Educational Materials

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