Postnatal Care

Presented by
Dr Rupak Kumar Rana
VCHS
2080
 Puerperium
• Period of 6 weeks following childbirth during
which the maternal organs, especially
reproductive organs return to the non
pregnant/near normal state

• Breasts are an exception: active during the

period
 Physiology
• Involution : normalization in the size of pelvic
organ
• Involution of uterus
• Involution of other pelvic organs
• Pelvic musculature
• Changes in non reproductive organs
• Menstruation, ovulation
• Breast feeding
 Involution of uterus
• Decrease in size
– Reduction in size of muscle fibers: removal of excess
of cellular cytoplasm by intracellular,
autolytic,proteolytic enzymes in form of peptones-
blood stream-excreted by kidneys
• Reduction in vascularity: thrombosis &
degeneration of uterine vessels
• Regeneration of endometrium: glandular
remnants, interglandular stroma , completed in 4-
6wks
 Involution of uterus
• Discharge emanating from uterus: Lochia
• Vaginal discharge in first 2 weeks of
puerperium, fishy odor, alkaline
• Lochia: sloughing decidual lining of uterus,
secretions from uterine cavity, cervix & vagina
• Lochia rubra: <7 days
• Lochia serosa: 7-10 days
• Lochia alba :10-14 days
 Lochia
• Lochia rubra:
– color is red
– Blood, leucocytes, sloughed decidua, mucus
• Lochia serosa: progressively pale, blood
tinged ,thinner in consistency
• Lochia alba:
– yellowish white in color, scanty
– Mucus, serous exudates, epithelia cells, leucocytes
• Clinical significance: odour, duration
 Involution of other pelvic organs
• Cervix:
– loose ,flabby, thrown into folds after delivery
– Contracts ,thickens feels tubular but remain
patulous, by 6 weeks involution is complete
• Vagina:
– soft, dusky, engorged, stretchable
– diminishes in size, caliber, never to prepregnant
state
 Urinary tract changes
• Renal pelvicalyceal dilatation: Normal in
8wks,may persist 12 weeks postpartum
• Increased renal plasma flow, GFR, creatinine
clearance: normal by 6 wks
• Bladder:
– During labor: edematous, hyperemic
– trauma to bladder innervations: instrumental,
difficult vaginal delivery: relatively insensitive,
retention of urine, infection
 Bowel changes
• Constipation
• Intestinal paresis following delivery
• Altered tone of perineal muscles following
delivery
• Painful perineal lesion

• Early ambulation, increased fluids, high fibre

diet
• Metabolic changes: reversal of changes
(hyperlipidemia , raised blood sugar)
• Circulation:
– CO increases by 70% following delivery: prelabor
values by 1 hr PP & pre-pregnant levels by 4wks
– Increase in peripheral resistance(loss of progesterone
effect)
– Normal total circulating blood volume by 3-6 wks
• Respiratory changes: rapid normalization of
residual volume, FRC
 Menstruation& ovulation
• Onset of menstruation: lactating/non lactating
• Lactation: increased prolactin levels-
– inhibits ovarian response to FSH(less follicular
growth),no menstruation
– Suppresses release of LH, no LH surge, no
ovulation
 menstruation ovulation

Non lactating By 6th wk(40%) 4wks

women By 12 th
wk(80%)
Lactating By 12 wks(70%) 10wks
women 6 months
 Management of normal puerperium:
objectives
• Restoration of health to pre-pregnancy state
• Promotion of lactation
• Prevent infection
• Care of the infant
• Advice on immunization
• Advice on discharge
 Immediate care
• Examine vital parameters : PR,BP
• P/A: uterus well retracted
• L/E: amount of bleeding, perineal wound( if any)
dressing by antiseptic, dry, application of sterile
pad
• Encouraged to pass urine
• Meet relatives, baby put to breast feed
• Allowed drinks, food
• Shifted to room/ward
 changes in post delivery period
• Pulse : tachycardia, settles in a day
• Blood pressure: normal/raised: increased
venous return, normalizes in 24 hrs
• Temperature: transient rise (99.0°F)
• Urine output: diuresis following delivery
• Emotional instability: anxiety, unfamiliar to
newborn, change in lifestyle, newer demands
cause psychological stress, puerperal blues
 Care during puerperium
• Rest & ambulation: adequate rest, no specified
period
• Early ambulation encouraged:
• Restores self confidence
• Accelerates recovery, encourages drainage of lochia,
involution
• Lessens venous thrombosis-embolism
• Hospital stay: 48 hrs( normal delivery)
5-7 days (cesarean delivery)
 Care during puerperium
• Diet: lots of fluid, easy to digest diet(milk,
green leafy vegetables, fresh fruits)
• Care of breasts
• Care of bowel & bladder: encouraged to pass
urine frequently, having more roughage,fluids
in diet corrects constipation
• Care of perineum: kept clean, dry after every
act of urination/defecation
 Rooming –in
• allowing mother & her baby to stay together
after birth
• Advantages:
– mother responds to her baby whenever is hungry
– helps bonding & breast feeding
– Confident about breast feeding, feeds on demand
– Better understanding of mother about baby
 Immunization
• Non immunized Rh negative mothers: fetal
cord blood- anti D immuno-
prophylaxis(300µg) IM ,within 72 hrs of birth
• Tetanus toxoid: booster dose, if not given
during pregnancy
• Rubella vaccine
 Management of ailments
• After pains: infrequent, spasmodic lower pain
abdomen after delivery
• Pain on the perineum: analgesics, sitz baths,
examination to rule out vulvovaginal
hematomas
• Correction of anemia: iron(oral/parenteral)
supplementation
• Treatment of BP
 Breast complications in puerperium
 Breast engorgement
 Cracked and retracted nipple
 Mastitis
 Breast abscess
 Lactation failure
 Breast engorgement

 Onset: 3 to 5 days after delivery

 Most common in primiparous and patient with

inelastic breasts

 Due to exaggerated normal venous and lymphatic

engorgement of the breast which precedes
lactation and preventescape of milk from lacteal
system
 Symptoms:
– Considerable pain in both breasts
– Feeling of heaviness in both breasts
– Generalized malaise or transient rise in
temperature
– Painful breastfeeding
 Cont...
 Prevention:
• Avoid prelacteal feeds
• Initiate breast feeding early and
unrestricted
• Exclusive breast feeding on demand
• Feeding in correct position
 Cont...
 Management:
• Support breasts with a binder
• Manual expression of any remaining milk after
each feed
• Administration of analgesics for pain
• Placing of baby to the breast regularly at frequent
intervals
• Use of breast pump helpful in severe cases
 Cracked nipple
• The nipple may be painful due to:
a) Loss of surface epithelium
b) Due to a fissure situated at tip or base of nipple or
at both area
• Causes:
a) Poor hygiene  formation of crust over the nipple
b) Retracted nipple
c) Trauma from baby’s mouth due to incorrect
attachment to mother’s breast.
Condition may be asymptomatic but becomes painful
when the infant sucks the breast.
 Contd..
• Prophylaxis
– Local cleanliness during pregnancy and puerperium,
before and after each breastfeeding to prevent crust
formation in the nipple

• Treatment
– Correct attachment will provide immediate relief from
pain and rapid healing
– Purified lanonin with mother’s milk applied 3-4 times a
day to hasten healing
 contd..

• Treatment
– Miconazole lotion applied over nipple as well as in
the baby’s mouth (if there is oral thrush).

– If fails to heal, rest is given to affected nipple using

breast pump while the nipple heals.

If ulcer persistent in spite of therapy, biopsy should

be done to exclude malignancy
 Retracted and flat nipple
• Commonly seen in primigravidae

• Babies can attach and are able to suck

adequately

• If unable to suck, manual expression of milk

and fed
 Lactation failure
• Inadequate milk production

• Causes:
– Infrequent suckling
– Depression or anxiety state in puerperium
– Reluctant or apprehension to nursing
– Ill development of nipples
– Painful breast lesions
– Endogenous suppression of prolactin(retained placental
bits)
– Prolactin inhibition(pyridoxine, ergot preparation, diuretics)
• Treatment:
– Antenatal:
• Counselling to the mother regarding breastfeeding
• Taking care of any breast abnormalities like retracted
nipple
• Maintain adequate breast hygiene
• Treatment contd…
– Puerperium
• Encourage adequate fluid intake
• Nurse the baby regularly
• Painful local lesion is to be treated to prevent nursing
phobia
• Metoclopramide, intranasal oxytocin and sulpiride help
in increasing breastmilk production
 Daily progress chart
• Pulse, Respiration, BP :twice a day
• Examination of breasts
• Measuring height of uterus above pubic
symphysis
• Character of lochia
• Bowel, bladder function
• Details of baby: feeding, bowel,bladder , exam
of umbilical stump ,skin color
 Involution of uterus

• Immediately following
delivery: at umbilicus
• Rate of involution:
1cm /day
• Becomes pelvic organ
by 10-12 days
 Postpartum FP services
• Barrier methods
• PPIUCD
• Oral pills ( progesterone only pills)
• Injectables (DIMPA)
• Sterilization (Tubectomy)
• LAM( Lactational amenorrhea method)
 Postpartum exercises

• To tone up the pelvic floor muscles

– Contract pelvic muscles (withhold act of
urination/defecation) & relax
• To tone up the abdominal muscles
– Dorsal, knees bent, contract & relax abdominal
muscles alternatively
• To tone up the back muscles
– Prone, arms by side, head & shoulders are slowly
moved up & down
 Postpartum exercises
• When to start: as soon as the pt appears to be
fit
• Initially: deep breathing, leg movements
• Adv:
– improves muscle tone
– Minimizes risk of DVT
– Prevent gynecological complications: prolapse
• Continued for 3 months
 Discharge
• Thorough checkup of mother & baby
• Measures to improve general health of
mother: diet,hematinics
• Postnatal exercises
• Breast feeding & care of newborn,
immunization
• Family planning advice
• Follow up after 6 wks
 Postnatal checkup /care
• Minimum of three checkups
• First <48hrs of delivery
• Second within 7 days
• Third at 6th week
 Objective
• Assess health status of mother
• Reassess ,detect & treat any
medical/gynecological complication
• Assess progress of baby
• Immunization of baby
• Impart family planning options to mother
 Postnatal checkup
• Examination of mother : general, breasts, local
examination if required
• Examination of baby: well baby clinic
• Advice
– General: health, feeding, immunization
– Postnatal exercises
– Impart family planning methods
Puerperal sepsis organism and
management
 Outlines:
• Definition

• Epidemiology

• Predisposing factors

• Causative organisms

• Clinical features

• Management

• References
 Definition
• It is said to have occurred if the patients
temperature is higher than 380C in more than 2
occasions at least 24 hours apart following the
1st 24 hours after delivery.

• Patient with post partum fever can be assumed

to have genital tract infection until proven
otherwise.
 Epidemiology:
• Occurs in 1-8% of vaginal delivery

• Risk increases by 5 to 10 times higher in

caesarean delivery.
 Predisposing factors:
• Poor health status of mother
• Malnutrition
• Anaemia
• Prolong labour
• Frequent vaginal examination
• PROM
• Intrauterine manipulation
– Amino infusion
– Instrumental delivery
– Caesarean section
 Causative organisms:
Site of infection
Endometritis
Wound cellulitis
Wound abscess
Abdominal incision
Episiotomy
Vaginal/cervical laceration
Necrotizing fasciitis
septicemia
Urinary infection
Cystitis
Pyelonephritis
Mastitis/breast abscess
Responsible microbes
Flora from cervix and vagina
Group A or B streptococcus and clostridium
Staphylococcus aureus
E. coli
Mixed organisms
Mixed organisms
Streptococcus
Staphylococcus and anaerobic streptococcus
Group A or B streptococci, Bacteroides
E. coli, group B streptococci
Proteus, klebsiella, enterobacter
Pseudomonas
Staphylococcus aureus
 Clinical features
• Endometritis:
– Presents 2-3 days after delivery
– Mild temperature rise, lower abdominal discomfort
and uterine tenderness
• Endomyometritis:
– High temperature
– Malaise, anorexia, abdominal pain
– Foul smelling lochia
• Peuperal sepsis:
– Rapidly progressive cellulitis, peritonitis and
septicaemia
MANAGEMENT
 Prophylaxis

• Antenatal

– Improvement of nutritional status

– Eradication of septic focus

• Intranatal:
– Full surgical asepsis during delivery

– Screening for group-B streptococcus in high risk

patient

– Prophylactic use of antibiotic at time of caesarean

section
• Immediate infusion of 1 gram ceftriaxone after cord
clamping and 2nd dose after 8 hours
• Post-partum:

– Aseptic precaution for at least 1 week following

delivery.

– Too many visitors are restricted

– Sterilized sanitary pads are to be used

– Infected mothers and babies are isolated

Treatment:
• General care:
– Isolation of the patient

– Adequate fluid and calorie by I.V infusion

– Correction of anemia

– Catheterization for urinary retention

– Maintenance of chart

– antibiotics
• Empirical antibiotics: ( for 7-10 days)

– Gentamycin 2mg/kg i.v loading dose followed by 1.5 mg/kg

i.v TDS
+

– Ampicillin 1 g i.v QID or clindamycin 900 mg i.v TDS

OR

– Ceftriaxone 1g TDS

– Metronidazole 0.5 g i.v TDS ( for anaerobes)

Surgical treatment
• Perineal wound:

– Stitches are removed to facilitate drainage of pus &

relieve pain

– Cleaned with sitz bath

– Antiseptic ointment or powder for dressing

– Secondary suture after control of infection

• Retained uterine products:
– Surgical evacuation if diameter more than 3 cm
– Antibiotic coverage a day prior

• Pelvic abscess:
– Drained by colpotomy under USG guidance

• Wound dehiscence:
– Scrubbing the wound 2 times a day
– Debridement of all necrotic tissue
– closing wound with secondary suture
– Appropriate antibiotic after culture
• Laparotomy:
– Unresponsive peritonitis
– Hysterectomy indicated if rupture or perforation,
presence of multiple abscess, gangrenous uterus or
gas gangrene infection

• Necrotizing fasciitis:
– Scrubbing the wound 2 times a day
– Debridement of all necrotic tissue
– closing wound with secondary suture
– Appropriate antibiotic after culture
• Bacteraemia and septic shock:
– Fluid and electrolyte balance

– Respiratory support

– Circulatory support ( dopamine and dobutamine)

– Infection control
• Antibiotic therapy
• Surgical removal of septic foci.

– Specific: dialysis if renal failure.

 61

Spectrum of Postpartum Mood Disorders

Postpartum Psychosis
Postpartum Depression
Postpartum (10-15%)
Symptom
Severity
Postpartum Blues
(50-85%)
None
 62

Postpartum Blues

• 50-85% of women
• Within first two weeks after delivery
• Mood lability, tearfulness, anxiety and
sleep disturbance
• Minimal or no impairment of functioning
• Time limited
• No specific treatment required
 63

Postpartum Depression
• Major and minor depression occurs in approximately
10% of women after live childbirth; range 5% to 15%
• May have acute early onset (within days) but
symptoms typically emerge over time
(within 3 months postpartum)5
• Often underdiagnosed and undertreated5
• Significant risks to mother and child if left untreated6

1. O’Hara MW, et al. J Abnorm Psychol. 1984;93:158-171.

2. O’Hara MW, et al. J Abnorm Psychol. 1991;100:63-73.
3. Kumar R, Robson RM. Br J Psychiatry. 1984;144:35-47.
4. Kendall K, et al. Br J Psychiatry. 1987;150:662-673.
5. Nonacs R, et al. J Clin Psychiatry. 1998;59(suppl 2):34-40.
6. Lyons-Ruth. Harv Rev Psychiatry. 2000;8:148-153.
7. Cogill SR, et al. Br Med J. 1986;292:1165-1167.
8. Murray L, et al. Child Dev. 1996;67:2512-2526.
 64

Postpartum Psychosis

• Rare, occurs in 1 to 2 per 1000 pregnancies

• Rapid, dramatic onset within first 2 weeks
• Resembles an affective (manic) psychosis
• Early signs: sleep disturbance, restlessness
• Depressed or elated mood, agitation, delusions,
depersonalization
• Risk of self-harm and harm to infant
 65

Postpartum Psychiatric Illness: Implications for

Early Detection

• Symptoms of postpartum depression may be difficult

to distinguish from normative postpartum symptoms
(sleep & appetite disturbance, loss of libido)

• Multiple contacts with health care providers

• PPD is frequently missed: role of obstetrician,
pediatrician
 66

Postpartum Depression Predictors Inventory

Stronger Predictors: Weaker Predictors:

 History of depression  Unwanted or
 Depression in pregnancy unplanned
pregnancy
 Anxiety in pregnancy
 Lower
 Stressful life events socioeconomic
 Marital dissatisfaction status
 Child care stress  Being single
 Inadequate social supports  Postpartum blues
 Difficult infant temperament
 Low self-esteem
 67

Postpartum Mood Disorders:

Treatment
 68

Postpartum Depression: Pharmacologic Strategies

• Data to support use of serotonergic agents

(sertraline, fluoxetine, venlafaxine, fluvoxamine)
and TCAs (nortriptyline)
• Other antidepressants may be effective
• Adequate dosage
• Adequate duration of treatment (>6 months)
• Adjunctive anxiolytic agents (lorazepam, clonazepam)
 69

Postpartum Psychosis: Treatment

• Psychiatric /Obstetric emergency

• Treat as an affective psychosis (antipsychotic
( atypical/typical), mood stabilizer, benzodiazepines)
• ECT is rapid and effective
• Duration of treatment not well established
• Need for maintenance treatment in patients with
recurrent affective disorder
Identification of women at high risk for
postpartum psychiatric illness

Is this disorder preventable?

 71

Stratification of Risk
No history Routine
LOW
Hx of MDD Consider Prophylaxis
Hx of PPD OR Antidepressant

Recurrent Severe MDD Prophylaxis

Hx of Bipolar Disorder Intense Monitoring

OR AND

PP Psychosis Li Prophylaxis
HIGH
THANK YOU