Female Problems

PUERPERIUM

PUERPERIUM Puerperium is the period following childbirth during which the body tissues, specially the pelvic organs revert approximately to the…

Dr. Shweta Bairagi · 21 May 2011

PUERPERIUMPuerperium is the period following childbirth during which the body tissues, specially the pelvic organs revert approximately to the prepregnant state both anatomically and physiologically.Begins as soon as the placenta is expelledLasts for 4-6 weeksDuration of PuerperiumImmediateWhen 24 hoursEarlyUp to 7 daysRemoteUp to 6 weeksInvolution of uterus􀂈 Recedes to nonpregnant state in 5-6weeks􀂈 1000 grams to 50-100grams􀂈 Breastfeedingaccelerates involutionChanges during PuerperiumLochiaDischarge through vagina for the first fortnight during puerperium􀂈 Lochia rubra􀂈 Lochia serosa􀂈 Lochia albaPerineum􀂈 Vulva heals within 1-2 weeks􀂈 Muscle tone regained by 6 weeksRestoration of ovulation and menstruation􀂈 Non-lactating mothers: 6-8 weeksafter delivery􀂈 Lactating mothers: about 36 weeksVagina􀂈 Shrinks to a nonpregnant state by 3 weeks􀂈 Does not completely return to pre-pregnant stateInvolution of uterusGeneral management of PuerperiumAdvise mother regarding AdviceDiet 􀂈 Mother should have light diet on first puerperal day. On subsequent days she can have full diet.􀂈 Diet should include adequate quantity of protein, fat, plenty of fluids, minerals and vitamins.􀂈 Liberal quantity of milk should be given.Lactating mothers Non-lactating mothersHigh calories, adequate protein, fat, plenty A diet as in non-pregnant womanof fluids, minerals and vitamins􀂈 As mother is in a state of physical fatigue, she should take 2-3 hours rest after delivery.• provides a sense of well-being.• reduces bladder complications and constipation.• facilitates uterine drainage, hastens involution of the uterus.• lessens puerperal venous thrombosis.• Considerably reduces the risk of embolic phenomenon.Care of the bowel 􀂈 Diet rich in fluids and fibre􀂈 Mild laxative such as Isabgol (Psyllum) husk, 2 teaspoons at bedtime if constipatedCare of the breasts 􀂈 Clean and dry nipples after each feeding.􀂈 Apply hind milk to the nipples after every feed and dry.􀂈 Treat cracked and sore nipples, if any.Maternal infant bonding (Rooming in) 􀂈 Keep the baby in mother’s bed or beside her cot.􀂈 This establishes mother-child relationship and breast feeding.Post-partum exercises􀂈 Maintain correct posture while getting up from the bed.These help to:􀂈 Practice correct method of lifting and working positions.􀂈 minimize the risk of puerperal thrombosis􀂈 Do regular exercises (mentioned at the end of chapter).􀂈 prevention of backache􀂈 prevent genital prolapse and stress incontinence􀂈 help toning up the abdominal and pelvic floor muscles.Maintain hygiene 􀂈 Always wash hands before using the bathroom or on changing pads.􀂈 Always wash hands after cleaning the perineum.Care of perineal area 􀂈 After using the bathroom, spray or pour warm water over the entire vaginal area.􀂈 Gently pat the area dry making sure to start at the front and end at the back to avoid spreading germs from the rectum to the vagina.To reduce the swellingApply Ice packs • Wrap the ice pack in a washcloth or other soft or absorbent material.• Do not directly apply the ice.Sitz bath • Sit in a tub with 2-3 inches of warm water for about 15 minutes.Care of perineal stitches 􀂈 Clean and dress the perineal area daily and cover with sterile pad.􀂈 Swabbing should be from above downwards.Examination of mother􀂈 Routine examination:weight, pallor, blood pressure, tone of abdominalmuscles, examination of breast􀂈 Pelvic examination Cervical smear for cytological examination􀂈 Laboratory investigations:Hemoglobin estimationPOSTNATAL CAREAims􀂈 Health check up to assess the health status of the mother􀂈 Detection of any gynecological condition and its management􀂈 Detection of risk at earlier stage and its management􀂈 Treatment of minor ailment􀂈 Treatment of anemia􀂈 Health and nutrition education􀂈 Referral of risk casesAdvice given to mother􀂈 To resume normal activities􀂈 Continue Post partum exercises for another 4-6 weeks􀂈 Continue breastfeeding for not less than 6 months􀂈 Family planning counseling and guidance􀂈 Management of ailments if anyExamination of baby􀂈 Check for progress of the baby.􀂈 Take preventive and curative measures􀂈 Start immunization.􀂈 Instruct woman to clean part after each act of micturition and defecation.􀂈 Try to keep the area clean and dry, hence frequent change of pads is required.Manage other ailments 􀂈 Treat for after pains.􀂈 Manage the pain of perineum.􀂈 Correct anemia.􀂈 Treat other medical ailments if present.First postnatal check up(Must be done within first 10 days)Schedule of Post natal examinationSecond postnatal check up(At the end of 6th week or 42 days)􀂈 General health check up• Ask mother about any complaints and its duration.• Enquire about bladder and bowel functions.• Check for pulse, temperature and blood pressure.• Note down features of lochia e.g. color and smell.• Inspect the perineum in case of episiotomy / perineal tear for normalhealing process or infection. There is no need for per speculum or per vaginal examination unless specifically indicated.􀂈 Monitoring of involution process􀂈 Check for satisfactory establishment oflactation.􀂈 Do the examination of newborn baby.􀂈 Objectives• To know about involution of genital tract. Involution should be complete by six weekspost partum.• To screen the client for her fitness for the contraceptive method especially in a casedesiring insertion of intrauterine device, or laparoscopic tubal ligation.􀂈 Examination required• Routine examination• Per abdominal examination• Per speculum examination (To know aboutcervical and vaginal conditions)• Per vaginal examination• Check for hemoglobin level􀂈 Note the progress of the baby.􀂈 Solve the feeding problem, if any.􀂈 Inform mother about the immunizationschedule for the baby.􀂈 Impart family planning guidance.Postnatal exercisesThe following exercises done during postpartum will help toning up the abdominal and pelvic floor muscles.Exercise Advantage How to do itPelvic floor exercises These exercises should be started as early as possible to • Can be performed at any time of the day in anyor Kegel exercises • prevent uterovaginal prolapse position - sitting, standing and lying down with legs• regain full bladder control slightly apart.• ensure normal sexual satisfaction in future for both • Tighten the anus as though stopping a bowel action,partners. then around the uterus and vagina like stopping theflow of urine midstream.• Hold for as long as possible, up to 10 seconds breathingnormally.• Repeat the exercise 10 times at a time, 3 to 4 timesdaily or more.• After 2-3 months, with a full bladder with legs slightlyapart, she should be able to jump up and down orcough deeply without leakage of urine.Abdominal • Prevents long term backache. • Can be done in any position while doing any othertightening • Helps to fill up the rectus gap. work.(The gap is wider than two fingers or not closed in • Sit comfortably.6-8 weeks, refer to a physiotherapist. An abdominal • Breathe in and out and then pull in the lower abdomensupport may berequired). below umbilicus while breathing normally.• Hold up for 10 seconds and repeat 10 times.• Repeat the exercise 3-4 times daily.Pelvic tilting or • It strengthens rectus abdominis muscle. • Lie down on back well supported with pillows withrocking • Helps to fill up the rectus gap. knees bent and feet flat.(If the gap is wider than two fingers or not closed in • Place one hand on the top of the abdomen and the6-8 weeks,refer to a physiotherapist. An abdominal other under the lower back.support may be required). • Tighten the buttocks and abdominal muscles andpress the lower back down on the underneath hand.• Breathe normally, hold up for 10 seconds and relax.• Repeat 10 times, 3-4 times daily.• Once learnt, can be done while sitting, standing orkneeling.• Once the muscles become stronger, do the exerciseof lifting the head and stretching the head towardsknees while holding the pelvis tilted. Keep the kneesbent. This is known as curl-up exercise.Hip hitching • Lie on the back, with one knee bent and the otherstraight.• Slide the heel of the straight leg downwards thuslengthening the leg.• Shorten the same leg by drawing the hip upwardstowards ribs of the same side.• Keeping the abdomen pulled in, change to oppositeside leg and repeat.• Repeat this exercise 10 times.Foot and leg Helps in restoration of circulation of legs in women • Sit or half lie with legs supported.exercises who are not ambulatory. • Bend and stretch the ankle 10 times.• Circle both feet at the ankle 20 times in each direction.• Brace both knees, hold for 10 seconds and then relax.• Repeat 10 times.• This is done before getting up from resting, last thing atnight and 3-4 times during day.199POST NATALHEALING OF PERINEUMIntroduction􀂈 Perineal injury remains the commonest form of maternal obstetric injury.􀂈 It is estimated that 85% of women who have a vaginal delivery have some degree of perineal trauma and about 60 to 70% requiresuturing.􀂈 The skin heals in about 2 to 3 weeks in cases of episiotomy.Perineal tears are more likely to occur with􀂈 Precipitate labor􀂈 Forceps deliveries􀂈 Narrow suprapubic arch􀂈 Big babies􀂈 Babies with poorly flexed heads􀂈 Shoulder dystociaSymptoms improving􀂈 Itching / pain in perineumabsent.􀂈 No foul smell or dischargesor bleeding from perineum.Assess every 6 hours to evaluate the conditionSymptoms worsening􀂈 Severe and persistent pain in the perineum􀂈 Any foul smell from the perineum􀂈 Pain interfering with bonding with the babyand the establishment of breast feedingDeveloping complications􀂈 Sexual dysfunction and dyspareunia􀂈 Infection􀂈 It may aggravate postnatal depression􀂈 Difficulty in micturition and defecation􀂈 Stop treatment􀂈 Continue general measuresReassess the case and manage under supervision of the ObstetricianCase with complaints of Check and look for Probable cause and treatmentAny one or more of the following • Stitches not dissolved Perineal tearscomplaints after within 3 weeks.3 weeks of delivery • Hematoma is observed. Four degrees of tears can occur during delivery• Prolonged itching in the perineum. • Any signs of infection in• Foul smell from perineum. the stitches with fever. Tear involving: What to do• Area of stitches feels raw andirritated. • Start• Urinary incontinence. • Perineal skin and muscles torn • Second degree tears homoeopathic• Fecal incontinence. but intact anal sphincter managementunder the• Perineal skin • Third degree tears supervision of an• Muscles experienced• Anal sphincter Surgeon/Obstetrician as• Perineal skin • Fourth degree tears the tear (esp.• Muscles second and third• Anal sphincter degree) require• Anal mucosa repair.• Advise generalmanagement.Follow up• Perineal or vaginal skin only • First degree tears200General managementProper care of the perineum after childbirth is very important in order to avoid infection and to promote healing of the rectal and pelvicmuscles. Swelling and pain in this area cause a lot of discomfort.􀂈 Ice pack: To reduce swelling ice packs can be used. Be sure to wrap the ice pack with a washcloth or other soft, absorbent material.Direct application of ice can damage tender tissue in this area if prolonged.􀂈 Sitz baths can also be taken by sitting in a tub with 2-3 inches of warm water for about 15 minutes. If there is pain while sitting in thebath, it may be helpful to sit on a doughnut shaped pillow or towels rolled into a doughnut shape.􀂈 Proper Cleansing: Here are some steps to proper perineal cleansing:• Always wash hands before using the bathroom or on changing pads.• After using the bathroom, spray or pour warm water over the entire vaginal area.• Gently pat the area dry with toilet paper, making sure to start at the front and end at the back to avoid spreading germs from therectum to the vagina.• Always wash hands after caring for the perineum.• Take care of the temperature of water applied to the perineum.􀂈 Avoid use of any douche or tampon. Nothing should be placed inside the vagina until after postpartum checkup.􀂈 Do not use powders, perfumes or lotions on the perineum unless directed by the doctor.• Begin by emptying the bladder.• Tighten the pelvic floor muscles and hold for a count of 10.• Relax the muscle completely for a count of 10.• Do 10 exercises, 3 times a day (morning, afternoon and night).• Caution: Some people feel that they can speed up the progress by increasing the number of repetitions and the frequency ofexercises. However, over exercising can instead cause muscle fatigue and increase urine leakage.Homoeopathic managementCommonly used medicines with their indicationsMedicines General indications Particular symptomsArnica montana One of the best medicines for trauma to any part of the • Promotes absorption of the extravasated blood andbody; trauma from mechanical injuries; putrid phenomenon, also prevents suppuration and septic conditions, PPHseptic conditions; prophylactic for purulent condition; and puerperal complications.offensiveness; bruised, soreness all over the body as if • Involuntary discharge of stool or urine after child birth.beaten; desire for sour food; aversion to meat and milk; • Cannot walk erect on account of bruised sore feeling innervous; fear of being touched or being approached; fear the pelvic region.of space; aversion to company.Bellis perennis Worse by heat, becoming chilled when hot; better by cold • Especially indicated for injury to deeper tissues, after(locally) and continued motion in general. major surgical operations.• Sore, bruised feeling in the pelvic region.• Traumatism of the pelvic organs.• Excellent remedy for sprains and bruises.Calendula A most remarkable healing agent; cuts, lacerated, open • For clean, surgical cuts or lacerated wounds; to preventwounds of the soft parts. excessive suppuration.• Wound raw and inflamed; painful, as if beaten; partsaround the wound become red.• Promotes healing after cesarean section.• Promotes healthy granulations and rapid healing byfirst intention if applied locally.• Painful as if beaten.Hypericum perforatum Injuries to parts rich in sentient nerves, preserves integrity of • Punctured and lacerated wounds.torn and lacerated tissues; much prostration from the loss • Intolerably violent, shooting, lancinating pains in theof blood. affected parts; very painful, sore parts.• Relieves pain after operations.• Can be used for the injury caused after forceps delivery.• Worse by touch, motion.Staphisagria Sickly, sharp, sunken and hollow eyed with blue rings around; • Mechanical injuries; for clean, incised wounds, fromailments from insults and threatened pride, envy or chagrin; sharp cutting instruments (blade) with stinging pain;sensitive subjects; bottled up emotions; always angry, easily after caesarean section / episiotomy.offended; apathetic; indifferent. • Painfully sensitive wounds, worse by least touch.• Nausea after abdominal operations.• Great urging to urinate after labor; has to sit in theurinal for hours.• Burning in urethra when urinating.• Genitals are very sensitive; worse sitting down.• If Arnica, Calendula and Bellis fail, then Staphisagariais often useful.Hepar sulphuris Extremely chilly patient; hypersensitive (to cold, pain), faints • For secondary infection occurring during puerperal periodeasily; scrawny; glandular constitution; sweats easily; slow to associated with high fever.act; worse in dry, cold air, better in damp weather; irritable, • Wounds with tendency to suppuration.difficult to please. • Inflammation ending in suppuration; thick pus.• Splinter like pains, worse from least touch.Silicea Extremely chilly patient; profuse offensive discharges; • Suppurating wounds.sweats profusely especially on feet; easy suppuration with • Indolent ulcers, foul smelling.glandular affinity; desires cold things, wants tea moderately • Unhealthy skin, every injury suppurates, slow healing.cold; aversion to warm food; intolerance of alcoholic stimulants; • May be associated with low-grade fever.