1. Physiology of Puerperium and Lactation Professor Abdulrahim Rouzi, FRCSC

2. Physiology of the Puerperium Anatomic changes Uterus Lochia-name given to blood and other necrotic debris shed from the uterus Uterus does not scar- tissue replaced by new growth from the basal endometrium Proliferative endometrium persists for about six weeks and first menses normally anovulatory Enlarges immediately after delivery to umbulicus by two weeks it resumes its position within the pelvis at six weeks returns to non pregnant size Enlarges immediately after delivery to umbulicus by two weeks it resumes its position within the pelvis at six weeks returns to non pregnant size

3. Physiology of the Puerperium Cervix Returns to normal within hours of delivery Transverse slit like external os persists due to laceration Vaginal and perineal tears may remain inflamed for several days but rapidly heal Vagina appears normal in 6 weeks in non lactating women Breast feeding women are hypoestrogenic resulting in vaginal mucosa being pale and smooth (causes dryness & friction dysparunia)

4. Physiology of the Puerperium Breasts Decline in Estrogen and Progesterone result in breast engorgement by day 3

5. Physiology of the Puerperium Cardiovascular changes Changes of pregnancy reversed over three weeks Marked increase stroke volume immediately post partum 500-1000ml blood loss in normal delivery

6. Physiology of the Puerperium Leukocytosis of labor persists for several days Reduces the value of leukocyte count to determine infection Serial counts may still be useful to follow infection

7. Physiology of the Puerperium Weight changes 5-6 kg weight loss expected at delivery Additional 3-4 kg over the next two weeks due to diuresis & loss of extracellular fluid GFR returns to normal within several days

8. Complications of Puerperium Blood loss & infection most common complicating 1-5% of pregnancies Blood loss Weigh bed clothes and pads for semi-quantitative method of determining blood loss VS- Q 15 minutes for 1 hour, Q 30 minutes for two hours then q4hours for the first day Failure to identify early post partum hemorrhage remains leading cause of maternal mortality

9. Complications of Puerperium Blood loss Early post partum hemorrhage Most common cause uterine Atony Normal uterine blood flow 500 ml/min If effective contraction of myometrium does not occur significant blood loss can occur Risk factors include: Use of oxytocin during labor High parity Distended uterus

10. Complications of Puerperium Uterine Atony (Cont’d) Treatment Uterine compression Oxytocics Early suckling causes endogenous release of oxytocin Oxytocin IV/IM 10 units Methylergonovine Methyl prostoglandin F

11. Complications of Puerperium Retained products of conception Causes early post partum hemorrhage Requires manual exploration of the uterus May require anesthesia and curettage

12. Complications of Puerperium Lacerations Repair immediately Uterine rupture Abdominal exploration and repair

13. Complications of Puerperium Blood replacement based on estimated loss Alterations in vitals signs may occur as late finding (Do not wait for hypotension to occur) R/O DIC by acquiring appropriate coagulation studies (split fibrin products etc)

14. Complications of Puerperium Placenta Accreta & Uterine Inversion Uncommon Accreta is when incomplete placental separation occurs Requires immediate hysterectomy Uterine inversion requires immediate reduction Hematomas

15. Complications of Puerperium Infections Endomyometritis Foul smelling lochia and tender uterus within first few days post partum Increased risk with c-section, PROM, Multiple exams during labor, & long labor Polymicrobial including anaerobes (Ecoli, Gardnerella, Peptostreptococcus) Treat with Gentamycin/Clindomycin (Gold Standard), extended spectrum penicillin or cephalosporin

16. Complications of Puerperium Fever UTI/Pyelonephritis DVT/Thrombophlebitis “Milk fever” (Lasts < 24 hours) Drug reaction Perineal infection(Day five) Pulmonary Atelectasis (48 hours) Mastitis (2-3 weeks post partum)

17. Complications of Puerperium Infection Maternal temperature best indicator of post partum infection Monitor Q6 hours for first twenty four and have patient report chills, temperature post hospitalization Inspect episiotomy site regularly for infection Monitor for return of bowel/bladder function

18. Analgesics Acetaminophen Aspirin NSAIDs Codeine- complicated by high incidence of constipation & light headedness Afterpains especially problematic during suckling due to oxytocin release

19. Immunizations Puerperium is ideal time to administer rubella vaccine for those found non immune Rh- women with Rh+ baby should receive appropriate amounts of Rh immune globulin

20. Contraception Ovulation may occur by week six Sexual intercourse often resumed by week two-three Oral contraceptives may be started 1-2 weeks post partum in non lactating female20

21. Discharge Instructions Review infant care feeding diapering Follow up visits Colic Infant care and needs Resuming sexual intercourse

22. Discharge Instructions Maternal follow up instructions Perineal care sits baths green water breast care Post partum blues/depression Support services due to early discharge

23. Medications & Breast Feeding Drugs and breast milk. Drugs concentrated in breast milk tend to be weak bases (such as metronidazole, antihistamines, erythromycin, or antipsychotics and antidepressants). Drugs absolutely contraindicated in breast feeding. Chemotherapeutic or cytotoxic agents, all drugs used recreationally (including alcohol and nicotine), radioactive nuclear medicine tracers, lithium carbonate, chloramphenicol, phenylbutazone, atropine, thiouracil, iodides, ergotamine and derivatives, and mercurials.

24. Medications & Breast Feeding Drugs to strongly avoid or consider bottle feeding. Antipsychotics, antidepressants, metronidazole, tetracycline, sulfonamides, diazepam, salicylates, corticosteroids ,phenytoin, phenobarbital, or warfarin. Drugs safe to use in normal doses. Acetaminophen, insulin, diuretics, digoxin, beta-blockers, penicillins, cephalosporins, erythromycin, birth control pills, OTC cold preparations, and narcotic analgesics (short term in normal doses). Lactation-suppressing drugs. Levodopa, anticholinergics, bromocriptine, trazodone, and large-dose estradiol birth control pills.

25. Breast Problems During Lactation Mastitis S/S Organisms Rx Obstructed ducts S/S Rx Other

26. Examples of Post Partum Orders Pitocin 10 units IM Bedrest Vital signs Q15 minutes for 1 hour, Q 1hour x 4, Then QID if stable Consider NPO for 1-2 hours Ice packs to perineum

27. Examples of Post Partum Orders Ambulate as tolerated when stable (caution check for orthostatic hypotension) Diet- as appropriate Tucks to perineum prn Sitz baths QID IV- discontinue when VS stable and uterine bleeding is normal

28. Examples of Post Partum Orders Urethral catherization if unable to void in 6-8 hours Breast binder if not nursing CBC post partum day 2 Medications Continue prenatal vitamins FeSO4 Acetaminophen 650 mg Q4h prn/Ibuprofen

29. Examples of Post Partum Orders Bowels Ducosate sodium 100 mg BID; MOM- 30 ml PO QD PRN Follow up Post partum check 4-6 weeks Newborn checkup 1-2 weeks

30. Post Partum Psychiatric Syndromes Underrecognized Undertreated Underresearched First recognized with publication of DSM IV because they were not felt to have distinguishable features from other psychiatric disorders Most classified as mood disorder subsets

31. Post Partum Psychiatric Syndromes Epidemiology Post partum psychosis 1:500 Risk for previously affected 1:3 Non psychotic depression 1:10-15 Risk of previously affected 1:2 In patients with history of mood disorder and previous post partum depression ~ 100%

32. Post Partum Psychiatric Syndromes Post partum blues affects 50-80% due to lack of major symptoms not classified as a disorder

33. Predisposing Factors Primiparous women Women with personal or family history of mood disorders Previous history of Postpartum depression/psychosis Perinatal death

34. Sheehan’s Syndrome 1967 Howard Sheehan described postpartum necrosis of the anterior pituitary blood loss during pregnancy followed by circulatory collapse of the pituitary causes array of multiglandular disorders causes agitation, hallucinations, delusions, & depression