PUEPERIUM PHYSIOLOGICAL CHANGES.pptx in reproductive health

Puerperium and physiological changes in reproductive health.

1. PUEPERIUM

2. INTRODUCTION The puerperium’ starts immediately after delivery of the placenta and membranes and continues for 6 weeks. B y 6 weeks after delivery all systems in the woman’s body will have recovered from the effects of pregnancy and returned to their non pregnancy state, other changes which occurred during pregnancy are reversed and lactation is established, the foundation of the relationship between the infant and his parents are laid.

3. DEFINITION Puerperium is defined as the period from the completion of delivery of the placenta and membranes to the end of the first six (6) postpartum weeks, during which time the woman’s body returns to the normal non gravid state. (Myles 2009, P 651)

4. PHYSIOLOGY OF PUERPERIUM All the changes that occurred throughout the woman’s body during pregnancy, as well as those that took place during labour are no longer necessary once the baby is born. The first hour, the first 24 hours and then the first week are extremely important and the woman should have constant care and assistance during these times.

5. ENDOCRINE/HORMONAL CHANGES Human chorionic gonadotrophin(HCG), Human Placental Lactogen (HPL), Oestrogen and progesterone. When the placenta becomes detached from the uterine wall and is expelled, the levels of the hormones HCG, HPL, oestrogen and progesterone, in the woman’s blood fall rapidly. Normally , after 7 days, HCG is not detected in urine and after 2 days, HPL is not detected in the plasma. Oestrogen and progesterone reach non gravid levels at about after 7 days .

6. Prolactin The levels of circulating estrogen and progesterone after the baby is born usually fall due to the high levels of circulating prolactin. The levels of prolactin increase the more frequently the baby suckles and levels remain high while the baby is totally breastfed. In a non lactating mother the levels of prolactin gradually fall.

7. Oxytocin The stimulation of the nipples during sucking also causes the release of oxytocin, which contracts the myoepithelial cells lining the lactiferous ducts and causes the let- down of milk. The oxytocin in the blood circulation also causes the contraction of uterine muscle and therefore, at the same time, assists in the involution of the uterus.

8. Restoration of ovulation and menstruation Ovulation and menstruation are the last major functions to return to normal. In women who breastfeed their babies ,ovulation seldom occurs before 20 weeks and may not occur up to 28 weeks in women who continue breastfeeding for 6 months.

9. REPRODUCTIVE TRACT Involution of the uterus T he enlarged uterus is no longer needed to nurture the fetus and there is a breakdown of the unwanted muscle fibres . This catabolism is mainly brought about by two factors:

10. Ischaemia of the M yometrium This is caused by the continuous contraction and retraction of the uterus after the expulsion of the placenta, rendering the uterus relatively anaemic and causing atrophy to the muscle fibers.

11. CONT.. The vast amount of blood which was contained within the uterus is pushed into the blood stream. This greatly increased blood volume of fluid in circulation has to be removed by the kidneys and results in a major diuresis in the early puerperium.

12. CONT.. Autolysis or a process of self digestion; Proteolytic enzymes break down the cytoplasm into a soluble substance which is then absorbed into the blood stream and finally excreted by the kidneys, increasing the diuresis. Phagocytes then invade the collagen fibers between the myometral cells and fat is removed, while thrombosed blood vessels are also broken down and absorbed.

13. The uterus which at full term weighs approximately 11 times its pre pregnancy weight, evolutes to approximately 500g by 1 week after birth and to 350g by 2 weeks after birth. At 6 weeks, it weighs 50 – 60 g. With each pregnancy, the weight and collagen content of the uterus is slightly increased and elastin is deposited around the blood vessels. With each successive pregnancy, therefore, the collagen and elastin contents increase, causing the uterine muscles to become less elastic and resulting in the uterus becoming a progressively less efficient organ for pregnancy and labour.

14. Placental site Bleeding from larger uterine vessels of the placenta site is controlled by compression of the retracted uterine muscle fibres . The clotted blood is eventually absorbed by the body. The placental site heals by exfoliation, which is one of the most important aspects of involution. This is because if healing of the placental site healed by fibrosis or left a scar, the space for further implantation would be limited .

15. Fundal height The uterine fundus is at approximately the level of the umbilicus on the day of birth. Within 12 hours, the fundus may rise to approximately 1cm above the umbilicus, by 24 hours post partum, the uterus is about the same size as it was at 20 weeks of gestation, (Resnik,2004 ).

16. CONT.. Involution progresses rapidly during the next few days. The fundus decedes by between 1cm to 1.5cm or about a finger’s breadth per day. This means that by about 10 -12 days after delivery, the fundus can be no longer be palpable abdominally, because it has sunk below the level of the symphysis pubis (pelvic brim).

17. Postpartum vaginal blood/fluid loss (lochia) One of the unique capabilities of the uterus is its ability to rid itself of the debris remaining after birth. This discharge, termed lochia, is classified according to appearance. The colour of the Lochia indicates the healing of the placental site.

18. TYPES OF LOCHIA Lochia rubra is red and consists of the red blood cells, pieces of deciduas and leucocytes dissolved clots, placental shreds from the chorion, lanugo, vernix caseosa . Its odor is of fresh blood. It is seen in the first 3 to 4 days of puerperium. Lochia serosa is a lighter (more brownish) and more serous discharge, it contains lymph, mucus, uterine debris, bacteria if any and leucocytes. It can be seen from the 5 th or 9 th day to approximately the 10 th day of puerperium.

19. CONT.. Lochia alba is pale white in colour because of the presence of leucocytes, bacteria debris from healing wounds lymph, cervical mucus, decidual . It is seen from the 10 th day -15 th day. Note The amount of lochia should be reducing every day. A persistent red or heavy lochia for more than 10days denotes sub involution and may suggest retained products of conception and offensive smelling lochia indicates infection.

20. CONT.. The cervix Following birth, the cervix is spongy, flabby and formless and may appear bruised. However, the original form of the cervix is regained within the first week and by the end of seven days the cervix admits only a finger tip. The paras cervix will never again look like the non paras cervix. The external os which resembled a dimple will be a slit.

21. The vagina The vaginal wall has been extensively stretched during delivery and is, therefore swollen, reddish blue and flabby after delivery. The vagina regains most of its tone by the end of puerperium that is the vagina decreases in size and rugae returns within 4 to 6weeks but they are never as prominent as they are in the nulliparous woman. Postpartum estrogen deprivation is responsible for the thinness of the vaginal mucosa and the absence of the rugae .

22. …. The Vulva Any superficial lacerations which may have occurred heal relatively quickly. The perineum Due to the liberal blood supply to the area, Perineal tears and episiotomies, which also require suturing, should be healed within 7 days, but severe lacerations may remain sensitive or even painful for weeks .

23. …. Pelvic ligaments, pelvic and abdominal muscles These tissues become overstretched during pregnancy and labour and should not be overstretched now. However exercise is important to help them regain their tone.

24. …. The Pelvis The pelvis joints which were under the influence of the hormone relaxin regain their normal form by the end of puerperium. The symphysis in particular may separate slightly during labour causing pain and discomfort, becomes stabilized by 6 to 8 weeks.

25. …. The abdomen The skin of the abdomen appears loose and flabby for weeks or even months. The stretch marks gradually fade but often do not disappear all together and instead, become silvery white streaks (stretch marks).  

26. …. Urinary tract There is a major dieresis (2000-3000ml of urine per day) in the first few days of puerperium, caused by decreased estrogen level resulting in substantial loss of fluid however, the neck of the bladder and the urethra may be edematous and bruised after delivery and could cause difficulties in passing urine. Dilatation of the renal pelvis and ureters decreases slowly after 3 rd to 6 th week. The functional activities of the kidney returns to it pre gravid state by end of 6 weeks.

27. …. Breast During pregnancy the increased amounts of oestrogen and progesterone in the woman’s blood circulation prepare the breast tissue for lactation but the high levels of oestrogen inhibit the secretion of prolactin.

28. …. This holds the production of milk in abundance until the puerperium, when the levels of oestrogen fall dramatically after the expulsion of the placenta In the 2 to 3 days colostrum is secreted by the breasts, which is an important component in the nourishment of the baby.

29. …. Cardiovascular The cardiac output which increased during labour rises even further after the third stage of labour when the large volume of blood from the uterus is squeezed into the circulation, decreases after the first few days of puerperium and has returned to the normal pre gravid output by the end of the third week.

30. …. Psychological changes A feeling of depression, usually on the 3 rd or 4 th day and these are called postpartum blues. Usually this is a reaction to the tension and excitement of birth. Anxiety about the baby. Sorrow in the event of a stillbirth, neonatal death or abnormal baby. The prime gravida may be worried of how they will nurse the baby .

31. END THANKYOU