normal and abnormal puerperium/postnatal period .pptx

Obstetrics

1. Puerperium

2. Puerperium The time from the delivery of the placenta through the first few weeks after the delivery Usually considered to be 6 weeks Body returns to the nonpregnant state

3. Uterus Immediately after the delivery, the uterus can be palpated at or near the umbilicus Most of the reduction in size and weight occurs in the first 2 weeks 2 weeks postpartum, the uterus should be located in the true pelvis

4. Lochia Vaginal discharge, lasts about 5 weeks 15% of women have lochia at 6 weeks postpartum Lochia rubra Red Duration is variable Lochia serosa Brownish red, more watery consistency Continues to decrease in amount Lochia alba Yellow

5. Cervix, Vagina, Perineum Tissues revert to a nonpregnant state but never return to the nulliparous state

6. Abdominal Wall Remains soft and poorly toned for many weeks Return to a prepregnant state depends greatly on exercise

7. Ovulation Breastfeeding Longer period of amenorrhea and anovulation Highly variable 50-75% return to periods within 36 weeks Not breastfeeding As early as 27 days after delivery Most have a menstrual period by 12 weeks

8. Breasts Changes to the breast that prepare for breastfeeding occur throughout pregnancy Lactation can occur by 16 weeks’ gestation Colostrum 1 st 2-4 days after delivery High in protein and immune factors Milk matures over the first week* Contains all the nutrients necessary *Continues to change thoughout the period of breastfedeing to meet the changing demands of the baby

9. Breastfeeding “Breastfeeding is neither easy nor automatic.” Should be initiated after delivery Feed baby every 2-3 hrs to stimulate milk production Production should be established by 36-96 hrs

10. Considerations Vaginal Birth Swelling and pain in the perineum Episiotomy? Laceration? Hemorrhoids Often resolve as the perineum recovers Cesarean Delivery Pain from the abdominal incision Slower to begin ambulating, eating, and voiding

11. Sexual Intercourse May resume when… Red bleeding ceases Vagina and vulva are healed Physically comfortable Emotionally ready *Physical readiness usually takes ~3 weeks

12. Concerns - Puerperal Period

13. Hemorrhage

14. Postpartum Hemorrhage Excessive blood loss during or after the 3 rd stage of labor Average blood loss is 500 mL Early postpartum hemorrhage 1 st 24 hrs after delivery Late postpartum hemorrhage 1-2 weeks after delivery (most common) May occur up to 6 weeks postpartum

15. Postpartum Hemorrhage Incidence Vaginal birth: 3.9% Cesarean: 6.4% Delayed postpartum hemorrhage: 1-2% Mortality 5% of maternal deaths

16. Postpartum Hemorrhage May result from: Uterine atony Lower genital tract lacerations Retained products of conception Uterine rupture Uterine inversion Placenta accreta adherence of the chorionic villi to the myometrium Coagulopathy Hematoma Most common

17. INFECTION Endometritis Ascending polymicrobial infection Usually normal vaginal flora or enteric bacteria Primary cause of postpartum infection 1-3% vaginal births 5-15% scheduled C-sections 30-35% C-section after extended period of labor May receive prophylactic antibiotics <2% develop life-threatening complications

18. Endometritis Risk factors: C-section Young age Prolonged labor Prolonged rupture of membranes Multiple vaginal exams Placement of intrauterine catheter Preexisting infection Twin delivery Manual removal of the placenta

19. Endometritis Clinical presentation Fever Chills Lower abdominal pain Malodorous lochia Increased vaginal bleeding Anorexia Malaise Exam findings Fever Tachycardia Fundal tenderness Treatment Antibiotics

20. Urinary Tract Infection Bacterial inflammation of the bladder or urethra 3-34% of patients Symptomatic infection in ~2%

21. Urinary Tract Infection Risk factors C-section Forceps delivery Vacuum delivery Tocolysis Induction of labor Maternal renal disease Preeclampsia Eclampsia Epidural anesthesia Bladder catheterization Length of hospital stay Previous UTI during pregnancy

22. Urinary Tract Infection Clinical Presentation Urinary frequency/urgency Dysuria Hematuria Suprapubic or lower abdominal pain OR… No symptoms at all Exam Findings Stable vitals Afebrile Suprapubic tenderness Treatment antibiotics

23. Mastitis Inflammation of the mammary gland Milk stasis & cracked nipples contribute to the influx of skin flora 2.5-3% in the USA Neglected, resistant or recurrent infections can lead to the development of an abscess (5-11%)

24. Mastitis Clinical Presentation Fever Chills Myalgias Warmth, swelling and breast tenderness Exam Findings Area of the breast that is warm, red, and tender Treatment Moist heat Massage Fluids Rest Proper positioning of the infant during nursing Nursing or manual expression of milk Analgesics Antibiotics stasis

25. Wound Infection Perineum (episiotomy or laceration) 3-4 days postpartum rare Abdominal incision (C-section) Postoperative day 4 3-15% prophylactic antibiotics 2%

26. Wound Infection Perineum Risk Factors: Infected lochia Fecal contamination Poor hygiene Abdominal incision Risk factors: Diabetes Hypertension Obesity Corticosteroid treatment Immunosuppression Anemia Prolonged labor Prolonged rupture of membranes Prolonged operating time Abdominal twin delivery Excessive blood loss

27. Wound Infection Clinical Presentation Perineal Infection: Pain Malodorous discharge Vulvar edema Abdominal Infection Persistent fever (despite antibiotics) Diagnosis Erythema Induration Warmth Tenderness Purulent drainage With or without fever

28. Endocrine Disorders

29. Postpartum Thyroiditis (PPT) Transient destructive lymphocytic thyroiditis occuring within the 1 st year after delivery Autoimmune disorder Thyrotoxicosis 1-4 months postpartum; self-limited Increased release (stored hormone) Hypothyroidism 4-8 months postpartum

30. Postpartum Thyroiditis (PPT) ~4% develop transient thyrotoxicosis 66-90% return to normal 33% progress to hypothyroid 10-3% develop permanent thyroid dysfunction Risk Factors Positive antithyroid antibody testing History of PPT Family or personal history of thyroid or autoimmune disorders

31. Postpartum Thyroiditis (PPT) Clinical Presentation Fatigue Palpitations Eat intolerance Tremulousness Nervousness Emotion liability *mild & nonspecific (may go undiagnosed) Hypothyroid Phase: Fatigue Dry skin Coarse hair Cold intolerance Depression Memory & concentration impairment

32. Postpartum Thyroiditis (PPT) Exam findings Tachycardia Mild exopthalmos Painless goiter Lab testing TSH ↓ thyrotoxicosis TSH ↑ hypothyroid Treatment Thyrotoxicosis No treatment (mild) Beta-blocker Hypothyroid No treatment (mild) Thyroxine (T4)

33. Postpartum Graves Disease Autoimmune disorder Diffuse hyperplasia of the thyroid gland Response to antibodies to the thyroid TSH receptors Increased thyroid hormone production and release Les common than PPT Accounts for 15% of postpartum thyrotoxicosis

34. Psychiatric Disorders

35. Postpartum Blues Transient disorder Lasts hours to weeks Bouts of crying and sadness Postpartum Depression(PPD) More prolonged affective disorder Weeks to months S&S of depression Postpartum Psychosis First postpartum year Group of severe and varied disorders (psychotic symptoms)

36. Etiology Unknown Theory: multifactorial Stress Responsibilities of child rearing Sudden decrease in endorphins of labor, estrogen and progesterone Low free serum tryptophan (related to depression) Postpartum thyroid dysfunction (psychiatric disorders)

37. Risk factors Undesired pregnancy Feeling unloved by mate <20 years Unmarried Medical indigence Low self-esteem Dissatisfaction with extent of education Economic problems Poor relationship with husband or boyfriend Being part of a family with 6 or more siblings Limited parental support Past or present evidence of emotional problems

38. Incidence 50-70% develop postpartum blues 10-15% of new mothers develop PPD 0.14-0.26% develop postpartum psychosis History of depression 30% chance of develping PPD History of PPD or postpartum psychosis 50% chance of recurrence

39. Postpartum Blues Mild, transient, self-limiting Commonly in the first 2 weeks Signs and symptoms Sadness Crying Anxiety Irritation Restlessness Mood lability Headache Confusion Forgetfullness Insomnia

40. Postpartum Blues Often resolves by postpartum day 10 No pharmacotherapy is indicated Treatment Provide support and education

41. Postpartum Depression (PPD) Signs and symptoms Insomnia Lethargy Loss of libido Diminished appetite Pessimism Incapacity for familial love Feelings of inadequacy Ambivalence or negative feelings towards the infant Inability to cope

42. Postpartum Depression (PPD) Consult a psychiatrist if… Comorbid drug abuse Lack of interest in the infant Excessive concern for the infant’s health Suicidal or homicidal ideations Hallucinations Psychotic behavior Overall impairment of function

43. Postpartum Depression (PPD) Lasts 3-6 months 25% are still affected at 1 year Affects patient’s ADLs Treatment Supportive care and reassurance (healthcare professionals and family) Pharmacological treatment for depression Electroconvulsive therapy

44. Postpartum Psychosis Signs and symptoms Acute psychosis Schizophrenia Manic depression

45. Postpartum Psychosis Treatment Therapy should be targeted to the patient’s specific symptoms Psychiatrist Hospitalization *Generally lasts only 2-3 months