Normal Puerperium - from delivery up to 6weeks by doctor.uterus

Puerperium is the the period of adjustment after childbirth during which the mother’s reproductive system returns to its normal pre-pregnant state

1. PUERPERIUM

2. Puerperium word puerperium is derived from Latin puer-child and parus-bringing forth Puerperium or postpartum period is defined as the period from delivery up to six weeks postpartum . Post-delivery period is a dynamic phase when the anatomical and physiological changes that occur during pregnancy revert back to near pre-pregnant state referred to as “ fourth trimester of pregnancy .”

3. DURATION OF PUERPERIUM Normal puerperium starts from expulsion of placenta and lasts upto 6 weeks further divided into the following three time periods- IMMEDIATE PUERPERIUM: The first 24 hours after delivery acute and serious postpartum or post anesthetic complications like PPH, acute inversion of uterus and Mendelson’s syndrome (acid aspiration) can occur EARLY PUERPERIUM : period of first week after delivery. REMOTE PUERPERIUM : Starts from the second week to six weeks post delivery

4. Physiological changes during puerperium

5. Genital tract Uterine involution- process which involves returning of the uterus from pregnant to non-pregnant state starts soon after delivery uterine fundus becomes firm and retracted immediately after delivery of placenta can be palpated just below the umbilicus. uterine height recedes at a rate of approximately 1cm/day on abdominal palpation . It becomes an intrapelvic organ by the 12th postpartum day takes about 4–6 weeks for completing involution to non-pregnant state

6. weighs nearly 1000 g immediate postpartum 500 g at the end of first week 300 g at second week 50–100 g by the end of 4–6 weeks Myometrial retraction ( brachystasis ) : unique characteristic of the uterine muscle that enables it to maintain its shortened length following successive contractions and is responsible for its involution Women may experience cramping pain caused by involuntary contractions during the phase of uterine involution known as ‘afterpains’ which usually resolve by the end of first postpartum week more common in multiparous women and exaggerated during breastfeeding due to the release of oxytocin

7. The superficial endometrial layer sloughs contributing to the lochia Basal layer is the source for regeneration of the new endometrial glands and stroma which begins in the first week, and by the third postpartum week, the entire endometrium is restored except at the placental site which takes about six weeks

8. B) Lochia- It is the physiological postpartum vaginal discharge resulting from sloughing of decidua Consists of erythrocytes, shredded decidua, epithelial cells and bacteria reddish in colour for the first three to four days after delivery because it contains more blood initially : called lochia rubra changes to brownish colour and serous consistency : lochia serosa which persists for about a week then becomes whitish turbid fluid: lochia alba

9. The total volume of postpartum lochial secretion is 200–500 ml, which is discharged over a mean duration of one month Up to 15% of women continue to pass lochia for 6–8 weeks The duration of lochia is not related to lactation or to the use of either estrogen-containing or progesterone-only contraceptives

10. c) Cervix- After delivery, the cervix is soft and floppy. cervix remains 2–3 cm dilated for the first few postpartum days lumen then reduces to less than 1 cm at one week forming the endocervical canal The external os never resumes its pre-gravid shape; the small, smooth, regular circular opening of the nulliparous cervix becomes a large, transverse slit after childbirth in vaginal delivery Small lacerations can be found at the margins of the external os Histologically, the cervix does not return to baseline for up to 3–4 months after delivery

11. d) Vagina and vulva- Vagina which distends during delivery involutes more slowly than the uterus Normal rugosities of the vaginal wall reappear at about third week, but pre-pregnant size and elasticity of the tissues is never regained Hymen is lacerated and represented by tags, known as caruncle myrtiformes

12. Abdominal wall Abdominal wall becomes flabby and remains soft and poorly toned for many weeks postpartum Postnatal exercises can play an important role in regaining the pre-pregnant tone of abdominal muscles Striae gravidarum or stretch marks are reddish linear lesions which often develop during pregnancy over the breasts, abdomen and thighs After the pregnancy, they do not disappear completely but tend to become depigmented and lighter in colour in due course of time, known as striae albicantes they can cause itching or burning, but it is the physical appearance which is more distressing

13. Aetiological factors- i)stretching and damage to the elastic fibres in the skin (ii)hormonal changes (iii) genetic predisposition – most important factor Regardless of the aetiology, the histological examination of the dermis shows atrophy and loss of rete ridges similar to scar tissue.

14. Hormonal changes Gonadotropins and sex steroids- low levels for the first 2–3 weeks postpartum- initial hyperprolactinemia also decreases GnRH and gonadotropin secretion Ovulation- suppressed for a variable period of time due to increased levels of prolactin stimulated by lactation The average time to first ovulation is about 45 days in non-breastfeeding and 189 days in the breast-feeding mothers.

15. Approximately 40% women remain amenorrheic for at least six months if they breastfeed exclusively Human chorionic gonadotropin (hCG) values typically return to normal non-pregnant levels 2–4 weeks after delivery return to normal level takes less time (median duration-12 days) if uterus is removed fall in serum beta-hCG level is clinically important as rising levels in postpartum period may point towards development of gestational trophoblastic disease

16. Haematological and coagulation factors Pregnancy-related hematologic changes return to baseline by 6–8 weeks after delivery Plasma volume- It decreases immediately after delivery with a rise again 2–5 days later because of a rise in aldosterone secretion then starts to decline with levels 10–15% above non-pregnant levels at three weeks postpartum and return to normal non-pregnant levels at six weeks postpartum b) Physiologic anaemia- Physiologic anaemia of pregnancy resolves by six weeks postpartum

17. c) Postpartum leucocytosis and neutrophilia normal physiological phenomena the mean postpartum white blood cell (WBC) : 13.39±0.24×109 /L (range 1.20−37.30×109 /L). falls to the normal non-pregnant range by the sixth day postpartum

18. d) Platelets- P latelet count remains within the normal range during pregnancy and does not change postpartum For individuals with gestational thrombocytopenia, mild thrombocytopenia begins to resolve soon after delivery and is no longer present at 3–4 weeks postpartum e) Coagulation and fibrinolysis- Postpartum normalization of coagulation parameters and return to baseline thromboembolic risk generally occurs by 6–8 weeks after delivery

19. Cardiovascular system Significant hemodynamic alterations start within the first 10 minutes following a term vaginal delivery, which include- Increase in cardiac output by 59% Increase in stroke volume by 71% At one hour postpartum, Cardiac output remain increased by 49 % Stroke volume remain increased by 67% Heart rate decreases by 15% Blood pressure remains unchanged

20. increase in stroke volume and cardiac output most likely results from raised cardiac preload from auto transfusion of utero-placental blood to the intravascular space As the uterus decompresses following delivery, a reduction in the mechanical compression of the vena cava allows for further increase in cardiac preload reduction in left ventricular size and contractility as early as two weeks postpartum Cardiovascular physiologic changes resolve slowly after delivery

21. Elevated glomerular filtration rate and renal plasma flow return to normal by six weeks Dilatation of renal calyces, pelvis, and ureters resolve by 2–8 weeks postpartum Because of the dilated collecting system, coupled with incomplete emptying and residual urine in traumatised bladder, symptomatic UTI is common in postpartum period

22. Routine postpartum care

23. Clinical assessment: Blood pressure and pulse rate : every 15 minutes for 2 hours Temperature : every 4 hours for first 8 hours and then 8 hourly Uterine fundus is closely monitored for 1 hour to ensure that it is well contracted and the amount of vaginal bleeding is checked

24. 2. Laboratory testing: Routine post-delivery haemoglobin for all the patients is not required should be done in women with pre-delivery anaemia or who have had PPH determination of the increased WBC count to predict impending infection is not required since leucocytosis as high as 15,000 cells/mm3 is normal in postpartum women Leucocytosis needs further evaluation only if there is clinical suspicion of infection or presence of large number of blasts

25. 3. Perineal care: The woman should be advised to clean the perineum from anterior to posterior- from vulva to the anus In the initial 24 hours after delivery, application of cool pack may help in reducing edema and pain if there is perineal laceration or episiotomy After 24 hours, moist heat in the form of sitz bath can be advised to relieve local discomfort Normally episiotomy heals by third week Oral NSAIDs can be prescribed to relieve pain, except in volume depleted cases like pre-eclampsia where acute kidney injury can be precipitated severe perineal, vaginal or rectal pain or difficulty in passing urine always warrants careful local examination to rule out hematoma on day 1 and infection after day 3

26. 4. Ambulation: Early ambulation within few hours after vaginal birth should be encouraged as it helps in early recovery, reduces bladder and bowel complications and reduces the risk of venous thromboembolism 5. Diet: Lactating women require an additional 500 kcal and 25 g of proteins/day For non-lactating women, dietary requirements remain same as for non-pregnant Iron and folic acid supplementation should be continued for at least three months

27. 6. Bladder care: In early puerperium, urinary retention and bladder overdistention is common Oxytocin-induced or augmented labor (antidiuretic effect), perineal lacerations, operative vaginal delivery, prolonged labor etc. are some of the factors which may increase likelihood of decreased bladder sensation and urinary retention In postpartum period, first urine void should be ensured within six hours If woman is not able to pass urine, she should be thoroughly examined to rule out any hematoma After ruling out hematoma, she should be catheterized It is best to leave the catheter in place for 24 hours even without a demonstrable cause it allows recovery of normal bladder sensation and tone and prevent any recurrence

28. 7. Bowel care: Constipation may occur in the early puerperium because of -decreased tone of bowel during pregnancy -decreased food intake during labour -presence of episiotomy or perineal lacerations or painful hemorrhoids Hemorrhoids often resolve spontaneously as the perineum recovers so only symptomatic relief with pain killers and laxatives is advocated 8. Support for breastfeeding: Exclusive breastfeeding for the first six months of life The WHO and UNICEF launched the Baby-friendly Hospital Initiative and recommend ‘Ten steps to successful breastfeeding’ to promote breastfeeding

29. 9. Mood and cognition: common for some postpartum women to have depressed mood for few days which is termed as postpartum blues disorder is usually mild and persists for 2–10 days If this persists for long, then thorough evaluation for depression disorders should be done and treated accordingly

30. 10. Resumption of coitus: no evidence-based data regarding resumption of coitus after delivery After two weeks, coitus may be resumed based on desire and comfort Due to postpartum hypoestrogenic state, vulvovaginal epithelium is thin and this state persists till ovulation is resumed To relieve this, small amount of topical estrogen cream may be applied Vaginal lubricants may be useful during coitus

31. 11. Postpartum immunization: Ideally, women should be vaccinated against preventable diseases in their environment prior to conception MMR and varicella vaccines are given postpartum to non-immune women, ideally prior to discharge These can be given safely to lactating mothers also since the virus is not transmitted through breast milk or casual contact Tdap should be given to postpartum women who have not received it during pregnancy This reduces the risk of maternal pertussis and transmission to the infant in whom pertussis can be lethal

32. RhD-negative mothers of Rh(D)-positive infants should be given anti-D immunoglobulin as soon as possible after delivery, within 72 hours of birth For RhD-negative women who have received anti-D Ig postpartum, MMR and/or varicella vaccine can still be administered immediately postpartum, if indicated. Postexposure prophylaxis for hepatitis A and B, rabies and tetanus is not altered by pregnancy or postpartum state

33. 12. Advice on discharge: At the time of discharge, women should be counselled regarding infant care and immunization, contraception and should be explained warning signs postpartum follow-up visit between four and six weeks is recommended in all

34. WHO recommendations for postpartum care According to the WHO, if birth is in a healthcare facility, mothers and newborns should receive postnatal care in the facility for at least 24 hours after birth If birth is at home, the first postnatal contact should be as early as possible within 24 hours of birth At least three additional postnatal contacts are recommended for all mothers and newborns, on day 3 (48–72 hours), between days 7 and 14 after birth and six weeks after birth

35. Postnatal care for the newborn 1) Breastfeeding- All babies should be exclusively breastfed from birth until six months of age Mothers should be counselled and provided support for exclusive breastfeeding at each postnatal visit 2) Cord care- Daily chlorhexidine application to the umbilical cord stump during the first week of life is recommended for newborns who are born at home in settings with high neonatal mortality Clean, dry cord care is recommended for newborns born in health facilities and at home in low neonatal mortality settings

36. 3) Bathing- Should be delayed until 24 hours after birth Appropriate clothing of the baby for ambient temperature is recommended This means one to two layers of clothes more than adults, and use of hats/caps 4) Rooming-in- The mother and baby should not be separated and should stay in the same room 24 hours a day 5) Communication and playing with the newborn to be encouraged

37. 6) Immunization should be promoted 7)Preterm and low-birth-weight babies should be identified immediately after birth and should be provided special care 8) Immediate contact to health facility/referral for further evaluation if any of the signs is present: Stopped feeding well, history of convulsions fast breathing (breathing rate ≥60/min) severe chest in-drawing no spontaneous movement fever (temperature ≥37.5 °C) low body temperature (temperature <35.5 °C) any jaundice in first 24 hours of life or yellow palms and soles at any age

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