The puerperal disorders Department of Obstetrics & Gynecology Dr. Dina Nawfal Department of Obstetrics & Gynecology College of Medicine University of Mosul

Puerperal disorders Symphysis pubis diastasis: caused by instrumental delivery severe abduction of the thigh during delivery (symphysiotomy) as in treating extreme cases of shoulder dystocia characterised by symphysial pain aggravated by weight bearing and walking, a wadling gait, pubic tenderness and palpable interpubic gap. treatment includes bed rest, anti inflammatory agents, physiotherapy and a pelvic corset

Thromboembolism: Puerperal pyrexia: The risk of thromboembolic disease increase during pregnancy and puerperium. the majority occurs after cesarean section. full anticoagulation should offered within 24 to 48 hours Puerperal pyrexia: Defined as a temperature of 38oC or more that occur in the first 10 days post partum excluding the first 24 hours. causes of puerperal pyrexia include: wound infection, chest infection, breast congestion, urinary tract infection, thromboembolic events.

Chest complications: this include complications that occurs after general anasthesia atalectasis prevented by regular chest physiotherapy mendelson's syndrome (aspiration pneumonia) is suspected when there is wheezes, dyspnea, spiking temperature, and evidence of hypoxia.

Psychiatric disorders: Postnatal depression: Usually present later after delivery (6 weeks post partum) it is variable in severity in severe form the patient present with (early morning wakening, poor appetite, worse depression at morning, low energy and libido, impaired concentration, feeling of guilt and failure, anxiety, thought of self harm and suicide, thoughts of harm to the baby) treatment include: psychotherapy, behavioural therapy, drug therapy with antidepressant.

Puerperal psychosis: it affect 1:1000 woman after delivery usually presents after third post partum day usually before 4 weeks its symptoms include: restless and agitation, insomnia, confusion, delusion and hallucinations, failure to eat and drink, thoughts of self harm, depressive symptoms, loss of insight treatment include referral to psychiatrist, admission to the hospital, drugs(neuroleptics such as haloperidol), electroconvulsive therapy, antidepressant drugs.

The Newborn Baby: Immediately following birth, infant survival depends on a prompt and orderly conversion to air breathing Fluid-filled alveoli expand with air, perfusion must be established, and oxygen and carbon dioxide exchanged.

Examination of the newborn infant A preliminary examination is made in the delivery room to establish that the baby does not have a major abnormality such as spina bifida and the full examination at a later time A full examination should be carried out on every baby in the presence of the mother before discharge from hospital Ideally it should take place 24–48 h after birth however if discharged before this the examination should still be under taken. It is then advisable to examine the baby again during the first week of life.

Methods Used to Evaluate Newborn Condition APGAR Score This scoring system is a useful clinical tool to identify those neonates who require resuscitation as well as to assess the effectiveness of any resuscitative measures each of the five easily identifiable characteristics—heart rate, respiratory effort, muscle tone, reflex irritability, and color—is assessed and assigned a value of 0 to 2 The total score, based on the sum of the five components, is determined 1 and 5 minutes after delivery.

Some flexion of the extrimities Body pink and extrimities blue 2 points 1 point O points Signs 100 BPM < 100 BPM absent Heart rate Good crying Slow , irregular Respiratory effort Active motion Some flexion of the extrimities flaccid Muscle tone Vigorous cry Grimace No response Reflex irritability Completely pink Body pink and extrimities blue Blue, pale Color

Resuscitation: Babies fall into one of three categories within a minute of birth: A healthy baby: cry within seconds with a good tone and activity a heart rate of more than 100 BPM resuscitation done by drying him and wrap him with a warm towel and give him back to his mother.

2. Non breathing regularly with a heart rate more than 100 BPM central cyanosis resuscitation done by drying the baby and place him under radiant heat source and gentle rubbing can also be used if there is no response begin active resuscitation with a bag and mask five inflations( breaths) and call for help.

3. Not breathing Or has heart rate of less than 100 BPM Or baby looks pale the baby is floppy and need prompt resuscitation with drying him quickly and place him on resuscitation surface in a warm, dry towel call for help and initiate basic resuscitation with mask ventilation if heart rate still less than 60 BPM if there is no rapid response proceed to intubation

Diagnosis of common minor problems: Erythema toxicum: Is a common rash which usually appears on second or third day and takes the form of white pinpoint (heads) on an oval erythematous base, it is harmless and last for few days.

Milia: Tiny yellowish-white spots specially common on the nose and elsewhere on the face it will disappear over one or two months and represents retention cyst of pilosebaceous follicles. Skin tags / extra digit: These should be surgically removed these are often familial.

Mongolian blue spots: Are blue-black macular lesions usually situated over the base of the spine commoner in Afro-carribean or Asian infants it will disappear slowly over few years.

Port wine stains: Are due to malformation of the capillaries within the dermis port wine stains in the region of the trigeminal nerve are sometimes associated with intracranial vascular abnormalities (Sturge-Weber syndrome). laser therapy can now produce an excellent cosmetic improvement for large facial lesions.

Danger signs in the well baby nursery: temperature instability a change in activity, including refusal to feed or having to be wakened for feeding unusual skin color, mottling, extreme pallor, jaundice on the first day an abnormal heart rate or respiratory rate including grunting or fast breathing

apnea abnormal repetitive movement delayed bowel motion (beyond 48 hours) or completely dry nappies abdominal distension, green vomit (bilious until proved otherwise) odd lumps or swelling lethargy or floppiness

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