Authors : Yayan A. Israr, S.Ked, Lestari, S.Ked, Apriani Dewi, S.Ked, Tengku Anita, S.Ked. Fakultas Kedokteran Universitas Riau. RSUD Arifin Acmad Pekanbaru.2008.
—-Although not officially sanctioned, traditionally the puerperium is supposed to end 6 weeks after birth. The period of 6 weeks fits very well into cultural traditions in many countries, where often the first 40 days after birth are considered a time of convalescence for the mother and her newborn infant. In many countries at that time a routine postnatal visit and examination are planned. Six weeks after delivery the body of the woman has largely returned to the non-pregnant state.1 Changes of genitalia organs generally called involution. Beside involution, also happen other important thing, there are hemoconcentrasion and lactation.2
—-Puerperium care is needed in this period because it is a critical period for the mother and also her child. Approximately 60% mother death due to pregnancy happen after the delivery, and 50% of it in puerperium period happen 24 hour after birth.3
—-The the puerperium (also called the the postpartum period), forms part of the normal continuum of the reproductive cycle. This fact should be mirrored by services which respect that continuum. Quality antenatal and intrapartum care can prepare a smoother postpartum. Links between all levels and types of Reproductive Health and Child Health services are vital, although it is important not to medicalise this time unnecessarily. Quality postpartum services are a long-term investment in the future health of women and their newborn.1
—-The puerperium is strictly defined as the period of confinement during and just after birth. By popular use, however, the meaning usually includes the six subsequent weeks.4 Multiple anatomic and physiologic changes occur during this time, and there is the potential for significant complications.5
II. ANATOMY AND PHYSIOLOGY
—-An overview of the relevant anatomy and physiology in the puerperium : 6
—-The pregnant term uterus (not including baby, placenta, fluids, etc) weighs approximately 1000 grams. The uterus recedes to a nonpregnant state, with a weight of 50-100 grams, during the 6 weeks after delivery. Immediately after delivery, the uterus can be palpated at or near the umbilicus. Most of the reduction in size and weight occurs in the first 2 weeks, at which time the uterus has shrunk enough to be located in the true pelvis.
—-The endometrial lining rapidly regenerates, so that by the seventh day the endometrial glands are already evident. By the 16th day, the endometrium is restored throughout the uterus, except at the placental site.
—-The placental site undergoes a series of changes in the postpartum period. Immediately after delivery, the contractions of the arterial smooth muscle and compression of the vessels by contraction of the myometrium result in hemostasis. The size of the placental bed decreases by half, and the changes in the placental bed result in the quantity and quality of the lochia that is experienced.6
—-The cervix also begins to rapidly revert to a nonpregnant state, but it never returns to the nulliparous state. By the end of the first week, the external os is closed to the extent that a finger could not be easily introduced. 6
—-The vagina, which was distended to accommodate the baby, shrinks to a nonpregnant state, but it does not completely return to its prepregnant size. Resolution of the increased vascularity and edema occurs by 3 weeks, and the rugae of the vagina begin to reappear in women who are not breastfeeding. At this time, the vaginal epithelium appears atrophic on smear. This is restored by weeks 6-10; however, it is further delayed in breastfeeding mothers because of persistently decreased estrogen levels. 6
—-The perineum has been stretched and traumatized, and sometimes torn or cut, during the process of labor and delivery. The swollen and engorged vulva rapidly resolves, and swelling and engorgement are completely gone within 1-2 weeks. Most of the muscle tone is regained by 6 weeks, with more improvement over the following few months. The muscle tone may or may not return to normal, depending on the extent of injury. 4,6
—-The abdominal wall remains soft and poorly toned for many weeks. The return to a prepregnant state depends greatly on exercise.4
—-The resumption of normal function by the ovaries is highly variable and is greatly influenced by breastfeeding the infant. The woman who breastfeeds her infant has a longer period of amenorrhea and anovulation than the mother who chooses to bottle-feed. The mother who does not breastfeed may ovulate as early as 27 days after delivery. Most women have a menstrual period by 12 weeks, the mean time to first menses is 7-9 weeks.
—-In the breastfeeding woman, the resumption of menses is highly variable and depends on a number of factors, including how much and how often the baby is fed and whether the baby’s food is supplemented with formula. The delay in the return to normal ovarian function in the lactating mother is caused by the suppression of ovulation due to the elevation in prolactin. Half to three fourths of women who breastfeed return to periods within 36 weeks of delivery.4,6
—-The changes to the breasts that prepare the body for breastfeeding occur throughout pregnancy. Lactation can occur by 16 weeks gestation. Lactogenesis is initially triggered by the delivery of the placenta, which results in falling levels of estrogen and progesterone, with the continued presence of prolactin. If the mother is not breastfeeding, the prolactin levels decrease and return to normal within 2-3 weeks.
—-The colostrum is the liquid that is initially released by the breasts during the first 2-4 days after delivery. High in protein content, this liquid is very protective for the newborn. The colostrum, which the baby receives in the first few days postpartum, is already present in the breasts, and suckling by the newborn triggers its release. The process, which begins as an endocrine process, switches to an autocrine process; the removal of milk from the breast stimulates more milk production. Over the first 7 days, the milk matures and contains all necessary nutrients in the neonatal period. The milk continues to change throughout the period of breastfeeding to meet the changing demands of the baby. 4,6
III. PUERPERIUM CARE
—-The immediate puerperium period most often occurs in the hospital setting, where the majority of women remain for approximately 2 days after a vaginal delivery and 3-5 days after a cesarean delivery. During this time, women are recovering from their delivery and are beginning to care for the newborn. This period is used to make sure the mother is stable and to educate her in the care of her baby (especially the first-time mother). While still in the hospital, the mother is monitored for blood loss, signs of infection, abnormal blood pressure, contraction of the uterus, and ability to void.
—-Routine practices include a check of the baby’s blood type and administration of the RhoGAM vaccine to the Rh-negative mother if her baby has an Rh-positive blood type. At minimum, the mother’s hematocrit level is checked on the first postpartum day. Women are encouraged to ambulate and to eat a regular diet. 6
a. Vaginal delivery
—-After a vaginal delivery, most women experience swelling of the perineum and consequent pain. This is intensified if the woman has had an episiotomy or a laceration. Routine care of this area includes ice applied to the perineum to reduce the swelling and to help with pain relief. Conventional treatment is to use ice for the first 24 hours after delivery and then switch to warm sitz baths. However, little evidence supports this method over other methods of postpartum perineum treatment. Pain medications are helpful both systemically as nonsteroidal anti-inflammatory drugs (NSAIDs) or narcotics and as local anesthetic spray to the perineum.
—-Hemorrhoids are another postpartum issue likely to affect women who have vaginal deliveries. Symptomatic relief is the best treatment during this immediate postpartum period because hemorrhoids often resolve as the perineum recovers. This can be achieved by the use of corticosteroid creams, witch hazel compresses, and local anesthetics.
—-Tampon use can be resumed when the patient is comfortable inserting the tampon and can wear it without discomfort. This takes longer for the woman who has had an episiotomy or a laceration than for one who has not. The vagina and perineum should first be fully healed, which takes about 3 weeks. Tampons must be changed frequently to prevent infection. 6
b. Cesarean delivery
—-The woman who has had a cesarean delivery usually does not experience pain and discomfort from her perineum but rather from her abdominal incision. This, too, can be treated with ice to the incision and with the use of systemic pain medication. Women who have had a cesarean delivery are often slower to begin ambulating, eating, and voiding; however, encourage them to quickly resume these and other normal activities. 6
c. Sexual intercourse
—-Sexual intercourse may resume when bright red bleeding ceases, the vagina and vulva are healed, and the woman is physically comfortable and emotionally ready. Physical readiness usually takes about 3 weeks. Birth control is important to protect against pregnancy because the first ovulation is very unpredictable.
d. Patient education
—-Substantial education takes place during the hospital stay, especially for the first-time mother. The mother (and often the father) is taught routine care of the baby, including feeding, diapering, and bathing, as well as what can be expected from the baby in terms of sleep, urination, bowel movements, and eating.
—-Provide education, support, and guidance to the breastfeeding mother. Breastfeeding is neither easy nor automatic. It requires much effort on the part of the mother and her support team. Breastfeeding should be initiated as soon after delivery as possible; in a normal, uncomplicated vaginal delivery breastfeeding is possible almost immediately after birth. Encourage the mother to feed the baby every 2-3 hours (at least while she is awake during the day) to stimulate milk production. Long feedings are unnecessary, but they should be frequent. Milk production should be well established by 36-96 hours.
—-In women who choose not to breastfeed, the care of the breasts is quite different. Care should be taken not to stimulate the breasts in any way in order to prevent milk production. Ice packs applied to the breasts and the use of a tight brassiere or a binder can also help to prevent breast engorgement. Acetaminophen or NSAIDs can alleviate the symptoms of breast engorgement (tenderness, swelling, fever) if it occurs. Bromocriptine was formerly administered to suppress milk production; however, its use has diminished because it requires 2 weeks of administration, does not always work, and can produce adverse reactions. 6
—-There are no dietary restrictions for women who have been delivered vaginally. Two hours after a normal vaginal delivery, if there are no complications likely to necessitate an anesthetic, the woman should be allowed to eat if she desires. The diet of lactating women, compared with that consumed during pregnancy, should be increased in calories and protein, as recommended by the Food and Nutrition Board of the National Research Council. If the mother does not breast feed, dietary requirements are the same as for a nonpregnant woman. It is standard practice in our hospitals to continue iron supplementation for at least 3 months after delivery and to check the hematocrit at the first postpartum visit. 6
—-Women who are not already immune to rubella or rubeola measles are excellent candidates for combined measles-mumps-rubella vaccination before discharge. Unless contraindicated, a diphtheria-tetanus toxoid booster injection is also given to postpartum women prior to discharge at Parkland Hospital.4
IV. TIME OF DISCHARGE
—-Early in the puerperium, sloughing of decidual tissue results in a vaginal discharge of variable quantity; this is termed lochia. It consists of erythrocytes, shredded decidua, epithelial cells, and bacteria. For the first few days after delivery, there is blood sufficient to color it red-lochia rubra. After 3 or 4 days, lochia becomes progressively pale in color-lochia serosa. After about the 10th day, because of an admixture of leukocytes and reduced fluid content, lochia assumes a white or yellowish-white color-lochia alba. 4 In another literature, there are 4 types of lochia : 2
1. Lochia rubra/cruenta : blood sufficient, red in color, found in 1st-2nd day.
2. Lochia sanguinolenta : blood mix with gelatinous, light-red, found in 3rd-6th days.
3. Lochia serous/sera : no blood, yellow in color, found in 7th-13rd days.
4. Lochia alba : white liquid, white in color, found after 2 weeks.
—-Lochia persists for up to 4 weeks and may stop and resume up to 8 weeks after delivery. Maternal age, parity, infant weight, and breast feeding do not influence the duration of lochia. Moreover, routine administration of oxytocic agents beyond the immediate postpartum period neither diminishes blood loss nor hastens uterine involution. 4
—-Each woman has her own pattern, with the various phases of the lochia lasting for different lengths of time. Fifteen percent of women have lochia at 6 weeks postpartum. Often, women experience an increase in the amount of bleeding at 7-14 days secondary to the sloughing of the eschar on the placental site. 6,4
—-The mother must be counseled about birth control options (contraception) before she leaves the hospital. She may not be ready to decide about a method, but she needs to know the options. Her decision will be based on a number of factors, including her motivation in using a particular method, how many children she has, and whether she is breast feeding. Many options are available, as follows :7
—-Natural methods can be used in highly motivated couples, to include the use of monitoring the basal body temperature and the quality and quantity of the cervical mucus to determine what phase of the menstrual cycle the woman is in and if it is safe to have intercourse.
- Barrier methods of contraception, such as condoms, are widely available, as are vaginal spermicides. Condoms are available over-the-counter, while diaphragms and cervical caps must be fitted.
- Hormonal methods of contraception are numerous. Combined estrogen-progestin agents are taken daily by mouth or monthly by injection. Progestin-only agents are available for daily intake or by long-acting injections that are effective for 12 weeks.
- Intrauterine devices can be placed a few weeks after delivery.
—-Permanent methods of birth control (tubal ligation, vasectomy) are best for the couple who has more than one child and who are sure that they do not want more. 7
Complication of puerperium period, as follows :6
—-Postpartum hemorrhage is defined as excessive blood loss during or after the third stage of labor. The average blood loss is 500 mL at vaginal delivery and 1000 mL at cesarean delivery. Since diagnosis is based on subjective observation, it is difficult to define clinically.
—-Early postpartum hemorrhage is described as that occurring within the first 24 hours after delivery. Late postpartum hemorrhage most frequently occurs 1-2 weeks after delivery but may occur up to 6 weeks postpartum.
—-Endometritis is an ascending polymicrobial infection. The causative agents are usually normal vaginal flora or enteric bacteria.
b. Urinary tract infections
—-A urinary tract infection (UTI) is defined as a bacterial inflammation of the bladder or urethra. Greater than 105 colony-forming units from a clean-catch urine specimen or greater than 10,000 colony-forming units on a catheterized specimen is considered diagnostic of a UTI.
—-Mastitis is defined as inflammation of the mammary gland.
d. Wound infection
—-Wound infections in the postpartum period include infections of the perineum developing at the site of an episiotomy or laceration, as well as infection of the abdominal incision after a cesarean birth. Wound infections are diagnosed on the basis of erythema, induration, warmth, tenderness, and purulent drainage from the incision site, with or without fever. This definition can be applied both to the perineum and to abdominal incisions.
3. Septic Pelvic Thrombophlebitis
—-Septic pelvic thrombophlebitis is defined as venous inflammation with thrombus formation in association with fevers unresponsive to antibiotic therapy.
4. Endocrine Disorders
—-Postpartum thyroid dysfunction can occur any time in the first postpartum year. Clinical or laboratory dysfunction occurs in 5-10% of postpartum women and may be caused by primary disorders of the thyroid, such as postpartum thyroiditis (PPT) and Graves disease, or by secondary disorders of the hypothalamic-pituitary axis, such as Sheehan syndrome and lymphocytic hypophysitis.
5. Psychiatric Disorders
—-Three psychiatric disorders may arise in the postpartum period: postpartum blues, postpartum depression (PPD), and postpartum psychosis.
- Postpartum blues is a transient disorder the lasts hours to weeks and is characterized by bouts of crying and sadness.
- PPD is a more prolonged affective disorder that lasts for weeks to months. PPD is not well defined in terms of diagnostic criteria, but the signs and symptoms do not differ from depression in other settings.
- Postpartum psychosis occurs in the first postpartum year and refers to a group of severe and varied disorders that elicit psychotic symptoms.6
—-Puerperium care should begin exactly after birth. There are important things or condition should be an attentions in puerperium, as follow :2
- Genitalia track laceration and episiotomy’s wound. Do wound sewing and wound care as good as possible.
- After delivery, educate patient to mobilize her body as soon as possible (before 8 hours) to reduce possibility of thrombosis.
- High quality, high calories and enough protein diet, liquid, and fruits. In Arifin Achmad hospital, this point maybe could not maximally done, so education for patient about this is necessary before patient leaving.
- Patient should emptying her bladder by her own as soon as possible after the delivery.
- Defecation must happen in 3 days time of postpartum.
- Breasts care should have done during the pregnancy, areola and nipple cleaned regularly using a soap and cream to keep its soft. The education about cleaning her breast in breastfeeding period is important.
- Patient could leaving hospital after 2 days care.
- Educate patient to do a move or method that could help her keep the muscle in good condition after the delivery.
—-Generally, patient want to pending their next pregnancy at least 2 years after delivery. The mother must be counseled about birth control options (contraception) before she leaves the hospital.7 The counseling could be given in antenatal, or after the delivery.
- There are so many thing could happen in puerperium period that influence mother’s mortality rate. So, the early and correct puerperium care is important.
- Choosing contraception method should be considered about a patient condition, which are ; age, children, and complication that could make her pregnancy worse, or the pregnancy makes the complication worse.
- World Health Organization (WHO). Postpartum Care Of The Mother And Newborn: A Practical Guide. Avalible from : http://www.who.int/reproductive-health/publications/msm_98_3/msm_98_3_2.htm. Last Update : January, 2006.
- Wiknjosastro H. Puerperium Normal dan Pengawasanya. Dalam : Ilmu Kebidanan, edisi ketiga cetakan keenam. Jakarta : Yayasan Bina Pustaka Sarwono Prawirohardjo. 2002, hal 237-45.
- Cunningham FG, Leveno KJ, Bloom SL, Hauth JC, Gilstrap III LC, Wenstrom KD. The Puerperium. In : Williams Obstetrics. 22nd edition. Mc Graw-Hill. New York : 2007.
- National Medical Lybrary. The Puerperium. Avaliable from : http://www.ccspublishing.com/journals2a/puerperium.htm. Last Update : July, 2006.
- Witt K. Normal and Abnormal Puerperium. Avaliable from : http://www.emedicine.com/med/topic3240.htm Last update : June 26, 2006.
- Tidy C. Posnatal Care (Puerperium). Avaliable from : http://www.patient.co.uk/showdoc/40000280.htm. Last update : January, 2008.