it describes in detail about puerperium and lactation and their associated complications and management.

1. DR. AYESHA SHERZADA
FCPS R1

2. OBJECTIVES
 Definition of puerperium, physiological changes in body
during puerperium.
 Management of puerperium.
 Complications.
 Importance of breastfeeding.
 Mental health during puerperium.

3. PUERPERIUM
 The puerperium is the period from the delivery of he
placenta to 6 weeks after the delivery.

4. PHYSIOLOGY OF PUERPERIUM
 Two major physiological events occur during the
puerperium:
 the establishment of the lactation
 the return of the physiological changes of pregnancy to the
non-pregnant state.
 During first two weeks----some changes are rapid.
 Others take 6-12 weeks to complete.

5. CHANGES DURING PUERPERIUM
 Involution of uterus.
 Lochia
 Ovulation and menstruation.
 Cervical changes.
 Cardiovascular and coagulation.
 Urinary tract.
 Weight loss.
 Thyroid functions.
 Hair loss.

6. UTERINE INVOLUTION
 Pregnant uterus at term weighing about 1 kg returns to pre-
pregnant state of < 100gms.
 Uterine fundus is no longer palpable abdominally by 10 days after
delivery, and uterus returns to normal size by 6 weeks.
 Involution is by autolysis, muscle cells diminish in size, not in
numbers.
 Involution appears to be accelerated by oxytocin in
breastfeeding.

7. CAUSES OF DELAYED INVOLUTION
 Full bladder
 Loaded rectum
 Uterine infection
 Retained products of conception
 Fibroids
 Broad ligament hematoma.

8. LOCHIA
 Blood stained uterine discharge comprised of blood and
necrotic decidua.
 Basal layer is involved in regeneration of new endometrium
after necrotic decidua is sloughed off.
 Regeneration is completed by 3rd week.
 Persistence of red or offensive lochia is suggestive of
pathology, should be manage accordingly.

9. OVARIAN FUNCTION
 In non-lactating women, ovulation occur as early as 27days after
delivery---mean time is approx. 70-75 days.
 In lactating women, mean time to ovulation is 6 months.
 Menstruation resumes by 12 weeks after birth in 70% non-
lactating women, mean time is 7-9 weeks.
 Risk of ovulation within 6 months after delivery in lactating
women is 1-5%.
 Reason of ovulation suppression in lactating women is ----
prolactin.

10. CARDIOVASCULAR & COAGULATION SYS.
Changes in the cardiovascular and coagulation systems
during the puerperium
cardiovascular Early puerperium Late puerperium
Heart rate Falls 14% by 48hrs Normal by 2wks
Stroke vol. Rises over 48hrs Normal by 2wks
Cardiac output Remains elevated & then
falls over 48hrs
Normal by 24wks
Blood pressure Rises over 4days Normal by 6wks
Plasma vol. Initial increases then falls. Progressive decline in 1st
wk.

11. CARDIOVASCULAR & COAGULATION SYS.
coagulation Early puerperium Late puerperium
fibrinogen Rises in 1st wk Normal by 6wks
Clotting factors Most remains elevated Normal by 3wks
Platelets count Falls and then rises Normal by 6wks
fibrinolysis Rapid reversal of
pregnancy inhibition of
tissue plasminogen
activator.
Normal by 3wks

12. OTHER SYSTEMS
 Urinary tract:
 Bladder and urethra may show mild trauma sustained at delivery
& are associated with localized edema.
 Completely returns to normal in 6-8wks.
 Thyroid function:
 Thyroid vol. inc by 30% during pregnancy.
 Returns to normal over 12wks.
 Thyroid hormones return to normal within 4wks.

13. OTHER SYSTEMS
 Weight loss:
 Immediate loss of 4.5-5kgs after delivery.
 28% women returns to pre-pregnancy weight by 6wks.
 Women with excessive weight gain 0f >15kg, still have 5kgs net gain at 6
months.
 Breastfeeding has no effect on postpartum weight loss unless lactation
cont. for 6months.
 Diet and exercise have no effect on growth of infant.
 Hair loss:
 This is transient phenomenon, more hair is lost than regrown.

14. MANAGEMENT OF NORMAL PUERPERIUM

15. DAILY ROUND SHOULD INCLUDE
 VITALS: pulse, BP, temp, resp rate.
 CHEST: auscultate in all pts, esp post C/S.
 BREASTS: examine for engorgement and signs of infection.
 UTERUS: palpate uterine fundus to evaluate level & tone.
 ABDOMEN: examine for distention, especially postoperatively.
 LOCHIA: for quality and unusual odor.
 PERINEUM: inspected for hematoma formation, signs of infection, or
wound breakdown.

16. DAILY ROUND SHOULD INCLUDE
 BLADDER: function may be abnormal after traumatic delivery or
epidural anesthesia.
(catheter may be left in place for 24hrs, if there is marked periurethral
edema or repair.)
 EXTREMITIES: because postpartum patients are at increase risk of
DVT, especially post C/S.

17. ADVISE AFTER DELIVERY
 Encourage for breastfeeding.
 Encourage for early mobilization after C/S.
 Counsel for effective contraception.
 Postpartum immunization in Rh-ve women.
 Health and nutrition education:
 Calories intake should be individualized on women’s BMI and activity level.
 Care of nipples and areola.
 Sexual intercourse can be resumed 6 weeks after delivery.
 Immunization of child.

18. COMPLICATIONS OF THE PUERPERIUM
 The most serious complications are thromboembolism,
infections and hemorrhage, as well as mental disorders and
breast problems.

19. PERINEAL COMPLICATIONS
 Pain in about 80% of women in 1st 3 days of delivery.
 Discomfort is greatest in those who sustain spontaneous tears,
episiotomy or instrumental delivery.
 Sitz bath, oral diclofenac or paracetamol, topical analgesics----for pain
relief.
 Spontaneous opening of repaired perineal tears and episiotomies ------
sec. infections.
 Avoid surgical repair------allow to heal by sec. intention.
 Sec. repair-----no exudate and cellulitis & granulation tissue present.

20. URINARY COMPLICATIONS

21. URINARY COMPLICATIONS
 Urinary retention.
 Causes--- painful episiotomy, epidural anesthesia, instrumental
deliver.
 Avoid urinary retention in immediate postnatal period, as over-
distension may leads to atonic bladder.
 After epidural anesthesia bladder may take up to 8 hrs. to regain
normal sensation.
 Fluid overloading prior to epidural + antidiuretic effect of high
conc. of oxytocin + inc. postpartum diuresis + inc. fluid intake
by lactating mother =inc. urine production in puerperium.

22. URINARY COMPLICATIONS
 Minimize the risk of over-distention of the bladder after C/S &
epidural anesthesia by leaving catheter in situ for 12-24 hrs.
 Investigate any incontinence to exclude vesico-vaginal, urethro-
vaginal and uretero-vaginal fistula.
 Prolonged obstructed labour----pressure necrosis and
incontinence.
 15% of women have urinary incontinence that persists for 3
months.

23. BOWEL PROBLEMS
 35% of women develop anal
sphincter injury after 1st vaginal
delivery.
 In 10%, it persists for 3 months.
 Common cause is instrumental
(forceps> vaccum) delivery.
 Incidence of 3rd & 4th degree tears
varies from centre to centre.

24. BOWEL PROBLEMS
 Constipation is common problem in puerperium, causes
are---interruption of normal diet, dehydration, fear of pain
d/t sutured perineum, prolapsed haemorrhoids, anal
fissures.
 Constipation can be prevent by giving lactulose, ispaghol
husk or methylcellulose immediately after repair, for 2wks
period.

25. THROMBOSIS AND EMBOLISM
 CEMACH shows that pulmonary embolism is
still a major cause of death in the puerperium.
 Risk of thromboembolism rises 5 fold during
pregnancy and puerperium.
 Three major risk factors are inc maternal age,
obesity & family hx.
 Can be avoid by early mobilization, DVT
stockings, and LMW heparin.

26. PUERPERAL PYREXIA
 Defined as temperature of 38C or higher on any two
occasions of the first 10 days postpartum, exclusive of the
first 24hrs.

27. GENITAL TRACT INFECTIONS
 Puerperal sepsis syn with older descriptions of puerperal
fever, milk fever & childbed fever.
 Sepsis in the puerperium remains an important cause of
maternal death, accounting for around 10 deaths per year
in the UK.

28. RISK FACTORS
 Obesity
 Impaired glucose tolerance/diabetes
 Impaired immunity / immunosuppressant medication
 Anaemia
 Vaginal discharge
 History of pelvic infection
 Amniocentesis and other invasive procedures
 Cervical cerclage
 Prolonged spontaneous rupture of membranes
 Vaginal trauma, caesarean section, wound haematoma
 Retained products of conception
 GAS infection in close contacts / family members
 Black or minority ethnic group origin

29. COMMON PATHOGENS
The major pathogens causing sepsis in the puerperium are:
 GAS, also known as Streptococcus pyogenes
 Escherichia coli
 Staphylococcus aureus
 Streptococcus pneumoniae
 meticillin-resistant S. aureus (MRSA), Clostridium septicum and
Morganella morganii

30. OTHER CAUSES OF SEPSIS
 Mastitis,
 urinary tract infection
 pneumonia
 skin and soft-tissue infection
 gastroenteritis and pharyngitis are likely causes of sepsis other than
the genital tract.
 Rarer causes include bacterial meningitis.

31. SYMPTOMS OF PUERPERAL SEPSIS
 Fever
 rigors (persistent spiking temperature suggests abscess). Beware: normal
temperature may be attributable to antipyretics or NSAIDs
 Diarrhoea or vomiting – may indicate exotoxin production (early toxic shock)
 Breast engorgement / redness
 Rash (generalised maculopapular rash)
 Abdominal /pelvic pain and tenderness
 Wound infection – spreading cellulitis or discharge
 Offensive vaginal discharge (smelly: suggestive of anaerobes; serosanguinous:
suggestive of streptococcal infection)
 Productive cough
 Urinary symptoms
 Delay in uterine involution
 heavy lochia
 General – non-specific signs such as lethargy, reduced appetite

32. SIGNS OF PUERPERAL SEPSIS
 Pyrexia
 Hypothermia
 Tachycardia
 Tachypnea
 Hypoxia
 Hypotension
 Oligouria
 Impaired consciousness & failure to respond o treatment.

34. MANAGMENT
 The focus of infection should be sought and dealt with.
 Administration of intravenous broad-spectrum antibiotics, till
sensitivity report is awaited.
 Breastfeeding limits the use of some antimicrobials.
 The presence of shock or other organ dysfunction in the woman is an
indication for admission to the ICU

35. Antimicrobial choices and limitations of
antimicrobials
Antimicrobial Limitations
Co-amoxiclav Does not cover MRSA, Pseudomonas or
ESBL-producing organisms
Metronidazole Only covers anaerobes
Clindamycin Covers most streptococci and
staphylococci, including many MRSA, and
switches off exotoxin production with
significantly decreased mortality. Not
renally excreted or nephrotoxic
Piperacillin/tazobactam and carbapenems Covers most organisms except MRSA and
are renal sparing (in contrast to
aminoglycosides) Piperacillin/tazobactam
does not cover ESBL producers
Gentamicin (as a single dose of 3–5
mg/kg)
Poses no problem in normal renal
function but if doses are to be given
regularly serum levels must be monitored

36. PREVENTION OF PUERPERAL SEPSIS
 Increase awareness of the principles of general hygiene.
 Good surgical approach and use of aseptic techniques.
 Prophylactic antibiotics in cesarean section.

37. SECONDARY POSTPARTUM HAEMORRHAGE
 Fresh bleeding from the genital tract btw 24hrs & 6wks
after delivery.
 Causes are;
 Endometritis.
 RPOCs
 Subinvolution of placental implantation site.
 Bleeding disorders

38. SPPH MANAGEMENT
 Assessment of vaginal microbiology(vaginal/endocervical).
 Appropriate use of antimicrobial therapy, when endometritis is
suspected.
 Pelvic ultrasound to exclude RPOCs.
 Surgical evacuation of retained placental tissue, if present.

39. PUERPERAL PSYCHOLOGICAL DISORDERS.
Most common are;
 Postpartum blues
 Postnatal depression.
 Puerperal psychosis.

40. POSTPARTUM BLUES
 The transient experience of tearfulness, anxiety and irritability,
frequently occur in 1st few days following delivery.
 Occur in 70% of women, and resolved by day 10 after delivery.
 May be associated with disrupted sleep pattern, adaptation & anxiety
of having newborn baby.
 No therapy is needed.

41. POSTNATAL DEPRESSION
 It does not differ from depression at other times of life, but is
associated with childbirth.
 Occurs in 8-15% of women. Vary in severity from mild to suicidal
depression.
 50% recurrence in subsequent pregnancies.
 Treatment includes cognitive-behavioural therapy & anti-depressants
(SSRI).
 Risk factors for postnatal depression includes; unmarried, age <20yrs,
brought up by single parent, poor parental support in childhood, poor
relationship with partner, socially disadvantaged, poor achievement
educationally, low self esteem, previous emotional problems, previous
depressive illness.

42. POSTNATAL DEPRESSION
Risk factors for postnatal depression includes;
 Unmarried
 age <20yrs
 brought up by single parent
 poor parental support in childhood
 poor relationship with partner
 socially disadvantaged
 poor achievement educationally
 low self esteem
 previous emotional problems
 previous depressive illness.

43. PUERPERAL PSYCHOSIS
 Occur in 0.1% of women.
 A severe mental disorder occurring in 1st 4 weeks after delivery,
characterized by presence of irrational ideas & unusual reaction to the
baby.
 Should be immediately referred to a psychiatrist, & transfer to a mother &
baby unit for better care.
 5% risk of suicide.
 5% risk of infanticide, if not treated.
 Treatment includes antidepressants, neuroleptics and sometimes electro-
convulsive therapy.

44. INFANT FEEDING
 The major physiological event of the puerperium is the
establishment of lactation.
 ADVANTAGES OF LACTATION:
 Nutritional aspects of breast milk.
 Protection against infection.
 Helps in neurological development.
 Helps to prevent atopic illness.
 Reduce risk of diseases later in life.
 Reduce risk of breast cancer.
 Effect on fertility.
 Effects on obesity.

45. COMPARISON OF HUMAN & COW’S MILK
constituent Human milk Cow’s milk
Energy (kcal/100ml) 75 66
Protein (g/100ml) 1.1 3.5
Fat (g/100ml) 4.5 3.7
Lactose (g/100ml) 6.8 4.9
Sodium (mmol/l) 7 2.2

46. PATHWAY INVOLVED IN SECRETION OF IgA IN
BREAST MILK BY ENTEROMAMMARY
CIRCULATION.

54. REFRENCES
 Centre for Maternal and Child Enquiries (CMACE). Saving Mothers’ Lives:reviewing maternal deaths to make
motherhood safer: 2006–08.The Eighth Report on Confidential Enquiries into Maternal Deaths in the United
Kingdom.BJOG 2011;118 Suppl 1:1–203.
 Lewis G (editor).The Confidential Enquiry into Maternal and Child Health (CEMACH). Saving Mothers’
Lives:Reviewing Maternal Deaths to Make Motherhood Safer 2003–2005.The Seventh Report on Confidential
Enquiries into Maternal Deaths in the United Kingdom. London:CEMACH; 2007.
 Dellinger RP, Levy MM,Carlet JM,Bion J, Parker MM,Jaeschke R, et al. Surviving Sepsis Campaign:
international guidelines for management of severe sepsis and septic shock.Crit Care Med 2008;36:296–
327.Erratum in Crit Care Med 2008;36:1394–6
 Barnham MR,Weightman NC.Bacteraemic Streptococcus pyogenes in the peri-partum period:now a rare
disease and prior carriage by the patient may be important.J Infect 2001;43:173–6.
 Stevens DL. Streptococcal toxic shock syndrome.Clin Microbiol Infect 2002;83:133–6
 Kovacs GT (1985) Post partum fertility – a review.Clin Reprod Fertil 3, 107–14.
 Greer IA(2003) Prevention of venous thromboembolism in pregnancy. Best Pract Res Clin Haematol 16, 261–
78.
 Rooney BL& Schauberger CW (2002) Excess pregnancy weight gain and long-term obesity: one decade later.
Obstet Gynecol 100, 245–52.
 Dewey KG (2004) Impact of breast feeding on maternal nutritional status. Adv Exp Med Biol 554, 91–100.
 Confidential Enquiry into Maternal and Child Health (2004) Why Mothers Die 2000–2002. London: RCOG
Press

55. MCQs
 An 18 year old patient finally delivered a 4kg infant
vaginally. Her prenatal course was complicated by
anemia, poor weight gain and maternal obesity. Her
labour was protracted, including a 3hrs 2nd stage, a
mid-forceps delivery with a sulcus laceration, and a
third degree tear.

56.  Q1: which of the following is the greatest predisposing
cause of puerperal infection in this patient?
 A) coitus during late pregnancy
 B) iron deficiency
 C) obesity
 D) Tissue trauma

57.  Q2: she developes a persistent fever of 101F on the 3rd
day postpartum.What is most likely etiology?
 A) cholecystitis
 B) endometritis
 C) mastitis
 D) pneumonia
 E) thrombophlebitis

58.  Q3: if this infection spreads to include the supporting
connective tissues of the uterus, what is it called?
 A) parametritis
 B) peritonitis
 C) phlebothrombosis
 D) pyemia
 E) thrombophlebitis

59.  Q4: puerperal infection may be spread by several
routes. Which of the following is the most common
route that results in serious complication of a septic
thrombophlebitis?
 A) arterial
 B) direct extension
 C) fomites
 D) lymphatic
 E) venous

60. ANSWERS
 Q1---E
 Q2---B
 Q3---A
 Q4---E

61. THANK
YOU!!