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Postpartum Phase Booklet POSTPARTUMPOSTPARTUM PHASEPHASE OUR CONTINUED RESPONSIBILTY Editor : Dr. Rishma Dhillon Pai Co-Editor : Dr. Sarita Bhalerao Dr. Geetha Balsarkar The Federation of Obstetric & Gynecological Societies of India C-5,6,7,12,13, 1st Floor, Trade World, D-wing Entrance, S. B. Marg, Kamala City, Lower Parel (W), Mumbai-400013. Ph: 022-24951648 / 24951654, [email protected] In Postpartum Anemia High Performance...Delivered Conveniently Int. J. Reprod Contracept. Obstet Gynecol. 2016 is first line drug in the Aug; 5 (8): 1 2566-2570 states management for PPA Achieves 4.68 gm% Hb rise & restores Iron stores faster1 Up to 1000 mg Achieves Safe & single infusion Hb rise... well tolerated4 over 15 mins2 quickly3 NO test dose required PPA: Post Partum Anemia 1. Joshi S D et al. Int. J. Reprod Contracept. Obstet Gynecol . 2016 Aug; 5 (8): 2566-2570 2. Port J Nephrol Hypert 2009;23(1):11-16 3. Am J of Obs & Gyn 2008;199:435e1-435e7c 4. Anemia 2012; volume 2012; article ID 172104,9 pages From the desk of Dr. Rishma Dhillon Pai FOGSI President 2017 Dear FOGSIANS, It gives me great pleasure to present to you the first FOGSI Focus of the year 2017. The subject ‘Post –Partum Phase – Our continued responsibility’ was chosen by me as a subject of extreme importance as many of us pay a lot of attention to our pregnant patients and attend meticulously to their delivery, however during the post partum phase, we often get lax. In this FOGSI Focus, we have addressed the common complications and problems, and have applied a multidisciplinary approach to the care of the post partum woman. We have expert inputs from psychiatrist, physical trainer, nutritionist, pediatrician and ofcourse obstetricians. This kind of integrated approach helps give best care to the patients. The days and weeks after childbirth – the postnatal or postpartum period – is a crucial phase in the lives of mothers and newborn babies. The postpartum period has been termed the “fourth stage of labor”, and has three distinct but Dr. Rishma Dhillon Pai continuous phases as per Romano’s description. The initial or acute period involves the first 6–12 hours immediately after delivery. This is a time of rapid change with a risk for serious complications such as postpartum hemorrhage, uterine inversion, amniotic fluid embolism, and eclampsia. The second phase is the subacute postpartum period, which lasts for 2–6 weeks. During this phase, the body is undergoing significant changes in terms of hemodynamics, genitourinary recovery, metabolism, and emotional status. These changes are quite slow and the patient can often perceive them herself. These may be ranging from perineal pain to peripartum cardiomyopathy or severe postpartum depression. The third phase is the delayed postpartum period, which can last up to 6 months. Changes during this phase are extremely gradual and severe problems are rare. This is the time of restoration of muscle tone and connective tissue to the pre-pregnant state. A woman’s body is not fully restored to pre-pregnant physiology until about 6 months post delivery. Changes to the genitourinary system take a long time to completely recover and may never fully come back to the pre-pregnant state. Vaginal delivery may in many cases lead later on to stress urinary incontinence, incontinence of flatus or feces, uterine prolapse, cystocele, and rectocele. Of course these depend on the patients intrinsic collagen support, the size of the baby and the extent of perineal trauma occurring. A meta-analysis by Carroli compared restrictive to liberal use of episiotomy in 4850 women, and concluded that liberal use of episiotomies conferred no benefit. Even Caesarean deliveries are not free of problems and complications. Bladder and ureteric injuries occur almost exclusively in caesarian births especially in repeat caesarean section. Even cesarean delivery does not definitely prevent postpartum anal incontinence. Many women when they resume sexual activity after 2 or more months after delivery have some sexual complaints, though the discomfort is much lesser in patients with caesarian section. During pregnancy most women do not realize what being mother will be like. The changes women undergo do not just include the physical changes that occur after delivery but social and psychological changes as well .Most women find the handling of a new baby quite difficult. Tiredness is a common problem. Many women feel alone or isolated as the husbands get back to work soon and they have to single handedly manage the baby. Women also feel a sense of loss- a loss of time, freedom or loss of control. Many women feel depressed and unable to cope. Having help and support obviously helps ease these problems and good knowledge and information about caring for a newborn baby helps women cope enjoy this wonderful phase of life. 1 INDEX 1. Postpartum Fever........................................................................... Dr. Anahita Chauhan - Differential Diagnosis and Management Dr. Namrata T Mishra 2. Getting back into shape after childbirth......................................... Dr. Rita Shah Dr. Shraddha K Dartanani 3. Tips for successful lactation........................................................... Dr. Kartikeya Bhagat Dr. Nanak Bhagat 4. Mastitis and Breast abscess............................................................ Dr. Kawita Bapat Dr. Rishma Dhillon Pai 5. Medical disorders in postpartum period ........................................ Dr. Gorakh G Mandrupkar 6. Postpartum Blues – Coping with Depression ................................ Dr. Anjali Chhabria Cursing Motherhood: Postpartum Disorders Dr. Forum V Lalka 7. Postpartum haemorrhage ............................................................... Dr. Parikshit Tank 8. Postpartum family planning........................................................... Dr. Anita Soni Dr. Ritu Joshi 9. Postpartum IUCD .......................................................................... Dr. Geetha D Balsarkar 10. Neonatal care what every obstetrcian should know....................... Dr. Swarup Kumar Dash Dr. Avasti 11. Effects of pregnancy & childbirth on perineum ............................ Dr. Vinit Mishra Dr. Priyankur Roy 12. WHO recommendations for postnatal care.................................... Dr. Sarita Bhalerao Dr. Kinjal Shah 2 1 Postpartum Fever Differential Diagnosis And Management Anahita Chauhan Namrata Tiwari Mishra MD, DGO, DFP MS, DNB Professor & Unit Head, Seth GS Assistant Professor, Medical College & KEM Hospital, Mumbai Seth GS Medical College & Honorary Consultant, Saifee Hospital, Mumbai KEM Hospital, Mumbai Clinical Secretary - The Mumbai Obstetric & Gynaecological Society Assistant Editor - Journal of Obstetric & Gynaecology of India Introduction Childbed fever has been described since Hippocratic times as devastating and tragic; in the 18th and 19th centuries it was the leading cause of maternal mortality mainly due to peritonitis and septicemia. The incidence of postpartum fever in Western literature is approximately 4 to 8%, and as high as 10 to 12% in India. Postpartum fever, also known as puerperal fever or puerperal infection, is defined as a temperature rise above 38.0° C (100.4° F) maintained over 24 hours or recurring from the end of the first to the end of the tenth day after childbirth or abortion. The fever may occur on any two of the first 10 days postpartum, exclusive of the first 24 hours. Benign single-day fevers in the first 24 hours after vaginal delivery are usually low grade and resolve spontaneously; they are more common in primigravid patients. In the absence of proper follow-up, many cases of puerperal infection go undiagnosed. Though fever is not an automatic indicator of puerperal infection, any fever within 10 days postpartum should be aggressively investigated and managed. Postpartum fever may be due to a wide range of entities occurring after child birth or during breast feeding. Endometritis, mastitis, wound and urinary tract infection and septic thrombophlebitis are the chief causes. This chapter discusses the common causes, their diagnosis and management. Pathogens Transmission of infecting organisms can be nosocomial (acquired in hospitals), exogenous due to unhygienic conditions and endogenous due to mixed flora present in the woman’s own genital tract. Various pathogens cause postpartum fever; major pathogens shown in Table 1 are: • Group A Streptococci (GAS), Streptococcus pyogenes • Escherichia Coli • Staphylococcus aureus • Methicillin Resistant Staphylococcus Aureus (MRSA), Clostridium septicum and Morganella morganii. Predisposing Factors1 General factors: • Unhygienic conditions during labor and delivery • Low socioeconomic status • Poor nutrition • Anemia • Diabetes mellitus • Obesity 3 • Preexisting genital or urinary tract infection • Chronic conditions like congestive heart failure, chronic liver disease and systemic lupus erthyematosus. • Immunosuppressant medication Obstetric factors: • Premature rupture of membranes • Prolonged labor > 24 hours • Repeated cervical examinations in labor • Use of fetal scalp electrode in labor • Obstetrical maneuvers • Cesarean delivery • Rescue cerclage • Postpartum hemorrhage • Retained products of conception • Nipple trauma during breastfeeding • GAS (Group A streptococcal) infection in close contact • Urinary catheterization Symptoms, Signs And Investigations A careful history may help differentiate endometritis from other causes of postpartum fever, as seen in Table 2. Common symptoms associated with puerperal
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