HIGH-YIELD FACTS IN - Postpartum ppt

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THE PUERPERIUM OF THE NORMAL LABOR AND DELIVERY

The period of confinement during birth and 6 weeks after. During this time,

the reproductive tract returns anatomically to a normal nonpregnant state.

Uterine Changes

INVOLUTION OF THE UTERINE CORPUS

Immediately after delivery, the fundus of the contracted uterus is slightly be￾low the umbilicus. After the first 2 days postpartum, the uterus begins to

shrink in size. Within 2 weeks, the uterus has descended into the cavity of the

true pelvis.

ENDOMETRIAL CHANGES: SLOUGHING AND REGENERATION

Within 2 to 3 days postpartum, the remaining decidua become differentiated

into two layers:

1. Superficial layer → becomes necrotic → sloughs off as vaginal dis￾charge = lochia

2. Basal layer (adjacent to the myometrium) → becomes new en￾dometrium

Placental Site Involution

Within hours after delivery, the placental site consists of many thrombosed

vessels. Immediately postpartum, the placental site is the size of the palm of

the hand. The site rapidly decreases in size and by 2 weeks postpartum = 3 to

4 cm in diameter.

Changes in Uterine Vessels

Blood vessels are obliterated by hyaline changes and replaced by new, smaller

vessels.

HIGH-YIELD FACTS IN

Postpartum

“Afterpains” due to uterine

contraction are common

and may require analgesia.

They typically decrease in

intensity by the third

postpartum day.

Lochia is decidual tissue

that contains erythrocytes,

epithelial cells, and

bacteria.

See Table 7-1.

Changes in the Cervix and Lower Uterine Segment

The external os of the cervix contracts slowly and has narrowed by the end of

the first week.

The thinned-out lower uterine segment (that contained most of the fetal

head) contracts and retracts over a few weeks → uterine isthmus.

Changes in the Vagina and Vaginal Outlet

Gradually diminishes in size, but rarely returns to nulliparous dimensions:

Rugae reappear by the third week.

The rugae become obliterated after repeated childbirth and menopause.

Peritoneum and Abdominal Wall

The broad ligaments and round ligaments slowly relax to the nonpregnant

state.

The abdominal wall is soft and flabby due to the prolonged distention and

rupture of the skin’s elastic fibers → resumes prepregnancy appearance in sev￾eral weeks, except for silver striae.

Urinary Tract Changes

The puerperal bladder:

Has an increased capacity

Is relatively insensitive to intravesical fluid pressure

Hence, overdistention, incomplete bladder emptying, and excessive residual

urine are common.

FLUID RETENTION AND THE RISK OF URINARY TRACT INFECTIONS

Residual urine + bacteruria in a traumatized bladder + dilated ureters and

pelves → increased risk of UTI. Between days 2 and 5 postpartum, “puerperal

diuresis” typically occurs to reverse the increase in extracellular water associ￾ated with normal pregnancy.

Dilated ureters and renal pelves return to their prepregnant state from 2 to 8

weeks postpartum.

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HIGH-YIELD FACTS Postpartum

TABLE 7-1. Lochia

Type Description When Observed

Lochia rubra Red due to blood in the lochia Days 1–3

Lochia serosa More pale in color Days 4–10

Lochia alba White to yellow-white due to leukocytes and Day 11 →

reduced fluid content

When involution is

defective, late puerperal

hemorrhage may occur.

At the completion of

involution, the cervix does

not resume its pregravid

appearance:

Before childbirth, the os is

a small, regular, oval

opening.

After childbirth, the orifice

is a transverse slit.

The uterine isthmus is

located between the uterine

corpus above and the

internal cervical os below.

All postpartum women who

cannot void should be

promptly catheterized.

What causes fluid

retention postpartum?

High estrogen levels in

pregnancy → fluid

retention

Increased venous pressure

in the lower half of the

body during pregnancy →

fluid retention

Changes in the Breasts

DEVELOPMENT OF MILK-SECRETING MACHINERY

Progesterone, estrogen, placental lactogen, prolactin, cortisol, and insulin act

together → growth and development of the milk-secreting machinery of the

mammary gland:

Midpregnancy—lobules of alveoli form lobes separated by stromal tis￾sue, with secretion in some alveolar cells

T3—alveolar lobules are almost fully developed, with cells full of pro￾teinaceous secretory material

Postpartum—rapid increase in cell size and in the number of secretory

organelles. Alveoli distend with milk.

DEVELOPMENT OF THE MILK

At delivery, the abrupt, large decrease in progesterone and estrogen levels

leads to increased production of alpha-lactalbumin → stimulates lactose syn￾thase → increased milk lactose.

COLOSTRUM

Colostrum can be expressed from the nipple by the second postpartum day

and is secreted by the breasts for 5 days postpartum.

MATURE MILK AND LACTATION

Colostrum is then gradually converted to mature milk by 4 weeks postpartum.

Subsequent lactation is primarily controlled by the repetitive stimulus of nurs￾ing and the presence of prolactin.

Breast engorgement with milk is common on days 3 to 4 postpartum:

Often painful

Often accompanied by transient temperature elevation (puerperal

fever)

Suckling stimulates the neurohypophysis to secrete oxytocin in a pulsatile

fashion → contraction of myoepithelial cells and small milk ducts → milk ex￾pression

Changes in the Blood

Leukocytosis occurs during and after labor up to 30,000/µL

There is a relative lymphopenia.

There is an absolute eosinopenia.

During the first few postpartum days, the hemoglobin and hematocrit

fluctuate moderately from levels just prior to labor.

By 1 week postpartum, the blood volume has returned to the patient’s non￾pregnant range.

CARDIAC OUTPUT

The cardiac output remains elevated for ≥ 48 hours postpartum.

By 2 weeks postpartum, these changes have returned to nonpregnant

levels.

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HIGH-YIELD FACTS Postpartum

Colostrum is a deep yellow￾colored liquid secreted by

the breasts that contains

minerals, protein, fat,

antibodies, complement,

macrophages, lymphocytes,

lysozymes, lactoferrin, and

lactoperoxidase.

Women with extensive

pituitary necrosis (Sheehan

syndrome) cannot lactate

due to the absence of

prolactin.

Milk letdown may be

provoked by the cry of the

infant or inhibited by stress

or fright.

Puerperal fever seldom

persists for > 4 to 16 hrs.

Other causes of fever (e.g.,

mastitis, endometritis, UTI,

thrombophlebitis) must be

excluded.

Elevation of plasma fibrinogen and the erythrocyte sedimentation rate re￾main for ≥ 1 week postpartum.

Changes in Body Weight

Most women approach their prepregnancy weight 6 months after delivery, but

still retain approximately 1.4 kg of excess weight. Five to six kilograms are lost

due to uterine evacuation and normal blood loss. Two to three kilograms are

lost due to diuresis. FACTORS THAT INCREASE

PUERPERAL

WEIGHT

LOSS

Weight gain during pregnancy Primiparity Early return to work outside the home Smoking

ROUTINE POSTPARTUM CARE

Immediately After Labor FIRST HOUR Take BP and HR at least every 15 minutes. Monitor the amount of vaginal bleeding. Palpate the fundus to ensure adequate contraction: If the uterus is relaxed, it should be massaged through the abdominal

wall until it remains contracted.

First Several Hours EARLY AMBULATION

Women are out of bed (OOB) within a few hours after delivery. Advantages

include: Decreased bladder complications Less frequent constipation Reduced frequency of puerperal venous thrombosis and pulmonary

embolism

CARE OF THE

VULVA

The patient should be taught to cleanse and wipe the vulva from front to back

toward the anus.

If Episiotomy/Laceration Repair An ice pack should be applied for the first several hours to reduce

edema and pain.

Periodic application of a local anesthetic spray can relieve pain as well. At 24 hours postpartum, moist heat (e.g., via warm sitz baths) can de￾crease local discomfort. The episiotomy incision is typically well healed and asymptomatic by

week 3 of the puerperium.

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HIGH-YIELD FACTS Postpartum

BLADDER FUNCTION

Ensure that the postpartum woman has voided within 4 hours of delivery. If

not:

This typically indicates further trouble voiding to follow.

An indwelling catheter may be necessary, with a prohylactic antibiotic

after catheter removal.

Consider a hematoma of the genital tract as a possible etiology.

The First Few Days

BOWEL FUNCTION

Lack of a bowel movement may be due to a cleansing enema administered

prior to delivery. Encourage early ambulation and feeding to decrease the

probability of constipation.

If Fourth-Degree Laceration

Fecal incontinence may result, even with correct surgical repair, due to injury

to the innervation of the pelvic floor musculature.

DISCOMFORT/PAIN MANAGEMENT

During the first few days of the puerperium, pain may result due to:

Afterpains

Episiotomy/laceration repair

Breast engorgement

Postspinal puncture headache

Treat with any of the following:

Codeine

Aspirin

Acetaminophen

ABDOMINAL WALL RELAXATION

Exercise may be initiated any time after vaginal delivery and after abdominal

discomfort has diminished after cesarean delivery.

DIET

There are no dietary restrictions/requirements for women who have delivered

vaginally. Two hours postpartum, the mother should be permitted to eat and

drink.

Continue iron supplementation for a minimum of 3 months postpartum.

IMMUNIZATIONS

The nonisoimmunized D-negative woman whose baby is D-positive is

given 300 µg of anti-D immune globulin within 72 hours of delivery.

Woman not previously immunized against/immune to rubella should be

vaccinated prior to discharge.

Unless contraindicated, woman may receive a diphtheria–tetanus tox￾oid booster prior to discharge.

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HIGH-YIELD FACTS Postpartum