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  1. 1. Sreelakshmi. M
  2. 2. Normal puerperium
  3. 3.  Six weeks following childbirth during which the pelvic organs return to prepregnant state & physiological changes of pregnancy are all reversed. Immediate: within 24 hours Early : up to 7 days Woman in puerperal period: puerpera
  4. 4. Physiologicalchanges
  5. 5. 1. Involution of the uterus• process by which postpartum uterus returns to prepregnant state• End of 3rd stage of labor: fundus just below umbilicus• By 2 weeks: descends into abdomen not palpable through abdomen• Weight: 1000g (immediately after delivery) 500g by 1 wk. 300g by end of 2nd wk.• Returns to prepregnant state 4 wks. after delivery• Achieved by decrease in size of muscle fibers• by autolysis of cytoplasm by proteolytic enzymes
  6. 6. • After pains : infrequent, spasmodic pain in lower abdomen for up to 3-4 days : common due to uterine contraction : during breast feeding (oxytocin)Due to blood clots uterus contract attempt to remove clotMore in primiparaIf severe: antispasmodics
  7. 7. 2. Endometrium• Decidua shed after childbirth• S.compactum & S.spongiosum shed• S.basale remains new endometrium from remnants of endometrial glands completed in 14 days.3. Placental site• Takes longer to recover• Arteries: obliterated by endarteritis & hyaline(1wk)• Veins: thrombosis• Last to involute• Regeneration: 6wks
  8. 8. 3. Lochia• Vaginal discharge for first few wks. following delivery• Blood from placental site + necrotic decidua• Lochia rubra: red color, 1st few days following delivery• Lochia serosa: paler , 3-4 days leucocytes, necrotic decidua + red cells• Lochia alba: yellowish white, after 10th day• Persists up to 4 wks.• Gives information about any abnormality like infection
  9. 9. 4. Cervix• Contract immediately after delivery• Remains patulous for few days• Starts closing (at end of 1st wk.), cervical canal reforms, completed by 6th week.• External os wont regain original appearance parous cervix has characteristic transverse slit• Lower segment: contract form small uterine isthmus (6 wks.)
  10. 10. Other Pelvic Organs Vagina: smooth & stretchable for first few days size reduced & rugose within 4 wks. Hymen: represented by caruncle myrtiformes (small tags of tissue) Relaxation of vaginal outlet & pelvic floor
  11. 11. Urinary systemBladder: sustains trauma mucosal edema& submucosal hemorrhages disappear in few daysProlonged& difficult delivery injury to bladder innervation insensitive bladder capacity & insensitive to intravesical fluid pressureOver distensionIncomplete emptyingResidual urine / retentionExaggerated in epidural & spinal anesthesiaAfter 1st week, recedes during the following weeks
  12. 12. Dilated ureters & pevicalyceal system: normal in 8 wksRenal plasma flow, GFR & creatinine clearance : normal by end of puerperiumIncreased extracellular water( in normal pregnancy) becomes normal with postpartum diuresis (2nd-5th days)Urea & creatinine elimination : remain high for 2 wks
  13. 13. Delivery intestinal paresis constipationPain in perineum also contributes (episiotomy & lacerations)Early ambulation, high fiber diet, increased fluid intake
  14. 14. • Rapid fall of plasma volume in 1st day• Slowly to non-pregnant volume: end of 1st week.• Red cell mass : normal within 24hours• Hb concentration: minimum on 4th day & normal by 6 weeks• ESR: in 1st week & normal by 4 weeks.• Increased leukocytosis (during & after labor) : subsides after 1 week• Platelets: in no. with adhesiveness• Fibrinogen: in 1st week.• Coagulation factors: increased & persists in
  15. 15. • Heart size returns to normal slowly• Heart sounds returns more rapidly• 3rd sound & systolic ejection murmurs: disappear in 1wk• C.O: for 24 hours : steady fall till 10th day: almost normal• Actual non-pregnant value: only by 6 months• C.O : due to in SV & HR• Heart rate ~ C.O• Fall in stoke volume is slow• BP : rises in 1st days & normal by 1 week• Peripheral Resistance: rises rapidly to
  16. 16. • Uterine evacuation• Normal blood loss• Further 2-3kg : diuresis• Prepregnant weight in 6 months
  17. 17. • Variable• Depends on lactation• Non-lactating: early resumption by 6-8 weeks• In nursing mothers: 70 % amenorrhea till 4-6 months• Total protection only for 10weeks: ovulation return by the end of lactational amenorrhea.• Additional contraceptives : after 3 months ( even in completely breast feeding)
  18. 18. Care inpuerperium
  19. 19. • Observed for minimum 2hours in labor ward : vital signs, bleeding, micturition• Uterus : well contracted. Bleeding: within normal limits• Before shifting to ward: >examine perineum, episiotomy site >sterile dressing with antiseptic• Relatives, food, fluids, good sleep• Encourage early ambulation
  20. 20. • Assessed by noting height of fundus above symphysis pubis• Day after delivery: 12 cm above symphysis• 1cm decrease per day• By end of 2nd week: no longer palpable
  21. 21. • Encouraged to void soon after delivery• Doesn’t void within 6-8 hours : bladder atony• Retention : common in early puerperium (esp. in epidural analgesia & traumatic delivery with perineal lacerations) : vulvovaginal hematoma Uterine atony hemorrhage Urinary infection• Local analgesics• Catheterization (for 24 hours) till tone restoration
  22. 22. • Constipation• Increase fluid intake & roughage• Prescription of mild laxatives
  23. 23. • Immediately start normal diet• Plenty of fluids & milk daily : lactation• Calorie & protein intake• Additional daily requirement: 500kcal & 25g proteins• Fresh fruits & green leafy veg : vitamins• Iron: continued for 3 months / whole lactating period
  24. 24. • Regular antiseptic cleaning of episiotomy wound• Wash with warm water & use sterile pads• Analgesics• Severe pain: hematoma• Infection : antibiotics• Episiotomy wound: healed by 3 weeks
  25. 25. • Must be adequate,• Rooming in : baby on mother’s cotEarly ambulation• Venous thrombosis & embolism
  26. 26. • Baby breast fed as soon as possible• No frequent & early feeding engorged & painful• Correct positioning &clean nipples• Draw out retracted nipples• Cracked nipples: painful : emollient creams after feeds
  27. 27. • Episiotomy & perineal lacerations, breast engorgement & after pains ( uterine contraction )• Caesarean section: pain at incision site, post spinal headache• Analgesics
  28. 28. • Common in early puerperium : postpartum blues• Reassurance & supportHospital stay Vaginal delivery: after 48hrs Caesarian section : 4-5 days
  29. 29. 1. Immunization of motherAnti-D IgG within 72hrsRubella vaccine / MMR2. ContraceptionPost partum sterilizationInterval sterilizationCounseling
  30. 30. 3. Medications Adviced to avoid medications as far as possible Take only on medical advice4. Infant advice Adequate follow up Rooming in BCG vaccine prior to going home Immunisation schedule Advice mother to feed on demand
  31. 31. 4. Postnatal exercisesEarly in puerperiumMove limbs, deep breathing exercises, abdominal muscle tightening exercises everydayRepeated 3-4 times a dayPerineal muscle exercises: improve vaginal muscle tone, prevent vaginal laxity & stress incontinenceBack muscle toning
  32. 32. Postnatalcheck-up
  33. 33. • Scheduled at 6 weeks• Maternal problems discussed• Breast-feeding• Lochia & menses• Clinical examination, abdomen, breasts• Local examination : episiotomy & discharge• Pelvic examination• PIH, GDM• Any medical problems• Advice on resuming job, coitus, other activities
  34. 34. • Breast feeding alone wont suffice as contraception• Various options given, partner included• IUCD inserted if acceptable• Other options which wont reduce breast milk amount Progesterone only pill Injectable progestogens (depot medroxy progesterone acetate)
  35. 35. Inform about possible side-effectsShould avoid estrogen-pregesterone combination: affect quantity & quality of milkPermanent sterilizations: postpartum/ interval sterilization/
  36. 36. • Seen by pediatrician• Checked for any problems• Weight , feeding problems• Reinforce immunization schedule
  37. 37. Restoration of maternal health to prepregnant statePromotion of breast feedingCorrection of any problems arising due to deliveryAdvice on baby care & immunizationContraceptive advice
  38. 38. Thank you