Physiological changes during puerperium

Shrooti ShahM.Sc. Nursing

Batch 2011

Objectives Introduce to puerperium Explain anatomical and physiological

changes during puerperium.

Introduction Puerperium is the period following childbirth

during which the body tissues, specially the pelvic organs revert back approximately to the pre-pregnant state both anatomically and physiologically.

Involution is the process whereby the reproductive organs return to their nonpregnant state.

Introduction cont… Duration: puerperium begins as soon as

the placenta is expelled and lasts for approximately 6 weeks when the uterus becomes regressed almost to the non-pregnant size.

The period is arbitrarily divided into –Immediate- within 24 hoursEarly- upto 7 daysRemote- upto 6 weeks.

Reproductive system changes

Involution of the uterusAnatomical consideration

Immediately following delivery, the uterus becomes firm and retracted with alternate hardening and softening.

The uterus measures about 20 X 12 X 7.5 cm.

Weight :about 1000 gms.

Anatomical consideration cont…

At the end of the first week, it weighs 500gm. By the 6 weeks, it weighs approx. 50g.

The placental site contracts rapidly presenting a raised surface which measures about 7.5 cm and remains elevated even at 6 weeks when it measures about 1.5 cm.

Lower uterine segment Immediately following delivery, the lower

segment becomes a thin, flabby, collapsed structure.

It takes a few weeks to revert back to the normal shape and size of the isthmus.

Cervix The cervix contracts slowly.

External os: admits two fingers for a few days but by the end of first week, narrow down to admit the tip of finger only. It never returns back to the nulliparous state, usually remains slightly open and appear slitlike or stellate (star shaped).

Internal os: Internal os closes as before.

Physiological consideration The physiological process of involution is

most marked in the body of the uterus. Changes occur in the following components:1. Muscles

2. Blood vessels

3. Endometrium

Muscles During puerperium, the number of muscles

fibers is not decreased but there is substantial reduction of the myometrial cell size.

Withdrawal of the steroid hormones, oestrogen and progesterone may lead to increase in the activity of the uterine collagenase and the release of the proteolytic enzyme.

Blood vessels The arteries are constricted by contraction of its

wall and thickening of the intima followed by thrombosis.

New blood vessels grow inside thrombi.

Fibrous tissue on the wall undergoes hyaline degeneration and the products are removed by macrophages.

There is also degeneration of the elastic tissues.

Endometrium The superficial layer becomes necrotic and

is sloughed in the lochia.

The basal layer adjacent to the myometrium remains intact and is the source of new endometrium.

The endometrium arises from proliferation of the endometrial glandular remnants and the stroma of the inter glandular connective tissue.

Endometrium By the 10th day: Regeneration of the

epithelium is completed.

By the day 16: the endometrium is restored.

At about 6 weeks: the endometrium of

placental site is restored

Placental site involution Complete extrusion of the placental site

takes up to 6 weeks.

When this process is defective, late-onset puerperal hemorrhage may ensue.

Size of placental site:Immediately after delivery: approx. the size of the

palm, but it rapidly decreases thereafter.

Placental site involution cont…

Within hours of delivery: normally consists of many thrombosed vessels.

By the end of the 2nd week: 3 to 4 cm in diameter.

Williams described placental site involution as a process of exfoliation, which is in great part brought about by the undermining of the implantation site by growth of endometrial tissue.

Uterine involution

Vagina Takes a long time(4-8 weeks) to involute.

It regains its tone but never to the virginal state.

The mucosa remains delicate for the first few weeks and submucous venous congestion persists even longer.

Rugae partially reappear at third week.

The introitus remains permanently larger than the virginal state.

Abdominal Wall As a result of ruptured elastic fibers in the

skin and prolonged distension caused by the pregnant uterus, the abdominal wall remains soft and flaccid.

Several weeks are required for these structures to return to normal.

Lochia It is the vaginal discharge for the first

fortnight during puerperium.

The discharge originates from the uterine body, cervix and vagina.

Odour and reaction: it has got a peculiar offensive fishy smell.

Its reaction is alkaline tending to become acid towards the end.

Lochia cont.. Colour: depending upon the colour

Lochia rubra (red): 1-4 daysLochia serosa (5-9) days: the color is yellowish

or pink or pale brownishLochia alba (plae white):10-15 days.

Composition

Amount: for the first 5-6 days, is estimated to be 250 ml.

Lochia cont… Normal duration: may extend up to 3 weeks.Clinical aspects1. Persistence of red lochia means subinvolution.

2. Offensive lochia means infection.

3. In severe infection with septicaemia, lochia is scanty and not offensive

4. The period of time the lochia can last varies, although it averages approximately 5 weeks

General Physiological changesEndocrine system

Placental hormones Insulinaze causes the diabetogenic effects of

pregnancy to be reversed.

Estrogen and progesterone levels decrease markedly after expulsion of the placenta, reaching their lowest levels 1 week into the postpartum period.

The estrogen levels in nonlactating women begin to increase by 2 weeks after birth, and higher by postpartum day 17.

 

Pituitary hormones and ovarian function

Lactating and non-lactating women differ in the time of the first ovulation.

In women who breast feed, prolactin levels remain elevated into the sixth week after birth.

Prolactin levels decline in nonlactating women, reaching the prepregnant range by third week.

Menstruation and ovulation If the woman does not breast fed her baby, the

menstruation returns by 6th week following delivery in about 40% and by 12th week in 80% of cases.

In non-lactating mothers, ovulation may occur as early as 4 weeks and in lactating mothers about 10 weeks after delivery.

A women who is exclusively breastfeeding, the contraceptive protection is about 98% upto 6 months postpartum. Thus, lactation provides a natural method of contraception.

Menstruation and ovulation cont..

However ovulation may precede the first menstrual period in about one-third and it is possible for the patient to become pregnant before she menstruates following her confinement.

Non-lactating mother should use contraceptive measures after 3 weeks and the lactating mothers after 3 months of delivery.

 

Urinary system The bladder wall becomes oedematous and

hyperaemic and often shows evidences of submucous extravasation of blood.

Because of relative insensitivity to the raised intravesical pressure due to trauma sustained to the nerve plexus during delivery, the bladder may be overdistended without any desire to pass urine.

Dilated ureters and renal pelvis return to normal size within 8 weeks

Blood and fluid changes Diuresis evident between second and fifth

day after birth, as well as blood loss at birth, acts to reduce the added volume accumulated during pregnancy.

Rapid reduction occurs, so that blood volume returns to its normal prepregnancy level by first or second week after birth.

Blood and fluid changes The white blood cell count sometimes

reaches 30,000/L, with the increase predominantly due to granulocytes.

There is a relative lymphopenia and an absolute eosinopenia.

Normally, during the first few postpartum days, hemoglobin concentration and hematocrit fluctuate moderately.

Blood and fluid changes Blood volume: Returned to normal level by

1 week after delivery

Cardiac Output: Remains elevated for 24 to 48 hrs postpartum and declines to nonpregnant values by 10 days.

Heart rate changes follow this pattern

SVR: follows inversely

The gastrointestinal system

Digestion and absorption begin to be active again soon after birth.

Bowel sounds are active, but passage of stool through the bowel may be slow because of the still present effect of relaxin on the bowel.

Bowel evacuation may be difficult because of the pain of episiotomy sutures or hemorrhoids.

Weight loss Rapid diuresis and diaphoresis during 2nd to 5th

days after birth result in weight loss of 5 lb (2 to 4kg), in addition to approx. 12 lb (5.8 kg) lost at birth.

Lochia flow- 2-3 lb(1kg) loss

Total weight loss- 19 lb

Additional weight loss depend on amount of weight gain in pregnancy and active measures to reduce weight.

Integumentary system Stretch marks in women’s abdomen still appear

reddened and may be even more prominent than pregnancy.

Excessive pigment on face and neck (Chloasma) and on abdomen (Linea nigra) barely detectable in 6 weeks time.

Diastasis recti ( Overstretching and separation of the abdominal musculature) if present, the area will be slightly indented.

Abdominal wall and ligaments require 6 weeks time to return to their former state.

Lactation Since midway through pregnancy, she has

been secreting colostrum, a thin, watery, prelactation secretion.

She continues to excrete this fluid the first 2 postpartum days.

On the third day, her breasts become full and feel tense or tender as milk forms within breast ducts.

Lactation cont… When breast milk first begins to form, the

milk ducts become distended. The nipple secretion changes from the clear colostrum to bluish white, the typical color of breast milk.

This feeling of tension in the breasts on the third or fourth day after birth is termed primary engorgement.

Vital sign changesTemperature

A woman may show a slight increase in temperature during the first 24 hours after birth.

Occasionally, when a woman’s breasts fill with milk on the third or fourth postpartum day, her temperature rises for a period of hours because of the increased vascular activity involved.

Pulse After the initial tachycardia associated with

labour and delivery, a bradycardia often develops in the early puerperium.

A woman’s pulse rate during the postpartal period is usually slightly slower than normal.

This increased stroke volume reduces the pulse rate to between 60 and 70 beats per minute.

Pulse cont… As diuresis diminishes the blood volume

and causes blood pressure to fall, the pulse rate increases accordingly.

By the end of the first week, the pulse rate will have returned to normal.

Blood pressure Systolic and diastolic blood pressures

remain unchanged from late pregnancy values until about 12 weeks post partum, after which they increase.

Within 2 weeks post partum, systemic vascular resistance increases by 30%

References1. Dutta D.C. Textbook of obstetrics. Sixth

edition. Calcutta, India; New Central Book agency (P) Ltd: 2004.

2. Pillitteri A. Maternal and child health nursing. Care of the childbearing and childrearing family. Sixth edition. Philadelphia; Lippincott Williams & wilkins: 2010.

3. Jacob A. A comprehensive textbook of midwifery. Second edition. India; Jaypee Brothers Medical publishers (P) ltd.

 

References4. Fraser DM, Cooper MA. Myles Textbook of

Midwives. Fourteenth edition. Edinburgh; Churchill Livingstone: 2003.

5. Cunningham, Leveno, Bloom. William’s obstetrics. 23rd edition. United states of America; Mcgraw Hill companies: 2010.

6. Silversides Ck, Colman JM. Retrieved from .http://www.blackwellpublishing.com/content/BPL_Images/Content_store/Sample_chapter/9781405134880/9781405134880.pdf

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