Puerperium

THE PUERPERIUM

Dr Hiba Ahmed SuhailM.B. Ch. B./F.I.B.O.G.College of medicineUniversity of Mosul

NORMAL PUERPERIUM

Definition:
It is the 6-8 weeks following delivery during which the anatomical and physiological changes of pregnancy regress .

Physiological changes:

(A) General changes:
1- Temperature:
normal but
- A reactionary rise may occur after difficult labour. It does not exceed 38 C and drops within 24 hours.
- A slight rise may occur at the 3rd day due to engorgement of the breasts.

2- Pulse:

normal but may rise if there is hemorrhage or infection.
3- Pains:
Painful uterine contractions occur in early puerperium increasing with suckling due to oxytocin release , If intolerable use analgesics.
Pain may be due to neuro muscular injuries


4- Breasts:
- Colostrum is secreted in the first 3 days.
- With the establishment of milk secretion at the 3rd to 4thday, the breast become engorged,larger
Painful , tender while suckling relieves discomfort.
- Suckling stimulates prolactin secretion, which causes milk production and oxytocin release, which stimulates milk ejection

5- Urine :

Diuresis by the 2nd - 4th day, lasting for 3-4 days.
Retention of urine may occur due to:
a- Atony of the bladder.
b- Laxity of the abdomen.
c- Reflex inhibition if the perineum is sutured.
d- Compression of the urethra by vulval odema or haematoma

6- Bowel :

Tendency to constipation due to:
a- Atony of the intestine.
b- Laxity of abdomen and perineum.
c- Anorexia.
d- Loss of fluids.
e-painful perineum.
7- Loss of weight:
due to
a- Evacuation of the uterine contents.
b- More fluid loss in urine and sweat.


8- Blood
Increased coagulability of the blood continues during the first two weeks
Haemoglobin concentration : tends to fall in the first 2-3 days.
9- Menstruation:
is regained by the 6th - 8th weeks after delivery but in lactating women a variable period of amenorrhea may be present

(B) Local changes:

(I) The uterus is involuted as follow:
1-Structure:
i) Autolysis of the excess muscle fibers.
ii) The blood vessels are obliterated by thrombosis and become degenerated while its remnants are transformed into elastic tissues
iii) The decidua, except basal layer is separated

.
2. Weight:
After delivery the uterine weight is 1000 gm . By the end of 6 weeks it is 50 gm.
3-Size :
After delivery the length of the uterus is 20 cm and felt at the level of umbilicus. After one week it is
midway between umbilicus and symphysis pubis. After 2 weeks it is at the level of symphysis. By the end
of the 6th week it is 7.5 cm long..
4. Uterine ligaments:
are involuted and subinvolution predisposes to prolapse and retroversion


(II) Lochia:
- It is the genital tract discharge in the first 15 days of peurperium.
- It is alkaline and composed of blood, decidual fragments, cervical mucus, vaginal transudation and bacteria.
a. Lochia rubra (red): consists mainly of blood and decidua. It lasts for 5 days.
b. Lochia serosa (pale): due to relative decrease in RBCs and predominance of leukocytes. It lasts for 5 days.
c.Lochia alba (white): consists mainly of leukocytes and mucus. It lasts for 5 days.
- Persistence of red lochia means subinvolution.
- Offensive lochia means infection.
- In severe infection with septicemia, lochia are profuse and offensive

(III) Cervix:

is closed by the end of the first week.
(IV) Vagina :
Vaginal rugae appear in the 3rd week.
(V) Perineum:
regains its tone by the end of puerperium while persistence of its laxity predisposes to prolapse

Management of The Puerperium:

(1) Rest and exercises:
- Rest in bed for 2 days is advised after uncomplicated vaginal delivery and for a longer few days in complicated or operative delivery.
- Semi sitting position encourage drainage of lochia.


- Movement in and outside the bed and breathing exercises are advised during this period to minimize the risk of deep venous thrombosis (DVT).
- Pelvic floor exercise is started in the 3rd day if there is no perineal wound by alternating contraction and relaxation of the pelvic floor muscles.
- Abdominal exercises are done later on.
These exercises have the following advantages:
i) Diminish respiratory and vascular complications.
ii) Minimize future prolapse and stress incontinence.

(2) Local antisepsis:

- The perineum is washed with antiseptic lotion after each micturition and bowel motion and a sterile pad is applied.
- If there is perineal stitches add local antibiotic.
(3) Diet:
Rich in proteins, vitamins, minerals and fluids.
(4) Care of the bowel:
Constipation is prevented by plenty of green vegetables and fruits, sufficient fluids and local glycerine
suppositories if needed.
(5) Care of the bladder:
Patient is encourage to micturate frequently. If there is retention a catheter is applied under aseptic conditions.

Contraception for Breast-Feeding

Ovulation may resume as early as 3 weeks after delivery,
in lactating women ,its timing depends on individual biological variation as well as the intensity of breast feeding.
Progestin-only contraceptives mini-pills, depot medroxyprogesterone, or progestin implants do not affect the quality or quantity of milk.
Estrogen-progestin contraceptives likely reduce the quantity ofbreast milk
IUCD after puerperium


Immunizations
The D-negative woman who is not isoimmunized and whose infant is D-positive is given immune globulin shortly after delivery
Women who are not already immune to rubella or measles are excellent candidates for combined measles-mumps-rubella vaccination before discharge

On Discharge

Following uncomplicated vaginal delivery, a woman should receive instructions concerning anticipated normal physiological changes of the puerperium, lactation and encourage to return to most activities, including bathing, and household Function

POST -NATAL EXAMINATION

Time:
At the end of the 6th week postpartum, but earlier in complicated pregnancy or delivery.
Aims:
1. Detection or follow up of complications of pregnancy or labour.
2. To be sure of involution of the genital tract.
3. Choice of the method of contraception

A- History:

Ask about:
* Vaginal bleeding or discharge.
*Breast disorders.
*Urinary or gastrointestinal symptoms.
B- General examination:
- Pulse
-Temperature
-Blood pressure
-Breasts


C- Abdominal examination:
- To ensure involution of the uterus ( not felt abdominally).
- For detection of abdominal wall tone.
D- Local examination:
1- Perineum:
for healing of the wound if present, bleeding or discharge,stress incontinence and tone of the pelvic floor.
2. Vagina :
for prolapse or vaginitis.
3. Cervix :
for ectopy, lacerations or cervicits.
4. Uterus:
for size, position, tenderness , consistency and mobility.
5. Adnexae:
for salpingitis, parametritis or adnexael swellings

Subinvolution of the uterus: The uterus did not regress to its pre-pregnancy size by the end of
the puerperium.
This may be due to :
a- Retained placental fragments.
b- Infection.
c- Retroversion causing congestion
d- Myomas.
e- Antepartum overdistension e.g. multiple pregnancy.
f- Non-lactating women.
g-Broad ligament hematoma .


PUERPERAL PYREXIA
Definition:
It is a rise of temperature reaching 38C or more and lasting for 24 hours or more during the puerperium

Causes:

1. Puerperal infection (sepsis).
2. Urinary tract infection.
3. Breast infection.
4. Respiratory infection.
5. Intercurrent febrile illness.
6. Thromboembolism.
7.Thrombophlibitis .

PUERPERAL SEPSIS

Definition:
It is a genital tract infection resulted from bacterial invasion during or after labour

Causative Organisms:

Puerperal infection is usually polymicrobial. The organism that usually contribute to this condition include group A and B beta-haemolytic streptococci, aerobic gram negative rods, Neisseria gonorrhoeae, and certain anaerobic bacteria.

Mode of Infection

(I) Endogenous origin:
It may be present in the genital tract as anaerobic streptococci which are normal non-pathogenic commensals that become pathogenic in presence of devitalized tissues.
It may be outside the genital tract as in the gastrointestinal tract, perineum or in a distant part as tonsils where it is transmitted by blood stream.
(II) Exogenous origin:
from infected attendants, dust, instruments,catheter..


Predisposing Factors:
1. Bad general condition: as anemia, diabetes and debilitating diseases.
2. Large number of bacteria: introduced into the genital tract due to improper asepsis .
3. Intrapartum factors:
-Premature rupture of membranes.
- Prolonged labour
- Instrumental delivery
-Lacerations
- Marked blood loss
- Retained fragments

Clinical features of puerperal sepsis

Symptoms:
• -Malaise, headache, fever, rigors
• -Abdominal discomfort,vomiting and diarrhoea
• -Offensive lochia
• -Secondary postpartum haemorrhage

Signs:

Pyrexia and tachycardia
Uterus soft , tender and larger
Infected wounds-caesarean/perineal
Peritonism
Paralytic ileus
Indurated adnexia (parametritis)
Mass in pelvis (abscess)


Diagnosis of the Cause of Puerperal Pyrexia:
(A) History :
1. Pre-existing infection before labour as chest or urinary tract infection.
2. Symptoms of infection else where as cough, dysuria, breast pain or sore throat.
3. Complicated labour as PROM, instrumental or prolonged delivery.
4. The onset of manifestations in relation to labour

(B) General examination:

1. Temperature, pulse ,blood pressure, level of consciousness.
2. Skin eruption or jaundice
3. Tonsils.
4. Breasts, chest and heart.
5. Lower limbs for signs of thrombophlebitis

(C) Abdominal examination:

1- Loin tenderness
2- Abdominal rigidity and tenderness.
3- Uterine size, tenderness and abdominal masses related to the uterus

(D) Local examination:

1. The perineum for infected episiotomy or lacerations.
2. Lochia for amount, colour and odour.
3. Bimanual examination for :
#Uterine size, consistency, tenderness, position and mobility.
#Cervix: closed or opened, contents felt through it or lacerations.
#Adnexae : mass.
# Douglas pouch: mass & or fluid .
4. Speculum examination : to visualize the cervix and vagina.


(E) Investigations:
1. Swab and culture: from the cervix and upper vagina for aerobic and anaerobic cultures.
2. Blood culture: taken at peak of temperature in case of septicemia.
3. Blood picture: hemoglobin and leukocytes.
4. Urine analysis and culture: midstream or catheter specimen
5.Ultrasound for pelvic pathology .

Prevention of Puerperal Sepsis

(A) Antenatal:
1. Proper diet , vitamins and minerals.
2. Anemia and diabetes should be treated.
3. Local or distant infection should be treated

(B) Intranatal:

1. Strict aseptic and antiseptic measures for the patient, attendants and instruments.
2. Minimize vaginal examinations.
3. Avoid bleeding and excessive blood loss should be replaced.
4. Lacerations should be properly sutured immediately.
5. Prophylactic antibiotics in PROM and prolonged or instrumental delivery

(C) Postnatal:

1. Maintenance of aseptic precautions.
2. Care of the perineal or abdominal wounds.
3. Minimize visitors and keep whom are infected away.
4. Early isolation of cases of puerperal sepsis.


Treatment of Puerperal Sepsis:
(A) General treatment:
1. Isolation in a separate room.
2. Diet: light diet rich in vitamins and minerals with plenty of fluids.
3. Supportive treatment: restoration of fluid and electrolyte balance, correction of anemia and tonics.
4. Symptomatic treatment:
- Analgesics.
- antipyretics and cold fomentations.
5. Observations : pulse, temperature, blood pressure, vaginal bleeding, lochia , manifestations of DVT.

(B) Antibiotic therapy:

1. Broad spectrum antibiotic (ampicillin or cephalosporin) + gentamycin + metronidazole or
2. Clindamycin + gentamycin.
One of these regimen is started till the result of culture and sensitivity.
Antitoxin serum is given in Cl. welchii infection

(C) Promotion of drainage:

1. Semi sitting position.
2. Removal of stitches if there is purulent discharge from a wound.
3. Ergot preparations: help drainage of lochia.
4. Incision and drainage of the abscess:
- In pelvic abscess& in parametric abscess incision + drain
5. Manual removal of retained parts: if felt during P/V examination


Breast Disorders in Puerperium
Physiology of Lactation:
The sudden fall in estrogen level after delivery is associated with reduction in the secretion of prolactin inhibiting factor from hypothalamus and release of prolactin from the anterior pituitary.
Prolactin is responsible for milk formation.
Oxytocin released from the posterior pituitary due to suckling is responsible for milk ejection

(I) Breast Engorgement:

Usually occurs in the 3rd day after delivery when secretion of milk begins.
Clinical picture:
- Breasts are over distended with visible dilated veins.
- Breasts are painful and tender.
- Pyrexia may develop.

Treatment:

1-Breast evacuation: in early stage baby suckling can be sufficient, but later on congestion press on the ducts preventing flow of milk so an electric breast pump is needed
2-One-two doses of bromocriptine (2.5 mg)
may occasionally needed and there is no risk of suppressing lactation.
. 3. Analgesics -antipyretics.
4- Antibiotics if infection develop

(II) Deficient Lactation:

Causes:
1- Constitutional.
2- Bad general condition and malnutrition.
3- Infrequent or irregular suckling.
4- Sheehan’s syndrome.
Treatment:
1. Regular breast feeding.
2. Good diet and plenty of fluids


(III) Cracked Nipples
Causes:
1. Lack of cleanness and dryness of the nipples.
2.Vigorous suckling of a hungry baby in deficient lactating breasts.
3.Repeated taking and leaving the nipple by the baby to breathe if its nose is obstructed by the breast.
4. Monilial infection.

Treatment:

1-Rest: the baby should not put on the affected breast till healing occurs while it is emptied manually. Gradual going back to the breast is recommended to prevent recurrence.
2.Use of bromocriptine .
3. Panthenol ointment or flavine in liquid paraffin: applied locally

(IV) Acute Mastitis

Causative organism:
Staphylococcus aureus which may reach the breast from infected baby.
Clinical picture:
1. Breast is painful, tender, red , tense and hot.
2. Axillary lymph nodes are enlarged.
3. High fever may reach 40.5 C

Treatment:

Proper treatment is indicated otherwise breast abscess will develop.
1-Stop lactation : from the affected breast and breast is emptied manually or by an electric pump. When the acute phase is over , breast feeding can be resumed.
2. Support the breast: over a pad of cotton wall.
3-Antibiotic therapy: A sample of milk is sent for culture and sensitivity then antibiotic started Flucloxacillin 500 mg/6 hours is suitable.
4. Analgesics & antipyretics


(V) Breast Abscess
Clinical picture:
A segment of the breast becomes painful tender and fluctuation can be detected.
Fever and enlarged axillary lymph nodes & the skin over it is edematous.
Treatment:
As soon as an abscess is formed it should be incised and drained under general anesthesia.
Do not wait for fluctuation as by that time breast disorganization would occur.

(VI) Galactocele:

#It is a retention cyst of a large mammary duct due to its obstruction.
#If it is persistent it is excised or aspirated.

secondary postpartum hemorrhage

secondary postpartum hemorrhage as bleeding from the genital tract from 24 hours to 6 -8weeks after delivery
Causes
Endometritis
Abnormal involution of the placental site.
Retention of a placental fragment
Bleeding disorder (von Willebrand
Diagnosis
Blood tests ,HVS ,US.
Management
retained placental fragments, we do perform curettage.
then oxytocin, ergot , or a prostaglandin analog is given. Antimicrobials are added if uterine infection is suspected t


Contraindication to breast feeding
• Nursing is contraindicated in women who
• have an infant with galactosemia
• Have human immunodeficiency virus (HIV) infection
• Have active ,untreated tuberculosis
• Take certain medications
• Undergoing treatment for breast cancer Breast
• *Other viral infections do not contraindicate breast feeding

Depression

It is fairly common for a mother to exhibit some degree of depressed mood a few days after delivery. Termed postpartum blues, it predisposed by :
*Emotional letdown that follows the excitement and fears experienced during pregnancy and delivery
*Discomforts of the early puerperium
*Fatigue from sleep deprivation
*Anxiety over the ability to provide appropriate infant care
In most women, effective treatment includes anticipation,
recognition, and reassurance. This disorder is usually mild and
self-limited to 2 to 3 days, although it sometimes lasts for up to
10 days.
If these moods persist or worsen, evaluation is done for symptoms of major depression.


Neuromuscular and JointProblems

Pain in the pelvic girdle, hips, or lower extremities may be due to stretching or tearing injuries sustained at normal or difficult delivery.
#Neuropathies Footdrop, which can be secondary to injury at the level of the lumbosacral root (sciatic (nerve injury
#Muscle Injuries (back &thigh)
#Pelvic Bone and Joint Problems( separation of the symphysis pubis

Separation of the symphysis pubis

symptomatic separations are uncommon. When they are
symptomatic, the onset of pain is often acute during delivery, but symptoms may manifest either antepartum or up to 48 hours postpartum
Treatment is generally conservative, with rest in a lateral position and an appropriately fitted pelvic binder.
Surgery is occasionally necessary in some symphyseal
separation
Recurrence is more than 50 percent in subsequent pregnancy,
cesarean delivery some time indicated .