PUERPERIUM Lower Uterine Segment

 markedly attenuated lower uterine segment contracts and

Puerperium retracts
 Latin—puer which means child and which parus means  During the next few weeks
bringing forth
 time following delivery during which pregnancy-induced clearly distinct
barely discernible uterine
maternal anatomical and physiological changes return to the substructure large
isthmus located between the
nonpregnant state enough to accommodate corpus and internal os.
 considered to be between 4 and 6 weeks the fetal head
 appreciable changes, some of which may be either bothersome
or worrisome for the new mother
Uterine Involution
 Postpartum, the fundus of the contracted uterus is slightly
Involution of the Reproductive Tract
below the umbilicus
Vagina and Vaginal Outlet
 consists mostly of myometrium covered by serosa and
Early Vagina and its outlet form a capacious, smooth- internally lined by basal decidua
Puerperium: walled passage that gradually diminishes in size but  Anterior and posterior walls, in close apposition, each measures
rarely returns to nulliparous dimensions 4 to 5 cm thick
rd
3 week ruggae begin to reappear Myrtiform Curuncles –  uterus weighs approximately 1000 g
scarred small tags of tissue in the hymen
th th  ischemic uterus
4 to 6 vaginal epithelium begins to proliferate o blood vessels are compressed by the contracted
week (coincidental with ovarian estrogen production) myometrium
o Compared with the reddish-purple hyperemic pregnant
Uterine Vessels organ
DURING PREGNANCY: AFTER DELIVERY 2 days after delivery uterus begins to involute
 Massively increased uterine  caliber of extrauterine 1 week postpartum it weighs about 500 g
blood flow vessels decreases to equal, 2 weeks postpartum it weighs about 300 g
 Significant hypertrophy and or at least closely soon thereafter to 100 g or less
remodeling of all pelvic approximates, that of the 4 weeks after uterus regains its previous nonpregnant
vessels prepregnant state. delivery size
 larger blood vessels are  total number of muscle cells does not decrease, but instead,
obliterated by hyaline the individual cells decrease markedly in size.
changes, gradually
resorbed, and replaced by
smaller ones.
 Minor vestiges of the larger
vessels, however, may
persist for years.

Cervix
ST
DURING LABOR END OF 1 WEEK
 external os is usually  Cervix narrows, thickens,
lacerated, especially and a canal reforms
laterally  external os does not
 cervical opening contracts completely resume its
slowly, and for a few days pregravid appearance Sonographic Findings:
immediately after labor  It remains wider and First week Uterine size dissipates rapidly
readily admits two fingers bilateral depressions at the 8 weeks after uterus and endometrium return to pregravid
site of laceration – PAROUS delivery size
CERVIX up to 2 months Demonstrable uterine cavity contents are
. seen
 By Doppler studies, there is continuously increasing uterine
artery vascular resistance during the first 5 postpartum days

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Clinical Aspect Histologic part of normal reparative process
Endometritis
After Pains
Acute Salpingitis seen in almost half of postpartum women
Primiparas uterus tends to remain tonically contracted
between 5 and 15 days
Multiparas uterus often contracts vigorously at intervals, and
gives rise to afterpains
 more pronounced as parity increases Placental Site Involution
 worsen when the infant suckles Placental Site Involution
o Oxytocin release  An exfoliation, consequence of sloughing of infarcted and
rd
 3 day necrotic superficial tissues followed by a reparative process
 decrease in intensity and become mild  extension and “downgrowth” of endometrium from the
margins of the placental site, as well as
Lochia  development of endometrial tissue from the glands and stroma
 sloughing of decidual tissue results in a vaginal discharge of left deep in the decidua basalis after placental separation
variable quantity After delivery placental site is about the size of
 Consists of: the palm of the hand, rapidly
o Erythrocytes decreases thereafter
o Shredded decidua end of the second week it is 3 to 4 cm in diameter
o Epithelial cells
o Bacteria 6 weeks Complete extrusion of the
LOCHIA RUBRA LOCHIA SEROSA LOCHIA ALBA placental site
first few days after After 3 or 4 days, After about the
delivery, there is blood lochia becomes 10th day, Subinvolution
sufficient to color it progressively pale in because of an  an arrest or retardation of involution
red color admixture of  Causes:
leukocytes and o Infection
reduced fluid o retained placental fragments
content, lochia o incompletely remodeled uteroplacental arteries
assumes a white  varied intervals of prolonged lochia
or yellowish-  irregular or excessive uterine bleeding
white color  uterus is larger and softer than would be expected
3-4 days postpartum 3 weeks postpartum 10 days - 6 Management of Subinvolution
weeks  Ergonovine or methylergonovine, 0.2 mg every 3 to 4 hours for
postpartum 24 to 48 hours
 Antibiotic therapy for infection
 Chlamydia trachomatis
o cause of almost third of late postpartum metritis
o treated with Azithromycin or Doxycycline

Late Postpartum Hemorrhage

 American College of Obstetricians and Gynecologists (2013b)
Decidua and Endometrial Regeneration defines secondary postpartum hemorrhage
 separation of the placenta and membranes involves the spongy  bleeding 24 hours to 12 weeks after delivery
layer  develops 1 to 2 weeks into the puerperium
 the decidua basalis is not sloughed  Causes:
 remaining decidua has striking variations in thickness, it has an o abnormal involution of the placental site
irregular jagged appearance, and it is infiltrated with blood, o retention of a placental fragments
especially at the placental site o uterine artery pseudo aneurysm
2 or 3 days after delivery remaining decidua becomes differentiated o on Willebrand disease or other inherited
into two layers coagulopathies
Superficial layer becomes necrotic, and it is sloughed in the  Placental Polyp
lochia  retained products undergo necrosis with fibrin deposition
Basal layer adjacent to the myometrium, remains intact  eschar of the polyp detaches from the myometrium,
and is the source of new endometrium hemorrhage may be brisk
Endometrium arises from proliferation of the endometrial  Treatment
glandular remnants stable patient; empty cavity oxytocin, ergonovine,
stroma of the interglandurlar connective tissue methylergonovine, or
Endometrial regeneration is rapid, except at prostaglandins
the placental site with infection Antimicrobial
Within week or so the free surface becomes covered by epithelium large clots Suction curettage
th
16 day onward Full restoration of the endometrium is if appreciable bleeding persists Curettage
obtained or recurs after medical
management

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Urinary Tract Changes Lactation
nd th
 diuresis that occurs postpartum (2 -5 day) is a physiological Colostrum
reversal of increase in extracellular water in normal pregnancy  deep lemon-yellow-colored liquid
nd
 puerperal bladder has an increased capacity and a relative  expressed from the nipples by the 2 postpartum day
insensitivity to intravesical fluid pressure  rich in immunological components and contains more minerals
 paralyzing effect of analgesics, especially epidural and spinal and amino acids
blocks are contributory  contains more protein, much of which is globulin, but less sugar
and fat
 Overdistention, incomplete emptying, and excessive residual  secretion persists for about 5 days, with gradual conversion to
urine are common mature milk during the ensuing 4 weeks
 2 to 8 weeks  content of immunoglobulin A (IgA) may offer protection for the
 dilated ureters and renal pelves return to their prepregnant newborn against enteric pathogens
state over the course  host resistance factors that are found in colostrum and milk:
 dilated renal pelves and ureters, and traumatized bladder o complement, macrophages, lymphocytes, lactoferrin,
create an optimal condition for the development of UTI lactoperoxidase, and lysozymes

Urinary Incontinence Mature Milk

 3% to 26% of women report daily episodes of incontinence in  fat, proteins, carbohydrates, bioactive factors, minerals,
the 3 to 6 months after delivery vitamins, hormones, and many cellular products.
 Can be due to Impaired muscle function in or around the  concentrations and contents of human milk change even during
urethra as a result of vaginal delivery a single feed
 correlated with obstetrical factors such as length of second-  influenced by maternal diet, as well as infant age, health, and
stage labor, infant head circumference, birthweight, and needs
episiotomy  600 mL of milk daily
 women whose deliveries had all been vaginal had a 70-percent
higher risk of incontinence than women whose deliveries had Human Milk
all been by caesarean  Whey is milk serum
o contain large amounts of interleukin-6 (IL-6)
Peritoneum and Abdominal Wall  positive correlation between its concentration and the number
of mononuclear cells in human milk
 broad and round ligaments o IL-6 was associated closely with local IgA production
 require considerable time to recover from stretching and by the breast
loosening during pregnancy  Prolactin and Epidermal growth factor
 abdominal wall remains soft and flaccid  All vitamins except K are found in human milk
 due to rupture of elastic fibers in the skin and the prolonged  Vitamin K administration to the infant soon after delivery is
distention caused by the pregnant uterus required to prevent hemorrhagic disease of the newborn
 several weeks are required for these structures to return to
normal aided EXERCISE Endocrinology of Lactation
 Progesterone ,estrogen, and placental lactogen, prolactin,
STRIAE silvery abdominal striae
cortisol, and insulin: stimulate the growth and development of
GRAVIDARUM
the milk-secreting apparatus of the mammary gland
DIASTASIS RECTI Marked separation of the rectus abdominis
muscles Decrease estrogen and progesterone

Blood and Fluid Changes

Removes the inhibitory influence of progesterone on the
 marked leukocytosis and thrombocytosis occur during and after production of alpha lactalbumin by the rough endoplasmic
labor reticulum
 relative lymphopenia and an absolute eosinopenia
during the first few hemoglobin concentration and
increased alpha lactalbumin stimulate lactose synthase
postpartum days hematocrit fluctuate moderately
1 week after deliver the blood volume has returned nearly to
its nonpregnant level
 Cardiac output increase milk lactose
o remains elevated for 24 to 48 hours postpartum
o declines to non pregnant values by 10 days  neurohypophysis secretes oxytocin in pulsatile fashion
 stimulates milk expression from a lactating breast by causing
Weight Loss contraction of myoepithelial cells in the alveoli and small milk
due to uterine evacuation and loss of about 5 to 6 kg ducts
normal blood loss
through diuresis loss of about 2 to 3 kg

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Immunological Consequences of Breastfeeding Lactation Inhibition
 predominant immunoglobulin in milk is secretory IgA  Milk leakage, engorgement, and breast pain peak at 3 to 5 days
 SECRETORY IgA postpartum
o secreted across mucous membranes  Ice packs and oral analgesics for 12 to 24 hours may be
o has important antimicrobial functions required to relieve
 breast-fed infants are less prone to enteric infections than  Bromocriptine ,a commonly used drug for lactation inhibition,
bottle-fed infants had been associated with strokes, myocardial infarctions,
 human milk also provides protection against rotavirus seizures, and psychiatric disturbances.
infections,Escherichia coli infections
 contains both T and B lymphocyte Contraception for Breastfeeding Women
 milk T lymphocytes are almost exclusively composed of cells  Recommendations for Hormonal Contraception if Used by
that exhibit specific membrane antigens Breast Feeding Women
 Progestin-only oral contraceptives prescribed or dispensed at
Nursing discharge from the hospital to be started 2–3 weeks
 Human milk is ideal food for neonates. postpartum—for example, the first Sunday after the newborn is
o provides species- and age-specific nutrients for the 2 weeks of age.
infant  Depot medroxyprogesterone acetate initiated at 6 weeks
a
o proper balance of nutrients, immunological factors, postpartum.
and antibacterial properties, human milk contains  Hormonal implants inserted at 6 weeks postpartum.
factors that act as biological signals for promoting  Combined estrogen–progestin contraceptives, if prescribed,
cellular growth and differentiation should not be started before 6 weeks postpartum, and only
 decreases the incidence and/or severity of diarrhea, lower when lactation is well established and the infant's nutritional
respiratory infection, otitis media, bacteremia, bacterial status well monitored
meningitis, botulism, urinary tract infection, and necrotizing
enterocolitis. Nipple Care
 possible protective effect of human milk feeding against  cleanliness and attention to fissures
sudden infant death syndrome, insulin-dependent diabetes  cleaning of the areola with water and mild soap is helpful
mellitus, Crohn disease, ulcerative colitis, lymphoma, allergic before and after nursing
diseases, and other chronic digestive diseases.  When the nipples are irritated, use a nipple shield for 24 hours
 Breast feeding has also been related to possible enhancement or longer
of cognitive development
Contraindications to Breastfeeding
Table 36-2 and 36-3 are supplemented from the book
(I found them interesting kasi )  in women who take street drugs or do not control their alcohol
use
 have an infant with galactosemia
 have human immunodeficiency virus (HIV) infection
 have active, untreated tuberculosis
 take certain medications
 undergoing treatment for breast cancer
 although hepatitis B virus is excreted in milk, breastfeeding is
not contraindicated if hepatitis B immune globulin is given to
infants of seropositive mothers.
 Maternal hepatitis C infection is also not a contraindication to
breast feeding
 Women with active herpes simplex virus may suckle their
infants if there are no breast lesions and if particular care is
directed to hand washing before nursing.

Drugs That Have Been Associated with Significant Effects on Some

Nursing Infants
Acebutolol Hypotension, bradycardia, tachypnea
5-Aminosalicylic acid Diarrhea (one case)
Aspirin (salicylates) Metabolic acidosis (one case)
Atenolol Cyanosis, bradycardia
Bromocriptine Suppresses lactation, may be hazardous to
the mother
Clemastine Drowsiness, irritability, refusal to feed,
high-pitched cry, neck stiffness (one case)
Ergotamine Vomiting, diarrhea, convulsions—doses
used in migraine medications
Lithium A third to half therapeutic blood
concentration in infants

caramelmacchiato(3B) 4
Phenindione Anticoagulant— increased prothrombin Galactocoele
and partial thromboplastin time in one  result of the clogging of a duct by inspissated secretion,milk
infant— not used in United States may accumulate in one or more lobes of the breast
Phenobarbital Sedation; infantile spasms after weaning  excess may form a fluctuant mass that may give rise to pressure
from milk containing phenobarbital; symptoms
methemoglobinemia (one case)  resolve spontaneously or require aspiration
Primidone Sedation, feeding problems
Sulfasalazine Bloody diarrhea (one case) Supernumerary Breast
 cytotoxic drugs may interfere with the cellular metabolism of  so small as to be mistaken for pigmented moles, or when
the infant and potentially cause immune suppression or without a nipple, for a lipoma
neutropenia, affect growth, or, at least theoretically, increase  situated in pairs on either side of the midline of the thoracic or
the risk of cancer abdominal walls, usually below the main breasts; also found in
1. cyclophosphamide the axillae, and more rarely on other portions of the body, such
2. cyclosporine as the shoulder, flank, groin, or thigh
3. doxurubicin  no obstetrical significance
4. methotrexate
 Radioactive isotopes of copper, gallium, indium, iodine, sodium, Abnormalities of NIPPLES
and technetium rapidly appear in breast milk. This ranges from Inverted-  draw the nipple out, using traction with
15 hours up to 2 weeks, depending on the isotope used. fingers.
Other Issues with Lactation Normal size and  may become fissured lesions
BREAST FEVER shape-  provide a convenient portal of entry for
 breasts become distended, firm, and nodular pyogenic bacteria
 a transient elevation of temperature (ranged from 37.8 to 39°)  effort should be made to heal such
 Treatment: fissures
o supporting the breasts with a binder or brassiere,
applying an ice bag, an analgesic, pumping of the Abnormalities with SECRETION
breast or manual expression of milk agalactia complete lack of mammary secretion
polygalactia mammary secretion is excessive
Mastitis
 infection of the mammary glands during the puerperium and Maternal Care During The Puerperium
lactation or antepartum Hospital Care
 unilateral, and marked engorgement usually precedes the  two hours after delivery, blood pressure and pulse should be
inflammation. taken every 15 minutes, or more frequently if indicated
 first sign of inflammation is chills or actual rigor, soon followed o amount of vaginal bleeding is monitored
by fever and tachycardia. o significant hemorrhage is greatest immediately
o About 10 % of women with mastitis develop an abscess postpartum
Etiology: o fundus should be palpated to ensure that it is well
 Staphylococcus aureus – 40 %; coagulase-negative contracted
staphylococci and viridans streptococci o If relaxation is detected, the uterus should be massaged
 Immediate source of organisms almost always the infant's nose through the abdominal wall until it remains contracted.
and throat o the uterus is closely monitored for at least 1 hour after
Treatment: delivery
 clinicians recommend that milk be expressed from the affected
breast onto a swab and cultured Early Ambulation
o initiate antimicrobial therapy:
 Women are out of bed within a few hours after delivery
 staphylococcal infections are usually sensitive to penicillin or a  Advantages of early ambulation
cephalosporin o fewer bladder complications,
o Dicloxacillin 500 mg orally four times daily, may be started o less frequent constipation,
empirically o reduced rates of puerperal venous thromboembolism
o Erythromycin is given to women who are penicillin
sensitive
Perineal Care
o Vancomycin is effective against MRSA
 cleanse the vulva from anterior to posterior (vulva toward
 treatment should be continued for 10 to 14 days
anus)
 If the infected breast is too tender to allow suckling, gently
 Cool pack applied to the perineum
pumping until nursing can be resumed is recommended.
o reduce edema and discomfort during the first 24
hours if there is a laceration or an episiotomy
Breast Abscess
 24 hours after delivery
 development is either from failure of defervescence within 48 o moist heat as provided with warm sitz baths can be
to 72 hours or development of a palpable mass
used to reduce local discomfort
Treatment:
o Tub bathing after uncomplicated delivery is allowed
o Traditional therapy is surgical drainage less invasive
o alternative is ultrasonographic-guided needle aspiration
using local anesthesia

caramelmacchiato(3B) 5
Bladder Function Thromboembolic Disease
 Oxytocin  Half of thromboembolic events associated with pregnancy
o antidiuretic effect, as a consequence of infused fluid develop in the puerperium,
o sudden withdrawal of the antidiuretic effect of  Pressure on branches of the lumbosacral nerve plexus during
oxytocin, rapid bladder filling is common labor may be manifest by complaints of intense neuralgia or
 bladder sensation and capability to empty spontaneously may cramplike pains extending down one or both legs as soon as the
be diminished head begins to descend into the pelvis
 If the woman cannot void after 4 hours, she should be  If the nerve is injured, pain continues after delivery and may be
catheterized and urine volume measured accompanied by variable degrees of sensory loss or muscle
 it usually is best to leave the catheter in place for at least 24 paralysis supplied by the damaged nerve
hours, whenever the bladder becomes overdistended
 If there is more than 200 mL of urine Obstetrical Neuropathies
 bladder is not functioning appropriately  If the nerve is injured, pain continues after delivery and may be
accompanied by variable degrees of sensory loss or muscle
Pain, Mood and Cognition paralysis supplied by the damaged nerve
Subsequent Discomfort o Lateral femoral cutaneous neuropathies were the
 Mother may be uncomfortable due to: most common
o Afterpains  Nulliparity and prolonged second-stage of labor were
o episiotomy and lacerations independent risk factors for nerve injury.
o breast engorgement  Separation of the symphysis pubis or one of the sacroiliac
o postspinal puncture headache synchondroses during labor may be followed by pain and
 Mild analgesics containing codeine, aspirin, or acetaminophen, marked interference with locomotion
preferably in combinations, are given as frequently as every 3
hours during the first few days Immunization
D-negative woman  not isoimmunized and whose
Depression infant is D-positive
 Postpartum blues  given 300 microgram of anti-D
o degree of depressed mood a few days after delivery immune globulin shortly after
 Emotional letdown that follows the excitement and fears that delivery
most women experience during pregnancy and delivery Women who are  combined measles-mumps-
 Discomforts of the early puerperium not already immune to rubella vaccination before
 Fatigue from loss of sleep during labor and postpartum rubella or rubeola discharge
 anxiety over the ability to provide appropriate infant care, and measles
body image concerns
Treatment
Time of Discharge
o anticipation, recognition, and reassurance
o Mild and self-limited to 2 to 3 days, although it sometimes  Following vaginal delivery, hospitalization is seldom warranted
lasts for up to 10 days for more than 48 hours.
 Receive instructions regarding:
Abdominal Wall Relaxation o normal physiological changes of the puerperium,
o lochia patterns
 Exercises to restore abdominal wall tone may be started any
o weight loss from diuresis
time after vaginal delivery and as soon as abdominal soreness
o when to expect milk let-down
diminishes after cesarean delivery
o Fever
o excessive vaginal bleeding
Diet
o leg pain, swelling, or tenderness
 NO dietary restrictions for women who have been delivered o Persistent headaches
vaginally o shortness of breath
a woman should be 2 hours after normal vaginal delivery o chest pain
allowed to eat
If breastfeeding Level of calories and protein consumed Early Discharge
during pregnancy should be increased
 “The norms are hospital stays of up to 48 hours following
slightly
uncomplicated vaginal delivery and up to 96 hours following
Not breastfeeding Dietary requirements are the same as for uncomplicated cesarean delivery.”
a nonpregnant woman (American Academy of Pediatrics, American Academy of
continue oral iron  for at least 3 months after delivery Obstetricians and Gynecologists, 2012)
supplementation

caramelmacchiato(3B) 6
Contraception Follow Up Care
 Effort should be made to provide family planning education  half expected a return to full duties within 2 weeks
 Not breastfeeding, menses usually return within 6 to 8 weeks  only half of women regained their usual level of energy by 6
 Ovulation is much less frequent in women who breast feed weeks postpartum
compared with those who do not lactating women,  Women who delivered vaginally were twice as likely to have
the first period may occur as early as the second OR normal energy levels compared with those with a cesarean
as late as the 18th month after delivery delivery
 Care and nurturing of the neonate should be provided by the
 Delayed resumption of ovulation with breast feeding mother with ample help from the father.
 Other findings included the following:
 Resumption of ovulation was frequently marked by return of
normal menstrual bleeding
 Breast feeding episodes lasting 15 minutes seven times each
day delayed resumption of ovulation.
 Ovulation can occur without bleeding.
 Bleeding can be anovulatory.

 The risk of pregnancy in breast feeding women was

approximately 4 percent per year.

Home Care
COITUS
 no definite time after delivery when coitus should be resumed
 Median interval between delivery and intercourse was 5 weeks
range was 1 to 12 weeks
 reasons cited for not resuming intercourse
o perineal pain
o bleeding
o fatigue
 coitus may be resumed based on the patient's desire and
comfort

INFANT FOLLOW UP
 importance of subsequent neonatal and well-baby care should
be stressed and an emphasis placed on infant immunizations.
 Any neonate discharged early should be term, normal, and
have stable vital signs.
 Initial hepatitis B vaccine should be administered, and all
screening tests required by law should be performed

Puerperal Morbidity in Percent Reported by Women After Hospital

Discharge
By 8 weeks 2 to 18 months
Morbidity
Postpartum Post-partum
Tiredness 59 54
Breast Problems 36 20
Anemia 25 7
Backache 24 20
Hemorrhoids 23 15
Headache 22 15
Tearfullness/depress 21 17
ion
Constipation 20 7
Stitches breaking 16 -
down
Vaginal discharge 15 8
Others 2-7 1-8
At least 1 of the 87 76
above

caramelmacchiato(3B) 7