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Puerperium

Puerperium. Nazila Karamy –MD Genecology and Obstetric Specialist www.doctorkaramy.ir. Puerperium. The time 6 w from the delivery tht body returns to the nonpregnant state. Uterus. Immediately after the delivery, the uterus can be palpated at or near the umbilicus

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Puerperium

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  1. Puerperium Nazila Karamy –MD Genecology and Obstetric Specialist www.doctorkaramy.ir

  2. Puerperium • The time 6 w from the delivery tht body returns to the nonpregnant state

  3. Uterus • Immediately after the delivery, the uterus can be palpated at or near the umbilicus • Most of the reduction in size and weight occurs in the first 2 weeks • 2 weeks postpartum, the uterus should be located in the true pelvis

  4. Lochia • Vaginal discharge, lasts about 5 weeks • 15% of women have lochia at 6 weeks postpartum Lochia rubra • Red • Duration is variable Lochia serosa • Brownish red, more watery consistency • Continues to decrease in amount Lochia alba • Yellow

  5. Cervix, Vagina, Perineum • Tissues revert to a nonpregnant state but never return to the nulliparous state

  6. Abdominal Wall • Remains soft and poorly toned for many weeks • Return to a prepregnant state depends greatly on exercise • Not depend on the root of delivery (c/s,nvd)

  7. Ovulation Breastfeeding • Longer period of amenorrhea and anovulation Not breastfeeding • As early as 1 month after delivery • Most have a menstrual period by 3 months • Suggest birth control &R/O PREGNANCY in doubtful cases

  8. Sexual Intercourse May resume when… • Red bleeding ceases • Vagina and vulva are healed • Physically comfortable • Emotionally ready *Physical readiness usually takes ~3 weeks

  9. Postpartum Period

  10. Concerns - Puerperal Period

  11. Hemorrhage

  12. Postpartum Hemorrhage • Excessive blood loss during or after the 3rd stage of labor • Average blood loss is 500 mL Early postpartum hemorrhage • 1st 24 hrs after delivery Late postpartum hemorrhage • 1-2 weeks after delivery (most common) • May occur up to 6 weeks postpartum

  13. Postpartum Hemorrhage

  14. Postpartum Hemorrhage Incidence • Vaginal birth: 3.9% • Cesarean: 6.4% • Delayed postpartum hemorrhage: 1-2% Mortality • 5% of maternal deaths

  15. Postpartum Hemorrhage May result from: • Uterine atony • Lower genital tract lacerations • Retained products of conception • Uterine rupture • Uterine inversion • Placenta accreta • adherence of the chorionic villi to the myometrium • Coagulopathy • Hematoma Most common

  16. Uterine Atony • Lack of closure of the spiral arteries and venous sinuses Risk factors: • Overdistension of the uterus secondary to multiple gestations • Polyhydramnios • Macrosomia • Rapid or prolonged labor • Grand multiparity • Oxytocin administration • Intra-amniotic infection

  17. Postpartum Hemorrhage

  18. Lower genital tract lacerations • Result of obstetrical trauma • More common with operative vaginal deliveries • Forceps • Vacuum extraction Other predisposing factors: • Macrosomia • Precipitous delivery • Episiotomy

  19. Infection

  20. Endometritis • Ascending polymicrobial infection • Usually normal vaginal flora or enteric bacteria • Primary cause of postpartum infection • 1-3% vaginal births • 5-15% scheduled C-sections • 30-35% C-section after extended period of labor • May receive prophylactic antibiotics • <2% develop life-threatening complications

  21. Risk factors: C-section Young age Low SES Prolonged labor Prolonged rupture of membranes Multiple vaginal exams Placement of intrauterine catheter Preexisting infection Twin delivery Manual removal of the placenta Endometritis

  22. Clinical presentation Fever Chills Lower abdominal pain Malodorous lochia Increased vaginal bleeding Anorexia Malaise Exam findings Fever Tachycardia Fundal tenderness Treatment Antibiotics Endometritis

  23. Urinary Tract Infection • Bacterial inflammation of the bladder or urethra • 3-34% of patients • Symptomatic infection in ~2%

  24. Risk factors C-section Forceps delivery Vacuum delivery Tocolysis Induction of labor Maternal renal disease Preeclampsia Eclampsia Epidural anesthesia Bladder catheterization Length of hospital stay Previous UTI during pregnancy Urinary Tract Infection

  25. Clinical Presentation Urinary frequency/urgency Dysuria Hematuria Suprapubic or lower abdominal pain OR… No symptoms at all Exam Findings Stable vitals Afebrile Suprapubic tenderness Treatment antibiotics Urinary Tract Infection

  26. Mastitis • Inflammation of the mammary gland • Milk stasis & cracked nipples contribute to the influx of skin flora • 2.5-3% in the USA • Neglected, resistant or recurrent infections can lead to the development of an abscess (5-11%)

  27. Clinical Presentation Fever Chills Myalgias Warmth, swelling and breast tenderness Exam Findings Area of the breast that is warm, red, and tender Treatment Moist heat Massage Fluids Rest Proper positioning of the infant during nursing Nursing or manual expression of milk Analgesics Antibiotics Mastitis stasis

  28. Perineum (episiotomy or laceration) 3-4 days postpartum rare Abdominal incision (C-section) Postoperative day 4 3-15% prophylactic antibiotics 2% Wound Infection

  29. Perineum Risk Factors: Infected lochia Fecal contamination Poor hygiene Abdominal incision Risk factors: Diabetes Hypertension Obesity Corticosteroid treatment Immunosuppression Anemia Prolonged labor Prolonged rupture of membranes Prolonged operating time Abdominal twin delivery Excessive blood loss Wound Infection

  30. Clinical Presentation Perineal Infection: Pain Malodorous discharge Vulvar edema Abdominal Infection Persistent fever (despite antibiotics) Diagnosis Erythema Induration Warmth Tenderness Purulent drainage With or without fever Wound Infection

  31. Psychiatric Disorders

  32. Postpartum Blues • Transient disorder • Lasts hours to weeks • Bouts of crying and sadness Postpartum Depression • More prolonged affective disorder • Weeks to months • S&S of depression Postpartum Psychosis • First postpartum year • Group of severe and varied disorders (psychotic symptoms) BF NOT SUGGESTED

  33. Etiology • Unknown • Theory: multifactorial • Stress • Responsibilities of child rearing • Sudden decrease in endorphins of labor, estrogen and progesterone • Low free serum tryptophan (related to depression) • Postpartum thyroid dysfunction (psychiatric disorders)

  34. Undesired pregnancy Feeling unloved by mate <20 years Unmarried Medical indigence Low self-esteem Dissatisfaction with extent of education Economic problems Poor relationship with husband or boyfriend Being part of a family with 6 or more siblings Limited parental support Past or present evidence of emotional problems Risk factors

  35. Incidence • 50-70% develop postpartum blues • 10-15% of new mothers develop PPD • 0.14-0.26% develop postpartum psychosis History of depression • 30% chance of develping PPD History of PPD or postpartum psychosis • 50% chance of recurrence

  36. Mood lability Headache Confusion Forgetfullness Insomnia Postpartum Blues • Mild, transient, self-limiting • Commonly in the first 2 weeks Signs and symptoms • Sadness • Crying • Anxiety • Irritation • Restlessness

  37. Postpartum Blue

  38. Postpartum Blues • Often resolves by postpartum day 10 • No pharmacotherapy is indicated Treatment • Provide support and education

  39. Signs and symptoms Insomnia Lethargy Loss of libido Diminished appetite Pessimism Incapacity for familial love Feelings of inadequacy Ambivalence or negative feelings towards the infant Inability to cope Postpartum Depression (PPD)

  40. Postpartum Depression (PPD) Consult a psychiatrist if… • Comorbid drug abuse • Lack of interest in the infant • Excessive concern for the infant’s health • Suicidal or homicidal ideations • Hallucinations • Psychotic behavior • Overall impairment of function

  41. Postpartum Depression

  42. Postpartum Depression (PPD) • Lasts 3-6 months • 25% are still affected at 1 year • Affects patient’s ADLs Treatment • Supportive care and reassurance (healthcare professionals and family) • Pharmacological treatment for depression • Electroconvulsive therapy

  43. Postpartum Psychosis Signs and symptoms • Acute psychosis • Schizophrenia • Manic depression

  44. Danger

  45. Postpartum Psychosis Treatment • Therapy should be targeted to the patient’s specific symptoms • Psychiatrist • Hospitalization *Generally lasts only 2-3 months

  46. Breastfeeding • Breastfeeding is the best feeding method for most infants • Contraindications include galactosemia of neonate, breast cancer,maternal hepatitis C,breast abcess,post partum psychosis, HIV infection, chemical dependency(immune suppressive medication), and use of certain medications • Structured behavior counseling and breastfeeding-education programs may increase breastfeeding success

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