Normal Puerperium PDF

Normal puerperium DR. BANAV NAJEEB puerperium Is the period following childbirth when anatomical and physiological changes of pregnancy are reversed and the body returns to the normal non pregnant state. Following delivery when the endocrine influences of the placenta are removed, the physiologica...

Normal puerperium DR. BANAV NAJEEB puerperium Is the period following childbirth when anatomical and physiological changes of pregnancy are reversed and the body returns to the normal non pregnant state. Following delivery when the endocrine influences of the placenta are removed, the physiological changes of pregnancy are reversed this occur during 6 wee& this return occur more rapidly during the 1st 2 weeks & slower there after.  Immediately after labor, the woman is in a state of physical fatigue, slight shivering, muscular tremors and chattering of teeth occur for about 10 – 15 minutes. Usually there is a slight rise in the temperature during the first day which is known as (reactionary fever), not exceed 38oC and drops within 24 hours and not accompanied by increased pulse rate There is a tendency of sweating. Uterus The principle changes is the uterine involution.  After delivery the uterine fundus is at the level of umbilicus &descend gradually till about 10- 14 days later it will disappear behind the symphysis pubis.  At time of delivery the uterus weight is about 1 kg and return to its prepregnancy state of less than 100 g by the process of autolysis whereby muscle cells diminish in size as a result of enzymatic digestion of cytoplasm.  Involution appears to be accelerated by the release of oxytocin in women who are Breastfeeding.  Delay in involution in the absence of any other signs or symptom Like bleeding is of no clinical significance.  vaginal discharge The vaginal discharge which result from decidual cast off from the endometrial cavity in the first 2 weeks postpartum is called Lochia which consist of blood, leucocytes,desidua & organisms. Initially Lochia rubra (Red) 1-4 day Lochia serosa(pink-yellowish) 5-9 day Lochia alba (whitish) 10-15 days Vaginal discharge usually cleared completely within 4 weeks of delivery If the lochia remain red in color & excessive in amount then this indicate delayed involution which may be due to infection or retained placental tissue. New endometrium will grow from the basal layer of the desidua & this will be influenced by the method of infant feeding.  vagina Its distended and the interoitus become larger, edematous which result from labour remain for few days then return to normal capacity but never to pre- pregnancy state. The hymen lacerated The rugae of the vagina start to appear 6-10 week. Tears or episiotomy will heal quickly provided adequate suturing is undertaken. The presence of infections or hematomas will impair their healing  Cervix In the first few days, the cervix can readily admit two fingers, but by the end of the first week it should become increasingly difficult to pass more than one Nulliparous multiparous finger, and certainly by the end of the second week the internal os should be closed It is very flaccid & is curtain like after delivery but within few days it will return to its normal form & consistency.  Cardiovascular system cardiac output and stroke volume rise in the first 48hr then they fall so, it’s a time of high risk for mother with cardiac disease plasma volume gradually return to normal during the first 2 weeks extravascular fluid decrease by diuresis. this will lead to marked loss of weight specially in the first 10days of delivery  Urinary system The urethra show minor trauma which heal within few days Hydroureter & caliceal dilatation which are observed during pregnancy, are less evident & disappear completely after 6 weeks from delivery. Also there will be diuresis during first few days of the puerperium when the excessive fluid of pregnancy is eliminated & there will be a decrease in plasma volume & hemoglobin concentration will increase.  Coagulation system  The level of clotting factors & platelets count will increases after delivery , but the inhibition of the fibrinolytic system which occur during pregnancy is reversed within 30 min after delivery of placenta.  fibrinogen and clotting factors raised in first few days then return to normal within 3-6 weeks. This increase the risk of thromboembolism  Over distention of the abdominal wall during pregnancy may result in rupture of the elastic fibers, persistent striae, and separation of the rectus abdominal muscles from midline at linea alba. It is not hernia. Involution of the abdominal musculature may require 6-7 weeks and vigorous exercises are not recommended until after that time.  Management of normal puerperium Immediately after delivery, the mother must remain in the delivery room for close observation for the following things:  The uterine fundus should be checked at frequent intervals to establish that it remain contracted firmly. If it is rising this may indicate that the uterus is atonic or is pushed by up by pelvic swelling such as distended bladder or pelvic hematoma.  Regular check for pulse rate, blood pressure, respiration & external vaginal blood loss.  The bladder should be checked & if it is thought to be full, the mother should be encouraged to pass urine. If retention of urine occur then catheterization is require under aseptic technique to avoid over distention of the bladder.  Precaution should be taken to prevent implantation of exogenous pathogenic organism into the birth canal during labor & puerperium  The vulva & the perineum should be kept clean and dry as possible with the use of sterile pads.  After the physical & mental stress of pregnancy & labour, the woman needs a period of rest.  If labor was normal & there is no gross injury to the pelvic floor or other complications, the woman is allowed to get up in the same day of delivery to encourage recovery in the tone of the pelvic floor & circulation of the legs will be improved& the incidence of venous thrombosis is reduced  After operative delivery it may be necessary to keep the mother in bed for a further day before active mobilization.  In the day after a normal delivery the woman should be given a normal diet  The food should contain adequate vitamins, proteins and fluid.  Constipation may develop due to laxity of abdominal muscle & perineal tears this should be avoided by increasing fluid intake or by giving bulk forming drugs as methylcellolose or giving laxative suppositories.  Family planning advice Contraceptive advice should be available at the time of postnatal visit this is done at the end of 6weeks of delivery. The method of contraception will vary according to each woman. The combined oral contraceptive pill enhances the risk of thrombosis in the early puerperium The combined oral contraceptive pill(contraception containing oestrogen) should not be given to women who are breast feeding before 6 months because they may inhibit lactation& progesterone only contraception can be used. Sterilization may be performed during puerperium if she had completed her family, but usually this is delayed till 6-12 weeks later to be sure that the woman really want this & the fallopian tubes retuned to their normal size If an intrauterine contraceptive device is preferred, it is best to wait at least 4–8 weeks to allow for involution. Suppression of ovarian function lactational amenorrhea is caused by a suckling induced effect or change in the hypothalamus sensitivity to the feedback effect of ovarian steroid during the 1st 6 moths of life the failure rate of exclusive breast feeding as contraceptive is 1-2% but increase to 10% after 6 months.  Complication of puerperium The most serious complications that may arise during the puerperium are: post partum hemorrhage Complications of breast feeding Puerperal pyrexia Infections Urinary complications Thromboembolism Mental disorders  Postpartum haemorrhage blood loss more than 500ml following vaginal delivery and 1000ml after cesarean section Primary PPH: its occur in the first 24 hours after delivery Secondary PPH: its occur after the first 24hr till 6 weeks after delivery usually 7-14 days after delivery  CAUSES of PPH 4T(tone, tissues, trauma, thrombin) ▶Uterine atony > 80% of the causes of PPH ▶Retained pieces of placenta ▶Birth canal laceration ▶Coagulopathy (DIC) Management: The patient should be admitted to hospital, resuscitation, correction of anemia and oxytocic agents. Then U/S should be don to exclude retained placental tissue ,which if present should be removed surgically. Infection also may cause secondary PPH & is treated by antibiotic  Perineal complication Perineal discomfort is the single major problem for mothers, and about 80 per cent complain of pain in the first 3 days after delivery. Discomfort is greatest in women who sustain spontaneous tears or have an episiotomy, but especially following instrumental delivery. local cooling and topical anaesthetics, such as 5 per cent lignocaine gel, provide short-term symptomatic relief. Effective analgesia following perineal trauma can be achieved with regular paracetamol. Infections of the perineum are generally uncommon considering the risk of bacterial contamination during delivery. Puerperal pyrexia Is the rise of temperature 38∘c or more in 2 separate occasion at 24 apart (excluding the first 24 hr of delivery). The causes are: mastitis Endometritis Wound infection UTI chest infection Septic pelvic thrombophlybitis DVT  Mastitis Is the Inflammation of the breast is not always due to an infective process. It can occur when a blocked duct obstructs the flow of milk and distends the alveoli. It usually develop usually is develops 2-4 weeks after delivery. The infective mastitids cause by organisim, usually by staphylococcus which originate from the infant mouth There is a red, painful, fluctuant swelling in the breast & the patient is feverish. Treatment: The milk should be expressed from the affected breast Use of antibiotic like dicloxacillin or Flucloxacillin for 7-10 days About 10 per cent of women with mastitis develop a breast abscess. Treatment is by a surgical drainage under anaesthesia.  Endometritis The most virulent organism is the B-hemolytis streptococcus(streptococcus pyogens) but other organism like gram negative(E.coli), anaerobes like bactroid may be the infective agents. Patient presents with fever, rigor, lower abdominal pain and tenderness, offensive lochia or secondary PPH and tachycardia If untreated it may lead to: ▶Parametritis ▶Pelvic abscess ▶systemic infection and septicemia ▶Chronic pelvic infection and secondary infertility ▶Chronic pelvic pain  Risk factors of endometritis prolonged rupture of membrane >18 hr Chorioamnionitis Prolonged labour Frequent vaginal examination Operative delivery like forceps Retained pieces of placenta Anemia and malnutrition Treatment of endometritis ▶Admission to the hospital ▶Fluid replacement ▶Antipyretic ▶intravenous broad spectrum antibiotic intravenous ampicillin or cephalosporin+ aminoglycoside and metronidazole ▶Correct anemia ▶Evacuation of retained tissues  UTI The common organisms causing UTI are Ecoli, klebsilla, staphylococcus, proteus and pseudomonas.UTI either cystitis or pyelonephritis UTI are more common in: ▶ women with folly's catheter ▶Previous recurrent UTI ▶Operative delivery The patient presents with urinary frequency, dysuria, urgency, Haematuria And lower abdominal or renal pain Treated by adequate fluid intake and antibiotic like cephalosporin ,trimethoprim, nitrofurantoin for 7-10 days Investigations of peurpural pyrexia ▶CBC(anemia, leukocytosis, thrombocytopenia) ▶Urine analysis(UTI) ▶Vaginal and endocervicle swab ▶Blood culture ▶Ultrasound of pelvis and uterus (retained pieces, hematoma) ▶CT and MRI(pelvic collection, foreign body) ▶ X-ray (pneumonia)  Mental disorder Postpartum blue : is defined as low mood and mild depressive symptoms that are transient and self-limited which occur within 4-5 days of delivery and do not last for more than 2 weeks after giving birth. Puerperal depression Its usually occur 1-6 months of delivery, they have a persistent feeling of sadness and low mood, feeling tired all the time, trouble sleeping at night and feeling sleepy during the day, finding it difficult to look after yourself and your baby and withdrawing from contact with other people Puerperal psychosis is the most extreme, and rarest, form of postnatal mood change in which the patient lose contact with reality  Urinery complication Retention of urin: if there is bruising or oedema around the bladder base or there is painful episiotomy or after epidural anaesthesia when the sensory stimuli from the bladder is temporarily interrupted. the bladder can hold a liter of urine & as it become more distended , retention with overflow may develop with the passage of 50 -100 cc of urine The treatment is to leave an indwelling catheter for 48 hours Stress incontinence may be a complication of childe birth but usually it resolve with physiotherapy & improving tone of pelvic floor. If continuous incontinence is present , it must be established if this is urethral or through a fistula. Urinary fistula may be caused by direct injury with obstetric forceps or other instrument or obstructed labour If the fetal head was pressed on the bladder for too long period during obstructed second stage of labour, necrosis of bladder tissue & subsequent sloughing with fistula formation will occur The management is by continuous bladder drainage for 3-4 weeks if Ithe fistula is small may close spontaneously or if not then surgical repair is required Lactation  Physiology of lactation The breast development occur during puberty mainly. Each breast compose of 20 lobules arranged radialy from the nipple. Each lobule compose of glandular tissue & ductal system which is branching & then unite to form a single duct which open on the nipple. The glandular tissue compose of alveoli. The duct & the alveoli are surrounded by myoepithelial contractile cells. During pregnancy there is hypertrophy of the alveoli & ductal system of the breast. This hypertrophy is due to the effect of estrogen , progesterone, prolactin, growth hormone & adrenal steroid.  Milk production Secretion of milk & colostrum begin in the 2nd trimester but it is minimal due to the inhibitory effect of estrogen. Establishment of lactation include 2 mechanisms:  The drop in the placental hormones particularly estrogen  The release of prolactin which acts upon the glandular cells of the breast to stimulate milk secretion.  The releases of oxytocin which acts upon the myoepithelial cells to induce milk ejection reflex. The release of both hormones is stimulated by an afferent neurological stimuli from the nipple( which become very sensitive to tactile stimuli immediately after delivery) to the hypothalamus. Advantage of breast milk  Breast milk is a natural food for the human infant.  Inexpensive  Always at appropriate temp.  Protect against infections.  Contribute to the development of infant – mother attachment.  Protection against diseases as juvenile DM , inflammatory diseases or atopic illnesses as asthma or eczema.  Improved neurological development.  Breast feeding decrease the incidence of breast cancer in premenopausal women.  Suppression of ovarian activity  Encouragement of uterine involution  Milk secretion  Prolactin is a polypeptide released from the lactotrophs in the anterior pituitary stimulated by the nipple stimulation during suckling. Its level is dependent on the strength, frequency & duration of suckling stimuli  Prolactin secretion is under the neuro-endocrine control of a prolactin inhibitory factors from hypothalamus which is dopamine, so its secretion is inhibited by dopamine agonist which is bromocriptine.  Prolactin will act on the secretary cells of the breast to stimulate the synthesis of milk proteins (casein, lactoglobulin& lacalbumin) , lactose & lipids.  Milk ejection reflex  This reflex Is mediated by the release of oxytocin from the posterior pituitary & it will stimulate contraction of the myoepithelial cells round the milk secreting glands & wall of the ducts longitudinally.So the contractions of these smooth muscle will cause expelling of milk from the gland, dilatation of the ducts & encouraging free flow of the milk. Oxytocin secretion is stimulated by tactile stimulation of the areola by suckling & also by sensory input such as the mother seeing or hearing her baby crying, while prolactin is stimulate by tactile stimulation of the areola. The milk ejection reflex may be inhibited by emotional stress.  Composition of colostrum & breast milk From the 1st 2 days after delivery colostrum is secreted & on the 3rd& 4th days the secretion is changed to normal breast milk. Colostrum is a yellow fluid containing large fat globules & has a high mineral, moderate proteins & relatively low sugar content It has a high content of Ab spatially secretary Ig A which has an important role against infections When the secretion changes from colostrum to milk, its color changes to white. Breast diseases  Breast engorgement Is usually occur on the 3rdor 4th day after delivery due to delayed initiation of breastfeeding, infrequent feeds, poor attachment, ineffective suckling lead to venous and lymphatic engorgement of breasts the breast become painful, tender, swollen and red. This is usually relieved by frequent feeding  Craked nipple The most common reasons mothers give for abandoning breastfeeding are inadequate milk production or sore and cracked nipples. Both these problems can be overcome by correct positioning of the baby on the Breast When the baby is properly attached, breastfeeding should be pain free. Treatment is:  Encourage frequent feeding  if the breast is so tens & engorged allow manual milk expression or expression by pump.  Educate the mother about correct position & fixation of the baby to the breast.  Lubricate the nipple e.g. 100% lanolin cream  Treatment of fungal infection if present.  Suppression of lactation Causes related to the infant Disease of the infant such as pneumonia or other infection. Disproportion between the size of the nipple & the baby’s mouth Cleft lip & cleft palate Nasal obstruction use mouth for breathing Causes related to the mother Retracted nipple. Death of baby Non-breastfeeding mothers may suffer considerable engorgement and breast pain. Dopamine receptor stimulants(dopamine agonist), such as bromocryptine and cabergoline, inhibit prolactin and thus suppress lactation. However, both have been associated with an increased risk of hypertension and stroke. Furthermore, fluid restriction and a tight brassiere have been shown to be equally effective as bromocryptine usage by the second week and therefore this is the method of choice for the suppression of lactation.  Drugs during lactation Drugs should be avoided during lactation unless there is definite clinical indication because some of the drug or its degradation product is likely to be secreted in the milk.  Secretion of drugs in the milk depend on its molecular wt. ,size, its binding protein, solubility in water or lipid.  The effect of the drug depend on whether it appear in the milk in its active or inactive metabolite, the rout of administration, the drug half life. Other factor to be determined is whether the infant gut can absorb the drug or the drug can be detoxified or excreted. The long acting form of the drug should be avoided The infant should be watched carefully for possible adverse effect such as change in feeding habits, sleeping pattern if the mother taking anti epileptic drugs, skin rash or other unusual signs as bleeding tendency in infant of a mother taking anticoagulant drugs.  Mrs Rahma a 27 year old woman who has just had a caesarean section for pre-eclampsia at 39weeks. She and the baby are well. Her Blood pressure is well controlled on Labetalol 200mg bd. She is also on Lamotrigine for her epilepsy which is well controlled. She wishes to breastfeed her baby.. Describe the physiology of breastfeeding and the composition of breast milk. How can women be supported toward successful breastfeeding? List three common drugs that are contraindicated with breastfeeding. On Day 3 she complains of pain and bleeding from her Right nipple. What features would you look for in the examination of her breast? She is diagnosed as having mastitis. Please describe your initial management plan and what advice you would give the patient. Mrs Salma is a 28 year old woman, who has recently had her second child. She had a history of depression and stopped taking her medications on her own accord when she found out she was pregnant. She planned to have a home-birth but ended up having a difficult forceps delivery in theatre with a post-partum haemorrhage, requiring a blood transfusion. Postnatally, she was noted to be withdrawn and lethargic, with a low mood which was attributed to her delivery. She was discharged home after 3 days. Two weeks later, the health visitor noted that Mrs Salma had a very low mood, was uncommunicative and complained of hearing voices. Her baby was severely malnourished and showed signs of neglect. What would be your main differential diagnosis? What risk factors in Mrs Salma’s history would support your differential diagnosis? What management steps should be taken?  Mrs Intisar is a 35-year-old unemployed primigravida, who lives with her 44-year-old husband, who is also unemployed. She presents for booking at 20 weeks gestation. Her BMI is 16; she smokes 10 cigarettes per day. Her past medical history includes epilepsy; she is stable on Carbamazepine and has been seizure free for over a year. Initial booking blood tests reveal mild iron deficiency anaemia, but are otherwise normal. Had Mrs Intisar consulted you for preconceptual counselling regarding her epilepsy, what advice would you have given her on her medication, and on risk reduction in pregnancy? Discuss the potential impact of low socio-economic status and other items in Mrs Intisar’s history, on her pregnancy. Apart from routine antenatal care, what additional tests do you think this patient should have during the course of her pregnancy?  Mrs Intisar is found to be anaemic on her booking bloods with a HB of 8.2gm/dl. ►What are the clinical consequences of anaemia in pregnancy, labour and purperium? ►What investigations would you perform to diagnose the type of Mrs Intisar’s anaemia? Mrs Intisar contacts her midwife at 24 weeks gestation. She is too distressed to talk on the phone, and the midwife therefore arranges a home visit. She finds Mrs Intisar with bruises on her face and her arm in a sling. It appears that her husband has been arrested for assaulting her. please outline the impact of domestic violence on pregnancy  Mrs Intisar's husband is remanded in custody, and she is now unsupported as she does not have family or friends locally. At 32 weeks gestation her neighbour calls an ambulance, as he finds her collapsed outside her front door. The actual collapse was unwitnessed. She is brought to hospital by ambulance. The admitting team assume that she had an epileptic seizure. On arrival she is more alert, and complains of a headache and epigastric pain. Her BP is 166/100 mm Hg. What would be your main differential diagnosis? What investigations would you request to confirm or refute your suspected diagnosis? Whilst you are assessing Mrs Intisar, you note that her BP has risen to 170/124 mm Hg, and you are more certain of the diagnosis. The fetal heart is normal. Describe how you would manage the patient and why. Describe methods of induction of labour and the relevance of the Bishop Score. What are potential maternal and fetal complications of the condition this patient has? Describe three different drugs from three different therapeutic groups that may be used to treat hypertension in pregnancy, including mode of action, usual dosage regimens, routes of administration, contraindications and side effects. Thank you