Physiological Process that occur in a woman who has given birth up to 6wks postpartum, abnormal processes and their risk factors, clinical assessment and management Lastly a brief review of anatomy of the breast

1. PUERPERIUM AND
LACTATION
By Oriba Dan Langoya, MBchB
Seminar
Obstetrics and Gynecology

2. Introduction
• The puerperium is the 6 wks period following
childbirth, when considerable adjustments occurs
before return to the pregnant state
 Physiologic change
 Psychological disturbances

3. Physiological Changes
Uterine 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.

4. 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

5. 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.

6. 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

7. 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

8. 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

9. 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.

10. 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 haemorrhoids
b. Anal fissures
c. Abdominal wound haematoma
d. Stool impaction on rectum

11. 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-virginal
b. Urethro-vaginal
c. Rarely uretero-varginal fistula

12. 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

13. Bowel function
• Constipation is common possibly due to diet factors
and dehydration.
• Advice on adequate fluid intake and fibre diet is
important
• Avoidance of constipation
And straining is important
In women with 3rd or 4th deg
tear

14. 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

15. 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 appropriate
Passage of bits of Placental tissue within the
cervix
Signs of infection

16. SPPH
• Other causes of Secondary PPH
a) Endometriosis
b) Hormonal contraception
c) Bleeding disorders e.g. von Willebrand’s disease
d) Choriocarcinomas

17. Obstetric Palsy
• One or both lower limbs may develop signs of a
motor &/ or sensory neuropathy following delivery.
• Presenting features include:
Sciatic pain,
Foot-drop
Parasthesia, Hypoaesthesia
Muscle wasting
• Mech of injury is unknown. Probably due to
compression of Lumbosacral trunk

18. 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

19. 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

20. Symphysis Pubis Diastasis
• Signs & symptoms
• Symphyseal pain, aggravated by walking & wt.
bearing, waddling gait, Pubic tenderness & palpable
interpubic gap
• Management,
Bed rest
Anti-inflammatory agents
Physiotherapy and pelvic corset

21. 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

22. 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

23. Dx and Management of puerperal Pyrexia

24. 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

25. 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)

26. 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

29. Investigations for Pueperal Genital Infections

33. Prevention of puerperal Sepsis
Increase awareness of the principles of general
hygiene
Good surgical approach and use of aseptic
technique
Prophylactic antibiotic in CS

34. REVIEW OF ANATOMY OF THE BREAST
ORIBA DAN LANGOYA, MBchB IV
Makerere University School of Medicine

35. 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

36. 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

37. Cross section

38. 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

39. Lymphatic Drainage

40. THE END!!!