Puerperium and abnormalities of puerperium

1. Normal Puerperium and
abnormalities of puerperium

2.  Def:6 week period following delivery when
the body returns to its prepregnant state
 Most neglected and left to nurses
 Morbidity and mortality associated with
pregnancy highest this time
 Lack of medical interest means that
problems go untreated or even
unrecognised

3.  Normal puerperium characterised by;
 Lactation
 Lochia
 Involution of the uterus
 Return of the genital tract to normal

4. Physiological changes in the
puerperium
 Genital tract
– Uterus contracts,criss-cross fibres of myometrium occlude
blood vessels formerly supplying placenta
– Uterine size reduces over 6/7, within 10/7 nolonger palpable
abdominally
– Contractions or after pains felt for 4/7
– Intrernal os closed by 3/7
– Lochia may be blood stained for up to 14/7, but later yellow
or white
– Menstruation at 6/52 if not lactating

5. Cardiovascular system
 CO and plasma volume decrease to
pregnant levels within 1/52
 Loss of oedema can take up to 6/52
 If transiently elevated BP is usually normal in
6/25

6. Urinary tract
 Damage to nerve plexus during delivery
leads to insensitivity,stagnation and UTI
 Physiological dilatation of ureters and renal
pelvis reduces over 3/12
 Pronouced diuresis on 2/7 to 3/7
 GFR decreases

7. GIT
 Increased thirst in in early part
 Slight paresis leads to constipation
 Wt loss due to uterine expulsion and 2kg
due to diuresis
– 2 litres lost in first week,1.5 liters in next 5/52

8. The blood
 U/E levels returns to normal because of
reduction in GFR
 In absence of haemorrhage ,HB and
haematocrit rise with haemoconcetration
 WBC falls
 Platelets and clotting factors rise,
predisposing to thrombosis

9. physiology of lactation
 Divided into 4 phases;
– Preparation of breasts(mammogenesis)
– Synthesis and secretion from breast
alveoli(lactogenesis)
– Ejection of milk(galactogenesis)
– Maintenance of lactation (galactopoiesis)

10.  Lactation dependant on prolactin and
oxytocin
 Prolactin from high at birth from ant pituitary
stimulates milk secretion
 Oxytocin from posterior pituitary stimulates
ejection in response to suckling

11. management
 Encourage to feed when baby is ready
 Feed on demand
 Correct position-baby`s lower lipshould be
planted below the nipple

12. Advantages of breast-feeding
 Ideal composition-easy digestion due to low osmotic
load,less caein, CHO maily lactose
 Protection against infection and deficiency states
– Vit D prevents rickets
– Lactoferrin hinders E.coli hence GE
– Bifidus factor promotes growth of lacto bacilli and inhibit
E.coli
– Iysozyme protects against infection and interferon an
antiviral
– Confers passive immunity to baby

13.  Is convenient,no preps ,cheap
 Natural contraception
 Additional
– Laxative
– No danger of allergy
– Promotes bonding
– Helps uterine involution
– Helps jaw development

14. Postnatal care
 Includes systematic examination of the
mother nad the baby and appropriate advice
given to the mother during the postpartum
period
 In uncomplicated cases patients seen at
least twice during purperium after discharge
from hospital

15.  1st visit is one week from discharge
– Aims to detect any immediate postpartum
problems with early intervention
 Second routine post natal care is conducted
at the end of the 6th week postpartum

16. Aims and objectives
– To assess the health status of the mother and
institute effective therapy to rectify the defect,if
any
– To detect and treat at the earliest any
gynaecological condition arising out of obstetric
legacy
– To note the progress of the baby and solve the
feeding problem,if any ,and to formulate any
preventive measures to be taken
– To impart family planning guidance

17. advantages
– It is an opportunity to detect and treat at the
earliest any gynaecological-medical
disability,either pre-existing or appearing after
childbirth
– The progress of the baby can be judged and
effective therapy can be instituted for ailments,if
detected
– Motivation and acceptance of FP methods can
best be imparted during this period

18. Procedures
 Procedure of check up includes:
– Exam of the mother
– Exam of the baby
– Advice given to mother

20.  Examination of the mother
– Enquiry is made about persistence or appearance
of any new ailments,if none routine enquiry about
sleep,appetite,sleep,bowel and urinary habit
,PVD,backache.Enquire on baby feeding
– Routine exam includes weight checking,BP,note
pallor,tone of abd muscles and examine breasts

21.  Pelvic exam as routine to note:
– Nature of healing of perineal wound
– Any tendency of prolapse or stress incontinence of urine
– Discharge if any ,and its character
– Uterine size,position and mobility
– Adnexal finding if any
– Tone of pelvic floor muscles
– Speculum exam to note evidences of laceration or
ectropion of the cervix

22.  Laboratory investigations include:
– Urine protein if indicated and if H/O UTI collect
urine for bacteriology
– HB estimation
– Pap smear if not previously done

23. Advices given
 General
– If if sound health may resume duties either home or in
employment
– May continue postpartum exercises for another 4-6 weeks
– Assure about abnormalities of menses which return to
normal after a variable period
– Generally may resume coitus
– Return after 6 months or earlier if complications arise

24.  Family planning guidance
– Importance of spacing and limitation of births
discussed
– Prescribe appropriate FP method
 Management of ailments
– Irregular PVB-not uncommon after 4-6 weeks
after delivery.May be 1st period in non lactating.If
dating from delivery may be due to POCs

25.  Leucorrhoea-profuse white discharge may be
due to ill health,vaginitis,cervicitis or
subinvolution.Specifically treat
 Cervical ectropion met during this time
without any symptom should not be treated
surgically.Hormonally induced may take up to
12 weeks to regress

26.  Backache
– Commonly found in ill-nourished and multiparous women
due to sacroiliac and lumboscral strain.Physiotherapy is
usually enough
 Slight degree of uterine descent with cystocoele and
relaxed perineum are common findings at this
stage.Cured by pelvic floor exercises and avoidance
of strain.If marked,effective surgery later after 3/12

27. Psychiatric problems of the
puerperium
 “Third day blues”, consist of temporary
emotional lability,affects 50% of
women.Support and reassurance are
required
 Postnatal depression affects 10% of women
– Common in women who are socially or
emotionally isolated,with previous history,or after
pregancy complications

28. – Consider postpartum thyroiditis
– Symptoms severity is variable and include
 Tiredness
 Guilt
 Feeling of worthlessness and even suicide
– Treament involves social support and
psychotherapy.Antidepressants may be used
along with these

29.  Puerperal psychosis -affects 0.2 of women
– Characterised by abrupt onset of psychotic
symptoms,usually around day 4
– Common in primigravida with family history
– Need psychiatric admission and major
tranquillizers ,after exclusion of organic illness
– Usually have full recovery
– Some develop mental disease later in life
– 10% relapse after subsequent pregnancy

30. Sepsis –puerperal pyrexia
 Defined as temp of 38 degrees celcius on
any occasion in the first 14/7 after delivery or
miscarriage
 A slight fever is not uncommon within the first
24 hours after delivery
 Possible causes include;
– UTI
– Genital tract infection

31. – Breast infection
– Deep vein thrombosis
– Respiratory infection
– Wound infection after C/S
– Other non-obstetric causes
 Carry out a full clinical investigation(including breasts and legs)
as well as MSU.cervical and high vaginal swabs,blood culture
and sputum culture CX-Ray (if possible)
 After investigations or if clinical situation warrants antibiotics
may be started

32. Investigation of puerperal pyrexia
 Principles
– Exclude possibility of puerperal sepsis
– Locate site of infection
– Identify the organisms
 A case of puerperal sepsis is considered to be due to
genital sepsis unless proven otherwise
 Obtain good history of risks for puerperal sepsis

33. Investigations include
 HSV and endocervical swabs
 “cleancatch” mid stream urine for m/c/s
 WBC
 Blood culture
 CXRay and MP

34. Puerperal sepsis
 Def:An infection of the genital tract which occurs as
a complication of delivery
 Main cause of puerperal pyrexia
 Predisposing factors include:
– Conditions lowering resistance
– Conditons favouring multiplication and increased virulence
of the organisms
– Introduction of organisms from outside
– Increased prevalence of organisms resistant to antibiotics
and chemotherapy

35.  Organisms
– Aerobic-staph
pyogenes,e.coli,klebsiella,pseudomonas,staph
aureus,non-haemolytic streptococcus
– Anaerobic-anaerobic
strep,bacteroides(fragilis),Cl.welchi.Cl.tetani

36. Mode of infection
 Puerperal sepsis is essentially a wound infection
– Endogenous-organisms present in genital tract before
delivery and become pathogenic in conditions mentioned
– Autogenous-organisms present elsewhere in the body
migrate to genital organs either through blood stream or
droplet or are conveyed to site by patient herself or
attendants
– Exogenous-infection is contracted some other sources
outside the patient.Organisms introduced by the attendants
usually from respiratory system

37. Pathology
 Puerperal infection basically would
infection.Primary sites of infection are
– Vagina-may have retained swab
– Cervix
– Uterus-appears on day 3-6 after delivery
– perineum

38. Spread of infection
 Pelvic cellulitis(parametritis)-infection of
retroperitoneal fibroareolar tissues occurs
which extends to pelvic peritoneum through:
– Direct
– Lymphatic spread
– Secondary to thrombophlebitis
 salpingitis

39.  Peritonitis may occur by:
– Spread through the tubes
– Micro abscesses of the tubes
– Lymphatic spread from myometrium
 Thrombophlebitis-mainly involve ovarian vein
draining the placental site
 Septicemia and pyaemia-may occur suudenly with
virulent organisms like beta hemolytic strep.May lead
to endorcaditis,pericarditis,renal abscess,lung
abscess ,meningitis and arthritis

40.  Clinical features are mainly of affected areas:
– Local infection
– Uterine infection
– Spreading infection
 Parametritis
 Pelvic peritonitis
 General peritonitis
 Thrombophlebitis
 septicaemia

41. prophylaxis
 Puerperal sepsis is to a great extent
preventable provided measures are taken
before ,during and following labour
 Antenatal
– Detect and eradicate septic foci as in
teeth,gums.tonsils,middle ear
– Minimise VEs
– No douching in pregnancy

42. – Avoid intercourse in later months to prevent
introduction of infection
– Avoid contact with patients with infectious disease
– Personal hygiene
 Intranatal
– All delivery with surgical asepsis
– Patient not to touch vulva in labour
– Membranes preserved as long as possible

43. – Attenders with RTI to avoid LW
– Avoid traumatic delivery
– Repair lacerations promptly
– Replace excessive blood loss promptly
– Prophylactic antibiotics in PROM
 Postpartum
– Aseptic precaution until one week following
delivery

44. – Use of sterilized sanitary pads
– Keep wars clean
– Isolate ifected babies with their mothers
 Treatment
– General
 Correct anaemia
 Chart TPR ,intake/output
– Specific antibiotics

45.  Surgical treatment
– Perineal wound- may have to remove stitches
– Infected retained POCs removed under cover of
antibiotics
– Drain pelvic abscess /peritonitis