New Normal Puerperium.ppt

NORMAL PUERPERIUM

Presented By:Ms.Dharati Prajapati

Definition:

Puerperium is the period following child birth during which the body tissues, especially the pelvic organs revert back approximately to the pre-pregnant state both anatomically & physiologically.  INVOLUTION:It is the process whereby the genital organs revert back approximately to the state as they were before pregnancy.  The women is termed as a puerpera.

DURATION: It begin soon after the expulsion of the placenta & normaly lasts for around 6 weeks. Generally devide thise period into... a) Immediate - within 24 hours b) Early- upto 7 days c) Remote - upto 6 weeks

Features of Normal Puerperium : Anatomically & physiologically, the generative organs come back to their pregravid state.  Rccuperation from physical, hormonal & emotional experience of paturition.  Lactation is started during puerperium.  PHYSIOLOGICAL CHANGES:Involution of the uterus  There is alternate harding and softning of the uterus after the delivery.  Involution is the process by which the reproductive organs especilly bulky uterus following the delivery progrssively returns to normal pregravid state.

Cont....  Rate of involution of uterus is assessed by taking fundal height in relation to symphysis pubis with measuring tap.  It should be measured at fixed time everday Before measuring fundal height, ask the woman to empty bowel & bladder, as this can give rise to raised level of fundal height.  Postnatal period starts after the delivery of the placenta.  It is very crucial period for the mother as well as the baby.  Weight of the uterus after delivery is reduced from 900 gm to 60 gm.

Rate of Involution : First 24 hours-no changes; from 2 nd to 11th day-fundus at the rate of 1.25 cm per 24 hours.  By 11th dayuterus sinks behind symphysis & becomes pelvic organ.  By 2 weeks, uterus can not be palpated by abdominal examination.

Character

Changes

Length

From 20 cm to 7.5 cm

Breadth

From 12 cm to 5 cm

Thickness

From 7.5 cm to 2.5 cm

Weight

from 1000 gm to 60 gm

Placement of uterus after delivery

Fundus of uterus 5 cm below the umblicus or 12 cm above symphysis pibis

Placement of uterus after 24 hour

At level of umblicus

After one week placenta of uterus

7.5 cm above symphysis pubis

After 12 days

Fundus is not palpable

Placental site end of 6 weeks

1.5 cm

Position of uterus

Uterus after 24 hour of deliviry reduces at rate of 1.25 cm until 11t day

Consistency of the uterus

Firm,Round,hard after delivery

Blood Vessels : Myometrial contraction and retraction compress the blood vessels of the uterus and so control the bleeding until the vessels are thrombosed. Within them new blood vessels grow. Fibroelastic tissue of old blood vessels degenerate and is removed by phagocytes. Placental Site : Involution of placental site takes upto 6 weeks. Placental site gets elevated immediately after delivery. It gets irrigular,friable and is composed of thrombosed vascular sinusoid. These undergo hyalinization. Most of deciduas basalis is shed over a period of weeks and is replaced by regenerating endometrium.

LOCHIA  Definition:- It is the vaginal discharge for the first fortnight during puerperium. This discharge originates from the uterine body, cervix & vagina.  Odour & Reaction:- It has got a peculiar offencine fishy smell. It's rection is alkaline tending to become acid towards the end  Colour:- Depending upon the varition of the colour of the discharge, it's named as 1.Lochia Rubra (Red) - 1 to 4 days 2.Lochia Serosa (Yellowish,pink,pale brownish) 5 to 9 days. 3.Lochia Alba (pale white) - 10 to 15 days

Composition 1. Lochia Rubra:- Consists of blood,shreds of fetal membranes & decidua, vernix caseosa, lanugo & meconium. 2. Lochia Serosa:- Consists of less RBC but more leucocytes, wound exudate, mucus from the cervix & microorganisms. The presence of bacteria it not pathoenic unless associated with clinical sign of sepsis. 3. Lochia Alba:- Contains plenty of decidual cell, leucocytes,mucus,cholestrin crystals, fatty & gramular epithelial cells & micro organisms

Amount:The average amount of discharge for the first 5-6 days, is estimated to be 250 ml.  Normal duration:Normal duration may extend upto 3 weeks. the red lochia may persist for longer duration specially following premature labour or may be excessive in twin delivery or hydramnios.  Clinical Importance:The character of the lochial discharge gives useful information about the abnormal puerperal state The vulval pads are to be inspected daily to get information.

I. Odour:- It malodorous indicates infection retained plug or cotton piece inside the vagina should be kept in mind II. Amount:- Scanty or absent signifies infection or lochiometra .If rxcessive indecates infection III. Duration:- Duration of the lochia alba beyond 3 weeks suggest local genital lesion.

LACTATION  Lactation is inflenced by sucking of baby & also on maternal emotions lactation establishment and maintance depend on three factors as discussed below Lactation (Establishment & maintenance)

Anatomical structur of

Mammary Glands

Lactogenesis

Development Ducts Nipples of alveoli

Sucking of baby

LACTOGENESIS Lactogenesis means milk initation which occur during later weeks of pregnancy as discussed below. Placental lactogen (A prolactin like substance)

Mammary alveolar

Secretion of colostrum

Cont....  Lactogenesis depend on sufficient production of prolactin (from pituitary gland) & nutrition of mother.  When a baby sucks at the breast, milk moved from alveoli to mouth of infant, which is known as 'let down reflex' It is also known as milk ejection reflex. This is an active process.  True milk production occur in between 3rd & 5th post partum day.  Before true milk colostrum is released.  Milk which is coming out at beginning of feeding is known as fore milk.  Lactation depend on the sucking of baby. Newborn baby possess reflexes to suck at breast. These reflexes are rooting,sucking & swallowing reflex.

Characteristics of COLOSTRUM : Yellow in colour & pre-milk substance  High in protein  Contain antibodies Fore milk

Hind milk

Milk coming at beginning of feeding

Milk at end of feeding

It has less fat

Contain more fat

Flows at faster rate

Flows at slower rate

Less calories

More calories

POSTNATAL ASSESSMENT AND MANAGEMENT

 Assessment during postnatal period is very important. Head to toe assessment is performed. It one of the most neglected in India. The postnatal checkups should be performed, first after the discharge of the delivered woman and second at 6 weeks after the delivery.  During the inital check up, general health of the mother including vital sign and breast are checked.  Involution of the uterus is assessed.  perineum is incepted & special attention is given to the lochia  Bladder & bowel function are enquired  Infant is also assessed from head to toe

Cont...  During 2nd postnatal checkup mother is assessed for duration of lochia,onset of first menses,sleep,bladder,bowel,perineal,wound,breast feeding etc...  Weight,pulse,blood pressure is checked  Pelvic organ are assessed for involution  Breast are examined & presence of anaemia is checked  Advantages of postnatal care: Hypertension and medical disease are treated. Anaemia is prevented  Progress of the baby can be checked and effective therapy can be given for ailments, if detected.  Positive health during postnatal period is maintained.

Cont...  Breast feeding practices & other related advice can be given  Motivation & acceptance of family planning methods can be best imparted during the period  Maternal morbidity is minimized  Growth of the baby can be monitored and infant morbidity and mortality is minimized.

Management of the discomforts of the puerperium : After-Pains :- This pain is felt for 2-4 days after the delivery due to continuning sequential contraction and relaxation of the uterus occuring because of certain reasons such as, presence of blood clots, increased parity or the woman who is breast feeding.  An empty bladder can give relief from the pain