the puerperium: haemorrhage,

amenorrhoea, postpartum thyroiditis, stress etc.

Dr.Nana