1. Puerperium and Lactation

2. It is a period about 6-8 weeks following delivery during which the changes produced by pregnancy regress

3. Physiologicxal Cahnges in the puerperium I. Involution of the Uterus:
Physiologicxal Cahnges in the puerperium I. Involution of the Uterus: * Fundal level: Immediately after delivery leve1 of umbilicus One week after delivery midway between umbilicus and symphysis pubis. Two weeks after delivery upper border of symphysis pubis  5-6 weeks after de1ivry non pregnant size

4. Uterine weight:. Immediately after delivery. 1000 gm. On
Uterine weight: Immediately after delivery gm. On. week after delivery 500 gm. Two weeks after delivery 250 gm weeks after delivery 50 gm.

5. II. Involution of Vaginal and Vulva: Vaginal rugae start to appear after 3 weeks. The hymen is transformed into caruncies myritifonn. The capacity of the vagina decreases gradually but never return to nullipara dimensions.

6. III. After pain: Painful uterine contractions develop in the early puerperium and increase with suckling due to oxytocin release. Severe after pains are due to retained part of the placenta in the uterus. Treatment: sedatives, massage the uterus, ergometrine.

7. Lochia
Red Lochia - from day 1-4, formed of RBCs and decidua. Pale Lochia - from day 5-10, due to relative decrease of number of RBCs and increase number of WBCs. White Lochia from day 11·15, formed of wacs and mucus. Persistent red lochia is due to retained part of the placenta, subinvolution of placental implantation site or both. Offensive lochia is due to infection. Sudden cessation of lochia is due to severe sepsis

8. The caliber of extra uterine vessels decre
The caliber of extra uterine vessels decre.se gradually to reach that of non pregnant state. Within the uterus, the blood vessels are obliterated due to hyaline changes. Small vessels develop in their place. Immediately after delivery, the cervix of lower uterine segment are formed of thin flabby structures. The cervix is closed after one week. The lower uterine segment undergoes gradual contraction and retraction to form the isthmus between the body of uterus and intenal os.

9. Total number of muscle cells does not decrease but the individual cell decreases markedly in size. The mechanism by which the muscle cell digests itself is Since separation of the placenta and foetal membranes occur at spongy layer, part of it remains adherent to uterine wall. 2-3 days after delivery, it can be differentiated into two layers, superficial layer which undergoes necrosis and cast off in lochia and deep layer which contains the fundi of the glands and responsible for regeneration of endometrium. Immediately after delivery, the placental site is about the palm of the hand. It is formed of thrombosed vessels that undergo typical organization of the

10. IV. Breasts: During pregnancy, the serum prolactin level increases gradually to reach its peak (200 ng/ml) at full term. Only colostrum is secreted during pregnancy as high level of estrogen and progesterone block the prolactin receptors at the level of alveolar cells. After delivery, estrogen and progesterone decrease rapidly, while prolactin level returns to normal level after 1 week in non lactating woman. This discordance in disappearance of hormones, liberates the alveolar cells and allows breast engorgement and mild secretion 3-4 days after delivery.

11. In lactating woman, the prolactin level returns to normal after 4 weeks. Maintenance of milk production depends upon anterior and posterior pitUitary factors. Suckling activates afferent neural arc and increase the level of prolactin and oxytocin. Prolactin is essential for mild synthesis in the alveolar cells and its secretion into alveolar spaces. Oxytocin stimulates contraction of myoepithelial cells and ejection of milk.

12. General Physiology: 1. Temperature:
General Physiology: 1. Temperature: Fever may develop in the first 24 hours due to dehydration, reaction to infusion of fetal protein or transient intrauterine infection. Fever may develop on the third or fourth day due to engorgement of the breast 2. Pulse and Blood pressure: It is normal unless there is infection or bleeding.

13. 3. Urinary system: Polyuria develops in the first few days after delivery due to excretion of water retained during pregnancy. There is high incidence of urine retention due to: a. Atony of the bladder and abdominal wall. b. Inability to micturate in recumbent position. c. Reflex retention due to painful lesion at the perineum. D. Compression of the urethra by oedema or hematoma.

14. 4. Blood changes:. a). Marked leucocytosis early in puerperium. b)
4. Blood changes: a). Marked leucocytosis early in puerperium. b). Increase fibrinogen level early in puerperium. c). Changes that developed during pregnancy gradually regress Menstruction: Occurs within 6-8 weeks after delivery in non lactating women. menstruate during lactation, as the pituitary gland concentrates in production of prolactin rather than gonadotropins. Also, prolactin inhibits pulsatile secretion of Gn-Rh.

15. Women of Puerperium:
1. Observation: Mother: pulse, blood pressure, temperature, breasts, involution of the uterus and lochia. Baby: Cord stump sepsis and neonatal jaundice.

16. 2. Asepsis: The vulva and perineum are washed three times daily by diluted dettol solution and after each micturition or defecation, then covered by sterile vulval pad. In case of perineal stitches, it should be painted with alcohol and dusted with antiseptic powder.

17. 3. Rest and Exercise: The patient is kept in bed in semisitting position or Fowler's position to promote drainage of lochia. The patient is allowed to move in bed and to do breathing exercises. Pelvic floor exercises are allowed from the third day unless there is a perineal wound. Later on abdominal exercises are advised. The exercises diminish the respiratory and vascular complications; minimize prolapse and stress incontinence; and leave the patient with a better figure. If the patient has insomnia, mild hypnotic may be given.

18. 4. Diet and care of bowel The diet should be rich in proteins, vitamins, minerals and sufficient fluids. If there is tendency for constipation, it can be prevented by fresh vegetables and fruits, sufficient fluids, mild laxative if necessary. Enema may be needed, in case of complete perineal tear do not do before the 5th day.

19. 5. Care of the bladder: Encourage the patient to evacuate the bladder in sitting position. If retention occurs, pass a catheter under aseptic precautions Gastrointestinal tract: Tendency to constipation in early period due to: a) Atony of the intestine abdominal wall and perineal muscles. b) Loss of fluids. C) Anorexia.

20. 7. Loss of body weight due to: a). Evacuation of the uterus. b)
7. Loss of body weight due to: a). Evacuation of the uterus. b). Involution of tissues. c). Losss of excessive fluids Care of the breasts The infant is applied to the breast every 8 hours in the first three days. Wash the nipple and areola by water and soap before and after lactation.

21. In case of breast engorgement, analgesics may be given
In case of breast engorgement, analgesics may be given. In severe cases, minimize fluid intake, evacuate the breast by massage or pump and in some cases, small doses of estrogen may be used. Cracked nipple is treated by panthenol and antibiotic ointment and the use of nipple shield. In case of acute mastitis, stop ;actation by bromocriptine 2.5 mg twice daily for 15 days; or injection of a large dose of estrogen; or stilbesterol 5 mg three times daily for three days; or twice daily for 4 days. Give antibiotics In cases of breast abscess, do surgical drainage in addition to the above.

22. Indications of suppression of lactation Maternal indications: 1
Indications of suppression of lactation Maternal indications: 1.- Open active pulmonary tuberculosis Decompensated heart disease Chronic renal disease. 4. Acute illness as pneumonia. 5. Breast abscess.

23. Infantile indications: 1. Death of the infant. 2. Marked prematurity. 3. Cleft palate. 4. Marked hare lip interfering with suckling.