Problems of the Problems of the PuerperiumPuerperium

Max Brinsmead MB BS PhDMax Brinsmead MB BS PhD

May 2015May 2015

Day 1Day 1

Primary postpartum Primary postpartum haemorrhagehaemorrhage– Beware of the patient who “trickles”Beware of the patient who “trickles”– Some objective measure of loss Some objective measure of loss

desirabledesirable

Hypertension and seizuresHypertension and seizures– Continue Mg sulphate for 24 hrsContinue Mg sulphate for 24 hrs– Look for a diuresisLook for a diuresis– Keep BP below 150/100Keep BP below 150/100

Day 1 cont.dDay 1 cont.d– Urine retentionUrine retention

Aggravated by trauma or PV packAggravated by trauma or PV pack Check voiding ? catheteriseCheck voiding ? catheterise

– Urine IncontinenceUrine Incontinence Await spontaneous resolutionAwait spontaneous resolution Exclude fistulaExclude fistula

AnalgesiaAnalgesia– Perineal painPerineal pain

Exclude paravaginal haematomaExclude paravaginal haematoma This requires evacuationThis requires evacuation

– After painsAfter pains NSAID usefulNSAID useful But not for hypertensive patientsBut not for hypertensive patients

Day 2 – 6 weeksDay 2 – 6 weeks Secondary postpartum haemorrhageSecondary postpartum haemorrhage

– Normal is not always as the books Normal is not always as the books describedescribe

– Uterine involutionUterine involution Also a bit variableAlso a bit variable

– Retained products of conceptionRetained products of conception To an extent there are always RPOCTo an extent there are always RPOC

– The importance of infectionThe importance of infection It is this that causes symptomsIt is this that causes symptoms

– The role of ultrasoundThe role of ultrasound Only useful when negativeOnly useful when negative

– Management optionsManagement options Should always include BS antibioticsShould always include BS antibiotics Curette gently please!Curette gently please!

Day 3Day 3 Boobs and bottomsBoobs and bottoms

– Breast engorgementBreast engorgement– Nipple issuesNipple issues

It’s all about attachmentIt’s all about attachment And detachmentAnd detachment

– Lactation suppressionLactation suppression Many options but the safest is nothingMany options but the safest is nothing Anti prolactin agents for stillbirth etcAnti prolactin agents for stillbirth etc

– Ectopic breast tissueEctopic breast tissue– ConstipationConstipation

Fruit, fibre and fluidsFruit, fibre and fluids

– HaemorrhoidsHaemorrhoids Beware of the cure that is worse than Beware of the cure that is worse than

the disease!the disease!

Day 4 – 6 monthsDay 4 – 6 months The “Baby Blues”The “Baby Blues”

– Up to 80% of parturientsUp to 80% of parturients– A combination of insomnia, anxiety, A combination of insomnia, anxiety,

pain and hormonal changespain and hormonal changes– Manage with sympathy & practical Manage with sympathy & practical

supportsupport Postnatal DepressionPostnatal Depression

– 5 – 20%5 – 20%– The patient at riskThe patient at risk– DiagnosisDiagnosis– ManagementManagement

CounsellingCounselling AntidepressantsAntidepressants

Some Less common ProblemsSome Less common Problems ThromboembolismThromboembolism

– The patient at riskThe patient at risk– ProphylaxisProphylaxis– Diagnosis and treatmentDiagnosis and treatment

Caesarean wound infectionCaesarean wound infection Episiotomy breakdownEpisiotomy breakdown MastitisMastitis Severe puerperal psychosisSevere puerperal psychosis Uterine prolapseUterine prolapse

Puerperal infectionPuerperal infection

Risk Factors for Puerperal SepsisRisk Factors for Puerperal Sepsis Poor/No antenatal carePoor/No antenatal care AnaemiaAnaemia ObesityObesity Harmful traditional practicesHarmful traditional practices Long labourLong labour

– Prolonged rupture membranesProlonged rupture membranes– Repeated vaginal examinationsRepeated vaginal examinations

ChorioamnionitisChorioamnionitis General anaesthesiaGeneral anaesthesia Operative deliveryOperative delivery

– Emergency Caesarean sectionEmergency Caesarean section– Traumatic vaginal birthTraumatic vaginal birth

PPH and manual removalPPH and manual removal Retained products of conceptionRetained products of conception

Causes of Puerperal FeverCauses of Puerperal Fever The work of labourThe work of labour

– Low gradeLow grade– Settles within hours with rehydrationSettles within hours with rehydration

Genital Tract InfectionGenital Tract Infection– EndometritisEndometritis– Lower genital tract infection with Lower genital tract infection with

trauma/haematomatrauma/haematoma– Severe puerperal sepsis/Septic shockSevere puerperal sepsis/Septic shock

Urinary Tract InfectionUrinary Tract Infection Lung infections and atelactasisLung infections and atelactasis

– Especially after GAEspecially after GA MalariaMalaria OtherOther

– MastitisMastitis– TyphoidTyphoid– Meningitis etc.Meningitis etc.

Organisms involved in Genital Tract Organisms involved in Genital Tract Sepsis and their TreatmentSepsis and their Treatment

Gram PositivesGram Positives Streptococcus B and AStreptococcus B and A StaphylococcusStaphylococcus ClostridiaClostridia

– Treat with Penicillin or CephalosporinTreat with Penicillin or Cephalosporin Gram NegativesGram Negatives (the gut organisms) (the gut organisms)

E Coli, Klebsiella, Proteus, Pseudomonas, E Coli, Klebsiella, Proteus, Pseudomonas, SalmonellaSalmonella

– Treat with “Mycins” e.g. GentamicinTreat with “Mycins” e.g. Gentamicin AnaerobicsAnaerobics

Bacteroides, StreptocociBacteroides, Streptococi– Treat with MetronidazoleTreat with Metronidazole

Role of vaginal and wound swabs limitedRole of vaginal and wound swabs limited Blood culture is the best optionBlood culture is the best option

Perineal Wound BreakdownPerineal Wound Breakdown

Begin with good perineal hygieneBegin with good perineal hygiene

Timely debridement and repair in theatreTimely debridement and repair in theatre

Use long-lasting interrupted suturesUse long-lasting interrupted sutures

Mastitis and Breast AbscessMastitis and Breast Abscess

Often begins with a ‘flu-like illness Often begins with a ‘flu-like illness characterised by temperatures >40characterised by temperatures >4000 C C

Do not stop breast feedingDo not stop breast feeding– Drain this breast firstDrain this breast first

Usually associated with nipple damageUsually associated with nipple damage– Plus incomplete breast emptyingPlus incomplete breast emptying

Staphylococcus aureus in the vast majorityStaphylococcus aureus in the vast majority– May require FluocloxacillinMay require Fluocloxacillin– But Erythromcin and any penicillin will often workBut Erythromcin and any penicillin will often work

Only a few should proceed to abscess that Only a few should proceed to abscess that requires drainagerequires drainage– Keep the patient out of the hands of surgeons!Keep the patient out of the hands of surgeons!

Recurrent mastitis usually associated with Recurrent mastitis usually associated with poor breast-feeding techniquepoor breast-feeding technique

Any Questions or Any Questions or Comments?Comments?

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