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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
no t in number, and it is accelerat ed by oxytocin,
Causes of delayed involution: -
- Full bladder
- Loaded rectum
- U terin e infection
- Re tained products of conception.
- Fibroids
- Broods ligament hema toma .

2- Gen ital tract changes: -

The lower seg m ent of the c ervix and uter us appe ars flappy
and sometimes have small lacerations. In the first few day s the
cervix can admit (2) fingers, by the end of first week p assing
only one finger, by the end of 2nd week the cer vix should be
closed.

3- Lochi a:-

It is blood st ained d uteri ne discharge compromised of
blood and necrotic decid ua.
It is red in the first few days, concerting to pink then after
th at becoming serous by the end of the 2nd week.
Persistently red lo chia indicat ing delayed involution either
due to infect ion or retained tissue. Offensive lochia indicating
infection if associa ted with tender u terus and by py rexia,
RX By antibiotics and eva cuation of re tai ned products.

4-Bladder function: -

Voiding difficulty and ov er distension are not un common
after child birth specially if associated with regional aesthesia.
Risk Factors: -
1- Regional a naesthesia :-
Bladder may take up to 8hr.s to again normal sensation. so
induelling cathe ter should be maintained for at least 12hr.s in
pt.s with regional a nasth esia to prevent bladder dis tension and
de trusor 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 tra uma tic delive ry su ch as instrumental
deli very, multiple vulvo va ginal lacerations vulv o-
vaginal haemato ma, prolapsed ha amorriod, anal
fissures, abdominal wound ha emotomas or even fecal
imp action may in terfere with voiding.

Every women who has not passed u rin e within 4 h ours

of delivery should be encour ag ed to urinate before
catheterization . women with difficulties in u rination
should have urin e sample sent for microscopy culture
and sensitivity and if the residual u rin e a
cathe ter should be left in to allo w free drainage for 48
hr.s.
5- Bowel function :-
Constipation is common pro ble m during puerperium . So
advice about adequa te fluid in take and fibre in take is necessary .
prolapsed hachorroid , anal fissure sutured perineum, women
with third or fourth degree t ear should a void constipation and
straining. So should be prescribed lactulose or m ethyl cellulose
for (2) weeks i mmediately 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 tempe r, difficulty sleeping, depressed mood and
tearfulness are common but usually mild, and resolve
spontaneously in the majority of cases.

P uerperal disorders: -

Daily m at er nal observation include temperature, pulse,
blood pressure, u rinar y and bowel functi ons, breast examination
and feeding, assessment of u terine involution, lochia, per in eal
inspection, examination of legs and pel vic floor exercises ,
hem og lobin checking of day (3) and a level of 8gm or less is an
indication for transfusion.
1- Per ineal complic ations:
About 80% of women complain of p ain in the first (3) days
after delivery. Which is more in patients with peri neal tears or
episio tom y local cooling, topical a neasthesia diclo fe nac
,paracetol are usually helpful.
Spon tan eous opening of repaired pe rineal 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 PP H :-
Defined as fresh bl eeding from the gen ital tract between
24hr.s and 12 weeks after delivery. Most common cause is
re ta ined placental tissue. Other causes are end ometeri tis ,
hormo nal contraception ,bleeding disorders VWD and rarely
ch oriocarcinoma .

Mgx include intrave nous infusion, cross m atched blood ,

syntocinon ,examination under a neasthesia, antibiotics if
placental tissue is found, and evacuation of the u terus.
4- Obstet ric p alsy: -
A condition in which one or both lower limbs may develop
signs of a m oto r or sensory neuropathy following delivery.
Pero neal n. palsy can occur when the nerv e is compressed
between the head of the fibula and the lithoto m y pole
unilat eral f oot 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 spon tan eously or by
delibra te surgical seperati on (symphysio tom y).
Risk factors are forcepes deliv ery , rapid second sta ge of labour
se vere abduction of the thighs during deli very.
RX bed rest, an tinflam ato ry agents, physio therapy and a pel vic
corset to provide support and stability.
6- Thromboembolism: -
The risk increase to 5 flods in pregnancy and p uerperium .
Majority of deaths are after C \S.

7-Puerperal Pyre xia :-

A temperature of 38C or higher on any two of the first 10
d.s post -pertum, exclusive of throat, breasts, u rinary tract, pelvic
organs, ces arean or pe rineal wounds and legs.
-Ch est complications , atelac ta sis, and aspiration
pneumonia.
-Genital tract infection :-
It is referred to as puerperal sepsis , it is oetiology: -
Following delivery natural b arriers to infection are
temp orarily removed and therefore arg anisms with pathogenic
potential can asce nd from the lo w er genital tract into the uterine
cavity. Placen tal separation exposes a large raw area equiv ale nt
to an open wound and retained products and clots can provide
an excellent culture medi a for infection, in addition if there is
any lacer at ions in the genital tract.
Factors which determine the clinical coarse are virulence
of offending orga nism s, presence of hae mat oma or re tain ed
products ,timing of antibiotic therapy and associa ted risk factors.
Risk factors are: -
- Antenatal I.U. infection.
- Cer vic al circla ge.
- Prolonged R OM .
- Prolonged labour.multiple va ginal examinations.
- Instru m ental delivery.
- Manual removal of placen ta.
- Retai ned products of conception.
- Others like obesity, DM. HI V .
Methods of spread of infection are: -

1- Asce ndi ng infection, from lo w er genital tract, or infection

of placental si te via fallo pian tubes to the ovaries,
salpi ngo -opteritis pe ritonitis pel vic a bcess.
2- By contiguity directly into the m yomet rium and
pera metri um meteri tis and p aram et ritis
pelvic cellulitis pe ritonitis and pel vic a bcess.
3- By lymphafics and blood vessels: -
By u terin e vessels into the IVC or via ovari an vessels
septic thrombo phlebitis, or septica emia.

Sym ptoms of puer per al p elv ic infection: -

Malaise, headache, fever, rigor abdomi nal discomfort,
vomiting di arrhea, offensive lochia and 2 PP h. pelvic
thrombophlebitis chere cte rised by spiking fever for 7 -10
days despise antibiotic therapy .

Signs :-

Pyrexia and tachycardia, boggy tender large u terus,
infected wounds, pe ritonism, paralytic ileus, indurated
ad nex ae.
Investigation :-
Full blood c ou nt, urea and electro ly tes, high va gin al swab,
pel vic U \S, clotting screen 7 and ar teri al blood gas, blood
cul ture.

T reatment: -

It is with bro ad spectrum antibiotics e.g. co - amaxiclav or
cephalosporine, plus m etro nida zole , the anibiotics should
be con tinued for at least 48 hr.s after the p t. becoming

afeb rile, Major pathogen resistant to this RX is

Bac teroi des f ragi lis, which is sensitive to cl inda m ycin with
either aminoglycosides or penicillin. If pel vic
thrombophlebitis is suspec ted or clinically dia gno sed
hep arin should be instituted and may continue for weeks or
months according to which pel vic vein is involved.

Necrotising fasciitis:

It is a rare but fat al infection of skin muscle and
fa scia, can o riginate in pe rin eal areas, episiotomies and
C \S wound. Comm onest org anism is unaerobes , Clost ridia
perfnrgens.
It needs wide debridement of necrotic tissues under
GA. Skin graft may be needed. I n addition to mgx of
septic shock if developed.

Prevent ion of puerperal Sepsis: -

1- General h yegine and a septic sur gical approach.
2- Prophylactic antibiotics during emergency C \S
with a single intr a-operative antibiotic dose before
clamping of cord.
3- Prophyla xes of elective C \S is recommended in
units with background of infectio us morbidity.
Diagnosis and management of puerperal pyrexia عﻼطﻼﻟ
Sym ptoms Diagnosis Special
investigation
management
Cough Chest
infection
Sputum M.C and S Physiotherapy
Purulent sputum Pneumonia Chest x.ray Antibiotics

Breasts Disorders: -

-Blood st ained nipple discharge: -
It is bila teral due of epi. Proliferation. Usually occur in the 2 nd or
3rd trimester, It is self -limited, needing just reassurance.
-Painful nipples :-
Sore throat Tonsillitis Throat swab Antibiotics
Cervical
lymphadenopathy

Headaches M eningitis Lumbar puncture Antibiotics

Neck stiffness (epidural/spinal anesthetic)
Dysuria Pyelonephritis Urine M.c and s Antibiotics
Loin pain and tenderness
Secondary PPH Metritis Pel vic ultrasound Antibiotics
Tender bul ky
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 fissu ring or denuded covered epithe lium,

either d. t poor positioning or candidiasis.
RX with nipple rest, manual milk experession and then rein t-
roduce feeding gradually .
Galacto ce le :-
It is cretention cyst of the memmary duct. Usually resolves
spondeheausely, if not aspertion.
Breast e ng orgerment: -
Usually begins by the 2 nd or 3 rd postp artum day and may give
rise to puerper al fever of up to 39C .
RX by allowi ng the baby easy access to the breast with manual
expression, firm support, ice bag and breast pump.
Mastitis :-
It is either d. t in fect ion or duct obstruction. The affected
segment of the breast appear red. Painful and ede m atous . F lu e
like symptoms develop associated with a tact hy cardia and
pyrexia. It is usually present in the third or fourth post -partum
week and is usually unilat. The most common ar ganism is S.
aureus other like coagula se negative staph and strepto cocc us
veri dens.
Mgx include isolation of the mother and baby c easing 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.


رفعت المحاضرة من قبل: Hatem Saleh
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