The puerperium & Puerperial Infections

1. The puerperium & Puerperial Infections DR. RAZAQ MASHA FRCOG Asst. Prof. & Consultant Ob/Gyn Dept.

2. During the puerperium, the pelvic organs return to the non-gravid state, the metabolic changes of pregnancy are reversed and lactation is established. • The objectives of the medical and nursing staffs during the puerperium can be summarized as follows. • To monitor the physiological changes of the puerperium • To diagnose and treat any postnatal complications • To establish infant feeding • To give the mother emotional support • To advise about contraception and other measures which will contribute to continuing health

3. Physiology of the Puerperium • The establishment of infant feeding is one of the main properties of the puerperium. • Breast milk has the following advantages a. It is the natural food for the human infant. b. It is inexpensive and always at the right temperature. c. It helps to protect the baby against infection d. It contributes to development of mother infant attachment. e. Inhibition of ovarian activity and encouragement of uterine involution

4. Artificial Feeding • If the mother does not wish to breast feed and artificially feed the baby: a. She may have some discomfort in the puerperium from breast distention due to milk which is secreted into the breast but not removed. Firm support to the breast may be all that is required and the milk will soon disappear. However, to suppress milk production completely, it is better to give bromocriptine for a period of 14 days.

5. Physiology of Lactation • During pregnancy only minimal amounts of milk are formed in the breast despite high levels of the lactogenic hormones, prolactin and lactogen. - They are inhibited by oestrogens and progestrone.

6. Two mechanisms are involved in the establishment of successful lactation. a. The first mechanism causes the release of prolactin which acts upon the glandular cells of the breast to stimulate milk secretion. b. The second induces the release of oxytocin which acts upon the myoepithelial cells of the breast to induce the milk ejection reflex.

7. Prolactin is a long-chain polypeptide. Following an episode of nipple stimulation, prolactin is released from the lactotrophs in the anterior pituitary. Thus prolactin levels during lactation are dependent upon the strength, frequency and duration of the suckling stimulus. Adequate milk secretion requires both the correct endocrine stimulus to the breast and satisfactory emptying of the milk from the stimulated gland.

8. Milk Ejection Reflex • This is mediated by the release of oxytocin from the posterior pituitary. Oxytocin causes contraction of the sensitive myoepithelial cells which are situated round the milk-secreting glands and also dilates the ducts by acting upon the muscle cells which lie longitudinally in the duct walls Contraction of these cells will therefore cause: a. Expulsion of the milk from the glands b. Free flow of milk along dilated ducts

9. Pelvic Organs • The principal change is uterine involution - After delivery, fundus is at the level of umbilicus , - By 10-14 days, the fundus is usually behind the symphysis pubis . This process is aided by the release of oxytocin during breast feeding.

10. Complications of the Puerperium • The most serious complications are thromboembolism, infection and haemorrhage, though breast infections, urinary complications and mental disorders may complicate this period. • A puerperial pyrexia may have several explanations but the principal sites to be investigated are the chest, pelvic organs, the urinary tract, any surgical wounds, the legs and the breast.

11. Pelvic Infection • Predisposing Factors: a. History of prolonged rupture of membranes. b. Protracted labour with multiple vaginal examinations. c. Retained products of conception Most common organism is  haemolytic strept. E. Coli may also be responsible. Clinical features: a. Pyrexia b. Offensive lochia c. Lower abdominal discomfort d. Tender uterus and cervical excitation tenderness If untreated may progress to peritonitis, septicaemia or bacteraemic shock

12. Diagnosis a. Clinically b. Swabs – from cervix, HVS, Urethra c. Blood culture a. Evacuate the uterine cavity under anaesthesia b. Intravenous broad spectrum antibiotics Cepahlosporin and Metronidazole Treatment

13. Breast Abscess • Develops usually after the 14th day. a. Red, painful, fluctuant swelling b. Fever and ill looking c. Antibiotics and incision and drainage under general anaesthesia