1. Puerperium Nazila Karamy –MD Genecology and Obstetric Specialist www.doctorkaramy.ir

2. Puerperium The time 6 w from the delivery tht body returns to the nonpregnant state

3. Uterus Immediately after the delivery, the uterus can be palpated at or near the umbilicus Most of the reduction in size and weight occurs in the first 2 weeks  2 weeks postpartum, the uterus should be located in the true pelvis

4. Lochia Vaginal discharge, lasts about 5 weeks  15% of women have lochia at 6 weeks postpartum Lochia rubra  Red  Duration is variable Lochia serosa  Brownish red, more watery consistency  Continues to decrease in amount Lochia alba  Yellow

5. Cervix, Vagina, Perineum Tissues revert to a nonpregnant state but never return to the nulliparous state

6. Abdominal Wall Remains soft and poorly toned for many weeks  Return to a prepregnant state depends greatly on exercise  Not depend on the root of delivery (c/s,nvd)

7. Ovulation Breastfeeding Longer period of amenorrhea and anovulation Not breastfeeding As early as 1 month after delivery Most have a menstrual period by 3 months Suggest birth control &R/O PREGNANCY in doubtful cases

8. Sexual Intercourse May resume when… Red bleeding ceases Vagina and vulva are healed Physically comfortable Emotionally ready *Physical readiness usually takes ~3 weeks

9. Postpartum Period

10. Concerns - Puerperal Period

11. Hemorrhage

12. Postpartum Hemorrhage Excessive blood loss during or after the 3 rd stage of labor  Average blood loss is 500 mL Early postpartum hemorrhage  1 st 24 hrs after delivery Late postpartum hemorrhage  1-2 weeks after delivery (most common)  May occur up to 6 weeks postpartum

13. Postpartum Hemorrhage

14. Incidence Vaginal birth: 3.9% Cesarean: 6.4% Delayed postpartum hemorrhage: 1-2% Mortality 5% of maternal deaths

15. Postpartum Hemorrhage May result from: Uterine atony Lower genital tract lacerations Retained products of conception Uterine rupture Uterine inversion Placenta accreta  adherence of the chorionic villi to the myometrium Coagulopathy Hematoma Most common

16. Uterine Atony Lack of closure of the spiral arteries and venous sinuses Risk factors:  Overdistension of the uterus secondary to multiple gestations  Polyhydramnios  Macrosomia  Rapid or prolonged labor  Grand multiparity  Oxytocin administration  Intra-amniotic infection

17. Postpartum Hemorrhage

18. Lower genital tract lacerations Result of obstetrical trauma  More common with operative vaginal deliveries Forceps Vacuum extraction Other predisposing factors:  Macrosomia  Precipitous delivery  Episiotomy

19. Infection

20. Endometritis Ascending polymicrobial infection  Usually normal vaginal flora or enteric bacteria Primary cause of postpartum infection  1-3% vaginal births  5-15% scheduled C-sections  30-35% C-section after extended period of labor May receive prophylactic antibiotics <2% develop life-threatening complications

21. Endometritis Risk factors: C-section Young age Low SES Prolonged labor Prolonged rupture of membranes Multiple vaginal exams Placement of intrauterine catheter Preexisting infection Twin delivery Manual removal of the placenta

22. Endometritis Clinical presentation Fever Chills Lower abdominal pain Malodorous lochia Increased vaginal bleeding Anorexia Malaise Exam findings Fever Tachycardia Fundal tenderness Treatment Antibiotics

23. Urinary Tract Infection Bacterial inflammation of the bladder or urethra 3-34% of patients  Symptomatic infection in ~2%

24. Urinary Tract Infection Risk factors C-section Forceps delivery Vacuum delivery Tocolysis Induction of labor Maternal renal disease Preeclampsia Eclampsia Epidural anesthesia Bladder catheterization Length of hospital stay Previous UTI during pregnancy

25. Urinary Tract Infection Clinical Presentation Urinary frequency/urgency Dysuria Hematuria Suprapubic or lower abdominal pain OR… No symptoms at all Exam Findings Stable vitals Afebrile Suprapubic tenderness Treatment antibiotics

26. Mastitis Inflammation of the mammary gland Milk stasis & cracked nipples contribute to the influx of skin flora 2.5-3% in the USA  Neglected, resistant or recurrent infections can lead to the development of an abscess (5-11%)

27. Mastitis Clinical Presentation Fever Chills Myalgias Warmth, swelling and breast tenderness Exam Findings Area of the breast that is warm, red, and tender Treatment Moist heat Massage Fluids Rest Proper positioning of the infant during nursing Nursing or manual expression of milk Analgesics Antibiotics stasis

28. Wound Infection Perineum (episiotomy or laceration) 3-4 days postpartum rare Abdominal incision (C-section) Postoperative day 4 3-15% prophylactic antibiotics  2%

29. Wound Infection Perineum Risk Factors:  Infected lochia  Fecal contamination  Poor hygiene Abdominal incision Risk factors:  Diabetes  Hypertension  Obesity  Corticosteroid treatment  Immunosuppression  Anemia  Prolonged labor  Prolonged rupture of membranes  Prolonged operating time  Abdominal twin delivery  Excessive blood loss

30. Wound Infection Clinical Presentation Perineal Infection: Pain Malodorous discharge Vulvar edema Abdominal Infection Persistent fever (despite antibiotics) Diagnosis Erythema Induration Warmth Tenderness Purulent drainage With or without fever

31. Psychiatric Disorders

32. Postpartum Blues Transient disorder  Lasts hours to weeks Bouts of crying and sadness Postpartum Depression More prolonged affective disorder  Weeks to months S&S of depression Postpartum Psychosis First postpartum year Group of severe and varied disorders (psychotic symptoms) BF NOT SUGGESTED

33. Etiology Unknown Theory: multifactorial Stress  Responsibilities of child rearing Sudden decrease in endorphins of labor, estrogen and progesterone Low free serum tryptophan (related to depression) Postpartum thyroid dysfunction (psychiatric disorders)

34. Risk factors Undesired pregnancy Feeling unloved by mate <20 years Unmarried Medical indigence Low self-esteem Dissatisfaction with extent of education Economic problems Poor relationship with husband or boyfriend Being part of a family with 6 or more siblings Limited parental support Past or present evidence of emotional problems

35. Incidence 50-70% develop postpartum blues 10-15% of new mothers develop PPD 0.14-0.26% develop postpartum psychosis History of depression  30% chance of develping PPD History of PPD or postpartum psychosis  50% chance of recurrence

36. Postpartum Blues Mild, transient, self-limiting Commonly in the first 2 weeks Signs and symptoms Sadness Crying Anxiety Irritation Restlessness Mood lability Headache Confusion Forgetfullness Insomnia

37. Postpartum Blue

38. Postpartum Blues Often resolves by postpartum day 10 No pharmacotherapy is indicated Treatment Provide support and education

39. Postpartum Depression (PPD) Signs and symptoms Insomnia Lethargy Loss of libido Diminished appetite Pessimism Incapacity for familial love Feelings of inadequacy Ambivalence or negative feelings towards the infant Inability to cope

40. Postpartum Depression (PPD) Consult a psychiatrist if… Comorbid drug abuse Lack of interest in the infant Excessive concern for the infant’s health Suicidal or homicidal ideations Hallucinations Psychotic behavior Overall impairment of function

41. Postpartum Depression

42. Postpartum Depression (PPD) Lasts 3-6 months  25% are still affected at 1 year Affects patient’s ADLs Treatment Supportive care and reassurance (healthcare professionals and family) Pharmacological treatment for depression Electroconvulsive therapy

43. Postpartum Psychosis Signs and symptoms Acute psychosis  Schizophrenia  Manic depression

44. Danger

45. Postpartum Psychosis Treatment Therapy should be targeted to the patient’s specific symptoms Psychiatrist Hospitalization *Generally lasts only 2-3 months

46. Breastfeeding Breastfeeding is the best feeding method for most infants  Contraindications include galactosemia of neonate, breast cancer,maternal hepatitis C,breast abcess,post partum psychosis, HIV infection, chemical dependency(immune suppressive medication), and use of certain medications Structured behavior counseling and breastfeeding-education programs may increase breastfeeding success