1. Puerperium Dr. Yasir Katib MBBS, FRCSC Perinatologest

2. Objectives Anatomical and physiological changes in pregnancy that led to normal lactation Understand the physiology and advantages of normal lactation Available methods of lactation suppression Prevent, recognize and manage breast-feeding complications Diffrentiate the causes of puerperal pyrexia Recognize the postpartum mental illnesses

3. Puerperium It is the time from the delivery of the placenta through the first 6 weeks after the delivery Why?? Anatomical and physiological changes of pregnancy return to pre-pregnancy state

4. Puerperium Examples Uterus –Weight –Cervix –Lochia (rubra, serosa then alba) Vagina –Pelvic floor –Vaginal vs. C/S –Episiotomy Menstruation –Breast feeding –Ovulation

5. Postpartum Care Discharge time Rh immunoglobulin Vaginal (episiotomy, pain and hemorrhoids) C/S (ambulation, eating and voiding) Sexual intercourse Education and discharge instruction Contraception

6. Breast Feeding Physiology Lactation can occur by 16 weeks' gestation Lactogenesis is initially triggered by the delivery of the placenta, which results in falling levels of estrogen and progesterone, with the continued presence of prolactin Suckling stimulates the release of prolactin and oxytocin secondly If the mother is not breastfeeding, the prolactin levels decrease and return to normal within 2-3 weeks

7. Breast Feeding Physiology Colostrum is the liquid that is initially released by the breasts during the first 2-4 days after delivery High in protein, lactose and water This liquid is very protective for the newborn

8. Breast Feeding Infants Maternal 1.Delays fertility 2.Decrease cancers (breast, uterine, ovarian) 3.Emotional health 4.Promote wt loss 5.Decrease osteoporosis Society

9. Breast Feeding Complications Breast engorgement Swelling of the breast and can occur early or late in the postpartum period During 1 st week (Day2 +/- 1day) Resolves spontaneously in the majority of cases, but may be exaggerated if the infant does not latch on Management

10. Breast Feeding Complications Cracked (sore) Nipples Pain (sensitivity vs. fissure trauma) Management –Good latch-on and proper suckling –Ankyloglossia –Topical care (Lanolin cream)

11. Breast Feeding Complications Mastitis An infection of the breast Causative agent (staphylococcus aureus, streptococcus, and Escherichia coli) 1 to 3% lactating women Management –Supportive measures –Antibiotic treatment (cloxacillin) Recurrent mastitis

12. Breast Feeding Complications Breast Abscess Incidence of 0.1 percent Risk factors (maternal age over 30 years of age, primiparity, gestational age ≥ 41wk and mastitis Management

13. Breast feeding Suppression Timing Indications –Medications (e.g. iodieds) –Infections (e.g. HIV) Methods –Mechanical –Medical (e.g. bormocryptin)

14. Puerperal Pyrexia It is a temperature of 38°C, maintained for or recurring within 24 hours, within 2-3 weeks of childbirth or abortion Causes –Womb Local infection –Wound Vaginal Vs. C/S –Water UTI –Walk DVT –Wind RTI –Wondering drugs Meds –Others Breast, IV

15. Womb

16. Puerperal Pyrexia History & Examination Investigations complete septic work up Treatment broad spectrum antibiotics wait for cultures

17. Mental illnesses Post-partum 'Blues' This occurs in around 50% of women within 4 to 5 days of delivery It is usually a self limiting condition Rarely progress

18. Mental illnesses Postnatal Depression It is a relatively common disorder Onset between 1-6 months after delivery May last 6 moths or longer Clinical features sleep disturbance depressed mood social withdrawal lack of worthiness about being a mother Suicidal thoughts

19. Mental illnesses Management Social support Psychiatric or psychological care Medications

20. Mental illnesses Puerperal Psychosis Psychotic illness occurs in 0.2% of mothers and the onset is earlier than postnatal depression. This is a serious condition and requires expert psychiatric evaluation and treatment