MahmoudYoussefAbdalla.

ProfessorofObstetrics&Gynaecology.
AinShamsUniversity.
PUERPERIU
Definition:
I i h i f d li il l l i f Itis:thetimefromdeliveryuntilcompleteresolutionof
thephysiologicalchangesofpregnancy.
Itisthefirst6weekspostpartum(afterdelivery).During
thistime,thereproductivetractreturnstothenon
pregnantstate.
Physiologicalchangesduringpuerperium.
I.SystemicChanges:
A.Vitalsigns:
1 Temperature:Thereisonlyslightrise0.5Cthatdropsbackto
normalwithin24hours.Slightrisemayoccuronthe3rddaydue
tobreastengorgement(startoflactation),
l A fi h i li h l i f l hi h h 2 Pulse: Atfirstthereisslightslowingofpulserate,whichthen
becomesnormal,exceptifhemorrhageorinfectionhasoccurred,
whereitwillbeaccelerated.
B.Cardiovascularchanges:
Cardiacoutput:Thenormalbloodlossatvaginaldeliveryis500mL
andatCesareansection1000mL.
Despitethisbloodloss,strokevolumeisincreased,secondaryto Despitethisbloodloss,strokevolumeisincreased,secondaryto
increasedvenousreturn,becauseoflossoftheplacentalshuntand
mobilizationofperipheralinterstitialfluid.
Cardiacoutputisnotchanged, thestrokevolumeisincreasedand
theheartrateisdecreased theheartrateisdecreased
Bytheendofthe2ndweekpostpartum,cadiacoutputreturnstothe
nonpregnantlevel.
RedcellcountandHb%: Theybecomenormalexceptiftherewas
bloodlossbefore during orafterlabor bloodlossbefore,during,orafterlabor.
CGastrointestinaltract:Tendencytoconstipation
isincreasedduringtheearlypuerperiumdueto:
1 Dehydration,loworalintakeoffluidandfood. y ,
2 Painfulepisiotomyleadstoreflexconstipation.
3 Atonyofintestinal,abdominalandperineal
muscles muscles.
DUrinarytract:
1Overdistensionofthebladderand/orincompletebladderemptying are
commonduetorecumbentposition,laxityofabdominalandurinary commonduetorecumbentposition,laxityofabdominalandurinary
bladdermuscles,reflexinhibitionduetopainproducedbystitchesof
perinealtearorepisiotomy,andurethralcompressionbyedemaor
hematoma.
2 Polyuria infirstfewdaysofpuerperiumhelpstoexcretewaterretained
d i duringpregnancy.
3 Renalfunctiondecreases tononprgnantlevelsby6weekspostpartum,but
theanatomicalchangessuchasureteralandcalycealdilatationmaypersist
forseveralmonths.
4 Stressincontinencemaycomplicateadifficultlabor 4 Stressincontinencemaycomplicateadifficultlabor.
E.Breasts:
Afterdeliveryoftheplacenta,withdrawalofestrogensand
progesterone(haveinhibitoryeffectupontheactionofprolactin
hormone(PRL)onthebreastacini).So,theaciniwillnowrespondto ( ) ) , p
thehyperprolactinemiabymilkformation,whichusuallystartson
thethirddaypostpartum.
Atthe3rdorthe4'day withestablishmentofmilksecretion,the
breastsbecomeengorged,larger,painfulandtenderandsuckling g g , g , p g
relievesthisdiscomfort.Milkengorgementisthecommonriseof
temperatureduringthepuerperium
Inthefirstfewdayspostpartum,adenseyellowishsubstancerich
inproteinsandimmunoglobulinsissecretedfromthebreastsandis p g
knownasthe"colostrum.
ColostrumHumanmilk
Protein6%1%
Fat2.5%3.5%
Carbohydrate3%7%
Sucklingeffects.
1 Sucklingstimulatesprolactinsecretionfromacidophilic
cellsoftheanteriorpituitary(lactotrophes)leadingto
d lk d b b increasedmilkproductionbybreastacini.
2 Sucklingstimulatesreleaseofoxytocinfromsupraopticand
paraventricularnucleiofthehypothalamusleading
A Contractionofmyoepithelialcellsaroundmilkacini
causingmilkejectionreflex(milkletdown).
B Ithasaroleininvolutionoftheuterus(contraction,
t ti ) retraction).
F.Weight:Thereislossofweightduetoevacuationofuterine
contents(fetus,placentaandamnioticfluid)andexcessivesweating.
G.Sweating:Excessiveespeciallybynight.
H.Postpartummoodchanges:Manypatientsexperiencesomemood H.Postpartummoodchanges:Manypatientsexperiencesomemood
swingsandevendepressionintheimmediatepostpartumperiod.
Theseareusuallyself limited.
J.Menstruation:resumptionofmenstruationisvariablewith
lactation.Withoutlactationitusuallystartswithin68weeks. lactation.Withoutlactationitusuallystartswithin6 8weeks.
K.Afterpains(abdominalpain):Itisduetopainfuluterine
contractionsoccuringintheearlypuerperium.Theyincreaseduring
sucklingduetooxytocinsecretion.
II.Localchanges:
1.Uterus:
Afterdelivery,thefundallevelisatorslightlybelowthelevelofthe
umbilicus. umbilicus.
Afteroneweek,theheightismidwaybetweentheumbilicusand
symphysispubis,.
After 2weekspostpartum,theuterusisagainapelvicorgan.
Af k h h After4weekspostpartum,theuterusreturnstothenonpregnant
dimensions.
Theglandsandstromaofthebasallayerofthedeciduaproliferateto
reformtheendometrium.Theendometriumisregeneratedbythe
hd h l l i h i k 6 k 10thday,exceptattheplacentalsite,whereittakes6weeks.
Theweightofuterus Justafterdelivery,is1000gramsanditslength
is 20cm.
Bytheendof6weeks,itsweightis50gramsanditslengthis7.5cm Bytheendof6weeks,itsweightis50gramsanditslengthis7.5cm
(returnstonormal).
Theuterusreducestoabout20thofitsweightinabout6weeks
althoughitneverreturnsexactlytoitsnulliparousproportions.
2.Cervix:
Atfirst,thecervixissofter,flabbyanddilated2to3 cm.Itregains
tonewithin2to3daysafterdeliveryanditbecomesclosed.

Byoneweekpostpartum,itregainsthenonpregnantappearance.
Itsexternalosbecomesslitlike.
3.Vagina,vulvaandpelvicfloor:
L i f i l ll d l i fl d i f h l Laxityofvaginalwallsandpelvicfloorandgapingofthevulva
decreasebytheendofpuerperium.
Vaginalrugae appearduringthe3rdweek.
Persistentweaknessofthepelvicfloorpredisposestogenital p p p g
prolapse.
4.Lochia: Itisthedischargeofthegenitaltractduringpuerperium.
Typesoflochia.
LochiarubraLochiaserosa Lochiaalba
Time1stweek2ndweek3rdweek
ColorRedPaleredYellowishwhite
ContentBloodandnecroticMainlyLeucocytes
decidualtissueleucocytesand decidualtissueleucocytesand
mucus
Persistanceofredlochia occursinsubinvolution Persistanceofredlochia occursinsubinvolution.
Offensivelochia indicatesinfection.
Suddensuppressionoflochiaandpyrexiamayindicateasevere
infection.
ManagementofPuerperium:
I Careforthenewborn:
Thebabyisobservedespeciallyforneonataljaundice Thebabyisobservedespeciallyforneonataljaundice
(physiologicalorpathological).
Umbilicalstumpisexaminedforinfection.
II Generalcareofthemother.
Thepatientisobservedasregards:pulse,temperature,lochia,levelof
fundus,conditionofbreastsandperinealwounds.
Thepatientisexaminedclinicallytwiceduringthepuerperium Thepatientisexaminedclinicallytwiceduringthepuerperium
(postnatalvisits:after2and6weeks):
oAfter2weeks:Examinationincludesbreasts,abdominalwall(fundal
level).
Vulvovaginalexamination:fortheperineum lochia conditionofcervix Vulvovaginalexamination:fortheperineum,lochia,conditionofcervix
positionandsizeofuterus,andanytendernessinpelvicorgans.
oAfter6weeks:
Examinationforstressincontinence,genitalprolapse,infection,size
andpositionofuterusandanyadnexaltenderness andpositionofuterusandanyadnexaltenderness.
Counselingforcontraception.
.
Restandexercise
Thepatientshouldsleepsomehoursafterlabor.
ShethensitsupinbedinFowler'spositiontohelpdrainageof
lochia. lochia.
Keepthepatientinbedforfewdaysbutallowhertomoveherlegs
inbedandtodobreathingexercises.
Gradualbedexercisesarestartedfromthe3rdday.
P l i fl i b i h l i fl l (if Pelvicfloorexercises bycontractingthepelvicfloormuscles(ifno
perinealwound).
Lateron,abdominalexercises areadvised.
Valueofpostnatalexercises:
1 Decreaserespiratoryandvascularcomplications. p y p
2 Decreasegenitalprolapseandstressincontinence.
3 Leavethepatientinabetterfigure.
4 Earlyambulationisadoptedfrom4thdayifthereisno
perinealwound,thisreducesvenousthrombosisandDVTand
helpsrapidinvolution.
3 Dietandcareofbowels:
Dietmustberichinproteins,minerals,vitaminsandsufficient
fluidintaketoallowbettermilkformation.
Thereistendencytoconstipation,whichispreventedbyfresh Thereistendencytoconstipation,whichispreventedbyfresh
vegetablesandfruits,sufficientfluidsandmildlaxativesifneeded.
4 Careofthebladder:
Thepatientisencouragedtopassurineevery6hours.
If i f i k l h i d d l Ifretentionofurine takesplace,catheterispassedundercomplete
asepticconditions.
Washthevulvaandperineumaftermicturitionwithdiluted
antisepticsolution(dettolsolutionorsavlon).
5 Reliefofpain:
A Afterpains;arerelievedbysedativesandergotpreparations
B Perinealsutures:
oSedatives analgesicsandantiprostaglandins oSedatives,analgesicsandantiprostaglandins.
oWashperineumandvulvaaftereachmicturitionanddefecation.
C Engorgementofbreast:istreatedbysedatives,sucklingand'
pumpsuctionofmilk.
D H id ( il ) S d i D Hemorroids (piles):Sedatives.
6 Vulvaandperineum:
Sterilepadsarechangedafterpassingurineorstools.
Perinealwoundsmustbekeptdryandclean Perinealwoundsmustbekeptdryandclean.
7 Careofthebreast:
Inthefirst3days,thebabyshouldbeputonthebreasteveryfew
hours.
Thenipplesarewashedwithsoapandwaterbeforeeachfeeding. Thenipplesarewashedwithsoapandwaterbeforeeachfeeding.
Crackednipples aretreatedbyantisepticointments,theuseof
nippleshieldandantifungalpreparations.
Breastengorgement mayoccuronthe3rdday,oratanytimewhen
sucklingisinefficientorweak sucklingisinefficientorweak.
Treatmentisbyhotfomentations,massageandevacuationofmilk
bybreastpump.
Ifmastitisdevelops:Stoplactationandgiveantibiotics.
Ifbreastabscessdevelops:stoplactation,giveantibioticsand
performsurgicaldrainage.
Thankyou.