Physiology of puerperium

Physiology of puerperium

1. Physiology and management of normal puerperium   Mrs.jagadeeswari.J m.Sc nursing

2. Introduction The puerperium is a period of approximately 6 weeks which commences following completion of third stage of labour. During this time the women recovers from stresses of pregnancy & delivery & the physiological adaptations which occur during pregnancy subside, facilitating the restoration of the non pregnant state.

3. Definition The puerperium is defined as the period following childbirth during which the body tissue, specially the pelvic organs revert back approximately to the pre-pregnant state both anatomically and physiologically ----- DC DUTTA

4. DURATION Puerperium begins as soon as the placenta id expelled and last for approximately 6 weeks when uterus becomes regressed almost to non-pregnant size.

5. Stages of puerperium The post partum period has been divided into: The immediate puerperium , the first 24 hours after parturition; when acute post anesthetic or post delivery complications may occur. The early puerperium , which extends until the first week post partum. The remote puerperium , which includes the period of time required for involution of the genital organs through the sixth weeks postpartum.

6. Reproductive system Uterus Involution: -is the return of the uterus to a non-pregnant state after childbirth Involution process begins immediately after expulsion of the placenta with contraction of uterine smooth muscles At the end of third stage of labor, the uterus is in the midline, about 2cm below the level of the umbilicus and weighs 1000g and measures about 20*12*7.5(length , breadth and thickness)

7. CONT … By 24 hours postpartum the uterus is about the same size it was at 20 gestational weeks The fundus descends about 1 to 2cm every 24 hours, and by the sixth postpartum day it is located halfway between the symphysis pubis and the umbilicus. -The uterus lies in the true pelvis within 2 weeks after childbirth.

8. Involution of the uterus return to the pelvis by about 2 weeks be at normal size by 6 weeks the weight changes of uterus 1000g immediately after birth (excluding the fetus, placenta, membrane and amniotic fluid. 500g 1 weeks after birth 300g 2 weeks after birth 50g 6 weeks after birth The endometrial lining rapidly regenerates (16 days) The placental site undergoes a series of changes in the postpartum period

9. - Subinvolution:- is the failure of the uterus to return to a nonpregnant state. - The most common causes of sub involution are retained placenta fragments and infection

10. LOWER UTERINE SEGMENT Immediately following delivery the lower segment becomes thin flabby ,collapsed structure It takes a few weeks to revert back to normal shape and size of the isthmus

11. cervix It is soft immediately after birth The cervix up to the lower uterine segment remains edematous, and thin for several days after birth. The cervical os which is dilated to 10cm during labor closes gradually, it may still possible to introduce 2 fingers into cervical os for the first 4-6 postpartum days. The external cervical os never regains its prepregnancy appearance, it is no longer shaped like a fish mouth. It return to its normal state at 4 weeks after birth

12. Physiological consideration The physiological process of involution is most marked in the body of the uterus changes occur in the following components Muscles Blood vessels Endometrium

13. muscles There is marked hypertrophy and hyperplasia of muscle fibers during pregnancy and the individual muscle fiber enlarges to the extent of 10times and 5 times of breadth During puerperium the number of muscle fibers is not decreased but this is substantial reduction of the myometrial cell size Withdrawal of the steroid hormones estrogen and progesterone may lead to increase in the activity of the uterine collganese and release of proteolytic enzyme

14. Blood vessels The arteries are constricted by contraction of its wall and thickening of the intima followed by thrombosis During the first week the arteries undergo thrombosis hyalinsation and fibrinsed end arteries The veins are obliterated by thrombosis hyalinsation and endophelebitis New blood vessels grow inside the thrombi.

15. endometrium Following delivery the major part of the decidua is cast off with expulsion of the placenta and the membranes more at the placenta site The endometrium left behind varies in thickness from 2-5mm The superficial part containing the degenerated decidua, blood cells and bits of fetal membranes becomes necrotic and is cast off in the lochia. Regeneration starts by 7 th completed by 10th day and restored by 16 th day except placental site it takes 6weeks It occur from the epithelium of the uterine gland mouths and interglandular stromal cells

16. Involution of other pelvic structures vagina The distensible vagina notices soon after birth takes a long time-4-8weeks It regains its tone but never to the virginal state The mucosa remains delicate for the first few weeks and sub- mucous venous congestion persist even longer, it is the reason to withhold surgery on puerperal vagina Rugae partially reappear at 3 rd week but nerve to the same degree as in pre-pregnant state The introits remains permanently larger than the virginal state The hymen is lacerated and represented by nodular tags the carunculae myritiformes

17. Broad ligament and round ligament Requires considerable time to recover from the stretching and laxation PELVIC FLOOR AND PELVIC FASCIA Takes a long time to involute from the stretching effect during parturition.

18. Lochia It is the vaginal discharge that occurs after birth. Lochia is discharge originates from the uterine body, cervix and vagina For the first 2 hours after birth the amount of lochia should be about that of a heavy menstrual period, after that time the lochial flow should steadily decrease.

19. Lochia-odour and reactions It has got a peculiar small It reactions is alkaline leading to become acid towards the end

20. color 1-lochia rubra-red color (1-4days) It consists of blood, shreds of fetal membranes and decidual ,vernix caseosa,lanugo and meconium. 2-lochia serosa-yellowish or pink or pale brownish colour(5-9 days) It consists of old blood, less of rbc, but more of leukocytes, and wound exudates mucus from cervix and micro organism (anaerobic streptococci and staphylococci 3-lochia serosa-pale white(10-15days) Contains plenty of decidual cells,leucocytes,mucus,cholestrin crystals,fatty and granular epithelial cells and micro organism.

21. amount The average amount of discharge for the first 5-6 days is estimated to be 250ml

22. Normal duration The normal duration may extend upto 3 weeks The lochia rubra may persist for longer specially in woman with twins and scanty in premature labour Can be more when women get up from bed in the later period

23. Clinical importance of lochia Odor: If offensive indicates retained plus or cotton pieces inside the vagina should be kept in mind

24. Cont.. Amount: Scanty or absent signifies infection or lochiametra If excessive also indicates infection

25. Cont.. Color: Persistence of lochia rubra beyond normal limit signifies Subinvolution or retained bits of conceptus

26. Cont.. Duration: Duration of the lochia alba beyond 3 weeks suggest local genital lesions

27. General physiological changes pulse After the initial tachycardia associated with labour and delivery, a bradycardia often develops in the early puerperium. A woman’s pulse rate during the postpartal period is usually slightly slower than normal. This increased stroke volume reduces the pulse rate to between 60 and 70 beats per minute. As diuresis diminishes the blood volume and causes blood pressure to fall, the pulse rate increases accordingly. By the end of the first week, the pulse rate will have returned to normal.

28. temperature A woman may show a slight increase in temperature during the first 24 hours after birth. Occasionally, when a woman’s breasts fill with milk on the 3 rd or 4 th postpartum day, her temperature rises for a period of hours because of the increased vascular activity involved. Genito-urinary tract infection should be excluded if there is rise of temperature

29. Urinary tract The bladder wall becomes oedematous and hyperaemic and often shows evidences of sub mucous extravasations of blood. Because of relative insensitivity to the raised intravesical pressure due to trauma sustained to the nerve plexus during delivery, the bladder may be over distended without any desire to pass urine. Dilated ureters and renal pelvis return to normal size within 8 weeks

30. Gastrointestinal system  Digestion and absorption begin to be active again soon after birth. Bowel sounds are active, but passage of stool through the bowel may be slow because of the still present effect of relaxin on the bowel. Bowel evacuation may be difficult because of the pain of episiotomy sutures or haemorrhoids. Increased thirst in early puerperium Slight intestinal paresis leads to constipation

31. weight Rapid diuresis and diaphoresis during 2nd to 5th days after birth result in weight loss of 5 lb (2 to 4kg), in addition to approx. 12 lb (5.8 kg) lost at birth. Lochia flow- 2-3 lb(1kg) loss Total weight loss- 19 lb Additional weight loss depend on amount of weight gain in pregnancy and active measures to reduce weight.

32. Fluid loss Net fluid loss of at least 2 liters during 1 st week Additional 1.5 liters during the next 5 th weeks The amount depends on amount retained during pregnancy ,dehydration during labour and blood loss during delivery.

33. Blood values Diuresis evident between 2 nd to 5 th day after birth, as well as blood loss at birth, acts to reduce the added volume accumulated during pregnancy. Rapid reduction occurs, so that blood volume returns to its normal prepregnancy level by 2 nd week after birth. Cardiac output rises soon after delivery to about 60% above the pre labour value but gradually returns to normal within one week.

34. Rbc volume and hematocrit It returns to normal by the end of 1 st week after the hydaemia disappears Leukocytosis to the extent of 30000 per cu mm occurs following delivery probably in response to stress of labour Platelet count decreases soon after the separation of the placenta but secondary elevation occurs with increase in platelet adhesiveness between 4-10dyas Fibrinogen level remains high upto the 2 nd week of puerperium resulting in persistent high level of esr in puerperium as during pregnancy A hypercoagulable state persist for 48hrs postpartum and fibrolytic activity is enhanced in first 4 days.

35. Menstruation and ovulation If the woman does not breast fed her baby, the menstruation returns by 6th week following delivery in about 40% and by 12th week in 80% of cases. In non-lactating mothers, ovulation may occur as early as 4 weeks and in lactating mothers about 10 weeks after delivery. A women who is exclusively breastfeeding, the contraceptive protection is about 98% upto 6 months postpartum. Thus, lactation provides a natural method of contraception. However ovulation may precede the first menstrual period in about one-third and it is possible for the patient to become pregnant before she menstruates following her confinement. Non-lactating mother should use contraceptive measures after 3 weeks and the lactating mothers after 3 months of delivery.

36. lactation 1 st two days following delivery no further anatomical changes in the breast occur The secretion from the breast called colostrum which starts during pregnancy becomes more abundant during this period

37. Composition of the colostrum It is deep yellow serous fluid alkaline in reaction It has got a higher specific gravity ,high protein, vitamin A, sodium and chloride content but has got lower carbohydrate ,fat and potassium than the breast milk It contains antibody (IgA)

38. Composition of colostrum and breast milk MILK PROTEIN FAT CARBOHYDRATE WATER COLOSTRUM 8.6 2.3 3.2 86 BREAST MILK 1.2 3.2 7.5 87

39. Advantages The antibodies (IgA,IgG,IgM) and hormonal factor (lactoferrin)provides immunological defense to the newborn It has laxative action on the because of large fat globules

40. Physiology of lactation The physiological basis of lactation is divided into four phases Preparation of breast (mammogenesis) Synthesis and secretion from the breast alveoli (lactogenesis) Ejection of milk (galactokinesis) Maintenance of lactation (galactopoiesis)

41. mammogenesis Pregnancy is associated with a remarkable growth of both the ductal and lobuloalveolar systems. An intact nerve supply is not essential for growth of the mammary glands during pregnancy.

42. lactogenesis Milk secretion actually starts on 3rd or 4th postpartum day. Around this time, the breasts become engorged, tense, tender and feel warmth. When the progesterone and oestrogen are withdrawn following delivery, prolactin begins its milk secretary activity in previously fully developed mammary gland.

43. galactokinesis Discharge of milk from the mammary glands depends not only on the suction exerted by the baby during suckling but also on the contractile mechanism which expresses the milk from the alveoli into the ducts. oxytocin is a the major galactokinesis.

44. Cont….

45. Cont…

46. galactopoiesis  Prolactin appears to be the single most important galactopoietics hormone. Continuous suckling is essential for removal of milk from glands, also release prolactin. Secretion is the continuous process unless suppressed by congestion or emotional disturbances

47. Milk production A healthy mother will produce about 500-800 ml of milk/day with about 500 kcal /day. This requires 600 kcal/day for the mother which must be made up from the mothers diet or from her body store. For this purpose a store of about 5 kg of fat during pregnancy is essential to make up any nutritional deficit during lactation.

48. Stimulation of lactation Mother is motivated about the benefits of breast feeding No prelacteal feed like honey ,water Following delivery important steps are….. I. To put baby to the breast at 2-3 hours interval from the first day. II. Plenty of fluids to drink III. To avoid breast engorgement.  IV.Early and exclusive breast feeding in correct position are encouraged as soon as 30minutes to 1hour

49. Inadequate milk production/ lactation failure It may be due to infrequent suckling or due to endogenous suppression of prolactin (ergot preparation, pyridoxine, diuretics or retained placental bits). Unrestricted feeding at short interval (2-3hrs.) Is helpful

50. Drugs to improve milk production  Metoclopramide (10 mg thrice daily) increases milk volume (60-100%) by increasing prolactin levels. Sulpuride (dopamine antagonist) has also been found effective. Intranasal oxytocin contracts myoepithelial cells and causes milk let down reflex.

51. Lactation suppression Suppression of lactation is necessary if the baby is born dead or dies in the neonatal period or if breast feeding is contradicted Mechanical methods : To stop breast feeding To avoid pumping or milk expression To wear brassieres Ice pack to relive pain and breast engorgement A tight compression bandage is applied for 2-3 days

52. Cont… Bromocriptine (dopamine agonist that inhibits prolactin) 2.5 mg, 1 tab daily for 10-14 days. Side effects are: hypotension, rebound breast engorgement, secretion, myocardial infarction and puerperal stroke

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