8[1].Normal-Puerperium

NormalPuerperiumPuerperiumistheperiodfollowingchildbirthduringwhichthebodytissuesspeciallythepelvicorgansrevertbackapproximatelytothepre-pregnantstatebothanatomicallyandphysiologically.Involutionistheprocesswherebygenitalorganrevertbackapproximatelytothestateastheywerebeforepregnancy.Thewomenistermedaspuerpera.Duration-Puerperiumbeginsassoonastheplacentaisexpelledandlastsapproximatelyfor6weekswhentheuterusbecomesregressedalmosttothenon-pregnantstage.Theperiodisarbitarilydividedinto-a.immediate-within24hrsB.early-upto7daysc.remote-upto6weeks.Similarchangesoccurfollowingabortionbuttakesshortertimeforinvolutiontocomplete.Involutionoftheuterus-Immediatelyfollowingdelivery,theuterusbecomesfirmandretractedwithalternatehardeningandsofteningandweighsabout1000gm.Attheendofthe6weeks,itsmeasurementissimilartothenon-pregnantstageandmeasuresabout60gm.Loweruterinesegment-Immediatelyfollowingthedeliverytheloweruterinesegmentbecomesthinandflabbyandcollapsedstructure.Ittakesfewweekstorevertbacktothenormalshapeandsizeofisthmus.Cervix-Thecervixcontractsslowly.Theexternalosadmitstwofingersforfewdaysbutbytheendofthefirstweeknarrowsdowntoadmitthetipoffingeronly.Ittakesalongertimetoregainbuttheexternalosneverrevertsbacktothenulliparousstate.Physiologicalchanges-Thephysiologicalprocessininvolutionismostmarkedinthebodyoftheuterus.Changesoccursinthefollowingcomponents-1.Muscles,2.Bloodvessels,3.Endometrium1.Muscles-Thereismarkedhypertrophyandhyperplasiaofmusclefibresduringpregnancy.Duringthepuerperiumthenumberofmusclefibrearenotdecreasedbutthereissubstantialreductionofthemyometrialcellsize.Withdrawlofthesteroidhormonesoestrogenandprogesteronemayleadtotheincreasedintheactivityoftheuterinecollegenaseandthereleaseoftheproteolyticenzyme.Autolysisoftheproteolyticenzymewiththeliberationofthepeptoneswhichenterthebloodstream.Theseareexcretedthroughkidneysasureaandcreatinine.Thisalsoexplainsincreasedexcretionoftheproductsinthepuerperalurine.Theconnectivetissuesalsoundergoessametypeofdegeneration.2.Bloodvessels-Thechangesinthebloodvesselsaremorepronouncedattheplacentalsite.Thearteriesareconstrictedbythecontractionofitswallandthickeningoftheintimafollowedbythethrombosis.Newbloodvesselsgrowinsidethethrombi.Fibroustissueonwallundergoeshyalinedegenerationandtheproductsareremovedbythemacrophages.Thereisalsodegenerationoftheelastictissues.3.Endometrium-Followingdeliverythemajorpartofthedeciduacastoffwiththeexpulsionoftheplacentaandthemembranesmoreattheplacentalsite.Thesuperficialpartcontainingdegenerateddecidua,bloodvesselsandbitsofthefetalmembranesbecomesnecroticandcastoffaslochia.Regenerationoccursfromtheepitheliumoftheuterineglandsmouthandintraglandularstromalcells.Regenerationoftheepitheliumiscompletedatthe10thdayandentireendometriumisrestoredat3weekexceptattheplacentalsitewhichtakes6weeks.Clinicalassesementoftheinvolution-Therateoftheinvolutionoftheuteruscanbeassesedbythefundalheightinrelationtothesymphysispubis.Thebladdermustbeemptiedbeforeasssesingit.Theuterusistobecentralisedandwiththemeasuringtapethefundalheightismeasuredabovethesymphispubis.Followingthedeliverytheuteruslies13.5cmabovesymphysispubis.Duringthefirst24hrsitremainsconstantandthereafteritdecreasesby1.25cmin24hrssobytheendofthesecondweekitbecomespelvicorgan.Subinvolution-Whentheinvoluitonisinterferredthenitiscalledsubinvolution.Superinvolution-Sometimestheinvolutionmaybeprolongedinwomenwhoarelactatingwhichiscalledsuperinvolution.Theuterusreturnstonormalsizeiflactationiswithheld.Vagina-Thedistensiblevaginaafterbirthtakeslongtimetoinvolutei.e4-8weeksbutitneverregainsitstoneasinvirginalstage.Theintroitusremainspermanentlylargerthanthevirginalstage.HymenislaceratedandrepresentedasNodulartagscalledcarnuculaemyritiformes.Othersstructuresasbroadligamentandroundligament,pelvicfloorandfasciatakeslongtimetocometothepre-pregnantstage.Lochia-Itisthevaginaldischargeforthefirstfortnightduringpuerperium.Thedischargeoriginatesfromtheuterinebody,cervixandvagina.Odourandreaction-Ithasgotpeculiaroffensivefishysmell.Itsreactionisalkalinetendingtobecomeacidicatend.Color-Dependinguponthevariationofthecolorofdischargeitisnamedas-1.Lochiarubra-1-4days.Itconsistsofblood,shedsoffetalmembranesanddecidua,vernixcaseosa(Awhitecheesysubstancethatcoversandprotectstheskinofthefetusandisstillallovertheskinofababyatbirth.Vernixcaseosaiscomposedofsebum(theoiloftheskin)andcellsthathavesloughedoffthefetus'skin,languoandmeconium.2.Lochiaserosa-5-9days.ItconsistsoflessRBCbutmoreleucocytes,woundexduate,mucusfromthecervixandmicroorganism(anaerobicstreptococciandstaphylococci).Thepresenceofbacteriaisnotassociatedwithsepsisunlessassociatedwithclinicalsigns.3.Lochiaalba-10-15days.Itconsistsofnumberofdecidualcells,leucocytes,mucus,chlosterincrystals,fattyandgranularepitheliumandmicroorganism.Amount-Theaverageamountis5-6days,itisestimatedtobe250ml.Normalduration-Thenormaldurationmayextendupto3week.Theredlochiapersistsforlongerduration.Thedischargemaybescantyfollowingprematurelabourandmaybeex