The puerperium

PROBLEMS OF PUERPERIUM

Dr.Zahraa’ Muhmmed Jameel
6 weeks Period following completion of the 3rd stage of labor
By 6 weeks after delivery, most of the changes of pregnancy resolved and the body have regained the non-pregnant state.
Physiological changes
Uterine Involution: is the process by which the post-partum uterus weighing about 1 kg returns to pre-pregnancy state of less than 100 gm.
Just after birth: 4cm below umbilicus (12 cm above symphasis pubis)
2weeks: Uterus descends into pelvic cavity (no longer be palpable above symphasis)
Involution occurs by process of autolysis; muscle diminish in size as a result of enzymatic digestion of cytoplasm, with no effect on cell number, & the excess protein produced from autolysis is absorbed into blood stream and excreted in urine
It appears to be accelerated by oxytocin in women who are breast feeding (smaller in breast feeding women)
A delay in involution in the absence of any other signs & symptoms, e.g. bleeding, is of no clinical significance.
Causes of delayed involution
Full bladder
Loaded rectum
Uterine infection
Retained product of conception
Fibroids
Broad ligament hematoma
Genital tract changesCervix:
Following delivery of placenta, the lower segment of the uterus & the cervix appear flabby & there may be small cervical laceration
1st few days; can admit 2 fingers
1st week: become increasingly difficult to pass 1 finger
The internal os should be closed by the end of the 2nd week, but the external os can remain open permanently, giving characteristic appearance of parous cervix.
Lochia: blood stained uterine discharge that comprised of blood & necrotic decidua (only the superficial layer of decidua become necrotic &is sloughed off)
The basal layer adjacent to the myometrium is involved in the regeneration of new endometrium & this regeneration is completed by 3rd week
1st few days: red
As the endometrium formed (after 3-4 days): pink
2nd week: serous
Persistent red lochia suggest delayed involution that is usually associated with infection or RPOC
Offensive lochia + pyrexia + tender uterus = infection: treated by broad spectrum antibiotics
RPOC is associated with increased RBC loss & clots, management include the use of antibiotics & evacuation of RPOC under regional or general anesthesia.
Puerperal disorders
Daily observation include
Temp, pulse, BP
Urinary function
Bowel function
Breast examination & feeding
Assessment of uterine involution & lochia
Perineal inspection
Examination of legs & pelvic floor exercises
In the UK: HB on day 3; if < 8g/l then blood transfusion is needed
Perineal complications
perineal discomfort occurs in 80% of women in the 1st 3 days after delivery, with ¼ continue to suffer on day 10
Greatest in women with sustained tears or episiotomy or following instrumental delivery
Care of perineum:
Local cooling (crushed ice, tape water)
Topical anesthesia (5% lignocaine gel)
Analgesia: paracetamol, diclofenac rectally or orally (codeine derivatives not preferable b/c constipation)
Infections (uncommon); signs (redness+ pain +swelling +heat) +raised temp
Swab taken for microbiological culture from infected perineum
Broad spectrum antibiotics, drainage if there is collection of pus, removal of any skin sutures.
Spontaneous opening of repaired perineal tears and episiotomies as result of 2ndary infection
Wound should be irrigated twice daily
Healing allowed to occur by 2ndary intention
Surgical repair should never attempted in the presence of infection
2ndary repair in large wound, only when infection cleared, no cellulitis or exudate present, & healthy granulation tissue can be seen
Bladder function
Voiding difficulty& over-distention of the bladder after child birth especially after regional anesthesia is not uncommon
In the puerperium there is increase urine production due to:
Fluid over loading prior to regional anesthesia (epidural, spinal)
Anti-diuretic effect of oxytocin
Increase fluid intake in breast feeding mothers
Increase postpartum diuresis (edema)
Difficulty to void because of pain or peri urethral edema (after traumatic delivery)
Other causes of pain: prolapsed hemorrhoids, anal fissures, abdominal wound hematoma, or even stool impaction may interfere with voiding
Incontinence should be investigated to exclude vesicovaginal, urethrovaginal or rarely uretrovaginal fistula, (due to pressure necrosis of bladder or urethra following obstructed labor) usually occurs in the 2nd week when slough separates.
Small fistulae may close spontaneously after few weeks of free bladder drainage; large fistulae will require surgical repair by a specialist.
To minimize risk of over distention of bladder in women undergoing c/s under regional anesthesia, a urinary catheter may be left in the bladder for the 1st 12-24 hour
Intake/ output chart
In women who has not pass urine within 4 hours of delivery encouraged to do so before resorting to catheterization
Clean catch specimen of urine should be sent for microscopy, culture & sensitivity.
If the residual urine in the bladder is <300ml, a catheter should be left in to allow free drainage for 48 hours
Bowel function
Constipation is a common problem due to interruption in the normal diet and possible dehydration, or of fear of evacuation due to pain(tear, pile, fissure)
Small Anovaginal fistula (wind passing from the vagina) will close spontaneously in 6 months, but larger fistula need repair
Long term anal incontinence, fistulae following primary repair of 3rd or 4th degree perineal tear can occur
Secondary post-partum hemorrhage
Fresh bleeding from genital tract b/w 24 hours & 6 week after delivery
Mostly occur b/w day 7 & 14
Most common cause is retained placental tissue& associated with crampy abd. Pain, larger uterus, passage of placental tissue from the cervix & signs of infection
Other causes : endometritis, hormonal contraception, bleeding disorders, e.g. von willebrand’ disease, and rarely choriocarcinoma
Mx: IV infusion, cross match of blood, syntocinon, examination under anesthesia, antibiotics; if placental tissue found, or infection.
Obstetric palsy or traumatic neuritis
A condition in which 1 or both LL may develops signs of a motor and/or sensory neuropathy following delivery
Symptoms: sciatic pain, foot-drop, parasthesia, hypoesthesia & muscle wasting
Peroneal n palsy can occur resulting in unilateral foot-drop
Urinary or fecal incontinence can occur
Mx; orthopedic opinion, bed rest with firm board beneath the mattress, analgesia & physiotherapy.
Symphysis pubis diastasis
Separation of the symphasis pubis that can occur spontaneously in at least 1 in 800 deliveries
After forceps delivary, rapid second stage of labor, sever abduction of the thigh, rarely due to symphysiotomy (shoulder dystocia)
S&s; symphysial pain aggravated by weight-bearing & walking, a waddling gate, pubic tenderness, &palpable interpubic gap
Mx: bed rest, anti- inflammatory agents, physiotherapy, & a pelvic corset to provide support & stability
Thromboembolism
Risk rise 5 folds during preg & pueriperium
Majority of deaths occur in pueriperium & are more common after c/s
If DVT or pulmonary embolism is suspected, full anticoagulant therapy should be commenced & LL ultrasound and/or lung scan should be carried out in 24-48 hours
Puerperal pyrexia
Temp of 38 °c or higher on any 2 of the 1st 10 days postpartum, exclusive of the 1st 24 hours (measured orally by a slandered technique)
The common sites include: chest, throat, breasts, urinary tract, pelvic organs, caesarean or perineal wounds & legs
Chest complications are most likely to appear in the 1st 24 hours after delivery, particularly after GA
Atelectasis may be ass with fever & largely prevented by early & regular physiotherapy
Aspiration pneumonia (mendleson’s syndrome) must be suspected if there is wheezing, dyspnea, a spiking temp, & evidence of hypoxia
Genital tract infection
Historically, childbed fever, milk fever, puerperal fever (puerperal sepsis) is an infection of the uterus in the pueriperium which can lead to septicemia, organ failer & death
Was a significant factor in maternal death
Its Poly microbial and involves contaminants from bowel that colonize in the perineum & lower genital tract
placental separation, RPOC, blood clots, lacerations& iatrogenic wounds(c/s & episiotomy) can become focus of infection.
Common risk factors
❑ prolonged rupture of the membranes
❑ prolonged (more than 24 hours) labor
❑ frequent or vaginal examinations
❑ retained products of conception
❑ cervical cerculage
❑ manual removal of placenta.
❑instrumental delivery
❑ cesarean section
❑antenatal intrauterine infection
❑non obstetric: obesity, DM, HIV
Symptoms: malaise, headache, fever, rigors, abdominal discomfort, vomiting & diarrhea, offensive odder, secondary PPH
Signs:
Pyrexia & tachycardia
Uterus –boggy, tender & larger
Infected wounds- c/s
Peritonisim
Indurated adnexae (parametritis)
Bogginess in pelvis ( abscess)
Factors that determine the Course & severity of the infection: general health & resistance of women, virulence of organism, presence of hematoma or RPOC, timing of antibiotic therapy, & associated risk factor
Investigations
abnormalities
investigations
Anemia, leukocytosis, thrombocytopenia
FBC
Fluid & electrolyte imbalance
Urea & electrolytes
Infection screen & blood products
HVS
Retained product, pelvic abscess
Pelvic ultrasound
DIC
Clotting screen( hemorrhage or shock)
Acidosis & hypoxia(shock)
Arterial blood gas
Commonly associated organisms
Aerobes
Gram-positive
Beta hemolytic streptococcus, groups A,B,D, Enterococci-streptococcus faecalis
Gram-negative
E coli, Heamophilus influenza, Klebsiela pneumonia, Pseudomonas aeruginosa, Proteus mirabilis
Gram-variable
Gardenella vaginalis
Anaerobes
Peptocoous sp., Peptostreptococcus sp.
Bacteroids –B. fragilis, B. bivius, B. disiens
Miscelleneous
Chlamydia trachomatis, Mycoplasma hominis, Ureaplasma urealyticum
Common methods of spread (& complications)
Ascending infections from lower genital tract or primary infection of placental site may spread via the fallopian tube to the ovaries: salpingo-ophritis &pelvic peritonitis, generalized peritonitis, pelvic abscess
By contiguity directly into myometrium & parametrium: metritis, parametritis, pelvic cellulitis, pelvic peritonitis & abcess
By lymphatic's & blood vessels to distant sites: septic thrombophlebitis, pulmonary infections, generalized septicemia &, endotoxic shock
Perisalpingitis rarely can lead to tubal occlusion & infertility; tubo-ovarian abscesses are also rare comp.
Management
Mild to moderate infections can be treated with a broad-spectrum antibiotic, e.g. co-amoxiclave, or a cephalosporin, such as cefalexim, +metronidazole. Depending on the severity 1st few doses should be given intravenously
With severe infection delay in appropriate management could be fatal
Necrotizing fasciitis is rare but frequently fatal infection of skin, fascia & muscle. It can originate in perineal tears, episiotomies & c/s wounds. Perineal infections can spread rapidly to involve the buttock, thighs, lower abd. Wall. A variety of bacteria involved but anaerobs predominate & clostridium perfringes is usually identified. In addition to signs of infections, there is extensive necrosis, crepitus & inflamation. As well management of septic shock, wide debridment of necrotic tissue under GA is absoulot to avoid mortality. Split-thickness skin grafts may be necessary at later date.
Prevention
Awareness of the principls of general hygiene
Good surgical approach
Use of aseptic technique
Prophylactic antibiotics during elective & emergency c/s ( single intra-operative dose of antibiotics (amoxiclave or cephalosporin + metronidazole) after clamping the cord)


Lactogenesis is initially triggered by the delivery of the placenta due to drop of placenta H ( esp. estrogen ) &↑prolactin-
In non nursing women : The prolactin levels decrease and return to normal within 2-3 weeks
Colostrum secreted from 16th week of org to day 2 post partum: contain high protein , IgA and IgG but less fat & sugar than breast milk
After 2 days: replaced by milk (protein , lactose , water and fat )
Breast disorders
Blood stain nipple discharge: typically bilateral believed to be due to epithelial proliferation occurs in the 2nd or 3rd trim & rarely persist beyond 3 m postpartum (reassure the pt. & no Vx or Rx)
Painful nipple: Cracked nipples occur due to poor positioning of the baby on the breast although candidiasis may also cause soreness & may be ass with breast abscess. Rx: resting the nipple, manually expressing milk then breast feeding reintroduced gradually
Galactocele: retention cyst of the mammary ducts following blockage by inspissated secretions. It is identified as fluctuant swelling with minimal pain & inflammation. It usually resolve spontaneously but also may be aspirated; or surgical excision
Breast engorgement: 2nd or 3rd postpartum day & if breast feeding not effectively established. S&S: fever (up to 39 °c) rarely last for 16 hr. Rx: allowing the baby easy access to breast (the best) ,manual expression, firm support, ice bag, electric pump.
Mastitis
Inflammation of the breast is not always due to infection. It can occur when a blocked duct obstructs the flow of milk & distends the alveoli. If this pressure persists, the milk extravasates into the perilobular tissue, initiating an inflammatory process.
The affected segment of the breast is painful, red, & edematous. With flue like symptoms, tachycardia & pyrexia
15% of women temp up to 39°c lasting < 24 hours, due to breast engorgement
In infective mastitis, the pyrexia develops later &persist longer
Suppurative mastitis: 3rd or 4th postpartum week & usually unilateral. Symptoms include rigors, fever, pain, reddened swollen breasts
The most common infecting organism is staphylococcus aureus, which is found in 40 % of women with mastitis. Other bacteria include coagulase-negative stapylococci & streptococcus viridanse
The most common source of infection is from baby nose & throat & 2nd from an infected umbilical cord
Management
Isolation of the mother from the baby
Ceasing breast feeding from the affected breast
Expression of milk either manually or by electric pump
Microbiological culture and sensitivity of a sample of milk
Flucloxacilline can be commenced while awaiting sensitivity results
About 10% of women with mastitis develop breast abscess: Rx by surgical incision & Drainage under GA.
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