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Physiology of Puerperium and Lactation

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Physiology of Puerperium and Lactation Professor Abdulrahim Rouzi, FRCSC Physiology of the Puerperium Anatomic changes Uterus Lochia-name given to blood and other ... – PowerPoint PPT presentation

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Title: Physiology of Puerperium and Lactation


1
Physiology of Puerperium and Lactation
  • Professor
  • Abdulrahim Rouzi, FRCSC

2
Physiology of the Puerperium
  • Anatomic changes
  • Uterus
  • Lochia-name given to blood and other necrotic
    debris shed from the uterus
  • Uterus does not scar- tissue replaced by new
    growth from the basal endometrium
  • Proliferative endometrium persists for about six
    weeks and first menses normally anovulatory

3
Physiology of the Puerperium
  • Cervix
  • Returns to normal within hours of delivery
  • Transverse slit like external os persists due to
    laceration
  • Vaginal and perineal tears may remain inflamed
    for several days but rapidly heal
  • Vagina appears normal in 6 weeks in non lactating
    women
  • Breast feeding women are hypoestrogenic resulting
    in vaginal mucosa being pale and smooth (causes
    dryness friction dysparunia)

4
Physiology of the Puerperium
  • Breasts
  • Decline in Estrogen and Progesterone result in
    breast engorgement by day 3

5
Physiology of the Puerperium
  • Cardiovascular changes
  • Changes of pregnancy reversed over three weeks
  • Marked increase stroke volume immediately post
    partum
  • 500-1000ml blood loss in normal delivery

6
Physiology of the Puerperium
  • Leukocytosis of labor persists for several days
  • Reduces the value of leukocyte count to determine
    infection
  • Serial counts may still be useful to follow
    infection

7
Physiology of the Puerperium
  • Weight changes
  • 5-6 kg weight loss expected at delivery
  • Additional 3-4 kg over the next two weeks due to
    diuresis loss of extracellular fluid
  • GFR returns to normal within several days

8
Complications of Puerperium
  • Blood loss infection most common complicating
    1-5 of pregnancies
  • Blood loss
  • Weigh bed clothes and pads for semi-quantitative
    method of determining blood loss
  • VS- Q 15 minutes for 1 hour, Q 30 minutes for two
    hours then q4hours for the first day
  • Failure to identify early post partum hemorrhage
    remains leading cause of maternal mortality

9
Complications of Puerperium
  • Blood loss
  • Early post partum hemorrhage
  • Most common cause uterine Atony
  • Normal uterine blood flow 500 ml/min
  • If effective contraction of myometrium does not
    occur significant blood loss can occur
  • Risk factors include
  • Use of oxytocin during labor
  • High parity
  • Distended uterus

10
Complications of Puerperium
  • Uterine Atony (Contd)
  • Treatment
  • Uterine compression
  • Oxytocics
  • Early suckling causes endogenous release of
    oxytocin
  • Oxytocin IV/IM 10 units
  • Methylergonovine
  • Methyl prostoglandin F

11
Complications of Puerperium
  • Retained products of conception
  • Causes early post partum hemorrhage
  • Requires manual exploration of the uterus
  • May require anesthesia and curettage

12
Complications of Puerperium
  • Lacerations
  • Repair immediately
  • Uterine rupture
  • Abdominal exploration and repair

13
Complications of Puerperium
  • Blood replacement based on estimated loss
  • Alterations in vitals signs may occur as late
    finding (Do not wait for hypotension to occur)
  • R/O DIC by acquiring appropriate coagulation
    studies (split fibrin products etc)

14
Complications of Puerperium
  • Placenta Accreta Uterine Inversion
  • Uncommon
  • Accreta is when incomplete placental separation
    occurs
  • Requires immediate hysterectomy
  • Uterine inversion requires immediate reduction
  • Hematomas

15
Complications of Puerperium
  • Infections
  • Endomyometritis
  • Foul smelling lochia and tender uterus within
    first few days post partum
  • Increased risk with c-section, PROM, Multiple
    exams during labor, long labor
  • Polymicrobial including anaerobes (Ecoli,
    Gardnerella, Peptostreptococcus)
  • Treat with Gentamycin/Clindomycin (Gold
    Standard), extended spectrum penicillin or
    cephalosporin

16
Complications of Puerperium
  • Fever
  • UTI/Pyelonephritis
  • DVT/Thrombophlebitis
  • Milk fever (Lasts lt 24 hours)
  • Drug reaction
  • Perineal infection(Day five)
  • Pulmonary Atelectasis (48 hours)
  • Mastitis (2-3 weeks post partum)

17
Complications of Puerperium
  • Infection
  • Maternal temperature best indicator of post
    partum infection
  • Monitor Q6 hours for first twenty four and have
    patient report chills, temperature post
    hospitalization
  • Inspect episiotomy site regularly for infection
  • Monitor for return of bowel/bladder function

18
Analgesics
  • Acetaminophen
  • Aspirin
  • NSAIDs
  • Codeine- complicated by high incidence of
    constipation light headedness
  • Afterpains especially problematic during suckling
    due to oxytocin release

19
Immunizations
  • Puerperium is ideal time to administer rubella
    vaccine for those found non immune
  • Rh- women with Rh baby should receive
    appropriate amounts of Rh immune globulin

20
Contraception
  • Ovulation may occur by week six
  • Sexual intercourse often resumed by week
    two-three
  • Oral contraceptives may be started 1-2 weeks post
    partum in non lactating female20

21
Discharge Instructions
  • Review infant care
  • feeding
  • diapering
  • Follow up visits
  • Colic
  • Infant care and needs
  • Resuming sexual intercourse

22
Discharge Instructions
  • Maternal follow up instructions
  • Perineal care
  • sits baths
  • green water
  • breast care
  • Post partum blues/depression
  • Support services due to early discharge

23
Medications Breast Feeding
  • Drugs and breast milk. Drugs concentrated in
    breast milk tend to be weak bases (such as
    metronidazole, antihistamines, erythromycin, or
    antipsychotics and antidepressants).
  • Drugs absolutely contraindicated in breast
    feeding. Chemotherapeutic or cytotoxic agents,
    all drugs used recreationally (including alcohol
    and nicotine), radioactive nuclear medicine
    tracers, lithium carbonate, chloramphenicol,
    phenylbutazone, atropine, thiouracil, iodides,
    ergotamine and derivatives, and mercurials.

24
Medications Breast Feeding
  • Drugs to strongly avoid or consider bottle
    feeding.
  • Antipsychotics, antidepressants, metronidazole,
    tetracycline, sulfonamides, diazepam,
    salicylates, corticosteroids ,phenytoin,
    phenobarbital, or warfarin.
  • Drugs safe to use in normal doses.
    Acetaminophen, insulin, diuretics, digoxin,
    beta-blockers, penicillins, cephalosporins,
    erythromycin, birth control pills, OTC cold
    preparations, and narcotic analgesics (short term
    in normal doses).
  • Lactation-suppressing drugs.
  • Levodopa, anticholinergics, bromocriptine,
    trazodone, and large-dose estradiol birth control
    pills.

25
Breast Problems During Lactation
  • Mastitis
  • S/S
  • Organisms
  • Rx
  • Obstructed ducts
  • S/S
  • Rx
  • Other

26
Examples of Post Partum Orders
  • Pitocin 10 units IM
  • Bedrest
  • Vital signs Q15 minutes for 1 hour, Q 1hour x 4,
    Then QID if stable
  • Consider NPO for 1-2 hours
  • Ice packs to perineum

27
Examples of Post Partum Orders
  • Ambulate as tolerated when stable (caution check
    for orthostatic hypotension)
  • Diet- as appropriate
  • Tucks to perineum prn
  • Sitz baths QID
  • IV- discontinue when VS stable and uterine
    bleeding is normal

28
Examples of Post Partum Orders
  • Urethral catherization if unable to void in 6-8
    hours
  • Breast binder if not nursing
  • CBC post partum day 2
  • Medications
  • Continue prenatal vitamins
  • FeSO4
  • Acetaminophen 650 mg Q4h prn/Ibuprofen

29
Examples of Post Partum Orders
  • Bowels
  • Ducosate sodium 100 mg BID MOM- 30 ml PO QD PRN
  • Follow up
  • Post partum check 4-6 weeks
  • Newborn checkup 1-2 weeks

30
Post Partum Psychiatric Syndromes
  • Underrecognized
  • Undertreated
  • Underresearched
  • First recognized with publication of DSM IV
    because they were not felt to have
    distinguishable features from other psychiatric
    disorders
  • Most classified as mood disorder subsets

31
Post Partum Psychiatric Syndromes
  • Epidemiology
  • Post partum psychosis
  • 1500
  • Risk for previously affected 13
  • Non psychotic depression
  • 110-15
  • Risk of previously affected 12
  • In patients with history of mood disorder and
    previous post partum depression 100

32
Post Partum Psychiatric Syndromes
  • Post partum blues affects 50-80
  • due to lack of major symptoms not classified as a
    disorder

33
Predisposing Factors
  • Primiparous women
  • Women with personal or family history of mood
    disorders
  • Previous history of Postpartum depression/psychosi
    s
  • Perinatal death

34
Sheehans Syndrome
  • 1967 Howard Sheehan described postpartum necrosis
    of the anterior pituitary
  • blood loss during pregnancy followed by
    circulatory collapse of the pituitary
  • causes array of multiglandular disorders
  • causes agitation, hallucinations, delusions,
    depression
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