Puerperium

Dr. Yasir KatibMBBS, FRCSCPerinatologest

Objectives

• Anatomical and physiological changes in pregnancy that led to normal lactation

• Understand the physiology and advantages of normal lactation

• Available methods of lactation suppression• Prevent, recognize and manage breast-feeding

complications• Diffrentiate the causes of puerperal pyrexia• Recognize the postpartum mental illnesses

Puerperium

Puerperium

It is the time from the delivery of the placenta through the first 6 weeks after the delivery

Why??

Anatomical and physiological changes of pregnancy return to pre-pregnancy state

PuerperiumExamples • Uterus

– Weight – Cervix – Lochia (rubra, serosa then alba)

• Vagina – Pelvic floor – Vaginal vs. C/S– Episiotomy

• Menstruation – Breast feeding – Ovulation

Postpartum Care

• Discharge time• Rh immunoglobulin• Vaginal (episiotomy, pain and

hemorrhoids)• C/S (ambulation, eating and voiding)• Sexual intercourse• Education and discharge instruction• Contraception

Breast Feeding

Physiology • 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

• Suckling stimulates the release of prolactin and oxytocin secondly

• If the mother is not breastfeeding, the prolactin levels decrease and return to normal within 2-3 weeks

Breast Feeding

Physiology

• Colostrum is the liquid that is initially released by the breasts during the first 2-4 days after delivery

• High in protein, lactose and water

• This liquid is very protective for the newborn

Breast Feeding

• Infants • Maternal

1. Delays fertility

2. Decrease cancers (breast, uterine, ovarian)

3. Emotional health

4. Promote wt loss

5. Decrease osteoporosis• Society

Breast Feeding Complications

Breast engorgement

• Swelling of the breast and can occur early or late in the postpartum period

• During 1st week (Day2 +/- 1day)

• Resolves spontaneously in the majority of cases, but may be exaggerated if the infant does not latch on

• Management

Breast Feeding Complications

Cracked (sore) Nipples

• Pain (sensitivity vs. fissure trauma)

• Management – Good latch-on and proper suckling– Ankyloglossia – Topical care (Lanolin cream)

Breast Feeding Complications

Mastitis • An infection of the breast • Causative agent (staphylococcus aureus,

streptococcus, and Escherichia coli)• 1 to 3% lactating women • Management

– Supportive measures– Antibiotic treatment (cloxacillin)

• Recurrent mastitis

Breast Feeding Complications

Breast Abscess

• Incidence of 0.1 percent

• Risk factors (maternal age over 30 years of age, primiparity, gestational age ≥ 41wk and mastitis

• Management

Breast feeding Suppression

• Timing

• Indications – Medications (e.g. iodieds)– Infections (e.g. HIV)

• Methods – Mechanical– Medical (e.g. bormocryptin)

Puerperal Pyrexia

• It is a temperature of 38°C, maintained for or recurring within 24 hours, within 2-3 weeks of childbirth or abortion

• Causes – Womb Local infection– Wound Vaginal Vs. C/S– Water UTI– Walk DVT– Wind RTI– Wondering drugs Meds– Others Breast, IV

Womb

Puerperal Pyrexia

• History & Examination

• Investigations

complete septic work up

• Treatment

broad spectrum antibiotics

wait for cultures

Mental illnesses

Post-partum 'Blues'

• This occurs in around 50% of women within 4 to 5 days of delivery

• It is usually a self limiting condition

• Rarely progress

Mental illnesses

Postnatal Depression• It is a relatively common disorder• Onset between 1-6 months after delivery• May last 6 moths or longer Clinical features• sleep disturbance• depressed mood• social withdrawal• lack of worthiness about being a mother• Suicidal thoughts

Mental illnesses

Management

• Social support

• Psychiatric or psychological care

• Medications

Mental illnesses

Puerperal Psychosis

• Psychotic illness occurs in 0.2% of mothers and the onset is earlier than postnatal depression.

• This is a serious condition and requires expert psychiatric evaluation and treatment