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Physiology of the Puerperium. Anatomic changesUterusLochia-name given to blood and other necrotic debris shed from the uterusUterus does not scar- tissue replaced by new growth from the basal endometriumProliferative endometrium persists for about six weeks and first menses normally anovulatory.
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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
Enlarges immediately after delivery to umbulicus by two weeks it resumes its position within the pelvis at six weeks returns to non pregnant size
Enlarges immediately after delivery to umbulicus by two weeks it resumes its position within the pelvis at six weeks returns to non pregnant size
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 < 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
1:500
Risk for previously affected 1:3
Non psychotic depression
1:10-15
Risk of previously affected 1:2
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/psychosis
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