Lecture 6 DELIVERY OF PLACENTA PUERPERIUM LACTATION Prof. Vlad TICA, M.D., Ph.D

Lecture 6Lecture 6

DELIVERY OF PLACENTA DELIVERY OF PLACENTA

PUERPERIUM PUERPERIUM

LACTATIONLACTATION

Prof. Vlad TICA, M.D., Ph.D.Prof. Vlad TICA, M.D., Ph.D.

THIRD STAGE THIRD STAGE

• DELIVERY OF PLACENTADELIVERY OF PLACENTA

sign of placental separation (sign of placental separation (uterine sign, vulva sign, uterine sign, vulva sign,

cord sign)cord sign)

Modified CredeModified Crede

BranBranddt Andrewt Andrew

Controlled cord traction Controlled cord traction

DELIVERY OF THE PLACENTADELIVERY OF THE PLACENTA


Controlled cord traction Controlled cord traction


• Prevent postpartum hemorrhagePrevent postpartum hemorrhage

oxytocic drugoxytocic drugss

• SyntocinonSyntocinon®® : IV push, IV drip, IM : IV push, IV drip, IM

• MetherginMethergin® ® : IM, IV : IM, IV


REPAIRING EPISIOTOMY WOUND REPAIRING EPISIOTOMY WOUND

Perineal tear during vaginal birthPerineal tear during vaginal birth

• First-degree tearFirst-degree tear

• Second-degree tearSecond-degree tear

• Third-degree tearThird-degree tear

• Fourth-degree tearFourth-degree tear



Repairing fourth-degree perineal tear Repairing fourth-degree perineal tear


POSTPARTUM CARE: 10 POSTPARTUM CARE: 10BBSS

• Blood pressureBlood pressure

• BladderBladder

• Bloody dischargeBloody discharge

• BasketBasket

• BowelBowel

• Breast engorgementBreast engorgement

• Breast feedingBreast feeding

• BabyBaby

• BlueBlue

• BrainBrain

PUERPERIUMPUERPERIUM

• is defined as the time from the delivery of the placenta through the first few weeks after the delivery

• This period is usually considered to be 6 weeks in duration

• By 6 weeks after delivery, most of the changes of pregnancy, labor, and delivery have resolved and the body has reverted to the nonpregnant state

• An overview of the relevant anatomy and physiology in the postpartum period follows

UTERUSUTERUS

• The pregnant term uterus (not including baby, The pregnant term uterus (not including baby, placenta, fluids, etc) weighs approximately 1000 placenta, fluids, etc) weighs approximately 1000 gg

• In the 6 weeks following delivery, the uterus In the 6 weeks following delivery, the uterus recedes to a weight of 50-100 grecedes to a weight of 50-100 g

• Immediately postpartum, the uterine fundus is Immediately postpartum, the uterine fundus is palpable at or near the level of the maternal palpable at or near the level of the maternal umbilicus umbilicus

• Thereafter, most of the reduction in size and Thereafter, most of the reduction in size and weight occurs in the first 2 weeks, at which time weight occurs in the first 2 weeks, at which time the uterus has shrunk enough to return to the the uterus has shrunk enough to return to the true pelvistrue pelvis


UTERUSUTERUS


UTERUSUTERUS


UTERUSUTERUS

• Over the next several weeks, the uterus Over the next several weeks, the uterus slowly returns to its nonpregnant state, slowly returns to its nonpregnant state, although the overall uterine size remains although the overall uterine size remains larger than prior to gestationlarger than prior to gestation

• The endometrial lining rapidly regenerates, The endometrial lining rapidly regenerates, so that by the so that by the 7th day7th day endometrial glands endometrial glands are already evidentare already evident

• By the By the 16th day16th day, the endometrium is , the endometrium is restored throughout the uterus, except at restored throughout the uterus, except at the placental sitethe placental site


UTERUSUTERUS

• The placental site undergoes a series of The placental site undergoes a series of changes in the postpartum periodchanges in the postpartum period

• Immediately after delivery, the contractions Immediately after delivery, the contractions of the arterial smooth muscle and of the arterial smooth muscle and compression of the vessels by contraction compression of the vessels by contraction of the myometrium ("physiologic ligatures") of the myometrium ("physiologic ligatures") result in hemostasis result in hemostasis

• The size of the placental bed decreases by The size of the placental bed decreases by half, and the changes in the placental bed half, and the changes in the placental bed result in the quantity and quality of the result in the quantity and quality of the lochia that is experiencedlochia that is experienced


UTERUSUTERUS• Immediately after delivery, a large amount Immediately after delivery, a large amount

of red blood flows from the uterus until the of red blood flows from the uterus until the contraction phase occurs contraction phase occurs

• Thereafter, the volume of vaginal discharge Thereafter, the volume of vaginal discharge (lochia) rapidly decreases(lochia) rapidly decreases

• The duration of this discharge, known as The duration of this discharge, known as lochia rubralochia rubra, is variable , is variable

• The red discharge progressively changes to The red discharge progressively changes to brownish red, with a more watery brownish red, with a more watery consistency consistency (lochia serosa)(lochia serosa)

• Over a period of weeks, the discharge Over a period of weeks, the discharge continues to decrease in amount and color continues to decrease in amount and color and eventually changes to yellow and eventually changes to yellow (lochia (lochia alba)alba)

• The period of time the lochia can last varies, The period of time the lochia can last varies, although it averages approximately although it averages approximately 5 weeks5 weeks


UTERUSUTERUS

• The amount of flow and color of the lochia The amount of flow and color of the lochia can vary considerablycan vary considerably

• 15% of women have continue to have lochia 15% of women have continue to have lochia 6 weeks or more postpartum6 weeks or more postpartum

• Often, women experience an increase in the Often, women experience an increase in the amount of bleeding at amount of bleeding at 7-14 days7-14 days secondary secondary to the sloughing of the eschar on the to the sloughing of the eschar on the placental siteplacental site

• This is the classic time for delayed This is the classic time for delayed postpartum hemorrhages to occurpostpartum hemorrhages to occur


CERVIXCERVIX

• The cervix also begins to rapidly revert to a The cervix also begins to rapidly revert to a nonpregnant state, but it never returns to nonpregnant state, but it never returns to the nulliparous state the nulliparous state

• By the end of the first week, the external os By the end of the first week, the external os closes such that a finger cannot be easily closes such that a finger cannot be easily introducedintroduced


VAGINAVAGINA

• The vagina also regresses but it does not The vagina also regresses but it does not completely return to its prepregnant sizecompletely return to its prepregnant size

• Resolution of the increased vascularity and Resolution of the increased vascularity and edema occurs by edema occurs by 3 weeks3 weeks, and the rugae of , and the rugae of the vagina begin to reappear in women who the vagina begin to reappear in women who are not breastfeedingare not breastfeeding

• At this time, the vaginal epithelium appears At this time, the vaginal epithelium appears atrophic on smearatrophic on smear

• This is restored by weeks 6-10; however, it This is restored by weeks 6-10; however, it is further delayed in breastfeeding mothers is further delayed in breastfeeding mothers because of persistently decreased estrogen because of persistently decreased estrogen levelslevels


PERINEUMPERINEUM

• The perineum has been stretched and The perineum has been stretched and traumatized, and sometimes torn or cut, traumatized, and sometimes torn or cut, during the process of labor and deliveryduring the process of labor and delivery

• The swollen and engorged vulva rapidly The swollen and engorged vulva rapidly resolves within resolves within 1-2 weeks1-2 weeks

• Most of the muscle tone is regained by Most of the muscle tone is regained by 6 6 weeksweeks, with more improvement over the , with more improvement over the following few monthsfollowing few months

• The muscle tone may or may not return to The muscle tone may or may not return to normal, depending on the extent of injury to normal, depending on the extent of injury to muscle, nerve, and connecting tissues. muscle, nerve, and connecting tissues.


ABDOMINAL WALLABDOMINAL WALL

• The abdominal wall remains soft and poorly The abdominal wall remains soft and poorly toned for many weeks toned for many weeks

• The return to a prepregnant state depends The return to a prepregnant state depends greatly on maternal exercise greatly on maternal exercise


OVARIESOVARIES

• The resumption of normal function by the The resumption of normal function by the ovaries is highly variable and is greatly ovaries is highly variable and is greatly influenced by breastfeeding the infant. influenced by breastfeeding the infant.

• The woman who breastfeeds her infant has a The woman who breastfeeds her infant has a longer period of amenorrhea and anovulation longer period of amenorrhea and anovulation than the mother who chooses to bottle-feed. than the mother who chooses to bottle-feed.

• The mother The mother who does not breastfeedwho does not breastfeed may may ovulate as early as ovulate as early as 27 days27 days after delivery. after delivery.

• Most women have a menstrual period by Most women have a menstrual period by 12 12 weeksweeks; the mean time to first menses is ; the mean time to first menses is 7-9 7-9 weeksweeks


OVARIESOVARIES

• In the breastfeeding woman, the In the breastfeeding woman, the resumption of menses is highly variable and resumption of menses is highly variable and depends on a number of factors, including depends on a number of factors, including how much and how often the baby is fed how much and how often the baby is fed and whether the baby's food is and whether the baby's food is supplemented with formula. supplemented with formula.

• The delay in the return to normal ovarian The delay in the return to normal ovarian function in the lactating mother is caused function in the lactating mother is caused by the suppression of ovulation due to the by the suppression of ovulation due to the elevation in prolactin. elevation in prolactin.

• ½½ to to ¾¾ of women who breastfeed return to of women who breastfeed return to periods within periods within 36 weeks36 weeks of delivery of delivery


BREASTSBREASTS

• The changes to the breasts that prepare the The changes to the breasts that prepare the body for breastfeeding occur throughout body for breastfeeding occur throughout pregnancypregnancy

• If delivery ensues, lactation can be If delivery ensues, lactation can be established as early as established as early as 16 weeks16 weeks' gestation' gestation

• Lactogenesis is initially triggered by the Lactogenesis is initially triggered by the delivery of the placenta, which results in delivery of the placenta, which results in falling levels of estrogen and progesterone, falling levels of estrogen and progesterone, with the continued presence of prolactinwith the continued presence of prolactin

• If the mother If the mother is not breastfeedingis not breastfeeding, the , the prolactin levels decrease and return to prolactin levels decrease and return to normal within normal within 2-3 weeks 2-3 weeks


BREASTSBREASTS

• The colostrum is the liquid that is initially The colostrum is the liquid that is initially released by the breasts during the released by the breasts during the first 2-4 first 2-4 daysdays after delivery. after delivery.

• High in protein content, this liquid is High in protein content, this liquid is protective for the newbornprotective for the newborn

• The colostrum, which the baby receives in The colostrum, which the baby receives in the first few days postpartum, is already the first few days postpartum, is already present in the breasts, and suckling by the present in the breasts, and suckling by the newborn triggers its releasenewborn triggers its release


BREASTSBREASTS

• The process, which begins as an endocrine The process, which begins as an endocrine process, switches to an autocrine process; process, switches to an autocrine process; the removal of milk from the breast the removal of milk from the breast stimulates more milk productionstimulates more milk production

• Over Over the first 7 daysthe first 7 days, the milk matures and , the milk matures and contains all necessary nutrients in the contains all necessary nutrients in the neonatal periodneonatal period

• The milk continues to change throughout The milk continues to change throughout the period of breastfeeding to meet the the period of breastfeeding to meet the changing demands of the babychanging demands of the baby


• The majority of mothers are perfectly well The majority of mothers are perfectly well during the puerperium and should be during the puerperium and should be encouraged to establish normal activities encouraged to establish normal activities

• Immediately following the delivery of the Immediately following the delivery of the placenta observation of :placenta observation of :

MANAGEMENT OF NORMAL MANAGEMENT OF NORMAL PUERPERIUMPUERPERIUM

1.1. Vital signsVital signs (P, BP, Temp, R.R) (P, BP, Temp, R.R)

+ + contraction of the uteruscontraction of the uterus (uterin involution) (uterin involution)

+ + lochialochia (amount; colour and odder) (amount; colour and odder)

= every 5 min. for ½ hours, then every ½ hourly for 2 = every 5 min. for ½ hours, then every ½ hourly for 2 hours, then transfer the mother to the postnatal ward hours, then transfer the mother to the postnatal ward and observation every 2 hours for 6 hourly; then 6 and observation every 2 hours for 6 hourly; then 6 hourly till dischargehourly till discharge



2.2. Breast examinationBreast examination

+ + lawer limb examinationlawer limb examination for the detection of signs of for the detection of signs of DVT every dayDVT every day

3.3. The mother should be encouraged to pass The mother should be encouraged to pass urineurine



4.4. Early mobilizationEarly mobilization

5.5. Management of episiotomy; and perineum tearsManagement of episiotomy; and perineum tears

6.6. In normal delivery the mother can go home 48 hours In normal delivery the mother can go home 48 hours after delivery; and 72 hours in C-section after delivery; and 72 hours in C-section

7.7. Diet regimeDiet regime

8.8. Postnatal visitPostnatal visit

9.9. Advising for contraception and spacing of pregnancyAdvising for contraception and spacing of pregnancy


BREAST FEEDINGBREAST FEEDING

LACTATION LACTATION

• In those mothers who breast feed, lactation is the In those mothers who breast feed, lactation is the most dominant physiological event of puerperiummost dominant physiological event of puerperium

• The primary function of breast feeding is to The primary function of breast feeding is to continuing of nutrition for newborncontinuing of nutrition for newborn

• The secondary functions:The secondary functions:

protection agonist infant infectionprotection agonist infant infection

inhibition of ovarian activityinhibition of ovarian activity

encouragement of uterine involutionencouragement of uterine involution

PHYSIOLOGY OF LACTATION PHYSIOLOGY OF LACTATION

• The major part of breast development occurs at The major part of breast development occurs at puberty before the first pregnancypuberty before the first pregnancy

• So, only requires minimal hormonal stimulation for So, only requires minimal hormonal stimulation for production of milkproduction of milk

• The skin of the areola is relatively insensitive to tactile The skin of the areola is relatively insensitive to tactile stimuli during pregnancy but, much more sensitive stimuli during pregnancy but, much more sensitive immediately after delivery immediately after delivery

BREAST CHANGES BREAST CHANGES

BREASTBREAST

• Two similar independent mechanisms for Two similar independent mechanisms for successful lactation :successful lactation :

1.1. Prolactin (PRL) release from A .p mammary Prolactin (PRL) release from A .p mammary glandular tissue stimulation of milk glandular tissue stimulation of milk secretion secretion

• PRL is long chain of polypeptide; it has only PRL is long chain of polypeptide; it has only physiological role that its action on lactating physiological role that its action on lactating breastbreast

MILK PRODUCTIONMILK PRODUCTION


2.2. Prolactin level during lactation depending on Prolactin level during lactation depending on the suckling ( strength , frequency and the suckling ( strength , frequency and duration ) duration )

PRL release from A.p reaching PRL release from A.p reaching peak blood level at peak blood level at 30 -45 min.30 -45 min. after suckling after suckling and returns to the basal level and returns to the basal level 2 hours2 hours after after sucklingsuckling

Adequate emptying of milk – secretary glandsAdequate emptying of milk – secretary glands


• Basal PRL is highest in the immediate puerperium Basal PRL is highest in the immediate puerperium but:but:

In breast feeding decline slowly as suckling In breast feeding decline slowly as suckling declines in later lactation revert to non pregnant declines in later lactation revert to non pregnant levels immediately after weaning (54 weeks)levels immediately after weaning (54 weeks)

In bottle feeding reverted to non pregnant levels In bottle feeding reverted to non pregnant levels immediately after delivery ( 10 weeks)immediately after delivery ( 10 weeks)

• So PRL appears essential for lactation due to So PRL appears essential for lactation due to bromocriptin or dopamine agonistbromocriptin or dopamine agonist which is which is selectively selectively inhibits PRL secretioninhibits PRL secretion and and decrease milk decrease milk secretionsecretion

• Milk ejection reflex ( milk lead down ) mediated by Milk ejection reflex ( milk lead down ) mediated by release of oxytocin from hypothalamus and (p.p):release of oxytocin from hypothalamus and (p.p):

causing contraction of myoepithelial cells around causing contraction of myoepithelial cells around the milk –secretarythe milk –secretary

dilatation of main ductsdilatation of main ducts

So , Expelling milk from glandsSo , Expelling milk from glands

• Oxytocin released in response to: suckling, and Oxytocin released in response to: suckling, and sensory input like mother seeing or hearing their sensory input like mother seeing or hearing their baby cryingbaby crying


• Highest levels of oxytocin occurring before suckling Highest levels of oxytocin occurring before suckling in response to the baby cryin response to the baby cry

• Milk ejection reflex may be inhibited by emotional Milk ejection reflex may be inhibited by emotional stress and maternal anxiety and leads to failure of stress and maternal anxiety and leads to failure of lactationlactation

• So, the key of both mechanisms activated by So, the key of both mechanisms activated by suckling and mediated through neuro-suckling and mediated through neuro-endocrianological pathwaysendocrianological pathways


BREAST FEEDING & FERTILITYBREAST FEEDING & FERTILITY

• The key event in lactating amenorrhea is suckling The key event in lactating amenorrhea is suckling induce changes in the hypothalamic sensitivity to induce changes in the hypothalamic sensitivity to the feed back effects of ovarian hormonesthe feed back effects of ovarian hormones

• During lactation hypothalamus is more sensitive to During lactation hypothalamus is more sensitive to the negative feedback and less sensitive to the the negative feedback and less sensitive to the positive feedbackpositive feedback

In bottle feeding:In bottle feeding:

• PRL returns to level of non pregnant ovarian PRL returns to level of non pregnant ovarian follicular development ( E2 > 10 micro – gm ).follicular development ( E2 > 10 micro – gm ).

• And ovulation occur ( P4 >1 mg ) menstruation And ovulation occur ( P4 >1 mg ) menstruation by 14 weeks post-delivery by 14 weeks post-delivery


In breast feeding:In breast feeding:

• During first week of suckling (60 min./day), During first week of suckling (60 min./day), the the ovarian activity is inhibitedovarian activity is inhibited and and menstruation is menstruation is suppressedsuppressed

• At At 32 weeks32 weeks suckling has fallen to 25 min/day the suckling has fallen to 25 min/day the ovarian follicular activity returns to the normal ovarian follicular activity returns to the normal (anovulatory cycles)(anovulatory cycles)

• At At 52 weeks52 weeks normal ovulatory cycles occurs normal ovulatory cycles occurs

• Breast feeding has important Breast feeding has important contraceptive effectcontraceptive effect but but not absolutelynot absolutely reliable especially after reliable especially after menstruation returns, and (1-10%) of women will menstruation returns, and (1-10%) of women will conceive during lactationconceive during lactation


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Lecture 6 DELIVERY OF PLACENTA PUERPERIUM LACTATION Prof. Vlad TICA, M.D., Ph.D