The puerperium period lasts from the third stage of labor until 6 weeks postpartum. During this time, the body returns to a non-pregnant state as the uterus shrinks back to normal size by 6 weeks. Women are at highest risk for venous thromboembolism in the early puerperium. Lochia discharge lasts around 3 weeks. Lactation is established and the endometrium regenerates within a few weeks if not breastfeeding and a few months if breastfeeding. The majority of postpartum psychological issues resolve spontaneously, but some women develop postpartum depression or psychosis and require treatment. Exclusive breastfeeding provides effective contraception for the first 6 months postpart

1. Puerperium and
Lactation

2. Puerperium
• The puerperium is the period from after 3rd stage of
labor to 6 weeks after delivery
• During the puerperium the pelvic organs return to the
non - gravid state, the metabolic changes of pregnancy
are reversed and lactation is established
• the early puerperium is especially dangerous and most
maternal deaths occur during this time
• It carries the highest risk of developing VTE

3. The uterus
• By 6 weeks after birth the uterus has returned to its
normal size (100 g )
• cells diminish in size &no effect on the number of
muscle cells
• Immediately after labor the uterus is 12 cm above the
symphysis pubis (4 cm below umbilicus)
• no longer palpable abdominally by 2 weeks after
delivery
• by the end of the second week the internal os
should be closed
2 weeks cant be felt , 6 weeks prepregnancy size

4. Time Uterus size
Day 1 post partum 18 weeks size
Day 7 14 weeks
Day 14 12 weeks
After day 14 Not palpable

5. • Hemostasis immediately by arterial smooth muscle
contraction and compression of vessels by the uterine
muscle.
• Lochia:
red (rubra )
yellow (serosa)(3rd-4th day)
white mucopurulent(alba)
mean duration of 22 – 27 days.

6. • A new endometrium will grow from the
basal layers of the decidua but this is
influenced by the method of infant
feeding
• new endometrium within 3 – 4 weeks if
non lactating and few months if lactating

7. Ovarian function
• Lactating women:
- Ovulation – after 6 months
- Prolactin levels decrease back to normal levels after 6 weeks
- Amenorrhea
• Non-lactating women:
- Ovulation – 70 days
- Menstruation resumes after 7 weeks.
- Prolactin levels decrease back to normal levels after 3 weeks

8. Hematological & CVS changes
COP , SV , HR will be normal in 2 days
Blood pressure and plasma volume will increased
initially for few days then return to normal
Coagulation factors and platelets will return to
normal in 3-6 weeks
Initial rise in platelets then back to normal
Initial rise in WBc then return to normal

9. Thyroid function
• Size will be normal by 12 weeks
and level of hormones will be
normal in 4 weeks

10. Weight loss
• There is an immediate loss of 5 kg following
birth due to the baby, the placenta, amniotic
fluid and blood loss that occurs at delivery
• Most will return to pre pregnancy weight by 6
months but some will gain a net weight of 5
kgs
• Breast feeding is not related to weight loss if
less than 6 months

11. Hair loss
• May occur … needs 6 months to 1 year to
return to normal

12. Changes in lab parameters

13. Urinary tract
• The hydrouretur and pelvic dilation in
the kidneys are almost eliminated by 2-
3 weeks and completely return to
normal by 6-8 weeks after birth
• Catheterization and manipulation may
lead to UTI (Ecoli )
• Urine retention is common
(PG, epidural and instrumental )
(48 hours catheterization )
To minimize the risk women with spinal
anesthesia , leave catheter for 12 hrs

14. Anal incontinence
• Especially those with 3rd and 4th degree tears
and forceps delivery
• Symptoms occur in 6-10 %
• Sonographic evidence in 1/3 of PG and 70 % in
patients delivered using(asymptomatic)
• Most of them will be asymptomatic by 12
months
• Pelvic floor exercise

15. Secondary postpartum
hemorrhage
Defined as : bleeding from the genital tract between 24
hours and 6 weeks after delivery
Rule out endometritis and retained POC
Antibiotic , uterotonic , evacuation ?
Secondary PPH , fever , abdominal pain and offensive discharge is
suggestive for endometritis and needs admission with IV
antibiotics

16. Nerve injury
• Meralgia (lateral cutaneous femoral nerve)
• Foot drop (common peroneal nerve)
• Nerve injuries in CS: ilioinguinal, iliohypogastic
• Femoral nerve palsy : medial anterior thigh
numbness and unable to flex knee

17. Perineal pain
• 80 % in the first 3 days (maybe up to 10 days)
• Spontaneous opening of repaired perineal
tears and episiotomies is usually the result of
secondary infection , leave for secondary
intention

18. VTE & PE
• Pulmonary embolism is the most serious cause
of death in the puerperium
• VTE is the most common cause of direct
maternal death
• Assess the risk and manage accordingly but
hydration and early manipulation is essential
+-LMWH

19. Postpartum fever
• It is the presence of fever > 38c, >2 occasions, >6 hours
apart excluding the first 24 hours
• UTI ( E Coli )
• Endometritis (polymicrobial and 50% GAS ) 5%
• wound infection(staph aureus )
• septic thrombophlebitis
• Mastitis (staph aureus )
• Sepsis (GAS )

20. Important causes of puerperal
sepsis

21. Sepsis

22. • Present with 2ry PPH , abdominal pain , uterine
tenderness , foul smelling discharge , signs of sepsis
• Polymicrobial
• Cs , PPROM , PTL , GBS and chlamydia positive are at
higher risk
• Treated as inpaitnet with IV amp, Genta +-
metronidazole , or by piperacillin azopactam
(other regimens are used )
Endometritis

23. Management

24. Regimen for chorioamnionitis
and endometritis

25. Mastitis
• Stasis of milk and engorgement of breast with
infection
• Most commonly by staph aureus
• Treated with antibiotic (flucloxacillin, clindamycin)
• Abscess needs breast ultrasound and drainage with
antibiotic cover

29. Psychological disorders
The ‘pinks’:
for the first 24–48 hours following
delivery elevation of mood, a feeling
of excitement, overactivity and
difficulty sleeping.

30. • 80%
• the first 2 weeks after delivery.
• Fatigue, short temper, difficulty sleeping, depressed mood
and tearfulness
• Resolves spontaneously in the majority of cases
• Reassurance & support
• (no need for admission or medications)
BLUES

31. Depression
• 10-15 %
• Occur around 6 weeks postnatal
• Screened by Edinburgh Postnatal Depression Scale
Risk factors for postnatal depressive illness
• Past history of psychiatric illness.
• Depression during pregnancy.
• Obstetric factors (e.g. caesarean section/fetal or
neonatal loss).
• Social isolation and deprivation.
• Poor relationships.
• Recent adverse life events (bereavement/illness).
• Severe postnatal ‘blues’.

32. • Symptoms :
Lack of interest
Impaired concentration.
Tearfulness.
Feelings of guilt and failure.
Anxiety
Treatment :
• Cognitive–behavioral therapy (1st line )
• Drug therapy (second line or history of depression) SSRI

33. Postpartum psychosis
• 0.1-0.2 %
• Occur after 4 weeks postnatally
• Usually there is a history of psychological
illness (personal or family )
• refer urgently to a psychiatrist
• Admit to a mother-and-baby unit

35. Lactation

36. Prolactin and return of
menstrual cycle
• Prolactin level return to normal in 3 weeks if
not lactating and remain elevated if lactating
• In lactating women average period for
menstruation is 7 months (28 weeks ) and
ovulation needs further 2 months (9 months )
• Lactational method as contraception has 98 %
success rate if * exclusively breastfeeding ,
less than 6 months , amenorrhea .

37. Lactation & breast milk

38. •Protection against infections:
(IgA ,lysosome, lactoferrin , enhance flora )
Breast-feeding largley protects against
gastrointestinal tract infections and to a lesser
extent against respiratory tract infections.
reduced incidence of diarrhea and vomitting
compared to thoses who are bottle-fed
Advantage of breast milk

39. • improved childhood cognitive functions
• decreases the incidence of atopic illness such as eczema
and asthma
• decreased risk of juvenile DM and neoplastic disease
- protects preterm infants from developing necrotizing
enterocolitis
- Artificially fed children have twice the risk of developing
childhood obesity and high blood pressure than breast-fed
children
- There is a decreased risk of breast cancer among women
who breastfeed their babies
• -
Advantage of breast milk…..

40. Physiology of lactation
• At puberty, estrogen , growth hormone promotes
ducts growth
• Progesterone promotes growth of milk-producing
alveolar cells
• After delivery, progesterone levels fall allowing the
positive effect of prolactin on milk production
• During pregnancy progesterone , estrogen , growth
hormone , HPL , prolactin helps in breast tissue
prperation and milk production

41. Milk production and ejection
• Milk production is stimulated by prolactin which acts on
glandular cells of the breast to stimulate milk secretion
• Milk ejection is stimulated by oxytocin which acts on
myoepithelial cells that contract causing milk ejection
• Prolactin and oxytocin secretion is stimulated by
suckling, and oxytocin secretion is also stimulated by
seeing the infant or hearing its cry

42. Medications while breastfeeding

43. Medications while breastfeeding

44. Lactation as a contraceptive
method
• Lactation can be 98% effective as
contraception if:
- The infant is exclusively breastfed,
- Lactation is done regularly at intervals of 4
hours during the day and 6 hours during the
night
- Before 6 months
- Amenorrhea

45. Mechanism of lactational amenorrhea:
- Suckling alters hypothalamic sensitivity to estrogen,
making it more sensitive to negative feedback than
positive feedback.
- The pituitary produces enough FSH and LH to start
follicle development but the consequent estrogen
secretion will inhibit gonadotropins production thus
failure of ovulation occurs .

46. Postpartum contraception
COC : 6 months if breast feeding
3 weeks if not breast feeding
POP :
after 3 weeks if breast feeding and immediately if not breast
feeding
IUCD : not less than 28 days or within 48 hrs*
Cap : 6 weeks
Injectable : 6 weeks (can be earlier )