1. NORMAL AND ABNORMAL
PUERPERIUM
DR. YIN MOE HAN
SENIOR LECTURER
UCSI UNIVERSITY

2. Definition
• Puerperium – a period from the expulsion of
the placenta until 6 – 8 weeks after birth,
during which time the uterus and other
organs and systems return to their pre
pregnant state and lactation is initiated.
• Many changes take place within the first 10 -
14 days.
• Role changes
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3. Endocrine changes
• Removal of the placenta alters the
physiological state – rapid clearance of
hormones from plasma and extra cellular fluid
• HPL disappears by 1-2 days
• hCG detected for 2 weeks
• Alpha feta protein – several weeks
• Oestrogens/progesterone – rapid loss
• Ovarian function – low for first 2 weeks
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4. • FSH/LH suppressed during pregnancy remain
low for 2 weeks following birth, both in
lactating and non lactating women, gradual
increase over 6 weeks.
• Tends to be a period of infertility
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5. Placental Site
• Dramatic decrease in size brings uterine walls into close
apposition and transforms uterus into hard globular
mass.
• This has the effect of applying pressure on the
placental site - prevents haemorrhage
• 18cm diameter- 9cm
• Promoted by continual action of oxytocin.
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6. Uterine Involution
Weight of uterus after birth 1 kg
6/52 no longer palpable
6/52 50-60g
? Caused by withdrawal of placental hormones
By day 5 - wt 500gms
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7. Involution – ‘turning inwards’
3 processes
• Ischemia occurs as a result of collapse of blood
vessels
• Autolysis is physiological process by which
involution of uterus is achieved. Breakdown of
intracellular protein by proteolytic & hydrolytic
enzymes.
• Phagocytocis – disposes of elastic/fibrous tissue
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10. Endometrium
• Regeneration begin 1-2 days after birth
• Differentiation into 2 layers
superficial – barrier to infection
basal – source of new
endometrium
• Regeneration takes approx 2-3 weeks.
• Placental site regenerates slowly over 6 -7
weeks
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11. Lochia
Reflects the process of involution and restoration
of the endometrium – characteristic postnatal
discharge
Mean duration – 21-33 days
Shorter in multips and with smaller babies
• Lochia rubra: fresh blood from placenta
• Lochia serosa: brownish pink after 4 days
• Lochia alba: white
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12. Cervix and Vagina
• Cervix bruised, swollen, oedematous and little tone.
• By end of 1st week cervix decreased in size, closed by
end 2nd week
• Vagina smooth, oedamatous, pouting and blue-ish.
• After 3-4 wks ruggae appear.
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14. • Episitomy
• Lacerations
• Sexual intercourse
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15. Cardiovascular Changes
• Following birth dramatic changes in haemodilution –
cardiovascular instability.
• Cardiac output elevated for 1-2 hours after birth
begins to stabilise after about 10 mins. Decreases until
10th day. Normal by 2 weeks.
• Cardiovascular system reverts to normal in 2 - 4 weeks.
• Days 2 -5 diuresis dissipates the extra cellular fluid, up
to 3 Kgs weight loss
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16. Coagulation
• Profound physiological changes in the blood and
dramatic changes in coagulation and haemostatic
mechanisms.
• Changes protect women from haemorrhage.
• Levels remain high for 10 days
• DVT/PE – increased risk if trauma, sepsis, immobility
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17. Blood Volume Changes
• Decreases rapidly over 24 hours. Increase in
haemconcentration, Hb rises.
• By 6-9 weeks returned to normal.
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18. Urinary Tract
• 24-48 hours rapid diuresis – decreases plasma
volume of blood to non-pregnant levels.
• High oestrogen augments effects of ADH -
increases blood volume
• Larger quantities of nitrogen – autolysis
• Trauma to bladder base, oedema
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19. c
• To provide sound family planning information and advice
• To care for and monitor the progress of the mother in
the postnatal period and to give all necessary advice to
the mother on infant care to enable her to ensure the
optimum progress of the newborn infant
• To examine and care for the newborn infant; to take all
initiatives which are necessary in case of need and to
carry out immediate resuscitation
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20. PUERPERAL PYREXIA
• A temperature of 38.0°C (100.4°F) or higher, which occurs
on any 2 of the first 10 days postpartum, exclusive of the
first 24 hours, and which is taken orally by a standard
technique at least four times daily. (Joint Committee on
Maternal Welfare)
• Some common sites of infection causing puerpural pyrexia
– Chest
– Throat
– Breasts
– Urinary tract
– Pelvic organs
– Wounds – caesarean, perineal
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21. PUERPERAL PYREXIA
CAUSE DESCRIPTION
Genital tract infection -Tender bulky uterus.
-Prolonged bleeding/pink or discoloured lochia.
-Painful inflamed perineum.
-Most common infective organisms; Escherichia coli, Group A
streptococcus spp., Staphylococcus spp.
Urinary tract infection -Frequency in micturation, painful micturation, haematuria.
-Rigors seen in cases of pyelonephritis
-Most common infective organisms; Escherichia coli, Proteus spp. and
Klebsiella spp.
Mastitis -Painful, hard, red breast abscess
-Nipple trauma and cellulitis
-Most common infective organism; Staphylococcus spp
Postoperative infection -high risk of postpartum septicaemia, wound problems and fever
(following Caesarean section) -Usual presentation; Painful, red suture line, tenderness on deep
palpation, lochia pink/coloured.
Deep venous thrombosis -Caused by venous stasis.
-Painful, swollen calf.
Others -Viral infection or chest infection.
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22. PUERPERAL PYREXIA
• Causative organisms
– Aerobic organisms include beta-hemolytic
streptococci, Escherichia coli, Klebsiella,
Proteus mirabilis, Pseudomonas,
Staphylococcus aureus, and Neisseria.
– Anaerobic organisms include Bacteroides,
Peptostreptococcus, Peptococcus, and
Clostridium perfringens.
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23. PUERPERAL PYREXIA
• Full examination of chest, breasts, legs,
lochia and bimanual vaginal examination
should be done.
• Majority of infections originate from the
urinary or genital tract.
• Caused by poor sterile technique, delivery
with significant manipulation, caesarean
birth, or overgrowth of local flora.
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24. 1) Post partum haemorrhage (PPH)
• Primary PPH is defined as bleeding from the genital tract
of 600 ml or more in the first 24 hours following delivery.
Such bleeding usually occurs very unexpectedly due to
retained placental tissue or birth canal trauma.
• Secondary PPH - bleeding occurs after the first 24 hours of
delivery until the end of the puerperium.
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25. 2) Puerperal sepsis:
• It is a fibrile changes occurring during puerperium due to
invasion of genital tract by pathogenic bacteria.
Sites of infection:
• Wound: mainly the placental site and wounds of the
perineum, vulva, vagina or cervix.
Dead tissue: usually blood clots, and retained placental
fragment.
Predisposing factors:
• General: as anaemia, ante partum hemorrhage, post partum
hemorrhage, malnutrition and toxaemia.
• Local: as lacerations, sloughing and premature rupture of the
membrane.
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26. Signs and Symptoms:
• Headache,
• Raised temperature,
• Vomiting,
• Dry tongue and lips.
• Abdominal examination revealed a supra pubic tenderness
and rigidity. The perineum, vulva, vagina or cervix are become
infected and lochia is foul odour.
Treatment:
• The primary goal of treatment is concerning the causes and its
predisposing factors for the infection.
• At this time lactation and physiotherapy program should be
stopped until fever disappear.
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27. URINARY PROBLEMS
• Urinary retention or voiding difficulties may occur postnatally
secondary to painful tears involving the bladder or use of epidurals
in labour.
• Retention occurs usually immediately after delivery and is partially
due to the sudden decrease in intra abdominal pressure
–there is a decreased stretch reflex response following bladder
filling.
• Methods that can encourage micturation
–early ambulation
–pelvic floor exercises
–hot baths
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28. URINARY PROBLEMS
 True incontinence occurs rarely but is usually
associated with a vesico-vaginal fistula
 After surgical repair, the patient is to undergo
physiotherapy to strengthen the pelvic floor muscles.
7/31/2012
© Reed Group
NORMAL AND ABNORMAL PUERPERIUM 28

29. THROMBOEMBOLISM
• Risk of thromboembolism rises 5 fold during pregnancy & puerperium
• Majority of deaths occur in the puerperium
• The symptoms and signs of venous thromboembolism:
– leg pain and swelling (usually unilateral)
– lower abdominal pain
– low-grade pyrexia
– dyspnoea
– chest pain
– haemoptysis
– Calf muscles are tender and painful on firm palpation.
• If DVT & pulmonary embolism is suspected
– bilateral venogram and/or lung scan should be carried out within 24-48
hrs.
– full anti-coagulant therapy (heparin) should be started immediately.
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30. PSYCHIATRIC PROBLEMS
• Divided into three conditions based on their severity
–”Baby blues”
–Postpartum depression
–Postpartum psychosis (most severe, may result in
suicide/infanticide)
• A syndrome seen among fathers is linked to the mood
changes of their wives.
–May be due to the added responsibility of having a
child and decreased attention from the wife.
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31. PSYCHIATRIC PROBLEMS
• Management
–Postpartum blues: no specific treatment other than
support and reassurance from family members and
friends.
–Postpartum depression: exclude medical causes (eg.
thyroid dysfunction), individual/group psychotherapy
for mild cases, medication (antidepressants)/
hospitalization/ electroconvulsive therapy for
moderate to severe cases.
–Postpartum psychosis: Inpatient treatment with
medication (mood stabilizers-eg. lithium/valproic acid)
and/or electroconvulsive therapy.
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32. CHARACTERISTIC “Baby Blues” Postpartum Depression Postpartum Psychosis
Incidence 30%-75% 10%-15% 1%-2%
Time of Onset 3-5 days after delivery Within 3 to 6 months after Within 8 weeks after delivery
delivery
Duration Days to weeks Months to years (if untreated) Months to years (if untreated)
Associated to stressors No Yes, especially lack of support Linked to hormonal changes
after delivery
History of mood disorder No association Strong association Strong association
Family history of mood No association Strong association Strong association
disorder
Tearfulness Yes Yes Yes
Mood Lability Yes Often present, but sometimes Yes
mood is uniformly depressed
Anhedonia No Often Yes
Sleep disturbances Sometimes Nearly always Always
Suicidal thoughts No Often Almost always in psychosis
stage
Thoughts of harming baby Rarely Often Almost always in psychosis
stage
Feelings of guilt, inadequacy Absent or mild Often and excessive Often and excessive
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33. OTHER PROBLEMS
• Haemorrhage
Type Timescale Presentation Predisposing factors
Primary In the first 24 Fresh bleeding, often severely Uterine atony [90%]
haemorrhage hours heavy. Uterus may be soft and Trauma, vaginal or
poorly contracted with the cervical
fundus still above the lacerations, labial
umbilicus tears
Coagulation
disorders
Secondary After 24 hours and May be fresh loss or old, Retained products of
haemorrhage up to 6 weeks altered blood, often conception
malodorous. The Endometritis
uterus may feel soft, poorly Dysfunctional
contracted and possibly bleeding
tender,
with the cervical os open
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34. OTHER PROBLEMS
• Bowel problems
– Haemorrhoids are a common problem after
childbirth, exacerbated by bearing down
during the second stage of labour.
–Treatment: Local application of 5% lidocaine
gel or anusol (hydrocortisone) cream together
with bulking agents (eg. Psyllium, fiber) to
soften the motions.
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35. OTHER PROBLEMS
• Musculoskeletal problems
– Painless divarication (spreading apart) of the
recti can occur antenatally due to the
enlarging uterus that exerts pressure on the
recti, causing them to separate.
– Treatment involves exercises that increase
muscle tone.
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36. OTHER PROBLEMS
• Musculoskeletal problems
– In pregnancy the pelvic ligaments become more
lax and the symphysis pubis will separate to some
extent. This is beneficial as the anterior-posterior
diameter is increased.
–In extreme situations the hemi-pelvices can be
widely separated causing severe pain making
walking difficult.
–Treatment: Milder cases: Analgesic and
orthopaedic belt
Severe cases: Zimmer frame and bed
rest
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37. Normal non-pregnant pelvis
Total gap width of up to 9mm is normal Abnormal gap is considered to be ≥10mm.
during pregnancy Note misalignment.
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38. REFERENCES
• Obstetrics by Ten Teachers, 18th edition
• Danforth’s Obstetrics and Gynaecology, 10th
Edition
• Obstetrics and Gynecology An Illustrated
Colour Text, 1st Edition
• Kaplan and Sadock’s Synopsis of Psychiatry-
Behavioral Sciences/Clinical Psychiatry, 10th
Edition
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39. THANK YOU
NORMAL AND ABNORMAL
PUERPERIUM