Puerperium

Question 1

Define the puerperium

Answer 1

From the third stage of labour until changes of pregnancy revert to non-pregnant state (usually 6 weeks postpartum)

Question 2

Describe uterine changes

Answer 2

Uterine involution. Is a process of autolysis and shrinks from 1kg to 60-80g in a few weeks. Uterus goes form

Question 3

Describe the lochia (vaginal discharge) changes

Answer 3

1. Similar volume of discharge in first week after pregnancy as during delivery
2. Made up of necrotic superficial decide and blood
   Red after delivery (until day 5-7)
   Red-brown till day 10-14
   Yellow until day 21
   New endometrium layer regenerates from basal layer within 7-10 days
   Placental site endometrium takes 6 weeks to regenerate

Question 4

Decribe change to cervix

Answer 4

Immediately is floppy and curtain like
Within a few days regains tone and consistency
External os remains expanded for a few weeks but internal os closes after a few days
Appearance of external os is permanently elliptical after partum

Question 5

Describe the changes to the vagina

Answer 5

First few days - smooth, soft, oedematous with distension from labour remaining
Gradually regains tone and returns to normal capacity at 3-6 weeks with rug reappearing
After multiple births permanently larger

Question 6

Describe 3 other structural changes

Answer 6

1. Pelvicalyceal dilatation in pregnancy will return to normal
2. Return of muscular tone (pelvic floor and abdominal muscles
3. Fading of striae gravidarum, lineament nigra (stretch marks)

Question 7

Describe hormone changes

Answer 7

Decreasing levels of progesterone, oestrogen, prolactin (unless breastfeeding) thyroid hormones (T3 and T4) over 4-6 weeks. Renin, aldosterone, cortisol.

Question 8

When does cyclical pituitary and ovarian function return?

Answer 8

First menstruation is anovulatory (at 7-9 weeks in non-lactating women)
Most will menstruate by 12 weeks postpartum

Question 9

Describe the hormones changes when suckling occurs

Answer 9

Suckling sends signals: to hypothalamus to inhibit release of prolactin release inhibiting hormone causing prolactin to be released from anterior pituitary.
Suckling inhibits gonadotrophin secretions so an ovulation.
Suckling causes oxytocin release from posterior pituitary to stimulate myoepithelial cells to contract to eject milk

Question 10

Describe maternal cardiovascular changes

Answer 10

Fall in plasma volume after day 3 then normal by day 10
Cardiac output increases immediately (due to increase in stroke volume due to increase in venous return) after birth then decline. By day 14 cardiac output decreased by 16%

Question 11

Describe haematological changes in mother

Answer 11

Rise in Hb immediately after birth then decreases to lowest on day 4-5 before increasing again
Leucocytes increase immediately then fall to normal by day 6
Platelets decrease until week 6
Highest risk of VTE in postpartum period
Hypercoagulation persists up to 6 weeks postpartum