PUERPERIUM AND LACTATION

By Oriba Dan Langoya, MBchBSeminar

Obstetrics and Gynecology

Introduction

• The puerperium is the 6 wks period following

childbirth, when considerable adjustments occurs

before return to the pregnant state

Physiologic change

Psychological disturbances

Physiological ChangesUterine Involution

• Postpartum uterus weighing about 1kg return to pre-pregnant

state of ˂ 100g.

• Uterus fundus is 4cm below umbilicus OR 12cm above pubic

symphysis.

• Involution is by autolysis, muscles cells diminish in size but not

number.

• Involution appears to be accelerated by oxytocin during

breastfeeding.

Uterine Involution

• Causes of delayed uterine Involution

a. Full bladder

b. Loaded rectum

c. Uterine infection

d. Retained products of conception

e. Fibroids

f. Broad ligament haematoma

Genital Tract Changes

• Following delivery the lower segment of the uterus and cervix

appears flabby.

• In 1st few days the cervix can admit 2 fingers

• By the end of 1st wk it can only admit 1 finger & by the end of the

2nd wk the internal OS should be closed.

• The ext OS can remain open through out ie xtics of parous cervix

• In the 1st few days vagina is smooth and edematous. Rugae appear

in 3rd wk.

Lochia• Blood stained uterine discharge comprised of blood and

necrotic decidua.

• Basal layer near adjacent to the myometrium helps in regeneration, ends by the 3rd wk

• Lochia is red in 1st few days, turns to pink and finally serous by 2nd week.

• Persistence of either red of offensive Lochia suggest pathology, Should be managed accordingly

Puerperal Disorders

• Daily observations: BP, Temp, Urinary function, Bowel function, PR, Breast exams, feeding, assess UI, Lochia

• High risk individuals, CS, High BP,

• Check also for Hb in 3 days

Perineal Complications• Pain in about 80% of women in 1st 3days of delivery

• Discomfort is greatest in those whose sustain spontaneous tears, instrument delivery

• Both pharmacologic & non-pharmacologic manag’t is successful

• Infections of the perineum is uncommon & signs of infections must be taken seriously

• Spontaneous opening of repaired perineal tears and episiotomies is usually assoc with 2nd bact infection

Bladder Function

• Voiding difficulty & over distension are common esp. in reg. anaesthesia.• In epidural anaesthesia, bladder take up to 8hrs to

regain normal sensation. • Damage is inflicted on the detrusor muscle,

overstretching can dampen bladder sensation, i.e. hypo-contractile• Fibrous replacement of smooth muscles• Urine production increases in puerperium.

Bladder Function

• Traumatic delivery such as difficult instrumentation delivery or multiple/ extended lacerations or V-V haematoma• Difficult voiding due to pain & periurethral edema.• Other complications i.e.

a. Prolapse haemorrhoidsb. Anal fissuresc. Abdominal wound haematomad. Stool impaction on rectum

Bladder Function

• Vigilance should be put on epidural or spinal anaesthesia in causing bladder distension

• Urinary catheter for 12-24hrs must be left after CS.

• Urine samples should be sent for micro cultures, & sensitivity.

• In vaginal delivery incontinence has to be investigated to exclude;

a. Vesico-virginalb. Urethro-vaginal c. Rarely uretero-varginal fistula

Bladder Function

• Pressure necrosis of the bladder or urethra may develop due to prolonged obstructed labour

• Incontinence occurs in the 2nd week when the slough separates

Bowel function

• Constipation is common possibly due to diet factors and dehydration.• Advice on adequate fluid intake and fibre diet is

important• Avoidance of constipationAnd straining is importantIn women with 3rd or 4th degtear

Bowel function

• Important to ensure that Lactulose and Ispaghula

husk or Methyl cellulose are prescribed.

• High prevalence of anal and faecal urgency

following childbirth evidence of occult anal

sphincter trauma

• Fistulae should be considered in anal incontinence

in post-partum period

Secondary Postpartum Haemorrhage

• Fresh bleeding from the genital tract btn 24hrs and 6wks after delivery.• SPPH most commonly occur btn 7th-14th, mostly due

to retained placental tissue.• Associated features;

Crampy abdominal pain,Uterus larger than appropriatePassage of bits of Placental tissue within the

cervixSigns of infection

SPPH

• Other causes of Secondary PPH

a) Endometriosis

b) Hormonal contraception

c) Bleeding disorders e.g. von Willebrand’s disease

d) Choriocarcinomas

Obstetric Palsy

• One or both lower limbs may develop signs of a motor &/ or sensory neuropathy following delivery.

• Presenting features include:Sciatic pain,Foot-dropParasthesia, HypoaesthesiaMuscle wasting

• Mech of injury is unknown. Probably due to compression of Lumbosacral trunk

Obstetric Palsy

• Herniation of Lumbosacral disc at L4 or L5 can

occur

• Esp in exaggerated Lithotomy or during instrument

delivery

• Management include Bed rest, analgesia & physio-

therapy

• Peroneal nerve Palsy can occur leading to foot drop

Symphysis Pubis Diastasis• Separation of symphysis pubis can occur

spontaneously in atleast 1 in 800 vaginal delivery.• Symphysiotomy can be performed in cases of

Borderline Cephalopelvic disproportionation• Sponteneous separation has been is usually noticed

after delivery and has ben associated with; • forceps delivery, rapid 2nd stage labour & severe thig

abduction

Symphysis Pubis Diastasis

• Signs & symptoms

• Symphyseal pain, aggravated by walking & wt. bearing, waddling gait, Pubic tenderness & palpable interpubic gap

• Management,Bed restAnti-inflammatory agentsPhysiotherapy and pelvic corset

Thromboembolism

• Risk rises 5 folds during pregnancy and the puerperium

• Majority of death are common after CS in puerperium

• If DVT or Pulmonay embolism is suspected, full anticoagulant therapy should be started

• Avenogram and/ or Lung scan should be carried out within 24-48Hrs

Puerperal Pyrexia

• A temp of 38 or 100.4degree F or higher on any two of the first 10 days postpartum excluding first 24hr.

• Any pyrexia assoc with tachycardia should be investigated

• Common sites assoc with Puerperal Pyrexia include• Chest, CS or perineal wounds• Throat, Breast• Urinary tract, Pelvic organs, and legs

Dx and Management of puerperal Pyrexia

Chest Complications• Most likely appear within 24hrs after delivery esp

after general anaesthesia

• Atalectasis may be assoc with fever

• Aspirated pneumonia ( Mendleson’s syndrome)

should be suspected if there is;

Wheezing dyspnoea, a spiking temp and

evidence of Hypoxia

Genital Tract Infections

• This is called puerperal sepsis syn with older descriptions

of puerperal, milk and child bed fever.

• Hygiene and overcrowding increase the risk

• Sulphonamides discovery lead to reduction in Hemolytic

strep and fall in maternal mortality

• Accounts for 7% of all direct maternal deaths excluding

death after abortion ( 4 per million maternities)

Etiology of genital tract infections

• Mixed flora colonize vagina with low virulence.• Polymicrobial, i.e. contaminants from bowel• Most frequently identified organisms were

Facultative Gram + cocci, particularly group B strep, coexisting with Mycoplasma species• Natural barrier temporarily remove after delivery• Placenta separation and retained products of

conception and blood clots are favorable for microorganisms

Investigations for Pueperal Genital Infections

Prevention of puerperal Sepsis

Increase awareness of the principles of general

hygiene

Good surgical approach and use of aseptic

technique

Prophylactic antibiotic in CS

REVIEW OF ANATOMY OF THE BREAST

ORIBA DAN LANGOYA, MBchB IV

Makerere University School of Medicine

INTRODUCTION

Embryology Epithelial/mesangial-

glandular tissues of breast 4th to 6th weeks

Develops from milk streak thoracic mammary bud

appears at approx. 49day. Rest involutes

Dermally derived Lies cushioned in fat Between layers of superficial pectoral fascia

Anatomy• Breasts form a 2ND

ary sexual feature of females.• Breast lies upon the

deep pectoral fascia, anterior, and inferiorly, external oblique and its aponeurosis as the latter forms the anterior wall of the sheath of rectus abdominis

Cross section

Blood Supply

• Arteries• Internal thoracic artery • Intercostal arteries• The axillary artery

• Lymph Drainage• Lateral quad drain into

ant axillary or pect• Some vessels comm with

lymph vessels of the opp breast & with those of the anterior abdominal wall• The med quad drain into

internal thoracic group

Lymphatic Drainage

THE END!!!