Normal puerperium .

1. Normal puerperium . DR MANAL BEHERY Assistant Professor Zagazig University 2013

2. Definition of Normal Puerperium It is the period following delivery of the baby and placenta to 6 weeks postpartum. It is the period during it ,the reproductive organs & maternal physiology returns towards the pre pregnancy state .

3. Divided into • First 24 hours • Early- up to 7 days • Remote- up to 6 weeks

4. Objectives • To monitor physiological changes of puerperium • To diagnose and treats any postnatal complications • To establish infant feeding • To advise about contraception

5. Physiological changes in Normal Puerperium • Changes in Genital Tract • Changes in breast and Lactation • Changes in other systems

6. Changes in Genital Tract • Involution of the Uterus • Lochia • Involution of Other Pelvic Organs • Menstruation

7. Uterine involution A. Immediately after delivery: fundus palpable at level of umbilicus B. 10-14 days later, At level of the symphysis pubis. C. 6 WKS post partun: non pregnant size

8. Endometrium Cavity  Decidua is cast off as a result of ischemia  lochial flow  Lochia= blood, leucocytes, shreds of decidua and organisms.  Initially; dusky red3-4 days(rubra), fades after one-two week(serosa), clears within 4 weeks of delivery(alba).  New endometrium grows from basal layer of decidua.

9. Cervix: • It has reformed within several hours of • delivery • it usually admits only one finger by 1 weeks • the external os is fish-mouth-shaped • it return to its normal state at 4 weeks after birth

10. Ovarian function Return of menstruation * non-nursing mothers: menstruation returns by 6 – 8 weeks. * nursing mothers: may develop lactating amenorrhea. • time of ovulation is 3 months in non- breast -feeding women

11. Changes in Breast and Lactation • Mamogenesis (Mammary duct-gland growth & dev.) • Lactogenesis (Initiation Of milk secretion in alveoli) • Galactopoiesis (Maintenance of Lactation)

12. Changes in other systems • Pulse slow • Temp. subnormal • Shivering • Fever up to first 24 hours • Hb. Rises • TLC increases • Diuresis- 2nd to 5th day post delivery

13. OTHER SYSTEMS: • OTHER SYSTEMS: Bladder & Urethra - Within 2-3 weeks Hydroureter and calycial dilatation of pregnancy is much less evident. - Complete return to normal  6-8 weeks Cardiovascular system *cardiac output & plasma volume gradually returns to normal during the first 2 weeks. * marked weight loss occurs in the first week as a result of the decrease of plasma volume and the deuresis of the extracellular fluid.

14. Management of Normal Puerperium

15. Daily round by physical staff should incluid: Uterus: palpate uterine funds to evaluate level and tone Abdomen: examine for distension especially postoperative Lochia :for quantity ,and unusual odors Perineum: inspected for hematoma formation ,signs of infections, or wound breakdown.

16. Bladder: function may be abnormal after traumatic delivery or epidural anethesia. (Catheter may be left in place for 24 hr if there is marked periurtheral edema or repair). Breasts :examined for engorgement or signs of infection Lungs :evaluated in all post CS patients. Extremities :because post partum pt are at increased risk of DVT especially post CS.

17. Post partum immunization Adminster a booster dose in Rubella non immune wommen or MMR vacine. Adminster 300 ug of RhoGAM within first 72 hours after delivery to RH –ve mothers .

18. Breast feeding should be Encouraged Help in rapid uterine involution, decreased risk of ovarian ,breast cancer,osteprosis. Women shouldn't breastfed if: Have infant with galactosemia Are infected with HIV. Have active untreated TB. Are being treated for breast cancer.

19. Contraceptive advice Breast feeding women shouldn’t relay on lactation amenorrhea as a method of contraception (98% protection in first 6 months provided that feeding every 4 hours daily ,6 hours at nigth ,formula supply 10-15%) Use a barrier method or hormonal contraception .POP 2-3 weeks postpartum DMPA 6 weeks postpartum

20. Health & nutrition education Health & nutrition education • Calorie need per day-2200+700 =2900 • Care of MLE stitches if any • Care of nipples and areola • Sexual intercourse can be resumed after 6 weeks after delivery • Immunization of child

21. Puerperal fever

22. Definition Temperatures reach 100.4F(38.0C) or higher on any two of the first 10 days postpartum, exclusive of the first 24 hours.

23. Benign single-day fevers following vaginal delivery • Fever in the first 24 hours after delivery often resolves spontaneously and cannot be explained by an identifiable infection.

24. Significance Significance • Fever is not an automatic indicator of puerperal infection. • A new mother may have a fever owing to prior illness or an illness unconnected to childbirth. • However, any fever within 10 days postpartum is aggressively investigated. • Physical symptoms such as pain, malaise, loss of appetite, and others point to infection.

25. Causes • Endometritis (most common), • Milk engorgment, Mastitis,breast abscess • Urinary tract infection • pneumonia\atlectasis, • CS ,perineal wound infection, fasiaties. • Septic pelvic thrombophlebitis.

26. Mastitis : = uncommon complication usually develops after 2 – 4 weeks. • symptoms & signs low grade fever , chills , indurated ,red and painful segment of the breast. caused by Staphylococcus aureus bacteria from the infant’s oral pharynx.

27. Mastitis

28. Treatment • Mother should start antibiotics immediately, such as dicloxacillin for 7-10 days. • Breastfeeding may be discontinued so, breast pump can be used to maintain lactation . • however , suppression of lactation is advisable. • if a breast abscess develops , it should be surgically drained.

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