PPT for section 10 in Williams OBSTETRICS 24th edition

1. PUERPERIUM
- Allen Rojer
AB Psychology, Study For MD

2. PUERPERIUM
• Period of time
encompassing the
first few weeks(between 4 t
o 6 weeks) after birth
• May be a time of
intense anxiety for
many women

3. ANATOMICAL, PHYSIOLOGICAL
AND CLINICALASPECTS
OF PUERPERIUM
VAGINA AND VAGINAL OUTLET
• Early Puerperium: Vagina and its outlet form a
capacious, smooth-walled passage that gradually
diminishes in size but rarely returns to nulliparous
dimensions.
• 3rd week : rugae begin to reappear but are less
prominent than before.
• Myrtiform caruncles –
scarred small tags of tissue in the hymen
• 4th to 6th week : vaginal epithelium begins to
proliferate (coincidental with ovarian estrogen
production)

4. ANATOMICAL, PHYSIOLOGICAL
AND CLINICALASPECTS
OF PUERPERIUM
• UTERINE
VESSELS During pregnancy:
• Massively increased uterine blood
flow
• Significant hypertrophy
and remodelling of all pelvic
vessels
• After delivery
• caliber of extrauterine vessels decr
eases to equal, or at least closely
approximates, that of the prepregn
ant state.
• larger blood vessels are obliterated
by hyaline changes, gradually
resorbed, and replaced by
smaller ones.
• Minor vestiges
of the larger vessels, however, may
persist for years.

5. ANATOMICAL, PHYSIOLOGICAL
AND CLINICALASPECTS
OF PUERPERIUM
CERVIX
• external os is usually lacerated, especially
laterally
• cervical opening contracts slowly, and for a
few days
immediately after labor readily admits two
fingers.
End of 1stweek:
• Cervix narrows, thickens, and a
canal reforms
• external os does not completely
resume its pregravid appearance
• It remains wider and bilateral depressions
at the site of laceration – PAROUS CERVIX

6. ANATOMICAL, PHYSIOLOGICAL
AND CLINICAL ASPECTS OF
PUERPERIUM
• UTERINE INVOLUTION
• after placental expulsion, the fundus of
the contracted uterus is slightly below
the umbilicus
• Anterior and posterior walls, in close
apposition, each measures 4 to 5 cm
thick
• ischemic organ (vessels are
compressed by the contracted
myometrium) -puerperal uterus
• reddish-purple hyperemic organ –
pregnant
• 2 days after delivery-uterus begins to
involute
• 2 weeks after delivery-uterus
descended into the cavity of the true
pelvis

7. ANATOMICAL, PHYSIOLOGICAL
AND CLINICAL ASPECTS OF
PUERPERIUM
• UTERINE INVOLUTION
• 4 weeks after delivery-uterus
regains its previous nonpregnant
size
• Immediately postpartum, the
uterus weighs approximately 1000 g
• 1 week later it weighs about 500 g
• 2 weeks later it weighs about 300 g,
and soon thereafter to 100 g or less
• total number of muscle cells does
not decrease, but instead, the
individual cells decrease markedly
in size.

8. CROSS SECTIONS OF
UTERI MADE AT THE
LEVEL OF THE
INVOLUTING PLACENTAL
SITE AT VARYING TIMES
AFTER DELIVERY CROSS
SECTIONS OF UTERI
MADE AT THE LEVEL OF
THE INVOLUTING
PLACENTAL SITE AT
VARYING TIMES AFTER
DELIVERY
Cross sections of uteri made at the level of the involuting
placental site at varying times after delivery. p.p. = postpartum.

9. ANATOMICAL, PHYSIOLOGICAL
AND CLINICAL ASPECTS OF
PUERPERIUM
• Sonographic Findings:
• It takes up to 5 weeks for
the uterine cavity to
regress to its
nonpregnant state of a
potential space
• By Doppler studies,
there is continuously
increasing uterine artery
vascular resistance
during the first 5
postpartum days
Sonographic measurements of uterine involution
during the first 9 days postpartum. AP = anteroposterior.
(Data from Hytten, 1995.)

10. ANATOMICAL, PHYSIOLOGICAL AND
CLINICAL ASPECTS OF PUERPERIUM
• ENDOMETRIAL REGENERATION
• 2 or 3 days after delivery, the remaining
decidua becomes differentiated into two layers
• superficial layer- becomes necrotic, and it is
sloughed in the lochia
• basal layer- adjacent to the myometrium,
remains intact and is the source of new
endometrium
• The endometrium arises from proliferation of
the endometrial glandular remnants and the
stroma of the intraglandular connective tissue

11. ANATOMICAL, PHYSIOLOGICAL AND CLINICAL
ASPECTS OF PUERPERIUM
• Endometrial regeneration is rapid, except at the placental site
• Full restoration of the endometrium is obtained 16th day onward
• HISTOLOGIC ENDOMETRITIS – part of normal reparative process
• ACUTE SALPINGITIS seen in almost half of postpartum women
between 5 and 15 days

12. ANATOMICAL, PHYSIOLOGICAL AND CLINICAL ASPECTS OF PUERPERIUM
• AFTER PAINS
• Similar but milder that the pain of labor
contractions
• primiparas, the puerperal uterus tends to
remain tonically contracted
• multiparas, the uterus often contracts
vigorously at intervals, and gives rise to
afterpains
• more pronounced as parity increases
• worsen when the infant suckles
• decrease in intensity and become mild by
the third day

13. ANATOMICAL, PHYSIOLOGICAL AND CLINICAL ASPECTS OF PUERPERIUM
• LOCHIA
• sloughing of decidual tissue results in a
vaginal discharge of variable quantity
• consists of erythrocytes, shredded decidua,
epithelial cells, and bacteria
• LOCHIA RUBRA- first few days after delivery,
there is blood sufficient to color it red
• LOCHIA SEROSA- After 3 or 4 days, lochia
becomes progressively pale in color
• LOCHIA ALBA- After about the 10th day,
because of an admixture of leukocytes and
reduced fluid content, lochia assumes a white
or yellowish-white color

14. ANATOMICAL,
PHYSIOLOGICAL
AND CLINICAL
ASPECTS OF
PUERPERIUM
PLACENTAL SITE INVOLUTION- a process of exfoliation,
consequence of sloughing of infarcted and necrotic
superficial tissues followed by a reparative process.
placental site is about the size of the palm of the hand,
rapidly decreases thereafter
end of the second week, it is 3 to 4 cm in diameter.
Complete extrusion of the placental site takes up to 6 weeks
when it is defective, late-onset puerperal hemorrhage may
ensue

15. ANATOMICAL,
PHYSIOLOGICAL
AND CLINICAL
ASPECTS OF
PUERPERIUM
• SUBINVOLUTION
• an arrest or retardation of involution
• prolongation of lochial discharge
• irregular or excessive uterine bleeding
• uterus is larger and softer than would be
expected
• due to retention of placental fragments and
pelvic infection

16. ANATOMICAL, PHYSIOLOGICAL AND
CLINICAL ASPECTS OF PUERPERIUM
• Management of Subinvolution
• Ergonovine or methylergonovine, 0.2 mg every 3 to 4 hours for 24 to 48 hours
• Antibiotic therapy for bacterial metritis
• Chlamydia trachomatis
• cause of almost third of late postpartum uterine infection;
• treated with Azithromycin or Doxycycline

17. LATE POSTPARTUM
HEMORRHAGE
• develops 1 to 2 weeks into
the puerperium
• result of abnormal
involution of the placental
site, retention of a portion
of the placenta
• initial treatment may be
best directed to medical
control of the bleeding with
intravenous oxytocin,
ergonovine,
methylergonovine, or
prostaglandins
• curettage is carried out only
if appreciable bleeding
persists or recurs after
medical management

18. URINARY TRACT
CHANGES
• diuresis that occurs postpartum (2nd-5th day) is a
physiological reversal of increase in extracellular
water in normal pregnancy
• puerperal bladder has an increased capacity and a
relative insensitivity to intravesical fluid pressure
• paralyzing effect of analgesics, especially epidural
and spinal blocks are contributory
• Overdistention, incomplete emptying, and
excessive residual urine are common
• dilated ureters and renal pelves return to their
prepregnant state over the course of 2 to 8 weeks
after delivery
• dilated renal pelves and ureters, and traumatized
bladder create an optimal condition for the
development of UTI

19. INCONTINENCE
3% to 26% of women
report daily episodes
of incontinence in the
3 to 6 months after
delivery
Can be due to
Impaired muscle
function in or around
the urethra as a result
of vaginal delivery
correlated with
obstetrical factors
such as length of
second-stage labor,
infant head
circumference,
birthweight, and
episiotomy
women whose
deliveries had all
been vaginal had a
70-percent higher risk
of incontinence than
women whose
deliveries had all
been by cesarean

20. PERITONEUM
AND
ABDOMINAL
WALL
abdominal wall remains soft and flaccid due
to rupture of elastic fibers in the skin and the
prolonged distention caused by the pregnant
uterus
several weeks are required for these
structures to return to normal
DIASTASIS RECTI- marked separation of the
rectus muscles ,midline abdominal wall is
formed only by peritoneum, attenuated
fascia, subcutaneous fat, and skin

21. BLOOD AND
FLUID
CHANGES
• marked leukocytosis and thrombocytosis occur
during and after labor
• relative lymphopenia and an absolute
eosinopenia
• during the first few postpartum days, hemoglobin
concentration and hematocrit fluctuate
moderately
• 1 week after delivery, the blood volume has
returned nearly to its nonpregnant level

22. WEIGHT LOSS
loss of about 5 to 6 kg due to
uterine evacuation and
normal blood loss
loss of about 2 to 3 kg
through diuresis

23. MAMMARY GLANDS
 composed of 15 to 25 lobes
 arranged radially and are
separated from one another by
varying amounts of fat
 lobe consists of several lobules,
which are made up of large
numbers of alveoli, every alveolus
is provided with a small duct
 alveolar secretory epithelium
synthesizes the various milk
constituents Schematic of the alveolar and ductal system during
lactation. Note the myoepithelial fibers (M) that surround
the outside of the uppermost alveolus. The secretions from the
glandular elements are extruded into the lumen of the alveoli (A)
and ejected by the myoepithelial cells into the ductal system (D),
which empties through the nipple. Arterial blood supply to the
alveolus is identified by the upper right arrow and venous drainage
by the arrow beneath.
A
A
D
D
M

24. BREASTFEEDING
• COLOSTRUM- deep lemon-yellow-colored liquid,
expressed from the nipples by the 2nd postpartum
day, contains more minerals and protein, much of
which is globulin, but less sugar and fat
• secretion persists for about 5 days, with gradual
conversion to mature milk during the ensuing 4
weeks
• content of immunoglobulin A (IgA) may offer
protection for the newborn against enteric
pathogens
• host resistance factors that are found in colostrum
and milk:
• complement, macrophages, lymphocytes,
lactoferrin, lactoperoxidase, and lysozymes

25. HUMAN MILK
• a suspension of fat and protein in a carbohydrate-mineral solution
• nursing mother easily makes 600 mL of milk per day
• Whey is milk serum and has been shown to contain large amounts of
interleukin-6 (IL-6)
• positive correlation between its concentration and the number of mononuclear
cells in human milk
• IL-6 was associated closely with local IgA production by the breast
• Prolactin and Epidermal growth factor
• All vitamins except K are found in human milk
• Vitamin K administration to the infant soon after delivery is required to prevent
hemorrhagic disease of the newborn

26. ENDOCRINOLOGY OF
LACTATION
Progesterone ,estrogen, and placental lactogen,
prolactin, cortisol, and insulin: stimulate the
growth and development of the milk-secreting
apparatus of the mammary gland
Decrease estrogen and progesterone
Removes the inhibitory influence of progesterone
on the production of alpha lactalbumin by the
rough endoplasmic reticulum
increased alpha lactalbumin stimulate lactose
synthase
increase milk lactose
neurohypophysis secretes oxytocin in pulsatile
fashion
stimulates milk expression from a lactating
breast by causing contraction of myoepithelial
cells in the alveoli and small milk ducts

27. IMMUNOLOGICAL CONSEQUENCES OF
BREASTFEEDING
predominant immunoglobulin in milk is secretory IgA
• SECRETORY IgA is secreted across mucous membranes and has important antimicrobial
functions
• breast-fed infants are less prone to enteric infections than bottle-fed infants
• human milk also provides protection against rotavirus infections,Escherichia coli infections
• contains both T and B lymphocyte
• milk T lymphocytes are almost exclusively composed of cells that exhibit specific membrane
antigens

28. NURSING
• Human milk is ideal food for neonates. It provides species- and age-specific
nutrients for the infant. In addition to the proper balance of nutrients,
immunological factors, and antibacterial properties, human milk contains
factors that act as biological signals for promoting cellular growth and
differentiation
• provides strong evidence that human milk feeding decreases the incidence
and/or severity of diarrhea, lower respiratory infection, otitis media,
bacteremia, bacterial meningitis, botulism, urinary tract infection, and
necrotizing enterocolitis. There are a number of studies that
• shows a possible protective effect of human milk feeding against sudden
infant death syndrome, insulin-dependent diabetes mellitus, Crohn disease,
ulcerative colitis, lymphoma, allergic diseases, and other chronic digestive
diseases.
• Breast feeding has also been related to possible enhancement of cognitive
development

29. NURSING
Ideal for neonates
Provides species and age specific nutrients
Promotes cellular growth & differentiation
Decreases incidence of infections
Protective against: SIDS, IDDM, IBD, Lymphoma,
Allergy, Chronic Digestive disease
Enhances Cognitive development

30. LACTATION
INHIBITION
• Milk leakage, engorgement, and breast pain
peak at 3 to 5 days postpartum
• Ice packs and oral analgesics for 12 to 24 hours
may be required to relieve
• Bromocriptine ,a commonly used drug for
lactation inhibition, had been associated with
strokes, myocardial infarctions, seizures, and
psychiatric disturbances.

31. CONTRACEPTION
FOR
BREASTFEEDING
WOMEN
• Recommendations for Hormonal Contraception if Used
by Breast Feeding Women
• Progestin-only oral contraceptives prescribed or
dispensed at discharge from the hospital to be started 2–3
weeks postpartum—for example, the first Sunday after the
newborn is 2 weeks of age.
• Depot medroxyprogesterone acetate initiated at 6
weeks postpartum.a
• Hormonal implants inserted at 6 weeks postpartum.
• Combined estrogen–progestin contraceptives, if
prescribed, should not be started before 6 weeks
postpartum, and only when lactation is well established
and the infant's nutritional status well monitored

32. CONTRAINDICATIONS
TO BREASTFEEDING
• in women who take street drugs or do not control their
alcohol use
• have an infant with galactosemia
• have human immunodeficiency virus (HIV) infection
• have active, untreated tuberculosis
• take certain medications
• undergoing treatment for breast cancer
• *although hepatitis B virus is excreted in milk, breast feeding
is not contraindicated if hepatitis B immune globulin is given
to infants of seropositive mothers.
• * Maternal hepatitis C infection is also not a
contraindication to breast feeding
• * Women with active herpes simplex virus may suckle their
infants if there are no breast lesions and if particular care is
directed to hand washing before nursing.

33. NIPPLE CARE
CLEANLINESS AND
ATTENTION TO FISSURES
CLEANING OF THE AREOLA
WITH WATER AND MILD
SOAP IS HELPFUL BEFORE
AND AFTER NURSING
WHEN THE NIPPLES ARE
IRRITATED, USE A NIPPLE
SHIELD FOR 24 HOURS OR
LONGER

34. Drugs That
Have Been
Associated with
Significant
Effects on Some
Nursing Infants

35. Drugs That Have Been Associated with
Significant Effects on Some Nursing
Infants
• *cytotoxic drugs may interfere with the cellular metabolism
of the infant and potentially cause immune suppression
or neutropenia, affect growth, or, at least theoretically,
increase the risk of cancer
• 1.cyclophosphamide
• 2.cyclosporine
• 3.doxurubicin
• 4.methotrexate
• * Radioactive isotopes of copper, gallium, indium, iodine,
sodium, and technetium rapidly appear in breast milk. This
ranges from 15 hours up to 2 weeks, depending on the
isotope used.

37. BREAST FEVER
• breasts become distended, firm, and nodular
• a transient elevation of temperature (ranged
from 37.8 to 39°)
• Treatment: supporting the breasts with a
binder or brassiere, applying an ice bag, an
analgesic, pumping of the breast or manual
expression of milk

38. MASTITIS
• infection of the mammary glands during the
puerperium and lactation or antepartum
• unilateral, and marked engorgement usually precedes
the inflammation.
• first sign of inflammation is chills or actual rigor, soon
followed by fever and tachycardia.
• About 10 % of women with mastitis develop an
abscess
• ETIOLOGY: Staphylococcus aureus – 40 %; coagulase-
negative staphylococci and viridans streptococci
• Immediate source of organisms almost always the
infant's nose and throat
•

39. TREATMENT:
MASTITIS
• clinicians recommend that milk be expressed from
the affected breast onto a swab and cultured
• initiate antimicrobial therapy:
• staphylococcal infections are usually sensitive to
penicillin or a cephalosporin
• Dicloxacillin 500 mg orally four times daily, may
be started empirically
• Erythromycin is given to women who are
penicillin sensitive
• Vancomycin is effective against MRSA
• treatment should be continued for 10 to 14 days
• If the infected breast is too tender to allow
suckling, gently pumping until nursing can be
resumed is recommended.

40. BREAST ABSCESS
• development is either from failure of defervescence within 48 to 72 hours or
development of a palpable mass
• TREATMENT: Traditional therapy is surgical drainage less invasive alternative is
ultrasonographic-guided needle aspiration using local anesthesia
• GALACTOCOELE
• result of the clogging of a duct by inspissated secretion,milk may accumulate in
one or more lobes of the breast
• excess may form a fluctuant mass that may give rise to pressure symptoms
• resolve spontaneously or require aspiration

41. SUPERNUMERARY
BREAST
• so small as to be mistaken for pigmented moles, or when without a
nipple, for a lipoma
• situated in pairs on either side of the midline of the thoracic or
abdominal walls, usually below the main breasts; also found in the
axillae, and more rarely on other portions of the body, such as the
shoulder, flank, groin, or thigh
• no obstetrical significance
ABNORMALITIES OF NIPPLES
• Inverted- draw the nipple out, using traction with fingers.
• Normal size and shape- may become fissured lesions
provide a convenient portal of entry for pyogenic bacteria effort
should be made to heal such fissures

42. ABNORMALITIES
WITH SECRETION
complete lack of mammary
secretion (agalactia)
mammary secretion is
excessive (polygalactia).

43. CARE OF THE MOTHER
DURING PUERPERIUM
• HOSPITAL CARE
• first hour after delivery, blood pressure and
pulse should be taken every 15 minutes, or more
frequently if indicated
• amount of vaginal bleeding is monitored
• significant hemorrhage is greatest immediately
postpartum
• fundus should be palpated to ensure that it is well
contracted
• If relaxation is detected, the uterus should be
massaged through the abdominal wall until it
remains contracted.

44. EARLY AMBULATION
• Women are out of bed within a few hours
after delivery
• Advantages of early ambulation include
less frequent bladder complications and
constipation
• Reduced the frequency of puerperal
venous thrombosis and pulmonary
embolism

45. CARE OF THE VULVA
• cleanse the vulva from anterior to
posterior (vulva toward anus)
• ice bag applied to the perineum may help
reduce edema and discomfort during the
first several hours after episiotomy repair.
• Beginning about 24 hours after delivery,
moist heat as provided with warm sitz
baths can be used to reduce local
discomfort. Tub bathing after
uncomplicated delivery is allowed

46. BLADDER
FUNCTION
OXYTOCIN, IN DOSES THAT
HAVE AN ANTIDIURETIC
EFFECT, AS A CONSEQUENCE
OF INFUSED FLUID AND THE
SUDDEN WITHDRAWAL OF THE
ANTIDIURETIC EFFECT OF
OXYTOCIN, RAPID BLADDER
FILLING IS COMMON
BLADDER SENSATION AND
CAPABILITY TO EMPTY
SPONTANEOUSLY MAY BE
DIMINISHED BY ANESTHESIA,
ESPECIALLY CONDUCTION
ANALGESIA, AS WELL AS BY
EPISIOTOMY, LACERATIONS,
OR HEMATOMAS
IT USUALLY IS BEST TO LEAVE
THE CATHETER IN PLACE FOR
AT LEAST 24 HOURS,
WHENEVER THE BLADDER
BECOMES OVERDISTENDED
IF THE WOMAN CANNOT VOID
AFTER 4 HOURS, SHE SHOULD
BE CATHETERIZED AND URINE
VOLUME MEASURED

47. BLADDER
FUNCTION IF THE WOMAN CANNOT VOID AFTER 4 HOURS, SHE
SHOULD BE CATHETERIZED AND URINE VOLUME
MEASURED.
IF THERE IS MORE THAN 200 ML OF URINE, IT IS
APPARENT THAT THE BLADDER IS NOT
FUNCTIONING APPROPRIATELY. THE CATHETER
SHOULD BE LEFT IN PLACE AND THE BLADDER
DRAINED FOR ANOTHER DAY. IF LESS THAN 200 ML
OF URINE IS OBTAINED, THE CATHETER CAN BE
REMOVED AND THE BLADDER RECHECKED
SUBSEQUENTLY AS DESCRIBED.

48. SUBSEQUENT
DISCOMFORT
uncomfortable for a variety of reasons, including
afterpains, episiotomy and lacerations, breast
engorgement, and at times, postspinal puncture
headache
Early application of an ice bag may minimize swelling
and discomfort
severe pain warrants careful examination
episiotomy incision normally is firmly healed and
nearly asymptomatic by the third week

49. DEPRESSION
• postpartum blues- degree of depressed
mood a few days after delivery
• The emotional letdown that
follows the excitement and fears
that most women experience
during pregnancy and delivery.
• The discomforts of the early
puerperium.
• Fatigue from loss of sleep during
labor and postpartum.
• Anxiety over her capabilities for caring
for her infant after leaving the hospital.
• Fears that she has become less attractive
• *effective treatment need be nothing
more than anticipation, recognition, and
reassurance
• *mild disorder is self-limited and usually
remits after 2 to 3 days, although it
sometimes persists for up to 10 days

50. ABDOMINAL WALL
RELAXATION
• Exercises to restore abdominal wall
tone may be started any time after
vaginal delivery and as soon as
abdominal soreness diminishes after
cesarean delivery

51. DIET
NO dietary restrictions for women who have been
delivered vaginally
• if there are no complications likely to necessitate an anesthetic, the
woman should be allowed to eat if she desires
The diet of lactating women, compared with that
consumed during pregnancy, should be increased in
calories and protein, as recommended by the Food
and Nutrition Board of the National Research Council
• If the mother does not breast feed, dietary requirements are the
same as for a nonpregnant woman

52. THROMBOEMBOLIC
DISEASE
• Half of thromboembolic events
associated with pregnancy develop in the
puerperium,
• Pressure on branches of the
lumbosacral nerve plexus during
labor may be manifest by
complaints of intense neuralgia or
cramplike pains extending down one
or both legs as soon as the head
begins to descend into the pelvis
• If the nerve is injured, pain
continues after delivery and may be
accompanied by variable degrees of
sensory loss or muscle paralysis
supplied by the damaged nerve

53. OBSTETRICAL
NEUROPATHIES
• If the nerve is injured, pain continues after
delivery and may be accompanied by variable
degrees of sensory loss or muscle paralysis
supplied by the damaged nerve
• Lateral femoral cutaneous neuropathies
were the most common
• Nulliparity and prolonged second-stage of
labor were independent risk factors for nerve
injury.
• Separation of the symphysis pubis or one of
the sacroiliac synchondroses during labor may
be followed by pain and marked interference
with locomotion

54. PELVIC JOINT
SEPARATION
• 1 in 600 to 1 in 30,000 deliveries
• the onset of pain is acute at delivery
• Treatment: lateral decubitus position and an appropriately
fitted pelvic binder
• surgery may be necessary when symphyseal
separation is more than 4 cm Recurrence is more
than 50 percent in subsequent pregnancy, cesarean
delivery be considered.
• IMMUNIZATION
• D-negative woman who is not isoimmunized and whose
infant is D-positive is given 300
• microgram of anti-D immune globulin shortly after
delivery

55. TIME OF DISCHARGE
• Following vaginal delivery, if there are no complications,
hospitalization is seldom warranted for more than 48
hours.
• Receive instructions regarding:
• normal physiological changes of the puerperium,
including lochia patterns, weight loss from diuresis,
and when to expect milk let-down
• what to do if she becomes febrile, has excessive
vaginal bleeding, or develops leg pain, swelling, or
tenderness,any shortness of breath or chest pain
warrants immediate concern
• EARLY DISCHARGE
• “”The norms are hospital stays of up to 48 hours
following uncomplicated vaginal delivery and up to 96
hours following uncomplicated cesarean delivery.”
• American Academy of Pediatrics, American Academy of
Obstetricians and Gynecologists, 2002

56. CONTRACEPTION
• effort should be made to
provide family planning
education
• If a woman is not
breastfeeding, menses
usually return within 6 to 8
weeks
• Ovulation is much less
frequent in women who
breast feed compared with
those who do not
• lactating women, the first
period may occur as early
as the second or as late as
the 18th month after
delivery

57. CONTRACEPTION
Clearly, there is delayed resumption of ovulation with breast feeding,
although as already emphasized, early ovulation is not precluded by
persistent lactation.
Other findings included the following:
1.Resumption of ovulation was frequently marked by return of normal
menstrual bleeding
2.Breast feeding episodes lasting 15 minutes seven times each day
delayed resumption of ovulation.
3. Ovulation can occur without bleeding.
4.Bleeding can be anovulatory.
5.The risk of pregnancy in breast feeding women was approximately 4
percent per year.

58. HOME CARE
• COITUS - no definite time after delivery when coitus should
be resumed
• The median interval between delivery and intercourse was 5
weeks range was 1 to 12 weeks
• reasons cited for not resuming intercourse included perineal
pain, bleeding, and fatigue
• -coitus may be resumed based on the patient's desire and
comfort
• B. INFANT FOLLOW UP
• importance of subsequent neonatal and well-baby care
should be stressed and an emphasis placed on infant
immunizations.
• Any neonate discharged early should be term, normal, and
have stable vital signs.
• Initial hepatitis B vaccine should be administered, and all
screening tests required by law should be performed

59. FOLLOW UP
CARE
• only half of women
regained their usual level
of energy by 6 weeks
postpartum
Postnatally, most
societies did not
restrict maternal
work activity, and
about half
expected a return
to full duties
within 2 weeks
• Ideally, the care and
nurturing of the neonate
should be provided by
the mother with ample
help from the father.
Women who
delivered vaginally
were twice as
likely to have
normal energy
levels at this time
compared with
those with a
cesarean delivery.

60. Puerperal
Morbidity in
Percent Reported
by Women After
Hospital Discharge
Morbidity By 8 weeks Post
partum
2 to 18 months Post-
partum
1 Tiredness 59 54
2 Breast Problems 36 20
3 Anemia 25 7
4 Backache 24 20
5 Haemorrhoids 23 15
6 Headache 22 15
7 Tearfulness/depression 21 17
8 Constipation 20 7
9 Stitches breaking down 16 -
10 Vaginal discharge 15 8
11 Others 2-7 1-8
12 At least one of the above 87 76

61. THANK YOU!!!