Puerperium: physiological changes in reproductive system and other systems of the body after child birth microbiologystudy

What is Puerperium?

• Puerperium is a duration in which the reproductive organs and all the system of the body revert to their normal condition.
• It is followed by the delivery of the placenta and ends approximately 6 weeks later.
• Puerperium can also be defined as a period following childbirth in which the body tissues, particularly the pelvic organs return back approximately to the pre-pregnants state both anatomically and physiologically.
• Puerperium or post partum period is term given for the first 6 weeks following the birth of an infant.
• Mothers experience several physiologic and psychological changes during this time.
• They are listed as follows:

• • Reverting of the reproductive organ to their pre-pregnant stage.
  • Initiation of Lactation.
  • Recovery of the mother from the physical and emotional experiences of parturition.
  • The foundations of the relationship between the infant and its parents are established.

A. Physiological changes in reproductive system:

I. Involution of the uterus:

• Involution is a term given to the changes that the reproductive organs, specifically the uterus, goes through after their childbirth to return to their pre pregnancy size and condition.
• Involution relies on three processes:
  • a. Contraction of muscle fibres
  • b. Catabolism
  • c. Regeneration of uterine epithelium

a. Contraction of muscle fibres:

• The involution starts immediately after placenta delivery when uterine muscle fibers contact around maternal blood vessels at the region where the placenta has been attached securely.
• As the muscle fibers that have been stretched for several months contract and gradually recover their original contour and size, the uterus decreases in size.

b. Catabolism:

• Although the total number of cells remains unchanged, catabolic changes in protein cytoplasm are experienced in the enlarged muscle cells of the uterus that cause a decrease in individual cell size.
• The catabolic process products are absorbed by the blood stream and are excreted as nitrogenous waste in urine.

c. Regeneration of uterine epithelium:

• Soon after childbirth, regeneration of the uterine line begins.
• With the placenta, the outer part of the endometrial layer is expelled within 2-3 days and the remaining deciduas are divided into two layers.
• The initial layer is superficial and is shed in lochia.
• The basal layer remains intact and is the new endometrium source.
• Endometrium regeneration, except at the site of placental attachment, occurs within 2-3 weeks.
• The placental site contracts rapidly providing an elevated surface measuring approximately 7.5cm and stays elevated even at 6 weeks, until it measures approximately1.5cm.
• Healing occurs more slowly at the placental site and takes about 6-7 weeks.
• The uterus is in the midline at the end of the third stage of labor, about 2cm below the umbilicus level.
• The uterus weighs about 1000gm at this time.
• Within 12 hrs, the fundus can rise to approximately 1 cm above the umbilicus. 
• The uterus is about the same size at 24 hours postparutm as it was at 20 weeks of gestation. Involution will develop rapidly over the next few days.
• The fundus descends every 24 hours by around 1-2 cm or 1 finger, so that it is in the pelvic cavity by the 8-10th day and can not be palpated abdominally.
• And there are individual variations linked to body size.
• The uterus, which weighs approximately 11 times its pregnancy weight in full, involutes approximately 500 gm per 1 week after birth and 300-350 gm per 2 weeks after birth.
• It weighs 60gm in 6 weeks.
• Increased levels of estrogen and progesterone are responsible for promoting massive uterine growth during pregnancy.
• Prenatal uterine development results from both hyperplasia, an increase in the number of muscle cells, and an enlargement of existing cells due to hypertrophy.
• The reduction of these hormones postnatally induces autolysis, the self-destruction of excess hyperthyroid tissue.
• The powerful frequency of myometrial contractions that regulate the flow of blood to the uterus stops, making it difficult.
• By palpating the uterus, its consistency can be measured. It ought to feel firm and round.

II. Cervix:

• The cervix is formless, flabby, and open enough to accommodate the entire hand immediately after birth.
• This makes it possible, if appropriate, to manually remove the placenta and to manually inspect the uterus.
• There can be minor tears and lacerations, and the cervix is sometimes edematous.
• Rapid healing happens and the cervix feels firm by the end of the first week.
• For the first 4-6 days postpartum, two fingers may still be inserted into the cervical os, but only the smallest curette can be introduced by the end of 2 weeks.
• The external cervical os never acquires its prepregnant appearance, it is no longer shaped like a circle, but appears as a jagged slit that is sometimes portrayed as a fish mouth.

III. Vagina:

• During birth, the vagina and the vagina introitus are substantially extended to enable the fetus to move.
• The vaginal walls appear edematous, smooth, soft and some minor lacerations may be present soon after childbirth.
• Vaginal mucosa becomes atrophic during the postpartum periods, and vaginal walls do not recover their thickness until ovarian estrogen production is reestablished.
• Due to ovarian activity, and thus the development of estrogen during lactation is not well known, breast feeding mothers are likely to experience vaginal dryness and may experience intercourse discomfort.
• Estrogen deficiency is also accountable for a reduced amount of vaginal lubrication.
• In the vaginal condition, the introitus remains permanently larger.
• The hymen is lacerated and is expressed by nodular tags.
• Adequate suturing has been done in well-healed vaginal tears.
• The vagina shrinks to a non-pregnant level, but it does not return to its pregnant size fully.

IV. Perineum:

• During the second stage of labor, as the fetal head applies pressure as it descends, the pelvic floor muscle stretches and thins considerably and rotates and then expands to be delivered.
•  And an intact perineum may be edematous, erythematous and painful after delivery.
•  Swelling and tenderness as a result of the birth of a baby are initially present.
•  Healing of an episiomoty is identical to any surgical incision.
• Healing should occur between 2-3 weeks.
• When episiotomy and perineal tears are done, a scar may be present.
• Pelvic floor supporting tissue that is torn or stretched during childbirth can take up to 6 months to recover tone.
•  Kegel exercises which helps enhance perineal muscles and promote healing are suggested after childbirth.
• Adequate suturing has been done with well episiotomies and perineal tears.

V. Ovaries:

• The resumption of the ovaries’ regular function is highly variable and is profoundly affected by the breastfeeding of infant.
• The woman who breastfeeds the baby has a longer amenorrhea and ovulation cycle than the mother who does not breastfeed will ovulate after 27 days of delivery.
• Most women have a menstrual cycle of 12 weeks, with a mean duration of 7-9 weeks for the first menstrual.

VI. Lochia:

• Lochia is vaginal discharge after child birth.
• The uterine body, cervix and vagina are the sources of the discharge.
• Blood leucocytes, decidua sheds, and organisms compose the lochia.
• Initially, the lochia is bright red, but after the first week the color fades and the flow usually clears entirely within 4 weeks of delivery.
•  As involution progresses, postchild birth uterine discharge undergoes sequential modifications.
• Lochia rubra: consist primarily of blood, sheds of fetal membranes and decidua, vernix caseosa, lanugo. It may consist few small blood clots.
• Lochia serosa: fewer RBC, more leucocytes, serum, mucus, and tissue debris. These are pink colored and are released over the next 5-9 days.
• Lochia alba: contains large number of deciduous cells, leukocytes, mucus, serum, epithelial cells and bacteria. The discharges are colored pale, creamy, brown and last 10-14 days. Any signs of discharged stained blood may continue to be seen for a further 2-3 weeks. The color of lochia indicates the placental site’s healing period.
• Odor and reaction:
  • It’s got a distinct unpleasant fishy scent.
  •  Its reaction is alkaline, tending to become acid at the end.
• Amount:
  • Estimating the quantity of lochia is difficult.
  •  Due to absorption in pads, sari, etc., the true amount may be concealed.
  • The weight of the pads can also be weighed and compared with the weight of the clean dry pad (1 g of weight equal to 1 ml) or based on the amount of stain on the perineal pad, providing a definition and an approximation in milliliters of 1 hour for lochia.
  • The average discharge level is calculated to be 250ml for the first 5-6 days.
  • Scanty: less than one 2 inch (5cm) stain in one hour on the peri pad= 10 ml
  • Light: stain on the perineal pad less than 4 inches (10cm) within 1 hour= 10ml to 25ml
  • Moderate: less than 6 inches (15cm) of stain within 1 hour on the perineal pad= 25-50ml.
  • Heavy: greater than 6 inches or heavy saturated pad= 50-80 ml within 1 hour.
• Normal charateristics of lochia:
  • Lochia rubra is 1-4 days in length. Bloody,small clots.
  • Lochia serosa is 5-9 days long. Decreased amount, serosanguneous, pink or brown.
  • For 10-15 days, Lochia aalba lasts. Creamy, yellowish color, decreasing amounts.
• Clinical importance:
  • Useful knowledge about the irregular puerpural condition is provided by the character of the lochia discharge.
  • – Severe lochia suggests infection when offensive.
  • – if scanty, denotes infection or lochiometra
  • – If persistence of red color further than normal limit suggests subinvolution or retained bits of conception.
  • – Local genital lesion is suggested when it lasts past 3 weeks.

B. Physiological changes in other systems of body:

1. Vital signs:

• 1. Pulse:
  • The pulse rate is likely to be raised for a few hours after normal delivery, calming down to normal during the second day.
  • The pulse rate, however, can also increase with pain or excitement afterwards.Any tachycardia (pulses > 110 or more bpm) may be suggestive of severe bleeding or the development of puerperal infection.
• 2. Temperature:
  • As an usual physiological reaction, the temperature may be labile within the first few days following delivery.
  • Temperatures within the first 24 hours should not be above 37.2^o C.
  • After delivery, there could be a small reactionary increase of 0.5^o F, but within 12 hours it comes down to normal.
  • Due to breast engorgement, which does not last for more than 24 hours, there might be a minor temperature increase on the 3rd day.
  • Puerperal pyrexia results from genital or urinary tract infection, breaches or inflammation within the venous system.
• 3. Blood pressure:
  • Because of an increased venous return, there may be a slight rise in the blood pressure.
  • Blood pressure differs with position and in order to gain accurate results, it should be measured with the mother in the same position each time.
  • A rise from the baseline indicates hypertension caused by pregnancy, a decrease may indicate dehydration or hypovolemia due to excessive bleeding.
  • Conduct a quick initial test.

2. Respiration:

• It is necessary to maintain a normal respiration rate of 16-20 per minute.

3. Gastrointestinal System:

• i. Appetite:
  • Shortly after birth, the mother is normally hungry and can handle a light diet.
  •  New mother is normally hungry due to the extreme energy lost in labor.
  • Besides that she is generally thirsty because of fluid loss during labor, in the lochia, diuresis and prespiration.

•  
• ii. Bowel evacuation:
  • For 2-3 days after childbirth, a bowel evacuation may not occur.
  • The decreased muscle tone in the intestine during childbirth and the immediate puerperium, prelabour diarrhea, lack of food or dehydration may explain this delay.
  • The mother often observes discomfort during the bowel movement due to lack of perineal muscles, reflex pain in the perineal region, slight intestinal paresis are factors contributing for constipation.
  • When the bowel tone returns, normal bowel patterns should be reestablished.
  • The strain and pressure on the lower bowel triggers the extrusion of internal hemorrhoids during delivery.
  • They decrease in size after delivery and can be manually re-inserted into the rectum.
  •  Hemorrhoids present during pregnancy often shrink and occasionally surgical reduction.
  • The rate at which the intestine is regulated depends on everyday life, food and fluids, exercise.

4. Neurologic System:

• Induced neurological pain in pregnancy disappears after birth.
• Removal of physiologic edema through the diuresis that accompanies childbirth relieves carpal tunnel syndrome by inducing compression of median nerve.

5. Integumentary System:

• Chloasma of pregnancy typically disappears at the end of pregnancy.
• After childbirth, areola and linea nigra hyperpigmentation does not regress entirely.
• These areas may have permanent darker pigmentation for some women.
• Breast, abdomen and thigh striae gravidarum (stretch marks) can fade (silvery color in light skinned women) but typically don’t disappear.
• Hair and nail development can return to pre-pregnant patterns in a few months.

6. Respiratory System:

• The diaphragm descends to its usual location after delivery, which decreases abdominal pressure, allowing for improved lung expansion and ventilation, but the respiratory rate does not change significantly.

7. Urinary System:

i. Physical changes:

• When the fetal head moves under the uterus, the urethra, bladder and tissue around the urinary meatus may become edematous and traumatized during childbirth.
•  This also results in reduced fluid pressure sensitivity, even though the bladder is distended.
•  Owing to the diuresis that accompanies childbirth, the bladder fills easily.
•  As a result, the mother is at risk for over distention of the bladder, incomplete emptying of the bladder.
•  Body water in the extra vascular spaces and excess plasma volume from pregnancy are quickly removed.
• Yet diuresis and polyurea occur up to 3 liters/day on the second postpartum day.
•  The urine passes for a few days and returns to the usual voiding pattern after one week.
•  Bladder boosts its ability, filling up to 1000 or 1500 ml of urine without pain.
•  Regional or general anesthesia can inhibit normal function temporarily, diminishing the bladder urinary sensation.
•  The woman at risk for haemorrhage from a poorly contracted uterus is followed by urinary retention.
•  Stasis also predispose to urinary tract infection.
• Weight Loss:
  • During childbirth, about 5.5 kg (12 pounds) of weight is lost.
  • This involves the weight lost during the birth of the fetus, placenta and aminotic fluid and blood.
  • During the first 2 weeks following childbirth, an additional 2-4 kg is lost.
  •  This includes the weight lost during the first few post partum days by diuresis and diaphoresis.
• Fluid loss:
  • Total fluid loss for the first week of at least 2 liters and for the next 5 weeks of an additional 1.5 liters.
  • The loss amount depends on the amount returned during the prenatal and natal phases.

8. Musculo-Skeletal System

• Abdominal muscles: The uterine ligaments remain loose and relaxed, with less tone in the abdominal muscles, resulting in the abdomen becoming flexible and flabby.
• During the first days after birth, as the woman stands up, her belly protrudes and gives her a pregnant look.
• The abdominal wall is relaxed during the first 2 weeks after birth.
• It takes about 6 weeks for the abdominal wall to return to its state of nearly non-pregnancy.
• The restoration of muscle tone relies on the previous tone, proper exercise, and the amount of adipose tissue.
• The abdominal wall muscle distinguishes a disorder called diastasis recti abdominis sometimes with or without overdistension due to a large fetus.
• Joints: The pelvic joint, especially the symphysis pubis, can separate slightly during labor under the influence of relaxation, causing pain and discomfort, stabilizing by 6-8 weeks.

9. Cardiovascular System:

• Change in blood volume: Changes in blood volume after birth depend on many factors, such as loss of blood during childbirth and mobilization and excretion of extravascular water (physiologic edema).
• Cardiac output:
  • Due to a rise in stroke volume, cardiac output tends to increase for at least the first 48 hours postpartum.
  • This increased volume of stroke is caused by the return of blood to the systemic venous circulation of the mother, resulting from a rapid reduction in the flow of uterine blood and extravascular fluid mobilization.
  •  By 6 weeks postpartum, cardiac output generally returns to normal.
  •  The heart rate and blood pressure return within a couple of days to non-pregnant levels.
  •  After delivery, body tries to compensate for increase central venous load, slowing the heart rate, to regulate cardiac output and avoid systemic overload and hypertension.
  • Hemorrhage, inflammation, thrombosis, anxiety, discomfort or excitement at delivery may be demonstrated by a rise in pulse rate.
  • In response to anesthesia, blood pressure may decrease in the early recovery period; orthostatic hypotension may occur due to fluid changes and reduced intra-abdominal pressure.
  •  It returns to normal within a few days after delivery, unless complications such as hypertension caused by pregnancy arise in women.
• Blood Components:
  • A greater decrease in plasma volume than in the amount of blood cells occurs within the first 72 hours after childbirth.
  • Haematocrit could rise in the first 3-7 days, slowly return to normal levels by 4-5 weeks as old cells die out and fewer new ones form.
• WBC count:
  • During first 10-12 days after child birth ,value between 20,000 and 25,000/mm³ are common. It falls to normal in 4-7 days.
  • Persistent elevation implies infection.
  • The large increase in WBCs is caused by neutrophils that increase in response to inflammation, pain and stress to protect against invading species.
• Coagulation factors:
  • During pregnancy, clotting factors and fibrinogen are typically increased and remain elevated in the immediate puerperium; during healing, platelet, fibrin and fibrinogen levels are elevated. Their function is to protect against bleeding.
  • This hypercoaguable condition causes an increased risk of thormboembolism when combined with vessel damage and immobility, in particular after cersarean birth.

10. Endocrine System

• The levels of estrogen and progesterone levels drop remarkably after expulsion of the placenta and reach their lowest levels 1 week postpartum.
• Reduced estrogen levels are related with breast engorgement and with the diuresis.
• In non-lactating women, estrogen begin to rise by 2 weeks after birth.
• Human chorionic gonadotropin (hCG) disappears from maternal circulation in 14 days.
• Oxytocin continues to acts upon the uterine muscle fibres maintaining their contraction, reducing the placental site and preventing haemorrhage.
• In women who choose to breast feed babies, the suckling of the infant stimulates further secretion of ocytocin and this aids the continuing involution of the uterus and expulsion of milk.
• Prolacting levels remain elevated in the sixth week after birth in women who breastfeed.
• The level of serum prolaction is affected by the frequency of breastfeeding, the length of each feeding, and the degree to which additional feeding is used.
• Individual variations in the intensity of the sucking stimulus of an infant probably also influence the levels of prolactin.
•  In woman who breast feed, the levels of prolactin remain high and the resumption of follicle stimIn women who are breast-feeding, prolactin levels remain high and the resumption of ovary follicle stimulation is suppressed.
• Prolactin levels decrease after birth in non-lactating women and enter the pregnant range by the two to third postpartum week; this enables the follicle stimulating hormone secreted by the anterior pituitary gland to act on the ovary, contributing to the restoration of normal patterns of development of estrogen and progesterone, follicle formation, ovulation, and menstruation.

11. Menstruation and Ovulation

• The occurrence of the first menstrual period following delivery is very variable and depends on lactation.
• If the woman If the woman does not breastfeed her infant, menstruation returns in around 40 percent by the 6th week after childbirth and in 80 percent of cases by the 12th week.does not breastfeed her baby, the menstruation returns by 6^th week following delivery in about 40% and by 12^th week in 80% of cases.
• Contractive protection for women who are primarily breastfeeding is roughly 98 percent up to 6 months postpartum.
•  Breastfeeding postpones the return of both menstruation and ovulation.
•  The duration of the delay depends on the duration of lactation and frequency of breastfeeding.
• Increased frequency, length of suckling is linked with high prolactin level, prolonged ovarian suppression and lactational amenorrhoea.