Pueperium care Facilitator Pawin Puapornpong Definition v After

Pueperium care Facilitator: Pawin Puapornpong

Definition v After 3 rd stage – normal v 6 weeks v Follow up

Anatomy & Physiology v Uterus n Size n Immediate – Umbilicus or lower, 1 Kg n Serosa, Myometrium, Basal decidua n 1 week – ½ > SP, 500 g n 2 weeks – not palpable, 300 g n 4 weeks – normal size

v Uterus n n Decidua n Superficial layer -> Lochia n Basal layer, endometrial gland – endometrium 10 days Placental site n Immediate – palm n 2 weeks – 3 -4 cm n Vessels - thrombosis

v Uterus n Vessels n Decreased size n In myometrium – hyalin change v Cervix & Lower segment Decreased size n Lateral tear of external os – parous cervix n Lower segment – isthmus n

v Vagina n n n Decreased size Rugae – 3 weeks Hymen – myritiform caruncles v Peritoneum & Abdominal wall n n Loosen ligaments Exercise Remained striae Diastasis recti

v KUB system n n Bladder n Overdistension n Risk – Prolonged labour, Procedures, Epidural block, Pain n Intermittent catheter Renal pelvis n Normal size – 2 -8 weeks n Normal GFR & RPF – 6 weeks n Cr. Clearance – 1 st week n Glycosuria – 2 -3 days

v Breasts n n n Lobe : separated by septum Nipple : 15 -20 lactiferous ducts 10 -100 Alveoli n Alveolar cells : prolactin => produce milk n Myoepithelial cells : oxytocin => contraction

v Breasts n n n Areola : smooth muscle Cooper’s ligament : between lobes, skin, pectoral fascia Breast : 200 g => 400 -600 g during pregnancy => 600 -800 g during feeding

Hormone v Estrogen : duct growth v Progesterone : alveolar growth v Prolactin : n n High during pregnancy but inhibited by estrogen & progesterone (lactogenesis inhibition) precolostrum during 2 nd trimester

v Postpartum n n n Decreased estrogen & progesterone from placenta Increased prolactin from sucking Oxytocin n Sucking => nerve at nipples => hypothalamus => oxytocin => milk let down

v Lactogenesis : Initiation of milk secretion n 1 st : 12 weeks before delivery n Breast enlargement 2 nd : postpartum n Decreased progesterone n High prolactin n 2 -3 days : not depend on feeding n 3 -4 days : depend on feeding Rapid during 36 -96 hours postpartum

v Galactopoiesis n n Continuation of feeding Supply-dependent response v Galactorrhea n n n Postpartum, post breastfeeding For weeks, months, years 30 % high prolactin

Neuroendocrine control of milk secretion and ejection v Prolactin reflex n n n n Sucking => anterior lobe of pituitary gland => prolactin => alveolar cells => milk High prolactin during sucking 30 minutes => baseline within 3 hours : frequency of feeding Milk for next meal Prolactin night > day Sufficient for at least 2 infants => same time Not influenced by other stimulation

Neuroendocrine control of milk secretion and ejection v Milk ejection reflex, Oxytocin reflex n n Posterior lobe of pituitary gland => oxytocin => myoepithelial cells => contraction Influenced by stimulation Pain, stress => inhibition Contracted uterus => after pain during 1 st week

Colostrums v Protein v Immunity : secretary Ig. A v Minerals v Vitamins : A, K v Less fat and sugar

Colostrums v 58 -67 calories/100 cc (17 calories/ounce) v Yellowish : carotene v 1 st day : 37 cc/day (7 cc/meal) v 2 nd day : 84 cc/day (14 cc/meal) v 3 rd-4 th day : 200 -400 cc/day

Colostrums v Decreased neonatal sepsis (rate 10%) v Secretary Ig. A n n 1 st day : 11000 mg/day Decrease to 1000 mg/day in 1 -2 months v Lactoferrin

Component (per 100 cc) Energy Colostrum Mature milk 58 -67 70 -75 Protein 2. 3 0. 9 Lactose 5. 3 7. 3 Fat 2. 9 4. 2

Immunity in breast milk(mg/24 hrs) Day after birth Ig. G Ig. M Ig. A 1 80 120 11000 3 50 40 2000 7 25 10 1000 8 -50 10 10 1000

Colostrums v Fat soluble vitamins n n Vitamin A : 3 times higher Carotene : 10 times Vitamin E : 2 -3 times Vitamin K : Supplement to prevent Hemorrhagic disease of the newborn v Epithelial growth factor : 5 times v Laxative : prevent jaundice

v Full term milk n Colostrum 0 -7 days v Premature milk n Colostrum 3 weeks v Colostrum : prevent infection

Breast milk v Protective components n n n Immunity : Ig, WBC, lactoferrin, lysozyme Maturation : epidermal growth factor, IGF, cytokines, immunomodulator GI & Hormones : Bile salt Stimulated Lipase, enzymes v Nutrients n n Macronutrient : carbohydrate, fat, protein Micronutrient : vitamins, minerals

Strategy v Effective suckling v Frequency v Stimulate oxytocin reflex n n No stress Supporting environment v Healthy mother & infant : nutrition v Prevent breast engorgement

ANC, during pregnancy v Serology n HIV : within 12 hours postpartum => breast binding, combined high dose pills (bid, 5 days) v Knowledge n n Benefits Process Working mother Diet v Activities n Supporting family

Labor room v Skin to skin contact n Within 30 minutes v First sucking n n n Bonding Oxytocin => prevent PPH Decreased breast engorgement

Postpartum v Avoid drugs v Rooming-in, bedding-in n n Sucking ½ -1 hour Frequency q 2 -3 hours Hand wash Positioning, latch on n Pillow n Sitting, lying

v Anti-infectives n Penicillins, cephalosporins, erythromycin, trimethoprim, acyclovir, mebendazole v Analgesics & NSAIDs n Paracetamal, codeine, diclofenac, ibuprofen, mefenamic acid v Anticonvulsants n Diazepam, Mg. SO 4, phenobarbetal, phenytoin, valproic acid v Hormonal contraceptives n n Progestogen-only pills DMPA ?

v Diuretics n Spironolactone v Thyroid hormones & antithyroid drug n Thyroxine, PTU v Corticosteroids v Mammoplasty (silicone) n no contraindication

v Contraindication n n n Amiodarone Antineoplastic agents Bromocriptine Chloramphenicol Gold salts Tetracycline Combined pills

v Maternal contraindicaitons n n Drug addiction HIV Active TB Cytomegalovirus

v Cardiovascular system n n Normal – 2 -3 weeks Immediate – increased cardiac output, increased venous return

v Respiratory system n n Increased residual volume Decreased vital capacity, inspiratory capacity 2 -3 days – increased p. CO 2 3 weeks - normal p. H

v HPO axis n n n Decreased placental hormone Undetectable h. PL in 1 st day h. CG < 1 IU/ml in 2 -4 days h. CG < 100 m. IU/ml in 7 days UPT negative n 7 days – latex agglutination n 11 -16 days - radioimmunoassay

n n Increased LH – ovulation week 4 -8 n 10 -15 % - week 6 n 30% - 90 days n Early – day 36 n In abortion or ectopic pregnancy – day 14 Delayed ovulation in breastfeeding

v Endocrine system n n n Decreased h. PL & growth hormone n Decreased insulin demand n Normal – 6 -8 weeks n Glucose tolerance test Increased thyroid hormone – decreased TBG Decreased corticosteroid & testosterone – normal in 1 st week

v After pain (uterine contraction after delivery) v Lochia n n n Lochia rubra – 3 days Lochia serosa – 10 days Lochia alba v Increased urine – day 2 -5 v Decreased weight 7 -9 kgs, normal in 6 months

v Postpartum blues n n 2 -3 days > 10 days – Psychiatrist v Anti-D immune globulin v Rubella v Discharge 48 hours, C/S 3 -5 days

v Contraception v Follow up 4 -6 weeks n Pap v Advice