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By Dr. ishraq mohammed

The puerperium refers to 6 weeks period following
childbirth , when considerable changes occur before
return to the pre - pregnancy state .

Physiological changes :

uterine involution:
Involution is the process by which the post - partum
uterus , weighing about 1 kg , return to its pre -
pregnancy state of less than 100 gm . Within 2
weeks, the uterus can no longer be palpable above
the symphysis .Involution occur by process of
autolysis , whereby muscle cells diminished in size
with no effect on number of muscle cells .Involution
appear to be accelerated by release of oxytocin in
women who are breastfeed.

Signs :causes of delayed involution :

1 - full bladder.
2 - loaded rectum.
3 - uterine infection.
4 - retained product of conception.
5 - fibriods.
6 - broad ligament haematoma .
A delay in involution in the absence of any
other signs or symptoms i.e. bleeding, is of
no clinical significance .

Genital tract changes :

In first few days, the cervix can readily admit
two fingers , but by the end of the second
weeks the internal os should be closed.
However, the external os can remain open
permanently , giving characteristic
appearance to the parous cervix.
In the first few days , the stretched vagina is
smooth & oedematous , but by the third week
rugae begin to reappear


Lochia :
Lochia is the bloodstained uterine discharge that is composed of blood &
necrotic decidua . Only the superficial layer of decidua becomes necrotic
& is sloughed off . The basal layer adjacent to the myometrium is
involved in the regeneration of new endometrium & this regeneration is
completed by the third week.
During the first few days after delivery , the lochia is red [ lochia rubra ]. 
LOCHIA SEROSA :serous discharge in the second week after delivery .
LOCHIA ALBA :whitish or yellow white discharge appear the second week.
Persistent red lochia suggest delayed uterine involution that is usually
associated with infection or a retained piece of placental tissue
.Offensive lochia suggest infection & should be treated with a broad -
spectrum antibiotics .Retained placental tissues associated with increase
blood loss . management includes the use of antibiotics & evacuation of
retained products.


 Puerpural disorders:
 1 - perineal complications:
 a- perineal discomfort : 80 % of patients, which last about 10 days .It is
greatest in women with episiotomies or tears & instrumental deliveries .
 Treatment is by – local cooling.
 - topical anesthesia.
 -analgesia : paracetamol , diclofenac suppositories.

 b -perineal infections: bacterial infection with signs of infections .
 management by : -swabs for microbiological culture .
 - broad spectrum antibiotics.
 - if there is pus , drainage should be encouraged by
removal of any skin sutures.

 c- spontaneous opening of repaired perineal tears & episiotomies :

 is the result of secondary infection . The wound should be irrigated twice

daily & healing should be allowed by secondary intention .Sometimes
secondary suturing may be required.

 2 - bladder complication :

 a - voiding difficulty &over - distension of the bladder :
 either due to pain or peri - urethral oedema especially in
those undergoing traumatic delivery &those with multiple
lacerations or tears &those with vulvo - vaginal haematoma
.Also voiding difficulties is common in those with regional
anesthesia (epidural/spinal) because the bladder may take
up to 8 hours to regain normal sensation . Therefor urinary
catheter may be left in the bladder for the first 12 - 24
hours .

 b - urinary incontinence :
 either stress I. which is rare or true I.due to vesico - vaginal
,urethra - vaginal, or uretero - vaginal fistula .I due to fistula
usually appear in the second week when slough separate .

 3 - bowel complication :

 a - constipation :may be due interruption in the
normal diet &dehydration during labor .Advice on
adequate fluid intake &increase fiber intake .It
may also due to pain &fear of evacuation of the
bowel .

 b - fecal incontinence :due to damage of anal
sphincter during delivery (occult damage ) .
Third &fourth degree vaginal tears are also
associated with anal incontinence .It may also
due to fistula (recto - vaginal fistula).

 4 - secondary post - partum haemorrhage :

 Is defined as fresh blood from the genital tract
between 24 hours & 6 weeks after delivery .The
most common time of secondary PPH is 7 - 14
days .Causes :
 1 - retained placental tissues treatment is
evacuation of the uterus after antibiotics cover .
 2 - infection : endometritis .
 3 - hormonal contraception.
 4 - bleeding disorders e.g. von willbrand's diseas .
 5 - choriocarcinoma.

 5 - obestetric palsy :

 Is a condition in which one or both lower limbs may develop sign
of a motor &/ sensory neuropathy following delivery .the patient
present with foot drop & parasthesia .the mechanism
 of injury is unknown &may be due to compression of the
lumbosacral trunk as it crosses the sacroiliac joint during
descent of the fetal head. Treatment is by bed rest , analgesia
&physiotherapy .

 6 - symphysis pubis diastasis :
 Separation if the symphysis pubis can occur spontaneously or
surgical separation of the pubis in labor ( symphysiotomy ) can be
performed in cases of cephalo - pelvic disproportion to increase
pelvic diameter .Sign & symptoms include symphyseal pain ,
waddling gait , pupic tenderness &a palpable interpubic gap .
Treatment includes bed rest , anti - inflammatory agents,
physiotherapy &a pelvic corset .

 7 - thromboembolism :

 There is a 5 folds increase in the risk of TE in
pregnancy & puerperium especially after C/S
.Management is by anticoagulant therapy .

 8 - puerpural pyrexia :
 Is defined as temperature of 38 c or higher on any two
of the first 10 days postpartum, exclusive of the first
24 hours.
 In about 80 % of women who develop a temperature in
the first 24 hours of vaginal delivery, no obvious
evidence of infection can be identified. The reverse
holds true for women delivering by C/S , when a
wound infection should be considered.

 Diagnosis &management of PP.:

 1 -chest infection &pneumonia: present with cough , purulent sputum
& dyspnoea . Diagnosed by seputum M ,C&S ,CHEST X -RAY .treatment by
physiotherapy &AB.

 2 -tonsillitis :throat swab, AB .

 3 -Pyelonephritis: urine M, C&S, treatment by AB.

 4 -Endometritis with or without retained placental tissues :diagnosed by
pelvic U/S, treatment with AB, &uterine evacuation .

 5 -Deep venous thrombosis /pulmonary embolism :Doppler/ venogram of
legs, lung perfusion scan angiogram, chest x - ray ,blood gases. Treatment
with heparin .

 6 -mastitis &breast abscess: milk M, C&S . treatment is with AB &incision
&drainage for breast abscess.
 7 -wound infection .
 8 -meningitis : lumber puncture ,treatment with AB .

 9 - chest complication:

 Chest complications are more likely to appear in
the first 24 hours after delivery , particularly after
general anesthesia .
 1 - atelactasis ;prevented with early ®ular
physiotherapy.
 2 - aspiration pneumonia ( mandleson's syndrome
).

 10 - genital tract infection :
 Genital tract infection following delivery is
referred to as puerperal sepsis .The incidence of
puerperal sepsis is 3 %.

 Aetiology of genital tract infection :

 Puerperal infection is usually polymicrobial &involves contaminants from the
bowel that colonize the perineum & lower genital tract. The most identified
organisms were facultative gram -positive cocci , particularly group B
streptococcus, frequently co -exist with Mycoplasma species .
 Factors that can facilitate infection:
 1-following delivery , natural barriers to infection are temporarily removed &
therefore pathogenic organisms can ascend from lower genital tract into the
uterine cavity .
 2-Placental separation exposes a large raw area equivalent to an open wound .
 3- retained products of conception & blood clots within the uterus can provide an
excellent culture media .
 4-lacerations of the genital tract , although may not need surgical repair , they
can become a focus for infection similar to iatrogenic wound such as C/S &
episiotomy .

 Haemolytic Streptococcus group A &staphylococcus aureus are two exogenous
organisms that can cause puerperal infection. The toxin produced by these
organisms can result in a rapid deterioration into septicaemic shock .

 Symptoms of puerperal pelvic infection :

 1 - malaise ,headache , fever, rigor .
 2 - abdominal discomfort , vomiting &diarrhea .
 3 - offfensive lochia .
 4 - secondary PPH.
 Signs of puerperal pelvic infection:
 1 - pyrexia &tachycardia.
 2 - uterus - boggy, tender& large.
 3 - infected wound - C/S, perineal .
 4 - peritonism, paralytic ileus .
 5 - indurated adnexia .
 6 - bogginess in pelvis.

 Investigation for puerperal genital infection:

 1 -full blood count : anaemia , leukocytosis , thrombocytopenia.
 2 -urea & electrolytes.
 3 -high vaginal swab &blood culture: infection screen .
 4 -pelvic U/S :retained product , pelvic abscess .
 5 -clotting screen (shock): DIC.
 6 -arterial blood gases: acidosis &hypoxia .

 The common methods of spread of puerperal infection:
 1 -ascending infection from the lower genital tract or spread via the
fallopian tubes to the ovaries , giving rise to a salpingo -oophritis &
pelvic peritonitis .
 2 -infection may spread by contiguity directly into the myometrium &the
parametruim .
 3 -infection may spread via lymphatics & blood vessels .
 In contrast to PID , tubal involvement in puerperal sepsis rarely cause
tubal occlusion & consequent infertility . Tubo -sepsis .

 Common risk factors for puerperal infection :




 1 - Antenatal intrauterine infection.
 2 - C/S.
 3 - cervical cerclage for cervical incompetence .
 4 - prolonged labor
 5 - prolonged rupture of membrane.
 6 - multiple vaginal examination .
 7 - instrumental delivery.
 8 - manual removal of placenta .
 9 - retained product of conception.
 10 - obesity, diabetes, HIV.

 Treatment:

 1 - mild to moderate infection can be treated with
a broad - spectrum antibiotics e.g. cephalosporin
& metronidazole .
 Depending on the severity of infection , the first
few doses should be given intravenously .
 2 - with sever infection , there is a release of
inflammatory & vasoactive mediators , this lead to
local vasodilatation &poor tissues perfusion
casing septic/ endotoxic shock ,&delay in
appropriate management could be fatal .

 Prevention of puerperal sepsis:

 1 - good surgical approach .
 2 - use of aseptic techniques.
 3 - use of prophylactic antibiotics during C/S
in the form of a single intraoperative dose of
antibiotics (cephalosporin plus metronidazole
or amoxiclav )should be given after clamping
of the umbilical cord to avoid unnecessary
exposure of the baby to the antibiotics.

 The breast :

 Breastfeeding:
 The advantage of breast feeding:
 1 - readily available at the right temperature &ideal
nutritional value .
 2 - cheaper than formula feed.
 3 - associated with a reduction in :
 - childhood infective illness, especially gastroenteritis.
 - fertility with amenorrhea .
 - atopic diseases e.g. eczema &asthma.
 - necrotizing enterocolitis in preterm babies .
 - juvenile diabetes .
 - childhood cancer, especially lymphoma .
 - premenopausal breast cancer.

 Breast disorders:

 1 - bloodstained nipple discharge.
 2 painful nipples .
 3 - calactocele.
 4 - breast engorgement :
 Usually begins in the second or third postpartum day & if
breastfeeding has not established effectively , the over -
distended &engorged breast becomes very painful &can
give rise to puerperal fever up to 39 c in 13 % of patients .
Although the fever rarely lasts more than 16 hours, other
infective causes need to be excluded .
 Treatment : allowing the baby easy access to the breast is
the most effective method of treatment &prevention .

 5 - mastitis :inflammation of the breast .

 The affected segment of the breast is painful
&red & oedematous . Flu like symptoms develop
associated with pyrexia &tachycardia. In infective
mastitis the fever developed later &persist
longer. The most common infective organism is
staphylococcus aureus . The most common
sources of infection are baby's nose or throat
.The milk should be sent for M& C&S &antibiotics
(flucloxacillin )can be commenced while awaiting
sensitivity result .
 If breast abscess developed , it require drainage .

 Contraception :

 1 - lactational amenorrhea :less than 2 %in the first 6
months after delivery .
 2 - IUCD: it is best to wait at least 4 weeks to allow for
involution .
 3 - COCP:increase the risk of thrombosis &affect
breastfeeding but in patients who don't desire lactation it
should be commenced 4 weeks postpartum.
 4 - progestgen - only pills (mini - pills): should be
commenced about day 21 following delivery .
 5 - injectable contraception ( depo - provera ):given 3 monthly
& preferably be given 5 - 6 weeks post - partum.
 6 - Sterilization :in patients who have completed their
families , it can be performed during C/S. However, it is
better delayed until after 6 weeks postpartum , when it can
be done by laparoscopy .

Thank you


رفعت المحاضرة من قبل: AyA Abdulkareem
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