Normal and Abnormal Puerperium

Assoc. Prof. Gazi YILDIRIM

Normal Puerperium

• Definition1. The time from the delivery of the placenta through

the first few weeks after the delivery. 2. 6 weeks in duration. 3. By 6 weeks after delivery, most of the changes of

pregnancy, labor, and delivery have resolved and the body has reverted to the nonpregnant state.

Normal Puerperium

• The relevant anatomy and physiology in the puerperium

1. Reproductive organs1) Uterus 1000g → 50-100g The endometrial lining rapidly regenerates (16

days) The placental site undergoes a series of changes in

the postpartum period

Normal Puerperium

2) Cervix it never returns to the nulliparous state. the external os is closed to the extent that a finger

could not be easily introduced.3) Vagina shrinks to a nonpregnant state resolution of the increased vascularity and edema

occurs by 3 weeks the vaginal epithelium appears atrophic on smear.

This is restored by weeks 6-10.

Normal Puerperium

4) Perineum swelling and engorgement are completely gone

within 1-2 weeks the muscle tone may or may not return to normal,

depending on the extent of injury.5) Ovaries ovulate as early as 27 days after delivery (not

breastfeed ); 12 weeks (most); 7-9 weeks (mean). the suppression of ovulation due to the elevation

in prolactin

Normal Puerperium

6) Breasts Lactation can occur by 16 weeks' gestation. Lactogenesis is initially triggered by the delivery of

the placenta (E↓P↓and prolactin). the prolactin levels decrease and return to normal

within 2-3 weeks (not breastfeeding) The colostrum (the first 2-4 days) The milk continues to change throughout the

period of breastfeeding to meet the changing demands of the baby.

Normal Puerperium

2. Systemic change1) Cardiovascular system Blood volume returns to nonpregnant levels by the

tenth days of puerperium Cardiac output ↑(immediately after delivery) →

slowly declines→ reach late pregnancy levels 2 days postpartum→ normal 2-6 weeks.

2) Hematologic changes Hemoglobin concentration↑on the first postpartum

days Several clotting factors (fibrinogen) ↑on the first days

Management of normal puerperium

The majority of mothers are perfectly well during the puerperium and should be encouraged to establish normal activities.

Immediately following the delivery of the placenta observation of :

Management of normal puerperium

1. Vital signs (P,BP,Temp,R.R)

+ contraction of the uterus (uterin involution) + Lochia (amount; colure ,and odder)

=Every 5 min. for ½ hours , then every ½ hourly for 2 hours, then transfer the mother to the postnatal ward and observation every 2 hours for 6 hourly; then 6 hourly till discharge.

Management of normal puerperium

2 ) - Breast examination+lawer limb examination for the detection of signs of DVT every day.

3 ) - The mother should be encouraged to pass urine.

Management of normal puerperium

4 ) - Early mobilization.

5 ) - Management of episiotomy ;and perennial tears.

6 ) -In normal delivery the mother can go home 48 hours after delivery ;and 10 days in C.S.

7 ) - Diet regime.

8 ) - postnatal visit.

9 ) - Advising for contraception and spacing of pregnancy.

breast feeding

Puerperal Infection

• Puerperal Infectionany bacterial infection of the genital tract after

delivery. Incidence: 6%. The most important cause of maternal death.

• Puerperal Morbidity temperature 38.0 or highter, the temperature to ℃

occur on any 2 of the first 10days postpartum, exclusive of the first 24 hours, and to be taken by mouth by a standard technique at least four times daily.

Puerperal Infection

• Risk factors1. PROM2. Anemia3. Hemorrhage4. EP and CS5. Placenta retain

Puerperal Infection

• Common pathogens1. Aerobes Group A, B, and D streptococci Gram-negative bacteria: Escherichia coli,

Klebsiella Staphylococcus aureus

Puerperal Infection

2. Anaerobes Petococcus species Petostreptococcus species Bacteroides fragilis group Clostridium species3. Other Chlamydia trachomatis Mycoplasma species

Puerperal Infection

• Manifestation Acute vulvitis vaginitis and cervicitis Uterine infection Adnexal infections Septic pelvic thrombophlebitis Sapremia

Puerperal Infection

• Diagnosis History Physical examination and PV Lab finding Differential diagnosis

Puerperal Infection

• Treatment1. Nutrition: anemia prevention2. Antimicrobial treatment broad-spectrum, high dose, long time 3. Drainage4. Treatment of thrombophlebitis

Late Postpartum Hemorrhage

• Definition Uterine bleeding by 24 hours after delivery.• EtiologyPlacenta or membrane or decidua retainAbnormal redintegration InfectionProblems of incision

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