Puerperium and associatededited notes -.pptx

Notes

1. POST PARTUM BSND

2. Definition The postpartum period, also known as the puerperium and the " fourth trimester ," refers to the time after birth when the physiologic changes related to pregnancy return to the nonpregnant state.

3. PHASES The initial or acute period involves the first 6–12 hours postpartum . The second phase is the subacute postpartum period, which lasts 2–6 weeks. The third phase is the delayed postpartum period, which can last up to 6 months.

4. PHYSIOLOGIC CHANGES Genitourinary Changes Involution of the uterus from a 1-kg structure to a 60-g structure Restoration of the normal endometrial lining occurs by the 16th day The cervix closes to about 1 cm over the 1st week postpartum The postpartum cervix often has a transverse or “smiling” appearance, as opposed to the nulliparous pinpoint appearance.

5. Resumption Of Menses For most non-breastfeeding mothers, the first postpartum menses occurs at approximately 55 to 60 days (range 20 to 120) postdelivery. Breastfeeding may delay return of menses by several months Ovulation has been demonstrated in 52% of women whose menses resumed less than 60 days following delivery. It is therefore of primary importance that women be provided adequate birth control very early in the postpartum period.

6. UTERUS, CERVIX AND VAGINA Tonic contractions help prevent postpartum hemorrhage Immediately after delivery, tonic-like activity is required to constrict the blood vessels It is usual for contractions to be felt as after-pains for several days postdelivery. The contractions are augmented by the hormone oxytocin stimulating the myometrium, as it is released during suckling.

7. Lochia removes waste The puerperal uterine contractions also help in the expulsion of blood, membranes and vernix from the uterine cavity, in a vaginal discharge known as lochia. The red colored discharge ( lochia rubra ) typically lasts 3–5 days. The discharge then becomes thinner and browner, as blood contributes less to it, ( lochia serosa ) Followed by a yellow to white discharge, composed of leukocytes and mucus but possibly also fat and cholesterol ( lochia alba ).

8. Pelvic Floor Support Childbirth is the initiation of a whole host of conditions including stress urinary incontinence, incontinence of flatus or feces, uterine prolapse, cystocele, and rectocele . Even when full recovery of pelvic floor integrity appears to be the case Aggressive program of pelvic floor exercises may be prescribed

9. Cervix and vagina Given the extensive collagenous composition of the cervix, along with cells of the immune and inflammation systems, that play the predominant role in this reconstruction of the cervix. The vagina and vulva will initially be edematous The vaginal walls will weaken slightly with each pregnancy, contributing to the age-related risk of genital prolapse. Tears and episiotomies , depending upon their size, will heal within the next 2–3 weeks Pain on intercourse during the first weeks and months of the puerperium is likely due to tears and episiotomies, as well as the trauma to the vagina during delivery.

10. DO NOT !

11. URINARY SYSTEM Conditions that affect the puerperium and the urinary system : urinary retention, incontinence and diuresis. Urinary retention is common, and the bladder can easily become over-distended in days 1–2 of the puerperium. Physiologically, there is a persistent reduction in the bladder’s smooth muscle tone. Neurologically, epidural analgesia temporarily further impairs bladder function, and micturition reflexes may be inhibited with suturing of the peritoneum. Mechanically, edema in the urethra, or urethral compression from postdelivery vulval edema, can contribute to retention. Stress incontinence

12. Cardiovascular Changes Blood volume increases by about 50% at the time of delivery. This massive volume shift result in measurable and significant changes in every cardiac function parameter This makes delivery and the few days following it extremely risky for patients with pre-existing cardiac conditions Hypertension may appear for the first time during the puerperium.

13. SKIN, HAIR AND JOINTS The dark pigmentation that occurs in the vulva, abdominal wall and face in some women, passes. Any edema of pregnancy is quickly dissipated. Stretch marks (striae gravidarum), become less apparent as the puerperium progresses. Most women experience hair loss

14. RESPIRATORY SYSTEM Although respiratory problems may be common in pregnancy, the respiratory system is little affected by the puerperium. Abnormal breathing patterns should alert clinicians to postpartum complications, such as infection.

15. Metabolic/Hormonal Changes The plummeting of estrogen and progesterone levels may play a role in the mood changes associated with the postpartum period Changes in blood volume, vascular bed area, all of the cardiac parameters, as well as activity level, sleep pattern, and emotional stressors are all profound during the first 2–6 weeks postpartum, and the ability of the body to metabolically compensate is astounding but imperfect. periods of profound exhaustion Weight changes

16. ENDOCRINE CHANGES Marked endocrine changes in the puerperal period affect p hysiology and emotions . Delivery of the placenta removes pCRH and plasma CRH levels return to normal within 15 hours postpartum. Cortisol levels fall rapidly in the first days and weeks postpartum. Prolactin is secreted by the end of gestation The actions of prolactin are inhibited by the presence of progesterone , but once progesterone levels drop, prolactin stimulates milk production. Suckling causes further release of prolactin and levels will remain elevated until such time as breastfeeding stops. Oxytocin has a critical role in the development of maternal behavior : attachment and bond and formation milk ejection .

17. OVARIAN FUNCTION AND CONTRACEPTION In non-lactating women, the first menstruation occurs 45–64  days Between 20 and 80% of first menses are anovulatory. In women who breastfeed, the return of ovulation and menses are delayed, potentially for long periods of time. Suckling suppresses the pulsatile release of gonadotropin-releasing hormone , which in turn inhibits the pulsatile release of luteinizing hormone , leading to depression of ovarian activity.

18. Breast Changes Several hormones interact to allow smooth production and excretion of milk, including the withdrawal of estrogen and progesterone, along with prolactin, glucocorticoid, insulin, and thyroid hormone activity. For approximately 3 days postpartum, the breast secretes colostrum, distinct from milk in having higher amounts of immunoglobulins and white blood cells and lower amounts of fat and lactose . Over 2 weeks, the milk assumes its typical nutritional properties. Breast milk excretion requires oxytocin release, which usually occurs through a reflex initiated by suckling.

19. Hematologic Changes Primary changes of the puerperium include the acute loss and gradual recovery of red blood cells and iron, and a sharp leukocytosis in the 1st postpartum day. Rise in white blood cell count of 25–99% from postpartum Maternal blood in the puerperium is in a hypercoagulable state , putting mothers at risk of thromboembolism . Conversely, decreases in plasma volume in the puerperium, lead to an elevated hematocrit.

20. PHYSIOLOGY OF LACTATION During pregnancy, the volume of breast tissue increases and formation of new alveolar-lobular structures Progesterone and prolactin are necessary for such development; as well as placental lactogen and growth hormone Little or no milk is produced during pregnancy because high levels of progesterone and estrogen block the secretory activity of the cells in the alveoli.

21. Milk production Prolactin stimulates mammary gland ductal growth, epithelial cell proliferation and induces milk production and secretion. After parturition, removal of the placenta stimulates a significant drop in progesterone, estrogen, and human placental lactogen , coinciding with an increase in prolactin, cortisol and insulin. Prolactin concentration increases rapidly by the tactile stimulation of the nipple-areolar complex with suckling of the nipple, stimulating nerve endings and subsequent release from the anterior pituitary regulated by the hypothalamus. Suckling, via neural connections, inhibits dopamine secretion which normally inhibits prolactin, thereby removing inhibition to allow increased prolactin secretion and stimulation of milk production.

22. Milk production…… Within the alveoli, milk proteins are packed into secretory vesicles and milk is released into the lumen of the alveoli by exocytosis and budding . Colostrum is the first milk produced by mothers during the first 4 days postpartum: it has more of an immunological function. It contains high levels of the antibody immunoglobulin A (IgA) and leukocytes From day 5, the nutritional constituents of the milk increase and by 2 weeks the main components include protein, fat and lactulose. The milk also contains micronutrients including vitamins A, B and D, and microbiota to aid the establishment of the baby’s initial intestinal microbiome.

23. Milk ejection The release of oxytocin occurs in a similar way to prolactin, but is mediated by an independent neuroendocrinological pathway Infant suckling leads to afferent signals to the hypothalamus, which in turn triggers release of oxytocin from the posterior pituitary gland in a pulsatile manner . Oxytocin then travels in the bloodstream and, in turn, stimulates the contractile myoepithelial cells in the alveolus. The resulting contraction forces milk into the ducts from the alveolar lumens and out through the nipple. Oxytocin can also be released in response to various sensory inputs including hearing a baby cry. It also has a psychological effect, which includes inducing a state of calm, and reducing stress and anxiety. It may also enhance feelings of affection between mother and child, an important factor in bonding.

24. Maintenance of lactation Milk expulsion by day 3 is critical for the establishment of successful breastfeeding. Subsequent regular removal of milk and stimulation of the nipple is essential to maintain the level of milk production. If milk is not removed, accumulation of a feedback inhibitor of lactation will lead to a fall in milk production and will initiate mammary involution . The physiological significance of the feedback inhibitor is to regulate the volume of milk produced to meet the needs of the baby; this is determined by how much milk the baby takes .

25. Pathophysiology of breastfeeding Milk ejection can be inhibited by emotional stress . The process of lactation and breastfeeding can be negatively affected by factors that prevent normal breast development . Inadequate milk production may also be due to inefficient calorie intake. The milk ejection reflex can be affected by incorrect fixing and suckling of the nipple or the infant’s inability to latch. Poor attachment or infrequent feeding can lead to breast engorgement and the development of mastitis, causing inflammation and swelling of the nipple which can also become infected. This emphasizes the importance of creating a supporting environment for new mothers providing encouragement from the healthcare team.

26. MANAGEMENT OF THE NORMAL PUERPERIUM Hospital Discharge The approved length of postpartum stay has decreased to less than 24 hours Follow-Up Visit is evidenced by the 50% no-show rate Timing of the visit has also varied, from 2 to 6 weeks postpartum Screening for readiness to resume employment responsibilities Screening for postpartum depression Screening for return to sexual activity The Pap smear Mood assessment Evaluation of uterus, breast, perineum, and thyroid status

27. SCHEDULE OF POSTNATAL VISITS First visit (could be a home visit) within 1 week, preferably on day 3 Second visit 7-14 days after birth Third visit 4-6 weeks after birth

28. MANAGEMENT…….. Perineal Care If delivery was uncomplicated, showering and bathing are allowed The vulva should be cleaned from front to back. Sitz baths can provide substantial comfort as well as cleansing Breast care For the non-breastfeeding patient, engorgement is an extremely uncomfortable condition and can account for substantial morbidity. For the breastfeeding woman, issues such as nipple care and maintenance of good milk flow are of concern. Medication Use In Lactation Each medication should be reviewed with regard to concentration in milk and effects on the infant. Alcohol slightly decreases milk production, and crosses easily into breast milk

29. MANAGEMENT…….. Rh Factor If the parturient is Rh-negative, the infant’s Rh status should be evaluated via cord blood. If the infant is Rh-positive and there was no evidence of an unusual fetal–maternal transfusion, the standard dose of 300 μg of Rh-immune globulin may be administered. Contraception Postpartum sterilization should be a selection made prior to labor consent form be signed at least 30 days Other excellent postpartum contraceptive choices include intrauterine devices (copper or levonorgestrel), depot medroxyprogesterone, and in some cases, combination or progestin-only oral contraceptives.

30. MANAGEMENT…….. Cesarean wound care Following cesarean delivery, patients should receive standard wound care and monitoring. Typically, the bandage is removed within 1 to 2 days postoperatively. Patients may shower after the dressing is removed Pain management Nonsteroidal anti-inflammatory drugs (NSAIDs) are effective for both perineal discomfort and uterine cramping If pain is significantly worsening, women should be evaluated for complications, such as vulvar hematoma or post-cesarean complications.

31. MANAGEMENT…….. Bladder and bowel function Voiding should be encouraged Pudendal nerve injury during delivery can cause bladder dysfunction Women are encouraged to defecate before leaving the hospital Diet and exercise After delivery, a regular diet may be given as soon the patient desires. Ambulation is encouraged as soon as possible. Whether pelvic floor muscle exercises (Kegel exercises) are helpful is unclear, but these exercises can begin as soon as the patient is ready.

32. MANAGEMENT…….. Breast engorgement Milk accumulation may cause painful breast engorgement during early lactation. Expressing milk by hand in a warm shower or using a breast pump between feedings to relieve pressure temporarily Breastfeeding the infant on a regular schedule Wearing a comfortable and supportive nursing bra 24 hours/day Sexual activity Sexual activity after vaginal delivery may be resumed as soon as desired and comfortable and after healing of any laceration or episiotomy repair. Sexual activity after cesarean delivery should be delayed until the surgical wound has healed.

33. PATHOLOGY OF POST PARTUM

34. PATHOLOGY ……   Postpartum Hemorrhage It is nonetheless the most common life-threatening condition Mastitis is associated with fevers that can be quite high, erythema of a portion of a breast, induration, exquisite tenderness, and systemic findings such as chills and malaise. Epidural Back Pain Back pain is a common complaint of pregnancy, but new-onset postpartum back pain has often been associated with use of epidural analgesia. Postpartum Renal Failure Postpartum renal failure is an idiopathic condition It is similar to hemolytic uremic syndrome, and is manifested by renal failure, microangiopathic hemolytic anemia, thrombocytopenia, and hypertension.

35. PATHOLOGY …… Sheehan’s Syndrome Postpartum pituitary necrosis, commonly known as Sheehan’s syndrome, may occur following profound hemorrhage or eclampsia. The mechanism of injury is thought to be hypoxic because the anterior pituitary is the area of the brain most sensitive to hypoperfusion. The posterior pituitary is generally spared. Peripartum Cardiomyopathy and Cerebrovascular Disease Peripartum cardiomyopathy may appear in the last month of pregnancy, but it more commonly occurs within the first 5 months postpartum.

36. Mental Health

37. Mental Health

38. Mental Health….. Postpartum Depression Few other life stressors besides delivery so frequently lead to mood disorders, and often the patient’s role as an infant’s caregiver may limit diagnostic and intervention measures. Most women experience some period of transient depressed mood within the 1st week of delivery, referred to as postpartum blues . This may represent a combination of physical exhaustion, an overwhelming sense of the responsibilities of parenthood, and massive hormonal and metabolic shifts.

39. Mental Health…..

40. Mental Health… Postpartum psychosis With postpartum psychosis — a rare condition that usually develops within the first week after delivery — the symptoms are severe. Symptoms may include: Feeling confused and lost Having obsessive thoughts about the baby Hallucinating and having delusions Having sleep problems Having too much energy and feeling upset Feeling paranoid Making attempts to harm self or the baby

41. Post partum complications Postpartum hemorrhage Postpartum preeclampsia Deep vein thrombosis (DVT) Pulmonary embolism Mental health conditions like postpartum rage or postpartum psychosis Sepsis

42. https://www.osmosis.org/learn/Postpartum_Physiologic_Changes_and_Nursing_Care https://www.osmosis.org/learn/Postpartum_Physiologic_Changes END