PUERPERIUM & ITS DISORDERS
DEFINITION:
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PUERPERIUM: THE TIME FROM DELIVERY OF THE PLACENTA TILL 6 WEEKS
AFTER DELIVERY, When the body returns to the non pregnant state
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Puerperium is a time of psychological adjustment for the mother as enjoyment of
the new boy with anxiety for the responsibility of caring of the new baby while she
is tierd after labour.
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It’s important to keep in mind that maternal death may still occurs in the
puerperium.
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Immediately after delivery the uterus can be palpated at or near the umbilicus
approximetely 1000 gm in weight,most of reduction in size occurs in the first 2
weeks, 2 weeks postpartum the uterus should be located in the true pelvis and
approximetely 50-100 gm in weight.
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The placental site undergoes a series of changes in the postpartum period
immediately after delivery large amount of blood leaks from the uterus until
contraction of the myometrium (physiological ligatures) result in haemostasis,
immediately after delivery the placental bed decrease to a half.
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VAGINAL DISCHARGE:
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Vaginal discharge (lochia) last about 5 weeks post partum, 15% have lochia 6
week postpartum.
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Lochia rubra: red, duration is variable ,
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Lochia serosa: brownish red, more watery consistency continues to decrease in
amount.
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Lochia alba: yellow.
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After delivery decidual necrosis begins by the first day and by the 7 th day a well
demarcated zone exist between necrotic and viable tissue .the presence of
mononuclear cells and lymphocytes persist for about 10 days and it’s presumed
that this acts as some form of antibacterial action sloughing over the placental site
occurs 7-14 days postpartum this correspond to the dramatic bleeding however it’s
self limiting and subsides within 1-2 hours. A new endometrium will grow from the
basal layer of the decidua but this is influenced by the method of infant feeding,if
lactation is suppresed this will last 3-4 weeks if lactation persist this may be
suppresed for many months.
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Uterine sub-involution: this term describes an arrest or retardation of involution. It is
accompanied by prolongation of lochial discharge and irregular or excessive
uterine bleeding.
Cervix ,vagina & perineum: The tissues return to a non pregnant state but never to the
nulliparous state.
Abdominal wall:
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Remains soft and poorly toned for many weeks.
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Return to non pregnant state depends greatly on exercise.
Ovulation & Breast feeding:
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longer period of amenorrhoea and anovulation.
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Persistent high level of prolactin.
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Highly variable.
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Mean time for ovulation is 6 months.
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70 % resume their periods within 12 weeks.
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Risk of ovulation within the first 6 months post partum is 1-5% in exclusively breast
feeding mothers.
Non breast feeding:
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Ovulation may occur as early as 27 days after delivery.
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First time of menstruation is 7-9 weeks.
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Prolactin level fall to normal range by 3rd week postpartum.
Breasts:
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Changes to the breast that prepare for breast feeding, occurs through out
pregnancy.
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Lactation can occur by 16 weeks gestation.
Colostrum:
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1st 2-4 days after delivery.
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High in protein am immune factors.
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Milk mature over the first week.
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Contains all the nutrients necessary.
Breast feeding is neither easy nor automatic:
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Should be initiated ASAP (as soon as possible) after delivery.
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Feed the baby every 2-3 hours to stimulate milk production.
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Production should be established by 36-96 hours.
Other body changes:
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Fibrinolytic activity is increased in the first 1-4 days and return to normal by 1 week.
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Platelet count increased sharply after delivery making it a time for
thromboembolism.
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After delivery there might be trauma to the bladder and urethra .hydroureter and
dilatation of renal pelvis are resolved by 6-8 weeks post partum.
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Immediate wt loss of 4.5-6 kg (placenta ,amniotic fluid ,and blood loss that occurs
after delivery.
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Thyroid function returns to normal by 4 weeks postpartum.
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Hair growth slow in the puerperium and more hair lost than regrown.
Considerations:
Vaginal birth:
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Swelling and pain in the perineum. (episiotomy and laceration).
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Haemorrhoids.
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Often resolve as the perineum recovers.
Caesarean delivery:
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Pain from the abdominal incision.
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Slower to begin ambulating, eating, and voiding.
Sexual intercourse:
May resume when:
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Red bleeding ceases.
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Vagina and vulval are healed.
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Physically comfortable.
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Emotionally ready.
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Physical readiness usually takes 3 weeks.
Postpartum Hemorrhage:
Introduction:
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Excessive blood loss during or after the 3rd stage of labor.
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Average blood loss is 500 mL.
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Early postpartum hemorrhage which occur within 1st 24hr after delivery.
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Late postpartum hemorrhage occurs1-2 weeks after delivery (most common) &
may occur up to 6 weeks postpartum.
Incidence & Mortality:
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3.9% in vaginal birth
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6.4% in Caesarean birth
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Delayed postpartum hemorrhage: 1-2%
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5% of maternal deaths
PPH may result from:
1. Uterine atony
2. Lower genital tract laceration most common
3. Retained products of conception
4. Uterine rupture
5. Uterine inversion
6. Placenta accreta (adherence of the chorionic villi to the myometrium)
7. Coagulopathy
8. Hematoma
Uterine Atony:
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Lack of closure of the spiral arteries and venous sinuses
Risk factors:
1. Overdistension of the uterus secondary to multiple gestations
2. Polyhydramnios
3. Macrosomia
4. Rapid or prolonged labor
5. Grand multiparity
6. Oxytocin administration
7. Intra-amniotic infection
8. Lower genital tract lacerations
9. Result of obstetrical trauma
More common with operative vaginal deliveries as in:
1. Forceps
2. Vacuum extraction
Other predisposing factors:
1. Macrosomia
2. Precipitous delivery
3. Episiotomy
INFECTIONS:
We will discuss:
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Endometritis
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Urinary Tract Infection
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Mastitis
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Wound Infection
I. ENDOMETRITIS:
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Ascending polymicrobial infection. Usually normal vaginal flora or enteric
bacteria.
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Primary cause of postpartum infection:
1. 1-3% vaginal births.
2. 5-15% scheduled C-sections.
3. 30-35% C-section after extended period of labor.
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May receive prophylactic antibiotics.
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<2% develop life-threatening complications.
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Risk factors:
1. C-section.
2. Young age.
3. Low SES.
4. Prolonged labor.
5. Prolonged rupture of membranes.
6. Multiple vaginal exams.
7. Placement of intrauterine catheter.
8. Preexisting infection.
9. Twin delivery.
10. Manual removal of the placenta.
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Clinical presentation:
1. Fever.
2. Chills.
3. Lower abdominal pain.
4. Malodorous lochia.
5. Increased vaginal bleeding.
6. Anorexia.
7. Malaise.
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Exam findings:
1. Fever.
2. Tachycardia.
3. Fundal tenderness.
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Treatment:
1. Antibiotics.
II. Urinary Tract Infection (UTI):
A. Bacterial inflammation of the bladder or urethra.
B. Develop in 3-34% of patients and it is symptomatic infection in ~2%.
C. Risk factors:
1. C-section.
2. Forceps delivery.
3. Vacuum delivery.
4. Tocolysis.
5. Induction of labor.
6. Maternal renal disease.
7. Preeclampsia.
8. Eclampsia.
9. Epidural anesthesia.
10. Bladder catheterization.
11. Length of hospital stay.
12. Previous UTI during pregnancy.
D. Clinical Presentation:
1. Urinary frequency / urgency.
2. Dysuria.
3. Hematuria.
4. Suprapubic or lower abdominal pain OR…No symptoms at all.
E. Exam Findings:
1. Stable vitals.
2. Febrile.
3. Suprapubic tenderness.
F. Treatment:
1. Antibiotics.
III. MASTITIS:
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Inflammation of the mammary gland.
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Milk stasis & cracked nipples contribute to the influx of skin flora.
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2.5-3% in the USA.
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Neglected, resistant or recurrent infections can lead to the development of an
abscess (5-11%).
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Clinical Presentation:
1. Fever.
2. Chills.
3. Mastalgias.
4. Warmth, swelling and breast tenderness.
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Exam Findings:
1. Area of the breast that is warm, red, and tender.
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Treatment:
1. Moist heat.
2. Massage.
3. Fluids.
4. Rest.
5. Proper positioning of the infant during nursing.
6. Nursing or manual expression of milk.
7. Analgesics.
8. Antibiotics.
IV. WOUND INFECTION:
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Perineum (episiotomy or laceration).
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3-4 days postpartum.
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Rare.
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Abdominal incision (C-section).
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Postoperative day 4.
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3-15%.
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Prophylactic antibiotics 2%.
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Risk Factors:
1. For Perineum (episiotomy or laceration):
(1) Infected lochia.
(2) Fecal contamination.
(3) Poor hygiene.
2. For Abdominal incision:
(1) Diabetes.
(2) Hypertension.
(3) Obesity.
(4) Corticosteroid treatment.
(5) Immunosuppression.
(6) Anemia.
(7) Prolonged labor.
(8) Prolonged rupture of membranes.
(9) Prolonged operating time.
(10)Abdominal twin delivery.
(11)Excessive blood loss.
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Clinical Presentation:
1. In Perineal wound Infection:
a) Pain.
b) Malodorous discharge.
c) Vulvar edema.
2. In Abdominal wound Infection:
a) Persistent fever (despite antibiotics)
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Diagnosis:
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Erythema.
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Induration.
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Warmth.
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Tenderness.
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Purulent drainage.
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With or without fever.