Normal puerpérium 6 weeks after pregnancy

Normal pueperium

1. NORMAL PUERPERIUM NAMUBIRU AISHA 2022-04-09883

2. PUERPERIUM DEFINITION ; Puerperium is the period following childbirth during which the body tissues, especially the pelvic organs revert back approximately to the prepregnant state both anatomically and physiologically. The retrogressive changes are mostly confined to the reproductive organs with the exception of the mammary glands which in fact show features of activity. INVOLUTION DEFINITION ; Is the process whereby the genital organs revert back approximately to the state as they were before pregnancy . The woman is termed as a puerpera.

3. Duration: Puerperium begins as soon as the placenta is expelled and lasts for approximately 6 weeks when the uterus becomes regressed almost to the non pregnant size. Divided into Immediate – within 24 hours Early – up to 7 days Remote – up to 6 weeks. Similar changes occur following abortion but takes a shorter period for the involution to complete .

4. THE FOURTH TRIMESTER Is the time from delivery until complete physiolgical involution and psychological adjustment. The weeks following childbirth are a critical period for the woman and her infant, An initial visit is recommended at 3 weeks post delivery and a final summary visit at 12 weeks. Between this time, visits can be added as needed. For example, women with chronic hypertension, overt diabetes, cardiovascular disease, and depression may require additional multidisciplinary care during this period.

5. REPRODUCTIVE TRACT INVOLUTION Birth Canal Return of the tissues in the birth canal to the non pregnant state begins soon after delivery. The vagina and its outlet gradually diminish in size but rarely regain their nulliparous dimensions. Rugae begin to reappear by the third week but are less prominent than before. The hymen is represented by several small tags of tissue, which scar to form the myrtiform caruncles . The vaginal epithelium reflects the hypoestrogenic state, and it does not begin to proliferate until 4 to 6 weeks. This timing is usually coincidental with resumed ovarian estrogen production. Lacerations or stretching of the perineum during delivery can lead to vaginal outlet relaxation. Some damage to the pelvic floor may be inevitable, and parturition predisposes to pelvic organ prolapse

6. Uterus The massively augmented uterine blood flow necessary to maintain pregnancy derives from significant hypertrophy and remodeling of pelvic vessels. After delivery, their caliber gradually diminishes to approximately that of the prepregnant state. Within the puerperal uterus, larger blood vessels become obliterated by hyaline changes. They are gradually resorbed and replaced by smaller ones. After delivery, the fundus of the contracted uterus lies slightly below the umbilicus. The lower uterine segment contracts and retracts, but not as forcefully as the uterine corpus. At this time, the uterus weighs approximately 1000 g. Myometrial involution is a truly remarkable feat of destruction or deconstruction that begins as soon as 2 days after delivery.

7. The total number of myocytes does not decline appreciably—rather, their size decreases markedly . Weights from removed uteri approximate 500 g by 1 week postpartum, 300 g by 2 weeks, and at 4 weeks, involution is complete and the uterus weighs approximately 100 g. After each successive delivery, the uterus is usually slightly larger than before the most recent pregnancy .

8. Decidual and Endometrial Regeneration Because separation of the placenta and membranes involves the spongy layer, the decidua basalis is not sloughed . The in situ decidua varies markedly in thickness, it has an irregular jagged border, and it is infiltrated with blood, especially at the placental site . Within 2 or 3 days after delivery, the remaining decidua becomes differentiated into two layers . The superficial layer becomes necrotic and is sloughed in the lochia . The basal layer adjacent to the myometrium remains intact and is the source of new endometrium. Decidual vessels are near normal by delivery and endovascular trophoblasts are diminished. These vessels and the spiral arteries also undergo involution

9. PLACENTAL SITE INVOLUTION Complete extrusion of the placental site takes up to 6 weeks . Immediately after delivery, the placental site is approximately palm sized. Within hours of delivery, it normally contains many thrombosed vessels that ultimately undergo organization. By the end of the second week, it measures 3 to 4 cm in diameter. Placental site involution is an exfoliation process, which is prompted in great part by undermining of the implantation site by new endometrial proliferation. Thus, involution is not simply absorption in situ. Exfoliation consists of both extension and “down growth” of endometrium from the margins of the placental site, as well as “upward” development of endometrial tissue from the glands and stroma left deep in the decidua basalis after placental separation. placental site exfoliation results from sloughing of infarcted and necrotic superficial tissues followed by a remodeling process.

10. Cervix During labor and vaginal delivery, the margin of the dilated cervix, which corresponds to the external os, may be lacerated . The cervical opening contracts slowly, and for a few days immediately after labor, it readily admits two fingers. By the end of the first week, this opening narrows, the cervix thickens, and the endocervical canal reforms. The external os does not completely resume its pregravid appearance. It remains somewhat wider, and typically, Ectocervical depressions at the site of lacerations become permanent. These changes are characteristic of a parous cervix

11. The rate of involution of the uterus can be assessed clinically by noting the height of the fundus of the uterus in relation to the symphysis pubis. The measurement should be taken carefully at a fixed time everyday, preferably by the same observer. Bladder must be emptied beforehand and preferably the bowel too, as the full bladder and the loaded bowel may raise thelevel of the fundus of the uterus. The uterus is to be centralized and with a measuring tape, the fundal height is measured above the symphysis pubis. Following delivery, the fundus lies about 13.5 cm (5 1/2") above the symphysis pubis. CLINICAL ASSESSMENT OF INVOLUTION

12. During the first 24 hours, the level remains constant; thereafter, there is a steady decrease in height by 1.25 cm (0.5") in 24 hours, so that by the end of 2nd week the uterus becomes a pelvic organ. The rate of involution thereafter slows down until by 6 weeks, the uterus becomes almost normal in size. The involution may be affected adversely and is called subinvolution. Sometimes, the involution may be continued in women who are lactating so that the uterus may be smaller in size—superinvolution. The uterus, however, returns to normal size if the lactation is withheld.

13. Clinical Aspects After pains. Several clinical findings coincide with uterine involution . In primiparas, the uterus tends to remain tonically contracted following delivery. In multiparas, however, it often contracts vigorously at intervals and gives rise to after pains, which are similar to but milder than labor contractions. These are more pronounced as parity increases and worsen when the newborn suckles, likely because of oxytocin release . Usually, after pains decrease in intensity and become mild by the third day . We have encountered unusually severe and persistent afterpains in women with postpartum uterine infections

14. Lochia. It is the vaginal discharge for the first fortnight during puerperium. The discharge originates from the uterine body, cervix and vagina . Early in the puerperium, sloughing of decidual tissue results in a vaginal discharge of variable quantity . The discharge is termed lochia and contains erythrocytes, shredded decidua, epithelial cells, and bacteria . Odor and reaction: It has got a peculiar offensive fishy smell. Its reaction is alkaline, tending to become acid toward the end

15. Lochia Rubra (red) 1–4 days Composition : Consists of blood, shreds of fetal membranes and decidua, vernix caseosa, lanugo and meconium. Lochia serosa (5–9 days) — the color is yellowish or pink or pale brownish. consists of less RBC but more leukocytes, wound exudate, mucus from the cervix and microorganisms (anaerobic streptococci and staphylococci). The presence of bacteria is not pathognomonic unless associated with clinical signs of sepsis. Lochia alba lochia alba — (pale white) — 10–15 days contains plenty of decidual cells, leukocytes, mucus, cholesterin crystals, fatty and granular epithelial cells and microorganisms.

16. After approximately the 10th day, because of an admixture of leukocytes and reduced fluid content, lochia assumes a white or yellow white color. The average duration of lochial discharge ranges from 24 to 36 days . Amount: The average amount of discharge for the first 5–6 days is estimated to be 250 mL. Normal duration: The normal duration may extend up to 3 weeks. The red lochia may persist for longer duration especially in women who get up from the bed for the first time in later period. The discharge may be scanty, especially following premature labors or may be excessive in twin delivery or hydramnios .

17. Clinical importance : The character of the lochial discharge gives useful information about the abnormal puerperal state. The vulval pads are to be inspected daily to get information of: Odor: If malodorous—indicates infection. Retained plug or cotton piece inside the vagina should be kept in mind. Amount: Scanty or absent — signifies infection. If excessive — indicates infection. Color: Persistence of red color beyond the normal limit signifies sub involution or retained bits of conceptus. Duration : Duration of the lochia alba beyond 3 weeks suggests local genital lesion

18. Sub involution In some cases, uterine involution is hindered because of incompletely remodeled spiral arteries retained placental fragments infection. Such subinvolution is accompanied by varied intervals of prolonged lochia and by irregular or excessive uterine bleeding . During bimanual examination the uterus is larger and softer than would be expected. With bleeding, pelvic sonography may help differentiate sub involution from retained placenta.

19. Characteristic findings of retained products include a thickened endometrium or endometrial mass. Vascularity within this area increases the likelihood of retained products. Comparatively, sub involution is characterized by an enlarged uterus with tubular hypoechoic areas in the myometrium. These tubular structures reflect neovascularization and dilated uterine vessels .

20. URINARY TRACT Normal pregnancy-induced glomerular hyperfiltration persists during the puerperium but returns to prepregnancy baseline by 2 weeks. Parturition induces a transient rise in excretion of glomerular podocytes. Dilated ureters and renal pelves return to their prepregnant state by 2 to 8 weeks postpartum. Because of this dilated collecting system, coupled with residual urine and bacteriuria in a traumatized bladder, symptomatic urinary tract infection remains a concern in the puerperium. Bladder trauma is associated most closely with labor length and thus to some degree accompanies normal vaginal delivery. Postpartum, the bladder has a greater capacity and a relative insensitivity to intravesical pressure.

21. Consequently, over distention, incomplete emptying, and excessive residual urine are frequent. Acute urinary retention is more common with epidural or narcotic analgesia. Stress urinary incontinence during the puerperium may occur in 5 percent of women.

22. PERITONEUM AND ABDOMINAL WALL The broad and round ligaments require considerable time to recover from stretching and loosening during pregnancy. The abdominal wall remains soft and flaccid as a result of ruptured elastic fibers in the skin and prolonged distention by the gravid uterus. If the abdomen is unusually lax or pendulous, an ordinary girdle is often satisfactory. An abdominal binder is another temporary measure. Several weeks are required for these structures to return to normal, and exercise aids recovery. These may be started anytime following vaginal delivery . After cesarean delivery, a 6-week interval to allow anterior abdominal wall fascia to heal and abdominal soreness to diminish is reasonable. Except for these, the abdominal wall usually resumes its prepregnancy appearance. When muscles remain atonic, however, the abdominal wall also remains lax.

23. Marked separation of the rectus abdominis muscles—diastasis recti— may result . This separation develops from a gradual thinning and widening of the linea alba and is coupled with a general laxity of the ventral abdominal wall muscles .

24. REFERENCES Williams obstetrics 26 th edition Dc Dutta’s Textbook of OBSTETRICS