Physiology of the Puerperium Flashcards
What is the puerperium?
The time after childbirth, lasting approx 6-8 weeks, during which the maternal physiological changes resolve and return to non pregnant state
Observations
New baseline for postnatal period
- changes to CV system
- changes to respiratory system
- pre eclampsia
- infection/sepsis
- lochia
- breasts
Cardiovascular System
- cardiac output elevated for 1-2 hours postpartum, this does return to pre pregnant levels
- withdrawal of oestrogen causes diuresis of up to 2l in the first week
- reduction of progesterone causes a return to normal vascularity
Respiratory System
- the increased respiratory rate will return to normal
- the birth of baby reduces uterine size, pressure on diaphragm
- 02 and C02 demands return
- subcostal angle remains 20% wider
Signs of Sepsis
- very high temp over 38
- very low temp below 36
- chills and shivering
- tachycardia
- tachypnoea
- headache/confusion/tiredness
Uterine Involution
Ischaemia - myometrium constricts the blood vessels, so blood circulating in uterus is considerably reduced
Autolysis - muscle fibres are digested by proteolytic enzymes, the waste products pass into the bloodstream eliminated by kidneys
Phagocytosis - removes excess fibrous and elastic tissue, process incomplete, some elastic tissue remains, so uterus never returns to pre pregnant state
What affects uterine involution?
- varies between women
- slower if uterus over distended in pregnancy e.g. large baby, polyhydramnious, multiple babies
- slow involution may be associated with retained products, blood clots, infection
Vaginal Loss - Placental Site
- When placenta is born, upper portion of spongy endometrial layer is sloughed off
- remaining decide is organised into basil and superficial layers
- superficial contains granulation tissue which becomes invaded by leucocytes which act as a barrier to prevent organisms invading remaining decidua
- this layer is sloughed off
- basal layer remains intact, source of regeneration of the endometrium
- healing of the placental site completed by 6 weeks
Vaginal Loss - Lochia
rubra - red - blood, amnion, chorion, decidiual cells, vernix, lanugo, meconium 1-3 days
serosa - pink - decidua, cervical mucous erythrocytes, micro organisms 4-10 days
alba - white - leucocytes, decimal cells, mucous, bacteria, epithelial cells 11-21 days
Cervix and Ovaries
Cervix - after delivery is soft, highly vascular, shortens and becomes firmer in 12-18 hours
External os remains partially dilated to admit one finger for weeks/months. internal os closed in 2nd week PP
Ovaries and Fallopian tubes return to pelvic cavity, ovulation should sear within 5 weeks if not breastfeeding
Endocrine Changes
oestrogen - returns to pre pregnancy levels by 7 days
progesterone - by 48 hours levels return to those found in luteal phase of menstrual cycle
FSH and LH - gradually increase with resumption of pituitary function by 4-6 weeks
Return of menstruation and ovulation
- onset of ovulation preceded by increase in plasma progesterone
- 25% ovulation may occur before menstruation and pregnancy may result
- breastfeeding women may not ovulate
Legs
OBSERVE- DVT, redness, pain, veins, cramps
Renal System
- kidneys have increased workload in PN period
- dilatation of the renal tract resolves with reduced levels of progesterone
- diuresis occurs from extra blood volume that is not longer needed
Vagina and Perineum
-vagina oedematous, decreased tone
-epithelium restored by 6-10 weeks, decreased lubrication
-vagina, vulva, pelvic floor respond to reduced amount of progesterone by regaining normal muscle tone but loss of elasticity, not fully restored to pre pregnancy state
PERINEUM - bruising or tears heal rapidly, episiotomy up to 4-6 months
