Normal and abnormal

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Normal and abnormal puerperium
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Normal puerperium(Postpartum care)
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Normal Puerperium

• Definition
• It is the period of adjustment after pregnancy
  and delivery when anatomical and physiological
  changes of pregnancy are reversed and the body
  returns to the normal non pregnant state..
  (reproductive tract returns to its normal,
  non-pregnancy state)
• 6 weeks in duration. (periods after birth )

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Stages of Puerperium

• The post partum period has been divide into
• The immediate puerperium, the first 24 hours
  after parturition when acute post anesthetic or
  post delivery complications may occur.
• The early puerperium, which extends until the
  first week post partum.
• The remote puererium, which includes the period
  of time required for involution of the genital
  organs through the sixth weeks postpartum.

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Anatomical and Physiological changes

• Immediately after labor, the woman is in a state
  of physical fatigue in many cases, slight
  shivering, muscular tremors and chattering of
  teeth occur for about 10 15 minutes.

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• Temperature
• Fever It is normal but usually there is a slight
  rise during the first day which is known as
  (reactionary rise), not exceed 38oC and drops
  within 24 hours and not accompanied by increased
  pulse rate, if it is more than 38oc or for more
  than 24 hours, it is called puerperal pyrexia).

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• Involution of the uterus
• return to the pelvis by about 2 weeks
• be at normal size by 6 weeks
• the weight changes of uterus
• 1000g immediately after birth (excluding the
  fetus,
• placenta, membrane and amniotic fluid.
• 500g 1 weeks after birth
• 300g 2 weeks after birth
• 50g 6 weeks after birth
• The endometrial lining rapidly regenerates (16
  days)
• The placental site undergoes a series of changes
  in the postpartum period
• Its fundus level approximates that of a 20 week
  pregnancy at the level of umbilicus, at the end
  first post partum week it is palpable at the
  symphysis pubic

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• Decidua
• discharge comes from the placental site and
  maintains for 4-6 weeks
• Lochia rubra
• Red in color for the first 3-4 days
• Lochia serosa
• Pink in color, maintains for 2 weeks
• Lochia alba
• White in color, maintains for 2-3 weeks

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After Pain

• After expulsion of fetus and placenta the uterus
  contracts to regain its normal size, weight and
  site, this called involution of uterus. Oxytocin
  is released from posterior lobe of the pituitary
  gland in response to the sucking, which
  facilitate uterine contraction.
• Characteristic of after pain
• Occur during the 1st 2-3 days of puerperium
• Abdominal pains (like cramps) and back pain.
• Strong, regular, and coordinated.
• The intensity, frequency and regularity of
  contraction decrease after the 1st postpartum day.

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Constipation

• It is common in the first few days of puerperium
  and is due to many factors. The womans food
  intake is interrupted, there may be dehydration
  during labor, the abdominal muscles are lax and
  perineal lacerations make defecation painful.

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• Cervix
• it never returns to the nulli-parous state.
• the external os is closed to the extent that a
  finger could not be easily introduced.
• It return to its normal state at 4 weeks after
  birth
• Vagina
• shrinks to a non-pregnant state
• resolution of the increased vascularity and edema
  occurs by 3 weeks
• the vaginal epithelium appears atrophic. This is
  restored by weeks 6-10.

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• Perineum
• Swelling completely gone within 1-2 weeks
• The muscle tone may or may not return to normal,
  depending on the extent of injury.

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The muscular walls of the pelvic organs

• The voluntary muscles of the pelvic floor and
  pelvic supports gradually regain their tone
  during the puerperium. Tearing or overstretching
  of the musculature or fascia at the time of
  delivery predispose to genital hernias. Over
  distention of the abdominal wall during pregnancy
  may result in rupture of the elastic fibers,
  persistent striae, and diastases of the recti
  muscles. Involution of the abdominal musculature
  may require 6-7 weeks and vigorous exercises are
  not recommended until after that time.

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• Preparation for lactation
• Lactation can occur by 16 weeks' gestation.
• Lacto genesis is initially triggered by the
  delivery of the placenta (E?P?and prolactin).
• the prolactin levels decrease and return to
  normal within 2-3 weeks (not breastfeeding)
• The colostrums (the first 2-4 days)
• The milk continues to change throughout the
  period of breastfeeding to meet the changing
  demands of the baby.

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Psychological changes.

• Mild degree of depression and emotional
  liability. (normal)
• Puerperal psychosis, confusion with
  disorientation in time, space and a complete loss
  of interest in the child (abnormal)

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Systemic change

• Cardiovascular system
• Blood volume returns to non-pregnant levels by
  the tenth days of puerperium
• Cardiac output ?(immediately after delivery) ?
  slowly declines? reach late pregnancy levels 2
  days postpartum? normal 2-6 weeks.
• Hematologic changes
• Hemoglobin concentration?on the first postpartum
  days
• Several clotting factors (fibrinogen) ?on the
  first days

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• Micturation
• There is diuresis in the first two days of
  puerperium. Retention of urine may occur either
  due to the sphincter or reflexly from perineal
  trauma.
• Skin
• There is a tendency to sweating.
• Body weight
• Is slightly lost during the first 10 days.

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Abnormal puerperium
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Abnormal puerperium

• Post natal problems
• Post partum hemorrhage.
• Puerperal Sepsis
• Retained placenta (the placenta still in the
  uterus for more than one hour after birth of the
  baby)
• Painful perineum. (laceration of the perineum)
• Circulatory problems (Varicose veins, Deep
  venous thrombosis (DVT) or superficial venous
  thrombosis (SVT)).
• After pain

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Management of painful perineum

• Cold baths
• Electrotherapy (TENS)
• Pelvic floor exercises (contract relax technique
• Teach the mother the correct defecation technique
• Use of an appropriate cushion when sitting.

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Deep venous thrombosis

• Venous thrombosis occurs most commonly in the
  superficial and deep veins of the lower
  extremities.
• Deep thrombi are most likely to develop in soleos
  muscle of the calf muscle.

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Management of Varicose veins

• Avoid prolonged standing and prolonged sitting.
• Apply well-fitted below knee support stocking
  before ambulating in the morning.
• Ask mother to elevate her leg on pillow while
  taking supine lying position.
• Intermittent compression.
• Bandaging.
• Burger?s Exercises.
• Not to sit with leg crossed or knee flexed.

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Management of DVT or SVT

• Prophylactic treatment
• Early ambulation.
• Avoidance of pressure on the thighs and calves.
• Sitting position with knee flexed.
• Encouragement of
• Circulatory ex., leg and deep breathing ex.

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Management of After Pain

• Analgesics.
• TENS.
• Frequent urination every 2 hours.
• Heat application.
• Relaxation on face.
• Prone lying position with tow pillows under the
  pelvis (to keep the back from hollowing and to
  stretch the abdominal muscles, small pillow under
  feet, the upper limbs extended beside the trunk,
  head turned to one side, or the upper limbs
  crossed with the forehead rested on the crossed
  upper limbs

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• Values of relaxation on face
• It is a relaxed position.
• Help involution of uterus.
• Help discharge of blood colts and lochia.
• Guard against retroversion flexion
• Relief after pain

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Diastasis of recti abdominal muscles

• It means separation of the rectus abdominal
  muscles from med-line at linea alba. It is not
  hernia.
• It is a gap between the recti muscles 25mm(2.5
  fingers)
• Palpated just superior to the umbilicus.
• It may occur during pregnancy after 20 weeks of
  pregnancy
• or expulsive stage of labour due to weakness
  and increases tension
• of abdominal muscles.

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Management of diastases of recti abdominal
muscles

• Static abdominal exercises.
• Graduated dynamic abdominal exercises.
• Neuromuscular electrical stimulation
• Using
• asymmetrical square
  current,
• frequency 80 pulse/second,
• Pulse duration 0.1?0.5 ms
  for ½ hour daily.

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