chapter 17. the puerperium obgy r1 변정미 `. definition period of confinement during and just...

Chapter 17. The PuerperiumChapter 17. The Puerperium

OBGYOBGY R1 R1 변정미변정미`̀

DefinitionDefinition

Period of confinement during and just after birth Period of confinement during and just after birth

includes 6 subsequent weeks postpartum during includes 6 subsequent weeks postpartum during which normal pregnancy involution occurs which normal pregnancy involution occurs

Chapter. 17 PuerperiumChapter. 17 Puerperium

Clinical and Physiological Aspects of the Clinical and Physiological Aspects of the PuerperiumPuerperium

Uterine ChangesUterine Changes

Urinary Tract ChangesUrinary Tract Changes

Relaxation of the Vaginal Outlet and PRelaxation of the Vaginal Outlet and Prolapse of the Uterusrolapse of the Uterus

Peritoneum and Abdominal WallPeritoneum and Abdominal Wall

Blood and Fluid ChangesBlood and Fluid Changes


Mammary GlandesMammary Glandes

Breast AnatomyBreast Anatomy

Breast FeedingBreast Feeding


Care of the Mother during the PuerperiumCare of the Mother during the Puerperium

Hospital CareHospital Care

Care at HomeCare at Home



Changes in the uterine vesselsChanges in the uterine vessels

CCaliber of extrauterine vesselsaliber of extrauterine vessels

: decrease to equal size of prepregnant state: decrease to equal size of prepregnant state

after delivery after delivery

Blood vessels within puerperal uterus Blood vessels within puerperal uterus

: obliterated by hyaline change : obliterated by hyaline change

replaced by smaller vessels replaced by smaller vessels



Changes in the Cervix & Lower Uterine SegmentChanges in the Cervix & Lower Uterine Segment

Cervical opening contracts slowly and for a few days immediaCervical opening contracts slowly and for a few days immediately after labor ( tely after labor ( ≒≒ 2fingers ) 2fingers )

: by the end of the 1st wk → it has narrowed : by the end of the 1st wk → it has narrowed

As the opening narrows the cervix thickens and aAs the opening narrows the cervix thickens and a canal reforms. canal reforms.

Bilateral depression at the site of lacerations remain as permanBilateral depression at the site of lacerations remain as permanent changes that characterize the parous cervixent changes that characterize the parous cervix



Changes in the Cervix & Lower Uterine SegmentChanges in the Cervix & Lower Uterine Segment

Markedly thinned-out lower uterine segmentMarkedly thinned-out lower uterine segment : contracts & retracts : contracts & retracts

→ → uterine isthmus located between the uterine corpus above uterine isthmus located between the uterine corpus above and the internal cervical os below - over the course of fewand the internal cervical os below - over the course of few weeks weeks



Involution of uterine corpusInvolution of uterine corpus

Fundus of contracted uterus Fundus of contracted uterus : slightly below umbilicus : slightly below umbilicus immediately after placental expulsion immediately after placental expulsion - within 2 wks - within 2 wks : descend into a cavity of true pelvis : descend into a cavity of true pelvis - within about 4 wks - within about 4 wks : regain previous nonpregnant size: regain previous nonpregnant size


Uterine ChangesUterine Changes Involution of uterine corpusInvolution of uterine corpus

Weight of uterus Weight of uterus : immediately postpartum, 1000g: immediately postpartum, 1000g - 1 week later : 500g - 1 week later : 500g - at the end of 2nd week : 300g, - at the end of 2nd week : 300g, - soon thereafter 100g or less - soon thereafter 100g or less : total number of muscle cells does not decrease : total number of muscle cells does not decrease → → individual cells decrease markedly in size individual cells decrease markedly in size

Separation of the placenta and membrane involves the spongy Separation of the placenta and membrane involves the spongy layerlayer

→ →decidua basalis remains in the uterus decidua basalis remains in the uterus



Afterpains Afterpains

Primiparas: puerperal uterus tends to remain tonically Primiparas: puerperal uterus tends to remain tonically contractedcontracted

Multiparas : contracts vigorously at interval Multiparas : contracts vigorously at interval → afterpain → afterpain Infant suckles →oxytocin release →Ut. contraction Infant suckles →oxytocin release →Ut. contraction

→ → afterpain afterpain Occasionally severe enough to require an analgesic Occasionally severe enough to require an analgesic

: usually become mild by the 3rd postpartum day: usually become mild by the 3rd postpartum day



Lochia Lochia Early in the puerperium, sloughing of decidual tissue → vaginal Early in the puerperium, sloughing of decidual tissue → vaginal

discharge of variable quantity discharge of variable quantity

lochia rubralochia rubra : first few days after delivery : first few days after delivery blood in lochia blood in lochia

lochia serosalochia serosa : after 3 or 4 days : after 3 or 4 days becomes progressively pale in color becomes progressively pale in color

lochia albalochia alba : after 10th day : after 10th day white or yellowish-white color, white or yellowish-white color,

lasted for approximately 2weeks after deliverylasted for approximately 2weeks after delivery



Endometrial regeneration Endometrial regeneration the remain decidua becomes the remain decidua becomes differentiated into 2 layersdifferentiated into 2 layers within 2 within 2

or 3 days after delivery or 3 days after delivery

superficial layersuperficial layer : become necrotic, sloughed in the lochia : become necrotic, sloughed in the lochia

basal layer basal layer : remains intact, source of new endometrium : remains intact, source of new endometrium



Endometrial regeneration Endometrial regeneration

Endometrial regeneration is rapid, except at the placental site Endometrial regeneration is rapid, except at the placental site - free surface becomes covered by epithelium within- free surface becomes covered by epithelium within a week or so a week or so - entire endometrium is restored during the 3rd week - entire endometrium is restored during the 3rd week - endometritis & salpingitis- endometritis & salpingitis : not infection but only part of the involutional : not infection but only part of the involutional process process



Subinvolution Subinvolution

an arrest or retardation of involution , the process by which the puan arrest or retardation of involution , the process by which the puerperal uterus is normally restored to its original proportions erperal uterus is normally restored to its original proportions

Cause Cause

: retention of placental fragments, pelvic infection : retention of placental fragments, pelvic infection

Accompanied by prolongation of lochial discharge & irregular or Accompanied by prolongation of lochial discharge & irregular or excessive uterine bleeding and sometimes by profuse hemorrhagexcessive uterine bleeding and sometimes by profuse hemorrhage e



Subinvolution Subinvolution

Bimanual examination Bimanual examination

: uterus is larger & softer than normal : uterus is larger & softer than normal

for the particular period of puerperium for the particular period of puerperium

Treatment Treatment

: ergonovine or methylergonovine(Methergine) : ergonovine or methylergonovine(Methergine)

oral antibiotics : usually effective in metritis oral antibiotics : usually effective in metritis



Placental site involution Placental site involution

: Complete extrusion of placental site takes up to 6 weeks : Complete extrusion of placental site takes up to 6 weeks

Immediately after delivery, palm size Immediately after delivery, palm size

→ → 3-4cm in diameter (end of 2nd week, )3-4cm in diameter (end of 2nd week, )

Placental sitePlacental site

: normally consists of many thrombosed vessels within hours of delivery : normally consists of many thrombosed vessels within hours of delivery

→ → ultimately undergo organization of thrombus ultimately undergo organization of thrombus

Placental site exfoliation Placental site exfoliation

: as the consequence of sloughing of infarcted and necrotic superficial: as the consequence of sloughing of infarcted and necrotic superficial

tissues followed by a reparative processtissues followed by a reparative process

- Anderson and Davis (1968)-- Anderson and Davis (1968)-



Late postpartum hemorrhageLate postpartum hemorrhage Serious uterine hemorrhage occasionally develops 1-2 weeks after deliverySerious uterine hemorrhage occasionally develops 1-2 weeks after delivery

Cause Cause abnormal involution of placental site (most often) abnormal involution of placental site (most often) retention of a portion of the placenta retention of a portion of the placenta

→ → usually undergo necrosis with deposition of fibrin usually undergo necrosis with deposition of fibrin → → form a placental polyp form a placental polyp

Treatment Treatment intravenous oxytocin, ergonovine, methylergonovine,intravenous oxytocin, ergonovine, methylergonovine, prostaglandins prostaglandins

curettagecurettage


Urinary Tract ChangeUrinary Tract Change

dilated renal pelvis & ureters dilated renal pelvis & ureters : return to prepregnant state 2-8 weeks after delivery : return to prepregnant state 2-8 weeks after delivery

Puerperal diuresisPuerperal diuresis physiological reversal of pregnancy-induced increase in extracellular water physiological reversal of pregnancy-induced increase in extracellular water : regularly occurs between 2nd and 5th day : regularly occurs between 2nd and 5th day

Puerperal bladderPuerperal bladder create optimal condition for development of create optimal condition for development of UTI UTI : increased capacity & relative insensitivity to intravesical fluid pressure : increased capacity & relative insensitivity to intravesical fluid pressure → → overdistention, incomplete emptying, excessive residual urine overdistention, incomplete emptying, excessive residual urine


Urinary Tract ChangeUrinary Tract Change

most women returned to normal micturition by 3months most women returned to normal micturition by 3months postpartum postpartum

Careful attention to all postpartum women, with prompt catCareful attention to all postpartum women, with prompt catheterization for those who cannot void, will prevent most urheterization for those who cannot void, will prevent most urinary problemsinary problems


Relaxation of the vaginal outlet and prolaRelaxation of the vaginal outlet and prolapse of the Uteruspse of the Uterus

Vagina and vaginal outlet gradually diminishes in sizeVagina and vaginal outlet gradually diminishes in size but rarely returns to nulliparous dimensions but rarely returns to nulliparous dimensions

Rugae : reappear by the 3rd week Rugae : reappear by the 3rd week

hymen: represented by several small tags of tissue, which during cicatrization hymen: represented by several small tags of tissue, which during cicatrization

are converted into the myrtiform caruncles are converted into the myrtiform caruncles

Relaxation of vaginal outlet Relaxation of vaginal outlet ← ← extensive laceration or overstretching of perineum during delivery extensive laceration or overstretching of perineum during delivery

Changes in pelvic supports during parturition Changes in pelvic supports during parturition : predispose to uterine prolapse & urinary stress incontinence : predispose to uterine prolapse & urinary stress incontinence → → operative correction is usually postponed until childbearing is ended operative correction is usually postponed until childbearing is ended


Peritoneum and Abdominal wallPeritoneum and Abdominal wall

Broad & round ligaments Broad & round ligaments : much more lax than nonpregnant : much more lax than nonpregnant : require considerable time to recover from stretching : require considerable time to recover from stretching & loosening & loosening

Abdominal wall Abdominal wall : return to normal → requires several weeks : return to normal → requires several weeks (aided by exercise)(aided by exercise) : usually resumes its prepregnancy state except for silvery : usually resumes its prepregnancy state except for silvery striae striae


Blood and Fluid ChangesBlood and Fluid Changes

leukocytosis and thrombocytosis occur during and after labor leukocytosis and thrombocytosis occur during and after labor

: by 1 week after delivery, blood volume return nearly to: by 1 week after delivery, blood volume return nearly to

nonpregnant level nonpregnant level

Cardiac output remains elevated for at least 48 hoursCardiac output remains elevated for at least 48 hours

postpartum postpartum

(due to increased stroke volume from venous return)(due to increased stroke volume from venous return)


Weight lossWeight loss

Uterine evacuation & normal blood loss : 5-6 kg Uterine evacuation & normal blood loss : 5-6 kg Further decrease through diuresis : 2-3 kg Further decrease through diuresis : 2-3 kg

factors of Weight lossfactors of Weight loss weight gain during pregnancy weight gain during pregnancy primiparity primiparity early return to work (outside the home) early return to work (outside the home) smoking smoking

not affect weight lossnot affect weight loss breastfeeding breastfeeding age age marital status marital status


Breast anatomyBreast anatomy

AA ducts ducts BB lobules lobules CC dilated section of duct to hold milk dilated section of duct to hold milk DD nipple nipple E E fat fat FF pectoralis major muscle pectoralis major muscle GG chest wall/rib cage chest wall/rib cage

Enlargement:Enlargement: AA normal duct cells normal duct cells BB basement membrane basement membrane CC lumen (center of duct) lumen (center of duct)



Lactation Lactation Colostrum Colostrum

the deep lemon-yellow colored liquid secreted initially by the breaststhe deep lemon-yellow colored liquid secreted initially by the breasts - expressed from the nipples by the second postpartum day - expressed from the nipples by the second postpartum day - contains more minerals and protein - globulin - contains more minerals and protein - globulin less sugar and fat less sugar and fat - Abs esp. IgA - Abs esp. IgA - persists for about 5days - persists for about 5days - gradual conversion to mature milk during the ensue 4weeks- gradual conversion to mature milk during the ensue 4weeks

Milk Milk - 600mL/day - 600mL/day - major proteins -including α-lactalbumin, β-lactoglobulin - major proteins -including α-lactalbumin, β-lactoglobulin and casein and casein - interleukin -6, epidermal growth factor - interleukin -6, epidermal growth factor



Endocrinology of lactation Endocrinology of lactation Progesterone, estrogen, placental lactogen, prolactin, cortisol, insulin Progesterone, estrogen, placental lactogen, prolactin, cortisol, insulin

: appear to act in concert to stimulate the growth & development of : appear to act in concert to stimulate the growth & development of milk-secreting apparatus of mammary glandsmilk-secreting apparatus of mammary glands

ProlactinProlactin is essential for lactation is essential for lactation Although plasma prolactin falls after delivery, suckling triggers a rise Although plasma prolactin falls after delivery, suckling triggers a rise

Milk ejection or letting down reflexMilk ejection or letting down reflex : initiated especially by suckling : initiated especially by suckling → → stimulates neurohypophysis to liberate oxytocin stimulates neurohypophysis to liberate oxytocin → → contraction of myoepithelial cells in the alveoli & small milk ducts contraction of myoepithelial cells in the alveoli & small milk ducts → → milk expression from lactating breast milk expression from lactating breast



Immunological Consequences of Breast FeedingImmunological Consequences of Breast Feeding

Predominant immunoglobulin in milk is secretory IgA Predominant immunoglobulin in milk is secretory IgA : contains secretory IgA antibodies against E. coli : contains secretory IgA antibodies against E. coli → → breast-fed infants are less prone to enteric infections breast-fed infants are less prone to enteric infections

Contains both T & B lymphocytes Contains both T & B lymphocytes

Nursing Nursing

Even though the milk supply at first appears insufficient, it become adequate Even though the milk supply at first appears insufficient, it become adequate

if suckling is continued if suckling is continued Nursing accelerates uterine involution Nursing accelerates uterine involution

: repeated stimulation of nipples release oxytocin : repeated stimulation of nipples release oxytocin → → contracts uterine muscle contracts uterine muscle



Lactation Inhibition Lactation Inhibition

Milk leakages, engorgement, & breast pain peak at 3 to 5 days postpartum Milk leakages, engorgement, & breast pain peak at 3 to 5 days postpartum → → support with well-fitting brassiere or breast binder, ice packs oralsupport with well-fitting brassiere or breast binder, ice packs oral analgesics analgesics

Inhibitors Inhibitors BromocriptineBromocriptine

bromocriptine has been associated with strokes, myocardial infarction,bromocriptine has been associated with strokes, myocardial infarction, seizures, and psychiatric disturbances in puerperal women seizures, and psychiatric disturbances in puerperal women



Contraception Contraception

Not needed in the first 3 weeks postpartum Not needed in the first 3 weeks postpartum

Progestin Progestin only contraceptives only contraceptives : mini-pills, depot medroxyprogesterone, levonorgestrel implant : mini-pills, depot medroxyprogesterone, levonorgestrel implant : do not affect the quality & increase the volume of milk very: do not affect the quality & increase the volume of milk very slightly slightly → → contraceptives of choicecontraceptives of choice for breast feeding women for breast feeding women

Estrogen-progestin contraceptivesEstrogen-progestin contraceptives : reduce the quantity & quality of breast milk : reduce the quantity & quality of breast milk : puerperal women have predisposition to venous thrombosis : puerperal women have predisposition to venous thrombosis → → increased by combination contraceptive pills increased by combination contraceptive pills ⇒ ⇒ low dose pills are preferred if used in lactating women low dose pills are preferred if used in lactating women



Contraindications Contraindications

take street drugs take street drugs

do not control alcohol use do not control alcohol use

have an infant with galactosemia have an infant with galactosemia

have HIV infection have HIV infection

have active, untreated tuberculosis have active, untreated tuberculosis

take certain medications take certain medications

are undergoing breast cancer treatment (ACOG, 2000) are undergoing breast cancer treatment (ACOG, 2000)

Cytomegalovirus and hepatitis B virus are excreted in milk Cytomegalovirus and hepatitis B virus are excreted in milk

Women with active herpes simplex virus Women with active herpes simplex virus



Drugs secreted in milkDrugs secreted in milk

Most drugs given to the mother are secreted in breast milk Most drugs given to the mother are secreted in breast milk

: but amount of drug ingested by the infant is typically small : but amount of drug ingested by the infant is typically small

Care of the breasts and nipples Care of the breasts and nipples

Dried milk is likely accumulate & irritate the nipples Dried milk is likely accumulate & irritate the nipples

→ → cleaning of areola with water & mild soap is helpful before and cleaning of areola with water & mild soap is helpful before and afterafter

nursing nursing



Breast feverBreast fever

For the first 24 hours after development of lacteal secretion, For the first 24 hours after development of lacteal secretion, : breasts to become distended, firm, & nodular : breasts to become distended, firm, & nodular ← ← exaggeration of normal venous & lymphatic engorgement ofexaggeration of normal venous & lymphatic engorgement of the breast the breast (not the result of overdistention of lacteal system with milk) (not the result of overdistention of lacteal system with milk)

Puerperal fever from breast engorgement is common Puerperal fever from breast engorgement is common : 37.8~39 , seldom persists for longer than 4~16 hours ℃: 37.8~39 , seldom persists for longer than 4~16 hours ℃ : : other causes (especially infection) of fever must be excludedother causes (especially infection) of fever must be excluded

Treatment Treatment : binder or brassiere, ice bag, analgesics, pumping or manual: binder or brassiere, ice bag, analgesics, pumping or manual expression expression



MastitisMastitis Parenchymatous infection of mammary glands Parenchymatous infection of mammary glands

seldom appear before the end of the 1st week postpartum not until the seldom appear before the end of the 1st week postpartum not until the

3rd or 4th week. 3rd or 4th week.

unilateral, breast becomes hard, reddened and painful unilateral, breast becomes hard, reddened and painful

Signs : chills (1Signs : chills (1stst), rigor, fever, tachycardia ), rigor, fever, tachycardia

Etiology Etiology

Staphylococcus aureus (most common) Staphylococcus aureus (most common)

※ ※ breast abscess : caused by group B streptococcus breast abscess : caused by group B streptococcus

- almost always from nursing infant's nose & throat - almost always from nursing infant's nose & throat

→ → the organism enters the breast through the nipple at the sitethe organism enters the breast through the nipple at the site

of a fissure or abrasion of a fissure or abrasion



Treatment Treatment swab and cultured swab and cultured antimicrovial therapy antimicrovial therapy

: penicillin or cephalosporin : penicillin or cephalosporin : MRSA →vancomycin : MRSA →vancomycin - continued for about 7-10days - continued for about 7-10days

Continue breast feeding Continue breast feeding : early Tx & continued lactation is successful in avoiding : early Tx & continued lactation is successful in avoiding abscess formation abscess formation

Breast abscessBreast abscess surgical drainage (essential) & general anesthesiasurgical drainage (essential) & general anesthesia



Attention immediately after laborAttention immediately after labor

for the first hour after delivery for the first hour after delivery - BP & PR : should be taken every 15 minutes - BP & PR : should be taken every 15 minutes

monitor amount of vaginal bleeding monitor amount of vaginal bleeding

Fundus should be palpated to ensure that it is well contracted Fundus should be palpated to ensure that it is well contracted if relaxation detected, uterus should be massaged throughif relaxation detected, uterus should be massaged through

abdominal wall until it remains contracted abdominal wall until it remains contracted


Hospital CareHospital CareEarly ambulationEarly ambulation

Advantages Advantages

less frequent bladder complications & constipation less frequent bladder complications & constipation

reduced frequency of puerperal venous thrombosis &reduced frequency of puerperal venous thrombosis &

pulmonary embolismpulmonary embolism

Care of the VulvaCare of the Vulva

Should be instructed to cleanse vulva from anterior to posterior (vulvaShould be instructed to cleanse vulva from anterior to posterior (vulva→anus) →anus)

Ice bag applied to perineum Ice bag applied to perineum

Warm sitz bathWarm sitz bath

: beginning about 24 hours after delivery: beginning about 24 hours after delivery

Tub bathing after uncomplicated delivery is allowed Tub bathing after uncomplicated delivery is allowed


Hospital CareHospital Care Bladder functionBladder function

Oxytocin : commonly infused after placental delivery Oxytocin : commonly infused after placental delivery sudden withdrawal of antidiuretic effect of oxytocin sudden withdrawal of antidiuretic effect of oxytocin → → rapid bladder filling rapid bladder filling

both bldder sensation and its capability to empty both bldder sensation and its capability to empty → → diminished by anesthesia (esp. conduction analgesia), diminished by anesthesia (esp. conduction analgesia), by episiotomy, laceration or hematomas by episiotomy, laceration or hematomas → → Urinary retention with bladder overdistention Urinary retention with bladder overdistention : common complication of the early puerperium : common complication of the early puerperium

woman who has not voided within 4 hours after delivery woman who has not voided within 4 hours after delivery → → indwelling catheter → prevent overdistension indwelling catheter → prevent overdistension



Tx of bladder overdistention Tx of bladder overdistention indwelling of catheter for at least 24 hours indwelling of catheter for at least 24 hours

empty the bladder completely empty the bladder completely prevent prompt recurrence prevent prompt recurrence allow recovery of normal bladder tone & sensation allow recovery of normal bladder tone & sensation

after catheter remove, if the woman cannot void after 4hours after catheter remove, if the woman cannot void after 4hours → → should be catheterized and urine vol. measured should be catheterized and urine vol. measured

≥≥200 cc of urine200 cc of urine : catheter should be left in place and the bladder drained: catheter should be left in place and the bladder drained for another day for another day

≤≤200cc of urine200cc of urine 　　 : remove the catheter & recheck the bladder. : remove the catheter & recheck the bladder.



Bowel functionBowel function early ambulation and early feeding early ambulation and early feeding → → constipation constipation ↓↓

Subsequent discomfortSubsequent discomfort during the first few days after vaginal deliveryduring the first few days after vaginal delivery

uncomfortable by afterpains, episiotomy & lacerations, breast engorgement uncomfortable by afterpains, episiotomy & lacerations, breast engorgement → → codeine, aspirin, acetaminophencodeine, aspirin, acetaminophen

Episiotomy & lacerations Episiotomy & lacerations - early application of an ice bag - early application of an ice bag - local analgesic spray - local analgesic spray - healed and nearly asymptomatic by the 3rd weeks - healed and nearly asymptomatic by the 3rd weeks



Mild depressionMild depression

Some degree of depression a few days after delivery is fairly common Some degree of depression a few days after delivery is fairly common

: Postpartum blues (= transient depression): Postpartum blues (= transient depression)

CauseCause

TThe emotional letdown that follows the excitement and fears that most whe emotional letdown that follows the excitement and fears that most women experience during pregnancy and deliveryomen experience during pregnancy and delivery

The discomforts of the early puerperiumThe discomforts of the early puerperium

Fatigue from loss of sleep during labor and postpartum in most hospital sFatigue from loss of sleep during labor and postpartum in most hospital settingsettings

Anxiety over her capabilities for caring for her infant after leaving the hoAnxiety over her capabilities for caring for her infant after leaving the hospital spital

Fears that she has become less attractiveFears that she has become less attractive

self-limited & usually remits after 2~3 daysself-limited & usually remits after 2~3 days



Abdominal wall relaxationAbdominal wall relaxation

Exercise to restore abdominal wall tone Exercise to restore abdominal wall tone

: any time after vaginal delivery,: any time after vaginal delivery,

as soon as abdominal soreness diminishes after cesarean delivery as soon as abdominal soreness diminishes after cesarean delivery

DietDiet

No dietary restrictions for women who have been delivered vaginally No dietary restrictions for women who have been delivered vaginally

2 hours after normal vaginal delivery, (if, no Cx) 2 hours after normal vaginal delivery, (if, no Cx)

lactating women : should be increased in calories and protein lactating women : should be increased in calories and protein

not breast feeding : dietary requirement as for a nonpregnant womannot breast feeding : dietary requirement as for a nonpregnant woman



ImmunizationsImmunizations Anti D-immune globulin 300 μg Anti D-immune globulin 300 μg

: nonimmunized women : nonimmunized women - within 72 hours of the birth of a D-positive infant - within 72 hours of the birth of a D-positive infant

Rubella vaccination Rubella vaccination Diphtheria-tetanus toxoid booster infectionDiphtheria-tetanus toxoid booster infectionMeasles immunization Measles immunization

Time of dischargeTime of discharge if, no complication (at vaginal delivery) if, no complication (at vaginal delivery) hospitalization period hospitalization period ≤≤ 48 hours 48 hours



CoitusCoitus Median interval between delivery and intercourse Median interval between delivery and intercourse

: 5 weeks (1~12 weeks): 5 weeks (1~12 weeks)

Best rule is one of common sense after 2 weeks, coitus may be resumed Best rule is one of common sense after 2 weeks, coitus may be resumed based on the pt's desire & comfort based on the pt's desire & comfort

* breast feeding : cause a prolonged period of suppressed estrogen* breast feeding : cause a prolonged period of suppressed estrogen

production with a resulting vaginal atrophy and drynessproduction with a resulting vaginal atrophy and dryness



Return of menstruation and ovulation Return of menstruation and ovulation

If not nursing If not nursing

: usually return within 6-8 weeks : usually return within 6-8 weeks

Lactating woman Lactating woman

: first period may occur 2: first period may occur 2ndnd~18~18thth months after delivery months after delivery

Ovulation Ovulation

- as early as 36-42 days(5-6 wks) after delivery - as early as 36-42 days(5-6 wks) after delivery

- delayed resumption of ovulation with breast feeding - delayed resumption of ovulation with breast feeding

but early ovulation is not precluded by persistent lactation but early ovulation is not precluded by persistent lactation

→ → pregnancy can occur with lactation pregnancy can occur with lactation



Follow-up care Follow-up care Normal delivery and puerperium Normal delivery and puerperium

: women can resume most activities (bathing, driving, household: women can resume most activities (bathing, driving, household functions) by the time of discharge functions) by the time of discharge

Follow-up examination during 3rd postpartum wk has proven quite satFollow-up examination during 3rd postpartum wk has proven quite satisfactory isfactory

- identify any abnormalities of later puerperium - identify any abnormalities of later puerperium - initiate contraceptive practice - initiate contraceptive practice



Thromboembolic disease Thromboembolic disease

in recent year : decreased in recent year : decreased identified during the antepartum periodidentified during the antepartum period

Pelvic venous thrombosisPelvic venous thrombosis

during the puerperium a thrombus may transiently form in any of the dilateduring the puerperium a thrombus may transiently form in any of the dilated pelvic veins d pelvic veins without associated thrombophlebitis – not incite clinical signs or symptomswithout associated thrombophlebitis – not incite clinical signs or symptoms

The massive and fetal pulm. emboli that develop without warning in the puThe massive and fetal pulm. emboli that develop without warning in the puerperiumerperium

: symptomatic puerperal pelvic thrombosis is most commonly associated: symptomatic puerperal pelvic thrombosis is most commonly associated with uterine infection with uterine infection



Obstetrical paralysis Obstetrical paralysis

Pressure on branches of lumbosacral plexus during labor Pressure on branches of lumbosacral plexus during labor

: complaints of intense neuralgia or cramplike pains: complaints of intense neuralgia or cramplike pains

extending down one or both legs as soon as the fetal headextending down one or both legs as soon as the fetal head

begins to descend the pelvis begins to descend the pelvis

Involved external popliteal n. femoral n. obturator n, sciatic n. Involved external popliteal n. femoral n. obturator n, sciatic n.

the gluteal m. are affected.the gluteal m. are affected.

Separation of the symphysis pubis or one of the sacroiliac synchondroses Separation of the symphysis pubis or one of the sacroiliac synchondroses during labor may be followed by pain and marked interference with locoduring labor may be followed by pain and marked interference with locomotion.motion.


감 사 합 니 다감 사 합 니 다

chapter 17. the puerperium obgy r1 변정미 `. definition period of confinement during and just...

Documents