Puerperium

Breastfeeding
Family Planning
Puerperium

▪ period of time after childbirth (4 to 6 wks) characterized by

anatomical and physiological changes in the woman in the
return to the pre-pregnant state
Involution

Uterine Size - 1000 gms post delivery, 500 grams after 1 week, less than 100
gms after about 4 wks
Lower uterine segment - thin, flabby & collapsed
arteries - constricted, caliber of pelvic blood vessels returns to pre-pregnant
state, new blood vessel grow
Decidua - differentiated in two layers
superficial area becomes necrotic, sloughed in the lochia

basal layer of decidua remains intact and is the source of new endometrium.
Involution

▪ exfoliation, extension and “downgrowth” of the endometrium from

margins of the placental site and development of endometrial tissue
from the glands and stroma left deep in the decidua basalis after
placental separation

cervix becomes parous, external os wider, bulkier especially on the sites

of healed lacerations.
Involution

vagina regains its tone but never its virginal state

introitus remains permanently larger than the virginal state

Rugae reappears at the 3rd week

abdominal wall remains soft & flaccid and requires time to return to
previous state.
Lochia

discharge consists of erythrocytes, shredded decidua, epithelial cells &

bacteria
fishy odor with alkaline reaction becoming acidic later on
▪ lochia rubra (red): 1-3 days
▪ lochia serosa (pale):
▪ lochia alba (white, yellowish): after about 10 days

may persist up to 4 to 6 wks.

Subinvolution

arrest or retardation of the involution process

Sx:
▪ prolonged lochial discharge.
▪ irregular or excessive uterine bleeding (sometimes profuse).
▪ uterus is larger and softer than expected on examination.
Common causes: - infection
- retained placental fragments
▪ give methylergometrine and antibiotics (doxycycline or
azithromycin) for infection (bacterial metritis)
Late Post Partum Hemorrhage

▪ bleeding 24 hours to 12 weeks postpartum

▪ result from abnormal involution at the placental site sometimes by
retained placental fragments
▪ Retained fragment undergoes necrosis forming a placental polyp
that detaches from the endometrium resulting to significant
bleeding.
Late Post Partum Hemorrhage

Treatment:
Stable patients with empty uterus (after sonar exam)
give uterotonics (oxytocin, methylergometrine) and antibiotics as
needed.
Curettage
may worsen the bleeding.
Manual Vacuum Aspiration to remove clots.
Do curettage only if bleeding persists or recurs.
Urinary system

Bladder wall - edematous & hyperemic

Sometimes bladder becomes overdistended without desire to pass

urine, incomplete emptying and excessive residual urine

Urinary tract infection may happen because of residual urine and

bacteriuria in a traumatized bladder

Dilated ureters and renal pelvis return to normal size within 2-8 weeks
Abdominal wall

ruptured elastic fibers of the skin + prolonged distention = remains

soft and flaccid

Exercise will aid in recovery.

Striae gravidarum may remain.

Diastasis recti may be noted when there is marked separation of the

recti muscles
Blood and fluid changes
leukocytosis and thrombocytosis -during and after labor

Hemoglobin concentration and hematocrit may fluctuate moderately in the

first post partum days

Blood volume returns to normal mostly by the first week after childbirth

Pregnancy-induced changes in blood coagulation factors persist for variable

periods
Post partum diuresis occurs between the second and fifth days postpartum.
Hormones and ovulation

▪ Estrogen and progesterone levels decrease markedly after delivery of

the placenta.
▪ For women who breastfeed, prolactin levels remain elevated into the
sixth week after birth
▪ For non lactating women prolactin levels decline to pre-pregnant
range by the third week post partum
▪ Ovulation may resume as early as three weeks after delivery, even in
lactating women.
▪ Ovulation may precede the first menstrual period.
Other issues

▪ Bowel evacuation may be difficult because of pain of

episiotomy or hemorrhoids.
▪ Weight loss due to evacuation of uterus and normal blood loss
(5-6 kg) and added 2-3 kg through diuresis.
▪ Added measures to reduce weight may lead to more weight loss
(e.g. exercise).
▪ In multiparous women, the uterus often contracts vigorously at
interval similar but milder than labor contractions.
▪ Afterpains more pronounced as parity increases and during
suckling
Puerperal Fever

Fever over 38 degrees Celsius after the first 24 hours and lasting 2
days or more.

Most persistent fevers are caused by genital tract infection. Other

causes are breast engorgement, urinary tract infection,
abdominal incisions, episiotomy & perineal lacerations

Postpartum uterine infection or puerperal sepsis (metritis) – Risk

factors are rupture of membranes, prolonged labor and multiple
cervical examinations and manual removal of the placenta.
Puerperal Fever

Pathogenesis of uterine infection in cesarean section is

infected surgical incision. For vaginal birth, it involves the
placental implantation site, decidua or cervicovaginal
lacerations.

Infections are polymicrobial

Uterine infection (metritis)

More common in cesarean delivery than in vaginal. Risk

factors are rupture of membranes, prolonged labor and
multiple cervical examinations and manual removal of the
placenta.

Pathogenesis of metritis following cesarean section is an

infected surgical incision. For vaginal birth, it involves the
placental implantation site, decidua or cervicovaginal
lacerations.
Perioperative Antibiotics

Perioperative antimicrobial prophylaxis at time of

cesarean section has reduced the rates of post
operative pelvic and wound infection. Use single dose
ampicillin or first generation cephalosporin
Postpartum blues

some degree of depressed mood a few days after delivery.

Possible causes are emotional letdown, following the

excitement and fears during labor and delivery, fatigue,
anxiety and body image concerns

Usually mild but if persistent or worsens, suicidal need urgent

attention.
BREASTFEEDING
Breastfeeding

After delivery the breast secretes colostrum & can

be expressed from the nipple on the second day.
Contains more minerals, amino acid, antibodies &
IgA . Secretion persists for 5 days

The intensity and duration of lactation is

controlled by repetitive nursing and emptying
of milk from the breast.
Human milk is ideal food for newborns
Advantages
▪ Nutritional
▪ Immunological
▪ Developmental
▪ Economical

▪ lower risk of breast and reproductive cancer

▪ less postpartum weight retention
▪ lower risk of coronary heart disease
Contraindication to breastfeeding

▪ Street drugs and alcohol use

▪ Infants with galactosemia
▪ HIV infection
▪ active, untreated tuberculosis
▪ breast cancer treatment
▪ Avoid drugs: cyclophosphamide & methotrexate
Breast engorgement

▪ Breast engorgement, milk leakage & breast pain are

common in women who do not breastfeed noted 3-5 days
after delivery.
▪ No specific treatment.
▪ Support the breast with well-fitting brassiere or breast binder.
▪ cool packs and oral analgesics
▪ Pharmacological and hormonal drugs are not recommended
Milk fever

▪ Fever form breast engorgement is common

▪ Fever seldom persists for longer than 4 -16 hours
▪ Rule out other possible causes of fever, especially those due to
infection
Mastitis

▪ unilateral and marked engorgement usually precedes inflammation

▪ Sign & symptoms are chills, then fever and tachycardia. Severe pain
and the breast becomes hard and red.
▪ Common organism is staphyloccus aureus, bacteria enters through
the nipple at site of fissure or abrasion.
▪ Continue breastfeeding. May do milk expression.
▪ Dicloxacillin 500 mg QID or Erythromycin for those sensitive to
penicillin
Breast abscess

▪ persists even after 48 -72 hours of mastitis treatment or when a mass

is palpable
▪ Treatment is surgical drainage. Multiple abscesses will require
multiple incisions.
▪ A sonar-guided needle aspiration is another alternative to drain the
abscess.
Family Planning
Ideal Contraceptive

▪ Highly efficient
▪ Free from unwanted side effect
▪ Absolute safety
▪ Simplicity of use
▪ Reversible
▪ Well tolerated
Note: No single method of birth control is the “best” one.
Each has its own advantages and disadvantages.
Abstinence is the only 100% effective way to prevent
pregnancy and STD’s
Methods of Contraception

A. Temporary
1.Hormonal (COC, POP, Injectables, Implants)
2.Mechanical (IUD, IUS)
3.Barrier (Condom, Diaphragm, Spermicides)
4.Fertility Awareness Based (SDM, CMM, BBT)
B.Permanent
1.Bilateral Tubal Ligation
2.Vasectomy
Contraceptive Benefits and Risks

Benefits often outweigh health SIDE EFFECTS: symptoms or

risks conditions that pose no
significant health risk

COMPLICATIONS: serious health

problems or conditions
Barrier Contraceptives

– Methods that physically or chemically

block sperm from reaching an egg AND
provide a BARRIER between direct skin to
skin contact
– Act as a physical block between you and
your sexual partner
– Great for STD protection!

– Do not use oil-based lubricants such as

massage oils, baby oil, lotions, or
petroleum jelly.They will weaken the
condom, causing it to tear or break.
Hormonal Methods

▪ Increase cervical mucus

▪ prevent the release of an egg (ovulation)
▪ Prevents a fertilized egg from implanting in the uterus (prevents
pregnancy).
▪ NO hormonal methods reduce chances of STD’s!
Oral Contraceptives

▪ “the pill,”
▪ Some contain estrogen, progestin, or mix of other hormones
depending on pill
▪ The pill is 91 to 99 percent effective at preventing pregnancy.
▪ Prescribed by doctor
▪ A pill is taken at the same time each day (once a day for three
weeks, no pill fourth week -will get menstrual period)
Non contraceptive health benefit Combined
Oral Contraceptives

Decreased incidence of:

– Ectopic pregnancies
– Endometrial cancer
– Ovarian cancer
– Pelvic inflammatory disease
– Benign breast disease
– Iron-deficiency anemia
– Dysmenorrhea
COCs lessen dysmenorrhea

▪ Reduction in production of prostaglandins, which are responsible in

large part for primary dysmenorrhea.

▪ Decrease in uterine tonicity in all women, the decrease being

accompanied by relief of dysmenorrheic pain.
Recommendations on COCs

▪ Not to be used by women who are older than 35 years

and who smoke 15 sticks or more per day.
▪ Healthy, non smoking women doing well on COCs can
continue their method until menopause after weighing
the risks and benefits.
DMPA

 Every 3 months (or 12 weeks), women get shots of the hormone

progestin in the buttocks or arm from their doctor.
 It is 94 to 99 percent effective at preventing pregnancy.
 It does not protect you from HIV or other STDs
Recommendations

Most common side effect of DMPA is unscheduled

bleeding variable pattern in the first 6-9 months of use.
DMPA can be used without restriction among women ages
18-45 years old.
Intrauterine Device

▪ Copper IUD: Can stay for up to 10 years

– Interferes with sperm, fertilization, and prevents
implantation
▪ LNG-IUS, long-term progestin release leads to endometrial
atrophy, which hinders normal implantation
Lactation Amenorrhea Method

temporary contraceptive method that relies on exclusive breast

feeding. It can be used from birth up to six months afterwards.

1. The baby must be under six months of age

2. The woman must not have had a period
3. The baby must be exclusively breastfed