Normal & abnormal puerperium

Question 1

PEUPERIUM

Answer 1

 Refers to 6 week period following completion of the 3rd stage of labour.
 Puerperium is the period following childbirth during which body tissues, esp. pelvic organs revert back approximately to pre-pregnant state both anatomically and physiologically
 There is a reversal of the physiological changes in pregnancy to the pre-pregnancy state.
 During this period of physiological changes, pt. is also prone to psychological disturbances that may be aggravated by adverse social circumstances.

Question 2

Involution

Answer 2

 Involution is the process by which genital organs revert back approximately to their pre-pregnant state

Question 3

Division of the puerperal period

Answer 3

 Period is arbitrarily divided into;
a) Immediate – within 24hrs;
b) Early – up to 7 days &
c) Remote – up to 6 weeks

Question 4

Uterine involution

Answer 4

 Involution is the process by which the postnatal uterus, weighing about 1kg returns to its pre-pregnancy state of < 100g.
 Soon after delivery, uterus becomes firm and retract with alternate hardening and softening, measures about 20 × 12 × 7.5 cm and weighs about 1000 gm, but by end of 6wks, weighs about 60 gm and return to pre-preg dimensions
 Immediately post-delivery, fundus lies about 4cm below umbilicus or more accurately,12cm above symphysis pubis
 Uterus begins to shrink after 2 days and descends into pelvis after 2 weeks
 The contraction of the uterus immediately after delivery is critical for the achievement of hemostasis.
 “Afterpains” due to uterine contraction are common and may require analgesia. They typically decrease in intensity by the 3rd postpartum day.
 There is no decrease in number of muscle fibers but there is substantial reduction of the myometrial cell size.
 Weighs 500g after 1 wk, 300g by 2nd week & to less than 100g thereafter.

Question 5

Physiology of uterine involution

Answer 5

 Involution occurs by autolysis, muscle cells diminish in size as a result of enzymatic digestion of cytoplasm, and
liberated peptones from autolysis is absorbed into bloodstream and excreted in urine as urea and creatinine.
 Withdrawal of steroid hormones, estrogen and progesterone, increase uterine collagenase activity and release of
proteolytic enzyme.
 It’s accelerated by oxytocin in breastfeeding women.
 Uterus contract tonically in prime paras and contracts vigorous at intervals in multiparas giving rise to after pains.
 Involution is favored by;
a) Efficacy of the enzymatic action and
b) Relative anoxia induced by effective contraction and retraction of the uterus.

Question 6

explain the physiological changes to Muscles (2) Blood vessels (3) Endometrium. during uterine involution

Answer 6

 Changes occur in: (1) Muscles (2) Blood vessels (3) Endometrium.
 Muscles: in pregnancy uterine muscle fibers undergo via marked hypertrophy and hyperplasia and each
muscle fiber can enlarges to the extent of 10 times in length and 5 times in breadth
 Number of muscle fibers is not decreased but there is substantial reduction of the myometrial cell size.
 Blood vessels: Changes are pronounced in blood vessels at placental site.
 Arteries constrict by contraction & thickening of intima followed by thrombosis.
 In 1 st week, arteries undergo thrombosis, hyalinization and fibrinoid end arteritis.
 Veins are obliterated by thrombosis, hyalinization & endophlebitis.
 Later new blood vessels grow inside the thrombi.
 Endometrium: major part of decidua is cast off with expulsion of placenta & membranes, more at placental
site, after delivery
 Endometrial thickness left behind varies from 2–5 mm.
 Within 2-3 days postpartum, the remaining decida becomes differentiated into 2 layers:
 Superficial layer: becomes necrotic, sloughs off as vaginal discharge (lochia)
 Superficial part containing degenerated decidua, bld cells and bits of fetal membranes becomes necrotic
and is cast off in lochia.
 Basal layer (adjacent to the myometrium) becomes new endometrium
 Regeneration starts by 7th day, completed by 10th day & by 16th day, entire endometrium is restored, except
at placental site where it takes about 6 wks.

Question 7

differentiate btwn Subinvolution & Superinvolution

Answer 7

 Subinvolution- adversely affected involution, resulting in the failure of the uterus to go back to pre-pregnnant state of <100g- present with prolonged lochia rubra- cause PPH
 Superinvolution - continued involution in lactating women present with a smaller size uterus.
Returns to normal size if the lactation is withheld.

Question 8

 Causes of delayed involution:

Answer 8

1. Uterine infection
2. Retained products of conception
3. Fibroids
4. Broad ligament hematoma
5. Full bladder and loaded rectum
6. Overdistension of the uterus- e.g. in multiple pregnancy, Polyhydramnios

Question 9

outline the physiological changes to the cervix in puerperium

Answer 9

Cervix
 Cervical opening contracts slowly within a few days leaving a parous cervix. In the first few days, the cervix can readily admit 2 fingers.
 Cervix- Following delivery of placenta, the lower segment and the cervix appear flabby & may‘ve small cervical lacerations.
 Cervix contracts slowly; 1st few days, can readily admit 2 fingers, 1st week become increasingly difficult to pass > 1 finger & by 2 nd week internal os is closed.
 External os remain open permanently as parous cervix (never reverts back to nulliparous state)
 Cervical contour takes a longer time to regain (6 weeks)
 The multiparous cervix takes on a characteristic fish mouth appearance.
 As a result of childbirth, the cervical epithelium undergoes much remodeling. Approximately 50% of women with high-grade cervical dysplasia will show regression
after a vaginal delivery due to the remodeling of the cervix.

Question 10

Lochia

Answer 10

 Blood stained uterine discharge that comprises erythrocytes and necrotic decidua for the 1st fortnight during
puerperium.
 Discharge originates from the uterine body, cervix and vagina.
 Only superficial layer of decidua becomes necrotic & is sloughed off & basal layer is involved in regeneration of
new endometrium which is complete by 3rd wk
 Amount of lochia: average amt of discharge for 1 st 5–6 days, is estimated to be 250 mL.
 Normal duration: may extend up to 3 weeks

Question 11

Types of lochia based on variation of the color

Answer 11

1. Lochia rubra (Red) - (0-3 days); - Consists of bld, shreds of fetal membranes & decidua, vernix caseosa, lanugo & meconium
2. Lochia serosa (Pale) - (4-10 days); -consists of less RBC but more leukocytes, wound exudate, cervical mucus and microorganisms (anaerobic streptococci and staphylococci). Presence of bacteria is not pathognomonic unless associated with clinical signs of sepsis
3. Lochia alba (yellow - White)- (> 10 days); - Contains plenty of decidual cells, leukocytes, mucus, cholestrin crystals, fatty and granular epithelial cells and microorganisms

Question 12

Clinical importance of lochia

Answer 12

 Character of lochial discharge gives useful information about abnormal puerperal state
 Persistent red lochia- suggests delayed involution (subinvolution) usually associated with infection or
retained products of conception.
 Offensive lochia- malodorous usually accompanied by pyrexia and tender uterus suggests infection. Exclude
Retained plug or cotton piece inside the vagina.
 Amount: Scanty or absent- signifies infection or lochiometra. If excessive- indicates infection.
 Duration: Duration of lochia alba beyond 3 weeks suggests local genital lesion

Question 13

outline the physiological changes to the Vulva / vaginal tissue in puerperium

Answer 13

 Return to normal over 1st several days
 Vaginal mucosa may demonstrate hypoestrogenic effect during lactation
 Fascial stretching /trauma from childbirth may result in pelvic muscle relaxation , which may not return to
pregravid state
 Pelvic floor muscles gradually regain tone; Kegel exercises (repeatitive contractions of pelvic floor muscle) may
streghen tone
 vagina gradually diminishes in size but rarely return to nulliparous dimensions:
 Rugae reappear by the third week. The rugae become obliterated after repeated childbirth and menopause

Question 14

outline the physiological changes to Cardiac output in puerperium

Answer 14

 Remains elevated for at least 48hrs after delivery due to decreased blood flow to the uterus (much smaller) and increased systemic intravascular
volume. Cardiac output rises soon after delivery to about 80% above pre-labor value.
 Contraction of uterus pushes 500-700mls of blood into maternal circulation
 Slight decrease of blood volume due to blood loss and dehydration & returns to non-pregnant level by 2nd week.
 By 1 week postpartum, the blood volume has returned to the patient’s non-pregnant range.

Question 15

outline the physiological changes to Haematology in puerperium

Answer 15

 RBC vol & Hct values returns to normal by 8th wk postpartum after hydremia disappears.
 Hb and HCT fluctuate moderately
 Leukocytosis to extent of 25,000/cumm occurs after delivery in response to labor stress. Leukocyte count may reach as high as 30,000/µL
 There is marked leucocytosis and thrombocytosis with relative lymphopenia and absolute eosinophilia
 Platelet count decreases soon after the separation of the placenta but secondary elevation occurs, with increase in platelet adhesiveness between 4-10 days
 Fibrinogen level remains high up to 2nd wk of puerperium & hypercoagulable state persists for 48hrs postpartum
and fibrinolytic activity is enhanced in 1st 4 days. Secondary increase in fibrinogen, factor VIII and platelets in 1st week increases risk for thrombosis

Question 16

outline the renal physiological changes in puerperium

Answer 16

 Normal pregnancy is associated with an appreciable increase of extracellular water
 ↑Diuresis occurs from 2nd to 5th day & corresponds to the loss of this water
 Bladder mucosa becomes edematous and hyperemic and often shows evidences of submucous extravasation of bld. Bladder capacity is increased & may be over distended without any desire to pass urine
 Puerperal bladder has increased capacity & a relative insensitivity to intravesical fluid pressure
 Urea and electrolyte levels return to normal because of the reduction in GFR
 Dilated ureters & renal pelves return to normal size within over 2-8 weeks
 Common urinary problems: over distension, incomplete emptying & presence of residual urine (urinary stasis- in more than 50%)  increasing risk of UTI.

Question 17

outline the physiological changes to PERITONEUM AND ABDOMINAL WALL in puerperium

Answer 17

 The broad ligaments and round ligaments slowly relax to the nonpregnant state.
 The abdominal wall is soft and flabby due to prolonged distension and rupture of the skin’s elastic fibers, it resumes pre-pregnancy appearance in severe weeks. However, the silver striae persist

Question 18

outline the physiological changes to WEIGHT in puerperium

Answer 18

 Most women approach their prepregnancy weight 6 months after delivery but still retain
approximately 1.4kg of excess weight.
 5 to 6kg lost due to uterine evacuation and normal blood loss.
 2-4 kg are lost due to diuresis