PUERPERIUM
PUERPERIUMPuerperium / Postpartum6-week period after delivery of the baby
InvolutionThe return of the reproductive organs
PRINCIPLES OF POSTPARTUM CAREA. Promote healing and return to normal (involution) of the different parts of the body.1. VASCULAR CHANGES30%-50% increase in total cardiac volume during pregnancy will be reabsorbed into the general circulation within 5-10 minutes after placental delivery.
Implications:Crucial to gravidocardiacs = not able to handle such workloadB. White blood cell counts increases to 20,000-30,000/mm3
Implications:
WBC cannot be used as indicator of postpartum infectionC. There is an extensive activation of the clotting factors, which encourage thromboembolization.
Thats the reason why;
Ambulation is done early after 4-8 hours in normal vaginal delivery.
Exercises are recommended:Kegels and abdominal breathing on postpartum day 1 (PPD 1)
Chin-to-chestOn 2nd day tighten and firm up abdominal muscles.
Knee-to-abdomenWhen perineum has healed, to strengthen abdominal and gluteal muscles.
Massage is contraindicatedD. All blood values are back to prenatal levels by the 3rd-4th week postpartum.2. GENITAL CHANGESA. Uterine involution is assessed by measuring the fundus by fingerbreadths (=1cm)/PPD
Subinvoluted uterusA big uterus and vaginal bleeding with clots.Blood clots are good media for bacteriaTherefore, sign of puerperal sepsisB. To encourage return of the uterus to its usual anteflexed position, prone and knee-chest positions.
C. Afterpains/Afterbirth painsStrong uterine contractions feltMultisDelivered macrosomias and twinsBreastfeedManagement:Never apply heat on abdomenGive analgesics as orderedExplain that it is normal and rarely lasts for more than 3 daysD. LochiaUterine discharge consisting of blood, decidua, WBC, mucus aand some bacteria
Pattern:Rubra 1st 3 days PPD, red and moderate in amount.
Serosa next 4-9 days; pink or brownish and decrease in amount
Alba from the 10th day up to 3-6 weeks; colorless and minimalCharacteristics:Pattern should not reverse.It should approximate menstrual flow. It should not have offensive odor.It should not contain large clots.It should never be absent, regardless of method of deliveryCS & NSD same pattern and amountE. Pain in the perineal region maybe relievedSims position minimizes strain on the suture line
Perineal heat lamp / Warm sitz bath vasodilation, increase blood supply, therefore, promotes healing
Application of topical analgesics or administration of oral analgesics, as orderedF. Sexual ActivityMaybe resumed by the 3rd to 4th week postpartum, if bleeding has stopped and episiorrhapy has healed
Decreased reactions to sexual stimulation on the first 3 months because of hormonal changes and emotional factorsG. MenstruationNo breastfeeding menstrual flow returns within 8 weeks after deliveryBreastfeeding after 3-4 months
Maybe ovulating even without mentrauation.
H. Postpartum check-upShould be done after the 6th week postpartum to assess involution
3. URINARY CHANGESThere is marked diuresis within 12 hours postpartum to eliminate excess tissue fluid accumulation during pregnancy
Some may complain of small frequent urinations4. GASTROINTESTINAL CHANGES delayed bowel PPD due to:Decreased muscle toneLack of food + enema during laborDehydrationPain from perineal tenderness d/t episiotomy , lacerations or hemorrhoids.5. VITAL SIGNSA. Temperature increases because of dehydration effects of labor
Implication:
Any increase in temperature postpartum is not a sign of infectionB. Bradycardia Heart rate of 50-70 per minute for 6-8 days postpartum
C. There is no change in respiratory rate
6. WEIGHTImmediate weight loss of 10-12 lbs. representing the weight of theFetusPlacentaAmniotic fluidBloodWeight loss will occur next days due to diaphoresis.B. Provide emotional support The psychological phases during the postpartum periodTaking-in PhaseFirst 1-2 days PPD when mother is passive and relies on others to take care for her and her newborn.
She keeps on verbalizing her feelings regarding the recent delivery to be able to integrate the experience into herself.Taking-in Phase
2. Taking-hold PhaseBegins to initiate action and make decisions.Postpartum blues An overwhelming feeling of sadness that cannot be accounted for may be observedd/t hormonal changes, fatigue, feelings of inadequacy in taking care of new baby.C. Prevent Postpartum ComplicationsHEMORRHAGEBlood loss of >500 ccNormal blood loss during labor and delivery is 250-350Leading cause of maternal mortality rateEARLY POSTPARTUM HEMORRHAGE first 24 hours postpartumUTERINE ATONY
Uterus is not well contracted, relaxed or boggyPredisposing factors:Management:OverdistentionCesarean sectionPlacental accidentsProlonged and difficult laborMassageIce compressOxytocin administrationEmptying the BladderBimanual CompressionHysterectomy
B. LACERATIONS
Mediolateral and midline
C. HYPOFIRINOGENEMIA
Clotting defectII. LATE POSTPARTUM HEMORRHAGEA. RETAINED PLACENTAL FRAGMENTSManagement:
Dilatation and curettage
B. HEMATOMADue to injury of the blood vessels during delivery
Commonly seen in precipitate delivery and with perineal varocositiesTreatment:Ice compress during 1st 24 hoursOral analgesics, as orderedSite is incised and bleeding is ligated2. INFECTIONSources:
Endogenous normal flora becomes dangerous
Exogenous pathogens are introduced from external resources
Anaerobic streptococci organism most frequently responsible for postpartum infectionsCommon exogenous sources:Hospital personnelExcessiveure obstetric manipulationBreaks in aseptic techniqueCoitus in late pregnancyPremature ruptue of membraneGeneral Symptoms:
MalaiseAnorexiaFeverChillsHeadacheManagement:
Complete bed restProper nutritionIncrease fluid intakeAntipyreticsAntibioticsAs oredered
