Puerperium pdf - حنان كاظم

Puerperium

It is a term refers to the six weeks period after completion

of the third stage of labour.

Physiological Changes:

1- Uterine involution

It is the process by which the postpartum uterus weighing

about 1kg returns to its pre-pregnancy state of less than 100gm.

Clinically the uterine fundus should lies 4cm below the

umbilicus or 12cm above the symphyses pubis immediately
after labour, and after (2) weeks the uterus should be no longer
palpable above the symphyses. These changes occur because a
process of autolysis where the muscle cells diminish in size but
not in number, and it is accelerated by oxytocin,

Causes of delayed involution:-

-  Full bladder
-  Loaded rectum
-  Uterine infection
-  Retained products of conception.
-  Fibroids
-  Broods ligament hematoma.

2- Genital tract changes:-

The lower segment of the cervix and uterus appears flappy

and sometimes have small lacerations. In the first few days the
cervix can admit (2) fingers, by the end of first week passing
only one finger, by the end of 2nd week the cervix should be
closed.

3- Lochia:-

It is blood stainedd uterine discharge compromised of

blood and necrotic decidua.

It is red in the first few days, concerting to pink then after

that becoming serous by the end of the 2nd week.

Persistently red lochia indicating delayed involution either

due to infection or retained tissue. Offensive lochia indicating
infection if associated with tender uterus and by pyrexia,

RX By antibiotics and evacuation of retained products.

4-Bladder function:-

Voiding difficulty and over distension are not uncommon

after child birth specially if associated with regional aesthesia.

Risk Factors:-

1- Regional anaesthesia:-

Bladder may take up to 8hr.s to again normal sensation. so

induelling catheter should be maintained for at least 12hr.s in
pt.s with regional anasthesia to prevent bladder distension and
detrusor overstretching.

2- Antidiuretic effect of high concentration of oxytocin.
3- Increased post-partum diuresis.
4- Increased fluid intake by breast feeding mothers.
5- Women with traumatic delivery such as instrumental

delivery,  multiple  vulvovaginal  lacerations  vulvo-
vaginal  haematoma,  prolapsed  haamorriod,  anal
fissures,  abdominal  wound  haemotomas  or  even  fecal
impaction may interfere with voiding.

Every women who has not passed urine within 4 hours
of  delivery  should  be  encouraged  to  urinate  before
catheterization  .  women  with  difficulties  in  urination
should  have  urine  sample  sent  for  microscopy  culture
and  sensitivity  and  if  the  residual  urine

catheter should be left in to allow free drainage for 48
hr.s.

5- Bowel function:-

Constipation is common problem during puerperium. So

advice about adequate fluid intake and fibre intake is necessary.
prolapsed hachorroid, anal fissure sutured perineum, women
with third or fourth degree tear should avoid constipation and
straining. So should be prescribed lactulose or methyl cellulose
for (2) weeks immediately after the repair.

6-Normal emotional and psychological changes

The ‘pinks’: for the first 24–48 hours following delivery, it is
very common for women to experience an elevation of mood, a
feeling of excitement, some

overactivity and difficulty sleeping.

The ‘blues’: as many as 80% of women may experience the
‘postnatal blues’ in the first 2 weeks after delivery. Fatigue,
short temper, difficulty sleeping, depressed mood and
tearfulness are common but usually mild, and resolve
spontaneously in the majority of cases.

Puerperal disorders:-

Daily maternal observation include temperature, pulse,

blood pressure, urinary and bowel functions, breast examination
and feeding, assessment of uterine involution, lochia, perineal
inspection, examination of legs and pelvic floor exercises,
hemoglobin checking of day (3) and a level of 8gm or less is an
indication for transfusion.

1- Perineal complications:

About 80% of women complain of pain in the first (3) days

after delivery. Which is more in patients with perineal tears or
episiotomy local cooling, topical aneasthesia diclofenac
,paracetol are usually helpful.

Spontaneous opening of repaired perineal treas and

episiotomies is usually the result of secondary infection, the
treatment is with wound irrigation twice daily, and healing with
secondary intention. Large gaping wound should be sutured
with secondary repair only after infection has cleared.

2- Bowel and bladder dysfunction

3-2 PPH:-

Defined as fresh bleeding from the genital tract between

24hr.s  and  12  weeks  after  delivery.  Most  common  cause  is
retained  placental  tissue.  Other  causes  are  endometeritis,
hormonal  contraception  ,bleeding  disorders  VWD  and  rarely
choriocarcinoma.

Mgx include intravenous infusion, crossmatched blood,

syntocinon ,examination under aneasthesia, antibiotics if
placental tissue is found, and evacuation of the uterus.

4- Obstetric palsy:-

A condition in which one or both lower limbs may develop

signs of a motor or sensory neuropathy following delivery.

Peroneal n. palsy can occur when the nerve is compressed

between the head of the fibula and the lithotomy pole
unilateral foot drop.

RX is by bed rest with afirm board beneath the mattress,

analgesia and physiotherapy.

5- Symphysis Pubis diastasis:-

It is separation of sym.Pub either spontaneously or by

delibrate surgical seperation (symphysiotomy).

Risk factors are forcepes delivery, rapid second stage of labour
severe abduction of the thighs during delivery.

RX bed rest, antinflamatory agents, physiotherapy and a pelvic
corset to provide support and stability.

6- Thromboembolism:-

The risk increase to 5 flods in pregnancy and puerperium.

Majority of deaths are after C\S.

7-Puerperal Pyrexia:-

A temperature of 38C or higher on any two of the first 10

d.s post-pertum, exclusive of throat, breasts, urinary tract, pelvic
organs, cesarean or perineal wounds and legs.

-Chest complications, atelactasis, and aspiration

pneumonia.

-Genital tract infection:-

It is referred to as puerperal sepsis, it is oetiology:-

Following delivery natural barriers to infection are

temporarily  removed  and  therefore  arganisms  with  pathogenic
potential can ascend from the lower genital tract into the uterine
cavity. Placental separation exposes a large raw area equivalent
to  an  open  wound  and  retained  products  and  clots  can  provide
an  excellent  culture  media  for  infection,  in  addition  if  there  is
any lacerations in the genital tract.

Factors which determine the clinical coarse are virulence

of offending organisms, presence of haematoma or retained
products ,timing of antibiotic therapy and associated risk factors.

Risk factors are:-

-  Antenatal I.U. infection.
-  Cervical circlage.
-  Prolonged ROM.
-  Prolonged labour.multiple vaginal examinations.
-  Instrumental delivery.
-  Manual removal of placenta.
-  Retained products of conception.
-  Others like obesity, DM. HIV.

Methods of spread of infection are:-

1- Ascending infection, from lower genital tract, or infection

of placental site via fallopian tubes to the ovaries,

salpingo -opteritis peritonitis pelvic abcess.

2- By contiguity directly into the myometrium and

perametrium meteritis and parametritis
pelvic cellulitis peritonitis and pelvic abcess.

3- By lymphafics and blood vessels:-

By uterine vessels into the IVC or via ovarian vessels
septic thrombo phlebitis, or septicaemia.

Symptoms of puerperal pelvic infection:-
Malaise,  headache,  fever,  rigor  abdominal  discomfort,
vomiting  diarrhea,  offensive  lochia  and  2   PPh.  pelvic
thrombophlebitis  cherecterised  by  spiking  fever  for  7-10
days despise antibiotic therapy.

Signs:-

Pyrexia  and  tachycardia,  boggy  tender  large  uterus,
infected  wounds,  peritonism,  paralytic  ileus,  indurated
adnexae.
Investigation:-
Full blood count, urea and electrolytes, high vaginal swab,
pelvic U\S, clotting screen 7 and arterial blood gas, blood
culture.

Treatment:-
It is with broad spectrum antibiotics e.g. co- amaxiclav or
cephalosporine,  plus  metronidazole,  the  anibiotics  should
be  continued  for  at  least  48  hr.s  after  the  pt.  becoming

afebrile,  Major  pathogen  resistant  to  this  RX  is
Bacteroides fragilis, which is sensitive to clindamycin with
either  aminoglycosides  or  penicillin.  If  pelvic
thrombophlebitis  is  suspected  or  clinically  diagnosed
heparin should be instituted and may continue for weeks or
months according to which pelvic vein is involved.

Necrotising fasciitis:

It is a rare but fatal infection of skin muscle and

fascia, can originate in perineal areas, episiotomies and
C\S wound. Commonest organism is unaerobes, Clostridia
perfnrgens.

It needs wide debridement of necrotic tissues under

GA. Skin graft may be needed. In addition to mgx of
septic shock if developed.

Prevention of puerperal Sepsis:-
1- General hyegine and a septic surgical approach.
2- Prophylactic antibiotics during emergency C\S

with a single intra-operative antibiotic dose before
clamping of cord.

3- Prophylaxes of elective C\S is recommended in

units with background of infectious morbidity.

Diagnosis and management of puerperal pyrexia

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Symptoms

Diagnosis

Special

investigation

management

Cough

Chest
infection

Sputum M.C and S

Physiotherapy

Purulent sputum

Pneumonia

Chest x.ray

Antibiotics

Breasts Disorders:-

-Blood stained nipple discharge:-

It is bilateral due of epi. Proliferation. Usually occur in the 2

trimester, It is self-limited, needing just reassurance.

-Painful nipples:-

Sore throat

Tonsillitis

Throat swab

Antibiotics

Cervical

lymphadenopathy

Headaches

Meningitis

Lumbar puncture

Antibiotics

Neck stiffness (epidural/spinal anesthetic)

Dysuria

Pyelonephritis

Urine M.c and s

Antibiotics

Loin pain and tenderness

Secondary PPH

Metritis

Pelvic ultrasound

Antibiotics

Tender bulky

uterus

Retained

placental

Uterine tissue

Pelvic/calfpain/

Tenderness

Deep vein
thrombosis

Doppler/venogram
of legs

Heparin

Chest pain

Pulmonary

embolism

Chest x-ray and

blood gases

Lung

perfusion
scan

angiogram

Painful engorged
breasts

Mastitis

Abscess

Milk c and s

Express milk

Antibiotics

Incision and
drainage

VI, c and s. microscopy, culture and sensitivity; PPH. postpartum

haemorrhage.

It is due to nipple fissuring or denuded covered epithelium,
either d.t poor positioning or candidiasis.

RX with nipple rest, manual milk experession and then reint-
roduce feeding gradually.

Galactocele:-

It is cretention cyst of the memmary duct. Usually resolves
spondeheausely, if not aspertion.

Breast engorgerment:-

Usually begins by the 2

or 3

postpartum day and may give

rise to puerperal fever of up to 39C .

RX by allowing the baby easy access to the breast with manual
expression, firm support, ice bag and breast pump.

Mastitis:-

It  is  either  d.t  infection  or  duct  obstruction.  The  affected
segment  of  the  breast  appear  red.  Painful  and  edematous.  Flue
like  symptoms  develop  associated  with  a  tacthycardia  and
pyrexia.  It  is  usually  present  in  the  third  or  fourth  post-partum
week  and  is  usually  unilat.  The  most  common  arganism  is  S.
aureus  other  like  coagulase  negative  staph  and  strepto  coccus
veridens.

Mgx include isolation of the mother and baby ceasing B.F from
affected breast, expression of milk manually and sending a milk
for  culture  and  sensitivity.  Flucloxacillin  can  be  commenced
while  awaiting  sensitivity  results.  If  breast  abcess  develop
drainage under G.A.