Physiology of Puerperium and Lactation

Professor Abdulrahim Rouzi, FRCSC

Physiology of the Puerperium



Anatomic changes
Uterus
Lochia-name given to blood and other necrotic Lochiadebris shed from the uterus Uterus does not scar- tissue replaced by new growth scarfrom the basal endometrium Proliferative endometrium persists for about six weeks and first menses normally anovulatory

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)

 

Physiology of the Puerperium



Breasts
Decline in Estrogen and Progesterone result in breast engorgement by day 3

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 500-

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

Physiology of the Puerperium



Weight changes
5-6 kg weight loss expected at delivery Additional 3-4 kg over the next two weeks due 3to diuresis & loss of extracellular fluid

GFR returns to normal within several days

Complications of Puerperium


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

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

Complications of Puerperium


Uterine Atony (Contd)

Treatment
 

Uterine compression Oxytocics Early suckling causes endogenous release of oxytocin Oxytocin IV/IM 10 units Methylergonovine Methyl prostoglandin F

Complications of Puerperium


Retained products of conception

Causes early post partum hemorrhage Requires manual exploration of the uterus May require anesthesia and curettage

Complications of Puerperium


Lacerations
Repair immediately

Uterine rupture
Abdominal exploration and repair

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)


Complications of Puerperium


Placenta Accreta & Uterine Inversion

Uncommon Accreta is when incomplete placental separation occurs Requires immediate hysterectomy Uterine inversion requires immediate reduction

Hematomas

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 clabor, & long labor Polymicrobial including anaerobes (Ecoli, Gardnerella, Peptostreptococcus) Treat with Gentamycin/Clindomycin (Gold Standard), extended spectrum penicillin or cephalosporin

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) (2-

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

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


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


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


Discharge Instructions


Review infant care

feeding diapering Follow up visits Colic Infant care and needs

Resuming sexual intercourse

Discharge Instructions
Maternal follow up instructions  Perineal care


sits baths green water breast care

Post partum blues/depression  Support services due to early discharge



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.

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 betapills, OTC cold preparations, and narcotic analgesics (short term in normal doses).

LactationLactation-suppressing drugs. Levodopa, anticholinergics, bromocriptine, trazodone, and large-dose largeestradiol birth control pills.

Breast Problems During Lactation



Mastitis
S/S Organisms Rx

Obstructed ducts
S/S Rx

Other

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 1 Ice packs to perineum


Examples of Post Partum Orders

Ambulate as tolerated when stable (caution check for orthostatic hypotension)  Diet- as appropriate Diet Tucks to perineum prn  Sitz baths QID  IV- discontinue when VS stable and uterine IVbleeding is normal


Examples of Post Partum Orders

Urethral catherization if unable to void in 668 hours  Breast binder if not nursing  CBC post partum day 2  Medications


Continue prenatal vitamins FeSO4 Acetaminophen 650 mg Q4h prn/Ibuprofen

Examples of Post Partum Orders



Bowels
Ducosate sodium 100 mg BID; MOM- 30 ml MOMPO QD PRN

Follow up
Post partum check 4-6 weeks 4 Newborn checkup 1-2 weeks 1-

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

Post Partum Psychiatric Syndromes



Epidemiology
Post partum psychosis
1:500 Risk for previously affected 1:3

Non psychotic depression

1:10-15 1:10 Risk of previously affected 1:2 In patients with history of mood disorder and previous post partum depression ~ 100%

Post Partum Psychiatric Syndromes



Post partum blues affects 50-80% 50 due to lack of major symptoms not classified as a disorder

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


Sheehans 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