Reproductive Health PDF

# HA OM COACHING CENTRE PVT. LTD. JANAKPUR REPRODUCTIVE HEALTH PREPARED BY:- SHYAM SINGH ## Reproductive Health - It is a branch of medical science that deals with the reproductive organs and related diseases. ### Gynecology - Study of the female reproductive organs and related diseases. ### Obst...

# HA OM COACHING CENTRE PVT. LTD. JANAKPUR REPRODUCTIVE HEALTH PREPARED BY:- SHYAM SINGH ## Reproductive Health - It is a branch of medical science that deals with the reproductive organs and related diseases. ### Gynecology - Study of the female reproductive organs and related diseases. ### Obstetrics - Study of providing care during pregnancy, labor, and the postpartum period. ### Pregnancy - Gestation #### Antenatal Period - Period between LMP and the onset of true labor pain. #### Intranatal Period - Period between the onset of true labor pain and the expulsion of the fetus and placental membrane. #### Postnatal Period - Period between the expulsion of the fetus and the placental membrane and 6 weeks following delivery. #### Perinatal Period - Period between 28 weeks of gestation and 7 days following delivery. - Fetal weight is more than 1000 gm. #### Extended Perinatal Period - Period between 22 weeks of gestation and 7 days following delivery. - Fetal weight is more than 500 gm. ### Gravida - Total number of conceptions. ### Primigravida - First-time pregnancy. ### Multigravida - More than one time pregnancy. ### Nulligravida - Never been pregnant. ### Para - Expulsion of a live or dead fetus after 22 weeks of gestation. ### Primipara - Expulsion of the first live fetus. ### Multipara - Expulsion of 2-3 live fetuses. ### Grand Multipara - Expulsion of more than 4 live fetuses. ### Nullipara - Never been expulsion of a live fetus. ### Still Birth - Expulsion of a dead fetus after 22 weeks of gestational period. ### IUD - Death of a fetus in the uterine cavity, but cannot be expelled out on its own by the mother. ### IUGR (Intra Uterine Growth Retardation) - Fetus is 10% less than the gestational weight. ### Mensuration - Sign of fertility. ### Pregnancy - Sign of ovulation. ### Pre-Term Delivery - 22 weeks of gestational period to before 37 weeks of gestation. ### Term Delivery - 37-42 weeks of pregnancy. ### Post-Term Delivery - After 42 weeks of pregnancy. ### Post Date - 40-42 weeks of gestation. ### Week of Gestation - LMP (1st day of last menstruation date of visit) - Date of Visit - LMP. ### EDD (Expected Date of Delivery) - LMP + 9 Months and 7 days. ### Elderly Primigravida - Pregnancy after 30 years old. ### Gametogenesis - Maturation of ovum in females and spermatozoa in males before uniting to form a zygote. ### Oogenesis - Development of a mature ovum. ### Spermatogensis - Development of spermatid to spermatozoa. ### Fertilization - Process of fusion of spermatozoa in a mature ovum. - Sperm + Ovum = Zygote (single cell). - Life span of ovum: 24-36 hours. - Life span of sperm: 48-72 hours. - Fertilization capacity of sperm: 12-24 hours. - Fertilization capacity of ovum: 8-24 hours. - Fertilization mostly occurs in the Ampulla (Fallopian tube). ### Implantation/Nidation - Implantation occurs in the anterior or posterior wall of the fundus. - Starts 6 days of fertilization or 20th day of menstruation and is complete 10-11 days of fertilization or 24-25 days of menstruation. ### Placenta (Fetal Lungs/After Birth) - Placenta is developed by trophoblast cells. ### Placenta Have 2 Surfaces - **Maternal Surface:** Chroin - **Fetus Surface:** Amnion **2-12 weeks:** It starts to form and completes during these weeks. **Diameter:** 15-20 cm and 3 cm thickness. **Weight:** 500-600 grams or 1/6th of baby weight. - Covers 30% of the uterine wall. - Stores 500 ml of blood. - Circulates 400ml of blood every minute. - It is the fetal respiratory organ. - Placenta membrane acts as a barrier between the fetus and mother's blood. ### Inflammation of Placenta: Chroinamionitis - It has a discoidal shape but is homocoidal. - 15-20 Lobes. - Functional unit: Cotyledon or sulci (Lobules = 15-30 or placentome) - 2 Layers: - **Mother Part:** Decidua basalis (amnion). - **Fetus Part:** Chorianfundosum. ### Functions (PNEER) - Protection - Nutrition supply - Excretory Function - Endocrine Function - Respiration ### Umbilical Cord (Life Line of Fetus) - It develops from the yolk sac and allantois. - Length: 48-50 cm. - Diameter: 2 cm. - More than 300 cm: Long umbilical. - Less than 20 cm: Short umbilical. - Carries deoxygenated blood in the artery and oxygenated blood in the vein (VOAT= Vein-Artery). - Contains Wharton's jelly (makes the cord soft and slippery). - Inflammation: Omphilitis. ### Vaginal Discharge - Normal discharge during: Ovulation, pregnancy, and coitus. - Greenish-yellow discharge: Trichomonas vaginalis (Trichomonasvaginalis). - Curd white discharge: Candida albican's. - Muco-puralent discharge: Calamydiatrichomatics (Silent epidemic for women). - Grey white to green: Bacterial vaginosis. - Cream yellow: Gonorrhea. ## Abnormal Mensuration Cycle Discharge - **Menarche:** 1st mensuration. - **Menopause:** Permanent stoppage of menstruation. Cessation of menstruation: 145 -55 years old. - **Amonerrhea:** Temporary stoppage of menstruation. - **Dysmenorrhea:** Painful menstruation. - **Polymenorrhea:** 21 day menstruation cycle. Normal bleeding and bleeding time. - **Oligomenorrhea:** 35 days menstruation cycle. - **Menorrhagia:** 80ml of bleeding or bleeding for more than 7 days. - **Menometrogia:** Infrequent, irregular, and acyclic, excessive bleeding, or a combination of both. Prolong bleeding. - **Epimenorrhea:** Less than 21 days of cycles with excessive bleeding or prolongation bleeding (one or both). - **Hypomenorrhea:** 35 days cycle with scanty bleeding (less than 30 ml or 2 days). - **Metrotaxsis, Metrorrhagia, Spotting bleeding, Inter Mensural Bleeding:** Frequently, irregular, and acyclic. It occurs between menstrual cycles. - **Cryptomenorrhoea:** Hidden menstruation/Obstructive menstruation. - **Pseudomenorrhoea:** Vaginal bleeding in children. - **Post Menopausal Bleeding:** Vaginal bleeding causes after menopause. - Most common causes of postmenopausal bleeding: Cervical cancer. ## Endometriosis - Uterine tissue or mucosa found outside of the uterine cavity. - Most common site: Ovary - 2nd most common site: Cul-de-sac - C/F: Dysmenorrhea, Dyspareunia, Dyschezia, Backache. - Main Complication: Infertility. - Painful bowel movement. ## Antenatal Care (ANC) - Focus ANC plus visit. - According to WHO, the ideal ANC visit is 8 times (12, 16, 26, 30, 34, 36, 38, 40 weeks). - FANC visit: 14 times. - First visit: 4 months or 8-12 weeks or as soon as pregnancy. - Second visit: 6 Months or 24-26 weeks. - Third visit: 8 Months or 32 weeks. - Fourth visit: 9 months or 36-38 weeks. - Ideal ANC visit: 11 times. - Iron (60 mg) and folic acid (400 mcg) should be started from the 91st day of pregnancy. Total 180 tablet for ANC and 145 tablets for PNC (total 225 tablets). - T.D. vaccine given 2 doses for primigravida and 1 dose for multigravida. - Albendazole (400mg) should be administered once after 90 days of pregnancy. - Sleep 8 hours at night and for 2 hours during the day during pregnancy. - Alcohol can cause alcohol shock syndrome. - X-ray can cause blood cancer and congenital abnormalities. - Folic acid prevents neural tube defects. - If pre-eclampsia or eclampsia, administer low-dose Acetyl salicylic acid (Aspirin) at 75 mg per day. ## High Risk Mother Group - Height less than 4 ft and 10 inch - Weight less than 40 kg - Old age during their pregnancy (more than 30 years old) - Less than 20 years of age or 35 years old - Unmarried women - Previous C/s - H/O of abortion, still birth, abnormal presentation, and congenital abnormalities - BP > 140/90 mm of Hg - RH-incompatibility between the mother and fetus. ## Danger Sign During Pregnancy - Sever Headache - Blurred Vision - Sever Fever - Face, leg, and hand edema - Sever lower abdominal pain - Vaginal bleeding - Convulsion / Eclampsia / Coma / Seizure ## Pregnancy - Reproductive age group of women: 15-49 years. - Period is 266 days after fertilization or 280 days after the LMP. ## Presumptive Sign/Possible Sign (What the mother says) - Amenorrhea - Fatigue - Morning sickness (Nausea and Vomiting) 50% (Elevated B-HCG) - Frequency of micturition - Quickening (16-20 weeks) - Primipara: 18-20 weeks - Multipara: 16-18 weeks. - Cholosma (24 weeks). - Tingling sensation on breasts, fullness, heaviness at 6 weeks. - Backache. ## Probable Sign - Mentogemer's tubercles (8 weeks): Hypertrophy of the sebaceous gland on the areola. - Chadwick's or Jackemer's sign (8 weeks: Bluish discoloration of the vulva and vagina. - Godell's sign (10 weeks): Softening of the cervix. - Ossinder sign (8 weeks): Pulsation is felt lateral to the fornix of the vagina. - Hegar sign (6-12 weeks): Softening of the uterus (8 weeks). - Baraxtonehick contraction (after 20 weeks of gestation): Painless uterine contraction after 20 weeks of gestation (10-20 minutes). ## Positive Sign - FHS, USG evidence of fetus, perception of fetal movement, and x-ray evidence. - Note: - Pulmer sign: Regular uterine contraction. - Doppler effect of USG: Detect FHS reliably by the 10th week. - Linea nigera (20 weeks). - Lightening (38 weeks): The fundus lowers to the level of 34 weeks. ## Fundal Height - 12 weeks: Symphasis pubis - 16 weeks: Between symphasis pubis and the U.M. (umbilicus) - 24 weeks: Umblical - 30 or 32 weeks: Between the umbilicus and the xyphoid process. - 36 weeks: Just below the xyphoid process. - Tingling sensation in breasts: 6 weeks - Primary area: 12 weeks - Secoundary areola: 16 weeks. - Montgomery tubercle: 8 weeks. - Colostrum (pale-yellow): 16 weeks - Early expressed colostrum: 12 weeks. ## Minor Disorder During Pregnancy - Edema - Itching - Morning sickness (N & V) - Heartburn/Indigestion - Constipation/Varicose veins - Piles - Backache - Frequency of micturition ## Major Disorder During Pregnancy - Abortion - IUD - Hyperemesis gravidum - H. Mole - Ectopic Pregnancy - PIH (Eclampsia) ## Teratogenic Effect - **Tetracycline:** Delayed teeth eruption and discoloration of teeth. - **Aspirin:** Bleeding disorder. - **Streptomycin:** Deafness. - **Thalidomide:** Loss of limbs. - **Vitamin A:** Abortion. - **Chloramphenicol:** Bone marrow disorder - **Sedative Drugs:** Tachycardia. - **Resiprine:** Epistaxis = Depression. - **Phenyton:** Cleft palate, cleft lip ## Antepartum Haemorrhage (APH) - Vaginal bleeding after 22 weeks of gestation until the 2nd stage of labor. ### Causes - **Placenta (70%):** - Placenta previa - Abruptio placenta - **Extra Placenta (5%):** - Cervical cancer - Genital polyps - **Unexplained (25%):** - Hypertension - Thrombocytopenia ### Placenta Previa - Placenta is implanted in the lower uterine segment partially or completely. #### Types or Degree: - **Type I (Low lying):** It is located in the lower segment but the cervix is not attached. - **Type II (Marginal):** Placenta reaches the margin of the internal OS but doesn't cover it. - **Type III (Incomplete or Partial Central):** The internal OS opens partially when it is dilated. - **Type IV (Central or Total):** Placenta covers totally the internal OS after fully dilated. **Note** - **Mild Degree:** Type I and II are anterior. - **Major Degree:** Type II posterior, III and IV. - Type II posterior is the most dangerous. **C/F:** Painless bleeding occurs at night (Bright Red) - Unavoidable or incidental bleeding. - Fetal part is on the upper segment. - It is dangerous for the mother. - Shock. **Note:** - Vaginal examination C/I **Choice of Tx:** Cesarean delivery. ### Abruptio Placenta - Premature separation of a normally situated placenta that occurs after 22 weeks of gestation. - **Note:** It is the most common cause of APH. - **More seen in:** The 3rd trimester or more than 35 years of pregnancy. #### Types: - **External or Relaxed (Most common type):** Blood is not accumulated behind the placenta. - **Internal or Concealed (Hidden type):** Blood is retained behind the placenta. - **Mixed:** Both types. **C/F:** - Painful vaginal bleeding. - Tenderness in the lower abdomen. - Accidental bleeding/Fetal distress. - Dark color vaginal bleeding. **Contraindication:** - PV examination. ### Ectopic Pregnancy - Fertilized ova implant outside of the uterine cavity. - **Note:** Implantation site: Uterine. #### Extrauterine: - Tubal (97%): - Ampulla (55%) - Isthmus (25%) - Infundibulum (18%) - Interstitial (2%) - Ovary (0.5%) - Abdominal (1%) ### Risk Factor - Tubal endometriosis. - Previous ectopic pregnancy. - IUCD user - PID & Salpingitis. - Contraceptive failure. - Previous abortion. ### C/F - Amenorrhea (6-8 weeks). - Lower abdominal pain (colicky pain). - Unilateral or bilateral pain (shoulder tip pain). - Vaginal bleeding, slight or continuous (dark color). - Vomiting attack. - Fainting attack. - Shock. ## PIH (Pregnancy Induced Hypertension) - A multi-system disorder in which blood pressure increases to above 140/90 mm Hg after 20 weeks of gestation. ### Mild Pre-Eclampsia - BP: > 140/90 mm of Hg - Proteinuria, and - Slight oedema. ### Sever Pre-Eclampsia - BP:> 160/110 mm of Hg. - Headache. - Blurred vision. - Oligouria (less than 400 ml of urine in 24 hours). - Massive oedema. - Sudden weight gain. - Proteinuria (2+ or more). ### Eclampsia - Coma - Convulsion - Seizure - Some symptoms of sever pre-eclampsia. ### Choice Drug for Pre-Eclampsia - Methyldopa: 250-500 mg. - Eclampsia is also known as Toxemia of pregnancy. ### Management of Sever Pre-Eclampsia and Eclampsia - Mg S04 50%. **Note:** - Toxicity effect of Mg S04: - R/R decrease less than 16/min. - Decrease urine output (less than 30 ml/hour). - Patellar reflex absent. - Antidote of MgSo4 Toxicity: Calcium glucose. ## Abortion - Termination of the products of conception before the 22nd week of gestation where fetal weight is less than 500 gm. ### Causes: - Most common cause: Genetic factor (down syndrome). - Endocrine disorder - Cervical incompetence (M.C. in the 2nd trimester). ### Types (2): - **Spontaneous:** - Threatened - Inevitable - Complete - Incomplete - Missed - Septic - **Induced:** - Legal - Illegal #### Threatened Abortion - Fetus is alive and pregnancy can continue. - **C/F:** - Slight vaginal bleeding (Bright Red). - Slight lower abdominal pain (dull pain). - Cervical os is closed. #### Management: - Complete bed rest. - Diazepam or phenobarbitone for pain relief. - Avoid heavy work for two weeks. #### Inevitable Abortion - It is impossible to continue the pregnancy. - **C/F:** - Perfuse vaginal bleeding. - Severe lower abdominal pain. - Internal o/s is open and the product of conception is felt on the cervix. #### Management: - IV fluids are maintained. - Perfuse vaginal bleeding. - Severe lower abdominal pain. - Internal os is open and the product of conception is felt on the cervix. - Methargin 0.2mg. #### Active Management - **Less than 12 weeks:** D&E by cutlerage. - **More than 12 weeks** : Inj. Oxytocin in N/S drip. #### Complete Abortion - Products of conception are expelled. - **C/F:** - Expulsion of fleshy masses through the vagina. - Cervix is closed. - Fundal height decreases. - Bleeding and pain are absent. #### Incomplete Abortion: - Fetous, placenta, or some parts of the placenta remain in the uterus. **C/F:** - Dangerous abortion. - Hanging out product of conception. - Cervical o/s partially open. - Severe lower abdominal pain. - Continuous vaginal bleeding #### Management: - D&E by cutlerage or MVA. #### Missed or Silent Abortion: - Fetous is dead and retained inside the uterus for a variable period. **C/F:** - Cessation of uterine growth. - Slight vaginal bleeding. - FHS is absent. - Height less than the period of gestation. - Immunological test (-) **Management:** - D&E by cutlerage. #### Septic Abortion - Abortion occur due to the infection of the genital tract. - **C/F:** - Vaginal bleeding. - Offensive muco-puralent discharge. - Temperature more than 38 degrees C. - Abdominal tenderness. #### Management: - Antibiotics: Ampicillin + Metronidazole. - Theraputicabortion: - Abortion legalized 2002. - Abortion policy 2003. - Abortion started 2004. - Safe abortion 2008. - Medical abortion: Less than 9 weeks or 63 days. - Surgical or MVA: Less than 12 weeks. - In rape and incest: 28 weeks. - If fetous or mother's health is at risk: 28 weeks. - If there is a chance of disease transmission from mother to child: 28 weeks - Congenital abnormalities: 28 weeks. ### Possible Causes of Early Bleeding (Less Than 22 Weeks) - Abortion - H. Mole. - Ectopic Pregnancy - PIH - Trauma. ### Possible Causes of Late Bleeding - Abruption placenta. - Placenta previa. - Trauma etc. ## Delivery - The expulsion or extraction of a viable fetus out of the womb. ## Labor - It is a normal physiological phenomenon in which the viable products of conception are expelled out through the vaginal canal. ### 2 Types: - **Normal (Eutocia)** - **Abnormal (Dystocia)** ### Factor Affecting of Labor - Passenger. - Power. - Position. - Placenta. - Psychological. ### Most Common Presentation: - Vertex (Cephalic presentation). ### Most Common Lie: - Longitudinal lie. ### Characteristics of Normal Labor: - Spontaneous onset of true labor pain starts at term (37 to 42 weeks) without any prolongation of the labor. - The fetus is in vertex presentation. - Minimum surgical instruments are used. - There are no complications with the mother or baby. ## Different Between True Labor Pain & False Labor ### True Labor - Pain starts from the groin region and radiates into the thigh or back. - Cervical os gradually dilate and increase with strong uterine contractions. - Show discharge. - Formation of bag water presentation. - Sedative used for pain relief. - There are 4 stages in labor. ### False Labor - Pain is concentrated in the lower abdomen. - Cervical os undilated. - Uterine Contraction week/irregular. - Show absent. - Absent. - Pain relief by sedative enema. **4 Stages in Labor/Many 3 Stages** #### 1st Stage: - It is the onset of true labor to the start of the cervix full dilation (10 cm). **Stages:** - **Latent Phase (0 to 4 cm):** - P.G.: 8-12 hours - M.G.: 6-8 hours - **Active Phase (4 to 7 cm):** - P.G.: 1.2 cm/h - M.G.: 1.5 cm/h - **Transitional Phase (8-10 cm):** - Cervical os dilation **Note:** - Partograph: Starts when the 4 cm os is dilated. - Geographic Representation - About mother and fetous status - Proper counseling and emotion & nutrotion support. - Mother should be in the left lateral position. #### Active Phase - Cervical dilation, color of amniotic fluid, head, decent every 4 hours. - Contractions every 30 min - Bp, Temperature every 2 hours. #### Universal Precautions Before Delivery - Clean surface. - Clean perineum. - Clean cloth - Clean instrument - Clean hand and nail. - Clean cord clamp. - Clean umbilical cord. #### 2nd Stage - Full dilation of cervix to expulsion of the fetus. - P.G 2 hours, M.G 30 minutes. - **Note:** A dangerous stage for the fetus. #### Management: - Mother shift to labor room. - Position: Lithotomy. - Be ready to delivery instrument, medicine, resuscitation set, etc. - Perinotomy or Episectomy: Planned surgical incision into the perineum (3 to 4 cm) when head is visible (ideal time). - Mediolateral side. - 7 o'clock. #### 4 Types: - Lateral - Mediolateral - Median - J-shaped (Given in shoulder dystocia) #### Purpose: - Strengthen the vaginal canal. - Prevent from perineal tear. - Prevent from birth asphyxia. - Breach presentation, solder dystocia, force delivery. #### After delivery of the fetus: - Tie and cut the umbilical cord: - Tie 2 fingers away from the abdomen. - Tie 3 fingers away from the abdomen. - Tie 4 fingers away from the abdomen. - Cut the cord between 2 and 3 fingers. #### Newborn care: 8 steps - Dry stimulate and wrapping of the baby. - Assess breathing and color. - Decide if the baby needs resuscitation or not (within 5 seconds). - Tie and cut cord. - Give identification tag mark. - KMC - Breast feeding. - Eye care. #### 3rd Stage - Expulsion of the fetus to the expulsion of placenta and membrane. - P.G and M.G.: 15 minutes. #### Separation of Placenta: - **Schultze Method (Central):** - **Mathew's Duncan Method (Marginal)** #### Placenta Removal - Maternal effort. - Fundal pressure. - CCT #### Active Management of 3rd Stage: - Inj. Oxytocin 10 IU × IM, - CCT, and - Uterine massage (2 hours, every 15 min for 5 min). #### 4th Stage - Observation (1 to 2 hours). #### Postpartum Haemorrhage (PPH) - Bleeding more than 500ml after delivery or to 6 weeks or 42 days of following deliveries. #### 2 Types - **Primary:** After delivery to 24 hours following delivery. - **Causes:** - Atony Uterus (70%). - Trauma (20%). - Retain tissue (10%). - Thrombin (less than 1%). #### Management - Hospitalization. - Remove placenta or retain tissue. - IV fluid maintain or BT. - Inj. Oxytocin (20 IU in N/S or RL) 40-60 drops/min. - If secondry PPH: Then given antibiotics (Ampicillin + Metrindazole). - Surgical Management: Uterine ligation, bi-annual compression, hysterectomy. **Note:** Bed side clothing test: Done in PPH, total time: 7 minutes. ### Retain Placenta - The placenta cannot be expelled within 30 minutes of childbirth (WHO: 15 minutes). #### Causes: - Atony uterus (MC). - Full bladder. - CCT. - Placenta Adherent. #### Management: - Empty bladder by plane catheter. - Inj. Oxytocin. - MRP (Manual Removal of Placenta). ### Uterine Prolapsed - The uterus falls down from it's original position due to the weakness of the uterine ligaments: - Round ligament. - Board ligament. - Trans-cervical ligament. - Utero-sacral ligament. #### Degree: - **1st Degree:** It is starting to fall in the vaginal canal (ISCHIAL Spina). - Backache. - Lower abdominal pain. - **2nd Degree:** The cervix drops to the level just inside the opening of the vagina. - The mother feels something coming out through the vagina - Backache - Dark color vaginal bleeding. - Lower abdominal pain. - **3rd Degree:** The cervix comes out of the vagina. - Offensive vaginal discharge - Vaginal bleeding. - **4th Degree (Procidental):** The uterus comes out completely from the lower vagina. #### Management: - 1st Degree: Kegel exercise. - 2nd Degree: Kegel exercise and vaginal ring. - 3rd and 4th Degree: Vaginal hysterectomy. ## Infertility - When a couple has unprotected coitus for 12 months without pregnancy. - Every week 2-3 times unprotected coitus. #### 2 Types: - **Primary:** No H/O of pregnancy. - **Secondary:** H/O of pregnancy. ### Most Common Causes of Infertility - Endometriosis. - **Note:** Cystocele: Prolapse of the urine bladder. - Rectocele: Prolapse of the rectum. - Entrocele: Prolapse of the intestine. - Urethrocele: Prolapse of the urethra. ## Breast Engorgement - Prevention of escape of milk from the lacteal system. - Usually seen in 3 to 4 days after delivery. - **C/F:** - Pain, tenderness of breasts. - Heaviness of both breasts. - Painful breast feeding. - Raised Temperature. ### Management: - **Breast support** - **Apply Ice Bag** - **Analgesic and Antipyretic** - **Manual expression of milk** ### Complication: - **Mastitis (inflammation of breast parenchyma):** #### Causative agent: - Staphylococcus aures (MC). - Streptococci. - Staphylococci. #### Cardinal Sign (+) - Fever, chills, and rigor. - Wedge shape swelling breast. - Breast feeding continues and is good with breast support #### Management - Rest. - Plenty fluid intake. - Infected side manually emptied with each side feed. ## Breast Abscess - Localized collection of pus in the breast. #### Causative Agent: - Step 1. #### C/F: - Thrombing type breast pain. - Tense and tender breast. - Tender with fluctuation. #### Management: - ISD. - Antibiotics: Cloxaciline 500 mg OTD **Note:** - Breast contraindication in breast abscess. ## Puerperium - The period between the expulsion of the placenta up to 42 days. #### 3 Parts: - **Immediate (within 24 hours).** - **Early period (up to 7 days).** - **Remote period (up to 42 days).** ### Lochia Formation - **Lochaerubra (4 days):** Red color discharge. - **Lochea serosa ( 5-9 days):** Pink color discharge. - **Lochea alba (10 to 14 days):** White color discharge. ### Post Natal Examinations - 1st visit: 24 hours. - 2nd visit: 3 days. - 3rd visit: 7 days. ### Physiological Changes During Puerperium - **Involution of the uterus** - **Production of milk** - **Lochea formation** - **Changes in endocrine activities** ### Breastfeeding - **Exclusive Breastfeeding:** Feeding only mother milk within 6 months. - Mother's breast milk is immediately after birth. - **Colostrum:** It is the first milk after childbirth. - **Colostrum** is also called "Beesting" or the first immune milk. - **Daily production by mothers:** 450 to 650 ml - **Energy content of breast milk:** 65 kcal/100 ml - **Protein content of breast milk:** 1.19 mm/ 100ml.