This document discusses normal puerperium and some abnormalities that can occur. The postpartum period is divided into three stages: immediate (first 24 hours), early (first week), and remote (up to 6 weeks). Physiological changes that occur include uterine involution and return of other systems like temperature and blood pressure to pre-pregnancy levels. Potential abnormalities covered include postpartum hemorrhage, puerperal pyrexia (infection), painful perineum, and psychological disorders. Causes, signs, and management are described for these complications.

1. Associate Clinical Prof. Dr. Aisha M. El-Bareg, MD, PhD .
Senior Consultant in (Obs & Gyn)/ Reproductive Medicine
Faculty of Medicine, Misurata .LIBYA
Puerperium for 4th year med.students

2. Normal Puerperium
Puerperium : Is a period during which the
anatomical and physiological changes of
pregnancy returns to pre-pregnancy state.
Time: approximately 6 weeks (± 42 days) after
delivery

3. The post partumof PuerperiumStages
period has been divided into:
o The immediate Puerperium, the first 24
hours after parturition; when acute post
anesthetic or post delivery complications
may occur.
o The early Puerperium, which extends until
the first week post partum.
o The remote Puerperium, which includes the
period of time required for involution of the
genital organs through the sixth weeks
postpartum.

4. PuerperiumNormal
When the endocrine influences of the placenta
removed, the physiological changes of pregnancy
is reversed.

5. Systemic changesA.

6. Immediately after labor, the woman is in a state
of physical fatigue in many cases, slight shivering,
muscular tremors and chattering of teeth occur
for about 10 – 15 minutes.
1. Temperature
Slight reactionary rise in the first 24 hrs (<38⁰C)
for <24hrs.
Slight rise may occur in the 3rd day-breast
engorgement.

7. 2. Pulse: Normal but tachycardia if infection or
hemorrhage.
3. Cardiovascular:
Blood volume returns to non-pregnant levels by
the tenth days of Puerperium.
Cardiac output ↑(immediately after delivery) →
slowly declines→ reach late pregnancy levels 2
days postpartum→ normal 2-6 weeks.

8. 4. Urinary tract
Polyuria in the first few days- excrete fluid
retained during pregnancy
Retention may occur in the first few days due
to:
Lax abdominal wall
Painful episiotomy or laceration
Atony of the bladder & urethral compression
by oedema or hematoma

9. 4. Urinary tract
Dilatation of UT resolves in 12 weeks.
Renal function return to normal by 6th weeks.
Lactosuria may appear.
SUI may follow difficult labour.

10. 5. GIT
Constipation:
Atony of intestinal muscle
lax abdominal wall
Decrease fluid and food intake
Painful episiotomy- reflex constipation

11. 6. blood changes
All changes become gradually reversed
RBC & Hb become normal
Increased risk of TE in the first few days
7. Skin changes
Increased sweating- eliminate excess fluids
Decreased pigmentation

12. 8. Body wt
Decreased during labour- expulsion of contents
Decreased during puerperium- loss of fluid
9. Joints
Laxity gradually decreased

13. 10. Breasts
Larger, firmer, heavier
Lactogenesis is initially triggered by the
delivery of the placenta (E↓P↓and prolactin).
Colostrum appears for first 3 days
Milk appear later, 3rd or 4 day
Breast become engorged, painful & tender
Suckling relieves this discomfort

14. colostrum milk
Proteins 6% 1%
Fat 2.5% 3.5%
CHO 3% 7%
10. Breasts

15. 11. Abdominal wall
Gradually return of tone- exercise
Striae- become white- albicans
12. After pain
Painful uterine contraction
In first few days-control blood loss
↑during suckling due to release of oxytocin

16. 13. Menstruation
Resumption of ovulation influenced by lactation
Variable in lactating women
Starts within 6-8 weeks in non-lactating women

17. 1.Involution
local changesB.

19. 1. Uterus
 Weight:
From 1000 gm just after delivery to 50-100
gm by the end of 6th weeks (involution)
 Levels:
Immediately after delivery- at umbilicus
After 1 wk- between umbilicus & SP
After 2 wk- at SP
Then gradually ↓to pre-pregnancy size.

20. Structural changes
Uterine Muscle
 Autolysis of excess muscle
 ↓ in muscle size
Uterine Blood vessels
 Obliteration, thrombosis
 Absorbed & replaced by elastic fibers

21.  Decidua
 Shedding as a result of ischemia
 Endometrial regeneration from the basal
layer of the decidua by the 10th day.
 Placental site takes 6 wks.
 Lochia: vaginal discharge after labour
1st wk- lochia rubra
2nd wk- lochia serosa
3rd wk- lochia alba

22. 2. Cervix
Closed in 1 wk- return to its original form and
consistency- become slit shaped EO
Failure to close- retained POC
3. Vulva, vagina
↓ laxity of vaginal wall, pelvic floor by the end
of 6 wks.
Vaginal rugea reappear in 3rd wk.
Persistent weakness predisposes to genital
prolapse

24. Management of perineum
Goals in the Puerperium
Prevention of infection
Careful nursing & observation of the newborn
Initiation of breast feeding
Exercise to prevent prolapse
Giving mother support and sympathy

25. Routine postpartum care
 Monitor for:
Vital signs, PV bleeding, contraction of
uterus, appearance of lochia, perineal
inspection, signs of infection, urinary and
bowel function, examination of legs, breast.
Encourage mobilization and eat regular high
fiber diet.
Continue with multivitamins.

28. Pain relief- analgesics, sedatives.
Care of vulva & perineum.
Care of the breasts.
Hemorrhoids- symptomatic relief during
immediate postpartum period, using
creams, local anesthetics.

29. Cesarean delivery
Pain and discomfort from abdominal incision-
ice and pain relief medication.
Heparinization until mobilization
Investigations
HB, hematocrit
baby’s blood type in Rh –ve women and
administration of anti D.

30. Patient education
Care of the baby-feeding, diapering, bathing,
what you expect from the baby in terms of
sleep, urination, bowel, eating.
Support and guidance to breastfeeding-
encourage breast feeding immediately and
every 2-3 hrs.
If not breastfeeding-prevent breast
engorgement

31. Postpartum pelvic floor and abdominal wall
exercise.
Resuming normal physical and sexual
activity.
Advise for pregnancy spacing- Birth control
Follow up visit at 6 weeks after delivery.

32. Abnormal Puerperium
• PPH
• PP pyrexia
• Painful perineum
• Varicose veins, DVT
• Endocrine disorders
• Psychological disorders

33. PPH & Management

34. Excessive blood loss during or after third
stage of labour. The average is 500 ml at
vaginal delivery and 1000 ml at C.S.
10% reduction in the hematocrit level or the
need for transfusion.
PPH complicate 4-6 % of all deliveries
)hemorrhage (PPHPostpartum.1

35. Control of bleeding after delivery
Contraction and retraction
of middle uterine muscle
Closure of the sinuses at
the placental site
Clotting mechanism

36. Early PPH:
Occurring within the first 24 hrs after delivery
Uterine atony, lower genital tract laceration,
retained POC, uterine rupture, uterine
inversion, placenta accreta, coagulopathy.
1. Postpartum hemorrhage (PPH)

37. Late PPH
Frequently occurs 1-2 weeks after delivery
but may up to 6 weeks postpartum.
Retained POC, sub -involution of placental
site, infection, hormonal contraception,
coagulopathy, choriocarcinoma.
US, examination under GA and evacuation
of ROC
Antibiotics

38. Management of PPH
History and examination: antepartum and
intrapartum identification of risk factors for PPH.
All women should be closely monitored within 2
hrs of delivery.
Shout for help- urgently mobilize all available
personnel.
Rapid assessment, general look, response, vital
sings

41. Management of PPH
Message the uterus to expel blood and blood
clots
Start an IV infusion, send blood for Hb, Hct, x-
matching and keep at least 4 units of blood
infuse IV fluids until the blood is ready.
Urinary catheter
Identify the cause treat accordingly

42. . Puerperal pyrexia2
Rise of temperature of 38 ⁰C or more on 2
occasions at 24 hrs apart (not first 24hrs)
within first 10 days following delivery.

43. Puerperal Infection

44. Causes of P. pyrexia
Puerperal sepsis (most dangerous)
Breast engorgement (most common)
Breast infection
Urinary tract infection
Surgical wound
Thrombophlebitis or Deep venous thrombosis
Respiratory infection
General diseases- typhoid, malaria

45. Puerperal sepsis
Puerperal pyrexia due to genital infection
Mode of infection
Endogenous - vaginal flora
Exogenous- attendants, instruments
Autogenous- Blood born- tonsils

46. Site of infection
1ry site
Placental site
Laceration
Uterus- remnants of POC
2ry site-spread from 1ry sites
Parametritis
Salpingoopheritis
Peritonitis, pelvic abscess
thrombophlebitis

47. Causative organisms
Usually mixed gram +ve and –ve
Anaerobic strept
Group A hemolytic strep.-severe
Staph- suppuration & pus formation
E coli, Cl welchii, tetani
Gonorrhea, Chlamydia.

48. Predisposing factors
Improper asepsis
Maternal disease- ↓ immunity
Prolonged or instrumental delivery
PROM
Retained placental tissue
Antepartum+ postpartum hemorrhage

49. Diagnosis
History
Suprpubic or pelvic pain
Generalized abdominal pain-peritonitis
Pain in lower limb-DVT
Excessive offensive lochia
Bleeding- 2ry PPH
Fever, malaise, headache

50. Vomiting- generalized peritonitis
Diarrhea, rectal tenderness-pelvic
abscess
Examination
A. General examination
Fever, tachycardia
Dehydration
Septicemia-

51. B. Abdominal and vaginal examination
Infected laceration
The wound is red, hot, tender, swollen
Greenish yellow discharge
Puerperal endometritis
Suprapubic or generalized tenderness
Uterus is subinvoluted
Lochia is excessive and offensive

52. Parametritis
Indurated tender mass lateral to the uterus
Parametric abscess-softening of the mass
Salpingo-ophoritis
Bilateral tenderness
Pain on moving the cervix

53. Thrombophlebitis
Deep seated pelvic tenderness
If extended to the femoral vein - Pain
and tenderness along the course of the
vessels
Limb is swollen, cyanosed, hot.

54. Investigation
o Swabs taken from vagina and cervix
o Urine analysis, C/S
o Blood culture at peak of fever
o USS for retained product of conception
o Doppler USS for DVT
o Chest x-ray, blood film for malaria
o Widal test for typhoid

55. Treatment
Supportive
• IV fluids
• Analgesics, antipyretics
Antibiotics
Evacuation of infected placenta
Promotion of abscess drainage
Anticoagulants for DVT

56. DVT

57. Breast infection
 Engorgement:
 Occurs on day 2-4 pp
 Vascular and lymphatic stasis
 Both breasts are heavy, painful, warm, firm
and tender
 Conservative: encourage breastfeeding, ice
packs, high-fitting bras, analgesia.
 ?Cabergoline for non-breastfeeding

58.  Mastitis
 Defined as inflammation of the mammary
gland
 Associated with
 milk stasis and cracked nipples
 Primiparity, incomplete emptying of the
breast, improper nursing technique
 Causes: Staphylococcus aureus, staph.
Epidermitis, s saprophyticus,
streptococcus viridans, and E coli.

59. S & S: fever, myalgia, erythema, warmth,
swelling, and breast tenderness
treatment:
Encourage breast feeding with proper
positioning of the infant, support breasts with
a binder or brassiere, apply cold compress
Analgesia, Antibiotic therapy
Drain if abscess

60. MASTITIS

61. Wound infection
infection of the perineal wound-episiotomy or
laceration-associated with infected lochia,
fecal contamination, and poor hygiene,
Caused by vaginal flora.
Infection of the abdominal incision- after CS-
contamination with vaginal flora. Also, s.
aureus, mycoplasma species.

62. WOUND INFECTIONS

63. Risk factors:
diabetes, PET, obesity, anemia,
Chorioamnionitis, prolonged labour,
prolonged ROM, prolonged operation time,
excessive blood loss.
Treatment:
Perineal infection: symptomatic relief-
NSAID, local anesthetic spray, sits path,
drain of abscess and antibiotics
CS wound- drainage and inspection of
underlying fascia, antibiotics

64. Septic pelvic thrombophlebitis
Venous inflammation with thrombus formation
in association with fever that unresponsive to
antibiotic therapy.
Preceded by endometritis
Risk factors: low socioeconomic status,
cesarean birth, prolonged rupture of
membranes, and excessive blood loss.

65. DD: pyelonephritis, appendicitis, broad ligament
hematoma, adnexal torsion, pelvic abscess,
drug fever, collagen vascular disease, and
pelvic abscess.
Management
Urinalysis, C/S, CBC with differentials
Imaging: CT scan and MRI- ovarian and
iliofemoral involvements
Treatment with antibiotics and/or
anticoagulants

66. Other causes of fever in Puerperium
Pneumonia, malaria, typhoid, hepatitis

67. Endocrine disorders.3
Postpartum thyroiditis:
transient destructive lymphocytic thyroiditis
occurring within the first year after delivery.
Thyrotoxicosis phase: 1-4 months pp, self-
limited
Hypothyroidism phase: 4-8 months pp
Self-limiting, no tt unless sever.

68. Postpartum Thyroiditis

69. Sheehan syndrome
Ischemia, congestion, and infarction of
pituitary gland resulting in panhypopituitrism
caused by severe PPH at the time of delivery.
Abnormal lactation, amenorrhea, signs of
cortisol and thyroid hormone deficiency
Hormonal assays
Hormonal replacement.

70. SHEEHAN’S SYNDROME

71. 4. Psychiatric disorders
Postpartum blue (50-70%)
A transient disorder arise in the first 2 weeks
pp and the lasts hours to weeks.
characterized by bouts of crying and
sadness, restlessness, mood lability,
insomnia.
 Resolve by day 10, provide support and
education

72. 4. Psychiatric disorders
Postpartum depression (PPD)- 10-15%
Develop 2-3 months pp and resolve slowly
over the following 6-12 months.
Insomnia, lethargy, loss of libido, negative
feeling toward the infant, suicidal or homicidal
ideas..etc..

73. Risk factors: history of depression or PPD,
Supportive care and reassurance.
Drugs: antipsychotics

74. 4. Psychiatric disorders
Postpartum psychosis - 0.14-0.26 %
Refers to a group of severe and varied
disorders that elicit psychotic symptoms.
Schizophrenia or manic depression.
Risk factors: young age, primiparity, personal
or family history of mental illness.

75. Symptoms start 10-14 days pp.
Treatment
Involve hospitalization and psychiatric
consultation
Drugs and/or electroconvulsant therapy
(ECT)
Recurrence: 25-30%

76. . Psychiatric disorders

77. Symphysis pubis diastasis
Separation of SP
Spontaneous or surgical
Symphyseal pain, waddling gait, pubic
tenderness, a palpable infrapubic gap
Best rest, anti-inflammatory agents,
physiotherapy, pelvic corset to provide
support and stability.

78. Symphysis pubis diastasis

79. Avoid prolonged standing and prolonged sitting.
Apply well-fitted below knee support stocking
before ambulating in the morning.
Ask mother to elevate her leg on pillow while
taking supine lying position.
Intermittent compression, Bandaging.
Not to sit with leg crossed or knee flexed.
Management of varicose vain

80. Management of varicose vain