The document discusses postpartum care and outlines the normal physiological changes during the puerperium period. It describes routine postpartum care including counseling on contraception, breastfeeding, immunizations and monitoring for postpartum mood disorders. Common postpartum problems like breast issues, urinary problems and venous thrombosis are outlined. Risk factors, diagnosis and management of postpartum infections like puerperal fever, sepsis and other morbidities are also described. The importance of health education, routine postnatal checkups, discharge instructions and postnatal exercises are emphasized.

1. PUERPERIUM AND POSTPARTUM CARE
Dr. Elhadi Miskeen, MBBS, MD, FAIMER, TUFH
Assistant professor-University of Gezira and University of Bisha, Saudi Arabia
Head department of OBGYN- University of Bisha
Head community-based medical Education unit, University of Bisha, KSA

3. SPECIFIC
LEARNING
OBJECTIVES
(SLOS)
List the normal anatomic and physiologic changes in the postpartum period
List
Describe the key components of routine postpartum care including patient counseling
regarding contraception, breastfeeding, and postpartum mood disorders.
Describe
Outline a basic approach for evaluation and management of common postpartum
problems.
Outline
Identify risk factors for postpartum disorders
Identify
Outline a basic approach to the evaluation and management of postpartum period
Outline

4. INTRODUCTION
Globally, approximately 140
million births occur every year .
The majority of these are
vaginal births among pregnant
women with no identified risk
factors for complications, either
for themselves or their babies,
at the onset of labour
However, in situations where
complications arise during
labour, the risk of serious
morbidity and death increases
for both the woman and baby.
The puerperium is the 6- to 8-
week period following birth
during which the reproductive
tract, as well as the rest of the
body, returns to the
nonpregnant state.
Some of the physiologic
changes of pregnancy have
returned to normal within 1 to
2 weeks postpartum.
The initial postpartum
examination should be
scheduled at 4–6 weeks after
delivery.

5. NORMAL
PUERPERIUM
AND POSTNATAL
CARE
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6. DEFINITION OF NORMAL
PUERPERIUM
Childbirth – 6 weeks(42 days)
• First 24 hours
• Early- up to 7 days
• Remote- up to 6 weeks
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7. POINTS TO
REMEMBER FOR
PUERPERIUM:
Prevention of sepsis at placental site
Newborn care
Initiation of breast feeding
Role of post-natal exercises

8. PHYSIOLOGICAL CHANGES
IN NORMAL PUERPERIUM
Reproductive Tract Changes
Urinary Tract Changes
Gastrointestinal Tract Changes
Psychosocial Problems
Changes in breast and Lactation
Changes in other systems
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9. Reproductive Tract Changes
Lochia. These are superficial
layers of the endometrial
decidua that are shed through
the vagina during the first 3
postpartum weeks.
Cramping. The myometrial
contractions after delivery
constrict the uterine venous
sinuses, thus preventing
hemorrhage.
Perineal Pain. Discomfort from
an episiotomy or perineal
lacerations can be minimized in
the first 24 hours with ice
packs to decrease the
inflammatory response edema.

10. 2. Urinary Tract Changes
1. Hypotonic Bladder. Intrapartum bladder trauma can result in increased postvoid residual
volumes.
If the residuals exceed 250 mL, the detrusor muscle can be stimulated to contract with
bethanechol (Urecholine).
Occasionally an indwelling Foley catheter may need to be placed for a few days.
2. Dysuria. Pain with urination may be seen from urethral irritation from frequent intrapartum
catheterizations.
Conservative management may be all that is necessary. A urinary analgesic may be required
occasionally.

11. • 3. Gastrointestinal Tract Changes
Ø Constipation. Decreased GI tract motility, because of
perineal pain and fluid mobilization, can lead to
constipation. Management is oral hydration and stool
softeners.
Ø Hemorrhoids. Prolonged second-stage pushing efforts
can exaggerate preexisting hemorrhoids.
Ø Management is oral hydration and stool softeners.
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12. 4.
PSYCHOSOCIAL
PROBLEMS
•Impaired maternal–infant bonding is seen in the first few days postdelivery.
•Lack of interest or emotions for the newborn is noted. Risk is increased if contact with
the baby is limited because of neonatal intensive care, as well as poor social support.
•Management is psychosocial evaluation and support.
A. Bonding:
•Postpartum blues are very common within the first few weeks of delivery. Mood
swings and tearfulness occur.
•Normal physical activity continues and care of self and baby is seen.
•Management is conservative with social support.
B. Blues.
•Postpartum depression is common but is frequently delayed up to a month after
delivery.
•Feelings of despair and hopelessness occur.
•The patient often does not get out of bed with care of self and baby neglected.
•Management includes psychotherapy and antidepressants.
C. Depression.
•Postpartum psychosis is rare, developing within the first few weeks after delivery.
•Loss of reality and hallucinations occur.
•Behavior may be bizarre.
•Management requires hospitalization, antipsychotic medication, and psychotherapy.
D.Psychosis.

13. 5. CHANGES IN
BREAST AND
LACTATION
Retracted / cracked nipples
Breast engorgement
Mastitis
Breast abscess
Failure of lactation

14. 6. CHANGES
IN OTHER
SYSTEM
Fatigue
Pulse slow
Temp. subnormal
Shivering
Fever up to first 24 hours
Diuresis- 2nd to 5th day post delivery

15. POSTNATAL
CARE
Postnatal Check Up
Detection of risk at earlier stage & its management
Management of Normal puerperium
Treatment of Minor Ailments
Treatment of anaemia
Health & nutrition education
Postnatal Exercise

16. MANAGEMENT
OF NORMAL
PUERPERIUM
First hour– important for PPH
Early ambulation
Avoid strenuous activities for 6 weeks
8-10 hours sleep
Needs 300 calories more
Care of MLE stitches if any
Care of nipples and areola.

17. POSTPARTUM
CONTRACEPTION
AND
IMMUNIZATIONS
Breast feeding. Lactation is associated with temporary anovulation, so
contraceptive use may be deferred for 3 months. A definitive method
should be used after that time.
Diaphragm. Fitting for a vaginal diaphragm should be performed after
involution of pregnancy changes, usually at the 6-week postpartum visit.
Intrauterine Device (IUD). Higher IUD retention rates, and decreased
expulsions, are seen if IUD placement takes place at 6 weeks postpartum.
Combination Modalities. Combined estrogen-progestin formulations
(e.g., pills, patch, vaginal ring) should not be used in breast-feeding
women because of the estrogen effect of diminishing milk production.
Progestin-only Contraception. Progestin steroids (e.g., mini-pill, Depo-
Provera, Nexplanon) do not diminish milk production so can safely be
used during lactation. They can be begun immediately after delivery.

18. POSTPARTUM
IMMUNIZATIONS
RhoGAM. If the mother is Rh(D) negative, and her
baby is Rh(D) positive, she should be administered
300 (g of RhoGAM IM within 72 hours of delivery.
Rubella. If the mother is rubella IgG antibody
negative, she should be administered active
immunization with the live-attenuated rubella virus.
She should avoid pregnancy for 1 month to avoid
potential fetal infection

19. ABNORMAL
PUERPERIUM

21. WHEN ARE
MOTHERS
AND
NEWBORNS
DYING?

22. PUERPERAL
FEVER/PYREXI
A
Definition
Oral temp. 38 degree C or more recorded twice in the first 10 days after delivery.
Associated symptoms
The associated symptoms depend on the site and nature of the infection.
The most typical site of infection is the genital tract.
Endometritis, which affects the uterus, is the most prominent of these infections.
Endometritis is much more common if a small part of the placenta has been retained in the uterus.
Examination
Physical examination Physical examination A pelvic examination is done and samples are taken from the genital tract to
identify the bacteria involved in the infection.
The pelvic examination can reveal the extent of infection and possibly the cause.
Laboratory:
Blood samples may also be taken for blood counts , CRP, or blood culture.
A urinalysis may also be ordered, especially if the symptoms are indicative of a urinary tract infection. Chest x-ray • Wound
culture

23. Treatment of Puerperal Fever/Pyrexia
Treatment of puerperal infection usually begins with I.V. infusion of broad-spectrum antibiotics and is
continued for 48 hours after fever is resolved.
Supportive care
Symptomatic treatment
Surgery may be necessary to remove any remaining products of conception or to drain local lesions,
such as An infected episiotomy (incision made during delivery) may need to be opened and drained.
In the presence of thrombophlebitis, heparin therapy will be needed to provide anticoagulation.
Preventions
Avoid the risk factors •
Keep the episiotomy site clean •
Careful attention to antiseptic procedures during childbirth is the basic underpinning of preventing
infection.
With some procedures, such as cesarean section, a doctor may administer prophylactic antibiotics as a
preemptive strike against infectious bacteria.

24. CAUSES OF
PUERPERAL
FEVER-
PYREXIA
Uterine infection
Breast infection
Urinary infection
Thrombophlebitis
Other incidental infections

25. PUERPERAL
SEPSIS
Definition
Risk Factors for Puerperal Sepsis
Diagnosis
Management
Complication

26. PUERPERAL
SEPSIS
Infection of genital tract : Delivery-
42 days after delivery
Two or > features to be present
pelvic pain, fever 38.50 C, vaginal
D/S, smell of D/S,

27. RISK FACTORS FOR
PUERPERAL SEPSIS
• Anaemia
• Malnutrition
• DM
• Prolonged labor
• Obstructed labor
• Prolonged PPROM
• Frequent vaginal examinations
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28. CONTD….
Operative delivery
Un-repaired tears
PPH
Poor hygiene
Poor aseptic technique for delivery
Manipulations high in the birth canal
Retained bits of placenta or membranes
Pre-existing STDs

29. DIAGNOSIS
Endometritis
Pelvic cellulites
Salpingitis & peritonitis
Pelvic thrombophlebitis
Septicaemia

30. MANAGEMENT
PUERPERAL
SEPSIS /PYREXIA
Preventive
Good antenatal care
Proper intra-natal care
Post natal care
Curative
General care
Antibiotics for infection
Local care of various wounds

31. COMPLICATION
Septicaemia
Septic shock
DIC
Pulmonary embolization
Distant spread of infection
Kidney failure
Death

32. CONTD….
Late complications:
Menstrual problems
Chronic pelvic pain
Chronic PID
Secondary infertility

33. BREAST
PROBLEMS
Retracted / cracked nipples
Breast engorgement
Mastitis
Breast abscess
Failure of lactation

34. URINARY
PROBLEMS
Retention
Incontinence
Infection

35. VENOUS
THROMBOSIS
Due to hypercoagulable state of pregnancy
Predisposing factors:
• Increasing maternal age
• Obesity
• Anaemia
• Dehydration
• Trauma
• Infection
• Smoking
• Reduced mobility

36. PUERPERAL
MORBIDITY
OTHER THAN
INFECTION
Secondary Hemorrhage
Puerperal Psychosis
Obstetric Palsy

37. SECONDARY
HEMORRHAGE
Due to:
Infection
Retained bits of placenta &
membranes
Subinvolution

38. PUERPERAL
PSYCHOSIS
Transient
Self limiting
Antidepressants & psychological
counseling

39. MANAGEMENT
OF THE
IMMEDIATE
POSTPARTUM
PERIOD
the postpartum hospital stay ranges from
48 hours after a vaginal delivery to 96 hours
after a cesarean delivery, excluding day of
delivery.
During the hospital stay, the focus should
be on preparation of the mother for
newborn care, infant feeding including the
special issues involved with breastfeeding,
and required newborn laboratory testing.

40. DRUG AND
BREAST
FEEDING
Drugs contraindicated during
breastfeeding include anticancer
drugs, lithium, oral retinoids,
iodine, amiodarone and gold salts.
An understanding of the principles
underlying the transfer into breast milk
is important, as is an awareness of the
potential adverse effects on the infant.

41. ROUTINE POSTNATAL CARE-WHO
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42. WHO
RECOMMONDATIONS

43. HEALTH EDUCATION TO PUERPERAL
WOMEN
• Health teaching items at this time include advice in relation to:
• Sexual intercourse, which should be prohibited during the first six postpartum weeks,
and allowed after that, provided that the woman is in good health, with a perfectly
healed genital tract.
• Spacing of pregnancies and counseling about the appropriate contraceptive method,
which should be prescribed and may be started at once.
• If prolapse of the genital tract is present, it should be treated by pelvic floor muscle
exercises and/or the insertion of a ring pessary. The patient should be advised to
abstain from bearing down. Chronic cough and constipation should be treated for this
purpose. However, operative treatment is not considered before the lapse of six months
when total involution of the genital tract is established.
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44. CONT.....HE
• Health education to puerperal women at this time should
also include instructions related to the possibility of
encountering menstrual irregularities during the following
months.
• These irregularities range from complete amenorrhea to
oligo-menorrhea, hypomenorrhae or polymenorrhea.
• Bleeding is expected at the end of the 6th puerperal week
in the majority of patients. In non-lactating mothers,
however, menstruation usually appears after 6-8 weeks.
• On the other hand, lactating women may have great
variations in this respect: about 1/3 of them will start
menstruation 3 months postpartum, and by the 6 month
more than half of them will menstruate.
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45. DISCHARGE
INSTRUCTIONS
Discharge Instructions Patients and their families should be
instructed to call the healthcare provider if the patient has any
of the following:
Fever Foul-smelling lochia Large blood clots, or bleeding
that saturates a pad in 1 hour
Discharge or severe pain from incisions Hot, red, painful areas
on the breasts or legs Bleeding and severe pain in the nipples
Severe headaches or blurred vision Chest pain or dyspnea
without exertion Frequent, painful urination

46. CONCLUSIONS
Importance of history
Systematic evaluation
Proper advise & motivation regarding
contraception
Importance of immunization for new born
Stress upon post natal exercises.
Puerperal pyrexia is the most serious and
common complication
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47. DISCUSSION AND
QUESTIONS
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50. THANKS