Puerperium Flashcards
What is puerperium?
- 6 week interval after delivery when everything goes back to normal
- Milk production begins
When does the uterus start to retun to the non-pregnant state?
Starts to return to the non-pregnant stage immediately after the placenta is delivered - involves shortening of the muscle fibres and death of the excess myometrial cells (known as involution)
Discuss oxytocin release after delivery
Oxytocin release continues days after delivery to compress the myometrial cells of the uterus. Excess cells die, the decidua is shed and replaced with endometrium. The loss consisting of decidual and trophoblastic debris = lochia, the lochia gradually decreases in volume and becomes less blood stained
At what rate does the fundus usually descend?
1-2cm daily
Why might a uterus fail to involute?
Retained placenta or infection
When does menstruation resume?
8 weeks after birth - in breast feeding women prolactin inhibits FSH secretion and prevents ovulation and as such the onset of menstruation is delayed
When are breasts capable of secreting milk?
From 20 weeks - progesterone inhibits this during pregnancy, after expulsion of the placenta progesterone levels drop and milk secretion is possible
Why does cardiac output increase during the puerperium?
Increases, blood from the placenta returns to the central circulation, excess extracellular fluid moves into the vascular compartment and caval compression reduces.
*this time is a high risk for women with cardiac conditions as they are unable to cope with the increased venous return and heart failure can occur
Why does urine output increase after women have given birth?
Declining levels of aldosterone and oxytocin leads to a decrease in tubular reabsorption of fluid - output increases to 3000mL/ day
Why is the puerperium important?
- Applicable to all women who deliver
- Physiological changes of pregnancy, delivery and iatrogenic interventions revert to non pregnant state
- Complications could be life threatening and changing for the mother
Anatomical and physiological changes during pregnancy
- Increased circulatory/ vascular volume: blood volume increases by 30%, plasma volume increases by 45%
- Cardiac output increases by 30-50%
- Stroke volume increases by 25%
- Heart rate increases by 15-25%
- Peripheral vascular resistance decreases by 15-20%
Cardiovascular changes after birth
- Stabilisation of cardiac output
- Diuresis 2-5 days postpartum dissipates extra volume
- Normalisation from 2 weeks post partum
Changes to the coagulation system in/ after pregnancy
- Pregnancy = hypercoagulable state
- Remains high for 10-14 days before starting to normalise
- Resulting haemostasis protects against haemorrhage but there is an increased risk of VTE
Uterine changes after delivery
- Involution occurs during the puerperium
- Fundus palpable at maternal umbilicus immediately post partum
- Returns to true pelvis within 2 weeks
- Recedes to only slightly larger than pre-pregnancy at the end of the puerperium
- Restoration of endometrium by 16th day apart from at site where placenta was attached
- Changes at the placental bed site results in the production of lochia
Breast changes during/ after pregnancy
- Changes to the breast occur during pregnancy
- Lactogenesis start at 16 weeks
- High levels of circulating progesterone activates mature alveolar cells in the breast
- Rapid decline in progesterone after delivery triggers onset of milk production
- Swelling/ engorgement of breasts in postpartum period
- Colostrum first 4 days after delivery
- Removal of milk from breast stimulates more production
- Breast milk matures over first 7 days
Primary vs secondary PPH
Primary: within 24hrs
Secondary: 24hrs - 12 weeks after delivery
