CBMP

1. CBMP

2. FOURTH YEAR MEDICAL STUDENTS COMMUNITY MEDICINE Obstetrics and Gynecology

3. THEME VII: TITLE: Normal and abnormal puerperium. Puerperium and breastfeeding.

4. SUMMARY Normal puerperium and puerperal infection. Physiology of breastfeeding.

5. OBJECTIVES • Define puerperium. • State physiological changes during puerperium. • Describe postnatal care given to the mother and baby.

6. NORMAL PUERPERIUM.DEFINITION. Puerperium is the period from the placenta expulsion to the time the reproductive organs return to pregravid state which lasts for 6 weeks.

7. PUERPERIUM • Immediate. • Intermediate. • Late.

8. PUERPERIUM. CHANGES. • Local changes. • General changes.

9. LOCAL CHANGES • Involution of theuterus. • Lochia. • Vagina and vulva changes. • Breasts.

10. INVOLUTION OF THE UTERUS The uterus returns to its normal site, tone & position of non pregnant state mechanism: Ischemia. Autolysis. Lining of the uterus.

11. LOCHIA Discharge from the uterus during puerperium. • Reaction of lochia is alkaline which favors growth of organisms. • The amount varies with each woman. • The odour is heavy and unpleasant but not offensive.

12. LOCHIA • Lochia rubra. • Lochia serosa. • Lochia alba.

13. VAGINA AND VULVA CHANGES. • Shrinks to a nonpregnant state. • Resolution of the increased vascularity and edema occurs by 3 weeks. • The vaginal epithelium appears atrophic on smear. This is restored by weeks 6-10.

14. BREASTS • In spite of this activity , lactation is inhibited during pregnancy, although levels of human prolactin rise. • Throughout pregnancy, the reason for this is that the high levels of estrogen occupy binding sites on the alveoli which prevent them from responding to the lactogenic properties of hpR. • In late pregnancy the breast secrets a thickish, yellowish fluid, colostrum, which is rich in immune antibodies. The production of colostrum increases after the birth until it is replaced by breast milk production. • During pregnancy the breasts develop considerably. • Fat deposits around the glandular parts of the breast. • Oestrogen leads to an increase in the size and number of ducts. • Progesterone increases the number of alveoli; hPL also stimulates alveolar development and may be involved in the synthesis of caseiun, lactalbumin and lactoglobulin by the alveolar cells.

15. PUERPERIUM. GENERAL CHANGES. • Temperature. • Pulse. • Blood. • Metabolism. • Weight. • Endocrine.

16. BREASTFEEDING.ADVANTAGES. • Inexpensive. • Accelerates uterine involution. • Immunologic advantages for the baby.

17. IMMEDIATE PUERPERIUM MANAGEMENT. • Bleedingcharacter: • Amount. • Color. • Character of the uterus. • Othercharacteristics: • Pulse and bloodpressure. • Episiotomy. • Administerabundantliquid. • Breastfeeding. • General assessment of thepatient.

18. IMMEDIATE PUERPERIUM MANAGEMENT. FIRST 24 HOURS AFTER THE BIRTH . MEASURES. • Bland diet. Abundant liquids. • Observe bleeding characteristics. • Take asepsia and antiasepsia measures in the vulvoperineal region and in the surgical wound (if any). • The patient should walk. • Maintain general hygiene. • Check vital signs every 4 hours. • Inspect the breasts. • Comprehensive assessment of the mother and newborn.

19. INTERMEDIATE PUERPERIUM MANAGEMENT. • Dailyassesssment of the patient. • Nursingobservation. • Check vital signsevery 8 or 12 hours. • Maintainbreastfeeding. • Assess the patient for dischargeafter 3 or 5 days.

20. LATE PUERPERIUM MANAGEMENT. • Maintain exclusive breastfeeding. • General assessment of the mother and newborn. • Counsellingconcerningfamilyplanning. • Sexual relations are prohibited.

21. ABNORMAL PUERPERIUM • Postpartum haemorrhage. • Puerperal infection • Thromboembolism. • Potspartum depression.

22. BREAST ANATOMY. A ducts B lobules C dilated section of duct to hold milk D nipple E fat Fpectoralis major muscle G chest wall/rib cage Enlargement: A normal duct cells B basement membrane C lumen (center of duct)

23. ENDOCRINOLOGY OF LACTATION. • Progesterone, estrogen, placental lactogen, prolactin, cortisol, insulin. 2. Prolactin is essential for lactation. 3. Milk ejection or letting down reflex.

24. BREAST FEEDING COLOSTRUM The deep lemon-yellow colored liquid secreted initially by the breasts: • Expressed from the nipples by the second postpartum day. • Contains more minerals and protein - globulin less sugar and fat. • IgA.        • Persists for about 5 days. • Gradual conversion to mature milk during the ensue 4 weeks. MILK • 600mL/day. • Major proteins -including α-lactalbumin, β-lactoglobulin and casein- interleukin -6, epidermal growth factor. 

25. PUERPERAL INFECTION. DEFINITION. It is definided as a rise in temperature to 38 dregree or over, maintained for 24 hours or recurring during the period from the end of the 1st to the end of the 10th day after childbirth or abortion.

26. PUERPERAL INFECTION. ETIOLOGY. GENITAL INFECTION • Potential pathogens which normally inhabit the vagina. • Bacteria introduced from adjacent viscera. • Bacteria introduced from distant organs or from outside. NON GENITAL INFECTION • Urinarytractinfection. • Breastinfection.

27. PUERPERAL INFECTION.RISK FACTORS. • Instrumental delivery. • Internal fetal monitoring. • Multiple vaginal examinations. • Prolonged ROM and chorioamnonitis. • Cervical cerclage. • Non obstetric: obesity, DM, HIV.

28. PUERPERAL INFECTION.DIAGNOSIS. SYMPTOMS • Fever, rigors, malaise, headache. • Vomiting and diarrhoea. • Abdominal discomfort. • Offensive lochia. SIGNS • Pyrexia and tachycardia. • Large and tender uterus. • Peritonism and paralytic ileus (severe cases). • Induratedadnexae due to parametritis. • Fullness in the pelvis due to abscess.

29. BIBLIOGRAPHY • Obstetrics and Gynaecology. DereckLlewellyn_ Jones. • Obstetrics by teamteachers. STUART CAMPBELL AND ASH MONGA.